内镜辅助微创入路人工腰椎间盘置换术的临床效果及矢状平衡分析

A prospective study of video-assisted minimal access total lumbar disc replacement:analysis of spinal sagittal balance

目的 探讨内镜辅助微创入路人工腰椎间盘置换术的临床效果及对矢状平衡的影响.方法 采用内镜辅助微创入路Maverick人工腰椎间盘置换术治疗腰椎间盘退变性疾病135例.术前MR检查评估小关节和椎旁肌退变程度;术前和随访时均摄腰椎正侧位、过伸过屈位及包括双侧股骨头的站立位脊柱全长正侧位X线片,测量假体位置和活动度、矢状平衡参数.结果 术后随访2～5年,平均3.5年.一个间隙手术时间平均60 min,术中出血平均170 ml.输尿管损伤1例,术中修补后效果好,交感神经损伤5例,术后神经根性痛4例,切口浅表感染1例,保守治疗后均好转.末次随访时Oswestry 评分由术前平均46.6%+12.0%降至23.2%±19.0%;腰痛和腿痛视觉类比评分(visual analogue scale,VAS)分别由术前平均7.6±2.3和3.6±3.0降至2.7±2.5和1.9+2.5.末次随访时间盘置换节段活动度平均7.5°±5.2°,节段性前凸较术前增加,但相邻节段前凸代偿性减少,腰椎前凸轻度增大,维持矢状平衡.L4-5 椎间盘置换同时行L5S1前路融合者L4,5前凸增大不明显;L5S1椎间盘置换者骨盆指数平均降低1.7°;骶骨上终板倾角＜35°者末次随访时平均增大2.1°,＞45°者平均减少3.8°.结论 内镜辅助微创人路Maverick人工腰椎间盘置换术在严格掌握适应证的情况下能取得良好的临床效果,保留椎间活动度,恢复和保持脊柱矢状平衡,间盘置换节段一般前凸增加,但受相邻节段融合手术的影响.

Objective To evaluate the clinical results of total disc replacement (TDR)and its influence on sagittal balance.Methods From January 2002 to February 2005,video-assisted retroperitoneal minimal access TDR with Maverick prosthesis was performed for 135 cases of lumbar degenerative disc disease(DDD).All the patients were followed up from 2 to 5 years(mean 3.5 years).Radiographic evaluation included flexion-extension films of lumbar spine and standing anteroposterior and lateral full spine films including femoral heads.Results For single level TDR.the mean operating time was 60 min and the mean intraoperative blood loss was 170 ml.At final follow-up,the Oswestry score improved from 46.6%±12.0%preoperatively to 23.2%±19.0%.the VAS of back pain and leg pain improved from 7.6±2.3 and 3.6+3.0 preoperatively to 2.7+2.5 and 1.9±2.5.respectively.The mean mobility of prosthesis Was 7.5°.The lumbar lordosis and spinal balance were well maintained with increased segmental lordosis at TDR level and compensatory decreased lordosis at adjacent level.The segmental lordosis of L4-5 prosthesis did not increase significantly when L5S1 anterior fusion was performed at the same time.The pelvic incidence(PI)decreased 1.7 degree after L5S1 TDR.The sacral slope(SS)increased 2.1° when it was less than 35°,and decreased 3.8° when it Was more than 45°.Conclusion Video-assisted minimal access TDR with Maverick prosthesis can give good result for DDD provided the patients were selected appropriately.The mobility of TDR level was preserved.and the spinal sagittal balance is well maintained.The increase of segmental lordosis at TDR level can be influenced by anterior fusion at adjacent level.