微创经椎间孔椎间融合术治疗腰椎退行性疾病

Preliminary experiences in minimally invasive transforaminal lumbar interbody fusion

目的探讨微创经椎间孔椎间融合术（TLIF）治疗腰椎退行性疾病的方法及疗效。方法2005年1月至2006年12月，采用微创TLIF治疗腰椎退行性疾病31例（微创TLIF组），年龄41～63岁，平均53．6岁。其中腰椎间盘突出症合并腰椎管狭窄7例，腰椎间盘突出症合并腰椎不稳16例，腰椎滑脱症8例。手术采用后路旁正中切口，在METRx X—Tube下置入双侧或单侧椎弓根钉，单枚矩形cage斜向45°椎间融合。统计手术时间、术中出血量、输血量、术后引流量、疼痛视觉模拟评分（VAS）值及术前、术后JOA评分，影像评估椎弓根钉位置及椎间融合情况，并与同期采用常规TLIF治疗的33例患者（常规TLIF组）进行比较。结果微创TLIF组4例采用单侧椎弓根钉固定，平均手术时间199min，平均术中出血量359ml，平均输血量32ml，术后平均引流量81ml，术后72hVAS值平均2．37。常规TLIF组3例采用单侧椎弓根钉固定，平均手术时问156min，平均术中出血量589ml，19例输血，平均输血量122ml，术后平均引流量120ml，VAS值4．65，两组比较差异具有统计学意义。微创TLIF组4枚常规TLIF组2枚螺钉偏出。平均随访18．4个月，微创TLIF组1例发生cage移位，两组无椎弓根钉断裂、松动。JOA评分及改善率两组差异无统计学意义。结论微创TLIF组织损伤小，术后康复快，长期疗效与常规方法相当。

Objective To explore clinical application of minimally invasive transforaminal lumbar interbody fusion （TLIF） for the management of lumbar disorders and discuss its indications, surgical techniques and clinical effectiveness. Methods From Jan 2005 to Dec 2006, 31 selected patients （22 males and 9 females, aged from 41 to 63 years）with degenerative lumbar diseases were treated with minimally invasive TLIF assisted by METRx X-Tube microendoscopes system. The index diagnosis was lumbar disc herniation with Lumbar spinal stenosis in 7,lumbar disc herniation with segmental instability in 16,grade 1 to 2 of lumbar spondylolisthesis in 8. The surgical methods was performed with bilateral or unilateral pedicle screws insertion and a single rectangle cage posterolateral placement. The operating time, blood loss, blood transfusion, drainage, visual analogue scale （VAS） , preoperative and postoperative JOA scores were observed as well as radiographic evaluation. The results were compared with standard TLIF group respectively. Results A total of 116 pedicle screws and 31 cages were implanted of which 4 patients were treated with unilateral pedicle screws fixation. Four pedicle screws were found misplaced in CT scans after surgery. The average operating time was 199 min, blood loss 359 ml, volume of transfusion 32 ml drainage 81 ml, and VAS was 2. 37 about 72 hours after surgery, which had statistic difference compared with control group. There was no statistic difference on postoperative improvement rate and JOA scores in two groups. Conclusions Minimally invasive TLIF minimizes paraspinal muscle trauma and blood loss, shortens the operating and recovery time. A good long-term outcome can be gained compared with standar procedures.