小切口与传统开放术式行后路腰椎椎体间融合术对脊旁肌损伤的对比研究

Comparison of paraspinal muscle injury about one-level lumbar posterior intervertebral fusion performed with minimally invasive or conventional open approach

目的对比小切口与传统开放术式进行单节段后路腰椎椎体间融合（posterior lumbar interbody fusion，PLIF）术对脊旁肌损伤程度的差别。方法2006年3月至2008年5月，应用PLIF术治疗单节段下腰椎病变患者91例。小切口组41例，男22例，女19例；年龄34-72岁，平均53．5岁；椎间盘突出伴椎间隙狭窄10例、椎管狭窄症7例、椎体后缘离断症4例、腰椎滑脱症20例。开放组50例，男23例，女27例；年龄28-75岁，平均53．4岁；椎间盘突出伴椎间隙狭窄13例、椎管狭窄症8例、椎体后缘离断症4例、腰椎滑脱症25例。比较两组病例的手术时间、术中出血及术前、术后第1、3、5、7天的肌酸激酶水平。对术后1年以上患者评估VAS疼痛评分和Oswestry功能障碍评分。分别对11例小切口和10例开放手术的患者手术节段水平多裂肌横截面积比较。结果小切口组术中出血及术后第1、3、5天肌酸激酶水平明显低于开放组。小切口组25例、开放组30例获得随访。VAS分值和ODI百分数两组患者术前均无明显差别，而术后小切口组均明显低于开放组。小切口组术后多裂肌横截面积无明显变化，脂肪化轻微；而开放组多裂肌萎缩明显，并且瘢痕化、脂肪化明显。结论与传统PLIF术相比，小切口PLIF术具有切口小、术中出血少、软组织损伤小、术后恢复快、多裂肌萎缩和腰背痛的发生率低等优点。

Objective To determine the differences of paraspinal muscle injury between the mini- mally invasive and conventional open approach for one-level instrumented posterior lumbar interbody fusion （PLIF）. Methods From March 2006 to May 2008, 91 patients underwent one-level instrumented PLIF procedure using 2 different approaches （minimally invasive approach in 41 patients and open approach in 50 patients） by one group of surgeons. The following data were compared between the 2 groups：surgical time, blood loss, changes of postoperative serum level of Creatinine Kinase. More than 1 year after operation, the patients were followed up with VAS scores and Oswestry disability questionnaire. Some patients accepted MRI evaluation by comparing the cross section area and fat degeneration grades at the operative level be- tween pre-operation and post-operation. Results There was no obvious difference in surgical time, but less blood loss, lower index of serum level of Creatinine Kinase, less postoperative back pain, and lower ODI per- cent in minimally invasive group. There was significant decrease in the cross sectional area of muhifidus muscle in the conventional group. In contrast, the results in the minimally invasive group showed no statisti- cal difference between preoperative results and that of the follow-up MRI. Conclusion Compared with con- ventional approach, minimally invasive approach PLIF can get smaller approach, less blood loss and soft tis- sue injury, faster recovery posteroperatively, and less incidence of muhifidus atrophy and low back pain.