侧前方入路治疗胸腰段椎间盘突出症

ANTEROLATERAL APPROACH FOR TREATMENT OF THORACOLUMBAR DISC PROTRUSION

目的探讨侧前方入路治疗胸腰段椎间盘突出症的疗效。方法2004年5月-2008年5月,采用侧前方入路行椎间盘摘除、椎间植骨融合、Z形钢板内固定术治疗胸腰段椎间盘突出症(T10～L3)11例。男9例,女2例;年龄26～57岁,平均42.8岁。病程1周～11年,平均2.7年。5例有腰背部外伤史。下肢无力9例,感觉障碍8例,腰背痛6例,下肢疼痛5例,括约肌障碍4例,足下垂3例。X线片、CT和MRI检查示,单节段突出9例,双节段突出2例。合并黄韧带骨化2例,后纵韧带骨化2例,Scheuermann病1例。术前椎间隙高度为(7.2±1.3)mm,JOA评分为(6.4±2.8)分。结果手术时间2.5～5.5h,平均3.5h;术中出血500～1200mL,平均750mL。术中发生胸膜、腹膜及硬膜破裂各1例,予修补缝合,放置负压引流管3～5d,术后无液气胸及脑脊液漏发生。术后切口均Ⅰ期愈合,无神经系统并发症发生。11例均获随访,随访时间1～4年,平均2.4年。X线片示植骨均于术后6～9个月融合,无钛板、螺钉断裂或松动现象。3例有10～15°脊柱侧弯,但不影响脊柱平衡。术后2周椎间隙高度增加至(12.3±1.5)mm,与术前比较差异有统计学意义(P<0.05);术后1年骨性融合时椎间隙高度降至(7.5±1.2)mm,与术前比较差异无统计学意义(P>0.05)。术后1年JOA评分升至(7.6±3.2)分,与术前比较差异有统计学意义(P<0.05)。患者术后症状及体征均有不同程度改善,按Hirabayashi等提出的改善率评定标准,优4例,良6例,可1例,优良率90.9%。结论侧前方入路是治疗胸腰段椎间盘突出症一种安全有效的方法。

Objective To evaluate the effect of anterolateral approach in treating thoracolumbar disc protrusion. Methods From May 2004 to May 2008,11 patients with thoracolumbar disc protrusion （T10-L3） underwent discectomy,autologous iliac bone graft,and internal fixation via anterolateral approach. There were 9 males and 2 females aged 26-57 years old （average 42.8 years old）. The course of disease was 1 week-11 years （average 2.7 years）. Nine patients showed the lower limbs weakness,8 had sensory disturbance,6 presented with lumbodorsal pain,5 had the lower limb pain,4 presented with sphincter muscle disturbance,3 suffered from foot drop,and 5 had a history of lower back injury. X-ray,CT,and MRI test showed that 9 cases had the single-segmental protrusion,2 cases had double-segmental protrusion,2 cases were accompanied with ossification of the thoracic vertebra yellow ligament,2 cases were combined with ossification of the vertebra posterior longitudinal ligament,and 1 was complicated with Scheuermann disease. Preoperatively,the intervertebral height was （7.2 ± 1.3） mm and JOA score was 6.4 ± 2.8. Results The time of operation was 2.5-5.5 hours （average 3.5 hours）; the blood loss during operation was 500-1 200 mL （average 750 mL）. During operation,intraoperative pleural tear occurred in 1 patient,peritoneal tear in 1 patient,and dural laceration in 1 patient. Repairing was performed intraoperative and preventive suction drainage was used for 3-5 days. No postoperative hydropneumothorax and cerebrospinal fluid leakage occurred. All incisions healed by first intention. No postoperative complications of nerve system occurred. All the patients were followed up for 1-4 years （average 2.4 years）. X-ray films showed that all the patients achieved bony fusion without the occurrence breakage and loosening of titanium plate and screw 6-9 months after operation. Three cases displayed subtle scoliosis （10-15°） without influence on spinal equilibration. The intervertebral height increased to （12.3 ± 1.5） mm 2 weeks after operation,indicating there was a significant difference compared with preoperative value （P 〈 0.05）. The intervertebral height 1 year after operation when the bony fusion was reached decreased to （7.5 ± 1.2） mm,indicating there was no significant difference compared to the preoperative value （P 〉 0.05）. The JOA score increased to 7.6 ± 3.2 at 1 year after operation,indicating there was a significant difference compared with preoperative value （P 〈 0.05）. The symptoms and signs of all the patients were improved to various degrees after operation. According to improvement rate evaluation system proposed by Hirabayashi et al.,4 cases were graded as excellent,6 as good,1 as fair,and the excellent and good rate was 90.9%. Conclusion Treating thoracolumbar disc protrusion via anterolateral approach is safe and effective.