多裂肌间隙入路单侧椎弓根螺钉固定治疗特殊类型腰椎间盘突出症

Surgical treatment for special type of lumbar disc herniation by transmultifidus approach and unilateral pedicle screws fixation

[目的]比较传统正中入路双侧椎弓根螺钉固定(A组)与多裂肌间隙入路单侧椎弓根螺钉固定(B组)治疗单节段特殊类型腰椎间盘突出症(special type lumbar disc herniation,STLDH)的临床效果。[方法]2007年3月～2009年3月采用椎弓根螺钉固定联合经椎间孔腰椎椎体间融合术治疗单节段STLDH患者73例,其中A组41例,B组32例。比较两组的手术创伤、全身炎性反应、临床疗效、融合率及椎旁肌损伤。[结果]A组随访时间平均2.8(2.2～4.1)年,B组2.7(2.1～4.2)年。两组手术时间、术中出血量、术后引流量、切口长度、术后3 d内的最高体温、术后24 h外周血的白细胞和C反应蛋白以及肌酸激酶、术后6 d C反应蛋白的比较差异有显著性(P<0.05),B组优于A组。末次随访时,两组的ODI及VAS评分均较术前明显改善(P<0.05),腿痛VAS评分差异无显著性(P>0.05),而ODI及腰痛VAS评分差异有显著性(P<0.05),B组优于A组;A组和B组椎间坚强融合率分别为92.7%、93.8%,差异无显著性(P>0.05);A组和B组多裂肌萎缩比分别为(36±14)%、(16±7)%,差异有显著性(P<0.05)。[结论]两种手术方法均能有效治疗单节段STLDH;与传统正中入路双侧椎弓根螺钉固定术相比,多裂肌间隙入路单侧椎弓根螺钉固定术具有手术创伤小、术后全身炎性反应轻、椎旁肌损伤小及术后腰背痛程度较轻的优势。

[Objective]To investigate the clinical outcomes of surgical treatment for single-level special type of lumbar disc herniation（STLDH） by traditional median approach and bilateral pedicle screw fixation（group A） versus transmultifidus approach and unilateral pedicle screw fixation（group B）.[Methods]Seventy-one patients（41 in group A,39 in group B） with single-level STLDH were treated between March 2007 and March 2009 by pedicle screw fixation combined with transforaminal lumbar interbody fusion.The indexes of surgical trauma,systemic inflammatory response,clinical outcomes,fusion rate and paravertebral muscle injury were compared between two groups.[Results]The mean time of following-up was 2.8 years（range,2.2-4.1 years） in group A and 2.7 years（range,2.1-4.2 years） in group B.There were significant differences（P0.05） between the 2 groups regarding to intraoperative blood loss,postoperative drainage,length of incision,peak temperature within 3 days postoperatively,leucocytes and C reactive protein and creatine kinase MM at 24 hours postoperatively and C reactive protein at 6 days postoperatively in peripheral blood,showing superiorities in group B.At the last following-up,the ODI and VAS scores were significantly improved in both groups（P0.05）.Group B showed better results regarding to ODI and back pain VAS scores（P0.05）,but not significantly（P0.05） to leg pain VAS scores in both groups.Strong fusion rates were 92.7% in group A and 93.8% in group B,showing no difference（P0.05）.The average atrophy ratio was（37±13）% versus（15±7）% in group A and B respectively,with statistically significant differences（P0.05）.[Conclusion]Both surgical treatments are effective for single-level STLDH.Compared with traditional median approach and bilateral pedicle screw fixation,transmultifidus approach and unilateral pedicle screw fixation has advantages of minimal surgical trauma,slighter postoperative systematic inflammatory response,less paravertebral muscle injury and lighter postoperative back pain.