显微内镜辅助经皮微创椎间孔入路腰椎椎体间融合术治疗腰椎退行性疾病

Minimally invasive percutaneous transpedicular screw fixation combined with microendoscopy-assisted transforaminal lumbar interbody fusion for lumbar degenerative diseases

背景:传统开放椎间孔入路腰椎椎体间融合术(transforaminal lumbar interbody fusion,TLIF)由于剥离肌肉广泛及长时间牵拉,可导致部分患者持续性腰背痛。随着脊柱微创技术的发展,采用微创手段实施TLIF技术取得了良好的临床效果,但小切口经扩张通道系统的微创TLIF仍不可避免存在肌肉剥离,需探索更加微创的手术方式。目的:探讨显微内镜辅助经皮微创TLIF治疗腰椎退行性疾病的近期疗效及安全性。方法:2010年9月至2011年7月,72例腰椎退行性疾病患者接受了单节段TLIF手术,腰椎失稳症36例,腰椎管狭窄症25例,复发型腰椎间盘突出症11例。采用VIPER经皮椎弓根螺钉系统结合椎间盘镜下TLIF手术32例(微创组),传统开放TLIF手术40例(开放组),对两组患者近期临床疗效、并发症、术中射线暴露指标等进行比较。结果:所有患者均获随访,随访时间6～15个月,平均9个月。两组手术时间无明显统计学差异(P>0.05),微创组术中出血量、伤口引流量、住院天数、术后应用镇痛药剂量均明显低于开放组(P<0.01);微创组术中射线暴露时间及剂量高于开放组(P<0.01);微创组术后疼痛(VAS评分)及ODI功能指数较开放组明显降低(P<0.01)。微创组出现术中减压错误1例,置钉位置错误1例,导针穿透椎体前壁1例,硬膜撕裂1例;开放组出现术中硬膜撕裂3例,术后伤口浅表感染1例。两组患者均未出现神经损伤并发症。结论:显微内镜辅助经皮微创TLIF较传统开放手术具有创伤小、出血少、恢复快、住院时间短等优点,具有良好的近期疗效,是治疗腰椎失稳症值得推荐的微创手术方式。

Background： TLIF （transforaminal lumbar interbody fusion） as traditional open surgery induce persistent low back pain because of wildly separating muscle and long time traction. With recent advances in minimal invasive spine surgery technological development, minimally invasive TLIF （MIS-TLIF） achieves good clinical results. More minimally invasive technique should be developed because of inevitable muscle separating as for mini-open MIS-TLIF. Objective： The aim of the present study is to evaluate the effectiveness of minimally invasive percutaneous transpedicular screw fixation combined endoscopically assisted TLIF for lumbar degenerative diseases. Methods： From September 2010 to July 2011, 72 patients with lumbar degenerative diseases, including 36 cases of lumbar instability, 25 cases of lumbar spinal stenosis and 11 cases of recurrent lumbar disc herniation, were divided into two groups and underwent different types of transforaminal lumbar interbody fusion surgery. MIS-TLIF group （32 patients） received minimally invasive treatment with DePuy Viper 1 system combined endoseopieally assisted TLIF. Open TLIF group （40 patients） underwent traditional open TLIF surgery. The blood loss, operation time, hospital stay, analgesics use, radiation exposure time were observed and compared between the two groups. Visual analogie scale （VAS） and the Oswestry disability index （ODI） wereused to evaluate pain and function in perioperative and follow-up time. Results： All cases had been followed up among 6 - 15months, average of 9 months. There was no significant differences in operation time between the two groups （ P 〉 0. 05 ）. Significant differences were found in surgical blood loss, surgical draining loss, hospital stay, analgesics use and radiation exposure time and dose （P 〈 0. 01 ） , which were less in MIS-TLIF group. The scores of VAS and ODI in MIS-TLIf group were more significant less than those in Open TLIF group （ P 〈 0. 01 ）. In MIS-TLIF group, there were 1 case of wrong level of decompression, 1 case of inappropriate place of pedicle screw, 1 case of penetrate the anterior wall of vertebral body, and 1 case of dural tear. Otherwise, there were 3 case of dural tear, 1 case of wound infection. None of nerve root injury was found in either MIS-TLIF or open TLIF group. Conclusions： The minimally invasive percutaneous transpedicular screw fixation combined microendoscopy-assisted transforaminal lumbar interbody fusion, which is less injury, less blood loss, less hospital stay, and satisfied function recovery, is a safe and effective minimally invasive surgical method for lumbar degenerative diseases.