单侧椎弓根螺钉结合对侧关节突螺钉固定应用于Wiltse入路经椎间孔腰椎椎间融合术的早期疗效观察

One-level lumbar decompression and TLIF with unilateral pedicle screws and contralateral percutaneous transpedicular facet screw fixation through Wiltse approach: Description of a new technique and its preliminary results

背景:目前,多数腰椎微创融合手术多需双侧的旁正中切口以完成椎管减压、椎间融合和后路固定。本研究介绍了一种新的术式,相比以往的方法更加简单、创伤更小,同时固定强度满意。目的:介绍一种用于微创腰椎经椎间孔融合术(transforaminal lumbar interbody fusion,TLIF)的新的后路内固定技术,并对其安全性和有效性进行评估。方法:回顾性分析2009年9月至2010年10月,采用单节段的腰椎管减压+TLIF,同时辅以同侧的椎弓根螺钉固定+对侧的关节突螺钉固定的40例患者。男20例,女20例,年龄27～82岁,平均57.5岁。手术节段:L4-523例,L5-S114例,L3-43例。总结临床疗效及并发症。结果:手术时间97～167min,平均124min。术中出血100～200ml,平均140ml,无输血。术后住院时间3d,平均1～6d。2例患者术后在关节突螺钉侧出现小腿疼痛,行翻修手术取出关节突螺钉,其中1例术后症状缓解,另1例无缓解。无伤口感染和脑脊液漏发生。所有患者术后随访时间均超过10个月,期间融合节段无脊柱不稳发生。结论:单侧椎弓根螺钉辅以对侧关节突螺钉可以用于单节段Wiltse入路的微创腰椎TLIF术,其固定强度满意。与传统的双侧旁正中入路相比,该技术可避免双侧切口的显露和剥离,减少组织损伤,同时具有缩短手术时间、减少出血的优点,但该技术在置入关节突螺钉时需要警惕神经根损伤的风险。

Background： Currently, most minimally invasive lumbar fusion requires bilateral parasagittal incision for decompression, interbody fusion, and posterior instrumentation. The purpose of this article is to describe a new surgical technique that is simpler, further minimizes the destruction of normal tissue with favorable biomechanical stability. Objective： The aim of the present study is to introduce a new fixation technique for one level minimally invasive lumbar decompression and TLIF through Wiltse approach. The efficacy and safety of this new technique is determined. Methods： By retrospectively reviewing the patients who had a one-level TLIF with pedicle screws insertion through a unilateral parasagittal approach and then with a contralateral percutaneous transpedicular facet screw placement. The efficacy and complications of this new technique was evaluated. Results： From September 2009 to December 2010, there were 40 patients who underwent a one-level lumbar decompression and TLIF with unilateral pedicle screws and then a eontralateral percutaneous transpedicular facet screw. There were 20 men and 20 women with average age of 57. 5 （ range, 27-82）. Twenty-three patients had surgery at the IA - L5 level, fourteen at the L5 - S1 level, and three at the L3 -L4 level. The average surgical time was 124 minutes （range, 97 -167）. The estimate blood loss of the surgery was 140 ml （ range, 100 - 200 ）. No blood transfusion in any of these patients. The average length of stay in the hospital after the surgery was 3 days （ range, 1 - 6 ）. Two patients developed delayed onset of new leg pain on the facet screw side, one patient recovery after the removal of the facet screw and the other one had no improvement. There were no post-operative complications such as wound infection or CSF leak. The average follow-up was at least 10 months, other than the two patients who had the facet screw removed, no patient had revision surgery. No patient developed radiographic instability such as abnormal motion at the level of fusion during the period of follow-up. Conclusions： This new technique of one-level TLIF surgery using unilateral Wiltse approach combined with contralateral percutaneous facet screw insertion has further advanced the minimally invasive lumbar fusion surgery by allowing even less normal tissue destruction and provide favorable biomechanical stability. This new technique also has the advantages of reducing surgical time and blood loss. However, high caution is needed during the insertion of the percutaneous traspedicular facet screw in order to avoid nerve root injury.