经椎间孔椎体间融合术在合并腰椎不稳的腰椎间盘突出症中的应用

Trausforaminal lumbar interbody fusion in the treatment of lumbar intervertebral disc herniation with lumbar instability

目的探讨经椎间孔椎体间融合（TLIF）治疗合并腰椎不稳的腰椎间盘突出症的疗效。方法2008年11月至2011年8月上海交通大学附属第一人民医院骨科应用TLIF技术治疗腰椎间盘突出症患者47例，男25例，女22例；年龄30～68岁，平均52岁。其中合并不稳16例，退变性滑脱9例，椎管狭窄15例，退变性侧弯7例。共融合63个节段，其中单节段31例，双节段16例。手术方法首先按椎弓根螺钉技术置入螺钉，切除一侧下关节突、上关节突内侧增生部分，暴露椎间孔，沿神经根管将神经根松解，减压至下位椎间孔，根据是否合并对侧症状，决定对侧是否行神经根管减压，椎管减压满意后按照常规方法完成TLIF。术前、术后采用日本骨科学会（JOA）、功能障碍指数（ODI）进行评分，根据X线片评价椎间隙高度的变化及椎间融合情况。结果本组病例术中无并发症，随访6—36个月，平均19．6个月。术前JOA评分（11．0±2．8），术后评分（15．4±3．4），术前术后JOA评分差异有统计学意义（t=13．464，P=0．000）；术前ODI评分（37．8±4．6），术后ODI评分（18．8±3．8），术前术后ODI评分差异有统计学意义（t=24．578，P=0．000）。1例出现融合器移位，翻修1例，椎弓根系统无松动及断裂，椎间融合率为98％，植骨融合时间平均为6．5个月。术后无明显并发症。结论TLIF治疗合并有腰椎不稳的腰椎间盘突出症，减压彻底，操作简单、安全，并发症较少，临床效果满意。

Objective To explore the surgical efficacy of transforminal lumbar interbody fusion （TLIF） technique in the treatment of lumbar intervertebral disc herniation with lumbar instability. Methods From November 2008 to August 2011, 47 patients of lumbar intervertebral disc herniation underwent TLIF. There were 25 males and 22 females with an average age of 52 years （ range： 30 - 68 ） . The preoperative diagnoses included lumber intervertebral disc herniation plus lumbar instability （ n = 16 ） ; lumbar degenerative spondylolisthesis （ n = 9 ） ; lumbar spinal stenosis （ n = 15 ） and degenerative lumbar scoliosis （n = 7）. A total of 63 levels were fused, including single level （n=31 ） and double levels （n = 16）. Posterolateral fixation was secured with pedicle screw. Unilateral resections of inferior articular facet of superior vertebra and superior articular facet of inferior vertebra were performed to expose unilateral intervertebral vertebral foramen. Decompression of vertebral canal was expanded to the opposite side if symptoms recurred when never root was decompressed satisfactorily. Finally TLIF was performed routinely. The standard criteria of JOA （ Japanese Orthopedic Association） and ODI （ Oswestry disability index） were applied for efficacy evaluations. And the intervertebral height and bone fusion were observed radiologically. Results All patients underwent surgery smoothly without severe complications. The average foUow-up period was 19.6 months （range：6 -36）. Significant differences existed in JOA score between preoperation （11.0 ± 2.8） and postoperation （15.4 ±3.4） （P = 0.01） and ODI score between preoperation （37. 8 ±4. 6） and postoperation （18. 8± 3.8）. At 6. 5 months postoperatively, all operated segments achieved fusion and there was no broken screw. There was 1 case of cage dislocation. Conclusion In select patients of lumbar intervertebral disc herniation with spinal instability, TLIF may be performed easily and safely with fewer complications and total root decompression.