微创通道结合经皮椎弓根螺钉固定治疗腰椎退变的个体化方案选择

Individualized options of minimally invasive decompression and fusion under extendable retractor combined with percutaneous pedicle screw fixation for lumbar degenerative diseases

目的探讨应用微创通道减压融合结合经皮椎弓根螺钉固定治疗腰椎退行性疾病的初步临床效果及手术方案选择。方法收集2009年8月至2011年7月第四军医大学唐都医院运用微创通道减压融合结合经皮椎弓根螺钉固定治疗并获得随访的64例腰椎退变患者的临床资料。采用Quadrant、Pipeline或Luxor通道系统,经椎间孔腰椎间融合(TLIF)或后路TLIF(PTLIF)入路,行髓核摘除或椎间处理并植入椎间融合器,通道内行椎弓根螺钉固定并安装连接棒。于对侧相应椎体处行椎弓根经皮植入Sextant、vipor或Mantis螺钉固定。微创策略的选择:(1)单侧通道下减压椎间植骨融合,常规椎弓螺钉内固定;(2)一侧通道下减压植骨融合通用螺钉固定 + 对侧通道下通用螺钉固定;(3)一侧通道下减压植骨融合通用螺钉固定 + 对侧经皮螺钉固定;(4)一侧通道下减压椎间植骨融合+双侧经皮螺钉固定。融合方式包括单节段融合、双节段融合和跨节段融合。观察患者术中出血量、手术时间、术后下床活动时间、住院天数、内固定位置以及术后症状改善情况。结果随访3～22 个月(平均 16 个月)。术中出血量 70～230 mL(平均 90 mL)、手术时间 70～210 min(平均 100 min)、下床活动时间为术后3～10 d(平均5 d)、住院天数5～15 d(平均7 d)。腰痛视觉模拟评分(VAS)和腿痛VAS分别由术前的(9.2 ± 1.4)分和(7.4 ± 1.2)分减少到末次随访的(2.6 ± 0.5)分和(2.2 ± 0.6)分,Oswestry功能障碍指数(ODI)由术前的(57.4 ± 6.4)%降至末次随访的(25.8 ± 4.3)%,差异均有统计学意义(P <0.05)。术中、术后X线片和/或 CT 检查显示内固定及融合器位置良好。结论一侧采用微创通道 TLIF 或 PTLIF 入路行单节段或双节段椎间处理融合,或在此基础上行对侧通道下通用螺钉/经皮椎弓根螺钉固定或双侧经皮螺钉固定等个体化方案治疗腰椎退行性疾病,术中出血少,手术时间短,术后可早期下床进行功能锻炼,初步临床效果优良。

Objective To investigate preliminary outcomes and surgical options of minimally invasivedecompression and fusion under extendable retractor,combined with percutaneous pedicle screws fixation for lumbar degenerative diseases.Methods Clinical follow-up results of 64 patients who suffered from lumbar degenerative diseases and then treated by minimally invasive decompression and fusion combined with percutaneous pedicle screws fixation were collected at Tangdu Orthopaedic Hospital of the Fourth Military Medical University from August 2009 to July 2011.The Quadrant,Pipeline or Luxor retractor system was applied through transforaminal lumbar interbody fusion（TLIF） or posterior TLIF（PTLIF） approach,and then the discectomy or interbody cage fusion was performed,vertebral pedicle screws were implanted and connecting rod was installed through the same channel.Sextant,Vipor or Mantis percutaneous screws were implanted in the corresponding contralateral vertebral pedicle for fixation.Minimally invasive strategy options were as follows：（1） unilateral channel decompression and interbody fusion followed by conventional pedicle screws fixation;（2） one side channel decompression and interbody fusion with common screws fixation followed by contralateral channel common screws fixation;（3） one side channel decompression and interbody fusion with common screws followed by contralateral channel percutaneous screws fixation;（4） one side channel decompression and interbody fusion followed by bilateral percutaneous screws fixation.Fusion methods included single segment,double segments and cross-segments fusion.Intraoperative estimate blood loss volume,operative time,hospital stay days,as well as postoperative ambulation time,fixation position and sysmptom improvement were observed.Results All of the 64 patients were followed up from 3 to 22 months,with the average of 16 months.The average intraoperative estimate blood loss volume was 90 mL（70-230 mL）,the mean operative time was 100 min（70-210 min）,the average postoperative ambulation time was 5 d（3-10 d）,and the mean hospital stay was 7 d（5-15 d）.Visual analogue score（VAS） of low back pain and leg pain decreased respectively,from preoperative（9.2 ± 1.4） and（7.4 ± 1.2） to（2.6 ± 0.5） and（2.2 ± 0.6） at the last follow-up.Oswestry disability index（ODI） decreased from（57.4 ± 6.4）% at preoperation to（25.8 ± 4.3）% at the last follow-up,the differences had statistical significance（P 0.05）.X-ray and/or CT radiographs showed internal fixation and fusion in good position during and after the surgery.Conclusion For patients with lumbar degenerative diseases,individulized options of one side minimally invasive channel through TLIF or PTLIF approach for decompression and interbody fusion,or combined with common screws or percutaneous pedicle screws for contralateral fixation,or combined with double sides percutaneous pedicle screw fixation can receive good preliminary clinical results because of less blood loss,shorter operative time and earlier ambulation.