微创经椎间孔减压腰椎融合内固定术与传统后路开放手术治疗腰椎退变性疾病的疗效比较

Outcomes of minimally invasive transforaminal lumbar interbody fusion via Quadrant retractor versus conventional posterior open surgery for degenerative lumbar spine disease

目的：比较Quadrant通道辅助下微创经椎问孔减压腰椎融合内固定术与传统后路开放手术治疗腰椎退变性疾病的临床效果。方法：2008年3月～2010年6月，选择经保守治疗无效的单一节段腰椎退变性疾病的患者80例，随机分为两组，每组40例，两组患者年龄、性别、体重、临床诊断与手术节段差异无统计学意义（P〉0．05），分别进行Quadrant通道辅助下微创经椎间孔减压腰椎融合内固定术与传统后路开放手术。随访24～36个月，平均29个月，比较两组患者的手术时间、术中出血量、术后引流量、住院时间、血清肌酸磷酸激酶、MRI-T2驰豫时间、VAS评分、Oswestry功能障碍指数（ODI）及融合率等。结果：两组手术时间（141．0±27．3min与139．5±33．7min）无统计学差异（P〉0．05）。微创手术组的术中出血量、术后引流量分别为268．0±122．2ml和25．6±32．4ml，明显少于传统开放手术组的370．0±147．1ml和277．8±167．4ml（P〈0．05）；术后住院时间为713±3．2d，短于传统开放手术组的9．5±2．7d（P〈0．05）。每组患者术后1个月、24个月时的VAS评分与ODI与术前比较均有明显改善（P〈0．05），术后1个月时微创手术组腰、腿痛VAS评分优于传统开放手术组（P〈0．05），术后24个月时腰、腿痛VAS评分及术后1个月、24个月时ODI两组比较均无统计学差异（P〉0．05）。肌酸磷酸激酶在术后1、3、5d时明显升高（P〈0．05），术后1d达到高峰，7d时基本恢复正常，并在术后1、3d时微创手术组明显低于传统开放手术组（P〈0．05）。术后3个月时手术节段多裂肌的T2驰豫时间微创手术组明显低于传统开放手术组（P〈0．05）。术后6个月及24个月随访时两组融合率无统计学差异（P〉0．05）。结论：Quadrant通道辅助下微创经椎间孑L减压腰椎融合内固定术与传统开放手术治疗单节段腰椎退变性疾病均可取得较好的近期疗效，但前者肌肉和软组织损伤小，有助于早期功能恢复。

Objectives： To compare clinical outcomes of minimally invasive transforaminal lumbar interbody fusion（MIS-TLlF group） via MAST Quadrant retractor vs conventional posterior open surgery（open group） for degenerative lumbar spine disease. Methods： From March 2008 to June 2010, 80 patients with single-level lumbar degenerative disease and failed with conservative treatment were enrolled in this study. All cases were divided into two groups randomly, with 40 patients in each group. There was no significant difference in age, gender, body weight, clinical diagnosis or the segment between the two groups（P〉O.05）. Minimally invasive transforaminal lumbar interbody fusion via MAST Quadrant retractor or the conventional posterior open surgery was performed randomly. The operation time, blood loss, postoperative drainage, hospital stay, creatine phos- phokinase（CPK） in serum, MRI-T2 relaxation time, visual analogue scores（VAS） for back and leg pain, Os- westry disability index（ODI）, and fusion rate by 24-36 months follow-up（mean time, 29 months） between two groups were compared. Results： The MIS-TLIF group had similar operation time to the open surgery group （141.0±27.3min vs 139.5±33.7min, P〉0.05）. Intraoperative blood loss, postoperative drainage in MIS-TLIFgroup was 268.0±122.2ml and 25.6±32.4ml, which was significantly less than 370.0±147.1ml and 277.8± 167.4ml of the open group, respectively （P〈0.05）; postoperative hospitalization time of MIS-TLIF group was shorter than that of open group （7.3±3.2d vs 9.5±2.7d, P〈0.05）. The VAS and ODI were lower at 1 and 24 months postoperatively than preoperative ones in both groups（P〈0.05）. At 1 month, the MIS-TLIF group had lower VAS score than open surgery group （P〈0.05）, while no significant differences with respect to VAS for back and leg pain at 24-month and ODI at 1 and 24 months were noted between the two groups （P〉0.05）. The CPK levels were significantly higher at 1, 3, 5 days after surgery（P〈O.05）, and peaked at 1 day after surgery, meanwhile, which were significantly lower in the MIS-TLIF group than the open group at 1, 3 days after surgery （P〈O.05）. The MR1-T2 relaxation time of the multifidus muscle was significantly better in the MIS-TLIF group than the open surgei＇y group at 3 months after surgery（P〈0.05）. Radiological analysis showed similar fusion rate at 6 and 24 months after surgery（P〉0.05）. Conclusions： Minimally invasive transforaminal lumbar interbody fusion via MAST Quadrant retractor surgery and conventional posterior open surgery both can achieve a good short-term efficiency, but the former surgery had less soft tissue intervention, and conducive to early functional recovery.