通道下经肌间隙入路椎间固定融合术的学习曲线

Learning curve of instrumented interbody fusion through intermuscular approach using channel system

[目的]研究通道下经肌间隙入路联合固定并椎间融合术(MIS-TLIF)治疗腰椎病变的学习曲线。[方法]回顾性分析本院2012年6月～2015年12月收治的192例腰椎退变性疾病患者,采用单侧切口肌间隙入路通道下进行MIS-TLIF手术,置入单侧椎弓根螺钉后同一切口置入对侧经椎板关节突螺钉,按时间先后顺序分成A、B、C、D四组,A、B、C三组每组30例,D组102例。组间比较手术时间、术中出血量、手术并发症、置钉失败率及术后疗效。[结果]手术时间和术中出血量B、C、D三组均明显低于A组,差异有统计学意义(P<0.05),B、C、D组间差异无统计学意义(P>0.05)。A组出现10例(33.3%)并发症,其中7例为切口愈合不良,2例为神经根损伤,1例为马尾神经损伤;B组出现2例(6.67%)并发症,其中1例为硬膜囊撕裂,1例为椎弓根骨折;C组出现1例(3.33%)并发症,为硬膜囊撕裂;D组出现3例(2.94%)并发症,1例发生迟发性椎管内血肿,1例迟发性切口感染,1例为终板损伤。各组腰痛视觉模拟量表VAS评分、JOA评分及ODI功能评分术后3个月、1年均较术前显著改善(P<0.05)。术后3个月、1年四组患者VAS、JOA及ODI评分组间比较差异无统计学意义(P>0.05)。[结论]MIS-TILF采用联合固定在通道下操作是一种有效且颇具优势的治疗腰椎病变术式,其学习曲线在30例左右达到平台期。

[Objective] To study the learning curve of instrumented interbody fusion through intermuscular approach using channel system for lumbar degenerative diseases. [Methods] From June 2012 to December 2015, a total of 192 patients with lumbar degenerative diseases underwent MIS-TLIF with unilateral pedicle screws combined with a contralateral translaminar facet screw through an unilateral intermuscular portal using channel system. Based on time sequence of the operation performed, the patients were divided into group A, B, C and D, with 30 patients in group A, B and C, while 102 patients in group D.The operation time, intraoperative bleeding, surgical complications, failure rate of implant placement and clinical outcomes were compared among groups. [Results]The operation time and intraoperative bleeding in group B, C and D were significantly lower than those in group A(P<0.05), although no significant differences were found among group B, C, and D(P>0.05). The group A had complications in 10 patients(33.3%)including poor wound healing in 7 case, nerve root injury in 2 cases and cauda nerve injury in 1 case. By contrast, the group B got only 2 patients with complications including rupture of dural sac in 1 case and pedicle fracture in another case, the group C had rupture of dural sac in only 1 case(3.33%), and the group D had complications in 3 cases(2.94%) including delayed intraspinal hematoma in 1, delayed incision infection in 1 and endplate injury in 1 case. The VAS and ODI significantly decreased, whereas the JOA scores significantly increased at 3 and 12 months after operation in all patients of the 4 groups compared with those before operation(P<0.05). However, no significant differences were proved regarding to VAS, ODI and JOA scores among the 4 group at 3 and 12 months postoperatively(P>0.05). [Conclusion] The MIS-TLIF through intermuscular approach using channel system is effective and advanced procedure for lumbar degenerative diseases. Its learning curve is about 30 cases to achieve the platform period.