椎弓根固定结合经椎间孔椎间融合治疗复发性腰椎间盘突出症伴腰椎不稳

Unilateral pedicle screw fixation and transforaminal lumbar interbody fusion through paraspinal muscle approach for recurrent lumbar disc herniation combined with lumbar instability

目的：探讨经肌间隙入路椎弓根固定结合经椎间孔椎间融合（transforaminal lumbar interbody fusion,TLIF）治疗复发性腰椎间盘突出症伴腰椎不稳的临床疗效。方法：2008年3月至2010年5月收治35例复发性腰椎间盘突出症,其中15例行经肌间隙入路单边椎弓根固定结合TLIF术式（单边固定组）,20例行后正中入路双边椎弓根固定结合后路椎间植骨融合（posterior lumbar interbody fusion,PLIF）术式（双边固定组）。观察手术时间、术中出血量,并比较手术前后两组患者JOA评分、腰痛及腿痛VAS评分及融合情况。结果：所有患者获得随访,时间6-30个月,平均16.8个月。两组患者腰腿痛等临床症状较术前明显缓解,X线片显示植骨融合良好（双边固定组中1例未融合）,无融合器移位、下沉及内固定器械松动或断裂。两组患者手术时间、术中出血量比较差异有统计学意义（P〈0.05）。术后JOA评分均较术前降低（P〈0.05）。术后1周,两组患者腰痛VAS评分比较差异有统计学意义（P〈0.05）,腿痛VAS评分比较差异无统计学意义（P〉0.05）;末次随访,腰痛及腿痛VAS评分两组比较差异无统计学意义（P〉0.05）。结论：两种术式在治疗复发性腰椎间盘突出症伴腰椎不稳均可达到满意的疗效,经肌间隙入路单边椎弓根固定结合TLIF术式切口较小,手术时间较短,术中出血量较少,术后腰痛缓解较快。

Objective：To explore the clinical effects of unilateral pedicle screw fixation and transforaminal lumbar interbody fusion （TLIF） through paraspinal muscle approach for recurrent lumbar disc herniation combined with lumbar instability. Methods：A total of 35 patients with recurrent lumbar disc herniation combined with lumbar instability were treated between March 2008 and May 2010,including 15 patients managed by the paraspinal muscle approach with unilateral pedicle screw fixation and transforaminal lumbar interbody fusion （TLIF） （unilateral fixation group） and 20 patients by the posterior midline approach with bilateral pedicle screw fixation and posterior lumbar interbody fusion （bilateral fixation group）. Operation time and intraoperative blood loss were observed ,preoperative and postoperative JOA score and VAS score in low back pain and legs pain,the interbody fusion condition were compared between two groups. Results：All patients were followed up from 6 to 30 months with an average 16.8 months. All clinical symptoms had obviously improved postoperatively. X rays showed good interbody fusion （only 1 case did not obtain fusion in bilateral fixation group ） without cage displacement or settlement and implant loosening or breakage. There was significant difference in operation time and the intraoperative blood loss between two groups （P〈0.05）. Postoperative JOA score had obviously decreased than preoperative one （P〈0.05）. At 1 week after surgery, there was significant difference in VAS score of low back pain between two groups and there was no significant difference in VAS score of legs pain between two groups （P〉0.05）;at final follow up,there was no significant difference in VAS score of low back pain and legs pain between two groups （P〉0.05）. Conclusion：Two methods both can obtain satisfactory effect in treating recurrent lumbar disc herniation combined with lumbar instability. Through the paraspinal muscle approach with unilateral pedicle screw fixation and TLIF has advantages of smaller surgical incision,shorter operation time,less intraoperative blood loss,faster relief in low back pain after operation,etc.