腰椎退行性变的经皮椎弓根螺钉固定结合微创腰椎间融合术治疗

Percutaneous pedicle screw fixation combined with minimally invasive lumbar interbody fusion in the treatment of lumbar degenerative disease

目的研究经皮椎弓根钉内固定联合微创腰椎间融合术治疗腰椎退变、不稳的安全性和有效性。方法选取2012年11月至2014年8月收治的腰椎退变、不稳患者127例,其中男86例,女41例,年龄18~79岁,平均58.4岁;腰椎滑脱16例,腰椎间盘突出症35例,腰椎管狭窄症76例。根据不同病理特点,分别采用结合经皮椎弓根螺钉固定的椎板间开窗减压入路（minimally invasive posterior lumbar interbody fusion,mini-plif）（44例）、关节突切除减压入路（minimally invasive transforaminal lumbar interbody fusion,mini-tlif）（49例）和扩大减压融合术（34例）治疗,术后随访3个月以上。术前均行腰椎正侧位、过屈过伸位X线和MRI检查。统计平均每颗椎弓根螺钉的置入时间、X线曝光次数,平均每个减压节段的术中出血量,术后引流量,记录住院时间,螺钉位置与并发症发生率;比较术前及术后3天、2周、3个月视觉模拟评分（visual analogue scale,VAS）和Oswestry功能障碍指数（oswestry disability index,ODI）评分。结果每颗椎弓根螺钉的平均置入时间为（12.6±6.3）min,每颗椎弓根螺钉的X线平均曝光次数为（4.2±2.3）次,每个减压节段的术中平均出血量为（67.9±16.7）ml,术后引流量为（52.6±13.8）ml,平均住院时间为（9.0±2.4）天。术后三组患者的VAS和ODI评分均有显著改善,与术前比较差异有统计学意义（P〈0.05）。共置入椎弓根钉635枚,其中椎弓根钉位置良好546枚（86.0%）,位置一般71枚（11.2%）,位置不良18枚（2.8%）。术中神经损伤6例（4.7%）,无脑脊液漏、术后血肿、伤口感染等并发症。结论经皮椎弓根钉内固定联合微创腰椎间融合术是一种安全、有效、可行的脊柱微创手术,值得临床推广。

Objective To investigate the safety and effectiveness of percutaneous pedicle screw fixation combined with minimally invasive lumbar interbody fusion in the treatment of lumbar degenerative disease. MethodsFrom November 2012 to August 2014, a total of 127 patients with lumbar degeneration and instability were recruited. There were 86 males and 41 females, with the mean age of 58.4 years（ range： 18-79 years）. There were 16 cases of spondylolisthesis, 35 cases of lumbar disc herniation, and 76 cases of lumbar stenosis. According to different pathological characteristics, percutaneous pedicle screw fixation combined with minimally invasive posterior lumbar interbody fusion（ mini-plif）（44 cases）, minimally invasive transforaminal lumbar interbody fusion（ mini-tlif）（ 49 cases） or extended decompression and fusion（ 34 cases） were performed respectively for treatment. The postoperative followed-up was at least 3 months. Before surgery, all patients received anteroposterior, lateral and flexion-extension X-ray examination of the lumbar spine, as well as lumbar MRI. The average insertion time and X-ray exposure times for each pedicle screw, average blood loss and postoperative drainage volume for each decompression level were analyzed. Hospital stay, pedicle screw position and complications were also recorded. Pre- and postoperative 3-days, 2-weeks, 3-months visual analogue scale（ VAS） and Oswestry disability index（ ODI） scores were compared. Results The average insertion time for each pedicle screw was（ 12.6±6.3） min. The average X-ray exposure times for each pedicle screw was（ 4.2±2.3） times. The mean blood loss for each decompression level was（ 67.9±16.7） ml, and the postoperative drainage volume was（ 52.6±13.8） ml. The average hospital stay was（ 9.0±2.4） days. The VAS and ODI scores were found to be significantly improved after surgery in 3 groups（ P0.05）. A total of 635 screws were inserted. The position of pedicle screws was good in 546 screws（ 86.0%）, acceptable in 71 screws（ 11.2%）, and malpositioned in 18 screws（ 2.8%）. Neurological injury occurred in 6 cases（ 4.7%）, and no cerebrospinal fluid leakage, postoperative hematoma, wound infection and other complications were noted. Conclusions Percutaneous pedicle screw fixation combined with minimally invasive lumbar interbody fusion is a safe, effective and feasible technique for minimally invasive spine surgery, and could be recommended for clinical use.