导航引导下腰椎峡部裂的微创外科修复

MINIMALLY INVASIVE SURGERY FOR DIRECT REPAIR OF LUMBAR SPONDYLOLYSIS BY UTILIZING INTRAOPERATIVE NAVIGATION AND MICROENDOSCOPIC TECHNIQUES

目的 探讨于O-arm成像、导航和显微内窥镜下植入椎板螺钉直接修复腰椎峡部裂的临床疗效。 方法 2012年2月－2014年5月，采用在显微内窥镜下进行峡部处理和自体髂骨移植，基于O-arm导航下放置椎板螺钉直接修复11例腰椎峡部裂患者。其中男7例，女4例；年龄19-47岁，平均28.4岁。腰痛时间8-23个月，平均10.5个月；无下肢神经症状及体征。影像学检查提示单节段双侧腰椎峡部裂，相应节段椎间盘无明显退变，无腰椎节段不稳或滑脱；峡部裂位于L4 2例，L5 9例。腰椎间盘退变按照改良Pfirrmann分级评价，2级退变7例，3级退变4例。记录手术时间、术中出血量和并发症发生情况；术后影像学检查峡部修复及螺钉位置；采用疼痛视觉模拟评分（VAS）评价腰痛改善情况。结果手术时间126-183 min，平均 147.6 min；术中出血量40-85 mL，平均54.9 mL。术后切口均Ⅰ期愈合，无神经根损伤、硬膜撕裂及感染等并发症发生。3例术后髂骨供骨区疼痛，3 周内消失。11例均获随访，随访时间10-23个月，平均15.7个月。腰痛VAS评分由术前（7.1±2.3）分下降为末次随访时的（1.8±0.4）分，比较差异有统计学意义（t=13.42，P=0.01）。11例患者共完成22处峡部植骨和22枚螺钉植入，其中7例双侧峡部融合，3例单侧融合，融合时间6-10个月，平均7.9个月；1例双侧峡部修复失败，峡部植骨吸收。结论通过显微内窥镜可有效处理腰椎峡部裂和充分植骨，基于O-arm导航可提高腰椎椎板螺钉植入准确性，峡部直接修复获得良好疗效，并具有微创外科技术优点。

Objective To analyze the effectiveness of direct screw repair for lumbar spondylolysis by using intraoperative O-arm based navigation and microendoscopic techniques. Methods Between February 2012 and May 2014, 11 consecutive patients with lumbar spondylolysis were treated with Buck’s procedure by the aid of intraoperative O-arm based navigation and minimally invasive approach. The debridement and autograft of pars interarticularis defects was performed under microendoscopy. There were 7 males and 4 females, with an average age of 28.4 years （range, 19-47 years） and an average disease duration of 10.5 months （range, 8-23 months）; no nerve symptoms or signs of lower limb was observed. The radiological examinations showed single level bilateral lumbar spondylolysis without obvious disc degeneration, lumbar instability, or spondylolisthesis. Isthmic injury located at L4 in 2 cases and at L5 in 9 cases. Of 11 patients, 7 were rated as grade 2 disc degeneration, and 4 as grade 3 disc degeneration according to the modified Pfirrmann classification system. The operation time, intraoperative blood loss, and complications were recorded. The fluoroscopic examinations were performed to assess defect repair and screw position. Visual analogue scale （VAS） score was used to evaluate the improvement of low back pain. Results The average operation time was 147.6 minutes （range, 126-183 minutes）. The average blood loss was 54.9 mL （range, 40-85 mL）. Primary healing of incision was obtained. There was no complication of nerve root injury, dural tear, or infection. Three patients had pain at donor site postoperatively, and pain disappeared within 3 weeks. The average follow-up duration was 15.7 months （range, 10-23 months）. VAS score of low back pain was significantly decreased from preoperative 7.1±2.3 to 1.8±0.4 at last follow-up （t=13.42, P=0.01）. Of 22 isthmic bone grafting, bilateral isthmic bony fusion was achieved in 7 patients and unilateral isthmic bony fusion in 3 patients at 6-10 months （mean, 7.9 months）. One patient failed bilateral isthmic bony fusion, and had bony resorption. Conclusion Debridement, autograft, and percutaneous intralaminar screw fixation by microendoscopy and O-arm based navigation may provide safe and effective treatment for spondylolysis. Minimally invasive direct repair can obtain satisfactory effectiveness.