微创经椎间孔腰椎间融合术联合经皮椎弓根螺钉内固定长节段融合术治疗退行性腰椎侧弯

Clinical study on minimally invasive transforaminal lumbar interbody fusion combined with percutaneous pedicle screw fixation for degenerative lumbar scoliosis

目的 探讨微创经椎间孔腰椎间融合术（MIS-TLIF）联合经皮椎弓根螺钉内固定长节段融合术治疗退行性腰椎侧弯的临床疗效。方法 采用MIS-TLIF联合经皮椎弓根螺钉内固定长节段融合术治疗17例退行性腰椎侧弯患者,比较术前和术后1周、3个月、末次随访时视觉模拟评分（VAS）、Oswestry功能障碍指数（ODI）和36条简明健康状况调查表（SF-36）评分,以及X线测量冠状位Cobb角、矢状位前凸角、冠状位和矢状位躯干偏移,X线或CT判断椎体融合率,MRI评价减压程度。结果 17例患者手术融合56个椎体节段（T12~S1节段）;平均手术时间200 min,术中出血量320 ml,住院时间8.21 d,术后随访12.13个月。与术前相比,术后1周、3个月和末次随访时VAS（均P=0.000）和ODI（均P=0.000）评分均减少,SF-36评分增加（均P=0.000）,冠状位Cobb角（均P=0.000）、矢状位前凸角（均P=0.000）、冠状位和矢状位躯干偏移（均P=0.000）均减小。至末次随访时,ODI改善率（86.51±6.02）%,椎体融合率达89.21%,且螺钉位置良好。无一例出现术后神经功能缺损、感染、脑脊液漏等严重并发症,无一例内固定失败、椎弓根螺钉和钛棒断裂或Cage移位,无死亡病例。结论 MIS-TLIF联合经皮椎弓根螺钉内固定长节段融合术治疗退行性腰椎侧弯具有手术创伤小、术中出血量少、并发症发生率低、矫形效果好、疗效确切等优点,尽管存在手术时间和学习曲度较长等缺点,但仍是退行性腰椎侧弯微创治疗的有效方法。

Objective To discuss the operative essentials and therapeutic effects of minimally invasive transforaminal lumbar interbody fusion （MIS- TLIF） combined with percutaneous pedicle screw fixation for degenerative lumbar seoliosis （DLS）. Methods A total of 17 DLS patients without prior spinal diseases were treated by MIS- TLIF and percutaneous pedicle screw fixation from January 2013 to September 2015 in Xuanwu Hospital, Capital Medical University. The operation time, intraoperative blood loss, hospital stay, and postoperative complication were recorded in each patient. Visual Analogue Scale （VAS） and Oswestry Disability Index （ODI） were used to evaluate postoperative improvement of low back and leg pain, and clinical effects were assessed according to Medical Outcome Study 36-hem Short-Form Health Survey （SF- 36）. Coronal Cobb angle, sagittal lordosis angle and spinal deviation distances on coronal and sagittal plane were measured before operation, one week, 3 months after operation and in the last follow-up in spinal full-length X-ray examination. Fusion rate was calculated according to X-ray or CT scan, and the degree of decompression was evaluated by MRI. Results Decompression and fusion levels ranged from T-S vertebrae, and interbody fusion was performed in 17 patients and 56 levels were fused. Average operation time was 200 rain （180-300 rain）, intraoperative blood loss was 320 ml （200-1000 ml） and hospital stay was 8.21 d （5-12 d）. All patients were followed-up for 12.13 months （5-24 months）. Compared with preoperation, VAS （P = 0.000, for all） and ODI scores （P = 0.000, for all） decreased significantly, SF-36 score increased （P = 0.000, for all）, coronal Cobb angle （P = 0.000, for all）, sagittal lordosis angle （P = 0.000, for all）, coronal and sagittal deviation （P = 0.000, for all） decreased significantly one week and 3 months after operation and in the last follow-up, The improvement rate of ODI was （86.51 ± 6.02）%, fusion rate of vertebral bodies was 89.21%, and the position of screws was good. No neurological defect, infection, or cerebrospinal fluid （CSF） leakage occurred after operation. No pedicle screw or rod breakage or Cage displacements was found. There was no death case. Conclusions MIS-TLIF combined with percutaneous pedicle screw fixation is an effective technique for treatment of DLS patients, with less injury, less intraoperative blood loss, low complication incidence, good scoliosis correction and definite therapeutic effects, even this method needs more operation time and longer learning curve.