经后外侧入路椎管减压椎间融合内固定术治疗胸椎间盘突出症

Posterior lateral approach of interbody fusion and internal fixation for thoracic intervertebral dis cherniation

目的：观察经后外侧入路椎管减压椎间融合内固定术治疗胸椎间盘突出症的手术疗效。方法：选择2009年1月～2015年8月收治的47例单节段胸椎间盘突出症患者，采用椎管减压椎间融合内固定术治疗，其中经后外侧入路组26例，经侧前方入路组21例．术前两组患者的年龄、性别分布、病程、病变节段、突出类型、脊髓受压情况、临床表现、随访时间均无统计学差异（P＞0.05）。记录两种术式的手术时间、术中出血量和手术并发症：术前及术后3d、6个月采用疼痛视觉模拟评分（VAS）评估疼痛情况；术后6个月采用Otani分级评定其临床疗效，采用改良胸脊髓神经功能JOA评分及神经功能Frankel分级评估神经功能恢复情况，影像学测算椎管矢状径残余率评估椎管减乐程度，CT薄层扫描审建评估椎间融合情况，动态X线片对固定情况进行评估。结果：经后外侧入路组的手术时间、术中出血量、切口长度和住院时间均优于经侧前方入路组，差异有统计学意义（P〈0．05）。经侧前方入路组术后发生胸腔积液4例、肺炎4例、脑脊液漏2例、肠麻痹5例，经后外侧入路组术后无上述并发症出现．两组并发症发生率的差异有统计学意义（P〈0．05）。术后6个月两组Otani分级优良率无统计学差异（P〉0．05）．术后3d经后外侧入路组VAS评分优于经侧前方入路组，差异有统计学意义（P〈0．05）。术后6个月两组患者的疼痛、神经功能及椎管有效容积均较术前明显改善，差异有统计学意义（P〈0．05）。术后6个月，两组间VAS评分、JOA评分、神经功能Frankel分级和椎管矢状径残余率比较均无统计学差异（P〉0．05），CT三维重建显示两组椎间融合率均为100％，差异无统计学意义（P〉0．05）；动态X线片检查脊柱连续性及稳定性良好，无钉棒断裂和松动现象，椎间高度无明显丢失，椎体间cage无下陷及移位。结论：后外侧入路椎管减压椎间融合内固定术治疗胸椎间盘突出症的近期效果满意。

Objectives： To observe the outcome of interbody fusion and internal fixation through posterior lateral approach for thoracic intervertebral disc herniation. Methods： From January 2009 to August 2015, 47 cases of thoracic intervertebral disc herniation were treated with spinal decompression and interbody fusion, 26 eases were treated by posterior lateral approach and 21 cases by lateral anterior approach. Preoperative age, sex distribution, course of disease, lesion segment, type of hernialion, spinal cord compression, clinical manifestations, follow-up time differences were not statistically significant between 2 groups（P〉0.05）. Comparation of operation time, blood loss, complications and surgery between two surgeries were recorded; clinical efficacy was assessed by Otani grading at 6 months after operation; the pain relief was assessed by visual analogue seale（VAS） at preoperation and 3 days and 6 months after operation; recovery with improvement in the neurological function of spinal cord was evaluated by JOA score and the neurological functional Frankel grading at 6 months after operation, the extent of spinal canal decompression was assessed by imaging measurement canal sagittal diameter residual rate; intervertebral fusion was assessed by CT scan reconstruction; fixation was evaluated by dynamic X-ray films. Results： The operation time, blood loss, incision length and length of stay in the posterior lateral approach group were better than those in the anterior approach group, and the difference was statistically significant （P〈0.05）. There were 4 cases of pleural effusion, 4 cases of pneumonia, 2 cases of cerebrospinal fluid leakage and 5 cases of intestinal paralysis in the anterior approach group. There was no complication noted in the posterior lateral approach group. The difference was statistically significant （P〈0.05）. According to the Otani classification, 6 months after surgery, the excellent rates of the two groups were not statistically significant（P〉0.05）. As for the pain VAS scores at postoperative 3 days, the lateral approach group was better than the anterior lateral approach group, the difference was statistically significant（P〈 0.05）. After operation, all patients had better VAS scores, JOA scores, Frankel grades and spinal sagittal diameter residual rates than before operation, the difference was statistically significant（P〈0.05）. VAS score, JOA score, neural function according to Frankel classification and sagittal spinal canal diameter residual rate comparison at 6-month follow-up were not statistically different between two groups （P〉0.05）. At 6 months after operation, three dimensional reconstruction of CT showed 100% bone healing rate of two groups, and there was no significant difference between two groups（P〉0.05）. Dynamic X-ray showed good stability. There were no screw breakage and loosening, no significant loss of intervertebral height and no cage subsidence. Conclusions： The short term effect of the posterior lateral approach spinal decompression and interbody fusion for thoracic intervertebral disc herniation is satisfactory.