单节段腰椎病变通道下肌间隙入路三种固定方式的对比研究

The comparative study of three different fixation methods via muscle-splitting approach to treat single segmental lumbar vertebral diseases

目的比较通道下肌间隙入路三种固定方式治疗单节段腰椎病变的优、缺点。方法选择2012年6月至2013年6月治疗的90例单节段腰椎病变患者，男34例，女56例；年龄27-76岁，平均（53．37±15．41）岁。采用单侧通道下肌间隙入路单侧椎弓根螺钉固定并椎间融合器植骨治疗27例（单侧固定组），单侧通道下肌间隙入路单侧椎弓根螺钉联合对侧椎板关节突螺钉固定并椎间融合器植骨治疗33例（联合固定组），双侧通道下肌间隙入路双侧椎弓根螺钉固定并椎间融合器植骨治疗30例（双侧固定组）。观察并对比三组病例的影像学及临床结果。结果三组患者的切口长度和术后引流量的差异无统计学意义；单侧固定组手术时间最短，双侧固定组最长；单侧固定组与联合固定组术中出血量相近，均少于双侧固定组。术后未发生切口感染，出现切口浅表坏死7例（单侧固定组1例，联合固定组4例，双侧固定组2例），神经根损伤3例（联合固定组2例，双侧固定组1例）。所有患者均获得12-36个月的随访，平均25．5个月。三组患者术后病变节段椎间隙高度均获得良好地恢复，且随访期间无明显丢失；术后1年多裂肌面积和等级与术前对比均无明显改变。随访过程中出现终板切割并融合器部分陷入椎体内7例（单侧固定组3例，联合固定组3例，双侧固定组1例）。均未出现内固定松动、移位、断裂或椎间融合器移位现象。除5例（单侧固定组2例，联合固定组2例，双侧固定组1例）不能明确外，其余患者均获得椎间融合。末次随访时三组JOA评分较术前均获得明显地改善，且单侧固定组与联合固定组优于双侧固定组。结论通道下肌间隙入路三种固定方式治疗单节段腰椎病变均获得了良好的临床效果，而通道下单侧固定和通道下联合固定具有更多的优势，特别是通道下联合固定方式是手术入路、显露方式和固定方式的创新组合。

Objective To compare the advantages and disadvantages of three different fixation methods via muscle-split- ting approach for the treatment of single segmental lumbar vertebral diseases. Methods All of 90 patients with the single seg- mental lumbar vertebral diseases were treated from June 2012 to June 2013, including 34 males and 56 females, at the age of 27- 76 years old, averagely （53.37_＋ 15.41） years. Twenty-seven patients were treated with unilateral pedicle screws via unilateral muscle-splitting approach （unilateral fixation group）. Thirty-three patients were treated with unilateral pedicle screws and contralateral translaminar facet screw via unilateral muscle-splitting approach （combined fixation group）. Thirty patients were treated with unilateral pedicle screws via bilateral muscle-splitting approach （bilateral fixation group）. Observe and compare the imaging and clinical results of these three groups. Results There were no significant difference in incision length and postoperative wound drainage between these three groups. The operation time was shortest in unilateral fixation group, while longest in bilateral fixation group. In the intraoperative blood loss, the unilateral fixation group was the same as the combined fixation group, while less than the bilateral fixation group. No infection was found after operations. Seven patients experienced epidermal necrosis of the incision, including 1 patient of unilateral fixation group, 4 patients of combined fixation group and 2 patients of bilateral fixation group. Three patients suffered from nerve injury, including 2 patients of combined fixation group and 1 patients of bilateral fixation group. The follow-up time was from 12 to 36 months, averagely 25.5 months. The intervertebral height of lesion segments was apparently recovered after surgery, and maintained during the follow-up in these three groups. No significant changes of area and grade of multifidus muscle were detected at 1 year after surgery compared with preoperative. Seven patients experienced endplate cutting and cage partially embedded into vertebral body, including 3 patients of unilateral fixation group, 3 patients of combined fixation group and 1 patient of bilateral fixation group. There was no loosening, displacement, breakage or cage shifting. Except 5 patients （2 patients of unilateral fixation group, 2 patients of combined fixation group and 1 patient of bilateral fixation group）, the remaining cases had well interbody fusion. At the final follow-up time, the JOA score significantly increased compared with preoperative. Besides, unilateral fixation group and combined fixation group were superior to bilateral fixation group. Conclusion Three differ- ent fixation methods via muscle-splitting approach for the treatment of single segmental lumbar vertebral diseases had well clin- ical results. The unilateral fixation and combined fixation via muscle-splitting approach had more advantages. The combined fixation via muscle-splitting approach is an innovation in approach, exposure and fixation aspects.