Wiltse入路下经椎间孔腰椎体间融合术治疗复发性腰椎间盘突出症

Transforaminal Lumbar Interbody Fusion through Wiltse Paraspinal Approach to Treat Recurrent Lumbar Disc Herniation

目的比较Wiltse入路下经椎间孔腰椎体间融合术(transforaminal lumbar interbody fusion,TLIF)与传统后路椎体间融合术(posterior lumbar interbody fusion,PLIF)治疗复发性腰椎间盘突出症(recurrent lumbar disc herniation,RLDH)的疗效。方法回顾性分析2009年1月至2014年6月手术治疗的RLDH患者41例,其中17例采用改良Wiltse入路下TLIF(TLIF组)治疗,24例采用传统PLIF(PLIF组)治疗。PLIF组复发间隔期长于TLIF组(P<0.05),其余术前一般资料比较组间差异无统计学意义(P>0.05)。对比两组围手术期指标(手术时长、术中失血与术后引流、下床活动时间及住院期)、疗效指标(腰腿痛视觉模拟评分、Oswestry功能障碍指数、骨性融合)及并发症情况。结果 41例患者术后随访24~60个月,平均37.6个月。TLIF组手术时长(115.6±24.5)min,术中失血(229.1±61.1)mL,术后引流(194.1±41.2)mL,下床活动时间(3.1±0.7)d,住院期(7.6±1.7)d,均小于PLIF组,差异具有统计学意义(P<0.001)。两组术后VAS及ODI较术前显著降低,术后第12个月、24个月随访组间差异无统计学意义(P>0.05)。术中硬膜撕裂共6例,其中TLIF组1例(4%),PLIF组5例(21%),均于术中缝合修补,PLIF组2例术后出现脑脊液漏;PLIF组发生切口脂肪液化1例;症状性邻近节段退变共3例(TLIF组2例,PLIF组1例),均接受扩大翻修手术;41例患者末次随访时均达到坚强或完全骨性融合。结论 Wiltse入路下TLIF治疗RLDH具有良好疗效,相比传统PLIF,可以减小手术创伤,相关并发症发生率也较低。

Objective To compare the clinical results between transforaminal lumbar interbody fusion（TLIF）through Wiltse paraspinal approach and traditional posterior lumbar interbody fusion（PLIF）in treatment of recurrent lumbar disc herniation（RLDH）.Methods A retrospective analysis was conducted of the 41 patients with RLDH who had lumbar interbody fusion from January 2009 to June 2014.Among them 17 cases received TLIF through Wiltse paraspinal approach（group TLIF）,and 24 cases received traditional PLIF（group PLIF）.The patients in group PLIF had a tendency to have longer duration between initial discectomy and recurrent herniation.The two groups were compatible in preoperative clinical data（P〉0.05）.The perioperative data（duration of procedure,intraoperative blood loss,postoperative drainage,time to ambulation,length of hospital stay）and primary efficacy outcome（visual analog scale for back and leg pain-VAS,Oswestry Disability Index-ODI）were compared between 2 groups along with bony fusion（Criteria for interbody fusion assessment on post-operative computer tomography scans by Siepe et al）and complication.Results 41 patients were followed up for 24 to 60 months（mean,37.6 months）.The operation time（115.6±24.5,110.0min）,intraoperative blood loss（229.1±61.1,250mL）,postoperative drainage（194.1±41.2,190.0 mL）,time to ambulation（3.1±0.7,3.0days）,length of hospital stay（7.6±1.7,7.0days）in group TLIF were significantly less than in group PLIF（P〈0.001）.The postoperative VAS scores and ODI were significantly lower in 2groups than the preoperative ones（P〈0.001）,but there was no significant difference between 2 groups at the12 months and 24 months follow up postoperatively（P〉0.05）.6cases had a dural tear in association with epidural fibrosis,1 case（4%）in group TLIF,5 cases（21%）in group PLIF,and these were treated by intra-operative repair.Cerebrospinal fluid leaks was found in2 cases in group PLIF postoperatively.1 patient from group PLIF suffered incisions fat colliquation.There was 3 cases of symptomatic adjacent segment disease in total,with 2 cases in group TLIF and 1 in group PLIF,expanded revision surgery was performed in thesepatients.Computer tomography scans revealed solid or complete interbody bony fusion at the last follow up in all cases.Conclusion TLIF through Wiltse paraspinal approach can achieve satisfactory clinical outcome in treatment of RLDH and it has several advantages including less invasive,lower incidence of complication such as intraoperative dural tear compared with traditional PLIF.