改良侧方入路腰椎椎体间融合术及其临床应用

A modified surgical technique of lateral lumbar interbody fusion

目的 总结改良侧方入路腰椎椎体间融合手术的技术要点,并探讨该技术的入路相关并发症。方法 2016年6月至2017年1月采用自行研发的改良侧方入路腰椎椎体间融合手术58例,男24例,女34例;年龄45~82岁,平均（66.1±12.1）岁。退行性脊柱侧凸24例,退行性腰椎管狭窄症16例,腰椎滑脱症14例,感染2例,创伤2例。该技术包括直视下操作、“安全”腰大肌入路及微型弹性拉钩的应用。患者取侧卧位,以目标椎间隙为中心取横或斜切口,沿肌纤维方向分离腹壁三层肌肉达到腹膜后,通过“安全”腰大肌入路劈开腰大肌,应用微型弹性拉钩建立工作通道行椎体间融合术。临床疗效评价采用Oswestry功能障碍指数（Oswestry disability index,ODI）,记录手术时间、术中出血量及入路相关并发症（包括大腿前方疼痛、麻木,腰大肌、股四头肌乏力等）。结果 所有患者均获得随访,随访时间6~12个月,平均（9.1±2.3）个月。58例共行腰椎椎体间融合132个节段,单节段19例、双节段10例、三节段23例、四节段6例。单节段手术时间平均（57.2±13.3） min,双节段为（94.5±31.3） min,三节段为（129.8±42.1） min,四节段为（208.3±22.7） min。估计术中出血量每个节段〈 10 ml。ODI术前平均为61.8%±20.1%,末次随访时22.5%±18.3%（t=7.572,P=0.000）。术后入路相关并发症的发生率12.1%（7/58）,包括大腿前方疼痛6例次（10.3%）、麻木5例次（8.6%）、腰大肌肌力减退3例次（5.2%）。无一例出现股四头肌肌力减退、血管损伤、交感神经损伤及输尿管损伤;三个或以上节段融合明显增加入路相关并发症（χ2=4.453,P=0.035）。结论 改良侧方入路腰椎椎体间融合术通过直视下操作、“安全”腰大肌入路及微型弹性拉钩的应用,明显降低了侧方入路腰椎椎体间融合术的入路相关并发症。

Objective To present the modified surgical technique of lateral lumbar interbody fusion and investigate its approach related complications. Methods Fifty-eight patients treated with novel surgical technique of lateral lumbar interbody fusion （LLIF） from June 2016 to January 2017 were studied retrospectively. There were 24 males and 34 females, aged from 45 to 82 years old （averaged at 66.1±12.1）. The diagnosis was as following： degenerative spinal scoliosis in 24 cases, degenerative lumbar spinal stenosis in 16, lumbar spinal spondylolisthesis in 14, spinal infection and spinal trauma in 2 respectively. The modified surgical technique included operation under direct visualization, the “safety” transpsoas approach and the adjustable microretractor. The patient was placed in a lateral decubitus position, and a transverse or oblique skin incision was planned using fluoroscopy to target the center of the desired disc spaces. The 3 abdominal layers were split longitudinally along the muscle fiber. The psoas major was split longitudinally along the muscle fiber according to the “safety” working window. The adjustable microretractor was used as working corridor to carry out interbody fusion. Oswestry disability index （ODI） was used to assess the clinical outcome. The surgical time, estimated blood loss and approach related complications （pain /numbness at anterior thigh, weakness of psoas muscle and quadriceps） were recorded. Results All patients were followed up from 6-12months, the mean follow-up time （9.1±2.3） months. A total of 132 levels were performed with novel surgical technique of LLIF, one level in 19 cases, 2 levels in 10, 3 levels in 23 and 4 levels in 6 cases. The mean surgical time was （57.2±13.3） min for 1 level, （94.5±31.3） min for 2 levels, （129.8±42.1） min for 3 levels and （208.3±22.7） min for 4 levels. The estimated blood loss during surgery was less than 10ml every level. Preoperative ODI was 61.8%±20.1%, it was 22.5%±18.3%（t=7.572, P=0.000） at the last time follow-up. The incidence rate of approach related complications was 12.1%（7/58）, with anterior thigh pain in 6 cases （10.3%）, numbness 5 cases （8.6%） and psoas major weakness 3 cases （5.2%）. No quadriceps weakness, vascular injury, sympathetic nerve injury, visceral injury and ureteral injury was found in these series. The incidence rate of complications increased significantly in patients underwent three or more levels interbody fusion （χ2=4.453, P=0.035）. Conclusion The modified surgical technique reduces the approach related complications of traditional lateral lumbar interbody fusion through the operation under the direct visualization, the “safety” transpsoas approach and the adjustable microretractor.