双侧肌间隙入路通道下椎弓根钉棒复位融合固定治疗腰椎滑脱症

Bilateral pedicle screw fixation combined with interbody fusion for the treatment of lumbar spondylolisthesis （degree Ⅱ or Ⅲ） through muscle-splitting approach

目的探讨双侧肌间隙入路通道下椎弓根钉棒复位融合固定治疗腰椎Ⅱ或Ⅲ度滑脱症啦可行性和有效性。方法2012年1月至2015年12月收治腰椎Ⅱ或Ⅲ度滑脱症患者52例，男16例，女36例；年龄35-70岁，平均（54．9±7．21）岁；病史时间10个月-15年，平均（66．6＋32．71）个月。L4.5 18例，L5S1 34例；退行性滑脱2例，双侧椎弓峡部裂型滑脱50例；Ⅱ度滑脱35例，Ⅲ度滑脱17例。开放组（27例）采用正中切口入路椎弓根钉棒复位固定并椎间融合器植骨治疗，微创组（25例）采用双侧肌间隙入路通道下椎弓根钉棒复位固定并椎间融合器植骨治疗。主要临床和影像学观察指标包括手术时间、术中出血量、术后引流液量、术后72h腰部切口疼痛VAS评分、术中和术后并发症，以及术后滑脱复位率、椎间融合率、术后1年多裂肌面积和等级变化、ODI恢复情况等，并进行统计学分析。结果52例病例均顺利完成手术，微创组中无转开放手术者。两组患者手术时间、术中出血量、术后引流量的差异均有统计学意义，开放组手术时间短，微创组在术中出血量、术后引流量优于开放组。术后72h腰部切口VA$评分：开放组2-6分，平均3．25分；微创组1~3分，平均1．62分，差异有统计学意义，即微创组术后切口疼痛轻于开放组。椎弓根螺钉位置不良率微创组低于开放组。所有患者均获得12~36个月的随访，平均25．5个月。术后1年时微创组多裂肌面积及等级优于开放组。除腰椎前凸角外，滑脱角、滑脱率、骶倾角和椎间隙高度方面，两组术后均较术前有明显改善。两组患者术后ODI均较术前明显好转，且末次随访时两组差异有统计学意义。微创组融合率为96．0％，开放组为92．6％，两组差异无统计学意义。两组患者术中、术后均未发生脑脊液漏、神经损伤和椎弓根骨折，术后亦未出现神经症状加重现象，切口均无感染。随访期间两组均未发现椎弓根螺钉松动、移位、断裂或椎间融合器移位现象，亦未观察到固定融合部位邻近节段的明显退变。结论与开放手术相比，双侧肌间隙人路通道下椎弓根钉棒复位融合固定治疗腰椎Ⅱ或Ⅲ度滑脱症具有切口小、创伤小、出血少、恢复快、临床效果好等优势，可作为外科治疗腰椎Ⅱ或Ⅲ度滑脱症的较好术式选择。

Objective To investigate the feasibility and effectiveness of bilateral pedicle screw fixation combined with in-terbody fusion for the treatment of lumbar spondylolisthesis （degree Ⅱ or Ⅲ） through muscle-splitting approach. Methods There were 52 patients （16 males and 36 females） analyzed in our study from January 2012 to December 2015. The average age was 54.9±7.21 years （from 35 to 70 years）. The history of disease was from 10 months to 15 years, with an average of 66.6±32.71 months. Diagnosis included： degenerative spondylolisthesis in 2 cases, and isthmic spondylolysis in 50 cases. The sites included L4.5 in 18 cases and L5S1 in 34 cases. The degree was in 35 cases Ⅱ and Ⅲ in 17 cases. 27 cases were treated by bilateral pedicle screw fixation combined with interbody fusion through median incision approach （open group） and 25 cases through muscle-split-ring approach （minimally invasive group）. The clinical and imaging results were observed and compared between the two groups, including operation time, intraoperative blood loss, postoperative incision drainage, VAS score of lumbar incision pain at 72h post-operative, intraoperative and postoperative complications, interbody fusion rate, multifidus muscle areas and grades at 1 year post-operative, and the improvement of ODI index. Results All the cases were operated successfully. The operation time of open group was shorter than minimally invasive group. However, the intraoperative blood loss and postoperative incision drainage of minimally invasive group was statistically less than open group. The VAS scores of postoperative 72 h were 3.25 （2 to 6） in open group and 1.62 （1 to 3） in minimally invasive group. And the difference was statistically significant. The misplacement rate of pedi-cle screws of minimally invasive group was lower than open group. The average follow-up time was 25.5 months （ranged from 12 to 36 months）. The multifidus muscle areas and grades of minimally invasive group were superior to open group at 1 year postopera-tively. Compared to preoperative, the slipping angle, slipping rate, sacral inclination angle and vertebral space height were signifi-cant improved after operation in two groups. The ODI index was improved postoperatively in both two groups, and the difference was statistically significant at the final follow-up. The interbody fusion rate was 92.6% in open group and 96% in minimally inva-sive group, and there was no significant difference between the two groups. No eerebrospinal fluid leak, never injury, pedicle frac-ture or wound infection was found after the operation in two groups. There was no pedicle screw loosening, cage shifting, or degen- eration of the adjacent segment observed during follow-up. Conclusion Bilateral pedicle screw fixation combined with inter-body fusion through muscle-splitting approach has advantages of small incision, less trauma, less bleeding, quick recovery and well clinical results, which can be a better choice in treating lumbar spondylolisthesis （degree Ⅱ or Ⅲ）.