微创经椎间孔椎间融合术治疗腰椎滑脱症的疗效分析

The efficacy and complications of minimally invasive vs. the traditional open transforaminal lumbar interbody fusion for the treatment of lumbar spondylolisthesis

目的探讨微创经椎间孔椎体间融合术（transforaminal lumbar interbody fusion，TLIF）治疗腰椎滑脱症的临床疗效及其并发症分析。方法2010年1月至2015年6月期间142例单节段腰椎滑脱接受TLIF手术治疗的患者，按手术方式分为微创TLIF组（68例）和开放TLIF组（74例）。分别记录两组患者一般资料（年龄、性别、类型、滑移程度及滑脱节段）、手术时间、术中出血量、术后住院时间、腰部及下肢疼痛的视觉模拟评分（visual analogue scale，VAS）、Oswestry功能障碍指数（Oswestry disability index，ODI），并测量椎间隙后缘高度、节段前凸角、滑移复位程度，硬膜囊面积恢复情况等参数。结果两组患者基线资料统计分析显示年龄、性别比、滑移程度及手术节段分布的差异均无统计学意义，表明两组患者具有基线可比性。微创组和开放组分别有66例和71例随访至术后2年，25例和31例随访至术后5年。微创TLIF组术中出血量为（164．7±51．7）ml，明显低于开放TLIF组（239±69．3）ml（t=-7．237，P〈0．001）；术后住院时间为（5．9±1．5）d，也明显少于开放TLIF组（7．3±3．1）d（t=-3．607，P〈0．001）。微创组和开放组手术时间分别为（146．3±21．9）min和（152．0±20．4）min，差异无统计学意义。术后2年微创组腰部和下肢疼痛VAS评分、ODI分别为（1．76±1．16）分、（1．91±1．36）分和23．5％±7．3％，开放组分别为（1．73±1．10）分、（1．83±1．36）分和23．8％±6．7％；微创组椎间隙后缘高度、节段前凸角分别为（9．52±1．67）mm和12．11°±3．44°，开放组分别为（9．88±1．54）mm和12．98°±3．83°，与术前比较差异均有统计学意义，但两组间比较差异均无统计学意义。术后5年微创组腰部和下肢疼痛VAS评分、ODI分别为（1．73±1．21）分、（1．93±1．21）分和25．4％±6．8％，开放组分别为（1．85±1．02）分、（1．85±1．33）分和26．1％±6．5％；微创组椎间隙后缘高度、节段前凸角分别为（9．37±1．46）mm和11．55°±2．77°，开放组分别为（9．66±1．68）mm和12．59°±4．23°；微创组和开放组滑移复位分别至5．2％±4．6％和5．6％±4．3％，硬膜囊面积分别扩大至（139．7±19．5）mm^2和（141．7±20．7）mm^2，两组间比较差异均无统计学意义。结论微创TLIF手术较开放TLIF手术术中出血量更少，术后住院时间更短，临床疗效相当，是治疗Ⅱ度及以下腰椎滑脱症安全、有效的术式。

Objective To investigate the clinical efficacy and complications of minimally invasive transforaminal lumbar-interbody fusion （TLIF） in the treatment of lumbar spondylolisthesis. Methods Total 142 patients with single level spondylolis-thesis who treated by TLIF from 2010.01 to 2015.06 were included in this study, with 68 cases in minimally invasive TLIF （MIS- TLIF） group and 74 cases in traditional open TLIF group. The general information （age, gender, isthmic or degenerative type, per-centage of slip degree, levels）, operative time, blood loss, length of postoperative hospital stay, Visual Analogue Scale （VAS） of low-back pain and leg pain, and Oswestry Disability Index （ODI） were recorded and collected. The posterior height of the interverte- bralpace and segmental lordosis, reduction of spondylolisthesis and cross-sectional area of spinal canal were measured. Results There was no statistically significant difference between the two groups in age, gender ratio, percentage of slip degree, and sur- gicallevels distribution. Total of 66 cases in MIS-TLIF group and 71 cases in Open TLIF group finished 2 years follow up, and 25 cases in MIS-TLIF group and 31 cases in Open TLIF group finished 5 years follow up. The blood loss of the MIS-TLIF group was 164.7±51.7 ml, significantly lower than the open TLIF group of 239±69.3 ml（P〈0.001）. The length of postoperative hospital stay was 5.9±1.5 days in MIS-TLIF group, significantly shorter than the open TLIF group of 7.3±3.1 days（P〈0.001）. The operative time of MIS-TLIF and Open TLIF was 146.3±21.9 mins, 152.0±20.4 mins, respectively, and no significant differ-ence was found between them. The VAS ofbaek pain, leg pain, ODI in MIS-TLIF group was 1.76±1.16, 1.91±1.36 and 23.5±7.3 at 2 years follow up, and in Open TLIF was 1.73±1.10, 1.83±1.36 and 23.8±6.7, respectively, all of them were significant-ly different to pre-operation, however, no significant difference was found between two groups. The VAS of back pain, leg pain, ODI in MIS-TLIF group was 1.73±1.21, 1.93±1.48, and 25.4±6.8 at 5years follow up, and in Open TLIF was 1.85±1.02, 1.85±1.33 and 26.1±6.5, respectively, no significant difference between twogroups. The posterior height of the intervertebral space and segmental lordosis of MIS-TLIF was 9.52±1.67 mm and 12.11°±3.44° at 2 years follow up, while the open TLIF was 9.88± 1.54 mm and 12.98±3.83°, all of them were significantly different to pre-operation,however, no significant difference between two groups. The posterior height of the intervertebral space and segmental lordosis of MIS-TLIF was 9.37＋ 1.46 mm and 11.55°±2.77°, while the open TLIF was 9.66±1.68 mm and 12.59°±4.23°, no significant difference between two groups. The percentage of slip degree was reduced to 5.2%±4.6% in MIS-TLIF and 5.6%±4.3% in open TLIF, the cross-sectional area of spinal canal was enlarged to 139.7±19.5 mm^2 and 141.7±20.7 mm^2, no significant difference between two groups either. Con-clusion MIS-TLIF has less blood loss, shorter postoperative hospital stay than open TLIF, and similar clinical pain and function-al outcomes. MIS-TLIF is suggested to be a safe and effective choice in the treatment of lower grade lumbar spondylolisthesis （Grade II or less）.