固定通道下微创经椎间孔腰椎椎间融合术治疗单节段腰椎退行性疾病的临床疗效

Clinical effect of single segment degenerative lumbar disease by minimally invasive transforaminal lumbar interbody fu-sion with tubular channel

目的探讨固定通道（Spotlight）下微创经椎间孑L腰椎椎间融合术（minimally invasive surgery-transforaminal lumbar interbody fusion，MIS-TLIF）治疗单节段腰椎退行性疾病的手术策略及操作要点。方法2013年11月至2015年12月行Spotlight通道下MIS-TLIF手术治疗97例单节段腰椎退行性疾病患者，男47例，女50例；年龄35～82岁，平均（57．6±12．3）岁。腰椎管狭窄症63例、腰椎滑脱症25例、腰椎失稳症9例。手术节段：L3.4 9例，L4.5 66例，L5S1 22例。根据术前临床表现级及影像学特点分别采用三种术式的固定通道下MIS-TLIF手术，即单侧人路单侧减压组（52例）、单侧入路双侧减压组（22例）及双侧人路双侧减压组（23例）。记录手术时间、术中出血量、术后引流量；测量手术前后及随访时手术节段椎间隙高度、节段前凸角及腰椎前凸角；采用视觉模拟评分法（visual analogue acale，VAS）评估患者腰部和下肢疼痛程度，Oswestry功能障碍指数（Oswestry disability index，ODI）评估腰椎功能状况；末次随访时采用Bridwell标准评估椎间融合，MacNab标准评价临床疗效。结果所有患者手术时间平均为（189．8±41．3）min，术中出血量（143．9±102．0）ml，术后引流量（75．0±59．0）ml。单侧人路单侧减压组手术时间（165．0±24．2）min，术中出血量（99．5±54．1）ml，术后引流量（48．4±27．6）ml；单侧人路双侧减压组分别为（208．9±46．0）min，（151．4±96．3）ml，（88．0±51．3）ml；双侧人路双侧减压组分别为（225．4±32．0）min，（236．0±126．3）ml，（122．8±81．7）ml。随访时间16-42个月，平均（24．9±7．0）个月。腰痛VAS评分由术前（6．10±0．84）分降低至末次随访时（1．59±0．49）分，下肢痛VAS评分由术前（6．56±0．85）分降低至末次随访时（1．59±0．57）分，ODI由术前59．36％±5．52％降低至末次随访时15．89％±2．90％，差异均有统计学意义。术前手术节段椎间隙高度平均为（9．92±2．25）mm增加至末次随访（12．24±1．78）mm，较术前明显恢复；节段前凸角由13．81°±6．10°增加至末次随访14．25°±5．57°，但差异无统计学意义；腰椎前凸角由32．32°±11．97°增加至末次随访时35．83°±9．89°，较术前明显增加。末次随访时按椎问融合按Bridwell标准I级和Ⅱ级为90例（92．8％）；按MacNab标准优69例、良23例、可5例，优良率为94．8。结论固定通道（Spotlight）下的MIS-TLIF手术治疗单节段腰椎退行疾病安全、有效，针对术前临床表现及影像学特点选择不同的术式。

Objective To investigate the operating strategies and essentials of minimally invasive transforaminal lumbar interbody fusion （MIS-TLIF） with tubular channel （Spotlight） to treat single-level lumbar degenerative diseases. Methods From November 2013 to December 2015, 97 patients （47 males and 50 females） underwent single-level lumbar degenerative diseases fol-lowing MIS-TLIF with Spotlight were analyzed, whose age were from 35-82 years old with the average age of 57.6± 12.3 years old. The preoperative diagnosis was lumbar spinal stenosis in 63 cases, lumbar spondylolisthesis in 25 cases, and lumbar instability in 9 cases. The affected level was L3.4 in 9 cases, L4.5 in 66 cases, and LsSI in 22 cases. According to distinct clinical manifestations and radiological characteristics, different approaches of Spotlight channels were employed. Unilateral decompression via unilateral channel was performed in 52 cases, bilateral decompression via unilateral channel was performed in 22 cases, and bilateral decom-pression via bilateral channel was performed in 23 cases. Clinical outcomes included operation duration, surgical blood loss, post-operative drainage volume and complications was recorded. Average intervertebral height, lumbar and surgical Cobb angle were utilized to evaluate the reduction of intervertebral height and lumbar lordosis. The low back and leg pain were represented as Visu- al Analogue Scale （VAS） score. The preoperative and postoperative Oswestry Disability Index （ODI） score were recorded individu- ally to evaluate patients＇ functional recovery. Besides, the Bridwell criterion was introduced to define the extent of the lumbar fu-sion. The MacNab criterion was used for assessment of postoperative efficacy. Results The operation duration was 189.8±41.3 min, the volume of surgical blood loss was 143.9± 102.0 ml and the volume of postoperative drainage 75.0±59.0 ml in all cases. Among them, operation time was 165.0±24.2 min, surgical blood loss was 99.5±54.1 ml and postoperative drainage was 48.4±27.6 ml in the operation group of unilateral decompression via unilateral channel. The date in the group of Bilateral decompression via unilateral channel were 208.9±46.0 min, 151.4±96.3 ml, 88.0±51.3 ml and in the group of bilateral decompression via bilateral channel were 225.4±32.0 min, 236.0±126.3 ml, 122.8±81.7 ml. All the patients were followed up for 16-42 months, the average follow-up time was 24.9±7.0 months. Low back VAS reduced from 6.10±0.84 preoperatively to 1.59±0.49 at the final follow-up, leg VAS decreased from 6.56±0.85 preoperatively to 1.59±0.57 at the last follow-up, and ODI reduced from $9.36%±5.52% preop- eratively to 15.89%±2.90% at the final follow-up, compared with preoperative, the differences were significant. Average interverte- bral height improved from 9.92±2.25 mm preoperatively to 12.24± 1.78 mm at latest follow-up time, which had statistically signifi-cant difference. Operative segment and lumbar Cobb angle were 13.81°±6.10° and 32.32°±11.97° preoperative, at the time of lat-est follow-up improved to 14.25°±5.57° and 35.83°±9.89%° Compared with preoperative, lumbar Cobb angle was significantly in-creased but operative segment Cobb had no significant difference. According to the criteria of Bridwell, intervertebral fusion at fi-nal follow-up of Ⅰ and Ⅱ grades were 90 cases in total （92.8%）. The MacNab criteria was used to evaluate the clinical efficacy, which 69 were excellent, 23 were good, and 5 were acceptable, the excellent and good rate was 94.8%. Conclusion The tech-nique of MIS-TLIF with the tubular channel （Spotlight） is safe and efficient for the treatment of single segment lumbar degener-ative diseases. Different strategies can be selected by different preoperative clinical manifestations and radiological features.