不同入路经椎间孔椎体间融合术治疗腰椎滑脱合并腰椎管狭窄的对比

Comparison of different approaches for transforaminal lumbar interbody fusion in treatment of lumbar spondylolisthesis combined with lumbar spinal stenosis

目的探讨不同手术入路经椎间孔腰椎椎体间融合(TLIF)术治疗腰椎滑脱合并腰椎管狭窄症的临床疗效。方法回顾性分析2014年11月至2016年11月在陕西省森工医院骨科行TLIF术的62例腰椎滑脱合并腰椎管狭窄患者的临床资料。62例中37例行传统后正中入路TLIF术(传统组),25例行椎旁肌间隙入路(Wiltse入路) TLIF手术(Wiltse组),比较两组患者手术时间、术中出血量、术后引流量、术后3 d切口疼痛视觉模拟(VAS)评分、术后植骨融合度,评定两组患者手术前及术后3个月、12个月的腰椎功能[日本骨科协会(JOA)评分]、生存质量[Oswestry功能障碍指数(ODI)]及腰腿部疼痛程度,并观察术后并发症发生情况。结果 Wiltse组患者植骨融合率为88. 00%,与传统组植骨融合率83. 78%比较差异无统计学意义(P> 0. 05)。两组手术时间比较,差异无统计学意义(P> 0. 05),但Wiltse组术中出血量、术后24 h引流量及术后3 d切口VAS评分均低于传统组(P均<0. 01)。两组患者术后JOA评分、ODI评分、腰痛VAS评分及腿痛VAS评分均较术前改善(P均<0. 05);术后3个月,Wiltse组JOA评分高于传统组(P <0. 05),ODI评分、腰痛VAS评分及腿痛VAS评分低于传统组(P均<0. 05);但术后12个月时两组间各项评分比较无统计学差异(P均> 0. 05)。磁共振检测两侧椎旁肌组织面积结果显示,术后Wiltse组患者较术前无明显变化(P均> 0. 05),而传统组患者两侧分别较术前明显缩小(P均<0. 01);且传统组均小于Wiltse组(P均<0. 01)。所有患者术后随访期间均未发现切口感染、螺钉松动、断裂等并发症。结论 TLIF术中传统后正中入路和Wiltse入路均具有较高的植骨融合率,但Wiltse入路能够明显降低术中出血量,提高腰椎术后恢复速度。

Objective To explore the clinical effects of transforaminal lumbar interbody fusion（TLIF） in different approaches for treatment of lumbar spondylolisthesis complicated with lumbar spinal stenosis. Methods The clinical data of 62 patients with lumbar spondylolisthesis complicated with lumbar spinal stenosis undergoing TLIF from November 2014 to November 2016 were analyzed retrospectively. There were 37 cases receiving TLIF surgery of traditional posterior approach（traditional group） and 25 cases undergoing TLIF surgery of paravertebral nuscle space approach（Wiltse approach,Wiltse group）. Between two groups,operation time,intraoperative bleeding volume,postoperative drainage volume,visual analogue score（VAS） of incision pain at postoperative 3 d and postoperative bone graft fusion degree were compared; lumbar function（JOA score）,quality of life Oswestry Disability Index（ODI） score,pain degrees of lumbar and leg were evaluated before operation and at postoperative 3-,and 12-month; postoperative complications were observed.Results There were no significant differences in bone graft fusion rates（88. 00% vs 83. 78%） and in operation time between Wiltse group and traditional group（all P〈0.05）,but intraoperative blood loss,volume of postoperative 1-day drainage and VAS score in Wiltse group were significantly lower than those in traditional group（all P〈0.01）. JOA score,ODI score,VAS score of waist and leg pain significantly improved compared with those before operation in both two groups（all P〈0.05）. At postoperative 3 months,JOA score in Wiltse group was significantly higher than that in traditional group（P〈0.05）,and ODI score,VAS scores of waist and leg pain were significantly lower than those in traditional group（all P〈0.05）,however,there were no significant differences in above scores at postoperative 12 months between two groups（all P〈0.05）. Magnetic resonance imaging（MRI） detection on the tissue area of the paravertebral muscles in both sides showed that the paravertebral muscle tissue area had no obvious changes after operation in Wiltse group（all P〈0.05）,while they were significantly smaller than those before operation in traditional group（all P〈0.01） and were statistically smaller than those in Wiltse group（all P〈0.01）. No complications such as incision infection,screw loosening or breakage were found in all patients during the follow-up period. Conclusion In TLIF operation,both the traditional posterior approach and the Wiltse approach have higher bone graft fusion rate,however,Wiltse approach can more obviously reduce intraoperative blood loss and improve postoperative recovery after lumbar surgery.