Wiltse入路Dynesys内固定术治疗老年腰椎椎管狭窄症

Application of Dynesys internal fixation through Wiltse approach in treatment of elderly lumbar spinal stenosis

目的老年腰椎椎管狭窄症发病率持续增高,既往多采取Wiltse肌间隙入路经椎间孔腰椎间融合术对患者予以治疗,但整体效果不佳,需探讨新治疗措施。本研究探讨Wiltse入路动态稳定中和系统(dynamic stable neutralizationsystem for wiltse entry,Dynesys)内固定术对老年腰椎椎管狭窄症患者术后疼痛程度及Oswestry功能障碍指数问卷(oswestry disability index questionnaire,ODI)评分的影响。方法选取2015-11-01-2017-10-31舞阳县人民医院收治的78例老年腰椎椎管狭窄症患者作为研究对象,分为对照组与研究组,各39例。研究组采取Wiltse入路Dynesys内固定术,对照组采取Wiltse肌间隙入路经椎间孔腰椎间融合术(transforaminal lumbar interbody fusion,TLIF)。统计两组手术情况、术前及术后6个月腿及腰疼痛程度(visual analogue scale,VAS)、ODI评分、手术节段和手术下位邻近节段和手术上位邻近节段活动度(range of movement,ROM)。结果研究组手术时间为(111.24±11.62)min,短于对照组的(153.32±17.96)min,t=12.285,P<0.001;术中失血量为(149.41±24.26)mL,少于对照组的(198.17±28.52)mL,t=8.133,P<0.001;术后引流量为(50.04±10.11)mL,少于对照组的(61.18±11.71)mL,t=4.497,P<0.001。术后6个月两组腰痛VAS评分、腿痛VAS评分、ODI评分较术前降低;研究组腰痛VAS评分为(1.32±0.51)分,低于对照组的(1.98±0.63)分,t=5.085,P<0.001;腿痛VAS评分为(1.46±0.72)分,低于对照组的(2.11±0.69)分,t=4.071,P<0.001;ODI评分为(14.69±3.51)分,低于对照组的(20.27±5.02)分,t=5.689,P<0.001。术后6个月两组手术节段ROM较术前缩小、手术下位及上位邻近节段ROM较术前增大,但研究组手术节段ROM为(5.18±0.41)°,大于对照组的(0.10±0.04)°,t=77.011,P<0.001;手术下位为(8.29±0.51)°,小于对照组的(9.68±0.69)°,t=10.117,P<0.001;上位邻近节段ROM为(8.18±0.61)°,小于对照组的(9.14±0.83)°,t=5.820,P<0.001。结论采取Wiltse入路Dynesys内固定术治疗老年腰椎椎管狭窄症创伤小,可对部分ROM予以保留,减少邻近节段过度活动,缓解术后疼痛感,促使腰椎功能恢复。

OBJECTIVE The incidence of lumbar spinal stenosis in elderly patients continues to increase.In the past, Wiltse muscle interstitial approach was used to treat patients with intervertebral foraminal lumbar interbody fusion.However,the overall effect is not good,and new treatment measures need to be explored.The study aims to investigate the effect of dynamic stabilization system(Dynesys) internal fixation through Wiltse approach on postoperative pain and the Oswestry Disability Index questionnaire(ODI) score in elderly patients with lumbar spinal stenosis.METHODS A total of 78 elderly patients with lumbar spinal stenosis from November 1,2015 to October 31,2017 were enrolled.According to the surgical plan,random number table method was used to divide the patients into control group (n=39) and study group (n=39).The study group received the Wiltse approach Dynesys internal fixation, the control group were treated with Wiltse muscle interstitial approach for intervertebral foramen lumbar interbody fusion (Transforaminal lumbar interbody fusion,TLIF).The operation,the leg and lumbar pain degree with Visual Analogue Scale/Score(VAS) before and after operation for 6 months, ODI score, range of movement (ROM) in surgical segment, lower adjacent segment and upper adjacent segment were collected and compared between the two groups.RESULTS The operation time of the study group was (111.24± 11.62) min,shorter than that of the control group (153.32± 17.96) min (t=12.285.P<0.001).And the intraoperative blood loss was (149.41 ± 24.26) ml in the study group* less than that in the control group (198.17 ± 28.52) ml,(t=8.133,P<0.001).The postoperative drainage was (50.04±10.11) ml in the study group, less than that in the control group (61.18± 11.71) ml,(t=4.497,P<0.001).The lumbar pain VAS,leg pain VAS,ODI score at postoperative 6 months of the two groups decreased obviously compared with those before operation.Compared with the control group,the study group had lower lumbar pain VAS (1.32±0.51 vs 1.98±0.63,t=5.085,P<0.001),lower leg pain VAS (1.46±0.72 ps 2.11 ±0.69,t=4.071 ,P<0.001),lower ODI score (14.69±3.51 ps 20.27±5.02,t=5.689,P<0.001).In both groups,at the 6th month after operation, the ROM of the surgical segment was smaller than that before operation,the ROM of the lower and upper adjacent segments increased.However,the surgical segment ROM of the study group (5.18±0.41) was greater than that of the control group (0.10±0.04 ,t=77.011 ,P<0.001).The ROM of lower and upper adjacent segments in study group were both smaller than those in the control group (8.29±0.51 vs 9.68±0.69,t=10.17,P<0.001;8.18±0.61 ps 9.14±0.83,r=5.820,P<0.001).CONCLUSION Dynesys internal fixation through Wiltse approach can preserve some ROM,reduce the excessive activity of adjacent segments,alleviate postoperative pain and promote the recovery of lumbar function in treatment of elderly lumbar spinal stenosis with small trauma.