斜外侧腰椎椎间融合术并发症的研究进展

Advances in research on complications of oblique lateral interbody fusion

斜外侧腰椎椎间融合术(oblique lateral interbody fusion,OLIF)采用腹膜后腹主动脉与左侧腰大肌之间的间隙建立手术通道,完成椎间盘切除与椎间融合术。相较于传统腰椎椎间融合手术,OLIF具有手术时间及住院时间短、术中失血量少、术后疼痛轻、恢复快等优点。目前OLIF手术已逐渐被应用于腰椎退变性疾病的治疗中,但术中血管、交感神经、腰骶丛神经、腹膜及输尿管损伤等并发症不容忽视。文献报道OLIF手术并发症的总体发生率为3%~53.1%,平均15.5%,包括术中并发症与术后并发症两类。L5S1节段OLIF手术中髂血管损伤的发生率为0.3%~15.4%,此节段主动脉已分支为左右髂总动脉,血管走行复杂,手术入路类似侧方前路腰椎椎间融合术(anterior lumbar interbody fusion,ALIF)而非常规OLIF的安全窗,因此髂血管损伤风险较大。其余并发症根据既往文献未见明显节段特异性。腹主动脉损伤发生率较低,仅为0.1%,损伤多与OLIF手术安全窗过小所致的直接损伤相关。腰椎节段动脉损伤的发生率为0.7%~5%,多由L4,5节段腰椎节段动脉的解剖变异所致,L4,5节段损伤风险较大。腰椎交感神经损伤的发生率为1.7%,术中操作时应注意保护腰大肌前缘走行的腰椎交感干。融合器相关并发症发生率为2.9%~13.4%,可能与患者高龄、骨质疏松及使用大尺寸融合器相关。输尿管损伤发生率为0.3%~1.6%,未放置输尿管时损伤较为隐匿,常于数日后被发现,需引起重视。

Oblique lateral interbody fusion (OLIF) surgery uses the retroperitoneal gap between the abdominal aorta and left psoas as the surgical approach to perform discectomy and interbody fusion. It has the advantages of shorter operation duration and hospital stay, less blood loss, lighter postoperative pain and quicker recovery compared with traditional lumbar interbody fusion surgery. OLIF surgery has been gradually applied in treating degenerative diseases of the lumbar spine. However, the complications, such as the injury of blood vessels, sympathetic nerves, lumbosacral plexus, peritoneum and ureteral, cannot be negligible. Previous studies reported that the overall incidence of complications about OLIF surgery was 3% to 53.1% with an average of 15.5%, which can be divided into intraoperative and postoperative complications. The incidence of iliac vascular injury was found to be 0.3%-15.4% in OLIF at the L5S1 segments. The anatomy about vascular in this area is complex because the aorta is branched into the left and right iliac artery. The surgical approach in L5S1 segments is also different from the traditional OLIF but similar to the lateral anterior lumbar interbody fusion, which could increase the risk of vascular injury. The other complications which do not show significant segmental difference were based on the previous literatures. The incidence of abdominal aortic injury is 0.1%, which is related to direct damage caused by the narrow operation window of OLIF. The incidence of lumbar segmental arterial injury was 0.7% to 5%, which may be caused by the anatomical variation of L4, 5 lumbar segmental artery. The incidence of lumbar sympathetic nerve injury is 1.7%. More attention should be paid to protect the lumbar sympathetic trunk which lying in the front of the psoas muscle. The incidence of cage-related complications ranges from 2.9% to 13.4%, which perhaps is associated with older age, osteoporosis and use of large-sized cages. Although the incidence of ureteral injury is 0.3% to 1.6%, care should also be taken due to not obvious injury without urinary tube.