通道下联合固定并椎间不同融合器植骨治疗腰椎疾患的病例对照研究

Different interbody fustion cages and combined fixation through intermuscular approach for lumbar diseases:a case-control study

目的:探讨肌间隙入路通道下联合固定并不同融合器椎间植骨治疗单节段腰椎疾患的临床疗效。方法:对2014年6月至2016年12月收治的123例单节段腰椎疾患的临床资料进行回顾性分析,其中男44例,女79例;年龄22~60岁;病程6~84个月。腰椎间盘退行性病变65例,腰椎管狭窄症30例,腰椎退行性滑脱症(MeyerdingⅠ度滑脱)21例,巨大型腰椎间盘突出症7例。L3,45例,L4,5101例,L5S117例。均采用肌间隙入路通道下单侧椎弓根螺钉联合对侧椎板关节突螺钉固定并椎间融合术,根据椎间不同融合器的应用分为单枚普通融合器组、双枚普通融合器组和香蕉型融合器组。观察3组患者的手术时间、术中出血量、术后切口引流量和切口长度;记录术后72 h腰部切口VAS评分、术前和末次随访时的JOA评分;通过影像学资料观察手术前后的椎间隙高度、腰椎冠状面和矢状面Cobb角变化情况,以及术后12个月的椎间融合情况。结果:在切口长度、手术时间、术中出血量、术后切口引流量和术后72 h腰部切口VAS评分方面,3组患者差异无统计学意义(P>0.05)。所有病例获得随访,时间12~36(23.70±4.52)个月。3组患者术后椎间隙高度均有明显恢复(P<0.05),末次随访时均有不同程度的丢失,其中丢失程度单枚普通融合器组>香蕉型融合器组>双枚普通融合器组。末次随访时3组患者的腰椎冠状面和矢状面Cobb角均有明显改善(P<0.05)。随访过程中出现融合器沉降42例,其中单枚普通融合器组26例,双枚普通融合器组5例,香蕉型融合器组11例,3组比较差异有统计学意义(P<0.05)。术后12个月椎间融合情况为:单枚普通融合器组融合率83%(35/42),双枚普通融合器组为95%(41/43),香蕉型融合器组为90%(4/39),双枚普通融合器组和香蕉型融合器组的椎间融合率优于单枚普通融合器组。未观察到固定部位邻近节段的明显退变现象。末次随访时3组患者的JOA评分与术前比较差异均有统计学意义(P<0.05),说明腰痛和腰椎功能均获得较好的改善;而3组间比较差异无统计学意义(P>0.05)。并发症情况:单枚普通融合器组发生率10%(4/42),双枚普通融合器组为9%(4/43),香蕉融合器组为10%(4/39),3组比较差异无统计学意义。结论:肌间隙入路通道下单侧椎弓根螺钉联合对侧椎板关节突螺钉固定并分别采用单枚普通融合器、双枚普通融合器或香蕉型融合器进行椎间植骨治疗单节段腰椎疾患,虽然不同融合器的应用并不能增加固定节段的轴向强度,但通过增加接触面积,促进了植骨融合的速度和质量,减少了融合器的沉降和椎间隙高度的丢失。因此,通过一侧植入2枚椎间融合器,对于采用单侧椎弓根螺钉联合对侧椎板关节突螺钉的固定方式具有积极的临床意义,且没有延长手术时间、增加手术并发症。

Objective:To explore the clinical effect of combined fixation and interbody bone grafting through intermuscular approach with different fusion cages in the treatment of single segment lumbar diseases.Methods:From June 2014 to December 2016,the clinical data of 123 cases of single segment lumbar diseases were analyzed retrospectively,including 44 males and 79 females,aged 22 to 60 years old,with the diseases course of 6 to 84 months.The disease types involved lumbar disc degeneration in 65 cases,lumbar spinal stenosis in 30 cases,MeyerdingⅠslip in 21 cases,giant lumbar disc herniation in 7 cases.Lesions was L3,4 in 5 cases,L4,5 in 101 cases,L5S1 in 17 cases.According to the application of different interbody fusion cage,patients were divided into single common cage group,double common cage group and banana type cage group.The operation time,intraoperative hemorrhage,postoperative incision drainage fluid and incision length were observed in three groups;VAS score of lumbar incision and JOA score of preoperative and final follow-up were recorded 72 hours after operation;the intervertebral space height,Cobb angle of lumbar coronal and sagittal plane before and after operation,and interbody fusion 12 months after operation were observed by imaging data.Results:There was no significant difference in incision length,operation time,intraoperative bleeding volume,postoperative drainage volume and VAS score of lumbar incision 72 hours after operation among three groups(P>0.05).All cases were followed up for 12 to 36(23.70±4.52)months.The height of intervertebral space in three groups recovered significantly(P<0.05),at the last follow-up,there were different degrees of loss,the loss degree of single common fusion cage group>banana type fusion cage group>double common fusion cage group.At the last follow-up,the Cobb angle in the coronal and sagittal planes of the three groups were significantly improved(P<0.05).During the follow-up,there were 42 cases of fusion cage subsidence,including 26 cases in the single common cage group,5 cases in the double common cage group,11 cases in the banana cage group,the difference was statistically significant(P<0.05).At 12 months after operation,the interbody fusion rate was 83%in the single common cage group,95%in the double common cage group and 90%in the banana cage group,the interbody fusion rate in the two common cage group and the banana cage group was better than that in the single common cage group.No obvious degeneration was observed in the adjacent segments.At the last follow-up,the JOA scores of the three groups were statistically significant(P<0.05).The incidence of single common fusion cage group was 10%(4/42),that of double common fusion cage group was 9%(4/43),and that of banana fusion cage group was 10%(4/39).There was no significant difference among the three groups.Conclusion:Through the intermuscular approach,single pedicle screw and contralateral facet screw were used for fixation,and single common fusion cage,double common fusion cage or banana type fusion cage were used for interbody grafting to treat single segment lumbar disease.Although the application of different fusion cage could not increase the axial strength of fixed segment,the speed of fusion was accelerated by increasing the contact area,and the quality of the fusion cage reduces the settlement of the cage and the loss of the height of the intervertebral space.Therefore,two interbody fusion cages implanted in one side are of positive clinical significance for the fixation of unilateral pedicle screw combined with contralateral facet screw,without prolonging the operation time and increasing the complications.