小切口肌间隙入路Dynesys动态内固定在治疗腰椎间盘突出症中的应用

Application of Dynesys dynamic fixation with small incision intramuscular approach in the treatment of lumbar disc herniation

目的:分析后正中小切口经双侧肌间隙入路Dynesys置入、开窗髓核摘除术治疗腰椎间盘突出症的可行性和临床疗效。方法:回顾性分析2014年4月~2016年4月间,我院采用后正中小切口经双侧肌间隙入路Dynesys置入、开窗髓核摘除治疗腰椎间盘突出症25例患者的临床及影像学资料,并选取相同时间段内行常规显露Dynesys置入、开窗髓核摘除术治疗的腰椎间盘突出症患者25例做对比。记录切口长度、手术时间、术中出血量、并发症;评估术前、术后3d、术后3个月及末次随访时腰痛及下肢放射痛VAS评分、ODI评分;测量围手术期血清C反应蛋白(CRP)结果;测量手术节段椎间隙高度、活动度、邻近节段活动度;测量术后1年时多裂肌残存率。结果:两组患者均获得完整随访,术后随访时间30~54个月。小切口组平均随访时间35.5±7.3个月,常规显露组平均随访时间34.8±5.1个月。两组患者术前VAS评分和ODI评分组间差异无统计学意义,末次随访时均较术前明显改善(P<0.05),两组间差异无统计学意义(P<0.05)。小切口组在手术时间、术中出血量、切口长度、术后引流量优于常规显露组(P<0.05)。两组患者术后腰痛VAS、腿痛VAS、ODI均较术前明显缓解(P<0.05),小切口组术后3d腰痛VAS评分优于常规显露组(P<0.05)。小切口组患者术后3d和5d的CRP水平低于常规显露组(P<0.05)。手术节段在末次随访时仍存在4.1°±1.5°的活动度,所有患者末次随访时均未发现断钉及螺钉松动病例,小切口组减压侧多裂肌残留率高于常规显露组(P<0.05)。手术椎间隙高度在术后3个月时有所增高,但在末次随访是恢复到术前水平(P<0.05)。小切口组2例切口延迟愈合,常规显露组1例切口延迟愈合。结论:后正中小切口经双侧肌间隙入路Dynesys置入、开窗髓核摘除术治疗腰椎间盘突出症,较常规显露方法手术时间短,出血量、引流量、切口长度较常规显露小,对肌肉组织损伤小,是手术治疗腰椎间盘突出症的选择之一。

Objectives:To observe the feasibility and clinical efficacy of posterior small incision in the treatment of lumbar disc herniation with bilateral intermuscular approach Dynesys implantation and discectomy.Methods:Retrospective analysis of clinical and imaging data of 25 patients with lumbar disc herniation treated with Dynesys implantation and discectomy through bilateral intermuscular approach from April 2014 to April 2016.Another 25 patients with lumbar disc herniation treated with conventional exposure were selected for comparison.Incision length,operative time,intraoperative blood loss,and complications were recorded.The VAS score of low back and leg pain,ODI score preoperatively,3 days and 3 months postoperatively,and at final follow-up were collected.Perioperative serum C-reactive protein was measured.The motion of surgical segment and proximal adjacent segment,and the disc height of surgical segment were measured at follow-up.The residual rate of multifidus muscle was measured.Results:Complete follow-up was achieved for patients in both groups,and the follow-up period was 30-54 months.The average follow-up time was 35.5±7.3 months in the small incision group,and 34.8±5.1 months in the control group.There was no significant difference in the preoperative VAS score and ODI score between the two groups.At final follow-up,both were significantly improved(P<0.05)without significant difference between the two groups(P<0.05).In the operation time,intraoperative blood loss,incision length,and postoperative drainage volume,the small incision group were better than those of the conventional exposed group(P<0.05).The postoperative low back pain VAS,leg pain VAS,and ODI of the two groups were significantly alleviated than preoperation(P<0.05).Three days after surgery,the VAS score of low back pain in small incision group was better than that of the conventional exposed group(P<0.05).The CRP levels of patients in the small incision group at 3 and 5 days after surgery were lower than those in the conventional exposure group(P<0.05).There was still some motion on surgical segment at final follow-up without cases of screw broken or loose.The residual rate of multifidus muscle in the decompression side of the small incision group was higher than that of the conventional exposed group(P<0.05).The height of the intervertebral space increased at 3 months after the operation,but returned to the preoperative level at final follow-up(P<0.05).There were 2 cases of delayed healing in the small incision group and 1 in the control group.Conclusions:Dynesys implantation and discectomy to treat lumbar disc herniation with posterior small incision bilateral intermuscular approach has shorter operation time,less intraoperative blood loss,less drainage volume and less length of the incision,less tissue damage than conventional exposure.It is one of the options for surgical treatment of lumbar disc herniation.