斜外侧腰椎椎间融合术与Quardrant通道下改良后路腰椎椎间融合术治疗腰椎管狭窄症合并腰椎不稳的疗效比较

A comparative study of the effects of oblique lateral lumbar interbody fusion and modified posterior lumbar interbody fusion under the Quardrant channel in the treatment of lumbar spinal stenosis with lumbar instability

目的:比较斜外侧腰椎椎间融合术(OLIF)与Quardrant通道下改良后路腰椎椎间融合术(misPLIF)治疗腰椎椎管狭窄症合并腰椎不稳的临床疗效。方法:2016年8月~2017年12月收治78例腰椎管狭窄症合并腰椎不稳的患者,其中36例采用OLIF治疗(A组),42例采用misPLIF治疗(B组)。两组患者年龄、性别、病程、骨密度、体重指数(BMI)、合并症和手术节段均无统计学差异。术后随访2年,比较两组间的创伤指标[手术时间、出血量、术后血红蛋白(Hb)下降量、住院时间]、临床疗效指标[疼痛视觉模拟评分(VAS)、腰椎Oswestry功能障碍指数(ODI)]及影像学指标(椎间隙高度、椎管矢状径、椎间融合率),并进行统计学分析。结果:两组均顺利完成手术。两组患者术后均无神经损伤等严重并发症,A组术后短期并发症发生率低于B组(P<0.05)。A组手术时间(69±27min)、出血量(38±14ml)、血红蛋白下降(11.0±2.5g/L)、术后住院时间(4.3±1.5d)均少于B组(113±33min、215±48ml、29.0±6.3g/L、7.1±2.1d)(P<0.05)。A组术前和术后2d、2周、3个月、半年、1年、2年时的疼痛VAS评分分别为7.35±2.84和2.78±1.26、2.48±1.21、2.23±1.29、1.63±1.29、1.60±0.97、1.53±0.87分;B组分别为7.43±2.66和4.12±1.84、3.78±1.46、2.81±1.31、2.11±1.31、1.91±0.90、1.84±0.90分,术后2d和2周时A组VAS评分显著性低于B组(P<0.05)。A组术前和术后3个月、1年、2年时的ODI分别为(68.45±16.21)%和(33.13±11.12)%、(25.23±8.15)%、(24.36±6.43)%,B组分别为(67.62±15.23)%和(35.27±10.85)%、(28.17±9.35)%、(26.58±7.51)%,两组同时间点比较均无统计学差异(P>0.05)。A组术前和术后3d、半年、2年时前/后缘椎间隙高度分别为14.11±1.56/7.36±1.28mm和18.52±2.11/10.13±1.16mm、16.67±2.07/8.98±1.38mm、16.61±2.11/8.79±1.41mm,B组分别为13.61±2.15/6.67±1.54mm和15.65±2.55/8.87±2.11mm、14.83±2.23/8.11±1.97mm、14.01±2.29/8.13±1.88mm,A组术后各时间点的椎间隙高度高于B组,差异有统计学意义(P<0.05)。术前和术后3d、半年时A组椎管矢状径分别为10.31±1.39mm和13.21±2.13、13.82±2.52mm,B组分别为9.86±1.12mm和17.33±2.25、15.82±2.31mm,两组术后均有统计学差异(P<0.05)。A组椎间融合率为94.44%,B组为92.86%,差异无统计学意义(P>0.05)。结论:OLIF治疗腰椎椎管狭窄症合并腰椎不稳可取得与misPLIF一致的满意疗效,但OLIF可更好地恢复椎间隙高度,具有组织创伤小、住院时间短、术后短期并发症发生率低的优势。

Objectives: To compare the clinical efficacy of modified posterior lumbar intervertebral fusion(misPLIF) under the Quardrant channel and oblique lateral lumbar intervertebral fusion(OLIF) in the treatment of lumbar spinal stenosis with lumbar instability. Methods: Seventy-eight patients with lumbar spinal stenosis and lumbar instability treated from August 2016 to December 2017 were divided into two groups. Group A,36 cases were treated with OLIF surgery, and group B, 42 cases were operated with misPLIF surgery. There was no difference significantly in age, genger, course of disease, bone mineral density, body mass index(BMI),complications and surgical segment between the two groups. Patients in both groups were followed up for 2 years. Comparison of trauma indicators [operation time, bleeding volume, postoperative hemoglobin(Hb)reduction, hospital stay], clinical efficacy indicators [pain visual analogue score(VAS), Oswestry dysfunction index(ODI)] and imaging indicators(vertebral space height, spinal canal sagittal diameter, and interbody fusion rate) between the two groups was performed, and statistical analyses were conducted. Results: The operations were successfully completed in both groups. There were no nerve injury, paralysis, and other serious complications found in the two groups. The incidence of short-term postoperative complications in group A was lower than that in group B, and the difference was statistically significant(P<0.05). The parameters of operation time(69 ±27 min), bleeding volume(38 ±14 ml), hemoglobin decrease(11.0 ±2.5 g/L), and postoperative hospital stay(4.3±1.5 d) were lower in group A than in group B(113±33 min, 215±48 ml, 29.0±6.3 g/L, 7.1±2.1 d).The difference was statistically significant(P<0.05). The VAS scores at preoperation and postoperative 2 d, 2 w,3 months, half a year, 1 year, 2 years were: group A(7.35 ±2.84, and 2.78 ±1.26, 2.48 ±1.21, 2.23 ±1.29,1.63±1.29, 1.60±0.97, and 1.53±0.87);group B(7.43±2.66, and 4.12±1.84, 3.78±1.46, 2.81± 1.31, 2.11±1.31,1.91 ±0.90, and 1.84 ±0.90). At 2 days and 2 weeks after surgery, the VAS scores of group A were significantly lower than that of group B(P<0.05). The ODI scores before surgery and at 3 months, 1 year, and2 years after surgery were: group A [(68.45 ±16.21)% and(33.13 ±11.12)%,(25.23 ±8.15)%, and(24.36 ±6.43)% ], and group B [(67.62 ±15.23)% and(35.27 ±10.85)%,(28.17 ±9.35)%, and(26.58 ±7.51)% ], and the difference was not statistically significant(P >0.05). The height of the anterior/posterior source intervertebral space at before and 3 d, half a year, and 2 years after surgery were: group A(14.11 ±1.56/7.36±1.28 mm and18.52±2.11/10.13±1.16 mm, 16.67±2.07/8.98±1.38 mm, 16.61±2.11/8.79±1.41 mm), and group B(13.61±2.1/56.67±1.54 mm, 15.65±2.55/8.87±2.11 mm, 14.83±2.23/8.11±1.97 mm, 14.01±2.29/8.13±1.88 mm). The height of the intervertebral space in group A was bigger than group B, and the difference was statistically significant(P<0.05). Before and 3 days and half a year after operation, the sagittal diameter of the spinal canal were: group A(10.31±1.39 mm and 13.21±2.13 mm, 13.82±2.52 mm), the parameters of which were smaller than group B(9.86±1.12 mm and 17.33±2.25 mm, 15.82±2.31 mm) with a statistical difference(P<0.05). The intervertebral fusion rate was 94.44% in group A and 92.86% in group B, and the difference was not statistically significant(P>0.05). Conclusions: OLIF is a satisfactory treatment for lumbar spinal stenosis combined with lumbar instability and consistent with misTLIF. OLIF was better than misPLIF in pain scores and recovery of intervertebral space height with less bleeding and less trauma.