后正中入路联合Wiltse入路治疗腰椎间盘突出症合并腰椎失稳的临床疗效

Clinical curative effects of surgery through posterior median approach combined with Wiltse approach for treatment of lumbar disc herniation with lumbar instability

目的:探讨后正中入路联合Wiltse入路治疗腰椎间盘突出症合并腰椎失稳的临床疗效。方法:回顾性分析接受椎弓根钉棒系统内固定联合改良经椎间孔减压椎间植骨融合术治疗的61例腰椎间盘突出症合并腰椎失稳患者的病例资料,其中采用后正中入路联合Wiltse入路28例、后正中入路33例。男32例,女29例。年龄(53.36±16.24)岁。病变部位,L3~45例、L4~536例、L5S120例。比较2组患者手术时间、术中出血量和术后引流量,分别比较术前、术后12个月2组患者的腰腿部疼痛视觉模拟量表(visual analogue scale,VAS)评分和Oswestry功能障碍指数(Oswestry disability index,ODI),并分别比较术前和末次随访时2组患者的腰椎凹陷值。结果:①一般指标。61例患者椎间隙植骨均获得骨性融合,其中52例术后3个月获得骨性融合、9例术后6个月获得骨性融合。2组患者手术时间比较,差异无统计学意义[(115±12)min,(119±10)min,t=-1.526,P=0.132];后正中入路联合Wiltse入路组术中出血量和术后引流量均小于后正中入路组[(161±27)mL,(343±44)mL,t=-19.003,P=0.000;(161±35)mL,(350±63)mL,t=-14.709,P=0.000]。②腰部疼痛VAS评分。术前2组患者腰部疼痛VAS评分比较,差异无统计学意义[(7.1±1.0)分,(7.0±1.1)分,t=0.398,P=0.692];术后12个月,后正中入路联合Wiltse入路组腰部疼痛VAS评分低于后正中入路组[(1.6±0.7)分,(2.8±1.1)分,t=-4.749,P=0.000],2组患者腰部疼痛VAS评分均低于术前(t=25.409,P=0.000;t=14.978,P=0.000)。③腿部疼痛VAS评分。术前和术后12个月,2组患者腿部疼痛VAS评分比较,差异均无统计学意义[(7.5±0.7)分,(7.6±0.8)分,t=-0.674,P=0.503;(1.4±0.4)分,(1.4±0.5)分,t=0.231,P=0.651];术后12个月,2组患者腿部疼痛VAS评分均低于术前(t=38.853,P=0.000;t=33.719,P=0.000)。④ODI。术前2组患者ODI比较,差异无统计学意义[(81.86±5.55)%,(83.21±5.92)%,t=-0.917,P=0.698];术后12个月,后正中入路联合Wiltse入路组ODI低于后正中入路组[(30.36±4.99)%,(43.82±7.83)%,t=-7.839,P=0.000],2组患者ODI均低于术前(t=37.354,P=0.000;t=21.891,P=0.000)。⑤腰椎凹陷值。术前2组患者腰椎凹陷值比较,差异无统计学意义[(12.2±1.9)mm,(12.8±1.9)mm,t=-0.174,P=0.862];末次随访时,后正中入路联合Wiltse入路组腰椎凹陷值大于后正中入路组[(11.6±1.7)mm,(10.0±2.0)mm,t=3.305,P=0.002],2组患者腰椎凹陷值均低于术前(t=9.065,P=0.000;t=18.101,P=0.000)。结论:后正中入路联合Wiltse入路治疗腰椎间盘突出症合并腰椎失稳,损伤小,能够缓解腰腿部疼痛,促进腰椎功能的恢复,有效保护一侧椎旁肌。

Objective:To explore the clinical curative effects of surgery through posterior median approach combined with Wiltse approach for treatment of lumbar disc herniation(LDH)with lumbar instability.Methods:The medical records of 61 patients who received pedicle screw-rod system internal fixation combined with modified transforaminal decompression and intervertebral bone graft fusion for treatment of LDH and lumbar instability were analyzed retrospectively.Twenty-eight patients were treated through posterior median approach combined with Wiltse approach(group A),and the others were merely treated through posterior median approach(group B).The patients consisted of 32 males and 29 females and ranged in age of 53.36+/-16.24 years.The pathological changes located at L3-4(5),L4-5(36)and L5S1(20).The operative time,intraoperative blood loss and postoperative drainage volume were compared between the 2 groups.The lumbago-leg pain visual analogue scale(VAS)scores and Oswestry disability index(ODI)obtained before the surgery and at 12 months after the surgery and the lumbar indentation values obtained before the surgery and at last follow-up were compared between the 2 groups respectively. Results: All patients in the 2 groups achieved intervertebral osseous bone graft fusion,in which 52 patients achieved osseous fusion at 3 months after the surgery and 9 patients at 6 months after the surgery. There was no statistical difference in operative time between the 2 groups( 115 +/-12 vs 119 +/-10 min,t =-1. 526,P = 0. 132). The intraoperative blood loss and postoperative drainage volume were less in group A compared to group B( 161 +/-27 vs 343 +/-44 m L,t =-19. 003,P = 0. 000;161 +/-35 vs 350 +/-63 m L,t =-14. 709,P = 0. 000). There was no statistical difference in low back pain VAS scores between the 2 groups before the surgery( 7. 1 +/-1. 0 vs 7. 0 +/-1. 1 points,t = 0. 398,P = 0. 692). The low back pain VAS scores were lower in group A compared to group B at12 months after the surgery( 1. 6 +/-0. 7 vs 2. 8 +/-1. 1 points,t =-4. 749,P = 0. 000),and the low back pain VAS scores of the 2 groups were lower at 12 months after the surgery compared to pre-surgery( t = 25. 409,P = 0. 000;t = 14. 978,P = 0. 000). There was no statistical difference in leg pain VAS scores between the 2 groups before the surgery and at 12 months after the surgery( 7. 5 +/-0. 7 vs7. 6 +/-0. 8 points,t =-0. 674,P = 0. 503;1. 4 +/-0. 4 vs 1. 4 +/-0. 5 points,t = 0. 231,P = 0. 651). The leg pain VAS scores of the 2 groups were lower at 12 months after the surgery compared to pre-surgery( t = 38. 853,P = 0. 000;t = 33. 719,P = 0. 000). There was no statistical difference in ODI between the 2 groups before the surgery( 81. 86 +/-5. 55 vs 83. 21 +/-5. 92%,t =-0. 917,P = 0. 698). The ODI was lower in group A compared to group B at 12 months after surgery( 30. 36 +/-4. 99 vs 43. 82 +/-7. 83%,t =-7. 839,P =0. 000),and the ODI decreased in both of the 2 groups at 12 months after surgery compared to pre-surgery( t = 37. 354,P = 0. 000;t =21. 891,P = 0. 000). There was no statistical difference in lumbar indentation value between the 2 groups before the surgery( 12. 2 +/-1. 9 vs 12. 8 +/-1. 9 mm,t =-0. 174,P = 0. 862). The lumbar indentation values were greater in group A compared to group B at last followup( 11. 6 +/-1. 7 vs 10. 0 +/-2. 0 mm,t = 3. 305,P = 0. 002),and the lumbar indentation values of the 2 groups were lower at last followup compared to pre-surgery( t = 9. 065,P = 0. 000;t = 18. 101,P = 0. 000). Conclusion: Surgery through posterior median approach combined with Wiltse approach can relieve lumbago-leg pain,promote the lumbar function recovery and effectively protect paraspinal muscle with less injury in treatment of LDH with lumbar instability.