Wiltse入路置钉联合对侧TLIF和传统术式治疗腰椎间盘突出症的病例对照研究

Wiltse approach combined with contralateral transforaminal lumbar interbody fusion and conventional surgery for lumbar disc herniation:a case-control study

目的:比较Wiltse入路置钉联合对侧经椎间孔腰椎椎间融合术(transforaminal lumbar interbody fusion,TLIF)和传统TLIF治疗腰椎间盘突出症的疗效及其对多裂肌损伤的影响方法:2014年6月至2017年9月收治90例腰椎间盘突出症合并腰椎不稳患者,根据手术方式不同分为Wiltse入路置钉组和传统TLIF组。Wiltse入路置钉组50例,采用一侧Wiltse入路置钉联合对侧TLIF治疗,其中男36例,女14例,年龄45~72岁(60.4±3.1)岁;传统TLIF组40例,采用传统TLIF术式治疗,其中男25例,女15例,年龄45~74(62.1±3.4)岁。记录两组的手术时间、术中出血量、螺钉置入的准确率、术后引流量和引流管拔除时间。评估两组患者术前和术后12个月的腰背痛视觉模拟评分(visual analogue scale,VAS)和Oswestry功能障碍指数(Oswestry Disability Index,ODI)。所有患者术前、术后12个月进行CT检查,并对两组患者两侧多裂肌进行CT值测量。结果:所有患者获得随访,其中传统TLIF组随访时间12~18(15.3±4.3)个月;Wiltse入路置钉组随访时间13~24(16.5±4.1)个月。两组患者手术时间、术中出血量差异无统计学意义(P>0.05),Wiltse入路置钉组置入准确率高于传统TLIF组(P<0.05)。VAS评分和ODI术前两组差异无统计学意义(P>0.05),术后12个月Wiltse入路置钉组明显低于传统TLIF组(P<0.05)。Wiltse入路置钉组术后引流量和引流管放置时间均少于传统TLIF组(P<0.05)。两组患者术前多裂肌CT值比较差异无统计学意义(P>0.05),术后12个月比较差异有统计学意义(P<0.05)。传统TLIF组术后减压侧和非减压侧多裂肌CT值较术前均有明显减少(P<0.05),Wiltse入路置钉组减压侧术后多裂肌CT值较术前明显减少(P<0.05),非减压侧手术前后差异无统计学意义(P>0.05)。结论:Wiltse入路置钉联合对侧TLIF相对于传统术式,具有置钉准确,减少多裂肌的损伤,降低术后顽固性腰背部疼痛的发生率等优点。

Objective:To compare the clinical effecty of Wiltse approach combined with contralateral transforaminal lumbar interbody fusion(TLIF)and traditional TLIF in the treatment of lumbar disc herniation and its affect on injury of multifidus muscle.Methods:From June 2014 to September 2017,90 patients with lumbar disc herniation combined with lumbar spine instability were divided into two groups(Wiltse approach group and traditional group)depend on the procedure of operation.Wiltse approach group was treated with Wiltse approach screw placement in one side combined with contralateral TLIF.There were 50 patients in Wiltse approach group,including 36 males and 14 females,aged 45 to 72 years with an average of(60.4±3.1)years.The traditional group was treated with traditional TLIF operation.There were 40 patients in the traditional group,including 25 males and 15 females,aged 45 to 74 years with an average of(62.1±3.4)years.The operative time,intraoperative blood loss,accuracy of screw implantation,postoperative drainage volume and drainage tube removal time were recorded in two groups.Visual analogue scale(VAS)and Oswestry Disability Index(ODI)were observed before and 12 months after operation.All patients underwent CT examination preoperative and 12 months postoperative,and the CT values of bilateral multifidus muscle were measured.Resutls:All the patients were followed up,40 patients in traditional group were 12 to 18 months with an average of(15.3±4.3)months;and 50 patients in Wiltse approach group were 13 to 24 months with an average of(16.5±4.1)months.There were no statistically significant differences in operative time and intraoperative blood loss between two groups(P>0.05).The accuracy of screw implantation in Wiltse approach group was higher than traditional group(P<0.05).There was no significant difference in preoperative VAS score and ODI between two groups,and 12 months after operation,VAS score and ODI in Wiltse approach group was significantly lower than traditional group(P<0.05).The postoperative drainage and drainage tube placement time in Wiltse approach group were lower than the traditional group(P<0.05).There was no statistically significant difference in CT value of multifidus muscle before operation between two groups(P>0.05),while there was statistically significant difference after operation(P<0.05).Postoperative CT values of multifidus muscles on decompression and non-decompression side were obviously reduced in traditional group(P<0.05).The CT value of the multifidus muscle on the decompression side of the Wiltse approach group was significantly lower than that before operation(P<0.05),and there was no significant difference before and after the operation on the non-decompression side(P>0.05).Conclusion:Compared with traditional surgical procedures,the Wiltse approach nail placement combined with contralateral TLIF has the advantage of accurate nail placement,reducing multifidus muscle damage,and reducing the incidence of postoperative intractable low back pain.