Wiltse入路与正中入路经椎间孔椎间融合术治疗单节段腰椎退行性疾病的疗效比较

Comparison of the Efficacy of Wiltse Approach vs.Midline Approach in the Treatment of Single Segment Lumbar Degenerative Diseases

目的比较Wiltse入路经椎间孔椎间融合术(transforaminal lumbar interbody fusion via Wiltse approach,W-TLIF)及正中入路经椎间孔椎间融合术(transforaminal lumbar interbody fusion via midline approach,M-TLIF)治疗腰椎退行性疾病的临床疗效。方法回顾性分析2015年1月至2018年6月西南医科大学附属医院脊柱外科收治的腰椎退变性疾病病人的临床资料,根据手术入路分为WTLIF组(107例)和M-TLIF组(88例)。采用疼痛视觉模拟评分量表(visual analogue scale,VAS)评估两组病人腰痛及下肢疼痛程度,采用Oswestry功能障碍指数(Oswestry disability index,ODI)评估腰椎功能状况。分析比较两组的置钉精准率、上位椎体螺钉对邻近关节突关节的侵犯情况、螺钉内倾角、手术节段椎间隙高度、椎间植骨融合情况及相邻节段退变发生情况。结果W-TLIF组的手术时间和术中出血量均明显少于M-TLIF组(P<0.05);两组术后各随访时间点的腰、腿痛VAS评分,ODI及手术节段椎间隙高度均较术前明显改善(P<0.05),其中W-TLIF组术后各时间点的腰痛VAS评分和ODI明显优于M-TLIF组(P<0.05);W-TLIF组同一水平椎体、同侧螺钉内倾角明显大于M-TLIF组(P<0.05),上位椎体螺钉损伤邻近关节突关节的发生率及邻近节段退变发生率均明显低于M-TLIF组(P<0.05)。两组的并发症发生率、置钉精准率、椎间植骨融合率比较,差异无统计学意义(P>0.05)。结论两种入路行TLIF治疗腰椎退行性疾病均能获得良好的临床疗效,但经Wiltse入路的术中出血量少、手术时间短、术后腰痛改善明显,且能获得更大的螺钉内倾角,提供更佳的力学强度和融合条件,更能避免螺钉损伤关节突关节,降低术后邻近节段退变的发生。

Objective To compare the clinical effects of transforaminal lumbar interbody fusion via Wiltse approach(W⁃TLIF)or midline approach(M⁃TLIF)in the treatment of lumbar degenerative diseases.Methods The data of patients with lumbar degenerative diseases in the Department of Spinal Surgery of Affiliated Hospital of Southwest Medical University from January 2015 to June 2018 were collected and analyzed.According to the surgical approach,the patients were divided into W⁃TLIF group(107 cases)and M⁃TLIF group(88 cases).The visual analogue scale(VAS)was used to evaluate the degree of low back pain and lower limb pain in the two groups,and Oswestry disability index(ODI)was used to evaluate the function of lumbar spine.The accuracy rate of pedicle screw placement,the position of screw with superior segment facet joint,transverse screw angle,intervertebral disc height,lumbar interbody fusion and adjacent segment degeneration were assessed in two groups.Results The operation time and intraoperative bleeding in W⁃TLIF group were significantly decreased as compared with those in M⁃TLIF group(P<0.05).The low back and leg pain VAS score,ODI and intervertebral disc height of the operation level were significantly improved in the two groups at each follow⁃up time after operation(all P<0.05),and the VAS score of low back pain and ODI in the W⁃TLIF group were significantly better than those in the M⁃TLIF group at each follow⁃up time(all P<0.05).Transverse screw angle of the same level of vertebral body in W⁃TLIF group was significantly greater than that in M⁃TLIF group(P<0.05),the superior segment facet joint violation,and the incidence of adjacent segment degeneration in W⁃TLIF group were significantly lower than that in M⁃TLIF group(P<0.05).There were no significant difference in the incidence of surgical complications,screw placement accuracy,and fusion rate between the two groups(all P>0.05).Conclusion Good clinical effects were obtained in the treatment of lumbar degenerative diseases by both W⁃TLIF and M⁃TLIF.However,W⁃TLIF has less blood loss,shorter operation time,and milder low back pain significantly.In addition,the Wiltse approach can obtain a larger transverse screw angle,which not only provides stronger biomechanical behavior and good interbody fusion,but also prevents screws from damaging the facet joints and reduces the occurrence of adjacent segment degeneration after surgery.