两种不同技术联合微创经椎间孔椎体间融合术治疗退行性腰椎滑脱症的病例对照研究

Two different techniques combined with MIS-TLIF in the treatment of degenerative lumbar spondylolisthesis:a case-control study

目的:分析Quadrant通道系统辅助微创经椎间孔椎体间融合术(minimally invasive transforaminal lumbar interbody fusion,MIS-TLIF)联合显微镜下后正中小切口和经皮椎弓根螺钉两种技术治疗退行性腰椎滑脱症的临床疗效。方法:对2015年6月至2019年2月收治的114例单节段退行性腰椎滑脱症患者进行回顾性分析。根据手术方式分为显微镜下MIS-TLIF手术组(显微镜组)、经皮椎弓根螺钉技术联合MIS-TLIF手术组(经皮组)和后路腰椎椎体间融合手术组(开放组)。其中显微镜组38例,男12例,女26例;年龄42~83(63.29±9.09)岁;经皮组38例,男16例,女22例;年龄45~82(63.37±7.50)岁;开放组38例,男12例,女26例;年龄51~82(63.76±8.21)岁。记录3组患者的手术时间、术中出血量、术后引流量、切口长度、术中透视次数、卧床时间等一般情况;术前和术后3 d,3、6、12个月采用疼痛视觉模拟评分(visual analgue scale,VAS)评价腰腿疼痛缓解程度;以Oswestry功能障碍指数(Oswestry Disability Index,ODI)和腰椎日本骨科协会(Japanese Orthopaedic Association,JOA)评分评估术前及术后12个月腰腿功能恢复情况;比较术前及术后12个月的腰椎滑脱率、椎间隙高度,评价滑脱复位情况;术后12个月时采用Siepe椎间融合标准分析椎间融合率。结果:114例患者均获得1年以上的随访,均无切口感染相关并发症发生。显微镜组有1例术后8 d皮下积液,经皮穿刺引流腰围加压后,延迟愈合;经皮钉组有2例出现减压侧椎旁肌肉肌肉坏死,经清创手术治疗后延迟愈合;开放组有1例术中硬脊膜撕裂,术中即予游离脂肪组织填压,术后未出现脑脊液漏等相关并发症。①与显微镜组比较,经皮组在手术时间、术中出血量、术后引流量、切口长度、术中透视次数、卧床时间均增加,开放组在术中出血量、术后引流量、切口长度、卧床时间均增加,但术中透视次数减少;与经皮组比较,开放组术中出血量、术后引流量、切口长度、卧床时间均增加,但手术时间、术中透视次数均减少(P<0.05)。②术后12个月3组患者ODI、JOA评分较术前均改善(P<0.05),但组间差异无统计学意义(P>0.05)。③与显微镜组比较,经皮组VAS腰痛评分在术后3 d时增高,开放组在术后3 d,3、12个月时均增高;与经皮组比较,开放组VAS腰痛评分在术后3个月时增高(P<0.05)。④术后12个月3组患者腰椎滑脱率较术前均减少(P<0.05),椎间隙高度较术前均增加(P<0.05),但组间差异无统计学意义(P>0.05)。⑤术后12个月3组患者腰椎融合率组间差异无统计学意义(P>0.05)。结论:显微镜辅助的MIS-TLIF和结合经皮椎弓根螺钉的MIS-TLIF治疗单节段Ⅰ、Ⅱ度退行性腰椎滑脱是安全有效的,显微镜下的MIS-TLIF手术可能更具有手术创伤小,失血少和短期疗效满意的优点。

Objective:To analyze the difference in clinical efficacy of minimally invasive transforaminal lumbar interbody fusion(MIS-TLIF)under Quadrant channel system combined with microscope and percutaneous pedicle screw in the treatment of degenerative lumbar spondylolisthesis.Methods:A total of 114 patients with single-segment degenerative lumbar spondylolisthesis from June 2015 to February 2019,were divided into three groups according to the surgical methods,such as the MIS-TLIF under the microscope surgery group(microscope group),MIS-TLIF combined with percutaneous pedicle screw technique surgery group(percutaneous group)and posterior lumbar interbody fusion surgery group(open group).In the microscope group,there were 12 males and 26 females,aged from 42 to 83 years with an average of(63.29±9.09)years.In the percutaneous group,there were 16 males and 22 females,aged from 45 to 82 years with an average of(63.37±7.50)years.In the open group,there were 12 males and 26 females,aged from 51 to 82 years with an average of(63.76±8.21)years.The general conditions of operation,such as operation time,intraoperative blood loss,postoperative drainage,length of surgical incision,frequency of intraoperative fluoroscopy and postoperative time of lying in bed were recorded to analyze the differences in surgical related indicators.Visual analogue scale(VAS)of waist and leg pain in preoperative and postoperative period(3 days,3 months,6 months and 12 months)were recorded to evaluate pain remission;Oswestry Disability Index(ODI),Japanese Orthopaedic Association(JOA)score were recorded to evaluate the recovery of waist and leg function on preoperative and postoperative 12 months.The lumbar spondylolisthesis rate and intervertebral height at 12 months after operation were recorded to evaluate the reduction of spondylolisthesis.The Siepe intervertebral fusion standard was used to analyze the intervertebral fusion rate at 12 months after operation.Results:①All 114 patients were followed up more than 1 year,and no complications related to incision infection occurred.In the microscope group,there was 1 case of subcutaneous effusion 8 days after operation.After percutaneous puncture and drainage,waist compression,and then the healing was delayed.In the percutaneous group,2 cases of paravertebral muscle necrosis occurred on the side of decompression,and the healing was delayed after debridement.In open group,there was 1 case of intraoperative dural tear,which was packed with free adipose tissue during the operation.There was no postoperative cerebrospinal fluid leakage and other related complications.①Compared with microscope group,percutaneous group increased in operation time,intraoperative blood loss,postoperative wound drainage,surgical incision length,intraoperative fluoroscopy times,and postoperative bed rest time.In open group,intraoperative blood loss,postoperative wound drainage,surgical incision length,and postoperative bed rest time increased,but the intraoperative fluoroscopy time decreased.Compared with percutaneous group,the intraoperative blood loss,wound drainage,surgical incision length,and postoperative bed rest time in open group increased,but operative time and the intraoperative fluoroscopy time decreased(P<0.05).②ODI and JOA scores of the three groups at 12 months after operation were improved compared with those before operation(P<0.05),but there was no significant difference between the three group(P>0.05).③Compared with microscope group,the VAS of low back pain in percutaneous group increased at 3 days after operation,and VAS of low back pain in open group increased at 3 days,and 12 month after operation.Compared with percutaneous group,the VAS low back pain score of the open group increased at 3 months after operation(P<0.05).④The lumbar spondylolisthesis rate of the three groups of patients at 12 months afrer operation was decreased compared with that before operation(P<0.05),and the intervertebral heigh was increased compared with that before operation(P<0.05),however,there was no significant difference among three groups at 12 months afrer operation(P>0.05).⑤There was no significant difference between three groups in the lumbar fusion rate at 12 months afrer operation(P>0.05).Conclusion:The MIS-TLIF assisted by microscope and the MIS-TLIF combined with percutaneous pedicle screw are safe and effective to treat the degenerative lumbar spondylolisthesis with single-segment,and the MIS-TLIF assisted by microscope may be more invasive,cause less blood loss and achieve better clinical efficacy.