腰椎融合术后邻近节段疾病的微创治疗现状

Status of minimally invasive treatment for adjacent segment disease after lumbar interbody fusion

邻近节段退变(adjacent segment degeneration,ASDeg)是腰椎融合术后的常见并发症之一,其主要表现为邻近椎间盘突出、邻近椎体骨折或滑脱、邻近节段侧凸畸形、椎管狭窄或关节突关节退变等。当具有影像学ASDeg表现的患者出现腰骶痛、根性下肢痛或间歇性跛行等临床症状时,则称为邻近节段疾病(adjacent segment disease,ASDis),此时往往需要再手术治疗。目前开放术式已广泛应用于ASDis的治疗,包括经后路融合术及经椎间孔入路融合术等,传统手术疗效显著,但其始终存在手术创伤大、术中失血多、手术时间和住院时间长、术后恢复慢等诸多弊端,所以外科医生正在积极尝试将各类微创术式应用于ASDis的治疗。前路腰椎椎体间融合术(anterior lumbar interbody fusion,ALIF)对椎间隙高度及腰椎生理前凸恢复效果更优,但同时也存在较高的血管、泌尿系统及腹腔脏器损伤风险。微创经椎间孔腰椎椎体间融合术(minimally invasive transforaminallumbar interbody fusion,MIS-TLIF)在肌肉(如多裂肌)及韧带保护方面效果显著,但较开放术式,MIS-TLIF对冠状面和(或)矢状面畸形的矫正效果有限,且存在较高的上关节突关节破坏发生率。外侧腰椎椎体间融合术(lateral lumbar interbody fusion,LLIF)的冠状面和(或)矢状面畸形矫正效果显著,椎间隙处理彻底、椎间融合率高,椎间隙高度恢复佳,但因髂嵴的遮挡使其应用受限,且有损伤腰丛及髂血管的风险。极外侧腰椎椎体间融合术(extreme lateral lumbar interbody fusion,XLIF)的髂血管损伤风险低,对原内植物影响小,椎间融合效果好,但不适用于曾有腹膜后手术史、罹患腹膜后脓肿或存在血管变异的患者,术中常需神经电生理监测。斜外侧腰椎椎体间融合术(oblique lumbar interbody fusion,OLIF)较开放术式存在手术创伤小、常见并发症(如硬脊膜损伤)风险低等优点,但因其术中需牵拉交感神经,可能会导致术后肢体冷热障碍,从而影响对手术减压效果的判断。经皮内镜腰椎间盘切除术(percutaneous endoscopic lumbar discectomy,PELD)在充分减压神经及硬膜囊的同时,对脊柱后方组织结构损伤较小,但是不适用于患有ASDis合并严重椎管狭窄、腰椎滑脱或马尾综合征的患者,同时,PELD的学习曲线较其他术式更为陡峭。经皮内镜腰椎椎体间融合术(percutaneous endoscopic lumbar interbody fusion,PELIF)同样存在学习曲线陡峭、易损伤出口神经的缺点,但较开放术式存在出血少、住院时间短、恢复快、并发症(如深静脉血栓、肺栓塞)少等优点。通过文献检索,对不同微创术式治疗ASDis的优、劣势以及不同微创术式的适应证进行综述,以期为未来微创手段治疗ASDis提供参考。

Adjacent segment degeneration(ASDeg)is a common complication occurring in patients after lumbar fusion,mainly manifested as adjacent disc herniation,adjacent vertebral fracture or spondylolisthesis,adjacent segment scoliosis,adjacent segment spinal canal stenosis or facet joint degeneration,etc.When patients with imaging manifestations of ASDeg present with clinical symptoms such as lumbosacral pain,root lower limb pain or intermittent claudication,it is called adjacent segment disease(ASDis),and reoperation is often required at this time.At present,open surgery has been widely used in the treatment of symptomatic ASDis,including fusion via posterior approach and transforaminal approach,etc.The traditional surgery is effective,but it always has many disadvantages,such as large surgical trauma,large intraoperative blood loss,long operation time and hospital stay,and slow postoperative recovery.Therefore,surgeons are actively trying to apply various minimally invasive procedures to the treatment for symptomatic ASDis.Anterior lumbar interbody fusion(ALIF)has better recovery effect on intervertebral space height and lumbar lordosis,but it also has higher risk of vascular,urinary system and abdominal organ injury.Minimally invasive transforaminallumbar interbody fusion(MIS-TLIF)has a significant effect on the protection of muscles(such as multifidus muscle)and ligaments.However,compared with open surgery,MIS-TLIF has a limited effect on the correction of coronal and sagittal malformations,and has a higher incidence of superior facet joint violation.lateral lumbar interbody fusion(LLIF)has significant correction effect on coronal and sagittal malformations,complete treatment of intervertebral space,high intervertebral fusion rate,and good intervertebral space height recovery.However,due to the influence of the iliac crest,the surgical segment of LLIF is limited,and there is a risk of injury to the lumbar plexus and iliac vessels at the lower lumbar spine.Extreme lateral lumbar interbody fusion(XLIF)has a low risk of iliac vascular injury,little impact on the original internal fixation,and good interbody fusion effect.However,XLIF is not suitable for patients with a history of retroperitoneal surgery,retroperitoneal abscess,or vascular anatomical abnormalities,and neurological monitoring is often needed during surgery.Compared with open surgery,oblique lumbar interbody fusion(OLIF)has the advantages of less surgical trauma and low risk of common complications(such as dural injury).However,due to the need to pull the sympathetic nerve during operation,OLIF may lead to postoperative limb cold and heat disorders,thus affecting the judgment of surgical decompression effect.Percutaneous endoscopic lumbar discectomy(PELD)can fully decompress the nerve and dural sac while causing less damage to the posterior spinal structure.However,it is not suitable for patients with ASDis complicated with severe spinal stenosis,lumbar spondylolisthesis or cauda equina syndrome.At the same time,PELD has a steeper learning curve than other procedures.Percutaneous endoscopic lumbar interbody fusion(PELIF)also has the disadvantages of steep learning curve and easy to damage outlet nerve,but it has the advantages of less blood loss,shorter hospital stay,faster recovery,and fewer complications(such as deep vein thrombosis and pulmonary embolism)compared with open surgery.This paper reviews the advantages and disadvantages of different minimally invasive procedures in the treatment of symptomatic ASDis and the indications of different minimally invasive procedures through literature retrieval,in order to provide reference for the future minimally invasive methods in the treatment of symptomatic ASDis.