后路中线腰椎椎间融合术与后路腰椎间融合治疗轻度退行性腰椎滑脱临床对比研究

A comparative study of MIDLIF and PILF in the treatment of degenerative lumbar spondylolisthesis

目的评估应用基于皮质骨轨迹(cortical bone trajectory,CBT)螺钉的后路中线腰椎椎间融合术(midline lumbar interbody fusion,MIDLIF)与传统后路腰椎间融合(posterior lumbar interbody fusion,PLIF)在退行性腰椎滑脱(degenerative spondylolisthesis,DS)中的治疗效果。方法回顾性分析2017年10月至2019年10月,应用MIDLIF技术和同组医师实行PLIF技术治疗DS患者共43例,其中男18例,女25例;年龄45~76岁,平均(61.81±5.63)岁。观察患者年龄、性别、随访时间、体质量指数(body mass index,BMI),术前合并糖尿病、高血压病、心脏病、骨密度(bone mineral density,BMD)、吸烟情况、手术时间、术中出血量和术后住院时间,以及手术前后腰椎前凸角(lumbar lordosis,LL)、骶骨倾斜角(sacral slope,SS)、骨盆倾斜角(pelvic tilt,PT)和骨盆入射角(pelvic incidence,PI)。PI与LL之差(pelvic incidence minus lumbar lordosismismatch,PI-LL);矢状面轴向距离(sagittal vertical axis,SVA)等影像学参数。滑脱参数包括滑脱百分比(slip percentage,SP)、滑脱角(slip angle,SA)和滑脱减少率(reduction rate,RR)。术后并发症包括椎间隙塌陷、螺钉松动和假关节形成。采用重复测量方差分析Oswestry功能障碍指数(oswestry disability index,ODI)、日本骨科协会(Japanese Orthopaedic Association,JOA)评分和腰部疼痛视觉模拟评分(visual analogue scale,VAS)。结果本组平均随访时间(35.63±8.14)个月,术前两组糖尿病、高血压病、心脏病和吸烟情况差异无统计学意义。平均骨密度值(-1.08±1.82)g/cm^(2),术中平均出血量(397.44±334.69)ml,平均手术时长(236.98±59.01)min,术后住院天数(16.21±3.97)天。CBT组术中出血量显著小于PS组,差异有统计学意义(P=0.011);CBT组手术时间显著小于PS组,差异有统计学意义(P=0.021);CBT组住院时间显著小于PS组,差异有统计学意义(P=0.027);术前和末次随访的脊柱骨盆参数LL、SS、SVA,末次随访PT、PI、PI-LL两组差异无统计学意义。PS组术前PT显著大于CBT组,差异有统计学意义(P<0.001);PS组术前PI显著大于CBT组,差异有统计学意义(P=0.010);PS组术前PI-LL显著大于CBT组,差异有统计学意义(P<0.001)。在腰椎滑脱方面,PS组与CBT组术前SA、末次随访SA、术前SP、末次随访SP和末次随访RR差异无统计学意义(P=0.148、P=0.148、P=0.196、P=0.982和P=0.411),PS组术后即刻SP显著小于CBT组,差异有统计学意义(P=0.019);两组术后并发症椎间隙塌陷、螺钉松动和假关节形成差异无统计学意义;两组ODI、JOA和VAS评分在观察时间单独效应差异均有统计学意义,但是ODI术后3个月PS组明显低于CBT组(P=0.000),术后3个月PS组VAS评分明显小于CBT组,差异有统计学意义(P=0.047)。结论MIDLIF技术在DS病例中实现了更加减创的椎板减压、椎间融合术和腰椎复位,为退行性腰椎滑脱的手术治疗提供了新的技术选择。

Objective To analyze the application of midline lumbar interbody fusion(MIDLIF)and traditional posterior lumbar interbody fusion(PLIF)in the evaluation of the treatment effect of degenerative lumbar spondylolisthesis.Methods From October 2017 to October 2019,43 patients(18 males and 25 females,aged 45-76 years,mean age 61.81±5.63 years)with DS were treated with MIDLIF and PLIF.Observe patient age,gender,follow-up time,body mass index(BMI),preoperative diabetes,hypertension,heart disease,bone mineral density(BMD),smoking,operation time,intraoperative blood loss and postoperative hospital stay;as well as preoperative and postoperative lumbar lordosis(LL),sacral slope(SS),pelvic tilt(PT)and pelvic incidence(PI),pelvic incidence minus lumbar lordosismismatch(PI-LL),sagittal axial distance(SVA)and other imaging parameters.The slip parameters include slip percentage(SP),slip angle(SA)and slip reduction rate(RR).Postoperative complications included:intervertebral space collapse,screw loosening,and pseudoarthrosis formation;repeated measures analysis of variance was used to analyze the Oswestry Disability Index(ODI),Japanese Orthopaedic Association(JOA)score,and visual analogue scale(VAS)for lumbar pain.Results The average follow-up time of this group was(35.63±8.14)months,and there were no significant differences in preoperative diabetes,hypertension,heart disease and smoking between the two groups.The mean bone mineral density was(-1.08±1.82)g/cm^(2),the mean intraoperative blood loss was(397.44±334.69)ml,the mean operation time was(236.98±59.01)min,and the mean postoperative hospital stay was(16.21±3.97)days.The intraoperative blood loss in CBT group was significantly less than that in PS group,and the differences were statistically significant(P=0.011);the operation time in CBT group was significantly shorter than that in PS group,and the differences were statistically significant(P=0.021);the intraoperative hospital stay in CBT group was significantly shorter than that in PS group,and the differences were statistically significant(P=0.027).The spinopelvic parameters LL,SS,and SVA before surgery and at the last followup,PT,PI,and PI-LL of the traditional PS screw group at the last follow-up were not significantly different from CBT group.Preoperative PT was significantly greater in the PS screw group than in the CBT group,and the differences were statistically significant(P<0.001);preoperative PI was significantly greater in the PS screw group than in the CBT group,and the differences were statistically significant(P=0.010);and preoperative PI-LL was significantly greater in the PS screw group than in the CBT group,and the differences were statistically significant(P<0.001).In terms of lumbar spondylolisthesis,there were no significant differences in preoperative SA,last follow-up SA,preoperative SP,last follow-up SP and last follow-up RR between the PS screw group and the CBT group(P=0.148,P=0.148,P=0.196,P=0.982 and P=0.411),and SP immediately after surgery in the PS screw group was significantly smaller than that in the CBT group,and the differences were statistically significant(P=0.019);there were no significant differences in postoperative complications of intervertebral space collapse,screw loosening and pseudoarthrosis formation between the two groups;there were significant differences in the individual effects of ODI,JOA and VAS between the two groups at observation time,but the PS group was significantly lower than the CBT group at 3 months after operation.ODI(P=0.000),and the VAS in the PS group was significantly smaller than that in the CBT group at 3 months after surgery,and the differences were statistically significant(P=0.047).Conclusions On the basis of less invasive through MIDLIF achieved high-quality interbody fusion and lumbar spine sequence reconstruction,excellent clinical results are provided.