机器人辅助微创通道下经椎间孔扩大入路治疗胸腰椎结核

Treatment of thoracolumbar tuberculosis with robot-assisted and minimally invasive access via transforaminal expansion approach

目的探讨机器人辅助微创通道下经椎间孔扩大入路治疗胸腰椎结核的可行性及临床疗效。方法回顾分析2017年1月—2022年5月收治且符合选择标准的40例胸腰椎结核患者临床资料。其中,15例采用机器人辅助微创通道下经椎间孔扩大入路病灶清除植骨内固定术(机器人组),25例采用传统单纯经后入路病灶清除椎间植骨术(传统组)。两组患者性别、年龄、病变节段以及术前美国脊髓损伤学会(ASIA)分级、后凸Cobb角、疼痛视觉模拟评分(VAS)、红细胞沉降率(erythrocyte sedimentation rate,ESR)、C反应蛋白(C reactive protein,CRP)等基线资料比较,差异均无统计学意义(P>0.05)。比较两组手术时间、术中出血量、住院时间、术后下床时间、并发症发生情况;术前、术后1周ESR、CRP;术后3 d血清白蛋白水平;术前及术后6个月VAS评分、神经功能ASIA分级;X线片及CT复查,观察植骨融合情况及融合时间,测量病变椎体后凸Cobb角并计算Cobb角丢失。ESR、CRP及VAS评分均计算手术前后差值(变化值)进行组间比较。结果机器人组手术时间、术中出血量均低于传统组,术后3 d血清白蛋白水平高于传统组,差异均有统计学意义(P<0.05);术后下床时间及住院时间亦较传统组缩短,但差异无统计学意义(P>0.05)。传统组术后出现2例切口愈合不良,机器人组术后无并发症发生,并发症发生率组间差异无统计学意义(P>0.05)。两组ESR变化值及CRP变化值差异有统计学意义(P<0.05)。术后患者均获随访;传统组随访时间12~18个月,平均13.0个月;机器人组12~16个月,平均13.0个月。影像学复查示两组植骨均融合,融合时间差异无统计学意义(P>0.05);两组组内术后后凸Cobb角与术前比较,差异有统计学意义(P<0.05);传统组Cobb角丢失大于机器人组(P<0.05)。两组术后6个月VAS评分较术前降低(P<0.05),VAS评分变化值组间差异无统计学意义(P>0.05)。两组患者术后均无脊髓神经功能损伤发生或加重,术后6个月ASIA分级与术前比较差异有统计学意义(P<0.05),组间差异无统计学意义(P>0.05)。结论与传统后路开放手术比较,机器人辅助结合微创通道下经椎间孔扩大入路病灶清除植骨内固定术治疗胸腰椎结核,手术时间及术中出血量均减少,手术创伤小,临床疗效确切。

Objective To investigate the feasibility and effectiveness of robot-assisted posterior minimally invasive access in treatment of thoracolumbar tuberculosis via transforaminal expansion approach.Methods A clinical data of 40 patients with thoracolumbar tuberculosis admitted between January 2017 and May 2022 and met the selection criteria was retrospectively analyzed.Among them,15 cases were treated with robot-assisted and minimally invasive access via transforaminal expansion approach for lesion removal,bone graft,and internal fixation(robotic group),and 25 cases were treated with traditional transforaminal posterior approach for lesion removal and intervertebral bone grafting(traditional group).There was no significant difference in the baseline data between the two groups(P>0.05)in terms of gender,age,lesion segment,and preoperative American Spinal Injury Association(ASIA)grading,Cobb angle,visual analogue scale(VAS)score,erythrocyte sedimentation rate(ESR),and C reactive protein(CRP).The outcome indicators were recorded and compared between the two groups,including operation time,intraoperative bleeding volume,hospital stay,postoperative bedtime,complications,ESR and CRP before operation and at 1 week after operation,the level of serum albumin at 3 days after operation,VAS score and ASIA grading of neurological function before operation and at 6 months after operation,the implant fusion,fusion time,Cobb angle of the lesion,and the loss of Cobb angle observed by X-ray films and CT.The differences of ESR,CRP,and VAS score(change values)between pre-and post-operation were calculated and compared.Results Compared with the traditional group,the operation time and intraoperative bleeding volume in the robotic group were significantly lower and the serum albumin level at 3 days after operation was significantly higher(P<0.05);the postoperative bedtime and the length of hospital stay were also shorter,but the difference was not significant(P>0.05).There were 2 cases of poor incision healing in the traditional group,but no complication occurred in the robotic group,and the difference in the incidence of complication between the two groups was not significant(P>0.05).There were significant differences in the change values of ESR and CRP between the two groups(P<0.05).All Patients were followed up,and the follow-up time was 12-18 months(mean,13.0 months)in the traditional group and 12-16 months(mean,13.0 months)in the robotic group.Imaging review showed that all bone grafts fused,and the difference in fusion time between the two groups was not significant(P>0.05).The difference in Cobb angle between the pre-and post-operation in the two groups was significant(P<0.05);and the Cobb angle loss was significant more in the traditional group than in the robotic group(P<0.05).The VAS scores of the two groups significantly decreased at 6 months after operation when compared with those before operation(P<0.05);the difference in the change values of VAS scores between the two groups was not significant(P>0.05).There was no occurrence or aggravation of spinal cord neurological impairment in the two groups after operation.There was a significant difference in ASIA grading between the two groups at 6 months after operation compared to that before operation(P<0.05),while there was no significant difference between the two groups(P>0.05).Conclusion Compared with traditional posterior open operation,the use of robot-assisted minimally invasive access via transforaminal approach for lesion removal and bone grafting internal fixation in the treatment of thoracolumbar tuberculosis can reduce the operation time and intraoperative bleeding,minimizes surgical trauma,and obtain definite effectiveness.