机器人辅助经皮内镜腰椎椎间融合术治疗腰椎管狭窄症合并腰椎节段不稳

Robot-assisted percutaneous endoscopic posterior/transforaminal lumbar interbody fusion for lumbar spinal stenosis with instability

目的探讨机器人辅助经皮内镜腰椎椎间融合术治疗腰椎管狭窄症合并腰椎节段不稳的有效性和安全性。方法2018年9月至2022年4月于广东省中医院脊柱微创科行机器人辅助经皮内镜腰椎椎间融合术治疗腰椎管狭窄症合并腰椎节段不稳患者26例,男13例、女13例,年龄(57.92±7.09)岁(范围44~75岁),体质指数为(24.05±2.64)kg/m^(2)(范围19.38~29.06 kg/m^(2))。共计31个节段包括单节段手术21例(L 3,42例、L 4,518例、L 5S 11例)、双节段手术5例(L 3~L 5)。术前,术后1、6、12个月及末次随访时采用疼痛视觉模拟评分(visual analogue scale,VAS)评估腰痛和下肢痛程度,采用Oswestry功能障碍指数(Oswestry disability index,ODI)评估脊椎神经功能;末次随访时采用MacNab标准评估临床疗效。影像学评价指标包括手术前后手术节段椎间隙高度、腰椎前凸角、融合率及椎弓根螺钉准确度。结果26例随访时间为(42.88±10.09)个月(范围12~55个月)。手术时间为(156.54±33.50)min,术后引流量为(27.23±20.20)ml。术前腰痛和下肢痛VAS为(4.35±1.23)、(6.08±0.63)分,术后1个月降至(2.08±0.69)、(1.85±0.54)分,术后6个月为(1.85±0.54)、(0.77±0.59)分,术后1年为(0.96±0.53)、(0.62±0.57)分,末次随访为(0.88±0.52)、(0.58±0.50)分,差异均有统计学意义(F=85.943,P=0.001;F=547.946,P=0.014)。术前,术后1、6、12个月及末次随访的ODI分别为55.38%±5.89%、28.38%±3.849%、17.77%±2.67%、12.58%±1.88%、12.12%±2.27%,差异有统计学意义(F=783.289,P=0.010)。根据MacNab标准末次随访时26例中优18例、良6例、可2例,优良率为92.3%。机器人辅助植入经皮椎弓根螺钉114枚,A级109枚、B级4枚、C级1枚。术前、术后及末次随访椎间隙高度分别为(10.55±1.96)、(13.53±1.37)、(12.54±1.42)mm,差异有统计学意义(F=42.190,P<0.001);腰椎前凸角分别为35.81°±10.80°、35.69°±11.07°、36.08°±11.29°,差异无统计学意义(P>0.05)。术后12个月获得骨性融合25例,融合率为96%(25/26)。结论机器人辅助经皮内镜腰椎椎间融合术治疗腰椎管狭窄症合并腰椎节段不稳能有效改善手术节段的椎间隙高度,是一种安全有效的微创手术方式。

ObjectiveTo analyze the effectiveness and safety of robot-assisted percutaneous endoscopic posterior/transforaminal lumbar interbody fusion(RPE-P/TLIF)in the treatment of lumbar spinal stenosis with instability.MethodsFrom September 2018 to April 2022,26 patients with lumbar spinal stenosis combined with lumbar segmental instability were treated with RPE-P/TLIF at the Department of Minimally Invasive Spine Surgery,Guangdong Provincial Hospital of Chinese Medicine.There were 13 males and 13 females,with a mean age of 57.92±7.09 years(range,44 to 75 years)and a mean body mass index of 24.05±2.64 kg/m^(2)(range,19.38 to 29.06 kg/m^(2)).A total of 31 segments were included,including 21 cases of single-segment surgery(L 3,4 in 2 cases,L 4,5 in 18 cases,and L 5S 1 in 1 case)and 5 cases of two-segment surgery(all L 3-L 5).Before surgery and at 1,6,and 12 months after surgery,as well as at the final follow-up,the visual analogue scale(VAS)was used to assess back pain and lower limb pain,and the Oswestry disability index(ODI)was used to evaluate spinal nerve function.Clinical efficacy was evaluated using the MacNab criteria at the final follow-up.Imaging evaluation indicators included pre-and post-operative intervertebral space height,lumbar lordosis angle,fusion rate,and accuracy of pedicle screw placement.ResultsThe follow-up time for the 26 patients was 42.88±10.09 months(range,12 to 55 months).The mean operation time was 156.54±33.50 min,and the mean postoperative drainage volume was 27.23±20.20 ml.The VAS scores for back pain and lower limb pain before surgery were 4.35±1.23 and 6.08±0.63,respectively.These scores decreased to 2.08±0.69 and 1.85±0.54 at 1 month postoperatively,1.85±0.54 and 0.77±0.59 at 6 months,0.96±0.53 and 0.62±0.57 at 1 year,and 0.88±0.52 and 0.58±0.50 at the final follow-up,respectively.The differences were statistically significant(F=85.943,P=0.001;F=547.946,P=0.014).The ODI scores before surgery and at 1,6,12 months after surgery,and at the final follow-up were 55.38%±5.89%,28.38%±3.849%,17.77%±2.67%,12.58%±1.88%and 12.12%±2.27%respectively,with statistically significant differences(F=783.289,P=0.010).According to the MacNab criteria,at the final follow-up,there were 18 cases of excellent,6 cases of good,and 2 cases of fair,with an excellent and good rate of 92.3%.A total of 114 percutaneous pedicle screws were implanted with grades A,B and C being 109,4 and 1,respectively.The preoperative,postoperative,and final follow-up intervertebral space heights were 10.55±1.96,13.53±1.37,and 12.54±1.42 mm respectively,with statistically significant differences(F=42.190,P<0.001).And the lumbar lordosis angles were 35.81°±10.80°,35.69°±11.07°,and 36.08°±11.29°respectively,with no statistically significant differences(P>0.05).At 12 months postoperatively,bone fusion was achieved in 25 cases,with a fusion rate of 96%(25/26).ConclusionRPE-P/TLIF for lumbar spinal stenosis combined with lumbar instability were favorable.Being a safe and effective minimally invasive surgical option,it effectively enhanced the intervertebral space height in the surgical segment with fewer complications.