双通道内镜下腰椎融合术治疗伴骨质疏松腰椎滑脱症的手术策略及早期疗效分析

Surgical strategy and early efficacy of biportal endoscopic transforaminal lumbar interbody fusion for lum⁃bar spondylolisthesis with osteoporosis

目的探讨双通道内镜下腰椎间融合术(biportal endoscopic transforaminal lumbar interbody fusion,BE-LIF)治疗合并骨质疏松的腰椎滑脱症的疗效。方法2021年6月至2022年6月采用BE-LIF治疗合并骨质疏松的腰椎滑脱症36例,男9例,女27例,年龄(65.94±6.83)岁(范围:51~76岁)。均为单节段,责任节段为L_(3/4)4例,L_(4/5)26例,L_5/S_16例;Ⅰ度滑脱28例,Ⅱ度滑脱8例;退变性滑脱24例,峡部裂型滑脱12例。术前腰椎平均骨密度T值为(-3.19±0.82)SD,股骨T值为(-2.26±0.86)SD。使用Oswestry功能障碍指数(Oswestry disability index,ODI)评估腰椎功能,疼痛视觉模拟评分(Visual Analogue Scale,VAS)评估腰痛及腿痛情况,分别记录术前、出院时及末次随访时的ODI、腰痛及腿痛VAS,末次随访时用MacNab标准评估手术疗效。在手术前后腰椎侧位X光片上测量椎间隙前后缘高度、手术节段前凸角及滑脱程度。所有患者术后均进行规范抗骨质疏松治疗。结果所有患者一期完成手术,手术平均时间为(160.97±35.01)min(范围:105~245 min),术中平均出血量为(72.50±47.53)mL(范围:20~150 mL)。术后随访时间为(15.17±6.53)月(范围:6~26个月)。出院时与末次随访时与术前ODI及腰痛、腿痛VAS评分的差异有统计学意义(F=107.48、103.66、55.52,P<0.001),MacNab疗效评分优21例,良12例,可3例,优良率为91.7%。术后即刻、术后末次随访时的椎体前后缘高度、手术节段角度与滑脱程度均比术前改善,但术后末次随访较术后即刻椎体前后缘高度、手术节段角度变小,差异有统计学意义(P<0.001)。末次随访时融合率为91.7%(33/36)。并发症发生率为13.8%(5/36),包括术中终板损伤、神经根袖撕裂各1例,术后伤口迟发性感染1例,融合器后移2例。结论BE-LIF治疗合并骨质疏松的腰椎滑脱症可获较好即刻复位效果,短期随访获良好临床疗效及较高融合率,但末次随访时椎间隙高度和手术节段角度部分丢失,且仍存在并发症情况,初学者应谨慎开展。术后规范抗骨质疏松治疗仍是保证手术疗效的重要措施。

Objective To investigate the efficacy of biportal endoscopic transforaminal lumbar interbody fusion(BE-LIF)in the treatment of lumbar spondylolisthesis complicated with osteoporosis.Methods From June 2021 to June 2022,36 cases of lumbar spondylolisthesis complicated with osteoporosis were treated with BE-LIF,including 9 males and 27 females,aged(65.94±6.83)years(range:51~76 years).All were single segment,and the responsible segment was L3/4 in 4 cases,L4/5 in 26 cases,and L5/S1 in 6 cases.Imagingexamination showed 1 and 2 degree of spondylolisthesis in 28 and 8 cases,and degenerative and ischemic spondylolisthesis in 24 and 12 cases respectively.Preoperative average bone mineral density T value of the lumbar spine was(-3.19±0.82)SD,and T value of the femur(-2.26±0.86)SD.Oswestry disability index(ODI)was used to evaluate lumbar spine function;visual analogue scale(VAS)to evaluate low back pain and leg pain.ODI,VAS of low back and leg pain were recorded respectively before the operation,at discharge and at the last follow-up.MacNab criteria were used to evaluate the surgical efficacy at the last follow-up.The anterior and posterior disc height,segmental lordotic angle and percentage of slip were measured on the lateral lumbar X-ray films before and after the operation.All patients received standard anti-osteoporosis treatment after surgery.Results All patients completed the opera-tion in one stage.The average operation time was(160.97±35.01)min(range:105~245 min),and the average intraoperative blood loss was(72.50±47.53)ml(range:20~150 mL).The mean follow-up time was(15.17±6.53)months(range:6~26 months).There were statistically significant differences in both VAS score of back and leg and ODI score at discharge and last follow-up when compared with those before the surgery(F=107.48,103.66,55.52,P<0.001).Macnab criteria of the last follow-up showed excellent in 21 cases,good in 12 cases,fair in 3 cases,and the excellent and good rate was 91.7%.Radiographic results showed that the height of the ante-rior and posterior disc height,segmental lordotic angle and percentage of slip were all improved immediately after surgery and at the last follow-up when compared with those before operation,but the anterior and posterior disc height,segmental lordotic angle at the last follow-up were decreased comparing with those immediate after the operation;the difference was statistically significant(P<0.001).The fusion rate at the last follow-up was 91.7%(33/36).The complication rate was 13.8%(5/36),including 1 case of intraoperative endplate injury,1 case of nerve root cuff tear,1 case of delayed postoperative wound infection,and 2 cases of posterior cage migration.Conclusion BE-LIF for the treatment of lumbar spondylolisthesis complicated with osteoporosis can achieve better immediate reduction effect,good clinical outcomes and high fusion rate in short-term follow-up,but the anterior and posterior disc height,segmental lordotic angle are partially lost at the last follow-up.There are still complications,and beginners should be cautious when performing the operation.Postoperative standardized anti-osteoporosis treatment is still an important measure to ensure the curative effect of surgery.