腰椎融合术后椎旁肌改变的研究进展

Advances in research of paravertebral muscle changes after lumbar fusion

腰椎融合术目前仍广泛应用于临床,但开放腰椎融合术后慢性腰背痛、邻近节段退变等问题常困扰着患者和临床医生。近年来的研究结果证实腰椎融合术后慢性腰背痛、邻近节段退变与术中对椎旁肌肉剥离、牵拉引起的肌肉缺血和失神经支配有关。腰椎手术后椎旁肌的质量被用于评价手术疗效。随着脊柱微创技术的进展,腰椎融合的微创术式也越来越多地应用于临床,各种微创术式对椎旁肌的影响也受到越来越多研究者的关注。开放腰椎融合术会加重椎旁肌退变,出现多裂肌肌纤维水肿、不透明纤维增加和肌纤维坏死,脂肪和结缔组织浸润等组织病理学表现;并出现失神经改变、运动单位减少的肌电表现,影像学表现为椎旁肌的体积缩小,肌肉力学上出现强度下降。腰椎融合不同手术方式对椎旁肌的影响也不相同,与开放腰椎融合术相比旁正中筋膜间入路、肌间隙入路腰椎融合术、微创经椎间孔入路腰椎融合术(minimally invasive transforaminal lumbar fusion,MIS-TLIF)和皮质骨通道(cortical bone trajectory,CBT)螺钉技术能减少医源性椎旁肌损伤;而单纯前路腰椎椎体间融合术(anterior lumbar interbody fusion,ALIF)、斜外侧入路腰椎椎体间融合术(oblique lateral interbody fusion,OLIF)、侧方入路腰椎椎体间融合术(lateral lumbar interbody fusion,LLIF)和全内镜下腰椎融合术能大幅减轻甚至避免椎旁肌损伤,提高临床疗效。

Lumbar fusion remains a widely used procedure in clinical practice;however,both patients and clinicians of-ten face challenges related to chronic low back pain and adjacent segment degeneration following traditional open lumbar fixation and fusion.Recent studies have demonstrated that these complications are associated with muscle ischemia and denervation caused by intraoperative dissection and traction of the paravertebral muscles.The postoperative mass of the paravertebral muscles has also been proposed as a predictor of surgical outcomes.With advancements in minimally invasive spinal techniques,minimal-ly invasive lumbar fusion has gained increasing clinical application,drawing more attention to its impact on the paravertebral mus-cles.After lumbar fusion,the paravertebral muscles undergo a series of histopathological and morphological changes.Traditional open lumbar fusion can exacerbate the natural degeneration of paraspinal muscles,manifesting histopathologically as multifidus muscle edema,an increase in opaque fibers,muscle fiber necrosis,and infiltration of fat and connective tissue.Denervation and a reduction in motor units have been observed through electromyography,while imaging has revealed reduced muscle volume and strength.Different lumbar fusion techniques exert varying effects on the paravertebral muscles.Compared to traditional lumbar fu-sion,approaches such as the paramedian interfascial approach(PIA),multifidus muscle bundle(MMB)approach,minimally inva-sive transforaminal lumbar fusion(MIS-TLIF),and cortical bone trajectory screw techniques reduce iatrogenic paravertebral mus-cle injury.Moreover,anterior lumbar interbody fusion,oblique lateral interbody fusion,lateral lumbar interbody fusion,and endo-scopic posterolateral transforaminal lumbar interbody fusion can significantly minimize or even prevent paravertebral muscle inju-ry,leading to improved clinical outcomes.