肌间隙入路和传统入路在腰椎融合术中的对比研究

A case control study of lumbar fusion surgery with the Wiltse approach and the traditional approach

目的:比较经肌间隙入路和传统入路对腰椎融合手术患者的影响。方法:对2016年5月至2017年5月因腰椎间盘突出或MeyerdingⅡ度以内腰椎滑脱行2个节段以内腰椎融合手术治疗的70例患者进行回顾性分析。70例患者根据手术入路分为两组,肌间隙入路组35例,男18例,女17例,年龄(52±11)岁;传统入路组35例,男19例,女16例,年龄(51±14)岁。70例患者中包括腰椎间盘突出症38例,腰椎滑脱32例。记录两组患者的手术时间、术中出血量,术后引流量、腰腿痛VAS评分、外周血CK浓度以及MRI上多裂肌横截面积。结果:肌间隙入路组手术时间、术中出血量和术后引流量均少于传统入路组(P<0.05)。术后7 d和3个月两组患者的VAS腰痛评分差异有统计学意义(P<0.05);两组患者VAS腿痛评分,术后7 d差异无统计学意义(P>0.05),术后3个月差异有统计学意义(P<0.05)。术后1 d和3 d外周血CK浓度:肌间隙入路组分别为(400±103) U/L和(176±58) U/L,传统入路组分别为(598±57) U/L和(222±50) U/L,两组间差异有统计学意义(P<0.05)。两组患者MRI上多裂肌横截面积:术前肌间隙入路组为(424±66) mm^2,传统入路组为(428±82)mm^2,组间差异无统计学意义(P=0.8);术后3个月肌间隙入路组为(347±73) mm^2,传统入路组为(239±78) mm^2,组间差异有统计学意义(P<0.05)。结论:行腰椎融合手术,肌间隙入路与传统后正中入路相比,确实拥有手术时间短、对椎旁肌损伤小、术后腰腿痛缓解明显等优势,但在确定手术方案时,术者也应充分认识到Wiltse间隙在不同层面的解剖学差异可能对手术操作产生的影响。

Objective:To compare the clinical results between the Wiltse approach and traditional approach in lumbar fusion.Methods:The clinical data of 70 patients with lumbar disc herniation or lumbar spondylolisthesis within MeyerdingⅡdegree who underwent lumbar fusion surgery from May 2016 to May 2017 were retrospectively analyzed.According to the surgical approach,the patients were divided into Wiltse approach group and traditional approach group.A total of 35 patients in Wiltse approach group,included 18 males and 17 females,with an average age of(52±11)years old;other 35 patients in traditional approach group,included 19 males and 16 females,with an average age of(51±14)years old.Included 38 patients with lumbar disc herniation and 32 patients with spondylolisthesis of MeyerdingⅡdegree.The operation time,intraoperative blood loss and postoperative drainage,the VAS score of low back pain and leg pain,the level of creatine phosphokinase(CK)and the cross-sectional area of multifidus muscl on MRI were recorded.Results:The operation time,intraoperative blood loss and postoperative drainage in Wiltse approach group were less than in traditional approach group(P<0.05).There were significant differences in VAS score of low back pain at 7 days and 3 months after operation between two groups(P<0.05).VAS of back pain at both 7 days and 3 months showed better results(P<0.05);VAS of leg pain showed better results in 3 months but had no significant difference in 7 days.There was no significant difference in VAS score of leg pain at 7 days after operation between two groups(P>0.05),but at 3 months had significant difference(P<0.05).The peripheral blood CK levels at 1 day and3 days after operation respectively were(400±103)U/L and(176±58)U/L in Wiltse approach group,while in traditional approach group were(598±57)U/L and(222±50)U/L,with statistical significance between the two groups(P<0.05).Preoperative cross-sectional area of multifidus muscl on MRI was(424±66)mm^2 in Wiltse approach group and(428±82)mm^2 in traditional approach group,there was no significant difference between two groups(P=0.8);at 3 months after operation,in Wiltse approach group was(347±73)mm^2 and in traditional approach group was(239±78)mm^2,there was significant difference between two groups(P<0.05).Conclusion:For lumbar spinal fusion surgery,compared with the traditional approach,Wiltse approach has advantages of shorter operation time,smaller paravertebral muscles injury,and obviously releasing postoperative low back and leg pain.However,in determining the surgery program,the surgical operater also should fully recognize that the anatomical differences of Wiltse approach may influence on operation.