Two-Year Outcomes of Midline lumbar Fusion Versus Minimally Invasive Transforaminal Lumbar Interbody Fusion in the Treatment of L4-L5 Degenerative Disease

Objective We aimed to compare the clinical and radiological outcomes of midline lumbar fusion(MIDLF)versus minimally invasive transforaminal lumbar interbody fusion(MI-TLIF)in patients with degenerative spondylolisthesis and/or stenosis in L4-L5 two years after surgery.Methods Consecutively treated patients with lumbar pathology who underwent MIDLF(n=16)and a historical control group who underwent MI-TLIF(n=34)were included.Clinical symptoms were evaluated using Oswestry Disability Index(ODI),the 36-Item Short-Form Health Survey,and visual analog scale(VAS)scores before surgery and 3,6,12,and 24 months after surgery.Results The mean operative time and hematocrit(HCT,Day 1)were significantly shorter and lower in MIDLF cases(174 min vs.229 min,P<0.001;0.34 vs.0.36,P=0.037).The MI-TLIF group showed better improvement than the MIDLF group in ODI and VAS back and leg pain at 3 months postoperatively.VAS leg pain was higher in MIDLF than in MI-TLIF cases at 6 months.At 24 months follow-up,VAS back pain was higher in MI-TLIF than in MIDLF cases(P=0.018).Conclusion MIDLF is comparable to MI-TLIF at L4-5 in clinical outcomes and fusion rates,and the results verified the meaningful advantage of using MIDLF for the elderly with osteoporosis.

Comparison of Clinical Outcomes of Cortical Bone Trajectory and Traditional Pedicle Screw Fixation in Posterior Lumbar Interbody Fusion

Posterior lumbar interbody fusion (PLIF) is a common surgical procedure and widely used in the treatment of lumbar degenerative disc disorders. Traditionally, posterior lumbar interbody fusion is done by using the traditional pedicle screw (PS) which offers great advantages, but at the same time it has some disadvantages which include the risk of superior facet joint violation and muscle damage. Recently, an alternative method of screw insertion via cortical bone trajectory (CBT) has been invented which has less invasive process and can be placed without the drawbacks associated with the traditional pedicle screw. However, it has to remain an interest whether CBT will provide similar or greater clinical outcomes compared to PS in PLIF. So the main aim of this review is to compare the clinical outcomes of cortical bone trajectory and traditional pedicle screw fixation in posterior lumbar interbody fusion based on the articles published on this topic. Compared to the traditional pedicle screw fixation, PLIF with CBT has similar clinical outcome based on pain intensity, ODI status and JOA score, as well as similar fusion rate and radiological evaluated complication such as loosening of screw. In addition PLIF with CBT has advantages of less facet joint violation, less blood loss, less intraoperative muscle damage and perioperative pain. On the basis of this study, we can suggest that PLIF with CBT can be considered as a reasonable alternative to PS in PLIF.

Correlation study between the changes of motor evoked potential and the improvement of spinal canal volume in minimally invasive transforaminal lumbar interbody fusion

Objective:To analyze the correlation between the amplitude changes of motor evoked potential(MEP),the 3D volume changes of spinal canal measuring by postoperative CT and the improvement rate of clinical symptoms after the spinal canal decompression in minimally invasive transforaminal lumbar interbody fusion(MIS-TLIF),and to explore the predictive value of the changes of both MEP amplitude and spinal canal volume in the assessment of long-term clinical prognosis in MIS-TLIF.Methods:A retrospective study of 68 patients with L4/5 spinal stenosis treated with MIS-TLIF was performed.The changes of both intraoperative MEP amplitude and 3D spinal canal volume during the spinal canal decompression,as well as the visual analogue scale(VAS)and Oswestry dysfunction index(ODI)scores in the long-term follow-up were all recorded.Results:The values of intraoperative MEP amplitude was 159.04%higher in 68 patients with MIS-TLIF after spinal canal decompression(P<0.01).The 3 postoperative 3D spinal canal volume(4.89±1.27)cm increased by 31.22%in comparison 3 with preoperative date(3.78±1.08)cm(P<0.01).The VAS and ODI scores were improved to 78.55%and 80.60%,respectively at the last follow-up(P<0.01).The improvement rate of MEP amplitude on the decompression side was positively correlated with the improvement rate of postoperative spinal canal volume(r=0.272,P=0.025).The improvement rate of postoperative spinal canal volume was positively correlated with the improvement rate of VAS and ODI at the last follow-up(r=0.656,r=0.490,P<0.01).Moreover,the improvement rate of MEP amplitude on the decompression side was also positively correlated with the improvement rate of VAS and ODI at the last follow-up(r=0.322 and 0.235,respectively,P<0.05).Conclusion:The increase of MEP amplitude after spinal canal decompression in patients with lumbar spinal stenosis treated by MIS-TLIF was closely correlated with both of the increase of spinal canal volume and the improvement of clinical symptoms.Therefore,MEP amplitude monitoring was not only the one of the important monitoring methods for predicting the prognosis of MIS-TLIF but also the reliably predictive value in the long-term clinical prognosis in MIS-TLIF.

Comparison between Minimally Invasive Transforaminal Lumbar Interbody Fusion and Conventional Open Transforaminal Lumbar Interbody Fusion： An Updated Meta-analysis

Background： The previous studies agree that minimally invasive transforaminal lumbar interbody fusion （MIS-TLIF） has better function outcomes, less blood loss, and shorter hospital stay, when compared to open-TLIF. However, there are no significance differences on operative time, complication, and reoperation rate between the two procedures. This could be from less relative literatures and lower grade evidence. The further meta-analysis is needed with more and higher grade evidences to compare the above two TLIF procedures. Methods： Prospective and retrospective studies that compared open-TLIF and MIS-TLIF were identified by searching the Medline, Embase, Web of Science, China National Knowledge Infrastructure, Wanfang, and VIP database （the literature search comprised Medical Subject Heading terms and key words or Emtree term）. The retrieval time ranged from the date when the database was founded to January 2015. Pooled risk ratios （RRs） and weighted mean differences （WMDs） with 95% confidence intervals were calculated for the clinical outcomes and perioperative data. Results： Twenty-four studies （n =1967 patients） were included in this review （n =951, open-TLIF, n 1016, MIS-TLIF）. MIS-TLIF was associated with a significant decrease in the visual analog score （VAS）-back pain score （WMD 0.44; P= 0.001）, Oswestry Disabilities Index （WMD 1.57; P =0.005）, early ambulation （WMD = -1.77; P = 0.0001）, less blood loss （WMD = -265.59; P 〈 0.00001）, and a shorter hospital stay （WMD =-1.89; P 〈 0.0001）. However, there were no significant differences in the fusion rate （RR =0.99; P = 0.34）, VAS-leg pain （WMD = -0.10; P = 0.26）, complication rate （RR = 0.84; P = 0.35）, operation time （WMD = 5.23; P = 0.82）, or reoperation rate （RR = 0.73; P = 0.32）. Conclusions： MIS-TLIF resulted in a similar fusion rate with better functional outcome, less blood loss, shorter ambulation, and hospital stay; furthermore, it did not increase the complication or reoperation rate based on the existing evidence.

Comparing minimally invasive and open transforaminal lumbar interbody fusion for treatment of degenerative lumbar disease： a meta-analysis

Background Transforaminal lumbar interbody fusion （TLIF） through a minimally invasive approach （mTLIF） was introduced to reduce soft tissue injury and speed recovery. Studies with small numbers of patients have been carried out, comparing mTLIF with traditional open TLIF （oTLIF）, but inconsistent outcomes were reported.

一种新型压配式腰椎椎间融合器的机械性能

背景:行经皮微创椎间孔腰椎椎间融合置入椎间融合器时,由于入路操作范围狭窄,有牵拉神经根损伤或置入融合器位置不良等风险,为了解决以上问题作者课题组发明了一种新型机械结构可变形压配式cage(Press-fit cage,YP-cage)。目的:对新型腰椎融合器YP-cage的机械强度特性进行初步评估。方法:对不同尺寸9,11,13 mm高度的新型YP-cage(n=9)和聚醚醚酮-cage(n=9)进行了静态轴向压缩实验和静态轴向扭转实验,分别采集力-位移曲线计算屈服位移及载荷、极限载荷位移及刚度,屈服角位移及扭矩、极限载荷角位移扭矩及刚度,并进行对比分析。结果与结论:(1)在静态轴向压缩测试中,YP-cage在3组测试中(9,11,13 mm),其刚度、屈服载荷、极限位移和载荷极限方面均优于聚醚醚酮-cage(P <0.01),但YP-cage的屈服位移小于聚醚醚酮-cage(P <0.05);(2)在静态扭转测试中,除了9 mm组的YP-cage和聚醚醚酮-cage在极限扭转角度上差异无显著性意义,YP-cage在屈服扭矩、屈服扭转角度及极限扭矩均小于聚醚醚酮-cage(P <0.01),而YP-cage扭转刚度在9 mm组和11 mm组大于聚醚醚酮-ccage(P <0.01);(3)结果表明新型压配式机械结构椎间融合器相较于聚醚醚酮材质cage具有更高的抗压强度,但抗扭强度不如聚醚醚酮-cage。

MIS TLIF与Open TLIF治疗单节段腰椎滑脱疾病疗效的Meta分析

目的:对微创经椎间孔椎体间融合(MIS TLIF)与开放经椎间孔椎体间融合(Open TLIF)技术治疗单节段腰椎滑脱疾病进行Meta分析,以判断2种手术方法的术后效果及临床价值。方法:通过对Pub Med、Embase、Cochrane library、中国期刊全文数据库、中国生物医学数据库、中文科技期刊全文数据库等进行系统检索;检索发表于2014年3月以前,以单节段腰椎滑脱疾病为研究对象,采用Rev Man5.2对微创与开放经椎间孔椎间融合手术临床疗效的研究并进行系统分析。分析指标包括:手术持续时间、术中出血量、术中及术后早期并发症、末次随访时融合率。结果:通过初次筛选、二次筛选及再次筛选,本系统分析共纳入8项研究,其中随机对照研究2项,队列研究6项。所纳入的研究患者共866例,其中微创手术组417例,开放手术组449例。与开放经椎间孔椎间融合手术相比,微创手术持续时间、术中及术后早期并发症、末次随访时融合率以及术前的VAS、ODI评分的差异无统计学意义(P>0.05),但是术中出血量、住院天数及末次随访时视觉模拟评分(VAS)、Oswestry功能障碍指数(ODI)评分的差异具有统计学意义(P<0.05)。结论:与Open TLIF相比,MIS TLIF并不会增加手术时间、术中及术后的早期并发症,也不会影响远期的融合率;此外,MIS TLIF在减少患者术中出血量和住院时间的同时可早期缓解术后疼痛与功能恢复,表明MIS TLIF是治疗单节段腰椎滑脱疾病比较理想的手术方式。

中药治疗腰椎椎体间融合术后发热的炎症信号通路

背景:术后发热是后路腰椎椎体间融合后常见临床症状之一,目前没有明确的病因病机,患者术后体温易反复,病程较久,西药治疗效果欠佳,影响患者术后恢复。目的:综述总结炎症信号通路和术后发热的关联及中药防治后路腰椎椎体间融合后发热的机制,为研究术后发热继续探索新的治疗药物。方法:检索CNKI中国期刊全文数据库、万方数据库和PubMed数据库2006年6月至2023年12月收录的文献,中文检索词为“中药,术后发热,炎症,白细胞介素1,白细胞介素6,白细胞介素8,干扰素γ,肿瘤坏死因子,前列腺素E2,p38丝裂原活化蛋白激酶,核因子κB,Toll样受体,Janus激酶/信号转导和转录激活因子,Notch信号通路”;英文检索词为“medicinal herb,postoperative fever,inflammation,interleukin-1,interleukin-6,interleukin-8,γ-interferon,tumor necrosis factor,Prostaglandin E2,p38 mitogen-activated protein kinase,nuclear factor-κB,toll-like receptor,janus kinases/signal transducer and activator of transcription,notch signaling pathway”。阅读文章剔除研究内容不相关、质量差的文献,纳入100篇文献进行归纳总结。结果与结论:(1)手术造成软组织创伤促使机体释放炎症因子,促炎因子作用于下丘脑前部的体温调节中心,促使发热;(2)术后切口内出血及渗液等的吸收,吞噬细胞吞噬坏死细胞的蛋白分解产物后,产生内生致热原(白细胞介素、肿瘤坏死因子、干扰素等)导致发热;(3)细胞因子通过炎症信号通路发挥致炎作用,促使发热;(4)中药或中药复方可以调控炎症信号通路发挥抗炎解热作用防治术后发热;目前中药作用机制尚无定论,应深入研究阐明中医药防治术后发热的相关信号通路,运用现代技术把细胞分子技术与中医药药理作用机制联系起来,以便指导临床医生用药,促进患者术后恢复;(5)中药联合西药治疗术后发热是未来的研究热点,应充分发挥中医药优势,明确不同证型应用中药单体或有效成分提取物和中药汤剂的靶点作用机制。

MIS-TLIF与OPEN-TLIF治疗腰椎退行性疾病的临床疗效研究

目的:对比分析微创经椎间孔椎间融合术(MIS-TLIF)与开放经椎间孔腰椎椎间融合术(OPEN-TLIF)治疗单节段腰椎退行性变的疗效。方法:回顾分析深圳大学第一附属医院62例行TLIF手术治疗单节段腰椎退行性疾病患者的临床资料。根据手术方式不同分为MIS-TLIF组(32例)和OPEN-TLIF组(30例)。比较MIS-TLIF组与OPEN-TLIF组出血量、手术时间、住院天数及手术前后视觉模拟评分法(VAS)、日本骨科协会(JOA)评分。结果:MIS-TLIF组出血量、手术时间、住院天数均低于OPEN-TLIF组,差异具有统计学意义(P<0.05)。术后2周及末次随访两组患者的VAS和JOA评分均较术前改善,差异具有统计学意义(P<0.05)。两组术后2周及末次随访VAS和JOA评分比较,差异具有统计学意义(P<0.05)。结论:MIS-TLIF可以取得与开放手术相当的临床效果,且微创技术具有术中出血少、术后疼痛轻、住院时间短及术后恢复快等优势。

MIS-TLIF与Wiltse-Open-TLIF治疗单节段腰椎间盘突出症的疗效比较

目的比较微创经椎间孔入路腰椎椎间融合术(MIS-TLIF)与开放经椎旁肌间隙入路经椎间孔腰椎椎间融合术(Wiltse-Open-TLIF)治疗单节段腰椎间盘突出症的疗效。方法选取127例单节段腰椎间盘突出症的手术患者,按手术方法的不同将其分为Wiltse-Open-TLIF组(62例)、MIS-TLIF组(65例),随访时间>12个月。比较2组患者围术期及预后相关指标。结果 2组手术时间、并发症、末次随访融合率、手术翻修率、术后下肢疼痛VAS评分、ODI评分比较差异无统计学意义(P>0.05)。MIS-TLIF组切口大小、术中出血量、术后切口引流量、术后卧床时间、住院时间均小于Wiltse-Open-TLIF组(P<0.05),术中透视次数多于Wiltse-Open-TLIF组(P<0.05)。腰痛VAS评分比较:术后1个月时MIS-TLIF组低于Wiltse-Open-TLIF组(P<0.05),术后3个月时差异无统计学意义(P>0.05)。结论 MIS-TLIF与Wiltse-Open-TLIF治疗单节段腰椎间盘突出症均能取得良好的疗效,而MIS-TLIF具有切口小、软组织损伤较小、术中出血少、术后恢复快等优势。

Transforaminal Lumbar Interbody Fusion for Traumatic Lumbar Spondylolisthesis

To evaluate the clinical outcome,effectiveness and safety of the surgical management of traumatic lumbar spondylolisthesis with transforaminal lumbar interbody fusion (TLIF) with short segmental instrumentation fixation.A retrospective review of a consecutive series of 24 patients with traumatic lumbar spondylolisthesis treated with TLIF procedure was carried out.Intraoperative spinal cord monitoring was used to confirm the peripheral neural function intact during the reduction of the spondylolisthesis.Preoperative clinical and radiographic evaluation of all cases were originally collected prospectively.Data regarding blood loss,operative time,duration of hospital stay,radiographic fusion,instrumentation failure and clinical result were collected and observed at regular follow-up periods.All patients were engaged in high-energy accidents in the lower back and 16 patients had concomitant injuries.The mean operative time was 124 min,mean blood loss was 350 mL,and mean hospital stay was 6.5 days.There were no complications such as incision infection,cerebrospinal fluide (CSF) leakage and nerve root injury and so on.All patients demonstrated a solid lumbar interbody fusion within 4 months,and no evidence of spondylolisthesis correction loss,instrumentation failure and loosing.They all were completely asymptomatic,with normal neurologic findings,and had resumed their previous level of physical activities on the final follow-up.Meticulous clinical examination and careful imaging assessment could assist an early diagonosis in cases of traumatic lumbar spondylolisthesis.Performing open reduction and the TLIF procedure as soon as possible could restore segmental stability and painless function.The TLIF procedure was a safe,effective technique to treat traumatic lumbar spondylolisthesis.

Biomechanical change of lumbar unilateral graded facetectomy and strategies of its microsurgical reconstruction:report of 23 cases

Objective： To evaluate the lumbar stability and the primary clinical results of unilateral facetectomy, transforaminal lumbar interbody fusion （TLIF） and unilateral pedicle screw fixation by X-Tube system. Methods： Five human lumbar cadaveric functional spine units（FSU） were obtained and graded facetectomy by 0, 1/4, 1/2, 3/4 and 4/4 were performed respectively on the left articular process of them. The stability of these 5 models was evaluated at flexion, extension, lateral bending and axial rotation. After a serial of biomechanical researches, 23 patients from June 2004 to March 2006 in our department underwent unilateral facetectomy, transforaminal lumbar interbody fusion （posterior lumbar interbody fusion） and unilateral pedicle screw instrumentation by X-Tube system. After general anaesthesia, with the guide of fluoroscopy and using X-Tube system, procedures of unilateral endoscopic facetectomy, spinal nerve root decompression, autologus spongy bone transplantation, one cage oblique insertion and unilateral pedicle screw instrumentation were performed. Results： There was no significant difference in flexion, extension, lateral bending and axial rotation of lumbar motion range after unilateral graded facetectomy. The stability of left/right axial direction was greatly affected when the range of graded facetectomy exceed 1/2. According to the Nakai criteria, for the 23 patients, the clinical result was excellent in 15 （65.2%）, good in 6 （26.1%） and fair in 2 （8.7%）. The fusion rate was 95.6% in excellent and good cases. Although partial absorption of bone grafts was observed in 1 case which might indicate a unsuccessful fusion, there was no loosing and replacement of instrument and no clinical symptoms occurred. Conclusion： The lumbar stability will be affected significantly when the range of graded facetectomy exceeds 1/2. Procedures of unilateral facetectomy, transforaminal lumbar interbody fusion and unilateral pedicle screw fixation is an optional strategy for microsurgical reconstruction, though the indications of the procedure should be carefully restricted.

Instrumentation-related complications of lumbar degenerative disc diseases treated by minimally invasive transforaminal lumbar interbody fusion

Objective:To analyze the instrumentation-related complications of patients with lumbar degenerative disc diseases(LDD)who underwent minimally invasive transforaminal lumbar interbody fusion(MISTLIF)and to discuss the potential strategy for the control of these complications.Methods:A total of 87 patients with LDD were treated with the MIS-TLIF procedure.Complications,including malposition or breakage of guide pin,percutaneous pedicle screw(PPS)or cages,neurological deficit,and superior-level facet joint violations,were determined during and after the surgery.Computed tomography(CT)was used to evaluate the PPS accuracy and the superior-level facet joint violations.Results:A total of 386 PPSs were used.During the surgery,3(0.8%)guide pin and 1(0.3%)PPS perforated the anterior wall of the vertebral body,respectively.One(0.3%)PPS was pulled out during the reduction of slip.Malposition of the cages occurred in 6(1.6%)PPSs.These were all adjusted accordingly during the surgery.All the patients received>2 years of follow-up.No loosening or breakage of PPS and cage was observed,but CT showed 27(7.0%)PPSs misplaced.No neurological deficit related to misplaced PPS was observed.The total facet joint violation(FJV)rate was 36.2%,with grade 2 and grade 3 violations is 21(12.1%)and 6(3.4%),respectively.Conclusion:MIS-TLIF has similar instrumentation-related complications with open TLIF.Accurate preoperative evaluation and improved surgical techniques can effectively reduce these instrumentation-related complications.

Biomechanical evaluation of two fusion techniques based on finite element analysis:Percutaneous endoscopic and minimally invasive transforaminal lumbar interbody fusion

As a novel minimally invasive technique,percutaneous endoscopic transforaminal lumbar interbody fusion(PETLIF)has been widely used in the treatment of lumbar degenerative diseases.The purpose of this study was to analyze these two operation types’biomechanical performances of PE-TLIF and traditional minimally invasive transforaminal lumbar interbody fusion(MIS-TLIF)using the finite element(FE)method.The intact FE models of L4-L5 were established and validated based on the CT images.On this basis,the FE models of MIS-TLIF and PETLIF were established and analyzed.It is demonstrated that for lumbar interbody fusion with the oblique asymmetrically implanted cage under bilateral pedicle screws and rods fixation,such as MIS-TLIF and PE-TLIF,different degrees of articular process resection have no significant effect on the cage subsidence,and the surgical segment can achieve similar stability.In addition,the maximum stress of the L4 inferior endplate of MIS-TLIF and PE-TLIF is greater than that of the L5 superior endplate,which indicates that MIS-TLIF and PE-TLIF can cause cage subsidence in the L4 inferior endplate.

MIS-TLIF与OPEN-TLIF治疗单节段腰椎管狭窄的疗效比较

目的探讨微创经椎间孔腰椎椎体间融合术(MIS-TLIF)与开放性TLIF(OPEN-TLIF)治疗单节段腰椎管狭窄的临床疗效。方法回顾性分析单节段腰椎管狭窄患者103例,随访过程中失访4例,根据不同的手术方式分为MIS-TLIF组(50例)和OPEN-TLIF组(49例)。比较两组患者的围手术期指标、手术疗效及术后并发症发生情况。在术前、术后3个月及术后1年,采用视觉模拟评分法(VAS)对两组患者进行疼痛程度评估,采用Oswestry功能障碍指数(ODI)问卷表评估腰部功能活动情况,采用日本骨科协会评估治疗分数(JOA)评估腰背部及下肢功能。术后1年应用CT平扫+二三维重建获取患者的椎间隙后高度和节段性脊柱前弯的影像学参数,并进行组间比较。结果两种术式的手术疗效比较,差异无统计学意义(P>0.05)。MIS-TLIF组的手术时间、术后卧床时间、术后住院时间均短于OPEN-TLIF组,术中出血量、术后引流量均少于OPEN-TLIF组,术后并发症总发生率低于OPEN-TLIF组,差异均有统计学意义(P<0.05)。术前、术后3个月及术后1年,两组的VAS评分、ODI指数及JOA评分比较,差异均无统计学意义(P>0.05)。术后1年两组患者的椎间隙后高度、节段性脊柱前弯角度比较,差异均无统计学意义(P>0.05)。结论MIS-TLIF是治疗单节段腰椎管狭窄的有效手段,具有手术时间短、术中出血量和术后引流量少、住院时间短、术后并发症发生率低的优势,能够有效改善患者腰椎功能,恢复椎间隙后高度和节段性前弯。

Fracture of allograft interbody spacer resulting in post-operative radiculopathy: A case report

BACKGROUND Allograft interbody spacers are utilized during transforaminal lumbar interbody fusion(TLIF) to reestablish anterior column support and disc height. While the TLIF technique offers many improvements over previous surgical methods,instrumentation and bone graft-related complications such as spacer misplacement or migration, screw fracture or misplacement, or rod breakage continue to be reported. The objective of this manuscript is to report on a fractured allograft interbody spacer that displaced into the neural foramen and resulted in impingement on the exiting nerve root that required revision.CASE SUMMARY A 50-year-old male had two-level TLIF with immediate post-operative right L5 radiculopathy. Computed tomography scan demonstrated a fractured allograft interbody spacer that displaced into the right neural foramen and impinged on the exiting L5 nerve root. Revision surgery was performed to remove the broken allograft fragments from the right L5 foramen and the intact portion of the spacer was left in place. The right leg L5 radicular pain resolved. At the last follow up 12 mo after the index procedure, computed tomography scan confirmed sound interbody and posterolateral fusion.CONCLUSION Displacement of broken allograft interbody spacer following TLIF procedures can result in neurological sequelae that require revision. To avoid such an occurrence,the authors recommend allowing sufficient time for the reconstitution of the graft in saline prior to use to decrease brittleness, to use an impactor size that is as close as possible to the spacer size and meticulous inspection of the cortical allograft spacer for any visible imperfection prior to insertion.

显微镜辅助微创经椎间孔腰椎椎间融合术治疗单节段腰椎滑脱症

目的探讨显微镜辅助经Quadrant通道结合经皮椎弓根钉固定行微创小切口经椎间孔腰椎椎间融合术(MIS-TLIF)治疗单节段腰椎退行性滑脱症的疗效。方法回顾性分析2018年4月至2021年3月行椎体间融合术治疗单节段腰椎退行性滑脱症患者的临床资料,其中采用开放经椎间孔腰椎椎间融合术(TLIF)治疗患者41例(开放组),经Wiltse入路Quadrant通道直视下TLIF治疗患者25例(微创组),显微镜下减压并采用经皮椎弓根钉TLIF治疗患者38例(显微组)。记录3组患者手术时间、术中出血量、X线透视次数、引流量、术后2天和7天切口周围疼痛视觉模拟评分(VAS)、并发症情况,术后CT检查评估椎弓根钉置钉准确率,记录术前及术后6个月、24个月日本骨科协会(JOA)评分和Oswestry功能障碍指数(ODI),末次随访时采用改良MacNab标准评价临床疗效。结果所有手术均顺利完成。显微组术中出血量、引流量、术后2天和7天切口周围疼痛VAS评分均小于微创组和开放组(P<0.05),椎弓根钉置钉准确率高于微创组和开放组(P<0.05),但术中X线透视次数高于微创组和开放组(P<0.05)。开放组发生术后切口浅表软组织感染1例,疑似感染1例,脑脊液漏1例;微创组出现术后短暂性神经症状2例。3组术后6个月、24个月JOA评分和ODI评分均较术前明显改善(P<0.05),3组间比较无统计学差异(P>0.05)。术后6个月和24个月融合率3组间比较无统计学差异(P>0.05)。按改良MacNab标准,3组患者疗效优良率无统计学差异(P>0.05)。结论显微镜辅助通道下MIS-TLIF治疗单节段腰椎退行性滑脱症,术中出血少、切口疼痛感小、并发症少,采用经皮椎弓根钉置钉准确率高,融合率、疗效优良率与开放手术一致,临床疗效好。

内镜、微创和开放式经椎间孔椎体间融合术治疗腰椎退行性疾病的效果比较

目的比较经椎间孔内镜腰椎椎间融合术(Endo-LIF)、微创腰椎椎间融合术(MIS-TLIF)和开放腰椎椎间融合术(PLIF)治疗腰椎退行性疾病(LDD)的临床疗效和安全性。方法回顾性分析2013年1月至2023年1月在百色市人民医院因LDD接受经椎间孔腰椎椎间融合术就诊的150例患者临床资料,按手术方式分为Endo-LIF组、MIS-TLIF组、PLIF组三组,每组各50例。比较患者手术时间、透视次数、术中失血量、住院时间、并发症以及术前和术后3个月的视觉模拟评分(VAS)、Oswestry功能障碍指数(ODI)评分、椎间隙高度指数、病变节段活动度(ROM)。结果PLIF组的手术时间长于Endo-LIF组和MIS-TLIF组,术中透视次数少于Endo-LIF组和MIS-TLIF组,差异有统计学意义(P<0.05)。Endo-LIF组和MIS-TLIF组的手术时间、术中透视次数比较,差异无统计学意义(P>0.05)。患者术中出血量Endo-LIF组少于MIS-TLIF组及PLIF组,MIS-TLIF组少于PLIF组,差异有统计学意义(P<0.05);患者术后卧床时间和住院时间Endo-LIF组短于MIS-TLIF组及PLIF组,MIS-TLIF组短于PLIF组,差异有统计学意义(P<0.05)。三组患者满意度比较,差异有统计学意义(P<0.05)。Endo-LIF组满意度高于PLIF组,差异有统计学意义(P<0.017)。三组患者术后3个月VAS及ODI评分低于手术前,差异有统计学意义(P<0.01)。三组患者并发症发生率、椎间隙高度指数、ROM比较,差异无统计学意义(P>0.05)。结论Endo-LIF、MIS-TLI、PLIF三种手术方法术后3个月的预后结果相似,PLIF术中透视次数最少,Endo-LIF创伤较小,在降低术中出血,缩短术后卧床时间和住院时间方面优势明显,术后恢复速度较快,适合临床推广。

腰椎融合术选择策略及发展趋势

腰椎融合术已经在腰椎退行性病变、畸形、腰椎骨折或脱位等疾病中广泛应用,是消除或缓解症状、维持疗效的重要方法,也是脊柱外科最重要的技术之一。目前,腰椎融合术式种类繁多,根据不同手术入路分为前侧入路、经侧方入路、后侧入路及椎间孔入路等;微创手术包括关节镜辅助、脊柱内窥镜等手术方式;根据不同植骨融合位置又分为椎体外植骨融合和椎体间植骨融合[1]。临床上腰椎融合手术方式的选择方面尚无完全定论。本文回顾、分析不同腰椎融合术的优缺点,结合脊柱微创融合技术等发展趋势展开评论,旨在为临床腰椎融合术的合理实施提供参考,期待未来深入探索、优化手术方法、提高融合效率,降低并发症的新策略,为腰椎疾病患者带来更好的疗效。

腰椎侧方不稳在退变性腰椎滑脱中的临床相关研究

目的探讨腰椎侧方不稳在退变性腰椎滑脱中的影像学特征及其对手术疗效的影响。方法回顾性分析2019年2月~2022年5月在本院接受手术治疗且随访>2年的97例退变性腰椎滑脱(degenerative lumbar spondylolisthesis,DLS)患者。根据在术前腰椎X线片上是否伴有腰椎侧方不稳(lumbar lateral instability,LLI)现象,将被纳入的患者分为侧方不稳定组(L组)和非侧方不稳定组(NL组)。记录两组患者术前、术后以及末次随访时的生活质量评估结果及矢状面和冠状面影像学参数。结果本研究有22例(22.7%)患者伴有LLI现象。L组患者术前滑脱角、腰椎冠状面平衡距离、L_(4)倾斜角和椎间隙楔变角均显著高于NL组,且L组患者腰椎前凸角度丢失更为严重(P<0.05)。术后及末次随访时,两组患者矢状面和冠状面参数无显著差异,且两组患者术后的生活质量均得到了显著提高。结论伴有LLI的DLS患者是一个与腰椎不稳定相关的独特亚群,手术治疗可有效改善伴LLI患者的冠状面形态。