斜外侧经肌间隙入路与改良侧方经腰大肌入路腰椎融合术联合后路经皮椎弓根螺钉内固定治疗退行性腰椎不稳的短期疗效比较

Short-term efficacy comparison of oblique lateral interbody fusion versus crenel lateral interbody fusion combined with posterior percutaneous pedicle screw fixation for degenerative lumbar instability

中文关键词:  退行性腰椎不稳  斜外侧经肌间隙入路腰椎融合术  改良侧方经腰大肌入路腰椎融合术  疗效

英文关键词:Degenerative lumbar instability  Oblique lateral interbody fusion  Crenel lateral interbody fusion  Efficacy

中文摘要:

  【摘要】 目的：比较采用斜外侧经肌间隙入路腰椎融合术（oblique lateral interbody fusion，OLIF）与改良侧方经腰大肌入路腰椎融合术（crenel lateral interbody fusion，CLIF）联合后路经皮椎弓根螺钉内固定治疗退行性腰椎不稳的短期疗效。方法：回顾性分析2019年6月~2022年6月30例在宁波大学附属第一医院和浙江大学医学院附属邵逸夫医院因退行性腰椎不稳进行OLIF或CLIF手术的患者资料，根据手术方式分为OLIF组和CLIF组，两组患者一期术后4周均进行二期后路经皮椎弓根螺钉内固定术。OLIF组18例，男7例，女11例，年龄69.9±7.9岁，身体质量指数（body mass index，BMI）为25.67±3.05kg/m2，2节段病变6例，3节段病变12例；CLIF组12例，男4例，女8例，年龄66.5±8.6岁，BMI 24.03±2.06kg/m2，2节段病变2例，3节段病变10例。收集两组一期手术术中出血量、手术时间、住院时间、术后并发症资料，术前和一期手术术后1个月、6个月、1年时进行背部和下肢疼痛视觉模拟评分（visual analogue score，VAS）、Oswestry功能障碍指数（Oswestry disability index，ODI）评估，测量手术节段椎间隙高度（disc height，DH）、腰椎前凸角（lumbar lordosis，LL），一期手术术后1年融合器沉降高度、融合器与冠状面的夹角。对两组所有数据进行统计学比较。结果：两组患者年龄、性别、BMI、病变节段数均无统计学差异（P>0.05），有可比性。OLIF组和CLIF组一期手术手术时间、术中出血量、住院时间分别为183.89±39.43min、55.56±27.49ml、8.39±4.804d和198.75±23.27min、65.00±44.62ml、8.75±2.30d，两组间比较均无统计学差异（P>0.05）。OLIF组术后5例出现大腿前方麻木和屈髋无力，经营养神经治疗1个月后恢复正常；1例切口感染，经抗感染治疗3周后治愈。CLIF组术后4例出现大腿前方麻木和屈髋无力，经营养神经治疗1个月后恢复正常；1例患者术中出现腰椎节段动脉损伤，出血量达到200ml；1例患者腰大肌积液伴感染，经抗生素治疗6周后治愈。两组术前VAS、ODI、LL及DH比较均无显著性差异（P>0.05），术后1个月、6个月和1年时与术前比较均有显著性改善（P<0.05），术后两组同时间点比较均无显著性差异（P>0.05），术后1个月和术后1年的LL差值（OLIF组12.47°±6.69° vs CLIF组6.26°±6.47°）有显著性差异（P<0.05）。术后1年随访时，OLIF组和CLIF组椎间融合率（83.33% vs 91.67%）、融合器沉降高度（1.54±0.72mm vs 1.44±0.61mm）无统计学差异（P>0.05），OLIF组融合器与冠状面夹角（8.94°±4.97°）显著性大于CLIF组（5.30°±3.69°）（P<0.05）。结论：OLIF与CLIF联合后路经皮椎弓根螺钉内固定治疗退行性腰椎不稳均能够获得满意的短期临床效果且疗效相当，而CLIF利用多角度融合器增加LL和维持腰椎曲度方面具有一定优势。

英文摘要:

  【Abstract】 Objectives: To compare the short-term efficacy of oblique lateral interbody fusion(OLIF) with crenel lateral interbody fusion(CLIF) combined with posterior percutaneous pedicle screw fixation for degenerative lumbar instability. Methods: The clinical data of 30 patients with degenerative lumbar instability treated with OLIF or CLIF at The First Affiliated Hospital of Ningbo University and Sir Run Run Shaw Hospital of Medical College of Zhejiang University from June 2019 to June 2022 were retrospectively analyzed. The patients were divided into OLIF group and CLIF group, and both groups of patients underwent posterior percutaneous pedicle screw fixation 4 weeks after the first-stage surgery. OLIF group(18 cases) consisted of 7 males and 11 females, aged 69.9±7.9 years old, body mass index(BMI) 25.67±3.05kg/m2, 6 cases of 2-segmental lesions and 12 cases of 3-segmental lesions; CLIF group(12 cases) consisted of 4 males and 8 females, aged 66.5±8.6 years old, BMI 24.03±2.06kg/m2, 2 cases of 2-segmental lesions and 10 cases of 3-segmental lesions. Data of intraoperative bleeding, operative time, hospital stay, and postoperative complications were collected for both groups of the first-stage surgery, and visual analogue scale(VAS) of back and lower limb pain, Oswestry disability index(ODI) were performed before surgery and at 1 month, 6 months, and 1 year after the first-stage surgery. The disc height(DH) of the operated segment, lumbar lordosis(LL), and the cage subsidence height and angle between cage and coronal plane 1 year after the first-stage surgery were measured. All data were compared statistically between groups. Results: There were no statistical differences in age, gender, BMI, or number of lesion segments between the two groups(P>0.05), which were comparable. The operative time, intraoperative bleeding, and hospital stay for the first-stage surgery were 183.89±39.43min, 55.56±27.49ml, and 8.39±4.804d in the OLIF group and 198.75±23.27min, 65.00±44.62ml, and 8.75±2.30d in the CLIF group, with no statistical difference between the two groups(P>0.05). In the OLIF group, 5 patients developed numbness in the anterior thigh and hip flexion weakness after surgery, which recovered after 1 month of nerve nutrition treatment; 1 case of incisional infection was cured after 3 weeks of anti-infection treatment. 4 cases in the CLIF group developed numbness in the anterior thigh and hip flexion weakness, which recovered after 1 month of nerve nutrition treatment; 1 patient developed intraoperative lumbar segmental artery injury, with bleeding volume reaching 200ml; 1 patient had psoas major muscle effusion with infection, cured after 6 weeks of antibiotic treatment. There were no significant differences in VAS, ODI, LL and DH between the two groups before surgery(P>0.05), significant improvements at 1 month, 6 months and 1 year after surgery compared with those before surgery(P<0.05), and no significant differences between groups at the same time point after surgery(P>0.05). The differences between 1 month postoperatively and 1 year postoperatively between OLIF and CLIF groups(12.47°±6.69° vs 6.26°±6.47°) were with statistical significance(P<0.05). At the 1-year postoperative follow-up, there was no statistical difference in the intervertebral fusion rate(83.33% vs 91.67%) and cage subsidence height(1.54±0.72mm vs 1.44±0.61mm) between the OLIF and CLIF groups. The angle between cage and coronal plane was significantly greater in the OLIF group(8.94°±4.97°) than that in the CLIF group(5.30°±3.69°)(P<0.05). Conclusions: Both OLIF and CLIF combined with posterior percutaneous pedicle screw fixation can achieve satisfactory short-term clinical results and comparable efficacy in degenerative lumbar instability, while CLIF has some advantages in increasing LL and maintaining lumbar curvature using a multi-angle fusion.