单侧双通道内镜下与Quadrant通道下经椎间孔腰椎间融合治疗单节段腰椎滑脱症的疗效比较

Comparison of the clinical efficacy of unilateral biportal endoscopic transforaminal lumbar interbody fusion(UBE-TLIF) with Quadrant channel transforaminal lumbar interbody fusion(Quadrant-TLIF) in the treatment of single-segment lumbar spondylolisthesis

中文关键词:  腰椎滑脱症  单侧双通道内镜  Quadrant通道  经椎间孔腰椎间融合术

英文关键词:Lumbar spondylolisthesis  Unilateral biportal endoscopy  Quadrant channel  Transforaminal lumbar interbody fusion

中文摘要:

  【摘要】 目的：比较单侧双通道内镜（unilateral biportal endoscopy，UBE）下与Quadrant通道下经椎间孔腰椎间融合（transforaminal lumbar interbody fusion，TLIF）治疗单节段Ⅰ～Ⅱ度腰椎滑脱症的临床疗效。方法：回顾性分析2019年1月~2024年6月收治的87例单节段Ⅰ～Ⅱ度腰椎滑脱症患者的临床资料，其中47例采用UBE下TLIF治疗，纳入UBE-TLIF组；40例采用Quadrant通道下微创TLIF治疗，纳入Quadrant-TLIF组。两组患者性别、年龄、体重指数、病程及随访时间等基线资料比较均无统计学差异（P>0.05）。记录两组手术时间、随访时间、术中出血量、术后引流量、术中透视次数、术后下地时间、术后住院时间、围手术期并发症；术前和术后1周、3个月和末次随访时进行腰腿痛视觉模拟量表（visual analog scale，VAS）评分、Oswestry功能障碍指数（Oswestry disability index，ODI）评定；在术前和末次随访时的X线片上测量椎间隙高度（intervertebral height，IH）、Cobb角、腰椎前凸角（lumbar lordosis，LL）；末次随访时采用Bridwell评估标准评定椎间融合等级，采用改良MacNab标准评估患者临床疗效。结果：患者均顺利完成手术，无转为开放手术病例。UBE-TLIF组手术时间（212.8±21.4min）显著性大于Quadrant-TLIF组（168.6±17.5min），术中出血量、术后引流量、术后下地时间、术后住院时间显著性小于Quadrant-TLIF组（P<0.05）。UBE-TLIF组术中出现1例硬脊膜破裂，术中缝合、硬脊膜补片覆盖，术后出现脑脊液漏，经补液、头低脚高处理痊愈出院；椎管内血肿1例，未出现放射性下肢疼痛，保守治疗后缓解；术后复查有3枚S1螺钉突破椎弓根内侧壁，患者无神经症状，未特殊处理。Quadrant-TLIF组术后出现1例 趾背伸无力，口服甲钴胺3个月后恢复正常；1例出现L5神经根支配区域烧灼感疼痛，给予神经根阻滞后缓解；术后复查有2枚S1螺钉突破椎弓根内侧壁，无神经症状，未特殊处理。两组均未出现切口感染等并发症。患者均获得随访，UBE-TLIF组随访15.7±2.5个月，Quadrant-TLIF组随访15.6±2.9个月，两组随访时间无统计学差异（P>0.05）。两组术后1周、3个月和末次随访时的IH、Cobb角及LL较术前均显著性改善（P<0.05），两组间同时间点比较均无统计学差异（P>0.05）。两组术后1周、3个月和末次随访的腰、腿痛VAS评分及ODI均较术前显著性改善（P<0.05），术后1周UBE-TLIF组腰痛VAS评分显著性低于Quadrant-TLIF组（P<0.05），其余时间点的腰痛VAS评分和各时间点腿痛VAS评分、ODI两组间均无显著性差异（P>0.05）。末次随访时UBE-TLIF组Ⅰ、Ⅱ、Ⅲ级融合分别为36例、5例、6例，融合率为87.23%；Quadrant-TLIF组Ⅰ、Ⅱ、Ⅲ级融合分别为30例、6例、4例，融合率为90.0%，两组植骨融合率比较无统计学差异（P>0.05）。改良MacNab标准评估UBE-TLIF组优36，良6例，可5例，差0例，优良率89.4%；Quadrant-TLIF组优31例，良6例，可3例，差0例，优良率92.5%，两组优良率比较无统计学差异（P>0.05）。结论：UBE-TLIF与Quadrant-TLIF治疗Ⅰ～Ⅱ度单节段腰椎滑脱症均可以有效改善滑脱程度和腰椎矢状位平衡；UBE-TLIF术中出血更少、住院时间更短、术后腰痛缓解更快。

英文摘要:

  【Abstract】 Objectives: To compare the clinical efficacy of transforaminal lumbar interbody fusion(TLIF) under unilateral biportal endoscopy(UBE) with TLIF under Quadrant channel in the treatment of single-segment grade I-II lumbar spondylolisthesis. Methods: A retrospective analysis was conducted on 87 patients with single-segment grade I-II lumbar spondylolisthesis treated between January 2019 and June 2024. Among them, 47 patients underwent UBE-TLIF(UBE-TLIF group), and 40 patients underwent Quadrant channel minimally invasive TLIF(Quadrant-TLIF group). No statistically significant differences were observed in baseline data between the two groups, including gender, age, body mass index, disease duration, and follow-up duration(P>0.05). Operative time, follow-up duration, intraoperative blood loss, postoperative drainage volume, intraoperative fluoroscopy frequency, time to ambulation, postoperative hospital stay, and intraoperative and postoperative complications were recorded. Visual analog scale(VAS) scores for low back pain and leg pain, and Oswestry disability index(ODI) were assessed preoperatively and at 1 week, 3 months postoperatively, and at the final follow-up. Intervertebral height(IH), Cobb angle, and lumbar lordosis(LL) were measured on X-ray films preoperatively and at the final follow-up. At the final follow-up, interbody fusion grade was evaluated using the Bridwell criteria, and clinical outcomes were assessed using the modified MacNab criteria. Results: All surgeries were successfully completed without conversion to open surgery. The UBE-TLIF group had a significantly longer operative time(212.8±21.4min) compared with the Quadrant-TLIF group(168.6±17.5min) (P<0.05), but demonstrated significantly less intraoperative blood loss, less postoperative drainage volume, shorter time to ambulation, and shorter postoperative hospital stay(P<0.05). In the UBE-TLIF group, one case of dural tear occurred intraoperatively, which was repaired with sutures and dural patch coverage; Postoperative cerebrospinal fluid leakage was resolved after fluid resuscitation and Trendelenburg positioning. One case of spinal hematoma occurred without radicular leg pain, which was resolved after administration of conservative treatment. Postoperative imaging revealed three S1 pedicle screws breaching the medial pedicle wall without neurological symptoms, requiring no special intervention. In the Quadrant-TLIF group, one patient developed great toe dorsiflexion weakness, which was recovered after three months of oral mecobalamin; One patient experienced burning pain in the L5 nerve root distribution, which was resolved after nerve root block. Postoperative imaging revealed two S1 screws breaching the medial pedicle wall without neurological symptoms, requiring no special intervention. No wound infections or other complications occurred in either group. All patients were followed up, with a mean follow-up of 15.7±2.5 months in the UBE-TLIF group and 15.6±2.9 months in the Quadrant-TLIF group, showing no statistically significant difference(P>0.05). Both groups showed significant improvements in IH, Cobb angle, and LL at the final follow-up compared with preoperative values(P<0.05), with no statistically significant differences between the two groups at any corresponding time point(P>0.05). VAS scores for low back pain and leg pain, as well as ODI, significantly improved in both groups at 1 week, 3 months, and the final follow-up compared with preoperative values(P<0.05). At 1 week postoperatively, the UBE-TLIF group had significantly lower low back pain VAS scores than the Quadrant-TLIF group(P<0.05); However, no significant differences were found between the two groups in low back pain VAS at other time points, or in leg pain VAS and ODI at any time point(P>0.05). At the final follow-up, in the UBE-TLIF group the fusion conditions according to Bridwell criteria were 36 of grade Ⅰ, 5 of grade Ⅱ, and 6 of grade Ⅲ, with a fusion rate of 87.23%; In the Quadrant-TLIF group, the fusion conditions were 30 of grade Ⅰ, 6 of grade Ⅱ, and 4 of grade Ⅲ, with a fusion rate of 90.0%. No statistically significant difference was found in fusion rates between the two groups(P>0.05). According to the modified MacNab criteria, the UBE-TLIF group achieved excellent results in 36 cases, good in 6, fair in 5, and poor in 0, with an excellent-to-good rate of 89.4%; The Quadrant-TLIF group achieved excellent in 31, good in 6, fair in 3, and poor in 0, with an excellent-to-good rate of 92.5%. No statistically significant difference was observed in the excellent-to-good rates between the two groups(P>0.05). Conclusions: Both UBE-TLIF and Quadrant-TLIF are minimally invasive procedures for treating grade Ⅰ-Ⅱ lumbar spondylolisthesis, which can effectively improve the degree of spondylolisthesis and lumbar sagittal balance. UBE-TLIF offers advantages of less intraoperative bleeding, shorter hospital stay, and faster early postoperative low back pain relief.