Wiltse入路经椎间孔椎体间融合术治疗腰椎滑脱症的疗效观察

The curative effect of Wiltse approach and transforaminal lumbar interbody fusion for the treatment of lumbar spondylolisthesis

中文关键词:  腰椎滑脱  TLIF  Wiltse入路

英文关键词:Lumbar spondylolisthesis  Transforaminal lumbar interbody fusion  Wiltse approach

中文摘要:

  【摘要】 目的：探讨Wiltse入路经椎间孔椎体间融合术（TLIF）治疗腰椎滑脱症的手术效果。方法：选择2010年9月～2012年8月收治的54例单节段腰椎滑脱患者，采用TLIF术式行椎体间植骨融合术，其中Wiltse入路组31例，传统后正中入路组23例。术前两组患者在性别、年龄、滑脱程度、节段分布等一般资料比较差异无统计学意义（P>0.05），具有可比性。比较两组患者的手术时间、术中出血量、术后引流量，比较两组术前1d、术后24h、术后1周外周血肌酸激酶含量；并分别于术前1d、术后3d及术后3、6个月和1年随访时采用疼痛视觉模拟评分（visual analogue scores，VAS）、Oswestry功能障碍指数（Oswestry disability index，ODI）以及两组患者手术前后滑脱角、椎体滑移度、椎间盘高度比较综合评价手术效果。根据术后1年腰椎X线片和CT平扫+三维重建评价腰椎序列、滑脱椎体复位及椎间植骨融合（根据Bridwell椎间融合评价标准）情况。结果：Wiltse入路组手术时间72.6±7.5min（65~85min），术中出血量86.8±78.9ml（80~175ml），术后引流量90.5±56.2ml（85~170ml）；后正中入路组手术时间79.0±6.7min（75~95min），术中出血量285.6±36.4ml（280~330ml），术后引流量195.6±20.7ml（190~220ml），两组间比较差异有统计学意义（P＜0.05）。Wiltse入路组术后24h外周血的肌酸激酶平均为271.4±128.6U/L（260~400U/L），而后正中入路组为553.7±201.5U/L（500~780U/L），两组间比较差异有统计学意义（P＜0.05）。两组术后不同时间点VAS及ODI评分与术前比较差异有统计学意义（P＜0.05）。Wiltse入路组术后3d腰痛VAS评分（4.5±1.6分）明显优于传统后正中入路组（6.9±2.5分），差异有统计学意义（P＜0.05）；术后3、6个月和1年随访时两组间VAS评分和ODI差异无统计学意义（P>0．05）。根据Bridwell椎间融合评价标准，后正中入路组Ⅰ级融合13例（56.5％），Ⅱ级融合10例（43.5％）；Wiltse入路组Ⅰ级融合18例（58．1％），Ⅱ级融合13例（41.9％），两组间比较差异无统计学意义（P>0.05）。CT平扫+三维重建均显示椎体间获得骨性融合。术前、术后两组患者在滑脱角、椎体滑移度、椎间盘高度等影像学结果比较差异无统计学意义（P>0.05）。结论：Wiltse入路TLIF术式治疗单节段腰椎滑脱症可获得与传统后正中入路TLIF相似的安全、有效的治疗效果，并且Wiltse入路TLIF术式具有操作更方便、对组织损伤小、出血少、恢复快的优点。

英文摘要:

  【Abstract】 Objectives: To explore the effect of the operation of Wiltse approach and transforaminal lumbar interbody fusion(TLIF) for the treatment of lumbar spondylolisthesis. Methods: 54 patients with lumbar spondylolisthesis between September 2008 and August 2010 in our hospital were randomly divided into the Wiltse approach group(31 cases) and the conventional approach group(23 cases). There were no statistically significant differences in the gender, age, slip degree, segmental distribution and other demographic data between the two groups(P>0.05). The differences of the operation time, intraoperative blood loss and postoperative drainage were compared. The contents of creatine kinase in peripheral blood in the two groups were compared at 1 day of preoperation, 24 hours and 1 week of postoperation. The visual analogue scores(VAS), Oswestry disability index(ODI) and other clinical outcome scores and the slip angle, slip degree, intervertebral disc height and other imaging results were used to assess the effect of the treatment at 1 day of preoperation, 3 days, 3 months, 6 months and 1 year of postoperation. The X-ray and three dimensional CT were used to evaluate lumbar spinal sequence, slippage vertebral reset and intervertebral bone graft fusion at 1 year of postoperation. Results： In the Wiltse approach group, the operation time was 72.6±7.5min(65-85min), the intraoperative blood loss was 86.8±78.9ml(80-175ml), the postoperative drainage was 90.5±56.2ml(85-170ml), the contents of creatine kinase at 24 hours of postoperation was 271.4U/L(260-400U/L); and in the conventional approach group, those data were 79.0±6.7min(75-95min), 285.6±36.4ml(280-330ml), 195.6±20.7ml(190-220ml) and 553.7U/L(500-780U/L), there were statistically significant differences between two groups(P<0.05). There were statistically significant differences in the VAS and ODI at the differrent postoperative time points of the two groups compared with the preoperation(P<0.05). There was statistically significant differences in the VAS of Wiltse approach group(4.5±1.6) compared with the conventional approach group(6.9±2.5) at 3 days of postoperation(P<0.05). There were no statistically significant differences in the VAS and ODI at 3 months, 6 months and 1 year of postoperation between two groups(P>0.05). According to the Bridwell evaluation criteria, grade Ⅰ fusion was in 13 cases(56.5％) and grade Ⅱ fusion in 10 cases(43.5％) in the conventional approach group; Ⅰ in 18 cases(58．1％) and Ⅱ in 13 cases(41.9％) in the Wiltse approach group, there was no significant difference between the two groups(P>0.05). There were no statistically significant difference in the slip angle, slip degree, intervertebral disc height at preoperation and postoperation between the two groups(P>0.05). Conclusions: The safe and effective operation effect acquired by Wiltse approach and TLIF for the treatment of lumbar spondylolisthesis is the same as the effect acquired by the conventional approach group, the operation of Wiltse approach and TLIF is more convenient, less tissue injury, less bleeding, faster recovery.