微创小切口侧前方腰椎间融合术治疗腰椎退变性疾病的近期疗效和围手术期并发症

Mini-open lateral-anterior lumbar interbody fusion for lumbar spinal degeneration diseases: short-term results and perioperative complications

中文关键词:  侧前方腰椎间融合术  腰椎退变性疾病  微创小切口  临床疗效  并发症

英文关键词:Lateral-anterior lumbar interbody fusion  Lumbar degenerative disease  Mini-open  Therapeutic effect  Complication

中文摘要:

  【摘要】目的：评估微创小切口侧前方腰椎间融合术（mini-open lateral-anterior lumbar interbody fusion，LaLIF）治疗腰椎退变性疾病的近期疗效和围手术期并发症。方法：分析2016年4月～2017年5月应用LaLIF治疗的63例（94个节段）腰椎退变性疾病患者的资料，男23例，女40例，年龄42～86岁（61±15岁）。腰椎间盘突出症8例，腰椎管狭窄症40例，腰椎滑脱症7例，成人退变性侧凸症8例。融合节段为单节段38例，双节段20例，3节段4例，4节段1例。L1/2 3例，L2/3 7例，L3/4 31例，L4/5 53例。不附加内固定即独立的（stand alone）LaLIF共56例；同时行二期后路内固定术7例，其中2例非计划内后路手术（1例腰椎管狭窄症因术中终板损伤而行后路内固定术，1例腰椎间盘突出症因术后cage下沉及症状缓解不满意而二期在外院行后路腰椎椎弓根内固定术），另5例退变性侧凸症行计划内后路减压或不减压椎弓根内固定术。记录手术时间、术中出血量、术后并发症，比较术前、术后1个月、术后3个月和末次随访时的腰痛VAS评分及Oswestry功能障碍指数（ODI），比较术前及末次随访时SF-36评分及X线片上手术节段椎间孔高度（intervertebral foramen height，FH）、椎间隙高度（intervertebral disc height，DH）和椎间孔面积（intervertebral foramen area，FA）。结果：63例患者完成随访，随访时间6.0±1.2个月（4~8个月）。单节段平均手术时间81±12min，平均术中出血量30±10ml；双节段平均手术时间130±21min，平均术中出血量50±12ml；3节段平均手术时间198±25min，平均术中出血量150±20ml；4节段手术时间220min，术中出血量300ml。术中出现静脉损伤1例，腹膜损伤1例，终板损伤2例（共3个节段）。术后1例出现切口红肿，对症治疗后缓解；4例出现一过性大腿前方疼痛或感觉异常，均在术后1个月内消失；1例出现下肢乏力，8周恢复正常。术后随访融合器下沉2例，融合器轻度移位8例。无病例因内置物失败、重要脏器损伤、术区感染等并发症而需行翻修手术。所有患者症状在随访过程中均逐渐改善，术后1个月、3个月及末次随访时VAS评分及ODI与术前比较均显著性改善（P<0.05）。末次随访时SF-36评分较术前显著性改善（P<0.05）。末次随访时手术节段FH、DH和FA较术前均显著性增加（P<0.05）。结论：小切口LaLIF作为一种微创腰椎融合术式，创伤小，出血少，手术时间短，围手术期并发症少，在治疗腰椎退变性疾病中具有较好的应用价值，严格选择手术适应证，不附加内固定的LaLIF可取得较好临床效果。

英文摘要:

  【Abstract】 Objectives: To evaluate the short-term clinical outcomes and complications of mini-open lateral-anterior lumbar interbody fusion(LaLIF) for lumbar spinal degeneration disease. Methods: From April 2016 to May 2017, total of 63 patients(94 levels) with lumbar spinal degeneration disease underwent LaLIF surgery in our hospital were reviewed. There were 23 males and 40 females, with an average age of 61±15 years old (range, 42-86 years). The diagnosis included lumbar spinal stenosis in 40 cases, lumbar spondylolisthesis in 7 cases, adult degenerative scoliosis in 8 cases, lumbar disc herniation in 8 cases. The fusion level included single level in 38 cases, double levels in 20 cases, three levels in 4 cases, four levels in 1 case, a total of 94 surgical fusion levels. The segmental distribution included L1/2 in 3 cases, L2/3 in 7 cases, L3/4 in 31 cases, L4/5 in 53 cases. 56 cases did not perform posterior internal fixation. 7 patients accepted second stage posterior fixation, including 2 unplanned posterior operation, among them 1 case of degenerative lumbar spinal stenosis plus posterior fixation due to intraoperative endplate injury and 1 case of lumbar intervertebral disc protrusion due to cage subsidence and dissatisfaction with symptomatic relief. 5 cases of degenerative lumbar scoliosis plus planned posterior internal fixation with or without decompression. The operation time, blood loss and postoperative complications were recorded. Visual analog scales(VAS) and Oswestry disability index(ODI) were assessed at preoperation and 1 month, 3 months and last follow-up after operation. SF-36 score, intervertebral disc height(DH), intervertebral foramen height(FH) and foramen area(FA) on X-ray were measured at preoperation and final follow-up. Results: 63 patients completed follow-up. The average time of follow-up was 6.0±1.2 months. The mean operation time and blood loss were 81±12min and 30±10ml of 1 level, 130±21min and 50±12ml of 2 levels, 198±25min and 150±20ml of 3 levels, 220min and 300ml of 4 levels respectively. Intraoperation complications included vein injury in 1 case, peritoneal injury in 1 case, endplate lesions in 2 cases. In the postoperation, 1 case incision appeared inflammatory edema and relieved after symptomatic treatment, 4 cases had transient pain in the front of legs and disappeared in 1 month, 1 case had lower limbs weakness and relieved after 8 weeks. In the postoperative follow-up, cage sunk(total 3 levels) was found in 2 cases, cage lightly shifted in 8 cases. No case needed revision surgery due to internal plant failure, important viscera injury, infection and so on. Compared to preoperation, the mean VAS scores and ODI of 1 month, 3 months and last follow-up after operation were improved significantly(P<0.05), and at last follow-up, SF-36 scores, DH, FH and FA on X-ray were increased significantly(P<0.05). Conclusions: Mini-open LaLIF is a minimally invasive lumbar fusion surgery. Due to less traumatic, less bleeding, short operation time and less complications in the perioperative period, LaLIF has a good application value in the treatment of lumbar degenerative disease. If surgical indications are selected strictly, stand alone LaLIF can achieve good clinical outcomes without the posterior internal fixation.