经皮内窥镜辅助下经椎间孔腰椎减压融合术治疗单节段腰椎管狭窄症对多裂肌的影响

Evaluation of multifidus muscle injury in PE-TLIF in the treatment of single-segment lumbar spinal stenosis

中文关键词:  经皮内窥镜辅助下经椎间孔腰椎减压融合术  腰椎管狭窄症  多裂肌

英文关键词:Percutaneous endoscopic transforaminal lumbar interbody fusion  Lumbar spinal stenosis  Multifidus muscle

中文摘要:

  【摘要】 目的：探讨经皮内窥镜辅助下经椎间孔腰椎减压融合术（PE-TLIF）治疗单节段腰椎管狭窄症对腰椎多裂肌的影响。方法：回顾性分析2017年3月~2018年10月首都医科大学附属北京朝阳医院收治并采用PE-TLIF术式治疗的10例单节段腰椎管狭窄症患者，其中男3例，女7例，年龄43~73岁，平均59.4±11.5岁。记录手术时间、术中出血量、术后伤口引流量、术后卧床时间、并发症发生情况，并通过术前1d、术后7d、术后3个月、术后6个月的腰痛与腿痛视觉模拟评分（VAS）以及术前1d、术后3个月、术后6个月的Oswestry功能障碍指数（ODI）评分等指标评价临床疗效；采用Bridwell标准评估术后6个月植骨融合情况；通过术前1d、术后7d、术后3个月、术后6个月的切口处多裂肌的最大横截面积（Max-CSA）和六氟化硫微泡造影剂峰值强度（PI）及术前1d、术后1d、术后7d的血清肌酸激酶（CK）水平，评估腰椎多裂肌损伤情况。结果：患者手术时间292.5±54.0min，术中出血量119.0±92.4ml，术后伤口引流量39.5±19.5ml，术后卧床时间21.6±3.2h，手术切口长度8.7±1.8mm。术后6个月，7例患者获得Ⅱ级椎间融合，3例患者获得Ⅲ级椎间融合；术前1d、术后7d、术后3个月、术后6个月腰痛VAS分别为7.20±0.78分、4.10±0.73分、1.40±0.51分、1.10±0.87分，腿痛VAS分别为5.90±1.19分、2.20±1.22分、1.10±0.73分、0.90±0.87分。术前1d、术后3个月、术后6个月ODI评分分别为（53.3±12.1）%、（23.9±8.0）%、（13.5±6.5）%。术后不同随访时间点的VAS及ODI评分均较术前明显改善，差异有统计学意义（P＜0.05）；术前1d、术后1d、术后7d的血清CK水平别为79.3±30.3U/L、428.1±78.3U/L、96.2±21.4U/L。血清CK水平在术后1d较术前增高，差异有统计学意义（P＜0.05），但在术后7d与术前比较无统计学差异（P＞0.05）；术前1d、术后7d、术后3个月、术后6个月的Max-CSA分别为501.7±127.6mm2、624.7±101.8mm2、521.5±60.4mm2、494.5±62.6mm2，以及PI分别为2.73±0.71db、4.61±1.18db、2.97±0.49db、2.58±0.34db。Max-CSA与PI在术后7d较术前增大，其差异有统计学意义（P＜0.05），但在术后3、6个月与术前比较，无统计学差异（P＞0.05）。随访期间，所有患者均无明显并发症发生，有1例患者术后出现短暂性右侧膝腱反射亢进。结论：PE-TLIF在治疗单节段腰椎管狭窄症可获得良好的早期临床疗效，同时对术后多裂肌的血流灌注以及形态变化无明显影响。

英文摘要:

  【Abstract】 Objectives: To investigate the effects of percutaneous endoscopic transforaminal lumbar interbody fusion(PE-TLIF) on multifidus muscle injury in the treatment of single-segment lumbar spinal stenosis. Methods: A retrospective analysis of 10 patients with single-segment lumbar spinal stenosis in the Beijing Chao-yang Hospital Affiliated to Capital Medical University from March 2017 to October 2018. There were 3 males and 7 females, whose mean age was 59.4±11.5 years old (range, 43-73 years old)． All patients were treated with PE-TLIF. Operation time, intraoperative blood loss, postoperative wound drainage, postoperative bed rest time, complications were recorded. The clinical efficacy was evaluated using the VAS scores of low back pain and leg pain 1 day before surgery and 7 days, 3 and 6 months after surgery, and ODI scores 1 day before surgery and 3, 6 months after surgery. The Bridwell criteria were used to assess bone graft fusion 6 months after surgery. In order to evaluate the damage of the lumbar multifidus muscle, the maximal cross-sectional area(Max-CSA) of the multifidus muscle at the surgical incision and the peak intensity(PI) of sulphur hexafluoride microbubble contrast agent at 1 day before surgery, 7 days, 3 and 6 months after surgerywere calculated, and serum creatine kinase(CK) levels at 1 day before surgery, 1 and 7 days after surgery were also recorded. Results: The average operation time was 292.5±54.0min, the average intraoperative blood loss was 119.0±92.4ml, the average postoperative wound drainage volume 39.5±19.5ml, and the postoperative bed rest time 21.6±3.2h, surgical incision length 8.7±1.8mm. At 6 months follow-up, grade Ⅱ intervertebral fusion was obtained in 7 patients and grade Ⅲ intervertebral fusion was obtained in 3 patients. The VAS-LBP scores of 1 day before surgery, 7 days after surgery, 3 months after surgery, and 6 months after surgery were 7.20±0.78, 4.10±0.73, 1.40±0.51, 1.10±0.87, and VAS-LP scores were 5.90±1.19, 2.20±1.22, 1.10±0.73, 0.90±0.87 respectively. The ODI scores of 1 day before surgery, 3 months after surgery and 6 months after surgery were (53.3±12.1)%, (23.9±8.0)%, and (13.5±6.5)%, respectively. Compared with the pre-operation status, significant differences were detected in the VAS-LBP score, VAS-LP score and ODI scores at the different postoperative time points(P＜0.05). The serum CK levels of 1 day before surgery, 1 days after surgery, and 7 days after surgery were 79.3±30.3U/L, 428.1±78.3U/L, and 96.2±21.4U/L, respectively. Serum CK levels of 1 day after surgery were higher than those before surgery, and the difference was statistically significant(P<0.05), but there was no significant difference between the 7th day post the surgery and the preoperative day(P>0.05). The Max-CSA of 1 day before surgery, 7 days after surgery, 3 months after surgery, and 6 months after surgery were 501.7±127.6mm2, 624.7±101.8mm2, 521.5±60.4mm2, 494.5±62.6mm2, and PI were 2.73±0.71db, 4.61±1.18db, 2.97±0.49db, 2.58±0.34db. Compared with preoperative status, Max-CSA and PI increased on the 7th day after surgery, the difference was statistically significant(P<0.05), but there was no significant difference in Max-CSA and PI at 3, 6 months after surgery(P>0.05). During the follow-up period, all patients had no significant complications. One patient presented transient hyperreflexia of the right knee tendon after surgery. Conclusions: PE-TLIF can achieve good early clinical results in the treatment of single-level lumbar spinal stenosis, with no significant effects on the blood perfusion and morphological changes of multifidus muscle.