经皮内镜下经椎间孔与传统后入路椎间融合术治疗伴有腰椎不稳的腰椎管狭窄症的疗效对比

Comparison of therapeutic effects of percutaneous endoscopic transforaminal lumbar interbody fusion (PE-TLIF) and posterior lumbar interbody fusion(PLIF) in the treatment of lumbar spine stenosis

中文关键词:  腰椎管狭窄症  微创手术  经皮内镜下经椎间孔减压融合术  后路减压融合内固定术

英文关键词:Lumbar spinal stenosis  Minimally invasive surgery  Transforaminal lumbar interbody fusion  Posterior lumbar interbody fusion

中文摘要:

  【摘要】目的：比较经皮内镜下经椎间孔腰椎椎间融合术（percutaneous endoscopic transforaminal lumbar interbody fusion，PE-TLIF）和传统后入路椎间融合术（posterior lumbar interbody fusion，PLIF）治疗伴有腰椎不稳的腰椎管狭窄症患者的临床疗效。方法：回顾性分析2017年12月~2018年12月因单节段腰椎管狭窄症在我院行腰椎减压融合手术患者36例，根据手术方式分为PE-TLIF组（15例）和PLIF组（21例）。两组间年龄、性别、手术节段等一般资料差异均无统计学意义（P>0.05）。记录两组患者手术时间、术中出血量、伤口长度、术后伤口引流量、术后卧床时间及术后并发症。通过术前、术后1d及术后7d的血清肌酸激酶（creatine kinase，CK）评估椎旁肌肉的损伤情况。通过术前1d、术后7d、术后3个月、术后6个月及最终随访时腰腿痛视觉模拟评分（visual analogue scale，VAS）和术前1d、术后3个月、术后6个月及最终随访时Oswestry功能障碍指数（Oswestry disability index，ODI）比较两组患者的临床疗效。术后6个月行CT检查，采用Bridwell标准评价椎间融合情况。结果：PE-TLIF组患者平均随访时间为16.4±4.7个月，PLIF组患者平均随访时间为17.4±4.9个月。两组患者手术时间无统计学差异（P＞0.05）。PE-TLIF组患者术中出血量、手术切口长度、术后引流量及术后卧床时间均小于PLIF组患者，并且差异具有统计学意义（P<0.05）。PE-TLIF组患者术后1d及术后7d的CK明显低于PLIF组患者，差异有统计学意义（P<0.05）。两组患者术后腰腿痛VAS及ODI较术前有明显下降（P<0.05）。PE-TLIF组患者术后1周及3个月时的腰痛VAS评分显著低于PLIF组患者（P<0.05）。PE-TLIF组1例术后出现一过性腱反射亢进；PLIF组有2例出现表浅切口感染，两组并发症发生率无显著性差（P>0.05）。术后6个月时，PE-TLIF组Ⅱ级融合7例，Ⅲ级融合8例；PLIF组Ⅱ级融合12例，Ⅲ级融合9例，两组患者椎间融合率差异无统计学意义（P>0.05）。结论：治疗腰椎管狭窄症患者时，PE-TLIF手术能够达到与传统后入路减压融合术相似的手术疗效，且接受PE-TLIF手术的患者术后椎旁肌肉损伤更少，术后腰部疼痛程度更轻，术后康复更快，但PE-TLIF组手术时间相对更长。

英文摘要:

  【Abstract】 Objectives: To compare the clinical efficacy of percutaneous endoscopic transforaminal lumbar interbody fusion(PE-TLIF) and posterior lumbar interbody fusion(PLIF) in the treatment of lumbar spinal stenosis. Methods: Retrospective analysis was performed on 36 patients who received lumbar decompression and fusion surgery in our hospital from December 2017 to December 2018 due to single-segment lumbar spinal stenosis(LSS). The patients were divided into PE-TLIF group(15 cases) and PLIF group(21 cases) according to the surgical methods. The operation time, intraoperative bleeding volume, incision length, postoperative drainage volume, postoperative bedridden time, and postoperative complications of patients in both groups were recorded. Serum creatine kinase(CK) was used to assess paravertebral muscle injury at 1 day preoperatively, 1 day postoperatively, and 7 days postoperatively. VAS(visual analogue scale for lumbar and leg pain at 1 day preoperatively, 7 days postoperatively, 3 months postoperatively, 6 months postoperatively, and final follow-up) and ODI (Oswestry disability index at 1 day preoperatively, 3 months postoperatively, 6 months postoperatively and final follow-up) scores were used to compare the clinical efficacy of the two groups. The Bridwell criteria was used to evaluate the intervertebral fusion via CT at 6 months after operation. Results: All the patients were followed up, with average follow-up periods of 16.4±4.7 months in PE-TLIF groupand 17.4±4.9 months in PLIF group. In addition to the operation time, the intraoperative bleeding volume, incision length, postoperative drainage volume and postoperative bedridden time in PE-TLIF group were less than those in PLIF group, and the difference was statistically significant(P<0.05). The operation time in PE-TLIF group was longer than that in the PLIF group, and the difference was statistically significant(P<0.05). The injury degrees of paravertebral muscle evaluated by CK at 1 day and 7 days after operation were significantly lower in PE-TLIF group than those in PLIF group(P<0.05). The VAS score and ODI of patients with lumbar and leg pain after surgery were significantly higher than those before operation(P<0.05). The VAS scores of PE-TLIF group at 1 week and 3 months after operation were significantly lower than those of PLIF group(P<0.05). One patient in PE-TLIF group had transient tendon hyperreflexia immediately after operation, and two patients in PLIF group had superficial incision infections. There was no significant difference inthe complication rate between the two groups(P>0.05). At the 6-month follow-up, the intervertebral fusion of all patients was evaluated. In PE-TLIF group, there were 7 cases of grade Ⅱ fusion and 8 cases of grade Ⅲ fusion. In PLIF group, there were 12 cases of grade Ⅱ fusion and 9 cases of grade Ⅲ fusion. There was no significant difference in the intervertebral fusion rate between the two groups(P>0.05). Conclusions: PE-TLIF technique could obtain comparable effective outcomes as conventional PLIF for the treatment of LSS. The patients with PE-TLIF have less muscle injury, less pain and quicker postoperative rehabilitation, but te operation time in PE-TLIF group was longer.