中线腰椎椎间融合术与微创通道下经椎间孔椎体间融合术单侧入路双侧减压治疗单节段腰椎管狭窄症的对比研究

A comparative study of MIDLIF and MIS-TLIF unilateral approach for bilateral decompression in the treatment of single-segment lumbar spinal stenosis

中文关键词:  腰椎管狭窄症  微创技术  椎管减压  单侧入路双侧减压

英文关键词:Lumbar spinal stenosis  Minimally invasive technology  Spinal canal decompression  Unilateral approach and bilateral decompression

中文摘要:

  【摘要】 目的：比较中线腰椎椎体间融合术（midline lumbar interbody fusion，MIDLIF）与微创通道下经椎间孔椎体间融合术（minimally invasive transforaminal lumbar interbody fusion，MIS-TLIF）单侧入路双侧减压治疗单节段腰椎管狭窄症的临床疗效。方法：回顾性分析2017年1月~2020年1月我院骨科采用MIDLIF技术与MIS-TLIF单侧入路双侧减压技术治疗的44例伴双侧症状的腰椎管狭窄症患者，其中L3-4 2例；L4-5 41例；L5-S1 1例。21例患者接受MIDLIF技术治疗，23例患者接受MIS-TLIF单侧入路双侧减压技术治疗。两组患者随访时间、性别无统计学差异（P＞0.05）；MIDLIF组年龄较MIS-TLIF组大（P＜0.05）。记录两组患者手术时间、下地时间、术中出血量、术后引流量、平均住院时间；于术前、术后1个月、3个月、6个月、12个月及末次随访采用视觉模拟评分法（visual analog scale，VAS）来评估腰痛及腿痛情况，术后6个月、12个月及末次随访采用腰椎Oswestry功能障碍指数（Oswestry disabity index，ODI）评定患者躯体功能、行走等整体生活质量。通过腰椎三维CT比较两组患者术前及末次随访时椎管横截面积（intervertebral canal cross-sectional area，ICCA）和硬膜囊横截面积 （dural sac cross-sectional area，DSCA），术前及末次随访时腰椎正侧位X线片比较椎间隙高度（椎间隙前侧、后侧及平均高度），并记录相关并发症。结果：44例患者均顺利完成手术。MIDLIF组出现1例脑脊液漏；MIS-TLIF组术后出现1例对侧神经症状加重患者；2例患者经对症处理后均好转。随访时间22~28个月，平均26.5个月。末次随访时44例植骨均融合，未出现内固定松动或断裂等情况。两组术后平均下地时间、平均住院时间无统计学差异（P＞0.05）；MIDLIF组手术时间（159.74±30.54min）比MIS-TLIF组（202.46±61.56min）短，有统计学差异（P＜0.05）；MIS-TLIF组术后引流量（55.35±53.24ml）比MIDLIF组（163.74±145.67ml）少，有统计学差异（P＜0.05）；两组患者术前腰痛及腿痛VAS评分及DOI无统计学差异（P＞0.05）；两组术后1个月、3个月、6个月、12个月及末次随访腰痛及腿痛VAS评分较术前降低，有统计学差异（P＜0.05）；术后两组间各时间点比较均无统计学差异（P＞0.05）。两组术后6个月、12个月及末次随访腰椎ODI较术前均降低，有统计学差异（P＜0.05）；术后两组间各时间点比较均无统计学差异（P＞0.05）；两组间术前ICCA、DSCA无统计学差异（P＞0.05）；两组患者术后ICCA、DSCA较术前均明显增大，有统计学差异（P＜0.05），且MIDLIF组ICCA（184.42±46.74mm2）较MIS-TLIF组（135.54±42.63mm2）增大更明显；两组术后椎间隙前侧及平均高度均较术前明显增高（P＜0.05），术后椎间隙前侧及平均高度无统计学差异（P＞0.05），术后椎间隙后侧高度有统计学差异（P＜0.05）。结论：MIDLIF和MIS-TLIF单侧入路双侧减压治疗双侧症状的腰椎管狭窄症患者临床疗效确切，且MIDLIF技术手术时间相对更少，术后ICCA增大更多。MIDLIF技术减压更广泛、更直接。

英文摘要:

  【Abstract】 Objectives: To comparative the clinical efficacies of midline lumbar interbody fusion(MIDLIF) and minimally invasive transforaminal lumbar interbody fusion (MIS-TLIF) unilateral approach bilateral decompression in the treatment of single-segment lumbar spinal stenosis(LSS). Methods: A retrospective analysis was made on 44 LSS patients with bilateral symptoms treated with MIDLIF and MIS-TLIF unilateral approach bilateral decompression in the Department of Orthopedics of our hospital from January 2017 to January 2020, involving 2 cases of L3-4, 41 cases of L4-5, and 1 case of L5-S1. Among the patients, 21 received MIDLIF operation(MIDLIF group) and 23 received MIS-TLIF unilateral approach bilateral decompression operation(MIS-TLIF group). There was no statistical difference between the two groups in follow-up period and gender ratio(P>0.05), and MIDLIF group was older in age(P<0.05). The operative time, leaving bed time, intraoperative blood loss, postoperative drainage volume, and average length of hospital stay were recorded. Visual analog scale(VAS) was used to assess low back and leg pain before operation, at postoperative 1, 3, 6 and 12 months, and final follow-up; and Oswestry disabity index(ODI) of lumbar spine was used to evaluate the overall quality of life of patients such as physical function and walking at postoperative 6 and 12 months, and final follow-up. The intervertebral canal cross-sectional area(ICCA) and dural sac cross-sectional area(DSCA) before operation and at final follow-up were compared between the two groups by lumbar 3D-CT. Anteroposterior and lateral lumbar X-ray images were taken before and at the last follow-up to compare the height of the intervertebral space(anterior, posterior and average heights), and complications were recorded. Results: All the patients successfully underwent the operation. 1 case of cerebrospinal fluid leakage occurred in the MIDLIF group and 1 case in MIS-TLIF group developed worsening contralateral neurological symptoms after operation, and both patients improved after symptomatic treatment. The mean follow-up time was 26.5 months(range, 22-28 months). At the last follow-up, 44 cases of bone graft were fused without loosening or fracture of internal fixation. There was no statistical significance between the two groups in postoperative leaving bed time or length of hospital stay(P>0.05). The operative time of MIDLIF group[(159.74±30.54)min] was significantly shorter than that of MIS-TLIF group[(202.46±61.56)min](P<0.05), and the postoperative drainage volume of MIS-TLIF group[(55.35±53.24)ml] was significantly less than that of MIDLIF group[(163.74±145.67)ml](P<0.05). There was no statistical difference in low back and leg pain VAS scores and ODI before operation between the two groups(P>0.05); and the VAS scores of low back pain and leg pain at 1, 3, 6 and 12 months postoperatively and final follow-up in both groups were significantly lower than those before operation, respectively(P<0.05), and no significant difference was found between groups at postoperative time points(P>0.05). At 6 and 12 months postoperatively and the final follow-up visit, the ODI of lumbar spine was lower than that before surgery of both groups(P<0.05), and there was no significant difference at postoperative time points between groups(P>0.05). There was no significant difference between the two groups in preoperative ICCA and DSCA(P>0.05); the ICCA and DSCA of the two groups were significantly increased after operation compared with those before operation, and the differences were statistically significant(P＜0.05). In addition, the ICCA in the MIDLIF group[(184.42±46.74)mm2] increased more significantly than that in the MIS-TLIF group [(135.54±42.63)mm2]. The anterior and average height of the postoperative intervertebral space in both groups were significantly greater than those before surgery(P<0.05), and there were no significant differences in anterior height and average height between the two groups (P>0.05)， while the posterior height of the postoperative intervertebral space was significantly different between groups(P<0.05). Conslusions: MIDLIF and MIS-TLIF unilateral approach bilateral decompression are both effective in the treatment of LSS patients with bilateral symptoms, and MIDLIF is relatively less in operative time and increases more in postoperative ICCA. MIDLIF is more extensive and direct in decompression.