不同手术次序全内镜下腰椎融合术治疗腰椎退变性疾病的疗效比较

Comparison of the efficacies of two operational sequences of endoscopic posterolateral lumbar interbody fusion in the treatment of lumbar degenerative diseases

中文关键词:  腰椎退变性疾病  脊柱内镜  腰椎融合术  手术顺序

英文关键词:Lumbar degenerative diseases  Spinal endoscopy  Lumbar fusion  Operation sequence

中文摘要:

  【摘要】 目的：比较不同手术次序全内镜下腰椎融合术治疗腰椎退变性疾病的临床效果。方法：回顾性分析2019年10月~2021年10月在我院行全内镜下腰椎融合术治疗的64例腰椎退变性疾病患者的资料，男29例，女35例，年龄40~79岁（59.7±13.5岁）；病程1~10年（3.1±1.6年），体质量指数（body mass index，BMI）10~31kg/m2（25.3±3.1kg/m2）；退变性腰椎滑脱伴椎管狭窄20例，腰椎间盘突出伴退变性椎管狭窄21例，退变性椎管狭窄伴腰椎不稳18例，退变性侧凸伴椎管狭窄5例；单节段病变59例，双节段病变5例。其中38例采用C型臂X线机辅助下定位标记-置入导丝-内镜下减压植骨融合-经皮置钉的手术顺序（A组）；26例采用C型臂X线机辅助下定位标记-内镜下减压植骨融合-置入导丝-经皮置钉的手术顺序（B组）。两组患者的年龄、性别、BMI、病程和病变节段均无显著性差异（P>0.05）。比较两组的围手术期指标（手术时间、术中透视次数、术中出血量、术后引流量、术后卧床时间、住院时间、并发症），按Gertzbein-Robbins等的标准评估椎弓根螺钉置入的准确性，术前和术后1年时随访的腰腿痛视觉模拟评分（visual analogue scale，VAS）、Oswestry功能障碍指数（Oswestry disability index，ODI）和腰椎前凸角、椎间隙高度、手术节段前凸角，观察术后1年时的椎间融合情况。结果：两组患者均顺利完成手术，两组手术时间、术中透视次数有统计学差异（A组189.6±35.4min、13.1±3.5次，B组210.4±33.5min、15.9±5.4次，P＜0.05）；术中出血量、术后引流量、术后卧床时间、住院时间和并发症发生率均无统计学差异（A组57.5±16.3ml、110.8±55.0ml、2.0±1.2d、7.3±1.2d和7.89%；B组60.4±18.8ml、119.8±49.0ml、2.2±0.9d、7.4±2.2d和19.23%）（P>0.05）。A组置钉优良率（91.8%）优于B组（77.8％）（P＜0.05）。两组术后1年时的VAS评分（A组1.9±1.0分，B组1.8±1.0分）、ODI[A组（27.6±7.2）%，B组（26.8±6.7）%]与术前VAS评分（A组6.7±1.5分，B组6.4±1.6分）、ODI[A组（72.4±11.2.2）%，B组（73.5±13.6）%]比较均有显著性改善（P＜0.05），两组同时间点比较比较均无显著性差异（P>0.05）。两组术后1年的腰椎前凸角、椎间隙高度、手术节段前凸角（A组36.2°±6.5°、15.8±2.4mm、11.4°±1.4°；B组32.9°±6.5°、15.3±2.0mm、11.2°±1.1°）与术前（A组21.6°±6.5°、12.6±2.0mm、8.5°±1.9°；B组22.2°±7.7°、12.3±2.0mm、8.0°±1.9°）比较均有显著性差异（P＜0.05），两组同时间点比较均无显著性差异（P>0.05）。两组术后1年椎间融合率均为100％。结论：两种手术顺序全内镜下腰椎融合术治疗腰椎退变性疾病均确切可行，但采用C型臂辅助下定位标记-置入导丝-内镜下减压植骨融合-经皮置钉的顺序手术时间更短，透视次数更少，置钉优良率更高。

英文摘要:

  【Abstract】 Objectives: To compare the clinical effects of two operational sequences of endoscopic posterolateral lumbar interbody fusion(Endo-PLIF) in the treatment of lumbar degenerative diseases(LDD). Methods: The data of 64 LDD patients treated with full-endoscopic lumbar fusion in our hospital from October 2019 to October 2021 were analyzed retrospectively. There were 29 males and 35 females, aged 40-79 years(59.7±13.5 years). The course of disease was 1-10 years(3.1±1.6 years) and body mass index(BMI) was 10-31kg/m2(25.3±3.1kg/m2). Among the patients, 20 were of degenerative lumbar spondylolisthesis with spinal canal stenosis, 21 were of lumbar disc herniation with degenerative spinal canal stenosis, 18 were of degenerative spinal canal stenosis with lumbar instability, and 5 were of degenerative scoliosis with spinal canal stenosis; And 59 cases were of single segment lesion and 5 cases were of double segment lesion. Of the patients, 38 cases were treated with the operational sequence of "Locating and marking of diseased segments under C-arm X-ray machine-Inserting nail guide wire-Endoscopic decompression and bone graft fusion-Percutaneous nail placement"(group A), and the other 26 cases were treated with sequence of "Locating and marking of diseased segments under C-arm X-ray machine-Endoscopic decompression and bone graft fusion-Inserting nail guide wire-Percutaneous nail placement"(group B). There was no significant difference in age, gender, BMI, course of disease, and lesion segment between the two groups(P>0.05). The perioperative indexes(operative time, intraoperative fluoroscopy times, intraoperative blood loss, postoperative drainage volume, postoperative bed rest time, hospital stay, and complications), preoperative and postoperative 1 year′s visual analogue scale(VAS), Oswestry disability index(ODI), lumbar lordosis angle, height of intervertebral space, surgical segmental lordosis angle, as well as the accuracy of pedicle screw placement according to the Gertzbein-Robbins criteria were compared between the two groups. Intervertebral fusion status at 1 year after operation was observed. Results: There were significant differences in operative time and intraoperative fluoroscopy times between the two groups (group A 189.6±35.4min, 13.1±3.5 times vs group B 210.4 ±33.5min, 15.9±5.4 times, P<0.05), while there was no significant difference in intraoperative blood loss, postoperative drainage volume, postoperative bed rest time, hospital stay and the incidence of complications in group A(57.5±16.3ml, 110.8±55.0ml, 2.0±1.2d, 7.3±1.2d, and 7.89%) and group B(60.4±18.8ml, 119.8±49.0ml, 2.2±0.9d, 7.4±2.2d, and 19.23%)(P>0.05). The excellent and good rate of nail placement in group A(91.8%) was better than that in group B(77.8%) (P<0.05). The postoperative 1 year′s VAS scores(group A 1.9±1.0, group B 1.8±1.0) and ODI[group A (27.6±7.2)%, group B (26.8±6.7)%] were significantly improved compared with the VAS(group A 6.7±1.5, group B 6.4±1.6) and ODI[group A (72.4±11.2.2)%, group B (73.5±13.6)%] preoperatively(P<0.05), and there was no significant difference between the two groups at the same time points(P>0.05). The lumbar lordosis angle, intervertebral space height, and surgical segmental lordosis angle in group A(36.2°±6.5°, 15.8±2.4mm, and 11.2° ±1.1°) and group B(32.9°±6.5°, 15.3±2.0mm, 11.2°±1.1°) at 1 year after operation were significantly different from those before operation(group A, 21.6°±6.5°, 12.6±2.0mm, 8.5°±1.9°; group B, 22.2°±7.7°, 12.3±2.0mm, 8.0°±1.9°)(P<0.05), and there was no significant difference between the two groups at the same time points(P>0.05). The fusion rate of both groups at 1 year after operation was all 100% in both groups. Conclusions: The two operational sequences of Endo-PLIF are both effective in the treatment of LDD. However, the operational sequence of "Locating and marking of diseased segments under C-arm X-ray machine-Inserting nail guide wire-Endoscopic decompression and bone graft fusion-Percutaneous nail placement" is superior in shorter operative time, less fluoroscopy times, and higher excellent and good rate of screw placement.