经椎间孔入路与经关节突入路脊柱内镜下腰椎椎间融合术的疗效与安全性比较

Comparison of the efficacy and safety of endoscopic lumbar interbody fusion between transforaminal approach and transarticular outburst approach

中文关键词:  腰椎椎间融合术  内镜  经椎间孔入路  经关节突入路

英文关键词:Lumbar interbody fusion  Endoscopy  Transforaminal approach  Transfacet approach

中文摘要:

  【摘要】 目的：比较单孔同轴大通道内镜下单节段腰椎椎间融合术（镜下融合）经椎间孔入路与经关节突入路的疗效与安全性。方法：纳入2018年6月～2022年2月共46例单节段镜下融合病例，男18例、女28例；年龄40～80岁，平均60.9±10.5岁，术后随访时间3～47个月。按手术入路不同分为两组，其中18例为经椎间孔入路，28例为经关节突入路，均采用工作内径7.1mm的大通道脊柱内镜。术前、术后3d及末次随访时使用腰椎Oswestry功能障碍指数（Oswestry disability index，ODI）、腰痛及腿痛的视觉模拟评分（visual analogue scale，VAS）、日本骨科协会评分（Japanese Orthopaedic Association，JOA）评价临床疗效。术后3d复查腰椎正侧位X线片及腰椎CT评价减压与内固定情况。术后随访超6个月且复查腰椎CT者，按照Bridwell标准判断融合情况。结果：两组患者的年龄、性别、术前诊断、术前椎间隙高度、手术节段，术前ODI评分、VAS评分及JOA评分等均无统计学差异（P＞0.05）。经椎间孔入路组72.2%的患者术前存在单侧根性症状，而经关节突入路组则有64.3%术前为双侧根性症状，二者存在统计学差异（P=0.020）。经椎间孔入路组手术时间平均327.7±89.9min，住院时间平均14.8±6.0d；经关节突入路组手术时间平均385.9±96.7min，住院时间平均19.5±7.8d，两组差异具有统计学意义（P=0.047；P=0.038）。经关节突入路组75%的患者接受了单侧入路双侧减压。两组术后及末次随访ODI评分、腰痛及腿痛VAS评分、JOA评分均较术前明显改善，差异有统计学意义（P＜0.05）；但各评分在两组间比较无统计学差异（P＞0.05）。两组术后椎间隙高度与术前比较显著增加（P<0.001），组间比较无统计学差异（P＞0.05）。两组术中、术后均无严重并发症发生，并发症发生率比较无统计学意义（P＞0.05）。末次随访时间大于6个月且复查CT者共21例，其中20例（95.2%）达到骨性融合，两组融合率比较无统计学差异。结论：经椎间孔入路与经关节突入路单孔同轴大通道内镜下行单节段腰椎椎间融合均安全、有效，经椎间孔入路的手术时间较短，住院时间较短。

英文摘要:

  【Abstract】 Objectives: To compare the clinical efficacy and safety of uni-portal endoscopic lumbar interbody fusion by using larger-diameter endoscope for single-level lumbar disease via transforaminal approach versus transfacet approach. Methods: 46 patients underwent single-level uni-portal endoscopic lumbar interbody fusion from June 2018 to February 2022 were enrolled. 18 of the patients were male and 28 were female. The mean age was 60.9±10.5 years old(40-80 years). The follow-up time was 3-47 months. Patients were divided into two groups according to the surgical approach, 18 of which were included in the transforaminal group, and the remaining 28 were included in the transfacet group, and a full spinal endoscope of 7.1mm inner-diameter working-channel was applied to all the patients. The clinical result was evaluated before surgery, at 3d after surgery and the final follow-up, by Oswestry disability index(ODI), visual analogue scale(VAS) for back pain and leg pain, and Japanese Orthopaedic Association(JOA) score. The decompression and implant were evaluated by anteroposterior and lateral X-ray plain film and lumbar CT at 3d after operation. Bridwell criteria were used to evaluate the fusion rate based on CT images for patients followed up for more than 6 months after surgery. Results: No significant differences were found in age, gender, diagnosis, preoperative intervertebral height, surgical segment, preoperative ODI, VAS and JOA score between the two groups(P＞0.05). 72.2% of the patients in transforaminal group complained unilateral radicular symptom, while 64.3% of the patients in transfacet group suffered from bilateral radicular symptoms(P=0.020). The average operation time was 327.7±89.9min in the transforaminal group, significantly longer than the 385.9±96.7min in the transfacet group(P=0.047), and the mean length of hospital stay in the transforaminal group was 14.8±6.0d, shorter than that of 19.5±7.8d in the transfacet group(P=0.038). 75% of the patients in transfacet group underwent unilateral laminotomy with bilateral spinal canal decompression(ULBD). The ODI scores, back and leg pain VAS scores and JOA score were significantly improved postoperatively and at the final follow-up in both groups(P<0.05), while no statistical differences between groups(P＞0.05). Postoperative intervertebral height significantly increased in both group(P<0.001), but no statistical difference was found between groups(P＞0.05). The complication rate was comparable between two groups, without severe intraoperative or postoperative complication. Among the 21 patients who were followed up for more than 6 months and received CT examinations, 20(95.2%) presented bony fusion at surgical segment, and there was no statistical difference between the two groups in fusion rate. Conclusions: Both the transforaminal approach and the transarticular protrusion approach are safe and effective for the single-level lumbar interbody fusion under single-hole coaxial large channel endoscopy, and the transforaminal approach results in shorter operation time and shorter hospital stay.