经皮内镜下经椎间孔椎体间融合术与后入路椎体间融合术治疗单节段腰椎管狭窄症的临床疗效及椎旁肌的变化

Clinical outcomes and changes in paraspinal muscles after posterior lumbar interbody fusion(PLIF) and percutaneous endoscopic transforaminal lumbar interbody fusion(PE-TLIF) in patients with single-segment lumbar spinal stenosis

中文关键词:  腰椎管狭窄症  经皮内镜下经椎间孔椎体间融合术  椎旁肌

英文关键词:Lumbar spinal stenosis  Percutaneous endoscopic transforaminal lumbar interbody fusion (PE-TLIF)  Paraspinal muscles

中文摘要:

  【摘要】 目的：比较后入路腰椎椎体间融合术（posterior lumbar interbody fusion，PLIF）和经皮内镜下经椎间孔腰椎椎体间融合术（percutaneous endoscopic transforaminal lumbar interbody fusion，PE-TLIF）治疗单节段腰椎管狭窄症的临床疗效及其对椎旁肌的影响。方法：本前瞻性研究纳入本院2019年1月~2022年1月收治的52例L4/5单节段腰椎管狭窄症患者。其中，PLIF组22例，女性10例，男性12例，年龄60.2±10.3岁；PE-TLIF组30例，女性14例，男性16例，年龄60.4±12.3岁。对比两组手术时间、术中出血量、术后引流量、术后卧床时间等围手术期指标；比较术前与术后1d及1周血清肌酸激酶（creatine kinase，CK），术前与术后6个月及12个月多裂肌（multifidus，MF）横截面积（cross-sectional area，CSA）、脂肪浸润（fatty infiltration，FI）评分及肌肉CT密度等椎旁肌评估指标；比较两组患者术前、术后1d、1周、6个月及12个月腰痛视觉模拟评分（visual analogue scale on low back pain，VAS-LBP）、腿痛视觉模拟评分（visual analogue scale on leg pain，VAS-LP）、Oswestry功能障碍指数（Oswestry disability index，ODI）。对两组术后并发症发生情况进行比较，术后12个月根据Bridwell标准评估两组椎间融合情况。结果：PE-TLIF组与PLIF组手术时间（211.2±38.5min vs 98.9±31.6min，P=0.000）、术后卧床时间（25.9±8.3h vs 52.4±14.8h，P=0.001）、术中失血量（112.8±79.6mL vs 232.5±122.5mL，P=0.002）、术后引流量（46.5±28.2mL vs 283.6±142.1mL，P=0.000）相比，差异均具有统计学意义。PE-TLIF组与PLIF组术前、术后6个月及12个月目标节段MF CSA组间比较均无明显差异（P＞0.05），两组术前与术后6个月及12个月的目标节段MF CSA组内比较无明显差异（P＞0.05）。PE-TLIF组与PLIF组术前、术后6个月目标节段MF FI评分组间比较无统计学差异（P＞0.05），术后12个月，PLIF组目标节段MF FI评分较PE-TLIF组高，差异具有统计学意义[3.0（3.0，4.0） vs 3.0（2.8，3.0），P=0.031]；PE-TLIF组术前与术后6个月、12个月目标节段MF FI评分组内比较无明显差异（P＞0.05），PLIF组术前与术后6个月目标节段MF FI评分组内比较未发现明显差异（P=0.257），而术前与术后12个月比较，差异具有统计学意义[3.0（2.0，3.3） vs 3.0（3.0，4.0），P=0.016]。术前、术后6个月两组患者MF CT密度相比较无明显差异（P＞0.05）。术后12个月，PLIF组目标节段MF密度明显降低，差异具有统计学意义[PE-TLIF：34.2（31.8，36.9）HU；PLIF: 30.5（28.5，32.1）HU，P=0.000]。组内比较，PE-TLIF组术前与术后6个月、12个月目标节段MF肌肉密度比较差异无显著统计学意义（P＞0.05）。PLIF组术前与术后6个月目标节段MF CT密度比较，未发现明显差异（P=0.516），术后12个月较术前明显升高，差异具有统计学意义[34.6（30.5，36.4）HU vs 30.5（28.5，32.5）HU，P=0.017]。PE-TLIF组与PLIF组术前CK值无明显差异（P=0.712）。术后1d、7d，PE-TLIF组CK值低于PLIF组（P<0.05）。PE-TLIF组与PLIF组患者术后随访VAS-LP、VAS-LBP评分以及ODI均优于术前，差异具有统计学意义（P＜0.05）。术后1d、7d，PE-TLIF组VAS-LBP评分表现优于PLIF组（P<0.05）。术后6个月、12个月，两组患者的VAS-LBP评分比较无明显差异（P＞0.05）。两组患者的VAS-LP评分以及ODI在随访时无明显差异（P＞0.05）。两组患者术后并发症发生率比较无统计学差异（P=0.379），术后12个月两组患者椎间融合情况比较无统计学差异（P=0.877）。结论：PE-TLIF治疗单节段腰椎管狭窄症可获得与传统PLIF手术相同的临床疗效，且减小了对椎旁肌的影响，可减轻手术创伤。

英文摘要:

  【Abstract】 Objectives: To compare the clinical outcomes of posterior lumbar interbody fusion(PLIF) and percutaneous endoscopic transforaminal lumbar interbody fusion(PE-TLIF) in treating single-segment lumbar spinal stenosis and their effects on the paraspinal muscles. Methods: This prospective study included 52 patients with L4/5 lumbar spinal stenosis treated in our hospital between January 2019 and January 2022. Among the patients, 22 were in the PLIF group(10 females, 12 males, aged 60.2±10.3 years old) and 30 were in the PE-TLIF group(14 females, 16 males, aged 60.4±12.3 years old). The two groups were compared of the perioperative indicators including operative time, intraoperative blood loss, postoperative drainage volume, and postoperative bed rest time; And paraspinal muscles related indicators such as creatine kinase(CK) before operation and at postoperative 1d and 1 week, and multifidus muscle(MF) cross-sectional area(CSA), fatty infiltration(FI) score, and muscle CT density before operation and at postoperative 6 and 12 months; Preoperative, postoperative 1d, 1 week, 6 months and 12 months′ visual analogue scale on low back pain(VAS-LBP), visual analogue scale on leg pain(VAS-LP), and Oswestry disability index(ODI). The complications of the two groups were analyzed and compared, and at 12 months after operation, the fusion rate was evaluated and compared according to the Bridwell criteria. Results: PE-TLIF group was different from PLIF group significantly in operative time(211.2±38.5min vs 98.9±31.6min, P=0.000), postoperative bed rest time(25.9±8.3h vs 52.4±14.8h, P=0.001), intraoperative blood loss(112.8±79.6mL vs 232.5±122.5mL, P=0.002), and postoperative drainage volume(46.5±28.2mL vs 283.6±142.1mL, P=0.000). The MF CSA before operation, at 6 and 12 months after operation was not significantly different between PE-TLIF group and PLIF group(P＞0.05), and there was no statistical difference between pre-operation MF CSA and MF CSA 6 months and 12 months after surgery within either group(P>0.05). The PE-TLIF group was not significantly different from the PLIF group in MF FI score before operation and at 6 months after operation(P＞0.05), while at 12 months after operation, the PE-TLIF group was lower than the PLIF group[3.0(2.8, 3.0) vs 3.0(3.0, 4.0), P=0.031]. There was no statistical difference in MF FI score between pre-operation, 6 months after surgery and 12 months after surgery within the PE-TLIF group(P>0.05). And, there was no statistical difference in MF FI score between pre-operation and 6 months after surgery in the PLIF group(P>0.05), while statistically significant difference was found between pre-operation and 12 months after surgery in the PLIF group[3.0(2.0, 3.3) vs 3.0(3.0, 4.0), P=0.016]. The difference in preoperative MF CT density and MF CT density 6 months after operation between the two groups was not statistically significant(P＞0.05). At the 12-month follow-up, MF CT density in the PLIF group was significantly lower than that in the PE-TLIF group[30.5(28.5, 32.1)HU vs 34.2(31.8, 36.9)HU, P=0.000]. There was no significant difference in MF density between pre-operation, and 6 months after surgery or 12 months after surgery within the PE-TLIF group(P>0.05). And there was no statistically significant difference in MF density between pre-operation and 6 months after surgery in the PLIF group(P=0.516), but there was a statistical difference between pre-operation and 12 months after surgery within the PLIF group[34.6(30.5, 36.4)HU vs 30.5(28.5, 32.5)HU, P=0.017). The PE-TLIF group and PLIF group was not significantly different in preoperative CK(P=0.712), while the PE-TLIF group was lower on 1d and 7d after operation(P<0.05). VAS-LBP, VAS-LP, and ODI at all follow-up time points after surgery of both groups were better compared to those before surgery(P<0.05). The VAS-LBP of the PE-TLIF group was better than that of the PLIF group at 1d and 1 week after surgery(P<0.05). There was no statistical difference in VAS-LBP between the PLIF and PE-TLIF at 6 months or 12 months after surgery. There was no statistical difference in VAS-LP or ODI between the PLIF and PE-TLIF at any follow-up time point(P>0.05). There was no significant difference in the incidence of postoperative complications between the two groups(P=0.379). And there was no significant difference in the fusion rate between the two groups(P=0.877). Conclusions: PE-TLIF can achieve similar clinical outcomes as traditional PLIF in the treatment of single-segment lumbar spinal stenosis, which reduces effects on paraspinal muscles and alleviate operative trauma.