超声骨刀辅助下单侧入路对侧潜行减压治疗退变性重度腰椎管狭窄症的临床疗效

Clinical efficacy of ultrasonic osteotome assisted unilateral approach contralateral undercutting decompression in the treatment of severe degenerative lumbar spinal stenosis

中文关键词:  腰椎管狭窄症  超声骨刀  潜行减压

英文关键词:Lumbar spinal stenosis  Ultrasonic osteotome  Undercutting decompression

中文摘要:

  【摘要】 目的：探讨超声骨刀辅助下单侧入路对侧潜行减压治疗退变性重度腰椎管狭窄症的效果和安全性。方法：收集2018年6月～2021年6月超声骨刀辅助下单侧入路对侧潜行减压治疗退变性重度腰椎管狭窄症患者174例[单侧入路双侧减压（对侧潜行减压）经椎间孔腰椎椎间融合术（transforaminal lumbar interbody fusion，TLIF）组，A组]，对比同期行双侧经椎间孔减压患者129例（双侧小切口TLIF组，B组），比较两组之间切口长度、手术时间、术中出血量、术后引流量、住院时间等围手术期参数，行肌酸磷酸激酶（creatine phosphokinase，CPK）检查评估肌肉破坏情况，术后采用疼痛视觉模拟量表（visual analogue scale，VAS）评分以及Oswestry功能障碍指数（Oswestry disability index，ODI）评估术后疗效，并比较两组之间术后并发症和融合情况。结果：两组间比较，两侧切口平均长度和住院时间无明显差异（P＞0.05），而手术时间、术中出血量及术后引流量A组较B组明显减少，差异有统计学意义（P<0.05）。两组患者术前CPK值差异无显著性意义（P>0.05），术后1d、3d时B组明显高于A组，差异具有显著性（P<0.05），术后5d两组比较差异无显著性（P>0.05）。术后3d、1个月、3个月、12个月，两组患者的VAS评分和ODI较术前均显著改善，术后3d、1个月、3个月、12个月时VAS评分和ODI两组均无明显差异（P>0.05），术后12个月时A组ODI和VAS评分均优于B组，但无统计学意义（P>0.05）。术后出现硬膜撕裂、切口脂肪液化、脑脊液漏、术后感染等并发症两组之间无明显差异。术后出现下肢麻木加重，和臀部/下肢症状反跳的患者比例，单侧入路双侧减压TLIF组均小于双侧小切口TLIF，差异有统计学意义（P<0.05）。术后1年时，单侧入路双侧减压TLIF组有12例尚未融合，双侧小切口TLIF组有8例未融合，两组患者的植骨融合情况差异无统计学意义（P>0.05）。结论：与双侧小切口TLIF手术相比，超声骨刀辅助下单侧入路对侧潜行减压治疗退变性重度腰椎管狭窄症亦可取得较好疗效，具有创伤小，对脊柱稳定性影响小，手术时间短,术中出血少等临床优势，值得临床推广。

英文摘要:

  【Abstract】 Objectives: To investigate the effectiveness and safety of unilateral approach contralateral undercutting decompression assisted with ultrasonic osteotome in treating severe degenerative lumbar spinal stenosis. Methods: 174 patients with severe degenerative lumbar spinal stenosis who were treated with ultrasonic osteotome assisted unilateral approach contralateral undercutting decompression between June 2018 and June 2021 were collected[unilateral approach bilateral decompression transforaminal lumbar interbody fusion(TLIF) group, group A], and 129 patients undergone bilateral transforaminal decompression during the same period were randomly selected as control(bilateral small incision TLIF group, group B). The perioperative parameters such as incision length, operative time, intraoperative blood loss, postoperative drainage, and length of hospital stay were recorded and compared between the two groups. Creatine phosphokinase(CPK) test was performed to evaluate muscle damage conditions, and visual analogue scale(VAS) and Oswestry disability index(ODI) were used to evaluate the postoperative therapeutic effects. The complications and fusion conditions were compared between the two groups. Results: There wasn′t significant difference in average length of bilateral incisions and length of hospital stays between the two groups(P>0.05). Group A was less significantly than group B in terms of operative time, intraoperative blood loss, and postoperative drainage, with statistical significance(P<0.05). The preoperative CPK value was comparable between the two groups(P>0.05), and on postoperative 1d and 3d it was statistically greater in group B than in group A(P<0.05), but on postoperative 5d it wasn′t significantly different between the two groups(P>0.05). The postoperative VAS scores and ODI improved compared with the preoperative values in both groups on postoperative 3d, at 1 month, 3 months, and 12 months(P<0.05), and there was no statistical difference between the two groups respectively at the same follow-up period(P>0.05), even though group A was better in ODI and VAS than group B at 12 months after operation. There was no significant difference between the two groups in postoperative complications such as dural tear, incision fat liquefaction, cerebrospinal fluid leakage and postoperative infection. Group A was less in the proportion of postoperative worsening lower limb numbness and rebound of hip/lower limb symptoms than in group B(P<0.05). 1 year after operation, 12 cases in group A were not fused, and 8 cases in group B were not fused. There was no statistically significant difference in the bone graft fusion between the two groups(P>0.05). Conclusions: Comparing with bilateral small incision TLIF, ultrasonic osteotome assisted unilateral approach contralateral undercutting decompression also can achieve good treatment results, which features in less trauma, less effects on spinal stability, shorter operative time, and less intraoperative blood loss, and therefore worth in clinical promotion.