经皮椎间孔镜下减压联合侧前方小切口椎体间融合钉棒固定与微创经椎间孔椎体间融合术治疗单节段腰椎不稳的疗效比较

Comparison of the efficacy of percutaneous transforaminal endoscopic surgery combined with mini-incision oblique lumbar interbody fusion and anterolateral screw-rod fixation with minimally invasive surgery-transforaminal lumbar interbody fusion for single-segment lumbar spinal instability

中文关键词:  腰椎不稳  经皮椎间孔镜  斜侧方椎体间融合术  经椎间孔椎体间融合术  钉棒固定

英文关键词:Lumbar instability  Percutaneous transforaminal endoscopsurgery  Oblique lumbar interbody fusion  Transforaminal lumbar interbody fusion  Screw rod fixation

中文摘要:

  【摘要】 目的：评估局麻下经皮椎间孔镜下减压（percutaneous transforaminal endoscopic surgery，PTES）联合侧前方小切口斜侧方椎体间融合（oblique lumbar interbody fusion，OLIF）钉棒固定术治疗单节段腰椎不稳的临床疗效和安全性，并与微创经椎间孔椎体间融合术（minimally invasive surgery-transforaminal lumbar interbody fusion，MIS-TLIF）进行对比。方法：回顾性分析2017年6月~2019年4月在复旦大学附属中山医院骨科治疗的伴有神经症状的68例单节段腰椎不稳患者的临床资料，其中33例采用PTES联合侧前方小切口OLIF钉棒固定治疗（PTES+OLIF，A组，男20例，女13例；年龄59.4±8.0岁；L3/4 4例，L4/5 29例）；35例采用MIS-TLIF治疗（B组，男22例，女13例；年龄61.2±7.5岁；L3/4 4例，L4/5 31例）。两组患者的年龄、性别比和节段均无统计学差异。比较两组手术时间、出血量、切口长度、透视次数和住院时间。记录并比较术前和术后即刻、1个月、2个月、3个月、6个月、1年、2年时的腰痛和腿痛视觉模拟量表（visual analog scale，VAS）评分；术前、术后即刻及术后2年时的Oswestry功能障碍指数（Oswestry disability index，ODI）、椎间高度(intervertebral space height，ISH)、腰椎前凸角（lumbar lordosis，LL）、手术节段前凸角（surgical segment lordosis angle，SLA）及术中和术后并发症，采用Bridwell 融合分级评估腰椎融合情况。结果：两组均顺利完成手术，术中均未发生并发症。A组局麻下PTES手术时间为49.5±7.6min，全麻下OLIF手术时间为75.3±13.1min；B组全麻下手术时间为103.9±17.6min。A组术中出血量30mL（15~110mL），B组80mL（50~310mL）。A组PTES切口长度8.0±1.2mm，OLIF切口长度39.0±3.3mm；B组切口长度41.5±2.8mm。A组PTES透视6次（5~8次），OLIF透视7次（5~10次）；B组透视7次（6~11次）。A组住院时间4d（3~5d），B组7d（6~10d）。术后两组均随访2年。与术前相比，两组术后各时点的腰痛、下肢痛VAS评分及ODI均显著性下降（P<0.05）；术后即刻A组腰痛VAS评分显著性低于B组（P<0.000），其余各时间点两组间腰痛和下肢痛VAS评分和ODI均无统计学差异（P>0.05）。A组术后即刻ISH及SLA均显著高于B组（P=0.018，P=0.002），术后2年随访时A组ISH显著性高于B组（P=0.004）。两组间术后各时间点LL无显著性差异（P>0.05）。A组中Ⅰ级融合25例（75.8%），Ⅱ级融合8例（24.2%）；B组中Ⅰ级融合21例（60.0%），Ⅱ级融合14例（40.0%），两组间融合等级无统计学差异（P=0.126）。A组1例术后发生屈髋疼痛和无力，在术后3d时缓解。B组2例发生硬膜撕裂、脑脊液漏，不伴神经症状，术后7d伤口愈合后拔除引流管。两组均无切口感染、永久性神经损伤、大血管破裂、内置物松动以及融合器下沉等并发症发生。两组术后并发症发生率无统计学差异（2.8% vs 5.7%，P=0.590）。结论：与MIS-TLIF治疗单节段腰椎不稳相比，PTES联合侧前方小切口OLIF钉棒固定创伤更小、出血更少、全麻手术时间更短、术后腰痛缓解更快、ISH和SLA恢复更好，PTES联合侧前方小切口OLIF钉棒固定是治疗需要直接减压腰椎不稳患者的良好选择。

英文摘要:

  【Abstract】 Objectives: To evaluate the clinical efficacy and safety of percutaneous transforaminal endoscopic surgery(PTES) combined with mini-incision oblique lumbar interbody fusion(OLIF) and screw-rod fixation under local anesthesia for the treatment of single-segment lumbar instability, and to compare it with minimally invasive surgery-transforaminal lumbar interbody fusion(MIS-TLIF). Methods: A total of 68 patients with single-segment lumbar instability and neurological symptoms who were treated in the Department of Orthopedics at Zhongshan Hospital, Fudan University, between June 2017 and April 2019 were retrospectively analyzed. Of the patients, 33 underwent PTES combined with mini-incision OLIF and screw-rod fixation(PTES+OLIF, Group A, 20 males and 13 females; age 59.4±8.0 years; L3/4 4 cases, L4/5 29 cases), while the other 35 underwent MIS-TLIF(Group B, 22 males and 13 females; age 61.2±7.5 years; L3/4 4 cases, L4/5 31 cases). There were no significant differences between the two groups in terms of age, sex ratio, or level of involvement. The operative time, blood loss, incision length, fluoroscopy times, and length of hospital stay were compared between the two groups. Visual analog scale(VAS) scores for back pain and leg pain were recorded and compared at preoperation, immediate postoperation, 1 month, 2 months, 3 months, 6 months, 1 year, and 2 year time points. The Oswestry disability index(ODI), intervertebral space height(ISH), lumbar lordosis(LL), surgical segment lordosis angle(SLA), intraoperative and postoperative complications, and fusion grade according to the Bridwell classification were also compared and evaluated at preoperation, immediate postoperation, and postoperative 2 years. Results: Both groups of patients successfully completed the surgeries without intraoperative complications. The operative time was 49.5±7.6min for PTES under local anesthesia, and 75.3±13.1min for OLIF under general anesthesia in group A, while it was 103.9±17.6min for MIS-TLIF under general anesthesia in group B. The intraoperative blood loss was 30mL(range 15-110mL) in group A and 80mL(range 50-310mL) in group B. The incision length was 8.0±1.2mm for PTES, and 39.0±3.3mm for OLIF in group A; The incision length was 41.5±2.8mm for MIS-TLIF in group B. The number of fluoroscopy was 6(range 5-8) for PTES and 7(range 5-10) for OLIF in group A, and 7(range 6-11) in group B. The length of hospital stay was 4d(range 3-5d) in group A and 7d(range 6-10d) in group B. Both groups were followed up for 2 years. Compared with preoperative levels, the VAS scores for back and leg pain, and ODI were significantly decreased at all postoperative time points(P<0.05) in both groups. The immediate postoperative VAS score for back pain in group A was significantly lower than that in group B(P<0.000). However, at subsequent time points, no significant differences in VAS scores for back and leg pain, or ODI were found between the two groups(P>0.05). The ISH and SLA at immediate postoperation in group A were significantly higher than those in group B(P=0.018, P=0.002). At 2 years′ follow-up, the ISH in group A remained significantly higher than that in group B(P=0.004). There was no significant difference in LL between the two groups at all postoperative time points(P>0.05). 25 cases(75.8%) in group A achieved grade Ⅰ fusion, and 8 cases(24.2%) achieved grade Ⅱ fusion; In group B, 21 cases(60.0%) achieved grade Ⅰ fusion, and 14 cases(40.0%) achieved grade Ⅱ fusion. There was no significant difference in the fusion grade between the two groups(P=0.126). One patient in group A developed hip flexion pain and weakness, which resolved at 3d after operation. Two cases of dural tear with cerebrospinal fluid leakage occurred in group B, without neurological symptoms, and resolved after drainage tube removal at 7d postoperatively. No incision infections, permanent nerve damage, major vascular injury, implant loosening, or subsidence were observed. The postoperative complication rate was not significantly different between the two groups(2.8% vs 5.7%, P=0.590). Conclusions: Compared with MIS-TLIF for the treatment of single-segment lumbar instability, PTES combined with mini-incision OLIF and screw-rod fixation offers smaller trauma, less blood loss, shorter general anesthesia duration, faster relief of back pain, and better recovery of ISH and SLA. PTES combined with mini-incision OLIF and screw-rod fixation is an excellent choice for treating patients with lumbar instability who need direct decompression.