Wiltse入路经椎间孔椎体间融合术治疗腰椎滑脱症的疗效分析
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摘要
目的探讨Wiltse人路经椎间孔椎体间融合术(transforaminal lumbar interbody fusion,TLIF)治疗腰椎滑脱症的疗效。方法回顾性分析2015年1月至2017年1月我院收治并获得随访的83例采用Wiltse入路TLIF技术治疗的腰椎滑脱病例。其中,男35例,女48例;年龄为(52.4±8.5)岁(33~75岁)。①记录病人手术时间、术中出血量及并发症等情况;②收集术前及末次随访时的腰痛和下肢痛的疼痛视觉模拟量表(visual analogue scale, V AS)评分和Oswestry功能障碍指数(Oswestry disability index, ODI);③通过观察影像学资料,测量椎间隙高度、椎间隙前凸角和腰椎前凸角,统计滑脱率。结果①本组手术时间为(135.0±15.7) min,术中出血量为(297.8±63.6) ml,术后随访时间为(28.6±6.7)个月(18-40个月),5例出现术后脑脊液漏,1例出现神经损伤,1例出现硬膜外血肿,2例发生浅表感染,1例出现深部感染。②腰痛VAS评分、下肢痛VAS评分及ODI分别由术前的(6.5±1.8)分、(5.0±3.0)分和59.7%±12.7%下降至末次随访时的(2.0±1.0)分、(1.4±1.2)分和19.5%±5.5%,差异均有统计学意义(P均<0.001)。③滑脱率由术前的21.4%±4.0%下降至末次随访时的7.3%±2.1%,椎间隙高度、椎间隙前凸角和腰椎前凸角分别由术前的(7.0±1.8)mm、3.0°±1.2°、38.5°±7.5°提高至末次随访时的(9.8±1.6)mm、5.2°±1.0°、41.3°±7.1°,差异均有统计学意义(P均<0.001)。结论经Wiltse人路TLIF技术能有效治疗腰椎滑脱症,对于恢复腰椎序列、缓解疼痛、功能改善是安全、可行、有效的。
Objective To explore the curative effect of transforaminal lumbar interbody fusion(TLIF)technique via the Wiltse approach in the treatment of lumbar spondylolisthesis. Methods A retrospectiveanalysis on 83 patients with lumbar spondylolisthesis treated by TLIF via the Wiltse approach from January2015 to January 2017 was made. Among them, there were 35 males and 48 females with the average age of(52.4±8.5) years(33-75 years). During the surgical operation, intraoperative blood loss and complications ofpatients were recorded. Visual analogue scale(VAS) scores of low back pain and lower limb pain and Oswestrydisability index(ODI) were collected before operation and at the last follow-up. The height of intervertebralspace, lumbar lordosis angle and lumbar lordosis angle were measured and the slippage rate was counted byobserving the imaging data. Results The operation time was(135.0±15.7) min and the amount of bleeding was(297.8 ± 63.6) mL. The follow-up time was(28.6 ± 6.7) months(18-40 months). There were 5 cases ofpostoperative cerebrospinal fluid leakage, 1 case of nerve damage, 1 case of epidural hematoma, 2 cases ofsuperficial infection and 1 case of deep infection. The VAS score of low back pain and lower limb pain and ODIdecreased from 6.5±1.8, 5.0±3.0 and 59.7%±12.7% before operation to 2.0±1.0, 1.4±1.2 and 19.5%±5.5% atthe last follow-up, respectively, and all the differences were statistically significant(all P<0.001). The meanslip rate decreased from 21.4%±4.0% preoperatively to 7.3%±2.1% at the last follow-up, the preoperativeintervertebral disc height(7.0±1.8) mm, segment lordosis angle was 3.0°±1.2° and lumbar lordosis angle 38.5°±7.5° increased to(9.8 ± 1.6) mm, 5.2° ± 1.0° and 41.3° ± 7.1° at the last follow-up, respectively, and all thedifferences were statistically significant(all P<0.001). Conclusion TLIF via the Wiltse approach caneffectively treat lumbar spondylolisthesis. It is safe, feasible and effective for restoring lumbar spine sequence,relieving pain and improving function.
Objective To explore the curative effect of transforaminal lumbar interbody fusion(TLIF)technique via the Wiltse approach in the treatment of lumbar spondylolisthesis. Methods A retrospectiveanalysis on 83 patients with lumbar spondylolisthesis treated by TLIF via the Wiltse approach from January2015 to January 2017 was made. Among them, there were 35 males and 48 females with the average age of(52.4±8.5) years(33-75 years). During the surgical operation, intraoperative blood loss and complications ofpatients were recorded. Visual analogue scale(VAS) scores of low back pain and lower limb pain and Oswestrydisability index(ODI) were collected before operation and at the last follow-up. The height of intervertebralspace, lumbar lordosis angle and lumbar lordosis angle were measured and the slippage rate was counted byobserving the imaging data. Results The operation time was(135.0±15.7) min and the amount of bleeding was(297.8 ± 63.6) mL. The follow-up time was(28.6 ± 6.7) months(18-40 months). There were 5 cases ofpostoperative cerebrospinal fluid leakage, 1 case of nerve damage, 1 case of epidural hematoma, 2 cases ofsuperficial infection and 1 case of deep infection. The VAS score of low back pain and lower limb pain and ODIdecreased from 6.5±1.8, 5.0±3.0 and 59.7%±12.7% before operation to 2.0±1.0, 1.4±1.2 and 19.5%±5.5% atthe last follow-up, respectively, and all the differences were statistically significant(all P<0.001). The meanslip rate decreased from 21.4%±4.0% preoperatively to 7.3%±2.1% at the last follow-up, the preoperativeintervertebral disc height(7.0±1.8) mm, segment lordosis angle was 3.0°±1.2° and lumbar lordosis angle 38.5°±7.5° increased to(9.8 ± 1.6) mm, 5.2° ± 1.0° and 41.3° ± 7.1° at the last follow-up, respectively, and all thedifferences were statistically significant(all P<0.001). Conclusion TLIF via the Wiltse approach caneffectively treat lumbar spondylolisthesis. It is safe, feasible and effective for restoring lumbar spine sequence,relieving pain and improving function.
引文
[1]Iguchi T, Wakami T, Kurihara A, et al. Lumbar multilevel degener-ative spondylolisthesis:radiological evaluation and factors relatedto anterolisthesis and retrolisthesis[J]. J Spinal Disord Tech,2002, 15(2):93-99.
[2]Jacobsen S, Sonne-Holm S, Rovsing H, et al. Degenerative lumbarspondylolisthesis:an epidemiological perspective:the CopenhagenOsteoarthritis Study[J]. Spine(Phila Pa 1976), 2007, 32(1):120-125.
[3]王力,邱南海.腰椎滑脱的手术治疗进展[J].赣南医学院学报,2017, 37(3):482-487.
[4]Lee N, Kim KN, Yi S, et al. Comparison of outcomes of anterior,posterior, and transforaminal lumbar interbody fusion surgery at asingle lumbar level with degenerative spinal disease[J]. WorldNeurosurg, 2017, 101:216-226.
[5]Kim SI, Ha KY, Kim YH, et al. A Comparative study of decompres-sive laminectomy and posterior lumbar interbody fusion in gradeⅠdegenerative lumbar spondylolisthesis[J]. Indian J Orthop,2018, 52(4):358-362.
[6]Schnake KJ, Schaeren S, Jeanneret B. Dynamic stabilization inaddition to decompression for lumbar spinal stenosis with degenera-tive spondylolisthesis[J]. Spine(Phila Pa 1976), 2006, 31(4):442-449.
[7]Orr RD. In patients with one-level lumbar degenerative spondylolis-thesis, a posterior approach with transforaminal lateral interbodyfusion improved radiographic but not clinical outcomes[J]. J BoneJoint Surg Am, 2018, 100(4):345.
[8]Rodgers WB, Lehmen JA, Gerber EJ, et al. Grade 2 spondylolisthe-sis at L4-5 treated by XLIF:safety and midterm results in the“worst case scenario”[J]. Sci World J, 2012:356712.
[9]方忠,高放,李锋,等.斜外侧腰椎椎间融合术联合后路导航经皮置钉固定治疗腰椎滑脱症的早期疗效[J].中华骨科杂志,2017, 37(16):980-988.
[10]de Kunder SL, van Kuijk SMJ, Rijkers K, et al. Transforaminallumbar interbody fusion(TLIF)versus posterior lumbar interbodyfusion(PLIF)in lumbar spondylolisthesis:a systematic review andmeta-analysis[J]. Spine J, 2017, 17(11):1712-1721.
[11]el-Masry MA, Khayal H, Salah H. Unilateral transforaminal lum-bar interbody fusion(TLIF)using a single cage for treatment of lowgrade lytic spondylolisthesis[J]. Acta Orthop Belg, 2008, 74(5):667-671.
[12]Rodriguez-Olaverri JC, Zimick NC, Merola A, et al. Comparing theclinical and radiological outcomes of pedicular transvertebralscrew fixation of the lumbosacral spine in spondylolisthesis versusunilateral transforaminal lumbar interbody fusion(TLIF)with pos-terior fixation using anterior cages[J]. Spine(Phila Pa 1976),2008, 33(18):1977-1981.
[13]Mehdian H, Kothari M. PLIF and modified TLIF using the PLIFapproach[J]. Eur Spine J, 2017, 26(Suppl 3):420-422.
[14]赵玲秀,杜心如,叶启彬,等.骶骨上关节突关节面5点7点螺钉进钉点的应用解剖学[J].中国临床解剖学杂志, 2003, 21(4):330-333.
[15]廖晖,李锋,熊伟,等. Wiltse入路和后正中入路治疗腰椎退行性疾病的疗效对比研究[J].骨科, 2013, 4(4):174-177.
[16]Wiltse LL, Bateman JG, Hutchinson RH, et al. The paraspinalsacrospinalis-splitting approach to the lumbar spine[J]. J BoneJoint Surg Am, 1968, 50(5):919-926.
[17]Gibson JN, Waddell G, Grant IC. Surgery for degenerative lumbarspondylosis[J]. Cochrane Database Syst Rev, 2000(2):CD001352.
[18]黄卫国,海涌.成人腰椎滑脱症复位程度对临床疗效的影响[J].实用骨科杂志, 2014, 20(4):293-298.
[19]Audat ZM, Darwish FT, Al Barbarawi MM, et al. Surgical manage-ment of low grade isthmic spondylolisthesis; a randomized con-trolled study of the surgical fixation with and without reduction[J].Scoliosis, 2011, 6(1):14.
[20]张志平,郭昭庆,孙垂国,等.退变性腰椎疾患后路减压术后脑脊液漏的相关因素分析及处理[J].中国脊柱脊髓杂志, 2014,24(10):906-911.
[21]中国医师协会骨科医师分会.中国医师协会骨科医师分会骨科循证临床诊疗指南:脊柱手术硬脊膜破裂及术后脑脊液渗漏的循证临床诊疗指南[J].中华外科杂志, 2017, 55(2):86-89.
[22]廖晖,徐卫国,李锋,等.人工硬脊膜联合生物蛋白胶修复颈椎术中硬脊膜损伤[J].生物骨科材料与临床研究, 2012, 9(4):17-19.
[23]Kao FC, Tsai TT, Chen LH, et al. Symptomatic epidural hematomaafter lumbar decompression surgery[J]. Eur Spine J, 2015, 24(2):348-357.
[24]Collins I, Wilson-MacDonald J, Chami G, et al. The diagnosis andmanagement of infection following instrumented spinal fusion[J].Eur Spine J, 2007, 17(3):445-450.
[25]Street JT, Andrew Glennie R, Dea N, et al. A comparison of theWiltse versus midline approaches in degenerative conditions of thelumbar spine[J]. J Neurosurg Spine, 2016, 25(3):332-338.
[2]Jacobsen S, Sonne-Holm S, Rovsing H, et al. Degenerative lumbarspondylolisthesis:an epidemiological perspective:the CopenhagenOsteoarthritis Study[J]. Spine(Phila Pa 1976), 2007, 32(1):120-125.
[3]王力,邱南海.腰椎滑脱的手术治疗进展[J].赣南医学院学报,2017, 37(3):482-487.
[4]Lee N, Kim KN, Yi S, et al. Comparison of outcomes of anterior,posterior, and transforaminal lumbar interbody fusion surgery at asingle lumbar level with degenerative spinal disease[J]. WorldNeurosurg, 2017, 101:216-226.
[5]Kim SI, Ha KY, Kim YH, et al. A Comparative study of decompres-sive laminectomy and posterior lumbar interbody fusion in gradeⅠdegenerative lumbar spondylolisthesis[J]. Indian J Orthop,2018, 52(4):358-362.
[6]Schnake KJ, Schaeren S, Jeanneret B. Dynamic stabilization inaddition to decompression for lumbar spinal stenosis with degenera-tive spondylolisthesis[J]. Spine(Phila Pa 1976), 2006, 31(4):442-449.
[7]Orr RD. In patients with one-level lumbar degenerative spondylolis-thesis, a posterior approach with transforaminal lateral interbodyfusion improved radiographic but not clinical outcomes[J]. J BoneJoint Surg Am, 2018, 100(4):345.
[8]Rodgers WB, Lehmen JA, Gerber EJ, et al. Grade 2 spondylolisthe-sis at L4-5 treated by XLIF:safety and midterm results in the“worst case scenario”[J]. Sci World J, 2012:356712.
[9]方忠,高放,李锋,等.斜外侧腰椎椎间融合术联合后路导航经皮置钉固定治疗腰椎滑脱症的早期疗效[J].中华骨科杂志,2017, 37(16):980-988.
[10]de Kunder SL, van Kuijk SMJ, Rijkers K, et al. Transforaminallumbar interbody fusion(TLIF)versus posterior lumbar interbodyfusion(PLIF)in lumbar spondylolisthesis:a systematic review andmeta-analysis[J]. Spine J, 2017, 17(11):1712-1721.
[11]el-Masry MA, Khayal H, Salah H. Unilateral transforaminal lum-bar interbody fusion(TLIF)using a single cage for treatment of lowgrade lytic spondylolisthesis[J]. Acta Orthop Belg, 2008, 74(5):667-671.
[12]Rodriguez-Olaverri JC, Zimick NC, Merola A, et al. Comparing theclinical and radiological outcomes of pedicular transvertebralscrew fixation of the lumbosacral spine in spondylolisthesis versusunilateral transforaminal lumbar interbody fusion(TLIF)with pos-terior fixation using anterior cages[J]. Spine(Phila Pa 1976),2008, 33(18):1977-1981.
[13]Mehdian H, Kothari M. PLIF and modified TLIF using the PLIFapproach[J]. Eur Spine J, 2017, 26(Suppl 3):420-422.
[14]赵玲秀,杜心如,叶启彬,等.骶骨上关节突关节面5点7点螺钉进钉点的应用解剖学[J].中国临床解剖学杂志, 2003, 21(4):330-333.
[15]廖晖,李锋,熊伟,等. Wiltse入路和后正中入路治疗腰椎退行性疾病的疗效对比研究[J].骨科, 2013, 4(4):174-177.
[16]Wiltse LL, Bateman JG, Hutchinson RH, et al. The paraspinalsacrospinalis-splitting approach to the lumbar spine[J]. J BoneJoint Surg Am, 1968, 50(5):919-926.
[17]Gibson JN, Waddell G, Grant IC. Surgery for degenerative lumbarspondylosis[J]. Cochrane Database Syst Rev, 2000(2):CD001352.
[18]黄卫国,海涌.成人腰椎滑脱症复位程度对临床疗效的影响[J].实用骨科杂志, 2014, 20(4):293-298.
[19]Audat ZM, Darwish FT, Al Barbarawi MM, et al. Surgical manage-ment of low grade isthmic spondylolisthesis; a randomized con-trolled study of the surgical fixation with and without reduction[J].Scoliosis, 2011, 6(1):14.
[20]张志平,郭昭庆,孙垂国,等.退变性腰椎疾患后路减压术后脑脊液漏的相关因素分析及处理[J].中国脊柱脊髓杂志, 2014,24(10):906-911.
[21]中国医师协会骨科医师分会.中国医师协会骨科医师分会骨科循证临床诊疗指南:脊柱手术硬脊膜破裂及术后脑脊液渗漏的循证临床诊疗指南[J].中华外科杂志, 2017, 55(2):86-89.
[22]廖晖,徐卫国,李锋,等.人工硬脊膜联合生物蛋白胶修复颈椎术中硬脊膜损伤[J].生物骨科材料与临床研究, 2012, 9(4):17-19.
[23]Kao FC, Tsai TT, Chen LH, et al. Symptomatic epidural hematomaafter lumbar decompression surgery[J]. Eur Spine J, 2015, 24(2):348-357.
[24]Collins I, Wilson-MacDonald J, Chami G, et al. The diagnosis andmanagement of infection following instrumented spinal fusion[J].Eur Spine J, 2007, 17(3):445-450.
[25]Street JT, Andrew Glennie R, Dea N, et al. A comparison of theWiltse versus midline approaches in degenerative conditions of thelumbar spine[J]. J Neurosurg Spine, 2016, 25(3):332-338.