微创经椎间孔腰椎椎体间融合术与传统开放手术的疗效和对多裂肌损伤的对比研究
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摘要
目的比较微创经椎间孔腰椎椎体间融合术(transforaminal lumbar interbody fusion,TLIF)与传统开放后路腰椎椎体间融合术(posterior lumbar interbody fusion,PLIF)之间的临床疗效和对多裂肌损伤程度。方法回顾性分析2014年1~12月,我院收治的110例患者的临床资料,其中60例采用传统开放PLIF治疗(开放组),50例采用微创Quadrant系统下TLIF治疗(微创组)。比较两组的手术时间、术中出血量、术后引流量、住院时间、住院花费、并发症发生率、融合率。采用术前与末次随访的疼痛视觉模拟评分(visual analogue scale,VAS)、Oswestry功能障碍指数(oswestry disability index,ODI)评分、日本骨科协会(Japanese orthopaedic association,JOA)评分评估临床疗效。22例(开放组12例;微创组10例)从MRI影像测量术前与末次随访的多裂肌横截面积(cross-sectional area,CSA)及萎缩分级。结果微创组术中出血量为(267.82±174.33)ml、术后引流量为(188.34±153.18)ml,均明显低于开放组的(443.03±347.64)ml和(323.27±278.31)ml,差异均有统计学意义(P=0.002、P=0.004)。微创组住院花费比开放组平均高1.5万元,其并发症发生率为22.00%,高于开放组的11.67%,但差异均无统计学意义(P>0.05)。开放组ΔVAS(VAS_(术前)-VAS_(末次随访))、ΔODI(ODI_(术前)-ODI_(末次随访))、JOA改善率分别为(4.49±1.61)分、(40.44±20.52)%、(59.73±24.74)%,微创组分别为(3.89±2.01)分、(37.81±23.02)%、(51.92±36.42)%,差异均无统计学意义(P>0.05)。开放组多裂肌ΔCSA(CSA_(术前)-CSA_(末次随访))为(171.63±93.51)mm~2,微创组为(127.66±71.43)mm~2,两组多裂肌ΔCSA及末次随访萎缩分级的差异均无统计学意义(P>0.05)。结论微创TLIF能明显减少术中出血量及术后引流量,但其临床疗效和对多裂肌的损伤并没有明显优于开放PLIF。
Objective To compare the clinical outcomes and multifidus injury between transforaminal lumbar interbody fusion( TLIF) and conventional posterior lumbar interbody fusion( PLIF). Methods From January 2014 to December 2014, 110 cases were selected. Sixty patients underwent open PLIF, while 50 patients underwent minimally invasive TLIF under Quadrant system. The following data were compared between the 2 groups: surgical time, intraoperative blood loss, postoperative drainage, length of hospitalization, costs, complication rate and fusion rate. Preoperative and postoperative results were evaluated by visual analogue scale( VAS), oswestry disability index( ODI) scores, Japanese orthopaedic association( JOA) scores. Multifidus cross-sectional area( CSA) and atrophy grading were measured on MRI in 22 cases( 12 cases in open PLIF group; 10 in TLIF group). ResultsIn TLIF group, intraoperative blood loss was( 267.82 ± 174.33) ml, and postoperative drainage was( 188.34 ± 153.18) ml, which were significantly lower than those in PLIF group( 443.03 ± 347.64) ml and( 323.27 ± 278.31) ml( P = 0.002, P = 0.004). The costs in TLIF group was 15 000 yuan which was on average higher than that in the PLIF group, and the complication rate was 22.00% in TLIF group which was higher than 11.67% in PLIF group, but there were no significant differences between the 2 groups( P > 0.05). The ΔVAS( VAS_(preoperative)-VAS_(last follow-up)), ΔODI( ODI_(preoperative)-ODI_(last follow-up)) and JOA improvement rate were( 4.49 ± 1.61),( 40.44 ± 20.52) %,( 59.73 ± 24.74) % in PLIF group, and( 3.89 ± 2.01),( 37.81 ± 23.02) %,( 51.92 ± 36.42) % in TLIF group respectively, with no significant differences between the 2 groups( P > 0.05). The multifidus ΔCSA( CSA_(preoperative)-CSA_(last follow-up)) was( 171.63 ± 93.51) mm2 in PLIF group and( 127.66 ± 71.43) mm2 in TLIF group, with no significant differences in ΔCSA and last follow-up atrophy grading( P > 0.05). Conclusions Minimally invasive TLIF can significantly reduce intraoperative blood loss and postoperative drainage, but its clinical outcomes are not significantly better and the injury to the multifidus is not significantly less than open PLIF.
Objective To compare the clinical outcomes and multifidus injury between transforaminal lumbar interbody fusion( TLIF) and conventional posterior lumbar interbody fusion( PLIF). Methods From January 2014 to December 2014, 110 cases were selected. Sixty patients underwent open PLIF, while 50 patients underwent minimally invasive TLIF under Quadrant system. The following data were compared between the 2 groups: surgical time, intraoperative blood loss, postoperative drainage, length of hospitalization, costs, complication rate and fusion rate. Preoperative and postoperative results were evaluated by visual analogue scale( VAS), oswestry disability index( ODI) scores, Japanese orthopaedic association( JOA) scores. Multifidus cross-sectional area( CSA) and atrophy grading were measured on MRI in 22 cases( 12 cases in open PLIF group; 10 in TLIF group). ResultsIn TLIF group, intraoperative blood loss was( 267.82 ± 174.33) ml, and postoperative drainage was( 188.34 ± 153.18) ml, which were significantly lower than those in PLIF group( 443.03 ± 347.64) ml and( 323.27 ± 278.31) ml( P = 0.002, P = 0.004). The costs in TLIF group was 15 000 yuan which was on average higher than that in the PLIF group, and the complication rate was 22.00% in TLIF group which was higher than 11.67% in PLIF group, but there were no significant differences between the 2 groups( P > 0.05). The ΔVAS( VAS_(preoperative)-VAS_(last follow-up)), ΔODI( ODI_(preoperative)-ODI_(last follow-up)) and JOA improvement rate were( 4.49 ± 1.61),( 40.44 ± 20.52) %,( 59.73 ± 24.74) % in PLIF group, and( 3.89 ± 2.01),( 37.81 ± 23.02) %,( 51.92 ± 36.42) % in TLIF group respectively, with no significant differences between the 2 groups( P > 0.05). The multifidus ΔCSA( CSA_(preoperative)-CSA_(last follow-up)) was( 171.63 ± 93.51) mm2 in PLIF group and( 127.66 ± 71.43) mm2 in TLIF group, with no significant differences in ΔCSA and last follow-up atrophy grading( P > 0.05). Conclusions Minimally invasive TLIF can significantly reduce intraoperative blood loss and postoperative drainage, but its clinical outcomes are not significantly better and the injury to the multifidus is not significantly less than open PLIF.
引文
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[18]Park Y,Ha JW.Comparison of one-level posterior lumbar interbody fusion performed with a minimally invasive approach or a traditional open approach[J].Spine,2007,32(5):537-543.
[19]Dhall SS,Wang MY,Mummaneni PV.Clinical and radiographic comparison of mini-open transforaminal lumbar interbody fusion with open transforaminal lumbar interbody fusion in 42 patients with long-term follow-up[J].J Neurosurg Spine,2008,9(6):560-565.
[20]Epstein NE.Minimally invasive/endoscopic vs"open"posterior cervical laminoforaminotomy:do the risks outweigh the benefits[J]?Surg Neurol,2009,71(3):330-331.
[21]Hu ZJ,Fang XQ,Fan SW.Iatrogenic injury to the erector spinae during posterior lumbar spine surgery:underlying anatomical considerations,preventable root causes,and surgical tips and tricks[J].Eur J Orthop Surg Traumatol,2014,24(2):127-135.
[22]Laasonen EM.Atrophy of sacrospinal muscle groups in patients with chronic,diffusely radiating lumbar back pain[J].Neuroradiology,1984,26(1):9-13.
[23]Sihvonen T,Herno A,Paljarvi L,et al.Local denervation atrophy of paraspinal muscles in postoperative failed back syndrome[J].Spine,1993,18(5):575-581.
[24]Adogwa O,Johnson K,Min ET,et al.Extent of intraoperative muscle dissection does not affect long-term outcomes after minimally invasive surgery versus open-transforaminal lumbar interbody fusion surgery:A prospective longitudinal cohort study[J].Surg Neurol Int,2012,3(Suppl 5):S355-361.
[25]Kawaguchi Y,Matsui H,Tsuji H.Back muscle injury after posterior lumbar spine surgery.Part 2:Histologic and histochemical analyses in humans[J].Spine,1994,19(22):2598-2602.
[26]Gejo R,Matsui H,Kawaguchi Y,et al.Serial changes in trunk muscle performance after posterior lumbar surgery[J].Spine,1999,24(10):1023-1028.
[2]Peng CW,Yue WM,Poh SY,et al.Clinical and radiological outcomes of minimally invasive versus open transforaminal lumbar interbody fusion[J].Spine,2009,34(13):1385-1389.
[3]Villavicencio AT,Burneikiene S,Roeca CM,et al.Minimally invasive versus open transforaminal lumbar interbody fusion[J].Surg Neurol Int,2010,1(1):12.
[4]Wu RH,Fraser JF,Hartl R.Minimal access versus open transforaminal lumbar interbody fusion:meta-analysis of fusion rates[J].Spine,2010,35(26):2273-2281.
[5]Stevens KJ,Spenciner DB,Griffiths KL,et al.Comparison of minimally invasive and conventional open posterolateral lumbar fusion using magnetic resonance imaging and retraction pressure studies[J].J Spinal Disord Tech,2006,19(2):77-86.
[6]Arts M,Brand R,van der Kallen B,et al.Does minimally invasive lumbar disc surgery result in less muscle injury tharn conventional surgery?A randomized controlled trial[J].Eur Spine J,2011,20(1):51-57.
[7]Mirza SK,Deyo RA,Heagerty PJ,et al.Towards standardized measurement of adverse events in spine surgery:conceptual model and pilot evaluation[J].BMC Musculoskelet Disord,2006,7(1):53.
[8]Bridwell KH,Lenke LG,Mcenery KW,et al.Anterior fresh frozen structural allografts in the thoracic and lumbar spine.Do they work if combined with posterior fusion and instrumentation in adult patients with kyphosis or anterior column defects[J]?Spine,1995,20(12):1410-1418.
[9]Kader DF,Wardlaw D,Smith FW.Correlation between the MRI changes in the lumbar multifidus muscles and leg pain[J].Clin Radiol,2000,55(2):145-149.
[10]Lee MJ,Mok J,Patel P.Transforaminal lumbar interbody fusion:traditional open versus minimally invasive techniques[J].J Am Acad Orthop Surg,2018,26(4):124-131.
[11]Narain AS,Hijji FY,Markowitz JS,et al.Minimally invasive techniques for lumbar decompressions and fusions[J].Curr Rev Musculoskelet Med,2017,10(4):559-566.
[12]Schwender JD,Holly LT,Rouben DP,et al.Minimally invasive transforaminal lumbar interbody fusion(TLIF):technical feasibility and initial results[J].J Spinal Disord Tech,2005,(18Suppl):S1-6.
[13]Payer M."Minimally invasive"lumbar spine surgery:a critical review[J].Acta Neurochir(Wien),2011,153(7):1455-1459.
[14]Imada AO,Huynh TR,Drazin D.Minimally invasive versus open laminectomy/discectomy,transforaminal lumbar,and posterior lumbar interbody fusions:a systematic review[J].Cureus,2017,9(7):e1488.
[15]Schizas C,Tzinieris N,Tsiridis E,et al.Minimally invasive versus open transforaminal lumbar interbody fusion:evaluating initial experience[J].Int Orthop,2009,33(6):1683-1688.
[16]Dasenbrock HH,Juraschek SP,Schultz LR,et al.The efficacy of minimally invasive discectomy compared with open discectomy:a meta-analysis of prospective randomized controlled trials[J].J Neurosurg Spine,2012,16(5):452-462.
[17]Ebata S,Sato H,Orii H,et al.Risk management in posterior spinal endoscopic surgery in lumbar diseases[J].J Orthop Sci,2013,18(3):369-373.
[18]Park Y,Ha JW.Comparison of one-level posterior lumbar interbody fusion performed with a minimally invasive approach or a traditional open approach[J].Spine,2007,32(5):537-543.
[19]Dhall SS,Wang MY,Mummaneni PV.Clinical and radiographic comparison of mini-open transforaminal lumbar interbody fusion with open transforaminal lumbar interbody fusion in 42 patients with long-term follow-up[J].J Neurosurg Spine,2008,9(6):560-565.
[20]Epstein NE.Minimally invasive/endoscopic vs"open"posterior cervical laminoforaminotomy:do the risks outweigh the benefits[J]?Surg Neurol,2009,71(3):330-331.
[21]Hu ZJ,Fang XQ,Fan SW.Iatrogenic injury to the erector spinae during posterior lumbar spine surgery:underlying anatomical considerations,preventable root causes,and surgical tips and tricks[J].Eur J Orthop Surg Traumatol,2014,24(2):127-135.
[22]Laasonen EM.Atrophy of sacrospinal muscle groups in patients with chronic,diffusely radiating lumbar back pain[J].Neuroradiology,1984,26(1):9-13.
[23]Sihvonen T,Herno A,Paljarvi L,et al.Local denervation atrophy of paraspinal muscles in postoperative failed back syndrome[J].Spine,1993,18(5):575-581.
[24]Adogwa O,Johnson K,Min ET,et al.Extent of intraoperative muscle dissection does not affect long-term outcomes after minimally invasive surgery versus open-transforaminal lumbar interbody fusion surgery:A prospective longitudinal cohort study[J].Surg Neurol Int,2012,3(Suppl 5):S355-361.
[25]Kawaguchi Y,Matsui H,Tsuji H.Back muscle injury after posterior lumbar spine surgery.Part 2:Histologic and histochemical analyses in humans[J].Spine,1994,19(22):2598-2602.
[26]Gejo R,Matsui H,Kawaguchi Y,et al.Serial changes in trunk muscle performance after posterior lumbar surgery[J].Spine,1999,24(10):1023-1028.