超声骨刀单侧开窗双侧减压后路腰椎椎体间融合术治疗退变性腰椎管狭窄症
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摘要
目的比较超声骨刀单侧开窗双侧减压后路腰椎椎体间融合术(posterior lumbar interbody fusion,PLIF)与传统工具全椎板切除减压PLIF治疗退变性腰椎管狭窄症患者的临床疗效。方法回顾分析2017年1月—6月收治的48例单节段退变性腰椎管狭窄症患者临床资料,其中采用超声骨刀行单侧开窗双侧减压PLIF治疗27例(A组),采用传统工具行全椎板切除减压PLIF治疗21例(B组)。两组患者性别、年龄、狭窄节段、椎管狭窄程度、病程比较,差异均无统计学意义(P>0.05),具有可比性。记录并比较两组患者椎板切除减压时间、术中出血量、术后引流量及手术相关并发症发生情况。末次随访时采用Bridwell植骨融合标准评估植骨融合情况。术后3 d及3、6个月采用疼痛视觉模拟评分(VAS)评估患者腰背部疼痛情况,术前及术后6个月采用Oswestry功能障碍指数(ODI)评分评估患者腰背部功能改善情况。结果 A组患者椎板切除减压时间显著多于B组,术中出血量及术后引流量显著少于B组,差异均有统计学意义(P<0.05)。两组患者均未出现神经根损伤、硬脊膜撕裂,术中、术后未出现脑脊液漏及血肿形成。两组患者术后均获随访,A组随访时间为6～18个月,平均10.5个月;B组为6～20个月,平均9.3个月。两组随访期间均未出现内固定物断裂、松动及拔钉等并发症。术后3 d两组VAS评分比较差异无统计学意义(t=1.448,P=0.154);术后3、6个月,A组VAS评分显著低于B组(P<0.05)。两组患者术后6个月ODI评分均较术前显著改善(P<0.05),术前及术后6个月两组间ODI评分比较差异均无统计学意义(P>0.05)。末次随访时根据Bridwell植骨融合标准,两组植骨融合情况比较差异无统计学意义(Z=–0.065,P=0.949);A、B组植骨融合率分别为96.3%(26/27)和95.2%(20/21),比较差异无统计学意义(χ2=0.001,P=0.979)。结论采用超声骨刀单侧开窗双侧减压PLIF治疗腰椎管狭窄症,可获得与传统工具全椎板切除减压PLIF相似的临床疗效,同时能减少术中出血量和术后引流量,短期随访可降低腰背部疼痛程度,是一种安全有效的手术方式。
Objective To compare the effectiveness of posterior lumbar interbody fusion(PLIF) by unilateral fenestration and bilateral decompression with ultrasounic osteotome and traditional tool total laminectomy decompression PLIF in the treatment of degenerative lumbar spinal stenosis. Methods The clinical data of 48 patients with single-stage degenerative lumbar spinal stenosis between January 2017 and June 2017 were retrospectively analyzed.Among them, 27 patients were treated with unilateral fenestration and bilateral decompression PLIF with ultrasonic osteotome(group A), and 21 patients were treated with total laminectomy and decompression PLIF with traditional tools(group B). There was no significant difference in gender, age, stenosis segment, degree of spinal canal stenosis, and disease duration between the two groups(P>0.05), which was comparable. The time of laminectomy decompression,intraoperative blood loss, postoperative drainage volume, and the occurrence of operation-related complications were recorded and compared between the two groups. Bridwell bone graft fusion standard was applied to evaluate bone graft fusion at last follow-up. Visual analogue scale(VAS) score was used to evaluate the patients' lumbar and back pain at3 days, 3 months, and 6 months after operation. Oswestry disability index(ODI) score was used to evaluate the patients' lumbar and back function improvement before operation and at 6 months after operation. Results The time of laminectomy decompression in group A was significantly longer than that in group B, and the intraoperative blood loss and postoperative drainage volume were significantly less than those in group B(P<0.05). There was no nerve root injury,dural tear, cerebrospinal fluid leakage, and hematoma formation during and after operation in the two groups. All patients were followed up after operation, the follow-up time in group A was 6-18 months(mean, 10.5 months) and in group B was6-20 months(mean, 9.3 months). There was no complication such as internal fixation fracture, loosening and nail pulling occurred during the follow-up period of the two groups. There was no significant difference in VAS scores between the two groups at 3 days after operation(t=1.448, P=0.154); the VAS score of group A was significantly lower than that of group B at 3 and 6 months after operation(P<0.05). The ODI scores of the two groups were significantly improved at6 months after operation(P<0.05), and there was no significant difference in ODI scores between the two groups before operation and at 6 months after operation(P>0.05). At last follow-up, according to Bridwell criteria, there was no significant difference in bone graft fusion between the two groups(Z=–0.065, P=0.949); the fusion rates of groups A and B were 96.3%(26/27) and 95.2%(20/21) respectively, with no significant difference(χ2=0.001, P=0.979). Conclusion The treatment of lumbar spinal stenosis with unilateral fenestration and bilateral decompression PLIF with ultrasonic osteotome can achieve similar effectiveness as traditional tool total laminectomy and decompression PLIF, reduce intraoperative blood loss and postoperative drainage, and reduce lumbar back pain during short-term follow-up. It is a safe and effective operation method.
Objective To compare the effectiveness of posterior lumbar interbody fusion(PLIF) by unilateral fenestration and bilateral decompression with ultrasounic osteotome and traditional tool total laminectomy decompression PLIF in the treatment of degenerative lumbar spinal stenosis. Methods The clinical data of 48 patients with single-stage degenerative lumbar spinal stenosis between January 2017 and June 2017 were retrospectively analyzed.Among them, 27 patients were treated with unilateral fenestration and bilateral decompression PLIF with ultrasonic osteotome(group A), and 21 patients were treated with total laminectomy and decompression PLIF with traditional tools(group B). There was no significant difference in gender, age, stenosis segment, degree of spinal canal stenosis, and disease duration between the two groups(P>0.05), which was comparable. The time of laminectomy decompression,intraoperative blood loss, postoperative drainage volume, and the occurrence of operation-related complications were recorded and compared between the two groups. Bridwell bone graft fusion standard was applied to evaluate bone graft fusion at last follow-up. Visual analogue scale(VAS) score was used to evaluate the patients' lumbar and back pain at3 days, 3 months, and 6 months after operation. Oswestry disability index(ODI) score was used to evaluate the patients' lumbar and back function improvement before operation and at 6 months after operation. Results The time of laminectomy decompression in group A was significantly longer than that in group B, and the intraoperative blood loss and postoperative drainage volume were significantly less than those in group B(P<0.05). There was no nerve root injury,dural tear, cerebrospinal fluid leakage, and hematoma formation during and after operation in the two groups. All patients were followed up after operation, the follow-up time in group A was 6-18 months(mean, 10.5 months) and in group B was6-20 months(mean, 9.3 months). There was no complication such as internal fixation fracture, loosening and nail pulling occurred during the follow-up period of the two groups. There was no significant difference in VAS scores between the two groups at 3 days after operation(t=1.448, P=0.154); the VAS score of group A was significantly lower than that of group B at 3 and 6 months after operation(P<0.05). The ODI scores of the two groups were significantly improved at6 months after operation(P<0.05), and there was no significant difference in ODI scores between the two groups before operation and at 6 months after operation(P>0.05). At last follow-up, according to Bridwell criteria, there was no significant difference in bone graft fusion between the two groups(Z=–0.065, P=0.949); the fusion rates of groups A and B were 96.3%(26/27) and 95.2%(20/21) respectively, with no significant difference(χ2=0.001, P=0.979). Conclusion The treatment of lumbar spinal stenosis with unilateral fenestration and bilateral decompression PLIF with ultrasonic osteotome can achieve similar effectiveness as traditional tool total laminectomy and decompression PLIF, reduce intraoperative blood loss and postoperative drainage, and reduce lumbar back pain during short-term follow-up. It is a safe and effective operation method.
引文
1 Azimi P, Mohammadi HR, Benzel EC, et al. Lumbar spinal canal stenosis classification criteria:a new tool. Asian Spine J, 2015, 9(3):399-406.
2 Ulutas M, Yaldiz C, Secer M, et al. Comparison of wiltse and classical methods in surgery of lumbar spinal stenosis and spondylolisthesis. Neurol Neurochir Pol, 2015, 49(4):251-257.
3李玉伟,王海蛟,崔巍,等.超声骨刀在颈椎后路单开门椎管扩大成形术中的应用.中国修复重建外科杂志,2017, 31(6):683-689.
4胡博文,周春光,杨曦,等.经后路超声骨刀双侧切除齿状突治疗颅底凹陷症合并不可复性寰枢关节脱位一例.中国修复重建外科杂志,2017, 31(12):1523-1525.
5陈萧霖,曾岩,陈仲强,等.超声骨刀与传统工具在退变性腰椎侧凸减压截骨术中的应用比较.中国脊柱脊髓杂志,2017, 27(5):418-422.
6 Morimoto D, Isu T, Kim K, et al. Microsurgical medial fenestration with an ultrasonic bone curette for lumbar foraminal stenosis. J Nippon Med Sch, 2012, 79(5):327-334.
7 Kalichman L, Cole R, Kim DH, et al. Spinal stenosis prevalence and association with symptoms:the Framingham Study. Spine J, 2009,9(7):545-550.
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? Spine(Phila Pa1976), 1995, 20(12):1410-1418.
9陈颖,罗晓宇,史文勇,等.超声手术刀的研制现状与应用.生物医学工程学杂志,2005, 22(2):377-380.
10 Ying C, Zhaoying Z, Ganghua Z, et al. Effects of different tissue loads on high power ultrasonic surgery scalpel. Ultrasound Med Biol, 2006, 32(3):415-420.
11 Nickele C, Hanna A, Baskaya MK. Osteotomy for laminoplasty without soft tissue penetration, performed using a harmonic bone scalpel:instrumentation and technique. J Neurol Surg A Cent Eur Neurosurg,2013, 74(3):183-186.
12 Hazer DB, Yasar B, Rosberg HE, et al. Technical aspects on the use of ultrasonic bone Shaver in spine surgery:experience in 307patients. Biomed Res Int, 2016,2016:8428530.
13 Onen MR, Yuvruk E, Akay S, et al. The reliability of the ultrasonic bone scalpel in cervical spondylotic myelopathy:a comparative study of 46 patients. World Neurosurg, 2015, 84(6):1962-1967.
14徐宝山,马信龙,胡永成,等.可动式椎间盘镜下单侧开窗双侧减压椎体间融合术治疗复杂的腰椎管狭窄症.中华骨科杂志,2016, 36(12):753-760.
15闫立伟,王文波.单侧开窗潜行减压治疗双侧腰椎管狭窄的临床研究.哈尔滨医科大学学报,2014, 48(6):509-512.
16 Sanderson PL, Getty CJ. Long-term results of partial undercutting facetectomy for lumbar lateral recess stenosis. Spine(Phila Pa1976), 1996,21(11):1352-1356.
17 Sanborn MR, Balzer J, Gerszten PC, et al. Safety and efficacy of a novel ultrasonic osteotome device in an ovine model. J Clin Neurosci, 2011,18(11):1528-1533.
18田伟,郎昭.进一步促进骨磨削技术在脊柱外科的应用.中华医学杂志,2015, 95(13):961-964.
19王岩,陈仲强,孙垂国.超声骨刀在胸椎管狭窄症手术中应用的有效性与安全性.中国脊柱脊髓杂志,2015, 25(6):518-523.
20张吉涛,陈佳,李政,等.超声骨刀在脊髓型颈椎病全椎板切除术中的应用.中国脊柱脊髓杂志,2018, 28(3):234-238.
21 Cho KJ, Suk SI, Park SR, et al. Complications in posterior fusion and instrumentation for degenerative lumbar scoliosis. Spine(Phila Pa 1976), 2007, 32(20):2232-2237.
22赵会,胡辰甫,海涌.脊柱畸形矫形术后严重并发症危险因素分析.中华医学杂志,2016, 96(23):1815-1817.
23 Hu X, Ohnmeiss DD, Lieberman IH. Use of an ultrasonic osteotome device in spine surgery:experience from the first 128patients. Eur Spine J, 2013, 22(12):2845-2849.
2 Ulutas M, Yaldiz C, Secer M, et al. Comparison of wiltse and classical methods in surgery of lumbar spinal stenosis and spondylolisthesis. Neurol Neurochir Pol, 2015, 49(4):251-257.
3李玉伟,王海蛟,崔巍,等.超声骨刀在颈椎后路单开门椎管扩大成形术中的应用.中国修复重建外科杂志,2017, 31(6):683-689.
4胡博文,周春光,杨曦,等.经后路超声骨刀双侧切除齿状突治疗颅底凹陷症合并不可复性寰枢关节脱位一例.中国修复重建外科杂志,2017, 31(12):1523-1525.
5陈萧霖,曾岩,陈仲强,等.超声骨刀与传统工具在退变性腰椎侧凸减压截骨术中的应用比较.中国脊柱脊髓杂志,2017, 27(5):418-422.
6 Morimoto D, Isu T, Kim K, et al. Microsurgical medial fenestration with an ultrasonic bone curette for lumbar foraminal stenosis. J Nippon Med Sch, 2012, 79(5):327-334.
7 Kalichman L, Cole R, Kim DH, et al. Spinal stenosis prevalence and association with symptoms:the Framingham Study. Spine J, 2009,9(7):545-550.
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? Spine(Phila Pa1976), 1995, 20(12):1410-1418.
9陈颖,罗晓宇,史文勇,等.超声手术刀的研制现状与应用.生物医学工程学杂志,2005, 22(2):377-380.
10 Ying C, Zhaoying Z, Ganghua Z, et al. Effects of different tissue loads on high power ultrasonic surgery scalpel. Ultrasound Med Biol, 2006, 32(3):415-420.
11 Nickele C, Hanna A, Baskaya MK. Osteotomy for laminoplasty without soft tissue penetration, performed using a harmonic bone scalpel:instrumentation and technique. J Neurol Surg A Cent Eur Neurosurg,2013, 74(3):183-186.
12 Hazer DB, Yasar B, Rosberg HE, et al. Technical aspects on the use of ultrasonic bone Shaver in spine surgery:experience in 307patients. Biomed Res Int, 2016,2016:8428530.
13 Onen MR, Yuvruk E, Akay S, et al. The reliability of the ultrasonic bone scalpel in cervical spondylotic myelopathy:a comparative study of 46 patients. World Neurosurg, 2015, 84(6):1962-1967.
14徐宝山,马信龙,胡永成,等.可动式椎间盘镜下单侧开窗双侧减压椎体间融合术治疗复杂的腰椎管狭窄症.中华骨科杂志,2016, 36(12):753-760.
15闫立伟,王文波.单侧开窗潜行减压治疗双侧腰椎管狭窄的临床研究.哈尔滨医科大学学报,2014, 48(6):509-512.
16 Sanderson PL, Getty CJ. Long-term results of partial undercutting facetectomy for lumbar lateral recess stenosis. Spine(Phila Pa1976), 1996,21(11):1352-1356.
17 Sanborn MR, Balzer J, Gerszten PC, et al. Safety and efficacy of a novel ultrasonic osteotome device in an ovine model. J Clin Neurosci, 2011,18(11):1528-1533.
18田伟,郎昭.进一步促进骨磨削技术在脊柱外科的应用.中华医学杂志,2015, 95(13):961-964.
19王岩,陈仲强,孙垂国.超声骨刀在胸椎管狭窄症手术中应用的有效性与安全性.中国脊柱脊髓杂志,2015, 25(6):518-523.
20张吉涛,陈佳,李政,等.超声骨刀在脊髓型颈椎病全椎板切除术中的应用.中国脊柱脊髓杂志,2018, 28(3):234-238.
21 Cho KJ, Suk SI, Park SR, et al. Complications in posterior fusion and instrumentation for degenerative lumbar scoliosis. Spine(Phila Pa 1976), 2007, 32(20):2232-2237.
22赵会,胡辰甫,海涌.脊柱畸形矫形术后严重并发症危险因素分析.中华医学杂志,2016, 96(23):1815-1817.
23 Hu X, Ohnmeiss DD, Lieberman IH. Use of an ultrasonic osteotome device in spine surgery:experience from the first 128patients. Eur Spine J, 2013, 22(12):2845-2849.