经肌间隙入路通道腰椎固定融合术的并发症
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摘要
[目的]总结肌间隙入路通道显露下腰椎固定融合术的并发症。[方法] 2012年6月～2015年12月共治疗腰椎疾病467例,男203例,女264例;平均年龄(57.63±9.16)岁;单节段病变415例,两节段病变52例。采用肌间隙入路通道下单侧椎弓根螺钉固定并椎间融合术治疗58例,肌间隙入路通道下单侧椎弓根螺钉联合对侧椎板关节突螺钉固定并椎间融合术治疗192例,肌间隙入路通道下双侧椎弓根螺钉固定并椎间融合术治疗217例。观察其临床结果及并发症。[结果]术中并发症:异常出血2例、腰椎病变节段定位错误6例、椎弓根骨折7例、终板损伤4例、硬脊膜撕裂和脑脊液漏3例、神经损伤9例、椎弓根螺钉位置不正确12例、椎板关节突螺钉位置不正确15例。术后并发症:切口表皮部分坏死19例、切口愈合不良3例、切口深部感染1例、椎间排斥反应1例、血肿2例、再次手术6例。共446例获得6～36个月,平均(19.65±5.87)个月的随访。随访期内未发现内固定松动或断裂现象,出现融合器向后移位2例,融合器沉降19例。随访病例中除23例不能明确外均获得椎间融合,JOA评分均获得明显改善。[结论]肌间隙入路通道下固定融合治疗腰椎病变临床效果良好,但也存在较高的并发症,特别在早期开展阶段。
[Objective] To summarize the complications of lumbar instrumented fusion through intermuscular channel.[Methods] A retrospective study was conducted on 467 patients who included 203 males and 264 females aged(57.63±9.16)years on an average, and underwent surgical treatment for lumbar degenerative diseases that involved a single segment in 415 cases and double segments in 52 cases. Of them, 58 patients received unilateral pedicle screw combined with interbody cage,192 patients had operation performed with unilateral pedicle screw combined with contralateral lamina-facet screw and interbody cage, while the remaining 217 patients received bilateral pedicle screw combined with interbody cage through the intermuscular channel. The clinical outcomes and com-plications were compared among them. [Results] In term of intraoperative complications, there were abnormal bleeding in 2 cases, positioning error of involved lumbar segment in 6, pedicle fracture in 7, endplate damage in 4, dural tear and cerebrospinal fluid leakage in 3, nerve root injuries in 9, improper pedicle screw placement in 12, as well as inappropriate lamina-facet screw insertion in 15 cases. In addition, there were partial necrosis of incision skin in 19 cases, poor incision healing in 3, deep incision infection in 1, intervertebral rejection in 1, hematoma formation in 2 and revision surgery conducted in 6 cases secondary to the primary operation. Among the patients, 446 patients were followed up for 6 to 36 months with mean of(19.65±5.87) months.No pedicle screw loosening or breaking was noted in anyone of them, however, posterior displacement of cage happened in 2 and cage subsidence occurred in 19 patients during the follow-up. All the patients achieved bony fusion except 23 patients who could not be identified on images. At the latest follow up, all the patients had significant improvement regarding to JOA scores.[Conclusion] The lumbar instrumented fusion through intermuscular channel does achieve satisfactory clinical outcomes for lumbar degenerative diseases, despite of the relatively high incidence of complications, especially at early stage of performing this procedure.
[Objective] To summarize the complications of lumbar instrumented fusion through intermuscular channel.[Methods] A retrospective study was conducted on 467 patients who included 203 males and 264 females aged(57.63±9.16)years on an average, and underwent surgical treatment for lumbar degenerative diseases that involved a single segment in 415 cases and double segments in 52 cases. Of them, 58 patients received unilateral pedicle screw combined with interbody cage,192 patients had operation performed with unilateral pedicle screw combined with contralateral lamina-facet screw and interbody cage, while the remaining 217 patients received bilateral pedicle screw combined with interbody cage through the intermuscular channel. The clinical outcomes and com-plications were compared among them. [Results] In term of intraoperative complications, there were abnormal bleeding in 2 cases, positioning error of involved lumbar segment in 6, pedicle fracture in 7, endplate damage in 4, dural tear and cerebrospinal fluid leakage in 3, nerve root injuries in 9, improper pedicle screw placement in 12, as well as inappropriate lamina-facet screw insertion in 15 cases. In addition, there were partial necrosis of incision skin in 19 cases, poor incision healing in 3, deep incision infection in 1, intervertebral rejection in 1, hematoma formation in 2 and revision surgery conducted in 6 cases secondary to the primary operation. Among the patients, 446 patients were followed up for 6 to 36 months with mean of(19.65±5.87) months.No pedicle screw loosening or breaking was noted in anyone of them, however, posterior displacement of cage happened in 2 and cage subsidence occurred in 19 patients during the follow-up. All the patients achieved bony fusion except 23 patients who could not be identified on images. At the latest follow up, all the patients had significant improvement regarding to JOA scores.[Conclusion] The lumbar instrumented fusion through intermuscular channel does achieve satisfactory clinical outcomes for lumbar degenerative diseases, despite of the relatively high incidence of complications, especially at early stage of performing this procedure.
引文
[1] Pipaola CP, Molinari RW. Posterior lumbar interbody fusion[J].Am Acad Orthop Sur, 2008, 16(3):130-139.
[2] Periasamy K, Shah K, Wheelwright EF. Posterior lumbar interbody fusion using cages, combined with instrumented posterolateral fusion:a study of 75 cases[J]. Acta Orthop Belg, 2008, 74(2):240-248.
[3] Zeng ZY, Wu P, Yan WF, et al. Mixed fixation and interbody fusion for treatment single-segment lower lumbar vertebral disease:midterm follow-up results[J]. Orthop Surg, 2015, 7(11):324-332.
[4] Moreland DB, Asch HL, Czajka GA, et al. Posterior lumbar interbody fusion:comparison of single intervertebral cage and single side pedicle screw fixation versus bilateral cages and screw fixation[J]. Minim Invasive Neurosurg, 2009, 52(3):132-136.
[5] Sethi A, Lee S, Vaidya R. Transforaminal lumbar interbody fusion using unilateral pedicle screws and a translaminar screw[J]. Eur Spine, 2009, 18(3):430-434.
[6]曾忠友,严卫锋,陈国军,等.单侧椎弓根螺钉联合对侧椎板关节突螺钉固定并椎间融合治疗下腰椎病变的临床观察[J].中华骨科杂志, 2011, 31(8):834-839.
[7]曾忠友,吴鹏,孙德弢,等.两种不同固定方式并椎间融合治疗腰椎双节段病变的临床对比研究[J].中国骨伤, 2015, 28(10):903-909.
[8] Foley KT, Holly LT, Schwender JD. Minimally invasive lumbar fusion[J]. Spine(Phila Pa 1976), 2003, 28(15 Suppl):26-35.
[9] Bagan B, Patel N, Deutsch H, et al. Perioperative complications of minimally invasive surgery(MIS):comparison of MIS and open interbody fusion techniques[J]. Surg Technol Int, 2008, 17(2):281-286.
[10] Seng C, Siddiqui MA, Wong KP, et al. Five-year outcomes of minimally invasive versus open transforaminal lumbar interbody fusion:a matched-pair comparison study[J]. Spine(Phila Pa 1976),2013, 38(23):2049-2055.
[11] Awad BI, Lubelski D, Shin JH, et al. Bilateral pedicle screw fixation versus unilateral pedicle and contralateral facet screws for minimally invasive transforaminal lumbar interbody fusion:clinical outcomes and cost analysis[J]. Global Spine J, 2013, 3(4):225-230.
[12] Sidhu GS, Henkelman E, Vaccaro AR, et al. Minimally invasive versus open posterior lumbar interbody fusion:a systematic review[J]. Clin Orthop, 2014, 472(6):1792-1799.
[13]曾忠友,宋永兴,吴鹏,等.肌间隙入路通道下椎间融合术治疗腰椎病变的近期疗效[J].中华骨科杂志, 2015, 35(12):1191-1199.
[14] Silva PS, Pereira P, Monteiro P. Learning curve and complications of minimally invasive transforaminal lumbar interbody fusion[J].Neurosurg Focus, 2013, 35(2):E7.
[15]曾忠友,宋永兴,吴鹏,等.通道下经肌间隙入路联合固定并椎间融合治疗腰椎病变的早期并发症分析[J].中国矫形外科杂志, 2016, 24(17):1537-1544.
[16] Xu RM, Nabil A, Ebraheim, et al. Anatomy considerations of pedicle screw placement in the thoracis spine:Roy-Camille technique versus open-lamina technique[J]. Spine, 1998, 23(9):1065-1068.
[17] Sclafani JA, Kim CW. Complications associated with the initial learning curve of minimally invasive spine surgery:a systematic review[J]. Clin Orthop, 2014, 472(6):1711-1717.
[18] Krishna M, Pollock RD, Bhatia C. Incidence, etiology, classification, and management of neuralgia after posterior lumbar interbody fusion surgery in 226 patients[J]. Spine, 2008, 8(2):374-379.
[19] Raley DA, Mobbs RJ. Retrospective computed tomography scan analysis of percutaneously inserted pedicle screws for posterior transpedicular stabilization of the thoracic and lumbar spine:accuracy and complication rates[J]. Spine(Phila Pa 1976), 2012, 37(12):1092-1100.
[20] Krishna M, Pollock RD, Bhatia C. Incidence, etiology, classification, and management of neuralgia after posterior lumbar interbody fusion surgery in 226 patients[J]. Spine, 2008, 8(2):374-379.
[21]曾忠友,裴斐,张建乔,等.腰椎病变椎弓根螺钉固定融合术并发神经损伤的临床分析[J].脊柱外科杂志, 2016, 14(2):92-95.
[22]曾忠友,吴鹏,宋永兴,等.小切口单侧椎弓根螺钉联合对侧经皮椎板关节突螺钉固定并椎间融合治疗腰椎病变的并发症分析[J].中国骨伤, 2016, 29(3):34-43.
[23] Jurícek M, Rehák L, Tisovsk P, et al. The effect of complications on the quality of life after surgery for lumbar spine degenerative disease[J]. Acta Chir Orthop Traumatol Cech, 2010, 77(2):112-117.
[24] Sandri A, Regis D, Marino MA, et al. Lumbar artery injury following posterior spinal instrumentation for scoliosis[J]. Orthopedics,2011, 34(4):117-119.
[2] Periasamy K, Shah K, Wheelwright EF. Posterior lumbar interbody fusion using cages, combined with instrumented posterolateral fusion:a study of 75 cases[J]. Acta Orthop Belg, 2008, 74(2):240-248.
[3] Zeng ZY, Wu P, Yan WF, et al. Mixed fixation and interbody fusion for treatment single-segment lower lumbar vertebral disease:midterm follow-up results[J]. Orthop Surg, 2015, 7(11):324-332.
[4] Moreland DB, Asch HL, Czajka GA, et al. Posterior lumbar interbody fusion:comparison of single intervertebral cage and single side pedicle screw fixation versus bilateral cages and screw fixation[J]. Minim Invasive Neurosurg, 2009, 52(3):132-136.
[5] Sethi A, Lee S, Vaidya R. Transforaminal lumbar interbody fusion using unilateral pedicle screws and a translaminar screw[J]. Eur Spine, 2009, 18(3):430-434.
[6]曾忠友,严卫锋,陈国军,等.单侧椎弓根螺钉联合对侧椎板关节突螺钉固定并椎间融合治疗下腰椎病变的临床观察[J].中华骨科杂志, 2011, 31(8):834-839.
[7]曾忠友,吴鹏,孙德弢,等.两种不同固定方式并椎间融合治疗腰椎双节段病变的临床对比研究[J].中国骨伤, 2015, 28(10):903-909.
[8] Foley KT, Holly LT, Schwender JD. Minimally invasive lumbar fusion[J]. Spine(Phila Pa 1976), 2003, 28(15 Suppl):26-35.
[9] Bagan B, Patel N, Deutsch H, et al. Perioperative complications of minimally invasive surgery(MIS):comparison of MIS and open interbody fusion techniques[J]. Surg Technol Int, 2008, 17(2):281-286.
[10] Seng C, Siddiqui MA, Wong KP, et al. Five-year outcomes of minimally invasive versus open transforaminal lumbar interbody fusion:a matched-pair comparison study[J]. Spine(Phila Pa 1976),2013, 38(23):2049-2055.
[11] Awad BI, Lubelski D, Shin JH, et al. Bilateral pedicle screw fixation versus unilateral pedicle and contralateral facet screws for minimally invasive transforaminal lumbar interbody fusion:clinical outcomes and cost analysis[J]. Global Spine J, 2013, 3(4):225-230.
[12] Sidhu GS, Henkelman E, Vaccaro AR, et al. Minimally invasive versus open posterior lumbar interbody fusion:a systematic review[J]. Clin Orthop, 2014, 472(6):1792-1799.
[13]曾忠友,宋永兴,吴鹏,等.肌间隙入路通道下椎间融合术治疗腰椎病变的近期疗效[J].中华骨科杂志, 2015, 35(12):1191-1199.
[14] Silva PS, Pereira P, Monteiro P. Learning curve and complications of minimally invasive transforaminal lumbar interbody fusion[J].Neurosurg Focus, 2013, 35(2):E7.
[15]曾忠友,宋永兴,吴鹏,等.通道下经肌间隙入路联合固定并椎间融合治疗腰椎病变的早期并发症分析[J].中国矫形外科杂志, 2016, 24(17):1537-1544.
[16] Xu RM, Nabil A, Ebraheim, et al. Anatomy considerations of pedicle screw placement in the thoracis spine:Roy-Camille technique versus open-lamina technique[J]. Spine, 1998, 23(9):1065-1068.
[17] Sclafani JA, Kim CW. Complications associated with the initial learning curve of minimally invasive spine surgery:a systematic review[J]. Clin Orthop, 2014, 472(6):1711-1717.
[18] Krishna M, Pollock RD, Bhatia C. Incidence, etiology, classification, and management of neuralgia after posterior lumbar interbody fusion surgery in 226 patients[J]. Spine, 2008, 8(2):374-379.
[19] Raley DA, Mobbs RJ. Retrospective computed tomography scan analysis of percutaneously inserted pedicle screws for posterior transpedicular stabilization of the thoracic and lumbar spine:accuracy and complication rates[J]. Spine(Phila Pa 1976), 2012, 37(12):1092-1100.
[20] Krishna M, Pollock RD, Bhatia C. Incidence, etiology, classification, and management of neuralgia after posterior lumbar interbody fusion surgery in 226 patients[J]. Spine, 2008, 8(2):374-379.
[21]曾忠友,裴斐,张建乔,等.腰椎病变椎弓根螺钉固定融合术并发神经损伤的临床分析[J].脊柱外科杂志, 2016, 14(2):92-95.
[22]曾忠友,吴鹏,宋永兴,等.小切口单侧椎弓根螺钉联合对侧经皮椎板关节突螺钉固定并椎间融合治疗腰椎病变的并发症分析[J].中国骨伤, 2016, 29(3):34-43.
[23] Jurícek M, Rehák L, Tisovsk P, et al. The effect of complications on the quality of life after surgery for lumbar spine degenerative disease[J]. Acta Chir Orthop Traumatol Cech, 2010, 77(2):112-117.
[24] Sandri A, Regis D, Marino MA, et al. Lumbar artery injury following posterior spinal instrumentation for scoliosis[J]. Orthopedics,2011, 34(4):117-119.