直接外侧入路椎间融合术治疗腰椎退变性疾病疗效观察
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摘要
目的探讨直接外侧入路椎间融合术(direct lateral interbody fusion,DLIF)治疗腰椎退变性疾病的疗效。方法回顾分析2013年5月-2014年5月采用DLIF治疗的符合选择标准的25例腰椎退变性疾病患者临床资料。男15例,女10例;年龄36~78岁,平均61.4岁。病程8个月~20年,平均5.7年。其中腰椎间盘突出症14例,腰椎退变性侧凸2例,腰椎滑脱症3例,腰椎节段不稳伴椎管狭窄6例。病变节段:L4、5 10例,L3、4 6例,L2、3 2例,L_(2~4) 2例,L_(3~5) 3例,L_(2~5) 2例。术前椎间隙高度为(6.20±0.88)mm;疼痛视觉模拟评分(VAS)为(8.26±0.49)分,Oswestry功能障碍指数(ODI)为40.80%±3.10%。记录手术时间、术中出血量、术后住院时间和围手术期并发症;术后采用VAS评分、ODI评价疗效,影像学检查评价椎间融合情况。结果手术时间85~155 min,平均105 min;术中出血量80~300 m L,平均158 m L;术后住院时间为2~5 d,平均3.2 d。术中未发生大血管、腹腔脏器(输尿管、肠管)损伤等并发症。术后患者切口均Ⅰ期愈合。25例均获随访,随访时间18~30个月,平均24.6个月。术后出现单纯屈髋乏力4例,屈髋乏力伴大腿前方或腹股沟区麻木5例,均于术后6个月内恢复。随访期间未发现椎间融合器下沉或滑移、螺钉断裂、逆行性射精等并发症。25例32个节段中,20个节段获完全骨性融合,12个节段部分融合;融合时间为6~18个月,平均10.8个月。术后2 d及末次随访时椎间隙高度分别为(11.98±1.20)mm和(11.80±1.33)mm,较术前显著增加(P<0.05);术后2 d与末次随访时比较差异无统计学意义(P>0.05)。末次随访时VAS评分为(3.43±0.53)分,ODI为15.41%±3.91%,均较术前显著改善(t=26.275,P=0.000;t=22.902,P=0.000)。结论DLIF具有创伤小、出血少、术后康复快的优点,是治疗腰椎退行性疾病的安全、有效方法。
Objective To investigate the effectiveness of direct lateral interbody fusion(DLIF) for lumbar degenerative diseases. Methods A retrospective study was done on 25 cases of lumbar degenerative diseases treated with DLIF between May 2013 and May 2014. There were 15 males and 10 females with an average age of 61.4 years(range, 36-78 years), including 14 cases of lumbar disc herniation, 2 cases of degenerative lumbar scoliosis, 3 cases of lumbar spondylolisthesis, and 6 cases of lumbar instability with spinal stenosis. The disease duration was 8 months to 20 years(mean, 5.7 years). The involved segments included L4, 5 in 10 cases, L3, 4 in 6 cases, L2, 3 in 2 cases, L2-4 in 2 cases, L3-5 in 3 cases, and L2-5 in 2 cases. The operation time, intraoperative bleeding volume, postoperative hospitalization time, and complications were recorded. The visual analogue scale(VAS) and Oswestry disability index(ODI) criteria were used to assess the effectiveness; X-ray film and CT were used to evaluate the bone fusion. Results The mean operation time was 105 minutes(range, 85-155 minutes), and mean intraoperative bleeding volume was 158 m L(range, 80-300 m L). The postoperative hospitalization time was 2-5 days(mean, 3.2 days). All incisions healed by first intension. There was no complication of wound infection, vascular injuries, or intraoperative visceral injuries. All cases were followed up 24.6 months on average(range, 18-30 months). Four cases had iliopsoas weakness, 5 cases had iliopsoas weakness and anterior thigh hypoesthesia, which disappeared within 6 months after operation. No retrograde ejaculation, Cage displacement, or loosening was found after operation. Full bony fusion was observed in 20 segments and partial bony fusion in 12 segments. The mean bony fusion time was 10.8 months(mean, 6-18 months). The height of intervertebral space was significantly increased to(11.98±1.20) mm at 2 days after operation and to(11.80±1.33) mm at last follow-up from preoperative(6.20±0.88) mm(P<0.05), but no significant difference was found between at 2 days and last followup(P>0.05). At last follow-up, VAS score was significantly decreased to 3.43±0.53 from preoperative 8.26±0.49(t=26.275, P=0.000), and ODI was significantly decreased to 15.41%±3.91% from preoperative 40.80%±3.10%(t=22.902, P=0.000). Conclusion DLIF is a safe and effective treatment for lumbar degenerative diseases, which has the advantages of less tissue damage, less blood loss, and fast rehabilitation.
Objective To investigate the effectiveness of direct lateral interbody fusion(DLIF) for lumbar degenerative diseases. Methods A retrospective study was done on 25 cases of lumbar degenerative diseases treated with DLIF between May 2013 and May 2014. There were 15 males and 10 females with an average age of 61.4 years(range, 36-78 years), including 14 cases of lumbar disc herniation, 2 cases of degenerative lumbar scoliosis, 3 cases of lumbar spondylolisthesis, and 6 cases of lumbar instability with spinal stenosis. The disease duration was 8 months to 20 years(mean, 5.7 years). The involved segments included L4, 5 in 10 cases, L3, 4 in 6 cases, L2, 3 in 2 cases, L2-4 in 2 cases, L3-5 in 3 cases, and L2-5 in 2 cases. The operation time, intraoperative bleeding volume, postoperative hospitalization time, and complications were recorded. The visual analogue scale(VAS) and Oswestry disability index(ODI) criteria were used to assess the effectiveness; X-ray film and CT were used to evaluate the bone fusion. Results The mean operation time was 105 minutes(range, 85-155 minutes), and mean intraoperative bleeding volume was 158 m L(range, 80-300 m L). The postoperative hospitalization time was 2-5 days(mean, 3.2 days). All incisions healed by first intension. There was no complication of wound infection, vascular injuries, or intraoperative visceral injuries. All cases were followed up 24.6 months on average(range, 18-30 months). Four cases had iliopsoas weakness, 5 cases had iliopsoas weakness and anterior thigh hypoesthesia, which disappeared within 6 months after operation. No retrograde ejaculation, Cage displacement, or loosening was found after operation. Full bony fusion was observed in 20 segments and partial bony fusion in 12 segments. The mean bony fusion time was 10.8 months(mean, 6-18 months). The height of intervertebral space was significantly increased to(11.98±1.20) mm at 2 days after operation and to(11.80±1.33) mm at last follow-up from preoperative(6.20±0.88) mm(P<0.05), but no significant difference was found between at 2 days and last followup(P>0.05). At last follow-up, VAS score was significantly decreased to 3.43±0.53 from preoperative 8.26±0.49(t=26.275, P=0.000), and ODI was significantly decreased to 15.41%±3.91% from preoperative 40.80%±3.10%(t=22.902, P=0.000). Conclusion DLIF is a safe and effective treatment for lumbar degenerative diseases, which has the advantages of less tissue damage, less blood loss, and fast rehabilitation.
引文
1 Wiltse LL,Spencer CW.New uses and refinements of the paraspinal approach to the lumbar spine.Spine(Phila Pa 1976),1988,13(6):696-706.
2 Carreon LY,Puno RM,Dimar JR 2nd,et al.Perioperative complications of posterior lumbar decompression and arthrodesis in older adults.J Bone Joint Surg(Am),2003,85-A(11):2089-2092.
3 Aebi M.The adult scoliosis.Eur Spine J,2005,14(10):925-948.
4 Marchesi DG,Aebi M.Pedicle fixation devices in the treatment of adult lumbar scoliosis.Spine(Phila Pa 1976),1992,17(8 Suppl):S304-309.
5 Cho KJ,Suk SI,Park SR,et al.Complications in posterior fusion and instrumentation for degenerative lumbar scoliosis.Spine(Phila Pa1976),2007,32(20):2232-2237.
6 Daubs MD,Lenke LG,Cheh G,et al.Adult spinal deformity surgery:complications and outcomes in patients over age 60.Spine(Phila Pa1976),2007,32(20):2238-2244.
7 Fantini GA,Pappou IP,Girardi FP,et al.Major vascular injury during anterior lumbar spinal surgery.Spine(Phila Pa 1976),2007,32(24):2751-2758.
8 Phillips FM,Isaacs RE,Rodgers WB,et al.Adult degenerative scoliosis treated with XLIF.Spine(Phila Pa 1976),2013,38(21):1853-1861.
9 Dakwar E,Cardona RF,Smith DA,et al.Early outcomes and safety of the minimally invasive,lateral retroperitoneal transpsoas approach for adult degenerative scoliosis.Neurosurg Focus,2010,28 (3):E8.
10 Madhok R,Kanter AS.Extreme-lateral,minimally invasive,transpsoas approach for the treatment of far-lateral lumbar disc herniaion.J Neurosurg Spine,2010,12(4):347-350.
11 Ozgur BM,Aryan HE,Pimenta L,et al.Extreme lateral interbody fusion(XLIF):a novel surgical technique for anterior lumbar interbody fusion.Spine J,2006,6(4):435-443.
12 Champain S,Benchikh K,Nogier A,et al.Validation of new clinical quantitative analysis software applicable in spine orthopaedic studies.Eur Spine J,2006,15(6):982-991.
13 Collins SL,Moore RA,Mcquay HJ.The visual analogue pain intensitv scale:what is moderate pain in millimetres?Pain,1997,72(1-2):95-97.
14 Fairbank JC,Pynsent PB.The Oswestry disability index.Spine(Phila Pa 1976),2000,25(22):2940-2952.
15 Pearcy M,Burrough S.Assessment of bony union after interbody fusion of the lumbar spine using a biplanar radiographic technique.J Bone Joint Surg(Br),1982,64(2):228-232.
16 董健,李超.腰椎手术失败综合征.中华骨科杂志,2012,32(10):984-989.
17 Fourney DR,Dettori JR,Norvell DC,et al.Does minimal access tubular assisted spine surgery increase or decrease complications in spinal decompression or fusion?Spine(Phila Pa 1976),2010,35(9Suppl):S57-65.
18 Duncan JW,Bailey RA.An analysis fusion cage migration in unilateral and bilateral fixation with transforminal lumbar interbody fusion.Eur Spine J,2013,22(2):439-445.
19 Brau SA.Mini-open approach to the spine for anterior lumbar interbody fusion:description of the procedure,results and complications.Spine J,2002,2(3):216-223.
20 Oliveira L,Marchi L,Coutinho E,et al.A radiographic assessment of the ability of the extreme lateral interbody fusion procedure to indirectly decompress the neural elements.Spine(Phila Pa 1976),2010,35(26 Suppl):S331-S337.
21 Anand N,Rosemann R,Khalsa B,et al.Mid-term to long-term clinical and functional outcomes of minimally invasive correction and fusion for adults with scoliosis.Neurosurg Focus,2010,28(3):E6.
22 Phillips FM,Isaacs RE,Rodgers WB,et al.Adult degenerative scoliosis treated with XLIF.Spine(Phila Pa 1976),38(21):1853-1861.
23 Rodgers WB,Gerber EJ,Patterson J.Intraoperative and early postoperative complications in extreme lateral interbody fusion:an analysis of 600 cases.Spine(Phila Pa 1976),2011,36(1):26-32.
24 Rodgers WB,Cox CS,Gerber EJ.Experience and early results with a minimally invasive technique for anterior column support through e Xtreme Lateral Interbody Fusion(XLIF).US Musculoskeletal Review,2007,1:28-32.
25 Sofianos DA,Brise?o MR,Abrams J,et al.Complications of the lateral transpsoas approach for lumbar interbody arthrodesis.Clin Orthop Relat Res,2012,470(6):1621-1632.
26 Knight RQ,Schwaegler P,Hanscom D,et al.Direct lateral lumbar interbody fusion for degenerative conditions:early complication profile.J Spinal Disord Tech,2009,22(1):34-37.
27 Cummock MD,Vanni S,Levi AD,et al.An analysis of postoperative thigh symptoms after minimally invasive transpsoas lumbar interbody fusion.J Neurosurg Spine,2011,15(1):11-18.
28 Le TV,Burkett CJ,Deukmedjian AR,et al.Postoperative lumbar plexus injury after lumbar retroperitoneal transpsoas minimally invasive lateral interbody fusion.Spine(Phila Pa 1976),2013,38(1):E13-20.
29 Santillan A,Patsalides A,Gobin YP.Endovascular embolization of iatrogenic lumbar artery pseudoaneurysm following extreme lateal interbody fusion(XLIF).Vasc Endovascular Surg,2010,44(7):601-603.
30 Uribe JS,Vale FL,Dakwar E.Electromyographic monitoring and its anatomical implications in minimally invasive spine surgery.Spine(Phila Pa 1976),2010,35(26 Suppl):S368-374.
31 Jahangiri FR,Sherman JH,Holmberg A,et al.Protecting the genitofemoral nerve during direct/extreme lateral interbody fusion(DLIF/XLIF)procedures.Am J Electroneurodiagnostic Technol,2010,50(4):321-335.
32 Voyadzis JM,Felbaum D,Rhee J.The rising psoas sign:an analysis of preoperative imaging characteristics of aborted minimally invasive lateral interbody fusions at L4-5.J Neurosurg Spine,2014,20(5):531-537.
2 Carreon LY,Puno RM,Dimar JR 2nd,et al.Perioperative complications of posterior lumbar decompression and arthrodesis in older adults.J Bone Joint Surg(Am),2003,85-A(11):2089-2092.
3 Aebi M.The adult scoliosis.Eur Spine J,2005,14(10):925-948.
4 Marchesi DG,Aebi M.Pedicle fixation devices in the treatment of adult lumbar scoliosis.Spine(Phila Pa 1976),1992,17(8 Suppl):S304-309.
5 Cho KJ,Suk SI,Park SR,et al.Complications in posterior fusion and instrumentation for degenerative lumbar scoliosis.Spine(Phila Pa1976),2007,32(20):2232-2237.
6 Daubs MD,Lenke LG,Cheh G,et al.Adult spinal deformity surgery:complications and outcomes in patients over age 60.Spine(Phila Pa1976),2007,32(20):2238-2244.
7 Fantini GA,Pappou IP,Girardi FP,et al.Major vascular injury during anterior lumbar spinal surgery.Spine(Phila Pa 1976),2007,32(24):2751-2758.
8 Phillips FM,Isaacs RE,Rodgers WB,et al.Adult degenerative scoliosis treated with XLIF.Spine(Phila Pa 1976),2013,38(21):1853-1861.
9 Dakwar E,Cardona RF,Smith DA,et al.Early outcomes and safety of the minimally invasive,lateral retroperitoneal transpsoas approach for adult degenerative scoliosis.Neurosurg Focus,2010,28 (3):E8.
10 Madhok R,Kanter AS.Extreme-lateral,minimally invasive,transpsoas approach for the treatment of far-lateral lumbar disc herniaion.J Neurosurg Spine,2010,12(4):347-350.
11 Ozgur BM,Aryan HE,Pimenta L,et al.Extreme lateral interbody fusion(XLIF):a novel surgical technique for anterior lumbar interbody fusion.Spine J,2006,6(4):435-443.
12 Champain S,Benchikh K,Nogier A,et al.Validation of new clinical quantitative analysis software applicable in spine orthopaedic studies.Eur Spine J,2006,15(6):982-991.
13 Collins SL,Moore RA,Mcquay HJ.The visual analogue pain intensitv scale:what is moderate pain in millimetres?Pain,1997,72(1-2):95-97.
14 Fairbank JC,Pynsent PB.The Oswestry disability index.Spine(Phila Pa 1976),2000,25(22):2940-2952.
15 Pearcy M,Burrough S.Assessment of bony union after interbody fusion of the lumbar spine using a biplanar radiographic technique.J Bone Joint Surg(Br),1982,64(2):228-232.
16 董健,李超.腰椎手术失败综合征.中华骨科杂志,2012,32(10):984-989.
17 Fourney DR,Dettori JR,Norvell DC,et al.Does minimal access tubular assisted spine surgery increase or decrease complications in spinal decompression or fusion?Spine(Phila Pa 1976),2010,35(9Suppl):S57-65.
18 Duncan JW,Bailey RA.An analysis fusion cage migration in unilateral and bilateral fixation with transforminal lumbar interbody fusion.Eur Spine J,2013,22(2):439-445.
19 Brau SA.Mini-open approach to the spine for anterior lumbar interbody fusion:description of the procedure,results and complications.Spine J,2002,2(3):216-223.
20 Oliveira L,Marchi L,Coutinho E,et al.A radiographic assessment of the ability of the extreme lateral interbody fusion procedure to indirectly decompress the neural elements.Spine(Phila Pa 1976),2010,35(26 Suppl):S331-S337.
21 Anand N,Rosemann R,Khalsa B,et al.Mid-term to long-term clinical and functional outcomes of minimally invasive correction and fusion for adults with scoliosis.Neurosurg Focus,2010,28(3):E6.
22 Phillips FM,Isaacs RE,Rodgers WB,et al.Adult degenerative scoliosis treated with XLIF.Spine(Phila Pa 1976),38(21):1853-1861.
23 Rodgers WB,Gerber EJ,Patterson J.Intraoperative and early postoperative complications in extreme lateral interbody fusion:an analysis of 600 cases.Spine(Phila Pa 1976),2011,36(1):26-32.
24 Rodgers WB,Cox CS,Gerber EJ.Experience and early results with a minimally invasive technique for anterior column support through e Xtreme Lateral Interbody Fusion(XLIF).US Musculoskeletal Review,2007,1:28-32.
25 Sofianos DA,Brise?o MR,Abrams J,et al.Complications of the lateral transpsoas approach for lumbar interbody arthrodesis.Clin Orthop Relat Res,2012,470(6):1621-1632.
26 Knight RQ,Schwaegler P,Hanscom D,et al.Direct lateral lumbar interbody fusion for degenerative conditions:early complication profile.J Spinal Disord Tech,2009,22(1):34-37.
27 Cummock MD,Vanni S,Levi AD,et al.An analysis of postoperative thigh symptoms after minimally invasive transpsoas lumbar interbody fusion.J Neurosurg Spine,2011,15(1):11-18.
28 Le TV,Burkett CJ,Deukmedjian AR,et al.Postoperative lumbar plexus injury after lumbar retroperitoneal transpsoas minimally invasive lateral interbody fusion.Spine(Phila Pa 1976),2013,38(1):E13-20.
29 Santillan A,Patsalides A,Gobin YP.Endovascular embolization of iatrogenic lumbar artery pseudoaneurysm following extreme lateal interbody fusion(XLIF).Vasc Endovascular Surg,2010,44(7):601-603.
30 Uribe JS,Vale FL,Dakwar E.Electromyographic monitoring and its anatomical implications in minimally invasive spine surgery.Spine(Phila Pa 1976),2010,35(26 Suppl):S368-374.
31 Jahangiri FR,Sherman JH,Holmberg A,et al.Protecting the genitofemoral nerve during direct/extreme lateral interbody fusion(DLIF/XLIF)procedures.Am J Electroneurodiagnostic Technol,2010,50(4):321-335.
32 Voyadzis JM,Felbaum D,Rhee J.The rising psoas sign:an analysis of preoperative imaging characteristics of aborted minimally invasive lateral interbody fusions at L4-5.J Neurosurg Spine,2014,20(5):531-537.