微创经椎间孔腰椎植骨融合术与开放后路腰椎植骨融合术治疗腰椎滑脱症的疗效比较
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摘要
目的比较微创经椎间孔入路腰椎椎间植骨融合术(minimally invasive transforaminal lumbar interbody fusion,MISTLIF)与传统开放后路椎间植骨融合术(posterior lumbar interbody fusion,PLIF)治疗单节段腰椎滑脱症的临床疗效,评价MIS-TLIF手术的安全性和疗效。方法对解放军总医院第一医学中心骨科2016年9月-2017年9月收治的83例单节段腰椎滑脱症患者进行回顾研究,分为MIS-TLIF组(36例)和PLIF组(47例)。比较两组患者围术期临床资料的差异,术前、术后3 d、3个月、6个月、12个月的视觉模拟评分(visual analogue scores,VAS)和术前、术后3个月、6个月、12个月Oswestry功能障碍指数(Oswestry dability index,ODI)的差异,术后椎间融合率和并发症的差异。结果两组患者性别、年龄、病变节段及滑脱程度差异无统计学意义。MIS-TLIF组手术切口[(2.90±0.21) cm vs (7.69±1.33) cm]、住院费用[(7.15±1.21)万vs (8.11±2.04)万]、术中出血量[(111.54±53.49) ml vs (160.54±73.73) ml]、术后引流量[0 ml vs(264.7±81.8) ml]、术后卧床时间[(1.23±0.43) d vs (2.08±1.21) d]和住院时间[(8.54±2.49) d vs (11.43±4.29) d]均小于PLIF组,差异有统计学意义(P均<0.01);两组手术时间差异无统计学意义。MIS-TLIF组和PLIF组术后各随访时间点腰、腿痛VAS评分和ODI评分均较术前明显降低(P <0.05),MIS-TLIF组术后3 d、3个月腰痛VAS评分低于PLIF组(P <0.05),两组术后6个月、1年腰、腿痛VAS评分差异无统计学意义(P> 0.05),ODI评分组间差异均无统计学意义(P> 0.05)。术后椎间融合率和并发症发病率差异均无统计学意义(P> 0.05)。结论 MIS-TLIF手术可获得与传统PLIF手术相同的临床疗效、椎间融合率和手术安全性,但微创经椎间孔腰椎融合术治疗腰椎滑脱症具有术中出血量少、卧床时间短、无需放置引流、住院费用少等优点,同时术后腰痛残留率更低,能更好地改善患者术后的生活质量。
Objective To compare the clinical outcomes of minimally invasive transforaminal lumbar interbody fusion(MIS-TLIF)versus traditional open posterior lumbar interbody fusion(PLIF) in the treatment of lumbar spondylolisthesis and evaluate the safety and effectiveness of MIS-TLIF. Methods Clinical data about 83 patients with lumbar spondylolisthesis treated in our center from September 2016 to September 2017 were retrospectively analyzed, of which 36 cases were treated by minimally invasive transforminal intervertebral fusion(MIS-TLIF group) and 47 cases were treated by open posterior intervertebral fusion(PLIF group).The differences of the perioperative clinical data, visual analogue scores(VAS) and ODI scores before surgery, at 3 days, 3 months,6 months and 12 months after surgery, and postoperative intervertebral fusion rate and complications between the two groups were compared. Results There was no statistically signi?cant difference in gender, age, level of vertebra involved and slip degree between two groups(all P > 0.05). The length of surgical incision [(2.90±0.21) cm vs(7.69±1.33) cm], hospitalization cost [(71.49±12.08)thousand yuan vs(81.1±20.4) thousand yuan], intraoperative blood loss [(111.54±53.49) ml vs(160.54±73.73) ml], postoperative drainage volume [0 ml vs(264.7±81.8) ml], postoperative time to ambulation [(1.23±0.43) d vs(2.08±1.21) d] and hospitalization time [(8.54±2.49) d vs(11.43±4.29) d] in the MIS-TLIF group were all signi?cantly lower than those in PLIF group(all P < 0.01).There was no signi?cant difference in operating time between the two groups(P > 0.05). The VAS of lumbago and leg pain and ODI scores in MIS-TLIF group and PLIF group at each postoperative time point were signi?cantly lower than those before surgery(P < 0.001), while the VAS score of lumbago at 3 day and 3 month after surgery in MIS-TLIF group were signi?cantly lower than that in PLIF group(P < 0.05). VAS scores of lumbago and leg pain between the two groups at 6 month and 1 year after surgery had no signi?cant difference(P > 0.05), and ODI score between the two groups had no signi?cant difference(P > 0.05). There was no signi?cant difference in postoperative complication incidence and intervertebral fusion rate between the two groups(P > 0.05).Conclusion MIS-TLIF surgery can obtain the same clinical effect, operation safety and intervertebral fusion rate as traditional PLIF surgery. But MIS-TLIF is superior to PLIF with less intraoperative blood loss, short duration of postoperative immobilization, less hospitalization expenses, lower postoperative back pain residual rate, which can improve the life-quality of patients.
Objective To compare the clinical outcomes of minimally invasive transforaminal lumbar interbody fusion(MIS-TLIF)versus traditional open posterior lumbar interbody fusion(PLIF) in the treatment of lumbar spondylolisthesis and evaluate the safety and effectiveness of MIS-TLIF. Methods Clinical data about 83 patients with lumbar spondylolisthesis treated in our center from September 2016 to September 2017 were retrospectively analyzed, of which 36 cases were treated by minimally invasive transforminal intervertebral fusion(MIS-TLIF group) and 47 cases were treated by open posterior intervertebral fusion(PLIF group).The differences of the perioperative clinical data, visual analogue scores(VAS) and ODI scores before surgery, at 3 days, 3 months,6 months and 12 months after surgery, and postoperative intervertebral fusion rate and complications between the two groups were compared. Results There was no statistically signi?cant difference in gender, age, level of vertebra involved and slip degree between two groups(all P > 0.05). The length of surgical incision [(2.90±0.21) cm vs(7.69±1.33) cm], hospitalization cost [(71.49±12.08)thousand yuan vs(81.1±20.4) thousand yuan], intraoperative blood loss [(111.54±53.49) ml vs(160.54±73.73) ml], postoperative drainage volume [0 ml vs(264.7±81.8) ml], postoperative time to ambulation [(1.23±0.43) d vs(2.08±1.21) d] and hospitalization time [(8.54±2.49) d vs(11.43±4.29) d] in the MIS-TLIF group were all signi?cantly lower than those in PLIF group(all P < 0.01).There was no signi?cant difference in operating time between the two groups(P > 0.05). The VAS of lumbago and leg pain and ODI scores in MIS-TLIF group and PLIF group at each postoperative time point were signi?cantly lower than those before surgery(P < 0.001), while the VAS score of lumbago at 3 day and 3 month after surgery in MIS-TLIF group were signi?cantly lower than that in PLIF group(P < 0.05). VAS scores of lumbago and leg pain between the two groups at 6 month and 1 year after surgery had no signi?cant difference(P > 0.05), and ODI score between the two groups had no signi?cant difference(P > 0.05). There was no signi?cant difference in postoperative complication incidence and intervertebral fusion rate between the two groups(P > 0.05).Conclusion MIS-TLIF surgery can obtain the same clinical effect, operation safety and intervertebral fusion rate as traditional PLIF surgery. But MIS-TLIF is superior to PLIF with less intraoperative blood loss, short duration of postoperative immobilization, less hospitalization expenses, lower postoperative back pain residual rate, which can improve the life-quality of patients.
引文
1 Bozkus H,Dickman CA.Transvertebral interbody cage and pedicle screw fixation for high-grade spondylolisthesis.Case report[J].JNeurosurg,2004,100(1 Suppl Spine):62-65.
2 Adogwa O,Parker SL,Bydon A,et al.Comparative effectiveness of minimally invasive versus open transforaminal lumbar interbody fusion:2-year assessment of narcotic use,return to work,disability,and quality of life[J].J Spinal Disord Tech,2011,24(8):479-484.
3周亮,刘郑生,毛克亚,等.MIS-TLIF与PLIF治疗单节段退行性腰椎疾病的肌肉损伤比较[J].解放军医学杂志,2013,38(12):972-975.
4周敏,张群虎,刘欢,等.MISTLIF与Open TLIF治疗单节段腰椎滑脱疾病疗效的Meta分析[J].南京医科大学学报:自然科学版,2015,35(1):131-138.
5 Meyerding HW.Spondylolisthesis;surgical fusion of lumbosacral portion of spinal column and interarticular facets;use of autogenous bone grafts for relief of disabling backache[J].J Int Coll Surg,1956,26(5 Part 1):566-591.
6王润生,毛克亚,黄承军,等.微创经椎间孔腰椎椎间融合术中横突定位法置钉的影像学评价[J].中国脊柱脊髓杂志,2018,28(4):336-342.
7 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.
8 Cho EK,Bang SM,Ahn JY,et al.Prognostic value of AML 1/ETOfusion transcripts in patients with acute myelogenous leukemia[J].Korean J Intern Med,2003,18(1):13-20.
9范国鑫,汪东冬,吴信波,等.微创经椎间孔腰椎椎体间融合术治疗腰椎滑脱原位与复位融合的比较[J].脊柱外科杂志,2016,14(6):335-339.
10 Poussa M,Remes V,Lamberg T,et al.Treatment of severe spondylolisthesis in adolescence with reduction or fusion in situ:long-term clinical,radiologic,and functional outcome[J].Spine,2006,31(5):583-590.
11 Cloward RB.The treatment of ruptured lumbar intervertebral discs by vertebral body fusion.I.Indications,operative technique,after care[J].J Neurosurg,1953,10(2):154-168.
12周跃,王健,初同伟,等.内窥镜下(X-Tube)经神经孔入路行腰椎减压、植骨融合内固定术(MI-TLIF)--附48例临床报道[C]//中华医学会第八届骨科学术会议暨第一届国际COA学术大会论文摘要集.北京:中华医学会骨科学分会,2006.
13 Foley KT,Gupta SK,Justis JR,et al.Percutaneous pedicle screw fixation of the lumbar spine[J].Neurosurg Focus,2001,10(4):E10.
14 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,2013,38(23):2049-2055.
15 Xie L,Wu WJ,Liang Y.Comparison between Minimally Invasive Transforaminal Lumbar Interbody Fusion and Conventional Open Transforaminal Lumbar Interbody Fusion:An Updated Meta-analysis[J].Chin Med J(Engl),2016,129(16):1969-1986.
16肖波,毛克亚,王岩,等.微创经椎间孔腰椎椎体间融合术与传统后路腰椎椎体间融合术并发症的比较分析[J].脊柱外科杂志,2013,11(1):23-27.
17冯建宏,辛欣.微创经椎间孔腰椎椎体间融合术与传统后路腰椎椎体间融合术治疗腰椎退变性疾病的疗效及并发症比较[J].临床和实验医学杂志,2016,15(8):799-801.
18 Tally WC,Temple HT,Subhawong TY,et al.Transforaminal Lumbar Interbody Fusion With Viable Allograft:75 Consecutive Cases at 12-Month Follow-up[J].Int J Spine Surg,2018,12(1):76-84.
19 Elmekaty M,Kotani Y,Mehy EE,et al.Clinical and Radiological Comparison between Three Different Minimally Invasive Surgical Fusion Techniques for Single-Level Lumbar Isthmic and Degenerative Spondylolisthesis:Minimally Invasive Surgical Posterolateral Fusion versus Minimally Invasive Surgical Transforaminal Lumbar Interbody Fusion versus Midline Lumbar Fusion[J].Asian Spine J,2018,12(5):870-879.
20姜威,毛克亚,钟睿,等.一次性可扩张通道辅助下微创经椎间孔融合术与开放手术治疗巨大腰椎间盘突出症的疗效比较[J].解放军医学院学报,2017,38(9):815-819.
21张海滨,刘先银,黎松波,等.微创可扩张通道下TILF术与开放PILF术治疗腰椎双侧峡部裂滑脱效果对比[J].山东医药,2018,58(21):88-90.
22曹渊武,陈子贤,梁运,等.单侧旁正中切口下椎弓根螺钉固定合并双侧椎管减压TLIF术的中长期疗效[J].复旦学报:医学版,2018,45(1):67-71.
2 Adogwa O,Parker SL,Bydon A,et al.Comparative effectiveness of minimally invasive versus open transforaminal lumbar interbody fusion:2-year assessment of narcotic use,return to work,disability,and quality of life[J].J Spinal Disord Tech,2011,24(8):479-484.
3周亮,刘郑生,毛克亚,等.MIS-TLIF与PLIF治疗单节段退行性腰椎疾病的肌肉损伤比较[J].解放军医学杂志,2013,38(12):972-975.
4周敏,张群虎,刘欢,等.MISTLIF与Open TLIF治疗单节段腰椎滑脱疾病疗效的Meta分析[J].南京医科大学学报:自然科学版,2015,35(1):131-138.
5 Meyerding HW.Spondylolisthesis;surgical fusion of lumbosacral portion of spinal column and interarticular facets;use of autogenous bone grafts for relief of disabling backache[J].J Int Coll Surg,1956,26(5 Part 1):566-591.
6王润生,毛克亚,黄承军,等.微创经椎间孔腰椎椎间融合术中横突定位法置钉的影像学评价[J].中国脊柱脊髓杂志,2018,28(4):336-342.
7 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.
8 Cho EK,Bang SM,Ahn JY,et al.Prognostic value of AML 1/ETOfusion transcripts in patients with acute myelogenous leukemia[J].Korean J Intern Med,2003,18(1):13-20.
9范国鑫,汪东冬,吴信波,等.微创经椎间孔腰椎椎体间融合术治疗腰椎滑脱原位与复位融合的比较[J].脊柱外科杂志,2016,14(6):335-339.
10 Poussa M,Remes V,Lamberg T,et al.Treatment of severe spondylolisthesis in adolescence with reduction or fusion in situ:long-term clinical,radiologic,and functional outcome[J].Spine,2006,31(5):583-590.
11 Cloward RB.The treatment of ruptured lumbar intervertebral discs by vertebral body fusion.I.Indications,operative technique,after care[J].J Neurosurg,1953,10(2):154-168.
12周跃,王健,初同伟,等.内窥镜下(X-Tube)经神经孔入路行腰椎减压、植骨融合内固定术(MI-TLIF)--附48例临床报道[C]//中华医学会第八届骨科学术会议暨第一届国际COA学术大会论文摘要集.北京:中华医学会骨科学分会,2006.
13 Foley KT,Gupta SK,Justis JR,et al.Percutaneous pedicle screw fixation of the lumbar spine[J].Neurosurg Focus,2001,10(4):E10.
14 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,2013,38(23):2049-2055.
15 Xie L,Wu WJ,Liang Y.Comparison between Minimally Invasive Transforaminal Lumbar Interbody Fusion and Conventional Open Transforaminal Lumbar Interbody Fusion:An Updated Meta-analysis[J].Chin Med J(Engl),2016,129(16):1969-1986.
16肖波,毛克亚,王岩,等.微创经椎间孔腰椎椎体间融合术与传统后路腰椎椎体间融合术并发症的比较分析[J].脊柱外科杂志,2013,11(1):23-27.
17冯建宏,辛欣.微创经椎间孔腰椎椎体间融合术与传统后路腰椎椎体间融合术治疗腰椎退变性疾病的疗效及并发症比较[J].临床和实验医学杂志,2016,15(8):799-801.
18 Tally WC,Temple HT,Subhawong TY,et al.Transforaminal Lumbar Interbody Fusion With Viable Allograft:75 Consecutive Cases at 12-Month Follow-up[J].Int J Spine Surg,2018,12(1):76-84.
19 Elmekaty M,Kotani Y,Mehy EE,et al.Clinical and Radiological Comparison between Three Different Minimally Invasive Surgical Fusion Techniques for Single-Level Lumbar Isthmic and Degenerative Spondylolisthesis:Minimally Invasive Surgical Posterolateral Fusion versus Minimally Invasive Surgical Transforaminal Lumbar Interbody Fusion versus Midline Lumbar Fusion[J].Asian Spine J,2018,12(5):870-879.
20姜威,毛克亚,钟睿,等.一次性可扩张通道辅助下微创经椎间孔融合术与开放手术治疗巨大腰椎间盘突出症的疗效比较[J].解放军医学院学报,2017,38(9):815-819.
21张海滨,刘先银,黎松波,等.微创可扩张通道下TILF术与开放PILF术治疗腰椎双侧峡部裂滑脱效果对比[J].山东医药,2018,58(21):88-90.
22曹渊武,陈子贤,梁运,等.单侧旁正中切口下椎弓根螺钉固定合并双侧椎管减压TLIF术的中长期疗效[J].复旦学报:医学版,2018,45(1):67-71.