改良MI-TLIF联合经皮椎弓根钉固定治疗退行性腰椎侧弯

目的探讨应用改良微创经椎间孔椎间融合术（MI-TLIF）联合经皮椎弓根钉固定治疗退行性腰椎侧弯（DLS）的手术要点和效果。方法对2012年3月至2014年3月广州医科大学附属第一医院和附属第四医院收治的32例DLS患者采用改良MI-TLIF凹侧有序撑开、Cage偏置、植骨融合联合经皮椎弓根钉固定进行治疗。记录切口长度、手术时间、术中出血量和住院时间,通过手术前后脊柱全长片测量腰椎Cobb角、腰椎前凸角、脊柱冠状面及矢状面失衡距离,采用视觉模拟量表（VAS）评分、Oswestry功能障碍指数（ODI）评分评估术后腰腿痛缓解情况,按Macnab标准评定临床疗效。结果切口长度4.2~5.3 cm（平均4.5 cm）,手术时间85~165 min（平均110 min）,术中出血量90~300 mL（平均120 mL）,住院时间11~17 d（平均14.5 d）。32例患者中30例获得随访,随访时间4~23个月（平均12.5个月）,未发现椎弓根钉棒断裂或Cage移位。腰痛、腿痛视觉模拟量表（VAS）评分分别从术前（6.8±2.3）分和（7.5±2.2）分降至末次随访时的（1.9±1.3）分和（2.4±1.5）分,ODI从术前（41.4±2.7）%降至末次随访的（13.6±2.5）%;Cobb角从术前的（33.7±3.5）°改善为末次随访时的（10.1±2.3）°,腰椎前凸角从术前偏离正常（22.6±8.0）°改善为术后偏离正常（3.3±1.4）°;矢状面、冠状面偏移距离分别从术前的（46.8±9.8）、（29.3±7.8）mm降至末次随访时的（19.7±7.6）、（10.7±6.3）mm;手术前后上述指标比较,差异均有统计学意义（P〈0.05）。依Macnab标准评定临床疗效,优20例、良6例、可3例、差1例,优良率87%（26/30）。结论改良MI-TLIF凹侧有序撑开、Cage偏置融合技术联合经皮椎弓根钉固定具有创伤小、手术时间短、出血少、并发症低、矫形效果好、疗效确切等优点,是DLS微创治疗的有效方法。

Treatment of degenerative lumbar scoliosis by using modified MI-TLIF and percutaneous pedicle screw fixation

Objective To discuss the operative essentials and therapeutic effects of modified minimally invasive-transforaminal lumbar interbody fusion （MI-TLIF） combined with percutaneous pedicle screw fixation for degenerative lumbar scoliosis （DLS）. Methods From march 2012 to march 2014, 32 DLS patients were treated by modified MI-TLIF （concave-side distraction step by step, cage insertion into the curved side of intervertebral space, and bone graft fusion） and percutaneous pedicle screw fixation in the First and Fouth Affiliated Hospital of Guangzhou Medical College. Incision length, operative time, intraoperative estimate blood loss and hospital stay were recorded, Cobb＆#＇s angle, lordosis angle and spinal imbalance distances on coronal and sagittal plane were measured according to preoperative and postoperative spinal full-length radiographs, postoperative improvement of low back and leg pain were evaluated by visual analogue scale （VAS） and Oswestry disability index （ODI） scoring, clinical effects were assessed according to Nakai standard. Results Incision length was 4.2-5.3 cm with the average of 4.5 cm, operative time was 85-165 min with the average of 110 min, intraoperative estimate blood loss was 120 mL （90-300 mL） and the hospital stay was 14.5 d （11-17 d）. Thirty patients were followed-up for 12.5 months （4-23 months）. No pedicle screw-rod breakage or cage displacement were found. Compared with preoperative and the last follow-up, the following results had statistical differences （P〈0.05）：VAS of low back pain and leg pain decreased from （6.8 ± 2.3）, （7.5 ± 2.2） to （1.9 ± 1.3）, （2.4 ± 1.5） respectively, ODI improved from （41.4 ± 2.7）% to （13.6 ± 2.5）%; Cobb＆#＇s angle decreased from （33.7 ± 3.5）° to （10.1 ± 2.3）°, lordosis angle deviation decreased from （22.6 ± 8.0）° to （3.3 ± 1.4）°; Imbalance distance on sagittal plane and coronal plane improved from （46.8 ± 9.8）, （29.3 ± 7.8） mm to （19.7 ± 7.6）,