经椎间孔椎体间融合术与经后路椎体间融合术治疗轻、中度退变性腰椎滑脱症临床疗效及安全的Meta分析

目的 :应用Meta分析综合评价经椎间孔椎体间融合术(transforaminal lumbar interbody fusion,TLIF)与经后路椎体间融合术(posterior lumbar interbody fusion,PLIF)治疗退变性腰椎滑脱症的临床疗效和安全性,为临床决策提供参考依据。方法:计算机检索中国期刊全文数据库(China national knowledge infrastructure,CNKI)、中国生物医学文献数据库(China biology medicine,CBM)、万方数据库(Wanfang Database)、Pub Med、The Cochrane Library、Elsevier Science Direct(SDOS)数据库中关于TLIF与PLIF治疗退变性腰椎滑脱症的文献,检索时限均是从各数据库建库时间至2017年8月。纳入文献包含以下参考指标中的两项以上:手术时间、术中出血量、融合例数、视觉模拟评分(visual analogue scale,VAS)、Oswestry功能残障指数(Oswestry disability index,ODI)、手术并发症例数、末次随访椎间高度、再手术例数。使用Cochrane Library提供的Rev Man 5.3软件进行Meta分析。结果:共纳入2篇随机对照研究,8篇队列研究。共纳入患者757例,其中TLIF组386例,PLIF组371例。两组在手术时间、术中出血量、并发症例数方面,TLIF组均少于PLIF组,差异有统计学差异(P0.05)。两组在VAS评分、ODI评分、融合例数、恢复椎间高度、再手术例数方面,差异无统计学意义(P0.05)。结论:两种椎间融合方式在术后VAS评分、ODI评分、融合例数、恢复椎间高度方面无显著性差异,临床疗效相当。TLIF在手术时间、术中出血量、总体并发症例数方面均少于PLIF,其安全性较高。     

Posterolateral fusion (PLF) versus transforaminal lumbar interbody fusion (TLIF) for spondylolisthesis: a systematic review and meta-analysis

Background Context

Lumbar fusion is an effective and durable treatment for symptomatic lumbar spondylolisthesis; however, the current literature provides insufficient evidence to recommend an optimal surgical fusion strategy.

经椎间孔入路与经后方入路椎间融合术治疗退变性腰椎失稳症的疗效比较

目的回顾性研究经后方入路椎体间融合术（posterior lumbar interbody fusion,PLIF）和切除上、下关节突的经椎间孔入路椎体间融合术（transforaminal lumbar interbody fusion,TLIF）治疗腰椎失稳症的疗效及并发症情况。方法采用PLIF和TLIF治疗2004年1月至2008年1月本院收治的退变性腰椎失稳症患者78例,其中PLIF31例,TLIF47例。比较两组手术时间、术中出血量、平均卧床时间、Nakai评分优良率、融合时间（按Suk标准）及术后并发症发生率。对两组术前及末次随访时的椎间隙高度及椎间孔高度进行对比研究。结果 78例患者均获随访,随访时间1.5～4.5年,平均3.5年。所有患者均获椎间骨性融合。对两组卧床时间、Nakai评分优良率、融合时间、同时间点椎间隙高度和椎间孔高度进行比较,差异无统计学意义（P〉0.05）;而在手术时间、出血量以及术后并发症发生率方面,两组之间的差异有统计学意义（P〈0.05）。两组末次随访时的椎间隙高度和椎间孔高度均较术前有明显改善（P〈0.05）。结论 TLIF和PLIF治疗退变性腰椎失稳症效果良好;与PLIF相比,TLIF操作简单,出血量小,并发症少。     

A systematic review with meta-analysis of posterior interbody fusion versus posterolateral fusion in lumbar spondylolisthesis

Purpose

To compare the clinical effectiveness of posterior lumbar interbody fusion (PLIF) and posterolateral fusion (PLF) for lumbar spondylolisthesis and to collect scientific evidence for determining which fusion method is better.

Methods

After systematic search, comparative studies were selected according to eligibility criteria. Checklists by Furlan and by Cowley were used to evaluate the risk of bias of the included randomized controlled trials (RCTs) and nonrandomized controlled studies, respectively. Weighed mean differences (WMDs) and risk differences were calculated for common outcomes. The final strength of evidence was expressed as different levels recommended by the GRADE Working Group.

Results

Four RCTs and five comparative observational studies were identified. Moderate-quality evidence indicated that PLIF was more effective than PLF for clinical satisfaction [odds ratios (OR) 0.49, 95 % confidence limits (95 % CI): (0.28, 0.88, P = 0.02)]. Moderate-quality evidence showed that no significant difference was found for the complication rate [OR 2.28, 95 % CI (0.97, 5.35), P = 0.06]. In secondary outcomes, moderate-quality evidence indicated that PLIF improved fusion rate [OR 0.32, 95 % CI (0.17, 0.61), P = 0.0006]. Low-quality evidence showed that PLIF resulted in a lower reoperation rate than PLF [OR 5.30, 95 % CI (1.47, 19.11), P = 0.01]. No statistical difference was found between the two groups with regard to blood loss [WMD = 76.52, 95 % CI (−310.68, 463.73), P = 0.70] and operating time [WMD = −1.20, 95 % CI (−40.36, 37.97), P = 0.95].

Conclusions

Moderate-quality evidence indicates that PLIF can improve the clinical satisfaction and increase the fusion rate compared to PLF. No superiority was found between the two fusion methods in terms of complication rate, amount of blood loss, and operating time for the treatment of lumbar spondylolisthesis.     

后路椎间融合术和经椎间孔入路融合术治疗腰椎滑脱症的临床比较

目的比较研究经椎间孔入路和后路椎间融合术治疗腰椎滑脱症的临床疗效、植骨融合率及术后并发症。方法 31例腰椎滑脱症的患者行椎间融合术附加双侧椎弓根螺钉固定术,PLIF组16例,TLIF组15例,比较两组的手术时间、术后并发症、临床疗效满意率和植骨融合率等。结果所有患者伤口均一期愈合。术后神经根痛加剧:PLIF组有3例,TLIF组1例。术中硬膜囊撕裂:PLIF组1例,TLIF组未出现该并发症。PLIF组临床疗效优良率为85.1%,而TLIF组优良率为90.2%,两者无显著性差异(P0.05)。植骨融合率:PLIF组植骨融合率为93.4%,TLIF组植骨融合率94.1%,两者无显著性差异(P0.05)。结论 PLIF和TLIF是治疗腰椎滑脱症的有效方法,两者在临床疗效满意率和植骨融合率方面没有显著性差异,但是在手术时间、创伤、并发症等方面,TLIF组明显优于PLIF。     

Effect of PLIF and TLIF on sagittal spinopelvic balance of patients with degenerative spondylolisthesis

Objective

The aim of this study was to evaluate the effects of PLIF and TLIF on sagittal spinopelvic balance and to compare radiological results of two surgical procedures with regard to spinopelvic parameters.

TLIF术式治疗双节段腰椎滑脱症的临床研究

【摘要】 目的 探讨经椎间孔椎间融合术(TLIF术)式治疗双节段腰椎滑脱症的手术疗效。方法 采用TLIF后路减压、复位、椎弓根螺钉内固定、椎间植骨融合术治疗双节段腰椎滑脱11例,按Lenke标准评价脊柱融合情况,按Henderson标准评价临床疗效。结果 所有病例均获得较大程度的复位,术后随访1~2年,根据Lenke标准评价脊柱植骨融合:A级10例,B级1例;根据Henderson标准评价临床疗效:优9例,良1例,可1例。结论〓TLIF术式治疗双节段腰椎滑脱症,其脊柱融合满意,疗效显著可靠。     

两种融合手术治疗腰椎滑脱症的影像学及临床疗效比较

目的 比较腰椎后路椎体间融合术(posterior lumbar interbody fusion,PLIF)和腰椎后外侧融合术(posterolateral lumbar fusion,PLF)治疗腰椎滑脱症患者手术前后及随访时影像学指标及临床疗效间的差异.方法 对2004年6月至2006年12月分别行上述两种手术治疗的113例腰椎滑脱症患者进行回顾性分析,PLIF组60例,PLF组53例.术前在腰椎侧佗X线片上测量椎间高度、滑脱率、节段角度、椎间孔面积等影像学指标,并采用Oswestry功能障碍指数(Oswestry disability index,ODI)、视觉模拟标尺(visual analogue scale,VAS)评分以及临床疗效主观评价表等指标对患者进行症状评分;术后即刻对卜述指标进行重复测量.并坚持随访,分别计算两组滑脱复位率和融合率.结果 两组平均手术时间及术中出血量分别为PLIF:(194.3±54.7)min.(402.2±123.9)ml;PLF:(179.3±45.7)min,(367.2±102.3)ml,差异均无统计学意义;术后PLIF组椎间高度、滑脱率、节段角度、椎间孔面积等影像学指标的恢复与维持均优于PLF组,末次随访时两组融合率分别为96.7%、88.6%(P=0.099);两组患者术后即刻及术后1年腰痛、腿痛VAS评分和Odl评分均较术前明显改善,临床疗效主观评价优秀率分别为56.7%(PLIF)与37.7%(PLF).结论 与PLF相比,PLIF对腰椎滑脱的矫正、椎间高度的维持、生理曲度的恢复以及椎间孔面积的扩大等指标均有显著的优越性,其临床疗效主观评价优秀率亦高于PLF组.     

经椎间孔入路腰椎椎间融合术治疗连续双节段腰椎滑脱

目的 分析经椎间孔入路腰椎椎间融合术(TLIF)治疗连续双节段腰椎滑脱(LS)的临床疗效。方法 2015年1月—2021年5月,采用TILF治疗连续双节段腰椎前滑脱患者36例,记录所有患者手术时间、术中出血量及并发症发生情况。术前、术后48 h及末次随访时采用腰腿痛视觉模拟量表(VAS)评分、日本骨科学会(JOA)评分、Oswestry功能障碍指数(ODI)评估腰椎功能情况。测量并比较术前、术后及末次随访时标准站立位全脊柱正侧位X线片上滑脱距离(SD)、滑脱角度(SA)、胸椎后凸角(TK)、腰椎前凸角(LL)、骨盆入射角(PI)、骨盆倾斜角(PT)、骶骨倾斜角(SS)、矢状位垂直轴(SVA)、T₁骨盆角(TPA)、T₁倾斜角(T₁S)、胸腰和谐角(TLA)、PI与LL差值(PI-LL)等影像学参数。结果 所有手术顺利完成,手术时间为120～275(190.28±6.12) min,术中出血量为210～550(345±11) m L。所有患者术后和末次随访SD、SA较术前明显改善,差异均有统计学意义(P<0.05)。...     

后外侧入路经皮内窥镜下腰椎椎间融合术治疗腰椎滑脱症的临床疗效分析

目的:分析后外侧入路经皮内窥镜下腰椎椎间融合术(posterolateral endoscopic lumbar interbody fu-sion,PELIF)治疗腰椎滑脱症的安全性和早期疗效.方法:回顾性分析2018年3月～2019年9月我科行PELIF治疗的22例轻度腰椎滑脱症患者.其中男性9例,女性13例;年龄...     

椎间植骨融合与横突间植骨融合治疗腰椎滑脱症的比较

目的:比较横突间植骨融合内固定与椎间植骨融合内固定治疗腰椎滑脱症的效果。方法:对111例腰椎滑脱症患者分别采用横突间植骨融合内固定(81例)与椎间植骨融合内固定(30例),回顾两组患者的临床资料,比较两种植骨方式术后植骨融合率及临床症状改善情况。结果:随访7~68个月,平均19.9个月。横突间植骨组融合率85.2%,椎间植骨组融合率96.7%,两组无显著性差异(P>0.05)。对于真性滑脱及Ⅰ度以上退变性滑脱,椎间植骨融合率100%,横突间植骨融合率75%,两组有显著性差异(P<0.05)。椎间植骨组优良率93.3%,横突间植骨组优良率88.9%,两组无显著性差异(P>0.05)。结论:椎间植骨与横突间植骨治疗腰椎滑脱症的疗效相近。对于Ⅰ度退变性滑脱,横突间植骨仍是有效的植骨融合方法,但对于真性滑脱或Ⅰ度以上退变性滑脱,应行椎间植骨融合。     

Transforaminal lumbar interbody fusion (TLIF) versus posterolateral instrumented fusion (PLF) in degenerative lumbar disorders: a randomized clinical trial with 2-year follow-up

Purpose

The aim of the present study was to analyze outcome, with respect to functional disability, pain, fusion rate, and complications of patients treated with transforaminal lumbar interbody fusion (TLIF) in compared to instrumented poserolateral fusion (PLF) alone, in low back pain. Spinal fusion has become a major procedure worldwide. However, conflicting results exist. Theoretical circumferential fusion could improve functional outcome. However, the theoretical advantages lack scientific documentation.

Methods

Prospective randomized clinical study with a 2-year follow-up period. From November 2003 to November 2008 100 patients with severe low back pain and radicular pain were randomly selected for either posterolateral lumbar fusion [titanium TSRH (Medtronic)] or transforaminal lumbar interbody fusion [titanium TSRH (Medtronic)] with anterior intervertebral support by tantalum cage (Implex/Zimmer). The primary outcome scores were obtained using Dallas Pain Questionnaire (DPQ), Oswestry disability Index, SF-36, and low back pain Rating Scale. All measures assessed the endpoints at 2-year follow-up after surgery.

Results

The overall follow-up rate was 94 %. Sex ratio was 40/58. 51 patients had TLIF, 47 PLF. Mean age 49(TLIF)/45(PLF). No statistic difference in outcome between groups could be detected concerning daily activity, work leisure, anxiety/depression or social interest. We found no statistic difference concerning back pain or leg pain. In both the TLIF and the PLF groups the patients had significant improvement in functional outcome, back pain, and leg pain compared to preoperatively. Operation time and blood loss in the TLIF group were significantly higher than in the PLF group (p < 0.001). No statistic difference in fusion rates was detected.

Conclusions

Transforaminal interbody fusion did not improve functional outcome in patients compared to posterolateral fusion. Both groups improved significantly in all categories compared to preoperatively. Operation time and blood loss were significantly higher in the TLIF group.     

Transforaminal lumbar interbody fusion: a safe technique with satisfactory three to five year results

The unilateral transforaminal approach for lumbar interbody fusion as an alternative to the anterior (ALIF) and traditional posterior lumbar interbody fusion (PLIF) combined with pedicle screw instrumentation is gaining in popularity. At present, a prospective study using a standardized tool for outcome measurement after the transforaminal lumber interbody fusion (TLIF) with a follow-up of at least 3 years is not available in the current literature, although there have been reports on specific complications and cost efficiency. Therefore, a study of TLIF was undertaken. Fifty-two consecutive patients with a minimum follow-up of 3 years were included, with the mean follow-up being 46 months (36–64). The indications were 22 isthmic spondylolistheses and 30 degenerative disorders of the lumbar spine. Thirty-nine cases were one-level, 11 cases were two-level, and two cases were three-level fusions. The pain and disability status was prospectively evaluated by the Oswestry disability index (ODI) and a visual analog scale (VAS). The status of bony fusion was evaluated by an independent radiologist using anterior–posterior and lateral radiographs. The operation time averaged 173 min for one-level and 238 min for multiple-level fusions. Average blood loss was 485 ml for one-level and 560 ml for multiple-level fusions. There were four serious complications registered: a deep infection, a persistent radiculopathy, a symptomatic contralateral disc herniation and a pseudarthrosis with loosening of the implants. Overall, the pain relief in the VAS and the reduction of the ODI was significant (P<0.05) at follow-up. The fusion rate was 89%. At the latest follow-up, significant differences of the ODI were neither found between isthmic spondylolistheses and degenerative diseases, nor between one- and multiple-level fusions. In conclusion, the TLIF technique has comparable results to other interbody fusions, such as the PLIF and ALIF techniques. The potential advantages of the TLIF technique include avoidance of the anterior approach and reduction of the approach related posterior trauma to the spinal canal.     

PLIF与PLF技术治疗腰椎滑脱症的疗效比较

目的 回顾性比较后路椎间融合术（PLIF）和椎体后外侧融合术（PLF）治疗腰椎滑脱症的临床疗效。方法 自2007-06-2013-02在后路减压复位、椎弓根系统内固定的基础上行融合术治疗腰椎滑脱症42例：PLIF组13例,PLF组29例。结果 术后所有滑脱椎体均获得不同程度的复位。PLIF组与PLF组术中平均出血量分别为（816.6±69.3）ml、（355.2±45.8）ml;2组术后椎间隙后高均较术前增加（P〈0.05）,而末次随访PLIF组椎间后高优于PLF组（P〈0.05）。PLIF组术后翻修1例,余均获得融合,融合率92.3%,术中硬脊膜撕裂2例,未遗留神经症状;PLF组术后26例获得融合,融合率为89.7%,3例融合失败,随访椎间隙高度丢失,出现腰臀部疼痛复发,该组未出现神经损伤。术后PLIF组与PLF组ODI评分均较术前明显改善（P〈0.05）。结论 PLIF与PLF技术均为治疗腰椎滑脱症有效的融合方式,前者具有良好的椎间撑开作用,适合术前椎间高度丢失较多的患者;而后者手术出血少、术中并发症少,较适合体弱、高龄、椎间高度丢失不显著的患者。     

改良TLIF联合术中撑开复位治疗退变性腰椎滑脱症

目的探讨改良经腰椎椎间孔椎体间融合术（TLIF）联合术中撑开复位技术治疗退变性腰椎滑脱症的可行性及其临床疗效。方法回顾性分析2007年3月至2011年10月复旦大学附属华山医院采用改良TLIF联合术中撑开复位技术治疗的84例单节段退变性腰椎滑脱症患者的临床资料,评估手术前后视觉模拟量表（VAS）疼痛评分、日本骨科学会（JOA）评分、融合节段椎间隙高度、腰椎前凸度（Cobb角）和椎体滑脱程度,X线片或CT扫描观察患者术后3个月、1年的影像学融合情况。结果平均手术时间（170±38）min、术中平均失血量（274±82）mL。截至术后3个月,全部患者获得有效随访;截至1年,84例患者中获随访79~EJ（94％）。术后3个月及1年,融合节段椎间隙高度较术前有明显提高（JP〈0．05）,但手术前后Cobb角无明显差异（P〉0．05）;术后3个月,腰椎滑脱完全复位34例（40％）,余50例患者术后腰椎滑脱得到不同程度复位;术后1年,椎体滑脱程度改善率为84％。术后3个月及1年,患者VAS评分、JOA评分均较术前明显好转（P〈0．05）;根据JOA评估标准,优59例、良20例、可5例,平均改善率为87％。57例（68％）患者术后3个月达到影像学融合标准,79例（100％）患者术后1年达到影像学融合标准。患者均未出现神经根损伤、硬膜囊撕裂、椎弓根螺钉松动断裂、椎间融合器移位下沉等。结论改良TILF联合术中撑开复位治疗单节段退变性腰椎滑脱症安全有效。     

椎弓根螺钉复位固定加不同融合方式治疗腰椎滑脱症疗效比较

目的对比分析椎弓根螺钉复位固定后后外侧融合（PLF）与后路椎间融合（PLIF）治疗腰椎滑脱症的临床疗效,评价两种融合方式的优劣。方法54例腰椎滑脱症患者中复位固定后行PLF（PLF组）26例,复位固定后行PLIF（PLIF组）28例。比较两组的临床疗效（ODI评分）、X线检查结果（包括滑脱矫正、滑脱节段椎间隙高度改变、滑脱节段前突角改变及植骨融合情况）及并发症。结果患者均获随访,时间2—6（3．5±0．4）年。术后即刻X线检查结果两组差异无显著性（P〉0,05）;术后2年随访时,两组间临床疗效、植骨融合率、滑脱节段前突角改变情况及并发症发生率差异均无显著性（P〉0．05）,但在滑脱矫正及滑脱节段椎间隙高度的维持上PLIF组优于PLF组（P〈0．05）,且内固定失败率亦低于PLF组。结论椎弓根螺钉复位固定后PLF或PLIF均为治疗腰椎滑脱症的有效方法,但PLIF在对腰椎滑脱矫正的维持及结构的稳定上较PLF具有更好的力学性能。     

经椎间孔椎体间植骨治疗下腰椎爆裂性骨折

目的 探讨在下腰椎爆裂性骨折中应用单一后路经椎间孔椎体间植骨融合术重建椎体前中柱的有效性.方法 2009年1月～2011 年6月,采用单一后路切开复位椎弓根内固定经椎间孔椎体间植骨融合术治疗下腰椎爆裂性骨折19例.分别评价术前、术后、末次随访时的影像学指标变化,及术前与术后末次随访时神经功能变化.结果 19例患者平均随访15.6 个月.所有患者术后未发生切口感染、神经功能损伤及内固定器松动断裂等并发症.末次随访时18例患者证实椎间融合,19例患者术前平均伤椎高度为正常椎体高度的（40.62±12.32）%,术后恢复至（96.52±10.62）%,末次随访时为（95.43%9.54）%.腰椎前凸角术前32.2°±5.1°,术后38.4°±5.2°,末次随访时为38.4°±7.2°.末次随访时伴有神经功能障碍的患者均有1级以上的恢复.结论 下腰椎爆裂性骨折行后路椎弓根螺钉内固定经椎间孔椎体间植骨融合术,能完成短节段三柱固定,同时修复了前柱及矫正脊柱后凸,取得满意的骨性融合率.     

后路腰椎椎间融合器融合术的并发症分析

目的：统计分析采用椎间融合器（cage）行后路腰椎间融合术（PLIF）的并发症，并提出预防措施。方法：对1996年10月．2004年10月145例置入cage的PLIF病例进行随访，统计各种术中、术后并发症，分析其发生的原因。结果：145例患者中16例（11．0％）发生术中并发症，其中手术操作导致硬脊膜撕裂11例（7．6％），神经根损伤5例（3．4％）。在平均20．3个月随访期内，32例（22．1％）出现术后并发症，其中椎间不愈合5例（3．5％），粘连性蛛网膜炎5例（3．5％），cage沉陷4例（2．8％），术后切口感染2例（1．4％），其中1例为浅表感染，另1例由浅表感染发展为椎间隙感染；cage后移位16例（11．0％），其中13例（8．9％）接受再手术治疗。结论：采用cage行PLIF的并发症并不少见．其发生与适应证选择、手术操作、固定方式以及cage的型号等因素有关。     

后路腰椎椎体间融合术治疗腰椎滑脱的临床疗效

目的：探讨后路腰椎椎体间融合术（posterior lumbar interbody fusion,PLIF）治疗腰椎滑脱的中期疗效,对腰椎滑脱症的临床治疗提供指导意见。方法回顾性分析采用PLIF治疗的腰椎滑脱40例,所有病例随访观察＞3年,对手术前后影像学资料、Oswestry功能障碍指数（Oswestry disability index,ODI）、视觉模拟量表（visual analog scale ,VAS）评分及日本骨科学会（Japanese Orthopaedic Association ,JOA）腰背痛手术治疗评分标准的评分变化情况进行比较分析。结果椎间隙高度、椎间孔高度术后1年、3年与术前比较差异均有统计学意义（P＜0．05）;术后1年与术后3年测量值比较差异不具有统计学意义（P＞0．05）。 ODI、腰痛VAS评分、腿痛VAS评分及JOA评分术前和术后1年、3年比较差异具有统计学意义（P＜0．05）;术后1年与术后3年比较差异不具有统计学意义（P＞0．05）。结论 PLIF手术能够恢复腰椎序列稳定性,改善临床症状,是治疗腰椎滑脱的理想术式,中期随访疗效满意。     

显微镜辅助Zista通道下MIS-TLIF治疗退行性腰椎滑脱症

目的:探讨显微镜辅助Zista通道下微创经椎间孔入路腰椎椎体间融合术(minimally invasive transforam-inal lumbar interbody fusion,MIS-TLIF)治疗Ⅰ、Ⅱ度退行性腰椎滑脱症的临床疗效及优势.方法:回顾性分析2017年1月至2018年3月采用显微镜辅助Zist...