微创手术治疗单节段腰椎管狭窄症的疗效评价

目的:对比微创手术与传统开放手术治疗单节段腰椎管狭窄症的临床效果,评价微创手术治疗腰椎管狭窄症的安全性和有效性。方法:2008年1月～2009年1月收治43例单节段腰椎管狭窄症患者,其中28例采用传统开放减压、后路椎体间融合手术(posterior interbody fusion,PLIF)治疗(A组),15例采用微创减压、经椎间孔融合手术(transforaminal lumbar interbody fusion,TLIF)治疗(B组),比较两组患者的手术时间、术中C型臂X线机照射时间、术中出血量、术后引流量、术后下地时间和术后平均住院时间,并分别采用Oswestrydisability index(ODI)、visual analogue scores(VAS)和X线评价治疗效果。结果:所有患者均获得随访,两组术前一般资料、VAS和ODI评分无显著性差异。B组手术时间和术中透视时间多于A组(P<0.01),而术中出血量和术后引流量B组明显低于A组(P<0.01),术后下地活动时间和术后平均住院日B组明显短于A组(P<0.01)。术后5d时VAS评分B组优于A组(P<0.05),而其他时间相比两组VAS评分与ODI评分相比均无显著性差异(P>0.05),术后X线评价融合率两组亦无显著性差异(P>0.05)。结论:与传统开放手术相比,微创手术治疗单节段腰椎管狭窄症,同样可以获得安全、有效的治疗结果,并且在手术出血量、术后引流量、术后下地活动时间和术后住院时间方面优于传统开放手术。     

Minimally invasive transforaminal lumbar interbody fusion: Results of 23 consecutive cases

Background:

The use of minimally invasive surgical (MIS) techniques represents the most recent modification of methods used to achieve lumbar interbody fusion. The advantages of minimally invasive spinal instrumentation techniques are less soft tissue injury, reduced blood loss, less postoperative pain and shorter hospital stay while achieving clinical outcomes comparable with equivalent open procedure. The aim was to study the clinicoradiological outcome of minimally invasive transforaminal lumbar interbody fusion.

Materials and Methods:

This prospective study was conducted on 23 patients, 17 females and 6 males, who underwent MIS-transforaminal lumbar interbody fusion (TLIF) followed up for a mean 15 months. The subjects were evaluated for clinical and radiological outcome who were manifested by back pain alone (n = 4) or back pain with leg pain (n = 19) associated with a primary diagnosis of degenerative spondylolisthesis, massive disc herniation, lumbar stenosis, recurrent disc herniation or degenerative disc disease. Paraspinal approach was used in all patients. The clinical outcome was assessed using the revised Oswestry disability index and Macnab criteria.

Results:

The mean age of subjects was 55.45 years. L4-L5 level was operated in 14 subjects, L5-S1 in 7 subjects; L3-L4 and double level was fixed in 1 patient each. L4-L5 degenerative listhesis was the most common indication (n = 12). Average operative time was 3 h. Fourteen patients had excellent results, a good result in 5 subjects, 2 subjects had fair results and 2 had poor results. Three patients had persistent back pain, 4 patients had residual numbness or radiculopathy. All patients had a radiological union except for 1 patient.

Conclusion:

The study demonstrates a good clinicoradiological outcome of minimally invasive TLIF. It is also superior in terms of postoperative back pain, blood loss, hospital stay, recovery time as well as medication use.     

Minimally invasive or open transforaminal lumbar interbody fusion as revision surgery for patients previously treated by open discectomy and decompression of the lumbar spine

Minimally invasive lumbar fusion techniques have been developed in recent 20 years. The goals of these procedures are to reduce approach-related soft tissue injury, postoperative pain, and disability while allowing the surgery to be conducted in an effective manner. There have been no prospective clinical reports published on the comparison of minimally invasive transforaminal lumbar interbody fusion as revision surgery for patients previously treated by open discectomy and decompression or a traditional open approach. A prospective clinical study was performed by evaluating the clinical and radiographic results of minimally invasive transforaminal lumbar interbody fusion as an alternative new technique in the revision surgery for patients previously treated by open procedure. 52 patients (28 M, 24 F) with an average age of 55.7 (31–76) were prospectively evaluated. All patients who had previous discectomy (n = 13), hemilaminectomy (n = 16), laminectomy (n = 12) and facetectomy (n = 11) underwent monosegmental and bisegmental minimally invasive transforaminal lumbar interbody fusion (MiTLIF) (n = 25) or open transforaminal lumbar interbody fusion (OTLIF) (n = 27) by two experienced surgeons at one hospital, from March 2006 to October 2008 (minimum 12-month follow-up). The following data were compared between the two groups: the clinical and radiographic results, operative time, blood loss, X-ray exposure time, postoperative back pain, and complications. Clinical outcome was assessed using the visual analogue scale and the Oswestry disability index (ODI). The operative time and clinical and radiographic results were basically identical in both groups. Comparing with the OTLIF group, the MiTLIF group had significantly less blood loss and less postoperative back pain at the second day postoperatively. The radiation time was significantly longer in the MiTLIF group. Complications included three cases of small dural tear in the MiTLIF group. There were five cases of dural tear and two cases of superficial wound infection in the OTLIF group. One case of nonunion was observed from each group. Minimally invasive TLIF is a safe and effective procedure for treatment of selected revision patients previously treated by open surgery with some potential advantages. However, this technique needs longer X-ray exposure time.     

Comparison of minimally invasive versus open transforaminal lumbar interbody fusion in two-level degenerative lumbar disease

Purpose

The purpose of this study was to compare the clinical and radiological outcomes of minimally invasive versus open transforaminal lumbar interbody fusion in two-level degenerative lumbar disease.

Methods

We conducted a prospective cohort study of 82 patients, who underwent two-level minimally invasive or open transforaminal lumbar interbody fusion (TLIF) from March 2010 to December 2011. Forty-four patients underwent minimally invasive transforaminal lumbar interbody fusion (MITLIF) (group A) and 38 patients underwent the traditional open TLIF (group B). Demographic data and clinical characteristics were comparable between the two groups before surgery (p > 0.05). Peri-operative data, clinical and radiological outcomes between the two groups were compared.

Results

The mean follow-up period was 20.6 ± 4.5 months for group A and 20.0 ± 3.3 months for group B (p > 0.05). No significant difference existed in operating time between the two group (p > 0.05). X-ray exposure time was significantly longer for MITLIF compared to open cases. Intra-operative blood loss and duration of postoperatively hospital stay of group A were significantly superior to those of group B (p < 0.05). On postoperative day three, MITLIF patients had significantly less pain compared to patients with the open procedure. No statistical difference existed in pre-operative and latest VAS value of back pain (VAS-BP) and leg pain (VAS-LP), pre-operative and latest ODI between the two groups. The fusion rate of the two groups was similar (p < 0.05). Complications included small dural tear, superficial wound infection and overlong screws. When comparing the total complications, no significant difference existed between the groups (p > 0.05).

Conclusions

MITLIF offers several potential advantages including postoperative back pain and leg pain, intra-operative blood loss, transfusion and duration of hospital stay postoperatively in treating two-level lumbar degenerative disease. However, it required much more radiation exposure.     

显微内镜辅助经皮微创椎间孑L入路腰椎椎体间融合术治疗腰椎退行性疾病

背景：传统开放椎间孔入路腰椎椎体间融合术（transforaminal lumbar interbody fusion,TLIF）由于剥离肌肉广泛及长时间牵拉,可导致部分患者持续性腰背痛。随着脊柱微创技术的发展,采用微创手段实施TLIF技术取得了良好的临床效果,但小切口经扩张通道系统的微创TLIF仍不可避免存在肌肉剥离,需探索更加微创的手术方式。 目的：探讨显微内镜辅助经皮微创TLIF治疗腰椎退行性疾病的近期疗效及安全性。 方法：2010年9月至2011年7月,72例腰椎退行性疾病患者接受了单节段TLIF手术,腰椎失稳症36例,腰椎管狭窄症25例,复发型腰椎间盘突出症11例。采用VIPER经皮椎弓根螺钉系统结合椎间盘镜下TLIF手术32例（微创组）,传统开放TLIF手术40例（开放组）,对两组患者近期临床疗效、并发症、术中射线暴露指标等进行比较。 结果：所有患者均获随访,随访时间6-15个月,平均9个月。两组手术时间无明显统计学差异（P〉0．05）,微创组术中出血量、伤口引流量、住院天数、术后应用镇痛药剂量均明显低于开放组（P〈0．01）;微创组术中射线暴露时间及剂量高于开放组（P〈0．01）;微创组术后疼痛（VAS评分）及ODI功能指数较开放组明显降低（P〈0．01）。微创组出现术中减压错误1例,置钉位置错误1例,导针穿透椎体前壁1例,硬膜撕裂1例;开放组出现术中硬膜撕裂3例,术后伤口浅表感染1例。两组患者均未出现神经损伤并发症。 结论：显微内镜辅助经皮微创TLIF较传统开放手术具有创伤小、出血少、恢复快、住院时间短等优点,具有良好的近期疗效,是治疗腰椎失稳症值得推荐的微创手术方式。     

单侧椎弓根钉结合对侧关节突螺钉内固定与双侧椎弓根钉固定治疗下腰椎退行性疾病的比较

目的比较后路减压椎间融合器植骨后行单侧椎弓根钉结合对侧椎板关节突螺钉固定与双侧椎弓根螺钉固定治疗下腰椎退行性疾病的优缺点。方法2010年1月至2012年1月采用后路减压椎间融合器植骨内固定治疗80例下腰椎退行性疾病患者,均为单节段病变。其中40例在可扩张管微创系统（Quadrant系统）辅助下行椎弓根钉结合对侧椎板关节突螺钉固定（微创组）,40例采用开放后路腰椎体间融合双侧弓根螺钉内固定（常规组）。使用0s—westry功能障碍指数（oswestry disability index,ODI）、疼痛视觉模拟评分（visual analogue score,VAS）评定临床疗效,并比较两组患者手术切口长度、手术时间、术中出血量、术后引流量、住院时间、并发症等指标。结果术后1周微创组腰痛VAS评分优于常规组（P〈0．05）。而其他时间相比两组VAS评分与ODI评分相比,差异均无统计学意义（P〉0．05）。两组患者手术切口长度、手术时间、术中出血量、术后引流量、住院时间比较差异均有统计学意义,微创组少于常规组。随访过程中两组病例均未出现内固定物松动、移位、断裂等。融合率差异无统计学意义（P〉0．05）。结论与传统后路开放减压双侧椎弓根螺钉内固定术相比,微创通道下单侧椎弓根钉结合对侧椎板关节突螺钉内固定方法具有操作简单、创伤出血少、稳定可靠、疗效确切等优点,更加符合微创原则。     

直视下微创与切开进行单节段经椎间孔腰椎融合术的临床效果比较

[目的]观察直视下微创(minimally invasive,MIS)采用普通椎弓根螺钉完成单节段经椎间孔腰椎融合(transforaminal lumbar interbody fusion,TLIF)的临床结果.[方法]2007～2009年期间26例患者直视下进行单节段腰椎MIS - TLIF手术,45例患者采用Open - TLIF进行单节段腰椎手术,均采用普通椎弓根螺钉内固定,比较两组临床效果.[结果]MIS组术中出血量、术后引流量、下地活动时间和平均住院日均明显低于Open组,术后5 d MIS组腰痛VAS评分优于Open组,而两组腿痛VAS、ODI评分和融合率无显著差异.[结论]直视下MIS与Open两组同样具有长期优良的临床治疗结果,但是MIS组的手术出血量、术后引流量、下地活动时间、术后住院时间和术后短期腰痛均优于Open组.     

微创斜外侧腰椎椎间融合术治疗腰椎融合术后邻近节段退行性变

目的探讨斜外侧腰椎椎间融合术(OLIF)在治疗腰椎融合术后邻近节段退行性变(ASD)的临床疗效。方法 2015年8月—2017年5月,行腰椎后路减压植骨融合椎弓根内固定术42～102(74.6±19.7)个月后,发生ASD需再次手术的患者11例。发生ASD的节段均位于原融合节段上方,应用OLIF联合/不联合椎弓根钉行内固定治疗。记录手术时间、术中出血量、并发症、住院天数等。临床疗效评价采用疼痛视觉模拟量表(VAS)评分及Oswestry功能障碍指数(ODI)。摄腰椎标准正侧位、过伸过屈位X线片及CT,测量手术前后椎间孔高度(IFH)、椎间隙背侧高度(DH)、椎间隙腹侧高度(VH)等影像学参数。结果所有患者顺利完成手术,术后随访(17.7±6.8)个月,手术时间(87±35)min,单节段手术时间(64±8)min(不含内固定操作),术中出血量(74.2±28.8)mL,住院(6.7±1.9)d。所有患者术后腰腿痛VAS评分及ODI均明显降低,影像学测量结果显示手术节段椎间隙VH、DH较术前分别增加(4.5±2.1)mm和(3.2±1.9)mm,IFH较术前增加(5.7±1.6)mm。2例(18.2%)患者在椎间隙处理过程中发生终板损伤,Cage下沉,术中联合椎弓根钉内固定,术后无相关临床症状;1例发生腹膜撕裂,术中请胃肠外科专家手术修复;1例出现交感神经链损伤致下肢症状,1例出现一过性术侧腰大肌无力,屈髋肌力3+级,经对症处理后恢复正常。结论 OLIF作为一种新的脊柱微创技术,为腰椎融合术后ASD提供了一项安全、有效的治疗方式,并获得良好的近期随访临床效果。     

Comparison of one-level minimally invasive and open transforaminal lumbar interbody fusion in degenerative and isthmic spondylolisthesis grades 1 and 2

Minimally invasive lumbar fusion techniques have only recently been developed. The goals of these procedures are to reduce approach-related soft tissue injury, postoperative pain and disability while allowing the surgery to be conducted in an effective manner. There have been no prospective clinical reports published on the comparison of one-level transforaminal lumbar interbody fusion in low-grade spondylolisthesis performed with an independent blade retractor system or a traditional open approach. A prospective clinical study of 85 consecutive cases of degenerative and isthmic lower grade spondylolisthesis treated by minimally invasive transforaminal lumbar interbody fusion (MiTLIF) or open transforaminal lumbar interbody fusion (OTLIF) was done. A total of 85 patients suffering from degenerative spondylolisthesis (n = 46) and isthmic spondylolisthesis (n = 39) underwent one-level MiTLIF (n = 42) and OTLIF (n = 43) by two experienced surgeons at one hospital, from June 2006 to March 2008 (minimum 13-month follow-up). The following data were compared between the two groups: the clinical and radiographic results, operative time, blood loss, transfusion needs, X-ray exposure time, postoperative back pain, length of hospital stay, and complications. Clinical outcome was assessed using the visual analog scale (VAS) and the Oswestry disability index. The operative time, clinical and radiographic results were basically identical in both groups. Comparing with the OTLIF group, the MiTLIF group had significantly lesser blood loss, lesser need for transfusion, lesser postoperative back pain, and shorter length of hospital stay. The radiation time was significantly longer in MiTLIF group. One case of nonunion was observed from each group. Minimally invasive TLIF has similar surgical efficacy with the traditional open TLIF in treating one-level lower grade degenerative or isthmic spondylolisthesis. The minimally invasive technique offers several potential advantages including smaller incisions, less tissue trauma and quicker recovery. However, this technique needs longer X-ray exposure time.     

单侧微创与开放经椎间孔腰椎椎体间融合内固定治疗腰椎椎间盘突出症的临床疗效比较

目的：比较微创经椎间孔融合内固定与传统开放经椎间孔融合内固定术治疗腰椎椎间盘突出症的临床疗效。方法2009年10月～2012年10月,对54例腰椎椎间盘突出症手术患者进行回顾性分析,其中男32例,女22例,年龄34～60岁,平均42．7岁;病变节段为L4/L534例,L5/S120例。依据手术方式将其分成微创经椎间孔腰椎椎体间融合（minimally invasive transforaminal lumbar interbody fusion , MiTLIF）组和开放经椎间孔腰椎椎体间融合（open transforaminal lumbar interbody fusion , OTLIF）组,分别为24例和30例。分析手术时间、手术出血量、住院时间、术中术后并发症,影像学观察术后1年椎间融合情况,采用日本骨科学会（ Japanese Orthopaedic Association ,JOA）评分评估临床效果。结果所有患者均获随访,随访时间12～36个月,平均21．4个月,MiTLIF组出血量（40．2±15．6） mL,住院时间（6．2±2．4） d,术后2周JOA评分18．7±1．9,OTLIF组出血量（203．6±52．8） mL,住院时间（10．8±4．2） d,术后2周JOA评分15．1±1．4,2组差异具有统计学意义（P＜0．05）。2组手术时间,术中术后并发症发生率,术后1个月、3个月和1年JOA评分,术后1年椎间融合率差异无统计学意义（P＞0．05）。结论在行单侧椎弓根固定治疗腰椎椎间盘突出症时,MiTLIF组出血量更少短期临床疗效更好。     

Single-position prone transpsoas fusion for the treatment of lumbar adjacent segment disease: early experience of twenty-four cases across three tertiary medical centers

Purpose

Prone transpsoas fusion (PTP) is a minimally invasive technique that maximizes the benefit of lateral access interbody surgery and the prone positioning for surgically significant adjacent segment disease. The authors describe the feasibility, reproducibility and radiographic efficacy of PTP when performed for cases of lumbar ASD.

Methods

Adult patients undergoing PTP for treatment of lumbar ASD at three institutions were retrospectively enrolled. Demographic information was recorded, as was operative data such as adjacent segment levels, operative time, blood loss, laterality of approach, open versus percutaneous pedicle screw instrumentation and need for primary decompression. Radiographic measurements including segmental and global lumbar lordosis, pelvic incidence, pelvic tilt, sacral slope and sagittal vertical axis were recorded both pre- and immediately post-operatively.

Results

Twenty-four patients met criteria for inclusion. Average age was 60.4 ± 10.4 years and average BMI was 31.6 ± 5.0 kg/m². Total operative time was 204.7 ± 83.3 min with blood loss of 187.9 ± 211 mL. Twenty-one patients had pedicle screw instrumentation exchanged percutaneously and 3 patients had open pedicle screw exchange. Two patients suffered pulmonary embolism that was treated medically with no long-term sequelae. One patient had transient lumbar radicular pain and all patients were discharged home with an average length of stay of 3.0 days (range 1–6). Radiographically, global lumbar lordosis improved by an average of 10.3 ± 9.0 degrees, segmental lordosis by 10.1 ± 13.3 degrees and sagittal vertical axis by 3.2 ± 3.2 cm.

Conclusion

Single-position prone transpsoas lumbar interbody fusion is a clinically reproducible minimally invasive technique that can effectively treat lumbar adjacent segment disease.

     

Percutaneous axial lumbar interbody fusion (AxiaLIF) of the L5-S1 segment: initial clinical and radiographic experience

INTRODUCTION: Anterior access to the L5-S1 disc space for interbody fusion can be technically challenging, frequently requiring the use of an approach surgeon for adequate exposure. We reviewed our experience with a novel minimally invasive technique for L5-S1 interbody fusion that exploits the presacral space and its relative dearth of critical structures. METHODS: 35 patients (20 F:15 M, mean age 54 years) were included in this analysis. Average follow-up was 17.5 months. Back pain was secondary to lumbar degenerative disc disease (DDD), degenerative lumbar scoliosis, or lytic spondylolisthesis. All patients had radiographic evidence of L5-S1 degeneration and underwent percutaneous paracoccygeal axial fluoroscopically-guided interbody fusion (axiaLIF) with cage, local bone autograft, and rhBMP. RESULTS: Mean operative time for the L5-S1 axiaLIF procedure was 42 minutes. Twenty-one patients underwent axiaLIF followed by percutaneous L5-S1 pedicle screw-rod fixation. Two patients underwent axiaLIF followed by percutaneous L4-L5 extreme lateral interbody fusion (XLIF) and posterior instrumentation. Ten patients had a stand-alone procedure. Unfavorable anatomy precluded access to the L5-S1 disc space during open lumbar interbody fusion in 2 patients who subsequently underwent axiaLIF at this level as part of a large construct. Thirty-two patients (91%) had radiographic evidence of stable L5-S1 interbody cage placement and fusion at the last follow-up. CONCLUSIONS: The percutaneous paracoccygeal approach to the L5-S1 interspace provides a minimally invasive corridor through which discectomy and interbody fusion can safely be performed. It can be used alone or in combination with minimally invasive or traditional open fusion procedures. It may provide an alternative route of access to the L5-S1 interspace in those patients who may have unfavorable anatomy for or contraindications to the traditional open anterior approach to this level.     

The effect of ketorolac on posterior minimally invasive transforaminal lumbar interbody fusion: an interim analysis from a randomized,double-blinded,placebo-controlled trial

BACKGROUND CONTEXTPostoperative pain control following posterior lumbar fusion continues to be challenging and often requires high doses of opioids for pain relief. The use of ketorolac in spinal fusion is limited due to the risk of pseudarthrosis. However, recent literature suggests it may not affect fusion rates with short-term use and low doses.PURPOSEWe sought to demonstrate noninferiority regarding fusion rates in patients who received ketorolac after undergoing minimally invasive (MIS) posterior lumbar interbody fusion. Additionally, we sought to demonstrate ketorolac's opioid-sparing effect on analgesia in the immediate postoperative period.STUDY DESIGN/SETTINGThis is a prospective, randomized, double-blinded, placebo-controlled trial. We are reporting our interim analysis.PATIENT SAMPLEAdults with degenerative spinal conditions eligible to undergo a one to three-level MIS transforaminal lumbar interbody fusion (TLIF).OUTCOME MEASURESSix-month and 1-year radiographic fusion as determined by Suk criteria, postoperative opioid consumption as measured by intravenous milligram morphine equivalent, length of stay, and drug-related complications. Self-reported and functional measures include validated visual analog scale, short-form 12, and Oswestry Disability Index.METHODSA double-blinded, randomized placebo-controlled, noninferiority trial of patients undergoing 1- to 3-level MIS TLIF was performed with bone morphogenetic protein (BMP). Patients were randomized to receive a 48-hour scheduled treatment of either intravenous ketorolac (15 mg every 6 hours) or saline in addition to a standardized pain regimen. The primary outcome was fusion. Secondary outcomes included 48-hour and total postoperative opioid use demonstrated as milligram morphine equivalence, pain scores, length of stay (LOS), and quality-of-life outcomes. Univariate analyses were performed. The present study provides results from a planned interim analysis.RESULTSTwo hundred and forty-six patients were analyzed per protocol. Patient characteristics were comparable between the groups. There was no significant difference in 1-year fusion rates between the two treatments (p=.53). The difference in proportion of solid fusion between the ketorolac and placebo groups did not reach inferiority (p=.072, 95% confidence interval, -.07 to .21). There was a significant reduction in total/48-hour mean opioid consumption (p<.001) and LOS (p=.001) for the ketorolac group while demonstrating equivalent mean pain scores in 48 hours postoperative (p=.20). There was no significant difference in rates of perioperative complications.CONCLUSIONSShort-term use of low-dose ketorolac in patients who have undergone MIS TLIF with BMP demonstrated noninferior fusion rates. Ketorolac safely demonstrated a significant reduction in postoperative opioid use and LOS while maintaining equivalent postoperative pain control.     

Clinical and radiological outcomes of axial lumbar interbody fusion

Axial lumbar interbody fusion is a novel percutaneous alternative to common open techniques, such as anterior, posterior, and transforaminal lumbar interbody fusion. This minimally invasive technique uses the presacral space to access the L5-S1 and L4-L5 disk space. The goal of this study was to examine outcomes following axial lumbar interbody fusion. The charts of all patients who underwent axial lumbar interbody fusion surgery at our institution between 2006 and 2008 were reviewed. Clinical outcomes included visual analog scale (VAS) and Oswestry Disability Index (ODI). Radiographs were also evaluated for disk space height, L4-L5 and/or L5-S1 Cobb angle, and fusion. Of the 50 patients (32 women, 18 men; mean age, 49.29 years) treated with axial lumbar interbody fusion, 48 had preoperative VAS scores and 16 had preoperative ODI scores available. Complete radiographic data were available at the preoperative, initial postoperative, and final postoperative time points for 46 patients (92%). At last follow-up (average, 12 months), ODI scores were reduced from 46 to 22, and VAS scores were lowered from 8.1 to 3.6. Of the 49 patients with postoperative radiographs, 47 (96%) went on to a solid fusion. There were no significant differences between pre- and postoperative disk space height and lumbar lordosis angle. The most common complications were superficial infection and pseudoarthrosis. Other complications were rectal injury, hematoma, and irritation of a nerve root by a screw. Overall, we found the axial lumbar interbody fusion procedure in combination with pedicle screw placement to have good clinical and radiological outcomes.     

扩张式椎间融合器在腰椎融合术中的应用

目的探讨扩张式椎间融合器（expanding cage,EC）在腰椎融合术中应用的适应性、技术要点和疗效。方法本组47例患者,均行后路扩张式椎间融合术（PELIC）。术前分别诊断为腰椎管狭窄、腰椎间盘突出、腰椎滑脱和退变性腰椎不稳,经非手术治疗无效后,以手术对椎管及神经根管减压,用EC融合固定并植骨。术前、术后对患者的腰疼情况进行视觉痛觉自我评定尺（VAS）评分。结果所有患者术前症状消失,术中未发生神经损伤,随访最长时间为61个月,最短53个月,平均57．3个月,无假关节形成,无明显椎体塌陷。结论EC在腰椎融合术应用中具有融合可靠、症状改善明显等优点。     

Minimally invasive lumbar spinal fusion

Minimally invasive techniques for lumbar spine fusion have been developed in an attempt to decrease the complications related to traditional open exposures (eg, infection, wound healing problems). Anterior minimally invasive procedures include laparoscopic and mini-open anterior lumbar interbody fusion as well as the lateral transpsoas and percutaneous presacral approaches. Posterior techniques typically use a tubular retractor system that avoids the muscle stripping associated with open procedures. These techniques can be applied to both posterior and transforaminal lumbar interbody fusion procedures. Many initial reports have shown similar clinical results in terms of spinal fusion rates for both traditional open and minimally invasive posterior approaches. However, the anterior minimally invasive procedures are often associated with significantly greater incidence of complications and technical difficulty than their associated open approaches. There is a steep learning curve associated with minimally invasive techniques, and surgeons should not expect to master them in the first several cases.     

微创通道结合经皮椎弓根螺钉固定治疗腰椎退变的个体化方案选择

目的探讨应用微创通道减压融合结合经皮椎弓根螺钉固定治疗腰椎退行性疾病的初步临床效果及手术方案选择。方法收集2009年8月至2011年7月第四军医大学唐都医院运用微创通道减压融合结合经皮椎弓根螺钉固定治疗并获得随访的64例腰椎退变患者的临床资料。采用Quadrant、Pipeline或Luxor通道系统,经椎间孔腰椎间融合（TLIF）或后路TLIF（PTLIF）入路,行髓核摘除或椎间处理并植入椎间融合器,通道内行椎弓根螺钉固定并安装连接棒。于对侧相应椎体处行椎弓根经皮植入Sextant、vipor或Mantis螺钉固定。微创策略的选择：（1）单侧通道下减压椎间植骨融合,常规椎弓螺钉内固定;（2）一侧通道下减压植骨融合通用螺钉固定 ＋ 对侧通道下通用螺钉固定;（3）一侧通道下减压植骨融合通用螺钉固定 ＋ 对侧经皮螺钉固定;（4）一侧通道下减压椎间植骨融合＋双侧经皮螺钉固定。融合方式包括单节段融合、双节段融合和跨节段融合。观察患者术中出血量、手术时间、术后下床活动时间、住院天数、内固定位置以及术后症状改善情况。结果随访3～22 个月（平均 16 个月）。术中出血量 70～230 mL（平均 90 mL）、手术时间 70～210 min（平均 100 min）、下床活动时间为术后3～10 d（平均5 d）、住院天数5～15 d（平均7 d）。腰痛视觉模拟评分（VAS）和腿痛VAS分别由术前的（9.2 ± 1.4）分和（7.4 ± 1.2）分减少到末次随访的（2.6 ± 0.5）分和（2.2 ± 0.6）分,Oswestry功能障碍指数（ODI）由术前的（57.4 ± 6.4）%降至末次随访的（25.8 ± 4.3）%,差异均有统计学意义（P 〈0.05）。术中、术后X线片和/或 CT 检查显示内固定及融合器位置良好。结论一侧采用微创通道 TLIF 或 PTLIF 入路行单节段或双节段椎间处理融合,或在此基础上行对侧通道下通用螺钉/经皮椎弓根螺钉固定或双侧经皮螺钉固定等个体化方案治疗腰椎退行性疾病,术中出血少,手术时间短,术后可早期下床进行功能锻炼,初步临床效果优良。     

类风湿关节炎合并腰椎退行性疾病患者腰椎椎间融合术后邻近节段退行性变的相关因素

目的探讨类风湿关节炎(RA)合并腰椎退行性疾病患者腰椎椎间融合术后发生邻近节段退行性变(ASD的危险因素。方法回顾性分析2008年1月—2016年12月收治的55例RA合并腰椎退行性疾病患者的临床资料,其中29例采用减压并椎间融合术(融合组)治疗,26例采用单纯减压术(非融合组)治疗。记录手术前后红细胞沉降率(ESR)、C反应蛋白(CRP)、基质金属蛋白酶-3(MMP-3)等指标,采用28个关节疾病活动度评分联合CRP水平(DAS28-CRP)评估RA活动度;采用日本骨科学会(JOA)评分评估患者神经功能;测量X线片上腰椎邻近节段头端椎间隙狭窄及椎体滑脱程度以评估ASD情况。运用多因素logistic回归分析检验术后继发ASD的危险因素。结果所有手术顺利完成,术后随访1.5～6.0年,平均3.2年。2组术后JOA评分较术前均明显改善,且融合组显著高于非融合组,差异均有统计学意义(P 0.05)。融合组手术翻修率、影像学ASD及症状性ASD发生率显著高于非融合组,差异均有统计学意义(P 0.05)。多因素logistic回归分析显示,DAS28-CRP评分 4.7分、术前血清MMP-3含量升高是术后继发ASD的独立危险因素。结论 RA合并腰椎退行性疾病患者采用腰椎减压并椎间融合术治疗后出现ASD和需行翻修手术的风险高于采用单纯减压术治疗的患者,术前血清MMP-3含量和DAS28-CRP评分升高可能与腰椎椎间融合术后ASD的发生相关。     

Minimally invasive versus open transforaminal lumbar interbody fusion: evaluating initial experience

The aim of this study was to compare our experience with minimally invasive transforaminal lumbar interbody fusion (MITLIF) and open midline transforaminal lumbar interbody fusion (TLIF). A total of 36 patients suffering from isthmic spondylolisthesis or degenerative disc disease were operated with either a MITLIF (n = 18) or an open TLIF technique (n = 18) with an average follow-up of 22 and 24 months, respectively. Clinical outcome was assessed using the visual analogue scale (VAS) and the Oswestry disability index (ODI). There was no difference in length of surgery between the two groups. The MITLIF group resulted in a significant reduction of blood loss and had a shorter length of hospital stay. No difference was observed in postoperative pain, initial analgesia consumption, VAS or ODI between the groups. Three pseudarthroses were observed in the MITLIF group although this was not statistically significant. A steeper learning effect was observed for the MITLIF group.     

微创经椎间孔入路腰椎椎间融合术治疗腰椎滑脱症的中短期随访

目的对比微创经椎间孔入路腰椎椎间融合术(MIS-TLIF)与传统开放后路腰椎椎间融合术(PLIF)治疗单节段腰椎滑脱症的中短期疗效,以评价MIS-TLIF的安全性。方法回顾性分析2015年3月—2017年9月166例单节段腰椎滑脱症患者临床资料,70例行MIS-TLIF治疗,96例行PLIF治疗。比较2组患者围手术期指标、疼痛视觉模拟量表(VAS)评分、Oswestry功能障碍指数(ODI)与术后并发症发生情况。结果 MIS-TLIF组术中出血量、术后引流量、切口长度、术后卧床天数、术后住院天数、住院费用和手术满意度均优于PLIF组,差异有统计学意义(P 0.05);但MIS-TLIF组术后血清肌酸激酶值显著高于PLIF组,差异有统计学意义(P 0.05);2组手术时间,手术前后VAS评分、ODI,并发症发生率和椎间融合率差异均无统计学意义(P 0.05)。结论 MIS-TLIF治疗腰椎滑脱症,疗效确切,安全性好,术后恢复快,住院费用低,手术满意度高;但MIS-TLIF术后血清肌酸激酶值偏高,考虑可能因术中使用电刀,通道空间狭小,术中吸引器使用少,肌酸激酶大量吸收入血所致,仍需进一步研究证实。