经椎间孔椎体间融合术治疗双节段腰椎退行性疾病的中期疗效

目的探讨经椎间孔椎体间融合术﹙TLIF﹚治疗双节段腰椎退行性疾病的中期疗效。方法自2005年9月~2009年3月,25例双节段腰椎退行性病变患者进行TLIF术治疗。其中男17例,女8例。年龄42~68岁,平均56.5岁。病程1.0~12年,平均3.4年。其中L3~L511例,L4~S114例。术前VAS评分为8.3±0.7分,ODI评分45.4±2.0分,改良Prolo评分8.5±2.1分。结果手术时间180~240分钟,平均206.2±51.5分钟。术中出血420~600 ml,平均503.2±30.5ml。住院天数14~30天,平均21.3±2.2天。所有病例随访时间2.5~5.5年,平均4.8年。术后腰背功能评分与术前比较有显著性差异﹙〈0.05﹚。改良Prolo评分优15例,良8例,可1例,差1例,总优良率92%。本组25例50个融合节段,术后1年三维CT扫描,有43个节段融合,融合率86%。术后3例发生切口浅表皮肤感染,2例连杆滑脱。无螺钉松动,断裂,假关节形成和椎间融合器下沉等并发症。结论 TLIF治疗双节段腰椎退变疾病中期疗效满意,具有较高的融合率,长期结果还需进一步随访。     

Do autologous growth factors enhance transforaminal lumbar interbody fusion?

Pseudarthrosis remains a significant problem in spinal fusion. The objective of our study was to investigate the effects of autologous growth factors (AGF) in instrumented transforaminal lumbar interbody spinal fusion (TLIF). A prospective review was carried out of 23 patients who underwent TLIF with application of AGF, with a minimum 2-year follow-up. Comparison with our historical cohort (without AGF application) was performed. Mean age at surgery was 44.3 years in the AGF treatment group. Twelve had a positive smoking history. Fourteen had undergone previous spinal surgeries. Thirteen received one-level fusions and ten received two-level fusions. The radiographic results showed a fusion rate of 100% in one-level fusions and 90% in two-level fusions. There was no significant difference in pseudarthrosis rates between the AGF treatment group and historical cohort. Excluding the cases with pseudarthrosis, there was faster bony healing in patients who had been treated with AGF application. This study indicates that although AGF may demonstrate faster fusions, it does not result in an overall increase in spinal fusion rates. Further studies are needed before AGF can routinely be used as an adjunct in spinal fusion.     

改良TLIF技术治疗腰椎管狭窄症的早期疗效研究

目的探讨在保留脊柱棘突韧带复合体的基础上,改良后的TLIF技术治疗退行性腰椎管狭窄症的疗效。方法回顾性分析我们2009年8月～2011年3月,采用改良后的TLIF技术治疗28例患者,其中男13例,女15例,病程6个月～7年;年龄43～75,平均9．2岁,其中L2/3间隙2例;L3/4间隙17例;L4/5n间隙15例;L5／S1间隙2例;伴L4椎体Ⅰ°滑脱6例;伴cobb角大于15。的退变性腰椎侧凸3例。根据术前影像学资料,三节段融合1例、二节段融合19例、单节段融合9例。全部进行椎弓根钉棒系统内固定,双侧开窗减压,完整保留棘上韧带、棘间韧带,切除增生黄韧带及部分增生内聚的小关节突,突出的椎间盘组织,椎间隙以行自体骨并单枚Cage融合。术中注意保证棘突、棘上韧带及棘间韧带的完整性。术后1-3天佩戴腰围下床活动。结果术后平均随访14个月,术前术后JOA改变量及VAS评分改变量有明显差异（P〈0．01）,随访x线片显示椎间植骨融合良好,无明显腰椎不稳征象。内固定系统无折断和松动,滑脱复位无丢失。结论保留腰椎后侧韧带复合结构,两侧开窗切除增生骨质、黄韧带,椎间盘椎管及神经根管彻底减压的改良TLIF技术,既能解除神经组织的压迫,又保留了后侧韧带复合体的完整,不仅可以有效的保护椎管内神经组织,而且很大程度上维持了脊柱原有的生物力学基础,进一步减少了手术创伤,是治疗腰椎管狭窄症的一种有效手术方法,临床治疗效果满意。     

Influence of transforaminal lumbar interbody fusion procedures on spinal and pelvic parameters of sagittal balance

Introduction

Restitution of sagittal balance is important after lumbar fusion, because it improves fusion rate and may reduce the rate of adjacent segment disease. The purpose of the present study was to describe the impact of transforaminal lumbar interbody fusion (TLIF) procedures on pelvic and spinal parameters and sagittal balance.

Materials and methods

Forty-five patients who had single-level TLIF were included in this study. Pelvic and spinal radiological parameters of sagittal balance were measured preoperatively, postoperatively and at latest follow-up.

Results

Age at surgery averaged 58.4 (±9.6) years. Mean follow-up was 35.1 months (±4.1). Twenty-nine percent of the patients exhibited anterior imbalance preoperatively, with high pelvic tilt (17.6° ± 7.9°). Of the 32 (71%) patients well balanced before the procedure, 22 (70%) had a large pelvic tilt (>20°), due to retroversion of the pelvis as an adaptive response to the loss of lordosis. Three dural tears (7%) were reported intraoperatively. Interbody cages were more posterior than intended in 27% of the cases. Disc height and lumbar lordosis at fusion level significantly increased postoperatively (p < 0.05 and p < 0.001). Pelvic tilt was significantly reduced (p < 0.01) postoperatively, whereas the global sagittal balance was not significantly modified (p = 0.07).

Conclusion

Single-level circumferential fusion helps patients reducing their pelvic compensation, but the amount of correction does not allow for complete correction of sagittal imbalance.     

Arthrodèses transforaminales : intérêts de l’abord minimal invasif

Background and purposeTransforaminal lumbar interbody fusion (TLIF) is an effective technique, which can achieve a fusion rate of up to 90%. The minimally invasive approach has become increasingly popular because it is able to minimize iatrogenic soft tissue and muscle injury. Although the minimally invasive TLIF technique has gained popularity, its effectiveness compared with open TLIF has yet to be established. The authors prospectively compared the outcomes of patients who underwent mini-open TLIF with patients who underwent open TLIF.MethodsBetween 2007 and 2008, 50 patients underwent TLIF for grade 1 spondylolisthesis; 25 mini-open TLIF and 25 open TLIF. The mean age in each group was 48 years, and there was no statistically significant difference between the groups. Data were collected perioperatively. Pain and functional disability were measured using a visual analogue scale (VAS) and the Oswestry disability index (ODI) at 3 months, 6 months, 1 year and 2 years. In addition, foraminal and disc height were measured at the same intervals and the fusion was evaluated at 1 year on CT-scan. Soft tissue damage was evaluated by measuring the serum myoglobin and creatine phosphokinase activity.ResultsThe mean VAS improved from 7 to 2.8 and the ODI decreased from 30/50 to 15/50 and fusion rate at 1 year was 98%. There was no statistical difference for the clinical and radiological outcomes between the groups. The mean operative time was 186 min for the open group, 170 min for the mini-open group (P < 0.05) and the mean blood loss was 486 mL for the open group and 148 mL for the mini-open group (P < 0.01).ConclusionThe mini-open TLIF procedure for symptomatic low grade spondylolisthesis is an effective option which achieves similar clinical and radiological outcomes and reduces perioperative morbidity as well as soft tissue damage.     

Expert’s comment concerning Grand Rounds case entitled “Minimal access bilateral transforaminal lumbar interbody fusion for high-grade isthmic spondylolisthesis” (by Nasir A. Quraishi and Y. Raja Rampersaud; doi:10.1007/s00586-012-2623-2)

Open in a separate windowThis Expert''s Comment discusses the Grand Rounds Case entitled “Minimal Access Bilateral Transforaminal Lumbar Interbody Fusion for High-Grade Isthmic Spondylolisthesis” by Nasir A Quraishi and Raja Y Rampersaud. It puts a technically elegant surgical method for minimally invasive reduction and arthrodesis of isthmic spondylolistheses into the context of short and long term outcomes and questions the motivations for performing such minimally invasive procedures in the absence of any proven mid or long term advantages over more traditional techniques. In addition, the use of BMP in spinal arthrodesis is discussed on the background of recently published IPD metaanalyses from the Infuse™ spinal FDA trials.     

Unilateral versus bilateral pedicle screw instrumentation for single-level minimally invasive transforaminal lumbar interbody fusion

Minimally invasive transforaminal lumbar interbody fusion (MIS TLIF) has become an increasingly popular method of lumbar arthrodesis. However, there are few published studies comparing the clinical outcomes between unilateral and bilateral instrumented MIS TLIF. Sixty-five patients with degenerative lumbar spine disease were enrolled in this study. Thirty-one patients were randomized to the unilateral group and 34 to the bilateral group. Recorded demographic data included sex, age, preoperative diagnosis, and degenerated segment. Operative time, blood loss, hospital stay length, complication rates, and fusion rates were also evaluated. The Oswestry Disability Index (ODI) score and Visual Analog Scale (VAS) pain score data were obtained. All patients were asked to follow-up at 3 and 6 months after surgery, and once every 6 months thereafter. The mean follow-up was 26.6 months (range 18–36 months). The two groups were similar in sex, age, preoperative diagnosis, and operated level. The unilateral group had significantly shorter operative time, lower blood loss, and shorter hospital time than the bilateral group. The average postoperative ODI and VAS scores improved significantly in each group. No significant differences were found between the two groups in relation to ODI and VAS. All patients showed evidence of fusion at 12 months postoperatively. The total fusion rate, screw failure, and general complication rate were not significantly different. Results showed that single-level MIS TLIF with unilateral pedicle screw fixation would be sufficient in the management of preoperatively stable patients with lumbar degenerative disease. It seems that MIS TLIF with unilateral pedicle screw instrumentation is a better choice for single-level degenerative lumbar spine disease.     

不同手术方案治疗腰椎间盘突出症 合并腰椎失稳临床对比研究

目的 探讨常规开放和微创改良经孔椎体间融合术（TLIF）对腰椎间盘突出症合并腰椎失稳患者 围手术期临床指标、ODI 评分及椎间融合率的影响。方法 研究对象选取腰椎间盘突出症合并腰椎失稳患者 共100 例,以随机数字表法分为A 组（50 例）和B 组（50 例）,分别采用常规开放和微创改良TLIF 术式治疗; 比较两组患者手术用时、术中出血量、术后引流量、首次下地活动时间以及手术前后VAS 评分、JOA 评分、 ODI 评分、椎间融合率等。结果 两组患者手术用时比较差异无统计学意义（P >0.05）;B 组患者术中出血 量、术后引流量及首次下地活动时间均优于A 组（P <0.05）;两组患者术后3、和12 个月VAS 评分低于术 前（P <0.05）;B 组患者术后3 个月VAS 评分低于A 组（P <0.05）;两组患者术后12 个月VAS 评分比较差 异无统计学意义（P >0.05）;两组患者术后3 和12 个月JOA 评分、ODI 评分均优于术前（P <0.05）;两组患 者术后3 和12 个月JOA 评分、ODI 评分比较差异无统计学意义（P >0.05）;同时两组患者椎间融合率比较 差异无统计学意义（P >0.05）。结论 常规开放和微创改良TLIF 术式治疗腰椎间盘突出症合并腰椎失稳具有 接近的临床疗效,但微创改良TLIF 术式应用在降低手术创伤程度、促进术后康复及减轻术后腰腿疼痛程度 方面更具优势。     

Awake spinal fusion

‘Awake spinal fusion’ is a novel approach to spine surgery that combines modern anaesthetic and surgical technique resulting in improved patient satisfaction and overall outcomes. Along with techniques of regional anaesthesia, minimally invasive or endoscopic surgical techniques are used to minimize surgical dissection and blood loss. Although, it is a relatively new concept with limited supporting evidence till date, it may prove to be highly effective in reducing post-operative hospital stays, in-hospital complications and cost of surgery while at the same time expediting recovery and rehabilitation. The current review focuses on techniques, advantages, limitations and the available evidence on awake spinal fusion.     

改良小切口肌间隙入路双侧固定单侧减压TILF手术临床疗效分析

目的　探讨改良小切口肌间隙入路双侧固定单侧减压TILF手术解剖学特点,及分析与传统术式对比治疗腰椎退变性疾病的临床疗效。 方法　回顾性分析2014年12月至2016年12月,应用改良小切口肌间隙入路双侧固定单侧减压TILF手术治疗单节段下腰椎病变患者30例（改良组）。传统术式组30例（传统组）。研究改良组TILF手术解剖学特点,比较两组病例的手术时间、术中出血量、术后引流量、术后2周VAS疼痛评分和Oswestry功能障碍评分。 结果　改良组采用双侧小切口,一侧通过Wiltse间隙入路单纯置钉固定,一侧通过改良肌间隙入路（多裂肌偏中心处间隙）置钉,减压,椎间融合固定。改良组手术时间、术中出血量、术后引流量均小于传统组（P<0.05）;两组术前VAS 评分与Oswestry功能障碍评分无显著性差异(P>0.05);改良组术后VAS 评分小于传统组（P<0.05）;两组术后Oswestry功能障碍评分无显著性差异(P>0.05)。 结论　与传统术式相比,改良组TLIF术通过肌间隙入路更适应人体解剖学特性,手术视野佳,手术操作更容易。同时改良组还具有、手术时间短、术中出血和术后引流少、术后疼痛轻等优点。值得临床推广。