Comparison of adjacent segment disease after minimally invasive or open transforaminal lumbar interbody fusion

Adjacent segment disease (ASD) is a potential long-term risk after lumbar fusion. Its incidence has been evaluated in anterior and posterior lumbar interbody fusions, but few studies have focused on transforaminal lumbar interbody fusion (TLIF). Relative risk of ASD with open or minimally invasive (MI) TLIF is poorly understood. To report our experience with risk for ASD in patients receiving TLIF and test its association with surgical approach, we performed a retrospective cohort study based on medical record review at a single institution. Eligible patients were ⩾18 years old at operation, underwent single-level TLIF during the period 2007–2008, and had at least 6 months postoperative follow-up. Patients were categorized by surgical approach (open versus MI). Primary outcome of interest was development of symptomatic ASD, defined by (1) new back and/or leg pain, (2) imaging findings adjacent to original surgical level, and (3) decision to treat. A total of 68 patients (16 open, 52 MI) were included in the analysis. Groups had similar baseline characteristics, except the open group tended to be older (p = 0.04). Seven (10%) patients developed ASD. Mean patient age was 62 years and three were male. Three underwent open and four underwent MI TLIF. Risk of ASD did not differ significantly by surgical approach. The MI group showed a trend toward decreased risk of ASD compared to the open group, although it was not statistically significant. This suggests MI TLIF may be associated with decreased long-term morbidity compared to the open approach. Large prospective studies are needed to confirm these findings.     

Evaluation of an injectable calcium phosphate cement as an autograft substitute for transpedicular lumbar interbody fusion: a controlled,prospective study in the sheep model

Anteroposterior procedures for lumbar interbody fusion usually combine posterior instrumentation with anterior techniques that achieve primary stability for compressive loading: tricortical strut-graft, anterior plating systems, or cages. In comparison to transpedicular lumbar interbody fusion (TLIF), these methods bear the burden of the additional anterior approach. TLIF with autograft, in contrast, does not prove to be clinically sufficient because of its lack of primary compressive stability. In a sheep model, we therefore developed a TLIF method providing primary stability for axial loading. In 24 sheep, L4-L6 were instrumented posteriorly. An endoscopically assisted L4/L5 TLIF procedure was performed via a bilateral approach. In 12 sheep, the defect was filled with an injectable calcium phosphate cement. After setting, this cement gains a stability against axial loading comparable to healthy vertebrae. Another 12 sheep were treated with autograft. The animals were killed at 8 weeks and evaluated by radiologic (plain X-ray, computed tomography), histologic and histomorphometric analysis, and fluorochrome labeling. Only ten autograft sheep were available for evaluation. Radiologically and histologically, TLIF with calcium phosphate led to a 2/12 fusion rate compared to autograft (1/10 fused) (P=0.70). Semiquantitative radiologic and histologic scoring did not reveal significant differences (P=0.88). In 4/12 calcium phosphate sheep, excessive resorption was responsible for local aseptic inflammation. The findings of this study show that calcium phosphate cement is not superior to autograft, despite enabling primary stability against compressive loading. Biointegration of the osteoconductive cement does not occur fast enough, and shear forces cause early cement fracture, subsequent fragmentation, and gross resorption with the possibility of severe inflammation.     

TLIF技术在腰椎手术中的应用

目的探讨经椎间孔入路的腰椎间盘摘除椎间融合技术（TLIF）在腰椎手术中的应用范围和优缺点。方法自2000年以来应用TLIF技术完成各种腰椎手术214例,其中男146例,女68例;初次手术173例,椎间盘突出术后复发41例;上位椎间盘突出（胸12腰1、腰1-2、腰2-3）的65例,下位椎间盘突出（腰3-4、腰4-5、腰5骶1）的149例;应用早期枢法模的标准的TLIF钛网式双Cage进行操作78例,应用单Cage进行操作136例。结果所有病例未出现手术造成的神经根和脊髓损伤的症状,亦未出现脑脊液漏及对侧神经根的刺激症状,随访1年X线片及CT显示197例患者获得椎间融合,17例患者因出现椎间盘炎、植骨量吸收等因素出现骨融合欠佳,随访3年后前方形成骨桥,椎间融合器未见下沉现象。随访1至8年未出现断钉和断棒现象。症状缓解情况：依据Oswestry评分平均由术前的10±1分,术后1周为3±1分,1年复查时为1±1分。结论TLIF技术可适用于各节段的中央型或单侧包括极外侧型腰椎间盘突出症,可减少对无症状侧神经根的激惹和椎小关节的破坏,对于高位椎间盘突出可避免发生脊髓损伤,二次椎间盘突出的患者,可防止经瘢痕区进入造成不必要的脑脊液漏和神经根损伤的现象,融合率高。     

TLIF治疗极外侧腰椎间盘突出症23例体会

目的探讨经椎间孔入路的腰椎间盘摘除椎间融合技术(TLIF)治疗极外侧腰椎间盘突出症的疗效及优缺点。方法自2006年以来应用TLIF技术治疗极外侧腰椎间盘突出23例,年龄33～67岁,其中男18例,女5例;L3~46例,L4~514例,L5S13例;单间隙突出4例,双间隙突出10例,多间隙突出9例;均应用单枚肾形Cage进行操作。结果采用中华骨科学会脊柱组腰背痛手术评定标准,优15,良6,可2例。优良率达91.3%。结论 TLIF治疗极外侧型腰椎间盘突出症,术野清晰,直视下操作不易损伤神经根,创伤小,对腰椎稳定性影响较小,是一种有效的治疗方法。     

经多裂肌间隙入路TLIF与传统PLIF治疗30例腰椎间盘突出症疗效比较

目的:比较经多裂肌间隙入路椎间孔椎体间融合术(TLIF)和传统腰椎后路腰椎间融合术(PLIF)在腰椎间盘突出症的临床疗效。方法:选择腰椎间盘突出症的患者60例,根据手术方式不同随机分为两组(PLIF组和TLIF组),每组各30例。比较两组患者手术时间、术中出血量、术后引流量、术后住院天数、椎体间融合率、椎体融合时间以及术后并发症;手术前后VAS评分和ODI功能障碍指数评分。结果:①TLIF组的手术时间、术中出血量、术后引流量均比PLIF组明显降低(P0.05);两组术后住院时间、椎体间融合率和椎体融合时间比较无显著差异(P0.05)。②TLIF组术后VAS评分和ODI评分均比PLIF组明显降低;③TLIF组的术后神经损伤、固定物松动移位和硬脊膜撕裂脑脊液漏发生率均比PLIF组明显降低(P0.05)。结论:采用经多裂肌间隙入路TLIF技术治疗腰椎间盘突出症较传统PLIF技术疗效好、创伤小、出血少、术后并发症少,值得临床推广应用。     

TLIF技术结合椎弓根螺钉系统治疗高位腰椎间盘突出症19例

2004年6月至2008年6月,我院应用经椎间孔人路腰椎椎体间融合术（Transforaminal lumbar interbody fusion,TLIF）结合椎弓根螺钉系统治疗高位腰椎间盘突出症患者19例,疗效满意,现总结报告如下。     

经椎间孔腰椎椎体间融合入路扩大减压结合椎弓根螺钉固定治疗老年腰椎管狭窄症

目的 观察经椎间孔腰椎椎体间融合(TLIF)入路减压结合椎弓根螺钉固定治疗老年退变性腰椎管狭窄症的疗效.方法 2007年1月至2010年8月我院收治老年腰椎管狭窄症患者75例,男28例,女47例.手术采用TLIF入路,凿除部分关节突关节,切除增厚的黄韧带,暴露椎间孔,切除椎体后缘骨赘及突出的椎间盘,使中央椎管及神经根管管径扩大.减压后结合椎弓根螺钉固定,同时行后外侧或椎间融合.术前、术后1d、3个月随访采用JOA进行评分,根据X线片评价椎间隙高度的变化及椎间融合情况.结果 75例均获随访,随访时间为6～36个月,平均12个月.临床疗效:术后3个月JOA评分(21.08±3.60)分,与术前(10.91±2.23)分相比,差异有统计学意义(t=20.79,P＜0.05);术后1dJOA评分(22.72±3.26)分,与术前(10.91±2.23)分相比,差异有统计学意义(t=25.89,P＜0.05).随访3个月JOA评分改善率(88.6±10.8)％,优良率98％.影像学评价:术后随访X线片示所有病例均无腰椎不稳征象,无内固定断裂,植骨融合良好,融合器移位2例,无明显神经症状.结论 经TLIF人路扩大减压结合椎弓根螺钉固定融合可有效保留腰椎后方韧带复合体,使腰椎稳定性的破坏减至最小,椎管减压充分,术后组织愈合好,并发症少,出血少,术后患者下床早,是治疗老年人腰椎管狭窄症的一个安全选择.