斜外侧椎间融合术联合Wiltse入路单侧椎弓根钉棒固定治疗腰椎管狭窄症

目的:探讨斜外侧椎间融合术(oblique lumbar interbody fusion,OLIF)联合Wiltse入路单侧椎弓根钉棒固定治疗腰椎管狭窄症的疗效。方法:对2017年7月至2019年1月采用OLIF联合Wiltse入路单侧椎弓根钉棒固定治疗腰椎管狭窄症90例进行回顾性分析,男38例,女52例,年龄43~75(59.9±8.8)岁。责任节段分布:单节段L₂-L₃ 8例,L₃-L₄ 12例,L₄-L₅ 30例;双节段中L₂-L₄ 10例,L₃-L₅ 22例;3节段L₂-L₅ 8例,共138个手术节段。记录患者的手术时间、术中出血量以及并发症发生情况,采用腰痛和腿痛视觉模拟评分(visual analogue scale,VAS)和Oswestry功能障碍指数(Oswestry Disability Index,ODI)以及SF-36评分量表评估临床疗效;术后3 d拍摄腰椎X线片和腰椎MRI,测量椎间隙高度、椎间孔高度、椎间孔面积和椎管面积变化;术后半年根据CT评价椎间融合情况,定期随访拍摄腰椎X线片及MRI检查相邻节段退变的情况。结果:所有病例获得随访,时间12~33(20.2±6.6)个月。手术时间(103.3±35.9) min,术中出血量(70.4±17.8) ml;腰痛和腿痛VAS和ODI分别由术前的(6.2±1.1)分、(6.1±0.9)分和(59.9±4.2)%下降至术后半年时的(2.7±0.5)分、(2.5±0.5)分和(31.3±8.8)%,SF-36量表由术前的(37.2±3.1)分增加到术后半年时的(54.9±6.1)分(P<0.05);术后3 d测量椎间隙高度、椎间孔高度、椎间孔面积、椎管面积均较术前明显改善(P<0.05);术后6个月CT检查3例融合欠佳,发生在单节段1例,多节段2例,余87例融合良好。总融合率96.7%(87/90),单节段融合率为98.0%(49/50),多节段融合率为95.0%(38/40)。总体并发症发生率为17.8%(16/90),其中一过性髂腰肌无力5例(5.6%),终板骨折2例(2.2%),腹膜损伤1例(1.1%),术后血肿1例(1.1%),邻椎病1例(1.1%),融合器沉降6例(6.7%)。3例患者术后随访复发神经根性疼痛,行翻修手术后症状缓解。所有并发症在随访期间得到不同程度地缓解或消失,无融合器移位、螺钉断裂等并发症发生。结论:OLIF联合Wiltse入路单侧椎弓根钉棒固定治疗腰椎管狭窄症疗效满意,具有创伤小、并发症少等微创优势,在严格掌握适应证的前提下,该术式应用于多节段时同样能取得满意的临床疗效。

Clinical efficacy of oblique lumbar interbody fusion combined with unilateral pedicle screw fixation via Wiltse approach in the treatment of lumbar spinal stenosis

Objective: To evaluate the efficacy of oblique lumbar interbody fusion combined with unilateral pedicle screw fixation via Wiltse approach in the treatment of lumbar spinal stenosis. Methods: From July 2017 to January 2019,90 patients with lumbar spinal stenosis,including 38 males and 52 females,aged from 43 to 75 years old with an average of(59.9±8.8) years old, and were treated with oblique lumbar interbody fusion(OLIF) combined with Wiltse unilateral pedicle screw fixation. Surgical decompression and fixation was performed in 50 cases of single segment,32 cases of double segments and 8 cases of three segments. The distribution of responsible segments included 8 cases of L₂-L₃,12 cases of L₃-L₄ and 30 cases of L₄-L₅ on single segment,10 cases of L₂-L₄ and 22 cases of L₃-L₅ on double segments,and 8 cases of L₂-L₅ on three segments. The operation time,blood loss and occurrence of complications were recorded,Visual analogue scale(VAS),Oswestry Disability Index(ODI) and SF-36 scale were used to evaluate clinical efficacy. Lumbar X-ray and MRI were taken at three days after operation,interverterbral space height,intervertebral foraminal height,interverterbral foraminal area,and spinal canal area were measured,and interbody fusion was evaluated according to CT at half a year after operation. Results: All patients were followed up from 12 to 33 months,with an average of (20.2±6.6) months. Mean operation time was (103.3±35.9) min,and mean intraoperative blood loss was (70.4±17.8) ml. VAS of low back pain leg pain,and ODI decreased from 6.2±1.1,6.1±0.9 and (59.9±4.2)% to 2.7±0.5,2.5±0.5 and (31.3±8.8)%. SF-36 scale significantly increased from (37.2±3.1) to (54.9±6.1) at the six months postoperation(P<0.05). The intervertebral space height,intervertebral foraminal height,intervertebral foraminal area,and spinal canal area were significantly improved at 3 days after operation(P<0.05). Six months after operation,CT scan showed well fusion in 87 cases,but 3 cases with poor fusion,including 1 case of single segment,2 cases of multi-segments. The total fusion rate was 96.7% (87/90),the single segment fusion rate was 98.0% (49/50),and the multi-segments fusion rate was 95.0%(38/40). The overall incidence of complications was 17.8%(16/90),including transient iliopsoas muscle weakness in 5 cases (5.6%),endplate fracture in 2 cases (2.2%),peritoneal injury in 1 case (1.1%),postoperative hematoma in 1 case (1.1%),adjacent segment disease in 1 case(1.1%),and fusion cage subsidence in 6 cases (6.7%). Three patients was followed up for recurrent nerve root pain and the symptoms were relieved after revision operation. All complications were relieved or disappeared in varying degrees during the follow-up period,and there were no complications such as cage displacement and screw fracture. Conclusion: OLIF combined with unilateral pedicle screw fixation via Wiltse approach is effective in treating lumbar spinal stenosis with minimally invasive advantages such as less trauma and less complications. Under the premise of strictly grasping the indications,this method could also achieve satisfactory clinical results in multi-segments oprations.