高位腰椎间盘突出症前后路植骨结合金属植入物内固定治疗效果的对比☆

目的：对比观察高位腰椎间盘突出症患者行前后路植骨结合金属植入物内固定治疗效果的比较。 方法：选择2002-09/2006-09中南大学湘雅二医院脊柱外科收治的高位腰椎间盘突出症患者33例，男20例，女13例；年龄34~61岁，平均52.5岁。全部为单一间隙椎间盘突出，其中T12~L1突出1例，L1/2突出6例，L2/3突出10例，L3/4突出16例。33例患者根据手术入路不同分为2组：后路组(n=18)：行后路双侧小关节切除自体小关节骨质及自体髂骨或异体人工骨椎间植骨及椎弓根钉内固定(经后方椎板切除入路)；前路组(n=15)：行前路椎间盘切除植骨及钛板内固定(经侧前方入路)。比较两组患者的临床治疗基本情况，应用JOA 评分评价患者金属内固定材料植入前后及随访时的神经功能，总结并发症，观察植骨融合情况。 结果：33例患者均获得随访，随访时间18~48(40.5±3.0)个月，在内固定时间及金属材料植入过程中出血量计算经后方椎板切除入路优于前外侧入路，但在临床症状改善率以及神经损伤发生率方面两种方式没有显著性差异。后路组植入中2例硬脊膜撕裂，1例椎弓根螺钉位置偏斜，JOA评分由内固定前(12.84±2.59)分提高到随访时的(25.63±3.06)分，优良率为88%，随访时骨性融合率为94%；前路组植入中1例硬脊膜破裂，1例植入后单侧神经根麻痹，1例植入后出现难制性呃逆，JOA评分由内固定前(11.96±2.14)分提高到随访时的(24.92±3.91)分，优良率为84%，随访时骨性融合率93%。 结论：前路或后路手术治疗高位腰椎间盘突出症均可获得良好的临床疗效，可根据术者的熟练程度选择术式，同时应进行内固定融合。

Clinical outcomes of posterior versus anterior lumbar interbody fusion for high level lumbar intervertebral disc herniation

OBJECTIVE: To investigate the curative effects of posterior versus anterior lumbar interbody fusion for the treatment of high level lumbar intervertebral disc herniation. METHODS: A total of 33 patients with high level lumbar intervertebral disc herniation admitted to Department of Spinal Surgery, Second Xiangya Hospital, Central South University between September 2002 and September 2006 were selected, including 20 males and 13 females with mean age of 52.5 years (ranging 34 to 61 years). All patients were lumbar intervertebral disc herniation of single space, including 1 at T12-L1, 6 of L1/2, 10 of L2/3, and 16 of L3/4. Of the 33 patients, 18 were treated with posterior lumbar interbody fusion (PLIF) using facet joint autograft and allograft artificial bone or autologous iliac bone additional of pedicle screw internal fixation (posterior approach group), and 15 were treated with anterior disckectomy, bone graft (allograft artificial bone or autologous iliac bone) and plates internal fixation (anterior approach group). The clinical results were compared between two groups. The JOA scores, clinical excellent and good rates, radiographic findings and complications were evaluated. RESULTS: The mean follow-up of 33 patients was (40.5±3.0) months (ranging 18 to 48 months). In respect of the operation time and amount of bleeding, the posterior approach group was superior to anterior approach group. But there was no obvious difference between two groups in clinical recovery rates and nerve injury rates. Complications included dural tear (n=2), and pedicle screw deviating (n=1) in the posterior approach group, and dural tear (n=1), unilateral transient lower extremity paresthesia (n=1), and hard controlled singultation (n=1) in the anterior approach group. The average preoperative and postoperative JOA scores were 12.84±2.59 and 25.63±3.06 in the posterior approach group, and 11.96±2.14 and 24.92±3.91 in the anterior approach group. Clinical outcome was excellent or good in 88% of patients in the posterior approach group, and 84% in the anterior approach group. The rates of bone fusion were 94% and 93% in the posterior and anterior approach groups respectively. CONCLUSION: Both posterior of anterior approaches can achieve excellent or good therapeutic effect for high level lumbar intervertebral disc herniation. The operators could select anyone according to their experience. In addition, internal fixation fusion is necessary.