微创Wiltse入路与传统后正中入路手术治疗双节段腰椎管狭窄症的疗效比较

目的:比较微创Wiltse入路与传统后正中入路手术治疗双节段腰椎管狭窄症的疗效.方法:2006年3月～2011年6月手术治疗215例双节段腰椎管狭窄症患者,其中113例采用微创Wiltse入路经椎间孔减压椎间植骨融合手术(transforaminal lumbar interbody fusion,TLIF,A组),男54例,女59例,L2/3～L3/4 6例,L3/4～L4/5 27例,L4/5～L5/S1 80例,年龄43～84岁,平均57岁；术前ODI为(59.16±21.47)％,腰痛VAS评分6.1±3.0分,腿痛VAS评分4.1±2.3分.102例采用传统后正中入路椎板切除减压椎间植骨融合手术(posterior lumbar interbody fusion,PLIF,B组),男50例,女52例,L2/3～L3/4 5例,L3/4～L4/5 30例,L4/5～L5/S1 67例,年龄48～76岁,平均55岁；术前ODI为(53.14±20.32)％,腰痛VAS评分5.4±2.9分,腿痛VAS评分4.3±2.2分.记录两组的手术时间、术中出血量、切口长度,随访患者腰痛和腿痛VAS评分和ODI改善情况,并进行统计分析.结果:两组患者在年龄结构、性别比例、手术节段构成比、术前ODI和腰腿痛VAS评分均无统计学差异(P＞0.05).A组平均随访19个月,B组平均随访21个月,两组间无统计学差异(P＞0.05).A组手术时间、术后末次随访时ODI和腿痛VAS评分分别为140～190min (165±37min)、(13.20±7.9)％和1.1±0.9分；B组分别为130～220min(155±46min)、(15.20±6.72)％和1.3±1.1分,两组比较均无统计学差异(P＞0.05),A组手术切口长度、术中出血量、术后末次随访时腰背痛残留率和腰痛VAS评分分别为4～5cm(4.5±1.1cm)、140～400ml (260±215ml)、1.2±1.1分和2.7％,B组分别11～18cm(14.2±2.4cm)、300～1200ml(420±437ml)、1.9±1.5分和18.6％,A组均明显优于B组(P＜0.05).两组术后ODI和腰腿痛VAS评分与术前比较均有显著性改善(P＜0.05).结论:微创Wiltse入路经椎间孔减压椎间植骨融合手术与传统后正中入路椎板切除减压椎间植骨融合手术治疗双节段腰椎管狭窄症均能达到良好的减压效果,但微创Wiltse入路手术损伤小,术后腰背痛残留率低.

The minimally invasive operation by Wiltse approach versus traditional posterior open surgery in treatment of dural-level lumbar spinal stenosis

Objectives:To compare the clinical results between minimally invasive operation by wiltse approach and traditional posterior open surgery in treatment of dural-level lumbar spinal stenosis.Methods:From March 2006 to June 2011,a total of 215 cases with dural-level lumbar spinal stenosis underwent surgical intervention were retrospectively analyzed.Among them,113 cases received minimally invasive operation(transforaminal lumbar interbody fusion,TLIF,group A):male 54 cases,female 59 cases,6 cases in L2/3-L3/4,27 cases in L3/4-L4/5,80 cases in L4/5-L5/S1,with an average age of 57(range from 43 to 84);preoperative ODI and the VAS of low back pain/leg pain was(59.16±21.47)%,6.1±3.0,and 4.1±2.3 respectively.102 cases received open surgery(posterior lumbar interbody fusion,PLIF,group B):male 50 cases,female 52 cases,5 cases in L2/3-L3/4,30 cases in L3/4-L4/5,67 cases in L4/5-L5/S1,with an average age of 55(range from 48 to 76);preoperative ODI and the VAS of low back pain/leg pain was(53.14±20.32)%,5.4±2.9,and 4.3±2.2 respectively.Operation time,intraoperative bleeding,and length of incision were recorded.Low back pain/leg pain was assessed by visual analogue scale(VAS),and lumbar function was evaluated by Oswestry Disability Index(ODI) during postoperative follow-up,then by statistical analysis.Results:There were no significant differences among age,sex,surgery segment between group A and group B(P>0.05).The mean follow-up time was 19 months in group A and 21 months in group B,no significant difference was detected(P>0.05).Both of the two groups got satisfactory clinical outcome and osseous fusion.Operation time,ODI and the VAS score of leg pain at the final follow-up in group A was 140-190min(165±37min),(13.20±7.9)% and 1.1±0.9 respectively;and which in group B was 130-220min(155±46min),(15.20±6.72)% and 1.3±1.1 respectively;there was no significant difference between group A and group B(P>0.05).Length of incision,intraoperative bleeding,rate of residual low back pain at the final follow-up and the VAS of low back pain in group A was 4-5cm(4.5±1.1cm),140-400ml(260±215ml),2.7% and 1.2±1.1 respectively;and which in group B was 11-18cm(14.2±2.4cm),300-1200ml(420±437ml),18.6% and 1.9±1.5 respectively;group A was superior to group B(P<0.05).There were significant improvements of ODI and the VAS of back/leg pain in two groups between preoperation and postoperation(P<0.05).Conclusions:Minimally invasive operation by wiltse approach as well as open surgery can get satisfactory clinical outcome.Minimally invasive operation by wiltse approach has advantages as follows:less invasive,less intraoperative bleeding,lower incidence of back pain in the duration of follow-up.