显微镜辅助下微创经椎间孔腰椎间融合术治疗单节段腰椎滑脱症的疗效观察

目的 探讨显微镜辅助下微创经椎间孔腰椎间融合术(MIS-TLIF)治疗单节段腰椎滑脱症的临床疗效。方法 回顾性分析陕西省人民医院骨科2015年6月—2016年8月采用显微镜辅助下MIS-TLIF治疗32例单节段腰椎滑脱症患者的临床资料,其中男18例、女14例,年龄32～64(52.4±6.2)岁。退变性滑脱25例,峡部裂性滑脱7例;Ⅰ度滑脱26例,Ⅱ度滑脱6例;L_3~4滑脱5例,L_4~5滑脱17例,L₅~S₁滑脱10例。记录手术时间、术中出血量、术后引流量、住院时间等。所有患者定期随访,比较并评价患者术前、术后第3天、术后3个月、术后12个月及末次随访时的腰/腿痛视觉模拟评分(VAS)、日本骨科协会(JOA)评分及Oswestry功能障碍指数(ODI);术前、术后3个月和末次随访时,测量椎间隙平均高度、腰椎Cobb角和手术节段Cobb角,评价椎间孔恢复及腰椎矢状位曲度改变情况。末次随访时采用改良MacNab标准评价临床疗效,根据Siepe标准评价椎间融合情况。结果 32例患者均顺利完成手术,手术时间(120.3±10.8) min,术中出血(85.2±35.6) mL,术后引流量(34.7±12.5) mL,术后(5.2±1.8) d出院,显微镜术中使用时间(56.4±8.2)min;均未出现硬膜破裂、神经根损伤、切口感染、融合器移位、下沉、内固定松动等并发症。患者均获得随访12~18个月。术后各时段腰痛VAS、腿痛VAS和ODI均低于术前,差异均有统计学意义(F=105.080、148.420、493.080, P值均＜0.05);术后各时间段JOA评分与术前比较均提高,差异均有统计学意义(F=154.870, P值均＜0.05)。术后3个月和末次随访时椎间隙高度分别为(10.4±1.7) mm和(10.1±1.8) mm,腰椎Cobb角分别为39.0°±5.4°和38.6°±7.3°,手术节段Cobb角分别为18.6°±3.2°和18.0°±5.1°,与术前相比差异均有统计学意义(F=87.310、33.820、3.950, P值均＜0.05)。末次随访时腰椎滑脱获得复位;按改良MacNab标准评价疗效:优27例,良3例,可2例,优良率为93.8%(30/32);根据Siepe标准评价椎间融合情况,完全融合29例,可能融合3例。结论 显微镜辅助下MIS-TLIF治疗单节段腰椎滑脱症是一种可靠、安全、有效的微创手术方式,具有术中出血少、创伤小,临床疗效确切等优势,值得临床推广应用。

Effects observation of microscope-assisted minimally invasive transforaminal lumbar interbody fusion in the treatment of single-segment spondylolisthesis

Objective To evaluate the clinical efficacy of microscope-assisted minimally invasive transforaminal lumbar interbody fusion (MIS-TLIF) in the treatment of single-segment spondylolisthesis.Methods From June 2015 to August 2016,32 patients with single-segment spondylolisthesis treated with microscope-assisted MIS-TLIF in Department of Orthopaedics of Shanxi Provincial People's Hospital were retrospectived analyzed, including 18 males and 14 females with an age of 32-64(52.4±6.2)years. In term of spondylolisthesis category, there were 25 patients of degenerative spondylolisthesis and 7 patients of isthmic spondylolisthesis. With respect to spondylolisthesis degree, 26 patients were grade I and 6 patients were grade Ⅱ. Besides, 5 patients were located at L_3-4 ,17 patients at L_4-5 and 10 patients at L₅-S₁. The operation time, intraoperative blood loss, postoperative drainage and hospital stay were recorded. All patients were followed up regularly. The visual analogue scale (VAS) scores, Japanese Orthopaedic Association(JOA) scores and Oswestry disability index (ODI) were compared and evaluated at preoperation and at 3 d, 3 months,12 months postoperation and last follow-up. Furthermore, to evaluate the recovery of the intervertebral foramen and of lumbar sagittal curvature,average height of intervertebral space, Cobb angles of lumbar vertebrae and operative segments were measured at preoperation and 3 months after operation and last follow-up. At the last follow-up, the clinical efficacy was evaluated using the modified MacNab criteria, and intervertebral fusion was assessed according to the Siepe criteria.Results All 32 patients underwent successfull operation. The operative time was (120.3±10.8)min, the intraoperative blood loss was (85.2±35.6)mL, the postoperative drainage was (34.7±12.5)mL, hospital stay was (5.2±1.8) days and microscope operative time was (56.4±8.2)min. No serious complications were noted, such as dural rupture, nerve root injury, incision infection, fusion cage displacement, sinking, loosening of internal fixation, etc. All patients were followed up for 12-18 months. The back pain VAS scores, leg pain VAS scores and ODI were significantly lower than those preoperation on each time stage after operation, and the difference was statistically significant(F=105.080, 148.420, 493.080, all P values＜0.05). The JOA scores were significantly higher than those preoperation on each time stage after operation,and the difference was statistically significant(F=154.870, all P values＜0.05). At the 3rd month postoperation and the last follow-up, the height of intervertebral space was (10.4±1.7) mm and (10.1±1.8) mm, respectively, Cobb angle was 39.0°±5.4° and 38.6°±7.3°, respectively. The Cobb angle of the operative segment was 18.6°±3.2°and 18.0°±5.1°, respectively. The difference was statistically significant compared with the preoperative (F=87.310, 33.820, 3.950, all P values＜0.05). All lumbar spondvlolisthesis vertebrae were restored completely at last follow-up. In terms of the modified MacNab at the last follow-up:excellent in 27 patients, good in 3 patients, and fair 2.The excellent and good rate was 93.8%(30/32). According to Siepe criterion for fusion, 29 patients obtained complete fusion, and 3 patients got possible fusion.Conclusions Microscope-assisted MIS-TLIF is a reliable,safe and effective minimally invasive surgery for single-level lumbar spondylolisthesis. It has the advantages of less bleeding, minimal trauma and precisely clinical effect. This method is worthy of clinical promotion and application.