林曦 尹曉明 林飛躍 徐楊
【摘要】 目的:探討微創(chuàng)經(jīng)椎間孔腰椎椎體間融合術(shù)(MIS-TLIF)與單切口雙側(cè)Wiltse入路的經(jīng)椎間孔腰椎椎體間融合術(shù)(W-TLIF)治療單節(jié)段腰椎椎管狹窄癥的臨床效果。方法:選取2015年7月1日-2017年7月1日筆者所在醫(yī)院收治的100例單節(jié)段腰椎椎管狹窄患者,根據(jù)治療方式不同將其分為MIS-TLIF和W-TLIF組,每組50例。比較兩組術(shù)中失血量、手術(shù)時間、住院時間、術(shù)后ODI、VAS評分及并發(fā)癥發(fā)生情況。結(jié)果:MIS-TLIF組手術(shù)時間長于W-TLIF組,術(shù)中出血量顯著少于W-TLIF組,差異均有統(tǒng)計學(xué)意義(P<0.05)。兩組住院時間比較差異無統(tǒng)計學(xué)意義(P>0.05)。術(shù)后6周兩組ODI及VAS評分比較差異均無統(tǒng)計學(xué)意義(P>0.05)。兩組并發(fā)癥發(fā)生率比較差異無統(tǒng)計學(xué)意義(P>0.05)。結(jié)論:與MIS-TLIF相比,W-TLIF手術(shù)時間較短,但失血量更多,但是兩種方法治療單節(jié)段的腰椎管狹窄癥的效果相近,術(shù)者可根據(jù)自己的經(jīng)驗選擇手術(shù)方式。
【關(guān)鍵詞】 腰椎椎管狹窄癥 經(jīng)椎間孔椎間融合術(shù) Wiltse入路 微創(chuàng) 腰椎 單節(jié)段
doi:10.14033/j.cnki.cfmr.2020.18.002 文獻(xiàn)標(biāo)識碼 A 文章編號 1674-6805(2020)18-000-03
Clinical Effect Analysis of MIS-TLIF and W-TLIF in the Treatment of Single-segment Lumbar Spinal Stenosis/LIN Xi, YIN Xiaoming, LIN Feiyue, XU Yang. //Chinese and Foreign Medical Research, 2020, 18(18): -5
[Abstract] Objective: To investigate the clinical effect of minimally invasive transforaminal lumbar interbody fusion (MIS-TLIF) and single incision bilateral Wiltse approach transforaminal lumbar interbody fusion (W-TLIF) in the treatment of single-segment lumbar spinal stenosis. Method: A total of 100 patients with single-segment lumbar spinal stenosis admitted in our hospital from July 1st, 2015 to July 1st, 2017 were selected and divided into the MIS-TLIF group and the W-TLIF group according to different treatment methods, with 50 patients in each group. The intraoperative blood loss, operation time, hospitalization time, postoperative ODI, VAS score and complications were compared between the two groups. Result: The operation time of MIS-TLIF group was longer than that of W-TLIF group, and the intraoperative blood loss was significantly less than that of W-TLIF group, the differences were statistically significant (P<0.05). There was no significant difference in the hospitalization time between the two groups (P>0.05). There were no significant differences in ODI and VAS scores between the two groups 6 weeks after operation (P>0.05). There was no significant difference in the incidence of complications between the two groups (P>0.05). Conclusion: Compared with MIS-TLIF, the operation time of W-TLIF is shorter, but the blood loss is greater. However, the two methods have similar effects in the treatment of single-segment lumbar spinal stenosis, and the operator can choose the operation method according to his own experience.
[Key words] Lumbar spinal stenosis Transforaminal lumbar interbody fusion Wiltse approach Minimally invasive Lumbar spine Single segment
MIS-TLIF應(yīng)用管道牽拉系統(tǒng)經(jīng)椎間孔減壓的微創(chuàng)手術(shù)技術(shù)[5],可以保留對側(cè)的肌肉、韌帶和骨組織,減少切口相關(guān)的軟組織損傷,術(shù)中失血量少,術(shù)后可早期活動[6],從而減少術(shù)后切口相關(guān)的疼痛及鎮(zhèn)痛藥的應(yīng)用。管道牽拉系統(tǒng)可以替代助手拉鉤,但因為管道牽張系統(tǒng)的限制,MIS-TLIF不利于多節(jié)段手術(shù)。為了精準(zhǔn)定位,MIS-TLIF術(shù)中X線的暴露更多[7]。利用皮下軟組織彈性行正中單切口雙側(cè)Wiltse入路[8],從肌肉間隙進(jìn)入,同樣可以更好地暴露后方韌帶復(fù)合體和椎旁肌肉[9]。本研究發(fā)現(xiàn),MIS-TLIF組失血量明顯少于W-TLIF組,差異有統(tǒng)計學(xué)意義(P<0.05);W-TLIF手術(shù)時間明顯短于MIS-TLIF組,差異有統(tǒng)計學(xué)意義(P<0.05)。表明MIS-TLIF出血更少,可能與管道牽張止血有關(guān)。MIS-TLIF手術(shù)時間更長,可能與手術(shù)視野小有關(guān)[10]。兩組住院時間及術(shù)后ODI及VAS評分比較差異無統(tǒng)計學(xué)意義(P>0.05)。兩種手術(shù)均可取得良好的效果,術(shù)后恢復(fù)快。
W-TLIF入路手術(shù)視野更好,初學(xué)者更容易掌握,相比MIS-TLIF更適合2個節(jié)段及以上的病變。MIS-TLIF的學(xué)習(xí)曲線較陡峭。術(shù)者熟練掌握后,手術(shù)時間會明顯縮短。本研究發(fā)現(xiàn)MIS-TLIF組手術(shù)時間長于W-TLIF組,可能與術(shù)中透視及操作視野較小有關(guān)。研究表明MIS-TLIF需要更多的透視[11]。MIS-TLIF術(shù)中操作的射線暴露平均是W-TLIF的2.5倍,而眼睛、甲狀腺和手部的射線暴露是W-TLIF的10~20倍[5]。
Phan等[12]通過meta分析表明MIS-TLIF的感染率明顯低于W-TLIF(1.2% VS 4.6%)。W-TLIF與傳統(tǒng)的雙側(cè)切開相比更加美觀,但是如果一味追求小切口可能造成過度牽拉,造成皮膚軟組織缺血,容易造成術(shù)后切口愈合不良。術(shù)者發(fā)現(xiàn)加長0.5~1 cm的切口,可明顯降低術(shù)中因過度牽拉造成的皮膚缺血壞死。本研究結(jié)果顯示,兩組術(shù)后并發(fā)癥發(fā)生率比較差異無統(tǒng)計學(xué)意義(P>0.05)。MIS-TLIF組出現(xiàn)1例腦脊液滲漏和1例神經(jīng)根損傷,可能和通道下得操作視野小有關(guān)。W-TLIF組因為單切口,皮膚牽拉時間較長,早期出現(xiàn)2例皮膚切口愈合不良,因此術(shù)中可適當(dāng)延長切口,避免皮膚過度牽拉,減少愈合不良情況發(fā)生。
脊柱微創(chuàng)手術(shù)目前已經(jīng)是一種發(fā)展趨勢,MIS-TLIF和W-TLIF技術(shù)都可以很好的保留后方韌帶復(fù)合體,對椎旁肌肉的損傷小,術(shù)后疼痛較少,可以早期下床活動,對于單節(jié)段腰椎椎管狹窄癥患者都可以取得良好的效果,MIS-TLIF操作視野小,手術(shù)時間更長,注意防止神經(jīng)相關(guān)并發(fā)癥得發(fā)生,W-TLIF可適當(dāng)延長切口,防止切口愈合不良,術(shù)者可以根據(jù)自己的經(jīng)驗,選擇自己擅長的手術(shù)方式。
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(收稿日期:2020-02-24) (本文編輯:桑茹南)