【摘要】 目的比较传统后路腰椎间盘再次摘除术、后路腰椎间融合术(posterior lumbar interbody fusion,PLIF)、椎间孔腰椎间融合术(transforaminal lumbar interbody fusion,TLIF)3种方法治疗复发性腰椎间盘突出症(recurrentlumbar disc protrusion,RLDP)的临床效果。方法2000年1月-2008年1月,对65例RLDP患者分别采用传统后路腰椎间盘再次摘除术(A组,25例)、PLIF(B组,22例)、TLIF(C组,18例)治疗。男44例,女21例;年龄26～65岁,平均41岁。均为单节段椎间盘突出(L4、533例,L5、S132例)。首次手术时行椎板开窗椎间盘摘除39例,半椎板切除椎间盘摘除15例,全椎板切除椎间盘摘除11例。复发时间13～110个月,平均64个月。与首次椎间盘突出同侧47例,对侧18例。3组患者一般资料比较差异均无统计学意义(P>0.05)。结果患者术后切口均Ⅰ期愈合。围手术期A、B、C组并发症发生率分别为24.0%、22.3%和5.6%,A、B组高于C组(P<0.05),A、B组间差异无统计学意义(P>0.05)。B组手术时间、术中出血量明显高于A、C组(P<0.05),A、C组间差异无统计学意义(P>0.05)。住院时间3组间比较差异无统计学意义(P>0.05)。术后61例获随访,随访时间12～36个月,平均20个月。术后1周A、B、C组患者满意率分别为84.0%、81.8%、88.9%(P>0.05)。B、C组椎间均融合。3组组间术前、末次随访时疼痛视觉模拟评分(visual analogue scale,VAS)和Oswestry功能障碍指数(Oswestry disability index,ODI)评分比较差异均无统计学意义(P>0.05);3组组内末次随访时VAS和ODI评分与术前比较均明显改善(P<0.05);3组评分改善率比较差异无统计学意义(P>0.05)。根据Roberts等椎间隙分级法评价椎间隙高度,A、B、C组术前分别为(2.04±0.93)(、2.18±0.91)(、2.11±0.90)分,末次随访时分别为(2.64±0.58)(、1.05±0.59)(、1.06±0.42)分;3组末次随访时与术前比较差异均有统计学意义(P<0.05)。结论3种手术方式均能有效治疗RLDP,但传统后路腰椎间盘再次摘除术和PLIF并发症较多,单纯椎间盘摘除会导致椎间隙进一步变窄和节段性不稳;TLIF更安全有效,是治疗RLDP的一种较理想方法。更多还原

【Abstract】 Objective To compare the therapeutic effect of conventional discectomy,posterior lumbar interbody fusion (PLIF),and transforaminal lumbar interbody fusion (TLIF) on the recurrent lumbar disc protrusion (RLDP). Methods From January 2000 to January 2008,65 patients with RLDP underwent different surgical procedures,namely conventional discectomy (group A,25 cases),PLIF (group B,22 cases),and TLIF (group C,18 cases). There were 44 males and 21 females aged 26-65 years old (average 41 years old). All the patients were single-level protrusion,including 33 cases at the L4,5 level and 32 cases at the L5,S1 level. The primary procedure included laminectomy discectomy in 39 patients,unilateral hemilaminectomy discectomy in 15 patients,and bilateral laminectomy and total laminectomy discectomy in 11 patients. The recurrent time to the primary operation was 13-110 months (average 64 months). The location of recurrent disc protrusion was at the ipsilateral side in 47 cases and the contralateral side in 18 cases. No significant differences among three groups were evident in terms of baseline data (P > 0.05). Results The incision all healed by first intention. The incidence of perioperative complication in group A (24.0%) and group B (22.3%) was significantly higher than that of group C (5.6%) (P < 0.05),and there was no significant difference between group A and group B (P > 0.05). The operation time and bleed loss during operation of group B were obviously higher than that of group A and group C (P < 0.05),and there was no significant difference between group A and group C (P > 0.05). There were no significant differences among three groups in terms of the length of hospitalization (P > 0.05). Six-one patients were followed up for 12-36 months (average 20 months). At 1 week after operation,the satisfied rate of patients was 84.0% in group A,81.8% in group B,and 88.9% in group C (P > 0.05). All the patients in group B and group C achieved fusion uneventfully. There were no significant differences among three groups in terms of visual analogue scale (VAS) and Oswestry disability index (ODI) when compared the preoperative value with the final follow-up value (P > 0.05). There was significant difference within group A,B,and C in terms of VAS and ODI when compared the preoperative value with the final follow-up value (P < 0.05),but there were no significant differences among three groups in the improvement rate (P > 0.05). The intervertebral space grading method proposed by Roberts et al. was adopted to evaluate the intervertebral space height (ISH),the preoperative value was 2.04 ± 0.93 in group A,2.18 ± 0.91 in group B,and 2.11 ± 0.90 in group C,and at the final follow-up,the value was 2.64 ± 0.58 in group A,1.05 ± 0.59 in group B,and 1.06 ± 0.42 in group C. There were significant differences among three groups in the ISH when compared the properative value with the final follow-up value (P < 0.05). Conclusion All of the three surgical procedures are effective for RLDP,but conventional discectomy and PLIF have more complications than TLIF. Conventional discectomy may result in the further narrow of the intervertebral space and the occurrence of segment instability,whereas TLIF is safer,more effective,and one of the ideal methods to treat RLDP.更多还原