【摘要】 目的比较腰椎Wiltse手术入路经椎间孔腰椎椎体间融合术(transforaminal lumbar interbody fusion,TLIF)与腰椎后正中入路改良TLIF治疗腰椎不稳症的临床疗效。方法 2012年1月至2015年5月,我科收治腰椎不稳症患者68例,其中男37例,女31例,年龄41~72岁,平均60.8岁;病程6个月~12年,平均22.6个月。改良TLIF组37例,行腰椎后正中入路改良TLIF术;Wiltse入路组31例,行腰椎后正中经椎旁肌间隙入路TLIF术。比较两组患者手术时间、术中出血量、血清肌酸激酶、引流管放置时间、术后引流量、术后卧床时间、住院天数、植骨融合率,采用疼痛视觉模拟评分(visual analogue score,VAS)和日本矫形外科学会评分(Japanese orthopedic association,JOA)、Oswestry功能障碍指数(oswestry disability index,ODI)等标准评价其临床疗效。结果 68例全部获得随访,随访时间24~38个月,平均28.6个月,改良TLIF组与Wiltse组在术中出血量(462.32±52.28)ml vs.(266.82±56.42)ml、术后引流量(301.92±68.22)ml vs.(140.52±58.65)ml、术后卧床时间(5.8±1.2)天vs.(3.1±0.9)天、住院天数(9.8±1.4)天vs.(6.2±1.2)天方面比较,Wiltse入路组均优于改良TILF组,差异有统计学意义(P<0.05);手术时间、融合率方面两组比较差异无统计学意义(P>0.05);两组患者术前血清肌酸激酶比较差异无统计学意义(P>0.05);术后12 h(864.26±61.43)IU/L vs.(408.32±70.35)IU/L、术后3天(521.82±50.22)IU/L vs.(328.53±60.84)IU/L两组比较差异有统计学意义(P<0.05);术后7天两组比较差异无统计学意义(P>0.05);两组患者腰腿痛VAS、JOA、ODI评分同术前比较,差异有统计学意义(P<0.05);两组VAS评分术后1周(3.63±0.43)分vs.(1.94±0.53)分、术后6个月(1.14±0.37)分vs.(0.67±0.26)分比较,差异有统计学意义(P<0.05),说明Wiltse入路组术后改善优于改良TILF组;两组术后6个月JOA评分(17.93±0.84)分vs.(21.26±0.64)分、ODI评分(9.52±5.36)分vs.(21.85±4.84)分比较,差异有统计学意义(P<0.05),说明Wiltse入路组术后临床功能改善优于改良TILF组。结论 Wiltse手术入路TLIF与改良TILF术式均是治疗腰椎不稳症的有效术式,但Wiltse手术入路TLIF术式经椎旁肌间隙入路,出血少,对椎旁肌及小关节囊损伤小,可以早下床活动,术后慢性腰痛发生率低等优点。更多还原

【Abstract】 Objective To evaluate the clinical efficacy of lumbar Wiltse transforaminal lumbar interbody fusion( TLIF) compared with improved lumbar midline approach TLIF in lumbar spine instability. Methods From January 2012 to May 2015, 68 patients( 37 males, 31 females, aged 41 to 72 years, mean 60.8 years, duration of 6 months to 12 years, average 22.6 months) with lumbar instability were included. Improved TLIF group included 37 patients. Wiltse group included 31 patients. Two groups were compared by operation time, blood loss, serum creatine kinase, drainage tube placement time, postoperative drainage, postoperative bed time, length of stay, fusion rate, visual analogue score( VAS), Japanese orthopedic association score( JOA), Oswestry disability index( ODI) and other standards to evaluate the clinical effi cacy. Results All 68 patients were followed up for 24 to 38 months with the average of 28.6 months. Improved TLIF group and Wiltse group: blood loss( 462.32 ± 52.28) ml vs.( 266.82 ± 56.42) ml, postoperative drainage( 301.92 ± 68.22) ml vs.( 140.52 ± 58.65) ml, bed time( 5.8 ± 1.2) days vs.( 3.1 ± 0.9) days, days of hospitalization( 9.8 ± 1.4) days vs.( 6.2 ± 1.2) days; Wiltse group results were better than the improved TLIF group in the data above( P < 0.05); no statistical significance existed in the operation time and fusion rate( P > 0.05); no statistical signifi cance existed in the preoperative serum creatine kinase( P > 0.05) and 7 days postoperatively( P > 0.05), while statistical signifi cant 12 hours postoperatively( 864.26 ± 61.43) IU / L vs.( 408.32 ± 70.35) IU / L, and 3 days postoperatively( 521.82 ± 50.22) IU / L vs.( 328.53 ± 60.84) IU / L( P < 0.05). Statistical signifi cance existed in VAS score, JOA score and ODI index compared with the preoperative data( P < 0.05). Postoperative VAS scores between the two groups: 1 week postoperatively( 3.63 ± 0.43) points vs.( 1.94 ± 0.53) points, 6 months postoperatively( 1.14 ± 0.37) points vs.( 0.67 ± 0.26) points; with statistical signifi cance( P < 0.05); Wiltse group results were better than the improved TILF group. Comparing JOA and ODI 6 months postoperatively:( 17.93 ± 0.84) points vs.( 21.26 ± 0.64) points,( 9.52 ± 5.36) points vs.( 21.85 ± 4.84) points; with statistical signifi cance( P < 0.05); Wiltse group results in the postoperative clinical function were better than the improved TILF group. Conclusions Wiltse surgical approach TLIF and modifi ed TILF surgical treatment of the lumbar spinal instability are both effective procedures. Wiltse TLIF through the paraspinal muscle has the advantages of less bleeding, less injury to the paraspinal muscle and facet joint capsule, early mobilisation, low incidence of chronic low back pain etc.更多还原