中国修复重建外科杂志

中国修复重建外科杂志

经椎间孔单侧入路双侧减压融合内固定术治疗腰椎管狭窄症的近期疗效观察

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目的 比较经椎间孔单侧入路双侧减压和双侧棘突旁小切口入路双侧减压并行椎间融合内固定术治疗腰椎管狭窄症的近期疗效,以评估经椎间孔单侧入路双侧减压的临床价值。 方法 2014 年 7 月—2015 年 6 月,将符合选择标准的 48 例拟行椎间融合内固定术的腰椎管狭窄症患者随机分为两组,分别为单侧入路双侧减压组(试验组,24 例)和双侧棘突旁小切口入路双侧减压组(对照组,24 例)。两组患者性别、年龄、病程、疾病类型、累及节段、合并内科疾病及术前肌酸磷酸激酶(creatine phosphokinase,CPK)水平、疼痛视觉模拟评分(VAS)、Oswestry 功能障碍指数(ODI)等一般资料比较,差异均无统计学意义(P>0.05),具有可比性。记录两组患者手术时间、术中出血量、术后引流量、住院时间、并发症发生率;术后 1、3、7 d 检查 CPK 水平;术后 3、6、12 个月定期随访,采用 VAS 评分及 ODI 评价临床疗效;随访期间行腰椎 X 线片或 CT 检查判断椎间是否达骨性融合。 结果 两组患者手术时间、术中出血量及住院时间比较,差异均无统计学意义(P>0.05);但试验组术后引流量明显少于对照组(t=5.547,P=0.000)。术后 1 d 试验组 CPK 水平显著低于对照组(t=3.129,P=0.005),术后 3、7 d 两组 CPK 水平比较差异均无统计学意义(P>0.05)。两组患者均获随访,随访时间 12~24 个月,平均 17 个月。所有患者术后切口均Ⅰ期愈合。试验组术后 1 例发生心脏衰竭;对照组术中 1 例发生脑脊液漏、1 例发生神经根损伤, 术后 1 例发生肺部感染;两组并发症发生率比较差异无统计学意义(χ2=0.273,P=0.602)。试验组和对照组分别有 1 例和 2 例未达椎间骨性融合,椎间融合率分别为 95.8%(23/24)和 91.7%(22/24),比较差异无统计学意义(χ2=0.356,P=0.551)。两组均未出现椎间融合器移位、沉降,未出现断钉、断棒和内固定物松动现象;随访过程中亦未发生邻近节段退变,未出现脊柱侧凸及腰椎矢状曲度改变。术后 3、6、12 个月两组 VAS 评分及 ODI 均较术前显著改善(P<0.05);术后 3、6、12 个月试验组 VAS 评分及 ODI 均显著优于对照组(P<0.05)。 结论 对于腰椎管狭窄症,经椎间孔单侧入路双侧减压或双侧棘突旁小切口入路双侧减压并行椎间融合内固定术治疗均可取得良好近期疗效。但前者具有手术创伤小、对椎旁肌损伤小、最大程度保留脊柱后方结构、术后引流量少、患者恢复快、住院时间短等优点。

Objective To assess the clinical application value of tranforaminal unilateral approach for bilateral decompression by comparing the short-term effectiveness of bilateral decompression via unilateral approach of intervertebral foramen with via small surgical incision of bilateral spinous process in lumbar interbody fusion for the treatment of lumbar spinal stenosis. Methods Between July 2014 and June 2015, 48 patients with lumbar spinal stenosis underwent decompression and internal fixation by unilateral approach in 24 cases (trial group) and by bilateral small incision approach in 24 cases (control group). There was no significant difference in gender, age, disease duration, disease type, involved segment, combined medical diseases, preoperative level of creatine phosphokinase (CPK), the visual analogue scale (VAS), and Oswestry disability index (ODI) between 2 groups (P>0.05). The operation time, intraoperative blood loss, postoperative drainage, hospitalization time, and the incidence of complications were recorded. The CPK levels were evaluated at 1, 3, and 7 days after operation. VAS score and ODI were used to evaluate the effectiveness, and lumbar X-ray film or CT scanning to determine the intervertebral bony fusion. Results There was no significant difference in operation time, intraoperative blood loss, and hospitalization time between 2 groups (P>0.05), but significant difference was found in postoperative drainage (t=5.547,P=0.000). At 1 day after operation, the level of CPK in the trial group was significantly lower than that in the control group (t=3.129,P=0.005), but there was no significant difference at 3 and 7 days after operation between 2 groups (P>0.05). The patients were followed up 12-24 months (mean, 17 months). All the wounds healed primarily. Heart failure occurred in 1 case of the trial group, and cerebrospinal fluid leakage and pulmonary infection, and nerve root injury occurred in 1 case of the control group respectively. There was no significant difference in the incidence of complications between 2 groups (χ2=0.273,P=0.602). The interbody fusion rate was 95.8% (23/24) in the trial group and was 91.7% (22/24) in the control group, showing no significant difference (χ2=0.356,P=0.551). No cage sink, dislocation or plate and screw loosening and breakage was found in 2 groups. No adjacent segment degeneration occurred during the follow-up, and there was no change of scoliosis and lumbar sagittal curvature. At 3, 6, and 12 months after operation, the VAS score and ODI were significantly improved when compared with the preoperative scores in 2 groups (P<0.05), and the VAS score and ODI of the trial group were significantly better than those of control group (P<0.05). Conclusion The bilateral decompression via unilateral approach of intervertebral foramen and small surgical incision of bilateral spinous process in lumbar interbody fusion have satisfactory efficacy for the treatment of lumbar spinal stenosis, but the tranforaminal unilateral approach has the advantages of less trauma, avoidance of bilateral muscle stripping and soft paraspinal muscle injury, retention of posterior spinal structure, faster postoperative recovery, shorter hospital stay and good short-term effectiveness.

关键词: 腰椎管狭窄症; 单侧入路双侧减压; 椎间融合内固定; 椎旁肌

Key words: Lumbar spinal stenosis; unilateral approach bilateral decompression; intervertebral fusion and internal fixation; paraspinal muscle

引用本文: 张磊, 方向前, 赵兴, 徐文斌, 刘刚. 经椎间孔单侧入路双侧减压融合内固定术治疗腰椎管狭窄症的近期疗效观察. 中国修复重建外科杂志, 2017, 31(5): 519-526. doi: 10.7507/1002-1892.201612131 复制

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