摘要
目的探讨后正中入路小切口经椎间孔椎体融合术(mini-open transforaminal lumbar interbody fusion,MO-TLIF)与微创TLIF(minimally invasive surgery of transforaminal lumbar interbody fusion,MIS-TLIF)治疗下腰椎退行性疾病的临床疗效。方法纳入2022年1月至2023年1月于苏州大学附属第二医院收治的需手术治疗的连续腰椎退行性疾病患者68例,按随机数字表法分为MO-TLIF组(34例,行经皮钉辅助后正中入路MO-TLIF)和MIS-TLIF组(34例,行Quadrant通道下经Wiltse入路MIS-TLIF)。比较两组围手术期指标(手术时间、切口长度、术中失血量、透视次数、术后卧床时间、住院时间)和手术并发症。于术前,术后第3天、3个月及1年时评估视觉模拟评分(visual analogue scale,VAS)和Oswestry功能障碍指数(Oswestry disability index,ODI)。通过术前和术后1年MRI分析有效椎旁肌面积(effective cross-sectional area,eC-SA)。比较两组的手术入路CT参数,包括棘突旁间隙-中线距离(spinous process-midline distance,SM)、Wiltse间隙-中线距离(Wiltse-midline distance,WM)、手术入路角度、深度及多裂肌位移。采用Pearson相关性分析两组手术入路CT参数与手术时间、术中失血量、eCSA萎缩的相关性,对eCSA萎缩与CT参数相关的组别进一步行多分类线性回归分析。结果MO-TLIF组与MIS-TLIF组患者一般资料的差异均无统计学意义(P>0.05)。MO-TLIF组的手术时间为(109.85±7.82)min、术中失血量为(77.21±21.83)ml、手术切口长度为(6.09±0.22)cm、术后卧床时间为(1.59±0.49)d,住院时间为(8.93±1.44)d,均小于MIS-TLIF组的(133.82±20.22)min、(141.18±31.44)ml、(7.00±0.43)cm、(2.38±0.50)d、(10.35±1.45)d,MO-TLIF组术中透视次数为(19.53±1.92)次,大于MIS-TLIF组的(16.29±1.78)次,差异均有统计学意义(P<0.05)。并发症包括脂肪液化及切口渗出5例(MO-TLIF组2例、MIS-TLIF组3例),术中硬膜微小撕裂2例(两组各1例)。两组术后随访各时间点的VAS和ODI较术前改善(P<0.05);术后第3天时MO-TLIF组VAS为(2.74±0.47)分、ODI为27.46%±2.16%,低于MIS-TLIF组的(3.35±0.48)分、30.42%±2.52%,差异有统计学意义(P<0.05)。两组术前eCSA的差异无统计学意义(P>0.05);术后1年MO-TLIF组与术前的差异无统计学意义(P>0.05);MIS-TLIF组较术前减小(P<0.05)。术后1年MO-TLIF组SM为(8.43±1.81)mm,较MIS-TLIF组的WM(31.15±6.53)mm小(P<0.05);MO-TLIF组的手术入路角度、深度和多裂肌位移均小于MIS-TLIF组(P<0.05)。MO-TLIF组CT参数与手术时间、失血量及eCSA萎缩均无相关性(r<0.3,P>0.05),MIS-TLIF组的CT参数与手术时间、失血量及eCSA萎缩均呈正相关(r>0.3,P<0.05)。MIS-TLIF组CT参数的综合作用与eCSA萎缩相关(R 2=0.4741,P<0.05)。结论与MIS-TLIF相比,MO-TLIF的手术入路术中失血少、术后恢复快、对椎旁肌侵扰更小。
ObjectiveTo compare the clinical efficacy and analyze the surgical approach differences using CT parameters between mini-open transforaminal lumbar interbody fusion(MO-TLIF)and minimally invasive surgery of transforaminal lumbar interbody fusion(MIS-TLIF)in the treatment of degenerative lumbar diseases.MethodsA total of 68 consecutive patients with degenerative lumbar diseases undergoing surgery at the Second Affiliated Hospital of Soochow University from January 2022 to January 2023 were randomized into the MO-TLIF group(34 cases,percutaneous screw-assisted posterior midline MO-TLIF)and the MIS-TLIF group(34 cases,Wiltse approach MIS-TLIF using the Quadrant channel).Perioperative indicators(operative time,incision length,intraoperative blood loss,fluoroscopy frequency,postoperative bedrest duration,and hospital stay)and complications were compared.Visual analogue scale(VAS)and Oswestry disability index(ODI)were assessed preoperatively and at 3 days,3 months,and 1 year postoperatively.Effective cross-sectional area(eCSA)of paraspinal muscles was evaluated on MRI preoperatively and 1 year postoperatively.CT parameters of surgical approaches,including spinous process-midline distance(SM),Wiltse-midline distance(WM),surgical approach angle,depth,and multifidus muscle displacement were compared.Pearson correlation and multivariate linear regression analyses were performed to explore associations between CT parameters,operative time,blood loss,and eCSA atrophy.ResultsBaseline characteristics showed no significant differences between groups(P>0.05).The MO-TLIF group exhibited shorter operative time(109.85±7.82 min vs.133.82±20.22 min),reduced blood loss(77.21±21.83 ml vs.141.18±31.44 ml),smaller incision length(6.09±0.22 cm vs.7.00±0.43 cm),shorter bedrest duration(1.59±0.49 d vs.2.38±0.50 d),and shorter hospital stay(8.93±1.44 d vs.10.35±1.45 d),but higher fluoroscopy frequency(19.53±1.92 times vs.16.29±1.78 times)compared to the MIS-TLIF group(P<0.05).Complications included fat liquefaction(5 cases)and dural tears(2 cases).Both groups showed improved VAS and ODI postoperatively(P<0.05).At 3 d postoperatively,the MO-TLIF group had lower VAS(2.74±0.47 points vs.3.35±0.48 points)and ODI(27.46%±2.16%vs.30.42%±2.52%)than the MIS-TLIF group(P<0.05).Postoperative eCSA decreased significantly in the MIS-TLIF group(P<0.05)but remained stable in the MO-TLIF group(P>0.05).The MO-TLIF group demonstrated smaller SM(8.43±1.81 mm vs.31.15±6.53 mm),approach angle,depth,and muscle displacement(P<0.05).CT parameters in the MO-TLIF group showed no correlation with operative time,blood loss,or eCSA atrophy(r<0.3,P>0.05),whereas parameters in the MIS-TLIF group correlated positively with these outcomes(0.3<r<0.6,P<0.05).Multivariate regression revealed a significant association between CT parameters and eCSA atrophy in the MIS-TLIF group(R 2=0.474,P<0.05).ConclusionCompared to MIS-TLIF,MO-TLIF reduces intraoperative blood loss,accelerates recovery,and minimizes paraspinal muscle trauma.
作者
王翔
徐良志
蒋凤仙
申科律
马宇航
黄振东
陆政峰
Wang Xiang;Xu Liangzhi;Jiang Fengxian;Shen Kelyu;Ma Yuhang;Huang Zhendong;Lu Zhengfeng(Department of Orthopedics,The Second Affiliated Hospital of Soochow University,Suzhou 215000,China;Department of Orthopedics,Xi'an Branch,the Second Affiliated Hospital of Soochow University,the Nuclear Industry 417 Hospital,Xi'an 710600,China)
出处
《中华骨科杂志》
北大核心
2025年第12期767-776,共10页
Chinese Journal of Orthopaedics
基金
国家自然科学基金面上项目(82074173,82474251)
苏州市卫健委临床重点病种诊疗技术科技项目(LCZX202307)
苏州市卫生健康委员会医学创新与应用研究项目(SKYD2023110)。
关键词
腰椎
最小侵入性外科手术
脊柱融合术
椎旁肌
CT参数
Lumbar vertebrae
Minimally invasive surgical procedures
Spinal fusion
Paraspinal muscles
CT parameters
