| 两种手术入路联合固定并椎间融合治疗腰椎单节段病变的临床研究 |
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投稿时间：2016-12-12
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| 作者 | Author | 单位 | Address | E-Mail |
| 曾忠友 |
ZENG Zhong-you |
武警部队骨科医学中心 武警浙江省总队医院骨二科, 浙江 嘉兴 314000 |
The Second Department of Orthopaedics, Hospital of Zhejiang General Corps of Chinese People's Armed Police Forces, Jiaxing 314000, Zhejiang, China |
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| 严卫锋 |
YAN Wei-feng |
武警部队骨科医学中心 武警浙江省总队医院骨二科, 浙江 嘉兴 314000 |
The Second Department of Orthopaedics, Hospital of Zhejiang General Corps of Chinese People's Armed Police Forces, Jiaxing 314000, Zhejiang, China |
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| 宋永兴 |
SONG Yong-xing |
武警部队骨科医学中心 武警浙江省总队医院骨二科, 浙江 嘉兴 314000 |
The Second Department of Orthopaedics, Hospital of Zhejiang General Corps of Chinese People's Armed Police Forces, Jiaxing 314000, Zhejiang, China |
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| 毛克亚 |
MAO Ke-ya |
解放军总医院骨科, 北京 100039 |
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| 籍剑飞 |
JI Jian-fei |
武警部队骨科医学中心 武警浙江省总队医院骨二科, 浙江 嘉兴 314000 |
The Second Department of Orthopaedics, Hospital of Zhejiang General Corps of Chinese People's Armed Police Forces, Jiaxing 314000, Zhejiang, China |
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| 张建乔 |
ZHANG Jian-qiao |
武警部队骨科医学中心 武警浙江省总队医院骨二科, 浙江 嘉兴 314000 |
The Second Department of Orthopaedics, Hospital of Zhejiang General Corps of Chinese People's Armed Police Forces, Jiaxing 314000, Zhejiang, China |
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| 吴鹏 |
WU Peng |
武警部队骨科医学中心 武警浙江省总队医院骨二科, 浙江 嘉兴 314000 |
The Second Department of Orthopaedics, Hospital of Zhejiang General Corps of Chinese People's Armed Police Forces, Jiaxing 314000, Zhejiang, China |
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| 裴斐 |
PEI Fei* |
武警部队骨科医学中心 武警浙江省总队医院骨二科, 浙江 嘉兴 314000 |
The Second Department of Orthopaedics, Hospital of Zhejiang General Corps of Chinese People's Armed Police Forces, Jiaxing 314000, Zhejiang, China |
1320894698@qq.com |
| 宋国浩 |
SONG Guo-hao |
武警部队骨科医学中心 武警浙江省总队医院骨二科, 浙江 嘉兴 314000 |
The Second Department of Orthopaedics, Hospital of Zhejiang General Corps of Chinese People's Armed Police Forces, Jiaxing 314000, Zhejiang, China |
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| 韩建福 |
HAN Jian-fu |
武警部队骨科医学中心 武警浙江省总队医院骨二科, 浙江 嘉兴 314000 |
The Second Department of Orthopaedics, Hospital of Zhejiang General Corps of Chinese People's Armed Police Forces, Jiaxing 314000, Zhejiang, China |
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| 俞伟 |
YU Wei |
武警部队骨科医学中心 武警浙江省总队医院骨二科, 浙江 嘉兴 314000 |
The Second Department of Orthopaedics, Hospital of Zhejiang General Corps of Chinese People's Armed Police Forces, Jiaxing 314000, Zhejiang, China |
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| 期刊信息：《中国骨伤》2017年，第30卷，第5期，第417-425页 |
| DOI：10.3969/j.issn.1003-0034.2017.05.018 |
| 基金项目:浙江省卫生厅科研项目资助（编号：2010KYB112） |
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中文摘要:
目的：探讨两种不同手术入路联合固定并椎间融合治疗腰椎单节段病变的优缺点。
方法：对2011年6月至2013年6月收治的腰椎单节段病变86例患者进行回顾性分析，其中男33例，女53例；年龄28～76岁，平均53.0岁；腰椎间盘退变39例，腰椎间盘突出伴椎管狭窄22例，巨大型腰椎间盘突出9例，腰椎退行性滑脱（MeyerdingⅠ度）16例；L3，4 5例，L4，5 70例，L5S1 11例。采用正中切口入路联合固定并椎间融合器植骨治疗45例（正中切口组），采用通道下肌间隙入路联合固定并椎间融合器植骨治疗41例（通道组）.记录两组病例切口长度、手术时间、术中出血量、术后引流液量。采用视觉模拟评分法（visual analogue scale，VAS）对术后72 h腰部切口疼痛进行评分，根据影像结果比较两组病例术前、术后3 d和末次随访时病变节段椎间隙高度的变化，术前和末次随访时腰椎冠状面和矢状面Cobb角变化，以及手术前后多裂肌面积和多裂肌脂肪组织沉积等级，观察椎弓根螺钉、椎板关节突螺钉有无松动、断裂，以及椎间融合器有无移位，评价椎间融合情况，术前、末次随访采用JOA下腰痛评分系统，评价两组病例的功能恢复情况。
结果：在切口长度和术后引流液方面，通道组优于正中切口组；在手术时间和术中出血量方面，正中切口组少于通道组。术后72 h腰部切口VAS评分两组差异有统计学意义（P<0.05）.术后均未发生切口感染，但通道组出现切口表皮坏死4例，切口愈合不良1例，神经损伤3例。椎弓根螺钉位置不良率：正中切口组为5.0%，通道组为3.6%，两组差异无统计学意义（P>0.05）.椎板关节突螺钉位置不良率：正中切口组6.6%，通道组12.2%，两组差异有统计学意义（P<0.05）.所有病例获得随访，时间12～36个月，平均22.8个月。两组患者术后3 d椎间隙高度均较术前有明显恢复，（P<0.05），而末次随访时与术后3 d相比差异无统计学意义（P>0.05）；两组间术后3 d及末次随访比较差异均无统计意义（P>0.05）.患者的腰椎冠状面和矢状面Cobb角末次随访时与术前相比差异有统计学意义（P<0.05），而两组间相比差异无统计学差异（P>0.05）.多裂肌面积：正中切口组术后1年为（789.00±143.15）mm2，术前为（1066.00±173.55）mm2，两者相比差异有统计学意义（P<0.05）；通道组术后1年为（992.00±156.75）mm2，术前为（1063.00±172.13）mm2，两者相比差异无统计学意义（P>0.05），两组间术后1年相比差异有统计学意义（P<0.05）.多裂肌等级方面：正中切口组术后1年与术前相比差异有统计学意义（P<0.05），通道组术后1年与术前相比差异无统计学意义（P>0.05），两组间术后1年相比差异有统计学意义（P<0.05）.随访过程中未发现椎弓根螺钉与椎板关节突螺钉松动、移位、断裂或椎间融合器前后向移位。椎间融合率：正中切口组为95.6%，通道组为95.1%，两组差异无统计学意义。两组病例均未发现固定部位邻近节段的明显退变。JOA评分：正中切口组由术前的8～16分（平均12.77分）提高到末次随访时的21～29分（平均25.20±2.43），两者比较差异有统计学意义（P<0.05）；通道组由术前的8～16分（平均12.64±2.27）提高到末次随访时的23～29分（平均26.70±1.82），两者比较差异有统计学意义（P<0.05），末次随访时两组比较差异有统计学意义（P<0.05）.
结论：与采用正中切口显露方式相比，通道下肌间隙入路单侧椎弓根螺钉联合对侧椎板关节突螺钉固定并椎间融合器植骨治疗腰椎单节段病变具有更多的优点，包括切口小、损伤小、恢复快等，但通道下肌间隙入路也存在手术并发症高等不足，特别是在早期开展病例。 |
| 【关键词】腰椎 椎弓根螺钉 椎板关节突螺钉 脊柱融合术 |
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| Case control study on two different surgical approaches combined fixation with lumbar interbody fusion for the treatment of single segmental lumbar vertebra diseases |
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ABSTRACT
Objective: To discuss the advantages and disadvantages of two different surgical approaches combined fixation with lumbar interbody fusion in treating single segmental lumbar vertebra diseases.
Methods: The clinical data of 86 patients with single segmental lumbar vertebra diseases treated from June 2011 to June 2013 was retrospectively analyzed. There were 33 males and 53 females,aged from 28 to 76 years old with an average of 53.0 years. Among them,there were 39 cases of lumbar disc degeneration,22 cases of lumbar disc herniation complicated with spinal canal stenosis,9 cases of huge lumbar disc herniation and 16 cases of lumbar degenerative spondylolisthesis (Meyerding degreeⅠ). Lesion sites contained L3,4 in 5 cases,L4,5 in 70 cases and L5S1 in 11 cases. All the patients were treated with internal fixation and lumbar interbody fusion with 45 cases by midline incision approach (median incision group) and the other 41 cases by channel-assisted by muscle-splitting approach(channel group). Incision length,operation time,intraoperative bleeding and postoperative drainage were recorded in two groups. Visual analogue scale(VAS) was used to assess lumbar incision pain 72 h after operation. Depended on imaging results to compare the changes of the disc space height in lesion in preoperative,postoperative and final follow-up,the coronal and sagittal Cobb angle in preoperative and final follow-up,the area of multifidus and the degree of multifidus fat deposition before and after operation between two groups. Loosening or fragmentation of internal fixation,displacement of intervertebral cage and interbody fusion were observed in each group. Japanese Orthopedic Association (JOA) scoring system was used to evaluate the function before operation and at the final follow-up.
Results: The channel group was superior to the median incision group in incision length and postoperative drainage while the median incision group was less than the channel group in the operation time and intraoperative bleeding. The average VAS score of lumbar incision 72 h after operation was 1.50 points in median incision group and 0.97 points in channel group,and there was significant difference between two groups(P<0.05). No incision infection was found,but there were 4 cases of incisional epidermal necrosis,1 case of incision healed badness,and 3 cases of nerve injury in channel group. The incidence of cacothesis of pedicle screw were 5.0% and 3.6% in median incision group and channel group respectively,and there was no significant difference between two groups(P>0.05). The incidence of cacothesis of translaminar facet screw were 6.6% and 12.2% in median incision group and channel group respectively,and there was significant difference between two groups(P<0.05). All the patients were followed up for 12 to 36 months with a mean of 22.8 months. The changes of disc space height had statistical difference between preoperative and postoperative(P<0.05) in all patients,but there was no significant difference between postoperative and final follow-up(P>0.05),however,there was no significant difference 3 days after operation and final follow-up between two groups(P>0.05). At final follow-up,coronal and sagittal Cobb angle were obviously improved in all patients(P<0.05),but there was no significant difference between two groups(P>0.05). One year after operation,the area of multifidus in median incision group was (789.00±143.15) mm2 less than preoperative(1 066.00±173.55) mm2(P<0.05),and in channel group,was(992.00±156.75) mm2 at 1 year after operation and(1 063.00±172.13) mm2 preoperatively,there was no significant difference between them(P>0.05),however,there was significant difference one year after operation between two groups (P<0.05) . About the degree of multifidus fat deposition,there was significant difference between one year after operation and preoperation in median incision group (P<0.05),but there was no significant difference between one year after operation and preoperation in channel group (P>0.05),and there was significant difference at one year after operation between two groups(P<0.05). During the follow-up period,neither pedicle screw and/or translaminar facet screw loosening,displacement or fragmentation nor displacement of intervertebral cage were found. The lumbar interbody fusion rate was 95.6% in median incision group and was 95.1% in channel group,and there was no significant difference between two groups(P>0.05). No obvious adjacent segmental degeneration was observed in fixed position. JOA score in median incision group was significantly increased from 8-16 points (average:12.77±2.56) preoperative to 21-29 points (average:25.20±2.43) at final follow-up(P<0.05);and in channel group was significantly increased from 8-16 points (average:12.64±2.37) preoperative to 23-29 points(average:26.7±1.82) at final follow-up(P<0.05);there was also significant difference between two groups at final follow-up.
Conclusion: Compared to the median incision approach,unilateral pedicle screw combined with contralateral translaminar facet screw fixation using channel-assisted by muscle-splitting approach has advantages of small incision,less trauma,fast recovery and so on. However,it also has shortages such as high surgical complications incidence,especially in cases that. |
| KEY WORDS Lumbar vertebra Pedicle screws Translaminar facet screw Spinal fusion |
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| 中文格式: | 曾忠友,严卫锋,宋永兴,毛克亚,籍剑飞,张建乔,吴鹏,裴斐,宋国浩,韩建福,俞伟.两种手术入路联合固定并椎间融合治疗腰椎单节段病变的临床研究[J].中国骨伤,2017,30(5):417~425 |
| 英文格式: | ZENG Zhong-you,YAN Wei-feng,SONG Yong-xing,MAO Ke-ya,JI Jian-fei,ZHANG Jian-qiao,WU Peng,PEI Fei*,SONG Guo-hao,HAN Jian-fu,YU Wei.Case control study on two different surgical approaches combined fixation with lumbar interbody fusion for the treatment of single segmental lumbar vertebra diseases[J].zhongguo gu shang / China J Orthop Trauma ,2017,30(5):417~425 |
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