双侧肌间入路与后正中入路经椎间孔椎间融合术比较

Bilateral intermuscular approaches versus a posterior midline approach for transforaminal lumbar interbody fusion

摘要:

［目的］ 比较双侧肌间入路与后正中入路经椎间孔椎间融合术手术后疗效。［方法］ 回顾性分析 2016 年 5 月—2018 年 5 月本院采用经椎间孔椎间融合术（transforaminal lumbar interbody fusion, TLIF）治疗的 L4/5椎管狭窄伴失稳 62 例患者的临床资料。依据术前医患沟通结果，31 例采用肌间隙入路，31 例采用后正中入路。比较两组围手术期、随访及影像结果。［结果］ 两组患者均顺利完成手术。肌间隙组切口总长度、手术时间、术中失血量和术后引流量均显著优于后正中组 （P<0.05），但两组术中透视次数、切口愈合等级、住院时间的差异无统计学意义（P>0.05）。两组患者均获随访 12 个月以上，两组完全负重时间差异无统计学意义 （P>0.05）。术后随时间推移，两组 VAS、ODI 评分均显著减少 （P<0.05），而 JOA 评分显著增加 （P< 0.05），术后 3 个月，肌间隙组上述评分均显著优于后正中组 （P<0.05），但末次随访时两组上述评分的差异均无统计学意义 （P>0.05）。影像方面，术后 6 个月和末次随访时，肌间隙组的 FCSA/TCSA 比值均显著大于后正中组 （P<0.05）。［结论］ 与后正中入路相比，双侧肌间隙入路 TLIF 手术时间短，出血量少，可保留更多的多裂肌的功能单位。

Abstract:

[Objective] To compare the clincal efficacy of bilateral intermuscular approaches (BIM) versus a posterior midline approach (PML) for transforaminal lumbar interbody fusion (TLIF) . [Methods] A retrospective study was conducted on 62 patient who received TLIF for L4/5 spinal canal stenosis accompanied with segmental instability in our hospital From May 2016 to May 2018. According to the preoper- ative doctor-patient communication, 31 patients had TLIF performed through the BIM approach, while the remaining 31 patients had the operation conducted through the PML approach. The documents regarding to perioperative period, follow- up and radiographs were com- pared between the two groups. [Results] All patients in both groups were operated on successfully without serious complications. The BIM group proved significantly superior to the PML group in terms of total incision length, operation time, intraoperative blood loss and postoper- ative drainage volume (P＜0.05) , but there were no significant differences in intraoperative fluoroscopy times, incision healing grades and hospital stay between the two groups (P＞0.05) . All patients in both groups were followed up for more than 12 months, and there was no sta- tistical significance in the time to resume total weight-bearing activity between the two groups (P＞0.05) . The VAS and ODI scores signifi- cantly decreased (P＜0.05) , while JOA scores significantly increased over time in both groups (P＜0.05) . The BIM group was significantly superior to the PML group in above-mentioned scores at 3 months after surgery (P＜0.05) , whereas which all became not statistically signifi- cant at the latest follow-up between the two groups (P＞0.05) . With respect to imaging evaluation, the BIM group had significantly greater FCSA/TCSA ratio of the paraspinal muscle than the PML group at 6 months after surgery and the latest follow-up (P＜0.05) . [Conclusion] Bilateral intermuscular approaches have advantages of shortening operation time, reducing blood loss, and preserving more functional units of multifidus over the posterior midline approach for TLIF.