Wiltse入路与后正中入路经椎间孔椎体间融合的比较

Transforaminal lumbar interbody fusion through Wiltse approach versus traditional posterior midline approach

摘要:

[目的] 探讨 Wiltse 入路与后正中入路经椎间孔腰椎融合术 （transforaminal lumbar interbody fusion, TLIF） 治疗腰椎管狭窄症的临床疗效。[方法] 回顾分析 2021 年 11 月—2022 年 9 月本院收治的 40 腰椎管狭窄症患者的临床资料，根据医患沟通结果，19 例采用 W-TLIF，21 例采用传统后正中入路 TLIF，比较两组临床及多裂肌检查资料。[结果]两组均顺利完成手术，两组手术时间、切口总长度、术中出血量、术后引流量、术中透视次数的差异均无统计学意义（P＞0.05）。W-TLIF 组地行走时间显著早于后正中 TLIF 组 [(2.3±0.8) d vs (4.0±1.1) d, P＜0.05]。随访时间平均 （7.1±0.9） 个月，随时间推移，两组 VAS 及 ODI 评分均显著减少 （P＜0.05）。术后 6 个月 W-TLIF 组 VAS [(1.0±0.5) vs (2.0±1.0), P=0.013] 及 ODI 评分 [(11.6±1.8) vs (16.0± 3.7), P＜0.001] 均显著优于 TLIF 组（P＜0.05）。多裂肌检测方面，与术前相比，两组术后 1、3、6 个月 LMCSA、MUAP 均显著减小 （P＜0.05），DPR 无显著变化 （P＞0.05）。术前两组 LMCSA、MUAP 的差异均无统计学意义 （P＞0.05）；术后 6 个月 W-TLIF 组 LMCSA [(510.8±54.9) mm² vs (280.7±32.2) mm² , P＜0.05] 和 MUAP [(504.4±58.1) μV vs (313.7±71.0) μV, P＜0.05] 均显著大于 TLIF 组。术后相应时间点 W-TLIF 组多裂肌失神经电位出现率均显著低于 TLIF 组（P＜0.05）。[结论]W-TLIF 组对多裂肌损伤低于后正中 TLIF 组，可减轻疼痛，有利于早期康复。

Abstract:

[Objective] To evaluate the clinical efficacy of Wiltse approach transforaminal lumbar interbody fusion (W-TLIF), by com- parison with the traditional posterior midline approach transforaminal lumbar interbody fusion (TLIF) in the treatment of lumbar spinal ste- nosis. [Methods] A retrospective study was conducted on 40 patients who received TLIFs for lumbar spinal stenosis in our hospital from No- vember 2021 to September 2022. According to doctor-patient communication, 19 patients were treated with W-TLIF, while other 21 pa- tients were treated with traditional TLIF. The clinical and multifidus examination data of the two groups were compared. [Results] All pa- tients in both groups had corresponding surgical procedures performed successfully without significant differences in operation time, total incision length, intraoperative blood loss, postoperative drainage volume, and intraoperative fluoroscopy times between the two groups (P＞ 0.05), while the patients in the W-TLIF group resumed postoperative ambulation significantly earlier than those in the TLIF group [(2.3± 0.8) days vs (4.0±1.1) days, P＜0.05]. With time of the follow-up period lasted for (7.1±0.9) months on a mean, the VAS and ODI scores were significantly decreased in both groups (P＜0.05). The W-TLIF group were significantly better than the TLIF group 6 months after oper- ation in terms of VAS score [(1.0±0.5) vs (2.0±1.0), P=0.013] and ODI socre [(11.6±1.8) vs (16.0±3.7), P＜0.001]. Regarding multifidus de- tection, the lean mutifidus cross sectional area (LMCSA) and motor unit action potential (MUAP) were significantly decreased in both groups 1, 3 and 6 months after operation compared with those before operation (P＜0.05), while the denervated potential ratio (DPR) re- mained unchanged (P＞0.05). Although there were no significant differences in LMCSA and MUAP between the two groups before surgery (P＞0.05), the W-TLIF group was significantly superior to the TLIF group in terms of LMCSA [(510.8±54.9) mm² vs (280.7±32.2) mm² , P＜ 0.05] and MUAP [(504.4±58.1) μV vs (313.7±71.0) μV, P＜0.05] 6 months postoperatively, additionally, the former was also significantly better than the latter in term of DPR at all time points postoperatively accordingly (P＜0.05). [Conclusion] The Wiltse approach TLIF has lower damage to the multifidus muscle than the traditional posterior midline approach TLIF, which does reduce pain and is conducive to early rehabilitation.