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曾忠友,张建乔,宋永兴,范时洋,俞伟,裴斐,王海峰.微创通道下肌间隙入路内固定融合术治疗巨大型腰椎椎间盘突出症[J].脊柱外科杂志,2021,19(1):26-33.
微创通道下肌间隙入路内固定融合术治疗巨大型腰椎椎间盘突出症     点此下载全文 (Fulltext)
曾忠友  张建乔  宋永兴  范时洋  俞伟  裴斐  王海峰
武警海警总队医院骨二科, 嘉兴 314000
基金项目:
DOI:10.3969/j.issn.1672-2957.2021.01.005
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摘要:
      目的 探讨微创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内固定并椎间融合术治疗巨大型腰椎椎间盘突出症(LDH)的可行性。方法 回顾性分析2012年6月—2017年12月收治的47例巨大型LDH患者临床资料,均采用单侧椎弓根螺钉联合对侧椎板关节突螺钉内固定并椎间植骨融合术治疗,其中采用正中切口入路22例(正中切口组),采用微创通道下肌间隙入路25例(肌间隙组)。观察并对比2组患者围手术期指标、影像学参数、疼痛视觉模拟量表(VAS)评分、日本骨科学会(JOA)评分及并发症发生情况。结果 所有手术顺利完成,无切口感染,2组手术时间差异无统计学意义(P>0.05)。所有患者随访12~48(26.50±7.45)个月。与正中切口组相比,肌间隙组切口较短、术中出血量较少、术后引流量较少、术后72 h腰部切口VAS评分较低,差异均有统计学意义(P<0.05)。2组患者椎弓根螺钉位置不良率差异无统计学意义(P>0.05)。椎板关节突螺钉位置不良率,肌间隙组高于正中切口组,差异有统计学意义(P<0.05)。2组患者术后椎间隙高度较术前明显恢复,但末次随访时较术后3~5 d出现丢失,差异均有统计学意义(P<0.05);2组间各时间点比较差异均无统计学意义(P>0.05)。末次随访时2组患者腰椎冠状面和矢状面平衡较术前获得改善,差异均有统计学意义(P<0.05)。肌间隙组术后12个月多裂肌面积和等级与正中切口组比较,差异有统计学意义(P<0.05)。2组患者随访期间均无内固定松动、断裂或融合器移位。正中切口组椎间融合率为95.5%,肌间隙组为92.0%,差异无统计学意义(P>0.05)。末次随访时2组JOA评分较术前明显改善,差异均有统计学意义(P<0.05);组间比较差异无统计学意义(P>0.05)。肌间隙组并发症发生率(20.0%,5/25)高于正中切口组(13.6%,3/22),差异有统计学意义(P<0.05)。结论 微创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内固定并椎间融合术治疗巨大型LDH具有可行性,与正中切口入路相比,切口小、创伤小、出血量少、术后恢复快,但学习曲线陡峭,早期并发症发生率较高。
关键词:腰椎  椎间盘移位  脊柱融合术  内固定器  外科手术,微创性
Minimally invasive internal fixation and fusion via intermuscular approach for giant lumbar disc herniation    Fulltext
Zeng Zhongyou  Zhang Jianqiao  Song Yongxing  Fan Shiyang  Yu Wei  Pei Fei  Wang Haifeng
Second Department of Orthopaedics, Hospital of Coast Guard General Corps of Armed Police Forces, Jiaxing 314000, Zhejiang, China
Fund Project:
Abstract:
      Objective To investigate the feasibility of minimally invasive unilateral pedicle screw combined with contralateral translaminar facet screw internal fixation and interbody fusion via intermuscular approach for giant lumbar disc herniation(LDH). Methods The clinical data of 47 patients with giant LDH from June 2012 to December 2017 were analyzed retrospectively. All the patients were treated with unilateral pedicle screw combined with contralateral translaminar facet screw internal fixation and interbody fusion,including 22 cases via median incision approach(median incision group),and 25 cases via minimally invasive intermuscular approach through minimally invasive channel(intermuscular group). The perioperative indexes,imaging parameters,visual analogue scale(VAS) score,Japanese Orthopaedic Association(JOA) score and complications were observed and compared between the 2 groups. Results All the operations were successfully completed without incision infection,and there was no significant difference in operation time between the 2 groups(P>0.05). All the patients were followed up for 12-48(26.50±7.45)months. Compared with the median incision group,the intermuscular group had shorter incision length,less intraoperative blood loss,less postoperative drainage volume and lower VAS score of lumbar incision pain 72 h after operation,and the differences were statistically significant(P<0.05). There was no significant difference between the 2 groups in the rate of pedicle screw misplacment(P>0.05),but the rate of translaminar facet screw misplacment in the intermuscular group was significant higher than that in the median incision group(P<0.05). The intervertebral space height in both groups recovered significantly after operation,but lost at the final follow-up compared with that at posteperative 3-5 d,and the differences were statistically significant(P<0.05). There was no significant difference in the intervertebral space height between the 2 groups at each time point(P>0.05). The coronal plane and sagittal plane balance of lumbar was improved in both groups at the final follow-up. At postoperative 12 months,the area and grade of multifidus were significantly better in the intermuscular group than in the median incision group(P<0.05). During the follow-up,no screw loosening,breakage and cage displacement were observed. The fusion rate was 95.5% in the median incision group and 92.0% in the intermuscular group,and there was no statistical difference between the 2 groups(P>0.05). The JOA scores were significantly improved at the final follow-up in 2 groups,but the differences were not statistically significant between the 2 groups(P>0.05). The incidence of complications was 13.6%(3/22) in the median incision group and 20.0%(5/25) in the intermuscular group,and the difference was statistically significant(P<0.05). Conclusion Minimally invasive unilateral pedicle screw combined with contralateral translaminar facet screw internal fixation and interbody fusion via intermuscular approach for the treatment of giant LDH is clinically feasible. Compared with the median incision approach,it has the advantages of small incision,less trauma,less blood loss,faster postoperative recovery,but steep learning curve and higher incidence of early complications.
Keywords:Lumbar vertebrae  Intervertebral disk displacement  Spinal fusion  Internal fixators  Surgical procedures,minimally invasive
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