Application of self-anchored lateral lumbar interbody fusion in lumbar degenerative diseases

Xu Baoshan; Xu Haiwei; Hu Yongcheng; Liu Yang; Ma Xinlong; Jiang Hongfeng; Liu Yue; Wang Tao; Li Ning

doi:10.3760/cma.j.cn121113-20200408-00234

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• 临床论著 •

自锚式腰椎侧方椎体间融合术在腰椎退行性疾病中的应用

中华骨科杂志, 2020,40(8) : 536-545. DOI: 10.3760/cma.j.cn121113-20200408-00234

摘要

目的

探讨自锚式腰椎侧方椎体间融合术（self anchored lateral lumbar interbody fusion，SA-LLIF）治疗腰椎退行性疾病的临床疗效。

方法

2019年1至12月采用SA-LLIF治疗腰椎退行性疾病患者41例，男18例，女23例；年龄（59.6±11.3）岁（范围49~77岁）。诊断包括腰椎失稳伴椎管狭窄17例、椎间盘退变性疾病8例、退变性滑脱8例、退变性侧凸5例、融合术后翻修3例，其中5例伴骨质疏松；责任节段包括L_{2, 3} 2例、L_{3, 4} 11例、L_{4, 5} 20例、L₂~L₄ 3例、L₃~L₅ 5例。手术采用侧卧位，取椎间隙中点斜向腹侧6 cm小切口，经腹膜外入路显露腰大肌前缘，向背侧牵开腰大肌，切除椎间盘及处理椎间隙，试模撑开，经同切口取髂骨填充融合器，正侧方植入融合器，以融合器远侧和近侧嵌片锚定融合器与相邻椎体。术后评估疼痛视觉模拟评分（visual analogue scale, VAS）、Oswestry功能障碍指数（Oswestry disability index，ODI）、融合器位置、腰椎前凸角、椎间隙高度和滑脱率。

结果

手术时间（79.0±19.5）min（范围60~100 min）；术中出血量（38.0±28.2）ml（范围15~70 ml）。术后随访（10.6±4.6）个月（范围4~15个月）。41例患者VAS评分由术前（6.2±2.1）分降低至术后3个月（1.9±1.2）分、末次随访时（1.6±1.1）分，手术前后的差异有统计学意义（F=107.48，P=0.00）；末次随访时VAS改善率为73.9%±16.4%，各病因组改善率的差异无统计学意义（F=0.13 ，P=0.97）。ODI由术前47.8%±15.1％降低至术后3个月14.6%±10.5%、末次随访时11.0%±7.3%，手术前后的差异有统计学意义（F=129.29 ，P=0.00）；末次随访时ODI改善率为75.8%±16.9%，各病因组改善率的差异无统计学意义（F=0.01，P=0.99 ）。腰椎X线片示脊柱序列明显恢复，融合器无移位或脱位。7例出现融合器下沉2~3 mm，除1例肥胖患者一过性腰痛外均无明显临床症状。末次随访时腰椎前凸角由术前36.4°±10.2°恢复至48.0°±10.7°，椎间隙高度由术前（8.3±2.5）mm恢复至（11.3±3.3）mm, 8例腰椎滑脱患者滑脱率由术前19.7%±4.4％减少至9.3%±5.3%，手术前后差异均有统计学意义（P<0.05）。

结论

SA-LLIF治疗腰椎退行性疾病可以增加单纯LLIF的即刻稳定性，避免后路内固定，术后近期疗效满意。

引用本文: 徐宝山, 许海委, 胡永成, 等. 自锚式腰椎侧方椎体间融合术在腰椎退行性疾病中的应用 [J] . 中华骨科杂志, 2020, 40(8) : 536-545. DOI: 10.3760/cma.j.cn121113-20200408-00234.

参考文献导出: Endnote NoteExpress RefWorks NoteFirst 医学文献王

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腰椎侧方椎体间融合术（lateral lumbar interbody fusion，LLIF）最早由Mayer^[1]在1997年报告。该术式可避免后侧结构损伤和前路复杂的分离，减少相关并发症。由于经腰大肌入路的极外侧融合术（extreme lateral interbody fusion，XLIF）、直接外侧融合术（direct lateral interbody fusion，DLIF）有干扰腰丛神经的问题，2012年Silvestre等^[2]报告了采用经腰大肌和大血管之间的自然间隙显露椎间盘的术式，可降低腰丛神经损伤的风险，并将其命名为斜外侧椎间融合术（oblique lateral lumbar interbody fusion，OLIF）。LLIF或OLIF均采用小切口撑开腹肌和腹膜外入路，切除椎间盘后撑开椎间隙，自侧方植入融合器，通过撑开压缩原理获得即时稳定^[1,2,3]。由于不进入椎管，降低了神经损伤和硬膜外粘连的风险，并有间接减压和复位作用，因此具有切口小、出血少、并发症少、恢复快等优点，近年来得到广泛推崇^[3,4,5]。

贡献者信息

徐宝山

天津市天津医院微创脊柱外科　300211

许海委

天津市天津医院微创脊柱外科　300211

胡永成

天津市天津医院微创脊柱外科　300211

刘阳

天津市天津医院微创脊柱外科　300211

马信龙

天津市天津医院微创脊柱外科　300211

姜洪丰

天津市天津医院微创脊柱外科　300211

刘越

天津市天津医院微创脊柱外科　300211

王涛

天津市天津医院微创脊柱外科　300211

黎宁

天津市天津医院微创脊柱外科　300211

关键词

腰椎; 椎间盘退行性变; 脊柱融合术; 外科手术，微创性;

基金项目

国家自然科学基金（31670983）

作者声明

【证据等级】治疗性研究Ⅳ级

历史

出版日期：2020-04-16

收稿日期：2020-04-08

本文编辑

马英

Clinical Original Article

Application of self-anchored lateral lumbar interbody fusion in lumbar degenerative diseases

Xu Baoshan, Xu Haiwei, Hu Yongcheng, Liu Yang, Ma Xinlong, Jiang Hongfeng, Liu Yue, Wang Tao, Li Ning

Published 2020-04-16

Cite as Chin J Orthop, 2020, 40(8): 536-545. DOI: 10.3760/cma.j.cn121113-20200408-00234

Abstract

Objective

To evaluate the efficacy of self-anchored lateral lumbar interbody fusion (SA-LLIF) for lumbar degenerative diseases.

Methods

During January to December in 2019, a total of 41 patients with lumbar degenerative disease were treated with SA-LLIF, included 18 males and 23 females, aged 59.6±11.3 (range 49-77) years. There were lumbar stenosis and instability in 17 cases, disc degenerative disease in 8 cases, degenerative spondylolisthesis in 8 cases, degenerative scoliosis in 5 cases, postoperative revision in 3 cases. And osteoporosis was diagnosed in 5 of them. The index level included L_{2, 3} in 2 cases, L_{3, 4} in 11 cases, L_{4, 5} in 20 cases, L₂-L₄ in 3 cases and L₃-L₅ in 5 cases. After general anesthesia, the patient was placed in decubitus position. The anterior edge of psoas major muscle was exposed through 6 cm incision and extraperitoneal approach. Further, the psoas major muscle was properly retracted to expose the disc. After discectomy, the intervertebral space was prepared and moderately distracted. A suitable fusion cage filled with auto iliac graft was implanted. Two anchoring plates were inserted into the cage. Then, the caudal and cephalic vertebral body and the fusion cage were locked.

Results

The operation was performed successfully in all the patients. The operation duration was 79.0±19.5 (range 60-100) min. Intraoperative bleed loss was 38.0±28.2 (range 15-70) ml. The patients were followed up for averagely 10.6±4.6 (range 4-15) months. The visual analogue scale decreased from preoperative 6.2±2.1 to 1.6±1.1 and Oswestry disability index decreased from 47.8%±15.1% to 11.0%±7.3%. X-ray showed that the spine alignment recovered satisfactorily. No cage displacement was found. Sinking (2-3 mm) of cage was found in 7 patients without obvious symptom despite transient lumbar pain in an obesity woman. The lumbar lordosis recovered from 36.4°±10.2° to 48.0°±10.7°, and intervertebral height recovered from 8.3±2.5 mm to 11.3±3.3 mm. The rate of spondylolisthesis recovered from 19.7%±4.4% to 9.3%±5.3%.

Conclusion

SA-LLIF can provide immediate stability and good results for lumbar degenerative diseases with stand-alone anchoring cage without posterior internal fixation.

Key words:

Lumbar vertebrae; Intervertebral disc degeneration; Spinal fusion; Surgical procedures, minimally invasive

Contributor Information

Xu Baoshan