侧方腰椎椎间融合技术在腰椎椎体次全切除与重建手术中的应用

摘要

目的 探讨侧方腰椎椎间融合技术(lateral lumbar interbody fusion,LLIF)应用于腰椎椎体次全切除与重建手术的临床疗效.方法 回顾性分析2014年04月至2016年5月采用LLIF手术治疗8例腰椎爆裂骨折脱位、1例腰椎骨折术后感染患者的病历资料,男8例,女1例;年龄28～59岁,平均(35.5±6.7)岁.损伤节段:L24例,L34例,L41例.临床表现均为腰痛与不同程度神经损伤引起的会阴部及下肢功能障碍.术前脊髓神经功能按美国脊柱损伤协会(American Spinal Injury Association,ASIA)神经损伤分级,A级1例、B级2例、C级3例、D级1例、E级2例.记录手术时间、术中出血量及住院时间.临床疗效评估采用ASIA脊髓神经分级、疼痛视觉模拟评分(visual analogue scale,VAS)、Oswestry功能障碍指数(Oswestry disability index,ODI);感染患者记录术前、术后体温、红细胞沉降率及C反应蛋白变化;影像学评估采用手术前后腰椎手术节段及腰椎矢状位Cobb角,评价腰椎前凸角度的恢复情况及植骨融合情况.结果 手术时间50～90 min,平均(73±12.7) min;术中出血量30～150 ml,平均(650±35.3 ml).切口均一期愈合,住院时间为4～7 d,平均(5.0±1.0)d.所有患者均获得随访,随访时间为11～24个月,平均(16.4±3.8)个月.术后腰痛VAS评分、ODI均较术前明显改善.1例感染患者手术3d后体温恢复正常,红细胞沉降率及C反应蛋白于术后第17天、第25天趋于正常.术后ASIA分级A级改善为C级1例,B级改善为D级与E级各1例,C级改善为D级与E级各1例,D级改善为E级1例.术后手术节段前凸角和腰椎前凸角均得到了恢复,分别增加了19.9°与5.1°.所有患者椎间植骨均获骨性融合,无屈髋乏力、大腿前侧疼痛、麻木、腹膜后血肿等并发症发生.结论 侧方腰椎椎间融合技术应用于腰椎爆裂性骨折、感染等椎体或腰椎前中柱病变安全、可靠,临床疗效满意,为脊柱前中柱病变需行椎体次全切除的处理提供了新的思路与方法.%Objective To investigate the clinical outcomes of lateral lumbar interbody fusion (LLIF) in lumbar corpectomy and reconstruction.Methods Overall,8 patients with lumbar burst fracture and dislocation and 1 patient with postoperative infection of lumbar fracture who were treated with LLIF from May 2014 to May 2016 in our hospital were retrospective analyzed.The included 9 patients,with 8 males and 1 female,had an average age of 5.5±6.7 years (28-59 years).Among them,4 cases were injured at L2 segment,4 cases at L3,and 1 case at L4.The main symptoms were back pain and dysfunction of perineum and lower extremity caused by nerve injury.Preoperative neurological functions were assessed according to the American Spinal Injury Association's modified Frankel classification,with 1 case at Grade A,2 Grade B,3 Grade C,1 Grade D,and 2 Grade E.The operation time,the amount of intraoperative bleeding,and the length of hospital stay were recorded.The clinical outcomes were evaluated by the ASIA grading,visual analog scale (VAS),and Oswestry disability index (ODI).The changes of body temperature,erythrocyte sedimentation rate (ESR),and C-reactive protein (CRP) before and after surgery were recorded for the patients with infection.The recovery of lumbar lordosis and the fusion of bone graft were evaluated by the radiographic examination of the lumbar spine and lumbar sagittal Cobb angle.Results The average operation time was 73± 12.7min,ranging from 50 to 90 min.The amount of intraoperative bleeding was 650±35.3 ml,with a range between 30 and 150 ml.All incisions were fully healed.The length of hospital stay was 5.0± 1.0 days,ranging from 4 to 7 days.All patients were followed up for 16.4±3.8 months (11-24 months).The VAS scores and ODI were improved significantly after surgery compared with pre-operation.For patients with infection,body temperature,ESR,and CRP went back to normal within 3,17,and 25 days after surgery,respectively.The ASIA improvement was observed in six patients,with one from grade A to C,one from grade B to D,one from grade B to E,one from grade C to D,one from grade C to E,and one from grad D to E.The lordosis of lumbar spine and surgical segments were restored significantly after surgery,with an increase by 19.9 and 5.1 degree,respectively.All the patients achieved bone fusion after operation.Hip weakness,thigh pain,numbness,retroperitoneal hematoma,and other complications were not observed in these patients.Conclusion The lateral lumbar interbody fusion is safe,reliable,and clinically satisfactory for the treatment of lumbar burst fractures,infections,or lumbar anterior and middle column pathology.This method provides new ideas for the treatment of lumbar anterior and middle column pathology.