| Objective: To compare clinical and radiographic effects of transforaminal lumbar interbody fusion via Wiltse approach(W-TLIF)and midline approach(M-TLIF)in treatment of lumbar degenerative diseases.Methods: From January 2015 to June 2018,a total of 195 cases of lumbar degenerative diseases treated by transforaminal lumbar interbody fusion in the spinal surgery department were retrospectively analyzed.Inclusion criteria:(1)18-70 years old,diagnosed as lumbar degenerative diseases(L3-S1);(2)Lumbar disc herniation with segmental instability;(3)Lumbar spinal stenosis with degenerative or iatrogenic lumbar instability;(4)Posterior edge rupture of the vertebral body;(5)L5/S1 extreme lateral disc herniation;(6)I°,II°degenerative or isthmic spondylolisthesis;(7)Complete clinical and imaging data and follow-up time ≥2 years;(8)The surgery was completed by senior physicians in the same group.Exclusion criteria:(1)History of lumbar spine surgery;(2)Need multi-segment fusion;(3)Exclude tandem spinal stenosis,osteoporosis,spinal deformity,lumbar fracture,lumbar tuberculosis and other diseases;(4)Exclude the inability to perform functional scoring due to mental illness.According to the inclusion and exclusion criteria,98 patients were excluded(61 cases were under-followed up,37 cases were lost in imaging data),and 97 patients were finally included in the analysis.According to the surgical approach,they were divided into W-TLIF group(53 cases)and M-TLIF group(44 cases).Operation time,intraoperative blood loss and incidence of surgical complications of two groups were recorded.Low back pain and leg pain were assessed with visual analogue scale(VAS),and lumbar function was evaluated with Japanese Orthopedic Association(JOA)and Oswestry disability index(ODI).The accuracy rate of pedicle screw placement,the position of pedicle screw with superior segment facet joint,transverse screw angle(TSA),intervertebral disc height,lumbar interbody fusion and adjacent segment degeneration(ASDeg)were assessed in two groups.Results: Both groups of patients successfully completed the operation.W-TLIF group operation time(115-135)min,average(126±6)min,M-TLIF group(120-150)min,average(137±9)min,statistical results show: the difference between the two groups in operation time was statistically significant(P<0.05),indicating that the operation time in the W-TLIF group was significantly less than that in the M-TLIF group.Intraoperative blood loss in W-TLIF group(140-170)ml,average(155±9)ml,M-TLIF group(160-190)ml,average(174±10)ml,statistics show that the difference between the two groups was statistically significant(P<0.05),indicating that the intraoperative blood loss of W-TLIF was significantly less than that in the M-TLIF group.There was1 case of cerebrospinal fluid leakage,2 cases of nerve root injury,and 2 cases of incision infection in the W-TLIF group,2cases of cerebrospinal fluid leakage,2 cases of nerve root injury,and 2 cases of incision infection in the M-TLIF group.There was no significant difference in common complications(P>0.05),indicating that the two groups of patients had similar postoperative complications.The low back pain VAS,JOA score and ODI of the two groups of patients 1 week after operation and each follow-up time were significantly lower than those before the operation(P<0.05),and the W-TLIF group patients postoperative and follow-up time low back pain VAS,JOA score and ODI were significantly better than those in the M-TLIF group,and the difference between the two groups was statistically significant(P <0.05),indicating that the postoperative lumbar and back pain reduction in the W-TLIF group was significantly better than that in the M-TLIF group.Lumbar function in the W-TLIF group was significantly better than the M-TLIF group.The VAS of leg pain in the two groups were significantly improved at 1 week after operation and at each follow-up time compared with that before operation(P<0.05),but there was no significant difference in the VAS of leg pain at 1 week after operation and at each follow-up time between the two groups(P>0.05),indicating that the leg pain which induced by nerve root after surgical decompression were significantly improved in the two groups.The overall accuracy of pedicle screw placement on both sides of the L3,L4,L5 and S1 pedicles of the two groups was 88.7% and 88.1%,respectively.There was no statistically significant difference between the two groups(P>0.05),indicating that the both approaches can acquire the requirements of screw placement.The incidence of facet joint violation in the W-TLIF(21.7%)group was significantly lower than that in the M-TLIF group(30.7%)(P<0.05),indicating that screw placement in the W-TLIF group is less likely to damage the facet joints of the upper vertebral body.The TSA on the right side of L3-S1 in W-TLIF group were(20.2°±7.2°),(25.0°±3.2°),(25.2°±3.2°),(18.4°±4.8°),and the TSA on the right side of L3-S1 in M-TLIF group were(15.4°±5.0°),(18.2°±5.1°),(15.7°±4.5°),(15.3°±4.2°);the TSA on the left side of L3-S1 in W-TLIF group were(21.3°±3.6°),(24.6°±3.3°),(25.0°±3.7°),(18.0°±5.2°),and the TSA on the left side of L3-S1 in M-TLIF group were(21.3°±3.6°),(24.6°±3.3°),(25.0°±3.7°),(18.0°±5.2°),respectively.The TSA of the same side at the same level in the W-TLIF group was significantly greater than that in the M-TLIF group(P all<0.05),showing that the W-TLIF group has a larger inclination angle compared with the M-TLIF group for pedicle screw placement in different vertebral bodies.The postoperative intervertebral disc height in the W-TLIF group was(10.4-17.1)mm,with an average of(13.8±1.8)mm,and the postoperative intervertebral disc height in the M-TLIF group was(10.4-17.0)mm with an average of(13.7±1.7)mm.The results showed that there was no statistically significant difference in the intervertebral disc height at 1 week postoperatively after the operation between the two groups(P>0.05),showing that both approaches for intervertebral space distraction can obtain satisfactory recovery of the intervertebral disc height.The intervertebral disc height of the surgical segment in the W-TLIF group was(8.5-15.8)mm,with an average of(11.1±1.4)mm,and the M-TLIF group was(8.4-13.2)mm,with an average of(10.9±1.2)mm at 1 year postoperatively.The results showed that the difference is not statistically significant(P>0.05),showing that a small part of the intervertebral disc height was lost in the two groups of patients at 1 year postoperatively after the operation and the last follow-up,but the intervertebral height was basically maintained.The two-year fusion rate of the W-TLIF group was 92.5% compared with 90.9% of the M-TLIF group,and there was no significant difference(P>0.05),showing that satisfactory intervertebral fusion can be obtained by both approaches at 2 years postoperatively.In the W-TLIF group,the incidence of adjacent upper segment degeneration of the surgical segment at 2 years after surgery was 13.2%,and that of the M-TLIF group was27.3%.The results showed that there was a significant difference in the incidence of adjacent segment degeneration between the two groups(P<0.05),indicating that the M-TLIF group is more prone to upper adjacent segment degeneration than the W-TLIF group.Conclusion: Good clinical effects could be achieved for the treatment of lumbar degenerative diseases by both approaches.However,less blood loss and shorter operation time were observed during the W-TLIF procedure,and low back pain was significantly improved postoperatively.In addition,a larger TSA could be obtained via the Wiltse approach,which not only provides stronger biomechanical strength,but also prevents pedicle screws from damaging the facet joints and reduces the occurrences of adjacent segment degeneration after surgery. |
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