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【Objective】 To compare the clinical efficacy of minimally invasive percutaneous approach with Wiltse approach in the treatment of thoracolumbar fracture without neurological deficit in young and middle-aged patients. 【Methods】 A prospective study was conducted in 108 patients with thoracolumbar fracture without neurological symptoms treated in Department of Orthopedics， The First Affiliated Hospital of Xi’an Jiaotong University from March 2015 to March 2018. We randomly assigned 54 patients to minimally invasive percutaneous approach group （Group A） and 54 ones to Wiltse approach group （Group B）. We compared the operation time， intraoperative blood loss， incision length， the number of intraoperative fluoroscopy times， and postoperative hospital stay of Group A and Group B. We also compared the VAS scores of the two groups before and 3 days after surgery and at each review， the vertebral frontal height compression ratio and Cobb Angle before and immediately after surgery， 3 months 1 year and 3 years after surgery， and ODI index before surgery and 3 months， 1 year and 3 years after surgery. 【Results】 All the 108 patients were followed up. There were no significant differences in operation time， intraoperative blood loss or postoperative hospital stay between the two groups （P>0.05）. The number of intraoperative fluoroscopy times was significantly smaller in Group B than in Group A （P0.05）， after operation， or at follow-up， while the anterior vertebral body height ratio and Cobb angle were significantly lower in Group B than in Group A （P<0.0125）. 【Conclusion】 Minimally invasive percutaneous approach and Wiltse approach are both safe and effective in the treatment of thoracolumbar fracture without neurological deficit. However， the number of intraoperative fluoroscopy times of Wiltse approach was significantly reduced， the incision length was smaller than that of the percutaneous pedicle group， and the postoperative anterior vertebral compression rate and Cobb Angle were lower than those of the percutaneous group， indicating better clinical efficacy.
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Objective To explore the application and clinical effect of ropivacaine incision infiltration combined with Wiltse approach in the analgesia of lumbar multi-segment decompression and fusion internal fixation. Methods A total of 120 patients with lumbar spinal stenosis and (or) lumbar disc herniation, who received posterior lumbar multisegmental (≥2) transforaminal lumbar interbody fusion (TLIF) in the Second Affiliated Hospital of Nantong University from Jan. 2016 to Jan. 2019, were randomly assigned to four groups: group A (ropivacaine incision infiltration＋Wiltse approach), group B (ropivacaine incision infiltration＋posterior median approach), group C (saline incision infiltration＋Wiltse approach) and group D (saline incision infiltration＋posterior median approach). The operation time, intraoperative blood loss, postoperative drainage volume, postoperative analgesic dosage, the visual analogue scale (VAS) score of low back pain before operation and 6 h, 1 d, 3 d, 7 d, 1 month and 3 months after operation, and the Oswestry disability index (ODI) before operation and 3 d, 7 d, 1 month and 3 months after operation, were compared among the four groups. Results There were no significant differences in gender, age, body weight, operative segments, low back pain VAS score or ODI before operation (all P＞0.05). The intraoperative blood loss, postoperative drainage volume and analgesic dosage were significantly lower in the groups A and C than those in the groups B and D (all P＜0.05). The VAS scores 6 h after operation were significantly lower in the groups A and B than those in the groups C and D, and the VAS scores 3 and 7 d after operation were significantly lower in the groups A and C than the groups B and D (all P＜0.05). The ODI values 3 d and 3 months after operation were significantly lower in the groups A and C than those in the groups B and D (all P＜0.05). Conclusion Preemptive analgesia using ropivacaine incision infiltration combined with Wiltse approach in lumbar multi-segment decompression and fusion internal fixation can effectively relieve postoperative pain, with remarkable analgesic effect and rapid functional recovery, benefiting early recovery of patients after operation.
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[Abstract] Objective To analyze the characteristics of lumbar spondylolysis in military patients, and explore the clinical effect of Wiltse approach pedicle screw-laminar hook internal fixation combined with autologous ilium transplantation in repairing single-segment lumbar spondylolysis. Methods Thirty-three military patients with single-segment lumbar spondylolysis were admitted to the 940 Hospital of Joint Service Support Force of Chinese PLA from January 2016 to January 2019. The Wiltse approach pedicle screw-lamina hook internal fixation combined with autogenous ilium transplantation was performed to repair the lumber spondylolysis, the patients were then followed up to evaluate the visual analogue scale (VAS) and Oswestry dysfunction index (ODI) of lumbar pain, and compared with that before surgery. 3-D CT of lumbar spine was used to evaluate the bone graft fusion in the isthmus. Results The army patients accounted for 63.6% (21/33) of all the cases. The injured segments were located at L4 and L5 segment, with the L5 segment (84.8%, 28/33) being the most common. The operation time was 85-150 min, the intraoperative blood loss was 50-150 ml, postoperative drainage volume was 10-30 ml. VAS score of lower back pain decreased from 5.8±0.7 before surgery to 1.4±0.8 three months after surgery, and to 0.4±0.5 at the last follow-up, the difference was statistically significant (P<0.05). ODI decreased from 41.2%±5.8% before surgery to 12%±3.9% 3 months after surgery, and to 9.5%±2.6% at the last follow-up, the difference was statistically significant (P<0.05). At 3 months, 6 months and 12 months follow-up, the bone graft fusion rate was 18.2% (6/33), 48.5% (16/33) and 84.8% (28/33), respectively, and the average bone graft fusion time was 7.0±2.8 months. Conclusion Wiltse approach pedicle screw-laminar hook internal fixation combined with autogenous ilium transplantation is a feasible and effective minimally invasive solution for repairing single-segment lumbar spondylolysis of military patients with shorter bone graft fusion time.
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Objective: To investigate the early effctiveness of oblique lateral interbody fusion (OLIF) combined with pedicle screw fixation via small incision Wiltse approach for the treatment of lumbar spondylolisthesis. Methods: Between January 2016 and December 2016, 21 patients with lumbar spondylolisthesis were treated with OLIF and pedicle screw fixation via small incision Wiltse approach. There were 9 males and 12 females, aged 57-73 years, with an average age of 64.5 years. The disease duration was 24-60 months, with an average of 34.6 months. All cases were spondylolisthesis at L 4 (15 cases of degreeⅠ, 6 cases of degreeⅡ); 1 case had vertebral arch isthmus, and 20 cases had spinal stenosis. Japanese Orthopaedic Association (JOA) scoring system was used to evaluate the effectiveness before operation and at last follow-up. Before operation and at 2 days after operation, anteroposterior and lateral X-ray films and CT were taken to measure the sagittal diameter and cross-sectional area of the spinal canal, and calculate the intervertebral height and degree of spondylolisthesis. At 6 months after operation, the intervertebral fusion was evaluated by CT. Results: The operation time was 120-180 minutes, with an average of 155 minutes; the intraoperative blood loss was 100-340 mL, with an average of 225.5 mL. One patient had slight injury of lower endplate, 1 patient had numbness of thigh and weakness of hip flexion after operation, 1 patient had sympathetic nerve trunk injury. All the cases were followed up 12-18 months, with an average of 14.3 months. The symptoms of low back pain, leg pain, and numbness of lower limbs significantly relieved after operation, and there was no complication such as protrusion of fusion cage, screw breakage, and endplate collapse. At 2 days after operation, the intervertebral height, degree of spondylolisthesis, sagittal diameter of spinal canal, and cross-sectional area of spinal canal significantly improved compared with preoperative ones ( P<0.05). At 6 months after operation, CT showed that 1 patient had poor interbody fusion (grade Ⅲ), the other 20 patients had good interbody fusion (grade Ⅰ and Ⅱ), and the interbody fusion rate was 95.2%. At last follow-up, JOA score of lumbar spine significantly increased compared with that before operation ( t=24.980, P=0.000). Conclusion: OLIF combined with pedicle screw fixation via small incision Wiltse approach for the lumbar spondylolisthesis has minimally invasive features, such as less trauma, fewer complications, and higher intervertebral fusion rate. It is a safe and effective method.
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Objetivo: Describir paso a paso el abordaje paraespinal de Wiltse y resaltar las principales ventajas y limitaciones relatadas en la literatura. Material y métodos: Se realizó una descripción del abordaje de Wiltse paso a paso y detalladamente paso a paso, haciendo hincapié en algunos trucos y limitaciones adquiridos con la práctica. Se revisó la literatura disponible con una búsqueda en PubMed y Lilacs bajo los términos Mesh: "Wiltse approach", "paraspinal approach", "muscle sparing approach", "lumbar spine", para destacar ventajas y desventajas de la técnica. Se analizaron 10 trabajos que tenían relación con el objetivo de esta publicación. Ninguno de los trabajos hallados en la búsqueda describía en detalle los pasos del abordaje paraespinal. Se describió: preparación, posicionamiento, incisión, apertura fascial, disección, identificación ósea, desperiostización, descompresión, discectomía, instrumentación, artrodesis y cierre. Resultados: La mayoría de los trabajos resaltaron la utilidad del abordaje como técnica de mínima invasión, con sangrado intraoperatorio mínimo, cortas estadías hospitalarias y bajo índice de infecciones. Conclusión: El abordaje clásico descripto por Wiltse sigue los principios de cirugía de mínima invasión, respetando los planos musculares y tejidos blandos paraespinales, permitiendo amplias descompresiones, discectomías y fusiones con bajos índices de complicaciones.
Objective: To provide a step-by-step description of the Wiltse paraspinal approach, and analyze the main advantages and limitations described in the literature. Methods: We provide a detailed step-by-step description of the Wiltse approach, focusing on some of the strategies we have learned and limitations we have seen in daily clinical practice. A literature review was conducted, consisting of Pub Med and Lilacs searches using the Mesh terms: "Wiltse approach", "paraspinal approach", "muscle sparing approach", and "lumbar spine". Ten papers related to our objectives were assessed, step by step considering patient preparation and positioning, skin incisions, fascial opening, dissection, bone identification, retraction, deperiostization, decompression, discectomy, instrumentation, arthrodesis, and closure. Results: Most papers underline the usefulness of the Wiltse paraspinal approach as a minimally-invasive procedure, emphasizing the minimal intra-operative bleeding, short hospital stays, and low infection rates. However, none of the identified papers thoroughly described specific steps taken using this approach. Conclusion: The classical approach described by Wiltse observes the principles of minimally-invasive surgical procedures, sparing both the muscle planes and soft tissues, thereby allowing for ample decompression, discectomies, and spinal fusions with low complication rates.
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Humans , Paraspinal Muscles , Diskectomy , Lumbosacral Region , MusclesABSTRACT
Objective To investigate the clinical efficacy and related complications of bilateral minimally invasive transforminal lumbar interbody fusion via Quadrant channels for the treatment of single-level degenerative lumbar spondylolisthesis.Methods Sixty selective pa-tients with single-level mild and moderate degenerative lumbar spondylolisthesis who underwent bilateral MIS-TLIF via Quadrant channels from August 2015 to May 2017 were retrospectived investigated.Operative time,blood loss,X-Ray exposure time,postoperative drainage and related complications were recorded.Lumbar functional improvement was defined as an improvement in the JOA.The VAS was also employed at pre and postoperation(6 months),to evaluate low back and leg pain.Intervertebral fusion was assessed by Bridwell evaluation criteria and the clinical outcome was assessed by the MacNab scale at 6 months.In addition,related complications also were be analyzed.Results All patients underwent a successful MIS-TLIF surgery,of whom 58 patients were followed up for 6 months.The operation time was 170~290 minutes (mean:220.17 minutes),intraoperative blood loss was 100~260 mL(mean:168.62 mL),intraoperative radiation exposure was 15~36 times (mean:25.60 times) and postoperative drainage was 50~163 mL(mean:103.43 mL).Different significance between 6 months post-operative follow-up and pre-operation was exhibited (P<0.05) in VAS scores (t=34.97,P=0.000).At 6 months post-operative follow-up,there were significant differences(P<0.05) compared with pre-operation in JOA scores(t=36.91,P=0.000).At 6 months post-operative follow-up,21 cases of grade 1 and 37 cases of grade 2 fusion were present as determined by the Bridwell evaluation criteria(100% fusion).MacNab scale as-sessment classified 2 patients having excellent clinical outcome and 54 patients in good clinical outcome(96.55% of patients had good to excel-lent results).Amomg 60 cases,complications observed in 6 patients,direct injuries to nerve root in 1 case,dural tears occurred in 1 case,super-ficial wound infection in 1 case,pedicle screw was pulled out during the reduction of slip because of severe osteoporosis in 1 case and leg numb-ness and pain in 2 cases. Conclusion Bilateral MIS-TLIF via Quadrant channels with less complications is a safe and effective approach for the treatment of single segment degenerative lumbar spondylolisthesis,but potential complications should be prevented as well.
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Objective To systematically evaluate the efficacy and safety of Wiltse approach and conven-tional posterior midline approach for single thoracolumbar fracture. Methods Databases including Embase, PubMed,cnki,WanFang Data were searched to collect the related literatures for single thoracolumbar fracture treated with surgery of Wiltse approach and conventional posterior midline approach. The data were collected and evaluated by different reviewers independently and the Meta analysis was conducted by using the RevMan 5.3. Results A total of 6 literatures involving 351 patients were included. The results of Meta-analysis showed that there were significant differences in surgical duration,intraoperative bleeding,postoperative discharge volume, and visual analog score(VAS)(P < 0.000 01). There was no significant difference between the Cobb angle(P =0.69)and the fanterior edge convex height(P=0.46).Conclusions Wiltse approach is superior to conventional posterior midline approach for single thoracolumbar fracture with shorter surgical duration,less intraoperative blood loss,less postoperative discharge and lower incidence of postoperative backache. It reduces spine malformation, maintains height of the fanterior edge convex.Wiltse approach is a safe and feasible surgical technique for treating single thoracolumbar fracture.
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Objective To compare the curative effect of transforaminal lumbar interbody fusion by Wihse approach and posterior median approach in treatment of lumbar spinal canal stenosis.Methods Ninety-six patients with lumbar spinal canal stenosis were treated with transforaminal lumbar interbody fusion by Wihse approach (42 cases,Wihse group) and posterior median approach (54 cases,control group).The operation time,exposure time,exposure bleeding volume,length of incision,intraoperative bleeding volume,visual analog score (VAS) of nick at the third day after surgery,and VAS of lumbar and leg,Japanese orthopedic association (JOA) score and Roland-Morris disability questionnaire (RDQ) score at 1 year after surgery were compared between the 2 groups.Results The length of incision,exposure time,operation time,exposure bleeding volume,intraoperative bleeding volume,VAS of nick at the third day after surgery and VAS of lumbar at 1 year after surgery in Wiltse group were (5.0 ± 1.2) cm,(20.0 ± 7.6) min,(150.0 ± 8.4) min,(10.6 ±5.4) ml,(125.5 ± 10.6) ml,(4.5 ±0.6) scores and (1.0 ±0.5) scores,and in control group were (8.0 ± 1.6) cm,(35.2 ±6.8) min,(162.0 ±5.6) min,(84.5 ±7.8) ml,(186.4 ± 15.4) ml,(6.8 ± 0.5) scores and (2.5 ± 0.8) scores],there were statistical differences between the 2 groups (P ＜ 0.01).But there were no statistical differences in the VAS of leg,JOA score and RDQ score at 1 year after surgery between the 2 groups (P ＞ 0.05).Conclusion Two kinds of approach transforaminal lumbar interbody fusions all have good therapeutic effect on lumbar spinal canal stenosis,but the Wiltse approach has advantages of small incision,less intraoperative dissection,less bleeding and low incidence of postoperative lumbodynia.