单侧双通道内窥镜下腰椎椎间融合术与微创经椎间孔入路腰椎椎间融合术治疗单节段腰椎退行性疾病的短期疗效.pdf

236于琪，等.单侧双通道内窥镜下腰椎椎间融合术与微创经椎间孔入路腰椎椎间融合术治疗单节段腰椎退行性疾病的短期疗效临床研究单侧双通道内窥镜下腰椎椎间融合术与微创经椎间孔入路腰椎椎间融合术治疗单节段腰椎退行性疾病的短期疗效于琪12，胡旭琪，潘学康，张建乔3，陆惠根1,21.蚌埠医学院研究生院，蚌埠2 330 302.嘉兴学院附属第二医院骨科，嘉兴3140 0 13.浙江中医药大学附属嘉兴市中医院骨科，嘉兴3140 15【摘要】目的比较单侧双通道内窥镜下腰椎椎间融合术（UBE-LIF）和微创经椎间孔人路腰椎椎间融合术（MIS-TLIF）治疗单节段腰椎退行性疾病的早期临床疗效和影像学结果。方法2 0 2 1年1月一2 0 2 1年8 月嘉兴学院附属第二医院收治单节段腰椎退行性疾病患者51例，其中2 3例采用UBE-LIF治疗（UBE-LIF组）,2 8 例采用MIS-TLIF治疗（MIS-TLIF组）。记录2 组患者手术时间、术中出血量、术后1dC反应蛋白（CRP）水平、术后1d血清肌酸激酶（CK）水平、术后住院时间及并发症发生情况；术前及术后1周、3个月、6 个月、12 个月采用疼痛视觉模拟量表（VAS）评分和Oswestry功能障碍指数(ODI)评价疼痛程度和功能状态；末次随访时观察融合情况并计算融合率。结果所有手术顺利完成，所有患者随访时间 12 个月。UBE-LIF组较MIS-TLIF组手术时间长，术后CK水平高，差异均有统计学意义（P0.05）。2 组术后各时间点腰腿痛VAS评分和ODI较术前明显改善，差异均有统计学意义（P0.05）。U BE-L I F组术后1周腰痛VAS评分低于MIS-TLIF组，差异有统计学意义（P0.05）。末次随访时，UBE-LIF组（8 7.0%）和MIS-TLIF组（9 2.9%）融合率差异无统计学意义（P0.05）。结论UBE-LIF和MIS-TLIF治疗单节段腰椎退行性疾病术后短期临床疗效相似，表明UBE-LIF在改善临床症状方面与MIS-TLIF同样有效。然而，较长的手术时间可能是当前UBE技术的局限性，随着技术的进步，UBE技术可能成为腰椎融合术的新选择。【关键词】腰椎；脊椎滑脱；椎管狭窄；脊柱融合术；外科手术，微创性【中图分类号】R681.533【D 0 1】10.39 6 9/j i s s n.16 7 2-2 9 57.2 0 2 3.0 4.0 0 5Short-term effect of unilateral biportal endoscopic lumbar interbody fusion and minimally invasivetransforaminal lumbar interbody fusion on single-segment lumbar degenerative diseaseYu Qil.2,Hu Xuqie,Pan Xuekang,Zhang Jianqiao,Lu Huigenl.21.Department of Graduate School,Bengbu Medical College,Bengbu 233030,Anhui,China2.Department of Orthopaedics,Second Affliated Hospital of Jiaxing University,Jiaxing 314001,Zhejiang,China3.Department of Orthopaedics,Jiaxing Hospital of Traditional Chinese Medicine,Zhejiang Chinese Medical UniversityJiaxing314015,Zhejiang,ChinaAbstract Objective To compare the early clinical and imaging results of unilateral biportal endoscopic lumbar interbodyfusion(UBE-LIF)and minimally invasive transforaminal lumbar interbody fusion(MIS-TLIF)in the treatment of single-segment lumbar degenerative diseases.Methods From January 2021 to August 2021,51 patients with single-segment lumbardegenerative disease were treated in the Second Affiliated Hospital of Jiaxing University,of which 23 were treated with UBE-LIF(UBE-LIF group)and 28 with MIS-TLIF(MIS-TLIF group).The operation time,intraoperative blood loss,C-reactive protein(CRP)level,serum creatine kinase(CK)level,postoperative hospital stay and complications were recorded;before and1 week,3 months,6 months and 12 months after operation,the pain intensity and functional status were evaluated by visualanalogue scale(VAS)score and Oswestry disability index(ODI);at the final follow-up,the fusion condition was observed*通信作者（Corresponding author)基金项目浙江省医药卫生科技计划项目（2 0 2 0 KY957，2 0 2 0 R C0 37）作者简介于琪（19 9 8），硕士在读，医师；2 8 2 0 2 58 411 通信作者陆惠根137 58 0 7 6 16 1 16 【文献标志码】A【文章编号】16 7 2-2 9 57（2 0 2 3）0 4-0 2 36-0 6脊柱外科杂志，2 0 2 3年8 月，第2 1卷第4期JSpinalSurg，A u g u s t 2 0 2 3，Vo l.2 1，No.4and the fusion rate was calculated.Results All the operations were successfully completed and all the patients were followedup for more than 12 months.The operation time of UBE-LIF group was longer than that of MIS-TLIF group,and the postoperativeCK level was higher,and the differences were statistically significant(P0.05).The VASscore of low back and leg pain and ODI at each time point after operation in the 2 groups were significantly improved comparedwith those before operation,and the differences were statistically significant(P0.05).The VAS score of low back pain atpostoperative 1 week in UBE-LIF group was lower than that in MIS-TLIF group,and the difference was statistically significant(P0.05).At the final follow-up,there was no significant difference in fusion rate between UBE-LIF group andMIS-TLIF group(87.0%vs.92.9%,P0.05).Conclusions The short-term clinical results of UBE-LIF and MIS-TLIF in thetreatment of single-segment lumbar degenerative disease are similar,indicating that UBE-LIF is as effective as MIS-TLIF inimproving clinical symptoms.However,long operation time may be the limitation of current UBE technology.With the progressof technology,UBE technology may become a new choice for lumbar fusion.Key Words Lumbar vertebrae;Spondylolysis;Spinal stenosis;Spine fusion;Surgical procedures,minimally invasive237J Spinal Surg,2023,21(4):236-241随着社会人口老龄化加剧，腰椎退行性疾病的1资料和方法发生率逐年上升，中老年人以腰椎滑脱、腰椎椎管狭窄较为常见1。临床表现主要为腰背部疼痛、下肢神经根性症状。腰椎融合术作为一种常用的治疗方法，在解除神经压迫的同时可提供脊柱稳定性2 3，但经典开放性融合术创伤较大，特别是椎旁肌受损所带来的术后腰背痛等问题备受外科医师重视45。因此，减少手术创伤和提高患者满意度成为外科医师努力的方向。近年来，随着微创脊柱外科的发展，单侧双通道内窥镜下腰椎椎间融合术（U BE-L IF）作为一种新兴的微创技术逐渐被接受和推广。有研究6-7 证明，与传统开放性腰椎融合术相比，UBE-LIF具有创伤小、术后恢复快的优点。但微创经椎间孔人路腰椎椎间融合术（MIS-TLIF）作为经典的微创腰椎融合方式，与之相比，UBE-LIF是否存在优势？本研究旨在比较UBE-LIF和MIS-TLIF治疗单节段腰椎退行性疾病的安全性及临床疗效，现报告如下。性别组别GendernGroup男女AgelyearMaleFemaleUBE-LIF2310MIS-TLIF281.2手术方法UBE-LIF组患者全身麻醉后取俯卧位，C形臂X线机透视定位目标椎间隙，在神经根症状侧椎弓1.1 一般资料纳入标准：明确的腰腿痛病史，伴有神经系统症状和体征；症状和体征与影像学检查结果一致；非手术治疗3个月以上无效；单节段腰椎滑脱（I度）或腰椎不稳（动力位上下终板间隙夹角15)需要减压融合。排除标准：单纯腰椎椎间盘突出或腰椎椎管狭窄不合并腰椎不稳；既往腰椎手术史；伴脊柱肿瘤、感染。按照上述标准，2 0 2 1年1月一2 0 2 1年8 月收治单节段腰椎退行性疾病患者51例，术前向患者讲解2 种术式，由患者自行选择手术方案，所有手术均由同一组医师完成。最终采用UBE-LIF治疗2 3例(UBE-LIF组）,采用MIS-TLIF治疗2 8 例（MIS-TLIF组）。2 组患者性别、年龄、体质量指数(BMI）术前血清肌酸激酶（CK)水平、术前C反应蛋白（CRP)水平、手术节段等资料差异无统计学意义（P0.05，表1），具有可比性。表12 组患者一般资料Tab.1 General data of patients in 2 groups术前CK水平/（UL-）术前CRP水平（mgL-）年龄/岁BMI/(kgm2)1364.30 7.3782061.25 9.53手术节段Operative segmentPreoperativeCK level/PreoperativeCRPlevel/(UL-1)24.62 2.30107.78 74.2025.254.3079.64 35.33根皮肤投影点做1.5cm横行切口，上、下距离目标椎间隙中线1.0 1.5cm；纵行切开深筋膜，并逐级插入扩张导管建立观察通道和工作通道。连接光源(mgL-1)1.24 1.172.294.38Lz/LsLa/L4La/LsLs/S1020201216238于琪，等.单侧双通道内窥镜下腰椎椎间融合术与微创经椎间孔入路腰椎椎间融合术治疗单节段腰椎退行性疾病的短期疗效并打开灌洗液系统，内窥镜置人观察通道。应用射个月、12 个月采用疼痛视觉模拟量表（VAS)评分8 频电刀清理椎板间隙的软组织并彻底止血，完成造和Oswestry功能障碍指数（ODI)9评价疼痛程度和腔。采用C形臂X线机再次透视定位目标节段上位功能状态。椎板下缘，应用骨凿或枪钳切除目标椎间隙上位椎术后12 个月在动力位X线片上判断融合情况板下缘和关节突关节部分骨质，咬除部分黄韧带，根据椎间融合分级系统Bridwell标准10 进行分暴露硬膜囊和神经根；用咬骨钳扩大侧隐窝和神经级，I、级所占总数百分比即为融合率。如X线根管，若合并对侧狭窄则去除棘突基底部，减压对片难以判断是否融合，可加行矢状位CT重建确定侧侧隐窝。使用神经拉钩将神经根或硬膜囊牵开，是否融合切除椎间髓核，直视下去除终板软骨，观察到终板1.4统计学处理骨质出现轻微渗血，用漏斗状植骨器插人椎间隙，采用SPSS20.0软件对数据进行统计分析。符并在椎间隙深部植入减压产生的自体骨颗粒；选合正态分布的计量资料以xS表示，组内手术前后择合适的椎间融合器（充填自体骨）置入椎间隙内，数据比较采用配对t检验，组间比较采用独立样本t分别于两侧经皮置人椎弓根螺钉系统固定。再次透检验；2 组手术前后不同时间点VAS评分和ODI比视确认内固定和椎间融合器位置良好后止血并逐层较采用重复测量资料的方差分析；计数资料以频数缝合切口。（%）表示，组间比较采用x检验；以P0.05为差MIS-TLIF组在可扩张通道（Quadrant通道）辅异有统计学意义。助下进行手术操作。患者全身麻醉后取俯卧位。透2 结 果视确认病变节段，于体表标记双侧上、下椎弓根位置；连接上下椎弓根体表投影点做一长约3cm纵向皮肤切口。依次切开皮肤、皮下组织和深筋膜；采用标准Wiltse人路，先于非减压侧置人椎弓根螺钉。减压侧逐级放置扩张管和Quadrant可扩张通道，纵向撑开暴露手术部位；使用椎板咬骨钳逐步咬除椎板下缘和关节突内侧部分骨质以打开椎间孔，逐步暴露并保护好神经根和硬膜囊，如存在神经根管狭窄则予以扩大成形。摘除椎间髓核组织，去除终板终骨，解除压迫。选择合适大小融合器（内植自体骨）置人椎间隙，手术节段置入椎弓根螺钉，影像透视融合器、螺钉位置满意后，预弯连接杆连接4枚椎弓根螺钉并固定。再次透视确认内固定和融合器位置良好后止血并消毒缝合切口。1.3评价指标记录2 组患者手术时间、术中出血量、术后1dCRP水平、术后1dCK水平、术后住院时间（出院标准为切口愈合良好无渗液，可佩戴腰围下床活动）及并发症发生情况；术前及术后1周、3个月、6术中出血量/mL组别手术时间/minnGroupUBE-LIFMIS-TLIF注：*与MIS-TLIF组相比，P0.05。Note:*P 12 个月。UBE-LIF组较MIS-TLIF组手术时间长，术后CK水平高，差异均有统计学意义（P 0.0 5，表2）。2 组术后各时间点腰腿痛VAS评分和ODI较术前明显改善，差异均有统计学意义（P0.05，表3）。UBE-LIF组术后1周腰痛VAS评分低于MIS-TLIF组，差异有统计学意义（P0.05，表3）。2 组均未发现切口感染或神经根损伤等并发症；UBE-LIF组2 例（8.7%）发生血肿压迫神经出现神经症状而进行了再手术。末次随访根据Bridwell标准，UBE-LIF组I、级融合分别为13、7 和3例，融合率为8 7.0%；MIS-TLIF组分别为18、8 和2 例，融合率为9 2.9%；2组融合率差异无统计学意义（P0.05）。2 组患者典型病例影像学资料见图1、2。表2 2 组患者围手术期指标Tab.2 Perioperative indicators of patients in 2 groups术后住院时间/dIntraoperativePostoperativeOperation time/minblood loss/mL23268.48 67.43*28151.39 32.10术后CK水平/（UL-）PostoperativeCKlevel/hospital stay/d(UL-1)103.48 62.795.74 3.5177.50 74.076.64 1.83术后CRP水平/（mgL-）PostoperativeCRPlevel/(mgL-)972.26 632.13*19.68 17.90421.82262.1515.06 13.26脊柱外科杂志，2 0 2 3年8 月，第2 1卷第4期JSpinalSurg，A u g u s t 2 0 2 3，Vo l.2 1，No.4腰痛VAS评分组别VASscore of low back painGroupnUBE-LIF23MIS-TLIF28组别GroupUBE-LIFMIS-TLIF组别GroupUBE-LIFMIS-TLIF注：*与术前相比，P0.05；与MIS-TLIF组相比，P0.05。Note:*P0.05,compared with pre-operation;P0.05,compared with MIS-TLIF group.239表32 组患者各时间点VAS评分和ODITab.3 VAS scores and ODI of patients in 2 groups at each time point术前术后6 个月Pre-operationPostoperative1week6.13 0.762.74 0.62*45.86 0.763.18 0.67*术前术后1周Pre-operationPostoperative1 week4.91 0.853.13 0.55*4.57 0.792.96 0.58*术前术后1周Pre-operationPostoperativelweek58.29 3.8031.57 4.10*58.69 4.2532.87 3.83*bC术后1周VAS scoreofleg pain术后3个月Postoperative3months2.30 0.47*2.29 0.46*ODI(%)术后3个月Postoperative3months25.52 2.69*26.39 2.41*d术后3个月Postoperative 3 months Postoperative 6 months Postoperative 12 months2.09 0.60*1.93 0.54*腿痛VAS评分术后12 个月1.52 0.51*0.91 0.67*1.32 0.48*0.86 0.59*术后6 个月术后12 个月Postoperative6monthsPostoperative12months1.39 0.50*0.74 0.54*1.64 0.560.82 0.61*术后6 个月术后12 个月Postoperative6monthsPostoperative12months19.13 2.68*13.57 2.31*19.70 2.6613.82 1.65*十g图1UBE-LIF组典型病例影像学资料Fig.1 Imaging data of a typical case in UBE-LIF group男，59 岁，腰痛4年，加重伴右下肢麻木、间歇性跛行1个月a：术前腰椎侧位X线片示L4/Ls椎间盘突出b：术前矢状位MRI示L4/Ls椎间盘突出c：横断面MRI示椎管狭窄d、e：术后1周X线片示融合器位置良好f、g：术后1年CT示椎间融合良好Male,59 years old,low back pain for 4 years,aggravated with right lower limb numbness and intermitent claudication for 1 month a:Preoperativelateral roentgenograph shows L/Ls disc herniation b:Preoperative sagttal MRI shows La/Ls disc herniation c:Preoperative transverse MRI showsspinal stenosis d,e:Roentgenographs at postoperative I week show that cage is in good position f,g:CTs at postoperative 1 year show goodinterbodyfusionaBdg图2 MIS-TLIF组典型病例影像学资料Fig.2 Imaging data of a typical case in MIS-TLIF group女，53岁，腰痛2 年，加重伴双下肢疼痛、麻木1年a：术前腰椎侧位线片示L/Ls椎间盘突出b：术前矢状位MRI示La/Ls椎间盘突出c:横断面MRI示椎管狭窄d、e：术后1周X线片示融合器位置良好f、g：术后1年CT示椎间融合良好Female,53years old,low back painfor2years,aggravated with pain in both lowerlimbs,numbness foryeara:Preoperativelateralroentgenographshows La/Ls disc herniation b:Preoperative sagittal MRI shows La/Ls disc herniation c:Preoperative transverse MRI shows spinal stenosis d,e:Roentgenographs at postoperativeI week show that cage is in good positionf,g:CTs at postoperative 1 year show good interbodyfusion240于琪，等.单侧双通道内窥镜下腰椎椎间融合术与微创经椎间孔入路腰椎椎间融合术治疗单节段腰椎退行性疾病的短期疗效技术引起的多裂肌损伤进行了评估，结果显示，多3 讨 论裂肌损伤与术中灌洗液对肌肉的影响之间存在直腰椎开放融合术包括后路腰椎椎间融合术接关系。UBE技术依赖水介质提供手术可视化的同（PL I F）、经椎间孔人路腰椎椎间融合术（TLIF）等时，所带来的持续水压冲击不可避免地使椎旁肌受经典术式。但开放融合术可能导致椎旁组织过度剥到刺激，从而导致术后血清CK水平升高。为减少离、创伤反应明显、术后顽固性腰痛等问题12 。运灌洗液对肌肉的冲击，术中应合理使用套管，保证用可扩张通道的MIS-TLIF以多裂肌与最长肌的肌组织出水顺畅，避免水压过高及过度灌注。间隙作为手术入路，不仅可以获得与开放性手术相本研究结果显示，2 组术后腰腿痛VAS评分和同的疗效，同时可减少椎旁肌的损伤131。ODI均明显改善，且术后1周UBE-LIF组腰痛VAS随着微创理念的不断发展，借助水介质的内窥评分低于MIS-TLIF组，表明UBE-LIF有利于患者早镜技术在临床取得广泛运用1415。UBE-LIF为开放期恢复。腰椎融合手术最终目的是帮助患者改善症融合手术的内窥镜化操作技术16 。基于独立成像和状、维持脊柱稳定性，最终手术节段达到骨性融合操作系统，通过生理盐水持续冲洗小范围剥离椎旁是手术成功的关键。Kim等2 3 报告UBE-LIF组融合肌，为术者创造良好的工作空间。UBE技术应用直率为9 3.7%，MIS-TLIF组为9 2.7%，组间差异无统计径为4mm的内窥镜，手术视野可推进到椎板内或学意义。本研究结果也显示2 组患者术后融合率无进入对侧侧隐窝，实现单侧人路双侧减压。传统的显著差异。但UBE技术可借助内窥镜系统进人椎间MIS-TLIF术中需要采用双侧通道实现双侧减压，过隙，直视下去除终板软骨，充分显露骨性终板，对多地破坏了正常解剖结构，加重了术后早期腰背部终板的处理更加可靠，有利于椎间融合2 42 5。疼痛17 。有研究19,2 6 报道，学习曲线起始阶段是UBE-理论上讲，UBE-LIF与传统TLIF的入路相似。LIF并发症的高发期，常见的并发症包括神经根损但由于术中出血影响视野、内窥镜下二维平面与实伤、硬膜撕裂、术后硬膜外血肿及内固定位置不良际三维结构空间转换及术者镜下操作熟练度等因素等。一般术后硬膜外血肿无临床症状，本研究中影响，UBE-LIF的学习曲线较陡峭18 。既往研究19 UBE-LIF组有2 例患者出现术后症状性硬膜外血肿。报道，UBE-LIF的手术时间普遍较长，与本研究结术中止血不彻底可能是术后形成硬膜外血肿的主要果相似。对脊柱外科医师而言，熟练创建工作空间原因。有研究18,2 7-2 8 报道，灌洗液在体内会产生一（造腔）、寻找手术标志物及熟练掌握经皮椎弓根螺定压力，导致术中止血不充分，建议退出操作通道钉固定技术是减少手术时间的有效方案。前关闭输液器后在镜下仔细观察，若存在活动性出目前，关于肌肉等软组织损伤的客观评价缺乏血则应用射频及时止血，骨面渗血必要时可用骨蜡统一标准，通常根据CT、M R I 等影像学检查，或源自封涂；退出操作通道后可放置负压引流管，避免血患者术前、术后生化指标的监测进行判断。CK主要肿形成。其次，UBE-LIF术中控制性降压，术中患者来源于肌肉组织，血清CK水平在肌肉损伤后12 h内血压较术前低，术后患者血压恢复至术前，甚至由开始升高，48 h内达到高峰，3 5d开始下降，可在于术后疼痛刺激高于术前血压，由此可导致术后手一定程度上反映手术中肌肉受损情况2 0 2 1。因此，术区终末血管广泛渗血。因此，术后早期需注意患血清CK水平升高被认为是肌肉损伤的标志之一。者血压控制，避免血压剧烈波动。本研究结果显示，UBE-LIF组术后1d的CK水平明无论采取哪种术式，有效减压的同时实现坚固显高于MIS-TLIF组，笔者认为影响UBE-LIF组术后的椎间融合才能取得良好的临床效果。尽管UBE-血清CK水平升高的因素主要有2 个：UBE-LIF通LIF和MIS-TLIF临床结果相似，但是UBE-LIF具有过清理椎旁组织创建工作空间，不可避免地在一定相对陡峭的学习曲线，且UBE-LIF术中灌洗液持续程度上破坏了椎旁肌肉，而MIS-TILF通过肌肉间隙冲洗，植入的自体骨内骨髓间充质干细胞及各种诱进入手术区域，降低了对椎旁肌的刺激。射频电导成骨因子的流失是否会对脊柱融合产生负面影响刀对椎旁肌肉也可能产生相关影响。持续的液体冲还需要进一步论证。洗可以防止射频电刀热能的积累，但同时电刺激通本研究的局限性：为回顾性研究，病例选择过液体的传导使得电刺激区域变得更广泛，引起更上可能存在偏倚；随访时间较短，2 种术式的远大范围肌肉损伤。另外，Ahn等2 2 通过MRI对UBE期效果有待进一步随访观察；病例数较少，尚需脊柱外科杂志，2 0 2 3年8 月，第2 1卷第4期JSpinalSurg，A u g u s t 2 0 2 3，Vo l.2 1，No.4要多中心、大样本、前瞻性随机对照研究对UBE技术进行全面客观的评估。综上所述，UBE-LIF和MIS-TLIF治疗单节段腰椎退行性疾病术后短期临床结果相似，然而，较长的手术时间可能是当前UBE技术的局限性，随着技术的进步，UBE技术可能成为腰椎融合术的新选择。参考文献1Vos T,Flaxman A,Naghavi M,et al.Years lived withdisability(YLDs)for 1160 sequelae of 289 diseases andinjuries 1990-2010:a systematic analysis for the GlobalBurden of Disease Study 2010J.Lancet,2012,380(9859):2163-2196.2Weinstein JN,Lurie JD,Tosteson TD,et al.Surgicalcompared with nonoperative treatment for lumbardegenerative spondylolisthesis.Four-year results inthe Spine Patient Outcomes Research Trial(SPORT)randomized and observational cohorts 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