Xuan Wenbin, Cheng Qinghua, Gao Yucheng, Song Ziyi, Gao Zengxin
Department of Orthopedics, Zhongda Hospital, Southeast University School of Medicine, Dingjiaqiao 87, Nanjing, 210009, China.
Nanjing Lishui People's Hospital, Zhongda Hospital Lishui Branch, Nanjing, 211200, China.
J Orthop Surg Res. 2025 Sep 26;20(1):841. doi: 10.1186/s13018-025-06235-8.
While previous studies frequently reported the clinical efficacy and minimal invasiveness of endoscopic lumbar interbody fusion (Endo-LIF) for lumbar spinal stenosis (LSS), few existing studies quantitatively measure early-stage postoperative paraspinal muscle injury. This study aimed to preliminarily quantify differences in early postoperative paraspinal muscle changes between Endo-LIF and transforaminal lumbar interbody fusion (TLIF) for single-level LSS. The observed alterations, if substantiated in future studies, might offer considerations for tailoring postoperative rehabilitation.
This retrospective cohort included 90 severe LSS patients undergoing single-level fusion, allocated to Endo-LIF group (n = 48) or TLIF group (n = 42). Comprehensive data encompassed demographics, operative metrics, patient-reported outcomes (PROs) including Oswestry Disability Index (ODI) and Visual Analogue Scale (VAS), and acute paraspinal muscle trauma biomarkers ((creatine kinase (CK), C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR)). The cross-sectional area (CSA) of paraspinal musculature (multifidus and erector spinae) was quantified at the index instrumented level using axial T2-weighted magnetic resonance imaging (MRI), with measurements obtained preoperatively and during early follow-up (FU). Muscle boundaries were delineated using semi-automated tools (ITK-SNAP v4.0.2) with manual correction, and CSA values were calculated via MATLAB-based custom algorithms.
Preoperative demographics, leg/back pain VAS, ODI, and inflammatory markers were comparable between Endo-LIF and TLIF groups. At 3 days postoperatively, Endo-LIF demonstrated superior back VAS and ODI (P < 0.001) but comparable leg pain VAS. Both groups achieved significant PRO improvements (P < 0.001). TLIF had significantly higher low back myofascitis incidence (P < 0.001). Endo-LIF showed significantly reduced blood loss (58.3[IQR 50, 75] days vs. 214.3[IQR 150, 250] mL) and shorter hospitalization (5.2 [IQR 5, 6] days vs. 7.1 [IQR 7, 8] days) (both P < 0.001), but longer operative time and greater fluoroscopy use (P < 0.001). Complication rates were similar (P = 0.27). CRP and CK levels at postoperative day 1 were significantly higher in TLIF (P < 0.001). Long-term follow-up revealed no significant intergroup differences in PROs (all P > 0.01). Postoperative paraspinal muscle CSA decreased in both cohorts, with a more pronounced reduction observed in the TLIF group, statistically associated with surgical approach and smoking status (both P < 0.001).
Compared with TLIF, Endo-LIF demonstrated relatively early back pain relief, reduced intraoperative blood loss, shorter hospital stays, and lower levels of acute muscle injury markers. These potential benefits were counterbalanced by longer operative durations and greater reliance on fluoroscopy. Both approaches achieved largely comparable long-term functional outcomes with similar safety profiles. Paraspinal muscle CSA measurements suggested a comparatively lesser degree of early muscle injury with Endo-LIF versus TLIF.
虽然既往研究经常报道内镜下腰椎椎间融合术（Endo-LIF）治疗腰椎管狭窄症（LSS）的临床疗效和微创性，但现有研究很少对术后早期椎旁肌损伤进行定量测量。本研究旨在初步量化Endo-LIF与经椎间孔腰椎椎间融合术（TLIF）治疗单节段LSS术后早期椎旁肌变化的差异。如果在未来研究中得到证实，观察到的改变可能为制定术后康复方案提供参考。
本回顾性队列研究纳入了90例接受单节段融合术的重度LSS患者，分为Endo-LIF组（n = 48）和TLIF组（n = 42）。综合数据包括人口统计学资料、手术指标、患者报告结局（PROs），包括奥斯威斯利功能障碍指数（ODI）和视觉模拟评分（VAS），以及急性椎旁肌损伤生物标志物（肌酸激酶（CK）、C反应蛋白（CRP）和红细胞沉降率（ESR））。使用轴向T2加权磁共振成像（MRI）在索引手术节段对椎旁肌肉组织（多裂肌和竖脊肌）的横截面积（CSA）进行量化，在术前和早期随访（FU）期间进行测量。使用半自动工具（ITK-SNAP v4.0.2）并手动校正来描绘肌肉边界，并通过基于MATLAB的自定义算法计算CSA值。
Endo-LIF组和TLIF组术前的人口统计学资料、腿部/背部疼痛VAS、ODI和炎症标志物具有可比性。术后3天，Endo-LIF组的背部VAS和ODI表现更优（P < 0.001），但腿部疼痛VAS相当。两组的PROs均有显著改善（P < 0.001）。TLIF组的下腰背肌筋膜炎发生率显著更高（P < 0.001）。Endo-LIF组的失血量显著减少（58.3[四分位间距50, 75]mL vs. 214.3[四分位间距150, 250]mL），住院时间更短（5.2[四分位间距5, 6]天 vs. 7.1[四分位间距7, 8]天）（均P < 0.001），但手术时间更长，透视使用更多（P < 0.001）。并发症发生率相似（P = 0.27）。TLIF组术后第1天的CRP和CK水平显著更高（P < 0.001）。长期随访显示两组在PROs方面无显著组间差异（均P > 0.01）。两个队列术后椎旁肌CSA均降低，TLIF组降低更明显，与手术方式和吸烟状态均有统计学关联（均P < 0.001）。
与TLIF相比，Endo-LIF表现出相对较早的背痛缓解、术中失血量减少、住院时间缩短以及急性肌肉损伤标志物水平降低。这些潜在益处被更长的手术时间和对透视的更大依赖所抵消。两种方法在长期功能结局方面基本相当，安全性相似。椎旁肌CSA测量表明，与TLIF相比，Endo-LIF术后早期肌肉损伤程度相对较轻。
