经椎弓根动态稳定系统（Dynesys）与后路椎间融合治疗腰椎管狭窄症的临床比较研究
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摘要
目的：比较单节段椎弓根动态稳定系统（Dynesys）与后路椎间融合治疗退行性腰椎管狭窄症的早期临床疗效与影像学改变。
方法：对2008年8月至2011年3月分别采用后路减压联合椎弓根动态稳定系统（A组，12例）与后路减压、椎间融合术（B组，12例）治疗并获完整随访的L4/5椎管狭窄症患者进行对比研究。A组：男5例，女7例；年龄30-68岁，平均53.9岁；B组：男7例，女5例；年龄44-72岁，平均55.7岁。术前两组患者一般资料具有可比性。分别观察2组病例的手术时间、术中出血量及手术切口长度。并按照Oswestry功能障碍指数(Oswestry Disability Index,ODI)，视觉模拟评分（VisualAnalogue Scale,VAS）及日本矫形外科学会（Japanese OrthopaedicAssociation,JOA）评分评估临床疗效，同时行影像学观察，包括相对椎间隙高度、椎间活动度及相邻节段的退行性改变。
结果：A组平均随访时间18.9个月（12-35个月），B组为16.9个月（12-30个月）。两组患者性别和年龄无统计学差异（P﹥0.05）。两组术后均取得较好临床疗效，术前症状和体征均缓解，两组临床优良率统计学上无显著差异（P﹥0.05）。两组手术时间及术中出血量有显著差异性（P﹤0.05），两组手术切口长度无统计学意义（P﹥0.05）。末次随访时A、B组VAS、JOA评分及ODI均优于术前（P﹤0.05）；且A、B两组各时间段差异无统计学意义（P﹥0.05）。L4/5相对椎间隙高度A组由术前的33.25±5.19％提高到末次随访的43.17±5.34％，B组由术前的32.67±5.31％提高到末次随访的44.83±5.11％，A、B两组手术前后比较差异均有统计学意义（P﹤0.05）。A、B两组间各时间段椎间高度差异无统计学意义（P﹥0.05）。A组手术前后L3/4椎间活动度比较差异无统计学意义（P﹥0.05），B组L3/4椎间活动度较术前增大（P﹤0.05）；A组L4/5末次随访时椎间活动度与术前比较差异有统计学意义（P>0.05）；B组末次随访时L4/5椎间隙已融合。A、B组L5S1手术前后椎间活动度比较差异无统计学意义（P﹥0.05）；A、B两组各时间段L3/4及L5S1椎间活动度差异无统计学意义（P﹥0.05）。术后A、B两组手术并发症无统计学意义。
结论：经椎弓根动态稳定系统（Dynesys）与后路椎间融合治疗退行性腰椎管狭窄症疗效相当，但前者内固定具有创伤小、手术时间短，出血少、可以提供足够的脊柱稳定性，延缓及防止相邻节段的退变。
Objective: To compare the effectiveness and radiological changes aftermonosegmental posterior dynamic stabilization and lumbar fusion for lumbar spinalstenosis．
Methods: Between August2008and March2011, a comparative study was carried outon patients with lumbar spinal stenosis at L4/5. In group A,12patients underwent posteriordecompression combined with Dynesys; there were5males and7females with an averageage of53.9years (range,30-68years); In group B,12patients underwent posteriordecompression combined with posterior lumbar interbody fusion treatment; there were7males and5females with an average age of55.7years (range,44-72years); There were nosignificant difference in gender and age. Observe two groups operative time, blood lossand incision length. Clinical outcomes were evaluated using Oswestry Disability Index(ODI), Visual Analogue Scale (VAS) score and Japanese Orthopaedic Association (JOA)before and after operation. Imaging examinations for the relative height of intervertebral,segmental movement and degeneration were obtained．
Results: The average follow-up was18.9months in group A and16.9months in groupB. The sex and age of two groups were no difference on statistics (P﹥0.05). All casesobtained preferably clinical effect after the operation. The symptoms, signs beforeoperation were released, and clinical choiceness rate of two groups had no difference onstatistics(P﹥0.05). There were significant difference between two groups of blood loss andoperative time (P<0.05) and no significant difference between two groups of incisionlength (P﹥0.05). At the last follow-up, the VAS, JOA scores, and ODI of groups A and Bwere significantly improved when compared with the preoperative values (P<0.05). Therelative height of intervertebral of L4/5of group A was improved remarkably from33.25±5.19%preoperatively to43.17±5.34%postoperatively. While the group B was increased from32.67±5.31%to44.83±5.11%. There was significant difference in therelative height of intervertebral of L4/5of groups A and B between pre-and post-operation(P<0.05). There were no significant difference in the intervertebral height in each timebetween groups A and B (P﹥0.05). There was no significant difference in the ROM ofL3/4in group A between pre-and post-operation (P>0.05). In group B, the ROM of L3/4was significantly reduction (P<0.05) compared with the preoperative one. Compared withpreoperative the ROM of L4/5in group A was significantly reduction (P<0.05), and itachiecved bone fusion in the group B at last follow-up. There was no significant differencein the ROM of L5S1in group A between pre-and post-operation (P>0.05). There were nosignificant difference in the ROM of L3/4and L5S1in each time between groups A and B(P﹥0.05). There was no significant difference in the complications in groups A and B atpostoperation(P>0.05).
Conclusion: Posterior decompression combined with Dynesys has the sameeffectiveness as posterior lumbar interbody fusion in treating lumbar spinal stenosis at L4/5.But the former has less invasive, shoter time and little hemorrhage, and it can provideenough stability, delay and prevent the adjacent segments degeneration.
方法：对2008年8月至2011年3月分别采用后路减压联合椎弓根动态稳定系统（A组，12例）与后路减压、椎间融合术（B组，12例）治疗并获完整随访的L4/5椎管狭窄症患者进行对比研究。A组：男5例，女7例；年龄30-68岁，平均53.9岁；B组：男7例，女5例；年龄44-72岁，平均55.7岁。术前两组患者一般资料具有可比性。分别观察2组病例的手术时间、术中出血量及手术切口长度。并按照Oswestry功能障碍指数(Oswestry Disability Index,ODI)，视觉模拟评分（VisualAnalogue Scale,VAS）及日本矫形外科学会（Japanese OrthopaedicAssociation,JOA）评分评估临床疗效，同时行影像学观察，包括相对椎间隙高度、椎间活动度及相邻节段的退行性改变。
结果：A组平均随访时间18.9个月（12-35个月），B组为16.9个月（12-30个月）。两组患者性别和年龄无统计学差异（P﹥0.05）。两组术后均取得较好临床疗效，术前症状和体征均缓解，两组临床优良率统计学上无显著差异（P﹥0.05）。两组手术时间及术中出血量有显著差异性（P﹤0.05），两组手术切口长度无统计学意义（P﹥0.05）。末次随访时A、B组VAS、JOA评分及ODI均优于术前（P﹤0.05）；且A、B两组各时间段差异无统计学意义（P﹥0.05）。L4/5相对椎间隙高度A组由术前的33.25±5.19％提高到末次随访的43.17±5.34％，B组由术前的32.67±5.31％提高到末次随访的44.83±5.11％，A、B两组手术前后比较差异均有统计学意义（P﹤0.05）。A、B两组间各时间段椎间高度差异无统计学意义（P﹥0.05）。A组手术前后L3/4椎间活动度比较差异无统计学意义（P﹥0.05），B组L3/4椎间活动度较术前增大（P﹤0.05）；A组L4/5末次随访时椎间活动度与术前比较差异有统计学意义（P>0.05）；B组末次随访时L4/5椎间隙已融合。A、B组L5S1手术前后椎间活动度比较差异无统计学意义（P﹥0.05）；A、B两组各时间段L3/4及L5S1椎间活动度差异无统计学意义（P﹥0.05）。术后A、B两组手术并发症无统计学意义。
结论：经椎弓根动态稳定系统（Dynesys）与后路椎间融合治疗退行性腰椎管狭窄症疗效相当，但前者内固定具有创伤小、手术时间短，出血少、可以提供足够的脊柱稳定性，延缓及防止相邻节段的退变。
Objective: To compare the effectiveness and radiological changes aftermonosegmental posterior dynamic stabilization and lumbar fusion for lumbar spinalstenosis．
Methods: Between August2008and March2011, a comparative study was carried outon patients with lumbar spinal stenosis at L4/5. In group A,12patients underwent posteriordecompression combined with Dynesys; there were5males and7females with an averageage of53.9years (range,30-68years); In group B,12patients underwent posteriordecompression combined with posterior lumbar interbody fusion treatment; there were7males and5females with an average age of55.7years (range,44-72years); There were nosignificant difference in gender and age. Observe two groups operative time, blood lossand incision length. Clinical outcomes were evaluated using Oswestry Disability Index(ODI), Visual Analogue Scale (VAS) score and Japanese Orthopaedic Association (JOA)before and after operation. Imaging examinations for the relative height of intervertebral,segmental movement and degeneration were obtained．
Results: The average follow-up was18.9months in group A and16.9months in groupB. The sex and age of two groups were no difference on statistics (P﹥0.05). All casesobtained preferably clinical effect after the operation. The symptoms, signs beforeoperation were released, and clinical choiceness rate of two groups had no difference onstatistics(P﹥0.05). There were significant difference between two groups of blood loss andoperative time (P<0.05) and no significant difference between two groups of incisionlength (P﹥0.05). At the last follow-up, the VAS, JOA scores, and ODI of groups A and Bwere significantly improved when compared with the preoperative values (P<0.05). Therelative height of intervertebral of L4/5of group A was improved remarkably from33.25±5.19%preoperatively to43.17±5.34%postoperatively. While the group B was increased from32.67±5.31%to44.83±5.11%. There was significant difference in therelative height of intervertebral of L4/5of groups A and B between pre-and post-operation(P<0.05). There were no significant difference in the intervertebral height in each timebetween groups A and B (P﹥0.05). There was no significant difference in the ROM ofL3/4in group A between pre-and post-operation (P>0.05). In group B, the ROM of L3/4was significantly reduction (P<0.05) compared with the preoperative one. Compared withpreoperative the ROM of L4/5in group A was significantly reduction (P<0.05), and itachiecved bone fusion in the group B at last follow-up. There was no significant differencein the ROM of L5S1in group A between pre-and post-operation (P>0.05). There were nosignificant difference in the ROM of L3/4and L5S1in each time between groups A and B(P﹥0.05). There was no significant difference in the complications in groups A and B atpostoperation(P>0.05).
Conclusion: Posterior decompression combined with Dynesys has the sameeffectiveness as posterior lumbar interbody fusion in treating lumbar spinal stenosis at L4/5.But the former has less invasive, shoter time and little hemorrhage, and it can provideenough stability, delay and prevent the adjacent segments degeneration.
引文
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