三种术式治疗单节段下腰椎退行性疾病的疗效观察
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摘要
目的：观察比较腰椎后外侧融合术（PLF）、腰椎后路椎体间融合术（PLIF）、经椎间孔腰椎椎体间融合术（TLIF）治疗单节段下腰椎退行性疾病的疗效。
方法：回顾性分析2008年1月至2011年8月我院收治资料完整且获得随访的73例单节段下腰椎退行性疾病患者。按其手术方式不同分为A组（PLF，21例）；B组（PLIF，27例）；C组（TLIF，25例）。比较三种植骨融合术的Oswestry功能障碍指数（汉化版ODI），腰腿痛VAS评分，融合率，断钉，腰椎前凸角，相对椎间隙高度等情况。
结果：术后随访18月～62月，平均27个月。3组ODI功能障碍指数、腰腿痛VAS评分均较术前明显降低，差异有统计学意义(P<0.05)；3组间无统计学意义(P>0.05)。CT二维重建观察到A、B及C组融合率分别为85.7％、100％、100％，3组间有显著性差异（P<0.05）；进一步比较B、C组融合率明显高于A组，差异有统计学意义(P<0.05)，B、C两组间，差异无统计学意义(P>0.05)。3组间断钉及腰椎前凸角无显著性差异(P>0.05)。B、C组相对椎间隙高度显著优于A组，差异有统计学意义（P<0.05），B、C两组间无显著性差异(P>0.05)。
结论：三种融合术式治疗单节段下腰椎退行性疾病效果良好，临床疗效观察无显著性差异。TLIF、PLIF在融合率、恢复和维持椎间隙高度明显优于PLF，建议作为治疗单节段下腰椎退行性疾病的优先选择术式。
Objective: To observe and compare the efficacy of lumbar posterolateral fusion(PLF)，posterior lumbar interbody fusion (PLIF) and transforaminal lumbar interbodyfusion (TLIF) in the treatment of single-level low lumbar degenerative disease．
Methods: Between January2008and August2011，the follow-up complete data of73patients who underwent fusion surgery because of single-leve low lumbar degenerativedisease were retrospectively analysed．The patients were divided into3groups：group A(PLF, n=21)；group B (PLIF, n=21)；group C (TLIF, n=25)．A visual analog scale(VAS)and the Chinese Oswestry Disability Index(ODI) were used to measure low back pain, legpain, and disability．For X-ray evaluation, instrumented breakage、lumbar lordosis、maintenance of disc height were analyzed．Bone fusion was examined by two-dimensionalreconstruction of CT．
Results: All patients were followed up for average of27months(range，18months～62months)．All methods indicated significant improvement in clinical assessments,using Oswestry、VAS for low back pain and leg pain(P<0.05)；no statistical differenceswere found among the3groups (P>0.05)．On radiologic assessment, the fusion ratesrespectively were85.7%,100%and100%with significant differences (P<0.05)．Furthercomparing the fusion rates of B,C with A, significant differences existed (P<0.05); nosignificant difference existed comparing B and C(P>0.05)．The incidence of broken nailsand lumbar lordosis in the3fusion methods had no statistically significantdifferences(P>0.05)．Statistical differences were found Between B、C and the A groups inthe relative disc height (P <0.05), indicating that A group having the highest loss in discheight,there was no significant difference between B and the C groups．
Conclusion: No significant differences in clinical results were found among the3 fusion methods in our observation，all are equally suitable for treating single-level lowlumbar degenerative disease．However，the fusion rates of TLIF and PLIF are better thanPLF．TLIF and PLIF have significant advantages in the correction and maintenance of discheight．TLIFand PLIF should be given priority to in the treatment of in single-level lowlumbar degenerative disease．
方法：回顾性分析2008年1月至2011年8月我院收治资料完整且获得随访的73例单节段下腰椎退行性疾病患者。按其手术方式不同分为A组（PLF，21例）；B组（PLIF，27例）；C组（TLIF，25例）。比较三种植骨融合术的Oswestry功能障碍指数（汉化版ODI），腰腿痛VAS评分，融合率，断钉，腰椎前凸角，相对椎间隙高度等情况。
结果：术后随访18月～62月，平均27个月。3组ODI功能障碍指数、腰腿痛VAS评分均较术前明显降低，差异有统计学意义(P<0.05)；3组间无统计学意义(P>0.05)。CT二维重建观察到A、B及C组融合率分别为85.7％、100％、100％，3组间有显著性差异（P<0.05）；进一步比较B、C组融合率明显高于A组，差异有统计学意义(P<0.05)，B、C两组间，差异无统计学意义(P>0.05)。3组间断钉及腰椎前凸角无显著性差异(P>0.05)。B、C组相对椎间隙高度显著优于A组，差异有统计学意义（P<0.05），B、C两组间无显著性差异(P>0.05)。
结论：三种融合术式治疗单节段下腰椎退行性疾病效果良好，临床疗效观察无显著性差异。TLIF、PLIF在融合率、恢复和维持椎间隙高度明显优于PLF，建议作为治疗单节段下腰椎退行性疾病的优先选择术式。
Objective: To observe and compare the efficacy of lumbar posterolateral fusion(PLF)，posterior lumbar interbody fusion (PLIF) and transforaminal lumbar interbodyfusion (TLIF) in the treatment of single-level low lumbar degenerative disease．
Methods: Between January2008and August2011，the follow-up complete data of73patients who underwent fusion surgery because of single-leve low lumbar degenerativedisease were retrospectively analysed．The patients were divided into3groups：group A(PLF, n=21)；group B (PLIF, n=21)；group C (TLIF, n=25)．A visual analog scale(VAS)and the Chinese Oswestry Disability Index(ODI) were used to measure low back pain, legpain, and disability．For X-ray evaluation, instrumented breakage、lumbar lordosis、maintenance of disc height were analyzed．Bone fusion was examined by two-dimensionalreconstruction of CT．
Results: All patients were followed up for average of27months(range，18months～62months)．All methods indicated significant improvement in clinical assessments,using Oswestry、VAS for low back pain and leg pain(P<0.05)；no statistical differenceswere found among the3groups (P>0.05)．On radiologic assessment, the fusion ratesrespectively were85.7%,100%and100%with significant differences (P<0.05)．Furthercomparing the fusion rates of B,C with A, significant differences existed (P<0.05); nosignificant difference existed comparing B and C(P>0.05)．The incidence of broken nailsand lumbar lordosis in the3fusion methods had no statistically significantdifferences(P>0.05)．Statistical differences were found Between B、C and the A groups inthe relative disc height (P <0.05), indicating that A group having the highest loss in discheight,there was no significant difference between B and the C groups．
Conclusion: No significant differences in clinical results were found among the3 fusion methods in our observation，all are equally suitable for treating single-level lowlumbar degenerative disease．However，the fusion rates of TLIF and PLIF are better thanPLF．TLIF and PLIF have significant advantages in the correction and maintenance of discheight．TLIFand PLIF should be given priority to in the treatment of in single-level lowlumbar degenerative disease．
引文
[1] Robinson Y，MichaelssonK，SandenB．Instrumentation in lumbar fusion improvesback pain but not quality of life2years after surgery [J]．Acta Orthopaedica,2013，84(1)：7-11．
[2] Cloward RB．The treatment of ruptured lumbar intervertebral discs by vertebral bodyfusion[J]．J Neurosurg,1953，10(2)：154-168．
[3] Kim KT，Lee SH，Lee YH，et al．Clinical outcomes of3fusion methods through theposterior approach in the lumbar spine[J]．Spine，2006,31(12)：1351-1357．
[4] Zhou ZJ，Zhao FD， Fang XQ，et al． Meta-analysis of instrumented posteriorinterbody fusion versus instrumented posterolateral fusion in the lumbar spine Areview [J]．Journal of neurosur-gery-Spine，2011,15（3）：295-310．
[5] Ekman P， Moller H， Tullberg T， et al． Posterior Lumbar InterbodyFusion Versus Posterolateral Fusion in Adult Isthmic Spondylolisthesis [J]．Spine，2007,32(20)：2178-2183．
[6] Harms J， Rolinger H． A one-stage procedure in operative treatment of ospondylolisthesis：dorsal traciton-reposition and anterior fusion[J]．ZOrthop，1983，l20：343-347．
[7] Xu H，Tang H，Guan XM，et al．Biomechanical Comparison of Posterior LumbarInterbody Fusion and Transforaminal Lumbar Interbody Fusion by Finite ElementAnalysis[J]．Neurosur Gery,2013,72,:21-26．
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[3] SelbyMD,ClarkSR,Hall DJ，etal．Radiologic Assessment of Spinal Fusion[J]．Journalof orthopaedic surgeons，2012，20(11)：694-703．
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[7] Suda K，Ito M，Abumi K，et al．Radiological Risk Factors of Pseudoarthrosis and/orInstrument Breakage After PLF With the Pedicle Screw System in IsthmicSpondylolisthesis[J]．Journal of Spinal Disorders&Techniques，2006，19(8)：541-546．
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[3] Kim KT，Lee SH，Lee YH，et al．Clinical outcomes of3fusion methods through theposterior approach in the lumbar spine[J]．Spine，2006,31(12)：1351-1357．
[4] Zhou ZJ，Zhao FD， Fang XQ，et al． Meta-analysis of instrumented posteriorinterbody fusion versus instrumented posterolateral fusion in the lumbar spine Areview [J]．Journal of neurosur-gery-Spine，2011,15（3）：295-310．
[5] Ekman P， Moller H， Tullberg T， et al． Posterior Lumbar InterbodyFusion Versus Posterolateral Fusion in Adult Isthmic Spondylolisthesis [J]．Spine，2007,32(20)：2178-2183．
[6] Harms J， Rolinger H． A one-stage procedure in operative treatment of ospondylolisthesis：dorsal traciton-reposition and anterior fusion[J]．ZOrthop，1983，l20：343-347．
[7] Xu H，Tang H，Guan XM，et al．Biomechanical Comparison of Posterior LumbarInterbody Fusion and Transforaminal Lumbar Interbody Fusion by Finite ElementAnalysis[J]．Neurosur Gery,2013,72,:21-26．
[1] Fairbank JC，Pynsent PB．The oswestry disability index [J]．Spine,200.25：2940-2953．
[2] Suk SI，Lee CK，Kim WJ，et al．Adding posterior lumbar interbody fusion to pediclescrew fixation and posterolateral fusion afte decompression inspondylolyticspondylolisthesis[J]．Spine，1997，22(2)：210-229．
[3] SelbyMD,ClarkSR,Hall DJ，etal．Radiologic Assessment of Spinal Fusion[J]．Journalof orthopaedic surgeons，2012，20(11)：694-703．
[4] Fogel GR，Toohey JS，Neidre A，et al．Fusion assessment of posterior lumbarinterbody fusion using radiolucent cages: X-ray films and helical computedtomography scans compared with surgical exploration of fusion[J]．The SpineJournal，2008，8(4)：570-577．
[5] Herzog RJ，Marcotte PJ．Assessment of spinal fusion-Critical evaluation of imagingtechniques[J]．Spine，1996，21(9)：1114-1118．
[6] Oda I，Abumi K，Yu BS，et al．Types of spinal instability that require interbodysupport in posterior lumbar reconstruction: an in vitro biomechanical investigation [J]Spine,2003，28：1573–1580．
[7] Suda K，Ito M，Abumi K，et al．Radiological Risk Factors of Pseudoarthrosis and/orInstrument Breakage After PLF With the Pedicle Screw System in IsthmicSpondylolisthesis[J]．Journal of Spinal Disorders&Techniques，2006，19(8)：541-546．
[8] Dantas FLR, Prandini MN, Ferreira MAT，et al． Comparison between posteriorlumbar fusion with pedicle screws and posterior lumbar interbody fusion with pediclescrews in adult spondylolisthesis[J]．Arquivos de neuro-psiquiatria．2007，65(38)：764-770．
[9] Dehoux E，Fourati E，Madi K，et al．Posterolateral versus interbody fusion in isthmicspondylolisthesis: functional results in52cases with a minimum follow-up of6years[J]．Acta orthopaedica Belgica，2004，70(6)：578-582．
[10] Wu YG，Tang H，Li ZH，et al．Outcome of posterior lumbar interbody fusion versusposterolateral fusion in lumbar degenerative disease[J]． Jourrnal of clinical ofneuroscience，2011，18(6)：780-783．
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