保留后方韧带复合体的腰椎融合术远期疗效观察
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摘要
目的对比是否保留后方韧带复合体(posterior ligamentous complex,PLC)的椎板开窗减压与全椎板切除减压腰椎融合术的远期临床疗效。方法回顾分析2000年1月—2005年1月收治的下腰椎单节段退变性疾病行腰椎融合术并随访10年以上的89例患者临床资料。根据手术方式不同分为2组,A组33例采用椎板开窗减压、椎间融合内固定术,B组56例采用全椎板切除减压、内固定融合术。两组患者性别、年龄、体质量指数、病变类型、病程、病变节段及术前日本骨科协会(JOA)评分、疼痛视觉模拟评分(VAS)、腰椎前凸Cobb角等一般资料比较差异无统计学意义(P>0.05),具有可比性。术后采用JOA下腰痛29分评分标准评价临床疗效,采用VAS评分评价疼痛改善情况,并记录末次随访时相邻节段退变(adjacent segment degeneration,ASD)发生情况。结果两组患者均获随访,随访时间10～17年,平均12.6年。A组3例(9.1%)、B组5例(8.9%)出现脑脊液漏,发生率比较差异无统计学意义(χ~2=0.001,P=0.979)。两组均无感染、神经根损伤及内固定物松动、移位等并发症发生。两组均获得椎间融合,A、B组融合时间分别为(3.4±1.2)、(3.7±1.6)个月,比较差异无统计学意义(t=0.420,P=0.676)。末次随访时两组JOA评分、VAS评分较术前显著改善(P<0.05);A组手术前后腰椎前凸Cobb角比较差异无统计学意义(t=0.293,P=0.772),B组末次随访时腰椎前凸Cobb角较术前显著丢失(t=14.920,P=0.000)。末次随访时A组VAS评分及腰椎前凸Cobb角均优于B组(P<0.05);两组JOA评分比较差异无统计学意义(t=0.217,P=0.828)。A、B组分别有3例(9.1%)和21例(37.5%)出现ASD,比较差异有统计学意义(χ~2=8.509,P=0.004)。结论两组均有满意的远期临床疗效,但在维持腰椎前凸和减少ASD发生率方面,保留PLC的腰椎融合术优于切除PLC的全椎板切除腰椎融合术。
Objective To compare the long-term effectiveness of wheather posterior ligamentous complex(PLC)preserved between posterior fenestration decompression interbody fusion and posterior total laminectomy interbody fusion. Methods The clinical data of 89 patients who suffered from single segmental degenerative diseases of lower lumbar spine and followed up more than 10 years after receiving lumbar spinal fusion between January 2000 and January 2005 were retrospectively analysed. The patients were divided into two groups according to the different surgical methods,the 33 patients in group A were treated with posterior lumbar fenestration decompression, interbody fusion, and internal fixation, while 56 patients in group B were treated with posterior total laminectomy resection decompression, interbody fusion, and internal fixation. There was no significant difference in gender, age, body mass index, type of lesion, disease duration, lesion segment, and preoperative Japanese Orthopedic Association(JOA) score, visual analogue scale(VAS)score, and Cobb angle of lumbar lordosis between the two groups(P>0.05). The effectiveness was evaluated by JOA score,and the improvement of pain was evaluated by VAS score. The incidence of adjacent segment degeneration(ASD) at last f ollow-up was recorded. Results Both groups were followed up 10-17 years(mean, 12.6 years). There were 3 cases(9.1%)in group A and 5 cases(8.9%) in group B complicated with cerebrospinal fluid leakage, showing no significant difference(χ~2=0.001, P=0.979). There was no complication such as infection, nerve root injury, internal plant loosening or transposition in both groups. Intervertebral fusion was satisfactory in both groups. The fusion time in groups A and B was(3.4±1.2) months and(3.7±1.6) months respectively, and there was no significant difference between the two groups(t=0.420, P=0.676). At last follow-up, the JOA score and VAS score of the two groups were significantly improved when compared with preoperative ones(P<0.05); there was no significant difference in Cobb angle of lumbar lordosis before and after operation in group A(t=0.293, P=0.772), but the Cobb angle of lumbar lordosis in group B was significantly lost at last follow-up(t=14.920, P=0.000). At last follow-up, the VAS score and Cobb angle of lumbar lordosis in group A were significantly superior to those in group B(P<0.05); there was no significant difference in JOA score between the two groups(t=0.217, P=0.828). There were 3 cases(9.1%) in group A and 21 cases(37.5%) in group B complicated with ASD,showing significant difference between the two groups(χ~2=8.509, P=0.004). Conclusion Long-term effectiveness of both groups was satisfactory, but in terms of maintaining lumbar lordosis and reducing the incidence of ASD, the lumbar fusion retaining PLC is superior to total laminectomy and lumbar fusion removing PLC.
Objective To compare the long-term effectiveness of wheather posterior ligamentous complex(PLC)preserved between posterior fenestration decompression interbody fusion and posterior total laminectomy interbody fusion. Methods The clinical data of 89 patients who suffered from single segmental degenerative diseases of lower lumbar spine and followed up more than 10 years after receiving lumbar spinal fusion between January 2000 and January 2005 were retrospectively analysed. The patients were divided into two groups according to the different surgical methods,the 33 patients in group A were treated with posterior lumbar fenestration decompression, interbody fusion, and internal fixation, while 56 patients in group B were treated with posterior total laminectomy resection decompression, interbody fusion, and internal fixation. There was no significant difference in gender, age, body mass index, type of lesion, disease duration, lesion segment, and preoperative Japanese Orthopedic Association(JOA) score, visual analogue scale(VAS)score, and Cobb angle of lumbar lordosis between the two groups(P>0.05). The effectiveness was evaluated by JOA score,and the improvement of pain was evaluated by VAS score. The incidence of adjacent segment degeneration(ASD) at last f ollow-up was recorded. Results Both groups were followed up 10-17 years(mean, 12.6 years). There were 3 cases(9.1%)in group A and 5 cases(8.9%) in group B complicated with cerebrospinal fluid leakage, showing no significant difference(χ~2=0.001, P=0.979). There was no complication such as infection, nerve root injury, internal plant loosening or transposition in both groups. Intervertebral fusion was satisfactory in both groups. The fusion time in groups A and B was(3.4±1.2) months and(3.7±1.6) months respectively, and there was no significant difference between the two groups(t=0.420, P=0.676). At last follow-up, the JOA score and VAS score of the two groups were significantly improved when compared with preoperative ones(P<0.05); there was no significant difference in Cobb angle of lumbar lordosis before and after operation in group A(t=0.293, P=0.772), but the Cobb angle of lumbar lordosis in group B was significantly lost at last follow-up(t=14.920, P=0.000). At last follow-up, the VAS score and Cobb angle of lumbar lordosis in group A were significantly superior to those in group B(P<0.05); there was no significant difference in JOA score between the two groups(t=0.217, P=0.828). There were 3 cases(9.1%) in group A and 21 cases(37.5%) in group B complicated with ASD,showing significant difference between the two groups(χ~2=8.509, P=0.004). Conclusion Long-term effectiveness of both groups was satisfactory, but in terms of maintaining lumbar lordosis and reducing the incidence of ASD, the lumbar fusion retaining PLC is superior to total laminectomy and lumbar fusion removing PLC.
引文
1彭俊,詹玉林,刘英杰,等.皮质骨通道螺钉与椎弓根螺钉行腰椎后路椎间融合的疗效比较.中国修复重建外科杂志, 2017,31(11):1341-1345.
2Anand N, Kong C. Can minimally invasive transforaminal lumbar interbody fusion create lordosis from a posterior approach?Neurosurg Clin N Am, 2018, 29(3):453-459.
3曾至立,荚龙,于研,等.双侧管状通道下微创经椎间孔腰椎间融合术治疗单节段腰椎滑脱症.中华外科杂志, 2017, 55(4):279-284.
4孙祥耀,海涌,张希诺.不同骨盆投射角与腰椎前凸角之差对退变性脊柱侧凸后路长节段内固定术后效果的影响.中华外科杂志, 2017, 55(6):435-440.
5刘振磊,段婉茹,菅凤增,等.微创后路椎间融合术治疗腰椎退行性疾病的初步研究.中华神经外科杂志, 2018, 34(9):926-930.
6田浩,王辉,狄鹤轩,等.跳跃式双节段经椎弓根截骨长节段融合治疗强直性脊柱炎胸腰椎后凸畸形.中国脊柱脊髓杂志, 2018,28(3):193-199.
7叶晓健,余将明,谢宁,等.侧方腰椎椎间融合技术在腰椎椎体次全切除与重建手术中的应用.中华骨科杂志, 2017, 37(20):1269-1277.
8李玉伟,王海蛟,王义生,等.基于术中CT扫描治疗新鲜胸腰段椎体爆裂骨折的疗效观察.中华医学杂志, 2017, 97(33):2573-2577.
9唐一村,林本丹.胸腰段脊柱后方韧带复合体相关研究进展.中国矫形外科杂志, 2016, 24(20):1881-1884.
10Lai PL, Chen LH, Niu CC, et al. Relation between laminectomy and development of adjacent segment instability after lumbar fusion with pedicle fixation. Spine(Phila Pa 1976), 2004, 29(22):2527-2532.
11叶记超,沈慧勇.腰椎融合术后邻近节段病变.中华骨科杂志,2017, 37(20):1294-1299.
12Wu CC, Jin HM, Yan YZ, et al. Biomechanical role of the thoracolumbar ligaments of the posterior ligamentous complex:a finite element study. World Neurosurg, 2018, 112:e125-e133.
13Tuli SM, Kapoor V, Jain AK, et al. Spinaplasty following lumbar laminectomy for multilevel lumbar spinal stenosis to prevent iatrogenic instability. Indian J Orthop, 2011, 45(5):396-403.
14Lee MJ, Bransford RJ, Bellabarba C, et al. The effect of bilateral laminotomy versus laminectomy on the motion and stiffness of the human lumbar spine:a biomechanical comparison. Spine(Phila Pa1976), 2010, 35(19):1789-1793.
15Saavedra-Pozo FM, Deusdara RA, Benzel EC. Adjacent segment disease perspective and review of the literature. Ochsner J, 2014,14(1):78-83.
16纪经涛,苗军,李文君,等.显微镜下微创保留后方韧带复合体及腰椎置钉融合治疗腰椎退变性疾病.中国组织工程研究, 2017,21(23):3682-3687.
17Xia XP, Chen HL, Cheng HB. Prevalence of adjacent segment degeneration after spine surgery:a systematic review and metaanalysis. Spine(Phila Pa 1976), 2013, 38(7):597-608.
18 Herren C, Simons RM, Bredow J, et al. Posterior lumbar interbody fusion versus dynamic hybrid instrumentation:a prospective randomized clinical trial. World Neurosurg, 2018, 117:e228-e237.
2Anand N, Kong C. Can minimally invasive transforaminal lumbar interbody fusion create lordosis from a posterior approach?Neurosurg Clin N Am, 2018, 29(3):453-459.
3曾至立,荚龙,于研,等.双侧管状通道下微创经椎间孔腰椎间融合术治疗单节段腰椎滑脱症.中华外科杂志, 2017, 55(4):279-284.
4孙祥耀,海涌,张希诺.不同骨盆投射角与腰椎前凸角之差对退变性脊柱侧凸后路长节段内固定术后效果的影响.中华外科杂志, 2017, 55(6):435-440.
5刘振磊,段婉茹,菅凤增,等.微创后路椎间融合术治疗腰椎退行性疾病的初步研究.中华神经外科杂志, 2018, 34(9):926-930.
6田浩,王辉,狄鹤轩,等.跳跃式双节段经椎弓根截骨长节段融合治疗强直性脊柱炎胸腰椎后凸畸形.中国脊柱脊髓杂志, 2018,28(3):193-199.
7叶晓健,余将明,谢宁,等.侧方腰椎椎间融合技术在腰椎椎体次全切除与重建手术中的应用.中华骨科杂志, 2017, 37(20):1269-1277.
8李玉伟,王海蛟,王义生,等.基于术中CT扫描治疗新鲜胸腰段椎体爆裂骨折的疗效观察.中华医学杂志, 2017, 97(33):2573-2577.
9唐一村,林本丹.胸腰段脊柱后方韧带复合体相关研究进展.中国矫形外科杂志, 2016, 24(20):1881-1884.
10Lai PL, Chen LH, Niu CC, et al. Relation between laminectomy and development of adjacent segment instability after lumbar fusion with pedicle fixation. Spine(Phila Pa 1976), 2004, 29(22):2527-2532.
11叶记超,沈慧勇.腰椎融合术后邻近节段病变.中华骨科杂志,2017, 37(20):1294-1299.
12Wu CC, Jin HM, Yan YZ, et al. Biomechanical role of the thoracolumbar ligaments of the posterior ligamentous complex:a finite element study. World Neurosurg, 2018, 112:e125-e133.
13Tuli SM, Kapoor V, Jain AK, et al. Spinaplasty following lumbar laminectomy for multilevel lumbar spinal stenosis to prevent iatrogenic instability. Indian J Orthop, 2011, 45(5):396-403.
14Lee MJ, Bransford RJ, Bellabarba C, et al. The effect of bilateral laminotomy versus laminectomy on the motion and stiffness of the human lumbar spine:a biomechanical comparison. Spine(Phila Pa1976), 2010, 35(19):1789-1793.
15Saavedra-Pozo FM, Deusdara RA, Benzel EC. Adjacent segment disease perspective and review of the literature. Ochsner J, 2014,14(1):78-83.
16纪经涛,苗军,李文君,等.显微镜下微创保留后方韧带复合体及腰椎置钉融合治疗腰椎退变性疾病.中国组织工程研究, 2017,21(23):3682-3687.
17Xia XP, Chen HL, Cheng HB. Prevalence of adjacent segment degeneration after spine surgery:a systematic review and metaanalysis. Spine(Phila Pa 1976), 2013, 38(7):597-608.
18 Herren C, Simons RM, Bredow J, et al. Posterior lumbar interbody fusion versus dynamic hybrid instrumentation:a prospective randomized clinical trial. World Neurosurg, 2018, 117:e228-e237.