腰椎融合/非融合技术治疗L4/5退变性疾病的疗效及对相邻节段退变的影响

Clinical outcome of different lumbar instrumentation with or without fusion and its effect on adjacent segment degeneration in lumbar degenerative diseases

中文关键词:  腰椎  内固定  相邻节段  椎间盘退变  磁共振  T1ρ序列

英文关键词:Lumbar vertebrae  Internal fixation  Adjacent segment  Intervertebral disc degeneration  Magnetic Resonance  T1ρ

中文摘要:

  【摘要】 目的：比较后路腰椎椎间融合术（posterior lumbar interbody fusion，PLIF）与棘突间动态固定术（Wallis）治疗腰椎间盘突出症/椎管狭窄症合并椎间失稳的临床效果及对相邻节段退变的影响。方法：回顾性分析2007年6月~2010年7月我科手术治疗L4/5腰椎间盘突出症/椎管狭窄症合并椎间失稳患者61例，其中腰椎间盘突出症患者29例，腰椎管狭窄症患者32例；采用PLIF术式固定融合患者32例，棘突间Wallis动态固定患者29例。术前、术后1个月、1年以及末次随访时，采用JOA评分及腰功能障碍指数（ODI）评估临床疗效；根据UCLA标准对相邻节段L3/4及L5/S1椎间盘进行退变分级；利用T1ρ-MRI技术量化相邻节段椎间盘髓核T1ρ值。结果：随访时间48~77个月，平均61.3个月，其中PLIF组和Wallis组平均随访时间分别为63.4和59.6个月，差异无统计学意义（P＞0.05）。术前2组患者年龄、性别、疾病构成比、相邻节段椎间盘退变分级及相邻节段椎间盘T1ρ 值均无明显差异（P＞0.05）。末次随访时，PLIF组与Wallis组ODI评分改善率分别为76.1%、78.5%，JOA评分改善率分别为69.2%、75.0%，均无统计学差异（P=0.78，0.85）。末次随访时，PLIF组L3/4以及L5/S1节段椎间盘退变分级差异均无统计学意义（P=0.91，0.70）。术前、术后1个月、末次随访时，PLIF和Wallis组L3/4椎间盘T1ρ值分别为115.4±8.9ms、111.6±12.3ms、91.6±11.1ms和112.4±10.0ms、109.9±9.2ms、103.5±10.8ms，L5/S1椎间盘T1ρ值分别为95.4±7.7ms、94.6±9.6ms、88.1±12.6ms和96.3±9.2ms、95.4±8.5ms、91.3±11.4ms，两组术后1个月L3/4、L5/S1椎间盘T1ρ值与术前比较均无统计学差异（PLIF组：P=0.67，0.75；Wallis组：P=0.72，0.64）；末次随访时，PLIF组L3/4椎间盘T1ρ值明显低于Wallis组，差异有统计学意义（P=0.02），而L5/S1椎间盘T1ρ值差异无统计学意义（P=0.89）。结论：PLIF术式与棘突间动态固定（Wallis）治疗腰椎退变性疾患均可获得满意的中期临床疗效，而后者在减少固定术后上位相邻节段退变方面更具优势。

英文摘要:

  【Abstract】 Objectives: To compare the clinical effects of posterior lumbar interbody fusion(PLIF) and Wallis interspinous implant in lumbar disc herniation or stenosis complicated with instability, and their effects on adjacent segment degeneration. Methods: A retrospective study of 61 patients undergoing PLIF or interspinous Wallis placement at L4/5 segment was carried out. Among these, 29 patients were diagnosed as lumbar disc herniation and 32 patients as lumbar stenosis, all of them were complicated with lumbar instability. All patients presented with low back pain. In this study, 32 cases underwent PLIF, and 29 underwent interspinous Wallis placement. The clinical results were assessed and compared by JOA score and Oswestry disability index(ODI) preoperatively, 1 month and 1 year postoperatively and at the final follow-up. The degenerative grades of adjacent segments of L3/4 and L5/S1 were recorded by using UCLA(university of California at Los Angeles) grading system. The T1ρ values of nucleus pulposus in adjacent segments of L3/4 and L5/S1 were also measured at the same time points. Results: The average follow-up period was 61.3 months(range: 48-77 months), and the average follow-up period for the PLIF and Wallis group was 63.4 and 59.6 months respectively, which showed no significant difference between groups(P>0.05). There were no significant differences with respect to the age, sex ratio, disease ratio, degenerative grading and T1ρ values of adjacent segment discs preoperatively(P>0.05). The recovery rate of ODI, JOA score for PLIF and Wallis groups was 76.1%, 69.2% and 78.5%, 75.0% respectively, which showed no significant difference between 2 groups(P=0.78, 0.85). According to the UCLA classification, no significant difference was found in the degenerative grading for adjacent segment of L3/4 and L5/S1 at the final follow-up(P=0.91, 0.70). The T1ρ value of L3/4 disc in the PLIF group preoperatively, 1 month postoperatively and at the final follow-up was 115.4±8.9ms, 111.6±12.3ms and 91.6±11.1ms respectively, and 112.4±10.0ms, 109.9±9.2ms and 103.5±10.8ms in the Wallis group respectively. The T1ρ value of L5/S1 disc in the PLIF group preoperatively, 1 month postoperatively and at the final follow-up was 95.4±7.7ms, 94.6±9.6ms and 88.1±12.6ms respectively, and 96.3±9.2ms, 95.4±8.5ms and 91.3±11.4ms respectively. There were no significant differences in the T1ρ value of L3/4 and L5/S1 disc compared with preoperative ones, at 1 month after operation in each group(PLIF: P=0.67, 0.75; Wallis: P=0.72, 0.64). The T1ρ value of L3/4 in PLIF group significantly decreased at the final follow-up, compared with that in the Wallis group(P=0.02). However, there was no significant difference in the T1ρ value of L5/S1 at the final follow-up between 2 groups(P=0.89). Conclusions: Both of the PLIF and the interspinous placement can achieve satisfactory clinical results for lumbar degenerative disease at the midterm follow-up, however the interspinous placement is superior to the PLIF in delaying the cranial adjacent segment degeneration.