侧方腰椎椎体间融合术联合前外侧螺钉固定或后路双侧椎弓根螺钉固定治疗腰椎退行性疾病的疗效比较

Comparative study of the efficacy of lateral lumbar interbody fusion combined with anterolateral screw fixation or bilateral pedicle screw fixation in the treatment of lumbar degenerative diseases

中文关键词:  侧方腰椎椎体间融合术  腰椎退行性疾病  椎弓根螺钉  内固定

英文关键词:Lateral lumbar interbody fusion  Lumbar degenerative disease  Pedicle screws  Internal fixation

中文摘要:

  【摘要】 目的：比较侧方腰椎椎体间融合术（lateral lumbar interbody fusion，LLIF）联合前外侧螺钉固定技术（anterolateral screw fixation，AF）或后路双侧椎弓根螺钉固定技术（bilateral pedicle screw fixation，BPSF）治疗腰椎退行性疾病（lumbar degenerative disease，LDD）的疗效及影像学参数。方法：回顾性研究2019年12月~2021年12月在昆明医科大学第一附属医院经LLIF-AF或LLIF-BPSF治疗的100例单节段LDD患者，根据内固定方法分为AF组和BPSF组（每组50例）。两组患者的性别、年龄、体质指数（body mass index，BMI）等一般资料比较，均无统计学差异（P>0.05）。收集患者围手术期资料（住院天数、手术时间、术中出血量）；术前、术后7d和术后6个月的腰部及腿部疼痛视觉模拟量表评分（visual analog scale，VAS）、Oswestry功能障碍指数（Oswestry disability index，ODI）；影像学参数如椎间隙高度（disc height，DH）、椎间孔高度（foraminal height，FH）、椎管横截面积（cross-sectional area，CSA）和手术并发症等资料进行分析比较，探讨椎间隙下沉及融合器不融合的危险因素。结果：AF组手术时间、术中出血量、住院天数均优于BPSF组[125.0±26.6min vs 221.6±52.2min，25.0mL（20.0~50.0mL） vs 100.0mL（90.0~150.0mL），12.5±4.8d vs 14.9±4.6d]，组间差异具有统计学意义（P<0.05）。在腰、腿痛VAS评分和ODI方面，术后7d和术后6个月相较于本组术前评分均具有统计学差异（P<0.05），两组间各时间点比较差异无统计学意义（P>0.05）。在影像学DH、FH和CSA参数方面，同组术后7d和术后6个月相较于本组术前均具有统计学差异（P<0.05），两组在术前、术后7d及术后6个月各时间点的组间比较无统计学差异（P＞0.05）。术后6个月AF组出现椎间隙下沉的患者有12例，BPSF组出现椎间隙下沉的患者有9例，组间比较无统计学差异（P＞0.05）。AF组和BPSF组患者术后6个月椎间隙出现下沉和未出现患者间的BMI、QCT比较具有统计学差异；融合器出现未融合和融合患者间的QCT比较具有统计学差异；BMI≥28kg/m2和QCT＜80mg/cm3均是AF组椎间隙下沉的独立危险因素，而不是BPSF组椎间隙下沉的独立危险因素；而QCT＜80mg/cm3在AF组、BPSF组中均为融合器发生不融合情况的独立危险因素。结论：LLIF联合AF或BPSF均是治疗LDD的可靠方法，对BMI≥28kg/m2的大体重患者或QCT＜80mg/cm3的骨密度下降患者，BPSF内固定能够为脊柱提供更强的机械稳定性，可以降低术后椎间隙下沉或融合器未融合情况的发生率；反之，AF内固定手术时间和住院时间更短、术中出血量少，可以优先考虑。

英文摘要:

  【Abstract】 Objectives: To compare the efficacy and imaging parameters of lateral lumbar interbody fusion(LLIF) combined with anterolateral screw fixation(AF) or bilateral pedicle screw fixation(BPSF) in the treatment of lumbar degenerative disease(LDD). Methods: A retrospective study was conducted on 100 patients with single-segment LDD who underwent LLIF-AF or LLIF-BPSF treatment at the First Affiliated Hospital of Kunming Medical University between December 2019 and December 2021. The patients were divided into the AF group(50 cases) and the BPSF group(50 cases). There was no statistical difference in the general information such as gender, age, and body mass index(BMI) between the two groups(P>0.05). The perioperative data(length of hospital stay, operative time, intraoperative blood loss); Pre-operative, postoperative 7d, postoperative 6 months′ visual analog scale(VAS) scores for low back and leg pain, Oswestry disablity index(ODI), imaging parameters such as disc height(DH), foraminal height(FH), cross-sectional area(CSA), as well as surgical complications were collected and analyzed, and the risk factors for intervertebral subsidence and non-fusion of fusion device were explored. Results: AF group was better than BPSF group in operative time, intraoperative blood loss, and hospital stay[125.0±26.6min vs 221.6±52.2min, 25.0mL(20.0-50.0mL) vs 100.0mL(90.0-150.0mL)，12.5±4.8d vs 14.9±4.6d], and the differences were statistically significant(P<0.05). For the low back and leg pain VAS scores and ODI, as well as DH, FH, and CSA, the postoperative 7d and 6 months′ values were signiticantly improved than before operation in both groups(P<0.05), while no statistically significant differences were found between groups at the same time points(P>0.05). Intervertebral subsidence occurred in 12 patients in each group, and there was no statistically significant difference between the two groups. There were statistically significant differences in BMI and QCT between the AF and BPSF groups of patients with subsidence of the intervertebral space and those without subsidence at 6 months after operation; There were statistically significant differences in QCT between the two groups of patients with non-fusion and fusion of the fusion device; BMI≥28kg/m2 and QCT＜80mg/cm3 were the independent risk factors for intervertebral subsidence in AF group, but not in the BPSF group; QCT＜80mg/cm3 was the independent risk facors for non-fusion of fusion device in both AF and BPSF groups. Conclusions: LLIF combined with AF or BPSF are both reliable methods for treating LDD. For patients with a high body weight of BMI≥28kg/m2 or decreased bone density of QCT＜80mg/cm3, BPSF internal fixation can provide stronger mechanical stability to the spine, reducing the incidence of postoperative disc space collapse or fusion device non-union; On the contrary, AF internal fixation has shorter operative time and hospital stay, less intraoperative blood loss, which can be considered as a priority.