术前腰大肌形态与斜外侧腰椎椎体间融合术联合侧入路螺钉内固定术后一过性神经肌肉损伤的关系

Relationship between preoperative psoas major morphology and transient neuromuscular injury after oblique lumbar interbody fusion combined with anterolateral screw fixation

中文关键词:  斜外侧腰椎椎体间融合术  腰大肌形态  腰丛神经损伤  术后并发症  危险因素

英文关键词:Oblique lumbar interbody fusion  Psoas major morphology  Lumbar plexus injury  Postoperative complications  Risk factors

中文摘要:

  【摘要】 目的：探讨行斜外侧腰椎椎体间融合术（oblique lumbar interbody fusion，OLIF）联合侧入路螺钉内固定术（anterolateral screw fixation，AF）治疗的患者术前腰大肌形态特征与术后发生一过性神经肌肉损伤之间的相关性。方法：回顾性分析2018年6月~2023年4月在我院行经左侧入路L4/5单节段OLIF联合AF治疗的腰椎管狭窄症（lumbar spinal stenosis，LSS）患者的临床资料。将术后出现术侧下肢一过性腰丛神经、腰大肌损伤的22例患者纳入A组，匹配35例未出现相关损伤症状的患者作为对照，纳入B组。收集两组患者性别、年龄和体质指数（body mass index，BMI）、病程、美国麻醉医师协会（American Society of Anesthesiologists，ASA）评分等一般资料和手术相关信息，并于术前L4/5椎间隙中点轴位MRI图像上测量腰大肌形态学参数，包括面积、长轴、宽轴以及腰大肌横截面最高点（a点）、腰大肌横截面最宽点（b点）的Moro分区位置，观察左侧椎体侧缘与腰大肌内侧间隙（cd间隙）是否存在。采用回归分析探讨术前腰大肌形态特征与术后发生一过性神经肌肉损伤的关系。结果：两组患者性别、年龄、BMI、病程和ASA评分均无统计学差异，具有可比性（P>0.05）。两组均顺利完成手术，手术时间、术中出血量和住院时间均无统计学差异（P>0.05）。A组患者共报告72例次腰大肌、腰丛神经损伤相关症状，其中大腿前外侧感觉异常16例（22.2%），大腿内侧感觉异常14例（19.4%），腹股沟区感觉异常11例（15.3%），髋关节内收异常12例（16.7%），膝关节伸展异常10例（13.9%），髋关节屈曲异常9例（12.5%）。两组患者腰大肌面积、长轴、宽轴及a点分布无统计学差异；A组cd间隙消失率和b点位于Moro Ⅰ区的比例分别为27.3%和36.4%；B组分别54.3%和2.8%，A组显著性高于B组（P<0.05）。回归分析结果显示cd间隙消失（OR=0.177，95%CI 0.037~0.852）与b点分布于Moro Ⅰ、Ⅱ区是术后发生一过性神经肌肉损伤并发症的独立危险因素。结论：术前腰大肌形态特征与L4/5节段OLIF联合AF术后发生一过性神经肌肉损伤相关；腰大肌横截面最宽点位于Moro Ⅰ、Ⅱ区和椎体侧缘和腰大肌内侧间隙(cd间隙)消失是其发生的危险因素。

英文摘要:

  【Abstract】 Objectives: To investigate the correlation between preoperative morphological characteristics of the psoas major muscle and the occurrence of transient neuromuscular injury in patients undergoing oblique lumbar interbody fusion(OLIF) combined with anterolateral screw fixation(AF). Methods: A retrospective analysis was conducted on the clinical data of patients with lumbar spinal stenosis(LSS) who underwent single-level L4/5 OLIF combined with AF via a left-sided approach at our hospital between June 2018 and April 2023. 22 patients who met the diagnostic criteria for postoperative transient lumbar plexus and psoas major muscle injury on the surgical side were included in group A. 35 matched patients without related injury symptoms were included in group B served as controls. General patient data including gender, age, body mass index(BMI), symptom duration, and American Society of Anesthesiologists(ASA) score, as well as surgery-related data were collected. Psoas major morphological parameters at the L4/5 disc level such as area, long axis, short axis, the distribution of the highest point(a-point) and the widest point(b-point) within the Moro zones were measured on the preoperative axial MRI, and the presence or absence of the space between lateral vertebral body edge and medial margin of the psoas major(cd space) on the left side was evaluated. Regression analysis was used to explore the relationship between preoperative psoas major morphological characteristics and postoperative transient neuromuscular injury. Results: There were no statistically significant differences in gender, age, BMI, symptom duration, or ASA score between the two groups, indicating comparability(P>0.05). All surgeries were successfully completed, with no significant differences in operative time, intraoperative blood loss, or hospital stay between the two groups(P>0.05). A total of 72 symptom events related to psoas/lumbar plexus injury were reported in group A, including anterolateral thigh paresthesia in 16 cases(22.2%), medial thigh paresthesia in 14 cases(19.4%), inguinal paresthesia in 11 cases(15.3%), hip adduction weakness in 12 cases(16.7%), knee extension weakness in 10 cases(13.9%), and hip flexion weakness in 9 cases(12.5%). There were no significant differences between the two groups regarding psoas major area, long axis, short axis, or a-point distribution. However, the rate of cd space absence and the proportion of the b-point located in Moro zone Ⅰ were 72.7% and 36.4% in group A, compared to 45.7% and 2.8% in group B, respectively, with group A showing significantly higher values(P<0.05). Regression analysis revealed that the absence of the cd space(OR=0.177, 95% CI: 0.037-0.852) and the distribution of the b-point in Moro zones Ⅰ-Ⅱ were independent risk factors for postoperative transient neuromuscular injury. Conclusions: Preoperative psoas major morphological characteristics are associated with the occurrence of transient neuromuscular injury after L4/5 OLIF combined with AF. Having the widest point of the psoas major cross-section located in Moro zones Ⅰ-Ⅱ and the loss of the space between the vertebral body and the medial psoas margin(cd space) are risk factors for transient neuromuscular injury after L4/5 OLIF combined with AF.