棘突间固定装置应用10年再思考

Reevaluation of interspinous fixation device for ten years application

中文关键词:  腰椎  棘突间动态稳定系统  相邻节段退变

英文关键词:Lumbar  Interspinous implants  Adjacent segment degeneration

中文摘要:

  【摘要】 目的：通过临床随访和影像学分析研究腰椎棘突间动态固定对相邻节段退变的影响。方法：2007年9月~2009年9月应用后路减压结合腰椎棘突间动态固定治疗L4/5单节段退变性疾患病例76例，其中应用静态Wallis固定系统45例，动态Coflex固定系统31例。主要适应证包括腰椎间盘突出症和轻度腰椎管狭窄症。采用腰痛VAS评分、下肢痛VAS评分、腰椎JOA评分（29分法）评定临床症状情况，采用Prolo腰椎功能评定标准和ODI评分评定功能情况，术前和末次随访各评价1次；在术前和末次随访腰椎正侧位X线片上测量手术节段（L4/5）前凸角和上、下位相邻节段（L3/4和L5/S1）的前凸角以及腰椎整体前凸角（L1~S1）；在术前和末次随访腰椎过伸过屈位X线片上测量L3/4、L4/5、L5/S1活动度及腰椎整体活动度。术前和末次随访分别对L3/4和L5/S1进行UCLA（University of California at Los Angeles）分级评定。结果：66例患者获得完整随访，Wallis组41例，Coflex组25例，随访时间57~81个月，平均64.6个月。末次随访时，两组患者的腰痛VAS评分、下肢痛VAS评分、腰椎JOA评分、Prolo腰椎功能评定标准和ODI评分较术前均有显著性改善（P<0.01）；L4/5的前凸角和腰椎整体前凸角较术前均有明显下降（P<0.01），L4/5活动度和腰椎整体活动度较术前均明显下降（P<0.01）；L3/4和L5/S1的前凸角较术前无显著性变化（P>0.05），L3/4的活动度较术前下降有统计学差异（P<0.05），而L5/S1的活动度较术前无显著性变化（P>0.05）。Wallis组末次随访时同术前相比，L3/4节段有2例由UCLA Ⅰ级变为UCLA Ⅱ级；L5/S1节段有4例由UCLA Ⅰ级变为UCLA Ⅱ级，1例由UCLA Ⅱ级变为UCLA Ⅲ级。Coflex组末次随访时同术前相比，L3/4节段只有1例由UCLA Ⅰ级变为UCLA Ⅱ级；L5/S1节段有2例由UCLA Ⅰ级变为UCLA Ⅱ级，1例由UCLA Ⅱ级变为UCLA Ⅲ级。结论：后路减压结合腰椎棘突间动态固定治疗腰椎单节段退变性疾病临床效果满意，未发现症状性相邻节段退变，但其对相邻节段退变的影响有待进一步对照研究的结果和更长时间的临床随访。

英文摘要:

  【Abstract】 Objectives: To study the effect of interspinous fixation on adjacent segment degeneration in degenerative lumbar diseases. Methods: From September 2007 to September 2009, 76 cases with L4/5 degenerative lumbar diseases were treated with interspinous fixation. The clinical results were assessed by VAS score on lumbar and lower limbs, lumbar JOA score, Prolo functional score and ODI score; the radiological results including segmental lordosis and segment movement ROM of L3/4, L4/5, L5/S1 and L1-S1 were assessed by dynamic lumbar X ray at final follow-up and compared with the pre-operative ones. Adjacent segment degenerations of L3/4 and L5/S1 were assessed by UCLA method. Results: 66 cases were followed up and the average time was 64.6 months. At final follow-up, lumbar VAS, lower limb VAS, lumbar JOA score, Prolo functional score and ODI score were all better than the pre-operative ones(P<0.01). Segmental lordosis angles of L4/5 and whole lumbar spine lordosis were less than the pre-operative ones(P<0.01); L4/5 and whole lumbar spine ROM were less than the pre-operative ones(P<0.01). Segmental lodosis angles of L3/4 and L5/S1 as well as L5/S1 ROM remained no significant change(P>0.05), while L3/4 ROM decreased slightly compared with the pre-operative one(P<0.05). In Wallis group, based on UCLA method, 2 cases changed from grade Ⅰ to grade Ⅱ in L3/4, 4 cases changed from grade Ⅰ to grade Ⅱ and 1 case changed from grade Ⅱ to grade Ⅲ in L5/S1. In Coflex group, 1 cases changed from grade Ⅰ to grade Ⅱ in L3/4, 2 cases changed from grade Ⅰ to grade Ⅱ and 1 case changed from grade Ⅱ to grade Ⅲ in L5/S1. Conclusions: Decompression and interspinous fixation for single segment degenerative lumbar diseases is effective with no symptomatic adjacent segment degeneration, while its effect on the adjacent segment degeneration needs further investigation and long-term follow-up.