高龄腰椎管狭窄症患者手术治疗的安全性及有效性

Safety and efficacy of surgical treatment for aged patients with degenerative lumbar spinal stenosis

中文关键词:  腰椎管狭窄症  腰椎融合术  高龄  并发症

英文关键词:Lumbar spinal stenosis  Lumbar fusion  Aged  Complication

中文摘要:

  【摘要】 目的：分析高龄腰椎管狭窄症患者接受手术治疗的临床疗效及并发症，评价其安全性和有效性。方法：自2015年12月~2017年6月，共有49例75岁以上的腰椎管狭窄症患者在我院接受腰椎后路减压融合内固定术，其中获得半年以上随访且资料完整的患者４４例，单节段融合１１例，双节段融合２１例，３节段融合７例，３节段以上融合５例。34例（77.3%）患者合并高血压，13例（29.5%）合并糖尿病，9例（20.5%）合并冠心病（3例曾行心脏支架植入术，1例曾行心脏搭桥术），6例（13.6%）有脑梗死病史但无明显后遗症，2例（4.5%）合并慢性阻塞性肺疾病，2例（4.5%）慢性肾功能不全。将患者分为短节段融合组（＜3节段，n=32）和长节段融合组（≥3节段，n=12）。统计两组患者的一般资料、术中出血量、手术时间、疼痛视觉模拟量表（visual analoge score，VAS）评分、Oswestry功能障碍指数（ODI）以及手术并发症。将患者对手术疗效的主观满意度分为满意、基本满意、不满意、非常不满意。结果：44例患者均顺利完成手术，手术时间为234.2±74.56min（100～411min），术中出血量为475.5±343.4ml（100～1400ml）。术后发生脑脊液漏２例，切口愈合不良５例。随访13.8±2.1个月（6～25个月），末次随访时，VAS评分由术前的7.53±1.19分改善至2.38±1.58分（P＜0.001），ODI由术前的（70.32±6.90）％改善至（46.38±9.89）％（P＜0.001）；８例出现螺钉松动，２例cａｇｅ后移，２例cａｇｅ下沉，再手术２例。30例对疗效满意，6例基本满意，5例不满意，3例非常不满意，满意率为81.8%。两组患者年龄和BMI无显著性差异，长节段融合组女性患者占比较高，手术时间较长，出血量较多；两组患者的VAS评分改善率和ODI改善率无显著性差异；与长节段融合组相比，短节段融合组再手术比例、螺钉松动比例以及cage后移比例较低。结论：高龄腰椎管狭窄症患者并存病较多，围手术期内固定相关并发症较多，且与融合节段有关。围手术期积极控制内科疾病，术中仔细操作，手术的安全性可以得到保障，术后临床症状和功能评分均可以获得显著性改善。

英文摘要:

  【Abstract】 Objectives: To investigate the clinical outcomes and complications after surgical treatment for aged patients with degenerative lumbar spinal stenosis, and to evaluate the safety and efficacy. Methods: From December 2015 to June 2017, a total of 49 aged patients with degenerative lumbar spinal stenosis were treated with posterior lumbar fusion in our hospital, in them only 44 patients had complete data and a follow-up time over 6 months. Among the patients, 11 cases underwent one segment fusion, 21 cases in two segments, 7 cases in three segments and 5 cases in more than 3 segments. About comorbidities, ３４ patients(77.3%) were with hypertension, 13 patients(29.5%) had diabetes, 9 patients(20.5%) had coronary heart disease(3 patients underwent heart stent surgery, 1 patient underwent bypass surgery), 6 patients(13.6%) once had cerebral infarction without obvious sequela, 2 patients(4.5%) had chronic obstructive pulmonary disease and 2 patients(4.5%) had renal insufficiency. Patients were divided into two groups according to the segments fused: short segment group(<3 segments) and long segment group(≥3 segments). Demographic data, intraoperative blood loss, operation time, visual analoge score(VAS), functional Oswestry score(ODI) and complications were compared between the two groups. There were four levels of patients′ satisfaction degrees: very satisfied, satisfied, dissatisfied and very dissatisfied. Results: Forty-four(89.8%) patients underwent posterior lumbar fusion. The average operation time was 234.2±74.56min(100－411min), and the average intraoperative blood loss was 475.5±343.4ml(100-1400ml). Two patients had cerebrospinal fluid leakage, 5 had poor wound healing. The average follow-up time was 13.8±2.1 months(6-25 months). VAS score improved from 7.53±1.19 preoperatively to 2.38±1.58 at the final follow-up(P<0.001), and ODI score improved from (70.32±6.90)% preoperatively to (46.38±9.89)% at the final follow-up(P<0.001). Screw loosening occurred in 8 patients, cage retroposition in 2 patients, cage residence in 2 patients, revision surgery in 2 patients. At the final follow-up, ３０ patients were very satisfied, 6 patients were satisfied, 5 patients were dissatisfied and 3 patients were very dissatisfied, and the overall satisfaction rate was 81.8%. The two groups had no difference in age and BMI, with more female patients, longer operation time and more blood loss in long segment group. The improvement rates of VAS score and ODI score in the two groups were not significantly different. Compared with those in long segment group, the reoperation rate, screw loosening rate and cage retroposition rate in short segment were lower. Conclusions: Aged patients with degenerative lumbar spinal stenosis always have many comorbidities and more perioperative complications related to fusion segments. However, with proper control of internal medicine diseases and cautious surgical procedures, the operation can be safe, and patients′ clinical and function score can be significantly improved.