微创经椎间孔腰椎椎体间融合术中上位关节突关节侵扰的危险因素分析

Risk factors of superior facet joint violation in minimally invasive transforaminal lumbar interbody fusion

中文关键词:  关节突关节侵扰  危险因素  关节突关节肥大  关节突关节角

英文关键词:Facet joint violation  Risk factors  Hypertrophic facet joint  Facet angle

中文摘要:

  【摘要】 目的：研究微创经椎间孔腰椎椎体间融合术（minimally invasive transforaminal lumbar interbody fusion,MIS-TLIF）中经皮椎弓根螺钉对上位关节突关节侵扰的发生情况，分析其相关危险因素。方法：回顾性分析我院2012~2018年行MIS-TLIF治疗的腰椎退行性疾病患者91例，其中男性34例，女性57例，年龄51.1±11.8岁（23~73岁），所有均采用经皮置钉的方式置入椎弓根螺钉，术后3个月均行腰椎CT三维重建，并在轴位、矢状位、冠状位上评价关节突关节侵扰程度并分级： 0级，无侵扰，螺钉不在关节突关节上，且未进入关节突关节面；1级，轻度侵扰，螺钉位于上关节突关节上，但未进入关节突关节；2级，中度侵扰，螺钉经过关节突关节面≤1mm；3级，重度侵扰，螺钉经过关节突关节面。收集患者一般情况[年龄、性别、体质指数（body mass index，BMI）、术前诊断、手术节段、关节突关节退变程度]，在术前、术后腰椎CT及正侧位X线片上测量：解剖相关因素（关节突关节轴径、矢状径、冠状径、关节突关节角、腰椎前凸角、腰椎前凸指数、椎板深度）、置钉相关因素（螺钉内倾角、螺钉尾倾角、螺帽-上关节突间距、近端连接棒露出距离、连接棒预弯），并分析潜在侵扰危险因素。结果：MIS-TLIF经皮置钉造成关节突关节侵扰的椎弓根螺钉总计62枚，轻度侵扰螺钉35枚，中、重度程度侵扰螺钉27枚。患者一般情况分析显示，BMI≥30kg/m2、L5为上位置钉节段作为关节突关节侵扰的独立危险因素（P＞0.05）；年龄、性别、术前诊断、关节突关节退变程度与侵扰无关（P＞0.05）。解剖因素分析显示，关节突关节轴径、矢状径、冠状径均≥12mm或关节突关节角≥40°时，侵扰率显著升高（P＜0.05）；关节突关节侵扰组与非侵扰组在腰椎前凸角、腰椎前凸指数及椎板深度上差异无统计学意义（P＞0.05）。置钉相关因素分析显示，侵扰组较非侵扰组存在较小的螺钉内倾角、螺帽-上关节突间距（P＜0.05），而在螺钉尾倾角、近端连接棒露出距离、连接棒预弯上组间差异无统计学意义（P＞0.05）。结论：对于BMI≥30kg/m2和L5为上位置钉节段的患者，应充分考虑经皮置钉造成关节突关节侵扰的高风险性，且关节突关节肥大（轴径、矢状径、冠状径均≥12mm时）、冠状走行（关节突关节角≥40°）时更易出现上位节段侵扰。

英文摘要:

  【Abstract】 Objectives: To explore the incidence of superior facet joint violation(FJV) during lumbar percutaneous pedicle screw insertion in minimally invasive transforaminal lumbar interbody fusion(MIS-TLIF) surgery, and the possible risk factors of FJV. Methods: A retrospective study was performed on 91 patients with lumbar degenerative diseases treated with MIS-TLIF from 2012 to 2018, including 34 males and 57 females with an average age of 51.1±11.8 years(ranging from 23 to 73 years). All patients underwent three-dimensional CT reconstruction of lumbar spine, and FJV was evaluated and graded on axial, sagittal and coronal plane of CT: grade 0, no encroachment, screw not in the facets or the articular surface; grade 1, mild encroachment, screw was in the surperior facet but did not enter the articular surface; grade 2, moderate encroachment, screw penetrated the articular surface≤1mm; grade 3, severe encroachment,screw entered the articular surface of the facet. Possible risk factors were collected and analyzed, including general condition of patients, the anatomical characteristics of facet joint(FJ)[axial, sagittal, coronal diameter of FJ, facet angle(FA), lumbar lordosis angle(LLA), lumbar lordosis index(LLI), depth of lamina], and the surgical factors(pedicle screw angle, screw-superior FJ distance, cranial angle, proximal rod length, rod contouring). Results: A total of 62 pedicle screws resulted in FJV during percutaneous pedicle screw placement in MIS-TLIF in which, 35 with mild violation, 27 with moderate and severe violation. The Logistic regression analysis revealed that, BMI≥30kg/m2, pedicle screw placement at L5 were independent risk factors of FJV. However, age, gender, preoperative diagnosis and FJD were not correlated with FJV. Anatomical factors showed that the incidence of FJV significantly increased when axial, sagittal, coronal diameter of facet joint were all ≥12mm(P＜0.05) or either the FA≥40°(P<0.05). There was no statistical difference in LLA, LLI and depth of lamina between the FJV group and the non-FJV group(P＞0.05). The FJV group had a smaller pedicle screw angle and screw-superior FJ distance than the non-FJV group(P＞0.05), while there was no statistical difference between the groups in cranial angle, proximal rod length and rod contouring(P＞0.05). Conclusions: BMI≥30kg/m2, pedicle screw placement at L5 were independent risk factors of FJV. FJV were more likely to occur in patients with a hypertrophic facet joint (axial, sagittal, coronal diameters ≥12mm) or acoronally oriented facet joint(facet angle ≥40°).