单节段镜下融合治疗合并骨质疏松症的腰椎退变性疾病的近期疗效

Short-term clinical outcomes of single-level full-endoscopic lumbar interbody fusion for degenerative lumbar spine disorders combined with osteoporosis

中文关键词:  镜下融合  骨质疏松症  脊柱退变性疾病  脊柱微创手术  临床疗效

英文关键词:Endoscopic fusion  Osteoporosis  Degenerative spine disorders  Minimally invasive spine surgery  Clinical outcomes

中文摘要:

  【摘要】 目的：探讨单节段镜下融合术治疗合并骨质疏松症的腰椎退变性疾病的临床疗效。方法：纳入2018年6月~2022年2月因腰椎退行性疾病接受腰椎单节段镜下融合手术，且住院期间完善双能X线吸收法（dual-energy X-ray absorptiometry，DXA）骨密度检测的病例24例，其中男7例、女17例；年龄44~80岁，平均66.0±9.9岁，术后随访时间21.6±12.6（3~47）个月。按是否合并骨质疏松症分为2组，其中8例合并骨质疏松症（骨质疏松组），16例不合并骨质疏松症（对照组）。骨质疏松症病例及时予抗骨松治疗。镜下融合手术均采用工作内径7.1mm的同轴水介质大通道脊柱内镜。比较两组患者一般资料及围手术期指标，术前、术后3d及末次随访时使用疼痛视觉模拟量表（visual analogue scale，VAS）评分、日本骨科协会（Japanese Orthopaedic Association，JOA）评分及Oswestry功能障碍指数（Oswestry disability index，ODI）评价临床疗效。术后3d复查腰椎数字X线摄影（digital radiography，DR）及腰椎计算机体层摄影（computed tomography，CT）评价减压与内固定情况；末次随访时行腰椎DR者，评估螺钉松动及融合器沉降情况；术后随访超过6个月且复查腰椎CT者，判断融合情况。记录并比较两组患者并发症发生情况。结果：两组患者的年龄、性别、术前诊断、术前椎间隙高度、手术节段，术前VAS、JOA评分及ODI等均无统计学差异。骨质疏松组最低骨密度平均值T=-3.2±0.6，明显低于对照组T=-1.4±0.8（P=0.000）。骨质疏松组平均手术时间为429.9±135.2min，对照组平均手术时间327.4±68.2min，差异具有统计学意义（P=0.020）。术中影像辅助方式、出血量、单侧入路双侧减压（unilateral laminotomy for bilateral decompression，ULBD）例数、术后椎间隙高度、住院天数两组间无统计学差异。两组术后3d及末次随访时腰痛/腿痛VAS评分、JOA评分及ODI均较术前明显改善，差异有统计学意义（P＜0.05）；但两组间比较均无统计学差异。两组术后3d椎间隙高度与术前比较显著增加（P<0.01），组间比较无统计学差异。并发症方面，骨质疏松组1例严重骨质疏松症患者（腰椎T=-4.4）术中置入融合器时损伤终板，出现融合器沉降，但无症状，无需特殊处理；另有1例硬膜撕裂合并神经根损伤，经神经营养等对症处理后症状缓解。末次随访时18例复查腰椎DR，随访时间超过6个月者10例复查腰椎CT，骨质疏松组与对照组相比，融合器沉降率、螺钉松动率与融合率均无统计学差异（P=1.000）。结论：单节段镜下融合术治疗合并骨质疏松的腰椎退变性疾病近期疗效安全有效。

英文摘要:

  【Abstract】 Objectives: To explore the clinical outcomes of single-level full-endoscopic lumbar interbody fusion for degenerative lumbar spine disorders combined with osteoporosis. Methods: 24 consecutive patients with degenerative lumbar spine disorders who underwent single-level full-endoscopic lumbar interbody fusion and were detected by dual-energy X-ray absorptiometry(DXA) during hospitalization for bone mineral density(BMD) from June 2018 to February 2022 were enrolled, including 7 males and 17 females with an average age of 66.0±9.9 years old(range 44-80 years). The follow-up period was 21.6±12.6（3-47） months after operation. And the patients were divided into two groups of osteoporosis group(containing 8 osteoporotic cases) and control group(containing 16 non-osteoporotic cases). Anti-osteoporosis therapy was initiated on the diagnosis of osteoporosis. The surgery was performed using a 7.1mm inner-diameter full-endoscope. The general data and perioperative parameters were compared between the two groups. Before operation, on 3d after operation and at final follow-up, visual analogue scale(VAS) score for back and leg pain, Japanese Orthopaedic Association(JOA) score and Oswestry disability index(ODI) were used for evaluating clinical outcomes. Digital radiography(DR) and computed tomography(CT) were performed on postoperative 3d for neural decompression and implant position assessment. For patients who received DR examination, cage subsidence and screw loosening were recorded at the final follow-up; For patients who were followed-up for 6 months and more and examined with CT, fusion rate was evaluated. The complications were recorded and compared between the two groups. Results: No significant differences were found in age, gender, diagnosis, preoperative intervertebral height, surgical segment, preoperative VAS scores, JOA scores and ODI between the two groups. The average of the lowest T value was -3.2±0.6 for osteoporosis group, lower than the -1.4±0.8 for control group(P=0.000). The mean operative time was 429.9±135.2min for osteoporosis group, more than the 327.4±68.2min for the controls(P=0.020). There was no significant difference in intraoperative imaging assistance, bleeding, number of cases received unilateral laminotomy for bilateral decompression(ULBD), postoperative intervertebral height and length of hospital stay between groups. The VAS scores for back and leg pain, JOA scores and ODI improved postoperatively and at the final follow-up in both groups comparing with those values before operation(P<0.05), and there was no significant difference between groups, respectively. The postoperative 3d intervertebral height in both groups increased after surgery(P<0.01), and none significant difference was found between groups. In the osteoporosis group, asymptomatic cage subsidence happened in 1 case with severe osteoporosis(T=-4.4) due to intraoperative endplate damage during cage implantation, but no symptoms were observed, therefore no special treatment was given; And dural tear and subsequent incomplete nerve root injury happened to another case in the osetoporosis group, whose symptoms were relieved after symptomatic treatment such as neurotrophy. 18 patients received lumbar DR at final follow-up, and 10 patients received CT evaluation at more than 6 months′ follow-up, no significant difference was found in cage subsidence and screw loosening rate and fusion conditions between groups(P=1.000). Conclusions: Single-level full-endoscopic lumbar interbody fusion is safe and effective in the short-term for the treatment of degenerative lumbar spine disorder combined with osteoporosis.