腰椎高椎间隙患者再手术原因及临床特点分析

Analysis of the causes and clinical characteristics of lumbar re-operative surgery for patients with high intervertebral space height

中文关键词:  腰椎退变性疾病  高椎间隙  椎间融合  邻椎病  腰椎矢状位力线

英文关键词:Lumbar degeneration  High intervertebral space height  Interbody fusion  Adjacent segment disease  Lumbar sagittal alignment

中文摘要:

  【摘要】 目的：分析腰椎高椎间隙患者再手术的原因及临床特点，探讨腰椎高椎间隙的充分恢复是否影响临床疗效，评估恢复高椎间隙对腰椎-骨盆力线的影响。方法：收集2014年1月~2024年11月在我院接受高椎间融合器（≥14mm）置入的42例腰椎再手术患者的临床资料，男23例，女19例；年龄41~85岁（59.5±8.6岁）。原节段再手术23例，纳入原节段再手术组（A组）；19例因邻椎退变再手术，纳入邻椎再手术组（B组）。统计患者再手术与前次手术时间间隔，术前与术后末次随访时的疼痛视觉模拟量表（visual analogue scale，VAS）评分和日本骨科协会（Japanese Orthopaedic Association，JOA）评分。测量B组患者椎间隙高度（intervertebral space height，IVSH）、前次融合节段融合面积、前次手术节段屈伸活动角度、再手术节段椎间盘Pfirrmann分级、骨盆入射角（pelvic inclination，PI）、骨盆倾斜角（pelvic tilt，PT）、腰椎前凸角（lumbar lordosis，LL），按前次手术融合节段椎间隙是否充分恢复分为高椎间隙组（B1组，充分恢复）和低椎间隙组（B2组，未充分恢复），比较两组患者的上述参数。结果：42例患者再手术均顺利完成，本次手术为第二次手术36例（85.7%），第三次手术5例（11.9%），第四次手术1例（2.4%）；共再手术54个下腰椎节段，其中L3/4 17个（31.5%），L4/5 30个（55.6%），L5/S1 7个（12.9%）。B1组两次手术间隔时间为9.55±3.47年，高于B2组（4.55±3.62年）及A组（3.29±5.36年）。随访0.25~11年（6.24±2.96年），末次随访时A组、B1组和B2组患者VAS评分及JOA评分较术前均显著性改善（P＜0.05）；B2组术前VAS评分高于A组（P＜0.05），JOA评分低于A组（P＜0.01），末次随访时JOA评分低于A组（P＜0.05），B1组术前JOA评分低于A组（P＜0.01）。B1组前次手术节段的椎间融合面积与B2组无显著性差异（1.26±0.3cm2 vs 1.13±0.15cm2，P＞0.05），活动度亦无显著性差异（5.22°±1.97° vs 3.93°±1.79°，P＞0.05）；B1组的椎间盘退变Pfirrmann分级较B2组好；B1组与B2组患者术前和术后的PI、PT及LL无统计学差异（P＞0.05），但B1组术前LL（46.57°±5.61°）显著性大于B2组（40.08°±6.5°）（P＜0.05）。结论：椎间隙高度是否充分恢复对于融合效果及节段稳定性无明显影响，但充分恢复椎间隙高度有助于改善LL，邻椎椎间盘Pfirrmann分级更好。

英文摘要:

  【Abstract】 Objectives: To analyze the causes and clinical characteristics of re-operative surgery of patients with high lumbar intervertebral space height(hIVSH), and to clarify the effect of hIVSH restoration on clinical results and lumbar-pelvic alignment. Methods: Clinical data from 42 patients who underwent re-operative surgery with high intervertebral cages(≥14mm) placement in our hospital from January 2014 to November 2024 were collected. The patients included 23 males and 19 females, aged 41-85 years old(59.5±8.6 years old). 23 patients undergone re-operation at the original segment were included in the original segment re-operation group(group A); 19 patients who were re-operated due to adjacent segment degeneration(ASD) were included in the adjacent segment re-operation group(group B). The time interval between re-operation and the previous surgery, preoperative and final follow-up visual analogue scale(VAS) score and Japanese Orthopaedic Association(JOA) score were collected and analyzed. In group B, the intervertebral space height(IVSH), fusion area of the previous fusion segment, range of motion of the previous surgical segment, Pfirrmann grades of the intervertebral disc at the re-operative segment, pelvic inclination(PI), pelvic tilt(PT), and lumbar lordosis(LL) were measured. Group B was further divided into the hIVSH group(group B1, full restoration of IVSH) and the low IVSH group(group B2, incomplete restoration of IVSH) based on whether the IVSH was fully restored in the previous fusion segment. The above parameters were thereby compared. Results: The re-operations were all completed successfully in 42 cases. Herein, 36 cases(85.7%) were the second surgeries, 5 cases(11.9%) were the third surgeries, and 1 case(2.4%) was the fourth surgery. A total of 54 lower lumbar segments were re-operated, including 17 at L3/4(31.5%), 30 at L4/5(55.6%), and 7 at L5/S1(12.9%). The time interval between surgeries in group B1 was 9.55±3.47 years, which was longer than that in group B2(4.55±3.62 years) and group A(3.29±5.36 years). The follow-up period was 0.25-11 years(6.24±2.96 years). At the final follow-up, VAS and JOA scores were significantly improved in groups A, B1, and B2 compared with preoperative scores(P<0.05); Group B2 was higher in VAS score(P<0.05) and lower in JOA score(P<0.01) than group A before operation, and was lower in JOA score than group A at final follow-up(P<0.05). B1 group was lower in JOA score than group A before operation(P<0.02). There was no significant difference in fusion area in previous operated segment between groups B1 and B2(1.26±0.30cm2 vs 1.13±0.15cm2, P>0.05) or range of motion(5.22°±1.97° vs 3.93°±1.79°, P>0.05). However, the Pfirrmann grades of intervertebral disc degeneration was better in group B1 than group B2. There was no significant difference in PI, PT, or LL between groups B1 and B2 preoperatively and postoperatively(P>0.05). Nonetheless, preoperative LL in group B1(46.57°±5.61°) was significantly greater than group B2(40.08°±6.5°)(P<0.05). Conclusions: Complete restoration of hIVSH does not significantly affect interbody fusion or segmental stability. However, it helps to improve LL which results in better Pfirrmann grade of adjacent segment.