中华骨科杂志2024，Vol.44Issue(10) ：658-668.DOI:10.3760/cma.j.cn121113-20231007-00221

责任节段上位固定椎与邻近上位椎体不稳的腰椎退行性疾病的手术策略

Surgical strategy for lumbar degenerative diseases with segment instability between upper instrument vertebra and ad-jacent upper vertebra

李熹 刘磊 张哲 徐玉柱 汪沛漾 李骁龙 刘国臻 张乐乐 谢志阳 陶禹澳 樊攀 王运涛
中华骨科杂志2024，Vol.44Issue(10) ：658-668.DOI:10.3760/cma.j.cn121113-20231007-00221
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责任节段上位固定椎与邻近上位椎体不稳的腰椎退行性疾病的手术策略

Surgical strategy for lumbar degenerative diseases with segment instability between upper instrument vertebra and ad-jacent upper vertebra

李熹 1刘磊 2张哲 3徐玉柱 1汪沛漾 1李骁龙 1刘国臻 1张乐乐 1谢志阳 2陶禹澳 1樊攀 2王运涛4
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作者信息

  • 1. 东南大学医学院,南京 210009
  • 2. 东南大学附属中大医院脊柱外科,南京 210009
  • 3. 盐城市第三人民医院,盐城 224001
  • 4. 东南大学医学院,南京 210009;东南大学附属中大医院脊柱外科,南京 210009
  • 折叠

摘要

目的 探讨术前存在责任节段上位固定椎(upper instrument vertebra,UIV)与邻近上位椎体(UIV+1)不稳定的腰椎退行性疾病患者中远期疗效及UIV与UIV+1不稳定的手术时机.方法 回顾性分析2014年1月至2018年12月在东南大学附属中大医院脊柱外科接受经椎间孔入路腰椎椎间融合固定术(transforaminal lumbar interbody fusion,TLIF)的265例腰椎退行性疾病患者的病历资料,男119例、女146例,年龄(64.93±9.76)岁(范围32～86岁).在术前动力位X线片上测量 UIV 与 UIV+1 节段的矢状面成角(sagittal angulation,SA)和矢状面平移(sagittal translation,ST),将SA＞10°或 ST＞2 mm的患者纳入不稳定组,再根据是否行包括UIV+1的扩大融合术分为不稳定非扩大手术组与不稳定扩大手术组,其余患者纳入稳定组.对比三组患者的影像学参数,末次随访SA、ST与术前的差值记作△SA、△ST;记录疼痛视觉模拟评分(visual analogue scale,VAS)、Oswestry 功能障碍指数(Oswestry disability index,ODI)、日本骨科协会(Japanese Orthopaedic Association,JOA)评分(29分法)并计算JOA评分改善率评估临床疗效.通过Pearson相关分析术前影像学指标与末次随访JOA评分改善率的相关性,应用受试者工作(receiver operating characteristic,ROC)曲线确定术前SA和ST的临界值.结果 全部患者随访(73.53±12.92)个月(范围61～108个月).稳定组124例,男61例、女63例,年龄(64.31±9.83)岁(范围44～82岁);不稳定非扩大手术组59例,男22例、女37例,年龄(65.76±11.01)岁(范围32～86岁);不稳定扩大手术组82例,男36例、女46例,年龄(65.26±8.68)岁(范围47～80岁).末次随访时不稳定非扩大手术组△SA为0.90°±1.97°、△ST为(0.77±1.27)mm,高于稳定组的0.25°±1.57°和(0.34±0.34)mm,差异有统计学意义(t=3.564,P＜0.001;t=2.311,P=0.022).末次随访时不稳定非扩大手术组VAS评分为(2.28±0.83)分、ODI为5.91％±3.46％、JOA评分为(24.11±1.78)分、JOA评分改善率为60％,低于稳定组的(1.51±0.69)分、3.71％±1.75％、(27.33±1.91)分、83％和不稳定扩大手术组的(1.46±0.83)分、3.46％±1.81％、(26.48±1.66)分、78％,差异有统计学意义(F=32.117,P＜0.001;F=24.827,P＜0.001;F=92.658,P＜0.001;F=93.341,P＜0.001).相关分析显示JOA评分改善率与术前SA呈低等强度负相关(r=-0.363,P＜0.001),与术前ST呈中等强度负相关(r=-0.596,P＜0.001).以JOA评分改善率为状态变量,ROC曲线分析确定术前SA临界值为11.5°、ST临界值为1.85 mm.结论 术前存在责任节段UIV与UIV+1不稳定(SA＞10°或ST＞2 mm)会在TLIF术后远期随访期间出现加重.术前UIV与UIV+1节段SA＞11.5°、ST＞1.85 mm时采用包括UIV+1的扩大固定融合术能够保证中远期随访的手术疗效.

Abstract

Objective To summarize long-term clinical follow-up results of segment instability between the upper instru-mented vertebra(UIV)and the adjacent upper vertebra(UIV+1)and to establish the optimal timing for surgery for UIV+1.Meth-ods A retrospective analysis was conducted on 265 patients with lumbar degenerative diseases who underwent transforaminal lumbar interbody fusion(TLIF)surgery at the Department of Spinal Surgery,Zhongda Hospital,from January 2014 to December 2018.The cohort included 119 male and 146 female patients,with an average age of 64.93 years(range:32-86 years).Preopera-tive dynamic imaging measured sagittal angulation(SA)and sagittal translation(ST)of the UIV+1/UIV segment.Patients with SA＞10° or ST＞2 mm were categorized into the unstable group,further divided into the unstable non-fusion group and the unstable fu-sion group based on whether UIV+1 expansion fusion was performed.The remaining patients were classified into the stable group.Imaging indicators,Visual Analogue Scale(VAS)scores,Oswestry disability index(ODI)scores,and Japanese Orthopaedic Associ-ation(JOA)scores were compared among the groups,with JOA improvement rates calculated to assess clinical efficacy.Pearson correlation coefficient analysis was employed to examine correlations between preoperative imaging indicators and final follow-up JOA improvement rates.Receiver Operating Characteristic(ROC)curves and the maximum Youden index were utilized to deter-mine thresholds for preoperative SA and ST.Results The follow-up duration for all patients was 73.53±12.92 months(range:61-108 months).The stable group(124 cases)included 61 males and 63 females,aged 64.31±9.83 years(range:44-82 years).The un-stable non-fusion group(59 cases)included 22 males and 37 females,aged 65.76±11.01 years(range:32-86 years).The unstable fusion group(82 cases)included 36 males and 46 females,aged 65.26±8.68 years(range:47-80 years).At the last follow-up,the unstable non-fusion group exhibited △SA 0.90°±1.97° and △ST 0.77±1.27 mm,both significantly higher than the stable group's△SA 0.25°±1.57° and △ST 0.34±0.34 mm(t=3.564,P＜0.001;t=2.311,P=0.022).Clinical improvements were lower in the unsta-ble non-fusion group compared to the other two groups:VAS(2.28±0.83),ODI(5.91％±3.46％),JOA(24.11±1.78),with a JOA im-provement rate of 60％.The stable group showed VAS(1.51±0.69),ODI(3.71％±1.75％),JOA(27.33±1.91),with a JOA improve-ment rate of 83％.The unstable fusion group had VAS(1.46±0.83),ODI(3.46％±1.81％),JOA(26.48±1.66),with a JOA improve-ment rate of 78％.These differences were statistically significant(F=32.117,P＜0.001;F=24.827,P＜0.001;F=92.658,P＜0.001;F=93.341,P＜0.001).The JOA improvement rate was negatively correlated with preoperative SA(r=-0.363,P＜0.001)to a low ex-tent,and with preoperative ST(r=-0.596,P＜0.001)to a moderate extent.ROC curve analysis determined the preoperative SA threshold as 11.5° and the preoperative ST threshold as 1.85 mm.Conclusion Pre-existing instability of the responsible segment UIV and UIV+1(SA＞10° or ST＞2 mm)may worsen during long-term follow-up after TLIF.When preoperative SA exceeds 11.5° and ST exceeds 1.85 mm between UIV and UIV+1,performing an extended fusion involving UIV+1 can ensure surgical efficacy over long-term follow-up.

关键词

腰椎/椎间盘退行性变/脊柱融合术/节段性不稳定/矢状面成角/矢状面滑移

Key words

Lumbar vertebrae/Intervertebral disc degeneration/Spinal fusion/Segmental instability/Sagittal angulation/Sagittal translation

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基金项目

江苏省自然科学基金青年基金(BK20220832)

出版年

2024
中华骨科杂志
中华医学会

中华骨科杂志

CSTPCD北大核心
影响因子：2.137
ISSN：0253-2352
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