应用不同术式的腰椎间盘突出症患者手术前后免疫学变化并与单纯脊柱手术患者比较

Preoperative and postoperative immunological changes among lumbar disc herniation patients by different operation approaches:Comparison with patients following spinal operation

目的:探讨接受不同手术方式的腰椎间盘突出症患者手术前后自身免疫反应的变化,并与单纯脊柱手术的非腰椎间盘突出症患者比较,分析免疫参数与腰椎间盘突出的关联性。方法:选择2004-01/06解放军第四军医大学西京医院全军骨科研究所拟行前侧经腹膜外腰椎间盘完全摘除术20例,后侧部分椎间盘摘除术36例与接受脊柱手术的非腰椎间盘突出(对照组)患者22例。于手术前和术后1,3,5,7,14d采集晨起空腹外周血样。采用免疫单向扩散法检测IgG,IgM。临床流式细胞仪检测淋巴细胞的分化抗原,采用荧光标记的单抗检测。采用LBY-XC全自动血沉测试仪测定血沉,采用酶联免疫吸附法测定C反应蛋白。结果:按意向处理分析,78例患者进入结果分析。①外周血液IgM、IgG水平:前侧经腹膜外腰椎间盘完全摘除术组与后侧部分椎间盘摘除术组中术前外周血液IgM、IgG水平比对照组高(P<0.001)。前侧经腹膜外腰椎间盘完全摘除术组与后侧部分椎间盘摘除术组术后下降很明显(P<0.001),并且前侧经腹膜外腰椎间盘完全摘除术组术后第1,3,5天的下降幅度和下降速度大于后侧部分椎间盘摘除术组(P<0.001)。两组术后第7,14天显示了较大的下降。②C反应蛋白、血沉、白细胞水平:前侧经腹膜外腰椎间盘完全摘除术组与后侧部分椎间盘摘除术组及对照组术前相差不大(P>0.05)。术后3组都明显上升(P<0.001),前侧经腹膜外腰椎间盘完全摘除术组术后第1,3,5,7天的上升幅度和上升速度大于后侧部分椎间盘摘除术组及对照组,但无显著区别(P>0.05)。前侧经腹膜外腰椎间盘完全摘除术组与后侧部分椎间盘摘除术组血清C反应蛋白及白细胞术后第14天显示基本趋于一致。③外周血液CD4、CD8、CD4/CD8水平:前侧经腹膜外腰椎间盘完全摘除术组与后侧部分椎间盘摘除术组术前外周血液CD4、CD8、CD4/CD8水平比对照组高(P<0.001)。前侧经腹膜外腰椎间盘完全摘除术组与后侧部分椎间盘摘除术组术后上升很明显(P<0.001),并且前侧经腹膜外腰椎间盘完全摘除术组术后第1,3,5,7天上升幅度和上升速度大于后侧部分椎间盘摘除术组,但差别无意义(P>0.05)。3组术后第14天显示基本趋于一致。结论:不论何种手术方式,都使患者在接受椎间盘手术前后免疫功能发生明显改变,检测IgG,IgM及T细胞亚群CD4、CD8、CD4/CD8比值能够客观、准确、全面地反映患者的免疫状态,说明腰椎间盘突出症患者存在着体液和细胞免疫异常,且其术后免疫状态的改变也提示手术能够减缓或不同程度阻断异常的自身免疫反应。

AIM:To investigate the changes of preoperative and postoperative immune respo nses in lumbar disc herniation(LDH) following different operation approaches,and analyze the association of some immunity parameters with LDH by comparing the o utcomes between above patients and non- LDH patients treated with spinal operat ion alone. METHODS:Twenty patients following complete anterior extraperitoneal discectom y,36 following partial posterior discectomy and non- LDH patients following spi nal operation(as controls) were selected from Military Institute of Orthopaedics ,Xijing Hospital,Fourth Military Medical University between January and June 200 4.Peripheral blood samples were drawn immediately after getting up in the mornin g before operation and at 1,3,5,7 and 14 days after operation.Single radial immu nodiffusion was employed to detect IgG and IgM.Differentiating antigen of T cell subgroup was examined by clinical flow cytometry and single- antibody detectio n with fluorescence labeling.The erythrocyte sedimentation was measured with LBY - XC fully automatic erythrocyte sedimentation testing machine,and the C- reac tive protein with enzyme- linked immunosorbent assay(ELISA). RESULTS:According to the intention management,all the 78 patients finished th e result analysis.① Preoperative serum IgM and IgG level of peripheral blood wa s significantly increased in the complete anterior extraperitoneal discectomy gr oup and partial posterior discectomy group,as compared with the control group(P< 0.001),and the postoperative serum IgM and IgG level of peripheral blood were s ignificantly decreased in the two discectomy groups as compared with group(P< 0. 001).At postoperative 1,3 and 5 days,the decrease amplitude and speed of serum I gM and IgG level was more significant in the complete anterior extraperitoneal d iscectomy group than in the partial posterior discectomy group(P< 0.001),and at postoperative 7 and 14 days,the serum IgM and IgG level was also decreased remar kably in the two discectomy groups.② The level of C- reactive protein,erythroc yte sedimentation and white blood cells were insignificantly different between t he complete anterior extraperitoneal discectomy group and the partial posterior discectomy group before operation(P >0.05),and significantly decreased in the al l three groups after operation(P< 0.001),but the increase amplitude and speed we re bigger and faster in the complete anterior extraperitoneal discectomy group t han in the partial posterior discectomy group and the control group,but without significant difference at postoperative 1,3,5 and 7 days(P >0.05).The level of C - reactive protein and white blood cells was similar in the two discectomy grou ps at 14 days after operation.③ The levels of CD4,CD8 and CD4/CD8 ratio in the peripheral blood in the two discectomy groups were significantly higher than tho se in the control group before operation(P< 0.001).They were both increased sign ificantly in the two discectomy groups as compared with the control group after operation(P< 0.001),and the increase amplitude and speed was bigger and faster i n the complete anterior extraperitoneal discectomy group than in the partial pos terior discectomy group,but with insignificant difference at postoperative 1,3,5 and 7 days(P >0.05).At 14 days,the levels of CD4,CD8 and CD4/CD8 ratio were bas ically coincident in the three groups. CONCLUSION:No matter what the operative procedure is,the immune function in p atients changes before and after discectomy.The detection of IgG,IgM,T cell subg roup,CD4,CD8 and CD4/CD8 ratio can reflect the immune status objectively,exactly and fully,indicating abnormal body fluid and cellular immunity in LDH patients. The postoperative alteration of cellular immunity also suggests that abnormal au toimmune reaction can be relieved or dissimilarly blocked by operation.