后路椎体间自体髂骨融合与Cage融合治疗下腰椎不稳的比较研究

INSTABILITY OF LOWER LUMBAR TREATED WITH POSTERIOR LUMBAR INTERBODY FUSION WITH AUTOLOGOUS ILIAC CREST OR INTERBODY FUSION CAGE:A COMPARATIVE STUDY

目的比较后路椎体间自体髂骨融合与Cage融合治疗成人下腰椎不稳的效果。方法2003年2月-2006年10月,收治60例下腰椎不稳患者。28例采用后路椎体间自体髂骨块融合治疗(植骨组):男17例,女11例;年龄(52.78±10.50)岁。病程3～16个月。退变性不稳12例,峡部裂性滑脱14例,医源性不稳2例。L3、41例,L4、517例,L5、S110例。相对椎间隙高度(23.24±6.62)mm,椎间隙活动度(10.50±5.07)°,矢状滑移距离(4.50±1.15)mm,JOA评分(18.56±2.68)分。32例采用Cage融合治疗(Cage组):男19例,女13例;年龄(51.75±10.44)岁。病程3.5～14.0个月。退变性不稳16例,峡部裂性滑脱14例,医源性不稳2例。其中L4、516例,L5、S116例。相对椎间隙高度(24.34±7.22)mm,椎间隙活动度(11.12±5.67)°,矢状滑移距离(4.38±0.75)mm,JOA评分(19.00±4.12)分。两组一般情况比较,差异均无统计学意义(P>0.05)。结果术后1、3、6、12个月两组患者获定期随访。两组手术时间及出血量差异无统计学意义(P>0.05);手术费用植骨组和Cage组分别为(2.0857±1.1451)万元和(3.3875±0.8706)万元,差异有统计学意义(P<0.01)。植骨组2例术后2周出现取骨区疼痛,未作处理;3例患者术后1～2d出现神经损伤症状,对症处理后症状消失。Cage组2例术后1～2d出现神经损伤症状,对症处理后症状消失。两组均无假关节形成、椎间隙感染及Cage移位。两组相对椎间隙高度手术前后比较差异均有统计学意义(P<0.01),且两组术后各时间点比较差异均有统计学意义(P<0.01)。术后1、3、6、12个月,植骨组椎体融合分别为0、0、7、23例;Cage组分别为0、0、8、29例;术后6、12个月两组融合率比较,差异无统计学意义(P>0.05)。术后各时间点两组JOA评分与术前比较,差异均有统计学意义(P<0.05);术后各时间点植骨组JOA评分与Cage组比较,差异均无统计学意义(P>0.05)。结论采用自体髂骨融合治疗下腰椎不稳在融合时间、融合率及临床症状缓解程度方面与Cage融合无显著差异。自体髂骨可作为下腰椎不稳椎间融合的植骨材料,临床疗效好,无免疫排斥,价格便宜。

Objective To compare the curative effect of posterior lumbar interbody fusion with autologous iliac crest to that of interbody fusion cage for adult instability of lower lumbar. Methods From February 2003 to October 2006, 60 inpatients with lower lumbar instability were treated. Patients were randomized into 2 groups： bone-graft group （n=28） was treated with posterior lumbar interbody fusion with two autologous iliac crests, while cage group （n=32） was treated with posterior lumbar interbody fusion with two quadrate cages. In the bone-graft group, 17 males and 11 females aged （52.78 ± 10.50） years with 3-16 months of disease course, there were 12 cases of degenerative instability, 14 isthmus slit olisthe and 2 iatrogenic instability, including 1 case of L3.4, 17 cases of L4.5 and 10 cases of L5, Sl. Relative disc space height was （23.24 ± 6.62） mm, disc space activity was （10.50 ± 5.07）^o, sagittal saw slippage distance was （4.50 ± 1.15） mm and the JOA score was 18.56 ± 2.68. In the cage group, 19 males and 13 females aged （51.75 ± 10.44） years with 3.5-14.0 months of disease course, there were 16 cases of degenerative instability, 14 isthmus slit olisthe and 2 iatrogenic instability, including 16 cases of L4.5 and 16 cases of L5, Sl. Relative disc space height was （24.34 ± 7.22） mm, disc space activity was （11.12 ± 5.67）^o, sagittal saw slippage distance was （4.38 ± 0.75） mm and the JOA score was 19.00 ± 4.12. There was no significant difference between the two groups in terms of age, gender, JOA score, disc space activity and relative disc space height preoperatively （P 〉 0.05）. Results All patients received the follow-up at the 1st, 3rd, 6th and 12th month postoperatively. There was no significant difference in operation timeand hemorrhage amount between the two groups （P 〉 0.05）, but significant difference in the cost of operation （P 〈 0.01）. Two cases in the bone-graft group suffered donor site pain and received no treatment. Three cases in the bone-graft group and 2 cases in the cage group had symptom of nerve injury 1-2 days after surgery, which were cured after expectant treatment. There were no pseudoarticulation formation, intervertebral space infection and cage aversion in both groups. Significant difference of relative disc space height was found in each group pre- and postoperatively （P 〈 0.01） and significant differences were evident between the two groups at any of the time points （P 〈 0.01）. One month after operation, there was significant difference between the two groups （P 〈 0.05）. There was also significant difference at the 3rd, 6th and 12th month after operation （P 〈 0.01）. No sign of fusion was found in each group at the ist and 3rd month after operation. In bone-graft group, there were 7 vertebral fusion cases 6 months after operation and 23 vertebral fusion cases 12 months after operation. In cage group, there were 8 vertebral fusion cases 6 months after operation and 29 vertebral fusion cases 12 months after operation. There was no significant difference in the rate of fusion at 6 and 12 months follow-up between the two groups （P 〉 0.05）. Significant difference of IOA scores was found in each group pre- and post- operatively （P 〈 0.05）. And no significant difference in ]OA scores at 1, 3, 6, and 12 months follow-up was evident between the two groups （P 〉 0.05）. Conclusion There is no significant difference between the two groups in the fusion time, the fusion rate and the clinical symptoms alleviation, indicating autologous iliac crest is applicable to interbody fusion for the treatment of adult instability of lower lumbar and good therapeutic effect can be achieved with no immunoreaction and lower cost.