手术治疗腰椎间盘突出症的长期疗效及其影响因素

Long-term outcome of lumbar disc herniation surgery and its associated factors

目的:评估腰椎间盘突出症手术治疗的长期疗效,探讨影响手术长期疗效的相关因素。方法:回顾性分析1996年2月～2002年12月在我院采用单纯开窗减压髓核摘除术治疗的125例单节段腰椎间盘突出症患者,记录患者性别、年龄、体重指数(body mass index,BMI)、病程、临床表现、体征、手术减压时椎间盘的突出类型和末次随访时复发性椎间盘突出症的例数。分别记录术前和末次随访时Oswestry伤残指数(Oswestry Disability Index,ODI)及腰痛/下肢根性痛的视觉模拟评分(visual analog scale,VAS)。根据Stauffer-Coventry′s(SC)疗效评定标准评价患者总体疗效。单因素分析患者术前与末次随访时的VAS以及ODI。患者总体疗效作为结果变量,单因素分析年龄、性别、BMI、吸烟、腰扭伤史、病程、术前腰痛VAS评分、术前下肢痛VAS评分、术前ODI、直腿抬高试验(straight-leg raise test,SLR)、肌力、感觉、椎间盘突出节段和类型等14项指标与疗效的关系。用非条件Logistic全回归分析和逐步回归分析来研究结果变量与术前各种指标的关系。结果:随访84～123个月,平均109个月,患者总体疗效优占32%,良占35.2%,可占23.2%,差占9.6%,复发率为8%。术前ODI为(72.23±25.72)%,末次随访时为(15.64±17.52)%,与术前比较有显著性差异(P<0.05)。腰痛VAS评分术前为5.44±3.43分,末次随访时为2.12±2.32分;下肢痛VAS评分术前为7.34±3.72分,末次随访时为1.42±2.74分;末次随访时与术前比较均有显著性差异(P<0.05)。全回归分析发现腰扭伤史、感觉减退是总体疗效不佳的相关因素,而非包含型突出类型是总体疗效佳的相关因素。逐步回归分析发现有4个有统计学意义的相关因素,其比值比(OR)及95%可信区间分别为:腰扭伤史(OR=6.50;95%CI 2.21-19.10)、吸烟(OR=4.48;95%CI 1.51-13.34)、感觉(OR=9.01;95%CI 1.75-46.46)、突出类型(OR=0.027;95%CI 0.005-0.145)。结论:手术治疗可以明显改善腰椎间盘突出症患者的腰痛、下肢痛和ODI。腰扭伤史、吸烟史、术前感觉和突出类型是影响腰椎间盘突出症手术长期疗效的相关因素。

Objectives： To evaluate the long-term outcome of surgical treatment for lumbar disc herniation and to investigate its associated factors. Methods： 125 cases suffering from lumbar disc herniation and un-dergoing discectomy at Ruijin Hospital from February 1996 to December 2002 were included in this study. All patients had single segment involved. The patients＇ gender, age, body mass index, disease course, clinical symptom, signs and the type of disc herniation were recorded. The postoperative recurrent disc herniation was also documented. The patients＇ functional conditions were reviewed by Oswestry disability index（ODI） pre-and postoperatively. Low back pain/leg pain was evaluated by visual analog scale（VAS）. Stauffer-Coventry＇s（SC） e-valuation criteria was used in determining the patient＇s overall efficacy. Preoperative and final follow-up＇s VAS and ODI were analyzed by means of Univariate analysis. Considering overall clinical results as the vari-able outcome, the relationship between the outcome and 14 related factors such as age, gender; BMI, smok-ing, history of lumbar sprain, duration, preoperative VAS of low back pain/leg pain, preoperative ODI, SLR,muscle strength, sensation, segment and type of disc herniation were processed by univariate analysis. The as- sociation between variable outcome and 14 related factors was analyzed by means of multivariate logistical re-gression of the full model with all prognostic variables included and the model with the variables selected by the stepwise procedure. Results： The average follow-up was 109 months. The overall excellent/good/fair/poor rate was 32%, 35.2%, 23.2% and 9.6% respectively, and the recurrence rate was 8%. ODI decreased from （72.23＋25.72）% preoperatively to （15.64±17.52）% at final follow-up, which had significant difference（P〈0.05）; VAS of low back pain decreased from 5.44±3.43 preoperatively to 2.12±2.32 at final follow-up, and VAS of leg pain decreased from 7.34±3.72 to 1.42±2.74. There were significant differences in low back pain and leg pain VAS between pre-and postoperatively （P〈0.05）. In the full-model logistic analysis for overall efficacy, history of lumbar sprain and preoperative abnormal sensory were negative predictors while type of herniation was a positive predictor. In the stepwise regression model, smoking（OR=4.48; 95%CI 1.51-13.34）, preoperative history of lumbar sprain（OR=6.50; 95%CI 2.21-19.10） and sensory（OR=9.01; 95%CI 1.75-46.46） were negative predictors and type of herniation（OR=0.027; 95%CI 0.005-0.145） was a positive predictor of overall efficacy. Conclusions： Discectomy can significantly improve the patient＇s low back and leg pain as well as patient＇s functional outcomes. History of lumbar sprain, smoking, sensory and type of lumbar disc herniation are the most-related predictors.