腰椎管狭窄症减压固定融合术后远期疗效及其影响因素分析

Long-term outcome and associated factors of lumbar decompression, internal fixation and fusion for lumbar spinal stenosis

目的：探讨腰椎管狭窄症减压固定融合术后远期疗效及其影响因素。方法：2002年1月-2006年12月因腰椎管狭窄症在我院骨科腰椎组行减压固定融合术的北京地区患者共计456例，其中回院随访118例。男性54例，女性64例；手术时年龄31-74岁，平均55.7岁；随访58-120个月，平均84.6个月。术前腰痛VAS评分为6.64±3.07分，腿痛VAS评分为7.40±2.78分，JOA评分为8.16±6.58分，ODI评分为30.55±11.30分。末次随访时，进行腰腿痛VAS、JOA、ODI评分，按Fischgrund标准判定疗效；行腰椎X线片及MRI检查观察手术区域的情况及相邻节段退变的情况。并将年龄、性别、体重指数、病程长短、跛行距离、术前下肢麻木、术前VAS和JOA及ODI评分、既往腰椎手术史、合并症、融合方式、融合固定节段长短、术后相邻节段退变情况等可能影响疗效的因素分别与末次随访时的腰腿痛VAS、ODI评分进行多元线性回归分析，分析影响疗效的相关因素。结果：末次随访时，腰痛VAS评分为4.06±3.70分，腿痛VAS评分为4.90±3.40分，JOA评分为19.98±14.0分，ODI评分为13.67±8.56分，与术前比较均有统计学差异（P〈0.05）；疗效评定，优21例，良60例，可28例，差9例，优良率为74.6%。末次随访时，X线片、MRI检查发现5例患者螺钉周围出现透亮线，2例明确出现螺钉松动，1例植骨区可疑未融合，1例出现横突植骨区骨吸收；71例相邻节段出现退变，退变率为60.2%，有症状的相邻节段退变13例（11.0%）。多元线性回归分析显示：性别与术后腰痛VAS评分显著相关，既往腰椎手术史、术前下肢麻木与术后腿痛VAS评分显著相关，年龄与术后ODI评分显著相关（P〈0.05）；合并症、体重指数、跛行距离、术前VAS与JOA及ODI评分、融合节段长短、融合方式和术后相邻节段退变等因素对术后远期疗效无影响（P〉0.05）。结论：腰椎管狭窄症减压固定融合术后远期疗效较满意，性别、年龄、既往腰椎手术史、术前下肢麻木可能是影响远期疗效的因素。

Objectives： To investigate the long-term outcome and associated factors of lumbar decompression, internal fixation and fusion for lumbar spinal stenosis. Methods： 456 patients in Beijing during January 2002 and December 2006 undergoing lumbar decompression, internal fixation and fusion in our hospital were reviewed retrospectively. 118 patients were followed up. There were 54 males and 64 females with a mean age of 55.7 years（range, 31-74 years）. The average follow-up period was 84.6 months（range, 58-120 months）. The preoperative back pain VAS score, leg pain VAS score, JOA score and ODI score was 6.64±3.07, 7.40±2.78, 8.16±6.58, and 30.55±11.30 respectively. The VAS, JOA, ODI scores and Fischgrund standard were used to evaluate the final follow-up outcome. All the patients took X-ray and MRI to evaluate the operative and adjacent segment. Factors that might affect the outcome such as age, gender, body mass index, duration of disease, neurological claudication distance, preoperative lower extremity numbness, comorbidities, preoperative VAS, JOA, ODI scores, previous history of lumbar spine surgery, fusion, the length of fusion, postoperative adjacent segment degeneration were analyzed retrospectively, and the results were selected to undergo multivariate regression analysis to determine the associated factors. Results： At final follow-up, the back pain VAS score, leg pain VAS score, JOA score and ODI score was 4.06±3.70, 4.90±3.40, 19.98±14.0, and 13.67±8.56 respectively, which showed significant difference compared with the preoperative ones（P〈0.05）. There were 21 excellent, 60 good, 28 fair and 9 poor, with an excellent-good rate of 74.6%. Based on the radiographic findings, 5 cases had radiolucent line around the screws, srew loosening in 2 cases, bony nonunion in 1 case, bone graft resorption in 1 case. 71（60.2%） cases showed adjacent segment degeneration. Symptomatic adjacent segment degeneration was noted in 13 cases（11.0%）. Multiple linear regression analysis showed that sex influenced the postoperative low back pain VAS score; previous history of lumbar surgery and preoperative limb numbness affected postoperative limb pain VAS score. Age affected postoperative ODI（P〈0.05）. Comorbidities, fusion methods, adjacent segment degeneration, the length of fusion had no effect on the outcome（P〉0.05）. Conclusions： Lumbar spinal stenosis decompression and fusion is still satisfied for at least five years.Gender, age, previous history of lumbar surgery, preoperative numbness affects the long-term efficacy.