Topping-off手术治疗腰椎退行性疾病的影像学分析

Efficacy of topping-off procedure for the lumbar degenerative disease: a radiographic study

目的：评价Topping-off手术治疗连续双节段腰椎退行性疾病的影像学改变。方法 ：2008年8月～2012年12月,35例连续双节段腰椎退行性椎管狭窄症（其中上位病变节段为轻或中度退变）患者在我院接受手术治疗。其中男23例,女12例,年龄62.6±18.9岁（30～79岁）。所有患者均接受腰椎单节段融合（PLIF）＋上位节段棘突间动态稳定（置入Coflex）手术（Topping-off手术）,其中L4/5置入Coflex＋L5/S1融合14例,L3/4置入Coflex＋L4/5融合21例。回顾性分析患者术前及末次随访时X线片上Coflex置入节段及其上位相邻节段的椎间隙高度、椎间活动度、椎体偏移、椎间隙角及腰椎前凸角;在MRI上对Coflex置入节段和其上位相邻节段椎间盘退变情况进行改良Pfirrmann分级。结果：患者均安全完成手术,手术时间为112±21min（95～155min）,出血量为403±111ml（300～520ml）。均未出现硬脊膜破裂、神经损伤等相关并发症。随访24.8±12.8个月（11～65个月）。术后末次随访时Coflex置入节段及其上位相邻节段椎间隙前缘高度、椎间隙后缘高度与术前比较均无统计学意义（P〉0.05）;Coflex置入节段椎间隙角较术前显著性增大（t=-1.8,P〈0.05）;Coflex上位相邻节段椎间隙活动度（过伸位角度-过屈位角度）、椎间隙角及腰椎前凸角与术前比较均无统计学意义（P〉0.05）。24例随访2年以上患者MRI检查显示Coflex置入节段及其上位相邻节段椎间盘的改良Pfirrmann分级情况与术前相同。结论：Topping-off手术可以保持Coflex置入节段良好的稳定性,并保留该节段部分运动功能及其上位相邻节段节段正常活动,减少了上位相邻节段退变发生的危险因素。

Objectives： To evaluate the imaging changes and efficacy of Topping-off procedure for lumbar degenerative disease. Methods： From August 2008 to December 2012, 35 cases of consecutive double seg-mental degenerative lumbar spine stenosis（the upper segment showed mild or moderate degeneration） were treated surgically. There were 23 males and 12 females with an average age of 62.2 ±18.9 years（range, 30-79years）. All patients received posterior lumbar interbody fusion（PLIF） and Coflex inter-spinous dynamic stabi-lization at the upper adjacent level. 14 patients underwent L4/5 Coflex＋L5/S1 PLIF and 21 patients underwent L3/4 Coflex＋L4/5 PLIF. Retrospective analysis was conducted to evaluate the efficacy of Topping-off proce-dure for the prevention of adjacent segment degeneration（ASD）, which included the following indexes：（1）the disc space height, range of motion, vertebra translation, inter-space angle and kyphosis angle both at the Coflex level and upper adjacent level through standing anteroposterior（AP） position, lateral and extension-flex-ion X-ray;（2）change of Pfirrmann disc degeneration grade at Coflex level and upper adjacent level through MRI examination. Results： All patients underwent surgery safely and no major complications occurred. The average surgery time was 112±21min. The average blood loss was 403±111ml. No spinal dura matter rupture,nerve damage or any other complication was noted. The average follow-up was 24.8 ±12.8 months（11-65months）. There was no significant difference in disc height at the Coflex segment or upper adjacent segment between pre-operation and final follow-up, as well as the lumbar kyphosis（P〉0.05）. Segmental lordosis at the Coflex level increased significantly（t=-1.8, P〈0.05）. There were no significant differences in the ROM and the sagittal translation between pre-operation and final follow-up, both at the Coflex level and upper adjacent level（P〉0.05）. For the 24 patients followed up for more than 24 months, MRI showed no significant change of Pfirrmann disc degeneration grade between pre-operation and final follow-up both at Coflex level and upper adjacent level（P〉0.05）. Conclusions： Topping-off procedure can maintain the stability as well as the adjacent unfused segment. Topping-off surgery decreases the rate of upper adjacent segment degeneration.