Topping—off术与融合术治疗双节段腰椎退变的中长期疗效的比较

Topping-off surgery versus double-segment fusion for treatment of lumbar degenerative disease with mid-long term follow-up

目的对比分析Topping-off技术与融合术治疗双节段腰椎退变的中长期临床疗效。 方法回顾性分析2009年3月至2012年3月期间首都医科大学附属北京朝阳医院骨科因双节段腰椎退行性疾病行手术治疗的126例患者临床资料，分为Topping-off组和双节段融合组。术前和术后各随访点进行腰痛和腿痛Oswestry功能障碍指数（ODI）和视觉模拟评分法（VAS）评分，计算各临床评估指标改善率；对比两组患者手术时间和手术出血量；测量术前和各随访时期腰椎前凸角、骶骨倾斜角、Coflex植入节段和邻近节段数据。记录两组末次随访相邻节段退变发生率，利用Logistic回归来分析影像学相邻节段退变发生的危险因素。结果两组术前性别、年龄、体量指数、椎间盘分级均匹配。Topping-off组平均手术时间（134.5±10.2）min，出血量（301.5±64.6）ml，明显优于融合组（158.6±19.3）min（P＝0.000）和（413.6±131.3）ml（P＝0.000）；各随访点VAS、ODI较术前显著改善（P〈0.05）；末次随访Topping-off组腰痛VAS评分较融合组显著改善。Coflex植入节段椎间孔的高度从术前（10.5±1.7）mm到术后1年改善为（11.8±2.2）mm，但末次随访为（10.7±1.9）mm；椎间盘高度和椎间孔宽度在Topping-off术后1年均显著增加（P〈0.05），但末次随访均有下降，与术前比差异无统计学意义，椎间活动度较术前差异也均无统计学意义（均P〉0.05）。Coflex术后邻近节段椎间孔高度、椎间孔宽度和椎间隙高度末次随访有降低趋势（P〉0.05）。末次随访Topping-off组8例（13.3%）相邻节段退变，而融合组18例（26.5%）相邻节段退变，两组异差异有统计学意义（P＝0.033）。结论Topping-off术式和双节段融合治疗单节段融合节段上位相邻节段存在轻中度退变的患者中长期临床疗效相近，Topping-off术式减少了手术时间和手术创伤，并保留了部分运动功能，降低了相邻节段退变的发生。在严格适应证下，Topping-off术能作为融合术治疗双节段退行性病变的有效替代手术方式。

ObjectiveTo compare the mid-long term clinical effect of Topping-off surgery and lumbar fusion surgery for two-segmental lumbar degenerative disease. MethodsFrom March 2009 to March 2012, one hundred and twenty-six consecutive patients （Topping-off surgery and two-segment PLIF surgery） were studied in Orthopedics Department, Beijing Chao-Yang Hospital, Capital Medical University.The VAS and ODI were used to assess clinical symptoms.All patients underwent flexion/extension radiographs examinations before surgery, 1, 2 years and last follow-up postoperatively.Lumbar lordosis, sacral slop, data of Coflex segment and adjacent segment （disc height index, range of motion, foraminal height, foraminal width and Pfirrmann classification of intervertebral disc in MRI） were recorded.The paired double-tailed t test was used to analyze the differences in the results from baseline to each postoperative time point.The paired double-tailed t test was used in both groups to analyze the differences in the results from baseline to each postoperative time point.The Chi-square test was used to evaluate the differences between the incidences of adjacent segment degeneration（ASD） in the groups. Logistic regression analysis was used to analyze risk factors for developing radiographic ASD. ResultsIn topping-off group, 60 patients, average operation time was （134.5±10.2） min. The average blood loss was （301.5±64.6） ml.In fusion group, 68 patients, average age （58.3±4.6） years.The average follow-up time was （47.5±5.1） months.The average operation time was （158.6±19.3） min （P=0.000）. The average blood loss was （413.6±131.3） ml （P=0.000）. Sex, age, body mass index and intervertebral disc grading were matched between the two groups.Better improvement in VAS back pain score was noted in the topping-off group over the fusion group （P=0.030）. Both groups achieved good recovery in ODI and improvement in VAS leg pain and back pain scores at last follow-up postoperatively.In the Topping-off group, FH increased from 10.5 mm at baseline to 11.8 mm at 1 year after surgery （P=0.000） and then decreased mildly in the third postoperative year, while in the fusion group, showed no significant change at all postoperative time points.In the fusion group, the disc height and FW at the same segment were no significant change after first year follow-up, while ROM was significantly decreased after surgery （P=0.000）. Foraminal height, foraminal width and intervertebral disc height of adjacent segment of Coflex implant level were found decreased at the end of the postoperative follow-up, while compared with preoperative data no significant difference （P〉0.05）. At last follow-up, eight patients （13.3%） in the Topping-off group and eighteen patients （26.5%） in the fusion group developed ASD （P=0.033）. ConclusionsTopping-off surgery compared with two-segment lumbar fusion surgery can achieve a good result in cases with pre-existing mild or moderate adjacent segment degeneration, restrict the adjacent segment＇s range of motion and reduce the adjacent segment degeneration. Under strict indications, Topping-off surgery is an acceptable alternative to fusion surgery for the treatment of two-segment lumbar disease.