Topping-off与融合固定治疗退行性腰椎疾病的临床疗效及邻近节段退变的对比研究

Topping-off versus fusion for treatment of degenerative lumbar disease:clinical outcomes and influence on adjacent segment degeneration

[目的]探讨Topping-off与融合固定治疗退行性腰椎疾病的临床疗效及对比性研究邻近节段的退变情况。[方法]回顾性研究2010年1月~2013年12月本院收治的99例L3~5退行性腰椎病变患者。根据手术方式不同,分为Topping-off组(L_(4~5)PLIF+L_(3~4)Coflex)45例,男21例,女24例,平均年龄61.50岁(46~77岁);融合固定组(L3~5PLIF)54例,男25例,女29例,平均年龄63.70岁(50~75岁)。记录手术时间、术中出血量及术后并发症。选用Oswestry功能障碍指数(Oswestry disability index,ODI)、视觉模拟评分(visual analogue scale,VAS)评价临床疗效。拍摄腰椎平扫MRI及站立位正侧屈伸位X线片,测量并记录术前、术后2年邻近节段L2-3椎间活动度及椎间盘MRI改良Pfirrmman分级,术前、术后2年Coflex置入节段L_(3~4)的椎间活动度,术后2年Topping-off组复合邻近节段活动度(Coflex置入节段L_(3~4)与其上位节段L_(2~3)椎间活动度之和)。[结果]平均随访时间(35.20±7.80)月(24~48月)。Topping-off组手术时间、出血量明显小于融合固定组(P<0.05)。术后2年腰痛及腿痛VAS、ODI评分与术前比较,两组均有明显好转(P<0.05)。术后2年L_(2~3)椎间活动度,与术前比较Topping-off组无明显变化(P>0.05),融和固定组明显增加(P<0.05);组间比较Topping-off组明显小于融合固定组(P<0.05)。术后2年Topping-off组复合邻近节段活动度与融合固定组L_(2~3)椎间活动度比较,差异无统计学意义(P>0.05)。术后2年腰椎MRI显示L_(2~3)椎间盘改良Pfirrman分级,Topping-off组明显优于融合固定组(P<0.05)。[结论]Topping-off对比融合固定治疗退行性腰椎疾病,具有创伤小、出血少、临床效果相似的特点,Coflex置入节段承担近端腰椎部分活动与应力,有助于减缓邻近节段的退变。

[Objective] To investigate the clinical outcomes of Topping-off and fusion for the treatment of degenerative lumbar disease and the effect on preventing adjacent segment degeneration. [Methods] From January 2010 to December 2013, 99 patients who with degenerative lumbar disease received surgery treatment, were divided into two groups by different surgery methods. Patients in the topping-off group （L-5 PLIF plus L3-4 Coflex, n=45 cases） included 21 males and 24 females, with the mean age of 61.50 years old （range, 46-77 years）, while those in the fusion group （L3-5 PLIF, n=54 cases） consisted of 25 males and 29 females, with the mean age of 63.70 years old （range, 50-75 years） . The operation time, intraoperative blood loss and postoperative complications were recorded. Oswestry disability index （ODI） and visual analogue scale （VAS） were used to evaluate clinical outeomes. The excessive flexion and extension lateral X-ray were obtained preoperatively and at 2 years postoperatively, to calculate the range of motion of adjacent segment （L2-3）, Coflex implant segment （L3-4） and the total range of motion of Coflex implant segment （L3-4）, as well as the upper adjacent segment （L2-3） in the topping-off group. The adjacent segment degeneration （L2-3） was classified by modified Pfirrmann grading system. [Results] All patients were followed up for an average of （35.20± 12.20） months （range, 24-48 months） . The operation time and bleeding volume in the topping-off group were sig- nificantly less than that of the fusion group （P〈0.05） . Compared with the data preoperatively, VAS, ODI scores were statistically improved at 2 year postoperativly in both groups （P〈 0.05） . The range of motion of adjacent segment L2-3 had no significant change in the topping-off group （P 〉 0.05）, while increased significantly in the fusion group （P 〈 0.05）, and the former was significantly lower than the letter at 2 years postoperatively （P 〈 0.05） . Compared with the preoperative parameters, the range of composite adjacent segment motion in the toppingoff group, and the range of adjacent segment L2-3 in the fusion group showed no significant difference at 2 years postoperatively （P 〉 0.05） . MRI T2 image indicated that the modified Pfirrmann grade of adjacent segment （L2-3） in the topping-off group was significantly better than that of the fusion group （P 〈 0.05） . [Conclusions] For the treatment of degenerative lumbar disease, topping-off has advantages of better overall composite clinical outcomes, shorter surgical time and less blood loss. Coflex implant takes part of the motion and stress from proximal lumbar, which helps to delay the degeneration of adjacent segments.