三种植骨材料在腰椎后路椎间融合中的应用比较

A clinical comparison of three bone graft materials for posterior lumbar interbody fusion

目的观察3种不同植骨材料在腰椎椎间融合术中的应用效果,探讨其应用的安全性及有效性。方法回顾性分析2013年9月至2016年12月收治单节段腰椎退行性疾病患者97例,其中腰椎管狭窄症43例,腰椎滑脱症22例,腰椎间盘突出症合并腰椎不稳32例;男51例,女42例;年龄39~70岁,平均52.4岁。病变节段:L_(3~4) 15例,L_(4~5) 52例,L_5~S_1 30例。手术方法均采用后路椎板减压、髓核摘除、椎间植骨融合内固定术,根据椎间植骨材料不同,分为同种异体冷冻干燥骨组(A组)、自体骨组(B组)和脱钙骨基质(demineralized bone matrix,DBM)组(C组),三组患者一般资料比较差异均无统计学意义(P>0.05),有可比性。所有患者术前、术后随访均应用Oswestry功能障碍指数(oswestry disability index,ODI)、疼痛视觉模拟评分(visual analogue scale,VAS),并行X线及CT检查评估植骨融合率、融合时间、椎间高度(disc height index,DHI)、内固定失败率。结果三组在手术时间、出血量方面差异无统计学意义(P>0.05)。A组39例获随访,随访时间12~48个月;B组31例获随访,随访时间13~49个月;C组27例获随访,随访时间10~18个月。A组术后3例切口渗液,其余患者切口均I期愈合;B组和C组无感染发生,切口均I期愈合。A组植骨融合时间为(15.8±4.3)个月,4例(11.8%)出现植骨不融合,其中断钉2例。在植骨融合率、融合时间、椎间高度丢失、内固定失败率方面,A组差于另两组,差异有统计学意义(P<0.05)。B组和C组植骨融合率分别为96.2%和92.0%,融合时间分别为(12.7±4.8)个月和(13.5±4.5)个月,两组之间差异无统计学意义(P>0.05)。结论后路腰椎椎间融合术中使用同种异体骨植骨融合率最低,且内固定失败发生率较高;自体骨与DBM植骨融合率高,内固定失败发生率小。应用DBM是一种安全、有效地促进腰椎椎间融合的方法。

Objective To observe the clinical and radiological results of posterior lumbar interbody fusion with 3 different types of bone grafting materials,and to evaluate the safety and efficiency.Methods Between September 2013 and December 2016,97 consecutive patients seeking medical treatment for one level lumbar degenerative disease were included in this study.There were 43 cases of lumbar spinal stenosis,22 cases of lumbar spondylolisthesis and 32 cases of lumbar disc herniation with lumbar instability.There were 51 males and 42 females,aged 39 to 70 years（mean：52.4 years）.The level of pathology：L（3-4） in 15 cases,L（4-5） in 52 cases,L5-S1 in 30 cases.All cases were treated with allogeneic freeze-dried bone（group A）,autologous cancellous bone（group B）and demineralized bone matrix（DBM）（group C）combined with posterior internal fixation after decompression and discectomy.Preoperative data and follow-up results were evaluated by Oswestry disability index（ODI）and the visual analogue scales（VAS）for low back pain and leg pain.Fusion rate,fusion duration,disc height index（DHI）of the operative segment,and failure of internal fixation were recorded and statistically analyzed.There were no significant differences in general data among 3 groups（P〈0.05）.Results There were no significant differences in the operation time and bleeding volume among the three groups（P〈0.05）.Group A：39 cases were followed up for 12-48 months;wound effusion was found in 3 cases,and other incisions healed by the first intention;the time range of bone graft healing was（15.8±4.3）months;4 cases（11.8%）were noted with nonfusion,including 2 cases of screw fracture;the lowest fusion rate,longest time range of fusion,highest rate of internal fixation failure and height loss of intervertebral space,with statistical significance compared with the other 2 groups（P〈0.05）.Group B：31 cases were followed up for 13-49 months;no infection occurred.Group C：27 cases were followed up for 10-18 months;no infection occurred.Group B and Group C achieved fusion rates of 96.2%and 92.0%,and the time of bone graft healing were（12.7±4.8）months and（13.5±4.5）months,respectively.Between the 2 groups,there were no significant differences in respects of fusion rate and bone graft healing time（P〈0.05）.Conclusions Among the 3 types of bone grafting materials,allogeneic bone has the lowest fusion rate and instrumentation failure.Satisfactory outcomes are achieved in autologous cancellous bone and DBM,and there are no significant differences between them.It is a safe and effective way to enhance the posterior lumbar interbody fusion with the DBM.