中老年患者后路腰椎椎体间融合术并发症及临床获益的年龄分层随访研究

An age-stratified follow-up of complications and clinical benefit of posterior lumbar intervertebral fusion procedure in middle-aged and older patients

目的比较不同年龄段中老年患者接受后路腰椎椎体间融合术(posterior lumbar intervertebral fusion,PLIF)的并发症及临床评分改善情况,为医务人员评估不同年龄段中老年患者接受PLIF的并发症风险和临床获益提供参考。方法回顾分析2013年6月-2016年6月符合选择标准的1 136例行PLIF治疗的55岁以上患者临床资料。根据患者接受手术时的年龄分为55~64岁组、65~74岁组和≥75岁组。比较3组患者一般特征、合并症情况及手术资料,统计并比较不同年龄组并发症发生例数及发病率,并按照最小临床显著标准(minimal clinical important difference,MCID),对患者的疼痛视觉模拟评分(VAS)评分和Oswestry功能障碍指数(ODI)的改善情况进行比较。采用单因素logistic回归比较不同年龄段并发症发病及VAS和ODI评分改善达到MCID的情况,并对并发症的危险因素进行多因素logistic回归分析。结果 3组患者手术融合节段数和合并骨质疏松情况比较,差异有统计学意义(P<0.05);性别、体质量指数、手术时间、术前美国麻醉医师协会(ASA)分级和合并症数量比较,差异无统计学意义(P>0.05)。所有患者均获随访,随访时间6~62个月,平均27.4个月。术后并发症结果中,3组术中并发症、系统性并发症、微小并发症总发生率以及术后ODI评分改善达到MCID比例比较,差异有统计学意义(P<0.05);远期随访终点并发症总发生率及术后VAS评分改善达到MCID比例比较,差异无统计学意义(P>0.05)。单因素logistic回归分析显示,调整混杂因素后,55~64岁组和65~74岁组间术中并发症发生情况和术后ODI评分改善达到MCID情况比较,差异有统计学意义(P<0.05);≥75岁组系统性并发症、微小并发症、远期随访终点并发症发生情况以及术后ODI评分改善达到MCID情况与其他两组比较,差异有统计学意义(P<0.05)。多因素logistic回归分析显示,年龄增长是系统性并发症、微小并发症和远期随访终点并发症的危险因素。除年龄外,手术时间长是术中并发症的危险因素,融合节段数增加是系统性并发症的危险因素,合并症数量是微小并发症的危险因素,合并骨质疏松是远期随访终点并发症的危险因素。结论与年龄<75岁的中老年患者相比,年龄≥75岁的腰椎退行性疾病患者PLIF手术并发症风险较高,但术后VAS和ODI评分改善相似。在严格把握手术适应证前提下行PLIF,对提高此类患者的生活质量具有积极意义。

Objective To compare the complications and clinical scores of posterior lumbar intervertebral fusion(PLIF) in middle-aged and older patients of different ages, and to assess the risk of complications of PLIF in different ages,providing a reference for clinical treatment. Methods The clinical data of 1 136 patients, who were more than 55 years old and underwent PLIF between June 2013 and June 2016, were retrospectively analyzed. According to the age of patients undergoing surgery, they were divided into 3 groups as 55-64 years old, 65-74 years old, and ≥75 years old. The general characteristics, comorbidities, and surgical data of the three groups were compared, with comparison the morbidity of complications. According to the minimal clinical important difference(MCID), the improvement of patient’s pain visual analogue scale(VAS) score and the Oswestry disability index(ODI) score were compared. Univariate logistic regression analysis was used to analyze the difference of complications and the improvement of VAS and ODI scores.Multivariate logistic regression analysis was performed for the risk factors of complications. Results There were significant differences in the number of surgical fusion segments and osteoporosis between groups(P<0.05);there was no significant difference in gender, body mass index, operation time, preoperative American Society of Anesthesiologists(ASA) classification, and comorbidities between groups(P>0.05). All patients were followed up 6-62 months with an average of 27.4 months. Among the results of postoperative complications, there were significant differences in the total incidence of intraoperative complications, systemic complications, minor complications, and the percentage of improvement of ODI score to MCID between groups(P<0.05);but there was no significant difference in the total incidence of complications at the end of long-term follow-up and the percentage of improvement of VAS score to MCID between groups(P>0.05). Univariate logistic regression analysis showed that after adjusting the confounding factors, there were significant differences in intraoperative complications and the percentage of improvement of ODI score to MCID between 55-64 and 65-74 years old groups(P<0.05);systemic complications, minor complications, complications at the end of long-term follow-up, and the percentage of improvement of ODI score to MCID in ≥75 years old group were significantly different from those in the other two groups(P<0.05). Multivariate logistic regression analysis showed that age was a risk factor for systemic complications, minor complications, and complications at the end of long-term followup. Except for age, long operation time was a risk factor for intraoperative complications, increased number of fusion segments was a risk factor for systemic complications, the number of comorbidities was a risk factor for minor complications, and osteoporosis was a risk factor for complications at the end of long-term follow-up. Conclusion The risk of surgical complications is higher in the elderly patients(≥75 years) with lumbar degenerative diseases than in the middle-aged and older patients(<75 years), while the improvements of postoperative VAS and ODI scores were similar. Under the premise of fully assessing surgical indications, PLIF has a positive effect on improving the elderly patients’ quality of life.