改良腰椎皮下指数预测经椎间孔入路腰椎椎体间融合术早期疗效的研究

Study of modified subcutaneous lumbar spine index as a predictor for short-term effectiveness in transforaminal lumbar interbody fusion

目的探讨改良腰椎皮下指数(modified subcutaneous lumbar spine index,MSLSI)预测经椎间孔入路腰椎椎体间融合术(transforaminal lumbar interbody fusion,TLIF)治疗腰椎退变性疾病(lumbar degenerative disease,LDD)早期疗效的效果。方法将2014年2月—2019年10月收治并接受单节段TLIF的450例LDD患者纳入研究。基于术前腰椎MRI测量的MSLSI,从小到大排序后将患者均分为3组(n=150)。其中,A组MSLSI0.11~0.49,B组0.49~0.73,C组0.73~1.88。3组患者性别、年龄、病程、病变类型、手术节段及改良Charlson合并症指数比较,差异均无统计学意义(P>0.05);L4椎体水平皮下脂肪厚度、BMI组间比较差异均有统计学意义(P<0.05)。比较3组患者手术时间、术中出血量、切口长度,以及术后引流管放置时间、术后第1天引流量、术后第2天引流量、总引流量、术后抗生素使用时间、术后下地时间、住院时间;以及手术及非手术相关并发症发生情况。采用Pearson相关分析MSLSI与BMI相关性,用偏相关分析研究MSLSI、BMI、改良Charlson合并症指数、L4椎体水平皮下脂肪厚度与并发症发生的相关性,采用ROC曲线分析SLSI以及MSLSI对TLIF术后并发症发生的预测价值。结果3组患者手术时间、切口长度以及术后抗生素使用时间、下地时间、引流管放置时间、第1天引流量、第2天引流量、总引流量比较,差异均无统计学意义(P>0.05)。C组术中出血量多于A、B组,住院时间长于B组,差异均有统计学意义(P<0.05)。A、B、C组分别有22例(14.7%)、25例(16.7%)、39例(26.0%)发生手术相关并发症;3组发生率差异无统计学意义(χ2=0.826,P=0.662)。其中,C组神经根损伤及切口无菌性并发症发生率高于A、B组,B组神经根损伤发生率高于A组,差异均有统计学意义(P<0.05)。A、B、C组分别有13例(8.7%)、7例(4.7%)、11例(7.3%)发生非手术相关并发症,3组发生率差异无统计学意义(χ2=2.128,P=0.345),且心血管系统、泌尿系统、中枢系统、呼吸系统并发症发生率组间比较差异均无统计学意义(P>0.05)。450例患者MSLSI与BMI成正相关(r=0.619,P=0.047);偏相关分析示MSLSI与切口无菌性并发症相关(r=0.172,P=0.032),与其余手术及非手术相关并发症均无相关性(P>0.05);BMI、改良Charlson合并症指数、L4椎体水平皮下脂肪厚度与手术及非手术相关并发症之间均无相关性(P>0.05)。ROC曲线分析显示MSLSI的AUC值为0.673(95%CI0.546~0.761,P=0.025),SLSI的AUC值为0.582(95%CI 0.472~0.693,P=0.191)。结论MSLSI能预测TLIF治疗LDD的早期疗效,高MSLSI患者术中出血更多、住院时间更长,且神经根损伤及术后切口并发症发生率较高。

Objective To explore the value of modified subcutaneous lumbar spine index(MSLSI)as a predictor for short-term effectiveness of transforaminal lumbar interbody fusion(TLIF)in treatment of lumbar degenerative disease(LDD).Methods Between February 2014 and October 2019,450 patients who were diagnosed as LDD and received single-segment TLIF were included in the study.Based on the MSLSI measured by preoperative lumbar MRI,the patients were sorted from small to large and divided into three groups(n=150).The MSLSI of group A was 0.11-0.49,group B was0.49-0.73,and group C was 0.73-1.88.There was no significance in gender,age,disease duration,diagnosis,surgical segment,and improved Charlson comorbidity index between groups(P>0.05).There were significant differences in the subcutaneous adipose depth of the L4 vertebral body and body mass index(BMI)between groups(P<0.05).The operation time,intra-operative blood loss,length of incision,drainage tube placement time,drainage volume on the 1 st day after operation,drainage volume on the 2 nd day after operation,total drainage volume,antibiotic use time after operation,walking exercise time after operation,hospital stay,the incidences of surgical or non-surgical complications in the three groups were compared.Pearson correlation analysis was used to analyze the correlation between MSLSI and BMI,and partial correlation analysis was used to study the relationship between MSLSI,BMI,improved Charlson comorbidity index,subcutaneous adipose depth of the L4 vertebral body and complications.The Receiver Operating Characteristic(ROC)curve was used to evaluate the value of SLSI and MSLSI in predicting the occurrence of complications after TLIF in treatment of LDD.Results There was no significant difference in operation time,length of incision,antibiotic use time after operation,walking exercise time after operation,drainage tube placement time,drainage volume on the 1 st day after operation,drainage volume on the 2 nd day after operation,and total drainage volume between groups(P>0.05).The amount of intra-operative blood loss in group C was higher than that in groups A and B,and the hospital stay was longer than that in group B,with significant differences(P<0.05).Surgical complications occurred in 22 cases(14.7%),25 cases(16.7%),and 39 cases(26.0%)of groups A,B,and C,respectively.There was no significant difference in the incidence between groups(χ2=0.826,P=0.662).The incidences of nerve root injury and wound aseptic complications in group C were higher than those in groups A and B,and the incidence of nerve root injury in group B was higher than that in group A,with significant differences(P<0.05).There were 13 cases(8.7%),7 cases(4.7%),and 11 cases(7.3%)of non-surgical complications in groups A,B,and C,respectively,with no significant difference(χ2=2.128,P=0.345).There was no significant difference in the incidences of cardiovascular complications,urinary system complications,central system complications,and respiratory system complications between groups(P>0.05).There was a correlation between MSLSI and BMI in 450 patients(r=0.619,P=0.047).Partial correlation analysis showed that MSLSI was related to wound aseptic complications(r=0.172,P=0.032),but not related to other surgical and non-surgical complications(P>0.05).There was no correlation between BMI,improved Charlson comorbidity index,subcutaneous adipose depth of the L4 vertebral body and surgical and non-surgical complications(P>0.05).ROC curve analysis showed that the area under ROC curve(AUC)of MSLSI was 0.673(95%CI 0.546-0.761,P=0.025),and the AUC of SLSI was 0.582(95%CI 0.472-0.693,P=0.191).Conclusion MSLSI can predict the short-term effectiveness of TLIF in treatment of LDD.Patients with high MSLSI suffer more intra-operative blood loss,longer hospital stay,and higher incidence of nerve root injury and postoperative incision complications.