斜外侧腰椎椎间融合联合侧方钢板与联合后路椎弓根螺钉内固定治疗腰椎退行性疾病的半年随访

Oblique lumbar interbody fusion combined with lateral plate versus combined with pedicle screw fixation via the posterior approach for lumbar degenerative diseases:a six-month follow-up

背景:斜外侧腰椎椎间融合技术治疗腰椎退行性疾病的优势受到术后融合器沉降的影响。内固定辅助可以提供更高的生物力学稳定性,可能减少沉降的发生,其中斜外侧腰椎椎间融合联合侧方钢板固定避免了后方切口的损伤。目的:分析斜外侧腰椎椎间融合联合侧方钢板治疗腰椎退行性疾病的早期临床和影像学结果,并与联合双侧椎弓根螺钉比较,分析融合器沉降程度是否存在差异。方法:14例(17个节段)斜外侧腰椎椎间融合联合侧方钢板内固定患者(侧方钢板组);12例(15个节段)斜外侧腰椎椎间融合联合双侧椎弓根螺钉内固定患者(双侧椎弓根螺钉组)。收集患者术前、术后3 d及术后6个月临床及影像学数据;临床评估患者腰痛及下肢痛目测类比评分和Oswestry残障指数评分(Oswestry disability index,ODI);影像学评估椎间隙高度、节段性脊柱前凸角,并测量融合器沉降程度。结果与结论:①两组患者在年龄、性别、体质量指数、定量CT骨密度、术前诊断方面无统计学差异;双侧椎弓根螺钉组手术时间显著长于侧方钢板组(P=0.025);侧方钢板组术后并发症发生率43%,双侧椎弓根螺钉组为33%;两组在手术节段、出血量及并发症发生率上差异无显著性意义;②两组间术前及术后6个月腰痛、下肢痛目测类比评分及术前ODI评分差异无显著性意义,术后6个月双侧椎弓根螺钉组ODI评分显著低于侧方钢板组(P=0.007);两组术后6个月相比术前在腰痛及下肢痛目测类比评分、ODI评分上均有显著改善(P<0.05);③两组术后3 d相比术前椎间隙高度和节段性脊柱前凸角均有显著性提高;术后6个月相比术后3 d椎间隙高度均出现显著性丢失(P<0.05);术前及术后3 d两组椎间隙高度差异无显著性意义,术后6个月侧方钢板组椎间隙高度显著小于双侧椎弓根螺钉组(P=0.044);④两组间节段性脊柱前凸角差异无显著性意义;⑤两组术后6个月融合器沉降率差异无显著性意义,侧方钢板组融合器重度沉降2例,双侧椎弓根螺钉组无重度沉降病例;⑥治疗腰椎退行性疾病时,斜外侧腰椎椎间融合联合侧方钢板内固定比联合双侧椎弓根螺钉内固定融合器早期沉降更加明显;对疼痛的缓解效果两者相似,但在生活质量评价上联合双侧椎弓根螺钉内固定优于联合侧方钢板内固定。

BACKGROUND:The advantage of oblique lumbar interbody fusion for lumbar degenerative diseases is affected by the cage settlement.Supplementary fixation can provide extra biomechanical stability and may reduce the occurrence of settlement.Among them,oblique lumbar interbody fusion combined with lateral plate fixation can avoid the damage caused by the posterior approach.OBJECTIVE:To analyze the early clinical and radiological results of oblique lumbar interbody fusion combined with lateral plate in the treatment of lumbar degenerative diseases,and to combine with bilateral pedicle screws to analyze whether there is a difference in the degree of cage settlement.METHODS:Fourteen patients(17 segments)with oblique lumbar interbody fusion combined with lateral plate fixation(lateral plate group)and 12 patients(15 segments)with oblique lumbar interbody fusion combined with bilateral pedicle screw fixation(bilateral pedicle screw group)were included.The clinical and radiological data of patients before operation,3 days and 6 months after operation were recorded.The clinical evaluation included low back pain and lower limb pain visual analogue scale scores and Oswestry disability index score.Radiological evaluation included measurement of disc height,segmental lordosis,and degree of cage settlement.RESULTS AND CONCLUSION:(1)There was no significant difference between the two groups in age,gender,body mass index,quantitative CT bone mineral density,and preoperative diagnosis.The operation time of the bilateral pedicle screw group was significantly higher than that of the lateral plate group(P=0.025).The complication rate was 43%in lateral plate group and 33%in bilateral pedicle screw group.There was no significant difference between the two groups in operation segment,blood loss,and complication rate.(2)There was no significant difference in low back pain and lower limb pain visual analogue scale scores and preoperative Oswestry disability index scores between the two groups.The Oswestry disability index score of the bilateral pedicle screw group was significantly lower than that of the lateral plate group at 6 months after operation(P=0.007).At 6 months after operation,the visual analogue scale scores and Oswestry disability index scores were significantly improved in both groups compared with those before the operation(P<0.05).(3)At 3 days after operation,disc height and segmental lordosis were significantly improved compared with before operation,but there was a significant loss of disc height in both groups at 6 months after operation(P<0.05).There was no significant difference in disc height between the two groups before and 3 days after the operation.The disc height of the lateral plate group was significantly lower than that of the bilateral pedicle screw group at 6 months follow-up(P=0.044).(4)No statistical difference was found in segmental lordosis between the two groups.(5)There was no significant difference in the cage settlement rate between the two groups at 6 months follow-up.There were two cases of severe subsidence in the lateral plate group and none in the bilateral pedicle screw group.(6)Compared with oblique lumbar interbody fusion combined with bilateral pedicle screws,oblique lumbar interbody fusion combined with lateral plate fixation in the treatment of lumbar degenerative diseases is less effective in preventing early cage settlement.Both have similar pain relief effects at the early stage,but in terms of quality of life,oblique lumbar interbody fusion combined with bilateral pedicle screw fixation is better than oblique lumbar interbody fusion combined with lateral plate fixation.