腰椎融合术后邻近节段疾病的危险因素分析

Risk factors of adjacent segment diseases after lumbar fusion

目的探讨腰椎融合术后邻近节段疾病(adjacent segment diseases,ASDis)的危险因素及其预防策略。方法回顾性分析2014年3月至2019年3月接受腰椎椎间融合术258例患者的病历资料,男95例、女163例;年龄(61.8±8.4)岁(范围39~77岁)。根据术后24个月随访时是否出现ASDis分为ASDis组和无ASDis组。记录患者个体因素[性别、年龄、体质指数(body mass index,BMI)、疾病种类、术前椎旁肌脂肪化程度等]及手术因素(术式、固定节段、融合节段等)、脊柱-骨盆矢状位参数[腰椎前凸角(lumba lordosis,LL)、骨盆入射角(pelvic incidence,PI)、骨盆倾斜角、骶骨倾斜角、PI-LL等],对潜在危险因素进行单因素分析后,将有统计学意义的因素代入logistic回归模型进行多因素分析,确定腰椎融合术后ASDis发生的危险因素。结果腰椎融合术后24个月时共发生ASDis 24例,发生率为9.3%(24/258)。单因素分析显示:年龄≥60岁、合并骨质疏松症、术前椎旁肌脂肪化程度GCS分级≥3级、后路腰椎椎体间植骨融合术(posterior lumbar interbody fusion,PLIF)、悬浮固定、全椎板切除、多节段融合(≥3个节段)是腰椎融合术后ASDis发生的潜在危险因素(P<0.05);而性别、受教育程度、伴侣情况、工种、肥胖(BMI≥24 kg/m2)、吸烟、应用双膦酸盐类药物、合并腰椎管狭窄症、LL、PI、骨盆倾斜角、骶骨倾斜角、PI-LL不是腰椎融合术后ASDis发生的危险因素。Logistic回归分析显示:年龄≥60岁[OR=5.63,95%CI为(1.56,20.29),P=0.008]、术前椎旁肌脂肪化GCS≥3级[OR=4.82,95%CI为(1.36,17.13),P=0.015]、合并骨质疏松症[OR=14.04,95%CI为(2.53,77.79),P=0.002]、PLIF手术[OR=9.69,95%CI为(1.91,49.03),P=0.001]、多节段固定[OR=9.36,95%CI为(1.77,49.41),P=0.008]是腰椎融合术后ASDis发生的危险因素;非全椎板切除[OR=0.09,95%CI为(0.02,0.37),P=0.001]、悬浮固定[OR=0.16,95%CI为(0.02,0.94),P=0.042]是腰椎融合术后ASDis发生的保护因素。结论对年龄≥60岁、合并骨质疏松症、术前椎旁肌脂肪化程度GCS分级≥3级的患者应慎重选择手术方式,尽量避免选择PLIF和多节段固定,可选择经椎间孔腰椎椎体间融合术、后外侧融合术、非全椎板切除的减压术式及悬浮固定以降低腰椎融合术后ASDis的发生率。

Objective To explore the risk factors of adjacent segment diseases(ASDis)after lumbar fusion,summarize the prevention strategies and provide reference for clinical treatment.Methods All of 258 patients who underwent lumbar interbody fusion from March 2014 to March 2019 were retrospectively analyzed,including 95 males and 163 females,the age of whom was 61.8±8.4 years(range,39-77 years).The patients were divided into ASDis group and non-ASDis group according to whether ASDis occurred at the follow-up of 24 months after operation.The patient's individual factors[gender,age,body mass index(BMI),main diagnosis,preoperative paraspinal muscle fatty degree,etc.]and surgical factors(operation type,fixed segment,fusion segment,etc.),sagittal parameters[lumbar lordosis(LL),pelvic incidence(PI),pelvic tilt(PT),sacral slope(SS),PI-LL]were recorded.After univariate analysis of potential risk factors,the factors with P<0.05 were substituted into logistic regression model for multivariate analysis to determine the risk factors of ASDis after lumbar fusion.Results ASDis occurred in 24 patients after lumbar fusion,with an incidence of 9.3%(24/258);univariate analysis showed that age≥60 years old,complicated with osteoporosis,preoperative fatty degree of paraspinal muscle(GCS grade≥3),PLIF operation,suspension fixation,total laminectomy and multi-segment fusion(≥3 segments)were the potential risk factors for ASDis after operation(P<0.05);Gender,education level,partner status,type of work,BMI,obesity(BMI≥24 kg/m2),smoking,use of bisphosphonates,concomitant lumbar spinal stenosis,lumbar lordosis angle,pelvic incidence angle,pelvic tilt angle,sacral slope angle,and PI-LL had no significant correlation with ASDis.Logistic regression analysis showed that age≥60 years(OR=5.63,95%CI:1.56,20.29,P=0.008),preoperative paravertebral muscle fatty GCS≥3(OR=4.82,95%CI:1.36,17.13,P=0.015),combined with osteoporosis(OR=14.04,95%CI:2.53,77.79,P=0.002),PLIF(OR=9.69,95%CI:1.91,49.03,P=0.001),and multi-segment fixation(OR=9.36,95%CI:1.77,49.41,P=0.008)were the risk factors for ASDis after lumbar fusion;Incomplete laminectomy(OR=0.09,95%CI:0.02,0.37,P=0.001)and suspension fixation(OR=0.16,95%CI:0.02,0.94,P=0.042)were the protective factors of ASDis after lumbar fusion.Conclusion The patients with age≥60 years old,osteoporosis and preoperative paraspinal muscle fatty degree≥3 grade GCS should be more careful in choosing the surgical methods,and try to choose transforaminal interbody fusion,posterolateral fusion,short segment fusion,decompression with preservation of vertebral lamina,suspension fixation and other surgical methods to reduce the incidence of postoperative ASDis.