保留近端上半椎板减压融合术治疗腰椎退变性疾病的疗效及其对预防邻近节段退变的作用

Clinical efficacy and prevention of adjacent segment degeneration in the treatment of lumbar degenerative diseases through decompression and fusion preserving proximal upper laminae

目的探讨保留近端上半椎板减压腰椎内固定融合术治疗腰椎退变性疾病的疗效及其对预防邻近节段退变(adjacent segment degeneration,ASD)的作用。方法回顾性分析2018年3月至2020年2月在南京大学医学院附属鼓楼医院采用保留近端上半椎板、上半棘突和近侧棘上、棘间韧带减压术联合内固定融合治疗且获得2年以上随访的腰椎退变性腰椎管狭窄患者124例(保留组),2016年1月至2018年2月行腰椎全椎板切除减压术联合内固定融合治疗的腰椎退变性腰椎管狭窄患者130例作为对照(全切组)。保留组男60例、女64例,年龄(58.3±10.3)岁,巨大腰椎间盘突出50例、腰椎间盘突出伴骨化11例、单纯腰椎管狭窄10例、退变性腰椎滑脱53例;全切组男62例、女68例,年龄(59.6±9.2)岁,巨大腰椎间盘突出51例、腰椎间盘突出伴骨化13例、单纯腰椎管狭窄11例、退变性腰椎滑脱55例。对两组患者手术节段数量、手术时间、术中出血量、术后住院时间、并发症、椎板保留范围、切除范围、硬膜囊面积及矢状面参数进行比较。末次随访时评估融合情况、邻椎稳定性及邻近节段退变(adjacent segment degeneration,ASD)发生率。使用Oswestry功能障碍指数(Oswestry disability index,ODI)、腰腿痛视觉模拟评分(visual analogue scale,VAS)评价临床疗效。结果保留组随访时间为(30.5±5.4)个月,全切组为(31.0±5.8)个月,差异无统计学意义(t=0.63,P=0.528)。在单节段手术患者中,保留组的手术时间[(173.6±47.3)min]、出血量[(351.7±102.0)ml]和术后住院时间[(7.8±3.1)d]均低于全切组[分别为(196.2±34.2)min、(401.9±97.2)ml、(9.9±3.6)d],差异有统计学意义(t=2.93,P=0.004;t=2.69,P=0.008;t=3.26,P<0.001)。两组硬膜囊面积术后均得到明显改善,但保留组的椎板切除范围[(22.8±4.5)mm]小于全切组[(29.5±4.8)mm],差异有统计学意义(t=7.62,P<0.001)。保留组双节段与三节段患者的上述指标均优于全切组,差异有统计学意义(P<0.05)。两组患者术后的骨盆入射角、骨盆倾斜角、骶骨倾斜角和腰椎前凸角较术前均有明显改善(P<0.05),组间差异无统计学意义(P>0.05)。末次随访时两组患者融合等级均达到BridwellⅠ、Ⅱ级。保留组邻椎不稳比例(11.3%,14/124)低于全切组(22.3%,29/130),差异有统计学意义(χ^(2)=5.48,P=0.019);保留组ASD总发生率(20.9%,26/124)低于全切组(36.2%,47/130),差异有统计学意义(χ^(2)=7.15,P=0.008);保留组中影像学ASD(16.9%,21/124)、症状性ASD(4.0%,5/124)和手术ASD(0,0/124)均低于全切组[分别为25.4%(33/130)、9.3%(12/130)、1.5%(2/130)],差异有统计学意义(χ^(2)=8.20,P=0.027)。两组患者ODI和腰、腿痛VAS评分均较术前降低,差异有统计学意义(P<0.05)。术后3个月、1年及末次随访时保留组的ODI和腰、腿痛VAS评分与全切组比较差异无统计学意义(P>0.05)。结论保留近端上半椎板减压术可以减少术中出血量,缩短手术时间和术后住院时间,达到与传统减压术相当的减压效果,同时能够降低邻椎不稳及ASD的发生率。

Objective To investigate the clinical results of decompression preserving proximal upper laminae combined with lumbar instrumental fusion in the treatment of lumbar degenerative diseases and the prevention of adjacent segment degeneration(ASD).Methods A retrospective analysis was conducted on 124 patients(the reserved group)with lumbar degeneration who underwent compression preserving proximal upper laminae combined with fusion surgery involving upper half of the lamina,upper half of the spinous process,adjacent facets,and interspinous ligament at Nanjing Drum Tower Hospital between March 2018 and February 2020.These patients were followed up for more than 2 years.Additionally,130 patients who underwent traditional total laminectomy decompression combined with fusion surgery from January 2016 to February 2018 were selected as the control group(total laminectomy group).In the reserved group,there were 60 males and 64 females,aged 58.3±10.3 years,including 50 cases of giant lumbar disc herniation,11 cases of lumbar disc herniation with ossification,10 cases of simple lumbar spinal stenosis,and 53 cases of degenerative lumbar spondylolisthesis.Total laminectomy group comprised 62 males and 68 females,aged 59.6±9.2 years,with 51 cases of giant lumbar disc herniation,13 cases of lumbar disc herniation with ossification,11 cases of simple lumbar spinal stenosis,and 55 cases of degenerative lumbar spondylolisthesis.The number of operative segments,operative time,intraoperative blood loss,postoperative hospital stay,complications,extent of laminectomy,dural sac area,and sagittal spinopelvic parameters were compared between the two groups.Fusion status,adjacent segment stability,and the incidence of ASD were assessed at the last follow-up.Oswestry disability index(ODI)and visual analogue scale(VAS)for back and leg were used to evaluate clinical effectiveness.Results The follow-up time was 30.5±5.4 months in the reserved group and 31.0±5.8 months in total laminectomy group,and the difference was not statistically significant(t=0.63,P=0.528).In patients undergoing single segment surgery,the operation time(173.6±47.3 min),blood loss(351.7±102.0 ml)and postoperative hospital stay(7.8±3.1 d)in the reserved group were lower than those in total laminectomy group(196.2±34.2 min,401.9±97.2 ml,9.9±3.6 d,respectively),and the differences were statistically significant(t=2.93,P=0.004;t=2.69,P=0.008;t=3.26,P<0.001).The dural sac area in both groups was significantly improved after surgery,but the extent of laminectomy in the reserved group(22.8±4.5 mm)was smaller than that in total laminectomy group(29.5±4.8 mm),and the difference was statistically significant(t=7.62,P<0.001).The above indicators of the patients with two segment or three segments in the reserved group were better than those in total resection group,with a statistically significant difference(P<0.05).PI,PT,SS,and LL showed significant improvement in both groups compared to preoperative values(P<0.05),with no statistically significant differences between the groups(P>0.05).At the last follow-up,both groups achieved Bridwell I or II fusion level.The proportion of adjacent vertebral instability in the reserved group(11.3%,14/124)was lower than that in total laminectomy group(22.3%,29/130),and the difference was statistically significant(χ^(2)=5.48,P=0.019).The total incidence of ASD in the reserved group(20.9%,26/124)was lower than that in total laminectomy group(36.2%,47/130),and the difference was statistically significant(χ^(2)=7.15,P=0.008).R-ASD(16.9%,21/124),S-ASD(4.0%,5/124)and O-ASD(0,0/124)in the reserved group were lower than those in total laminectomy group[(25.4%(33/130),9.3%(12/130)and 1.5%(2/130),respectively)],and the difference was statistically significant(χ^(2)=8.20,P=0.027).ODI and VAS of back and leg were significantly reduced in both groups compared to preoperative values,and the differences were statistically significant(P<0.05).There were no significant differences in ODI and VAS scores of back and leg in the reserved group compared with total laminectomy group at 3 months,1 year,and the last follow-up(P>0.05).Conclusion Decompression with preservation of the upper half of the lamina can reduce intraoperative blood loss,shorten operation time and postoperative hospital stay,achieve comparable decompression effects to traditional decompression surgery,and effectively reduce the occurrence of adjacent segment instability and ASD.