腰椎间盘突出症经皮内窥镜术后并发相邻椎间盘退变的风险预测研究

Risk Prediction of Adjacent Intervertebral Disc Degeneration after Percutaneous Endoscopic Surgery for Lumbar Disc Herniation

目的探究腰椎间盘突出症(LDH)经皮内窥镜术后并发相邻椎间盘退变的影响因素,建立术后并发相邻椎间盘退变的风险预测模型并评价其预测效能。方法回顾性分析本院2018年1月~2022年1月收治的513例经皮内窥镜治疗的LDH患者的临床资料,按照2:1的比例将其分为建模组(342例)和验证组(171例)。根据术后是否并发相邻椎间盘退变将建模组分为并发组(38例)和未并发组(304例)。采用多因素Logistic回归分析法分析LDH经皮内窥镜术后并发相邻椎间盘退变的风险因素,并采用R3.4.3软件包绘制列线图模型,采用Bootstrap法进行内、外部验证;绘制受试者工作特征(ROC)曲线对列线图预测LDH经皮内窥镜术后并发相邻椎间盘退变的效能进行分析,采用决策曲线(DCA)验证模型的临床净获益率。结果并发组年龄≥60岁、体质量指数(BMI)≥25kg/m^(2)、糖尿病史、病程≥12个月、重度腰椎间盘突出、Pfirrmann分级为Ⅳ~Ⅴ级、营养不良、术后椎间活动度≥10°患者占比以及白细胞介素-6(IL-6)、转化生长因子(TGF-β1)水平均高于未并发组(P<0.05);经多因素Logistic回归分析,年龄≥60岁、BMI≥25kg/m^(2)、糖尿病史、病程≥12个月、重度腰椎间盘突出、Pfirrmann分级为Ⅳ~Ⅴ级、营养不良、术后椎间活动度≥10°以及IL-6、TGF-β1水平升高均是LDH经皮内窥镜术后并发相邻椎间盘退变的危险因素(P<0.05)。依据以上影响因素构建的列线图模型经Bootstrap法进行建模组、验证组验证,其一致性指数分别为0.831、0.824,校正曲线和标准曲线拟合度较好;ROC曲线结果显示,建模组预测LDH经皮内窥镜术后并发相邻椎间盘退变的AUC、灵敏度、特异度分别0.826、84.21%、88.49%,验证组预测LDH经皮内窥镜术后并发相邻椎间盘退变的AUC、灵敏度、特异度分别为0.814、82.35%、83.12%;DCA曲线分析显示当患者的阈值概率为0~0.9,列线图模型进行风险评估可获得满意的净收益。结论年龄≥60岁、BMI≥25kg/m^(2)、糖尿病史、病程≥12个月、重度腰椎间盘突出、Pfirrmann分级为Ⅳ~Ⅴ级、营养不良、术后椎间活动度≥10°以及IL-6、TGF-β1水平升高均是LDH经皮内窥镜术后并发相邻椎间盘退变的危险因素,基于此构建的列线图模型可为临床筛选术后并发相邻节段椎间盘退变的高危患者提供依据。

Objective To explore the influencing factors of adjacent intervertebral disc degeneration after percutaneous endoscopic surgery for lumbar discectomy herniation(LDH),establish a risk prediction model of adjacent intervertebral disc degeneration after operation and evaluate its predictive efficacy.Methods The clinical data of 513 patients with LDH treated by percutaneous endoscopy in our hospital from January 2018 to January 2022 were retrospectively analyzed.According to the ratio of 2:1,they were divided into modeling group(342 cases)and verification group(171 cases).The modeling group was divided into concurrent group(38 cases)and non-concurrent group(304 cases)according to whether adjacent disc degeneration occurred after operation.Multivariate logistic regression analysis was used to analyze the risk factors of adjacent disc degeneration after LDH percutaneous endoscopic surgery.R3.4.3 software package was used to draw a nomogram model,and Bootstrap method was used for internal and external verification.The receiver operating characteristic(ROC)curve was drawn to analyze the efficacy of the nomogram in predicting the adjacent intervertebral disc degeneration after LDH percutaneous endoscopic surgery,and the decision curve(DCA)was used to verify the clinical net benefit rate of the model.Results The proportion of patients with age≥60 years,body mass index(BMI)≥25 kg/m^(2),history of diabetes,course of disease≥12 months,severe lumbar disc herniation,Pfirrmann grade Ⅳ~Ⅴ,malnutrition,postoperative intervertebral activity≥10°and the levels of interleukin-6(IL-6)and transforming growth factor(TGF-β1)in the concurrent group were higher than those in the non-concurrent group(P<0.05).Multivariate logistic regression analysis showed that age≥60 years old,BMI≥25 kg/m^(2),history of diabetes,course of disease≥12 months,severe lumbar disc herniation,Pfirrmann grade IV-V,malnutrition,postoperative intervertebral activity≥10°and elevated levels of IL-6 and TGF-β1 were risk factors for adjacent disc degeneration after LDH percutaneous endoscopic surgery(P<0.05).The nomogram model constructed based on the above influencing factors was verified by the Bootstrap method for the modeling group and the verification group.The consistency indexes were 0.831 and 0.824,respectively.The calibration curve and the standard curve fit well.ROC curve results showed that the AUC,sensitivity and specificity of the modeling group in predicting the adjacent intervertebral disc degeneration after LDH percutaneous endoscopic surgery were 0.826,84.21% and 88.49%,respectively.The AUC,sensitivity and specificity of the validation group in predicting the adjacent intervertebral disc degeneration after LDH percutaneous endoscopic surgery were 0.814,82.35% and 83.12%,respectively.DCA curve analysis showed that when the patient threshold probability was 0-0.9,the nomogram model could obtain satisfactory net income for risk assessment.Conclusion Age≥60 years,BMI≥25kg/m^(2),history of diabetes,course of disease≥12 months,severe lumbar disc herniation,Pfirrmann grade Ⅳ~Ⅴ,malnutrition,postoperative intervertebral activity≥10°and elevated levels of IL-6 and TGF-β1 are risk factors for adjacent disc degeneration after LDH percutaneous endoscopic surgery.The nomogram model based on this can provide a basis for clinical screening of high-risk patients with adjacent disc degeneration after surgery.