单通道内镜腰椎融合联合骨水泥强化经皮椎弓根螺钉固定治疗腰椎退行性疾病的临床疗效

Clinical effect of single-channel endoscopic lumbar fusion combined with bone cement-augmented percutaneous pedicle screws

目的探讨单通道内镜下腰椎管减压椎间融合术联合骨水泥强化经皮椎弓根螺钉固定治疗腰椎退行性疾病的临床疗效。方法回顾性队列研究。纳入2021年1月—2022年12月南京医科大学附属淮安第一医院骨科的腰椎退行性疾病患者60例,其中男26例、女34例,年龄60~84(69.8±4.7)岁。60例患者均采用单通道内镜下腰椎管减压椎间融合术治疗,根据术中是否应用骨水泥强化经皮椎弓根螺钉分为2组:非强化组患者32例,在腰椎管减压、椎间融合器后,直接行经皮椎弓根钉棒系统固定;强化组患者28例,采用经中空椎弓根螺钉注入骨水泥后行经皮椎弓根钉棒系统固定。观察2组患者围手术期和随访期手术相关并发症发生情况,采用腰痛觉视觉模拟评分法(VAS)评分、Oswestry功能障碍指数(ODI)、邻近椎间隙高度、固定节段Cobb角丢失等指标评价并比较2组患者临床疗效。结果2组患者的年龄、性别、骨密度、BMI等基线资料比较,差异均无统计学意义(P值均>0.05)。所有患者手术顺利,其中强化组3例患者术中发现骨水泥渗漏,强化组和非强化组各1例患者术中发生神经根外膜撕裂,经处理或观察未发生严重后果。患者术后均获随访10~18(12.8±2.6)个月。组内比较,强化组和非强化组术后1个月、末次随访与术前相比,VAS评分、ODI、邻近椎间隙高度明显降低,术前分别为(7.3±1.5)分和(7.5±1.3)分、33.3%±5.1%和34.0%±4.8%、(6.62±1.37)mm和(6.59±1.47)mm,术后1个月时分别为(1.7±0.8)分和(2.4±0.6)分、14.7%±2.9%和15.1%±2.8%、(6.12±1.29)mm和(5.96±1.11)mm,末次随访时分别为(1.3±1.0)分和(1.5±0.9)分、9.2%±2.9%和10.1%±2.2%、(4.32±0.97)mm和(5.22±1.10)mm;固定节段Cobb角明显升高,术前分别为15.20°±3.38°和14.73°±2.48°,术后1个月时分别为27.06°±1.55°和26.58°±2.28°,末次随访时分别为26.42°±1.51°和23.43°±2.15°:3个时间点比较差异均有统计学意义(P值均<0.05)。组间比较,术后1个月VAS评分及末次随访时邻近椎间隙高度、固定节段Cobb角比较,差异均有统计学意义(t=3.60、3.36、6.14,P值均<0.05),其余时间点比较差异均无统计学意义(P值均>0.05)。结论与非骨水泥强化的单通道内镜下腰椎管减压椎间融合术相比,应用骨水泥强化经皮椎弓根螺钉的单通道内镜下腰椎管减压椎间融合术同样能够实现椎管的有效减压,且有助于维持骨质疏松患者术后早期的椎间稳定性,但可能加速邻近椎间隙的退变,不应常规作为预防螺钉松动的处理措施。

Objective This study aimed to observe the clinical efficacy of single-channel endoscopic lumbar interbody fusion bone cement-augmented percutaneous pedicle screws in the treatment of lumbar degenerative diseases.Methods A retrospective cohort study was employed in this work.The study included 60 patients(26 males and 34 females)with lumbar degenerative diseases,aged 60-84(69.8±4.7)years,who were treated with single-channel endoscopic lumbar decompression and interbody fusion in the Department of Orthopedics of our hospital from January 2021 to December 2022.According to whether bone cement was used to strengthen percutaneous pedicle screws during operation,the patients were divided into the enhanced and the nonenhanced group.A percutaneous pedicle screw system was applied directly in the nonenhanced group,and PMMA bone cement was injected through hollow pedicle screws in the enhanced group.The incidence of surgery-related complications during the perioperative and follow-up periods was observed,and the clinical efficacy of the two groups was compared in terms of visual analogue scale(VAS)score,Oswestry disability index(ODI)score,adjacent vertebral space height,and Cobb angle loss at a fixed level.Results There were no significant differences in age,gender,bone mineral density,BMI and other baseline data between 2 groups(all P values>0.05).All patients underwent successful surgery.Bone cement leakage was found in three patients in the enhanced group,and nerve root tearing occurred in two patients during operation.All patients were followed up for 10-18(12.8±2.6)months.One month after surgery,the VAS score,ODI score,and the height of adjacent intervertebral space of the enhanced and nonenhanced groups decreased significantly,i.e.,from(7.3±1.5)points and(7.5±1.3)points,33.3%±5.1%and 34.0%±4.8%,and(6.62±1.37)mm and(6.59±1.47)mm to(1.7±0.8)points and(2.4±0.6)points,14.7%±2.9%and 15.1%±2.8%,and(6.12±1.29)mm and(5.96±1.11)mm,respectively;at the last follow-up,they were(1.3±1.0)points and(1.5±0.9)points,9.2%±2.9%and 10.1%±2.2%,(4.32±0.97)mm and(5.22±1.10)mm,respectively.The Cobb angle of the fixed segment significantly increased,i.e.,from 15.20°±3.38°and 14.73°±2.48°before surgery to 27.06°±1.55°and 26.58°±2.28°one month after surgery,respectively;at the last follow-up,they were 26.42°±1.51°and 23.43°±2.15°,respectively,the difference of the three time points was statistically significant(all P values<0.05).No significant differences were found between the two groups at other time points(all P values>0.05),except for the VAS score one month after surgery and the height of adjacent intervertebral space and Cobb angle at the last follow-up(t=3.60,3.36,6.14;all P values<0.05).Conclusion Bone cement-augmented percutaneous pedicle screws can help maintain early intervertebral stability and promote intervertebral fusion in patients with osteoporosis after single-channel endoscopic lumbar interbody fusion but may accelerate the degeneration of the adjacent vertebral space and thus should not be used as a routine treatment measure to prevent screw loosening.