椎弓回植与椎板切除治疗轻中度峡部裂性腰椎滑脱症疗效比较
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摘要
目的比较椎弓回植与椎板切除治疗单节段峡部裂性腰椎滑脱症的临床疗效。方法回顾分析2014年3月—2016年7月采用椎弓回植或椎板切除治疗的66例单节段峡部裂性腰椎滑脱症患者临床资料,根据手术方式不同分为试验组(34例,采用椎弓完整回植固定椎间融合内固定术)和对照组(32例,采用椎板切除并椎间融合内固定术)。两组患者性别、年龄、病程、病变节段、Meyerding分度及术前疼痛视觉模拟评分(VAS)、Oswestry功能障碍指数(ODI)、日本骨科协会(JOA)评分等一般资料比较差异,均无统计学意义(P>0.05),具有可比性。记录并比较两组患者手术时间、术中出血量、并发症情况、术后试验组回植椎弓融合情况及两组硬膜外瘢痕形成情况。术前及术后3、6、12个月和末次随访时行腰痛VAS评分、JOA评分及ODI评分,并参照侯树勋等提出的标准进行临床疗效评价。结果所有患者均顺利完成手术,无神经损伤加重、硬脊膜撕裂、感染等并发症发生。试验组手术时间与对照组比较差异无统计学意义(t=0.583,P=0.562),但术中出血量显著低于对照组(t=2.134,P=0.037)。66例患者均获随访,随访时间13～18个月,平均16.2个月。所有患者术后临床症状明显改善。对照组7例于术后3个月发现体位变动时椎管狭窄症状,5例于术后18个月出现轻度双下肢麻木症状;其余患者未发生感染、神经损伤等并发症。试验组34例硬膜外瘢痕组织均被完全阻滞于回植椎弓以外,对照组有11例硬膜外瘢痕组织侵入椎管内。末次随访时试验组椎间植骨及椎弓回植融合率均为100%,对照组椎间植骨融合率亦为100%。两组术后各时间点VAS评分、ODI评分、JOA评分均较术前显著改善(P<0.01);试验组术后3个月和末次随访时ODI评分、JOA评分显著优于对照组(P<0.05),其余时间点两组间各评分比较差异无统计学意义(P>0.05)。参照侯树勋等提出的标准进行临床疗效评价,试验组优良率为91.2%,与对照组优良率84.4%比较差异无统计学意义(χ2=1.092,P=0.573)。结论与椎板切除相比,椎弓回植能更好地改善术后神经症状,最大程度重建了骨性椎管,恢复了椎管内环境稳定性,对于峡部裂性腰椎滑脱是一种较好的手术方式。
Objective To compare the effectiveness of vertebral arch replantation and laminectomy in the treatment of mild to moderate isthmic spondylolisthesis. Methods The clinical data of 66 patients with isthmic spondylolisthesis treated with vertebral arch replantation or laminectomy between March 2014 and July 2016 were retrospectively analyzed. They were divided into trial group(34 cases, treated with complete replantation of vertebral arch,intervertebral fusion, and internal fixation) and control group(32 cases, treated with laminectomy with intervertebral fusion and internal fixation) according to different surgical methods. There was no significant difference in general data of gender, age, disease duration, lesion segment, Meyerding grade, and preoperative visual analogue scale(VAS) score,Oswestry disability index(ODI) score, Japanese Orthopaedic Association(JOA) score between the two groups(P>0.05).The operation time, intraoperative blood loss, complications, vertebral arch fusion of trial group, and epidural scar formation of the two groups were recorded. The VAS score, JOA score, and ODI score were evaluated at preoperation, 3,6, 12 months after operation, and at last follow-up. The effectiveness was evaluated according to HOU Shuxun's criteria.Results All the patients successfully completed the surgery, without any aggravation of nerve injury, dural tear, infection,etc. There was no significant difference in the operation time between the two groups(t=0.583, P=0.562), but the intraoperative blood loss was significantly lower in the trial group than that in the control group(t=2.134, P=0.037). All the 66 patients were followed up 13-18 months(mean, 16.2 months). Postoperative clinical symptoms of all patients were significantly improved. In the control group, 7 cases were found to have symptoms of spinal canal stenosis with postoperative posture changes at 3 months after operation, and 5 cases showed mild lower limb numbness at 18 months after operation. No complication such as infection and nerve injury occurred in other patients. In the trial group, 34 cases of epidural scar tissue were completely blocked outside the replantation vertebral arch, while in the control group, 11 cases of epidural scar tissue invaded the spinal canal. At last follow-up, the fusion rate of intervertebral bone grafting and vertebral arch replantation in the trial group was 100%, and the fusion rate of intervertebral bone grafting in the control group was also 100%. The VAS score, ODI score, and JOA score were significantly improved at each time point after operation(P<0.01). The ODI score and JOA score of the trial group were significantly better than those of the control group at 3 months after operation and at last follow-up(P<0.05), and there was no significant difference in scores between the two groups at other time points(P>0.05). According to HOU Shuxun's criteria, the excellent and good rate was91.2% in the trial group and 84.4% in the control group, showing no significant difference(χ~2=1.092, P=0.573).Conclusion Compared with laminectomy, vertebral arch replantation can better improve postoperative neurological symptoms, maximize the reconstruction of the bone spinal canal, restore the stability of the intraspinal environment, and it is a better surgical method for lumbar isthmic spondylolisthesis.
Objective To compare the effectiveness of vertebral arch replantation and laminectomy in the treatment of mild to moderate isthmic spondylolisthesis. Methods The clinical data of 66 patients with isthmic spondylolisthesis treated with vertebral arch replantation or laminectomy between March 2014 and July 2016 were retrospectively analyzed. They were divided into trial group(34 cases, treated with complete replantation of vertebral arch,intervertebral fusion, and internal fixation) and control group(32 cases, treated with laminectomy with intervertebral fusion and internal fixation) according to different surgical methods. There was no significant difference in general data of gender, age, disease duration, lesion segment, Meyerding grade, and preoperative visual analogue scale(VAS) score,Oswestry disability index(ODI) score, Japanese Orthopaedic Association(JOA) score between the two groups(P>0.05).The operation time, intraoperative blood loss, complications, vertebral arch fusion of trial group, and epidural scar formation of the two groups were recorded. The VAS score, JOA score, and ODI score were evaluated at preoperation, 3,6, 12 months after operation, and at last follow-up. The effectiveness was evaluated according to HOU Shuxun's criteria.Results All the patients successfully completed the surgery, without any aggravation of nerve injury, dural tear, infection,etc. There was no significant difference in the operation time between the two groups(t=0.583, P=0.562), but the intraoperative blood loss was significantly lower in the trial group than that in the control group(t=2.134, P=0.037). All the 66 patients were followed up 13-18 months(mean, 16.2 months). Postoperative clinical symptoms of all patients were significantly improved. In the control group, 7 cases were found to have symptoms of spinal canal stenosis with postoperative posture changes at 3 months after operation, and 5 cases showed mild lower limb numbness at 18 months after operation. No complication such as infection and nerve injury occurred in other patients. In the trial group, 34 cases of epidural scar tissue were completely blocked outside the replantation vertebral arch, while in the control group, 11 cases of epidural scar tissue invaded the spinal canal. At last follow-up, the fusion rate of intervertebral bone grafting and vertebral arch replantation in the trial group was 100%, and the fusion rate of intervertebral bone grafting in the control group was also 100%. The VAS score, ODI score, and JOA score were significantly improved at each time point after operation(P<0.01). The ODI score and JOA score of the trial group were significantly better than those of the control group at 3 months after operation and at last follow-up(P<0.05), and there was no significant difference in scores between the two groups at other time points(P>0.05). According to HOU Shuxun's criteria, the excellent and good rate was91.2% in the trial group and 84.4% in the control group, showing no significant difference(χ~2=1.092, P=0.573).Conclusion Compared with laminectomy, vertebral arch replantation can better improve postoperative neurological symptoms, maximize the reconstruction of the bone spinal canal, restore the stability of the intraspinal environment, and it is a better surgical method for lumbar isthmic spondylolisthesis.
引文
1王林锋,陆成武,陈小杰,等.棘突椎板复合体回植联合空心螺钉固定在胸腰椎椎管内肿瘤切除术中的应用.中国脊柱脊髓杂志,2017, 27(9):795-799.
2金国良,梁文清.椎板棘突后方韧带复合体回植在椎管内肿瘤切除术中的应用.中国骨与关节损伤杂志,2017, 32(3):285-286.
3 Kotil K, Akcetin M, Tari R, et al. Replacement of vertebral lamina(laminoplasty)in surgery for lumbar isthmic spondylolisthesis. A prospective clinical study. Turk Neurosurg, 2009,19(2):113-120.
4 Kadir Kotil. Replacement of vertebral lamina(laminoplasty)in surgery for lumbar isthmic spondylolisthesis:5-year follow-up results. Asian Spine J, 2016, 10(3):443-449.
5段大鹏,陈志龙,徐洪海,等.椎板截骨原位回植椎间融合术治疗单节段腰椎退行性疾病疗效分析.中国骨伤,2018, 31(4):347-353.
6 Sakeb N,Ahsan K. Comparison of the early results of transforaminal lumbar interbody fusion and posterior lumbar interbody fusion in symptomatic lumbar instability. Indian J Orthop, 2013,47(3):255-263.
7侯树勋,史亚明,吴闻文,等.腰椎滑脱症手术治疗适应症和术式选择.中华骨科杂志,1998,18(12):707-710.
8 Park MS, Moon SH, Kim TH, et al. Asymptomatic stenosis in the cervical and thoracic spines of patients with symptomatic lumbar stenosis. Global Spine J, 2015, 5(5):366-371.
9胥鸿达,刘佳男,李宏达,等.腰椎峡部裂滑脱相邻节段三维瞬时运动特征的在体研究.中国修复重建外科杂志,2018, 32(12):1560-1566.
10 Lozano-alvarez C, Perez-Prieto D, Salo-Bru G, et al.Can epidemiological factors affect the 2-year outcomes after surgery for degenerative lumbar disease in terms of quality of life, disability and post-surgical pain? Rev Esp Cir Ortop Traumatol, 2014, 58(2):78-84.
11 Invergo D, Googe M, Seibly J. Indications for lumbar fusion in degenerative spine disease. Tech Region Anesthesia Pain Manag,2013,17(2):43-47.
12 Duggal N, Mendiondo I, Pares HR, et al. Anterior lumbar interbody fusion for treatment of failed back surgery syndrome:an outcome analysis. Neurosurgery, 2004, 54(3):636-463.
13 Sucu HK, Sevin IE, Rezanko T, et al. Prevention of anterior scar formation following discectomy with a MediShield adhesion barrier:randomized experimental trial. Turk Neurosurg, 2013,23(3):317-322.
14陈建民,刘国印,贾小宝,等.椎板回植椎管重建内固定术的生物力学研究.中国矫形外科杂志,2017,25(24):2262-2268.
15 Albinana-Cunningham J N, Ripalda-Cemborain P, Labiano T, et al.Mechanical barriers and transforming growth factor beta inhibitor on epidural fibrosis in a rabbit laminectomy model. J Orthopa Surg Res, 2018, 13(1):72.
16邹德威,欧阳甲,阮狄克,等.关于腰椎滑脱治疗中一些问题的讨论.中国脊柱脊髓杂志,2006,16(1):17-10.
17华强,赵慧毅,陈辉东,等.腰椎板棘突复合体回植椎板交叉螺钉固定重建腰椎椎管的研究.脊柱外科杂志,2008, 6(2):92-94.
18 Wang H, Sun W, Fu D, et al. Update on biomaterials for prevention of epidural adhesion after lumbar laminectomy. J Orthop Translat, 2018, 13:41-49.
2金国良,梁文清.椎板棘突后方韧带复合体回植在椎管内肿瘤切除术中的应用.中国骨与关节损伤杂志,2017, 32(3):285-286.
3 Kotil K, Akcetin M, Tari R, et al. Replacement of vertebral lamina(laminoplasty)in surgery for lumbar isthmic spondylolisthesis. A prospective clinical study. Turk Neurosurg, 2009,19(2):113-120.
4 Kadir Kotil. Replacement of vertebral lamina(laminoplasty)in surgery for lumbar isthmic spondylolisthesis:5-year follow-up results. Asian Spine J, 2016, 10(3):443-449.
5段大鹏,陈志龙,徐洪海,等.椎板截骨原位回植椎间融合术治疗单节段腰椎退行性疾病疗效分析.中国骨伤,2018, 31(4):347-353.
6 Sakeb N,Ahsan K. Comparison of the early results of transforaminal lumbar interbody fusion and posterior lumbar interbody fusion in symptomatic lumbar instability. Indian J Orthop, 2013,47(3):255-263.
7侯树勋,史亚明,吴闻文,等.腰椎滑脱症手术治疗适应症和术式选择.中华骨科杂志,1998,18(12):707-710.
8 Park MS, Moon SH, Kim TH, et al. Asymptomatic stenosis in the cervical and thoracic spines of patients with symptomatic lumbar stenosis. Global Spine J, 2015, 5(5):366-371.
9胥鸿达,刘佳男,李宏达,等.腰椎峡部裂滑脱相邻节段三维瞬时运动特征的在体研究.中国修复重建外科杂志,2018, 32(12):1560-1566.
10 Lozano-alvarez C, Perez-Prieto D, Salo-Bru G, et al.Can epidemiological factors affect the 2-year outcomes after surgery for degenerative lumbar disease in terms of quality of life, disability and post-surgical pain? Rev Esp Cir Ortop Traumatol, 2014, 58(2):78-84.
11 Invergo D, Googe M, Seibly J. Indications for lumbar fusion in degenerative spine disease. Tech Region Anesthesia Pain Manag,2013,17(2):43-47.
12 Duggal N, Mendiondo I, Pares HR, et al. Anterior lumbar interbody fusion for treatment of failed back surgery syndrome:an outcome analysis. Neurosurgery, 2004, 54(3):636-463.
13 Sucu HK, Sevin IE, Rezanko T, et al. Prevention of anterior scar formation following discectomy with a MediShield adhesion barrier:randomized experimental trial. Turk Neurosurg, 2013,23(3):317-322.
14陈建民,刘国印,贾小宝,等.椎板回植椎管重建内固定术的生物力学研究.中国矫形外科杂志,2017,25(24):2262-2268.
15 Albinana-Cunningham J N, Ripalda-Cemborain P, Labiano T, et al.Mechanical barriers and transforming growth factor beta inhibitor on epidural fibrosis in a rabbit laminectomy model. J Orthopa Surg Res, 2018, 13(1):72.
16邹德威,欧阳甲,阮狄克,等.关于腰椎滑脱治疗中一些问题的讨论.中国脊柱脊髓杂志,2006,16(1):17-10.
17华强,赵慧毅,陈辉东,等.腰椎板棘突复合体回植椎板交叉螺钉固定重建腰椎椎管的研究.脊柱外科杂志,2008, 6(2):92-94.
18 Wang H, Sun W, Fu D, et al. Update on biomaterials for prevention of epidural adhesion after lumbar laminectomy. J Orthop Translat, 2018, 13:41-49.