微创与开放后路腰椎椎体间融合术的远期疗效对比研究

摘要

Objective To compare the long-term effect between minimally invasive (MIS) and open approaches in one-level posterior lumbar interbody fusion (O-PLIF) after more than 10 years follow up. Methods All 131 patients (lumbar spine le-sions) in our hospital were randomized into MIS-PLIF group and O-PLIF group from March 2006 to March 2008. In MIS-PLIF group, there are 66 patients, 34 males and 32 females, with the average of 52.3 ± 6.7 years old (range from 40 to 63). In O-PLIF group, there are 65 patients, 29 males and 36 females, with the average of 51.1 ± 6.9 years old (range from 46 to 63). Regarding March 2018 as last follow-up, differences in intervertebral disc height and segmental lordosis restoration of the operation segment , lumbar lordosis restoration, multifidus cross section area (CSA), multifidus atrophy rate, fusion rate, visual analogue scale (VAS) for back and leg pain, Oswestry Disability Index(ODI), Japanese Orthopaedic Association cores (JOA) and postoperative long-term compli-cations were evaluated between the two groups. The related risk factors of postoperative long-term complications were evaluated in further analysis. Results Complete follow-up data were available on 37 patients in MIS-PLIF group and 35 patients in O-PLIF group, with the follow-up rate of 56.1％and 53.8％respectively,and with the mean follow-up time of 134.5 ±8.4 and 137.1±5.8 months respectively. At three time nodes of one year after operation, five years after operation and last follow-up after operation, there were significant differences in lumbar lordosis restoration (one year after operation and last follow-up after operation)( 5.0°± 2.3° vs. 3.9°±1.4°;4.7°±2.4° vs. 3.7°±1.5°), multifidus CSA (965.4±164.9 mm2 vs. 884.9±168.2 mm2;891.1±155.9 mm2 vs. 783.2± 163.0 mm2; 764.8 ± 148.3 mm2 vs. 643.5 ± 150.0 mm2), multifidus atrophy rate (8.5％± 2.5％ vs. 16.6％± 5.8％; 15.6％± 3.5％ vs. 26.2％±7.4％;27.6％±6.5％vs. 39.3％±9.3％), postoperative VAS for back pain (2.2±1.0 vs. 2.9±1.2;1.7±0.9 vs. 2.2±1.0;1.4±1.0 vs. 2.2±1.2), JOA score (22.3±3.8 vs. 19.9±4.2;23.1±4.3 vs. 19.3±3.9;22.4±4.2 vs. 19.6±4.0) and ODI (11.6％±4.8％vs. 22.0％± 7.7％;9.4％±3.9％vs. 12.3％±4.9％;8.6％±4.0％vs. 11.0％±4.6％) between the two groups (P<0.05). However, there were no sig-nificant differences in segmental lordosis, intervertebral height restoration, lumbar lordosis restoration (one year after operation), fusion rate or postoperative VAS for leg pain between MIS-PLIF and O-PLIF(P>0.05). Intractable back pain and adjacent segment disease were the major postoperative long-term complications for MIS-PLIF group (3 cases and 2 cases) and O-PLIF group (10 cas-es and 7 cases), and the difference was statistically significant in the intractable back pain incidence rate ( 8.5％vs. 28.6％,χ2=5.090, P=0.024), but not in the adjacent segment disease(5.4％vs. 20％,χ2=0.002, P=0.061). What's more, patients with intracta-ble back pain suffered more obviously multifidus atrophy than patients without intractable back pain at three time nodes of one year after operation (19.4±4.4％vs. 10.9±5.1％, P<0.05), five years after operation (30.2±5.4％vs. 18.7±6.7％, P<0.05) and last fol-low-up after operation (44.5±5.7％vs. 30.8±8.9％, P<0.05) . Conclusion In the long-term follow up, compared with O-PLIF, MIS-PLIF had advantages in better maintenance of lumbar lordosis, protection of the multifidus muscle, reduced lower back pain, JOA score, ODI score and intractable back pain incidence rate. Multifidus atrophy may be a related risk factor of intractable back pain.%目的 前瞻性对比微创与开放后路单节段腰椎椎体间融合术(posterior lumbar interbody fusion,PLIF)的远期疗效.方法 2006年3月1日至2008年3月1日期间131例腰椎退变患者,随机分为微创组和开放组,分别施以微创和开放单节段PLIF手术.微创组66例,男34例,女32例,年龄40～63岁,平均(52.3±6.7)岁;开放组65例,男29例,女36例,年龄46～63岁,平均(51.1±6.9)岁.对上述病例进行术后随访,以2018年3月1日作为末次随访的时间节点,比较两组患者术后手术节段椎间隙高度、节段性前凸角和腰椎前凸角的恢复,多裂肌横截面积和萎缩率,腰椎融合率,腰部及下肢疼痛视觉模拟评分(visual analog scale,VAS),日本骨科协会(Japanese Orthopaedic Association cores,JOA)评分,Oswestry功能障碍指数(Oswestry Disability Index,ODI)以及术后中、远期并发症发生情况,并分析术后中、远期并发症的相关危险因素.结果 微创组和开放组分别成功随访37例和35例,随访率分别为56.1％和53.8％,随访时间分别平均为(134.5±8.4)个月和(137.1±5.8)个月.在术后1年,术后5年及末次随访三个时间节点,微创组在腰椎前凸角恢复值(术后5年5.0°±2.3°vs.3.9°±1.4°;末次随访4.7°±2.4°vs.3.7°±1.5°),多裂肌横截面积[(965.4±164.9)mm2 vs.(884.9±168.2)mm2;(891.1±155.9)mm2 vs.(783.2±163.0)mm2;(764.8±148.3)mm2 vs.(643.5±150.0)mm2],多裂肌萎缩率(8.5％±2.5％vs.16.6％±5.8％;15.6％±3.5％vs.26.2％±7.4％;27.6％±6.5％vs.39.3％±9.3％),腰痛VAS评分[(2.2±1.0)分vs.(2.9±1.2)分;(1.7±0.9)分vs.(2.2±1.0)分;(1.4±1.0)分vs.(2.2±1.2)分],腰椎JOA评分[(22.3±3.8)分vs.(19.9±4.2)分;(23.1±4.3)分vs.(19.3±3.9)分;(22.4±4.2)分vs.(19.6±4.0)分]及ODI(11.6％±4.8％vs.22.0％±7.7％;9.4％±3.9％vs.12.3％±4.9％;8.6％±4.0％vs.11.0％±4.6％)均优于开放组,差异均有统计学意义(P<0.05);而在手术节段椎间隙高度恢复值、节段性前凸角恢复值、腰椎前凸角恢复值(术后1年)、腰椎融合率及下肢痛VAS评分,两组的差异均无统计学意义(P>0.05).顽固性腰背痛和邻椎病是微创组(3例、2例)和开放组(10例、7例)术后主要的中、远期并发症,微创组顽固性腰背痛发生率较开放组明著降低(8.5％vs.28.6％,χ2=5.090,P=0.024),微创组邻椎病发生率较开放组存在降低趋势(5.4％vs.20％,χ2=0.002,P=0.061).顽固性腰背痛患者多裂肌的萎缩率在术后1年(19.4％±4.4％vs.10.9％±5.1％),术后5年(30.2％±5.4％vs.18.7％±6.7％)及末次随访(44.5％±5.7％vs.30.8％±8.9％)均明显高于无顽固性腰背痛患者(P<0.05).结论 与开放手术相比,微创单节段PLIF手术具有腰椎前凸角维持好,多裂肌萎缩程度轻,腰痛VAS评分、JOA评分和ODI缓解明显,顽固性腰背痛发生率低等优点;PLIF术后多裂肌萎缩可能是顽固性腰背痛发生的一个危险因素.