类风湿关节炎合并腰椎退行性疾病患者腰椎椎间融合术后邻近节段退行性变的相关因素

目的探讨类风湿关节炎(RA)合并腰椎退行性疾病患者腰椎椎间融合术后发生邻近节段退行性变(ASD的危险因素。方法回顾性分析2008年1月—2016年12月收治的55例RA合并腰椎退行性疾病患者的临床资料,其中29例采用减压并椎间融合术(融合组)治疗,26例采用单纯减压术(非融合组)治疗。记录手术前后红细胞沉降率(ESR)、C反应蛋白(CRP)、基质金属蛋白酶-3(MMP-3)等指标,采用28个关节疾病活动度评分联合CRP水平(DAS28-CRP)评估RA活动度;采用日本骨科学会(JOA)评分评估患者神经功能;测量X线片上腰椎邻近节段头端椎间隙狭窄及椎体滑脱程度以评估ASD情况。运用多因素logistic回归分析检验术后继发ASD的危险因素。结果所有手术顺利完成,术后随访1.5～6.0年,平均3.2年。2组术后JOA评分较术前均明显改善,且融合组显著高于非融合组,差异均有统计学意义(P 0.05)。融合组手术翻修率、影像学ASD及症状性ASD发生率显著高于非融合组,差异均有统计学意义(P 0.05)。多因素logistic回归分析显示,DAS28-CRP评分 4.7分、术前血清MMP-3含量升高是术后继发ASD的独立危险因素。结论 RA合并腰椎退行性疾病患者采用腰椎减压并椎间融合术治疗后出现ASD和需行翻修手术的风险高于采用单纯减压术治疗的患者,术前血清MMP-3含量和DAS28-CRP评分升高可能与腰椎椎间融合术后ASD的发生相关。

Factors related to adjacent segment degeneration after lumbar interbody fusion in patients with rheumatoid arthritis and degenerative lumbar diseases

Objective To explore the risk factors of adjacent segmental degeneration (ASD) after lumbar interbody fusion in patients with rheumatoid arthritis (RA) and lumbar degenerative diseases. Methods The clinical data of 55 patients with RA and lumbar degenerative diseases from January 2008 to December 2016 were analyzed retrospectively. Among them, 29 patients underwent lumbar decompression and interbody fusion (fusion group) and 26 did simple decompression (non-fusion group). Preoperative and postoperative erythrocyte sedimentation rate (ESR), C-reactive protein (CRP) and matrix metalloproteinase 3 (MMP-3) were recorded. The disease activity score of 28 joints combined with CRP levels (DAS28-CRP) was used to evaluate the RA activity. The Japanese Orthopaedic Association(JOA) score was used to evaluate the neurological function. The intervertebral space and spondylolisthesis of the lumbar adjacent cranial segment on roentgenograph were measured to evaluate the ASD status. The multivariate logistic regression analysis was used to determine the risk factors of postoperative ASD. Results All the operations were successfully completed. The follow-up time was 1.5-6.0 years, with an average of 3.2 years. The postoperative JOA scores of the 2 groups were significantly improved compared with those of the pre-operation, and the fusion group was significantly higher than the non-fusion group, all with statistically significant differences (P<0.05). The rate of revision, radiologic ASD and symptomatic ASD in the fusion group were significantly higher than those of the non-fusion group, all with statistically significant differences (P<0.05). The multivariate logistic regression analysis showed that the DAS28-CRP score > 4.7 and preoperative MMP-3 elevation were independent risk factors for postoperative ASD. Conclusion The risk of ASD and revision surgery in patients with RA and lumbar degenerative diseases after lumbar decompression and interbody fusion is higher than that in patients treated with decompression alone, and the increased preoperative MMP-3 and DAS28-CRP scores may be related to development of ASD after lumbar interbody fusion.