腰椎两种不同椎间融合方式终板损伤的病例对照研究

目的:总结并比较肌间隙入路通道下经椎间孔椎间融合联合椎弓根螺钉固定方式与斜外侧椎间融合联合椎弓根螺钉固定方式治疗腰椎病变终板损伤的特点与临床结果。方法:回顾性分析2016年1月至2019年6月收治的213例腰椎病变患者,男73例,女140例;年龄24~81(54.9±10.5)岁;病程6~180(40.30±28.71)个月;腰椎间盘退行性病变35例,巨大型腰椎间盘突出症22例,椎间盘源性腰痛15例,炎症转归期原发性腰椎间隙炎9例,腰椎管狭窄症52例,腰椎退行性滑脱47例,腰椎椎弓峡部裂伴或不伴椎体滑脱33例;单节段191例(L_2,3 5例、L_3,4 24例、L_4,5 162例),双节段22例(L_2,3和L_3,4 3例、L_3,4和L_4,5 19例)。采用后方肌间隙入路通道下双侧椎弓根螺钉固定并椎间融合术110例(后路融合组),斜外侧椎间融合联合后方肌间隙入路通道下双侧椎弓根螺钉固定术103例(斜外侧融合组)。观察两组患者终板损伤的发生特点,并比较两组患者的临床和影像结果及并发症情况。结果:后路融合组发生终板损伤8例9个节段,发生率7.27%(8/110),男1例,女7例,年龄(63.22±3.51)岁;8例中术前存在骨量减少或骨质疏松7例;使用香蕉型融合器5例,解剖型融合器3例;发生于椎体上终板3个节段,椎体下终板6个节段。斜外侧融合组发生终板损伤21例24个节段,发生率20.39%(21/103),男4例,女17例,年龄(62.50±5.02)岁;21例中术前存在骨量减少或骨质疏松16例;使用融合器偏大(指融合器高度)5例,终板解剖形态异常4例,髂嵴过高3例;发生于椎体上终板20个节段,椎体下终板4个节段;21例终板损伤中合并椎体骨折2例。后路融合组终板损伤发生率低于斜外侧融合组。两组患者均未发生切口感染,随访时间12~48个月,中位数12个月。随访中后路融合组出现融合器沉降22例,斜外侧融合组43例,两组各发生1例融合器移位,均无内固定松动、移位或断裂。斜外侧融合组并发症发生率33.98%(35/103),高于后路融合组23.64%(26/110),两组比较差异有统计学意义(P=0.039)。两组患者术后椎间隙高度均获得良好的恢复,但在随访时出现不同程度的丢失。融合率后路融合组为94.5%(104/110),斜外侧融合组为96.1%(99/103),两组差异无统计学意义(P=0.083)。末次随访时两组患者临床症状均得到明显改善。结论:两种方法治疗单或双节段腰椎病变均能获得良好的临床效果。两种融合方式终板损伤的特点不完全相同。虽然两种固定融合方式的终板损伤没有影响最终的临床结果,但仍需要加以重视,做好终板损伤的预防和有效处理,尤其是对于斜外侧椎间融合方式。

Case-control study on endplate injury of lumbar spine with two different intervertebral fusion methods

Objective: To summarize and compare the endplate injury occurrence characteristics and clinical results of transforaminal intervertebral fusion combined with pedicle screw fixation through intermuscular approach and oblique lateral intervertebral fusion combined with pedicle screw fixation in the treatment of lumbar disease. Methods: A retrospective analysis of 213 cases of lumbar disease admitted from January 2016 to June 2019,including 73 males and 140 females. The age ranged from 24 to 81 years old,with an average of(54.9±10.5) years old. The courses of disease ranged from 6 to 180 months,with an average of (40.30±28.71) months. There were 35 cases of degenerative lumbar intervertebral disc disease,22 cases of giant lumbar disc herniation,15 cases of discogenic low back pain,9 cases of primary lumbar intervertebral inflammation at the turn of inflammation,52 cases of lumbar spinal stenosis,47 cases of lumbar degenerative spondylolisthesis,33 cases of lumbar spondylolysis with or without spondylolisthesis. There were 191 cases of single-segment lesions,including 5 cases on L_2,3,24 cases on L_3,4,162 cases on L_4,5. And there were 22 cases of two-segment lesions,including 3 cases on L_2,3 and L_3,4,and 19 cases on L_3,4 and L_4,5. One hundred and ten cases were taken by bilateral pedicle screw fixation and interbody fusion under the posterior muscle space approach (abbreviated as posterior fusion group),and 103 cases were taken by oblique lateral interbody fusion combined with bilateral pedicle screw fixation under the posterior muscle space approach (oblique lateral fusion group). Observed the characteristics of endplate injury in the two groups,and compared the clinical and imaging results and complications of the two groups. Results: There were 8 cases of endplate injury occurred in 9 segments in the posterior fusion group. According to the number of cases,the incidence rate was 7.27%(8/110),1 case was male,7 cases were female,with an average age of (63.22±3.51) years old. Among the 8 cases,there were 7 cases of bone loss or osteoporosis before the operation,5 cases using banana fusion cages,3 cases using anatomical fusion cages. Three cases occurred in the upper endplate of the vertebral body and 6 cases in the inferior endplate of the vertebral body. In the oblique lateral fusion group,there were 21 cases of endplate injury in 24 segments,and the incidence rate was 20.39%(21/103). There were 4 males and 17 females, with an average age of (62.50±5.02) years old. Among the 21 cases,16 cases were bone loss or osteoporosis before operation. There were 5 cases used large fusion cages,4 cases had abnormal endplate anatomy,and 3 cases had iliac crest hypertrophy. It occurred in 20 segments of the upper endplate of the vertebral body,and 4 segments of the lower endplate of the vertebral body. Two of the 21 cases of endplate injury combined with vertebral body fractures. The incidence of endplate injury of the posterior fusion group was significantly lower than that of the oblique lateral fusion group. No incision infection occurred in the two groups,the follow-up time was ranged from 12 to 48 months,and the median follow-up period was 12 months. In the follow-up,22 cases occurred fusion cage subsidence in the posterior fusion group,43 cases in the oblique lateral fusion group,and 1 case in each group occurred fusion cage displacement. There was no loosening,displacement or breakage of the internal fixation. The incidence of complications in the oblique lateral fusion group 33.98%(35/103) was significantly higher than that in the posterior fusion group 23.64%(26/110),P=0.039. The height of the intervertebral space in both groups recovered well after the operation,but it was lost to varying degrees during follow-up. The fusion rate of the posterior fusion group was 94.5%(104/110),and 96.1%(99/103) in the oblique lateral fusion group(P=0.083). At the latest follow-up,the clinical symptoms of the two groups of patients were significantly improved. Conclusion: Two methods in treating single or two-segment lumbar spine lesions obtained good clinical effects. The characteristics of endplate injury in the two fusion methods are not completely the same. Although the endplate injury did not affect the final clinical results of the two fixed fusion methods,it still needs to be paid attention to and emphasize the prevention and effective treatment of endplate injury,especially for oblique lateral intervertebral fusion.