腰椎融合术后邻近节段退变研究进展

腰椎融合术主要用于治疗腰椎滑脱症或不稳定、腰椎管狭窄症、腰椎间盘突出症等,其术后邻近节段退变越来越引起临床上广泛关注.影响邻近节段退变的因素中女性、绝经、高龄、术前邻近节段已存在退变可增加术后邻近节段退变风险,手术融合长度、融合方式、融合平面、脊柱矢状位平衡、椎间隙过度牵开等可影响术后邻近节段退变发生.合理选择非融合技术、合理应用融合方式及手术入路、重建脊柱生理前凸及腰骶-骨盆参数等有助于预防术后邻近节段退变发生.该文就腰椎融合术后邻近节段退变相关概念、发生率、发生原因、影响因素及预防对策等作一简要综述.     

斜前方腰椎间融合术治疗腰椎融合术后邻近节段退行性变

目的 探讨斜前方腰椎间融合术(OLIF)治疗腰椎融合术后邻近节段退行性变(ASD)的效果.方法 回顾性分析2019-01-2020-04间佛山健翔医院收治的31例腰椎融合术后ASD患者的临床资料.男18例,女13例;年龄46～73岁,平均57.68岁.腰椎间盘突出症15例,腰椎管狭窄症9例,腰椎滑脱症7例.L3～419...     

腰椎融合术后邻近节段退变的诊断与治疗

目的：探讨腰椎融合术后邻近节段退变的特点及再手术治疗的术式与疗效.方法：回顾性分析2002年1月至2004年12月间收治的10例因腰椎管狭窄症或腰椎滑脱症曾行后路减压、植骨及椎弓根内固定术,术后12～132个月（平均41.6个月）出现新的腰腿痛症状的病例.对所有患者进行影像学检查,与术前资料比较,并行手术治疗.结果：X线片显示融合的上方（1个节段7例,2个节段1例）或下方（1个节段2例）邻近节段出现了退变,首次术前及术后上述邻近节段均未见退变征象.8例MRI显示邻近节段出现了新的椎管狭窄,且有明显的神经压迫.采用后路术式,将减压及固定融合范围向邻近退变节段延伸.经7～36个月平均12.1个月的随访,优良率80%.结论：腰椎融合术后邻近节段退变是术后症状复发的原因之一,应仔细鉴别症状复发的原因.对于有明显神经压迫者,再手术治疗仍可取得较好的疗效.     

腰椎融合术后发生邻近节段退行性变的研究进展

随着脊柱手术方法的日趋成熟和内固定器械的日新月异,脊柱融合术的成功率有了明显提高。然而术后长期随访并发症也日益引起脊柱外科医师的关注,尤其是融合内固定术后邻近节段退变（adjacent segment degenera-tion,ASD）的问题变得更为突出,因其可引起临床症状,影响预后,正成为基础和临床研究的热点。本文从ASD发生的机制,影响ASD的因素,ASD的治疗策略,ASD的预防做一综述。     

腰椎后路融合术后邻近节段退变疾病再手术的危险因素分析

目的分析腰椎后路融合术后邻近节段退变疾病(ASD)再次手术的危险因素。方法对自2002-01—2008-05行腰椎后路手术的492例腰椎退行性疾病进行中远期随访,分析性别、年龄、融合术式、融合节段、椎板切除、悬浮固定对ASD再手术的影响。采用多因素Logistic回归分析ASD再手术的危险因素。结果492例均获得随访48~136个月,平均84.2个月。24例出现ASD,需再次手术,ASD发生率为4.88%。单因素分析显示年龄、融合术式对ASD再手术有影响,差异有统计学意义(P0.05)。多因素Logistic回归分析显示年龄(P=0.032)、融合术式(P=0.021)是ASD再手术的危险因素。结论年龄≥60岁及PLIF术后患者更易发生ASD,临床医师在选择首次融合术式时应充分考虑这些因素。     

腰椎内固定融合术后邻近节段退变的影响因素

目的探讨腰椎内固定融合术后邻近节段退变的影响因素。方法对1998年3月至2002年5月33例行腰椎内固定融合术的病例进行随访研究,观察其术后邻近节段退变的发生率、发生年龄、部位、影像学特点以及临床表现,对是否“悬浮固定”、内固定融合范围、不同邻近节段退变的风险进行对比。结果33例患者随访34～82个月,平均4年7个月。发现影像学上有退变表现10例（占30．3％）,10例中有9例退变发生在头侧节段。发生邻近节段退变以60岁以上患者为主。是否进行“悬浮固定”对内固定融合术后邻近节段退变的影响无统计学差异。多节段融合术后较单节段融合术后邻近节段退变有增多的趋势。L2／L3作为邻近节段时退变风险较高,而L5／L1,作为邻近节段退变风险较低。结论头侧邻近节段较尾侧节段更容易发生退变。如果L2／L3可能作为邻近节段,术前有退变表现,术中需将其进行固定融合,而如果L5／S1在术前没有明显退变证据,则不需要将其进行固定融合。腰椎内固定融合时,尽量避免长节段固定融合。     

腰椎融合术后发生邻近节段椎间盘退变的系统评价

[目的]对腰椎融合术加速邻近节段椎间盘退变进行系统评价.[方法]按照Coehrane协作网制订的检索策略进行检索,计算机检索MEDLINE(1966～2010年8月)、EMBASE(1974～2010年8月)、Cochrane图书馆(2010年第8期)、中国生物医学文献数据库(CBM,1978～2010年8月)、中国期刊全文数据库(CNKI,1994～2010年8月)、中文科技期刊全文数据库(VIP,1989～2010年8月)及万方数据库(1979～2010年8月).手工检索相关的中英文骨科杂志和会议论文.纳入腰椎融合术后发生邻近节段椎间盘退变的所有临床试验,由2名评价员独立提取资料,并对其方法学质量进行评价.对符合纳入标准的研究用RevMan 5.0软件进行Meta分析.[结果]共纳入4个试验,451例患者.Meta分析结果显示:相对功能洲练(保守治疗)来说腰椎融合术后发生邻近节段椎问盘退变(adjacent segment disc degeneration,ASD)的概率增高[RR=0.63,95%CI(0.52,0.78)P<0.000 1];腰椎融合术中椎板切除后ASD发生率比不行椎板切除的高[RR=3.74,95%CI(0.99,14.18)P=0.05];腰椎融合术前存在ASD比术前无ASD在术后发生ASD的概率高[RR=3.13,95%CI(1.20,8.15)P=0.02];腰椎融合术后ASD的发生与是否有内固定和融合节段的多少无关.[结论]腰椎融合术能增加术后ASD的发生率,与椎板切除和术前就存在ASD有关,但与是否有内固定和融合节段的多少无关.限于纳入研究在方法学方面的局限性,尚需开展大样本、高质量的RCT进一步论证其疗效和安全性.     

斜外侧腰椎体间融合术初次术后邻近节段退变

[目的]评价斜外侧腰椎体间融合术(oblique lumbar interbody fusion,0LIF)治疗腰椎融合术后邻近节段退变的临床效果。[方法]回顾性分析2016年12月一2019年12月本院脊柱外科采用0LIF术治疗腰椎融合术后邻近节段退变50例患者的临床资料。[结果]50例患者均顺利完成手术,均未发生严重并发症。所有患者随访12?16个月,平均(13.74±1.63)个月。术后(12.66±3.64)周患者恢复完全负重活动。随访期间,患者术后疼痛逐步减缓,功能逐步改善。与术前相比较,末次随访时VAS和0DI评分均显著下降(P<0.05)。影像方面,与术前相比,末次随访时患者的腰椎前凸角(LL)显著增加(P<0.05),而侧凸Cobb角显著减少(P<0.05)。至末次随访时,50例患者再次手术椎间隙均达到骨性融合,椎间融合器无移位、下沉。[结论]采用0LIF治疗腰椎融合术后邻近节段退变具有较好的安全性和有效性。     

斜外侧腰椎间融合术治疗腰椎融合术后症状性邻近节段退变的临床疗效分析

目的:探讨斜外侧腰椎间融合术(OLIF)治疗腰椎融合术后症状性邻近节段退变的近期疗效。方法:回顾性分析我院2015年1月～2018年7月采用手术治疗腰椎融合术后症状性邻近节段退变患者62例。采用OLIF治疗38例,男16例,女22例,年龄39～74岁,平均58.2±14.5岁;采用后路腰椎椎体间融合术(PLIF)治疗24例,男13例,女11例,年龄41～70岁,平均56.6±11.7岁。记录手术时间、术中出血量、并发症情况评估患者的围手术期情况。记录并比较术前、术后3个月、末次随访时腰痛和患肢痛视觉模拟评分(VAS)、Oswestry功能障碍指数(ODI)评定临床疗效。通过测量腰椎正侧位X线片比较术前、末次随访时椎间隙高度(IDH)、椎间孔高度(IFH)、椎间孔面积(IFA)改变情况比较影像学改善情况。结果:两组患者随访时间18.4±8.2个月(8～36个月)。OLIF组术中出血量129.2±15.2ml,手术时间81.2±17.4min;PLIF组术中出血量205.6±23.8ml,手术时间127.8±26.2min,OLIF组均较PLIF组显著降低(P0.05)。OLIF组未发生血管、神经、腹膜、脏器损伤等术中并发症,PLIF组出现3例术中硬膜囊破裂,行术中硬膜囊修补术,其中2例出现术后脑脊液漏。OLIF组术后3个月时腰痛、患肢痛VAS评分、ODI为2.39±0.82分、1.43±0.58分、(20.61±4.24)%;末次随访时腰痛、患肢痛VAS评分、ODI为1.97±0.66分、1.22±0.75分、(13.47±4.56)%。PLIF组术后3个月时腰痛、患肢痛VAS评分、ODI为2.75±1.28分、1.54±0.79分、(21.88±5.94)%;末次随访时腰痛、患肢痛VAS评分、ODI为1.60±1.14分、1.61±1.15分、(15.12±4.71)%。两组术后VAS评分与ODI均较术前显著改善(P0.05),但两组间同时间点比较无显著性差异(P0.05)。OLIF组末次随访时IDH、IFH、IFA分别为10.54±0.88mm、20.86±2.67mm、206.24±11.45mm2;PLIF组末次随访时IDH、IFH、IFA分别为8.52±1.27mm、23.18±2.26mm、227.74±12.89mm2。两组末次随访时IDH、IFH、IFA均较术前显著改善(P0.05),两组间比较无统计学差异(P0.05)。结论:OLIF和PLIF治疗腰椎融合术后症状性邻近节段退变临床疗效一致,但OLIF在缩短手术时间、减少手术相关并发症方面具有优势。     

腰椎融合术后邻近节段退行性变危险因素研究进展

腰椎融合术是治疗腰椎退行性疾病最常用的治疗手段,然而该术式可能带来一系列问题,如假关节形成、相邻腰椎滑脱、邻近节段退行性变（ASD）等,其中 ASD是影响腰椎融合术后疗效的重要因素之一。ASD的发生可能与减压节段数量、融合平面、融合节段长度、椎间隙处理及患者个体因素等有关。该文就腰椎融合术后ASD危险因素研究进展作一综述。     

Risk factors for adjacent segment disease after lumbar fusion

The incidence of adjacent segment problems after lumbar fusion has been found to vary, and risk factors for these problems have not been precisely verified, especially based on structural changes determined by magnetic resonance imaging. The purpose of this retrospective clinical study was to describe the incidence and clinical features of adjacent segment disease (ASD) after lumbar fusion and to determine its risk factors. We assessed the incidence of ASD in patients who underwent lumbar or lumbosacral fusions for degenerative conditions between August 1995 and March 2006 with at least a 1-year follow-up. Patients less than 35 years of age at the index spinal fusion, patients with uninstrumented fusion, and patients who had not achieved successful union were excluded. Of the 1069 patients who underwent fusions, 28 (2.62%) needed secondary operations because of ASD and were included in this study. In order to identify the risk factors, we matched a disease group and a control group. The disease group consisted of 26 of the 28 patients with ASD, excluding the 2 patients for whom we did not have initial MRI data. Each patient in the disease group was matched by age, sex, fusion level and follow-up period with a control patient. The assumed risk factors included disc and facet degeneration, instability, listhesis, rotational deformity, and disc wedging. The mean age of the 28 patients with ASD requiring surgical treatment was 58.4 years, which did not differ significantly from that of the population in which ASD did not develop (58.2 years, p = 0.894). Of the 21 patients who underwent floating fusion, only 1 developed distal ASD. Facet degeneration was a significant risk factor (p < 0.01) on logistic regression analysis. The incidence of distal ASD was much lower than that of proximal ASD. Pre-existing facet degeneration may be associated with a high risk of adjacent segment problems following lumbar fusion procedures.     

腰椎融合术后相邻节段退变的相关因素分析

【摘要】 目的：探讨腰椎融合术后影响相邻节段退变（adjacent segment degeneration,ASD）的因素。方法：回顾性分析北京大学第三医院骨科2009年1月~2011年1月因腰椎管狭窄症行腰椎后路融合手术患者109例,其中男39例,女70例,年龄24~79岁,平均54岁。门诊随访2~4年,平均3.4年。测量术前融合节段角度（fusion angle,FA）、融合节段头尾端相邻节段角度（proximal angle,PA;distal angle,DA）、腰椎前凸角（lumbar lordosis,LL）、骶骨倾斜角（sacral slope,SS）、骨盆入射角（pelvic incidence,PI）、融合与非融合相邻节段移位距离（slip distance,SD）等参数。以术后2年时站立位X线片相邻节段滑移≥3mm定义为ASD,将患者分为退变组（A组）和非退变组（B组）。同时记录两组患者性别、年龄、骨密度、融合节段数等。采用t检验及χ2检验比较两组间各指标的差异,应用Logistic回归分析ASD的影响因素。结果：A组18例（16.5%）,B组91例（83.5%）。发生ASD患者均为融合节段头端相邻节段退变。A组患者术前LL为29.8°±12.5°,B组为32.4°±11.2°;A组SS为31.5°±12.1°,B组为37.4°±13.4°;A组FA为18.3°±9.0°,B组为14.8°±10.5°; A组PA为6.8°±3.2°,B组为7.2°±5.2°;A组PI为42.3°±9.8°,B组为49.9°±9.8°;两组比较均有统计学差异（P＜0.05）。两组患者性别、年龄、骨密度、融合节段数及DA等均无统计学差异（P＞0.05）。Logistic回归分析显示PI与ASD发生率有显著相关性（P＜0.05）,SS、LL、FA、PA与ASD发生率无相关性（P＞0.05）。结论：在腰椎融合术后影响ASD的诸多因素中,过小的PI值可能是导致ASD的重要因素。     

腰椎单节段固定融合术后上位相邻节段退变及其与临床疗效的关系

目的:探讨腰椎单节段固定融合术后上位相邻节段退变及其与临床效果的关系,分析退变的相关因素。方法:回顾性分析2004年10月～2009年5月采用后路单节段椎弓根螺钉固定并椎体间cage植骨融合术治疗的49例L4/5退变性失稳患者,男22例,女27例,年龄28～72岁(平均53.4岁)。所有患者术前均行骨密度检测。在X线片上测量固定节段及其上位相邻节段椎间盘高度、椎间隙动态角度变化、椎体滑移距离以及固定节段和腰椎前凸角、腰骶关节角,并通过JOA评分及腰功能障碍指数(ODI)评价临床效果。根据末次随访时上位相邻节段有无影像学退变,分为退变组与非退变组,比较两组间临床效果及影像学测量结果。结果:随访时间为13～52个月,平均为29.3个月,所有患者术后均无神经损害加重症状。末次随访时11例患者(22%)出现上位相邻节段影像学退变。两组患者手术时的平均年龄有显著性差异(P<0.05);术前骨密度、腰椎前凸角、腰骶关节角、L4/5前凸角和椎体间滑移距离均无显著性差异(P>0.05);末次随访时L3/4椎体间滑移距离、L3/4椎间盘高度以及椎间隙动态成角变化值均存在显著性差异(P<0.05),ODI和JOA评分改善率无显著性差异(P>0.05)。患者年龄与末次随访时固定上位相邻节段椎间盘高度、椎间隙动态成角、椎体间滑移距离变化值存在正相关性,相关系数分别为0.353、0.521、0.472,余测量指标与固定上位相邻节段影像学指标变化均无显著相关性。结论:单节段腰椎固定融合术后上位相邻节段影像学退变与临床效果之间无显著相关性。此退变与患者年龄相关,而与骨密度和术前腰椎影像学测量指标无显著相关性。     

Stand-alone lateral lumbar interbody fusion for the treatment of symptomatic adjacent segment degeneration following previous lumbar fusion

Background Context

Revision posterior decompression and fusion surgery for patients with symptomatic adjacent segment degeneration (ASD) is associated with significant morbidity and is technically challenging. The use of a stand-alone lateral lumbar interbody fusion (LLIF) in patients with symptomatic ASD may prevent many of the complications associated with revision posterior surgery.

Sublaminar wiring stabilization to prevent adjacent segment degeneration after lumbar spinal fusion

Introduction  Adjacent segment degeneration (ASD) is a complication of lumbar spinal fusion. There are some reports on the cause of this degeneration but none concerning its prevention. We performed sublaminar wiring stabilization to prevent ASD after posterolateral lumbar spinal fusion with instrumentation. The purpose of this study was to prospectively evaluate the efficacy of this procedure. Patients and methods  Between 2003 and 2004, 54 consecutive patients with lumbar spinal canal stenosis and multilevel instability of the lumbar spine underwent posterior decompression and posterolateral fusion with instrumentation. The mean age at the time of surgery was 66.7 ± 1.3 years, and the mean follow-up period was 40.0 ± 1.1 months, with a minimum of 29 months. Twenty-seven of the patients underwent conventional sublaminar wiring stabilization at the cephalad segment adjacent to the site of fusion to prevent ASD (group A), and the other 27 patients did not (group B). Some items were assessed, including clinical outcome using Japanese Orthopaedic Association (JOA) score, sagittal global lumbar alignment, and segmental motion in flexion–extension radiographs of the cephalad vertebral body adjacent to the site of fusion. Results  There were no significant differences in JOA scores between two groups, but 2 patients in group B underwent subsequent surgery due to ASD. Sagittal lumbar alignment did not change in group A but was significantly decreased in group B. With respect to segmental motion in flexion–extension radiographs, group A showed a significant decrease from 6.9° before surgery to 3.4° after surgery, on the other hand group B showed a significant increase from 5.6° before surgery to 8.4° after surgery. Conclusions  In this study, it was suggested that sublaminar wiring stabilization significantly reduces the range of motion of the adjacent segment and preserves sagittal lumbar alignment, which lead to prevention of ASD. The clinical outcome of the subsequent surgeries is relatively poor, so it is important to prevent ASD by any prevention such as sublaminar wiring stabilization.     

邻近节段关节突关节退变对腰椎融合固定术后邻近节段疾病的影响

目的:探究邻近节段关节突关节退变对腰椎融合固定术后邻近节段疾病的影响。方法:对2016年6月至2019年6月接受L₅S₁腰椎后路椎间融合固定术(posterior lumbar interbody fusion,PLIF)的138例患者进行回顾性分析。根据术前L_4,5关节突关节是否有退变(采用Weishaupt分级标准)分为退变组68例,无退变组70例。收集两组患者年龄、性别、身体质量指数、随访时间、术前L_4,5椎间盘退变情况(采用Pfirrmann分级)等数据,采用疼痛视觉模拟评分(visual analogue scale,VAS)、Oswestry功能指数(Oswestry disability index,ODI)评估术后1、3个月的临床疗效,分析术后邻近节段疾病(adjacent segment disease,ASD)发生情况以及发生ASD时间。结果:两组患者在年龄、性别、身体质量指数、随访时间、术前L_4,5椎间盘退变情况方面比较,差异无统计学意义(P>0.0...     

Correlation between sagittal plane changes and adjacent segment degeneration following lumbar spine fusion

Adjacent segment degeneration following lumbar spine fusion remains a widely acknowledged problem, but there is insufficient knowledge regarding the factors that contribute to its occurrence. The aim of this study is to analyse the relationship between abnormal sagittal plane configuration of the lumbar spine and the development of adjacent segment degeneration. Eighty-three consecutive patients who underwent lumbar fusion for degenerative disc disease were reviewed retrospectively. Patients with spondylolytic spondylolisthesis and degenerative scoliosis were not included in this study. Mean follow-up period was 5 years. Results were analysed to determine the association between abnormal sagittal configuration and post operative adjacent segment degeneration. Thirty-one out of 83 patients (36.1%) showed radiographic evidence of adjacent segment degeneration. Patients with normal C7 plumb line and normal sacral inclination in the immediate post operative radiographs had the lowest incidence of adjacent level change compared with patients who had abnormality in one or both of these parameters. The difference was statistically significant (P<0.02). There was no statistically significant difference in the incidence of adjacent level degeneration between male and female patients; between posterior fusion alone and combined posterolateral and posterior interbody fusions; and between fusions extending down to the sacrum and fusions stopping short of the sacrum. It was concluded was that normality of sacral inclination is an important parameter for minimizing the incidence of adjacent level degeneration. Retrolisthesis was the most common type of adjacent segment change. Patients with post operative sagittal plane abnormalities should preferably be followed-up for at least 5 years to detect adjacent level changes.