有限减压保留后方韧带复合体结构在腰椎减压融合手术中的意义

目的探讨术中保留相邻节段关节突关节囊、部分棘突、椎板及韧带复合体,对腰椎融合内固定手术后腰椎稳定性的影响,及预防相邻间隙退变的作用。方法回顾性分析2006-05-2014-05实施腰椎融合手术患者132例,依据手术方案的不同,将其分为两组:A组42例采用全椎板减压腰椎融合内固定术,B组90例行有限减压腰椎融合内固定术,术中保留相邻节段关节突关节囊、部分棘突、椎板及韧带复合体等后方结构。结果 132例患者术后随访2~5年,A组术后发生相邻间隙退变13例,占32.5%。B组发生8例,占8.9%。两组的差异有统计学意义(P0.05)。结论与传统的全椎板减压脊柱融合手术相比,采取有限减压、术中保留相邻间隙关节突关节囊、部分棘突、椎板及韧带复合体,能最大限度地维持脊柱的稳定性,降低相邻间隙退变的发生率。     

腰椎后外侧融合术对已存在退变的相邻节段的中远期影响

目的评估腰椎后外侧融合对已经存在退变但未纳入融合范围的相邻节段的中远期影响。方法对本院2004年1月—2005年12月因腰椎退行性疾患接受后路椎板切除减压、经椎弓根内固定、后外侧植骨融合的158例患者进行随访,采用影像学方法对其相邻节段的转归进行分析,比较相邻节段术前无退变和已存在退变的椎间盘的远期进一步退变情况及相应的临床功能。结果 102例病例获得完整随访,平均随访65.2个月(54~71个月),其中26例(25.5%)出现了相邻节段的影像学退变。在相邻上位节段中,术前无退变和已存在退变的椎间盘随访时出现进一步退变的发生率分别为13.5%(10/74)和35.7%(10/28),差异有统计学意义(P0.05)。在相邻下位节段中,术前没有退变和已存在退变的椎间盘随访时出现进一步退变的发生率分别为12.5%(6/48)和22.2%(4/18),差异无统计学意义。临床评价显示无论术前相邻节段有无退变,Oswestry功能障碍指数(ODI)在术后6个月时均较术前明显改善(P0.05),并在最终随访时得到保持,但术前相邻节段存在退变组随访时ODI明显高于无退变组(P0.05)。结论与术前无退变的相邻节段椎间盘相比,术前已存在退变的相邻椎间盘融合术后更容易出现进一步退变,而且会影响其远期的临床疗效。     

退行性腰椎侧凸后路固定减压选择性植骨融合术后邻近节段退变的临床分析

目的观察后路椎弓根钉内固定、椎管减压、选择性椎间植骨融合术治疗退行性腰椎侧凸术后邻近节段退变发生的情况。方法回顾性分析自2012-01—2015-12采用后路椎弓根钉内固定、椎管减压、选择性椎间植骨融合术治疗的72例退行性腰椎侧凸,A组35例选择L4、5节段融合,B组37例选择L5S1节段融合。比较2组多节段固定比例、多椎板间隙减压比例,术后1周矢状面Cobb角、冠状面Cobb角、JOA评分,以及邻近节段退变发生率。结果 A组随访(14.1±1.2)个月,B组随访(12.8±0.2)个月。A组单椎板间隙减压比例低于B组,且多椎板间隙减压比例高于B组,多节段固定比例明显高于B组,差异有统计学意义(P 0.05)。B组1周矢状面Cobb角大于A组,差异有统计学意义(P 0.05);但2组术后1周冠状面Cobb角、JOA评分差异无统计学意义(P0.05)。A组邻近节段退变发生率明显高于B组,差异有统计学意义(P 0.05)。结论后路椎弓根钉内固定、椎管减压、选择性椎间植骨融合术治疗退行性腰椎侧凸时,固定、减压节段越多,术后发生邻近节段退变的概率越大。     

退变性腰椎滑脱后路融合术后的远期疗效分析

[目的]探讨后路减压复位融合内固定术治疗退变性腰椎滑脱的远期疗效.[方法]2001年1月～2005年7月行后路减压、植骨融合、椎弓根螺钉复位内固定术,资料完整并获得未次随访的退变性腰椎滑脱患者62例,随访5～9年(平均6.4年).融合方式有后外侧融合(PLF)、自体髂骨椎问融合(PLIF)、椎间Cage植入融合(PLJF+Cage).评价JOA评分改善率、优良率、满意度、融合及临近节段退变情况等,对术前、术后及末次随访时滑脱率、椎问高度、椎间盘角、节段侧凸角等影像学指标进行比较和分析.[结果]JOA评分改善率(67.7±19.4)%,优良率85.5%,满意度87.1%,融合率95.2%,临近节段退变或原有退变加重26例(41.9%),各融合方式间均无显著性差异(P>0.05).术后滑脱率、椎间高度、椎间盘角及节段侧凸角较术前均显著改善(P<0.05),末次随访时滑脱复位、椎间高度、椎间盘角有所丢失,椎间Cage植入融合丢失最少.[结论]后路减压、植骨融合、椎弓根螺钉复位内固定术治疗退变性腰椎滑脱远期疗效满意,椎间Cage植入融合的放射学表现更佳.     

保留近端上半椎板减压融合术治疗腰椎退变性疾病的疗效及其对预防邻近节段退变的作用

目的探讨保留近端上半椎板减压腰椎内固定融合术治疗腰椎退变性疾病的疗效及其对预防邻近节段退变(adjacent segment degeneration, ASD)的作用。方法回顾性分析2018年3月至2020年2月在南京大学医学院附属鼓楼医院采用保留近端上半椎板、上半棘突和近侧棘上、棘间韧带减压术联合内固定融合治疗且获得2年以上随访的腰椎退变性腰椎管狭窄患者124例(保留组), 2016年1月至2018年2月行腰椎全椎板切除减压术联合内固定融合治疗的腰椎退变性腰椎管狭窄患者130例作为对照(全切组)。保留组男60例、女64例, 年龄(58.3±10.3)岁, 巨大腰椎间盘突出50例、腰椎间盘突出伴骨化11例、单纯腰椎管狭窄10例、退变性腰椎滑脱53例;全切组男62例、女68例, 年龄(59.6±9.2)岁, 巨大腰椎间盘突出51例、腰椎间盘突出伴骨化13例、单纯腰椎管狭窄11例、退变性腰椎滑脱55例。对两组患者手术节段数量、手术时间、术中出血量、术后住院时间、并发症、椎板保留范围、切除范围、硬膜囊面积及矢状面参数进行比较。末次随访时评估融合情况、邻椎稳定性及邻近节段退变(adjacen...     

后方韧带复合体对腰椎椎间融合术后早期相邻节段退变的影响

目的探讨后方韧带复合体对腰椎椎间融合术后早期相邻节段退变的影响。方法 2000年1月至2010年1月在我科实施后路腰椎减压椎间融合内固定治疗L4~5椎间盘突出患者60例。A组(30例)行保留后方韧带复合体的腰椎椎间融合术(posterior lumbar interbody fusion,PLIF),B组(30例)行切除后方韧带复合体的PLIF术。比较两组手术前、后日本骨科协会(Japanese orthopaedic association,JOA)评分及改善率。术前、末次随访时测量腰椎X线片上L3~4椎间盘的高度和椎间隙动态角度、L3~4椎体滑移距离并进行比较。术前及末次随访时对L3~4椎间盘进行Pfirrmann分级。结果手术前、后两组患者的JOA评分差异有统计学意义(P0.05),术后两组JOA评分差异均无统计学意义(P0.05),两组之间改善率差异无统计学意义(P0.05)。A组9例患者出现了L3~4节段的邻近节段退变(adjacent segment disease,ASD),B组17例出现了L3~4节段的ASD。其中A、B两组均有2例患者为有症状的ASD。术前两组患者X线片上L3~4椎间盘的高度、椎间隙动态角度、L3~4椎体滑移距离相比差异均无统计学意义(P0.05),而末次随访时差异有统计学意义(P0.05)。A组末次随访时Pfirrmann分级1级6例,2级22例,3级2例,无4、5级病例。B组末次随访时Pfirrmann分级1级4例,2级24例,3级2例,无4、5级病例。结论腰椎椎间融合术中保留后方韧带复合体可减少术后早期相邻节段退变的发生。     

保留棘突韧带复合体腰椎管扩大术的早期疗效

[目的]探讨保留棘突韧带复合体腰椎管扩大减压术与传统椎板减压植骨融合内固定术治疗腰椎管狭窄症的早期疗效。[方法] 2014年12月～2017年12月1～2节段腰椎管狭窄症患者60例,分为两组,每组30例,椎管扩大组采用保留棘突韧带复合体腰椎管扩大减压术,减压融合组采用传统的椎板减压植骨融合内固定术。记录围手术期资料,采用视觉疼痛指数(VAS)腰痛/腿痛评分、Oswestry功能障碍指数(ODI)、连续行走距离、手术满意度等评价疗效。[结果]两组患者均顺利手术,无严重并发症。两组随访6～12月,平均(8.53±2.53)月。椎管扩大组手术时间、手术出血量、术后引流量显著优于减压融合组。随时间延长,两组患者的腰痛VAS、下肢痛VAS和ODI评分均显著减少,而两组患者的连续行走距离均显著增加,不同时间点间差异有统计学意义。术前、术后1周时两组间上述指标差异均无统计学意义,但末次随访时,椎管扩大组在腰痛VAS、ODI评分和连续行走距离方面显著优于减压融合组。末次随访时,患者自我非常满意度椎管扩大组优于减压融合组(86.67%vs 60.00%)。减压融合组平均椎间融合时间为(7.26±1.32)个月,未出现内固定相关并发症;末次随访时,椎管扩大组椎管矢状径及椎管横径较术前明显增大,且差异有统计学意义。两组均未见明显相邻节段退变或病椎间隙变窄。[结论]对于1～2节段无腰椎失稳的腰椎管狭窄症,保留棘突韧带复合体腰椎管扩大减压术比传统椎板减压植骨融合内固定术创伤更小,术后恢复更快,且在术后早期缓解腰痛方面更有优势。     

腰椎融合术后相邻节段旋转角度、椎间活动度及椎间隙高度变化的临床分析

目的:利用脊柱云纹系统(DIERS Formetric 4D誖,Diers International GmbH,Schlangenbad,Germany)和影像学检查评估腰椎固定融合术对相邻节段旋转角度、椎间活动度及椎间隙高度的影响,并探讨预测邻近节段退变的敏感指标。方法:收集2016年1月～2016年6月期间,73例行单节段腰椎后路减压融合固定术患者的临床资料,其中男40例,女33例,平均年龄47.2±10.3岁(40～60岁),手术节段:L2/3 6例,L3/4 10例,L4/532例,L5/S1 25例。应用DIERS脊柱云纹系统分别于术前、术后6个月、1年、2年收集并计算融合节段与上、下邻椎旋转角度的差值(相对旋转角度)。术前及末次随访时通过腰椎X线测量相邻节段活动范围(range of motion,ROM)及椎间隙高度(disc height,DH)。末次随访时采用视觉模拟评分(visual analogue scale,VAS)及Oswestry功能障碍指数(Oswestry disability index,ODI)评估患者腰腿痛及腰椎功能情况;根据相邻节段有无影像学退变,将患者分为退变组与非退变组并进行对比分析。结果:术前患者融合椎与上、下邻椎相对旋转角度分别为5.2°±2.1°和3.1°±2.1°,术后各随访时间点邻椎的旋转角度均较术前明显增大(P0.05),末次随访时上、下邻椎相对旋转角度分别为8.8°±4.9°和5.9°±3.2°,上邻椎相对旋转角度大于下邻椎(P0.05),其中L2/3融合时,上、下邻椎(L1、L4)的相对旋转角度变化最明显。末次随访时11例患者出现邻近节段退变,退变组上邻椎相对旋转角度为10.6°±3.0°,非退变组为8.2°±2.8°,两组间有显著性差异(P0.05);退变组与非退变组腰痛VAS评分分别为1.4±0.7分和1.2±0.8分,腿痛VAS评分分别为1.2±1.0分和1.3±0.7分,ODI分别为(10.3±8.2)%和(9.5±6.3)%,两组间无显著性差异(P0.05);两组间椎间隙高度及ROM均无明显差异(P0.05)。结论:腰椎固定融合术后相邻节段动态相对旋转度增大,尤以上邻椎明显,与腰椎屈伸活动度及椎间隙高度相比,相邻节段旋转角度可能是预测邻近节段退变更敏感的指标。     

长节段减压短节段融合治疗多节段退行性腰椎管狭窄症

目的:探讨长节段减压短节段融合治疗多节段退行性腰椎疾患的临床疗效。方法:2002年5月～2008年1月采取长节段减压短节段融合的方法治疗多节段腰椎管狭窄症患者27例,男15例,女12例;年龄51～80岁,平均67.3岁。术前根据患者临床表现及影像学特点确定减压及融合节段,均在充分减压的基础上选择性融合,使融合节段少于减压节段。对于术前计划保留活动度的节段仅行单侧或双侧椎板间开窗减压。临床疗效采用JOA、VAS及ODI评估方法评定。随访拍摄腰椎动态X线片及腰椎MRI,观察单纯减压未行融合节段腰椎稳定性及融合相邻节段退变情况。结果:27例患者共减压56个节段,固定29个节段。随访14～84个月,平均38个月,末次随访时,临床功能JOA评分由术前11.4±2.8分提高到21.1±4.4分(P<0.01);ODI评分由术前平均65.0%±22.1%改善至23.0%±10.7%(P<0.01);腰痛VAS评分由术前6.0±2.3分改善至2.3±1.8分(P<0.01),腿痛VAS评分由术前7.9±1.6分改善至2.9±2.2分(P<0.01)。27例患者中26例对术后疗效满意。动态X线片检查未融合节段无医源性失稳;MRI复查未见需再次手术干预的相邻节段退变。结论:应用长节段减压短节段融合治疗多节段退行性腰椎管狭窄症可取得良好临床效果,在保留更多运动节段的同时未影响腰椎稳定性。     

同节段出口根减压对严重腰椎间盘脱出症治疗的影响

目的研究同节段出口根减压对严重腰椎间盘脱出手术效果的影响,探讨同节段出口根减压与腰椎术后邻近节段退变的关系。方法选择70例严重腰椎间盘脱出症患者,将其随机分为两组,所有患者均行腰椎后路全椎板减压植骨融合内固定术。实验组:术中对双侧同节段出口根进行充分减压;对照组:未对同节段出口根进行减压。对两组进行JOA评分,测量术后腰椎动力位像上手术邻近节段椎间隙高度和椎间活动度。结果实验组与对照组JOA改善指数比较有统计学意义(P<0.05),两组间术前与术后椎间高度差及邻近节段椎间活动度变化比较无明显统计学意义(P>0.05)。结论对于严重腰椎间盘脱出症患者行腰椎后路椎间融合术+同节段出口根减压术,可以有效缓解腰腿痛症状,并且术后6个月内不会增加邻近节段退变的危险。     

A prospective randomised study on the long-term effect of lumbar fusion on adjacent disc degeneration

The existence and importance of an accelerated adjacent segment disc degeneration (ASD) after lumbar fusion have previously not been demonstrated by RCTs. The objectives of this study were, to determine whether lumbar fusion in the long term accelerates degenerative changes in the adjacent disc and whether this affects the outcome, by using a prospective randomised design. A total of 111 patients, aged 18–55, with isthmic spondylolisthesis were randomised to exercise (EX, n = 34) or posterolateral fusion (PLF, n = 77), with (n = 37) or without pedicle screw instrumentation (n = 40). The minimum 10 years FU rate was 72%, with a mean FU time of 12.6 years (range 10–17 years). Three radiographic methods of ASD quantification were used, i.e. two digital radiographic measurement methods and the semi quantitative UCLA grading scale. One digital measurement method showed a mean disc height reduction by 2% in the EX group and by 15% in the PLF group (p = 0.0016), and the other showed 0.5 mm more disc height reduction in the PLF compared to the Ex group (ns). The UCLA grading scale showed normal discs in 100% of patients in the EX group, compared to 62% in the PLF group (p = 0.026). There were no significant differences between instrumented and non-instrumented patients. In patients with laminectomy we found a significantly higher incidence of ASD compared to non laminectomised patients (22/47 vs. 2/16 respectively, p = 0.015). In the longitudinal analysis, the posterior and anterior disc heights were significantly reduced in the PLF group, whereas in the EX group only the posterior disc height was significantly reduced. Except for global outcome, which was significantly better for patients without ASD, the clinical outcome was not statistically different in patients with and without ASD. In conclusion, the long-term RCT shows that fusion accelerates degenerative changes at the adjacent level compared with natural history. The study suggests that not only fusion, but also laminectomy may be of pathogenetic importance. The clinical importance of ASD seems limited, with only the more severe forms affecting the outcome.     

保留棘突韧带复合体经椎间孔椎体间融合治疗腰椎滑脱症

目的 探讨保留棘突韧带复合体经椎间孔椎体间融合(TLIF)治疗腰椎滑脱症的疗效.方法 将108例行TLIF治疗的腰椎滑脱症患者根据治疗方式不同分为观察组(术中保留棘突韧带复合体,55例)和对照组(术中不保留棘突韧带复合体,53例).比较两组术后24个月椎间融合情况、术后各时间点腰椎JOA评分、末次随访时邻椎退变情况.结...     

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。     

后路腰椎椎间融合术对邻近节段退变的影响

目的 腰椎融合术改变了腰椎的生物力学环境,使邻近节段应力集中,本研究就后路腰椎椎间融合术(posterior lumbar interbody fusion,PLIF)对邻近节段退变(adjacent segment degeneration,ASD)的影响进行探讨.方法 2002～2006年,采用PLIF治疗腰椎退...     

Effects of lumbar spinal fusion on the other lumbar intervertebral levels (three-dimensional finite element analysis)

The risk of accelerating the degeneration of adjacent disc levels after lumbar spinal fusion is a controversial issue. A finite element model consisting of L1 to L5 lumbar spines was used to assess the effect on adjacent disc level after lumbar spinal fusion. We compared intact, L4/5 posterior interbody fusion (PLF), and L4/5 posterior lumbar interbody fusion (PLIF) models. The loading conditions applied were compressive force, compressive force plus flexion moment, and compressive force plus extension moment. Evaluations were made for von Mises stress on each vertebral end-plate, Tresca stress of all the annulus fibrosus, and Tresca stress of the annulus fibrosus from the posterior surface of the disc to the neural foramen. As the result, the von Mises stress adjacent to the fusion level was higher than the other nonfusion levels; it was higher under conditions of flexion moment loading plus compression loading [112% (2.59PMa) in the PLF model and 117% (2.72Mpa) in the PLIF model] than in the intact model. The Tresca stress of all the annulus fibrosus adjacent to the fusion level was higher than that on other nonfusion intervertebral levels; it was higher under conditions of flexion moment loading plus compression loading [127% (0.57PMa) in the PLF model and 209% (0.89Mpa) in the PLIF model] than in the intact model. The Tresca stress of the annulus fibrosus from the posterior surface of the disc to the neural foramen adjacent to the fusion level was higher than that on other nonfusion intervertebral levels; and it was higher under conditions of flexion moment loading plus compression loading [107% (1.48PMa) in the PLF model and 112% (1.54Mpa) in the PLIF model] than in the intact model. These findings demonstrate that with lumbar fusion, stresses on the vertebral end-plate and the annulus fibrosus were high adjacent to the fusion level; furthermore, stresses were higher in the PLIF model than in the PLF model. These results suggested that lumbar spinal fusion might bring with it a risk of damage to the annulus fibrosus and the vertebral end-plate adjacent to the fusion level.     

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.     

Long-term outcomes evaluation after pars defect repair in adult low-grade isthmic spondylolithesis

Adult low-grade isthmic spondylolisthesis is often treated by posterolateral lumbar fusion (PLF), with a certain rate of complications and non-return to work. Alternatives to fusion, like pars defect repair (PDR), were used with encouraging results in young populations and athletes but their outcomes were rarely evaluated for adult patients. This retrospective study quantitatively analysed the long-term outcomes in adult isthmic spondylolisthesis patients treated by PLF or PDR. At a mean follow-up of 9 years, clinical, socio-professional, radiological data and Stauffer-Coventry score were available for 59 patients (39 cases treated by PLF and 20 treated by PDR). The overall clinical outcomes were comparable in both populations (88% in the PDR and 80% in PLF group 1), with a larger proportion of excellent results (56% vs. 10%) and of return to work in the PDR group. Radiological quantitative analysis highlighted stationary evolution and comparable outcomes for the two groups, except for vertebral slip evolution and adjacent level degeneration rate. Abnormal kinematic patterns outlined for PLF patients 20% of pseudarthrosis and 42% of adjacent levels hypermobility and for PDR ones low mobility for the levels adjacent to instrumented vertebra in 40% of cases. Quantified analysis of biomechanical parameters interpreted altogether with clinical outcome, complications and economic burden of the patient, provided accurate objective data for a better appreciation of global outcome, allowing for a preliminary view on long-term outcomes after PDR in adult low-grade isthmic spondylolisthesis, which were not presented in literature until now.     

三种植骨融合方式在治疗腰椎滑脱症中的应用

目的 比较后路椎弓根螺钉系统固定加后外侧植骨融合(PLF)、椎间单纯植骨融合(PLIF)及环形植骨融合(PCF)治疗腰椎滑脱症的效果.方法 回顾性分析2003年1月至2008年12月收治且获得随访的232例腰椎滑脱患者的临床资料.手术均采用后路椎弓根螺钉系统固定,根据植骨方式不同分为后外侧植骨组(66例),椎间植骨组(54例)及环形植骨组(112例).比较三种植骨方式的融合率及临床症状改善情况.结果 患者均获随访,随访时间6个月～5年,平均2年7个月.后外侧植骨组融合率为80.1%,椎间植骨组融合率为92.5%,环形植骨组融合率为93.7%,三组融合率差异无统计学意义(P＞0.05).对于真性滑脱及≥Ⅱ度的退变性滑脱,后外侧植骨组融合率为60.7%,椎间植骨组融合率为90.0%,环形植骨组融合率为93.3%,三组融合率差异有统计学意义(P＜0.05);进一步比较,后外侧植骨组融合率与其他两组比较,差异有统计学意义(P＜0.05);而椎间植骨组融合率与环形植骨组比较,差异无统计学意义(P＞0.05).三组患者手术治疗后效果优良率分别为84.8%、90.7%和93.6%,差异无统计学意义(P＞0.05).结论 在椎弓根螺钉系统固定基础上,椎间植骨和环形植骨融合与后外侧植骨融合方式相比更符合生物力学,有更高的植骨融合率,对于腰椎滑脱应是首选的手术方式.     

腰椎经后路椎体间融合后单边或双边固定对邻近节段退变的影响

背景：在行后路椎体融合内固定术中,椎弓根钉置入不可避免会损伤邻近关节突关节。目前一致认为单边固定因保留一侧关节突关节可明显降低邻近节段退变的发生率,但仍缺乏对邻近节段退变的影响因素及不同节段退变发生率的长期随访研究。目的：对比经后路椎体间融合术（posterior lumbar interbody fusion,PLIF）后单边或双边椎弓根螺钉固定对邻近节段退变的影响。方法：2006年2月至2007年12月,101例行PLIF手术的L4-L5椎间盘突出症患者纳入本研究。采用单边固定42例,双边固定59例。所有患者术后随访时间均超过5年。邻近节段分为三个节段：第1个近端邻近节段、第2个近端邻近节段及远端邻近节段。依据末次随访的影像学资料评估邻近节段退变的情况,并记录末次随访时的ODI评分评价腰椎功能。结果：单边固定组第1个近端邻近节段、第2个近端邻近节段及远端邻近节段退变的发生率分别为57.1%（24/42）、45.2%（19/42）、38.1%（16/42）;双边固定组第1个近端邻近节段、第2个近端邻近节段及远端邻近节段退变的发生率分别为72.9%（43/59）、68.0%（40/59）、50.8%（30/59）。两组第1个近端邻近节段和远端邻近节段退变发生率无统计学差异,而第2个近端邻近节段退变发生率具有统计学差异。末次随访时单边固定组和双边固定组的ODI评分分别为25.6±5.9、28.4±5.2,两组具有显著统计学差异（t=-2.503,P=0.014）。结论：对于行腰椎后路减压融合术的单节段腰椎间盘突出症患者,单边固定者邻近节段退变发生率低于双边固定者,尤其对于第2个近端邻近退变节段的患者。