后路椎弓根螺钉植入物置入内固定腰骶椎融合后相邻节段的病变

背景：椎弓根螺钉植入物置入内固定椎体融合目前仍然为大多数脊柱疾病的主要治疗方法，术后并发症依然是学者们关注的重点，相邻节段疾病是主要并发症之一，严重影响椎体融合内固定的疗效。目的：探讨后路椎弓根螺钉植入物置入内固定腰骶椎融合后相邻节段病变的发病原因和治疗效果。方法：回顾分析1998年4月至2011年12月采用后路椎弓根螺钉植入物置入内固定并椎间融合器植骨融合治疗的536例患者，男341例，女195例，年龄34-71岁，平均年龄51.3岁。其中单节段融合412例，多节段融合124例。对有相邻节段病变的患者均行腰椎正侧位、过伸过屈位X射线片及腰椎核磁共振检查，在X射线片上测量相邻椎间隙角度变化、上位椎体滑移距离及变化，通过JOA评分及腰功能障碍指数评价治疗前后的临床效果。经统计学分析，探讨相邻节段病变患者的发病原因、发病率、潜在风险以及治疗方法。结果与结论：采用后路椎弓根螺钉植入物置入内固定腰骶椎融合治疗的536例患者中，发现有症状的相邻节段病变患者31例。单节段融合18例，多节段融合13例。腰椎间盘突出症6例，腰椎失稳13例，腰椎滑脱9例，腰椎狭窄症3例。相邻节段病变患者均经过6个月以上的规律保守治疗，12例获得好转并稳定，其余19例接受手术治疗。随访9-64个月，平均26.7个月，按JOA评分，优4例，良11例，可3例，差1例，优良率78.94%。腰功能障碍指数平均下降33.8(8.5-42.3)，改善率79.91%。统计学t检验显示相邻节段病变患者的平均年龄、融合节段比例、JOA评分和腰功能障碍指数差异均有显著性意义(P < 0.05)。椎弓根螺钉植入物置入内固定腰骶椎融合后远期发生相邻节段病变，其发病与邻近椎体生物力学的变化等因素相关。多数相邻节段病变患者再次手术治疗后效果良好，早期综合考虑致病的潜在因素是防止相邻节段病变发病的主要手段。

Adjacent segment disease after posterior pedicle screw internal fixation and lumbosacral fusion

BACKGROUND:Pedicle screw internal fixation and lumbosacral fusion has become the main treatment method for various spinal diseases, and the postoperative complications have attracted more and more attention of the scholars, while the adjacent segment disease is the main complication which seriously affects the efficacy of interbody fusion and internal fixation.OBJECTIVE:To investigate the course and treatment efficacy of adjacent segment disease after posterior pedicle screw internal fixation and lumbosacral fusion.METHODS:A retrospective analysis was performed on 536 patients (male 341, female 195, age 34-71, average in 51.3 years old) treated with posterior pedicle screw internal fixation and fusion in the cervical vertebrae fusion cage from April 1998 to December 2011. Among the patients, 412 cases experienced single segment fusion and 124 cases with multi-segment fusion. The patients with adjacent segment disease received lateral lumbar spine X-ray examination, over flexion-extension position X-ray examination and magnetic resonance image examination of the lumbar spine, and the changes of adjacent intervertebral angle and the slip distance and changes of upper vertebral were measured on the X-ray film, then the treatment effect was evaluated according to the Japanese Orthopaedic Association sores and Oswestry disability index. We investigated the causes, incidence rate, the potential risks and the treatment of adjacent segment disease according to the statistical analysis.RESULTS AND CONCLUSION:Among the 536 patients treated with posterior pedicle screw internal fixation and lumbosacral fusion, 31 cases of patients with adjacent segment disease symptom, 18 cases with single segment fusion, 13 cases with multi-segment fusion, 6 cases has lumbar disc herniation, 13 cases has lumbar instability 9 cases affected lumbar spondylolis thesis and 3 cases has lumbar spinal stenosis. All the patients were followed-up for 9-64 months, average in 26.7 months. According to the Japanese Orthopaedic Association sores, excellent in 4 cases, good in 11 cases, average in 3 cases, poor in 1 case, and the excellent and good rate was 78.94%. The Oswestry disability index was reduced by an average of 33.8 (8.5-42.3), the improvement rate was 79.91%. Statistical t-test showed that there was significant difference of average age, ration of fusion segments, Japanese Orthopaedic Association sores and the Oswestry disability index among the patients with adjacent segment disease (P < 0.05). There was adjacent segment disease after treated with posterior pedicle screw internal fixation and lumbosacral fusion, the incidence may related with the biomechanics changes of the adjacent vertebral. Majority of adjacent segment disease patients achieved the good results after reoperation; early consideration of the pathogenic potential factors is the main means to prevent the incidence of adjacent segment disease.