可变向腰椎融合器在经腰椎间孔椎体间融合术中的应用
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摘要
目的探讨改良可变向腰椎融合器(Cage)在经腰椎间孔椎体间融合术(transforaminal lumbar interbody fusion,TLIF)中的应用效果。方法回顾分析2013年1月—2015年12月收治的单节段L4或L5峡部裂性滑脱症患者161例,根据Cage植入情况分为试验组(85例,TLIF术中植入改良可变向Cage)和对照组(76例,TLIF术中植入传统非变向Cage)。两组患者性别、年龄、病程、滑脱节段、滑脱分度等一般资料比较差异无统计学意义(P>0.05),具有可比性。比较两组Cage术中植入时间、Cage位置调整次数、植入Cage透视次数、曝光时间、总手术时间;术前及术后3、6、12个月分别行疼痛视觉模拟评分(VAS)、Oswestry功能障碍指数(ODI)评分评价患者临床疗效,记录分析并发症发生情况;分别于术后6、12个月行CT检查,采用Bridwell标准评价腰椎融合情况。结果试验组Cage术中植入时间、Cage位置调整次数、植入Cage透视次数、曝光时间和总手术时间均显著少于对照组(P<0.05)。161例患者均获随访,随访时间12～18个月,平均14.3个月。试验组术中发生1例硬膜囊撕裂,对照组发生1例切口浅表感染;其余患者均未出现硬膜囊撕裂、切口感染等并发症。术后6个月试验组融合率为76.5%(64/85),显著大于对照组的57.9%(44/76)(χ2=6.44,P=0.02);术后12个月试验组融合率为96.5%(82/85),对照组为90.8%(69/76)(其中Cage移位3例、螺钉断裂4例),两组融合率比较差异无统计学意义(χ2=1.54,P=0.26)。两组患者术后3、6、12个月VAS评分和ODI评分逐渐降低,均较术前明显改善(P<0.05);手术前后各时间点两组VAS评分和ODI评分比较差异均无统计学意义(P>0.05)。结论两组Cage可获得相似的临床疗效,采用改良可变向Cage能有效减少TLIF术中的透视次数和辐射剂量,缩短手术时间,有效降低患者和医护人员的受辐射量。
Objective To investigate the effectiveness of modified direction-changeable lumbar Cage in transforaminal lumbar interbody fusion(TLIF). Methods A retrospective analysis was made of 161 patients with single segment L4 or L5 isthmic spondylolisthesis treated between January 2013 and December 2015. According to the implantation of Cage, they were divided into trial group(85 cases, modified direction-changeable lumbar Cage implanted in TLIF) and control group(76 cases, traditional nondirection-changeable Cage implanted in TLIF). There was no significant difference in the general data of gender, age, disease duration, slippage segment, and slippage grade between the two groups(P>0.05). The intraoperative implantation time of Cage, Cage position adjustments times, fluoroscopy times during implantation of Cage, fluoroscopy exposure time, and total operation time were recorded and compared between the two groups. Visual analogue scale(VAS) and Oswestry disability index(ODI) scores were used to evaluate the effectiveness of the patients before operation, and at 3, 6, and 12 months after operation, and the incidence of complications was recorded and analyzed. CT examinations were performed at 6 and 12 months after operation, and lumbar fusion was evaluated by Bridwell criteria. Results The intraoperative implantation time of Cage, Cage position adjustments times, fluoroscopy times during implantation of Cage, fluoroscopy exposure time, and total operation time in trial group were significant less than those in control group(P<0.05). All the 161 patients were followed up 12-18 months(mean, 14.3 months). There was 1 case of dural sac tear in the trial group and 1 case of superficial infection in the control group; no complication such as dural tear and infection occurred in other patients. The fusion rate was 76.5%(64/85) in the trial group and 57.9%(44/76) in the control group at 6 months after operation, showing significant difference(χ2=6.44,P=0.02); at 12 months after operation, the fusion rate was 96.5%(82/85) in the trial group and 90.8%(69/76) in the control group(including 3 cases of Cage displacement and 4 cases of screw breakage), showing no significant difference in the fusion rate between the two groups(χ2=1.54, P=0.26). The VAS and ODI scores of the two groups decreased gradually at 3,6, and 12 months after operation, and improved significantly when compared with those before operation(P<0.05). There was no significant difference in VAS and ODI scores between the two groups before and after operation(P>0.05).Conclusion Both Cages can obtain the similar effectiveness. The modified direction-changeable lumbar Cage can significantly reduce the fluoroscopy times and radiation dose during TLIF, shorten the operation time, and effectively reduce the radiation exposure of patients and medical staff.
Objective To investigate the effectiveness of modified direction-changeable lumbar Cage in transforaminal lumbar interbody fusion(TLIF). Methods A retrospective analysis was made of 161 patients with single segment L4 or L5 isthmic spondylolisthesis treated between January 2013 and December 2015. According to the implantation of Cage, they were divided into trial group(85 cases, modified direction-changeable lumbar Cage implanted in TLIF) and control group(76 cases, traditional nondirection-changeable Cage implanted in TLIF). There was no significant difference in the general data of gender, age, disease duration, slippage segment, and slippage grade between the two groups(P>0.05). The intraoperative implantation time of Cage, Cage position adjustments times, fluoroscopy times during implantation of Cage, fluoroscopy exposure time, and total operation time were recorded and compared between the two groups. Visual analogue scale(VAS) and Oswestry disability index(ODI) scores were used to evaluate the effectiveness of the patients before operation, and at 3, 6, and 12 months after operation, and the incidence of complications was recorded and analyzed. CT examinations were performed at 6 and 12 months after operation, and lumbar fusion was evaluated by Bridwell criteria. Results The intraoperative implantation time of Cage, Cage position adjustments times, fluoroscopy times during implantation of Cage, fluoroscopy exposure time, and total operation time in trial group were significant less than those in control group(P<0.05). All the 161 patients were followed up 12-18 months(mean, 14.3 months). There was 1 case of dural sac tear in the trial group and 1 case of superficial infection in the control group; no complication such as dural tear and infection occurred in other patients. The fusion rate was 76.5%(64/85) in the trial group and 57.9%(44/76) in the control group at 6 months after operation, showing significant difference(χ2=6.44,P=0.02); at 12 months after operation, the fusion rate was 96.5%(82/85) in the trial group and 90.8%(69/76) in the control group(including 3 cases of Cage displacement and 4 cases of screw breakage), showing no significant difference in the fusion rate between the two groups(χ2=1.54, P=0.26). The VAS and ODI scores of the two groups decreased gradually at 3,6, and 12 months after operation, and improved significantly when compared with those before operation(P<0.05). There was no significant difference in VAS and ODI scores between the two groups before and after operation(P>0.05).Conclusion Both Cages can obtain the similar effectiveness. The modified direction-changeable lumbar Cage can significantly reduce the fluoroscopy times and radiation dose during TLIF, shorten the operation time, and effectively reduce the radiation exposure of patients and medical staff.
引文
1郜德龙,方忠,孙允龙,等.同种异体骨Cage在经椎间孔腰椎椎间融合手术中的应用.中国修复重建外科杂志,2018, 32(7):927-932.
2 Chaudhary MM. Infected nonunion of tibia. Indian J Orthop, 2017,51(3):256-268.
3 Chen L, Yang H, Tang T. Cage migration in spondylolisthesis treated with posterior lumbar interbody fusion using BAK cages.Spine(Phila Pa 1976), 2005, 30(19):2171-2175.
4张建锋,周志杰,赵凤东,等.腰椎融合器后移的重要因素——间隙上终板后部损伤.中华骨科杂志,2016, 36(14):914-920.
5 Zhang H, Jiang Y, Wang B, et al. Direction-changeable lumbar cage versus traditional lumbar cage for treating lumbar spondylolisthesis:A retrospective study. Medicine(Baltimore), 2018,97(7):e9984.
6郝建学,周斐,钟娜,等.椎间植骨量对腰椎椎间融合内固定术后融合效果的研究.实用骨科杂志,2016,22(3):205-208, 245.
7 Le TV, Baaj AA, Dakwar E, et al. Subsidence of polyetheretherketone intervertebral cages in minimally invasive lateral retroperitoneal transpsoas lumbar interbody fusion. Spine(Phila Pa 1976), 2012, 37(14):1268-1273.
8 Abbushi A, Cabraja M, Thomale UW, et al. The influence of cage positioning and cage type on cage migration and fusion rates in patients with monosegmental posterior lumbar interbody fusion and posterior fixation. Eur Spine J, 2009,18(11):1621-1628.
9苗惊雷,张朝跃,詹瑞森,等.置人椎间融合器行腰椎融合后Cage移位的原因.中国组织工程研究与临床康复,2011,15(39):7307-7310.
10 Zhao FD, Yang W, Shan Z,et al. Cage migration after transforaminal lumbar interbody fusion and factors related to it.Orthop Surg, 2012, 4(4):227-232.
11赵军然.腰椎后路椎间植骨融合术后Cage后移的相关因素分析.颈腰痛杂志,2017, 38(2):106-110.
12陈家麟,茅祖斌,吴小涛.四种经椎间孔腰椎间融合固定方式的三维有限元分析.中国组织工程研究与临床康复,2008, 12(39):7605-7610.
13甘锋平,谭海涛,江建中,等.直接外侧入路椎间融合术治疗腰椎退变性疾病疗效观察.中国修复重建外科杂志,2016, 30(6):716-720.
14 Villard J, Ryang YM, Demetriades AK, et al. Radiation exposure to the surgeon and the patient during posterior lumbar spinal instrumentation:a prospective randomized comparison of navigated versus non-navigated freehand techniques. Spine(Phila Pa 1976), 2014, 39(13):1004-1009.
15 Erken HY, Burc H, Saka G, et al. Can radiation exposure to the surgeon be reduced with freehand pedicle screw fixation technique in pediatric spinal deformity correction? A prospective multicenter study Spine(Phila Pa 1976), 2014, 39(6):521-525.
2 Chaudhary MM. Infected nonunion of tibia. Indian J Orthop, 2017,51(3):256-268.
3 Chen L, Yang H, Tang T. Cage migration in spondylolisthesis treated with posterior lumbar interbody fusion using BAK cages.Spine(Phila Pa 1976), 2005, 30(19):2171-2175.
4张建锋,周志杰,赵凤东,等.腰椎融合器后移的重要因素——间隙上终板后部损伤.中华骨科杂志,2016, 36(14):914-920.
5 Zhang H, Jiang Y, Wang B, et al. Direction-changeable lumbar cage versus traditional lumbar cage for treating lumbar spondylolisthesis:A retrospective study. Medicine(Baltimore), 2018,97(7):e9984.
6郝建学,周斐,钟娜,等.椎间植骨量对腰椎椎间融合内固定术后融合效果的研究.实用骨科杂志,2016,22(3):205-208, 245.
7 Le TV, Baaj AA, Dakwar E, et al. Subsidence of polyetheretherketone intervertebral cages in minimally invasive lateral retroperitoneal transpsoas lumbar interbody fusion. Spine(Phila Pa 1976), 2012, 37(14):1268-1273.
8 Abbushi A, Cabraja M, Thomale UW, et al. The influence of cage positioning and cage type on cage migration and fusion rates in patients with monosegmental posterior lumbar interbody fusion and posterior fixation. Eur Spine J, 2009,18(11):1621-1628.
9苗惊雷,张朝跃,詹瑞森,等.置人椎间融合器行腰椎融合后Cage移位的原因.中国组织工程研究与临床康复,2011,15(39):7307-7310.
10 Zhao FD, Yang W, Shan Z,et al. Cage migration after transforaminal lumbar interbody fusion and factors related to it.Orthop Surg, 2012, 4(4):227-232.
11赵军然.腰椎后路椎间植骨融合术后Cage后移的相关因素分析.颈腰痛杂志,2017, 38(2):106-110.
12陈家麟,茅祖斌,吴小涛.四种经椎间孔腰椎间融合固定方式的三维有限元分析.中国组织工程研究与临床康复,2008, 12(39):7605-7610.
13甘锋平,谭海涛,江建中,等.直接外侧入路椎间融合术治疗腰椎退变性疾病疗效观察.中国修复重建外科杂志,2016, 30(6):716-720.
14 Villard J, Ryang YM, Demetriades AK, et al. Radiation exposure to the surgeon and the patient during posterior lumbar spinal instrumentation:a prospective randomized comparison of navigated versus non-navigated freehand techniques. Spine(Phila Pa 1976), 2014, 39(13):1004-1009.
15 Erken HY, Burc H, Saka G, et al. Can radiation exposure to the surgeon be reduced with freehand pedicle screw fixation technique in pediatric spinal deformity correction? A prospective multicenter study Spine(Phila Pa 1976), 2014, 39(6):521-525.
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