Berg Svante
Stockholm Spine Center, Löwenströmska Hospital, SE-194 89 Upplands Väsby, Sweden.
Acta Orthop Suppl. 2011 Feb;82(343):1-29. doi: 10.3109/17453674.2011.575327.
Low back pain consumes a large part of the community's resources dedicated to health care and sick leave. Back disorders also negatively affect the individual leading to pain suffering, decreased quality-of-life and disability. Chronic low back pain (CLBP) due to degenerative disc disease (DDD) is today often treated with fusion when conservative treatment has failed and symptoms are severe. This treatment is as successful as arthroplasty is for hip arthritis in restoring the patient's quality of life and reducing disability. Even so, there are some problems with this treatment, one of these being recurrent CLBP from an adjacent segment (ASD) after primarily successful surgery. This has led to the development of alternative surgical treatments and devices that maintain or restore mobility, in order to reduce the risk for ASD. Of these new devices, the most frequently used are the disc prostheses used in Total Disc Replacement (TDR). This thesis is based on four studies comparing total disc replacement with posterior fusion. The studies are all based on a material of 152 patients with DDD in one or two segments, aged 20-55 years that were randomly treated with either posterior fusion or TDR. The first study concerned clinical outcome and complications. Follow-up was 100% at both one and two years. It revealed that both treatment groups had a clear benefit from treatment and that patients with TDR were better in almost all outcome scores at one-year follow-up. Fusion patients continued to improve during the second year. At two-year follow-up there was a remaining difference in favour of TDR for back pain. 73% in the TDR group and 63% in the fusion group were much better or totally pain-free (n.s.), while twice as many patients in the TDR group were totally pain free (30%) compared to the fusion group (15%). Time of surgery and total time in hospital were shorter in the TDR group. There was no difference in complications and reoperations, except that seventeen of the patients in the fusion group were re-operated for removal of their implants. The second study concerned sex life and sexual function. TDR is performed via an anterior approach, an approach that has been used for a long time for various procedures on the lumbar spine. A frequent complication reported in males when this approach is used is persistent retrograde ejaculation. The TDR group in this material was operated via an extra-peritoneal approach to the retroperitoneal space, and there were no cases of persistent retrograde ejaculation. There was a surprisingly high frequency of men in the fusion group reporting deterioration in ability to have an orgasm postoperatively. Preoperative sex life was severely hampered in the majority of patients in the entire material, but sex life underwent a marked improvement in both treatment groups by the two-year follow-up that correlated with reduction in back pain. The third study was on mobility in the lumbar spinal segments, where X-rays were taken in full extension and flexion prior to surgery and at two-year follow-up. Analysis of the films showed that 78% of the patients in the fusion group reached the surgical goal (non-mobility) and that 89% of the TDR patients maintained mobility. Preoperative disc height was lower than in a normative database in both groups, and remained lower in the fusion group, while it became higher in the TDR group. Mobility in the operated segment increased in the TDR group postoperatively. Mobility at the rest of the lumbar spine increased in both treatment groups. Mobility in adjacent segments was within the norm postoperatively, but slightly larger in the fusion group. In the fourth study the health economics of TDR vs Fusion was analysed. The hospital costs for the procedure were higher for patients in the fusion group compared to the TDR group, and the TDR patients were on sick-leave two months less. In all, these studies showed that the results in the TDR group were as good as in the fusion group. Patients are more likely to be totally pain-free when treated with TDR compared to fusion. Treatment with this new procedure seems justified in selected patients at least in the short-term perspective. Long-term follow-up is underway and results will be published in due course.
腰痛消耗了社区用于医疗保健和病假的大量资源。背部疾病也会对个人产生负面影响，导致疼痛、生活质量下降和残疾。当保守治疗失败且症状严重时，因椎间盘退变疾病（DDD）导致的慢性腰痛（CLBP）如今常采用融合手术治疗。这种治疗在恢复患者生活质量和减少残疾方面与髋关节置换术治疗髋关节炎一样成功。即便如此，这种治疗仍存在一些问题，其中之一是在初次手术成功后，相邻节段（ASD）出现复发性CLBP。这促使了旨在维持或恢复活动度以降低ASD风险的替代手术治疗方法和器械的发展。在这些新器械中，最常用的是用于全椎间盘置换（TDR）的椎间盘假体。本论文基于四项比较全椎间盘置换与后路融合的研究。这些研究均基于152例年龄在20 - 55岁、患有一个或两个节段DDD的患者资料，他们被随机分为接受后路融合或TDR治疗。第一项研究关注临床结果和并发症。一年和两年的随访率均为100%。结果显示，两个治疗组均从治疗中明显获益，并且在一年随访时，TDR组患者在几乎所有结局评分方面都更好。融合组患者在第二年持续改善。在两年随访时，背痛方面仍存在有利于TDR组的差异。TDR组73%的患者和融合组63%的患者病情明显好转或完全无痛（无统计学差异），而TDR组完全无痛的患者比例（30%）是融合组（15%）的两倍。TDR组的手术时间和住院总时间更短。并发症和再次手术方面无差异，只是融合组有17例患者因取出植入物而再次手术。第二项研究关注性生活和性功能。TDR通过前路进行，这种入路在腰椎的各种手术中已使用很长时间。使用这种入路时，男性中常见的并发症是持续性逆行射精。本研究中的TDR组通过腹膜外入路进入腹膜后间隙，没有持续性逆行射精的病例。令人惊讶的是，融合组中有相当高比例的男性报告术后性高潮能力下降。在整个研究对象中，大多数患者术前性生活严重受限，但到两年随访时，两个治疗组的性生活均有显著改善，这与背痛减轻相关。第三项研究是关于腰椎节段的活动度，术前和两年随访时均拍摄了腰椎在完全伸展和屈曲位的X线片。对这些片子的分析显示，融合组78%的患者达到了手术目标（无活动度），而TDR组89%的患者保持了活动度。两组术前椎间盘高度均低于正常数据库水平，融合组术后仍较低，而TDR组术后椎间盘高度升高。TDR组手术节段的活动度术后增加。两个治疗组腰椎其余节段的活动度均增加。相邻节段术后活动度在正常范围内，但融合组略大。在第四项研究中，分析了TDR与融合术的卫生经济学情况。融合组患者的手术医院费用高于TDR组，且TDR组患者病假时间少两个月。总体而言，这些研究表明TDR组的结果与融合组一样好。与融合术相比，TDR治疗的患者更有可能完全无痛。至少从短期来看，这种新手术治疗方法在特定患者中似乎是合理的。长期随访正在进行，结果将适时公布。
