Department of Orthopaedic Surgery, Shandong University Qilu Hospital, Jinan, Shandong, China.
J Neurosurg Spine. 2013 Aug;19(2):201-6. doi: 10.3171/2013.5.SPINE12650. Epub 2013 Jun 14.
During the past decades, lumbar fusion has increasingly become a standard treatment for degenerative spinal disorders. However, it has also been associated with an increased incidence of adjacent-segment degeneration (ASD). Previous studies have reported less ASD in anterior fusion surgeries; thus, the authors hypothesized that the integrity of the posterior complex plays an important role in ASD. This study was designed to investigate the effect of the posterior complex on adjacent instability after lumbar instrumentation and the development of ASD.
To evaluate different surgical interventions, 120 patients were randomly allocated into 3 groups of 40 patients each who were statistically similar with respect to demographic and clinical data. Patients in Group A were allocated for facet joint resection and L4-5 fusion, Group B for semilaminectomy and fusion, and Group C for complete laminectomy and fusion. All of the patients were followed up for 5-7 years (mean 5.9 years). The disc height, intervertebral disc angle, dynamic intervertebral angular range of motion (ROM), L3-4 slip, and the total lordosis angle were each measured before the operation and at the final follow-up. The Japanese Orthopaedic Association (JOA) score was determined before surgery and at the final follow-up to evaluate the clinical results.
Among the 3 groups, no significant differences were detected in all clinical and demographic assessments before surgery. At 3 months after surgery, the JOA score of all groups improved significantly and showed no significant differences among the groups. At the final follow-up, Group C had a significantly (p < 0.05) lower JOA score than the other 2 groups. Moreover, the disc height and total lumbar lordosis in patients of Group C were significantly decreased compared with disc height and total lumbar lordosis in the other 2 groups. In contrast, disc angle, dynamic angular ROM, and listhesis were significantly higher in Group C than in the other 2 groups. Twenty-four patients showed signs of ASD after the operation (3 patients in Group A, 4 in B, and 17 in C). The number of patients in Group C showing ASD was significantly different from that in Groups A and B.
During follow-up for 6 years, a significantly higher number of patients with ASD were noted in the complete-laminectomy group. The number of reoperations for treating ASD was much higher in this patient group than in the patients undergoing facet joint resection and L4-5 fusion or semilaminectomy and fusion. Therefore, preserving the posterior complex as much as possible during surgery plays an important role in preventing ASD and in reducing the reoperation rate.
在过去几十年中，腰椎融合术已逐渐成为治疗退行性脊柱疾病的标准治疗方法。然而，它也与相邻节段退变（ASD）的发生率增加有关。先前的研究报告称，前路融合术的 ASD 较少；因此，作者假设后复合体的完整性在 ASD 中起重要作用。本研究旨在探讨腰椎内固定术后后复合体对相邻节段不稳定及 ASD 发展的影响。
为了评估不同的手术干预措施，将 120 例患者随机分为 3 组，每组 40 例，每组在人口统计学和临床数据方面均具有统计学可比性。A 组患者行关节突切除术和 L4-5 融合术，B 组患者行半椎板切除术和融合术，C 组患者行全椎板切除术和融合术。所有患者均随访 5-7 年（平均 5.9 年）。分别在术前和末次随访时测量椎间盘高度、椎间盘角、动态椎间角活动范围（ROM）、L3-4 滑移和总腰椎前凸角。手术前和末次随访时采用日本矫形协会（JOA）评分评估临床结果。
3 组患者的所有临床和人口统计学评估在术前均无显著差异。术后 3 个月，所有组的 JOA 评分均显著改善，且组间无显著差异。末次随访时，C 组的 JOA 评分明显低于其他 2 组（p < 0.05）。此外，与其他 2 组相比，C 组的椎间盘高度和总腰椎前凸明显降低。相反，C 组的椎间盘角、动态角 ROM 和滑脱明显高于其他 2 组。术后 24 例患者出现 ASD 征象（A 组 3 例，B 组 4 例，C 组 17 例）。C 组出现 ASD 的患者人数明显多于 A 组和 B 组。
在 6 年的随访中，全椎板切除术组 ASD 患者数量明显较多。该患者组治疗 ASD 的再手术率明显高于行关节突切除和 L4-5 融合或半椎板切除术和融合的患者组。因此，在手术中尽可能保留后复合体对于预防 ASD 和降低再手术率具有重要意义。
