Maruo Keishi, Moriyama Tokuhide, Tachibana Toshiya, Inoue Shinichi, Arizumi Fumihiro, Kusuyama Kazuki, Yoshiya Shinichi
Department of Orthopaedic Surgery, Hyogo College of Medicine, Nishinomiya, Japan.
Department of Orthopaedic Surgery, Takarazuka City Hospital, Japan.
J Orthop Sci. 2017 Mar;22(2):248-253. doi: 10.1016/j.jos.2016.12.003. Epub 2016 Dec 24.
Lumbar destructive spondyloarthropathy (DSA) is a serious complication in long-term hemodialysis patients. There have not been many reports regarding the surgical management for lumbar DSA. In addition, the adjacent segment pathology after lumbar fusion surgery for DSA is unclear. The objective of this study was to assess the clinical outcome and occurrence of adjacent segmental disease (ASD) after lumbar instrumented fusion surgery for DSA in long-term hemodialysis patients.
A consecutive series of 36 long-term hemodialysis patients who underwent lumbar instrumented fusion surgery for DSA were included in this study. The mean age at surgery was 65 years. The mean follow-up period was 4 years. Symptomatic ASD was defined as symptomatic spinal stenosis or back pain with radiographic ASD. The Japanese Orthopedic Association score (JOA score), recovery rate (Hirabayashi method), complications, and reoperation were reviewed.
The mean JOA score significantly increased from 13.5 before surgery to 21.3 at the final follow-up. The mean recovery rate was 51.4%. Six of the 36 patients died within 1 year after index surgery. One patient died due to perioperative complication. Symptomatic ASD occurred in 43% (13 of 30) of the cases. Of these 13 cases, 5 had adjacent segment disc degeneration and 8 had adjacent segment spinal stenosis. Three cases (10%) required reoperation due to proximal ASD. Multi-level fusion surgery increased the risk of ASD compared with single-level fusion surgery (59% vs. 23%). The recovery rate was significantly lower in the ASD group than the non-ASD group (38% vs. 61%).
This study demonstrated that symptomatic ASD occurred in 43% of patients after surgery for lumbar DSA. A high mortality rate and complication rate were observed in long-term hemodialysis patients. Therefore, care should be taken for preoperative planning for surgical management of DSA.
腰椎破坏性脊椎关节病（DSA）是长期血液透析患者的一种严重并发症。关于腰椎DSA手术治疗的报道并不多。此外，DSA腰椎融合手术后相邻节段病变尚不清楚。本研究的目的是评估长期血液透析患者DSA腰椎器械融合手术后的临床疗效及相邻节段疾病（ASD）的发生情况。
本研究纳入了36例因DSA接受腰椎器械融合手术的连续长期血液透析患者。手术时的平均年龄为65岁。平均随访期为4年。有症状的ASD定义为有症状的椎管狭窄或伴有影像学ASD的背痛。回顾了日本骨科学会评分（JOA评分）、恢复率（平林法）、并发症和再次手术情况。
JOA评分平均从术前的13.5显著提高到末次随访时的21.3。平均恢复率为51.4%。36例患者中有6例在初次手术后1年内死亡。1例患者死于围手术期并发症。43%（30例中的13例）的病例发生了有症状的ASD。在这13例病例中，5例有相邻节段椎间盘退变，8例有相邻节段椎管狭窄。3例（10%）因近端ASD需要再次手术。与单节段融合手术相比，多节段融合手术增加了ASD的风险（59%对23%）。ASD组的恢复率明显低于非ASD组（38%对61%）。
本研究表明，腰椎DSA手术后43%的患者出现了有症状的ASD。长期血液透析患者的死亡率和并发症发生率较高。因此，在DSA手术治疗的术前规划中应谨慎。
