多节段微创腰椎体间融合术临床收益递减。
Diminishing Clinical Returns of Multilevel Minimally Invasive Lumbar Interbody Fusion.
机构信息
Department of Orthopedic Surgery, NYU Langone Orthopedic Hospital, New York, NY.
Department of Orthopedic Surgery, Hospital for Special Surgery, New York, NY.
出版信息
Spine (Phila Pa 1976). 2019 Oct 15;44(20):E1181-E1187. doi: 10.1097/BRS.0000000000003110.
STUDY DESIGN
Single institution retrospective clinical review.
OBJECTIVE
To investigate the relationship between levels fused and clinical outcomes in patients undergoing open and minimally invasive surgical (MIS) lumbar fusion.
SUMMARY OF BACKGROUND DATA
Minimally invasive spinal fusion aims to reduce the morbidity associated with conventional open surgery. As multilevel arthrodesis procedures are increasingly performed using MIS techniques, it is necessary to weigh the risks and benefits of multilevel MIS lumbar fusion as a function of fusion length.
METHODS
Patients undergoing <4 level lumbar interbody fusion were stratified by surgical technique (MIS or open), and grouped by fusion length: 1-level, 2-levels, 3+ levels. Demographics, Charlson Comorbidity Index (CCI), surgical factors, and perioperative complication rates were compared between technique groups at different fusion lengths using means comparison tests.
RESULTS
Included: 361 patients undergoing lumbar interbody fusion (88% transforaminal, 14% lateral; 41% MIS). Breakdown by fusion length: 63% 1-level, 22% 2-level, 15% 3+ level. Op-time did not differ between groups at 1-level (MIS: 233 min vs. Open: 227, P = 0.554), though MIS at 2-levels (332 min vs. 281) and 3+ levels (373 min vs. 323) were longer (P = 0.033 and P = 0.231, respectively). While complication rates were lower for MIS at 1-level (15% vs. 30%, P = 0.006) and 2-levels (13% vs. 27%, P = 0.147), at 3+ levels, complication rates were comparable (38% vs. 35%, P = 0.870). 3+ level MIS fusions had higher rates of ileus (13% vs. 0%, P = 0.008) and a trend of increased adverse pulmonary events (25% vs. 7%, P = 0.110). MIS was associated with less EBL at all lengths (all P < 0.01) and lower rates of anemia at 1-level (5% vs. 18%, P < 0.001) and 2-levels (7% vs. 16%, P = 0.193). At 3+ levels, however, anemia rates were similar between groups (13% vs. 15%, P = 0.877).
CONCLUSION
MIS lumbar interbody fusions provided diminishing clinical returns for multilevel procedures. While MIS patients had lower rates of perioperative complications for 1- and 2-level fusions, 3+ level MIS fusions had comparable complication rates to open cases, and higher rates of adverse pulmonary and ileus events.
LEVEL OF EVIDENCE
研究设计
单机构回顾性临床研究。
目的
研究接受开放式和微创外科（MIS）腰椎融合术的患者融合水平与临床结果之间的关系。
背景资料总结
微创脊柱融合术旨在降低与传统开放式手术相关的发病率。随着越来越多的多节段关节融合术采用 MIS 技术进行，有必要权衡多节段 MIS 腰椎融合术作为融合长度的功能的风险和益处。
方法
根据手术技术（MIS 或开放）对接受 <4 节段腰椎椎间融合术的患者进行分层，并按融合长度分组：1 节段、2 节段、3+ 节段。在不同的融合长度下，使用均值比较检验比较技术组之间的人口统计学、Charlson 合并症指数（CCI）、手术因素和围手术期并发症发生率。
结果
纳入：361 例接受腰椎椎间融合术（88%经椎间孔，14%侧方；41% MIS）。按融合长度分层：63%为 1 节段，22%为 2 节段，15%为 3+ 节段。1 节段时手术时间在组间无差异（MIS：233 分钟 vs. 开放：227 分钟，P=0.554），但 2 节段（332 分钟 vs. 281 分钟）和 3+ 节段（373 分钟 vs. 323 分钟）的 MIS 时间更长（P=0.033 和 P=0.231，分别）。虽然 MIS 在 1 节段（15% vs. 30%，P=0.006）和 2 节段（13% vs. 27%，P=0.147）的并发症发生率较低，但在 3+ 节段，并发症发生率相似（38% vs. 35%，P=0.870）。3+ 节段 MIS 融合的肠梗阻发生率较高（13% vs. 0%，P=0.008），且有更多不良肺部事件的趋势（25% vs. 7%，P=0.110）。在所有长度上，MIS 均与更少的 EBL 相关（均 P<0.01），并且在 1 节段（5% vs. 18%，P<0.001）和 2 节段（7% vs. 16%，P=0.193）时贫血发生率较低。然而，在 3+ 节段，两组的贫血发生率相似（13% vs. 15%，P=0.877）。
结论
MIS 腰椎椎间融合术对多节段手术的临床效果呈递减趋势。虽然 MIS 患者的 1 级和 2 级融合术的围手术期并发症发生率较低，但 3+ 级 MIS 融合术的并发症发生率与开放病例相似，且肺部和肠梗阻不良事件的发生率更高。
证据等级
3。
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