斜外侧腰椎椎间融合术中椎体骨折的原因和临床结果分析
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作者Author单位AddressE-Mail
曾忠友 ZENG Zhong-you 武警海警总队医院骨二科, 浙江 嘉兴 314000 The Second Department of Orthopaedics, Hospital of Coast Guard General Corps of Armed Police Forces, Jiaxing 314000, Zhejiang, China zjzengzy@126.com 
赵兴 ZHAO Xing 浙江大学医学院附属邵逸夫医院骨科, 浙江 杭州 310016 Department of Orthopaedics, Sir Run Run Shaw Hospital Affiliated to Zhejiang University School of Medicine, Hangzhou 310016, Zhejiang, China  
张玙 ZHANG Yu 皖南医学院戈矶山医院脊柱外科, 安徽 芜湖 241001 Department of Spine Surgery, the First Affiliated Hospital of Wannan Medical College, Wuhu 241001, Anhui, China  
陈平泉 CHEN Ping-quan 嘉兴市中医医院骨伤科, 浙江 嘉兴 314001 Department of Orthopaedics and Traumatology, Jiaxing Hospital of Traditional Chinese Medicine, Jiaxing 314001, Zhejiang, China  
俞伟 YU Wei 武警海警总队医院骨二科, 浙江 嘉兴 314000 The Second Department of Orthopaedics, Hospital of Coast Guard General Corps of Armed Police Forces, Jiaxing 314000, Zhejiang, China  
宋永兴 SONG Yong-xing 武警海警总队医院骨二科, 浙江 嘉兴 314000 The Second Department of Orthopaedics, Hospital of Coast Guard General Corps of Armed Police Forces, Jiaxing 314000, Zhejiang, China  
范顺武 FAN Shun-wu 浙江大学医学院附属邵逸夫医院骨科, 浙江 杭州 310016 Department of Orthopaedics, Sir Run Run Shaw Hospital Affiliated to Zhejiang University School of Medicine, Hangzhou 310016, Zhejiang, China  
裴斐 PEI Fei 武警海警总队医院骨二科, 浙江 嘉兴 314000 The Second Department of Orthopaedics, Hospital of Coast Guard General Corps of Armed Police Forces, Jiaxing 314000, Zhejiang, China  
范时洋 FAN Shi-yang 武警海警总队医院骨二科, 浙江 嘉兴 314000 The Second Department of Orthopaedics, Hospital of Coast Guard General Corps of Armed Police Forces, Jiaxing 314000, Zhejiang, China  
宋国浩 SONG Guo-hao 武警海警总队医院骨二科, 浙江 嘉兴 314000 The Second Department of Orthopaedics, Hospital of Coast Guard General Corps of Armed Police Forces, Jiaxing 314000, Zhejiang, China  
王海峰 WANG Hai-feng 武警海警总队医院骨二科, 浙江 嘉兴 314000 The Second Department of Orthopaedics, Hospital of Coast Guard General Corps of Armed Police Forces, Jiaxing 314000, Zhejiang, China  
期刊信息:《中国骨伤》2023年,第36卷,第5期,第406-413页
DOI:10.12200/j.issn.1003-0034.2023.05.003
基金项目:浙江省医药卫生科技计划项目(编号:2020KY968)
中文摘要:

目的:分析斜外侧椎间融合(oblique lateral interbody fusion,OLIF)治疗腰椎病变术中椎体骨折的原因,总结临床结果,提出预防措施。

方法:回顾性分析3家医疗中心2014年10月至2018年12月采用斜外侧椎间融合治疗腰椎病变并出现椎体骨折的8例病例资料。8例均为女性,年龄50~81岁,平均66.4岁;腰椎退行性病变1例,腰椎管狭窄症3例,腰椎退行性滑脱2例,腰椎退行性侧后凸2例;术前双能X线骨密度检测,2例T值>-1 SD,2例T值-1~-2.5 SD,4例T值<-2.5 SD;单节段融合5例,双节段融合1例,3节段融合2例;采用Stand-alone OLIF 4例,OLIF联合后路椎弓根螺钉固定4例。术后影像检查均提示椎体骨折,且均为单椎体骨折。表现为融合节段上椎体右下缘骨折2例,融合节段下椎体骨折6例;合并终板损伤且融合器部分嵌入椎体6例。3例Stand-alone OLIF病例给予后路肌间隙入路椎弓根螺钉固定,另1例Stand-alone OLIF病例和4例OLIF联合后路椎弓根螺钉固定病例未予特殊处理。

结果:未予特殊处理的5例与再次手术的3例均未出现切口皮肤坏死或切口感染,随访时间12~48个月,平均22.8个月。腰痛视觉模拟评分(visual analogue scale,VAS)由术前的4~8分(平均6.3分)下降至末次随访时的1~3分(平均1.7分),腰痛明显改善;Oswestry功能障碍指数(Oswestry disability index,ODI)由术前的39.7%~52.4%(平均40.2%)恢复至末次随访时的7.9%~11.2%(平均9.5%)。随访过程中未出现椎弓根螺钉系统松动或断裂现象,发生椎体骨折节段的融合器均出现明显沉降,融合器无横向移位。椎体骨折节段椎间隙高度由术前的6.7~9.2 mm(平均8.1 mm)恢复至术后的10.5~12. 8 mm(平均11.2 mm),术后与术前比较改善率为37.98%;末次随访时为8.4~10.9 mm(平均9.3 mm),与术后比较丢失率为16.71%;说明腰椎融合节段术后椎间隙高度获得明显的恢复,而在随访过程中出现了明显的丢失。末次随访时除1例不能明确外,其余均获得椎间融合。

结论:斜外侧椎间融合治疗腰椎病变术中椎体骨折的发生率较低,发生骨折的原因较多,包括患者术前存在骨量减少或骨质疏松、终板损伤、终板形态不规则、融合器选择过大和病变节段骨赘增生等。椎体骨折只要发现及时,处理得当,多预后良好,但仍需要加强预防。
【关键词】腰椎  内固定  脊柱融合术  并发症  再手术
 
Analysis of the causes and clinical results of vertebral fracture during oblique lateral lumbar interbody fusion
ABSTRACT  

Objective To analyze the causes of vertebral fracture during oblique lateral interbody fusion in the treatment of lumbar spondylopathy,summarize the clinical results,and propose preventive measures.

Methods Retrospective analysis was made on the data of 8 cases of lumbar spondylopathy and vertebral fracture treated by oblique lateral interbody fusion in three medical centers from October 2014 to December 2018. All were female,aged from 50 to 81 years with an average of 66.4 years. Disease types included 1 case of lumbar degenerative disease,3 cases of lumbar spinal stenosis,2 cases of lumbar degenerative spondylolisthesis and 2 cases of lumbar degenerative scoliosis. Preoperative dual energy X-ray bone mineral density test showed that 2 cases had T-value >-1 SD,2 cases had T-value -1 to -2.5 SD,and 4 cases had T-value <-2.5 SD. Single segment fusion was in 5 cases,two segment fusion in 1 case and three segment fusion in 2 cases. Four cases were treated with OLIF Stand-alone and 4 cases were treated with OLIF combined with posterior pedicle screw fixation. Postoperative imaging examination showed vertebral fracture,and all of them were single vertebral fracture. There were 2 cases of right lower edge fracture of upper vertebral body at fusion segment,6 cases of lower vertebral body fracture at fusion segment,and 6 cases with endplate injury and fusion cage partially embedded in vertebral body. Three cases of OLIF Stand-alone were treated with pedicle screw fixation via posterior intermuscular approach,while one case of OLIF Stand-alone and four cases of OLIF combined with posterior pedicle screw fixation were not treated specially.

Results The 5 cases of initial operation and 3 cases of reoperation did not show wound skin necrosis or wound infection. The follow-up time was from 12 to 48 months with an average of 22.8 months. Visual analogue scale (VAS) of low back pain was preoperative decreased from 4 to 8 points (averagely 6.3 points) and postoperative 1 to 3 points (averagely 1.7 points) at the final follow-up. Oswestry disability index (ODI) was preoperative 39.7% to 52.4% (averagely 40.2%),and postoperative 7.9% to 11.2% (averagely 9.5%) at the final follow-up. During the follow-up,there was no loosening or fracture of the pedicle screw system,and no lateral displacement of the fusion cage;however,the fusion cage at the vertebral fracture segment had obvious subsidence. The intervertebral space height of vertebral fracture segment was preoperaive 6.7 to 9.2 mm (averagely 8.1 mm),and postoperative 10.5 to 12.8 mm (averagely 11.2 mm). The improvement rate after operation was 37.98% compared to preoperative. The intervertebral space height at final follow-up was 8.4 to 10.9 mm (averagely 9.3 mm),and the loss rate was 16.71% compared with that after operation. At the final follow-up,interbody fusion was achieved in all cases except for one that could not be identified.

Conclusion The incidence of vertebral fracture during oblique lateral interbody fusion in the treatment of lumbar spondylopathy is lower,and there are many reasons for fracture,including preoperative bone loss or osteoporosis,endplate injury,irregular shape of endplate,excessive selection of fusion cage,and osteophyte hyperplasia at the affected segment. As long as vertebral fracture is found in time and handled properly,the prognosis is well. However,it still needs to strengthen prevention.
KEY WORDS  Lumbar vertebrae  Internal fixation  Spinal fusion  Complication  Reoperation
 
引用本文,请按以下格式著录参考文献:
中文格式:曾忠友,赵兴,张玙,陈平泉,俞伟,宋永兴,范顺武,裴斐,范时洋,宋国浩,王海峰.斜外侧腰椎椎间融合术中椎体骨折的原因和临床结果分析[J].中国骨伤,2023,36(5):406~413
英文格式:ZENG Zhong-you,ZHAO Xing,ZHANG Yu,CHEN Ping-quan,YU Wei,SONG Yong-xing,FAN Shun-wu,PEI Fei,FAN Shi-yang,SONG Guo-hao,WANG Hai-feng.Analysis of the causes and clinical results of vertebral fracture during oblique lateral lumbar interbody fusion[J].zhongguo gu shang / China J Orthop Trauma ,2023,36(5):406~413
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