自体下关节突骨块应用于骨质疏松患者腰椎椎间融合术的疗效分析

doi:10.19723/j.issn.1671-167X.2023.05.019

摘要/Abstract

摘要：

目的: 比较骨质疏松患者腰椎椎间融合术中植入自体下关节突骨块或聚醚醚酮(polyetheretherketone, PEEK)椎间融合器的疗效, 评估自体下关节突骨块替代椎间融合器的可行性。方法: 回顾性分析2018年12月至2021年6月在中国人民解放军总医院第四医学中心接受后路腰椎改良开窗减压、椎间植骨融合内固定术治疗且术前合并骨质疏松(双能X线骨密度T值≤-2.5)患者的病例资料, 随访时长不低于术后12个月。根据椎间融合材料的差异分为两组, 椎间植入自体下关节突骨块的患者纳入下关节突组, 植入PEEK椎间融合器的患者纳入PEEK组, 比较两组患者的一般资料(年龄、性别、体重指数、发病时长、主诊断及融合节段分布、腰椎骨密度、术前合并症的发病率)、围手术期资料(手术时长、术中失血量、术后引流量、围术期异体血输血率)及术后并发症的差异, 同时对比两组术前、术后1周、术后3个月、术后6个月及末次随访时的影像学参数(椎间隙高度、腰椎前凸角、节段前凸角、融合间隙角、椎间隙高度改善率、融合率)以及腰椎功能评分[视觉模拟评分(visual analogue scale, VAS)、Oswestry功能障碍指数(Oswestry disability index, ODI)、下腰痛日本骨科协会(Japanese Orthopedics Association, JOA)评分], 评价两种椎间融合材料的临床疗效。结果: 共纳入118例患者, 其中下关节突组68例, PEEK组50例, 两组病例在年龄、性别、体重指数、发病时长、主诊断及融合节段分布、腰椎骨密度、术前合并症的发病率、术前各影像学参数及腰椎功能评分方面差异无统计学意义(P>0.05), 组间具有可比性。两组在手术时长、术中出血量、术后引流量、异体血输血率方面差异也无统计学意义(P>0.05)。术后下关节突组有3例浅表手术部位感染, PEEK组有2例; 末次随访时下关节突组有3例椎间移植物塌陷, PEEK组有5例; 下关节突组有1例移植物后退, PEEK组也有1例。各随访时间节点两组的椎间隙高度、腰椎前凸角、节段前凸角、融合间隙角均明显大于术前(P < 0.05), 但术后3个月与术后1周相比, 上述参数均明显下降(P < 0.05)。组间比较显示, 术后1周时下关节突组的椎间隙高度及融合间隙角小于PEEK组(P < 0.05), 椎间隙改善率小于PEEK组(P < 0.05)。两组病例自术后3个月开始出现椎间融合, 术后6个月时下关节突组的融合率为75%, 明显高于PEEK组的56%(P < 0.05), 但两组末次随访时的融合率差异无统计学意义(P>0.05)。腰椎功能评分的组内比较显示, 两组术后的腰痛VAS评分、ODI均明显低于术前(P < 0.05), JOA评分明显高于术前(P < 0.05);组间比较显示, 下关节突组术后6个月时的ODI更低, 而JOA评分更高(P < 0.05)。结论: 骨质疏松患者腰椎椎间融合术中, 椎间植入自体下关节突骨块或PEEK椎间融合器均能获得良好的椎间融合率及腰椎功能改善, 但术后6个月时自体下关节突骨块的融合率及腰椎功能改善优于PEEK椎间融合器。PEEK椎间融合器在术后早期的椎间撑开及椎间隙前凸改善作用优于自体下关节突骨块。骨质疏松患者腰椎椎间融合术后3个月内会出现明显的椎间隙沉降, 椎间植入PEEK椎间融合器比自体下关节突骨块的沉降更为明显。

关键词: 脊柱融合术, 下关节突, 骨移植, 骨质疏松, 腰椎

Abstract:

Objective: To compare and analyze the feasibility of autologous facet joint bone block as an alternative to polyetheretherketone (PEEK) cage in lumbar intervertebral fusion surgery for patients with osteoporosis. Methods: From December 2018 to June 2021, the case data of patients with osteoporosis (T value ≤ -2.5 on dual energy X-ray bone density) who underwent posterior lumbar interbody fusion in the Fourth Medical Center, Chinese PLA General Hospital were retrospectively reviewed. All the cases were followed up for no less than 12 months and were divided into two groups according to the differences of interbody fusion materials: the autologous facet joint bone block group (autogenous bone group) and the PEEK cage group (PEEK group). The general data [such as age, gender, body mass index (BMI), primary diagnosis, distribution of fusion segments, bone mineral density of lumbar (BMD), incidence of preoperative complications], the perioperative data (such as duration of operation, intraoperative blood loss, postoperative drainage, perioperative allogeneic blood transfusion rate), and the incidence of postoperative complications were compared between the two groups. Imaging parameters (disc height, lumbar lordosis angle, segment lordosis angle, segmental lordosis angle, disc height improvement rate, and fusion rate) and lumbar functional scores [visual analogue scale (VAS), Oswestry disability index (ODI), Japanese Orthopedics Association (JOA) score for lower back pain] were compared to evaluate the clinical efficacy between the kinds of intervertebral fusion materials 1 week, 3 months and 6 months postoperative and at the last follow-up. Results: A total of 118 patients were enrolled, including 68 cases in the autogenous bone group and 50 cases in the PEEK group, there were no statistical differences in age, gender, BMI, primary diagnosis, distribution of fusion segments, BMD, incidence of preoperative complications, duration of operation, intraoperative blood loss, postoperative drainage, perioperative allogeneic blood transfusion rate, incidence of postoperative complications, all the preoperative imaging parameters and all the lumbar function scores between the two groups (P>0.05). Postoperative superficial surgical site infections occurred in 3 patients in the autogenous bone group and 2 patients in the PEEK group. At the last follow-up, 3 cases of intervertebral graft collapse occurred in the autogenous bone group and 5 cases in the PEEK group, 1 case of graft subsidence in the autogenous bone group and 1 case in the PEEK group. All the imaging parameters showed significant differences between postoperation and preoperation (P < 0.05), and all the imaging parameters showed significant differences between 1 week and 3 months postoperative in both groups (P < 0.05). The height, angle of fusion gap in the autogenous bone group were lower than those in the PEEK group 1 week postoperatively (P < 0.05), and the fusion gap height improvement rate in the autogenous bone group was lower than that in the PEEK group (P < 0.05). The cases in both groups started to show final fusion 3 months after surgery, and the fusion rate in the autogenous bone group was 75% 6 months postoperatively, which was significantly higher than the rate of 56% in the PEEK group (P < 0.05), and there was no statistically significant difference in the final fusion rate between the two groups (P>0.05). The ODI, the postoperative VAS score was significantly lower than that in preoperation, while the postoperative JOA score was significantly higher than that in preoperation (P < 0.05). The ODI was lower while the JOA score was higher of the autogenous bone group than that of the PEEK group 6 months postoperatively (P < 0.05). Conclusion: In osteoporosis patients, good interbody fusion rate and improvement of lumbar vertebral function can be obtained by using autologous facet joint bone block or PEEK cage, while the fusion rate and the improvement of lumbar function with autologous facet joint bone block are better than those with PEEK cage 6 months post-operatively. PEEK cage is superior to autologous facet joint bone block in intervertebral distraction and improvement of lumbar lordosis. Significant disc space subsidence occurred in osteoporotic patients within 3 months after lumbar interbody fusion, and the subsidence of PEEK cage was more obvious than that of autologous facet joint bone block.

Key words: Spinal fusion, Autologous facet joint, Bone transplantation, Osteoporosis, Lumbar vertebrae

中图分类号:

R681.5

汪大伟,王华东,李利,尹欣,黄伟,郭继东,杨亚锋,刘义灏,郑扬. 自体下关节突骨块应用于骨质疏松患者腰椎椎间融合术的疗效分析[J]. 北京大学学报（医学版）, 2023, 55(5): 899-909.

Da-wei WANG,Hua-dong WANG,Li LI,Xin YIN,Wei HUANG,Ji-dong GUO,Ya-feng YANG,Yi-hao LIU,Yang ZHENG. Efficacy analysis of autologous facet joint bone block in lumbar interbody fusion of osteoporosis patients[J]. Journal of Peking University (Health Sciences), 2023, 55(5): 899-909.

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参考文献 34

1	Wolfert AJ , Rompala A , Beyer GA , et al. The impact of osteoporosis on adverse outcomes after short fusion for degenerative lumbar disease[J]. Am Acad Orthop Surg, 2022, 30 (12): 573- 579. doi: 10.5435/JAAOS-D-21-01258
2	Reid PC , Morr S , Kaiser MG . State of the union: A review of lumbar fusion indications and techniques for degenerative spine disease[J]. Neurosurg Spine, 2019, 31 (1): 1- 14. doi: 10.3171/2019.4.SPINE18915
3	Zou D , Jiang S , Zhou S , et al. Prevalence of osteoporosis in patients undergoing lumbar fusion for lumbar degenerative diseases: A combination of DXA and Hounsfield units[J]. Spine (Phila Pa 1976), 2020, 45 (7): E406- E410. doi: 10.1097/BRS.0000000000003284
4	孟海, 杨雍, 孙天胜, 等. 腰椎后路手术椎间融合器应用的专家共识[J]. 中国脊柱脊髓杂志, 2021, 31 (4): 379- 384.
5	王东亮, 毛兆虎, 杨文玖, 等. 自体下关节突骨块在腰椎椎间融合中的应用解剖[J]. 中华实验外科杂志, 2013, 30 (12): 2726- 2727.
6	Kai Y , Oyama M , Morooka M . Posterior lumbar interbody fusion using local facet joint autograft and pedicle screw fixation[J]. Spine (Phila Pa 1976), 2004, 29 (1): 41- 46. doi: 10.1097/01.BRS.0000103940.57588.50
7	张绍东, 唐天驷, 杨惠林, 等. 保留部分关节突后路腰椎间融合治疗腰椎间盘退变性疾病[J]. 中国脊柱脊髓杂志, 2004, 14 (6): 360- 363.
8	Siepe CJ , Stosch-Wiechert K , Heider F , et al. Anterior stand-alone fusion revisited: A prospective clinical, X-ray and CT investigation[J]. Eur Spine J, 2015, 24 (4): 838- 851. doi: 10.1007/s00586-014-3642-y
9	高志强, 李洋, 罗飞, 等. 对脊柱椎间融合的影像学评价策略[J]. 中国组织工程研究, 2015, 19 (48): 7825- 7830.
10	Yao YC , Chou PH , Lin HH , et al. Risk factors of cage subsi-dence in patients received minimally invasive transforaminal lumbar interbody fusion[J]. Spine (Phila Pa 1976), 2020, 45 (19): E1279- E1285. doi: 10.1097/BRS.0000000000003557
11	Park MK , Kim KT , Bang WS , et al. Risk factors for cage migration and cage retropulsion following transforaminal lumbar interbody fusion[J]. Spine J, 2019, 19 (3): 437- 447. doi: 10.1016/j.spinee.2018.08.007
12	Strage KE , Parry JA , Mauffrey C . Standardizing statistics and data reporting in orthopaedic research[J]. Eur J Orthop Surg Traumatol, 2021, 31 (1): 1- 6. doi: 10.1007/s00590-020-02843-8
13	杨喆, 谭志军, 张杨, 等. 医学研究中计量资料组间比较统计分析方法的正确应用[J]. 中国儿童保健杂志, 2019, 27 (10): 1157- 1160.
14	Kuslich SD , Ulstrom CL , Griffith SL , et al. The Bagby and Kuslich method of lumbar interbody fusion: History, techniques, and 2-year follow-up results of a United States prospective, multicenter trial[J]. Spine (Phila Pa 1976), 1998, 23 (11): 1267- 1278. doi: 10.1097/00007632-199806010-00019
15	唐强, 钟德君, 王清, 等. 椎间自体骨植骨面积比与椎间融合率的关系[J]. 中国组织工程研究, 2021, 25 (36): 5821- 5826.
16	Amorim-Barbosa T , Pereira C , Catelas D , et al. Risk factors for cage subsidence and clinical outcomes after transforaminal and posterior lumbar interbody fusion[J]. Eur J Orthop Surg Traumatol, 2022, 32 (7): 1291- 1299.
17	Meng B , Bunch J , Burton D , et al. Lumbar interbody fusion: Recent advances in surgical techniques and bone healing strategies[J]. Eur Spine J, 2021, 30 (1): 22- 33. doi: 10.1007/s00586-020-06596-0
18	白文媛, 顾洪生, 廖振华, 等. 正常成人腰椎间盘相关参数的测量和意义[J]. 中国临床解剖学杂志, 2013, 31 (5): 505- 510.
19	中国健康促进基金会基层医疗机构骨质疏松症诊断与治疗专家共识委员会. 基层医疗机构骨质疏松症诊断和治疗专家共识(2021)[J]. 中国骨质疏松杂志, 2021, 27 (7): 937- 944.
20	Wagner SC , Kang DG , Steelman T , et al. Diagnosing the undiagnosed: Osteoporosis in patients undergoing lumbar fusion[J]. Spine (Phila Pa 1976), 2016, 41 (21): E1279- E1283. doi: 10.1097/BRS.0000000000001612
21	Khalid SI , Nunna RS , Maasarani S , et al. Association of osteopenia and osteoporosis with higher rates of pseudarthrosis and revision surgery in adult patients undergoing single-level lumbar fusion[J]. Neurosurg Focus, 2020, 49 (2): E6.
22	Yu Y , Robinson DL , Ackland DC , et al. Influence of the geometric and material properties of lumbar endplate on lumbar interbody fusion failure: A systematic review[J]. J Orthop Surg Res, 2022, 17 (1): 224.
23	赵龙, 曾建成, 谢天航, 等. 腰椎椎间融合术后椎间融合器沉降的研究进展[J]. 中国修复重建外科杂志, 2021, 35 (8): 1063- 1067.
24	郭新虎, 孟妍, 齐强, 等. 后路腰椎椎体间融合术后cage移位的危险因素分析及处理策略[J]. 中国脊柱脊髓杂志, 2022, 32 (1): 42- 49.
25	Govindarajan V , Diaz A , Perez-Roman RJ , et al. Osteoporosis treatment in patients undergoing spinal fusion: A systematic review and meta-analysis[J]. Neurosurg Focus, 2021, 50 (6): E9.
26	Tani S , Ishikawa K , Kudo Y , et al. The effect of denosumab on pedicle screw fixation: A prospective 2-year longitudinal study using finite element analysis[J]. J Orthop Surg Res, 2021, 16 (1): 219.
27	金贺荣, 崔敬斌, 邵苍, 等. 椎间融合器材料: 临床应用的优势与关注热点[J]. 中国组织工程研究, 2022, 26 (22): 3592- 3597.
28	Formica M , Vallerga D , Zanirato A , et al. Fusion rate and influence of surgery-related factors in lumbar interbody arthrodesis for degenerative spine diseases: A meta-analysis and systematic review[J]. Musculoskelet Surg, 2020, 104 (1): 1- 15.
29	万东东, 胡茂忠, 许东浩, 等. 髂骨取骨术后并发症的研究进展[J]. 中国矫形外科杂志, 2016, 24 (12): 1096- 1100.
30	刘军, 万豫尧, 王慧敏, 等. 改良自体棘突腰椎椎体间植骨融合术的临床应用[J]. 广东医学, 2006, 27 (7): 994- 996.
31	Tavares WM , de Franca SA , Paiva WS , et al. A systematic review and meta-analysis of fusion rate enhancements and bone graft options for spine surgery[J]. Sci Rep, 2022, 12 (1): 7546.
32	Geurts J , Ramp D , Schären S , et al. Georg-Schmorl-Prize of the German Spine Society (DWG) 2016: Comparison of in vitro osteogenic potential of iliac crest and degenerative facet joint bone autografts for intervertebral fusion in lumbar spinal stenosis[J]. Eur Spine J, 2017, 26 (5): 1408- 1415.
33	万标林, 梁伟国, 王斌, 等. 自体椎板关节突柱状植骨融合治疗腰椎退行性疾病的疗效分析[J]. 中国矫形外科杂志, 2012, 20 (11): 964- 967.
34	王璐璐, 陈晓亮, 马进峰, 等. 自体下关节突骨块与Cage椎体间融合效果比较[J]. 青岛大学医学院学报, 2012, 48 (1): 30- 32.

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Parameters	Autogenous bone group	PEEK group	P value
Male	33.8%	34.0%	0.984
Age/years, ${\bar x}$±s	64.46±5.67	64.60±5.18	0.888
BMI/(kg/m²), ${\bar x}$±s	23.84±2.64	23.81±2.83	0.943
Main diagnosis(A/B/C/D)	18/31/11/8	14/23/8/5	0.991
Fusion segment(L₄-L₅/L₅-S₁)	41/27	30/20	0.974
Bone density of lumbar/(g/cm²), ${\bar x}$±s	0.78±0.11	0.76±0.12	0.939
Operation time/min, ${\bar x}$±s	126.00±12.29	127.16±10.34	0.590
Blood loss/mL, ${\bar x}$±s	221.99±49.17	223.40±54.39	0.883
Postoperative drainage/mL, ${\bar x}$±s	281.69±58.85	283.40±46.47	0.865
Allogeneic blood utilization	11.8%	14.0%	0.719
Length of hospitalization/d, ${\bar x}$±s	12.32±1.72	12.18±1.48	0.636
Follow-up time/months, ${\bar x}$±s	16.43±2.59	16.42±2.38	0.989

Parameters	Preoperation	1 week postoperative	3 months postoperative	6 months postoperative	Last follow-up
DH/mm, ${\bar x}$±s
Autogenous bone group	6.83±1.63	10.29±1.53^abc	10.02±1.62^a	9.82±1.62^a	9.72±1.61^a
PEEK group	6.81±1.48	11.01±1.48^ab	10.04±1.43^a	9.78±1.47^a	9.69±1.43^a
DH improvement rate
Autogenous bone group		50.4%	47.1%	44.4%	44.1%
PEEK group		61.8%	47.5%	44.1%	44.1%
DL/(°), ${\bar x}$±s
Autogenous bone group	8.59±4.12	14.73±3.06^abc	13.22±3.14^a	12.74±3.14^a	12.71±5.02^a
PEEK group	8.62±4.32	15.95±3.07^ab	13.24±3.17^a	12.25±3.26^a	12.12±3.23^a
SL/(°), ${\bar x}$±s
Autogenous bone group	12.72±4.74	17.81±2.88^ab	16.63±2.83^a	16.32±2.93^a	16.26±3.00^a
PEEK group	12.71±5.02	18.71±2.82^ab	16.65±2.93^a	16.04±3.05^a	15.81±3.14^a
LL/(°), ${\bar x}$±s
Autogenous bone group	34.69±8.45	40.10±6.75^ab	38.24±6.64^a	37.39±6.40^a	37.18±6.56^a
PEEK group	34.73±8.49	41.57±7.06^ab	38.24±6.80^a	37.36±6.60^a	37.09±6.75^a
Fusion rate
Autogenous bone group			7.4%	75.0%^c	94.1%
PEEK group			6.0%	56.0%	90.0%

Parameters	Preoperation	1 week postoperative	3 months postoperative	6 months postoperative	Last follow-up
VAS score, ${\bar x}$±s
Autogenous bone group	5.18±0.83	1.82±0.73^a	1.03±0.73^a	0.53±0.50^a	0.41±0.49^a
PEEK group	5.18±0.87	1.82±0.66^a	1.02±0.69^a	0.52±0.50^a	0.41±0.50^a
ODI, ${\bar x}$±s
Autogenous bone group	36.54±2.92		26.06±3.39^ab	20.34±3.13^ab	16.46±2.30^a
PEEK group	36.54±3.11		25.98±2.98^a	21.42±2.56^a	16.46±2.32^a
JOA score, ${\bar x}$±s
Autogenous bone group	12.62±1.31		20.37±1.89^a	23.78±1.60^ab	25.82±2.04^a
PEEK group	12.60±1.36		20.36±2.04^a	22.98±1.74^a	25.82±1.72^a

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