胸椎黄韧带骨化椎板减压后回植与椎弓钉固定的比较

Lamina re-implantation versus pedicle screw fixation after laminectomy for thoracic ossification of the ligamentum flavum

摘要:

[目的] 比较胸椎黄韧带骨化椎板减压后回植与固定治疗胸椎黄韧带骨化症的临床疗效。[方法] 回顾性分析2020年1月—2023年12月南昌大学第一附属医院骨科医院手术治疗胸椎黄韧带骨化症（thoracic ossification of the ligamentum flavum, TOLF）54例患者的资料。依据术前医患沟通结果，21例采用胸椎黄韧带骨化物切除+椎板回植术（回植组），33例采用胸椎全椎板切除+椎弓根钉内固定术（固定组），比较两组围手术期、随访和影像结果。[结果] 两组均顺利完成手术，回植组的手术时间[min, (153.4±41.1) vs (222.4±131.2), P=0.031]、术中失血量[mL, (309.5±172.2) vs (570.0±482.5), P=0.018]、术中透视次数[次, (3.5±0.8) vs (6.1±1.0), P=0.018]均显著优于固定组。两组切口总长度、下地行走时间、住院天数、并发症发生率的差异无统计学意义（P>0.05），所有患者均获得12个月以上随访，回植组恢复完全负重活动时间[d, (37.1±9.1) vs (44.5±10.0), P=0.009]显著早于固定组。与术前相比，末次随访时两组JOA、ODI评分及ASIA评级均显著改善（P<0.05），末次随访时，回植组的ODI评分显著优于固定组[%, (25.8±12.3) vs (37.2±14.4), P=0.004]，两组JOA评分、ASIA评级的差异无统计意义（P>0.05）。影像方面，末次随访时回植组椎间隙高度[mm, (6.0±1.0) vs (5.5±0.8), P=0.039]显著大于固定组，两组胸椎后凸角、硬膜囊面积、椎管面积的差异均无统计学意义（P>0.05）。[结论] 两种手术都能促进神经功能的恢复，回植组较固定组手术时间更短、术中出血量更少，在减少术后腰背部疼痛、僵硬，提高患者生活质量的方面有着更大的优势。

Abstract:

[Objective] To compare the clinical efficacy of lamina re-implantation versus pedicle screw fixation after laminectomy in the treatment of thoracic ossification of the ligamentum flavum (TOLF). [Methods] A retrospective study was conducted on 54 patients who underwent surgical treatments for TOLF at the Orthopedic Hospital of the First Affiliated Hospital of Nanchang University from January 2020 to December 2023. According to the preoperative doctor-patient communication, 21 patients underwent thoracic ligamentum flavum osteophyte resection and laminoplasty with re-implantation (the re-implantation group), while the other 33 patients underwent thoracic laminectomy and pedicle screw fixation (the fixation group). The perioperative, follow-up, and imaging data of the two groups were compared. [Results] All patients in both groups had the matched surgical procedures performed successfully. The re-implantation group proved significantly superior to the fixation group in terms of operation time [min, (153.4±41.1) vs (222.4±131.2), P=0.031], intraoperative blood loss [mL, (309.5±172.2) vs (570.0±482.5), P=0.018], and intraoperative fluoroscopy [times, (3.5±0.8) vs (6.1±1.0), P=0.018], whereas there were no statistically significant differences in total incision length, time to ambulation, hospital stay, and complication rate between the two groups (P>0.05). All patients were followed up for more than 12 months, and the re-implantation group achieved full weight-bearing activity significantly earlier than the fixation group [days, (37.1±9.1) vs (44.5±10.0), P=0.009]. Compared with those preoperatively, both groups showed significant improvements in JOA, ODI scores, and ASIA grades at the last follow-up (P<0.05). At the last follow-up, the reimplantation group was significantly better than the fixation group regarding ODI [%, (25.8±12.3) vs (37.2±14.4), P=0.004], while there were no statistically significant differences in JOA score and ASIA grade between the two groups (P>0.05). With respect of imaging, the re-implantation group had significantly greater intervertebral space height than the fixation group at the last follow-up [mm, (6.0±1.0) vs (5.5±0.8), P=0.039], while no statistically significant differences were found in thoracic kyphosis angle, dural sac area, and spinal canal area between the two groups (P>0.05). [Conclusion] Both surgical methods can promote the recovery of neurological function. The re-implantation has advantages over the fixation in terms of shorter operation time, less intraoperative blood loss, and earlier recovery of full weight-bearing activity, which can reduce postoperative low back pain and stiffness and improve the quality of life of patients.