皮质骨轨道螺钉与常规椎弓根螺钉治疗合并骨质疏松的腰椎退行性疾病的对比研究

目的探讨皮质骨轨道(CBT)螺钉技术与传统轨道(TT)椎弓根螺钉技术治疗伴有骨质疏松症但不合并椎体Ⅰ度以上滑脱或脊柱侧凸的单节段腰椎退行性疾病患者的临床疗效。方法回顾性分析2017年2月—2019年2月在郑州大学第一附属医院接受L3/4或L4/5单节段腰椎融合术并且伴有骨量减少或骨质疏松症同时不合并椎体Ⅰ度以上滑脱或脊柱侧凸的52例女性患者资料,年龄40~71岁,其中22例接受了CBT螺钉手术(CBT组)、30例接受了TT螺钉手术(TT组)。对比观察两组患者手术时间、术中出血量、手术切口长度和手术并发症;术后第5天经摄腰椎X线片和CT扫描观察融合器、内固定位置,以及近端关节突关节侵扰(FJV)发生率;术后3、6、12、24个月复查腰椎正侧位X线片,评估植骨融合和内固定等情况;对比两组患者手术前及末次随访的Oswewtry功能障碍指数(ODI)和疼痛视觉模拟评分(VAS)。结果CBT组与TT组手术时间分别为(125.7±16.0)min和(123.8±18.3)min,差异无统计学意义(t=0.389,P>0.05);术中出血量CBT组[(74±39.8)mL]比TT组[(129±45.3)mL]少,手术切口长度CBT组[(5.7±0.6)cm]比TT组短[(8.4±0.92)cm],差异均有统计学意义(t=4.548、12.004,P值均<0.05)。术中TT组有1例患者L42枚椎弓根螺钉出现固定强度不佳,遂采用骨水泥强化椎弓根螺钉,其余患者手术置钉过程均未出现置钉失败、皮质骨钉道骨折断裂等情况;所有患者均未出现置钉引起的血管、神经损伤。术后第5天经摄腰椎X线片和CT扫描观察融合器、内固定位置良好;CBT组有3例患者共4个近端关节突关节发生FJV(4/44,9.09%),而TT组中有22例患者共35个近端关节突关节发生FJV(35/60,58.33%),两组比较差异有统计学意义(χ^2=26.263,P<0.01)。术后随访5~24个月,两组患者症状均得到改善,与术前相比末次随访的ODI及VAS均降低,差异均有统计学意义(t=16.549、18.490,P<0.01);而手术前后ODI和VAS组间比较差异均无统计学意义(P值均>0.05)。术后影像学随访未见螺钉松动、脱出和切割等,螺钉、连接棒、融合器均位置佳。结论与TT椎弓根螺钉技术相比,采用CBT螺钉技术治疗伴有骨量减少或骨质疏松症但不合并椎体Ⅰ度以上滑脱或脊柱侧凸的单节段腰椎退行性疾病患者的短期疗效同样可靠,而且CBT螺钉固定强度更佳、更为微创,值得临床推广应用。

Comparison of cortical bone trajectory screws and traditional trajectory screws in treatment of lumber degenerative patients with osteoporosis: a retrospective analysis

Objective To investigate and compare the clinical outcome of cortical bone trajectory (CBT) screws and traditional trajectory (TT) screws in treatment of single segment lumber degenerative patients with osteoporosis but without scoliosis or spondylolisthesis above degree I.Methods From February 2017 to February 2019, a retrospective analysis was made of 52 female patients who underwent L_3/4 or L_4/5 lumbar fusion with CBT screws or TT screws, aged 40-71 years, and accompanied by osteopenia or osteoporosis and without spondylolisthesis or scoliosis above grade I. Among them, 22 received CBT screw operation (CBT group) and 30 received TT screw operation (TT group). The operation time, intraoperative blood loss, surgical incision length and surgical complications were compared between the two groups.On the 5th day after operation, lumbar spine X-rays and CT scans were used to observe the fusion device, internal fixation position, and the incidence of proximal articular process joint infiltration (FJV). At 3, 6, 12, and 24 months after surgery, the lumbar spine X-ray film was reviewed to evaluate bone graft fusion and internal fixation.The Oswestry dysfunction index (ODI) and pain visual analogue score (VAS) were compared between the two groups of patients before surgery and the last follow-up.Results The operative time of CBT group and TT group was (125.7±16.0) min and (123.8±18.3) min respectively, the difference was not statistically significant (t=0.389, P>0.05); the intraoperative blood loss of CBT group was (74±39.8) mL, less than that of TT group (129±45.3) mL, and the incision length of CBT group was (5.7±0.60) cm, shorter than that of TT group (8.4±0.92) cm, the difference was statistically significant (t=4.548, 12.004, all P values < 0.05). Because of the poor fixation strength, one case in TT group ended up in using bone cement augmented pedicle screw in L₄.The remaining patients did not experience nail placement failure or cortical bone fracture fractures during surgical nail placement.No vascular or nerve damage was found in any patient. X-ray and CT scan of the lumbar spine were taken on the 5th day after operation, showing that the fusion cage and internal fixation were in good position; the incidence of FJV in CBT group was 9.09% (4/44), and was 58.33% (35/60) in TT group, the difference was statistically significant (χ²=26.263, P<0.01). The symptoms of all patients were relieved after operation. The ODI and VAS scores of the last follow-up decreased significantly. There were no significant differences between two groups in VAS and ODI(all P values>0.05). The follow-up period was 5 to 24 months. The symptoms of all patients were relieved. Compared with that before operation, the scores of ODI and VAS in the last follow-up were lower, the difference was statistically significant (t=16.549, 18.490, all P values<0.01), but there was no significant difference between the two groups (all P values>0.05). No screw looseness, detachment or cutting was found, and the screw, connecting rod and fuser were all in good position.Conclusions Compared with TT screw, CBT screw has the same short-term effect in the treatment of single segment lumbar degenerative disease with osteopenia or osteoporosis but without scoliosis or spondylolisthesis above degree I. Moreover, CBT screw has better fixation strength and is more minimally invasive, which is worthy of clinical application.