Lateral lumbar interbody fusion for adult degenerative scoliosis: how to provide evidence supports

doi:10.3969/j.issn.2095-4344.2017.27.025

Abstract

Abstract:

BACKGROUND: Most of evidence-based studies include both adult degenerative scoliosis and adult idiopathic scoliosis, which lead to indirectness in the results, and suppress the promotion of the evidence.

OBJECTIVE: To systematically analyze the current clinical researches, and to review the curative efficacy of lateral lumbar interbody fusion for adult degenerative scoliosis.

METHODS: A computer-based research of Medline, EMBASE, CENTRAL, WanFang and CNKI databases from December 2015 to December 2016, was performed with the key words of “lateral lumbar interbody fusion, direct lumbar interbody fusion, extreme lateral interbody fusion, minimal invasive surgery, adult scoliosis”. The articles were screened based on the inclusion criteria, and the clinical symptom improvement and radiological changes were analyzed.

RESULTS AND CONCLUSION: Totally 13 articles were included. In the treatment of adult degenerative scoliosis, lateral lumbar interbody fusion shows less blood loss, short hospitalization time, significantly improved symptoms, satisfactory correction at the coronal plane, and low incidence of long-term complications. However, it has the poor correction at the

sagittal plane and high incidence of short-term postoperative complications. Therefore, intraoperative neurologic monitoring is necessary and the combination with internal fixation has obtained good effectiveness.

中国组织工程研究杂志出版内容重点：人工关节；骨植入物；脊柱；骨折；内固定；数字化骨科；组织工程

Key words: Tissue Engineering, Spine, Aged

CLC Number:

R318

Jin Yuan-zhe, Gong Wei-quan, Zhang Shao-kun. Lateral lumbar interbody fusion for adult degenerative scoliosis: how to provide evidence supports [J]. Chinese Journal of Tissue Engineering Research, 2017, 21(27): 4409-4415.

Figures/Tables 3

2.3 侧入路椎体间融合方法在3篇单独报告椎体间融合的出血量研究当中[21-22，29]，其血量在54-154 mL；当联合其他入路手术时，平均出血量增加200 mL[29]。但除了McAfee等[30]的研究外，其他研究平均出血量均未超过400 mL。单纯椎体间融合所需时间在137-253 min，平均每个节段所需时间为45-76 min。单纯椎体间融合后平均住院时间为1.4-2.9 d，合并其他内固定手术时住院时间在3.7-9.3 d。所有研究中使用的植骨融合器大小较一致，长度均在45-60 mm，宽为18-22 mm，高为8-12 mm。在联合前路松解术的研究组中，使用的融合器长50-60 mm，高8-22 mm，宽22 mm，后倾角约30°。 2.4 侧入路椎体间融合治疗的临床指标共有7篇文献报道了目测类比评分值的变化[5，24-26，28，30]，其中有4篇报道了患者腿和后背的目测类比评分值在固定后较术前的改善差异有显著性意义[5，21，24-25]。除了McAfee等[30]的报道之外，其他研究中腿和背部的目测类比评分平均变化值均在2分以上(范围：腿2.3-3.6分；腰背2.2-4.1分)。共有5篇文献报道了Oswestry功能障碍指数问卷表评分值术前固定后的变化[5，21-22，24，28]，其中4篇报道了其变化有显著性意义[5，21-22，24]。除了Caputo等于2012年发表的文献外，其他文献Oswestry功能障碍指数问卷表评分减少值都在20分以上(20-24分)。 2.5 侧入路椎体间融合的影像学资料见表4。共有9篇文献报道了侧入路椎体间融合固定后冠状面Cobb角的矫正结果，所有的研究中Cobb角均有降低[5，20-23，25-26，28，30]。其中7篇文献表明固定前后Cobb角之间差异有显著性意义，矫正幅度范围在5.7°-28.5°之间[5，20-23，25-26]。矫正幅度在研究间的差异较大，但固定后Cobb角都在5.8°-16.6°。共有7篇文献报道了术前固定后的腰椎前凸角变化幅度[5，20-23，25-26]，其中6篇中变化值有显著性意义[5，20-23，25]，范围5°-12.2°。除了Khajavi等的研究外[21]，其他研究均小于10°。仅Manwaring等的文献报道了矢状面轴向垂直轴，骨盆倾斜角，骨盆入射角与腰椎前凸角之差等值得固定前后变化[20]，其中联合前路松解术组在固定后矢状面轴向垂直轴较术前的变化明显有显著性意义(术前8.3 cm，固定后3.5 cm，P < 0.017)，骨盆倾斜角由术前的25.7°降低到19.1°，骨盆入射角与腰椎前凸角之差由术前的26.1°矫正为固定后的9.7°。无前路松解术组的矢状面轴向垂直轴由2.3升高到3.8，骨盆倾斜角由24.9°升到28.6°，骨盆入射角与腰椎前凸角之差由术前的23.1°矫正为19.9°[20]。Khajavi等[21]的文章中仅发表了固定后矢状面轴向垂直轴，PI和骨盆倾斜角的值，其中固定后矢状面轴向垂直轴为2.07 cm，骨盆倾斜角为19.8°，腰椎前凸角与PI之差为5.6°。共有6篇文献报告了固定后融合的成功率，92%-100%的患者和84%-98%的节段显示了骨性融合[5，21-23，25，28]。 2.6 侧入路椎体间融合的并发症研究结果表明，固定后立即发生神经症状的风险较高。Tormenti[26]等的研究结果表明，6例(75%)患者出现了大腿感觉障碍或运动障碍；Caputo等[24]于使用了“相当一部分的患者”来形容发生此并发症的发生率。其他的研究中，此并发症的发生率在12%-30%。尽管在固定后此并发症发生率较高，但是大部分的症状均在6个月内可缓解。绝大部分研究的报告中，6个月内未得到缓解的比例患者比例为0%-5%(表5)。 3个研究报告了椎间融合器下陷的发生率，其中使用了前路钢板或者后路椎弓根进行固定的组中发生率为4%，而在行单纯椎体间融合的研究中，发生率为29%[20，22，28]。因为骨不融合而需要重新手术的并发症发生率为2%-3%。"

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