腰椎退行性疾患诊疗学术进展2023.docx

腰椎退行性疾患诊疗学术进展2023当代医学领域日新月异，研究者们在探索腰椎退行性疾患的前沿，持续为医学界贡献着新的认识和解决方案。随着2023年的谢幕，让我们一同回顾这一年在腰椎退行性疾患诊疗学术领域取得的丰硕成果以期为从事腰椎退行性疾患领域研究的同道们提供最新的学术进展参考。笔者对5个脊柱外科领域顶级专业期刊(SpinezEuropeanSpineJournal,TheSpineJournal,JournalofNeurosurgery,GlobalSpineJournal),以及骨科(TheJoUrnalofBoneandJOintSUrgery)、神经脊柱外科(Neurosurgery)的权威期刊在2023年发表的原创性研究进行了全面检索。检索关键词包括：腰椎退行性疾患(Lumbardegenerativedisease),腰椎间盘突出症(Lumbardischerniation),腰椎管狭窄症(Lumbarstenosis),腰椎滑脱症(Lumbarspondylolisthesis),椎间盘源性月要痛(Discogeniclowbackpain)o在与腰椎退行性疾患相关的201项研究中，我们从发表杂志、作者国家、研究群体、研究主题、研究设计这5个维度进行全面盘点，并根据不同患者人群，筛选出12项代表性研究。一、发表杂志分布情况7个期刊发表的腰椎退行性疾患相关文章共201篇,其中EuropeanSpineJournal84篇,Spine54篇,TheSpineJournal31篇zGlobalSpineJournal20篇，Neurosurgery6篇，TheJournalofBoneandJointSurgery5篇,JournalofNeurosurgery1篇。图1发表杂志分布情况二.发表国家分布情况文章第一/通讯作者来自的国家部分分布参见图2o其中排名前6位的国家分别为：美国（63）,中国（36）,日本（22）,韩国（18）,加拿大（11）,瑞士（11）。三.研究群体分布情况在各类腰椎退行性疾患中，腰椎管狭窄症的研究最多，其次依次为腰椎滑脱症、腰椎间盘突出症和椎间盘源性腰痛。鉴于在脊柱侧弯领域已对退行性脊柱侧弯进行总结，故本文将聚焦于其他几大腰椎退行性疾患。图3研究群体分布情况四.研究主题分布情况针对不同类型的腰椎退行性疾患,手术效果和术后并发症发生一直是持续的研究热点。而随着研究的进一步深入，更多研究聚焦于退变发生的机制以及影像学在该疾患中诊治的重要性。对于腰椎退行性疾患，手术治疗是常见的治疗方式，不少研究者推陈出新，对手术技术进行不断创新，为我们提供了新的手术思路。止匕外，随着医学领域对人工智能应用的广泛探索，腰椎退行性疾患领域也迎来了一系列高水平的研究。图4研究主题分布情况五.研究类型分布情况对于研究设计,绝大多数的临床研究采用回顾性队列研究或病例对照研究（82%）,前瞻性队列研究和随机对照试验仅占12%o由于在临床中开展随机对照试验的难度较高,少部分学者逐渐开始使用基于倾向性评分匹配的队列研究（2%）以模拟随机对照试验的研究设计。在所有研究中，单中心研究占比94%,多中心研究仅占6%o鉴于我国拥有众多临床中心和庞大的患者人群基数,未来我们应注重临床资源的充分利用，积极开展前瞻性及多中心研究，以提升研究质量和证据等级。图5研究设计分布情况六.代表性研究1.腰椎管狭窄症(1)HwangRW,BriggsCM,GreenwaldSD,etal.SurgicalTreatmentofSingle-LevelLumbarStenosisIsAssociatedwithLower2-YearMortalityandTotalCostComparedwithNonsurgicalTreatment:ARisk-Adjusted,PairedAnalysis.JBoneJointSurgAm.2023;105(3):214-222.doi:10.2106JBJS.22.00181.美国波士顿塔夫茨大学医学院RaymondW.Hwang教授团队报道了美国单节段腰椎管狭窄的手术治疗与非手术治疗2年死亡率和总成本的一项风险调整的配对分析研究。该研究对2011年至2017年美国医疗保险国家数据库中的数据进行回顾性分析，共纳入61534例腰椎管狭窄症患者。研究结果显示，在美国医疗保险人群中，单节段腰椎管狭窄的手术治疗与非手术治疗相比，2年死亡率和总医疗费用显著降低。该研究发表在2023年2月JBJS杂志上得到了哈佛大学医学院DanielGTobert教授的高度肯定。TiuIovknalorBor&JoiktSukgvrv*ii11.okgSurckbyfobSikgibLtvLumbakStknomsIsAssociatkpwithVolumkIOS-ANvmbek5*FibkuaryI.2025Lower2-YbakMortalityandTotalCostTABLEIPMtentClwractwlstk*ITotalTioatmemPValueFusionLaninecioniyLamnectcxnyandFusionNOmUf9caNaofpetienu14534731.0922325012<23878.7676X079(43.4¾ofwxal)12.17(39船H.115(47.8%)4.196(343%)35.601(4&2%)<O(XX>ltAgOf007X9(54)73.1<l>742(5.7)732(5.1)742(5.6»<0,0001jRSIotdaositDiagnosis4(X)lXB(6)4.9(a0)3.7(6.1)5u4(8)<0.0001$Stenosis6L534673<10.7%)13.567(22.1%)2.568(4.2%)38,826(W.1%)Ste<x>sandSPOaMa印Sg泠&X81324519(2939.683(11.6%)9.70(119539.941(47.7%)PefccrtAgMareoftheLtortherow.euettormaleset.wichisoftheIOttlpopulation.fPearsonchsquaretest.fTevaluesare©venmthemeanwitthestandardCteViatJOnmparcnmeaes.§Anegi3oforianoe.TABLEIlUnmatchedActualMortality,PredictedMortality,ResourceUtilizatbn,andTotalCost:AllTreatmentsDiagnosisTreatmentNo.OutpatientActual”earMottafity2YeafMOrtaIityPrwfctedbyMeanRSIIncOenceTa2-YearCost,FromTimefDiagnosisfromTonedSurgwyPainMedtatnnSpnaiInjectionMRIPhysicaiTfeapyReMSlonSEStenoseLamneetcmy13,5678,32753172178011,9847.754839710,311359$41.134(61.4%)(3.9%1(5.3%)(5)(883%)1572%)(6L9(76.0K)2jMIarhnectomy2.5681501061201142,3471J6313101.81656$65.020andfusion(5)(4.1W)(4mMM)(914%)(53.1M)(5L0H(70.7¾)Q然）Fteion6.5732842463003066.0023.55235844.751223$73.453(4.3%)(3.7%)(4.6%)(4.7¾)(913%)(54.0%)(54.5(72.3%)134«)Nonsugcal38,8262.3382.45735.22419.66823166328,441$71421(6.0»)(6涮(90.7%)(50.7%)(60.9%1(733»)SteroseandLemnectcmy9.6834,3722274084378.7246>2586.7907.880632$51.401sponWstes(45M(23%(4.2%)(4.5%)(90.1»)(64.6%)(70叫(81.4%)(65%)Larnneaomy9.6703532283383218.7955.77865467.352274S6159andfus«n(3.7%)(2.4%)(3.5%)(3)(91.0%)(5081)(67.7MJ(76.0»)(2)RSion24.51976557288185422.20914.810162419.259974$68.68613.1%)(2.3%)(3.6%)(3.»)(90.6%)(604%)(68.6%)(785(4JWNonsurgicat39.9411.455l£1036.6262327527,79131.753一$75.097(3%)(4.5*)(91.7%)(583)(69.6%)(795%J,Mean,adjustedIamortaiity.(2)GetzmannJMzAshouriH,BurgstallerJM,etal.TheEffectofParaspinalFattyMuscleInfiltrationandCumulativeLumbarSpineDegenerationontheOutcomeofPatientswithLumbarSpinalCanalStenosis:AnalysisoftheLumbarStenosisOutcomeStudy(LSOS)Data.Spine(PhilaPa1976).2023;48(2):97-106.doi:10.1097BRS.0000000000004477.瑞士苏黎世大学医院JonaSM.GetZmann教授团队探究了椎旁脂肪肌浸润和累积性腰椎退变对腰椎管狭窄症患者预后的影响。共纳入非手术治疗组116例（74.8±8.5岁），手术治疗组300例（72.3±8.2岁）。研究结果发现，在LSOS队列中，椎旁脂肪肌浸润较重与腰椎管狭窄症患者更高的残疾率和更差的健康相关生活质量相关,累积性腰椎退变与手术或非手术治疗患者的预后之间没有显著差异。IigMrr2.AswummtOifattymufcicinfikrtionCWIhrp>rApinjmulnoftheIcmvr«PinrUtingtheGcxJtaiIirrgrading,trmonaxialT2WcighlrdmAgnrticrcmnccimage%.NOmMlmuwlrgrdcOl（八）;wmrfattyStrgkSIgrAdr1)(B);<50%faOymuteIrXroPhy(gp&2)(Q;50%fotfymulratrophyIgrAcir3)(D);>50%btyrmclc*atrophy电Qdr4)CKMnuarv 2023102MWw.neioufrwlxomIEMRDegenerationScoreWithRespectiveItemsfortheAnteriorandPosteriorColumnsofltheLowerSpineClassificatiofiZGradingIDescriptionPointsAnteriorcolumnDiskd<cncrationKirmvinngrdcIHomogcncoiAdi$kwithhypcrintcn¼cT2weighcdMgnalandnormalheight0PfirnnanngradeIlInhomogencoiHd滋withhypcrintenseT2-weightedSignaIandDOnTulheight0PfirrmanngradeIIIInhomogeneousdi&withanintermittentgrayT2-vehtedsignalintensityandnormalorSIWItIydecreasedheight0RirrmanngradeWInhomogeneousdiskwithhypntensedarkgrayT2-wdghtedsignalintensityandsiigly/mcxieratelyCTeasedheight1KirrmanngradeVInhomogencousdiskWithahypointenseblackT2zeigftedsignalintensityanddiskspacecollapse1EndplatechangesMocfictypeITllowsignalT2highsignalT1÷Cenhancement0MocfcctypeIlTlhighsignal,T2isotohighsignal1MocSctypeIIITlandT2lowsignal1SpondyloltsthcsisMcycrdinggr<ukIO%-25%ofanteriordilacrment1MeyerdinggradeIl26%-50%ofanteriordtspUcement1McycrdinggradeIII51%-75%ofanteriordisplacement1McycrdinggradeIV76%-100%ofanteriordisplacement1.MeyerdinggradeV>100%ofanteriordisplacement1PosteriorcolumnFacetjointdegenerationYes()inteffusion,irregulararticularsurface1LigamentumflavmhypertrophyYesSubjectivevisualthickening1EpiduralIifxxnatosisYCIncfVJSCoiepiduralfjtcompartmcnt1wwJpEoumaUom101(3)CorazzelliG,CapeceM,PizzutiV,etal.Antithrombotictherapyandspinalsurgery:aretrospectivecohortstudyof289consecutiveelderlypatientswithdegenerativelumbarstenosis.JNeurosurgSpine.2023;40(2):125-131.Published2023Oct27.doi:10.3171/2023.8.SPINE221332.意大利那不勒斯费德里克二世大学GiuseppeCorazzelli教授团队对289名退行性腰椎管狭窄症患者脊柱外科手术中的抗血栓治疗进行了回顾性队列研究。其中183例接受抗血小板治疗为实验组，106例未服用抗血小板药物的患者为对照组。研究结果表明，在腰椎管狭窄症患者脊柱外科手术中使用抗凝和抗血小板治疗可以避免早期并发症,并且可以安全地继续进行围手术期治疗。2.腰椎滑脱症(1)AndresenAK,Wickstr0mLA,HolmRB,etal.InstrumentedVersusUninstrumentedPosterolateralFusionforLumbarSpondylolisthesis:ARandomizedControlledTrial.JBoneJointSurgAm.2023;105(17):1309-1317.doi:10.2106JBJS.22.00941.丹麦利勒贝尔特医院脊柱外科与研究中心AndreasK.Andresen教授团队报道了腰椎滑脱后外侧融合术与非融合术的一项随机对照试验研究。研究团队将54名患者随机分为两组，实验组为融合组，对照组为非融合组，并进行2年随访。研究结果显示，退行性椎体滑脱患者的内固定融合术和非内固定融合术，患者的满意度没有显著差异。但是非内固定融合术组2年骨不愈合和再手术率明显较高。(2)ThornleyP,UrquhartJCzGlennieA,etal.Functionaloutcomescorrelatewithsagittalspinalbalanceindegenerativelumbarspondylolisthesissurgery.SpineJ.2023;23(10):1512-1521.doi:10.1016/j.spinee.2023.06.004加拿大西部大学健康科学中心ChristopherSBailey教授团队报道了退行性腰椎滑脱外科手术结果与矢状面脊柱平衡关系的一项回顾性队列研究。该研究共纳入243例退行性腰椎滑脱患者，随访1年。研究结果发现，术后1年PI-LL匹配不佳，背部疼痛和腿部疼痛与术前LL以及SVA密切相关。作者认为，为了优化腰椎退行性滑脱治疗的功能结果，术前应重点关注局部和整体矢状面脊柱的相关参数。wvpmnc>c*pt.ywncMCmNr*(X*nil)rwr%MflP*arRUirralImuM4mcaH2AMraa1St>>IWMltWlMraItSDlWAKm甲Al>MB7>M4(*l)½0<<bI4K3134K.1)Iy4«U.(lT57<KhU4<ll(bI4kM7<X2ICM4»ISgo13仲“241ft.l)MKI46hr<*»2甲41NIiX4X6<KS>>o<x1462X51K3y4023Js第22N(K224M<M614522<H2)3”1»-A7C-I7<75>-I2<4*Hrli11T41574II2*9IiIOhI*41ll2»146u?<m»y40h55T4(IO7U6<lAtI4t>1<l>»»I)<wU05N.K-IUea-OI<6*11410(M(VXU.Ar40454I54M4YOHOI4M(¼V14741OH.1V>1y«54JI15rd<K5<IIXi47><I4.MHI4«H123»I,naUMI6<91“心1«)4Jl<103»H-U.A>w甲I12<I5>MIIM2J5HI42>145Il6<I4<IIy1.4m>»WH2A»1231116»IW7J<119>3Iyea2»-4J<I2J><4-1I91-X*(M7IW*-4.Vd2AlVtnn11V154444I05144I145Mi½.<552>117“IZhIy如15O1112册U0|«7»117¼s4o>iS2-IO214(W*47“Iih-I7SiM.6>IlO-ra.4j7<lMMefMnlw4*rTaNe5Summar)ofmultiplelinearregressionxtcomcsat12InOmh5andradi(graphicpara(crsal12monthsOutcomeme;IWlVRadiogniphicmeasureR2R2AdjustedUZandaM.Cocflicient±S(d.e*oc95%Clof£p-valueNRSlegPainLL0.0520.031-O.O3±O.O2-0.07.-0.002PI-LL0.0590.037O.O4±O.O20.008.0.07.014SVA0.0610.0360.0l10.0l0.(101.0.03.046ASVA0.0650.0380.02±0.0l0.002.0.02.oxNRSbackPamLL0.1350.116-0.(M±0,0l-0.06.-0.01.(M)7PI-LL0.1520.1350.05±0,0l0.02.0,(11<001SVA0.1700.14X0.02±0.0l0.01.0.03<MHSVA0.1360.1Il0.01±0.01(HX)1.0.02.029ODILL0.1680.15()-021±0.09-0.39.-0.02.027PI-LL0.1790.160O.25±O,O90.08.0.42SVA023602160.12±«.(M0.05.0.20.UOlASVA02100.1X70.0610.05-0.002,0.12(IH)SS.sacralslope;PT.pelvi<tilt;PLpelvicincidence;SVA.Wghtalverticalaxis：LLlumbarl<>nk>si;NRS.numericalGilingscale,rangeOIo10,withhigher>ccwvsindicatingwor>cpain;CLConhdCnCCintcnaiODI.(KwesUyDIqhilityIndex,rangeO(oKMhui(hhigher、corcindicatingwoedisabilityandpain.Eachlinearrvgres>i(>nm<ieli、JdjUMalfbrpotentialCOnfoUndingdueIoAge.BMI.Sex.PHQ1).=(lungefromkiMrline:('l=COntideIKeinterval.Allboldedvaluesrepresentiho«valueswhichrrpreMrncdMaliMicaIsignitkance.(3)WangD,ChenXzHanD,etal.Radiographicpredictorsofreachingminimalclinicallyimportantdifferencefollowinglumbarfusionsurgeryinpatientswithdegenerativelumbarspondylolisthesis.EurSpineJ.PublishedonlineDecember13,2023.doi:10.1007s00586-023-08051-2.中国首都医科大学宣武医院骨科鲁世保教授团队探究了退行性腰椎滑脱患者腰椎融合术后达到最小临床差异的影像学预测指标。该研究共纳入91例单节段退行性腰椎滑脱患者，接受腰椎后路融合术且随访至少1年。研究结果显示腰椎后路融合术后达到最小临床差异的退行性腰椎滑脱患者表现出术后脊柱-骨盆参数明显的改善。较高的腰椎节段性前凸角差值较高的既骨倾斜角差值和较高的术后既骨倾斜角是与退行性腰椎滑脱患者实现最小临床差异相关的关键参数。No SubMantial diflenenccs in demographic characteristics WerC ObWrVed Miwccn the rMCID and mMCID groups in crms of ODI. VAS back and leg painrMCID. reached minimal clinically important difference; mMCID. missed minimal clinically important difference; Dl-S. degenerative lumbar spondyldislhcsis; PI-LL. pelvic incidence minus lumbar Ionlosis; BMl. body mass index; EBL. estimated blood loss: LOS. length of StayFig. 3 A 67-year-old female DLS patient with complaints of Iou back pain, leg pain, and neurgenic claudication over 3 months. This patient missed MCID for ODI (44.5% to 35.6%) and VAS back pain (5.0 to 3.0) one year after surger). A and B Preoperative radiographic assessments revealed lumbar Iordosis (LL) of 32.5°, segmental lumbar Iordosis (SLL) of 5.3c. sacral slope (SS) of 23.7°. pelvic tilt (PT)of 2l.6 pelvic incidence (Pl) of 45.4r . and slip percentage of 15.59?. C and D Pivoperalive MRI indicated SeVeg lumbar canal stenosis at the 1.4L5 segment. E and V One year POaoPCQuVCM the radiographic assessments Jemonstraled LL of 290. SLL of 4.2°. SS of 22.” PTof2I. Pl of 44.8°. and slip percentage of 12%EuropeanSpineJournalTaNe1DemographiccharacteristicsofenrolledpatientswhoreachedormissedMCIDVariablesODIVASbackpainVASlegpainrMCID(n=62)mMCID(n=29)rMCID(n=66)mMGD(n=25)rMCID(n=70)mMCID(n=2l)Age.yr66.73±8.7265.93±72966.64±8.6666.O4±7.246654±8.0768.57±831Gender(femalema)e)52/1021/853/1320/558/121V6BMLmVkg226.35±3.602531±4.7826.03±3.8325.99±4.5526.10±4.25.76±4.16Smoker,n768585ComorbiditicsHypertension,n391943154711Diabetes,n158176194Corvnaiyarterydisease,n758475Anxiety,n212I3ODepression,n2O2O2OOsteoponosis.n114132123CardinalsymptomBackpain,n3713351539IlIxgpain,n147174165Back=Icg.n119146155SymP(Qmduration<6months,n1751571936-12months,n126135IO8>12months,n331838134110Meyerdinggrade(1II)4WI324/55WI623/256/1417/4Operatingtime,min204.65±55.61208.2«±49.90203.76±524121120±53382O1.69±53.2O2I9.52±53.92EBL.ml296.61±177.76264.14±144.38290.6117730274.80±142.0428129±171.01299.52±159.61LOS.d12.66±3.9213.66±4.OI12.48±3.8414.28±4.0312.63±3.36I4J4±S.4S3.腰椎间盘突出症(1)ParkSJzHornungALBarajasJNzetal.Predictionoflumbardischerniationresorptioninsymptomaticpatients:aprospective,multi-imagingandclinicalphenotypestudy.SpineJ.2023;23(2):247-260.doi:10.1016/j.spine.2022.10.003美国拉什大学医学研究中心DinoSamartZiS教授团队对腰椎间盘突出再吸收的问题进行了一项前瞻性、多影像和临床表型研究。共纳入93例诊断为急性症状性LDH的患者，其中早期吸收组23例，晚期吸收组67例，平均年龄48.7±11.9岁。该研究是第一个全面的影像学和临床表型的前瞻性研究,并且确定了早期LDH吸收的不同决定因素。24.7%的LDH患者可发生早期吸收其决定因素主要有椎间盘突出体积大小，1.4椎体后缘的高度以及舐骨倾斜角。Baseline3h MonthBaseline3ld Month6tfe Month9 M<>nh12fc MonthF. I. SagilUiI T2-weighted MRhof the Iuntbar 叩Ine >u鹏(A)early di* hcni*wn rvMMpii< m a4lcwcld mkand(B> Iale rrMXp(in in a36-ye>r CAd fctmlc. Aucrnk denote% level of the di hernbion. The Vn)W deicu the pn>cvMon of 飙 imaidns frum earliest (ICfbk) ktcsi follow up <rijU(2)HanPzJiangF,ZhangLTheroleofADAMTS6andADAMTS17polymorphismsinsusceptibilitytolumbardischerniationinChineseHanpopulation.EurSpineJ.2023;32(4):1106-1114.doi:10.1007s00586-023-07586-8中国西安医学院第二附属医院骨科团队对ADAMTS6和ADAMTS17两个基因多态性与汉族人群腰椎间盘突出症的关系进行了一项基础研究。对509名患者和510名健康对照组的5个SNP进行基因分型，采用多因子降维法(MDR)评价SNP-SNP相互作用对LDH易感性的影响。研究发现，基因ADAMTS6-rs2307121和ADAMTS17-rs4533267与LDH易感性相关，特别是ADAMTS17-rs4533267与LDH风险降低有很强的相关性。EuropeanSpineJournal(2023)32:1106-11141113jr3307121rs453327rs257362Sr172077_IJJJ今WTIyIrMMSS93一Fig. 1 MUlIlfack)T dimenMonality tv<hrion (MI)Rl aruiyxis of nier- action between the two candidate SNPi of DAMTS6 (rd72O6779 rs2307I2!) and three candidate SNPs of 4 DAAfr(rs2573625.4965593. and 4533267). Tbe COlOUr re preNenix he degree of redundancy or synergy between SNP-SNP;