| BackgroundThe multi-segmental degenerative disease occurs in elderly patients,often with one or several degenerative changes,and lower back pain and/or sciatica is the main clinical symptoms,the majority of patients could relieve clinical symptoms by conservative treatments.However,some patients have to undergo surgery,and the current multi-segmental lumbar fusion,which was the primary surgical produce can effectively alleviate the clinical symptoms.After surgery,the loss of lumbar motion function can cause decreased ability of life,chronic low back pain,bone graft non-fusion,pseudarthrosis,screw loosening,adjacent segment disease(ASD)and other complications.With the improvement of the quality of life requirements,increasingly number of surgeons began to think about how to not only get good clinical efficacy and reduce postoperative complications at the same time but also can get short-term rapid recovery and reduce the impact on postoperative life ability.The concept of Enhanced Recovery After Surgery(ERAS)gradually attracted the attention of surgeons and became the focus in spinal surgery.In view of this series of problems,more and more surgeons began to think about how to adopt non-fusion treatment,which was both to achieve the purpose of relieving the clinical symptoms of patients and to retain more lumbar motor function,improve patient quality of life,and avoid the occurrence of ASD.In recent years,the development of dynamic stabilization was expected to become an effective solution,which can effectively r etain part of the activity,reduce the adjacent segment of the abnormal stress load,in order to alleviate the clinical symptoms and reduce long-term complications.However,compared with the traditional fusion,especially for multi-segment patients,whether it can get a good fast recovery? What is the clinical effect? Is it possible to reduce long-term complications? Still,lack evidence-based medical evidence and there was a lot of controversy in the understanding.PurposesThe prospective study was to evaluate the effect of Dynesys dynamic stabilization and fusion on the ERAS of multi-segment degenerative disease,and the effect of two kinds surgery on life ability in the early term after surgery.The retrospective study was to evaluate the long-term clinical efficacy and the impact of adjacent segment degeneration of Dynesys dynamic stabilization and Fusion in the treatment of multi-segmental degenerative lumbar disease cases,in order to analysis of the influence of ASD by two surgical procedures.MethodsPart 1: Prospective study included patients who underwent multi-segment Dynesys dynamic fixation in our department during March 2015-May 2016,and according to inclusion criteria included in 48 cases(26 males and 22 females),the average age of 61.3(50 ~ 70)years old.There were 46 patients(23 males and 23 females)who underwent multi-segment fusion surgery,the average age of 59.8(50 ~ 70)years old.All patients were followed-up for 1 month,3 months,6 months and 12 months postoperatively.The o peration risk and postoperative recovery were evaluated according to the amount of operation bleeding,operation time and anesthesia time.The Visual Analogue Scale(VAS)score and Oswestry Disability Index(ODI)score were used to evaluate the clinical effect.The lumbar Range of Motion(ROM)and surgical segment ROM were measured before and after operation,in order to evaluate the lumbar function.The ERAS was assessed.Part 2: Collected from patients of our department who underwent three segments and more Dynesys dynamic fixation cases in March 2010-December 2013,according to inclusion criteria included in 24 cases,of which were 11 males and 13 females,the average age of 65.8(55 ~ 71).There were 27 patient(14 males and 13 females)of three segments and more fusion surgery as control group,with an average age of 63.9(55 ~ 70)years old.The VAS score and ODI score were used to evaluate the clinical outcomes.The lumbar ROM,the operative segmental ROM,the first adjacent segment ROM,the intervert ebral height of the first adjacent segment,the MRI T2 signal change of the intervertebral disc,the degree of degeneration of facet joints of the CT,were measured to evaluate the effect on the ASD.ResultsPart 1: All 94 patients were followed up.The average follow-up time was 17.85 ± 3.66 months in the Dynesys group,and 18.86 ± 3.28 months in the fusion group.Dynesys dynamic fixation group had less operative time and less hemorrhage than the fusion group(P <0.05).The postoperative low back pain was relieved(P <0.05).Leg pain VAS between the two operations at the postoperative 1st month,3rd months,6th months and 12 th months was no significant difference(P> 0.05).The VAS score of the lumbar pain in the Dynesys dynamic fixation group was lower than that in the fused group at the postoperative 1st month,3rd months,6th months(P <0.05),but there was no difference in the postoperative 12 th months(P> 0.05).The ODI score of both groups was declined significantly after surgery(P <0.05).The ODI of the Dynesys dynamic group was more obvious than that of the fusion group at the postoperative 3rd months and 6th months(P <0.05).There was no significant difference between the two groups at the postoperative 1st months and 12 th months(P> 0.05).The lumbar ROM of the two groups was decreased,and the Dynesys dynamic fixation group retained about 7 ° ROM more than the fusion group at the postoperative 3rd months,and 6 ° ROM at the postoperative 6th months and,12 th months.Dynesys dynamic fixation group retain more ROM(P <0.05).Compared with the preoperatively,the Dynesys dynamic fixation group maintain 22% of the surgical segments ROM at the postoperative 1st month,36% at the postoperative 3rd months,44% at the postoperative 6th months,and 51% at the postoperative 12 th months,the difference was significant(P <0.05).Part 2: The average follow-up time was 44.86 ± 8.54 months in the Dynesys group and 46.54 ± 10.18 months in the fusion group.(P <0.05).The Dynesys dynamic fixation group had less operative time than the fusion group and less hemorrhage(P <0.05).The VAS score and ODI score of the two groups have improvement(P <0.05).There was no significant difference between the two groups(P> 0.05).Dynesys dynamic fixation group had more lumbar ROM than the fusion group,the difference was significant(P<0.01).Dynesys dynamic fixation group retained part of the operation segment ROM,fusion group due to fusion and loss of ROM,the difference between groups was significant(P <0.01).There was no difference of the ROM of the first adjacent segment between the preoperatively and final follow-up in the Dynesys group(P> 0.05),but the ROM of the first adjacent segment between the preoperatively and final follow-up was a significant induced in the fusion group(P <0.05).In the disc height of the first adjacent segment between preoperatively and final follow-up in the Dynesys group was no significant difference(P> 0.05),but at the final follow-up,the disc height of the first adjacent segment decreased 9.2% in the fusion group(P <0.05).There was no significant difference of the Wooden score between the preoperatively and the final follow-up in Dynesys group.There were 6 Modic changes of the first adjacent segment in the Dynesys group before surgery.There were no new Modic changes in the last follow-up.There were 9 cases of Modic changes in the adjacent segment of the fusion group,1 new case was found at the last visit(P> 0.05).Both group patients` low back pain symptoms were improved after surgery.Twenty-four patients with muscle strength decreased and recovered after surgery.32 patients with postoperative symptoms of numbness,it was disappeared by nutrition nerve and other conservative treatments.There were 2 cases of adjacent segment degeneration in Dynesys,and no clinical intervention was found.There were 7 cases of adjacent segment degeneration in the fusion group,2 cases underwent revision surgery because of the adjacent level disc herniation.There was no non-fusion,pseudoarthrosis and other complications in the fusion group.ConclusionsBoth of two surgery could relieve patients` clinical symptoms.Compared with fusion,Dynesys dynamic fixation has the advantages of short operation time,less bleeding and less surgical trauma,and is more conducive to the rapid recovery of elderly patients with multi-segment degenerative diseases.Dynesys dynamic fixation can maintain part of lumbar ROM,reducing the stress load of the adjacent segment,leading to slow down the adjacent segment disc,facet joints degenerative process. |
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