| Objective:For the surgical treatment of lumbar degenerative diseases(LDD)such as lumbar disc herniation(LDH),traditional open surgery is relatively traumatic,which will lead to epidural scar,potential iatrogenic instability,and the occurrence or aggravation of postoperative adjacent segment degeneration(ASDeg).Preoperative degeneration of adjacent segments have been shown to be a risk factor for the occurrence or exacerbation of postoperative ASDeg during open surgery.Endoscopy techniques,such as percutaneous transforaminal endoscopic discectomy(PTED),have become the commonly used method for treating LDH.Although PTED is minimally invasive and the precise shaping of the joint process will not cause extensive deterioration of the postoperative biomechanical environment of the lumbar spine,the effect of PTED on the occurrence or aggravation of postoperative ASDeg is not clear.Our team has previously confirmed that "Jiawei Sanbi Decoction" has pharmacological effects,such as reducing the inflammatory response in intervertebral disc,reducing the apoptosis of nucleus pulporeus cells and promoting the proliferation of extracellular matrix,which can delay the progress of intervertebral disc degeneration in the early and middle stages.Therefore,this paper retrospectively studies the effects of PTED technology and "Jiawei Sanbi Decang" on postoperative ASDeg,and uses finite element analysis to collect detailed biomechanical parameters to evaluate the changes of PTED to the overall biomechanical environment after lumbar surgery,so as to provide a reference for the risk of postoperative ASDeg.Method:(1)Patients with L4/5 segments of LDH treated with surgery at the Department of Orthopedics and Traumatology of Jiangsu Hospital of Integrated Chinese and Western Medicine from January 2018 to January 2020 were selected.Retrospective analysis was performed,and ODI,JOA and VAS scores were recorded and summarized,as well as follow-up visits at 1 month and 1 year after surgery.Preoperative and postoperative MRI examinations were performed with PFIRRMANN grading.According to the aggravation of adjacent segment degeneration(L5/S1)one year after surgery and whether the patients took Jiwei SanBi Decoction after surgery,the patients were divided into six groups:no ASD group,no ASD+Chinese medicine group,ASDEG group,ASDEG+Chinese medicine group,ASDIS group and ASDIS+Chinese medicine group.To observe the clinical efficacy of surgery on PTED and whether surgery on PTED and Jiwei SanBi Decoction affect the occurrence or aggravation of postoperative ASD.(2)This study was completed based on the L3-S1 segment 3D finite element model that the research team had previously completed model reconstruction and validity verification of modeling.CT data import,density division,region growth,layer by layer rubbing,import into 3MATIC software,smooth operation to export the reverse reconstruction part of the model,and then through part import,layer by layer division,smooth curve fitting,model cutting forward modeling and surgical model reconstruction.Finally,the model was preprocessed by finite element method(including material attribute setting,mesh division,boundary condition setting),stress loading,simulation calculation and data collection.Simulation of surgery was performed on lumbar models with different degrees of intervertebral disc degeneration at adjacent segments,and changes in the biomechanical environment of intervertebral discs at adjacent segments were evaluated under six conditions,including flexion,extension,lateral flexion and lateral torsion,to assess the risk of postoperative ASDeg.Result:(1)A total of 292 patients were included in the retrospective case study,including L5/S1 preoperative Pfirrmann classification of grade 1 108 cases,grade 2 69 cases,and grade 3115 cases.There were 109 cases in the non-ASD group,124 cases in the non-ASD+ Chinese medicine group,27 cases in the ASDeg group,15 cases in the ASDeg+Chinese medicine group,12 cases in the ASDis group,and 5 cases in the ASDis+Chinese medicine group.? A total of 144 patients took the Jiawei Sanbi Decoction,20 of them showed exacerbation of ASD(including ASDeg and ASDis)after surgery.148 patients did not take the Jiawei Sanbi Decoction,39 of them showed exacerbation of ASD(including ASDeg and ASDis)after surgery,taking Chinese medicine can reduce the incidence of ASD after surgery,and the difference was statistically significant.?2=7.031,P=0.008.?6 cases in patients with preoperative level 1 Pfirrmann showed exacerbation of ASD(including ASDeg and ASDis)after surgery,12 cases in patients with preoperative level 2 Pfimnann showed exacerbation of ASD(including ASDeg and ASDis)after surgery,41 cases in patients with preoperative level 3 Pfirrmann showed exacerbation of ASD(including ASDeg and ASDis)after surgery,which indicated the higher preoperative Pfirrmann grade it was,the higher the incidence of postoperative ASD occured,and the difference was statistically significant.?2=31.734,P=0.000.?Efficacy evaluation:According to the analysis of variance test of repeated measurement design,the ODI scores of the same group of observed subjects at different evaluation time points were statistically significant(F=6080.177,P=0.000).In terms of the whole process of observation,there were statistically significant differences in ODI scores among different groups(F=5.245,P=0.000).Different groups and assessment time points had interactive effects on the differences in ODI scores(F=5.338,P=0.000),which together led to the differences in ODI scores.There were statistically significant differences in JOA scores between the same group of observed subjects at different evaluation time points(F=782.434,P=0.000).In terms of the whole observation process,there were statistically significant differences in JOA scores among different groups(F=5.083,P=0.000).Different groups and assessment time points had interaction effects on the differences in JOA scores(F=8.345,P=0.000),which jointly led to the differences in JOA scores.The difference in VAS scores of the same group of observed subjects at different evaluation time points was statistically significant(F=779.424,P=0.000).In terms of the whole observation process,there was a statistically significant difference in VAS scores among different groups(F=12.186,P=0.000).Different groups and evaluation time points had interaction effects on the difference of VAS score(F=10.176,P=0.000),which jointly led to the difference of VAS score.The mean ODI curves of "postoperative ASDis" and "Chinese medicine+postoperative ASDis group" were significantly not parallel with the other four groups during the period of "1 month to 1 year after surgery",and there was inversion and crossover,which was considered as the main reason for the difference.It can be seen that the ODI,JOA and VAS scores of the 6 groups at 1 month and 1 year after surgery are improved compared with those before surgery,the difference is statistically significant,indicating that the clinical curative effect is significantly improved compared with that before surgery,whether or not the patients are treated with Jiwei Sanbi Decoction.The ODI and VAS scores one year after surgery increased again compared with the scores of "postoperative ASDis" and "Chinese medicine+postoperative ASDis group" before surgery and the scores of the other four groups,and the JOA scores one year after surgery decreased again compared with the scores of "postoperative ASDis" and "Chinese medicine+postoperative ASDis group" before surgery and the scores of the other four groups,with statistical significance.It indicated that ASDis had not yet shown symptoms,and when ASDeg was only present,ODI,JOA and VAS scores had no significant changes.However,once the corresponding clinical symptoms appear in ASDis,ODI and VAS scores significantly increase,while JOA scores significantly decrease,indicating poor postoperative clinical efficacy.(2)In the finite element model without intervertebral disc degeneration,the stress on annular von Mises and intervertebral disc pressure of the model after surgery only slightly increase under most loading conditions and slightly decrease under a few loading conditions,and there is no significant trend of change before and after surgery.In the original degenerative adjacent segment intervertebral disc models,the biomechanical indicators related to intervertebral disc degeneration significantly deteriorated before and after surgery,leading to a higher potential risk of ASD.Conclusion:(1)The clinical effect of PTED surgery on LDH is significant,with or without the use of Jiwei Sanbi Decoction;(2)The onset of Asdeg is insidient and there are no obvious clinical symptoms.Once the corresponding clinical symptoms of ASDIS appear,the postoperative clinical efficacy is poor.(3)Clinical retrospective studies show that the higher Pfirrmann grading grade of adjacent intervertebral discs before surgery,the higher the incidence of postoperative ASD.Preoperative degeneration of adjacent intervertebral discs is an important risk factor for the incidence of postoperative ASD.(4)Jiawei Sanbi Decoction can reduce the incidence of ASD after PTED surgery.(5)PTED surgery will not significantly lead to a worse biomechanical environment of non-degeneration of adjacent segment disc postoperatively,and the original adjacent segment disc degeneration is one of the important risk factors for postoperative ASD incidence. |
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