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1、邻椎病Adjacent Segment Disease，ASD浙江大学医学院附属第二医院 骨科 徐 侃前言融合节段的上或者下一节段的退变50年前，腰椎和腰骶椎融合术后少见的并发症目前，特别是内固定的增多，ASD的发生增多，是脊柱 融合术后长期的潜在的并发症ASD的进展会降低疗效提高对ASD的认识CERVICAL SPINEPRE OPPOST OPPOST OPLUMBAR SPINE定义广义：脊柱融合术后邻近 活动节段出现的任何 一种异常（影像学 ASD）发生率：100% 椎间盘退变 滑移 不稳定 椎间盘突出 椎管狭窄 关节突关节肥厚 骨赘 侧弯 椎体压缩骨折狭义：有临床症状的ASD发病率5
2、.2-18.5%，其中经内固定融合的为7.8% Paul Park. Adjacent Segment Disease after Lumbar or Lumbosacral Fusion: Review of the Literature. SPINE 2004 29(17): 1938-44原因不明？原因尸体和动物实验有限元 关节突关节负荷增 加 节段的活动增加 椎间盘内压增高Dekutoski MB, et al. Comparison of in vivo and in vitro adjacent segment motion after lumbar fusion. Spine 1
3、994;19:174551. Seitsalo S, et al. Disc degeneration in young patients with isthmic spondylolisthesis treated operatively or conservatively: a longterm follow-up. Eur Spine J 1997;6:3937.临床：生物力学的变化正常退变可能的原因：多节段退变原因临床结果都是回顾性结论，包含不同人群和方法无前瞻性研究生物力学变化和正常的退变在ASD致病中的比 重并不清楚，应该是两者都起着一定作用危险因素内固定 后路椎体间融合术PLIF
4、 损伤邻近节段的小关节突 融合长度 矢状面平衡 存在邻近节段的椎间盘退 变 椎管狭窄 年龄 骨质疏松 女性 绝经后期L5S1L5S1危险因素内固定/PLIFAota影像学不稳定发生在术后25月Etebar和Cahill症状性ASD发生于术后26.5月相反，非内固定融合，ASD分别发生在术后第8和13 年推测，即刻的稳定使相邻节段受力增加导致邻椎病发 生Etebar S. Risk factors for adjacent-segment failure following lumbar fixation with rigid instrumentation for degenerative i
5、nstability. J Neurosurg 1999;90:1639. Hsu K. The long-term effect of lumbar spine fusion: deterioration of adjacent motion segments. Lumbar Fusion and Stabilization. Tokyo: Springer; 1993: 5464.危险因素邻近关节突关节损伤置钉时损伤邻椎的下关节突，关节突关节的载荷变 化导致ASDWiltse LL. Comparative study of the incidence and severity of de
6、generative change in the transition zones after instrumented versus noninstrumented fusions of the lumbar spine. J Spinal Disord 1999; 12:2733. Aota Y. Postfusion instability at the adjacent segments after rigid pedicle screw fixation for degenerative lumbar spinal disorders. J Spinal Disord 1995;8:
7、46473.危险因素融合节段融合节段越长，由于杠杆的作用使邻近活动节段的受 力增加，导致ASDEtebar和Cahill：78%的ASD发生于2个节段以上融合多节段融合容易发生ASDChow DH. Effects of short anterior lumbar interbody fusion on biomechanics of neighboring unfused segments. Spine 1996; 21:54955. Chen CS. Stress analysis of the disc adjacent to interbody fusion in lumbar spi
8、ne. Med Eng Phys 2001;23:48391.腰椎全椎板切除融合内固定术后继发L2/3椎管狭窄lateralAP viewMRIstenosisL2危险因素矢状面平衡Umehara在L4/S1融合术后发现融合节段的 生理前凸减少，而邻近活动节段前凸增加， 受力增加导致ASDKumar发现正常的平衡发生变化时/骶骨倾 斜角变化时，容易发生ASDUmehara S. The biomechanical effect of postoperative hypolordosis in instrumented lumbar fusion on instrumented and adja
9、cent spinal segments. Spine 2000;25:161724.805050术前术后随访：L2后移铅垂线Kumar MN. Correlation between sagittal plane changes and adjacent segment degeneration following lumbar spine fusion. Eur Spine J 2001;10:3149.危险因素邻近节段椎间盘退变和椎管狭窄融合后邻近椎间盘退变加速Guigui发现由于椎管狭窄而作融合的ASD的发生率较 高退变的脊柱对融合后应力增加的耐受力减弱Guigui P. Long-t
10、erm outcome at adjacent levels of lumbar arthrodesis. Rev Chir Orthop Reparatrice Appar Mot 1997;83: 68596.危险因素年龄老年脊柱对融合后应力变化的耐受力降低Aota发现55岁以上的ASD发生率较高Rahm MD. Adjacent-segment degeneration after lumbar fusion with instrumentation: a retrospective study. J Spinal Disord 1996;9:392400. Wiltse LL. Com
11、parative study of the incidence and severity of degenerative change in the transition zones after instrumented versus noninstrumented fusions of the lumbar spine. J Spinal Disord 1999; 12:2733.危险因素确切的作用不明Rahm和Hall并没有发现矢状面的失衡与ASD之间有关Kumar也没有发现融合长度和ASD之间有关Wiltse甚至发现内固定组比非内固定组的ASD发生率降 低这些不同可能与回顾性观察和方法学
12、不同有关治疗非手术手术影像学ASD与治疗预后无关治疗保守治疗制动：颈围，各式支具NSAID药物神经营养药物：弥可保女，44岁，神经根型颈椎病术后5年，保守治疗治疗手术适应症：保守治疗无效的情况下邻椎的病理变化和产生的症状相关治疗手术方式：减压融合椎间盘置换治疗减压术前术前术后融合术前术后1年术后2年术后2年，横断面术后2年翻修术后女，50岁，脊髓型颈椎病术前，C4/5融合术前术前术后FLEXIONEXTENSION男，71岁，L1/2，L4/5融合继发L2/3，L3/4不稳定L1L2L3L4L5L3L3L3全椎板减压椎间植骨融合术后L3治疗椎间盘置 换治疗手术的预后：不好Whitecloud手
13、术14例ASD，大部分症状没有改善或 轻微改善Schlege37例减压/融合ASD，26例症状改善（2年）Chen39例减压+融合ASD，73%改善（5年），5例 ASD复发Whitecloud TS III. Spine 1994;19:5316. Schlegel JD. Spine 1996; 21:97081. Chen WJ. Spine 2001;26:51924.小结基础：邻近节段的退变椎间盘内压增高关节突负荷增加邻椎活动增加邻邻椎病（）内固定融合预防融合时不使用内固定？安装椎弓根螺钉时保护邻近节段的关节突关节不受损伤融合节段不宜过长矢状面平衡 椎间盘置换？FLEXIONEXTE
14、NTIONBRYAN DISCIt remains to be seen whether restoration of motion with disc arthroplasty will alter the rate of Adjacent Segment degeneration or Disease.Alan S. Hilibrand, et al. Adjacent segment degeneration and adjacent segment disease: the consequences of spinal fusion? The Spine Journal 4 (2004
15、) 190S194S结论?When faced with radiographs showing adjacent level degenerative changes, it is necessary to know theirclinical impact. In this long term follow-up of 30 years, there was a significantly higher incidence of radiographic changes at adjacent levels following lumbar fusion, but this was not accompanied by a significant change in the functional outcomes.Kumar MN, et al. Correlation between sagittal plane changes and adjacent segment degeneration following lumbar spine fusion. Eur Spine J 2001;10:3149.THANK YOU FOR YOUR ATTENTION
