微創脊椎融合手術治療年長者腰椎退化性脊椎病變之成效分析

Assessing the Effectiveness of Minimally Invasive Spinal Fusion Surgery for Degenerative Lumbar Spondylosis in Geriatric Population

陳元森(Yuan-Shen Chen)

指導教授 ： 陳秀熙

共同指導教授 ： 劉宏輝(Horng-Huei Liou)

國立臺灣大學/公共衛生學院/公共衛生碩士學位學程/碩士(2022年)

https://doi.org/10.6342/NTU202203561

摘要

研究背景與目的
隨著老年人口的增加，臨床上遇到因為退化性的脊椎病變造成的背痛及神經壓迫的老年病患也跟著增加。在許多嚴重腰椎脊椎退化合併失穩及神經壓迫的病人，傳統的腰椎脊椎骨融合及神經減壓手術為標準的治療方式。然而傳統手術療法對於年老的病人，具有較高的手術風險及容易產生併發症之缺點。同時，這些年老的病患常常合併其他內科問題及骨質疏鬆，因此即便內科保守治療無法改善症狀，許多年紀大的長者仍害怕接受手術治療。近期許多的文獻提及以微創脊椎骨融合手術(minimally invasive spine surgery，MIS)來治療退化性腰椎病變獲得不錯的短期及中期的臨床成效而成為目前對於此疾患的主要治療選擇之一。然而對老年病患族群此是否能有如此的效果還有待進一步的研究。
研究目的
本研究的目的為
(1) 為透過對接受腰椎微創脊椎融合手術後的老年族群病人與年輕族群病人的比較，分析手術後初期的成效與長期追蹤的結果。驗證微創脊椎融合手術在老年族群的成效，
(2) 探討影響年長病患族群MIS治療短期臨床成效的相關危險因子，以及
(3) 建立對於年長病患族群MIS治療短期臨床成效之預測模式。
研究方法
本研究利用回溯性的病歷研究收集從西元2014年到西元2021年7月期間在中台灣一家醫院接受腰椎微創脊椎融合手術的病人。將病人分成年紀大於或等於65歲的老年族群及小於65歲的年輕族群兩組來比較短期臨床成效。所收集的臨床成效評估指標包含疼痛指數、需使用藥物控制之疼痛、活動度，以及工作公能狀況四個面向並分類為優良、好、尚可，以及差四個等序位類別。所收集的病患臨床資料包含接受手術的節數、手術時間的長短，術中失血量、住院天數，以及共病症等。本研究亦收集長期追蹤評估指標包含是否產生鄰近節退化，術後的X光影像判讀變化，以及鄰近節退化發生的比率。本研究運用貝式二元羅吉斯迴歸與累積多項羅吉斯迴歸，以及機器學習中的決策樹方法評估對於短期臨床結果之影響因子並且據以建立預測模式。對於各個預測模式準確度之比較則運用接受者操作特徵(receiver-operation characteristics，ROC)曲線以及曲線下面積(area under curve，AUC)進行評估。
研究結果
本研究依據收案的標準，總共收錄了138位病人進行MIS治療效益評估。老年族群與年輕族群病人在短期臨床成效能夠達到優良及好的比例相當均可達到86%以上。雖然年紀大於等於65歲及具有內科共病症在單變項二元羅吉斯迴歸分析中為短期臨床成效不佳的危險因子，但是在調整其他的變項之後，此兩因子對短期臨床成效的影響則未達統計顯著水準。在術後的併發症方面兩組沒有明顯差別。但是在長期追蹤期間，老年族群有較高的骨釘鬆脫及腰椎支架位移的比例，但是老年族群並未有病患因此須接受再次手術。運用所收集的臨床預測因子，貝式二元羅吉斯迴歸、貝式累積多項式羅吉斯迴歸，以及機器學習決策樹演算法對於MIS治療後短期臨床成效之曲線下面積分別為74.4%、74.8%，以及90.6%。
結論
以腰椎微創脊椎骨融合手術治療老年族群的腰椎退化性脊椎病變可以得到與年輕族群相當的短期臨床成效。長期追蹤後的結果，雖然在老年族群有影像上較高比例的鄰近節退化及植入物位移的比例。但是因為微創手術保留了腰椎大部分完整結構，就老年族群長期的追蹤結果而言，用腰椎微創脊椎骨融合手術來治療退化性脊椎病變可以降低老年人再手術的風險。運用臨床因子實證資料結合機器學習決策樹演算法，本研究建立了以MIS治療對於短期臨床成效之預測模式，可運用於對此年長族群手術決策之輔助。

關鍵字

腰椎退化性脊椎病變 ； 微創脊椎融合手術 ； 鄰近節段退化 ； 短期效益

並列摘要

Background
With the increase in geriatric population, the disease burden of lumbar degenerative disorder, a pathology mainly affecting the elderly with painful and disabling consequences, requiring spinal fusion is soaring. The conventional treatment of surgical approach involves with neural decompression and fusion by using transforaminal lumbar interbody fusion (TLIF) technique, which is associated with a high incidence of perioperative complications and increased morbidity and mortality, especially in this elder population.
As an alternative, minimally invasive spine surgery (MIS) has gained popularity in recent years due the comparable short- and medium- time outcomes and a decreasing chance of adverse impact for this vulnerable group compared with the conventional approach. However, the effectiveness of MIS has barely been addressed among the elder population.
Study Aims
The purpose of this study is to
(1) to assess the effectiveness of MIS in treating degenerative lumbar spondylosis in terms of early postoperative outcomes and long-term follow-up results,
(2) to explore factors associated with the outcomes of MIS in treating the elder degenerative lumbar spondylosis patients, and
(3) to develop a prediction model for short-term clinical outcomes of MIS among this target patient group.
Material and methods
A retrospective study design was used to collect patients who underwent MIS for treating degenerative lumbar spondylosis at a hospital in Central Taiwan from 2014 to July 2021. The short-term clinical outcomes were assessed for the elder (patients aged 65 years or older) and the young (patients younger than 65 years) patient group. The clinical outcomes including pain index, medication required for pain control, activity, and work status were evaluated and categorized into the ordinal scale of excellent, good, fair, and poor. Clinical measurements including surgery spine levels, length of operation time, intraoperative blood loss, length of hospital stay, and comorbidities were also collected for this patient cohort. The long-term tracking of the occurrence of adjacent segment degeneration, postoperative X-ray image interpretation, and the occurrence of adjacent segment degeneration were evaluated. To elucidate the factors associated with short-term clinical outcomes, the approaches including Bayesian binary logistic regression model and cumulative multinomial logistics regression model and machine learning with decision was applied. The predictive models for short-term clinical outcomes were constructed accordingly with their performance indexed by receiver-operation characteristics (ROC) curve and area under curve (AUC).
Results
According to the inclusion criteria, a total of 138 patients were enrolled for chart review during the study period. More than 86% of patients reached the short-term clinical outcomes of excellent and good. Although the old (65 years and older) and having medical comorbidities were the risk factors for poor short-term clinical outcomes in univariate logistic regression analysis, their impact were not statistically significant in multivariable analysis. There was no significant difference in postoperative complications between the two groups. While the elder group has a higher rate of screw loosening and lumbar cage displacement during the long-term follow-up period, no patients required a reoperation. By using the collected clinical measurements, the AUC in predicting excellent short-term clinical outcomes were estimated as 74.4%, 74.8%, and 90.6% for Bayesian binary logistic regression, Bayesian cumulative multinomial logistic regression, and the prediction algorithm derived from machine learning with decision tree, respectively.
Conclusion
The treatment of lumbar degenerative spondylosis in the elderly population with MIS can reach the short-term clinical outcomes comparable to those in the younger population. As MIS preserves most of the structures of the lumbar spine and reduce the surgical impact, such an approach can be an feasible treatment decision for the vulnerable elder group. The prediction algorithm established by applying the machine learning with decision tree to our empirical data provides an guide to post-operative clinical outcomes in short-term for the elder patient group.

並列關鍵字

lumbar degenerative spondylosis ； minimally invasive spine surgery ； adjacent segment degeneration ； short-term effectiveness

參考文獻

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