腰椎融合术后邻近节段病变与脊柱-骨盆矢状位参数的相关性
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摘要
目的分析腰椎融合术后邻近节段病变(ASDis)与脊柱-骨盆矢状位参数的相关性,并探讨其危险因素。方法纳入2013年1月至2017年10月在海军军医大学(第二军医大学)长海医院骨科脊柱外科因腰椎融合术后ASDis行翻修手术的患者为ASDis组,匹配同期行腰椎融合手术且经过相同时间随访未发生明显ASDis的患者为对照组。回顾性分析两组患者的病例资料,比较两组患者一般资料及末次随访时的脊柱-骨盆矢状位参数的差异,前者包括年龄、性别、体质量指数(BMI)、随访时间及初次手术病因,后者包括胸椎后凸角(TK)、矢状位躯干偏移(SVA)、腰椎前凸角(LL)、手术节段腰椎前凸角(sLL)、骨盆入射角(PI)、骨盆倾斜角(PT)、骶骨倾斜角(SS)等。结果共纳入ASDis组患者25例,对照组患者50例,两组患者的年龄、性别、BMI、随访时间及初次手术病因差异均无统计学意义(P均>0.05)。ASDis组患者LL、sLL、SS均小于对照组(36.00°±5.44°vs43.88°±10.62°,17.80°±5.79°vs27.62°±6.74°,27.50°±5.30°vs31.06°±7.48°,P均<0.05),PT大于对照组(26.12°±8.24°vs 18.80°±7.67°,P<0.01),两组间TK和PI差异均无统计学意义(P均>0.05);同时,ASDis组中SVA>50 mm、PI与LL的差值(PI-LL)≥10°及sLL占LL比例(RL)<60%的患者比例均高于对照组(18/25 vs 21/50、16/25 vs 11/50、21/25 vs 17/50,P均<0.05)。结论腰椎融合术后矢状位失衡与ASDis的发生密切相关,手术节段前凸恢复不良导致邻近节段腰椎代偿性后凸可能是引起腰椎融合术后ASDis的原因之一。
Objective To analyze the correlation between adjacent segment disease(ASDis) after lumbar fusion and spinopelvic sagittal parameters, and to explore the risk factors. Methods From Jan. 2013 to Oct. 2017, the patients undergoing revision surgery for ASDis after lumbar fusion in Changhai Hospital of Naval Medical University(Second Military Medical University) were enrolled as ASDis group, and the patients who did not have ASDis after lumbar fusion during the same follow-up period were taken as controls. The clinical data of the patients in the two groups were retrospectively analyzed. The differences of the general data(age, gender, body mass index [BMI], follow-up time and the etiology of the first operation) and the spinopelvic sagittal parameters(thoracic kyphosis [TK], sagittal vertical axis [SVA],lumbar lordosis [LL], segmental lumbar lordosis [sLL], pelvic incidence [PI], pelvic tilt [PT] and sacral slope [SS]) were compared between the two groups. Results There were 25 patients in the ASDis group and 50 patients in the control group.There were no significant differences in the age, gender, BMI, follow-up time or the etiology of the first operation between the two groups(all P>0.05). Compared with the control group, the LL, sLL and SS were significantly lower in the ASDis group(36.00°±5.44°vs 43.88°±10.62°, 17.80°±5.79°vs 27.62°±6.74°, 27.50°±5.30°vs 31.06°±7.48°; all P<0.05),while the PT was significantly greater(26.12°±8.24°vs 18.80°±7.67°, P<0.01). There were no significant differences in the TK or PI between the two groups(both P>0.05). Meantime, the proportion of patients with SVA>50 mm, the difference of PT and LL(PT-LL)≥10°, and the ratio of sLL to LL(RL)<60% were significantly higher in the ASDis group than those in the control group(18/25 vs 21/50, 16/25 vs 11/50, 21/25 vs 17/50; all P<0.05). Conclusion The sagittal imbalance after lumbar fusion is closely associated with ASDis, and compensatory kyphosis of adjacent lumbar segments due to surgical segmental lordosis may be one of the causes of ASDis after lumbar fusion.
Objective To analyze the correlation between adjacent segment disease(ASDis) after lumbar fusion and spinopelvic sagittal parameters, and to explore the risk factors. Methods From Jan. 2013 to Oct. 2017, the patients undergoing revision surgery for ASDis after lumbar fusion in Changhai Hospital of Naval Medical University(Second Military Medical University) were enrolled as ASDis group, and the patients who did not have ASDis after lumbar fusion during the same follow-up period were taken as controls. The clinical data of the patients in the two groups were retrospectively analyzed. The differences of the general data(age, gender, body mass index [BMI], follow-up time and the etiology of the first operation) and the spinopelvic sagittal parameters(thoracic kyphosis [TK], sagittal vertical axis [SVA],lumbar lordosis [LL], segmental lumbar lordosis [sLL], pelvic incidence [PI], pelvic tilt [PT] and sacral slope [SS]) were compared between the two groups. Results There were 25 patients in the ASDis group and 50 patients in the control group.There were no significant differences in the age, gender, BMI, follow-up time or the etiology of the first operation between the two groups(all P>0.05). Compared with the control group, the LL, sLL and SS were significantly lower in the ASDis group(36.00°±5.44°vs 43.88°±10.62°, 17.80°±5.79°vs 27.62°±6.74°, 27.50°±5.30°vs 31.06°±7.48°; all P<0.05),while the PT was significantly greater(26.12°±8.24°vs 18.80°±7.67°, P<0.01). There were no significant differences in the TK or PI between the two groups(both P>0.05). Meantime, the proportion of patients with SVA>50 mm, the difference of PT and LL(PT-LL)≥10°, and the ratio of sLL to LL(RL)<60% were significantly higher in the ASDis group than those in the control group(18/25 vs 21/50, 16/25 vs 11/50, 21/25 vs 17/50; all P<0.05). Conclusion The sagittal imbalance after lumbar fusion is closely associated with ASDis, and compensatory kyphosis of adjacent lumbar segments due to surgical segmental lordosis may be one of the causes of ASDis after lumbar fusion.
引文
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[9]VIDEBAEK T S,EGUND N,CHRISTENSEN F B,GRETHE JURIK A,BüNGER C E.Adjacent segment degeneration after lumbar spinal fusion:the impact of anterior column support:a randomized clinical trial with an eight-to thirteen-year magnetic resonance imaging followup[J].Spine(Phila Pa 1976),2010,35:1955-1964.
[10]GHASEMI A A.Adjacent segment degeneration after posterior lumbar fusion:an analysis of possible risk factors[J].Clin Neurol Neurosurg,2016,143:15-18.
[11]ZHONG Z M,DEVIREN V,TAY B,BURCH S,BERVEN S H.Adjacent segment disease after instrumented fusion for adult lumbar spondylolisthesis:incidence and risk factors[J].Clin Neurol Neurosurg,2017,156:29-34.
[12]RAMIREZ-VILLAESCUSA J,LóPEZ-TORRESHIDALGO J,MARTIN-BENLLOCH A,RUIZ-PICAZOD,GOMAR-SANCHO F.Risk factors related to adjacent segment degeneration:retrospective observational cohort study and survivorship analysis of adjacent unfused segments[J].Br J Neurosurg,2019,33:17-24.
[13]BAE J S,LEE S H,KIM J S,JUNG B,CHOI G.Adjacent segment degeneration after lumbar interbody fusion with percutaneous pedicle screw fixation for adult low-grade isthmic spondylolisthesis:minimum 3 years of follow-up[J].Neurosurgery,2010,67:1600-1608.
[14]UMEHARA S,ZINDRICK M R,PATWARDHAN A G,HAVEY R M,VRBOS L A,KNIGHT G W,et al.The biomechanical effect of postoperative hypolordosis in instrumented lumbar fusion on instrumented and adjacent spinal segments[J].Spine(Phila Pa 1976),2000,25:1617-1624.
[15]LEE C S,CHUNG S S,PARK S J,KIM D M,SHIN S K.Simple prediction method of lumbar lordosis for planning of lumbar corrective surgery:radiological analysis in a Korean population[J].Eur Spine J,2014,23:192-197.
[2]SUN J,WANG J J,ZHANG L W,HUANG H,FU NX.Sagittal alignment as predictor of adjacent segment disease after lumbar transforaminal interbody fusion[J/OL].World Neurosurg,2018,110:e567-e571.doi:10.1016/j.wneu.2017.11.049.
[3]MATSUMOTO T,OKUDA S,MAENO T,YAMASHITAT,YAMASAKI R,SUGIURA T,et al.Spinopelvic sagittal imbalance as a risk factor for adjacent-segment disease after single-segment posterior lumbar interbody fusion[J].J Neurosurg Spine,2017,26:435-440.
[4]LEE J H,KIM K T,LEE S H,KANG K C,OH H S,KIMY J,et al.Overcorrection of lumbar lordosis for adult spinal deformity with sagittal imbalance:comparison of radiographic outcomes between overcorrection and undercorrection[J].Eur Spine J,2016,25:2668-2675.
[5]LEE C S,CHUNG S S,PARK S J,KIM D M,SHIN S K.Simple prediction method of lumbar lordosis for planning of lumbar corrective surgery:radiological analysis in a Korean population[J].Eur Spine J,2014,23:192-197.
[6]NAKASHIMA H,KAWAKAMI N,TSUJI T,OHARAT,SUZUKI Y,SAITO T,et al.Adjacent segment disease after posterior lumbar interbody fusion:based on cases with a minimum of 10 years of follow-up[J/OL].Spine(Phila Pa 1976),2015,40:E831-E841.doi:10.1097/BRS.0000000000000917.
[7]GHISELLI G,WANG J C,BHATIA N N,HSU W K,DAWSON E G.Adjacent segment degeneration in the lumbar spine[J].J Bone Joint Surg Am,2004,86-A:1497-1503.
[8]MIN J H,JANG J S,JUNG B J,LEE H Y,CHOI WC,SHIM C S,et al.The clinical characteristics and risk factors for the adjacent segment degeneration in instrumented lumbar fusion[J].J Spinal Disord Tech,2008,21:305-309.
[9]VIDEBAEK T S,EGUND N,CHRISTENSEN F B,GRETHE JURIK A,BüNGER C E.Adjacent segment degeneration after lumbar spinal fusion:the impact of anterior column support:a randomized clinical trial with an eight-to thirteen-year magnetic resonance imaging followup[J].Spine(Phila Pa 1976),2010,35:1955-1964.
[10]GHASEMI A A.Adjacent segment degeneration after posterior lumbar fusion:an analysis of possible risk factors[J].Clin Neurol Neurosurg,2016,143:15-18.
[11]ZHONG Z M,DEVIREN V,TAY B,BURCH S,BERVEN S H.Adjacent segment disease after instrumented fusion for adult lumbar spondylolisthesis:incidence and risk factors[J].Clin Neurol Neurosurg,2017,156:29-34.
[12]RAMIREZ-VILLAESCUSA J,LóPEZ-TORRESHIDALGO J,MARTIN-BENLLOCH A,RUIZ-PICAZOD,GOMAR-SANCHO F.Risk factors related to adjacent segment degeneration:retrospective observational cohort study and survivorship analysis of adjacent unfused segments[J].Br J Neurosurg,2019,33:17-24.
[13]BAE J S,LEE S H,KIM J S,JUNG B,CHOI G.Adjacent segment degeneration after lumbar interbody fusion with percutaneous pedicle screw fixation for adult low-grade isthmic spondylolisthesis:minimum 3 years of follow-up[J].Neurosurgery,2010,67:1600-1608.
[14]UMEHARA S,ZINDRICK M R,PATWARDHAN A G,HAVEY R M,VRBOS L A,KNIGHT G W,et al.The biomechanical effect of postoperative hypolordosis in instrumented lumbar fusion on instrumented and adjacent spinal segments[J].Spine(Phila Pa 1976),2000,25:1617-1624.
[15]LEE C S,CHUNG S S,PARK S J,KIM D M,SHIN S K.Simple prediction method of lumbar lordosis for planning of lumbar corrective surgery:radiological analysis in a Korean population[J].Eur Spine J,2014,23:192-197.