退变性腰椎侧凸后路长节段固定融合术后冠状面失平衡的危险因素分析
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摘要
目的探讨退变性腰椎侧凸后路长节段固定融合术后发生冠状面失平衡的危险因素。方法回顾研究2011年8月—2016年7月行后路选择性经腰椎间孔椎体间融合术(transforaminal lumbar interbody fusion,TLIF)结合Ponte截骨矫形长节段固定手术的41例退变性腰椎侧凸患者临床资料,按末次随访时是否出现冠状面失平衡分为失平衡组(A组,11例)和平衡组(B组,30例)。术前及末次随访时测量以下影像学参数:冠状面Cobb角、冠状面平衡距离(coronal balance distance,CBD)、顶椎偏距(apical vertebra translation,AVT)、顶椎旋转(apical vertebra rotation,AVR)、腰骶弯(lumbar sacral curve,LSC)Cobb角和L5倾斜角(L5 tilt angle,L5TA),计算术前与末次随访时上述影像学参数变化值。对两组患者性别、年龄、术前骨密度T值、固定椎体数、上端固定椎、下端固定椎、TLIF椎间融合器植入节段数、减压节段数、Ponte截骨节段数,以及将有统计学意义的术前影像学参数连续变量转换为二分类变量,进行单因素分析,初步筛选术后冠状面失平衡的影响因素。再将上述初步筛选的影响因素和组间有统计学意义的影像学参数变化值采用多因素logistic回归分析,筛选危险因素。结果 A、B组随访时间分别为(3.76±1.02)年和(3.56±1.03)年,比较差异无统计学意义(t=0.547,P=0.587)。A组患者术前冠状面Cobb角、AVT、LSC Cobb角、L5TA显著大于B组(P<0.05);末次随访时,A组各影像学参数均显著大于B组(P<0.05)。手术前后冠状面Cobb角、AVT、LSC Cobb角变化值两组间比较差异无统计学意义(P>0.05),CBD、L5TA和AVR变化值两组间比较差异有统计学意义(P<0.05)。单因素分析显示,术前L5TA是术后冠状面失平衡的影响因素(P<0.05)。多因素logistic回归分析显示,术前L5TA≥15°是术后冠状面失平衡发生的独立危险因素,手术前后AVR变化值是冠状面失平衡的保护因素。结论术前L5TA≥15°是退变性腰椎侧凸后路长节段固定融合术后发生冠状面失平衡的独立危险因素。
Objective To explore the risk factors of coronal imbalance after posterior long-level fixation and fusion for degenerative lumbar scoliosis. Methods Retrospectivly analyzed the clinical records of 41 patients with degenerative lumbar scoliosis who had received posterior long-level fixation and fusion with selective transforaminal lumbar interbody fusion(TLIF) accompanied by Ponte osteotomy between August 2011 and July 2016. Patients were divided into imbalance group(group A, 11 cases) and balance group(group B, 30 cases) according to state of coronal imbalance measured at last follow-up. The radiographic parameters at preoperation and last follow-up were measured,and the variance of preoperative and last follow-up parameters were calculated. The radiographic parameters included coronal Cobb angle, coronal balance distance(CBD), apical vertebral translation(AVT), apical vertebral rotation(AVR),Cobb angle of lumbar sacral curve(LSC), and L5 tilt angle(L5 TA). Univariate analysis was performed for the factors including gender, age, preoperative T value of bone mineral density, number of instrumented vertebra, upper and lower instrumented vertebra, segments of TLIF, decompression, and Ponte osteotomy, as well as the continuous variables of preoperative imaging parameters with significant difference were converted into two-category variables, obtained the influence factors of postoperative coronal imbalance. Multivariate logistic regression analysis was performed to verify the risk factors from the preliminary screened influence factors and the variance of imaging parameters with significant difference between the two groups. Results The follow-up time of groups A and B was(3.76±1.02) years and(3.56±1.03)years respectively, there was no significant difference between the two groups(t=0.547, P=0.587). The coronal Cobb angle,AVT, LSC Cobb angle, and L5 TA in group A were significantly higher than those in group B before operation(P<0.05),and all the imaging parameters in group A were significantly higher than those in group B at last follow-up(P<0.05).There was no significant difference between the two groups in parameters including the variance of coronal Cobb angle,AVT, and LSC Cobb angle before and after operation(P>0.05), and there were significant differences between the two groups in parameters including the variance of CBD, L5 TA, and AVR(P<0.05). Univariate analysis showed that preoperative L5 TA was the influencing factor of postoperative coronal imbalance(P<0.05). Multivariate logistic regression analysis showed that preoperative L5 TA≥15° was an independent risk factor of postoperative coronal imbalance, and variance of pre-and post-operative AVR was a protective factor. Conclusion Preoperative L5 TA≥15° is an independent risk factor for coronal imbalance in patients with degenerative lumbar scoliosis after posterior long-level fixation and fusion.
Objective To explore the risk factors of coronal imbalance after posterior long-level fixation and fusion for degenerative lumbar scoliosis. Methods Retrospectivly analyzed the clinical records of 41 patients with degenerative lumbar scoliosis who had received posterior long-level fixation and fusion with selective transforaminal lumbar interbody fusion(TLIF) accompanied by Ponte osteotomy between August 2011 and July 2016. Patients were divided into imbalance group(group A, 11 cases) and balance group(group B, 30 cases) according to state of coronal imbalance measured at last follow-up. The radiographic parameters at preoperation and last follow-up were measured,and the variance of preoperative and last follow-up parameters were calculated. The radiographic parameters included coronal Cobb angle, coronal balance distance(CBD), apical vertebral translation(AVT), apical vertebral rotation(AVR),Cobb angle of lumbar sacral curve(LSC), and L5 tilt angle(L5 TA). Univariate analysis was performed for the factors including gender, age, preoperative T value of bone mineral density, number of instrumented vertebra, upper and lower instrumented vertebra, segments of TLIF, decompression, and Ponte osteotomy, as well as the continuous variables of preoperative imaging parameters with significant difference were converted into two-category variables, obtained the influence factors of postoperative coronal imbalance. Multivariate logistic regression analysis was performed to verify the risk factors from the preliminary screened influence factors and the variance of imaging parameters with significant difference between the two groups. Results The follow-up time of groups A and B was(3.76±1.02) years and(3.56±1.03)years respectively, there was no significant difference between the two groups(t=0.547, P=0.587). The coronal Cobb angle,AVT, LSC Cobb angle, and L5 TA in group A were significantly higher than those in group B before operation(P<0.05),and all the imaging parameters in group A were significantly higher than those in group B at last follow-up(P<0.05).There was no significant difference between the two groups in parameters including the variance of coronal Cobb angle,AVT, and LSC Cobb angle before and after operation(P>0.05), and there were significant differences between the two groups in parameters including the variance of CBD, L5 TA, and AVR(P<0.05). Univariate analysis showed that preoperative L5 TA was the influencing factor of postoperative coronal imbalance(P<0.05). Multivariate logistic regression analysis showed that preoperative L5 TA≥15° was an independent risk factor of postoperative coronal imbalance, and variance of pre-and post-operative AVR was a protective factor. Conclusion Preoperative L5 TA≥15° is an independent risk factor for coronal imbalance in patients with degenerative lumbar scoliosis after posterior long-level fixation and fusion.
引文
1 Xu L, Sun X, Huang S, et al. Degenerative lumbar scoliosis in Chinese Han population:prevalence and relationship to age,gender, bone mineral density, and body mass index. Eur Spine J,2013,22(6):1326-1331.
2 Koerner JD, Reitman CA, Arnold PM, et al. Degenerative lumbar scoliosis. JBJS Rev, 2015, 3(4):pii:1874474-201504000.
3 Zhu Y, Wang B, Wang H, et al. Long-term clinical outcomes of selective segmental transforaminal lumbar interbody fusion combined with posterior spinal fusion for degenerative lumbar scoliosis. ANZ J Surg, 2014, 84(10):781-785.
4张志成,任大江,孙天胜,等.退变性腰椎侧凸合并椎管狭窄的阶梯性治疗策略.中国修复重建外科杂志,2011,25(8):951-955.
5王孝宾,吕国华,王冰,等.后路长节段固定治疗成人退行性脊柱畸形的疗效及其远端并发症.中国脊柱脊髓杂志,2016, 26(8):689-695.
6 Lenke LG. Sagittal balance. J Neurosurg Spine, 2014, 20(5):512-514.
7周思宇,孙卓然,李危石.矢状位平衡影像学评价之争议与现状.中国修复重建外科杂志,2018, 32(11):1365-1370.
8 Glassman SD, Berven S, Bridwell K, et al. Correlation of radiographic parameters and clinical symptoms in adult scoliosis.Spine(Phila Pa 1976), 2005, 30(6):682-688.
9 Cho W, Mason JR, Smith JS, et al. Failure of lumbopelvic fixation after long construct fusions in patients with adult spinal deformity:clinical and radiographic risk factors:clinical article. J Neurosurg Spine, 2013,19(4):445-453.
10邱勇,朱泽章,主译.成人脊柱畸形.济南:山东科学技术出版社,2017:78-93.
11李明,王岩,邱勇,等.脊柱侧凸外科学.上海:第二军医大学出版社,2013:12-13.
12 Hey HWD, Kim CK, Lee WG, et al. Supra-acetabular line is better than supra-iliac line for coronal balance referencing-a study of perioperative whole spine X-rays in degenerative lumbar scoliosis and ankylosing spondylitis patients. Spine J, 2017, 17(12):1837-1845.
13 Ploumis A, Simpson AK, Cha TD, et al. Coronal spinal balance in adult spine deformity patients with long spinal fusions:a minimum2-to 5-year follow-up study. J Spinal Disord Tech, 2015, 28(9):341-347.
14 Bao H, Yan P, Qiu Y, et al. Coronal imbalance in degenerative lumbar scoliosis:Prevalence and influence on surgical decisionmaking for spinal osteotomy. Bone Joint J, 2016, 98-B(9):1227-1233.
15 Swamy G, Berven SH, Bradford DS. The selection of Ls versus S, in long fusions for adult idiopathic scoliosis. Neurosurg Clin N Am,2007,18(2):281-288.
16商振国,李永民.退变性脊柱侧凸手术融合节段选择的研究进展.中国修复重建外科杂志,2016, 30(8):1044-1048.
17 Burns CB, Dua K, Trasolini NA, et al. Biomechanical comparison of spinopelvic fixation constructs:iliac screw versus S2-alar-iliac screw. Spine Deform, 2016, 4(1):10-15.
18 Kebaish KM. Sacropelvic fixation:techniques and complications.Spine(Phila Pa 1976), 2010, 35(25):2245-2251.
19 Shen FH, Mason JR, Shimer AL, et al. Pelvic fixation for adult scoliosis. Eur Spine J, 2013, 22 Suppl 2:S265-S275.
20 Yasuda T, Hasegawa T, Yamato Y, et al. Lumbosacral junctional failures after long spinal fusion for adult spinal deformity-which vertebra is the preferred distal instrumented vertebra? Spine Deform, 2016, 4(5):378-384.
2 Koerner JD, Reitman CA, Arnold PM, et al. Degenerative lumbar scoliosis. JBJS Rev, 2015, 3(4):pii:1874474-201504000.
3 Zhu Y, Wang B, Wang H, et al. Long-term clinical outcomes of selective segmental transforaminal lumbar interbody fusion combined with posterior spinal fusion for degenerative lumbar scoliosis. ANZ J Surg, 2014, 84(10):781-785.
4张志成,任大江,孙天胜,等.退变性腰椎侧凸合并椎管狭窄的阶梯性治疗策略.中国修复重建外科杂志,2011,25(8):951-955.
5王孝宾,吕国华,王冰,等.后路长节段固定治疗成人退行性脊柱畸形的疗效及其远端并发症.中国脊柱脊髓杂志,2016, 26(8):689-695.
6 Lenke LG. Sagittal balance. J Neurosurg Spine, 2014, 20(5):512-514.
7周思宇,孙卓然,李危石.矢状位平衡影像学评价之争议与现状.中国修复重建外科杂志,2018, 32(11):1365-1370.
8 Glassman SD, Berven S, Bridwell K, et al. Correlation of radiographic parameters and clinical symptoms in adult scoliosis.Spine(Phila Pa 1976), 2005, 30(6):682-688.
9 Cho W, Mason JR, Smith JS, et al. Failure of lumbopelvic fixation after long construct fusions in patients with adult spinal deformity:clinical and radiographic risk factors:clinical article. J Neurosurg Spine, 2013,19(4):445-453.
10邱勇,朱泽章,主译.成人脊柱畸形.济南:山东科学技术出版社,2017:78-93.
11李明,王岩,邱勇,等.脊柱侧凸外科学.上海:第二军医大学出版社,2013:12-13.
12 Hey HWD, Kim CK, Lee WG, et al. Supra-acetabular line is better than supra-iliac line for coronal balance referencing-a study of perioperative whole spine X-rays in degenerative lumbar scoliosis and ankylosing spondylitis patients. Spine J, 2017, 17(12):1837-1845.
13 Ploumis A, Simpson AK, Cha TD, et al. Coronal spinal balance in adult spine deformity patients with long spinal fusions:a minimum2-to 5-year follow-up study. J Spinal Disord Tech, 2015, 28(9):341-347.
14 Bao H, Yan P, Qiu Y, et al. Coronal imbalance in degenerative lumbar scoliosis:Prevalence and influence on surgical decisionmaking for spinal osteotomy. Bone Joint J, 2016, 98-B(9):1227-1233.
15 Swamy G, Berven SH, Bradford DS. The selection of Ls versus S, in long fusions for adult idiopathic scoliosis. Neurosurg Clin N Am,2007,18(2):281-288.
16商振国,李永民.退变性脊柱侧凸手术融合节段选择的研究进展.中国修复重建外科杂志,2016, 30(8):1044-1048.
17 Burns CB, Dua K, Trasolini NA, et al. Biomechanical comparison of spinopelvic fixation constructs:iliac screw versus S2-alar-iliac screw. Spine Deform, 2016, 4(1):10-15.
18 Kebaish KM. Sacropelvic fixation:techniques and complications.Spine(Phila Pa 1976), 2010, 35(25):2245-2251.
19 Shen FH, Mason JR, Shimer AL, et al. Pelvic fixation for adult scoliosis. Eur Spine J, 2013, 22 Suppl 2:S265-S275.
20 Yasuda T, Hasegawa T, Yamato Y, et al. Lumbosacral junctional failures after long spinal fusion for adult spinal deformity-which vertebra is the preferred distal instrumented vertebra? Spine Deform, 2016, 4(5):378-384.