Lenke 5型特发性脊柱侧凸选择性固定融合术后矢状位颈椎曲度变化特点
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摘要
目的探讨Lenke 5型特发性脊柱侧凸(adolescent idiopathic scoliosis,AIS)选择性胸腰椎/腰椎固定融合术后矢状面颈椎曲度的变化特点,并分析其影响因素。方法回顾性分析2010-03至2017-01在河北医科大学第三医院接受选择性固定融合手术治疗的56例Lenke 5型AIS患者的临床资料。分析患者术前的颈椎矢状位分型,比较手术前后患者的临床及影像学测量指标如轴性症状发生率、侧凸Cobb's角、颈椎前凸角(cervical lordosis,CL)、胸椎后凸角(thoracic kyphosis,TK)、胸腰段角度(thoracolumbar junction,TLJ)、腰椎前凸角(lumbar lordosis,LL)、骨盆入射角(pelvic incidence,PI)、骨盆倾斜角(pelvic tilt,PT)、骶骨倾斜角(sacrum slop,SS)。采用Pearson相关性检验,评估矢状位颈椎曲度变化与其他影像学参数的相关性。结果 (1)56例术前颈椎矢状位分型包括前凸型20例、直线型17例、S型3例、后凸型16例;术前轴性症状发生率为44.6%(25/56)显著高于末次随访的19.6%(11/56),差异具有统计学意义(χ~2=8.023,P=0.005)。(2)与术前相比,术后一周患者侧凸Cobb's角显著减小、LL显著增大,差异有统计学意义(P<0.017);末次随访时侧凸Cobb's角、PT显著减小,CL、LL、SS显著增大,差异均有统计学意义(P<0.017)。(3)Pearson相关性检验显示CL变化与LL的变化呈线性相关(r=0.589,P<0.01)。结论 Lenke 5型AIS选择性固定融合术后CL增大,轴性症状发生率降低,腰椎前凸的重建与颈椎曲度的代偿变化具有相关性。对于该类患者手术策略的制定,腰椎前凸重建与腰椎侧凸矫正具有同等重要的意义。
Objective The objective of this study was to investigate the variation characteristics of cervical curvature in sagittal alignment after selective thoracolumbar/lumbar fusion for Lenke 5 adolescent idiopathic scoliosis(AIS), and to analyze its influencing factors. Methods The clinical data of 56 patients with AIS who received selective thoracolumbar/lumbar fusion from March 2010 to January 2017 in the Third Hospital of Hebei Medical University were retrospectively analyzed. The sagittal alignment classification of the cervical spine before the operation was analyzed. The clinical and radiological evaluation indexes, such as the incidence of axial symptoms, Cobb's angle, cervical lordosis(CL), thoracic kyphosis(TK), thoracolumbar junction(TLJ), lumbar lordosis(LL), pelvic incidence(PI), pelvic tilt(PT), and sacrum slop(SS) were compared before and after the operation. The correlation between the alteration of cervical curvature in sagittal position and other radiological parameters were evaluated using Pearson correlation test. Results(1) The sagittal classification of the cervical spine before operation included 20 cases of lordosis, 17 straight line, 3 S type, and 16 kyphosis. The incidence of axial symptoms before the operation was 44.6%(25/56), which was significantly higher than that at the last followup [19.6%(11/56)], and the difference was statistically significant(χ~2=8.023, P=0.005).(2) Compared with preoperative, the Cobb's angle decreased, LL increased at one week after operation, and the differences were statistically significant(P<0.017), and the Cobb's angle, PT decreased, CL, LL, SS increased at the last follow-up, and the differences were statistically significant(P<0.017).(3) Pearsoncorrelation test showed that the alteration of CL was linearly related to the change of LL(r=0.589, P<0.01). Conclusions The CL increases and axial pain decreases after selective thoracolumbar/lumbar fusion for Lenke 5 AIS. Reconstruction of LL is correlated with the compensatory change of CL. Both LL reconstruction and scoliosis correction play an important role in developing surgical strategy.
Objective The objective of this study was to investigate the variation characteristics of cervical curvature in sagittal alignment after selective thoracolumbar/lumbar fusion for Lenke 5 adolescent idiopathic scoliosis(AIS), and to analyze its influencing factors. Methods The clinical data of 56 patients with AIS who received selective thoracolumbar/lumbar fusion from March 2010 to January 2017 in the Third Hospital of Hebei Medical University were retrospectively analyzed. The sagittal alignment classification of the cervical spine before the operation was analyzed. The clinical and radiological evaluation indexes, such as the incidence of axial symptoms, Cobb's angle, cervical lordosis(CL), thoracic kyphosis(TK), thoracolumbar junction(TLJ), lumbar lordosis(LL), pelvic incidence(PI), pelvic tilt(PT), and sacrum slop(SS) were compared before and after the operation. The correlation between the alteration of cervical curvature in sagittal position and other radiological parameters were evaluated using Pearson correlation test. Results(1) The sagittal classification of the cervical spine before operation included 20 cases of lordosis, 17 straight line, 3 S type, and 16 kyphosis. The incidence of axial symptoms before the operation was 44.6%(25/56), which was significantly higher than that at the last followup [19.6%(11/56)], and the difference was statistically significant(χ~2=8.023, P=0.005).(2) Compared with preoperative, the Cobb's angle decreased, LL increased at one week after operation, and the differences were statistically significant(P<0.017), and the Cobb's angle, PT decreased, CL, LL, SS increased at the last follow-up, and the differences were statistically significant(P<0.017).(3) Pearsoncorrelation test showed that the alteration of CL was linearly related to the change of LL(r=0.589, P<0.01). Conclusions The CL increases and axial pain decreases after selective thoracolumbar/lumbar fusion for Lenke 5 AIS. Reconstruction of LL is correlated with the compensatory change of CL. Both LL reconstruction and scoliosis correction play an important role in developing surgical strategy.
引文
[1]Horne J P,Flannery R,Usman S.Adolescent idiopathic scoliosis:diagnosis and management[J].Am Fam Physician,2014,89(3):193-198.
[2]Lenke L G,Betz R R,Harms J,et al.Adolescent idiopathic scoliosis:a new classification to determine extent of spinalarthrodesis[J].J Bone Joint Surg Am,2001,83-A(8):1169-1181.
[3]Burton M S.Diagnosis and treatment of adolescent idiopathic scoliosis[J].Pediatr Ann,2013,42(11):224-228.DOI:10.3928/00904481-20131022-09.
[4]Vigneswaran H T,Grabel Z J,Eberson C P,et al.Surgical treatment of adolescent idiopathic scoliosis in the United States from 1997 to 2012:an analysis of 20,346 patients[J].J Neurosurg Pediatr,2015,16(3):322-328.DOI:10.3171/2015.3.PEDS14649.
[5]Trobisch P D,Ducoffe A R,Lonner B S,et al.Choosing fusion levels in adolescent idiopathic scoliosis[J].J Am Acad Orthop Surg,2013,21(9):519-528.DOI:10.5435/JAAOS-21-09-519.
[6]Kelly D M,Mc Carthy R E,Mc Cullough F L,et al.Longterm outcomes of anterior spinal fusion with instrumentation for thoracolumbar and lumbar curves in adolescent idiopathic scoliosis[J].Spine(Phila Pa 1976),2010,35(2):194-198.DOI:10.1097/BRS.0b013e3181bc948e.
[7]Abel M F,Singla A,Feger M A,et al.Surgical treatment of Lenke 5 adolescent idiopathic scoliosis:Comparison of anterior vs posterior approach[J].World J Orthop,2016,7(9):553-560.DOI:10.5312/wjo.v7.i9.553.
[8]Okada E,Watanabe K,Pang L,et al.Posterior correction and fusion surgery using pedicle-screw constructs for Lenke type 5C adolescent idiopathic scoliosis:a preliminary report[J].Spine(Phila Pa 1976),2015,40(1):25-30.DOI:10.1097/BRS.0000000000000652.
[9]Berthonnaud E,Dimnet J,Roussouly P,et al.Analysis of the sagittal balance of the spine and pelvis using shape and orientation parameters[J].J Spinal Disord,2005,18(1):40-47.
[10]Lehman R A Jr,Lenke L G,Keeler K A,et al.Operative treatment of adolescent idiopathic scoliosis with posterior pedicle screw-only constructs.minimum three-year followup of one hundred fourteen cases[J].Spine(Phila Pa 1976),2008,33(14):1598-1604.DOI:10.1097/BRS.0b013e318178872a.
[11]Ito K,Imagama S,Ito Z,et al.Analysis of cervical kyphosis and spinal balance in young idiopathic scoliosis patients classified by the apex of thoracic kyphosis[J].Eur Spine J,2016,25(10):3220-3225.DOI:10.1007/s00586-016-4699-6.
[12]Yu M,Silvestre C,Mouton T,et al.Analysis of the cervical spine sagittal alignment in young idiopathic scoliosis:a morphological classification of 120 cases[J].Eur Spine J,2013,22(11):2372-2381.DOI:10.1007/s00586-013-2753-1.
[13]Hilibrand A S,Tannenbaum D A,Graziano G P,et al.The sagittal alignment of the cervical spine in adolescent idiopathic soliosis[J].J Pediatr Orthop,1995,15(5):627-632.DOI:10.1007/s00586-016-4701-3.
[14]王连雷,刘新宇,原所茂,等.青少年特发性脊柱侧凸患者颈椎矢状位曲度变化及影响因素分析[J].中国临床解剖学杂志,2015,33(6):712-716.DOI:10.13418/j.issn.1001-165x.2015.06.020.
[15]Legarreta C A,Barrios C,Rositto G E,et al.Cervical and thoracic sagittal misalignment after surgery for adolescent idiopathic scoliosis:a comparative study of all pedicle screws versus hybrid instrumentation[J].Spine(Phila Pa 1976),2014,39(16):1330-1337.DOI:10.1097/BRS.0000000000000403.
[16]Palmer S,Davison L.Minimally invasive surgical treatment of lumbar spinal stenosis:Two-year followup in 54 patients[J].Surg Neurol Int,2012,3:41.DOI:10.4103/2152-7806.94294.
[17]Yung M S,Shin J K,Goh T S,et al.Relationship between cervical sagittal alignment and health-related quality of life in adolescent idiopathic scoliosis[J].Eur Spine J,2016,25(10):3114-3119.DOI:10.1007/s00586-016-4488-2.
[18]王辉,丁文元,申勇,等.颈椎后纵韧带骨化症间接减压术后轴性症状分析[J].中华外科杂志,2012,50(7):601-606.DOI:10.3760/cma.j.issn.0529-5815.2012.07.008.
[19]Wagner S C,Formby P M,Kang D G,et al.Persistent axial neck pain after cervical disc arthroplasty:a radiographic analysis[J].Spine J,2016,16(7):851-856.DOI:10.1016/j.spinee.2016.02.043.
[20]Dugailly P M,Coucke A,Salem W,et al.Assessment of cervical stiffness in axial rotation among chronic neck pain patients:A trial in the framework of a non-manipulative osteopathic management[J].Clin Biomech(Bristol,Avon),2018,53:65-71.DOI:10.1016/j.clinbiomech.2018.02.005.
[2]Lenke L G,Betz R R,Harms J,et al.Adolescent idiopathic scoliosis:a new classification to determine extent of spinalarthrodesis[J].J Bone Joint Surg Am,2001,83-A(8):1169-1181.
[3]Burton M S.Diagnosis and treatment of adolescent idiopathic scoliosis[J].Pediatr Ann,2013,42(11):224-228.DOI:10.3928/00904481-20131022-09.
[4]Vigneswaran H T,Grabel Z J,Eberson C P,et al.Surgical treatment of adolescent idiopathic scoliosis in the United States from 1997 to 2012:an analysis of 20,346 patients[J].J Neurosurg Pediatr,2015,16(3):322-328.DOI:10.3171/2015.3.PEDS14649.
[5]Trobisch P D,Ducoffe A R,Lonner B S,et al.Choosing fusion levels in adolescent idiopathic scoliosis[J].J Am Acad Orthop Surg,2013,21(9):519-528.DOI:10.5435/JAAOS-21-09-519.
[6]Kelly D M,Mc Carthy R E,Mc Cullough F L,et al.Longterm outcomes of anterior spinal fusion with instrumentation for thoracolumbar and lumbar curves in adolescent idiopathic scoliosis[J].Spine(Phila Pa 1976),2010,35(2):194-198.DOI:10.1097/BRS.0b013e3181bc948e.
[7]Abel M F,Singla A,Feger M A,et al.Surgical treatment of Lenke 5 adolescent idiopathic scoliosis:Comparison of anterior vs posterior approach[J].World J Orthop,2016,7(9):553-560.DOI:10.5312/wjo.v7.i9.553.
[8]Okada E,Watanabe K,Pang L,et al.Posterior correction and fusion surgery using pedicle-screw constructs for Lenke type 5C adolescent idiopathic scoliosis:a preliminary report[J].Spine(Phila Pa 1976),2015,40(1):25-30.DOI:10.1097/BRS.0000000000000652.
[9]Berthonnaud E,Dimnet J,Roussouly P,et al.Analysis of the sagittal balance of the spine and pelvis using shape and orientation parameters[J].J Spinal Disord,2005,18(1):40-47.
[10]Lehman R A Jr,Lenke L G,Keeler K A,et al.Operative treatment of adolescent idiopathic scoliosis with posterior pedicle screw-only constructs.minimum three-year followup of one hundred fourteen cases[J].Spine(Phila Pa 1976),2008,33(14):1598-1604.DOI:10.1097/BRS.0b013e318178872a.
[11]Ito K,Imagama S,Ito Z,et al.Analysis of cervical kyphosis and spinal balance in young idiopathic scoliosis patients classified by the apex of thoracic kyphosis[J].Eur Spine J,2016,25(10):3220-3225.DOI:10.1007/s00586-016-4699-6.
[12]Yu M,Silvestre C,Mouton T,et al.Analysis of the cervical spine sagittal alignment in young idiopathic scoliosis:a morphological classification of 120 cases[J].Eur Spine J,2013,22(11):2372-2381.DOI:10.1007/s00586-013-2753-1.
[13]Hilibrand A S,Tannenbaum D A,Graziano G P,et al.The sagittal alignment of the cervical spine in adolescent idiopathic soliosis[J].J Pediatr Orthop,1995,15(5):627-632.DOI:10.1007/s00586-016-4701-3.
[14]王连雷,刘新宇,原所茂,等.青少年特发性脊柱侧凸患者颈椎矢状位曲度变化及影响因素分析[J].中国临床解剖学杂志,2015,33(6):712-716.DOI:10.13418/j.issn.1001-165x.2015.06.020.
[15]Legarreta C A,Barrios C,Rositto G E,et al.Cervical and thoracic sagittal misalignment after surgery for adolescent idiopathic scoliosis:a comparative study of all pedicle screws versus hybrid instrumentation[J].Spine(Phila Pa 1976),2014,39(16):1330-1337.DOI:10.1097/BRS.0000000000000403.
[16]Palmer S,Davison L.Minimally invasive surgical treatment of lumbar spinal stenosis:Two-year followup in 54 patients[J].Surg Neurol Int,2012,3:41.DOI:10.4103/2152-7806.94294.
[17]Yung M S,Shin J K,Goh T S,et al.Relationship between cervical sagittal alignment and health-related quality of life in adolescent idiopathic scoliosis[J].Eur Spine J,2016,25(10):3114-3119.DOI:10.1007/s00586-016-4488-2.
[18]王辉,丁文元,申勇,等.颈椎后纵韧带骨化症间接减压术后轴性症状分析[J].中华外科杂志,2012,50(7):601-606.DOI:10.3760/cma.j.issn.0529-5815.2012.07.008.
[19]Wagner S C,Formby P M,Kang D G,et al.Persistent axial neck pain after cervical disc arthroplasty:a radiographic analysis[J].Spine J,2016,16(7):851-856.DOI:10.1016/j.spinee.2016.02.043.
[20]Dugailly P M,Coucke A,Salem W,et al.Assessment of cervical stiffness in axial rotation among chronic neck pain patients:A trial in the framework of a non-manipulative osteopathic management[J].Clin Biomech(Bristol,Avon),2018,53:65-71.DOI:10.1016/j.clinbiomech.2018.02.005.