摘要
目的 :探讨骨盆入射角与腰椎前凸角匹配度(pelvic incidence and lumbar lordosis mismatch,PI-LL)对强直性脊柱炎(ankylosing spondylitis,AS)后凸畸形矫形术后脊柱骨盆矢状面平衡的影响。方法:回顾性研究2010年1月~2019年10月本团队行改良经椎弓根椎体截骨术治疗的85例AS后凸畸形患者,男75例,女10例;年龄37.1±8.8岁(20~67岁),其中63例行单节段截骨矫形,22例行双节段截骨矫形。脊柱全长侧位片上测量术前、术后(3~4周)及末次随访时脊柱骨盆矢状面参数:骨盆入射角(pelvic incidence,PI)、骨盆倾斜角(pelvic tilt,PT)、骶骨倾斜角(sacral slope,SS)、腰椎前凸角(lumbar lordosis,LL)、PI-LL、截骨角(osteotomized vertebral angle,OVA)和矢状面躯干偏移(sagittal vertical axis,SVA)。术前及末次随访时采用脊柱侧凸研究学会-22(Scoliosis Research Society-22,SRS-22)问卷和Oswestry功能障碍指数(Oswestry disability index,ODI)评估患者的肢体功能和生活质量。末次随访时SVA>5cm为脊柱矢状面失衡,PT>25°为骨盆矢状面失衡。通过Pearson相关系数分析术后PI-LL与末次随访SVA和PT的相关性,并运用受试者操作特征(receiver operating characteristic,ROC)曲线和最大约登指数计算术后PI-LL的阈值,获得PI-LL的最佳匹配度。根据术后PI-LL是否满足最佳匹配度分组,分析不同术后PI-LL对末次随访脊柱骨盆矢状面序列的影响。运用线性回归分析腰椎OVA与PI-LL矫正值的线性关系,计算线性回归方程。结果:85例AS患者术后平均随访30.8±6.3个月(24~84个月),末次随访时LL(-31.6°)、PT(31.8°)、SS(15.5°)、PI-LL(16.7°)和SVA(8.6cm)均较术前明显改善(P<0.05),ODI(23.45%)和SRS-22(3.91分)评分显著性优于术前(P<0.05)。术后PI-LL与末次随访时的SVA和PT呈显著性正相关(r=0.525和0.659,P<0.01)。以末次随访时SVA为状态变量,通过ROC曲线分析获得术后PI-LL的阈值为12.8°;以末次随访时的PT为状态变量,计算得到术后PI-LL的阈值为10.5°。当术后PILL≤10.5°时,可同时满足预防脊柱和骨盆矢状面失衡的要求。与术后PI-LL>10.5°组比较,术后PI-LL≤10.5°组患者末次随访时PT (25.4°vs 36.6°)、LL (-40.8°vs-24.1°)、PI-LL (4.0°vs 26.2°)和SVA (5.6cm vs10.9cm)更小(P<0.05),脊柱(36.1%vs 75.5%)和骨盆(38.9%vs 85.7%)矢状面失衡率更低(P<0.05)。腰椎OVA与PI-LL矫正值呈较高强度线性正相关(r=0.707,P<0.01),腰椎OVA=17.12+0.62×(PI-LL矫正值),R2=50.1%。结论:AS后凸畸形患者截骨矫形术后的PI-LL与末次随访SVA和PT紧密相关,术后重建PI-LL≤10.5°可维持良好的脊柱骨盆矢状面平衡,降低中远期随访脊柱和骨盆矢状面失衡的风险。
Objectives: The current study aimed to investigate the effect of pelvic incidence and lumbar lordosis mismatch(PI-LL) on sagittal imbalance of ankylosing spondylitis(AS) following corrective osteotomy.Methods: 85 AS patients(75 men, 10 women) who underwent modified pedicle subtraction osteotomy(PSO) between January 2010 and October 2019 were enrolled in this study, with an average age of 37.1 ±8.8 years(20-67 years). 63 underwent one-level osteotomy, and 22 underwent two-level osteotomy. The preoperative,postoperative(3-4 weeks after surgery) and final follow-up radiographic parameters were measured, including pelvic incidence(PI), pelvic tilt(PT), sacral slope(SS), lumbar lordosis(LL), PI-LL, osteotomized vertebral angle(OVA), and sagittal vertical axis(SVA). The function of limbs and health-related quality of life before operation and at the final follow-up were evaluated using Scoliosis Research Society-22(SRS-22) patient questionnaire and Oswestry disability index(ODI). At the final follow-up, SVA>5cm was regarded as spinal imbalance,and PT>25° was considered pelvic imbalance. Correlations between postoperative PI-LL and final follow-up SVA and PT were analyzed using Pearson correlation coefficient. Threshold of PI-LL was figured out using receiver operating characteristic(ROC) curve and maximum Youden index to obtain the optimal postoperative PI-LL. Patients were divided into two groups by whether meeting the optimal postoperative PI-LL, and effects of different postoperative PI-LL on spino-pelvis sagittal alignment at the final follow-up were compared and evaluated. Subsequently, linear regression was used to evaluate the relationship between lumbar OVA and PILL correction to figure out the regression equation. Results: 85 AS patients were followed up for 30.8±6.3months(24-84 months). The final follow-up LL(-31.6°), PT(31.8°), SS(15.5°), PI-LL(16.7°) and SVA(8.6cm)were improved significantly(P<0.05);and the final follow-up ODI(23.45%) and SRS-22 score(3.91) were better than those before surgery(P<0.05). Postoperative PI-LL positively correlated with the final follow-up SVA and PT(r=0.525 and 0.659 respectively, P<0.01). Calculated with SVA using ROC and maximum Youden index,the optimal threshold of postoperative PI-LL was 12.8°;while, calculated with PT, it was 10.5°. Postoperative PI-LL of ≤10.5° met the needs for preventing both spinal and pelvic imbalance. Patients with postoperative PI-LL≤10.5° had better PT(25.4° vs 36.6°), LL(-40.8° vs-24.1°), PI-LL(4.0° vs 26.2°) and SVA(5.6cm vs10.9cm) than those with postoperative PI-LL>10.5°, and significantly deceased the rate of spinal(36.1% vs75.5%) and pelvic(38.9% vs 85.7%) imbalance at the final follow-up(P<0.05). Lumbar OVA highly correlated with PI-LL correction(r=0.707, P<0.001), and the equation was Lumbar OVA=17.12+0.62×(PI-LL correction),adjusted R^(2)=50.1%. Conclusions: Postoperative PI-LL strongly correlated with final follow-up SVA and PT in AS patients after kyphosis correction. Reconstructing postoperative PI-LL ≤10.5° could achieve better spinopelvis sagittal alignment for AS kyphosis, and decrease the risk of spinal and pelvic imbalance in mid-to long-term follow-up.
作者
罗建周
吴太林
杨子立
李宪
黄政基
罗振娟
段春光
陶惠人
LUO Jianzhou;WU Tailin;YANG Zili(Department of Spine Surgery,Shenzhen University General Hospital,Shenzhen,518000,China)
出处
《中国脊柱脊髓杂志》
CAS
CSCD
北大核心
2022年第7期577-585,共9页
Chinese Journal of Spine and Spinal Cord
基金
广东省基础与应用基础研究基金项目(2020A1515010726)
深圳市科技计划项目基础研究(自由探索)项目(JCYJ20180305124242438)
深圳市基础研究专项(自然科学基金)基础研究重点项目(JCYJ20200109114233670)
广东省重点领域研发计划项目(2020B0909020002)
深圳市医疗卫生三名工程项目(SZSM201911011)。
