摘要
目的探讨前路或后路选择性融合手术对Lenke 5C型青少年特发性脊柱侧凸(adolescent idiopathic scoliosis,AIS)患者术后冠状面形态转归的影响,以及前路手术中上端椎(upper end vertebra,UEV)-1策略对术后冠状面平衡的影响。方法2005年1月至2020年12月于南京鼓楼医院接受前路或后路选择性融合手术治疗且随访时间超过2年的Lenke 5C型AIS患者108例,前路组51例、后路组57例。依据术前冠状面形态分为三型[A型,C_(7)中垂线(C_(7) plumb line,C_(7)PL)至骶骨中垂线(center sacral vertical line,CSVL)的垂直距离(C_(7)PL-CSVL)<20 mm;B型,C_(7)PL-CSVL≥20 mm且C_(7)PL偏向主弯凹侧;C型,C_(7)PL-CSVL≥20 mm且C_(7)PL偏向主弯凸侧],比较前路组和后路组术前不同冠状面形态下冠状面平衡的转归。比较前路或后路选择性融合手术中采用UEV或UEV-1策略患者术后冠状面平衡的转归。记录两组术前、术后1周和末次随访时胸弯及胸腰弯或腰弯Cobb角、胸弯及胸腰弯或腰弯柔韧性、冠状面平衡、胸弯及胸腰弯或腰弯顶椎偏移、双肩倾斜角、冠状面失衡率及脊柱侧凸研究学会-22简明量表调查问卷(Scoliosis Research Society questionnaires-22,SRS-22)评分。结果前路组融合节段(5.2±0.7)个,少于后路的(5.6±0.9)个,差异有统计学意义(t=2.497,P=0.014)。前路组中术前冠状面形态A型27例,术后1周23例维持A型,其中2例末次随访时转为C型;4例术后1周转为C型,末次随访时恢复为A型。术前C型23例,术后1周4例维持C型,其中1例末次随访时维持C型;19例术后1周转为A型,末次随访时均维持A型。后路组中术前冠状面形态A型26例,术后1周22例维持A型,其中2例末次随访时转为C型;4例术后1周转为C型,末次随访时恢复A型。术前C型29例,术后1周13例维持C型,其中7例末次随访时维持C型;16例术后1周转为A型,其中2例末次随访时转为C型。术前C型患者前路组术后1周及末次随访时冠状面失衡率分别为17%和4%,均小于后路组的45%和31%,差异有统计学意义(P<0.05)。后路手术中UEV-1组末次随访时冠状面失衡率小于UEV组(3%和38%,P<0.05),前路手术中二者差异无统计学意义(P>0.05)。除末次随访时前路组胸弯Cobb角为19.5°±7.3°,大于后路组的16.4°±5.6°,差异有统计学意义(t=2.427,P=0.017),其余影像学参数及SRS-22评分的组间差异均无统计学意义(P>0.05)。多因素logistic回归分析显示后路手术(OR=21.138,P=0.030)及Risser征(OR=0.406,P=0.048)是术前C型患者术后冠状面失衡的独立危险因素。结论对术前冠状面形态A型患者采用前路或后路手术均可获得满意的冠状面平衡重建;而对术前C型患者前路手术可以获得更好的冠状面平衡重建。前路手术中采用UEV或UEV-1策略重建冠状面平衡的疗效相似,均无法降低术后的冠状面失衡率;而后路手术中采用UEV-1策略可有效降低术后冠状面失衡率。
ObjectiveTo investigate the effect of anterior and posterior selective fusion strategy on evolution of coronal pattern in patients with Lenke 5C adolescent idiopathic scoliosis(AIS)and whether upper end vertebra(UEV)-1 strategy in anterior surgery would have an effect on postoperative coronal balance.MethodsA total of 108 Lenke 5C AIS patients with at least 2 years follow-up who underwent anterior or posterior selective thoracolumbar fusion surgery from January 2005 to December 2020 were enrolled,with 51 patients in the anterior group and 57 patients in the posterior group.The patients were categorized into three groups(type A,C 7PL-CSVL<20 mm;type B,C 7PL-CSVL≥20 mm with C 7PL toward the concave side of the main curve;and type C,C 7PL-CSVL≥20 mm with C 7PL toward the convex side of the main curve)to investigate the evolution of coronal balance of each preoperative coronal pattern at the anterior and posterior groups.Parameters such as thoracolumbar Cobb angle,rate of coronal imbalance,and SRS-22 score were recorded at preoperative,1 week postoperatively,and final follow-up in both groups.ResultsThe differences of basic date between the two groups were not statistically significant except for the fusion level(5.2±0.7 vs.5.6±0.9,t=2.497,P=0.014).In the anterior group,a total of 27 patients with preoperative type A,23 patients with preoperative type A maintained type A at the 1 week postoperatively,and 2 of them were converted to type C at the final follow-up.Four patients with preoperative type A converted to type C at the 1 week postoperatively,and all of them returned to type A at the final follow-up.A total of 23 patients with preoperative type C,four patients with preoperative type C maintained type C at the 1 week postoperatively,and one of them maintained type C at the final follow-up.Nineteen patients with preoperative type C converted to type A at the 1 week postoperatively,and all of them maintained type A at the final follow-up.In the posterior group,a total of 26 patients with preoperative type A,22 patients with preoperative type A maintained type A at the 1 week postoperatively,and only 2 of these patients converted to type C at the final follow-up.Four of the preoperative type A patients converted to type C at the 1 week postoperatively,and all of them returned to type A at the final follow-up.A total of 29 patients with preoperative type C,thirteen patients with preoperative type C maintained type C at the 1 week postoperatively,and 7 of them maintained type C at the last follow-up.Sixteen patients with preoperative type C converted to type A at the 1 week postoperatively,of whom two converted to type C at the final follow-up.For patients with preoperative type C the rate of coronal imbalance was significantly lower in the anterior group than in the posterior group both in the immediate postoperative period(17%vs.45%,P<0.05)and at the final follow-up(4%vs.31%,P=0.038).The rate of coronal imbalance at final follow-up was significantly lower in the UEV-1 group than in the UEV group in the posterior approach(3%vs.38%,P<0.05),and there was no difference between the two groups in the anterior approach.There were no significant differences in radiographic parameters and SRS-22 scores between the two groups,except for the thoracic Cobb angle at the final follow-up,which was greater in the anterior group than in the posterior group at the final follow-up(19.5±7.3 vs.16.4±5.6,t=2.427,P=0.017).Multivariate logistic regression analysis revealed that anterior surgery and Risser were risk factors for postoperative CIB of preoperative type C(OR=21.138,P=0.030 and OR=0.406,P=0.048 respectively).ConclusionFor patients with preoperative type A,both anterior and posterior procedures lead to a satisfactory reconstruction of coronal balance.In patients with preoperative type C,anterior surgery acquire a better reconstruction of coronal balance.The strategy of proximal UEV-1 was similar to the strategy of UEV in terms of restoring coronary balance in anterior approach and it was unable to lower the rate of postoperative coronal imbalance.In contrast,UEV-1 strategy in posterior surgery was effective in reducing the rate of postoperative coronal imbalance.
作者
王玉
方寅羽
李劼
阿布都哈卡尔·克拉木
胡宗杉
王斌
刘臻
朱泽章
邱勇
Wang Yu;Fang Yinyu;Li Jie;Abdukahar·Kiram;Hu Zongshan;Wang Bin;Liu Zhen;Zhu Zezhang;Qiu Yong(Division of Spine Surgery,Department of Orthopaedic Surgery,Nanjing Drum Tower Hospital,the Afffliated Hospital of Medical School,Nanjing University,Nanjing 210008,China)
出处
《中华骨科杂志》
北大核心
2025年第9期561-570,共10页
Chinese Journal of Orthopaedics
基金
江苏省医学创新中心项目(CXZX202214)。
