摘要
目的探讨Lenke5型青少年特发性脊柱侧凸 （ adolescent idiopathic scoliosis, AIS）选择性腰椎融合手术人路对术后脊柱矢状面重建的影响。方法2005年1月至2010年12月接受前路或后路选择性胸腰椎融合术且有2年以上完整随访资料的Lenke5型AIS患者102例，前路手术组56例、后路手术组46例。对两组患者术前、术后3个月、术后1年及末次随访时胸腰弯Cobb角、腰弯Cobb角、胸椎后凸角（ thoracic kyphosis, TK）、腰椎前凸角（lumbar lordosis, LL）、骶骨倾斜角（sacral slope，SS）、矢状面整体平衡（sagittal vertical axis, SVA ）、胸腰段交界性后凸角（thoracolumbar junctional kyphosis,TJK）、内固定节段角（instrumented segments angle, ISA ）、内固定近端交界角（proximal junctional angle, PJA ）等影像学参数及SRS-22评分进行比较。结果两组平均随访（6．1±2．1）年和（5．3±1．5）年。术前影像学参数的差异均无统计学意义。前路组平均融合节段小于后路组[（5．3±0．5）个、（5．9±0．8）个]；前路组和后路组远端保留节段[（1．8±0．7）个、（1．7±0．7）个]的差异无统计学意义。两组术后腰弯平均矫正率分别为73．2％±6．9％和74．8％±10．8％，末次随访时矫正丢失率分别为3．8％±8．7％与2．0％±0．2％；胸弯均获得良好的自发性矫正，术后及末次随访时两组腰弯、胸弯的差异无统计学意义。术后3个月，两组TK均较术前增大，末次随访时均较术后3个月增大。术后3个月，前路组LL较术前减小，末次随访时较术后3个月无明显变化；后路组LL较术前无明显变化，末次随访时较术后3个月增大。术后3个月，前路组SS较术前减小，末次随访时较术后3个月增大；后路组SS较术前增大，末次随访时较术后3个月增大。术后3个月，两组SVA、TJK均较术前减小，末次随访时均较术后3个月增大。术后3个月，前路组ISA较术前无明显变化，末次随访时前凸较术后3个月减小；后路组ISA前凸较术前增大，末次随访时较术后3个月无明显变化；两组术后3个月PJA均较术前增大，末次随访时后路组PJA较术后3个月增大。术后3个月，两组LL的差异有统计学意义，末次随访时两组LL、ISA及PJA的差异有统计学意义。前路组发生断棒1例、假关节3例、叠加现象3例、近端交界性后凸1例；后路组发生叠加现象1例、近端交界性后凸5例。两组患者均未行翻修手术，末次随访时SRS-22评分的差异无统计学意义。结论Lenke5型AIS前路或后路选择性胸腰椎融合术均可获得满意的冠状面畸形矫正。后路手术能够重建更大的矢状面腰椎前凸，内固定节段前凸成角维持更好，但近端交界性后凸的发生率更高。
Objective To compare the effects of anterior or posterior selective thoracolumbar/lumbar fusion （ASF or PSF） on the reconstruction of sagittal profile in Lenke type 5 adolescent idiopathic scoliosis （AIS）. Methods A total of 102 Lenke type 5 AIS patients who underwent ASF or PSF from January 2005 to December 2010 with a minimum of 2 years follow-up were retro- spectively evaluated. Fifty-six patients underwent ASF, while 46 patients underwent PSF. Pre- and postoperative radiologieal pa- rameters were measured as follows： curve magnitude of thoraeolumbar/lumbar （TL/L） and thoracic curve, thoracic kyphosis （TK）, lumbar lordosis （LL）, sacral slope （SS）, sagittal vertical axis （SVA）, thoraeolumbar junctional kyphosis （TJK）, instrumented seg- ments angle （ISA）, and proximal junctional angle （PJA）. Results The mean follow-up duration was 6.1 ±2.1 years and 5.3± 1.5 years in ASF and PSF group respectively. Preoperative radiographic parameters and demographic data showed no significant differ- ence between two groups. The fusion levels in ASF group were shorter than that in PSF group （5.3±0.5 vs. 5.9±0.8, P〈0.05）, where-as the distal preserved motion segments were similar between two groups （1.8±0.7 vs. 1.7±0.7, P〉0.05）. The correction rate of the TL/L curve was 73.2%±6.9% in ASF group and 74.8%±10.8% in PSF group at 3 month after surgery, with a 3.8%＋8.7% and 2.0%±0.2% of correction loss at final follow-up. Thoracic curve was corrected spontaneously in both groups, and the correction rate of TL/L and thoracic curve was similar between two groups at final follow-up. In both groups, TK increased after surgery and increased at final follow-up compared to that after surgery （P〈0.05）. LL decreased in ASF group after surgery （P〈0.05） and re- mained unchanged at final follow-up. In PSF group, LL remained unchanged after surgery and increased at final follow-up com- pared to that after surgery （P〈0.05）. SS decreased after surgery in ASF group and increased at final follow-up compared to that af- ter surgery （P〈0.05）. In PSF group, SS increased after surgery and increased at final follow-up compared to that after surgery （P〈 0.05）. SVA and TJK decreased in both groups after surgery and increased at final follow up compared to that after surgery （P〈 0.05）. ISA remained unchanged after surgery and decreased at final follow-up compared to that after surgery in ASF group （P〈 0.05）. In PSF group, ISA increased after surgery （P〈0.05） and remained unchanged at final follow-up. PJA increased after surgery in both groups, and increased at final follow-up compared to that after surgery in PSF group （P〈0.05）. At 3 month after surgery, LL was larger in PSF group. At final follow-up, LL, ISA and PJA was significantly larger in PSF group （P〈0.05）. In ASF group, three patients had pseudarthrosis, one had rod breakage, three had adding-on phenomenon, and one had proximal junctional kyphosis （PJK）. In PSF group, five patients had PJK and one had adding-on phenomenon. SRS-22 scores showed no significant difference between two groups. Conclusion When Lenke type 5 AIS patients were treated with selective TL/L fusion, coronal correction could be obtained by both ASF and PSF. In sagittal plane, PSF can offer larger restoration of LL and better maintenance of lordosis in the in- strumented segment than those in ASK Additionally, the incidence of PJK in PSF group was higher than that in ASF group.
作者
李劼
刘臻
朱泽章
王斌
俞杨
钱邦平
孙旭
邱勇
Li Jie;Liu Zhen;Zhu Zezhang;Wang Bin;Yu Yang;Qian Bangping;Sun Xu;Qiu Yong(Department of Spine Surgery, Drum Tower Hospital, Medical School of Nanjing University, Nangfing 210008, China)
出处
《中华骨科杂志》
CAS
CSCD
北大核心
2018年第11期666-674,共9页
Chinese Journal of Orthopaedics
基金
江苏省临床医学中心（YXZXA2016009）
江苏省卫计委青年科研课题（Q201510）
关键词
青少年
脊柱侧凸
脊柱融合术
疗效比较研究
Adolescent
Scoliosis
Spinal fusion
Comparative effectiveness research
作者简介
通信作者：邱勇，E-mail：scoliosis2002@sina．com.
