摘要
背景:老年人群腰椎管狭窄症是脊柱最常见的退变性疾病,其症状和术后疗效与局部序列和整体平衡均相关,而关于该人群脊柱-骨盆矢状位参数的合理范围尚未可知。目的:探究并验证腰椎管狭窄症患者手术前后腰椎-骨盆矢状位参数的匹配范围。方法:选择2016年6月至2019年12月北京大学人民医院收治的腰椎管狭窄症患者376例,根据倾向性匹配评分原则,按照(2-3)∶1的配比分为先导组(n=276)与验证组(n=100),在术前与术后末次随访时进行影像学检查,获取脊柱-骨盆矢状位参数,包括胸椎后凸角、腰椎前凸角、骨盆入射角、骨盆倾斜角和矢状位垂直距离,上述参数在术前和末次随访时获得,其中|骨盆入射角-腰椎前凸角|、骨盆倾斜角和矢状位垂直距离为主要参数。以Oswestry生活障碍指数为生活质量评价指标,将手术前后Oswestry生活障碍指数取值范围分为轻度、较轻度、较重度、重度4个区间,手术前后Oswestry生活障碍指数所对应的矢状位参数合理阈值通过线性回归分析和Logistic回归进行双重判定。验证组主要对先导组结论进行验证。结果与结论:(1)先导组患者术后末次随访Oswestry生活障碍指数明显改善,术前Oswestry生活障碍指数与|骨盆入射角-腰椎前凸角|呈正相关(P=0.011),术后末次随访Oswestry生活障碍指数与|骨盆入射角-腰椎前凸角|和骨盆倾斜角呈正相关(P=0.029,P=0.008),与矢状位垂直距离无明确相关性。(2)先导组患者术前Oswestry生活障碍指数轻度、较轻度、较重度、重度对应的分值为15-35分、36-39分、40-43分、44-50分,术后末次随访轻度、较轻度、较重度、重度对应的分值为0-4分、5-8分、9-12分、13-40分。多元回归分析显示,术前Oswestry生活障碍指数的独立影响因素为|骨盆入射角-腰椎前凸角|,存在拟合公式Oswestry生活障碍指数=0.19×|骨盆入射角-腰椎前凸角|+36.9。通过双重判定,术前|骨盆入射角-腰椎前凸角|平均阈值为10.7°。术后Oswestry生活障碍指数的独立影响因素为骨盆倾斜角,骨盆倾斜角的独立影响因素为|骨盆入射角-腰椎前凸角|,存在公式Oswestry生活障碍指数=0.21×骨盆倾斜角+3.16和骨盆倾斜角=0.60×|骨盆入射角-腰椎前凸角|+12.22。(3)通过线性回归和logistic回归分析双重判定得出,术后|骨盆入射角-腰椎前凸角|的平均阈值为16.0°、骨盆倾斜角为23.1°。(4)验证组中,术后|骨盆入射角-腰椎前凸角|小于阈值的患者平均Oswestry生活障碍指数优于|骨盆入射角-腰椎前凸角超过阈值者|(P=0.046)。(5)|骨盆入射角-腰椎前凸角|=16.0°或许是针对老年腰椎管狭窄症后路手术矢状位参数的合理范围,提示针对该人群可适当放宽腰椎-骨盆的匹配程度。
BACKGROUND:Lumbar spinal stenosis is the most common degenerative disease of the spine in the elderly,and its symptoms and postoperative efficacy are related to both local sequence and overall balance.However,the reasonable range of spinal-pelvic sagittal parameters in this population is unknown.OBJECTIVE:To determine and validate the acceptable interval of sagittal lumbo-pelvic parameters for lumbar spinal stenosis patients.METHODS:A total of 376 patients with lumbar spinal stenosis who were admitted to Peking University People’s Hospital from June 2016 to December 2019were selected.According to the scoring principle of propensity matching and the ratio of(2-3):1,they were divided into a derivation cohort group(n=276)and a validation cohort group(n=100).Imaging examinations were performed preoperatively and at the final postoperative follow-up to obtain sagittal spinopelvic parameters,containing thoracolumbar kyphosis,lumbar lordosis,pelvic incidence,pelvic tilt and sagittal vertical axis.|Pelvic incidence-lumbar lordosis|,pelvic tilt and sagittal vertical axis were seen as the main parameters.Quality-of-life was evaluated by the Oswestry disability index,which contained four quarters orderly:mild,sub-mild,sub-severe and severe dysfunction.The reasonable threshold of parameters corresponding to Oswestry disability index was determined by both linear regression and logistic regression.Cases in the validation cohort were used to verify the results concluded from derivation cohort.RESULTS AND CONCLUSION:(1)Oswestry disability index got improvement in the final follow-up.At baseline,Oswestry disability index was positively correlated to|pelvic incidence-lumbar lordosis|(P=0.011)while at final Oswestry disability index was positively correlated to|pelvic incidence-lumbar lordosis|and pelvic tilt(P=0.029,P=0.008)but not correlated to sagittal vertical axis in the derivation cohort.(2)Mild,sub-mild,sub-severe and severe dysfunctions of Oswestry disability index were 15-35,36-39,40-43,and 44-50 preoperatively,but 0-4,5-8,9-12,and 13-40 in the final follow-up,respectively in the derivation cohort.Multiple regression analysis showed that the independent factor affecting preoperative Oswestry disability index was|pelvic incidence-lumbar lordosis|,with Oswestry disability index=0.19×|pelvic incidence-lumbar lordosis|+36.9 and the mean threshold of preoperative|pelvic incidence-lumbar lordosis|was 10.7°.At final,pelvic tilt was the influencing factor of Oswestry disability index and|pelvic incidence-lumbar lordosis|was the influencing factor of pelvic tilt with Oswestry disability index=0.21×pelvic tilt+3.16 and pelvic tilt=0.60×|pelvic incidence-lumbar lordosis|+12.22.(3)The mean threshold of postoperative|pelvic incidence-lumbar lordosis|was 16.0°and pelvic tilt was 23.1°by both linear regression and logistic regression.(4)In validation cohort,Oswestry disability index in patients less than the threshold of|pelvic incidence-lumbar lordosis|was superior to cases with over-larged|pelvic incidence-lumbar lordosis|(P=0.046).(5)It is concluded that|pelvic incidence-lumbar lordosis|=16.0°was probably the reasonable sagittal range for lumbar spinal stenosis with posterior surgery and we should be tolerate to spino-pelvic matching for this population.
作者
肖士鹏
郭辰
李士春
李钦亮
许勇
徐帅
Xiao Shipeng;Guo Chen;Li Shichun;Li Qinliang;Xu Yong;Xu Shuai(Department of Orthopedics,Beijing Shijingshan Hospital,Beijing 100040,China;Department of Spinal Surgery,Peking University People’s Hospital,Beijing 100044,China)
出处
《中国组织工程研究》
CAS
北大核心
2023年第18期2903-2909,共7页
Chinese Journal of Tissue Engineering Research
基金
北京大学人民医院研究与发展基金(RDY2021-12),课题名称:基于立体视觉的脊柱无损评价系统对Lenke 1/2型特发性侧弯的诊疗评估,项目负责人:徐帅。
作者简介
第一作者:肖士鹏,男,1971年生,北京市人,汉族,医学硕士,副主任医师,主要从事脊柱畸形研究。https://orcid.org/0000-0003-1362-0025;通讯作者:徐帅,医学博士,主治医师,北京大学人民医院脊柱外科,北京市100044。
