强直性脊柱炎胸腰段后凸矫形手术近端固定椎的选择

The selection of upper instrumented vertebra in ankylosing spondylitis thoracolumbar kyphosis

中文关键词:  强直性脊柱炎  后凸畸形  经椎弓根截骨  脊椎去松质骨截骨  近端固定椎

英文关键词:Ankylosing spondylitis  Kyphosis  Pedicle subtraction osteotomy  Vertevertebral column decancellation  Upper instrumented vertebra

中文摘要:

  【摘要】 目的：探讨强直性脊柱炎（ankylosing spondylitis，AS）胸腰段后凸畸形截骨矫形手术时近端固定椎（up?鄄per instrumented vertebra，UIV）的选择。方法：回顾性分析2010年1月~2013年5月于解放军总医院骨科行单节段或双节段经椎弓根截骨或脊椎去松质骨截骨治疗AS胸腰段后凸畸形患者123例，其中男110例，女13例；年龄21~56岁（36.1±6.1岁），截骨椎（osteotomied vertebra，OV）均分布于T11~L4。根据UIV与近端OV的位置关系将患者分组：A组，UIV为近端OV头侧第3个椎体（n=64）；B组，UIV为近端OV头侧第4个或更多椎体（n=59）。分别对两组患者的基本情况、手术前后脊柱矢状面参数[全脊柱后凸角（global kyphosis，GK），胸后凸角（thoracic kyphosis，TK），胸腰段后凸角（thoracolumbar kyphosis，TLK），腰前凸角（lumbar lordosis，LL）及矢状面偏移（sagittal vertical axis，SVA）]、Oswestry功能障碍指数（Oswestry disability index，ODI）及并发症发生率进行比较。根据UIV是否跨过后凸顶椎（apical vertebra，AV），将患者分为AV组（n=34）和Non-AV组（n=89），同样比较两组患者的上述参数。结果：随访24~60个月（29.3±3.2个月），随访期内所有病例均未发生内固定失败。A组患者年龄、性别构成与B组比较均无显著性差异（P>0.05），A组平均固定节段明显少于B组（7.2±1.0 vs. 8.2±1.5，P<0.05）；两组矢状面参数及ODI在术前、末次随访时以及末次随访时的改善率均无显著性差异（P>0.05）。A组患者末次随访时胸背部疼痛或异物感的发生率（10/64）明显低于B组患者（25/59）（P<0.05）。A组交界性后凸（proximal junctional kyphosis，PJK）发生率与B组比较无显著性差异（1/64 vs. 2/59，P>0.05）。AV组和Non-AV组比较，AV组平均固定节段明显多于Non-AV组（P<0.05），两组矢状面参数及ODI在术前、末次随访时及末次随访时的改善率比较均无显著性差异（P>0.05），末次随访时AV组的胸背部疼痛或异物感发生率明显高于Non-AV组（P<0.05），两组PJK发生率无显著性差异（1/34 vs. 2/89，P>0.05）。结论：AS胸腰段后凸畸形行截骨矫形时，UIV选择近端OV头侧端第3个椎体矫形与固定融合的效果满意，且患者出现胸背部疼痛或异物感的发生率更低；UIV跨过后凸顶椎时，易出现胸背部疼痛或异物突出感的情况。

英文摘要:

  【Abstract】 Objectives: To determine the optimal selection of upper instrumented vertebra(UIV) in ankylosing spondylitis(AS) thoracolumbar kyphosis. Methods: From January 2010 to May 2013, in Chinese People′s Liberation Army General Hospital, 123 AS thoracolumbar kyphosis cases(110 males, 13 females) treated with pedicle subtraction osteotomy(PSO) or vertevertebral column decancellation(VCD) were retrospectively reviewed. Osteotomied vertebra(OV) of all cases distributed from T11 to L4. According to the relationship between UIV and proximal OV, all cases were divided into Group A, UIV was the third vertebra cranial to the proximal OV(n=64), and Group B, UIV was the forth vertebra or more cranial to the proximal OV(n=59). The two groups were compared between preoperative and the last follow-up with respect to sagittal radiographic parameters[global kyphosis(GK), thoracic kyphosis(TK), thoracolumbar kyphosis(TLK), lumbar lordosis(LL), sagittal vertical axis(SVA)], Oswestry disability index(ODI) and complication occurrence rate. All patients were divided into groups based on the relative position of UIV and apical vertebra(AV): Group AV(the UIV was AV or above, n=34) and Group Non-AV(n=89), the above-mentioned parameters and data were compared again. Results: During the 29.3±3.2(24-60) months of follow-up, no fixation failure occurred. Group A and Group B had no significant differences with respect to age and gender(P>0.05). The mean instrumented segments of Group A were less than those in Group B(P<0.05). Two groups had similar deformity correction rate(P>0.05), ODI improvement(P>0.05) and proximal junctional kyphosis(PJK) occurrence(1/64 vs. 2/59, P>0.05) at the last follow-up. The incidence of complaining about back pain orprotrudent sensation in Group A was lower than that in Group B(P<0.05). The incidence of complaining about back pain or protrudent sensation in Group AV was higher than that in Group Non-AV(P<0.05). Two groups had similar deformity correction rate(P>0.05) and ODI improvement(P>0.05) at the last follow-up. There was no significant difference between two groups in PJK incidence(1/34 vs. 2/89, P>0.05). Conclusions: When PSO or VCD is considered to treat the AS thoracolumbar kyphosis, the 3rd vertebra cranially to the proximal OV is enough for the correction and fixation due to its low incidence of complaining about the protrudent sensation. When UIV is above AV, patient is apt to develop back pain or protrudent sensation.