术前脊柱后方肌群肌力对长节段固定融合纠正退行性脊柱侧凸矢状位失衡的影响

Relationship between the endurance of preoperative spinal extensor muscles and clinical outcomes after correction of sagittal imbalance with long segment fusion in adult degenerative scoliosis

中文关键词:  退行性脊柱侧凸  肌肉力量  矢状位平衡  脊柱手术

英文关键词:Degenerative scoliosis  Muscle endurance  Sagittal balance  Spine surgery

中文摘要:

  【摘要】 目的：评估退行性脊柱侧凸畸形患者术前脊柱后方肌群肌力对长节段固定融合纠正矢状位失衡效果的影响。方法：回顾性研究2014年1月~2015年10月于我院接受长节段固定融合手术的退行性脊柱侧凸畸形患者32例。于术前对所有患者进行腰背肌力量测试，将可完成“小燕飞”动作的12例患者分为A组，年龄55~73岁（65.2±4.7岁）；将无法完成“小燕飞”动作的20例患者分为B组，年龄55~75岁（64.8±4.9岁）。随访1.3~2年（1.5±0.5年）。比较两组术前、术后即刻及末次随访时矢状位影像学参数[腰椎前凸角（lumbar lordosis，LL）、胸椎后凸角（thoracic kyphosis，TK）、胸腰段后凸角（thoracic lumbar kyphosis，TLK）、骨盆倾斜角（pelvic tilt，PT）、骶骨倾斜角（sacral slope，SS）、矢状位垂直偏距（sagittal vertical axis，SVA）、近端交界区后凸角（proximal junctional angle，PJA）等]以及临床功能评分[Oswestry功能障碍指数（ODI）、JOA评分和腰背痛VAS评分]。结果：两组患者的年龄、手术时长、术中出血量及平均住院日均无统计学差异，具有可比性。术前A组的LL、TLK、TK、SVA、PT、PI、SS、ODI、腰背痛VAS评分、JOA评分为29.6°±3.2°、33.5°±4.6°、54.6°±5.1°、9.9±2.1cm、28°±2.4°、54.8°±4.1°、26°±3.7°、（75.4±3.5）%、7.3±0.9分、8.7±0.5分；B组为29.7°±3.6°、35.3°±3.8°、55.2°±3.7°、9.4±1.6cm、28°±1.6°、52.2°±1.7°、23.4°±2.9°、（76.4±2.2）%、7.2±0.7分、8.5±0.5分。术后即刻A组的LL、TLK、TK、SVA、PJA、PT、SS、ODI、腰背痛VAS评分、JOA评分为41.5°±4.1°、8.8°±3.6°、25.8°±2.1°、3.6±1.0cm、3.6°±1.1°、14.8°±1.2°、40.8°±2.5°、（21.9±2.3）%、2.4±0.7分、23.2±1.4分；B组为40.6°±2.2°、10.1°±3.2°、27.3°±1.9°、3.5±1.0cm、3.8°±1.1°、16.9°±2.3°、35.3°±2.7°、（20.3±2.2）%、2.9±0.6分、23.0±1.3分；末次随访时A组为43.6°±4.3°、10.8°±3.6°、28.7°±1.8°、4.8±1.0cm、4.4°±1.5°、15.8°±1.2°、41.8°±2.7°、（14.5±5.1）%、2.0±1.6分、24.7±0.7分；B组为43.2°±2.0°、18.6°±3.2°、38.4°±3.2°、8.7±1.6cm、8.3°±2.6°、23.6°±2.6°、9.1°±3.3°、（28.7±3.2）%、4.6±1.7分、24.0±1.0分。两组术前和术后即刻的矢状位参数以及功能评分无统计学差异（P>0.05）；末次随访时两组LL无显著性差异（P>0.05），TK、TLK、PT、SS、SVA、PJA均有统计学差异（P<0.05），B组3例出现近端交界性后凸（proximal junctional kyphosis，PJK）。末次随访时两组ODI、腿痛VAS评分有统计学差异（P<0.05），A组优于B组；JOA评分无统计学差异（P>0.05）。结论：术前脊柱后方肌群肌力对退行性脊柱侧凸畸形长节段固定术后矢状位纠正起到重要作用，术前良好的腰背肌力量可减少长节段固定术后矢状位纠正的丢失，从而降低交界性后凸等并发症的发生率。

英文摘要:

  【Abstract】 Objectives: To investigate the influence of endurance of spinal extensor muscles on clinical outcomes after long segment fusion in adult degenerative scoliosis(ADS). Methods: Thirty-two patients with ADS who underwent long segment fusion surgery from January 2014 to October 2015 were reviewed. After spinal extensor muscle evaluation(swallow fly), patients were divided into two groups: 12 patients(55-73 years old, mean age of 65.2±4.7 years old) could complete the test(group A), and the other 20 patients(55-75 years old, mean age of 64.8±4.9 years old) failed(group B). The mean follow-up time was 1.5±0.5 years(1.3-2 years). The preoperative and postoperative radiographic parameters and clinical outcomes were recorded, including sagittal vertical axis(SVA), lumbar lordosis(LL), thoracic kyphosis(TK), thoracic lumbar kyphosis(TLK), pelvic tilt(PT), pelvic incidence(PI), sacral slope(SS), proximal junctional angle(PJA), and visual analogue scale(VAS), Japanese Orthopaedic Association(JOA), Oswestry disability index(ODI). Results: There was no significant difference in age, time of surgery, blood loss, or the average hospitalization(P>0.05) between the two groups. The preoperative LL, TLK, TK, SVA, PT, PI, SS, ODI VAS, JOA, in group A were 29.6°±3.2°, 33.5°±4.6°, 54.6°±5.1°, 9.9°±2.1cm, 28°±2.4°, 54.8°±4.1°, 26°±3.7°, (75.4±3.5)%, 7.3±0.9, 8.7±0.5; those were 29.7°±3.6°, 35.3°±3.8°, 55.2°±3.7, 9.4±1.6cm, 28°±1.6°, 52.2°±1.7°, 23.4°±2.9°, (76.4±2.2)%, 7.2±0.7, 8.5±0.5 in group B. And the immediately postoperative LL, TLK, TK,SVA, PJA, PT, SS, ODI, VAS, JOA in group A were 41.5°±4.1°, 8.8°±3.6°, 25.8°±2.1°, 3.6°±1.0°, 3.6°±1.1°, 14.8°±1.2°, 40.8°±2.5°, (21.9 ±2.3)%, 2.4±0.7, 23.2±1.4; and those were 40.6°±2.2°, 10.1°±3.2°, 27.3°±1.9°, 3.5±1.0cm, 3.8°±1.1°, 16.9°±2.3°, 35.3°±2.7°, (20.3±2.2)%, 2.9±0.6, 23.0±1.3 in group B. At the final follow-up, parameters and scores in group A were 43.6°±4.3°, 10.8°±3.6°, 28.7°±1.8°, 4.8±1.0cm, 4.4°±1.5°, 15.8°±1.2°, 41.8°±2.7°, (14.5±5.1)%, 2.0±1.6, 24.7±0.7, and 43.2°±2.0°, 18.6°±3.2°, 38.4°±3.2°, 8.7±1.6cm, 8.3°±2.6°, 23.6°±2.6°, 9.1°±3.3°, (28.7±3.2)%, 4.6±1.7, 24.0±1.0 in group B. There were no significant differences in the radiographic parameters and clinical outcomes(P>0.05) between the two groups before operation and immediately after operation. At the last follow-up, there was no significant difference in LL, but there were significant differences in TK, TLK, PT, SS, SVA, PJA between the two groups. Meanwhile, proximal junctional kyphosis occured in 3 patients. There were significant differences in DOI and VAS scores between the two groups at final follow-up, scores in group A were better than those in group B(P＜0.05). Conclusions: Endurance of spinal extensor muscles is important to protect the sagittal balance after long segment fusion surgery in adult degenerative scoliosis. Good preoperative endurance of spinal extensor muscles may decrease the rate of proximal junctional kyphosis.