多节段前外侧入路腰椎椎间融合联合后路内固定术治疗腰椎退行性侧凸伴矢状面失衡的疗效分析

Clinical evaluation of multi-level oblique lumbar interbody fusion combined with posterior internal fixation in the treatment of lumbar degenerative scoliosis with sagittal imbalance

中文关键词:  腰椎退行性侧凸  前外侧入路腰椎椎间融合  脊柱矢状面失平衡

英文关键词:Lumbar degenerative scoliosis  Oblique lumbar interbody fusion  Spinal sagittal imbalance

中文摘要:

  【摘要】 目的：探讨多节段前外侧入路腰椎椎间融合（oblique lumbar interbody fusion，OLIF）联合后路内固定治疗腰椎退行性侧凸伴脊柱矢状面失平衡的效果。方法：回顾性分析2017年9月～2020年4月于我院就诊并接受多节段OLIF联合后路内固定治疗的17例腰椎退行性侧凸伴脊柱矢状面失平衡患者，男3例，女14例；年龄55～81岁（67.8±6.3岁）；随访时间13～39个月（25.9±7.6个月）。在术前、术后与末次随访时的全脊柱X线片测量脊柱冠状面及矢状面相关参数，包括：腰椎侧凸Cobb角、C7铅垂线-骶骨中垂线距离（C7 plumb line-center sacral vertical line，C7PL-CSVL）、胸椎后凸角（thoracic kyphosis，TK）、胸腰段后凸角（thoracolumbar kyphosis，TLK）、腰椎前凸角（lumbar lordosis，LL）、腰椎前凸分布指数（lordosis distribution index，LDI）、脊柱矢状面垂直轴（sagittal vertical axis，SVA）、脊柱骶骨角（spino-sacral angle，SSA）、躯干整体倾斜角（global tilt，GT）、GAP评分（Global Alignment and Proportion score）、骨盆入射角（pelvic incidence，PI）、骨盆倾斜角（pelvic tilt, PT）、骶骨倾斜角（sacral slope，SS）。记录术前、术后与末次随访时的Oswestry功能障碍指数（Oswestry disability index，ODI）、日本骨科协会（Japanese Orthopaedic Association，JOA）评分、腰部和下肢疼痛视觉模拟（visual analogue scale，VAS）评分。对术前、术后和末次随访时的影像学和临床指标进行统计学分析。结果：17例患者均顺利完成手术，手术时间120～480min（327.4±85.4min），出血量50～1100ml（504.7±275.1ml），融合节段3～8个（3.8±1.2个）。1例患者术后左侧大腿外侧腹股沟区感觉减退，给予营养神经药物后20d症状缓解；1例患者术中发生椎体终板骨折，调整融合器置入路径避开骨折部位，同时一期附加后路椎弓根螺钉内固定，随访未发现融合器进一步沉降。术后和末次随访时的腰椎侧凸Cobb角、C7PL-CSVL、TK、TLK、LL、LDI、GT、GAP评分、PT、SS与术前比较均有显著性差异（P＜0.05），腰椎矢状面平衡相关参数均获得改善；术后与末次随访时比较均无显著性差异（P>0.05）。术后和末次随访时的ODI、JOA评分、腰部VAS和下肢VAS评分与术前比较均有显著性改善（P＜0.05），末次随访时进一步改善，与术后比较差异均有显著性（P＜0.05）。结论：多节段OLIF联合后路内固定术可以有效缓解腰椎退行性侧凸患者的症状，同时矫正脊柱三维畸形、重建矢状面和冠状面平衡，提高患者生活质量。

英文摘要:

  【Abstract】 Objectives: To retrospectively analyze the effect of multi-level oblique lumbar interbody fusion (OLIF) combined with posterior internal fixation in the treatment of lumbar degenerative scoliosis with sagittal and coronal imbalance. Methods: 17 patients with lumbar degenerative scoliosis who were treated with multi-level OLIF combined with posterior internal fixation in our hospital from September 2017 to April 2020 were retrospectively analyzed, including 3 males and 14 females with a mean age of 67.8±6.3 years(55-81 years) and mean follow-up time of 25.9±7.6 months(13-39 months). The coronal and sagittal parameters of spine were measured and analyzed at preoperation, postoperation, and the last follow-up, including scoliosis Cobb angle, C7 plumb line-center sacral vertical line(C7PL-CSVL), thoracic kyphosis(TK), thoracolumbar kyphosis (TLK), lumbar lordosis(LL), lordosis distribution index(LDI), sagittal vertical axis(SVA), spino-sacral angle (SSA), global tilt(GT), global alignment and proportion score(GAP score), pelvic incidence(PI), pelvic tilt(PT), and sacral slope(SS). The function scores of patients were recorded and analyzed at preoperation, postoperation, and the last follow-up, including Oswestry disability index(ODI), Japanese Orthopaedic Association(JOA) scores, and visual analogue scale(VAS) of the low back and the lower limbs. The imaging and clinical indicators of preoperative, postoperative and the last follow-up were analyzed statistically. Results: All the 17 patients underwent surgical intervention with a mean operation time of 327.4±85.4mins(120-480mins), mean intraoperative blood loss of 504.7±275.1ml(50-1100ml), and mean fusion levels of 3.8±1.2(3-8). The surgical complications occurred in 2 patients, with 1 case of numbness over the inguinal area on the left side relieved with mecobalamin 20 days after surgery; 1 case of vertebral endplate fracture coped with changing insertion pathway away from fracture area and immediate posterior pedicle screw fixation, with no subsidence of cage occurred at follow up. The Cobb angle, C7PL-CSVL, TK, TLK, LL, LDI, GT, GAP scores, PT and SS were significantly improved after surgery and at last follow-up(P<0.05), indicating the sagittal balance of lumbar spine was significantly improved after surgery. The postoperative functional scores of patients with lumbar degenerative scoliosis(ODI, JOA scores, and VAS of the low back and the lower limbs) were significantly improved after surgery and at the last follow-up(P<0.05). Conclusions: Multi-level OLIF combined with posterior internal fixation is a safe and effective treatment strategy, which can help patients with lumbar degenerative scoliosis relieve the symptoms and improve the quality of life, with the correction of three-dimensional deformity, stabilization of spine, and reconstruction of sagittal and coronal balance.