低位三柱截骨术对成人脊柱畸形冠矢状面平衡重建的疗效分析

The effect of lower level three-column osteotomies(L-3COs) on the reconstruction of coronal and sagittal balance in adult spinal deformity

中文关键词:  三柱截骨  成人脊柱畸形  脊柱侧后凸  冠状面失衡  矢状面失衡

英文关键词:Lower level three-column osteotomies  Adult spinal deformity  Kyphoscoliosis  Coronal imbalance  Sagittal imbalance

中文摘要:

  【摘要】 目的：分析低位三柱截骨术（lower level three-column osteotomies，L-3COs）重建成人脊柱畸形（adult spinal deformity，ASD）冠状面及矢状面平衡的效果。方法：回顾性分析2012年1月～2022年5月在我院接受L-3COs（L4、L5水平）治疗的ASD患者的资料。共纳入34例患者，其中男7例，女27例，年龄51.4±16.2岁（18~72岁）。冠状面鼓楼分型A型10例、B型13例、C型11例；先天性脊柱畸形9例，特发性3例，退变性20例，神经肌源性2例；翻修ASD患者7例。所有患者采用L-3COs+骨盆固定，且随访时间≥2年。在术前、术后即刻及末次随访时测量影像学参数来评价矫形效果，包括Cobb角、冠状面平衡距离（coronal balance distance，CBD）、L4倾斜角（L4 tilt angle）、骶骨倾斜角（sacral slope，SS）、骨盆倾斜角（pelvic tilt，PT）、骨盆入射角（pelvic incidence，PI）、腰椎前凸角（lumbar lordosis，LL）、L4~S1前凸角（L4~S1 lordosis）、胸椎后凸角 （thoracic kyphosis，TK）、矢状面垂直轴 （sagittal vertical axis，SVA）。记录手术时间、术中出血量、截骨水平及并发症的发生情况。应用脊柱侧凸研究学会-22（Scoliosis Research Society-22，SRS-22）患者问卷评价临床疗效。结果：手术时间5.7±0.9h（4.6~7.0h），术中出血量1870±550mL（1320~3840mL）。截骨水平为L4 25例，L5 9例。除PI外，所有冠状面及矢状面参数较术前均显著性改善（P<0.05），术前CBD为24.52±19.60mm，术后即刻显著矫正至11.94±10.74mm（P=0.032）；术前SVA为98.25±48.40mm，术后即刻矫正至31.26±36.06mm（P<0.001）；术前LL为8.59°±11.76°，术后即刻矫正至36.82°±10.73°（P<0.001）。术后共8例发生力学相关并发症，无并发症导致翻修，其中近端交界性后凸（proximal junctional kyphosis，PJK）2例，断棒断钉5例，螺钉松动拔出1例，术后冠状面失衡1例（1例患者同时发生PJK与冠状面失衡）。末次随访时SRS-22问卷各维度评分（活动功能、疼痛、自我形象、心理健康、总评分）均较术前显著提高（P<0.001）。结论：L-3COs对ASD患者冠矢状面重建效果显著，可以有效缓解患者疼痛，改善远期生活质量，且术后力学并发症发生率相对较低，是一种有效的矫形技术。

英文摘要:

  【Abstract】 Objectives: To investigate the effect of lower-level three-column osteotomies(L-3COs) on the restoration of coronal and sagittal balance in adult spinal deformity(ASD). Methods: The clinical data of ASD patients treated with L-3COs (L4, L5 level) in our hospital between January 2012 and May 2022 were retrospectively analyzed. A total of 34 patients were included in this study, including 7 males and 27 females, aged 51.4±16.2 years (range 18-72 years). According to the Qiu classification, 10 cases were classifies as type A, 13 cases as type B, and 11 cases as type C； 9 cases were of congenital spinal deformity, 3 cases were of idiopathic scoliosis, 20 cases were of degenerative scoliosis, and 2 cases were of neurogenic scoliosis; 7 patients underwent subsequent revision. All the patients underwent L-3COs+pelvic fixation and were followed up for ≥2 years. Imaging parameters assessing coronal and sagittal spine and trunk balance were measured at preoperation, immediate postoperatively, and at the final follow-up to evaluate the corrective outcomes. Coronal parameters included the Cobb angle, coronal balance distance(CBD), and L4 tilt angle. Sagittal parameters included sacral slope(SS), pelvic tilt(PT), pelvic incidence(PI), lumbar lordosis(LL), L4-S1 lordosis, thoracic kyphosis(TK), and sagittal vertical axis(SVA). The operative time, intraoperative blood loss, osteotomy level, and complications were documented, and clinical outcomes were appraised using the Scoliosis Research Society-22(SRS-22) questionnaire. Results: The operative time was 5.7±0.9h(4.6-7.0h), and the intraoperative blood loss was 1870±550mL(1320-3840mL). The osteotomy level was L4 in 25 cases and L5 in 9 cases. Except for PI, all the coronal and sagittal parameters significantly improved postoperatively compared to preoperative values(P<0.05). The CBD of the patients was 24.52±19.60mm preoperatively and was corrected to 11.94±10.74mm immediately postoperatively(P=0.032). The SVA was 98.25±48.40mm preoperatively and reconstructed to 31.26±36.06mm immediately postoperatively(P<0.001). The LL was 8.59°±11.76° preoperatively and was significantly corrected to 36.82°±10.73° immediately postoperatively(P<0.001). 8 patients suffered with postoperative mechanical complication, no revision for complications, and there were 2 cases of proximal junctional kyphosis(PJK), 5 instances of rod or screw breakage, 1 case of screw loosening or pullout, and 1 case of coronal imbalance(1 case presented with both PJK and coronal imbalance). The scores of all dimensions of SRS-22 questionaire(function, pain, self-image, mental health, total score) at final follow-up were significantly higher than those preoperatively(P<0.001). Conclusions: L-3COs demonstrate significant correction effects for ASD patients with severe coronal and sagittal imbalance and loss of LL, which successfully alleviates pain and enhances long-term quality of life, with a relatively low incidence of postoperative mechanical complications, making it an effective orthopaedic technique.