胸椎三皮质椎弓根螺钉斜向固定技术在成人退变性脊柱侧后凸畸形中应用的临床疗效观察

Clinical outcomes of tri-cortical pedicle screw oblique fixation technique in correction surgery of degenerative kyphoscoliosis in adult patients

中文关键词:  脊柱侧后凸  三皮质螺钉  近端交界性后凸  退变性脊柱畸形

英文关键词:Kyphoscoliosis  Tri-cortical pedicle screw  Proximal junctional kyphosis  Degenerative spinal deformity

中文摘要:

  【摘要】 目的：探究三皮质螺钉（tri-cortical pedicle screw，TPS）斜向固定技术在治疗退变性脊柱侧后凸畸形中应用的临床疗效。方法：回顾性分析2020年1月~2022年11月于南京鼓楼医院接受矫形手术治疗的93例退变性脊柱侧后凸畸形患者，其中42例术中在O-arm导航系统指引下于上端固定椎行双侧置入三皮质螺钉斜向固定，纳入TPS组；51例行传统椎弓根螺钉固定技术，纳入椎弓根螺钉组，两组患者的年龄、术前影像学等各项基线资料无统计学差异（P>0.05)。TPS组随访时间33.2±4.2个月，椎弓根螺钉组随访时间32.1±9.0个月，两组间无统计学差异（P=0.458）。在术前、术后即刻以及末次随访时的X线片上测量Cobb角、局部后凸角（regional kyphosis，RK）、矢状面平衡（sagittal vertical axis，SVA）以及冠状面平衡距离（corneal balance distance，CBD）；术前及末次随访时采用脊柱侧凸研究学会（Scoliosis Research Society，SRS-22）问卷和Oswestry功能障碍指数（Oswestry disability index，ODI）评估生活质量，并记录随访期间并发症发生情况。结果：93例患者均顺利完成手术。TPS组术前Cobb角为39.9°±20.8°，术后即刻为19.8°±10.8°；RK角术前47.8°±19.6°，术后即刻23.6°±10.5°；椎弓根螺钉组术前Cobb角为36.8°±24.3°，术后即刻为21.3°±13.0°；RK角术前47.8°±19.6°，术后即刻23.6°±10.5°。两组患者术后即刻Cobb角、RK、SVA和CBD与术前相比，均显著性改善（P<0.05），两组间比较均无统计学差异（P＞0.05）。在末次随访时，椎弓根螺钉组SVA较术后即刻显著性增大，并显著性高于TPS组（P＜0.05），其余Cobb角、RK、CBD与术后即刻相比均无统计学差异（P＞0.05）。相较于术前，SRS-22评分在活动/功能状况、自我形象、疼痛、心理状况维度等维度上末次随访时均有明显改善（P＜0.05）；末次随访时椎弓根螺钉组中疼痛相关评分显著性高于TPS组。两患者术前ODI无统计学差异（P=0.528），末次随访时均较术前有显著改善，末次随访时两组间比较无显著性差异（P＞0.05）。TPS组随访中3例患者出现PJK（7.1%），1例患者行翻修手术治疗；椎弓根螺钉组14例患者出现近端交界性后凸（proximal junctional kyphosis，PJK）（27.5%），PJK发生率显著高于TPS组（P=0.011）。结论：三皮质斜向螺钉固定技术用于治疗成人退变性脊柱侧后凸畸形可取得良好的矫形效果，同时显著降低PJK发生率。

英文摘要:

  【Abstract】 Objectives: To evaluate the clinical outcomes of tri-cortical pedicle screw(TPS) oblique fixation technique utilized in degenerative kyphoscoliosis. Methods: 93 patients treated in Nanjing Drum Tower Hospital between January 2020 and November 2022 were retrospectively reviewed. Among the patients, 42 underwent intraoperative O-arm navigation system guided bilateral TPS oblique fixation at upper instrumented vertebra(UIV) were enrolled in the TPS group, and the other 51 patients underwent traditional pedicle screw fixation were enrolled in the pedicle screw group. There were no statistical differences in baseline data such as age and preoperative imaging between the two groups(P>0.05). The follow-up period was 33.2±4.2 months in the TPS group and 32.1±9.0 months in the pedicle screw group, with no significant difference between the two groups(P=0.458). Cobb′s angle, regional kyphosis(RK), sagittal vertical axis(SVA), and coronal balance distance(CBD) were measured on X-ray images taken before operation, immediate after operation, and at final follow-up. The Scoliosis Research Society(SRS-22) questionnaires and Oswestry disability index(ODI) were utilized to evaluate the patient-reported outcomes. Complications during follow-up were also recorded. Result: 93 patients all successfully completed the surgery. In TPS group, the pre-operative Cobb angle was 39.9°±20.8°, and the immediate post-operative Cobb angle was 19.8°±10.8°; RK was 47.8°±19.6° and 23.6°±10.5°immediate post-operation. In pedicle screw group, the pre-operative Cobb angle was 36.8°±24.3°, and the immediate post-operative Cobb angle was 21.3°±13.0°; RK was 47.8°±19.6° and 23.6°±10.5° immediate post-operation. In both groups, the immediate postoperative Cobb angle, RK, SVA, and CBD all improved significantly compared with the preoperative values(P<0.05), while no statistical difference was observed between groups(P>0.05). At final follow-up, the SVA of pedicle screw group was increased significantly compared with that at immediate postoperation, which was significantly bigger than that of TPS group(P<0.05), while Cobb angle, RK, CBD of the pedicle screw group were not significantly different from those at immediate postoperation(P>0.05). Compared to preoperative scores, significant improvements were noted in the quality of life scores across multiple domains, including activity/functional status, self-image, pain, and mental health(P<0.05). Pain-related scores were significantly higher in the pedicle screw group than in the TPS group. There was no statistically significant difference in ODI score between the two groups at preoperation. The ODI score at final follow-up was improved significantly in both groups, while no significant difference was observed between groups(P>0.05). In the TPS group, 3 cases developed proximal junctional kyphosis(PJK) during follow-up(7.1%), with one patient undergoing revision surgery. In contrast, 14 patients in the pedicle screw group developed PJK(27.5%), indicating a significantly higher incidence compared to the TPS group(P=0.011). Conclusions: The TPS oblique fixation technique can obtain satisfying orthopedic effects in treating degenerative kyphoscoliosis in adult patients, and reduce the incidence of PJK significantly.