退变性腰椎侧凸长节段融合术后远端交界性问题分析

Distal junctional problem after posterior long instrumented spinal fusion in degenerative lumbar scoliosis

中文关键词:  退变性腰椎侧凸  长节段融合手术  远端交界性问题  机械并发症

英文关键词:Degenerative lumbar scoliosis  Long instrumented spinal fusion  Distal junctional problem  Mechanical complications

中文摘要:

  【摘要】 目的：探讨退变性腰椎侧凸（degenerative lumbar scoliosis，DLS）长节段固定融合术后远端交界性问题（distal junctional problem，DJP）的发生率、危险因素及对患者生活质量的影响。方法：2009年4月~2017年10月在我院确诊为DLS、年龄≥40岁、行长节段（≥4个节段）固定融合手术、随访时间≥1年的患者132例，将随访时出现DJP的13例患者纳入DJP组，未出现任何机械性并发症的41例患者纳入对照组。对个体因素[手术时的年龄、性别、体重指数（body mass index，BMI）、骨密度（bone mineral density，BMD）和T值、合并糖尿病和高血压情况、美国麻醉医师学会（ASA）分级等因素]、手术因素[固定融合节段数、远端固定椎（lowest instumented vertebra，LIV）位置、截骨操作和椎间融合情况]以及术前和术后影像学参数[侧凸Cobb角、顶椎的旋转程度（Nash-Moe）、顶椎偏移距离（apical vertebral translation，AVT）、冠状位平衡（coronal vertical axis， CVA）、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）、骨盆入射角（pelvic incidence，PI）、骨盆倾斜角（pelvic tilt，PT）、骶骨倾斜角（ sacral slope，SS）、矢状位平衡（sagittal vertical axis，SVA）、T1骨盆角（T1 pelvic angle，TPA）、躯干整体倾斜角（global tilt，GT）等]进行单变量和多变量分析。比较两组术前和随访时的腰痛视觉模拟（visual analog scale，VAS）评分、下肢痛VAS评分、Oswestry功能障碍指数（Oswestry disability index，ODI）、日本骨科学会（Japanese Orthopaedic Association，JOA）-29评分、脊柱研究学会（Scoliosis Research Society-22，SRS-22）评分和健康状况调查简表（short form 36 health survey questionnaire，SF-36）评分。结果：本组患者DJP的发生率为9.8%（13/132），其中6例（46.2%）患者进行了翻修手术。DJP组患者骨密度T值显著低于对照组，DJP患者骨量减少及骨质疏松的比例显著高于对照组（P<0.05），其他个体因素无显著性差异。两组手术因素均无显著性差异。与对照组相比，DJP组患者术前TLK较大、PT较小、SVA＞70mm的比例较高（53.85% vs 19.51%，P=0.040）；术后即刻TLK、SVA显著大于对照组，矢状位失衡患者比例显著高于对照组（46.15% vs 14.63%，P=0.046），其他影像学参数无显著性差异。Logistic回归分析提示骨质疏松（OR=8.90，95% CI=1.95～40.51，P=0.005）、术后即刻矢状位失衡（OR=5.82，95% CI=1.15～29.42，P=0.033）发生DJP的风险分别增加了7.9倍、4.8倍。两组患者术前各项健康相关生活质量评分均无统计学差异；对照组患者术后各项健康相关生活质量评分较术前均有显著性提高（P<0.05），而DJP组患者ODI、JOA评分、SF-36精神健康较术前无明显提高（P>0.05）；与对照组比较，DJP组随访时腰痛VAS评分、ODI、JOA评分、SRS疼痛、SRS功能状况、SRS亚总分、SRS治疗满意度、SF-36生理健康评分、SF-36精神健康评分更差。结论：DLS长节段固定融合术后9.8%的患者发生了远端交界性问题，严重影响患者术后生活质量改善；骨质疏松和术后即刻矢状位失衡是发生DJP的独立危险因素。

英文摘要:

  【Abstract】 Objectives: To evaluate the incidence, risk factor, and clinical influence of distal junctional problem(DJP) after long instrumented spinal fusion in degenerative lumbar scoliosis(DLS). Methods: From April 2009 to October 2017, a total of 132 DLS patients who underwent one stage posterior long instrumented spinal fusion in our spinal center was reviewed. The inclusion criteria included: ①age≥40 years; ②fusion level≥4 levels; ③follow-up time≥1 years. Patients with DJP during follow-up were included in the DJP group(13 cases), and patients without mechanical complications were included in the control group(41 cases). To investigate risk factors for DJP, three kinds of factors were statistically analyzed: ①patient-related risk factors including age, sex, body mass index(BMI), bone mineral density(BMD), T-score and so on; ②surgery-related risk factors including the number of instrumented levels, lowest instumented vertebra(LIV), osteotomy and interbody fusion; ③pre- and postoperative radiographic parameters including Cobb angle, vertebral axial rotation(Nash-Moe), apical vertebral translation(AVT), coronal vertical axis(CVA), thoracic kyphosis(TK), thoracolumbar kyphosis(TLK), lumbar lordosis(LL), pelvic incidence(PI), pelvic tilt(PT), sacral slope(SS), sagittal vertical axis(SVA), T1 pelvic angle(TPA), global tilt(GT) and so on. Preoperative and follow-up visual analog scale(VAS) for low back pain and leg pain, Oswestry disability index(ODI), Japanese Orthopaedic Association-29(JOA-29) scores, Scoliosis Research Society-22(SRS-22) scores and short form 36 health survey questionnaire(SF-36) scores were compared between the DJP group and the control group. Results: DJP was developed in 13 of the 132 patients(9.8%). The T-score in the DJP group was significantly lower than that in the control group, and the proportion of patients with osteopenia and osteoporosis in DJP patients was significantly higher than that in the control group. DJP patients had a higher preoperative TLK, a lower preoperative PT and a higher proportion of patients with preoperative SVA>70mm. Comparing with the control group, the DJP group had a higher postoperative TLK, a higher postoperative SVA and a higher proportion of sagittal imbalance(46.15% vs 14.63%, P=0.046). Multiple logistic regression analysis indicated that osteoporosis(OR=8.90, 95% CI=1.95-40.51, P=0.005) and immediately postoperative sagittal imbalance(OR=5.82, 95% CI=1.15-29.42, P=0.033) were independent risk factors of DJP. In the control group, all baseline quality of life score values had improved significantly at follow-up(P<0.05), while no significant improvement of ODI score, JOA score or SF-36 mental component summary scale(MCS) score was observed in the DJP group. The following scores were worse at final follow-up in the DJP group: VAS score for lumbar pain, ODI, JOA, SRS-22 pain, SRS-22 function, SRS subtotal score, SRS satisfaction, SF-36 phyisical component summary scale(PCS), SF-36 MCS score. Conclusions: Distal junctional problem occurred in 9.8% of DLS patients after long instrumented spinal fusion, and seriously affected the improvement of patients′ quality of life. Osteoporosis and immediately postoperative sagittal imbalance were independent risk factors of DJP.