先天性颈胸段脊柱畸形后路截骨矫形术后颈椎序列变化及其影响因素

Change and risk factors of cervical alignment after posterior osteotomy correction of congenital cervicothoracic deformity

中文关键词:  先天性脊柱侧凸  畸形  颈胸段  截骨矫形术  颈椎序列

英文关键词:Congenital scoliosis  Deformity  Cervicothoracic junction  Osteotomy  Cervical alignment

中文摘要:

  【摘要】 目的：分析先天性颈胸段脊柱畸形经后路截骨矫形术后颈椎序列变化及其影响因素。方法：回顾性分析2012年3月~2017年3月于我院行后路截骨矫形术治疗的26例先天性颈胸段脊柱畸形患者的临床及影像学资料，男10例，女16例，年龄14.2±4.6岁（9~20岁），随访时间38.0±6.4个月（24~96个月）。畸形节段位于C6~T5，其中半椎体5例，楔形椎2例，蝴蝶椎3例，半椎体合并蝴蝶椎4例，半椎体合并骨桥7例，阻滞椎5例。融合节段7.7±3.2个（3~13个）。收集患者术前、术后2周及末次随访时站立全脊柱正侧位X线片，测量冠状面影像学参数，包括原发及远端代偿弯Cobb角、冠状面T1倾斜角（T1 tilt）、锁骨角（clavicle angle，CA）、颈部倾斜（neck tilt，NT）、头部偏斜（head shift，HS）及冠状面平衡距离（coronal balance distance，CBD）；测量矢状面影像学参数，包括颈椎矢状垂直轴（C2-C7 sagittal vertical axis，C2-C7 SVA）、颈椎前凸角（cervical lordosis，CL）、颈胸后凸角（cervicothoracic kyphosis，CTK）、矢状面上端椎（upper end vertebrae，UEV）/T1倾斜角、胸椎后凸角（thoracic kyphosis，TK）、胸段后凸角（UEV/T1-T12）、腰椎前凸角（lumbar lordosis，LL）、骨盆入射角（pelvic incidence，PI）、骨盆倾斜角（pelvic tilt，PT）、矢状垂直轴（sagittal vertical axis，SVA）偏距。根据术前颈椎序列将患者分为前凸组（CL<-5°）及僵直/后凸组（CL≥-5°），前凸组8例，僵直/后凸组18例。根据术后至末次随访期间颈椎僵直/后凸是否发生进展（△CL>5°为进展）将术前僵直/后凸组患者分为后凸进展亚组（7例）与后凸无进展亚组（11例）。比较组间影像学参数差异，通过Pearson相关系数分析术前、术后及末次随访时可能影响颈椎曲度变化的影像学参数，评估SRS-22量表评分。应用Pearson卡方检验、Fisher精确检验、配对及独立t检验及Pearson相关系数分析比较组间影像学参数及SRS-22量表评分差异。结果：26例患者原发弯平均矫正率67.0%，远端代偿弯平均矫正率47.9%，HS、NT、CBD、T1 tilt、CA末次随访时均较术前明显改善（P<0.05）。颈椎前凸组术前、术后、末次随访时矢状面参数无统计学差异（P>0.05）。颈椎前凸组术前UEV/T1倾斜角及术前UEV/T1-T12较颈椎僵直/后凸组有统计学差异（分别为20.2°±0.5° vs 16.4°±4.3°，49.3°±5.2° vs 36.3°±14.3°，均P<0.05）。颈椎僵直/后凸组术前4例伴颈椎矢状面失平衡（C2-C7 SVA≥4cm），颈椎后凸进展组与无进展组比较，术前矢状面参数均无明显差异；术后CTK（2.4°±3.9° vs 12.7°±4.3°，P<0.05）、UEV/T1-T12（18.7°±3.6° vs 37.8°±7.6°，P<0.05）有统计学差异，其余无统计学差异；末次随访时，CTK（5.2°±4.9° vs 11.7°±6.5°，P<0.05）、UEV/T1-T12（20.4°±7.5° vs 38.5°±9.4°，P<0.05）、LL（-46.4°±7.9° vs -36.4°±5.2°，P<0.05）、SVA（-5.3cm±1.2cm vs -2.8cm±2.0cm，P<0.05）有统计学差异，其余无统计学差异（P>0.05）。术前颈椎后凸与术前UEV/T1-T12呈负相关（r=-0.398，P=0.045），术后颈椎后凸与术后CTK呈正相关（r=0.673，P<0.001），末次随访颈椎后凸进展与术后-末次随访△LL（r=0.557，P=0.020）及△SVA呈正相关（r=0.496，P=0.034）。SRS-22量表评估术前颈椎僵直/后凸组自我形象及心理健康维度评分低于颈椎前凸组（P<0.05），末次随访时颈椎后凸进展组疼痛评分低于颈椎前凸组及颈椎后凸无进展组（P<0.05），颈椎前凸组、颈椎后凸无进展组总评分均优于颈椎后凸进展组（P<0.05）。结论：先天性颈胸段脊柱畸形患者颈椎后凸发生率较高，术前颈椎后凸可能与UEV/T1-T12过小有关。一期后路截骨矫形术后，CTK过小、术后LL增大及SVA后移可导致远期颈椎后凸进展。

英文摘要:

  【Abstract】 Objectives: To analyze the characteristic and risk factors of sagittal cervical alignment after posterior osteotomy correction of congenital cervicothoracic deformity. Methods: 26 patients with congenital cervicothoracic deformity receiving posterior osteotomy correction between March 2012 and March 2017 in our hospital were analyzed. There were 10 males and 16 females with an average age of 14.2±4.6 years old(9-20 years). The mean follow-up period was 38.0±6.4 months(24-96 months). The pathological classification included hemivertebra in 5 cases, wedge vertebra in 2 cases, butterfly vertebra in 3 cases, hemivertebra with butterfly vertebra in 4 cases, hemivertebra with unilateral unsegment in 7 cases, block vertebra in 5 cases, respectively. The average fusion segments were 7.4±2.3(3-13). Imaging parameters of AP film of standing full spine X ray were collected to compare the coronal [clavicle angle(CA), neck tilt(NT), head shift(HS), coronal balance distance(CBD), main curve Cobb angle, caudal curve and T1 tilt] and sagittal [C2-C7 sagittal vertical axis(C2-C7 SVA), cervical lordosis(CL), cervicothoracic kyphosis(CTK), upper end vertebrae UEV/T1 slope(UEV/T1 slope), thoracic kyphosis(TK), UEV/T1-T12, lumbar lordosis(LL), pelvic incidence(PI), pelvic tilt(PT) and sagittal vertical axis(SVA)] parameters. 26 patients were divided into the lordosis group (8 patients, CL <-5°) and the straight/kyphosis group (18 patients, CL≥-5°) according to CL, and 18 patients in the straight/kyphosis group were subdivided into the deteriorate group(7 patients) and the non-deteriorate group(11 patients). The simplified Chinese version of SRS-22 questionnaire was collected as well. Pearson chi-square test, Fisher exact test, paired sample t-test, independent sample t-test and Pearson correlation coefficient analysis were used for statistical analysis of imaging parameters and SRS-22 questionnaire scores. Results: The average correction rate of primary curve and caudal curve were 67.0% and 47.9% respectively. HS, NT, CBD, T1 tilt and CA significantly improved at final follow-up. There was no significant difference of sagittal parameters among preoperative, postoperative or final follow-up in cervical lordosis group. There was significant difference of UEV/T1 slope(20.2°±0.5° vs 16.4°±4.3°, P<0.05) and UEV/T1-T12 (49.3°±5.2° vs 36.3°±14.3°, P<0.05) between lordosis group and straight/kyphosis group. There were significant differences in the two subgroups of postoperative CTK (2.4°±3.9° vs 12.7°±4.3°, P<0.05), postoperative UEV/T1-T12 (18.7°±3.6° vs 37.8°±7.6°, P<0.05) and CTK(5.2°±4.9° vs 11.7°±6.5°, P<0.05), UEV/T1-T12(20.4°±7.5° vs 38.5°±9.4°, P<0.05), LL(-46.4°±7.9° vs -36.4°±5.2°, P<0.05), SVA(-5.3±1.2cm vs -2.8±2.0cm, P<0.05) at final follow-up. Correlation coefficient tests showed correlations between preoperative cervical kyphosis and preoperative UEV/T1-T12(r=-0.398, P=0.045), postoperative cervical kyphosis and postoperative CTK(r=0.673, P<0.001), postoperative-final follow- up ΔLL(r=0.557, P=0.020) and ΔSVA(r-0.496, P=0.034). The results of SRS-22 questionnaire showed that the patients in the straight/kyphosis group had lower self-image scores and mental scores than those in the lordosis group(P<0.05). And patients in the deteriorate group owned the lowest pain scores and total scores(P<0.05). Conclusions: Congenital cervicothoracic deformity patients have a high cervical kyphosis incidence. Preoperative cervical kyphosis may be related to low preoperative UEV/T1-T12. Low postoperative CTK, increased LL and retrusive SVA may lead to long-term cervical kyphosis deterioration after posterior correction.