退行性脊柱侧凸合并髋关节疾病的外科治疗策略

Surgical strategy for degenerative scoliosis combined with hip disorder

中文关键词:  退行性脊柱侧凸  髋关节疾病  脊柱手术  关节置换

英文关键词:Degenerative scoliosis  Hip disorder  Spinal surgery  Hip replacement

中文摘要:

  【摘要】 目的：探讨合并髋关节疾病的退行性脊柱侧凸（degenerative scoliosis，DS）患者的外科治疗策略。方法：2012年6月~2015年6月在解放军总医院与北部战区总医院接受腰椎后路固定融合手术的DS患者180例，其中合并髋关节疾病并手术治疗的患者共26例。先行全髋关节置换术（total hip arthroplasty，THA）后行腰椎手术患者11例（A组），先行腰椎手术再行THA患者15例（B组）。随访时间1~3年（平均1.5年）。分别比较两组患者的一般情况，包括年龄、性别、腰椎手术时间、THA手术时间、腰椎术中出血量、THA术中出血量以及住院日。同时比较两组术前及末次随访时的双肩平衡情况、Cobb角、矢状位垂直偏距（sagittal vertical axis，SVA）、腰椎前凸角（lumber lordosis，LL）、胸椎后凸角（thoracic kyphosis，TK）、骨盆倾斜角（pelvic tilt，PT）、骶骨倾斜角（sacral slope，SS）、髋臼前倾角（anteversion of acetabulum，AA）、Oswestry功能障碍指数（ODI）评分、腿痛VAS评分及髋关节Harris评分。结果：A、B两组年龄分别为58~69岁（64.2±3.4岁）和60~68岁（64.3±2.5岁）；THA出血量分别为420.9±2.6ml和331.3±26.7ml，手术时间分别为2.3±0.2h和1.6±0.2h，住院时间分别为6.8±0.6d和5.9±0.8d；腰椎手术出血量分别为873.6±37.8ml和812.0±19.7ml，手术时间分别为6.6±0.3h和6.4±0.3h，住院日分别为14.7±0.6d和17.4±0.7d；其中，A组的THA出血量、手术时间及住院日均多于B组，腰椎手术住院日少于B组（均P＜0.01）。两组术前Cobb角、LL、PT、SS、SVA、TK、AA、ODI评分、腿痛VAS评分及髋关节Harris评分均无统计学差异（P＞0.05），两组具有可比性。末次随访时，A、B组Cobb角分别为2.8°±1.7°和3.0°±1.3°，LL分别为43.7°±1.7°和44.9°±1.8°，PT分别为23.3°±0.9°和23.8°±1.4°，SS分别为39.9°±1.3°和39.9°±0.8°，SVA分别为5.7±0.4cm和5.7±0.2cm，TK分别为28.4°±2.1°和27.9°±2.7°，腿痛VAS评分分别为2.8±0.8分和2.9±1.0分，两组间比较均无统计学差异（P＞0.05）；但AA分别为26.8°±1.0°和20.5°±1.5°，ODI评分分别为25.8±1.0分和17.5±2.0分，髋关节Harris评分分别为81.3±1.8分和88.0±1.2分，A组的AA值大于B组，ODI评分明显高于B组，髋关节Harris评分低于B组（均P＜0.01）。术后随访，A组出现5例双肩不等高，躯干向一侧倾斜。B组腰椎术后未行THA之前，有8例患者因髋关节活动受限无法走路，活动受限程度重于腰椎术前。结论：对于合并髋关节疾病的DS患者，先行脊柱手术解决腰椎神经症状并纠正脊柱矢状位平衡，再行髋关节置换，既简化了关节置换难度，也可以通过关节置换最后调整脊柱手术残留下来的不平衡因素。但同时也面临腰椎术后、THA术前的手术间隔时间直立和行走活动的严重受限。

英文摘要:

  【Abstract】 Objectives: To investigate the surgical strategy for degenerative scoliosis combined with hip disorder. Methods: Data of 180 patients treated with the posterior fixation of lumbar spinal fusion from June 2012 to June 2015 in Chinese PLA General Hospital and The General Hospital of Northern Theater Command were retrospectively reviewed. Among which, 26 patients undergone the spinal surgery and total hip replacement were divided into group A and group B. Group A consisted of 11 patients who underwent the total hip replacement first, and group B consisted of 15 patients who underwent the lumbar spinal surgery first. The average follow-up period was 1.5 years(range, 1-3 years). The general conditions were compared, including age, gender, operative time, blood loss, and hospitalization period. Then the shoulder balance, Cobb angle, sagittal vertical axis(SVA), lumbar lordosis(LL), thoracic kyphosis(TK), pelvic tilt(PT), sacral slope(SS), anteversion of acetabulum(AA), the Oswestry disability index(ODI) score, VAS score and Harris score were compared between the 2 groups before operation and at the last follow-up. Results: For group A and group B, the mean ages were 64.2±3.4 years(58-69) and 64.3±2.5 years(60-68) respectively; in THA, the blood loss were 420.9±2.6ml and 331.3±26.7ml, the operative time were 2.3±0.2 hours and 1.6±0.2 hours, and the hospitalization time were 6.8±0.6 days and 5.9±0.8 days respectively; in spinal surgery, the blood loss were 873.6±37.8ml and 812.0±19.7ml, the operative time were 6.6±0.3 hours and 6.4±0.3 hours, and the hospitalization time were 14.7±0.6 days and 17.4±0.7 days respectively in the two groups. The blood loss and operative time of THA, the hospitalization time in group A were more than that in group B(P<0.01). But the hospitalization time of the spinal surgery in group A was less than that in group B(P<0.01). The Cobb angle, LL, PT, SS, SVA, TK, AA, ODI score, leg pain VAS score and hip joint Harris score between the two groups before operation were not statistically different(P＞0.05), and were comparable. At the final follow-up, in group A and group B the Cobb angle were 2.8°±1.7° and 3.0°±1.3°, LL were 43.7°±1.7° and 44.9°±1.8°, PT were 23.3°±0.9° and 23.8°±1.4°, SS were 39.9°±1.3° and 39.9°±0.8°, SVA were 5.7±0.4cm and 5.7±0.2cm, TK were 28.4°±2.1° and 27.9°±2.7°, and VAS scores were 2.8±0.8 and 2.9±1.0 respectively, and all these were with no significant differences(P>0.05) between the two groups. Whereas, the AA were 26.8°±1.0° and 20.5°±1.5°, ODI were 25.8±1.0 and 17.5±2.0, and Harris scores were 81.3±1.8 and 88.0±1.2 respectively in group A and group B. The AA and ODI score of group A were more than that of group B(P<0.01), and Harris scores of group A were less than that of group B(P<0.01). At postoperative follow-up, 5 patients in group A showed imbalance shoulders and inclined trunk; and after spinal surgery and before THA, 8 patients in group B were unable to walk due to limited motion of the hip joint, which were more severe than that before the spinal surgery. Conclusion: To perform spinal surgery before THA can solve the lumbar nerve symptoms and correct the sagittal imbalance of the spine in the treatment of the coexisting of degenerative scoliosis and hip disease, which simplifies the difficulty of the joint replacement and correct the sagittal imbalance left by spinal surgery. However, at the same time there was the risk of severe limitation of walking during the period after spinal surgery and before THA.