GAP评分及其对成人脊柱畸形矫形术后力学并发症预测的可信度研究

Reliability of the global alignment and proportion score in predicting mechanical complications after correction surgery of adult spinal deformities

中文关键词:  成人脊柱畸形  GAP评分  力学并发症  可靠性

英文关键词:Adult spinal deformity  Global alignment and proportion  Mechanical complication  Reliability

中文摘要:

  【摘要】 目的：评估GAP（global alignment and proportion）评分的可信度和可重复性，并探究其在成人脊柱畸形（adult spinal deformity，ASD）矫形术后力学并发症预测中的可靠性。方法：回顾性分析2014年12月~2016年12月在我院行脊柱后路矫形内固定术且随访超过2年的ASD患者98例，其中男性31例，女性67例，年龄38.8±8.6（20~71）岁，随访时间34.4±9.3个月。其中退变性脊柱侧后凸29例、先天性脊柱侧后凸28例、特发性脊柱侧凸19例、创伤后脊柱后凸9例、神经源性脊柱侧凸9例、休门氏病后凸畸形2例，综合征型脊柱侧凸2例（马凡综合征和类马凡综合征各1例）。通过患者术后全脊柱侧位X线片测量骨盆入射角（pelvic incidence，PI）、骶骨倾斜角（sacral slope，SS）、腰椎前凸角（lumbar lordosis，LL）、下腰椎前凸角（lower lumbar lordosis，LLL）和躯干整体倾斜（global tilt，GT）等影像学参数，并计算得出GAP评分，比较GAP评分的观察者间可信度和观察者内可重复性。根据GAP评分结果将患者分为3组：协调组（GAP评分0～2分）；中等不协调组（GAP评分3～6分）；严重不协调组（GAP评分7～13分），记录所有患者随访中出现的力学并发症，包括内固定失败、近端交界性后凸/失败（proximal junctional kyphosis/failure，PJK/PJF）、远端交界性后凸/失败（distal junctional kyphosis/failure，DJK/DJF），比较各组间力学并发症的发生率。收集患者术前及末次随访时疼痛视觉模拟评分（visual analogue scale，VAS）、Oswestry功能障碍指数（Oswestry disability index，ODI）问卷表和健康调查简表（the MOS item short form health survey，SF-36）评估结果，比较三组间生活质量评分。结果：3名观察者共进行了588次（98×3×2）次评分，纳入协调组共192（32.7%）次、中等不协调组共250（42.5%）次、严重不协调组共146（24.8%）次。观察者间GAP评分可信度Kappa值为0.765（基本可信），观察者内可重复性Kappa值为0.822（完全可信）。随访中发现力学并发症15例，包括内固定断裂5例（8.2%）、PJK 9例（9.2%）、螺钉松动1例（1.0%）。协调组、中等不协调组和严重不协调组并发症发生率分别为9.1%（3/33）、14.6%（6/41）和25.0%（6/24），三组之间差异无统计学意义（χ2=2.74，P=0.254）。三组患者术前生活质量评分未见明显差异（ODI：P=0.167；VAS：P=0.668；SF-36生理功能评分：P=0.896；SF-36心理功能评分：P=0.211）。末次随访时发现ODI（P=0.038）和SF-36生理功能评分（P=0.020）在三组间存在差异，而VAS（P=0.729）和SF-36心理功能评分（P=0.277）无组间差异。结论：GAP评分具有良好的观察者内和观察者间一致性，但评分结果与术后力学并发症发生风险无明显相关性。

英文摘要:

  【Abstract】 Objectives: To determine the intra- and inter-observer reliabilities of global alignment and proportion(GAP) score in predicting the mechanical complications after correction surgery of adult spinal deformities(ASD). Methods: A total of 98 ASD patients undergone correction surgery between December 2014 and December 2016 with at least 2 years follow-up were retrospectively reviewed, including 31 male and 67 female subjects that aged 38.8±8.6(20-71) years on average. Patients′ age were documented and radiographic parameters including PI, SS, LL, LLL and GT were independently measured twice by 3 spine surgeons on postoperative lateral full-spine X-rays to determine the GAP scores and classifications. Patients were classified into 3 groups: proportion group with GAP scores between 0-2, moderate disproportion group with GAP scores between 3-6, severe disproportion group with GAP scores between 7-13. All mechanical complications including implant-related failures, PJK/PJF and DJK/DJF were documented. The intra- and inter-observer reliabilities were analyzed and the incidence of mechanical complications between the 3 groups was compared with Chi-square tests. The visual analogue scale(VAS), Oswestry disability index(ODI) and the MOS item short form health survey(SF-36) were compared among three groups. Results: Of all 588(98×3×2) measurements of GAP scores obtained, 192(32.7%) measurements were classified into the proportion group, 250(42.5%) into the moderate disproportion group, and 146(24.8%) into the severe disproportion group. The Kappa coefficients were 0.765 for inter-observer and 0.822 for intra-observer reliabilities. A total of 15 patients were identified to have mechanical complications during follow-up, and the incidences were 9.1%(3/33), 14.6%(6/41) and 25.0%(6/24) for proportion group, moderate disproportion group and severe disproportion group, respectively (χ2=2.74, P=0.254). At pre-operation, the VAS(P=0.668), ODI(P=0.167), SF-36 PCS(P=0.896) and SF-36 MCS(P=0.211) were not significantly different between the 3 groups. During the last follow up, the ODI(P=0.038) and SF-36 PCS(P=0.020) were significantly different between groups, no statistically significant difference was found in terms of VAS(P=0.729) and SF-36 MCS(P=0.277). Conclusions: The GAP scores have good to excellent intra- and inter-observer reliabilities in ASD patients undergoing correction surgery. The GAP scores are unable to predict the occurrence of mechanical complications during follow-up.