Lenke 5+型青少年特发性脊柱侧凸患者后路选择性融合术后胸弯的转归

Prognosis of thoracic curve in Lenke 5+ type adolescent idiopathic scoliosis after posterior selective fusion

中文关键词:  Lenke 5型  青少年特发性脊柱侧凸  自发性矫正  选择性融合  非选择性融合

英文关键词:Lenke 5  Adolescent idiopathic scoliosis  Spontaneous correction  Selective fusion  Non-selective correction

中文摘要:

  【摘要】 目的：探讨Lenke 5+型脊柱侧凸患者不同融合策略疗效及选择性融合术后胸弯自发矫正情况。方法：回顾性分析2010年1月～2018年12月期间在我院接受手术治疗且随访2年以上Lenke 5+型青少年特发性脊柱侧凸（adolescent idiopathic scoliosis，AIS）患者资料，共80例，男13例，女67例。按照手术策略不同，将纳入患者分成非选择性融合（non-selective，NS）组（n=21）和选择性融合（selective，S）组（n=59）；根据末次随访时胸弯进展是否＞5°，S组患者进一步分为进展（progressive group，P）组和非进展（non-progressive，NP）组。通过术前影像学参数对S组和NS组进行匹配，对匹配后S组和NS组，P组和NP组术前、术后即刻及末次随访时临床疗效及影像学参数进行比较分析。包括胸弯柔韧度、胸腰弯/腰弯（thoracolumbar/lumbar curve，TL/L）、胸弯Cobb角（thoracic curve，T）、胸弯顶椎偏移（apical vertebrae translation of thoracic curve，AVT-T）、胸腰弯/腰弯顶椎偏移（apical vertebrae translation of thoracolumbar curve，AVT-TL）、双肩倾斜角（shoulder tilt，ST）、冠状面平衡（coronal balance，CB）、上端固定椎（uppermost instrumented vertebrae，UIV）或UIV+1倾斜角、T5～T12胸椎后凸角（thoracic kyphosis，TK）及腰椎前凸角（lumbar lordosis，LL）。术前和末次随访时脊柱侧凸研究协会问卷调查表（scoliosis research society-22，SRS-22）评分用于评估临床疗效。Spearman相关性分析用于分析胸弯进展相关因素，二元逻辑回归用于探讨胸弯进展危险因素。结果：两组患者胸弯、胸腰/腰弯较术前均有明显改善，NS组患者胸弯矫正较S组更明显（12.8°±5.6° vs 20.6°±4.0°，P<0.001），而在随访过程中大部分患者胸弯、胸腰弯/腰弯均维持良好的矫正状态。末次随访时，S组中9例患者胸弯进展＞5°（P组）；另50例患者胸弯进展≤5°（NP组）。P组患者较NP组患者年龄小（14.0±0.6岁 vs 15.4±1.1岁，P=0.004），Risser征低（2.3±1.3 vs 3.9±0.7，P<0.001），UIV+1倾斜角更大（22.7°±4.5° vs 19.7°±3.5°，P<0.05）。逻辑回归分析显示Risser征≤2（P=0.003）、术后UIV+1倾斜角（P=0.042）及UIV-上端椎（upper end vertebrae，UEV）<0（P=0.028）是术后胸弯进展的主要危险因素。P组和NP组患者SRS-22自我形象维度评分均提高，但两组间无明显统计学差异（P>0.05）。结论：Lenke 5+型患者后路选择性融合后胸弯可获得满意的自发性矫正，且术后至少两年随访期间胸弯未发生进展。但对于年龄偏小、Risser征低的Lenke 5+型患者，选择性融合策略的应用应谨慎考虑。

英文摘要:

  【Abstract】 Objectives: To compare the clinical and radiological outcomes after selective and non-selective fusion in Lenke 5+ AIS and to investigate the prognosis of thoracic curve in Lenke 5+ adolescent idiopathic scoliosis(AIS) patients after posterior selective fusion(PSF). Methods: Lenke 5+ AIS patients who received correction surgery in our hospital from January 2010 to December 2018 with a minimum of 2 years follow up were retrospectively reviewed. There were 80 cases, including 13 males and 67 females. According to the surgical strategy, patients were classified into non-selective fusion(NS) group(n=21) and the selective fusion(S) group(n=59). Then, the patients in S group were subdivided into two groups of progressive(P) group with thoracic curve progression >5° and non-progressive(NP) group with progression ≤5° at the final follow-up. Comparison analysis was made in terms of radiological and clinical outcomes between well-matched patients in S group and NS group and between patients of P group and NP group. SRS-22(scoliosis research society-22) was used to evaluate clinical outcomes. Imaging parameters included chest bend flexibility, thoracolumbar/lumbar curve(TL/L), thoracic curve(T), apical vertebrae translation of thoracic curve(AVT-T), apical vertebrae translation of thoracolumbar curve(AVT-TL), shoulder tilt(ST), coronal balance(CB), uppermost instrumented vertebrae(UIV) or UIV+1 tilt angle, thoracic kyphosis(TK), lumbar lordosis(LL). Spearman correlation analysis was used to analyze the related factors of thoracic curvature progression, and binary Logistic regression was used to explore the risk factors of thoracic curvature progression. Results: Both groups demonstrated significant corrections in thoracolumbar curve and in thoracic curve comparing with the conditions before operation(P＜0.05). Comparing with S group, NS group demonstrated greater correction rate in thoracic curve(12.8°±5.6° vs 20.6°±4.0°, P<0.001), and the thoracic curve and thoracolumbar curve of most patients were found stable during follow-up. 9 patients(P group, 15.2%) in the S group demonstrated progression more than 5° in thoracic curve while 50 patients(NP group, 84.8%) maintained a well-corrected thoracic curvature at the final follow-up. Comparing with NP group, patients in P group were younger(14.0±0.6 vs 15.4±1.1, P=0.004), with a lower Risser sign(2.3±1.3 vs 3.9±0.7, P<0.001) and greater postoperative UIV+1 tilt(22.7±4.5 vs 19.7±3.5, P<0.05). Logistic regression analysis showed Risser sign≤2(P=0.003) and UIV+1 tilt(P=0.042) and UIV-UEV(upper end vertebrae)＜0(P=0.028) were independent risk factors of thoracic curve progression. Self-image scores were improved after selective surgery in both P group and NP group, but there was no significant difference(P＞0.05). Conclusions: Satisfying correction could be achieved regardless of selective or non-selective strategy in Lenke 5+ type AIS. Spontaneous correction of thoracic curve could be achieved after selective surgery in Lenke 5+ type AIS and remained stable during minimum of 2 years′ follow up. However, selective fusion should be carefully considered for patients with younger age and lower Risser sign.