Lenke 5型青少年特发性脊柱侧凸患者前路选择性融合术后腰椎后滑脱的发生率及危险因素分析

The incidence rate and risk factors of lumbar retrolisthesis after anterior selective fusion in patients with Lenke 5 adolescent idiopathic scoliosis

中文关键词:  青少年特发性脊柱侧凸  Lenke 5型  前路选择性融合术  后滑脱  矢状面  危险因素

英文关键词:Adolescent idiopathic scoliosis  Lenke 5  Anterior selective fusion  Retrolisthesis  Sagittal alignment  Risk factors

中文摘要:

  【摘要】 目的：分析Lenke 5型青少年特发性脊柱侧凸（AIS）患者行前路选择性融合术后腰椎后向滑脱的发生率及其危险因素。方法：回顾性分析2005年1月～2010年12月在我院接受前路选择性胸腰椎融合手术的49例Lenke 5型AIS患者的临床资料。在术前、术后3个月及末次随访时的站立位全脊柱正侧位X线片上测量胸腰弯Cobb角、胸弯Cobb角、腰椎前凸角（lumbar lordosis，LL）、胸椎后凸角（thoracic kyphosis，TK）、胸腰段后凸角（thoracolumbar junctional kyphosis，TJK）、骶骨倾斜角（sacral slope，SS）、骨盆倾斜角（pelvic tilt，PT）、骨盆入射角（pelvic incidence，PI）、C7矢状位垂直距离（C7 sagittal vertical axis，SVA）。统计患者性别、年龄、Risser征、随访时间、融合椎体数、下端固定椎位置。按照Roussouly分型对患者术前矢状面形态进行分型。根据末次随访时发生腰椎后滑脱与否将患者分为滑脱组与非滑脱组。对两组患者术前、术后3个月及末次随访时的各参数进行统计学分析与比较。末次随访时采用脊柱侧凸研究会（SRS）-22量表评估两组患者生活质量。对有统计学差异的参数进行Logistic回归分析。结果：末次随访时24例（48.9%）患者发生后滑脱（滑脱组），25例未发生后滑脱（非滑脱组）。两组患者性别、年龄、Risser征、矢状面Roussouly分型分布、融合节段、下端固定椎位置均无统计学差异（P>0.05）。滑脱组与非滑脱组患者随访时间为81.5±16.8个月与78.7±12.3个月。滑脱组患者术前、术后3个月及末次随访时的LL均显著性高于非滑脱组（P<0.039），SVA均显著性低于非滑脱组（P<0.038）。术前及末次随访时，滑脱组TK显著性高于非滑脱组（P<0.041）。末次随访时，滑脱组SS显著性高于非滑脱组（P=0.036）。两组患者末次随访时SRS-22量表疼痛、功能等各项评分均无统计学差异（P>0.05）。Logistic回归分析显示SVA[比值比（odds ratio，OR）＝0.959，95%可信区间（confidence interval，CI） 0.925～0.994，P=0.024]与TK（OR＝1.158，95%CI 1.003～1.337，P=0.045）为术后后滑脱发生的危险因素。结论： Lenke 5型AIS患者接受前路选择性融合术后融合节段远端邻近节段发生后滑脱比例较高；术前较小的SVA与较大的TK为术后后滑脱发生的危险因素，而术前矢状面Roussouly分型与后滑脱发生无明显相关性；滑脱对腰椎椎间盘退变以及患者生活质量的影响仍需要远期随访评估。

英文摘要:

  【Abstract】 Objecctives: To explore the incidence rate and risk factors of lumbar retrolisthesis after anterior selective fusion in patients with Lenke 5 adolescent idiopathic scoliosis(AIS). Methods: From January 2005 to December 2010, a total of 49 patients with Lenke 5 AIS who underwent anterior selective fusion in our hospital were retrospectively reviewed. The following radiographic parameters in standing full spine X-ray films before surgery, at 3-month after surgery and final follow-up were measured: The Cobb angle of thoracolumbar(TL) curve and thoracic(T) curve, lumbar lordosis(LL), thoracic kyphosis(TK), thoracolumbar junctional kyphosis(TJK), sacral slope(SS), pelvic tilt(PT), pelvic incidence(PI), and C7 sagittal vertical axis(SVA). Patients′ demographic data including gender, age, Risser sign, follow-up period, as well as surgical parameters including the number of levels fused and location of lower instrumented vertebra(LIV) were recorded. The Roussouly classification was used to describe the preoperative sagittal alignment. Patients were divided into the retrolisthesis group(R group) and non-retrolisthesis group(NR group) based on the presence of retrolisthesis or not at final follow-up. Within-group or between-group comparisons of parameters at different time points were made statistically. Scoliosis Research Society(SRS)-22 questionnaires were used at the final follow-up to assess the health-related quality of life(HRQoL) of both groups of patients. Logistic regression analysis was performed on the parameters with statistical differences. Results: At the last follow-up, 24 patients(48.9%) developed retrolisthesis(R group), and the other 25 patients did not(NR group). The age, gender, Risser sign, levels fused, distribution of Roussouly classification and LIV location did not differ significantly between the two groups(P>0.05). The follow-up duration was 81.5±16.8 and 78.7±12.3 months for R group and NR group. At all time points, the patients in R group had significantly larger LL(P<0.039) and smaller SVA(P<0.038) than NR group. Compared with NR group, the patients in R group had significantly larger TK before surgery and at final follow-up(P<0.041), and larger SS at final follow-up(P=0.036). The SRS-22 scores including pain and function domains did not differ significantly between the two groups(P>0.05). Logistic regression analysis showed that preoperative SVA[odds ratio(OR)=0.959, 95% confidence interval(CI) 0.925-0.994, P=0.024] and TK(OR=1.158, 95%CI 1.003-1.337, P=0.045) were the risk factors for the occurrence of retrolisthesis after surgery. Conclusions: There is a high incidence rate of retrolisthesis below the fusion levels of patients with Lenke 5 AIS who underwent anterior selective fusion surgery. Smaller preoperative SVA and larger LL are found to be the risk factors for postoperative retrolisthesis, whereas the distribution of preoperative Roussouly classification is not obviously coorelated. The impact of retrolisthesis on the disc degeneration and patients′ HRQoL still requires long-term follow-up for further investigation.