经椎弓根不对称截骨术矫正强直性脊柱炎胸腰椎侧后凸畸形的疗效分析

Analysis of surgical outcomes of asymmetrical pedicle subtraction osteotomy for thoracolumbar kyphoscoliosis caused by ankylosing spondylitis

中文关键词:  胸腰椎侧后凸畸形  强直性脊柱炎  经椎弓根截骨术  经椎弓根不对称截骨术  对比分析

英文关键词:Thoracolumbar kyphoscoliotic deformity  Ankylosing spondylitis  Pedicle subtraction osteotomy  Asymmetrical pedicle subtraction osteotomy  Comparative analysis

中文摘要:

  【摘要】 目的：分析经椎弓根不对称截骨术（asymmetrical pedicle subtraction osteotomy，APSO）对强直性脊柱炎（ankylosing spondylitis，AS）胸腰椎侧后凸畸形患者的临床疗效，并比较其与传统经椎弓根椎体截骨术（pedicle subtraction osteotomy，PSO）对矢状面平衡重建的疗效。方法：回顾性分析2016年1月~2019年6月在我院行脊柱截骨术且随访超过1年的55例AS胸腰椎畸形患者。仅有矢状面畸形的AS患者采用PSO，双平面畸形患者采用APSO。在术前、术后和末次随访时的站立全脊柱正侧位X线片上测量冠状面Cobb角、冠状面平衡距离（coronal balance distance，CBD）、全脊柱后凸角（global kyphosis，GK）、矢状面偏移（sagittal vertical axis，SVA）、骨盆倾斜角（pelvic tilt，PT）、骶骨倾斜角（sacral slope，SS）、腰椎前凸角（lumbar lordosis，LL）、截骨角（osteotomized vertebral angle，OVA）、融合节段角（angle of fused segments，AFS）；在术前和末次随访时由患者填写疼痛视觉模拟（visual analogue scale，VAS）评分量表和Oswestery功能障碍指数（Oswestry disability index，ODI）量表。结果：55例患者中20例接受APSO，35例接受PSO。两组患者年龄、性别比、融合节和截骨位置均无统计学差异（P＞0.05）。随访27.3±8.1个月（12~48个月），APSO组术前、术后和末次随访时的冠状面Cobb角分别为18.9°±7.8°、7.3°±3.6°和9.5°±4.4°，CBD分别为64.7±24.8mm、26.7±13.4mm和27.4±15.3mm，术后和末次随访时较术前显著性改善（P＜0.05），末次随访时与术后比较无显著性差异（P＞0.05）。两组间术前、术后和末次随访时的SVA、GK、PT、LL、SS均无显著性差异（P＞0.05）；两组术后和末次随访时的SVA、GK、PT与同组术前比较均显著性减小（P＜0.05），LL、SS显著性增大（P＜0.05）；两组SVA、GK、PT、LL、SS矫正量均相似（P＞0.05）。末次随访时两组的VAS评分和ODI较术前均显著性改善（P＜0.05）；两组同时点比较无统计学差异（P＞0.05）。APSO组和PSO组末次随访时OVA和AFS均无明显改变（P＞0.05），APSO组OVA显著大于PSO组（P＜0.05）。APSO组1例截骨椎脱位，1例术中硬脊膜撕裂，1例体位性臂丛神经麻痹；PSO组2例截骨椎脱位，1例体位性臂丛神经麻痹；两组并发症发生率无显著性差异（P=0.462）。结论：APSO在矢状面畸形矫正效果上与PSO一致；APSO能够同时恢复AS胸腰椎侧后凸畸形患者的冠状位平衡。

英文摘要:

  【Abstract】 Objectives: To analyze the clinical outcomes of asymmetrical pedicle subtraction osteotomy(APSO) in ankylosing spondylitis(AS) patients with thoracolumbar kyphoscoliotic deformity and to compare its effect of reconstructing sagittal balance with pedicle subtraction osteotomy(PSO). Methods: 55 patients with AS-related thoracolumbar deformity underwent spinal osteotomy in our hospital between January 2016 and June 2019 and were followed up for more than one year were analyzed retrospectively. PSO was performed in AS patients with sagittal deformity only, and APSO was performed in patients with biplanar deformity. Radiological parameters including Cobb angle in the coronal plane, coronal balance distance(CBD), global kyphosis(GK), sagittal vertical axis(SVA), pelvic tilt(PT), sacral slope(SS), lumbar lordosis(LL), osteotomized vertebral angle(OVA) and angle of fused segments(AFS) were measured on the standing full-spine anteroposterior X-rays preoperatively, postoperatively, and at the final follow-up. Oswestry disability index(ODI) and visual analogue scale(VAS) were filled in by the patients preoperatively and at the final follow-up. Results: Of the 55 patients, 20 received APSO and 35 received PSO. The average follow-up period was 27.3±8.1 months(range, 12-48 months). In APSO group, the Cobb angle was 18.9°±7.8°, 7.3°±3.6°, and 9.5°±4.4°, and CBD was 64.7±24.8mm, 26.7±13.4mm, and 27.4±15.3mm respectively at preoperation, postoperation, and the final follow-up, which were improved significantly at postoperation and final follow-up than those before operation(P<0.05), while no significant differences were observed between postoperation and final follow-up(P>0.05). The preoperative, right postoperative, and final follow-up SVA, GK, PT, LL, and SS were not significantly different between groups(P>0.05); the SVA, GK, and PT at postoperation and final follow-up of each group were reduced significantly than those before operation, respectively(P<0.05), and LL and SS were increased significantly(P<0.05); and the corrections of SVA, GK, PT, LL, and SS in the two groups were similar(P>0.05). In addition, the ODI and VAS score were also significantly improved at final follow-up than before operation(P<0.05); and there was no significant difference between groups at same follow-up time point(P>0.05). Concerning the OVA and AFS, no statistically significant differences were noted at the last follow-up respectively in APSO and PSO groups(P>0.05). But the OVA in APSO group was larger than that in PSO group significantly(P<0.05). The complications in the APSO group included 1 case of vertebral subluxation, 1 case of intraoperative dural tear, and 1 case of positional brachial palsy, while those in the PSO group included 2 cases of vertebral subluxation and 1 case of positional brachial palsy. There was no significant difference in the incidence of complications between the two groups(P=0.462). Conclusions: APSO and PSO have similar therapeutic effect on sagittal deformity correction; APSO can reconstruct biplanar balance in AS patients with thoracolumbar kyphosis and scoliosis.