后路多节段Ponte截骨与经椎弓根椎体截骨矫形手术治疗胸腰型休门氏病后凸畸形的疗效分析

Efficacy analysis of posterior multi-segment Ponte osteotomy and pedicle subtraction osteotomy in treating Scheuermann′s thoracolumbar kyphosis

中文关键词:  休门氏病  后凸  Ponte截骨  经椎弓根椎体截骨  矫形  疗效

英文关键词:Scheuermann′s disease  Kyphosis  Ponte osteotomy  Pedicle subtraction osteotomy  Efficacy

中文摘要:

  【摘要】 目的：对比分析后路多节段Ponte截骨术（multi-segment Ponte osteotomy）与经椎弓根椎体截骨术（pedicle subtraction osteotomy，PSO）治疗胸腰型休门氏病后凸畸形（Scheuermann′s thoracolumbar kyphosis，STLK）的疗效。方法：回顾性分析2011年12月~2021年6月于我院诊断为休门氏病后凸畸形、分型为胸腰型（顶椎位置低于T10椎体）并行多节段Ponte截骨或PSO矫形内固定手术患者的资料，共纳入18例患者，随访26~55个月（35.83±8.41个月），Ponte组共10例患者，均行3节段截骨，PSO组共8例患者，均为单节段截骨。记录两组患者的年龄、性别、身体质量指数（body mass index，BMI）、顶椎位置、病变节段、固定节段、手术时间、术中出血量、术后引流量、住院天数、随访时间及手术相关并发症；记录两组患者术前、术后1周及末次随访时的疼痛视觉模拟评分（visual analogue scale，VAS），术前及末次随访时的Oswestry功能障碍指数（Oswestry disability index，ODI）及SRS-22（Scoliosis Research Society-22）问卷评分；测量术前、术后1周及末次随访时的胸椎后凸角（thoracic kyphosis，TK）、整体后凸Cobb角（global kyphosis，GK）、T1骨盆角（T1 pelvic angle，TPA）、T1-L1骨盆角（T1-L1 pelvic angle，TLPA）、腰椎前凸角（lumbar lordosis，LL）、骨盆倾斜角（pelvic tilt，PT）、骶骨倾斜角（sacral slope，SS）、骨盆入射角（pelvic incidence，PI）、PI-LL及矢状面轴向距离（sagittal vertical axis，SVA），计算GK矫正率、GK矫正丢失率，比较两组一般资料、手术相关资料、影像学参数及功能评分之间的差异。结果：所有患者均手术顺利，术后Ponte组出现2例浅表手术部位感染，PSO组出现1例，均经伤口换药处理后二期愈合，无其他并发症发生。两组的年龄、性别、BMI、顶椎位置分布、病变节段、固定节段及随访时间均无统计学差异（P＞0.05）；但Ponte组比PSO组手术时间及住院时间更短且其术中出血量及术后引流量更少（P＜0.05）。两组患者术后1周及末次随访时的VAS评分与术前比较明显降低（P＜0.05），但各时间点组间比较均无统计学差异（P＞0.05）；两组患者末次随访时ODI较术前明显降低而SRS-22评分明显升高（P＜0.05），且Ponte组相对PSO组在末次随访时的ODI更低而其SRS-22评分中的功能状况及自我形象两项评分更高（P＜0.05）。两组术后的TK、GK、TPA、TLPA、LL及SS较术前均明显降低（P＜0.05），且末次随访时上述参数较术后1周升高（P＜0.05）；两组术后PT、PI及PI-LL均明显升高（P＜0.05），且末次随访时上述参数较术后1周降低（P＜0.05），两组术后SVA同术前比较均无统计学差异（P＞0.05）。末次随访时两组均存在矫正丢失，Ponte组GK矫正丢失率为（4.3±1.3）%，PSO组为（4.9±2.4）%，两组间比较无统计学差异（P＞0.05）。所有影像学参数各时间点组间比较均无统计学差异（P＞0.05）。结论：采用后路多节段Ponte截骨或PSO联合融合内固定手术治疗STLK均能得到优良的后凸矫正效果；多节段Ponte截骨比PSO手术时间、住院时间更短，术中出血量及术后引流量更少，中期ODI及SRS-22评分改善更佳。

英文摘要:

  【Abstract】 Objectives: To compare and analyze the efficacies of posterior multi-segment Ponte osteotomy and pedicle subtraction osteotomy(PSO) in the treatment of Scheuermann′s thoracolumbar kyphosis(STLK). Methods: We retrospectively analyzed the data of patients with STLK(apex below T10) who underwent multi-segment Ponte osteotomy or PSO at our hospital from December 2011 to June 2021, and 18 patients were included with a mean follow-up of 35.83±8.41 months(26-55 months). 10 out of the 18 patients were included in the Ponte group(three-segment osteotomy on average), and the other 8 were include in the PSO group(single-segment osteotomy). Data such as age, gender, body mass index(BMI), apical vertebra, lesion segments, surgical segments, operative time, intraoperative blood loss, postoperative drainage volume, length of hospital stay, follow-up period, and surgical complications of both groups of patients were recorded. The visual analogue scale(VAS) was compared between the two groups before operation, at 1 week post-operation and the final follow-up, the Oswestry disability index(ODI) and Scoliosis Research Society-22(SRS-22) patient questionnaire scores were compared between the two groups before operation and at the final follow-up. Thoracic kyphosis(TK), global kyphosis(GK), GK correction ratio, GK correction loss ratio, T1 pelvic angle(TPA), T1-L1 pelvic angle(TLPA) and lumbar lordosis(LL), pelvic tilt(PT), sacral slope(SS), pelvic incidence(PI), PI-LL and sagittal vertical axis(SVA) were measured and compared between the two groups before operation, at 1 week after operation and the final follow-up. Results: All the patients were successfully operated, with superficial surgical site infection occurred in 2 cases in Ponte group and 1 case in PSO group, and no other surgical complications. There were no statistically differences between the two groups in age, gender, BMI, apical vertebra, lesion segments, surgical segments and follow-up time(P>0.05); However, the operative time, intraoperative blood loss, and postoperative drainage were less and length of hospital stay was shorter in the Ponte group than those in the PSO group(P<0.05). The VAS significantly improved in both groups at postoperative 1 week and final follow-up than preoperation(P<0.05), while there was no significant difference between the two groups at each time points(P＞0.05). The ODI and SRS-22 scores were significantly improved at final follow-up in both groups compared with preoperation(P<0.05), and the ODI was lower while the functional status and self-image scores in the SRS-22 were higher in Ponte group than PSO group(P<0.05). The postoperative TK, GK, TPA, TLPA, LL and SS were significantly lower than those preoperatively in both groups(P<0.05), which all significantly increased at the final follow-up compared with those at postoperative 1 week(P<0.05); the postoperative PT, PI and PI-LL were significantly higher than those before operation in both groups, which were lower at the final follow-up compared with those at postoperative 1 week(P<0.05). There was no statistical difference in SVA before and after surgery in both groups(P>0.05). Correction loss occurred in both groups after operation, with an average GK correction loss ratio of (4.3±1.3)% in Ponte group and (4.9±2.4)% in PSO group. There was no statistical difference between groups for all imaging parameters at different time points(P>0.05). Conclusions: For STLK patients, both posterior multi-segment Ponte osteotomy and PSO with internal fixation can achieve excellent kyphosis correction; and multi-segment Ponte osteotomy is less in operative time, intraoperative blood loss, and postoperative drainage, shorter in length of hospital stay, and better in midterm efficacy with preferable ODI and SRS-22 scores improvement than PSO.