三种截骨矫形术治疗Lenke 5型青少年特发性脊柱侧凸的疗效比较

Comparative analysis of the clinical efficacies of three surgical methods for the treatment of Lenke type 5 adolescent idiopathic scoliosis

中文关键词:  青少年特发性脊柱侧凸  Lenke 5型  后路椎间隙松解  截骨术

英文关键词:Adolescent idiopathic scoliosis  Lenke 5  Posterior intervertebral space release  Osteotomy

中文摘要:

  【摘要】 目的：比较脊柱侧凸研究学会（Scoliosis Research Society，SRS）Ⅰ级、Ⅱ级截骨及Ⅱ级截骨联合椎间隙松解矫治Lenke 5型青少年特发性脊柱侧凸（adolescent idiopathic scoliosis，AIS）的临床疗效。方法：回顾性分析2016年1月~2022年9月在我院行手术治疗且随访超过2年的101例Lenke 5型AIS患者的临床资料，其中男性30例，女性71例，年龄10~18岁（15.1±2.1岁），根据手术方式分为三组：A组（37例）行SRS Ⅰ级截骨，B组（33例）行SRS Ⅱ级截骨，C组（31例）行SRS Ⅱ级截骨联合椎间隙松解术。三组患者的年龄、性别、体质指数（body mass index，BMI）、Risser征等一般资料无统计学差异（P＞0.05）。随访24~43个月（30.3±4.1个月）。比较三组的手术时间、术中估计失血量、融合节段数、并发症及术后住院时间；术前、术后1个月及末次随访时于站立位全脊柱正侧位X线片上测量患者胸腰弯/腰弯（thoracolumbar/lumbar，TL/L）侧凸Cobb角、顶椎偏移距离（apex vertebral translation，AVT）、腰椎前凸角（lumbar lordosis，LL）、胸椎后凸角（thoracic kyphosis，TK），术前使用Nash-Moe分级评估顶椎旋转程度，术后1个月及末次随访时根据Upasani的X线椎体旋转分级标准评价顶椎去旋转的效果；术前及末次随访时由患者填写脊柱侧凸研究学会-22项量表（Scoliosis Research Society-22 questionnaire，SRS-22）进行临床疗效评估。结果：手术相关指标中，C组相比于A、B组手术时间延长（P＜0.001），术中估计失血量、融合节段数及术后住院时间均无统计学差异（P>0.05）。三组患者术前侧凸Cobb角、AVT、LL及TK差异无统计学意义（P>0.05），术后三组患者TL/L侧凸Cobb角矫正率分别为（72.66±6.24）%、（73.16±5.49）%、（76.99±4.30）%，C组高于A、B组，差异有统计学意义（P＜0.05），A组与B组之间的差异无统计学意义（P＞0.05）。术前顶椎旋转Nash-Moe分级Ⅱ级以内者，三组的矫正率组间比较差异无统计学意义（P＞0.05）；Nash-Moe分级Ⅱ级以上者，A、B、C三组的矫正率分别为（68.16±7.23）%、（68.69±4.70）%、（76.64±5.75）%，C组较A、B组具有更高的矫正率（P＜0.001）。术后及末次随访时三组顶椎旋转度分级的差异具有统计学意义（P＜0.05），C组较A、B组获得更明显的去旋转效果（P＜0.05）。末次随访时三组患者SRS-22量表自我形象维度评分均较术前获得显著性改善（P＜0.05），C组比A、B组改善更加显著（P＜0.05）。结论：与SRS Ⅰ、Ⅱ级截骨相比，Ⅱ级截骨术联合后路椎间隙松解可显著提高Lenke 5型AIS患者胸腰弯/腰弯侧凸Cobb角矫正率及顶椎去旋转效果。

英文摘要:

  【Abstract】 Objectives: To compare the clinical efficacies of Scoliosis Research Society(SRS) level Ⅰ, level Ⅱ osteotomy and level Ⅱ osteotomy combined with intervertebral space release for the correction of Lenke 5 adolescent idiopathic scoliosis(AIS). Methods: A retrospective analysis was conducted on the clinical data of 101 Lenke 5 AIS patients who underwent surgical treatment in our hospital from January 2016 to September 2022 and had a follow-up period of over 2 years. There were 30 male and 71 female patients, aged 10-18 years(15.1±2.1 years). The patients were divided into three groups based on the surgical methods: group A of 37 patients underwent SRS Ⅰ level osteotomy, group B of 33 patients underwent SRS Ⅱ level osteotomy, and group C of 31 patients underwent SRS Ⅱ level osteotomy combined with intervertebral disc space release. There was no statistically significant difference in age, gender, body mass index(BMI), Risser sign, and other general data between the three groups(P>0.05). The patients were followed up for 24-43 months(30.3±4.1 months). The operative time, estimated intraoperative blood loss, number of fused segments, complications, and postoperative hospital stay were compared between the three groups. The thoracolumbar/lumbar(TL/L) scoliosis Cobb angle, apical vertebral translation(AVT), lumbar lordosis(LL), and thoracic kyphosis(TK) were measured on standing full-spine anteroposterior and lateral X-rays before surgery, one month after surgery, and at final follow-up. The preoperative apical vertebral rotation was assessed using the Nash-Moe grading system, and the postoperative apical vertebral derotation effect was evaluated according to the Upasani X-ray vertebral rotation grading criteria at 1 month after operation and final follow-up. The Scoliosis Research Society-22 questionnaire(SRS-22) was filled out by the patients before surgery and at the final follow-up to evaluate the clinical outcomes. Results: In terms of surgical-related indicators, group C had longer operative time compared with groups A and B(P<0.001), and no statistically significant differences were observed in estimated intraoperative blood loss, fusion segments, or hospital stay(P>0.05). Before surgery, there were no statistically significant differences in the Cobb angle of scoliosis, AVT, LL, and TK between the three groups(all P>0.05). The correction rates of the TL/L Cobb angle for the three groups after surgery were (72.66±6.24)%, (73.16±5.49)%, and (76.99±4.30)%, respectively. Group C had a higher correction rate than groups A and B, with statistical significance(P<0.05), while there was no significant difference between groups A and B(P>0.05). For preoperative apical vertebral rotation graded as Nash-Moe grade Ⅱ or lower, there were no statistically significant differences in correction rates between the three groups(P>0.05). For those graded greater than Nash-Moe grade Ⅱ, the correction rates for groups A, B, and C were (68.16±7.23)%, (68.69±4.70)%, and (76.64±5.75)%, respectively. Group C had a higher correction rate than groups A and B(P<0.001). The differences in postoperative and final follow-up apical vertebral rotation grades among the three groups were statistically significant(P<0.05), with group C achieving a more significant derotation effect compared with groups A and B(P<0.05). At final follow-up, the self-image domain scores of the SRS-22 questionnaire for all three groups were significantly improved compared with preoperative scores(P<0.05), and group C showed a more significant improvement than groups A and B(P<0.05). Conclusions: Compared with SRS level Ⅰ and Ⅱ osteotomies, the combination of SRS level Ⅱ osteotomy and posterior intervertebral space release can significantly improve the correction rate of TL/L scoliosis and the derotation effect of the apical vertebra in patients with Lenke 5 AIS.