腰椎退行性疾病术后近端交界性后凸的危险因素及治疗

Risk factors and treatment of proximal junctional kyphosis after lumbar degenerative disease

背景:老年腰椎退行性疾病的手术治疗中,有时需要进行长节段固定融合,在获得稳定的同时,可能带来固定节段近端交界性后凸(PJK)。目的:回顾腰椎长节段固定融合病例,对PJK发生的危险因素、发生后的处理、预防方法等进行分析。方法:选取2013年1月至2018年6月行腰椎长节段固定融合术后患者117例,最终82例获得随访(随访率70%),记录患者年龄、性别、身高、体重、随访时间、骨密度、体重指数、固定节段等。手术前后及随访时行X线检查,使用Surgimap软件测量胸椎后凸角(TK)、腰椎前凸角(LL)、脊柱矢状轴(SVA)、近端交界角(PJA)、脊柱整体力线(GSA)、骨盆入射角(PI)、骨盆倾斜角(PT)、骶骨倾斜角(SS),记录Oswestry功能障碍指数(ODI)。对发生PJK的患者记录Hart-ISSG PJKSS量表得分。结果:远端固定到S1的患者以及近端固定到胸腰段的患者PJK发生比例更高。PJK组术前LL、SS较非PJK组更小,术前SVA、PI-LL、GSA较非PJK组更大。末次随访时,27例患者发生PJK(32.9%,27/82),其中9例患者行翻修手术。结论:长节段固定融合手术时远端固定椎应尽量选择L5及L5近端,而近端固定椎尽可能避开胸腰段。对于术前矢状位失衡明显的患者应重视矢状位平衡的恢复,Hart-ISSG PJKSS量表对PJK患者翻修手术具有一定指导价值。

Background:In the surgical treatment of elderly degenerative lumbar disease,sometimes long-segment fixation and fusion are needed.But it may cause the proximal junctional kyphosis(PJK)of fixed segments.Objective:To review longsegment fixed cases and analyze risk factors,treatment and prevention of PJK.Methods:A total of 117 patients who underwent long-segment lumbar fusion surgery between January 2013 and June 2018 were collected,and 82 of them were followed up and enrolled in this study.The age,sex,height,weight,follow-up time,bone mineral density(BMD),body mass index(BMI),fixed segments were recorded.Thoracic kyphosis(TK),lumbar lordosis(LL),sagittal vertical axis(SVA),proximal junctional angle(PJA),global spine alignment(GSA),pelvic incidence(PI),pelvic tilt(PT),and sacral slope(SS)were measured with Surgimap software before and after surgery.The Oswestry disability index(ODI)and Hart-ISSG PJKSS(PJK severity scale)of patients with PJK was evaluated.Results:There was higher proportion of PJK in patients with distal fixation to S1 and those with uppermost instrumented vertebra(UIV)in T11-L1.The patients with PJK had smaller preoperative LL and SS,and larger preoperative SVA,PI-LL and GSA than those without PJK.At the last follow-up,PJK occurred in 27(32.9%,27/82)patients.Nine of these PJK patients underwent revision surgery.Conclusions:In long-segment fusion surgery,L5 or proximal vertebra should be selected as the lowest instrumented vertebra as far as possible and do not leave the UIV in the T11-L1.It should be paid more attention to the recovery of sagittal balance in patients with obvious preoperative sagittal imbalance.The Hart-ISSG PJKSS scale has certain guiding value for revision surgery of PJK patients.