成人退行性腰椎侧凸的术式选择与疗效分析

Surgical options and result analyses in adult degenerative lumbar scoliosis

目的回顾性分析根据不同程度成人退行性腰椎侧凸采用不同术式治疗后的中远期疗效。方法自1998年5月至2002年11月手术治疗31例成人退行性腰椎侧凸患者。平均年龄55．8岁（45～71岁）。全部患者共分4组：A组为腰椎冠状位畸形较轻、矢状位畸形明显者13例；B组为腰椎冠状位畸形明显、矢状位畸形轻微，行椎管减压、内固定植骨融合术者5例；C组为腰椎冠状位、矢状位均畸形严重，行后路椎管减压、冠状位原位融合、矢状位矫形内固定植骨融合术者5例；D组为腰椎冠状位、矢状位轻微畸形伴腰椎管狭窄，行单纯减压者8例。所有病例术后至少随访5年，收录I隘床结果和影像学资料。术前、术后1年和5年所有患者完成Oswestry下腰痛功能障碍问卷调查表。结果30例患者全程随访，平均随访74个月（60～94个月）。内固定组患者术后1年较术前冠状位、矢状位Cobb角显著改善（q=10．125，P〈0．05），术后1年和术后5年差异无统计学意义（q=1．031，P〉0．05）；术后5年，单纯减压组（D组）腰椎冠状位Cobb角较术前呈增大趋势（q=3．071，P〉0．05），矢状位Cobb角呈减小趋势（q=0．928，P〉0．05）。所有患者术后1年ODI评分功能障碍指数较术前显著改善（12．4±7．69比56．8±13．2，q=6．453，P〈0．05）；术后5年较术后1年略有反弹，但仍显著优于术前（24．9±5．3比12．4±7．69，q=8．148，P〈0．05）。结论退变性腰椎侧凸手术治疗的主要目的为彻底减压、重建矢状面和冠状面力学平衡。尽管成人退行性脊柱侧凸临床情况复杂多变，按照不同患者具体畸形情况、根据个体化原则，合理选择术式，可以有效改善患者生活质量。

Objective To investigate the clinical and radiographic outcomes for varying degrees of degenerative lumbar scoliosis using different surgical options with a minimal 5-year follow-up. Methods From May 1998 to November 2002, 31 patients with degenerative lumbar scoliosis underwent operations at our hospital. The mean age of 19 females and 12 males was 55. g years old （range： 45 to 71）. All patients were divided into 4 groups： Group A, mild coronal deformity with obvious sagittal deformity, 13 cases; Group B, obvious coronal deformity with mild sagittal deformity; Group C, both significant coronal and sagittal deformities; Group D, both mild coronal and sagittal deformities. Posterior decompression, internal fixation and bone graft fusion were performed in Groups A, B and C. And posterior decompression was performed in Group D. All patients were followed up for at least 5 years. Patients answered the Oswestry low back pain disability questionnaire at pre-operation, and 1 year, 5 year post-operation. Results Thirty patients were followed up for the whole process. According to Cohh＇s angle methods, there was great post- operative improvement for patients with internal fixation （ Groups A, B, C） while there was no significant difference for patients with posterior decompression at pre-and post-operation. After surgery, the average Oswestry Disability Index score in the patients with internal fixation （Groups A, B, C） was significantly lower than the preoperative score （25.8 vs 58.0; P 〈0. 001 ）. However there was statistical difference for patients with internal fixation between 1 year and 5 year postoperatively. No perioperative death or major medical complications occurred. Ten patients had adjacent segment degeneration. Conclusions The surgical aim for adults with a spinal deformity is to achieve a stable, balanced and pain-free spine. Surgical treatments should consist of decompression and fusion with segmental instrumentation to avoid instability and curb progression. Despite the complexity of adult lumbar degenerative scoliosis, it might improve the quality of life for patients by choosing an appropriate operation option on the basis of varying degrees of lumbar deformity.