单节段脊柱去松质骨截骨与双节段经椎弓根截骨矫正强直性脊柱炎后凸畸形的临床效果比较

Comparison of the clinical effect in ankylosing spondylitis-related kyphosis between one-level vertebral column decancellation and two-level pedicle subtraction osteotomy

目的 ：比较单节段脊柱去松质骨截骨（vertebral column decancellation,VCD）与双节段经椎弓根截骨（pedicle subtraction osteotomy,PSO）矫正强直性脊柱炎后凸畸形的临床效果,探索两者之间的差异性。方法 ：2007年1月~2013年3月共有33例需行40°~65°截骨的强直性脊柱炎后凸畸形矫形术后患者纳入研究,其中男31例,女2例,年龄19~56岁（35.2±8.9岁）,后凸畸形以胸腰段后凸为重,脊柱胸腰段后凸Cobb角42.3°±15.2°,腰段前凸Cobb角4.4°±16.4°。A组15例行单节段VCD,B组18例行双节段PSO,记录手术前后胸椎后凸角、胸腰段后凸角、腰椎前凸角、矢状面垂直轴、骨盆入射角、骨盆倾斜角、骶骨倾斜角、截骨角度、脊柱侧凸研究学会（Scoliosis Research Society,SRS）-22量表评分、Oswestry功能障碍指数（Oswestry disability index,ODI）、术中出血量及手术时间,比较两组观察指标及其变化量之间的差异。结果 ：A组截骨部位分别为T12 1例、L2 6例、L3 8例,截骨角度46.7°~64.2°（53.6°±6.7°）;B组截骨部位分别为L1、L3 13例,T12、L2 4例,T12、L3 1例,截骨角度45.1°~63.9°（55.6°±6.0°）。固定节段于截骨部位近端及其远端延伸至少2个椎体,B组截骨部位之间椎体均固定。A、B两组患者术后均未出现神经系统并发症。A、B两组术后胸腰段后凸角、腰椎前凸角、骶骨倾斜角、骨盆倾斜角、矢状面垂直轴、ODI、SRS-功能评分、SRS-疼痛评分、SRS-外观评分、SRS-心理评分、SRS-满意度评分均较术前明显改善（P〈0.05）,A组术后胸椎后凸角与术前相比差异无统计学意义（P〉0.05）,B组术后胸椎后凸角与术前相比变小且差异有统计学意义（P〈0.05）。两组观察指标对比,除胸椎后凸角变化量、术中出血量和手术时间两组间有统计学差异（P〈0.05）外,余均无统计学差异（P〉0.05）。结论：对于需行40°~65°截骨角度的强直性脊柱炎后凸畸形患者,单节段VCD可取得与双节段PSO相似的矫正效果,且术中出血量更少,手术时间更短,在重建矢状面平衡与改善生活质量方面效果满意。

Objectives： To investigate the surgical outcome differences of ankylosing spondylitis（AS）-related kyphosis between one-level vertebral column decancellation and two-level pedicle subtraction osteotomy.Methods： From January 2007 to March 2013, 33 patients（31 males and 2 females） with an osteotomy angle between 40° and 65°, and with an average age of 35.2 years（19-56 years） were reviewed. The thoracolumbar kyphosis angle was 42.3°±15.2° and the lumbar lordosis angle was 4.4°±16.4°. Group A included 15 cases who underwent one-level vertebral column decancellation, and group B included 18 cases who underwent two-level pedicle subtraction osteotomy. The thoracic kyphosis, thoracolumbar kyphosis, lumbar lordosis, sagit-tal vertical axis, pelvic incidence, pelvic tilt, sacral slope, osteotomy angle, Scoliosis Research Society（SRS）-22 and Oswestry disability index（ODI） score at the pre- and post-operation were recorded between 2 groups. The observational indexes before and after surgery as well as the differences of the observational index variation between group A and group B were compared, respectively. Results： The osteotomy sites of group A included 1in T12, 6 in L2 and 8 in L3, respectively. Osteotomy angle ranged from 46.7° to 64.2°（53.6°±6.7°）. The osteotomy sites of group B included 13 in L1 and L3 respectively; 4 in T12, L2 and 1 in T12 and L3 each.Osteotomy angle ranged from 45.1° to 63.9°（55.6°±6.0°）. The fixed segment in the proximal and distal segments extended at least two vertebral bodies, the vertebral body between osteotomy sites in group B must be fixed.The neurological complication was not noted in 2 groups after operation. The thoracic kyphosis, thoracic kyphosis, lumbar lordosis, sagittal vertical axis, pelvic tilt, sacral slope, SRS-22 and ODI of two groups improved significantly（P〈0.05） after operation except of the thoracic kyphosis of group A（P〉0.05）. The differences of observational index variation between group A and group B showed no statistical significance（P〉0.05） except of the changes of thoracic kyphosis, peri-operative bleeding and operation time（P〈0.05）. Conclusions： One-level vertebral column decancellation and two-level pedicle subtraction osteotomy have similar outcomes for AS patients with the osteotomy angle between 40° and 65°. While for sagittal balance and improvement of the quality of life, one-level vertebral column decancellation is more satisfactory.