退变性腰椎侧凸患者腰椎前凸矫正程度与疗效的关系

The relationship between lumbar lordosis reconstruction and clinical outcomes in degenerative lumbar scoliosis

目的：评价退变性腰椎侧凸（degenerative lumbar scoliosis，DLS）患者行长节段固定矫形术的疗效，探讨合适的腰椎前凸矫正程度。方法：回顾性分析55例行长节段矫形固定术（至少4个椎体）的DLS患者的临床和影像学资料，随访时间至少2年。采用腰痛和下肢痛VAS评分、ODI评价患者的健康相关生活质量。在全脊柱正侧位X线片上测量脊柱骨盆矢状位参数。根据末次随访时骨盆入射角（pelvic incidence，PI）与腰椎前凸角（1umbarlordosis，LL）之差（PI—LL）是否在±9°范围内分为PI—LL在±9°范围内（PI—LL＋组）和不在±9°范围内组（PI—LL-组），使用独立样本￡检验比较两组影像参数和生活质量；用散点图和拟合曲线探索合适的LL范围，用独立样本t检验比较该范围内（A组）、外（B组）患者的评分差异；并分组比较不同矢状位平衡（SVA）范围的ODI差异。结果：55例DLS患者年龄为40～75岁（63．2±6．9岁），术前Cobb角为10．2°～52.3°（25．1°±11，5°），PI为23．4°～72．7°（47．5°±11．2°）。术前LL为-19．7°～50．1°（27．6°±15．2°），末次随访时为6．6°～64°（34．5°±11．9°），差异有显著性（P〈0．01）；术前和末次随访时SVA无显著性差异（46．1±47．7mmvs49．6±36．9mm，P〉0．05）。末次随访时PI—LL＋患者15例，PI-LL-患者40例，PI—LL＋患者末次随访时腰痛VAS评分较PI—LL-患者高（4．6±2．5vs．2．9±2．1，P=0．015），下肢痛VAS评分和ODI无显著性差异（P〉0．05）。散点图及拟合曲线显示腰痛VAS评分和ODI在PI—LL为15°～28°时较低．在15°-28°的19例患者与不在15°～28°的36例患者比较．术后腰痛VAS评分更低（P〈0．05），下肢痛VAS评分和ODI无显著性差异（P〉0．05）。29例SVA〈50mm患者的ODI与17例50≤SVA〈80mm患者无最著性差异（P〉0．05），9例SVA≥80mm患者的ODI高于50≤SVA〈80mm的患者（P〈0．01）。结论：L=PI＋9°可能并不适合作为国人DLS患者的矫形目标，按照PI—LL=15°～28°的对应关系矫正腰椎前凸可获得较好的疗效；对于老年DLS患者而言，SVA=80mm作为矢状位失衡的评价标准可能更加准确．

Objectives： To assess the health-related quality of life after long-segment corrective surgery for degenerative lumbar scoliosis （DLS）, and to explore the ideal lumbar lordosis reconstruction. Methods： The study included 55 patients with DLS who underwent long-segment fixation（at least 4 vertebrae）, with at least 2 years follow-up. Pre- and post-operative symptoms were assessed by using the visual analog scale（VAS） for low back pain and leg pain; Oswestry disability index（ODI） was used to quantify disability. The sagittal parameters of spine were measured on the anteroposterior and lateral radiographs. Patients were categorized based on whether the postoperative goal of pelvic incidence minus lumbar lordosis （PI-LL） within ＋ 9° was achieved（group PI-LL＋） or not（group PI-LL-）. Parameters and clinical outcomes were compared by using independent t-test. Scatter diagrams and fitting curves were used to determine the optimal LL range, an independent t-test was used to compare the symptom scores between patients in（group A） and out（group B） in this range. The difference of ODI between different SVA groups were also analyzed. Results： The 55 DLS patients （40-75, 63.2±6.9 years） showed an average Cobb angle of 25.1°±11.5°（10.2°-52.3°）, the preoperative PI was 47.5°±11.2°（23.4°-72.7°）. The LL at the final follow-up was lower than the preoperative LL （34.5°±11.9° vs 27.6°±15.2°）, while there was no difference between the preoperative SVA and the postoperative value. Group PI-LL＋（15 patients） showed worse VAS score for low back pain（4.6±2.5 vs 2.9±2.1, P=0.015） than group PI- LL-（40 patients）, while there was no difference in VAS score for leg pain or ODI between the two groups（P〉 0.05）. Scatter diagrams and fitting curves showed that the VAS score for low back pain and the ODI were lower in the PI-LL range of 15°-28°. Patients in group A（19 cases） had better VAS score for low back pain and ODI than group B （36 cases） at the final follow-up （P〈0.05）, while there was no difference in VAS（leg pain） or ODI （P〉0.05）. There was no difference in ODI among the 29 patients with SVA〈50mm and the 17 patients with 50mm≤SVA〈80mm （P〉0.05）, and the other 9 patients with SVA≥80mm had higher ODI than patients with 50mm≤SVA〈80mm（P〈0.01）. Conclusions： The goal of LL=PI±9° may be not suitable for Chinese DLS corrective surgery. A surgical plan based on LL=PI-20°（PI-LL=15°-28°） is related to better outcomes. For elderly DLS patients, it is more accurate to use SVA=80mm as the threshold of sagittal imbalance rather than SVA=50mm.