长节段近端融合固定椎的选择对治疗退变性腰椎侧凸疗效的影响

Clinical effects of different methods of the proximal fusion for long segmental lumbar vertebrae fusion in treatment of degenerative lumbar scoliosis

目的 探讨退变性腰椎侧凸（DLS）长节段近端融合治疗的方法。方法 回顾性分析2007年1月至2014年3月南京医科大学附属上海一院临床医学院（35例）和南京医科大学附属淮安第一医院（20例）55例经不同近端融合椎的长节段固定融合治疗DLS患者的临床及影像学资料。根据近端融合椎的不同选择，分为A组（17例，固定至水平椎）、B组（18例，固定至中立椎体）和C组（20例，固定至侧凸上端椎）。采用视觉模拟量表（VAS）评分法对术前、末次随访时的腰腿痛分别进行评分；采用Oswestry指数（ODI）对术前、末次随访时的腰腿痛及腰部功能情况进行评估；测量脊柱X线片冠状面和矢状面参数；对3个组的临床和影像学做组内比较及组间比较。结果 55例患者中1例因术后肺部严重感染死亡，54例获得2～4年的随访。各组术前与末次随访之间的腰痛VAS、ODI指数、冠状面平衡指标、矢状面平衡指标比较差异有统计学意义（P〈0.05）。末次随访时A、B、C组的冠状面Cobb角矫正率分别为75.8%±12.8%、69.6%±11.8%、63.4%±15.3%，A和C组之间差异有统计学意义（P〈0.05）。A、B、C组早期并发症率52.9%、22.0%和15.0%比较差异有统计学意义（P〈0.05）。A、B、C组近端邻近节段病变发生率12.5%、22.2%、50.0%，差异有统计学意义（P＝0.045）。结论 3种近端融合椎的长节段固定融合治疗DLS可以获得明显的临床疗效；但是在改善冠状面畸形方面固定至水平椎优于侧凸的上端椎；固定至侧凸的上端椎有利于减少早期并发症，但是较选择水平椎更容易发生影像学上的远期近端邻近节段病变。

Objective To explored the clinical effects of different methods of the proximal fusion for long segmental lumbar vertebrae fusion in treatment of degenerative lumbar scoliosis（DLS）.Methods From January 2007 to March 2014 fifty-five cases of DLS treated by the posterior proximal fusion of long segmental lumbar vertebrae fusion were analyzed in Department of Orthopaedics, Shanghai general Hospital of Nanjing Medical University （35）HuaiAn The First Hospital Affiliated to Nanjing Medical University（20）. According to various upper instrumented vertebra（UIV） the patients were divided into Group A（upper horizontal vertebra, UHV, n=17）, Group B （upper natural vertebra, UNV n=18 ）, and Group C（upper end vertebra, UEV, n=20）. The VAS, ODI, spinal balance parameters and postoperative complications in each group were assessed.Results Except for 1 case death of serious lung infection in early postoperative, 54 cases were received 2-4 years follow-up. No statistical differences in improvements and fusion rates were found among 3 groups （P〉0.05）. The improvements of the coronal Cobb′s angle in the A group were significantly more than the C group （75.8%±12.8%, 69.6%±11.8%, 63.4%±15.3%, P〈0.05）. The incidences of early postoperative complications in A group were the highest, next in B group, and lowest C group （52.9%, 22.0%, 15.0%, P〈0.05）. The incidences of proximal ASD in the C group were significantly more than the A group （12.5%, 22.2%, 50.0%, P=0.045）.Conclusion UHV, UNV and UEV had similar clinical outcomes for treatment of degenerative lumbar scoliosis in short term. Correction of the coronal deformity of UHV was superior to UEV. UEV was beneficial to reduce early complications, but more likely to happen proximal adjacent segment degeneration in the long run.