经第2骶椎骶髂螺钉与髂骨螺钉技术治疗成人退变性脊柱侧后凸的矫形疗效比较

Comparison of clinical outcome between utilized second sacral alar-iliac and iliac screw on kyphoscoliosis patients

目的 比较后路经第2骶椎骶髂（S2 AI）螺钉固定技术与髂骨螺钉（IS）固定技术治疗成人退变性脊柱侧后凸患者的矫形效果.方法 回顾性分析2013年1月至2016年1月在南京大学医学院附属鼓楼医院脊柱外科行后路经S2 AI螺钉固定术（S2 AI组）和IS固定术（IS组）的成人退变性脊柱侧后凸患者的病例资料.其中S2AI组14例,男性2例,女性12例,年龄（58.8±7.3）岁;IS组8例,男性1例,女性7例,年龄（63.0±7.6）岁.所有患者在术前、术后和随访时行站立位全脊柱正侧位X线检查,记录患者术后及随访时的并发症,包括断棒、断钉、冠状面和矢状面矫正丢失等.在术前及末次随访时收集生活质量相关量表：疼痛视觉模拟评分（VAS）、Oswestry功能障碍指数问卷表（ODI）、健康调查简表（SF-36）.在末次随访时对患者进行体检以诊断骶髂关节功能障碍.分别采用重复测量方差分析、配对t检验或非参数检验对数据进行统计学分析.结果 两组患者年龄、随访时间、术前Cobb角、C7铅垂线至骶骨中垂线的距离（C7 PL-CSVL）、矢状面轴向距离（SVA）等一般资料的差异均无统计学意义（P值均〉0.05）.S2 AI组患者术前、术后、末次随访时的Cobb角分别为44.4° ±14.0°、20.2°±7.2°、18.3°±7.1°,C7PL-CSVL分别为（25.3±16.0）mm、（10.3±5.7）mm、（9.2±4.2）mm,RK角中位数为33°（-12°,50°）、-20°（-33°,9°）、-19°（-29°,9°）,SVA分别为（31.5±34.4）mm、（12.1±8.4）mm、（10.9±7.2）mm,术后较术前均明显改善（t=6.18、5.94,Z=-2.37,t=2.44,P〈0.05）,末次随访时未见明显矫正丢失.术前和末次随访时S2 AI组患者SF36-生理功能总分（PCS）分别为（39.8±14.3）分和（68.2±21.5）分,SF36-心理功能总分（MCS）分别为（44.9±14.8）分和（73.9±19.9）分,ODI指数分别为（37.7±16.9）分和（19.8±15.8）分,VAS分别为（4.8±2.1）分和（1.8±0.9）分,所有评分较术前均有明显改善（t=4.38、3.52、2.26、4.29,P值均〈0.05）.IS组患者术前、术后、末次随访时的Cobb角分别为54.3°±18.3°、26.1°±13.2°、25.6°±18.3°,C7PL-CSVL分别为（31.0±16.0）mm、（13.9±7.0）mm、（12.4±6.6）mm,RK角分别为47.0°（15.0°,57.0°）、4.0°（-10.0°,16.0°）、7.0°（-9.0°,12.0°）,SVA分别为（27.1±23.9）mm、（13.1±7.5）mm、（13.6±6.0）mm,各参数术后较术前均明显改善（t=5.28、4.70,Z=-3.06,t=2.20,P值均〈0.05）,末次随访时未见明显矫正丢失.术前和末次随访时IS组患者SF36-PCS分别为（29.7±7.1）分和（61.1±11.2）分,SF36-MCS分别为（35.9±7.1）分和（64.0±11.1）分,ODI指数分别为（48.6±13.4）分和（19.0±10.7）分,VAS分别为（4.9±1.8）分和（2.6±1.3）分,所有评分较术前均明显改善（t=7.96、6.72、8.52、4.25,P值均〈0.05）.两组患者术前、术后及末次随访时的Cobb角、SVA、RK和C7 PL-CSVL均无差异,术前和末次随访时两组患者生活质量量表SF-36、ODI指数和VAS亦无差异.结论 对于退变性脊柱畸形患者,S2 AI螺钉固定技术可提供与IS固定技术相似矫形效果,且S2 AI组患者不会因螺钉走行于骶髂关节而影响生活质量.

Objective To compare the clinical outcome and health related quality of life（ HRQoL） of patients with degenerative spinal deformity who underwent spino-pelvic fixation utilized second sacral alar-iliac（S2AI）with patient utilized traditional iliac screw（IS）. Methods Patients diagnosed as degenerative spinal deformity who underwent spino-pelvic fixation utilized either S2 AI screw or Iliac screw at Department of Spine Surgery of Drum Tower hospital from January 2013 to January 2016 were retrospectively analyzed. Patients were divided into two groups according to the pelvic fixation technique. Cobb′s angle, coronal balance distance（ CBD） ,regional kyphosis（ RK） ,sagittal vertical axis（ SVA） were recorded at pre-operation, post-operation and last follow up. The MOS item short from the health survey（ SF-36） ,visual analogue scale （ VAS） , Oswestry disability index （ ODI ） were also recorded at pre-operation and last follow up. Five physical examinations were administered to all patient at the last follow up to diagnose sacroiliac joint dysfunction,three tests resulting positive were regarded as dysfunction. Repeated measurement analysis of variance,t-test or non-parametric test was used to analyzed the data, respectively. Results A total of 22 patients who met the inclusion were recruited in this study. Fourteen patients were utilized S2 AI screw and 8 patients were utilized iliac screw. There were no significant differences in age,gender,follow up time between two groups. Cobb′s angle,CBD,RK,SVA at pre- and post-operation and last follow up showed no significant difference between two groups. SF-36, ODI, VAS at pre-operation and last follow up showed no significant difference between two groups. Compared with baseline,Cobb′s angle（44. 4°±14. 0° vs. 20. 2°± 7.2° vs. 18.3°±7.1°）,C7PL-CSVL（（25.3±16.0）mm vs. （10.3±5.7）mm vs. （9.2±4.2）mm）,RK （ 33. 0° （-12. 0° , 50. 0° ） vs. 20. 0° （-33. 0° , 8. 5° ） vs. -19. 0° （-29. 0° , 19. 0° ） ） , SVA （ （ 31. 5 ± 34.4）mm vs. （12.1±8.4）mm vs. （10.9±7.2）mm）,SF36-physical function summary（PCS）（39.8± 14. 3 vs. 68. 2±21. 5）,SF36-mental component summary（MCS）（44. 9±14. 8 vs. 73. 9±19. 9）,ODI（37. 7± 16. 9 vs. 19. 8±15. 8）,VAS（4. 8±2. 1 vs. 1. 8±0. 9） were significantly improved postoperatively in S2AI group（P〈0. 05）. In the IS group,compared with baseline,Cobb′s angle（54. 3°±18. 3° vs. 26. 1°±13. 2° vs. 25.6°±18.3°）,C7PL-CSVL（（31.0±16.0）mm vs. （13.9±7.0）mm vs. （12.4±6.6）mm）,RK （47. 0°（15. 0°,57. 0°） vs. 4. 0°（-10. 0°,16. 0°） vs. 7. 0°（-9. 0°,12. 0°））,SVA（（27. 1±23. 9）mm vs. （13. 1±7. 5）mm vs. （13. 6±6. 0）mm）,SF36-PCS（29. 7±7. 1 vs. 61. 1±11. 2）,SF36-MCS（35. 9±7. 1 vs. 64. 0±11. 1）,ODI（48. 6±13. 4 vs. 19. 0±10. 7）,VAS（4. 9±1. 8 vs. 2. 6±1. 3） were also significantly improved postoperatively（ all P〈0. 05） . There were two patients need revision surgery in the IS group due to the instrumentation-related complication. None of the patients in the S2 AI group needed revision surgery. There were no instances of sacroiliac joint dysfunction in both groups at last follow up. Conclusion Spino-pelvic fixation utilizing S2 AI screw could provide similar correction rate to iliac screw and the sacroiliac joint penetration due to S2 AI won′t affect the HRQoL in patient with degenerative deformity who utilized S2 AI.