腰骶半弯对成人脊柱畸形术后冠状面失平衡的影响

Lumbosacral fractional curve effected on the postoperative coronal imbalance in adult spinal deformity

目的:分析成人胸腰椎/腰椎畸形矫形术后冠状面失平衡的原因和危险因素,探讨腰骶半弯(L4-S1)对术后失平衡的影响。方法:回顾性分析2008年1月~2018年9月间在我院接受手术治疗的成人脊柱畸形患者,病例入选标准:(1)年龄≥20岁;(2)影像学检查胸腰弯/腰弯为主弯(顶椎位于T12-L4之间),腰骶半弯为代偿弯;(3)胸腰弯/腰弯冠状面Cobb角度≥30°;(4)脊柱内固定融合≥5个节段;(5)随访时间6个月以上且具有完整影像资料。统计分析患者的人口学特点、手术方式、影像学参数、冠状面平衡与腰骶半弯的关系,以及治疗效果的健康相关生活质量评分改善情况。结果:共有157例成人胸腰椎脊柱畸形患者纳入本研究,包括男性52例,女性105例,平均年龄56.5岁(26~77岁)。病因学诊断包括先天性脊柱畸形39例,成人特发性脊柱畸形35例,退行性脊柱侧凸83例。术后总共有24例(15.3%)患者发生了冠状面失平衡,失平衡患者的ODI和SF-12 PCS评分较术前无明显改善。影像学评估冠状面平衡组与失平衡组患者的主弯Cobb角与柔韧性,腰骶半弯Cobb角与柔韧性,以及L4、L5椎体术前的倾斜角,手术截骨方式,上、下固定点选择,主弯矫正度和残余角度,腰骶半弯矫正度均没有统计学差异(P>0.05)。平衡组患者的腰骶半弯残余角度明显小于失平衡组患者(6.3°vs 12.2°,P=0.000),L4和L5椎体倾斜度明显小于失平衡组的患者(L4:8.2°vs 17.3°,P=0.000;L5:6.4°vs 15.2°,P=0.000)。术前冠状面向腰弯凸侧偏移的患者发生冠状面失平衡的概率显著增加(23.2%)。结论:冠状面失平衡以后患者的健康相关生活质量受到明显影响。术前冠状面向腰弯凸侧偏移,术后腰骶半弯残余角度过大,术后L4、L5椎体过度倾斜倾是发生冠状面失平衡的危险因素。

Objectives:To investigate the risk factors for postoperative coronal imbalance after adult thoracolumbar/lumbar spinal deformity surgery,and evaluate the impact of lumbosacral fractional curve(L4-Sl,LFC)on the postoperative coronal imbalance.Methods:Patients with adult spinal deformity who received correction treatment from January 2008 to September 2018 were retrospectively reviewed.Inclusion criteria included age older than twenty years,major thoracolumbar/lumbar curve(Cobb angle≥30°)with apex located between T12-L4,and compensatory lumbosacral fractional curve.All the patients underwent long segment fusion(more than 5 levels),and had at least six months follow-up.Demographic and radiographic data,surgical parameters,health-related quality of life(HRQOL)outcomes,as well as the relationship between lumbosacral fractional curve and postoperative coronal imbalance were analyzed.Results:A total of 157 adult spinal deformity patients were included in this study,52 males and 105 females,with an average age of 56.4 years old(range,26-77 years).There were 39 cases of congenital deformity,35 cases of idiopathic scoliosis and 83 cases of de novo scoliosis.Twenty-four patients(15.3%)occurred coronal imbalanced after surgery,in whose postoperative ODI and SF-12 PCS outcomes had no significantly changed when compared with the preoperative level.In radiographic analysis,there was no significant difference(P>0.05)of the following parameters between balance group and imbalance group,including major curve angle and flexibility,LFC angle and flexibility,preoperative L4,L5 vertebral tilt,osteotomy method,upper and lower instrumentation level,correction rate and remnant angle of the major curve.There was significant difference of the following parameters between balance and imbalance group,including remnant angle of LFC curve(6.3°vs 12.2°,P=0.000),postoperative L4 tilt(8.2°vs 17.3°,P=0.000),and postoperative L5 tilt(6.4°vs 15.2°,P=0.000).The incidence of postoperative coronal imbalance significantly increased in patients with coronal C7 plumb line at convexity side of the major thoracolumbar/lumbar curve(23.2%).Conclusions:The health-related quality of life(HQOL)is significantly affected in patient with postoperative coronal imbalance.Preexist C7 plumb line at convexity side of the major thoracolumbar/lumbar curve,large remnant angle of LFC,large postoperative L4 and L5 tilt are risk factors of postoperative coronal imbalance.