分期微创与开放手术治疗成人退变性脊柱侧凸的疗效比较

Clinical and radiological outcomes of staged minimally invasive surgery for adult degenerative scoliosis comparing with the conventional open surgery

目的 比较分期微创手术与开放手术治疗成人退变性脊柱侧凸的疗效和并发症发生情况.方法 2013年6月至2017年6月,共42例退变性脊柱侧凸患者接受手术治疗,23例采用分期微创矫形手术(微创组),19例采用后路开放矫形手术(开放组).记录患者的手术时间、术中出血量等情况,临床疗效评估采用Oswestry残疾指数(Oswestry Disability Index, ODI)和疼痛视觉模拟评分(visual analogue scale, VAS),影像学评估采用侧凸Cobb角及矢状面垂直轴(sagittal verti-cal axis,SVA)、骨盆入射角(pelvic incidence,PI)与腰椎前凸角(lumbar lordosis,LL)差值(PI-LL)、骨盆倾斜角(pelvic tilt, PT)等矢状面平衡参数,并记录患者的并发症发生情况.结果 两组患者性别、年龄和内科合并症情况的差异无统计学意义,两组患者均平均随访2年以上.微创组两次手术总的出血量(405.7±144.8)ml明显少于开放组(2 005.3±528.4)m(l t=10.31,P<0.001);微创组患者总的手术时间(414.3±63.0)min明显长于开放组(304.2±51.8)min(t=6.10,P<0.001),但每次手术的时间均较开放组的时间短.两组患者手术后腰痛、腿痛和腰椎功能均明显改善,两组间的差异无统计学意义,但术后3个月微创组腰痛VAS评分(t=2.52,P=0.02)和OD(I t=2.63,P=0.01)优于开放组;两组患者术后冠状面Cobb角和矢状面平衡均有明显改善,微创组患者术后冠状面畸形矫正优于开放组,两组矢状面平衡参数改善程度的差异无统计学意义.开放组患者总的并发症发生率(63.2%)高于微创组(34.8%),但差异无统计学意义(χ^2=3.36,P=0.07);开放组严重并发症的发生率明显高于微创组(Fisher确切概率法,P=0.014).结论 分期微创手术可以明显缓解成人退变性脊柱侧凸患者的疼痛和腰椎功能,改善冠状面和矢状面平衡,其短期疗效与开放手术相当;且具有术中出血量明显减少,严重并发症的发生率也低于开放手术;但微创手术的长期疗效仍有待进一步随访观察.

Objective To evaluate the clinical and radiological outcomes,and the complications of staged minimally inva-sive surgery for adult degenerative scoliosis,comparing with that of the conventional open surgery.Methods From Jun 2013 to Jun 2017,a total of 42 cases of degenerative scoliosis underwent surgical treatment.Among which,23 cases underwent staged min-imally invasive surgery(MIS group)and 19 cases underwent posterior open surgery(open group).The intra-operative bleeding,and operation time were recorded.The clinical outcomes were assessed using the Oswestry Disability Index(ODI),Visual Analogue Scale(VAS)for low back pain and leg pain.The radiological outcome was evaluated with Cobb angles and sagittal balance parame-ters(Sagittal Vertical Axis(SVA),Pelvic Incidence(PI)-Lumbar Lordosis(LL),Pelvic Tilt(PT)).The occurrence of complications was recorded.Results The baseline demographic features of both groups(gender,age,medical comorbidity,etc.)were similar.The mean follow-up period for both groups was more than 2 years.The intraoperative bleeding in the MIS group 405.7±144.8 ml was significantly lower than that in the open group(2 005.3±728.4 ml,t=10.31,P<0.001);The total operation time 414.3±63.0 min of MIS group was significantly longer than that of the open group(304.2±51.8 min,t=6.10,P<0.001),but the operating time of each stage was shorter than the open group.The VAS score for back pain and leg pain,the ODI scores were significantly improved after surgery for both group,there was no significant difference between the two groups,but the low back pain and function in MIS group were better than the open group.The parameters of the coronal and sagittal deformity were significantly improved in both groups,correction of coronal deformity in MIS groupwassignificantly superior to the open group(F=12.02,P=0.001),there was no significant difference in sagittal balance correction between the two groups.The overall complication rate(63.2%)was slightly higher in the open group than in the MIS group(34.8%)without significant difference(χ^2=3.36,P=0.07).The incidence of major complications in the open group was significantly higher than that in the MIS group(P=0.014).Conclusion Staged minimally in-vasive surgery can significantly relieve the patient's pain,improve functionand the coronal and sagittal balance of the patient,the early clinical and radiological outcomes were comparable to the open surgery;Minimally invasive surgery may significantly reduce the amount of bleeding and major complications.Minimally invasive surgery is safe and effective for carefully selected patients with degenerative scoliosis.However,the long-term outcomes of minimally invasive surgery remains to be followed up.