腰椎微创侧路椎体间融合术改善成人退变性脊柱侧弯的矢状面平衡疗效分析

Minimally invasive lateral lumbar interbody fusion significantly improves the sagittal balance for adult degenerative scoliosis

目的评估微创腰椎侧方入路椎体间融合术(LLIF/OLIF)对于成人退变性脊柱侧弯矢状面平衡的影响。方法2014年1月至2017年6月,共有23例退变性脊柱侧弯患者在上海瑞金医院行分期微创矫形术,所有患者在第一期从侧方植入LLIF或者OLIF融合器,二期进行后路经皮椎弓根螺钉内固定融合术或经Wiltse入路行腰椎椎弓根内固定术,若患者一期手术矢状面畸形矫正不满意,可在二期手术时进行后路截骨矫形。在两次手术前后使用EOS系统拍摄站立位脊柱全长X线片,应用EOS软件系统测量、评估患者的矢状面平衡参数,包括骨盆投射角(PI)、骨盆倾斜角(PT)、腰椎前凸角(LL)、矢状面垂直轴(SVA)及冠状面Cobb角。评估比较患者手术前后的腰痛视觉模拟评分(VAS评分)和Oswestry功能障碍指数(ODI指数)。手术前后数据采用配对t检验或重复测量方差分析进行比较。结果患者男6例,女17例,平均年龄(72±4)岁(62~79岁)。9例患者采用LLIF手术,14例采用OLIF手术。16例植入3个融合器,5例植入2个融合器,2例植入4个融合器。平均随访24.2个月(15~42个月)。一期手术后,患者侧弯Cobb角(18°±7°)较术前(33°±8°)明显改善(t=13.2,P<0.01);PI-LL(20°±8o比31°±8°)、SVA[(5.3±2.0)cm比(8.2±3.5)cm)、PT(16°±6°比23°±4°)等矢状面参数均较术前明显改善(t=6.8、4.5、9.0,均P<0.01)。患者末次随访时腰痛VAS评分(3.4±1.1比6.3±1.0)和ODI指数(27.3%±3.0%比47.1%±5.9%)也均显著改善(t=11.3、17.8,均P<0.01)。全组无严重并发症发生。结论LLIF/OLIF可以显著改善成人退变性脊柱侧弯的冠状面和矢状面平衡;分期微创手术可以显著缓解患者的疼痛,改善患者的功能。

Objectives To evaluate the effect of minimally invasive lateral lumbar interbody fusion(LLIF/OLIF)on the sagittal balance of adult degenerative scoliosis.Methods From January 2014 to June 2017,a total of 23 patients with degenerative scoliosis underwent staged minimally invasive surgery in Shanghai Ruijin Hospital.All patients were implanted with LLIF or OLIF cage from the lateral approach first,and was followed by the posterior percutaneous pedicle screw fixation or pedicle screw fixation via Wiltse approach.If the sagittal deformity correction was not satisfactory after the first surgery,a posterior osteotomy can be performed during the second stage operation.A biplanar X-ray of the whole spine was taken with the EOS imaging system before and after surgery.The EOS software was used to measure and evaluate the patient′s sagittal balance parameters including pelvic incidence(PI),pelvic tilt(PT),lumbar lordosis(LL),the sagittal vertical axis(SVA)and the coronal Cobb angle.The visual analogue scale(VAS)score for low back pain,the Oswestry Disability Index(ODI)score were evaluated before and after surgery.Paired t test or repeated measures ANOVA was used to compare the data before and after surgery.Results There were 6 males and 17 females with a mean age of(72±4)years(62-79 years).Nine patients were treated with LLIF and 14 patients with OLIF.Sixteen cases were implanted with three cages,five with two cages and two with four cages.The mean follow-up period was 24.2 months(15-42 months).After the first operation,the Cobb angle of the patient was significantly improved(18°±7°vs 33°±8°,t=13.2,P<0.01).All the parameters for sagittal balance,including PI-LL(20°±8°vs 31°±8°),SVA((5.3±2.0)cm vs(8.2±3.5)cm),PT(16°±6°vs 23°±4°)were all significantly improved as well(t=6.8,4.5,9.0,ALL P<0.01).At the last follow-up,the VAS score of low back pain(3.4±1.1 vs 6.3±1.0)and ODI scores(27.3%±3.0%vs 47.1%±5.9%)were also significantly improved(t=11.3,17.8,both P<0.01).No major complications occurred in this group.Conclusions Minimally invasive LLIF/OLIF can significantly improve the coronal and sagittal balance of adult degenerative scoliosis.Staged minimally invasive surgery can significantly alleviate pain and improve function in these patients.