脊柱融合手术治疗高龄退变性脊柱侧凸的临床疗效及影响因素分析

The clinical efficacy and influencing factors of spinal fusion surgery in the treatment of elderly degenerative scoliosis

目的 探讨老年成人退变性脊柱侧凸 (adult degenerative scoliosis,ADS) 患者的病情特点与手术治疗后临床疗效和相关并发症之间的关系。方法 回顾性分析 318 例接受经后路腰椎椎体间融合术的 ADS 患者的临床资料,这些患者在手术时至少 60 岁,随访至少 2 年。收集患者基本信息、术前合并症、术前及术后影像学参数、临床功能评分以及术后并发症等相关信息。纳入分析的影像学参数包括脊柱侧凸 Cobb’s 角 (Cobb’s angle,CA)、矢状位垂直轴 (sagittal vertical axis,SVA)、骶骨倾斜角 (sacrial slope,SS)、腰椎前凸角 (lumbar lordosis,LL)、骨盆投射角 (pelvic incidence,PI)、骨盆倾斜角 (pelvic tilt,PT) 以及骨盆投射角与腰椎前凸角之差 (pelvic incidence minus lumbar lordosis mismatch,PI-LL)。采用 Oswestry 功能障碍指数(oswestry disability index,ODI)、日本骨科协会 (Japanese Orthopaedic Association,JOA) 评分、腰椎僵硬残障指数 (lumbar stiffness disability index,LSDI) 和疼痛视觉模拟评分 (visual analog scale,VAS) 评估临床疗效。将患者分为年轻组 (年龄 < 80 岁,n=252) 和高龄组 (年龄 ≥ 80 岁,n=66),并将并发症分为内科并发症和外科并发症进行分析比较。年龄与术后预后的相关性采用线性回归模型进行分析或采用基于 Wald 统计的单变量 Logistic 回归模型进行分析。使用受试者操作特征曲线 (receiver operating characteristic,ROC) 结果来确定年龄对术后结局的可预测性。结果 本组患者的手术治疗效果良好,随访过程中矢状面平衡逐渐接近术前状态。单变量线性回归分析发现,末次随访 SVA (B=0.129,P=0.021)、术后 ODI (B=0.219,P < 0.001)、术后 JOA (B=0.197,P < 0.001) 与年龄呈正相关。近端交界性后凸 (proximal joint kyphosis,PJK) (B=0.043,P=0.012)、内固定松动 (B=0.054,P=0.009) 与年龄呈正相关。采用 ROC 曲线分析计算年龄对 PJK 及内固定松动风险的阈值 (cut-off 值)。年龄对 PJK 和内固定松动的预测阈值分别为 71.5 (AUC=0.591) 和 80.5 (AUC=0.606)。结论 高龄 ADS 患者采用脊柱矫形手术治疗有效。高龄 ADS 患者与年轻 ADS 患者的术后并发症发生率较为相似。手术治疗高龄 ADS 的主要目标是改善患者的术后客观运动功能情况。高龄 ADS 患者在手术治疗后难以避免术后并发症的发生。

Objective To explore the relationship between the characteristics of elderly adult degenerative scoliosis (ADS) patients and the clinical efficacy or related complications after surgical treatment.Methods In this study,data of ADS patients (at least 60 years of age) after PLIF were reviewed and followed up for at least 2 years.Patients’ basic information,preoperative complications,preoperative and postoperative imaging parameters,clinical functional scores and postoperative complications were collected.Radiographic parameters included Cobb’s angle (CA),sagittal vertical axis (SVA),sacrial slope (SS),lumbar lordosis (LL),pelvic incidence (PI),pelvic tilt(PT) and pelvic incidence minus lumbar lordosis mismatch (PI-LL).Oswestry disability index (ODI),Japanese Orthopaedic Association score (JOA),lumbar stiffness disability index (LSDI) and visual analog scale (VAS) were used to evaluate clinical efficacy.Patients were divided into young patient group (age < 80 years old,n=252) and old patient group (age ≥ 80 years old,n=66) for comparison;in addition,complications were divided into medical complications and surgical complications for analysis.The correlation between age and postoperative outcomes was analyzed by either linear regression model or univariate logistic regression model based on Wald statistics.ROC curve analysis was used to determine the predictability of age on postoperative outcomes.P < 0.05 was considered as statistically significant.Results A total of 318 patients were enrolled in this study.There were 252 patients in the young group and 66 patients in the old group.The patient received good surgical treatment,and the sagittal plane balance gradually approached the preoperative state during the follow-up.Univariate linear regression analysis found that SVA was positively correlated with age at the last follow-up (B=0.129,P=0.021),postoperative ODI(B=0.219,P < 0.001),and postoperative JOA (B=0.197,P < 0.001).PJK (B=0.043,P=0.012) and internal fixation looseness (B=0.054,P=0.009) were positively correlated with age.ROC curve was used to analyze and calculate the cut-off value of the age to predict the risk of PJK and internal fixation loosening.The predictive thresholds of age for PJK and internal fixation loosening were 71.5 (AUC=0.591) and 80.5 (AUC=0.606),respectively.Conclusions Surgical treatment is more effective for elderly ADS patients.The incidence of postoperative complications is similar between the elderly and young ADS patients.The main objective in surgical treatment of elderly ADS is to improve postoperative motor functions.It is difficult to avoid postoperative complications in elderly ADS patients after surgical treatment.