后路减压并内固定术治疗退行性脊柱侧凸对脊柱-骨盆矢状面参数和疗效的影响

Effect of posterior decompression and internal fixation in treatment of degenerative scoliosison sagittal spinopelvic parameters and efficacy

目的评估后路减压并内固定术对退行性脊柱侧凸(DS)患者术后生活质量和矢状面参数的影响,以及对矢状面重建策略的初步探索。方法2015年1月—2020年5月,重庆市中医骨科医院采用后路减压并椎弓根螺钉内固定融合术治疗DS患者64例,记录手术时间、术中出血量、术中透视次数、住院时间及并发症发生情况。采用疼痛视觉模拟量表(VAS)评分评估腰痛和下肢痛程度,采用Oswestry功能障碍指数(ODI)评价腰椎功能。术前及末次随访时在标准站立位全脊柱X线片上测量腰椎前凸角(LL)、胸椎后凸角(TK)、胸腰段后凸角(TLK)、骨盆入射角(PI)、骨盆倾斜角(PT)、骶骨倾斜角(SS)、冠状位Cobb角及矢状位垂直轴(SVA)等影像学参数,并评价SVA及PI-LL改善程度对疗效的影响。结果所有手术顺利完成,所有患者随访12~46(22.3±6.2)个月。末次随访时,所有患者腰痛和下肢痛VAS评分和ODI均较术前明显改善,差异有统计学意义(P<0.05)。末次随访时,长节段内固定患者TLK、PT、冠状位Cobb角、SVA、PI-LL较术前明显减小,LL和SS较术前明显增大;短节段内固定患者PT、冠状位Cobb角较术前减小,SS较术前增大;差异均有统计学意义(P<0.05)。末次随访SVA≥95 mm的患者腰痛VAS评分和ODI均高于SVA≤50 mm的患者,差异有统计学意义(P<0.05);PI-LL>9°患者腰痛VAS评分与PI-LL≤9°患者相比,差异有统计学意义(P<0.05);PI-LL>9°患者下肢痛VAS评分及ODI与PI-LL≤9°患者相比,差异无统计学意义(P>0.05)。结论后路减压并内固定术对DS患者的生活质量和矢状面参数均有较好的改善作用,国人中老年DS患者术后残留轻度的矢状面失衡对生活质量影响不明显,LL=PI±9°可能不适合作为国人的矫形目标。

Objective To evaluate the effect of posterior decompression and internal fixation on postoperative quality of life and sagittal spinopelvic parameters in patients with degenerative scoliosis(DS),and to explore the strategy of sagittal reconstruction.Methods From January 2015 to May 2020,64 DS patients were treated with posterior decompression and pedicle screw internal fixation and fusion in Chongqing Orthopaedic Hospital of Traditional Chinese Medicine.The operation time,intraoperative blood loss,intraoperative fluoroscopy times,hospital stay and complications were recorded.Visual analogue scale of pain(VAS)was used to evaluate the intensity of low back and lower limb pain,and Oswestry disability index(ODI)was used to evaluate lumbar function.The imaging parameters such as lumbar lordosis(LL),thoracic kyphosis(TK),thoracolumbar kyphosis(TLK),pelvic incidence(PI),pelvic tilt(PT),sacral slope(SS),coronal Cobb angle and sagittal vertical axis(SVA)were measured on the whole spine standing roentgenograph before operation and at the final follow-up.The effect of SVA and PI-LL on the therapeutic effect was evaluated.Results All the operations were completed successfully and the follow-up period was 12-46(22.3±6.2)months.At the final follow-up,VAS scores and ODI of low back pain and lower limb pain in all the patients were significantly improved compared with those before operation,all with a statistical significance(P<0.05).At the final follow-up,TLK,PT,coronal Cobb angle,SVA and PI-LL in the patients with long segment internal fixation were significantly decreased,while LL and SS were significantly increased;in the patients with short segment internal fixation,PT and coronal Cobb angle decreased,and SS increased;all with a statistical significance(P<0.05).The low back pain VAS score and ODI were higher in patients with SVA≥95 mm than in patients with SVA≤50 mm at the final follow-up,and the differences were statistically significant(P<0.05).The VAS score of low back pain in patients with PI-LL>9°was significantly higher than that of patients with PI-LL≤9°(P<0.05).There was no significant difference in lower limb pain VAS score and ODI between patients with PI-LL>9°and patients with PI-LL≤9°(P>0.05).Conclusions Posterior decompression and internal fixation can improve the quality of life and sagittal spinopelvic parameters of DS patients.The residual mild sagittal imbalance has no obvious impact on the quality of life in Chinese middle-aged and elderly DS patients.LL=PI±9°may not be suitable as an orthopedic target for Chinese people.