影响Lenke 1型青少年特发性脊柱侧凸术后满意度的肩平衡影像学指标

Radiological shoulder parameter associated with postoperative satisfaction in Lenke type 1 adolescent idiopathic scoliosis

目的分析影响Lenke 1型青少年特发性脊柱侧凸(adolescent idiopathic scoliosis,AIS)术后满意度的肩平衡影像学指标。方法回顾性分析2017年8月至2020年7月于空军军医大学西京医院接受后路全椎弓根螺钉矫形融合术的AIS患者98例,男26例、女72例,年龄(15.2±5.3)岁(范围10~24岁)。上端固定椎分布:T258例(59%)、T325例(26%)、T415例(15%);下端固定椎分布:T1263例(64%)、L128例(29%)、L24例(4%)、L33例(3%)。比较手术前后锁骨角(clavicle angle,CA)、影像学肩高(radiographic shoulder height,RSH)、喙突高度差(coracoid height difference,CHD)、锁骨肋骨交点高度差(clavicle-rib cage intersection difference,CRID)、T1倾斜角、第1肋倾斜角、锁骨胸廓角度差(clavicle chest angle difference,CCAD)及脊柱侧凸研究学会22项量表(Scoliosis Research Society-22,SRS-22)结果。采用二分类logistic回归分析影响Lenke 1型AIS术后满意度的肩平衡影像学指标。绘制受试者工作特征(receiver operating characteristic,ROC)曲线,确定该影像学指标的阈值。结果所有患者均顺利完成手术,手术时间为(260±80)min(范围220~320 min),术中出血量为(360±110)ml(范围300~700 ml),术中无一例出现神经、硬膜及血管损伤。末次随访时RSH、CHD、CRID、T1倾斜角、第1肋倾斜角、CCAD分别为4.0(0,13.9)mm、7.0(0,12.9)mm、4.0(0,10.0)mm、4.8°(3.3°,8.2°)、5.3°±3.9°、5.5°(3.0°,8.9°),小于术前的10.6(2.0,20.3)mm、10.3(2.5,15.9)mm、8.0(1.0,15.2)mm、7.6°(3.5°,12.2°)、7.5°±6.9°、8.5°(3.6°,18.3°),差异有统计学意义(P<0.05)。末次随访时SRS-22功能、疼痛、外观、心理评分分别为4.6(4.0,4.9)分、(4.1±0.5)分、(4.1±0.7)分、4.2(3.9,4.8)分,均大于术前的4.2(3.8,4.6)分、(4.0±0.7)分、(3.5±0.7)分、4.0(3.5,4.4)分,差异有统计学意义(P<0.05)。二分类logistic回归结果显示,CCAD是影响AIS矫形术后满意度的独立肩平衡影像学指标(OR=0.826,P=0.040)。ROC曲线示曲线下面积及95%CI为0.726(0.572,0.865),阈值为6.6°。结论CCAD是影响AIS矫形术后满意度的独立肩平衡影像学指标,术后CCAD≤6.6°时患者更容易达到疗效满意,可作为评估脊柱矫形手术疗效的影像学指标应用于临床。

Objective To analyze the radiographic parameters of shoulder balance that affect the postoperative satisfaction of Lenke type 1 adolescent idiopathic scoliosis(AIS).Methods A total of 98 patients with AIS who underwent posterior pedicle screw fusion in Xijing Hospital of Air Force Medical University from August 2017 to July 2020 were retrospectively analyzed.There were 26 males and 72 females,aged 15.2±5.3 years(range,10-24 years).Distribution of upper instrumented vertebrae:T258 cases(59%),T325 cases(26%),T415 cases(15%);Distribution of lower instrumented vertebrae:T1263 cases(64%),L128 cases(29%),L24 cases(4%),L33 cases(3%).Clavicle angle(CA),radiographic shoulder height(RSH),and coracoid height difference(CHD),clavicle-rib cage intersection difference(CRID),T1 tilt angle,first rib tilt angle,clavicle chest angle difference(CCAD)and Scoliosis Research Society-22(SRS-22)scale were compared before and after operation.Binary logistic regression was used to analyze the radiographic indicators of shoulder balance that affected the postoperative satisfaction of Lenke type 1 AIS.The receiver operating characteristic(ROC)curve was drawn to determine the threshold value of the imaging index.Results All operations were successfully completed.The operation time was 260±80 min(range,220-320 min),and the intraoperative blood loss was 360±110 ml(range,300-700 ml).There was no nerve,dural or vascular injury during operation.RSH,CHD,CRID,T1 tilt angle,first rib tilt angle,and CCAD at the final follow-up were 4.0(0,13.9)mm,7.0(0,12.9)mm,4.0(0,10.0)mm,4.8°(3.3°,8.2°),5.3°±3.9°,and 5.5°(3.0°,8.9°),respectively,which were less than the preoperative 10.6(2.0,20.3)mm,10.3(2.5,15.9)mm,8.0(1.0,15.2)mm,7.6°(3.5°,12.2°),7.5°±6.9°,8.5°(3.6°,18.3°),and the difference was statistically significant(P<0.05).The SRS-22 function,pain,appearance,and psychological scores at the final follow-up were 4.6(4.0,4.9),4.1±0.5,4.1±0.7,and 4.2(3.9,4.8)points,respectively,which were greater than the preoperative scores of 4.2(3.8,4.6),4.0±0.7,3.5±0.7,and 4.0(3.5,4.4)points,the difference was statistically significant(P<0.05).Binary logistic regression showed that CCAD was an independent radiographic indicator of shoulder balance that affected the satisfaction of AIS patients after orthopaedic surgery(OR=0.826,P=0.040).ROC curve showed that the area under the curve and 95%CI was 0.726(0.572,0.865),and the threshold was 6.6°.Conclusion CCAD is an independent radiographic parameter of shoulder balance that affects the postoperative satisfaction of AIS.Patients are more likely to achieve a satisfactory outcome when their postoperative CCAD is≤6.6°,which can be used clinically as a radiographic parameter to assess the efficacy of orthopaedic spine surgery.