脊柱外科杂志  2022, Vol.20 Issue(4): 223-229   PDF    
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
刘颖1Δ, 李远强2Δ, 洪浩1, 丁浩洋1, 陈举1, 衣龙云1, 赵军1     
1. 重庆市中医骨科医院脊柱外科, 重庆 400012;
2. 陆军军医大学附属西南医院骨科, 重庆 400038
摘要: 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。
关键词: 腰椎    脊柱侧凸    内固定器    骨盆测量    生物力学    
Effect of posterior decompression and internal fixation in treatment of degenerative scoliosison sagittal spinopelvic parameters and efficacy
Liu Ying1Δ, Li Yuanqiang2Δ, Hong Hao1, Ding Haoyang1, Chen Ju1, Yi Longyun1, Zhao Jun1     
1. Department of Spinal Surgery, Chongqing Orthopaedic Hospital of Traditional Chinese Medicine, Chongqing 400012, China;
2. Department of Orthopaedics, Southwest Hospital, Army Medical University, Chongqing 400038, China
Abstract: 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.
Key words: Lumbar vertebrae    Scoliosis    Internal fixators    Pelvimetry    Biomechanics    

退行性脊柱侧凸(DS)是骨骼发育成熟后因脊柱非对称性退行性变导致的原发性畸形(Cobb角>10°),多合并冠状面和矢状面失衡,临床常表现为慢性下腰痛和神经根性症状,严重影响患者生活质量[1]。目前,常规的手术治疗方案有单纯减压及减压联合内固定。近年研究[2-5]表明,与冠状面相比,矢状面平衡对患者生活质量的影响更大,然而重建矢状面平衡的手术策略尚存争议[6-7]。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,评估内固定对矢状面参数和生活质量的影响,并初步探索矢状面重建策略,以期为临床提供一定的理论依据,现报告如下。

1 资料与方法 1.1 一般资料

纳入标准:①明确诊断为DS(Cobb角>10°);②术前均有严重的间歇性跛行、根性症状,伴/不伴顽固性腰痛;③经严格非手术治疗无效。排除标准:①既往有脊柱手术史;②有脊柱骨折、脊柱恶性肿瘤、脊柱感染、强直性脊柱炎等疾病;③下肢畸形,影响行走及脊柱平衡;④凝血功能异常。按照上述标准,纳入DS患者64例,均采用后路减压并椎弓根螺钉内固定融合术治疗,所有患者均有不同程度神经根压迫症状,其中57例(89.1%)有下腰痛症状。其中28例Cobb角≥30°、冠状面和矢状面严重失衡且可耐受者行长节段内固定(固定节段>3个),36例Cobb角 < 30°、无明显畸形进展风险或严重失衡者行短节段内固定(固定节段≤3个)。患者术前一般情况见表 1。本研究通过重庆市中医骨科医院伦理委员会审批备案,所有手术由同一手术组完成。

表 1 2组患者一般资料 Tab. 1 General data of 2 groups
1.2 手术方法及术后处理

患者全身麻醉后取俯卧位,根据术前脊柱矢状面、冠状面失衡程度确定矫形、固定范围,根据术前症状、体征和影像学检查结果确定神经压迫节段。常规做后正中切口,骨膜下剥离双侧椎板和关节突,椎板开窗、半/全椎板切除,行责任神经根彻底减压,减压后不稳节段行椎间融合。融合节段行Ponte截骨(侧凸僵硬的患者可加做1~2个节段,并在术中采用电生理监测),充分松解周围组织以提高曲度恢复。先于凸侧利用已预弯的钛棒进行加压和去旋转,重建腰椎前凸角,再于凹侧放置另一根钛棒,适度撑开进一步矫正侧凸畸形。最后对固定节段的椎板、棘突、关节突去皮质化,将咬除的骨质修剪成颗粒状行椎板间植骨,重点植骨区域为两侧端椎及顶椎区域,切口内置双侧引流管,缝合关闭切口。术后常规使用抗生素预防感染3 d,同时予以对症支持治疗。术后第2天逐步行腰背肌功能锻炼(五点支撑或三点支撑),第3天可在支具保护下下床室内活动,支具佩戴3个月。

1.3 评价指标

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[8]评估腰痛和下肢痛程度,采用Oswestry功能障碍指数(ODI)[9]评价腰椎功能。在术前及末次随访时标准站立位全脊柱X线片上测量腰椎前凸角(LL,L1上终板与S1上终板延长线间的夹角)、胸椎后凸角(TK,T4上终板与T12下终板延长线间的夹角)、胸腰段后凸角(TLK,T11上终板与L1下终板延长线间的夹角)、骨盆入射角(PI,股骨头中心和骶骨上终板中点的连线与骶骨上终板垂线间的夹角)、骨盆倾斜角(PT,股骨头中心和骶骨上终板中点的连线与重力垂直线间的夹角)、骶骨倾斜角(SS,骶骨上终板与水平线间的夹角)以及冠状位Cobb角(上端椎上终板与下端椎下终板延长线间的夹角)和矢状位垂直轴(SVA,C7铅垂线到骶骨上终板后上方的距离)。以上影像学参数由2名经培训的骨科住院医师测量,取2次测量平均值,若测量值差异超过30%,经讨论达成统一意见后再次测量,若无法统一则排除该病例。

1.4 统计学处理

使用SPSS 21.0软件对数据进行统计分析,符合正态分布的计量资料以x±s表示,手术前后数据比较采用配对t检验,末次随访不同SVA和PI-LL组间比较采用独立样本t检验;以P < 0.05为差异有统计学意义。

2 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、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,表 2)。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,表 2)。

表 2 手术指标、疼痛程度、腰椎功能与影像学参数 Tab. 2 Ssurgical indicators, pain symptoms, lumbar function and imaging parameters

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,表 3);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,表 3);PI-LL >9°患者下肢痛VAS评分及ODI与PI-LL≤9°的患者相比,差异均无统计学意义(P>0.05,表 3)。

表 3 不同SVA及PI-LL对疗效的影响 Tab. 3 Effects of different SVA and PI-LL on curative effect

长节段内固定患者共11例发生术后并发症,并发症发生率为39.3%;其中脑脊液漏4例、深部切口感染1例、浅部切口感染2例、近端交界区融合失败(PJF)1例、假关节形成1例、钉棒断裂伴明显移位1例、螺钉断裂1例。短节段内固定患者共6例发生术后并发症,并发症发生率为16.7%;其中脑脊液漏2例、浅部切口感染1例、近端交界性后凸(PJK)伴矢状面失衡3例。发生脑脊液漏的患者予以切口处垫毛巾加压,间断开放引流管后好转。深部切口感染者行清创联合庆大霉素持续灌洗后好转。发生PJF者予经皮椎体成形术后好转。假关节形成者经非手术治疗6个月仍不融合,后行翻修手术,取髂骨进行充分植骨,同时远端椎体用骨水泥强化螺钉固定,翻修术后5个月骨性融合。钉棒断裂伴明显移位和螺钉断裂者,经更换内固定装置后恢复。PJK伴矢状面失衡的3例患者,1例矢状面失衡加重伴神经压迫,近端交界后凸畸形严重程度量表评分(Hart-ISSG PJKSS)[10]12分,行神经压迫节段减压融合,将近端延长固定2个椎体,并在近端固定椎中使用横突钩固定以减少肌肉和小关节剥离,随访期间无矢状面再失衡;2例无明显神经压迫症状,Hart-ISSG PJKSS量表评分 < 7分,对症处理后好转。长节段、短节段内固定典型病例影像学资料见图 12

图 1 长节段内固定典型病例影像学资料 Fig. 1 Imaging data of a typical case with long segment internal fixation 女,65岁,内固定节段T10~S1  a、b:术前脊柱全长正侧位X线片示冠状位Cobb角32.35°、SVA 63.35 mm、TK 19.63°、TLK 9.35°、LL 19.28°、PI 43.03°、PT 20.37°、SS 23.99°  c~g:术前腰椎左右侧曲位X线片及MRI示椎间盘突出伴椎管狭窄,L5水平椎旁肌脂肪浸润明显  h、i:术后1个月脊柱全长正侧位X线片示Cobb角5.41°、SVA 19.34 mm、TK 17.53°、TLK 6.79°、LL 36.28°、PI 41.42°、PT 14.66°、SS 26.02° Female, 65 years old, internal fixation segments T11-S1   a, b: Preoperative whole spine anteroposterior and lateral roentgenographs show coronal Cobb angle is 32.35°, SVA 63.35 mm, TK 19.63°, TLK 9.35°, LL 19.28°, PI 43.03°, PT 20.37°, SS 23.99°   c-g: Preoperative left and right bending roentgenographs and MRIs show disc herniation with spinal stenosis and significant paraspinal muscle fat infiltration at L5 level   h, i: Whole spine anteroposterior and lateral roentgenographs at postoperative 1 month show coronal Cobb angle is 5.41°, SVA 19.34 mm, TK 17.53°, TLK 6.79°, LL 36.28°, PI 41.42°, PT 14.66°, SS 26.02°

图 2 短节段内固定典型病例影像学资料 Fig. 2 Imaging data of a typical case with short segment internal fixation 女,63岁,内固定节段L3~S1  a、b:术前脊柱全长正侧位X线片示冠状位Cobb角30.13°、SVA 10.06 mm、TK 12.36°、LL 28.57°、PI 44.45°、PT 21.43°、SS 24.14°  c~e:术前腰椎左右侧曲位X线片和水平位MRI示椎管狭窄  f:术前水平位CT示椎体边缘骨质增生  g:术前矢状位MRI示L3/L4、L5/S1椎间盘突出伴椎管狭窄  h、i:术后1年脊柱全长正侧位X线片示冠状位Cobb角10.41°、SVA 34.34 mm、TK 24.53°、TLK 13.79°、LL 28.28°、PI 45.42°、PT 17.68°、SS 27.43° Female, 63 years old, internal fixation segments L3-S1  a, b: Preoperative whole spine anteroposterior and lateral roentgenographs show coronal Cobb angle is 30.13°, SVA 10.06 mm, TK 12.36°, LL 28.57°, PI 44.45°, PT 21.43°, SS 24.14°  c-e: Preoperative left and right bending roentgenographs and horizontal MRI show spinal stenosis  f: Preoperative horizontal CT shows hyperosteogeny at edge of vertebral body   g: Preoperative sagittal MRI shows disc herniation at L3/L4 and L5/S1 with spinal stenosis  k, i: Whole spine anteroposterior and lateral roentgenographs at postoperative 1 year show coronal Cobb angle is 10.41°, SVA 34.34 mm, TK 24.53°, TLK 13.79°, LL 28.28°, PI 45.42°, PT 17.68°, SS 27.43°
3 讨论 3.1 DS的矢状面平衡

随着椎间盘高度的丢失以及椎体楔形变,DS患者出现重心前移、腰椎前凸角减小、骨盆后倾,最终导致矢状面失衡(SVA >50 mm)[5]。王辉等[11]指出,中国DS患者约40.5%发生矢状面失衡,在本研究中矢状面失衡率达48.3%。既往研究[2, 5, 12]表明,矢状面参数与患者生活质量密切相关。因此,成人脊柱侧凸委员会(SRS)根据SRS-Schwab分型[13]提出,矢状面重建的目标为PI-LL < 10°,SVA < 50 mm,PT < 20°。

近年来,学者们意识到DS治疗的首要目的是解除神经压迫,保留轻度失衡并不影响患者生活质量,而过度矫形却可能带来更多的并发症[2, 7, 14]。本研究中,患者术后SVA≥95 mm时腰痛VAS评分和ODI与SVA < 50 mm者差异才有统计学意义,提示术后残留95 mm以内的矢状面失衡对患者生活质量无明显影响。Hikata等[7]和Dohzono等[15]也得出了相似结论,对无明显脊柱失稳的患者,重建矢状面平衡并非绝对必要。Lafage等[16]通过对773例健康成人的矢状面参数分析发现,当患者年龄>75岁时,SVA增至79.3 mm。因此,笔者认为中老年DS患者术后可以残留轻度的矢状面失衡,因为老年患者的骨骼、肌肉、关节等结构可能适应了脊柱前倾状态,如果完全矫正矢状面平衡,患者很难适应重心点后移,反而引起不适和不必要的并发症。Pichelmann等[17]报道了643例成人脊柱畸形随访22年的结果,发现再手术率为9%,最常见的翻修原因是假关节形成、畸形进展和术后感染。本研究的再手术率为4.68%(3/64),其中1例在长节段内固定术后8个月时发生PJF,其发生的原因除了合并骨质疏松症外,还可能与矢状面过度矫形有关。Kim等[18]观察PJF翻修的患者发现,PJF患者术后的SVA(8 mm)小于未发生PJF的患者(41 mm),SVA矫正值(90 mm)大于未发生PJF的患者(40 mm);值得注意的是,术后SVA小于10 mm的患者术后均发生PJK并行翻修手术。本研究中发生PJF的患者术后SVA为9.3 mm,SVA矫正值为91.2 mm,矢状面存在过度矫正,机体只能通过其余非融合节段的调整实现机体新的平衡,导致近端非融合节段应力较为集中,从而发生压缩性骨折。

3.2 DS患者重建矢状面平衡的策略

重建矢状面平衡主要包括2个方面:一是脊柱上、下端固定椎的选择;二是矢状面力线的矫正。上、下端固定椎的选择决定了固定节段的长短,笔者的经验是宜选择稳定、中立的椎体,避免旋转、脱位和应力较集中的椎体,无明显矢状面失衡的患者,上端固定椎考虑在L2以下,若侧凸严重伴明显失衡的患者则尽量固定至T10及以上;若患者年龄 < 60岁,L5/S1椎间盘退行性变在Modic分型[19]Ⅱ度以下,可将下端固定终止于L5,即使邻近节段退行性变加重,患者仍有条件接受翻修手术,可保证5~10年的生活质量[20]。在矢状面力线的矫正过程中,LL是唯一可以通过术前体位摆放、术中钛棒折弯角度以及截骨等方式被直接矫正的参数[14],因此,PI-LL是否匹配成为术者手术规划的核心要素。目前,较为认可的匹配度是Schwab等[5]提出的LL=PI±9°。但本研究结果显示,PI-LL >9°者下肢痛VAS评分及ODI与PI-LL≤9°者相比,差异均无统计学意义。孙祥耀等[21]报道了69例DS患者,认为10°≤PI-LL≤20°时均可获得较好的治疗效果。马清伟等[22]的研究发现,国人的PI(约45°)低于西方人群(约50°),且术后15°≤PI-LL≤28°时患者生活质量更高。李远强等[23]提出DS的治疗方针,神经减压是关键,器械矫形为辅助,尽量短节段,谨慎长节段。因此,笔者认为,在充分减压的前提下,应适当重建脊柱的冠状面和矢状面平衡,对于国人中老年DS患者LL可能不需要矫正到PI±9°,可依据术前测量的PI适当减小LL的矫形角度。同时,随着技术的发展,脊柱外科趋向于微创化、精准化,例如前路斜外侧腰椎椎间融合术(OLIF)从脊柱侧前方减压融合,可同时恢复矢状面和冠状面力线,也为进一步减少内固定节段提供了新思路[24]

综上所述,后路内固定对DS患者的生活质量和矢状面参数均有较好的改善作用,术后残留轻度的矢状面失衡对患者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,在选择手术方式时,须综合评估患者年龄、基础疾病等整体情况,制订个体化治疗方案。此外,本研究尚存在一定不足,纳入的患者可能存在一定选择偏倚,同时随访时间短、病例相对较少、未分析脊柱参数和症状缓解的相关性等,有待后续进一步研究证实。

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