中国修复重建外科杂志

中国修复重建外科杂志

退变性腰椎侧凸后路长节段固定融合术后冠状面失平衡的危险因素分析

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目的探讨退变性腰椎侧凸后路长节段固定融合术后发生冠状面失平衡的危险因素。方法回顾研究 2011 年 8 月—2016 年 7 月行后路选择性经腰椎间孔椎体间融合术(transforaminal lumbar interbody fusion,TLIF)结合 Ponte 截骨矫形长节段固定手术的 41 例退变性腰椎侧凸患者临床资料,按末次随访时是否出现冠状面失平衡分为失平衡组(A 组,11 例)和平衡组(B 组,30 例)。术前及末次随访时测量以下影像学参数:冠状面 Cobb 角、冠状面平衡距离(coronal balance distance,CBD)、顶椎偏距(apical vertebra translation,AVT)、顶椎旋转(apical vertebra rotation,AVR)、腰骶弯(lumbar sacral curve,LSC)Cobb 角和 L5 倾斜角(L5 tilt angle,L5TA),计算术前与末次随访时上述影像学参数变化值。对两组患者性别、年龄、术前骨密度 T 值、固定椎体数、上端固定椎、下端固定椎、TLIF 椎间融合器植入节段数、减压节段数、Ponte 截骨节段数,以及将有统计学意义的术前影像学参数连续变量转换为二分类变量,进行单因素分析,初步筛选术后冠状面失平衡的影响因素。再将上述初步筛选的影响因素和组间有统计学意义的影像学参数变化值采用多因素 logistic 回归分析,筛选危险因素。结果A、B 组随访时间分别为(3.76±1.02)年和(3.56±1.03)年,比较差异无统计学意义(t=0.547,P=0.587)。A 组患者术前冠状面 Cobb 角、AVT、LSC Cobb 角、L5TA 显著大于 B 组(P<0.05);末次随访时,A 组各影像学参数均显著大于 B 组(P<0.05)。手术前后冠状面 Cobb 角、AVT、LSC Cobb 角变化值两组间比较差异无统计学意义(P>0.05),CBD、L5TA 和 AVR 变化值两组间比较差异有统计学意义(P<0.05)。单因素分析显示,术前 L5TA 是术后冠状面失平衡的影响因素(P<0.05)。多因素 logistic 回归分析显示,术前 L5TA≥15° 是术后冠状面失平衡发生的独立危险因素,手术前后 AVR 变化值是冠状面失平衡的保护因素。结论术前 L5TA≥15° 是退变性腰椎侧凸后路长节段固定融合术后发生冠状面失平衡的独立危险因素。

ObjectiveTo explore the risk factors of coronal imbalance after posterior long-level fixation and fusion for degenerative lumbar scoliosis.MethodsRetrospectivly analyzed the clinical records of 41 patients with degenerative lumbar scoliosis who had received posterior long-level fixation and fusion with selective transforaminal lumbar interbody fusion (TLIF) accompanied by Ponte osteotomy between August 2011 and July 2016. Patients were divided into imbalance group (group A, 11 cases) and balance group (group B, 30 cases) according to state of coronal imbalance measured at last follow-up. The radiographic parameters at preoperation and last follow-up were measured, and the variance of preoperative and last follow-up parameters were calculated. The radiographic parameters included coronal Cobb angle, coronal balance distance (CBD), apical vertebral translation (AVT), apical vertebral rotation (AVR), Cobb angle of lumbar sacral curve (LSC), and L5 tilt angle (L5TA). Univariate analysis was performed for the factors including gender, age, preoperative T value of bone mineral density, number of instrumented vertebra, upper and lower instrumented vertebra, segments of TLIF, decompression, and Ponte osteotomy, as well as the continuous variables of preoperative imaging parameters with significant difference were converted into two-category variables, obtained the influence factors of postoperative coronal imbalance. Multivariate logistic regression analysis was performed to verify the risk factors from the preliminary screened influence factors and the variance of imaging parameters with significant difference between the two groups.ResultsThe follow-up time of groups A and B was (3.76±1.02) years and (3.56±1.03) years respectively, there was no significant difference between the two groups (t=0.547, P=0.587). The coronal Cobb angle, AVT, LSC Cobb angle, and L5TA in group A were significantly higher than those in group B before operation (P<0.05), and all the imaging parameters in group A were significantly higher than those in group B at last follow-up (P<0.05). There was no significant difference between the two groups in parameters including the variance of coronal Cobb angle, AVT, and LSC Cobb angle before and after operation (P>0.05), and there were significant difference between the two groups in parameters including the variance of CBD, L5TA, and AVR (P<0.05). Univariate analysis showed that preoperative L5TA was the influencing factor of postoperative coronal imbalance (P<0.05). Multivariate logistic regression analysis showed that preoperative L5TA≥15° was an independent risk factor of postoperative coronal imbalance, and variance of pre- and post-operative AVR was a protective factor.ConclusionPreoperative L5TA≥15° is an independent risk factor for coronal imbalance in patients with degenerative lumbar scoliosis after posterior long-level fixation and fusion.

关键词: 退变性腰椎侧凸; 冠状面失平衡; 危险因素; 并发症

Key words: Degenerative lumbar scoliosis; coronal imbalance; risk factor; complication

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