侧路-后路分期腰椎间融合术治疗退变性脊柱畸形

doi:10.3969/j.issn.1672-6731.2024.12.004

摘要/Abstract

摘要：

目的: 探讨侧路-后路分期腰椎间融合术治疗退变性脊柱畸形的有效性和安全性。方法: 纳入2021年12月至2022年6月在首都医科大学宣武医院行侧路-后路分期手术的22例退变性脊柱畸形患者，一期行侧路手术、二期行后路截骨术+内固定术，分别于术前和末次随访时（术后2年）采用视觉模拟评分（VAS）评估疼痛程度，Oswestry功能障碍指数（ODI）评估功能障碍程度，记录冠状位指标[包括冠状位平衡距离（CBD）、Cobb角]以及矢状位指标[包括矢状位垂直轴（SVA）、骨盆入射角（PI）、腰椎前凸角（LL）、骨盆入射角与腰椎前凸角匹配度（PI-LL）、骨盆倾斜角（PT）]。结果: 与术前相比，末次随访时（术后2年）腰痛VAS评分（Z=4.107，P=0.000）、腿痛VAS评分（Z=3.669，P=0.000）和ODI指数（Z=4.107，P=0.000）均减少，表明症状有效改善。经侧路-后路分期手术后，Cobb角（χ²=40.364，P=0.000）、SVA（χ²=22.455，P=0.000）、LL（χ²=26.329，P=0.000）、PI-LL（χ²=26.329，P=0.000）、PT（χ²=12.091，P=0.002）均改善，与术前相比，一期侧路手术后Cobb角（Z=2.714，P=0.000）、LL（Z=3.844，P=0.000）、PI-LL（Z=3.844，P=0.000）、PT（Z=2.563，P=0.010）减小，二期后路微创手术后Cobb角（Z=6.332，P=0.000）、SVA（Z=4.673，P=0.000）、LL（Z=4.749，P=0.000）、PI-LL（Z=4.749，P=0.000）、PT（Z=3.317，P=0.001）进一步减小；与一期侧路手术后相比，二期后路微创手术后仅Cobb角（Z=3.618，P=0.000）、SVA（Z=3.015，P=0.003）减小，表明冠状位和矢状位失衡改善、畸形进一步矫正。2例（9.09%）术后1年出现近端交界性失败，4例（18.18%）术后2年出现椎间融合器沉降。结论: 侧路-后路分期腰椎间融合术在改善退变性脊柱畸形患者临床症状和恢复脊柱平衡方面显示出良好疗效，但手术长期稳定性和安全性尚待大样本队列研究验证。

关键词: 脊柱侧凸, 椎间盘退行性变, 腰椎, 脊柱融合术, 矫形外科手术

Abstract:

Objective: To evaluate the efficacy and safety of a staged lateral-posterior lumbar interbody fusion in the treatment of degenerative spinal deformity (DSD). Methods: A retrospective analysis was performed on 22 patients with degenerative spinal deformity who underwent staged lateral-posterior surgery at Xuanwu Hospital, Capital Medical University from December 2021 to June 2022. The first stage involved lateral surgery, while the second stage consisted of posterior osteotomy combined with internal fixation. Pain severity was assessed by Visual Analog Scales (VAS), and disability was evaluated by Oswestry Disability Index (ODI). Radiographic measurements included the coronal balance distance (CBD), Cobb angle, sagittal vertical axis (SVA), lumbar lordosis (LL), pelvic incidence (PI), pelvic incidence and lumbar lordosis (PI-LL) and pelvic tilt (PT). Results: Compared with preoperation, the VAS score of low back pain (Z=4.107, P=0.000), the VAS score of leg pain (Z=3.669, P=0.000) and the ODI (Z=4.107, P=0.000) were decreased at the last follow-up. After staged lateral-posterior surgery, Cobb angle (χ² =40.364, P=0.000), SVA (χ²=22.455, P=0.000), LL (χ²=26.329, P=0.000), PI-LL (χ²=26.329, P=0.000), PT (χ²=12.091, P=0.002) improved. Compared with preoperation, Cobb angle (Z=2.714, P=0.000), LL (Z=3.844, P=0.000), PI-LL (Z=3.844, P=0.000), PT (Z=2.563, P=0.010) decreased after lateral surgery, while Cobb angle (Z=6.332, P=0.000), SVA (Z=4.673, P=0.000), LL (Z=4.749, P=0.000), PI-LL (Z=4.749, P=0.000), PT (Z=3.317, P=0.001) decrease after posterior surgery. Compared with the lateral surgery, only Cobb angle (Z=3.618, P=0.000) and SVA (Z=3.015, P=0.000) decreased after the posterior surgery. Proximal junction failure (PJF) occurred in 2 patients (9.09%) one year after surgery, and interbody fusion sink occurred in 4 patients (18.18%) 2 years after surgery. Conclusions: The staged lateral-posterior lumbar interbody fusion demonstrated good efficacy in improving clinical symptoms and restoring spinal balance in patients with degenerative spinal deformity. However, the long-term stability and safety of the procedure require further validation through large-scale cohort studies.

Key words: Scoliosis, Intervertebral disc degeneration, Lumbar vertebrae, Spinal fusion, Orthopedic procedures

刘振磊, 王凯, 李康, 张雷, 菅凤增, 吴浩. 侧路-后路分期腰椎间融合术治疗退变性脊柱畸形[J]. 中国现代神经疾病杂志, 2024, 24(12): 992-999.

Zhen-lei LIU, Kai WANG, Kang LI, Lei ZHANG, Feng-zeng JIAN, Hao WU. Staged lateral-posterior lumbar interbody fusion for degenerative spinal deformity[J]. Chinese Journal of Contemporary Neurology and Neurosurgery, 2024, 24(12): 992-999.

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链接本文: https://journal11.magtechjournal.com/cjcnn/CN/10.3969/j.issn.1672-6731.2024.12.004

https://journal11.magtechjournal.com/cjcnn/CN/Y2024/V24/I12/992

图/表 4

表 1 退变性脊柱畸形患者手术前后VAS评分和ODI指数的比较[n = 22，M（P₂₅，P₇₅）]

Table 1. Comparison of VAS and ODI at preoperation and last follow ‐up after surgery in the patients with DSD[n = 22, M(P₂₅, P₇₅)]

观察指标	术前	末次随访时	Z值	P值
腰痛VAS（评分）	5.00（5.00，6.00）	1.00（1.00，2.00）	4.107	0.000
腿痛VAS（评分）	3.00（2.00，4.00）	1.00（0.00，1.25）	3.669	0.000
ODI（%）	55.50（45.00，67.50）	14.50（11.75，18.25）	4.107	0.000

表 2 退变性脊柱畸形患者手术前后冠状位和矢状位指标的比较[n = 22，M（P₂₅，P₇₅）]

Table 2. Comparison of coronal and sagittal indicators at preoperation and postoperation in the patients with DSD[n = 22, M (P₂₅, P₇₅)]

观察指标	术前	一期侧路手术后	二期后路微创手术后	χ²值	P值
冠状位
CBD（mm）	21.35（‐6.10，40.80）	16.00（‐1.30，33.40）	8.30（‐15.10，19.30）	2.455	0.293
Cobb角（°）	38.95（26.90，44.60）	26.10（18.33，29.60）	11.85（7.55，16.60）	40.364	0.000
矢状位
SVA（mm）	58.20（46.75，109.60）	24.95（6.98，70.90）	‐2.05（‐20.00，38.10）	22.455	0.000
LL（°）	‐26.10（‐33.10，‐21.93）	33.00（‐43.63，‐28.40）	‐42.20（‐52.73，‐29.28）	26.329	0.000
PI‐LL（°）	18.10（13.45，30.90）	11.40（1.90，16.60）	7.60（‐2.83，16.33）	26.329	0.000
PT（°）	23.90（19.13，31.50）	20.40（12.15，23.78）	19.05（12.95，27.80）	12.091	0.002

表 3 退变性脊柱畸形患者手术前后冠状位和矢状位指标的两两比较

Table 3. Pairwise comparison of coronal and sagittal indicators at preoperation and postoperation in the patients with DSD

两两比较	Cobb角		SVA		LL		PI‐LL		PT
两两比较	Z值	P值	Z值	P值	Z值	P值	Z值	P值	Z值	P值
术前∶一期侧路手术后	2.714	0.000	1.658	0.097	3.844	0.000	3.844	0.000	2.563	0.010
术前∶二期后路微创手术后	6.332	0.000	4.673	0.000	4.749	0.000	4.749	0.000	3.317	0.001
一期侧路手术后∶二期后路微创手术后	3.618	0.000	3.015	0.003	0.905	0.366	0.905	0.366	0.754	0.451

图 1 手术前后全脊柱X线检查所见 1a，1b 术前前后位和侧位X线显示明显脊柱侧弯 1c，1d 一期侧路手术后前后位和侧位X线显示脊柱畸形明显矫正 1e，1f 二期后路L_3~5 Ponte截骨术+ T₁₂~L₅经皮椎弓根螺钉内固定术后前后位和侧位X线显示脊柱畸形进一步矫正 1g，1h 术后1年前后位和侧位X线显示矫形效果持续，骨盆后旋有所缓解 1i，1j 术后2年前后位和侧位X线显示矫形效果持续

Figure 1 Full spine X ‐ray findings before and after surgery Preoperative anteroposterior (Panel 1a) and lateral (Panel 1b) X ‐ray showed obvious scoliosis deformity. After the first‐stage lateral surgery, anteroposterior (Panel 1c) and lateral (Panel 1d) X‐ray showed significant improvement. After the second ‐stage posterior L_3-5 Ponte osteotomy + T₁₂-L₅ percutaneous screw internal fixation, anteroposterior (Panel 1e) and lateral (Panel 1f) X‐ray showed further correction. One year after surgery, anteroposterior (Panel 1g) and lateral (Panel 1h) X ‐ray showed the orthopedic effect was maintained, and the pelvic posterior rotation was relieved. Two years after surgery, anteroposterior (Panel 1i) and lateral (Panel 1j) X‐ray showed the orthopedic effect was maintained.

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2 侧路-后路分期腰椎间融合术治疗退变性脊柱畸形

Staged lateral-posterior lumbar interbody fusion for degenerative spinal deformity

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2 侧路-后路分期腰椎间融合术治疗退变性脊柱畸形

Staged lateral-posterior lumbar interbody fusion for degenerative spinal deformity

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