退变性腰椎侧凸畸形出现冠状位一致性脊柱序列的原因及矫形术后失平衡的危险因素分析  

The causes for consistent coronal alignment and the risk factors for coronal imbalance after corrective surgery in degenerative lumbar scoliosis

作　　者：张子方[1,2] 郑国权 宋凯[1] 薛超[1] 王岩[1] 王征[1] ZHANG Zifang;ZHENG Guoquan;SONG Kai(Orthopedic Department,the Fourth Medical Center of the Chinese PLA General Hospital,Beijing,100853,China)

机构地区：[1]解放军总医院第四医学中心骨科,北京市100853 [2]济宁医学院附属医院脊柱外科,济宁市272007

出　　处：《中国脊柱脊髓杂志》2023年第3期205-212,共8页Chinese Journal of Spine and Spinal Cord

基　　金：以临床应用为导向的医疗创新基金(编号:2021-NCRC-CXJ-ZH-17);国家重点研发课题(编号:2020YFC1107404)。

摘　　要：目的:探讨退变性腰椎侧凸(degenerative lumbar scoliosis,DLS)患者冠状位躯干偏移与侧凸同向性(冠状位一致性)脊柱序列的相关因素及矫形术后早期冠状位失平衡的危险因素.方法:纳入2015年5月~2020年1月在解放军总医院单一中心手术治疗的75例DLS患者,均行后路截骨矫形长节段固定融合术(固定椎体≥5).根据术前C7铅垂线(C7 plumb line,C7PL)偏移与侧凸方向的关系,将患者分为两型:Ⅰ型,C7PL与侧凸同向;Ⅱ型,C7PL与侧凸相悖.定义C7PL到骶骨中点的距离为冠状位平衡距(coronal balance distance,CBD),CBD≥30mm即为冠状位失平衡(coronal imbalance,CIB).根据术后CBD将Ⅰ型患者分为A组(CBD≥30mm)和B组(CBD<30mm).记录所有患者性别、年龄及体重指数(body mass index,BMI),手术前后影像学参数包括CBD、主弯 Cobb 角(major curve Cobb,MCC)、腰骶弯 Cobb 角(fractional Cobb,FC)、L4 及 L5 椎体倾斜度、顶椎侧方滑移度(滑向凸侧为+;滑向凹侧为-)、主弯累及椎体数;手术参数包括主弯矫正度及其矫正率、固定椎体数、上端固定椎(upper instrumented vertebra,UIV)及下端固定椎(lower instrumented vertebra,LIV).应用观测者操作特征(receiver operating characteristic,ROC)曲线分析Ⅰ型患者顶椎侧方滑移度临界值及Ⅰ型患者主弯矫正率,根据曲线下面积(the area under ROC curve,AUC)得出相应临界值,并计算95%可信区间(confidence interval,CI).组间正态分布参数采用独立样本t检验,非正态分布采用Mann-Whitney U检验.定性变量则采用卡方检验或Fisher检验,并计算相应比值比(odds ratio,OR).结果:75例DLS患者中男15例,女60例;年龄62.93±8.42岁.Ⅰ型和Ⅱ型冠状位序列分别有33例和42例,其中Ⅰ型术前CIB患者12例、术后12例;Ⅱ型患者术前CIB有5例、术后6例,Ⅰ型患者手术前后CIB发生率均显著大于Ⅱ型患者(P<0.05).Ⅰ型患者术前CBD(P=0.01)、顶椎侧方滑移度(P<0.001)及L4椎体倾斜度(P=0.015)显著大于Objectives:To explore the parameters associated with trunk shifting and scoliosis in the same direction-consistent coronal alignment(CA),and to investigate the risk factors associated with early postoperative coronal imbalance(CIB)after corrective surgery in patients with degenerative lumbar scoliosis(DLS).Methods:A total of 75 DLS patients underwent the posterior osteotomy and orthopedics surgery of long-segment fusion(fixed vertebras≥5)with instrumentations from May 2015 to January 2020 were enrolled.According to relations of the C7 plumb line(C7PL)and major curve direction,the patients were divided into type I(C7PL locating at the convex side of the major curve)and type II(C7PL locating at the concave side of the major curve).The distance from C7PL to the midpoint of S1 was defined as the coronal balance distance(CBD),and coronal imbalance(CIB)w)as concerned if the CBD≥30mm.All the patients with type I CIB were divided into group A(CBD≥30mm)and group B(CBD<3Omm)according to the CBD postoperatively.The age,gender,and body mass index(BMI);radiographic parameters before and after surgery,including CBD,major curve Cobb(MCC),lumbosacral fractional Cobb(FC),L4 and L5 coronal tilt,coronal apical lateralisthesis degree(proximal vertebra sliding to the convex side was recorded as+;if not as-),and the vertebras including in the major curve;and surgical data including major curve correction degree and correction rate,number of fixed vertebras,upper instrumented vertebra(UIV),and lower instrumented vertebra(LIV)were recorded.The apical lateralisthesis degree and the MCC correction in patients with the type I CIB were analyzed using the receiver operating characteristic(ROC)curve analysis,the best cutoff value and 95%confidence interval(CI)were obtained by the area under the curve(AUC).The normal distribution parameters were analyzed using the independent sample t test,the Mann-Whitney U test was for non-normal distribution data,and qualitative data were tested using chi-square test or Fisher test,and the odds ratio(

关 键 词：退变性腰椎侧凸 冠状位失平衡 冠状位平衡距 相关因素 观测者操作特征曲线 

分 类 号：R682.3[医药卫生—骨科学] R687.3[医药卫生—外科学] R619[医药卫生—临床医学]