Comparative analysis of 3 surgical strategies for adult spinal deformity with mild to moderate sagittal imbalance
Comparative analysis of 3 surgical strategies for adult spinal deformity with mild to moderate sagittal imbalance
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DOI：
10.3171/2017.5.spine161370
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发表时间：
2018-01-01
影响因子：
2.8
通讯作者：
Deviren, Vedat
中科院分区：
文献类型：
--
作者：
Bae, Junseok;Theologis, Alexander A.;Deviren, Vedat
目的成人脊柱畸形（ASD）的手术治疗是一项有效的努力，可以通过多种手术策略来实现。在这里，作者评估并比较了ASD患者的影像学资料、并发症和健康相关的生活质量（HRQoL）结果评分，这些患者分别接受了后路脊柱固定（PSF）、后路联合侧位腰椎体间融合术（LLIF+PSF）或后路联合前路腰椎体间融合术（ALIF+PSF）。方法回顾2003年至2013年在同一机构连续接受胸腰椎融合术治疗ASD的成人病历。包括从骨盆到L-1或以上接受内固定，矢状垂直轴(SVA) < 10 cm，并接受至少2年随访的患者。接受三柱截骨术的患者被排除在外。三组患者根据所执行的手术进行比较，LLIF+PSF， ALIF+ PSF和仅PSF。对各组围手术期脊柱畸形参数、并发症和HRQoL结果评分（Oswestry残疾指数[ODI]、脊柱侧凸研究学会22题问卷[SRS-22]、36题简短健康调查[SF-36]、背部/腿部疼痛视觉模拟量表[VAS]）进行评估，并采用方差分析进行比较。使用的最小临床重要差异为-1.2 （VAS背部疼痛），-1.6 （VAS腿部疼痛），-15 (ODI), 0.587/0.375/0.8/0.42 （SRS-22疼痛/功能/自我形象/心理健康）和5.2 （SF-36，身体成分总结）。结果221例患者（LLIF 58例，ALIF 91例，PSF 72例）符合纳入标准。平均畸形包括SVA < 10 cm，骨盆-腰椎前凸（LL）不匹配>0度，骨盆倾斜> 20度，腰椎Cobb角> 20度，胸椎Cobb角> 15度。术前SVA、LL、骨盆发生率-LL不匹配、腰椎和胸椎Cobb角组间相似。单纯PSF组的患者有更多的合并症，ALIF+ PSF组的患者平均年龄更小，体重指数比LLIF+PSF组低，LLIF+PSF组的患者比ALIF+ PSF组和单纯PSF组的患者有更高的平均体间融合水平。在最后随访时，两组间所有影像学参数和平均并发症数相似。LLIF+PSF组的患者有近端关节后凸，需要翻修手术的次数明显减少，近端关节骨折和椎体滑移也更少。各组术前HRQoL评分相似。术后，LLIF+PSF组ODI评分明显降低，SRS-22自我形象/总分较高，SRS-22疼痛评分达到最小临床重要差异。结论对于有轻中度矢状面畸形的ASD患者，这3种手术入路均可获得满意的影像学结果。与接受ALIF+ PSF或仅接受PSF手术策略的患者相比，接受LLIF+PSF的患者近端关节后凸和上固定椎体机械衰竭的发生率较低，背部疼痛较少，残疾较少，SRS-22评分较高。
OBJECTIVE Surgical treatment of adult spinal deformity (ASD) is an effective endeavor that can be accomplished using a variety of surgical strategies. Here, the authors assess and compare radiographic data, complications, and health-related quality-of-life (HRQoL) outcome scores among patients with ASD who underwent a posterior spinal fixation (PSF)only approach, a posterior approach combined with lateral lumbar interbody fusion (LLIF+PSF), or a posterior approach combined with anterior lumbar interbody fusion (ALIF+PSF).METHODS The medical records of consecutive adults who underwent thoracolumbar fusion for ASD between 2003 and 2013 at a single institution were reviewed. Included were patients who underwent instrumentation from the pelvis to L-1 or above, had a sagittal vertical axis (SVA) of < 10 cm, and underwent a minimum of 2 years' follow-up. Those who underwent a 3-column osteotomy were excluded. Three groups of patients were compared on the basis of the procedure performed, LLIF+PSF, ALIF+ PSF, and PSF only. Perioperative spinal deformity parameters, complications, and HRQoL outcome scores (Oswestry Disability Index [ODI], Scoliosis Research Society 22-question Questionnaire [SRS-22], 36-Item Short Form Health Survey [SF-36], visual analog scale [VAS] for back/leg pain) from each group were assessed and compared with each other using ANOVA. The minimal clinically important differences used were -1.2 (VAS back pain), -1.6 (VAS leg pain), -15 (ODI), 0.587/0.375/0.8/0.42 (SRS-22 pain/function/self-image/mental health), and 5.2 (SF-36, physical component summary).RESULTS A total of 221 patients (58 LLIF, 91 ALIF, 72 PSF only) met the inclusion criteria. Average deformities consisted of a SVA of < 10 cm, a pelvic incidence-lumbar lordosis (LL) mismatch of > 10 degrees, a pelvic tilt of > 20 degrees, a lumbar Cobb angle of > 20 degrees, and a thoracic Cobb angle of > 15 degrees. Preoperative SVA, LL, pelvic incidence-LL mismatch, and lumbar and thoracic Cobb angles were similar among the groups. Patients in the PSF-only group had more comorbidities, those in the ALIF+ PSF group were, on average, younger and had a lower body mass index than those in the LLIF+PSF group, and patients in the LLIF+PSF group had a significantly higher mean number of interbody fusion levels than those in the ALIF+ PSF and PSF-only groups. At final follow-up, all radiographic parameters and the mean numbers of complications were similar among the groups. Patients in the LLIF+PSF group had proximal junctional kyphosis that required revision surgery significantly less often and fewer proximal junctional fractures and vertebral slips. All preoperative HRQoL scores were similar among the groups. After surgery, the LLIF+PSF group had a significantly lower ODI score, higher SRS-22 self-image/total scores, and greater achievement of the minimal clinically important difference for the SRS-22 pain score.CONCLUSIONS Satisfactory radiographic outcomes can be achieved similarly and adequately with these 3 surgical approaches for patients with ASD with mild to moderate sagittal deformity. Compared with patients treated with an ALIF+ PSF or PSF-only surgical strategy, patients who underwent LLIF+PSF had lower rates of proximal junctional kyphosis and mechanical failure at the upper instrumented vertebra and less back pain, less disability, and better SRS-22 scores.