Spinopelvic sagittal imbalance as a risk factor for adjacent-segment disease after single-segment posterior lumbar interbody fusion
Spinopelvic sagittal imbalance as a risk factor for adjacent-segment disease after single-segment posterior lumbar interbody fusion
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DOI：
10.3171/2016.9.spine16232
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发表时间：
2017-04-01
影响因子：
2.8
通讯作者：
Iwasaki, Motoki
中科院分区：
文献类型：
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作者：
Matsumoto, Tomiya;Okuda, Shinya;Iwasaki, Motoki
目的脊柱关节融合术后脊柱骨盆平衡的重要性及其对临床预后的影响已有报道。然而，腰椎融合术后的相邻节段疾病(ASD)与脊柱骨盆排列之间的关系却知之甚少。本研究的目的是明确L4-5单节段腰椎间融合术(PLIF)术后脊柱骨盆影像参数与症状性房间隔缺损(ASD)的关系。纳入2005-2012年间因L4-5 PLIF后因症状性ASD而行翻修手术且在初次手术和翻修手术前有全脊柱站立X线片的20名患者。作为对照组，选择了100例年龄、性别和病理相匹配的患者，这些患者在同一时期接受了L4-5 PLIF，3年以上没有症状性ASD的迹象，术前和最后一次随访时有完整的脊柱X线片。ASD组初次手术时的平均年龄为68.9岁，对照组为66.7岁。矢状位测量骨盆矢状面纵轴(SVA)、胸椎后凸(TK)、骶骨斜度(SS)、骨盆倾斜度(PT)、骨盆倾斜度(PI)、腰椎前凸(LL)、L4-5节段前凸度(SL)，冠状位测量C7-C7-CSVL。结果两组患者手术前后的X线参数均无明显变化。在术前X线片参数方面，房间隔缺损组的LL值显著低于对照组(40.7°vs47.2°，p<；0.01)，PT值显著高于对照组(27°vs22.9°，p<；0.05)。ASD组20例患者中有10例(50%)SVA>；=50 mm，对照组100例患者中有21例(21%，p<；0.01)。ASD组20例患者中有15例(75%)术前X线片PI-LL>；=10，对照组100例患者中有40例(40%，p<；0.01)。术后ASD组TK(22.5°vs 30.9°，p<；0.01)和Ll(39.3°vs 48.1°，p<；0.05)均显著低于对照组。ASD组20例患者中有15例(75%)PI-LL>；=10度，对照组100例患者中有43例(43%，p<；0.01)。结论术前全矢状面失衡(SVA>；50 mm及以上PT)、术前术后较低的Ll和PI-Ll不匹配与ASD显著相关。因此，即使是单节段PLIF，在手术中也应获得适当的SL和LL，以改善骨盆矢状面的不平衡。结果还表明，达到适当的L1和PI-L1可预防L4-5PLIF术后ASD的发生。
OBJECTIVE The importance of spinopelvic balance and its implications for clinical outcomes after spinal arthrodesis has been reported in recent studies. However, little is known about the relationship between adjacent-segment disease (ASD) after lumbar arthrodesis and spinopelvic alignment. The purpose of this study was to clarify the relationship between spinopelvic radiographic parameters and symptomatic ASD after L4-5 single-level posterior lumbar interbody fusion (PLIF).METHODS This was a retrospective 1:5 matched case-control study. Twenty patients who had undergone revision surgery for symptomatic ASD after L4-5 PLIF and had standing radiographs of the whole spine before primary and revision surgeries were enrolled from 2005 to 2012. As a control group, 100 age-, sex-, and pathology-matched patients who had undergone L4-5 PLIF during the same period, had no signs of symptomatic ASD for more than 3 years, and had whole spine radiographs at preoperation and last follow-up were selected. Mean age at the time of primary surgery was 68.9 years in the ASD group and 66.7 years in the control group. Several radiographic spinopelvic parameters were measured as follows: sagittal vertical axis (SVA), thoracic kyphosis (TK), sacral slope (SS), pelvic tilt (PT), pelvic incidence (PI), lumbar lordosis (LL), and segmental lordosis at L4-5 (SL) in the sagittal view, and C7-central sacral vertical line (C7-CSVL) in the coronal view. Radiological parameters were compared between the groups.RESULTS No significant change was found between pre- and postoperative radiographic parameters in each group. In terms of preoperative radiographic parameters, the ASD group had significantly lower LL (40.7 degrees vs 47.2 degrees, p < 0.01) and significantly higher PT (27 degrees vs 22.9 degrees, p < 0.05) than the control group. SVA >= 50 mm was observed in 10 of 20 patients (50%) in the ASD group and in 21 of 100 patients (21%, p < 0.01) in the control group. PI -LL >= 10 was noted in 15 of 20 patients (75%) in the ASD group and in 40 of 100 patients (40%, p < 0.01) in the control group on preoperative radiographs. Postoperatively, the ASD group had significantly lower TK (22.5 degrees vs 30.9 degrees, p < 0.01) and lower LL (39.3 degrees vs 48.1 degrees, p < 0.05) than the control group had. PI -LL >= 10 degrees was seen in 15 of 20 patients (75%) in the ASD group and in 43 of 100 patients (43%, p < 0.01) in the control group.CONCLUSIONS Preoperative global sagittal imbalance (SVA > 50 mm and higher PT), pre- and postoperative lower LL, and PI -LL mismatch were significantly associated with ASD. Therefore, even with a single-level PLIF, appropriate SL and LL should be obtained at surgery to improve spinopelvic sagittal imbalance. The results also suggest that the achievement of the appropriate LL and PI -LL prevents ASD after L4-5 PLIF.