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不同骨盆投射角与腰椎前凸角之差对退变性脊柱侧凸后路长节段内固定术后效果的影响

Effects of different pelvic incidence minus lumbar lordosis mismatch after long posterior instrumentation and fusion for adult degenerative scoliosis

摘要:

目的 探讨后路长节段内固定术治疗退变性脊柱侧凸术后即刻不同骨盆投射角与腰椎前凸角之差(PI-LL)对术后脊柱侧凸矫正度、生活质量及内固定相关并发症的影响.方法 回顾性分析2010年1月至2015年1月于首都医科大学附属北京朝阳医院骨科行后路长节段椎弓根螺钉内固定植骨融合治疗的79例退变性脊柱侧凸患者的资料,男性21例,女性58例,年龄55~72岁,平均(63.4±4.8)岁.将患者按照术后即刻PI-LL的大小,分为<10°组(25例)、10°~20°组(32例)和>20°组(22例).比较手术前后Cobb角、PI-LL、日本骨科协会(JOA)评估治疗分数、Oswestry功能障碍指数(ODI)、视觉模拟评分(VAS)、腰椎僵硬功能障碍指数(LSDI).计量资料比较采用t检验和方差分析,非连续变量采用χ2检验;采用一元线性回归分析比较术后PI-LL与临床疗效及影像学参数的关系.结果 所有患者均手术成功,术中无并发症发生.手术时间145~310 min,平均(235.3±42.0)min,出血量300~5 300 ml,平均(1 021±787)ml,住院时间12~18 d,平均(14.5±1.3)d.共4~10个节段进行固定融合,平均(7.0±1.1)个.与术前相比,术后脊柱侧凸Cobb角[(4.2±1.8)°比(20.1±2.7)°]、PI-LL [(16.1±8.6)°比(36.0±4.3)°]、JOA(3.0±1.3比5.5±1.2)、ODI(24.4±8.1比62.9±2.7)、VAS(3.0±1.0比6.8±1.3)均降低(t=18.539~53.826,P值均<0.01).与术前相比,<10°组、10°~20°组和>20°组患者术后脊柱侧凸Cobb角[(4.1±2.7)°比(19.5±2.7)°、(4.0±1.4)°比(20.2±2.4)°、(4.7±0.9)°比(20.6±3.0)°](t=21.148~45.355,P值均<0.01)和PI-LL[(5.2±2.8)°比(35.8±4.9)°、(17.9±2.9)°比(37.2±3.9)°、(25.8±2.7)°比(34.5±4.0)°](t=7.227~38.250,P值均<0.01)均降低,三组PI-LL的差异有统计学意义(F=326.163,P<0.01).与术前相比,<10°组、10°~20°组和>20°组患者末次随访时ODI(27.7±4.9比63.3±2.6、17.7±5.9比63.1±2.8、30.6±6.5比62.3±2.5)(t=21.218~50.858,P值均<0.01)、JOA(2.8±1.2比5.2±1.2、3.3±1.1比5.7±1.1、2.8±1.7比5.7±1.2)(t=9.042~16.025,P值均<0.01)、VAS(2.9±1.2比7.0±1.3、3.3±0.9比7.0±1.4、2.9±0.8比6.3±1.2)(t=16.073~22.214,P值均<0.01)均降低;三组之间末次随访时ODI和LSDI的差异有统计学意义(F=38.477,P<0.01;F=37.063,P<0.01).线性回归结果显示,末次随访时PI-LL与LSDI呈负相关(B=-5.838,P<0.01).所有患者均获得随访,随访时间2~5年,平均(3.1±0.7)年.术后3年出现近端交界性后凸形成(PJK)19例,内固定松动6例;8例患者因明显局部疼痛及下肢症状进行了翻修手术;<10°组、10°~20°组和>20°组三组之间PJK发生率的差异有统计学意义(χ2=6.464,P=0.039).结论 后路长节段内固定融合术治疗成人退变性脊柱侧凸后将术后PI-LL矫正至10°~20°疗效最好,可明显降低PJK的发生.为了矫正PI-LL而使术后LL过大,可能加重术后腰椎僵硬程度.

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abstracts:

Objective To evaluate the influence of PI-LL (pelvic incidence minus lumbar lordosis mismatch) on scoliosis correction, living quality and internal fixation related complications for adult degenerative scoliosis (ASD) after long posterior instrumentation and fusion.Methods A total of 79 patients with ADS underwent long posterior instrumentation and fusion in the Department of Orthopedics at Beijing Chao Yang Hospital from January 2010 to January 2014 were retrospectively reviewed.There were 21 males and 58 females aging from 55 to 72 years with the mean age (63.4±4.8)years.The patients were divided into three groups according to immediately postoperative PI-LL: PI-LL<10°,10°≤PI-LL≤20°, PI-LL>20°.Compare the Cobb′s angles, PI-LL, Japanese Orthopaedic Association (JOA) score, Oswestry Disability Index (ODI), Visual Analog Scale (VAS) and Lumbar Stiffness Disability Index (LSDI).Measurement data were compared via t test and ANOVA, enumeration data were compared via Kruskal-Wallis test, noncontiguous data was performed by χ2 test.Univariate linear regression equation was performed to investigate the relative influences of postoperative PI-LL on postoperative radiographic parameters and clinical outcome.Results All the operations were successful without intraoperative complications.The operation time was 145-310 minutes (235.3±42.0) minutes, the intraoperative blood loss was 300-5 300 ml (1 021±787) ml, the duration of hospital was 12-18 d (14.5±1.3) d.A total of 4 to 10 (7.0±1.1) vertebra levels were fused.Compared to preoperative, the Cobb′s angle of scoliosis ((4.2±1.8)° vs.(20.1±2.7)°), PI-LL ((16.1±8.6)° vs.(36.0±4.3)°), JOA (3.0±1.3 vs.5.5±1.2), ODI (24.4±8.1 vs.62.9±2.7), VAS (3.0±1.0 vs.6.8±1.3) were significantly decreased postoperative (t=18.539~53.826,P<0.01).Compared to preoperative, postoperative Cobb′s angle of scoliosis ((4.1±2.7)° vs.(19.5±2.7)°, (4.0±1.4)° vs.(20.2±2.4)°, (4.7±0.9)° vs.(20.6±3.0)°) (t=21.148-45.355, P<0.01) and PI-LL ((5.2±2.8)° vs.(35.8±4.9)°, (17.9±2.9)° vs.(37.2±3.9)°, (25.8±2.7)° vs.(34.5±4.0)°) (t=7.227-38.250,P<0.01) were significantly reduced postoperative in PI-LL<10° group, 10°≤PI-LL≤20° group and PI-LL>20° group.Compared to preoperative, ODI (27.7±4.9 vs.63.3±2.6,17.7±5.9 vs.63.1±2.8,30.6±6.5 vs.62.3±2.5) (t=21.218~50.858, P<0.01), JOA (2.8±1.2 vs.5.2±1.2, 3.3±1.1 vs.5.7±1.1, 2.8±1.7 vs.5.7±1.2) (t=9.042-16.025, P<0.01) and VAS (2.9±1.2 vs.7.0±1.3, 3.3±0.9 vs.7.0±1.4, 2.9±0.8 vs.6.3±1.2) (t=16.073-22.214, P<0.01) were all significantly reduced at last follow-up.There were statistic differences in ODI and LSDI (F=38.477, P<0.01;F=37.063, P<0.01) at the last follow-up among the three groups.There was a negative correlation in PI-LL and LSDI according to linear regression (B=-5.838, P<0.01) in the last follow-up.All the patients were followed up, the follow-up duration were 2 to 5 years with the mean (3.1±0.7) years.The internal fixation failure related complications in 3 years included proximal junctional kyphosis (PJK) in 19 cases, internal fixation loosening in 6 cases.Eight patients received reoperation for severe local pain and low extremity symptoms.PJK occurrences were significantly different among PI-LL<10° group, 10°≤PI-LL≤20° group and PI-LL>20° group.Conclusions The PI-LL between 10° and 20° may be the best choice in ADS patients after long posterior instrumentation and fusion for its better clinical outcome and less proximal junctional kyphosis (PJK).The overcorrection of LL may lead to more serious postoperative lumbar stiffness.

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