摘要目的:比较单纯椎板减压术和椎间内固定融合术治疗腰椎管狭窄伴矢状位失衡老年患者的临床疗效，并分析术后1年Oswestry功能障碍指数（Oswestry disability index，ODI）改善的独立预测因素。方法:回顾性分析2020年1月至2024年1月于天津市人民医院行单纯椎板减压术（1~2个节段）或椎间内固定融合术的61例腰椎管狭窄症伴矢状位失衡患者资料，按手术方式分为减压组（31例）和融合组（30例）。减压组男14例、女17例，年龄（71.2±10.5）岁（范围64~83岁）；融合组男14例、女16例，年龄（69.8±9.4）岁（范围61~81岁)。记录两组术前及术后3个月、6个月、1年随访时ODI、背部和腿部疼痛视觉模拟评分（visual analogue scale，VAS）。于术前及术后3个月、6个月、术后1年的全脊柱正侧位X片上测量脊柱-骨盆参数，包括腰椎前凸角（lumbar lordosis，LL）、骨盆倾斜角（pelvic tilt，PT）、矢状面垂直轴（sagittal vertical axis，SVA）以及骨盆入射角（Pelvic incidence，PI）并计算PI-LL。根据最小临床重要性差值（术后1年ODI改善8分）将61例患者分为改善组（ODI改善≥8分）和未改善组（ODI改善<8分），比较两组的性别、年龄、体质指数、手术节段数、手术方式、术前背部和腿部VAS、脊柱-骨盆参数，将差异有统计学意义的指标纳入多因素logistic回归分析，确定腰椎管狭窄术后1年ODI改善的独立预测因素。结果:减压组手术时间为（85.2±12.1）min，低于融合组的（116.0±15.8）min，差异有统计学意义（ t=8.762， P<0.05）；减压组和融合组的术中出血量分别为（142.5±18.1）ml和（151.3±20.0）ml，差异无统计学意义（ P>0.05）。两组患者均随访1年，减压组和融合组术后不同时间点的背部和腿部VAS、ODI、SVA、LL、PI-LL均较术前改善，差异有统计学意义（ P<0.05）。减压组术后1年的腿部VAS为（3.7±2.2）分，高于融合组的（2.3±1.6）分；术后3个月LL为29.0°±12.1°，低于融合组的37.9°±14.8°，差异均有统计学意义（ t=2.878， P=0.006； t=2.579， P=0.013），其余手术前后指标的组间差异均无统计学意义（ P>0.05）。术前背部VAS低是腰椎管狭窄术后1年ODI改善的独立预测因素[ OR值0.67，95% CI（0.58，0.84）， P<0.05）]。 结论:对短节段腰椎管狭窄伴矢状面失衡的老年患者，单纯椎板减压术与融合手术的早期影像学结果相似，融合手术早期腿部疼痛较轻。术前背部VAS低是腰椎管狭窄术后1年ODI改善的独立预测因素。

abstractsObjective:To compare the clinical efficacy of limited decompressive laminectomy and fusion with internal fixation for elderly patients with lumbar spinal stenosis accompanied by sagittal imbalance, and to identify independent predictors of a clinically relevant improvement in the Oswestry disability index (ODI) one year post-operatively.Methods:A retrospective analysis was conducted on the data of 61 consecutive patients with lumbar spinal stenosis accompanied by sagittal imbalance who underwent limited decompressive laminectomy [1-2 segments, n=31, 14 males and 17 females, aged 71.2±10.5 years (range, 64-83 years)] or fusion with internal fixation [(n=30, 14 males and 16 females, aged 71.2±10.5 years (range, 64-83 years)] at Tianjin Union Medical Center from January 2020 to January 2024. The ODI and visual analogue scale (VAS) scores for back and leg pain were recorded preoperatively, and at 3 months, 6 months, and 1 year postoperatively. At the same time spots, full-length anteroposterior and lateral X-ray images were used to measure spinal-pelvic parameters, including lumbar lordosis (LL), pelvic tilt (PT), sagittal vertical axis (SVA), and pelvic incidence (PI), and PI-LL was calculated. According to the minimal clinically important difference, the 61 patients were classified into an improvement group (ODI improvement ≥8 points) or a non-improvement group (ODI improvement <8 points). Inter-group comparisons were conducted for gender, age, body mass index, operative segments, surgical approach, preoperative back and leg VAS scores, and spinal-pelvic parameters. The indicators exhibiting statistically significant inter-group differences were entered into a multivariate logistic regression, to determine independent predictors of post-operative ODI improvement in patients with lumbar spinal stenosis.Results:Mean operative time of the decompression group was 85.2±12.1 min, gnificantly shorter than that of the fusion group (116.0±15.8 min, t=8.762, P<0.05). The intraoperative blood loss of the was 142.5±18.1 ml in the decompression group and versus 151.3 ± 20.0 ml in the fusion group, with a difference that did not reach statistical significance ( P>0.05). All patients were followed up for at least one year. The pos-operative back and leg VAS scores, ODI, and imaging parameters SVA, LL, and PI-LL in both groups improved significantly relative to baseline ( Ρ<0.05). One-year leg VAS remained higher in the decompression cohort (3.7±2.2) than in the fusion cohort (2.3±1.6); at 3 months LL was 29.0°± 12.1° versus 37.9°±14.8°. Both differences were statistically significant ( t=2.878, Ρ=0.006; t= 2.579, Ρ=0.013). There were no statistically significant differences in the other preoperative and postoperative indicators between the two groups ( Ρ>0.05). A lower preoperative back VAS score emerged as an independent predictor of ODI improvement at 1-year post-operatively in patients with lumbar spinal stenosis [ OR=0.67, 95% CI(0.58, 0.84), P<0.05]. Conclusions:In elderly patients with short-segment lumbar spinal stenosis accompanied by sagittal imbalance, limited decompressive laminectomy can achieve comparable early radiological efficacy to those of fusion with internal fixation, while suffers more leg pain. A lower preoperative back VAS score emerged as an independent predictor of ODI improvement at 1-year post-operatively in patients with lumbar spinal stenosis.