脊柱侧后凸/后凸畸形SRS-Schwab四级截骨术后近端交界性后凸的危险因素分析

目的:探讨脊柱侧后凸/后凸畸形患者SRS-Schwab四级截骨术后发生近端交界性后凸(proximal junctional kyphosis,PJK)的相关危险因素。方法:回顾性分析2011年5月～2015年12月于我院行SRS-Schwab四级截骨手术且具有完整临床及影像学资料的46例脊柱侧后凸/后凸畸形患者,其中男性24例,女性22例,手术时年龄23.1±19.7岁。记录患者体重指数、融合节段、最上端固定椎(upper instrumented vertebra,UIV)位置及置钉密度等。测量术前、术后3个月及末次随访时的胸椎后凸角(thoracic kyphosis,TK)、腰椎前凸角(lumbar lordosis,LL)、骨盆入射角(pelvic incidence,PI)、局部后凸角(segmental kyphosis,SK)、主弯Cobb角(main curve,MC)、矢状面平衡(sagittal vertical axis,SVA)及近端交界角(proximal junctional angle,PJA)。根据患者术后是否发生PJK分为非PJK组和PJK组,采用t检验、χ2检验或Fisher精确检验对比两组临床资料及影像学参数,利用多因素Logistic回归分析确定PJK发生的危险因素。结果:46例患者术后随访24～63个月(36.9±13.4个月),其中11例(23.9%)发生PJK,以Ⅰ型PJK(8/11)最为常见,8例发生于术后6个月内。PJK组和非PJK组患者性别、年龄、随访时间、体重指数、融合节段、骨密度、置钉密度、UIV位置均无统计学差异(P0.05)。PJK组患者术前TK40°(6/11)和SK矫正30°(7/11)的比例均高于非PJK组(P0.05)。两组患者间术前PJA、LL、MC、PI、SVA和术后及末次随访时TK、LL、MC、SK、PI、SVA改变均无统计学差异(P0.05)。回归分析结果显示术后SK矫正30°(OR=7.000,95%CI=1.591-30.800,P=0.010)是PJK发生的独立危险因素。PJK组术前PJA为7.5°±3.0°,术后3个月为20.8°±4.1°,末次随访时为22.0°±4.5°,交界性后凸未见明显加重。结论:脊柱侧后凸/后凸畸形患者SRS-Schwab四级截骨术后PJK发生率为23.9%,其主要发生于术后6个月内,脊柱后凸畸形过度矫正是其独立危险因素。     

固定至骨盆的长节段矫形手术治疗老年重度胸腰椎后凸畸形机械性并发症的危险因素分析

【摘要】 目的：研究采用骶2骶髂（sacral-2 alar iliac,S2AI）螺钉固定至骨盆的长节段矫形手术治疗老年重度胸腰椎后凸畸形的机械性并发症的发生情况,并对其危险因素进行分析。方法：回顾性分析2015年1月~2018年12月因退行性胸腰椎重度后凸畸形于我院行长节段矫形手术且远端采用S2AI螺钉技术固定至髂骨的23例患者,其中男2例,女21例,年龄60~84岁（68.0±6.5岁）。手术节段9.1±2.4个,随访32.2±6.2个月。记录患者的并发症情况,并根据末次随访时患者是否发生机械性并发症将患者分为A组（无机械性并发症）和B组（有机械性并发症）。比较两组患者术前及末次随访腰痛视觉模拟评分（visual analogue scale,VAS）、腰椎Oswestry功能障碍指数（Oswestry disability index,ODI）。比较两组患者的一般资料和术前、术后1个月及末次随访时的骨盆投射角（pelvic incidence,PI）、骨盆倾斜角（pelvic tilt,PT）、骶骨倾斜角（sacral slope,SS）、腰椎前凸（lumbar lordosis,LL）、骨盆腰椎匹配值（PI-LL）、胸椎后凸（thoracic kyphosis,TK）、胸腰段后凸角（thoracolumbar kyphosis,TLK）、T1骨盆角（T1 pelvic angle,TPA）、矢状垂直轴（sagittal vertical axis,SVA）、冠状面侧凸角（Cobb angle,CA）、冠状面偏移距离（C7 plumb line-center sacral vertical line,C7PL-CSVL）,矢状面全脊柱序列比例（global alignment and proportion,GAP）评分等。采用受试者工作特征（receiver operator characteristic,ROC）曲线分析评价术后1个月时矢状位参数对机械性并发症的预测价值,并运用Logistic回归分析判断机械性并发症的危险因素。结果：末次随访时,13例患者未出现机械性并发症（A组）,10例患者出现机械性并发症（B组）;4例进行了翻修,翻修率为17.4%。两组患者性别、年龄、体质指数、骨密度、手术节段、手术时间、截骨方式、术中出血、随访时间均无统计学差异（P>0.05）。术前两组患者VAS评分和ODI无统计学差异（P>0.05）。末次随访A组患者VAS评分为2.2±0.9分,ODI为（28.6±7.8）％,B组患者VAS评分为3.3±1.2分,ODI为（49.5±9.6）％,均较术前明显改善,且两组间有统计学差异（P<0.05）。A组术后1个月时LL为39.6°±6.7°,SS为28.8°±8.5°,PI-LL为11.4°±11.3°,GAP评分为6.9±2.0分。B组术后1个月时LL为24.4°±9.9°,SS为20.2°±8.6°,PI-LL为22.7°±12.5°,GAP评分为10.9±2.4分。两组间有统计学差异（P<0.05）。末次随访时A组LL为35.2°±8.5°,PI-LL为17.3°±9.6°,B组LL为16.3°±9.8°,PI-LL为30.0°±12.1°,两组间有统计学差异,且均较术后1个月有统计学差异（P<0.05）。术后1个月时的SS、LL、PL-LL及GAP评分预测机械性并发症的曲线下面积分别为0.762（P=0.035）、0.896（P=0.001）、0.754（P=0.041）和0.885（P=0.002）。最佳临界值分别为24.1°、32.8°、12.0°和9.5。多因素Logistic回归分析显示术后1个月的LL值<32.8°是机械性并发症的独立危险因素（OR：48.0,95%CI：3.7~622.0,P=0.003）。结论：固定至骨盆的后路长节段矫形手术治疗老年重度后凸畸形术后仍存在较高的机械性并发症发生率,建议术后应使SS>24.1°、LL>32.8°、PI-LL<12.0°。GAP评分≥10提示术后机械性并发症的发生风险高。     

Indications for surgery in so-called “regular” thoracic and thoracolumbar kyphosis

Idiopathic thoracic, thoracolumbar, and Scheuermann's kyphosis do not figure in the same global entity. We propose a classification for so-called regular kyphosis. This classification is based on the location of the most rigid curvature segment. Segmental kyphosis may be short, in which case we can distinguish between four types: high kyphosis (type I), middle kyphosis (type II), low or thoracolumbar kyphosis (type III), and segmental kyphosis, which can extend along the entire thoracic spine (type IV). The symptomatology and therapeutic indications are different for each type. We report a series of 15 patients (6 female, 9 male), aged between 18 and 33 years (average age 24 years). The mean kyphosis angle (Cobb angle) in type I patients (n = 3) was 75° in type II patients (n = 3) it was 82°, and in type III patients (n = 9) it was 78°. The pain was greater in type III patients. All patients were operated on using a double approach. As the first step, we performed an anterior approach, disc excision, and bone graft. Ten days later, a posterior approach with CD instrumentation was carried out on ten levels. The mean follow-up is 4 years (range 9 months in 7 years). We noticed no neurological complications and one case of late sepsis. Mean angular loss of correction was 6°. The correction obtained dependend on the type of kyphosis. We obtained a mean postoperative Cobb angle of 63° in type I curves, 55° in type II, and 45° in type III. The new classification allows a better understanding of regular kyphosis and helps to define clinical and therapeutic approaches. An analysis of the resulting surgical correction can also be made by comparing homogeneous groups of patients.Paper read at the ESDS Meeting, Birmingham, 1994, and selected for full publication.     

复位五法结合内固定治疗胸腰段脊柱骨折脱位

目的:探讨手法复位技术在胸腰椎骨折脱位中的应用。方法:自2007年至2017年共诊治胸腰椎骨折脱位患者72例,分为治疗组与对照组。治疗组共37例,采用山东省名中医徐展望"牵压旋扳撑"复位五法,手术切开前先行手法复位,术中椎弓根钉棒系统撑开固定矫正残余移位及维持复位后位置。对照组35例只采用术中器械撑开复位固定。术后3 d所有患者均佩戴支具在床上坐起,下肢肌力在3级以上者下地活动。比较两组术后后凸Cobb角的改善以及侧方角度的改善情况,两组椎骨旋转角度改善情况及视觉模拟评分法(VAS)评分。结果:治疗组在侧方角度改善及椎骨旋转角度的改善方面明显优于对照组,治疗组侧方成角从平均17.46°±3.67°恢复到4.39°±1.23°;对照组从18.39°±4.12°恢复到8.12°±2.10°。两组比较差异有统计学意义(P0.01)。在椎骨旋转角度方面,治疗组恢复到6.02°±1.64°,对照组则恢复到14.91°±3.50°,两组比较差异有统计学意义(P0.01)。术后VAS均有明显改善,两组间对比差异无统计学意义。治疗组37例患者中治愈16例(43.24%),好转19例(51.35%),优良率94.59%。对照组35例中治愈11例(31.43%),好转19例(54.29%),优良率为85.71%。组间对比差异无统计学意义。选取典型病例,详细介绍了复位五法的应用情况。结论:手法复位可明显改善移位复杂严重的胸腰段骨折脱位,特别是脊柱的侧方成角以及椎骨的旋转移位。配合术中椎弓根钉棒系统撑开固定可达到满意的复位,且安全实用。     

Outcomes of Short Fusion versus Long Fusion for Adult Degenerative Scoliosis: A Systematic Review and Meta‐analysis

The objective of this study was to evaluate differences in clinical and radiographic outcomes between short (<3 levels) and long (≥3 levels) fusions in the setting of degenerative lumbar scoliosis. A literature search was performed from six electronic databases. The key terms of “degenerative scoliosis” OR “lumbar scoliosis” AND “fusion” were combined and used as MeSH subheadings. From relevant studies identified, demographic data, complication rates, Oswestry Disability Index (ODI), and radiographic parameters were extracted and the data was pooled and analyzed. Long fusion was associated with comparable overall complication rates to short fusion (17% vs 14%, P = 0.20). There was a significant difference in the incidence of pulmonary complications when comparing short versus long fusion (0.42% vs 2.70%; P = 0.02). No significant difference was found in terms of motor, sensory complications, infections, construct‐related or cardiac complications, pseudoarthrosis, dural tears, cerebrospinal fluid (CSF) leak, or urinary retention. A longer fusion was associated with a greater reduction in coronal Cobb angle and increases in lumbar lordosis, but both findings failed to achieve statistical significance. The ODI was comparable across both cohorts. If shorter fusion lengths are clinically indicated, they should be used instead of longer fusion lengths to reduce perioperative time, costs, and some other complications. However, there are no statistically significant differences in terms of radiographically measurable restoration associated with a short or long fusion.     

The effect of prophylactic vertebroplasty on the incidence of proximal junctional kyphosis and proximal junctional failure following posterior spinal fusion in adult spinal deformity: a 5-year follow-up study

Background Context

The incidence of proximal junctional kyphosis (PJK) ranges from 5% to 46% following adult spinal deformity surgery. Approximately 66% to 76% of PJK occurs within 3 months of surgery. A subset of these patients, reportedly 26% to 47%, develop proximal junctional failure (PJF) within 6 months postoperatively. To date, there are no studies evaluating the impact of prophylactic vertebroplasty on PJK and PJF incidence at long-term follow-up.

An unusual cause of cervical kyphosis

Background Context

Acute fixed cervical kyphosis may be a rare presentation of conversion disorder, psychogenic dystonia, and potentially as a side effect from typical antipsychotic drugs. Haldol has been associated with acute dystonic reactions. In some cases, rigid deformities ensue. We are reporting a case of a fixed cervical kyphosis after the use of Haldol.

远端固定椎-矢状面稳定椎位置关系对特发性胸椎侧凸矫形术后远端交界性后凸发生率的影响

目的:探讨远端固定椎(lowest instrumented vertebra,LIV)和矢状面稳定椎(sagittal stable vertebra,SSV)位置关系对特发性脊柱侧凸患者后路矫形选择性胸弯融合术后远端交界性后凸(distal junctional kyphosis,DJK)发生率的影响。方法:回顾性分析153例行后路主胸弯选择性融合术的Leneke 1A型青少年特发性脊柱侧凸(AIS)患者的临床资料。SSV定义为骶骨后上角垂线接触的最远端下终板所在的椎体。根据术后远端固定椎(lowest instrumented vertebra,LIV)与SSV的关系分为两组:LIV位于SSV近端椎体为LIVSSV组,LIV位于SSV或其远端椎体为LIV≥SSV组。测量患者术前、术后和随访时的冠状面主弯Cobb角和脊柱-骨盆矢状面相关参数,比较两组患者术后DJK的发生率以及发生DJK与未发生DJK患者的影像学参数和SRS-22评分。结果:LIVSSV组31例,LIV≥SSV组122例,两组患者在性别、年龄、Risser征、手术时间、手术出血量、融合节段数、随访时间、术前影像学参数及SRS-22评分均无统计学差异(P0.05)。术后随访24~69个月,共有13例患者发生DJK,发生率为8.4%,LIVSSV组患者DJK发生率(25.8%)高于LIV≥SSV组(4.1%)(χ~2=12.320,P0.001)。发生DJK患者与未发生DJK患者术前影像学参数及SRS-22评分均无显著性差异(P0.05),但末次随访时,发生DJK患者的胸椎后凸角、胸腰段后凸角、矢状面轴向距离、远端交界角均高于未发生DJK患者,且SRS-22疼痛评分低于未发生DJK患者,差异均有统计学意义(P0.05)。结论:远端固定椎-矢状面稳定椎位置关系显著影响Lenke 1A型AIS患者术后DJK的发生率,远端融合至SSV或其远端椎体可以显著降低术后DJK的发生率,更好地维持矢状面平衡。     

Self-Assessed Kyphosis and Chewing Disorders Predict Disability and Mortality in Community-Dwelling Older Adults

Objective

It is clear that each trend of kyphosis with increased age and the ability to eat firm foods with the back teeth (chewing ability) has a strong influence on both the physical and mental condition of older people. Thus, this study aimed to examine whether the combination of kyphosis and chewing disorders was associated with mortality or the need for care under the new long-term care insurance (LTCI) service requirement, over 3 years in community-dwelling older Japanese adults.

成人脊柱侧凸矫形术后近端交界性后凸的影响因素分析

目的 测量成人脊柱侧凸患者脊柱矢状位参数和骨盆参数,探讨矫形术后发生近端交界性后凸（PJK）的主要因素。方法 回顾性分析2014年1月至2016年9月于我院接受手术治疗的45例成人脊柱侧凸患者的病例资料。根据近端交界角（PJA）是否>20°将患者分为PJK组和非PJK组。在脊柱正侧位X线片上测量两组患者术前、术后1周和末次随访时的胸椎后凸角（TK）、胸腰椎后凸角（TLK）、腰椎前凸角（LL）、矢状面躯干偏移（SVA）、骨盆投射角（PI）、骨盆倾斜角（PT）和骶骨倾斜角（SS）。采用logistic多元回归分析探讨成人脊柱侧凸矫形术后发生PJK的主要影响因素。结果 PJK组19例、非PJK组26例。两组患者在性别、年龄、随访时间、上端固定椎位置、下端固定椎位置方面差异均无统计学意义（P均>0.05）。PJK组患者末次随访时LL、末次随访时SVA、术前PT、末次随访时PT均大于非PJK组,术前SS、末次随访时SS均小于非PJK组,差异均有统计学意义（P均<0.05）,其他参数在两组间差异均无统计学意义（P均>0.05）。Logistic多元回归分析显示,术前TK、末次随访时TK、末次随访时LL、末次随访时PT、术前SS是成人脊柱侧凸矫形术后发生PJK的主要影响因素（P均<0.05）。结论 术前TK、末次随访时TK、末次随访时LL、末次随访时PT、术前SS是成人脊柱侧凸患者矫形术后发生PJK的主要影响因素。