脊柱骨盆参数在颈椎病术后轴性症状与退变性侧凸生活质量改善中的作用

发布时间：2018-09-11 18:31

【摘要】：背景近年来,脊柱骨盆影像学参数在脊柱疾病诊疗中的作用越来越受到重视;脊柱骨盆影像学参数不但在脊柱畸形的诊治中具有重要意义,并且也逐渐认识到在颈椎病、腰椎间盘突出症、腰椎滑脱症、胸腰椎压缩性骨折等疾病的诊治中同样具有重要意义。脊柱骨盆影像学参数可分为整体参数与局部参数。大量研究认为临床症状、生活质量与整体脊柱冠状面参数失常无明显相关性,而与整体矢状面参数失常密切相关。如研究表明整体矢状面平衡是改善成人脊柱畸形临床疗效最重要的因素。和整体脊柱参数一样,局部脊柱参数也是影响手术并发症及生活质量的重要因素。如腰椎前凸角是影响成人脊柱畸形术后疼痛及患者生活质量重要的局部影像学参数。脊柱骨盆参数失常可导致脊柱畸形、疼痛、功能障碍和手术并发症等,均严重影响患者生活质量;而脊柱骨盆参数的恢复与良好的治疗效果密切相关。脊柱外科医生将脊柱骨盆影像学参数与患者症状、手术并发症和生活质量联系起来的能力将对脊柱疾病手术决策和手术规划非常有益。目前,虽然对脊柱骨盆参数在脊柱疾病中的作用有了部分的了解,但是脊柱骨盆参数在脊柱疾病中的作用尚处于初步发展阶段,仍存在许多理论上的盲区,如哪些参数影响了手术并发症、哪些参数的变化对患者生活质量的改善最有预测意义等问题,均需要进一步的研究。所以,本论文拟对局部脊柱骨盆参数和整体脊柱骨盆参数在脊柱疾病手术并发症和生活质量改善两方面进行研究。脊髓型颈椎病(CSM)是老年人群中最常见的脊柱神经系统疾病之一。1977年Hirabayashi等设计的传统颈椎单开门椎管扩大成形术(CL)已被广泛用于治疗CSM。CL技术简单,也带来了满意的临床结果,但是它也产生了多种并发症,如术后轴性症状(post-AS),椎板再关门,颈椎活动度丢失和C5神经根麻痹等。因此很多改良的术式被发明应用以减少这些并发症。微型钛板固定技术是一种改良术式(ML)。然而post-AS仍然是此改良术式一个常见的严重并发症。颈椎椎管扩大成形手术的post-AS总发生率为29%到73. 3%。虽然post-AS不致命,但post-AS往往严重到足以扰乱患者正常的日常生活,并成为术后主要并发症。Post-AS的病因尚不清楚。重要的是要知道哪些术前颈椎影像学参数和临床参数是术后轴性症状的预测影响因素。一些研究试图描述post-AS和危险因素之间的关系。然而,这些研究仅是间接的和回顾性的,或只使用单因素分析。一个只包括改良术式组的回顾性研究结果表明,颈椎活动范围、小关节的破坏等因素可能与post-AS有关。上述回顾性研究的主要不足是缺乏一个对照组,因此它不能确定哪种手术方法在减少术后轴性症状方面更有优势。因此需要一个前瞻性的、对比的、多因素回归分析来确定影响post-AS最有预测力的术前因素,主要是术前颈椎影像学参数。成人退变性脊柱侧凸(ADS)主要症状有腰痛、腿痛和脊柱畸形,并且这种畸形多伴有矢状面和冠状面失平衡。ADS作为成人脊柱侧凸中最常见的类型,是最具挑战性的复杂脊柱畸形之一。对ADS进行手术干预是技术上的巨大挑战,并可带来严重并发症和不良后果,像疼痛加重、神经损伤、功能降低、交界性后凸等,这些并发症都扰乱患者正常的日常生活,严重影响患者生活质量。现在,逐步认识到成人脊柱畸形的治疗效果评价不但包括影像学参数评价,更重要的是对患者生活质量的评价。在成人脊柱侧凸中,一些研究已经显示了部分脊柱骨盆参数与临床症状的关系,但是这些研究只是关注了术前脊柱骨盆参数与术前临床症状的关系,或只是关注了术后脊柱骨盆参数与术后临床症状的关系。另外,ADS需要区别于成人脊柱侧凸其他类型,因为ADS是由于脊柱结构性元素进行性退变导致的脊柱畸形,而成人脊柱侧凸是一个集体名词,包括所有骨骼发育成熟后的脊柱畸形类型。据我们所知,目前文献缺少只包括成人退变性脊柱侧凸患者的脊柱骨盆参数的即刻变化和生活质量改善相关性的研究。而在面对此类病人时,这个相关性对脊柱外科医生计划手术方案和推测预后是非常有用的。因此,本研究的目的是探讨脊柱骨盆参数在颈椎病术后轴性症状与退变性侧凸患者生活质量改善中的作用。本研究共分两个部分,第一部分是研究局部脊柱骨盆影像学参数—颈椎参数:术前颈椎影像学参数在影响脊髓型颈椎病术后轴性症状中的作用;第二部分是研究整体和局部脊柱骨盆影像学参数:脊柱骨盆参数的术后即刻变化与成人退变性脊柱侧凸患者生活质量改善的相关性。第一部分术前颈椎影像学参数在脊髓型颈椎病单开门术后轴性症状中的作用目的采用多因素逻辑回归分析研究影响术前轴性症状的术前颈椎参数和临床参数;通过前瞻性的对比不同术式和多因素回归分析来阐明影响(危险或保护)post-AS的术前颈椎参数和临床参数。材料与方法选择山东省聊城市人民医院脊柱外科自2009年3月至2015年9月行颈椎后路单开门椎管扩大成形术的脊髓型颈椎病患者。根据手术日期,患者被前瞻性的分配至不同的手术方式组。从2009年3月至2011年7月,病人是被安排行传统手术(粗丝线固定,CL组)。从2011年9月至2015年9月,病人是被安排行改良手术(微型钛板固定,ML组)。评价指标:①术前颈椎影像学参数:颈椎前凸角(CCA),颈椎管前后径(APD),颈椎矢状面平衡(C2-7SVA),颈髓参数(HSI);②临床指标:年龄、性别、手术方式(CL、ML)、手术时间、失血量、术前JOA评分及是否有术前轴性症状(pre-AS)。轴性症状(AS)评价:根据Hosono等的标准,把AS分为四级,其中评价为良好或轻微的是被定义为无AS,评价为较重或严重的并症状持续1个月是被定义为有AS。Pre-AS及post-AS都被评价记录。其中post-AS是在术后6-8个月时评价。SPSS 20.0统计软件进行数据分析:多因素逻辑回归分析确定影响术前轴性症状的术前因素;两种术式的术后轴性症状进行前瞻性对比分析研究;最后用多因素逻辑回归分析确定影响术后轴性症状的术前因素。统计检验的显著性均设定为P0.05。结果:1.纳入患者例数:共有102例患者被纳入本研究,其中CL组:44例,ML组:58例。组间比较:在CL组和ML组之间,年龄、性别、手术时间、失血量、术前JOA评分、是否有pre-AS、CCA、APD、C2-7SVA、HSI无显著差异。2.总的术前轴性症状的发生率为29.4% (30/102)。传统术式组pre-AS的发生率为25.0% (11/44),改良术式组为32.8% (19/58)。两组间pre-AS发生率无显著差异(P=0.394)。多因素回归分析表明术前CCA是影响pre-AS的颈椎影像学因素(P=0.011,oddsratio=0.930),其他术前因素都不是。进一步分析表明,与未患有pre-AS的患者相比,患有pre-AS的患者具有更小的术前 CCA(P=0.004)。3.总的术后轴性症状的发生率为40.2% (41/102)。传统术式组post-AS的发生率为54.5% (24/44),改良术式组为29.3% (17/58)。两组间post-AS发生率有显著差异(P=0.010)。多因素回归分析表明ML和CCA是影响post-AS的术前因素(ML: P=0.011,odds ratio=0.302; CCA: P=0.042, odds ratio=0.947),其他因素都不是。进一步分析表明,与未发生post-AS的病人相比,发生post-AS的病人具有更小的术前CCA(P=0.043)。结论:该部分研究表明更小的术前颈椎前凸角是术前轴性症状的危险因素;通过选择有更大术前颈椎前凸角的患者或应用微型钛板固定技术可以降低脊髓型颈椎病单开门手术的术后轴性症状。第二部分脊柱骨盆参数的即刻变化与退变性侧凸矫形患者生活质量改善的相关性分析目的在成人退变性脊柱侧凸患者中,对比分析手术前、后脊柱骨盆参数和生活质量的差异;通过单变量和多变量线性回归分析评估脊柱骨盆参数的即刻变化与患者生活质量改善的相关性。材料与方法我们对收集了成人退变性脊柱侧凸矫形手术的单中心数据库进行了回顾性研究。脊柱骨盆参数包括脊柱冠状位参数、脊柱矢状位参数和骨盆参数。脊柱冠状位参数包含最大Cobb角、冠状位平衡(CVA);脊柱骨盆矢状面平衡包含矢状面平衡(SVA)、腰椎前凸角(LL)、胸椎后凸角(TK)、骨盆倾斜角(PT)和骶骨倾斜角(SS)。生活质量的评估采用两个调查问卷(ODI和VAS)对患者进行功能障碍程度、疼痛的评分。脊柱骨盆参数的即刻变化(△)和生活质量改善(△)是被分别定义的。用配对t检验和线性回归分析进行数据统计分析。结果共52名患者符合标准,包括13名男性和39名女性。随访时间平均为40个月(范围,25-78个月)。手术时的平均年龄为56岁(范围,50-67岁)。平均融合节段为8.4个椎体(范围,5-11个椎体)。患者术前和术后即刻的脊柱骨盆参数,在Cobb角(P0.001)、SVA(P0.001)、LL (P0.001)、TK (P=0.025)、PT (P=0.009)和 SS (P=0.007)表现出显著性差异,但CVA(P=0.937)未见显著性差异。最后一次随访时ODI和VAS评分与术前相比有显著性改善(二者均P0.001)。单因素回归分析发现,△ SVA(P=0.002)、△ LL (P=0.002)和 △ TK (P=0.009)与△ODI呈显著相关性。多因素回归分析发现只有△SVA(P=0.009)和△LL(P=0.016)仍和△ ODI呈显著相关性,△ TK (P=0.581)被排除在外。也就是说,SVA每增加1mm, ODI预计增加0.347; LL每增加1°,ODI预计减少0.336。单因素回归分析发现,△SVA(P0.001)、△LL(P=0.017)和 △TK(P=0.032)与△ VAS呈显著相关性。多因素回归分析发现只有△SVA(P0.001)和△LL(P=0.046)仍和△ VAS呈显著相关性,△ TK (P=0.926)被排除在外。也就是说,SVA每增加1mm, VAS预计增加0.520; LL每增加1°,VAS预计减少0.264。结论矫形手术显著改善了成人退变性脊柱侧凸患者的脊柱骨盆参数(除了 CVA)和生活质量。对成人退变性脊柱侧凸患者来说,减少SVA和增加LL是手术获得较高生活质量改善的关键目标。TK的即刻改变是影响患者生活质量改善的混杂因素,同时脊柱冠状位参数和骨盆参数的即刻改变都不是患者生活质量改善的显著性预测因素。
[Abstract]:Background In recent years, more and more attention has been paid to the role of spinal and pelvic imaging parameters in the diagnosis and treatment of spinal diseases; spinal and pelvic imaging parameters are not only important in the diagnosis and treatment of spinal deformities, but also gradually recognized in the diagnosis and treatment of cervical spondylosis, lumbar disc herniation, lumbar spondylolisthesis, thoracolumbar compression fractures and other diseases. The imaging parameters of the spine and pelvis can be divided into global parameters and local parameters. Many studies have shown that clinical symptoms, quality of life and overall spinal coronal parameters are not significantly correlated, but with overall sagittal parameters are closely related. For example, studies have shown that overall sagittal balance is to improve the imminence of adult spinal deformity. As with the overall spinal parameters, local spinal parameters are also important factors affecting postoperative complications and quality of life. For example, lumbar lordosis angle is an important local imaging parameter affecting postoperative pain and quality of life in adult spinal deformities. Dysfunction and surgical complications severely affect the patient's quality of life, and the recovery of spinal and pelvic parameters is closely related to good treatment outcomes. At present, although the role of spine and pelvis parameters in spinal diseases has been partly understood, the role of spine and pelvis parameters in spinal diseases is still in the initial stage of development, there are still many theoretical blind spots, such as which parameters affect the surgical complications, which parameters change the most to improve the quality of life of patients. Therefore, this paper intends to study the local spine and pelvis parameters and the overall spine and pelvis parameters in the aspects of surgical complications and quality of life. Cervical spondylotic myelopathy (CSM) is one of the most common spinal and nervous system diseases in the elderly. Hirabayas, 1977 Hi and other traditional open-door cervical laminoplasty (CL) has been widely used in the treatment of CSM.CL with simple technique and satisfactory clinical results, but it also produces a variety of complications, such as post-AS, lamina reopening, loss of cervical mobility and C5 nerve root paralysis. Mini-titanium plate fixation is an improved procedure (ML). However, post-AS remains a common and serious complication of this modified procedure. The overall incidence of post-AS in cervical spinal canal dilatation surgery ranges from 29% to 73.3%. Although post-AS is not fatal, post-AS is often severe enough to disrupt the patient's normal day. The etiology of Post-AS remains unclear. It is important to know which preoperative cervical imaging parameters and clinical parameters are predictors of postoperative axial symptoms. Some studies attempt to describe the relationship between post-AS and risk factors. However, these studies are only indirect and retrospective, or A retrospective study involving only the modified procedure group showed that the range of motion of the cervical spine and the destruction of facet joints might be associated with post-AS. Therefore, a prospective, comparative, multivariate regression analysis is needed to determine the most predictive preoperative factors affecting post-AS, mainly preoperative cervical spine imaging parameters. The main symptoms of adult degenerative scoliosis (ADS) are low back pain, leg pain, and spinal deformities, which are often associated with sagittal and coronal imbalances. Adult scoliosis is one of the most common and challenging complex spinal deformities. Surgical intervention with ADS is a major technical challenge and can lead to serious complications and adverse consequences, such as increased pain, nerve injury, dysfunction, borderline kyphosis, and so on. These complications disrupt the normal daily life of patients. In adult scoliosis, some studies have shown the relationship between some spinal pelvic parameters and clinical symptoms, but these studies are only relevant. In addition, ADS needs to be distinguished from other types of adult scoliosis, because ADS is a spinal deformity caused by progressive degeneration of spinal structural elements, and adult scoliosis is a collection. Body terms, including all types of spinal deformities after bone maturation. As far as we know, there is a lack of literature on the correlation between immediate changes in spinal pelvic parameters and improved quality of life in adults with degenerative scoliosis. The purpose of this study was to investigate the role of spinal and pelvic parameters in improving the quality of life in patients with cervical spondylosis and degenerative scoliosis after surgery. The second part is to study the overall and local spinal and pelvic imaging parameters: the correlation between immediate changes of spinal and pelvic parameters and the improvement of quality of life in adult patients with degenerative scoliosis. Objective To analyze the preoperative cervical spine parameters and clinical parameters affecting preoperative axial symptoms by multivariate logistic regression analysis, and to clarify the preoperative cervical spine parameters and clinical parameters affecting (risk or protection) post-AS by prospective comparison of different surgical methods and multivariate regression analysis. Patients with cervical spondylotic myelopathy who underwent posterior open-door laminoplasty in the Department of Spinal Surgery of Liaocheng People's Hospital from March 2009 to September 2015 were prospectively assigned to different surgical groups according to the date of operation. From March 2009 to July 2011, patients were assigned to traditional surgery (coarse-wire fixation, CL group). From September 11 to September 2015, patients were scheduled to undergo modified surgery (mini-titanium plate fixation, ML group). Evaluation indicators: 1. Preoperative cervical imaging parameters: cervical lordosis angle (CCA), anterior and posterior diameter of cervical spinal canal (APD), cervical sagittal balance (C2-7SVA), cervical spinal cord parameters (HSI); 2. Clinical indicators: age, sex, operation mode (CL, ML), operation time, blood loss, and operation. Pre-JOA score and preoperative axial symptoms (pre-AS). Assessment of axial symptoms (AS): According to Hosono's criteria, AS was classified into four grades, in which good or mild AS was defined as absence, in which severe or severe symptoms lasting for one month were defined as AS. Pre-AS and post-AS. Post-AS was recorded during surgery. SPSS 20.0 statistical software for data analysis: multivariate logistic regression analysis to determine preoperative factors affecting preoperative axial symptoms; two types of postoperative axial symptoms for prospective comparative analysis; and finally multivariate logistic regression analysis to determine preoperative factors affecting postoperative axial symptoms. Results: 1. A total of 102 patients were enrolled in this study, including CL group: 44 cases, ML group: 58 cases. Intergroup comparison: between CL group and ML group, age, sex, operation time, blood loss, preoperative JOA score, whether pre-AS, CCA, APD, C2-7SVA, HSI had no significant difference. The incidence of pre-AS was 25.0% (11/44) in the traditional operation group and 32.8% (19/58) in the modified operation group. There was no significant difference in the incidence of pre-AS between the two groups (P = 0.394). Multivariate regression analysis showed that preoperative CCA was a cervical imaging factor affecting pre-AS (P = 0.011, odds ratio = 0.930), and other preoperative factors were not. The overall incidence of postoperative axial symptoms was 40.2% (41/102). The incidence of post-AS was 54.5% (24/44) in the traditional group and 29.3% (17/58) in the modified group. The incidence of post-AS was significantly different between the two groups (P = 0.010). The analysis showed that ML and CCA were the preoperative factors affecting post-AS (ML: P = 0.011, odds ratio = 0.302; CCA: P = 0.042, odds ratio = 0.947), and none of the other factors. Further analysis showed that patients with post-AS had smaller preoperative CCA (P = 0.043) than patients without post-AS. Anterior kyphosis angle is a risk factor for preoperative axial symptoms. Selection of patients with greater preoperative cervical kyphosis angle or application of mini-titanium plate fixation technique can reduce postoperative axial symptoms in patients with cervical spondylotic myelopathy undergoing open-door surgery. Part II Immediate changes in spinal and pelvic parameters are associated with improved quality of life in patients undergoing orthopedic scoliosis. Objective To compare and analyze the differences of spinal pelvic parameters and quality of life before and after surgery in adult patients with degenerative scoliosis, and to evaluate the correlation between immediate changes of spinal pelvic parameters and improvement of quality of life by univariate and multivariate linear regression analysis. The single-center database of orthopaedic surgery for scoliosis was retrospectively studied. Spinal and pelvic parameters included spinal coronal, spinal sagittal, and pelvic parameters. Spinal coronal parameters included maximum Cobb angle, coronal balance (CVA); spinal and pelvic sagittal balance included sagittal balance (SVA), lumbar lordosis (LL), and thoracic kyphosis. TK, PT, and SS. Quality of life was assessed using two questionnaires (ODI and VAS) to assess the degree of dysfunction and pain. Immediate changes in spinal and pelvic parameters (delta) and improvement in quality of life (delta) were defined separately. Matched t test and linear regression analysis were used for data statistics. Results A total of 52 patients met the criteria, including 13 males and 39 females. The mean follow-up time was 40 months (range, 25-78 months). The mean age at surgery was 56 years (range, 50-67 years). The mean fusion segment was 8.4 vertebral bodies (range, 5-11 vertebral bodies). The preoperative and postoperative spinal and pelvic parameters were at Cobb angle (P 0.001), SVA. (P = 0.001), LL (P 0.001), TK (P = 0.025), PT (P = 0.009) and S S (P = 0.007) showed significant differences, but CVA (P = 0.937) showed no significant difference. At the last follow-up, ODI and VAS scores were significantly improved compared with those before surgery (both P 0.001). Univariate regression analysis showed that delta SVA (P = 0.002), Delta LL (P = 0.002) and delta TK (P = 0.009) and delta O.009. Multivariate regression analysis showed that only SVA (P = 0.009) and LL (P = 0.016) remained significantly correlated with ODI, and TK (P = 0.581) was excluded. That is to say, ODI was expected to increase by 0.347 for every 1 mm increase in SVA, and 0.336 for every 1 degree increase in LL. Multivariate regression analysis showed that only SVA (P = 0.001) and LL (P = 0.046) remained significantly correlated with VAS, and TK (P = 0.926) was excluded. Spinal pelvic parameters (except CVA) and quality of life in patients with degenerative scoliosis. For adults with degenerative scoliosis, reduce S
【学位授予单位】：山东大学
【学位级别】：博士
【学位授予年份】：2017
【分类号】：R687.3

【参考文献】