摘要
目的 探讨合并骨质疏松症的脊柱畸形长节段融合术后近端交界性后凸(proximal junctional kyphosis,PJK)的危险因素.方法 回顾性分析2013年6月至2019年12月在北京朝阳医院骨科接受长节段脊柱融合术的骨质疏松性脊柱畸形患者76例,男19例、女57例,年龄(66.26±6.10)岁(范围54～78岁).根据术后2年随访期间是否发生PJK分组,其中PJK组21例、非PJK组55例.对比两组患者临床资料、术前及术后脊柱骨盆参数、椎体亨氏单位(Hounsfield Unit,HU)值及椎旁肌形态.脊柱骨盆参数包括主弯Cobb角、腰椎前凸(lumbar lordosis,LL)、腰骶椎前凸(lumbosacral lordosis,LSL)、矢状面轴向距离(sagittal vertical axis,SVA)、T1骨盆角(Ti pelvic angle,TPA)、骨盆倾斜度(pelvic tilt,PT)、骶骨倾斜角(sacral slope,SS)、骨盆入射角(pelvic incidence,PI).通过术前 CT分别测量上端固定椎(upper instrumented vertebra,UIV),UIV远端第1个椎体(UIV+1)、UIV远端第2个椎体的HU值.通过术前MRI测量L4下终板水平椎旁肌的相对功能横截面积(relative functional cross-sectional area,rFCSA)和功能肌肉-脂肪指数(functional muscle-fat index,FMFI).使用ROC曲线确定UIV、UIV+1、UIV+2椎体HU值及椎旁肌rFCSA、FMFI的最佳截断值.使用二分类变量logistic回归分析确定PJK的独立危险因素.结果 PJK组与非PJK组患者术前PT(17.60°±8.39°和24.12°±9.37°)、术后LL(35.61°±10.62°和42.22°±13.11°)、LSL(30.24°±10.10° 和35.87°±11.12°)、SVA(37.82°±20.46°和21.37°±17.35°)的差异均有统计学意义(P＜0.05);两组 UIV椎体 HU值(113.62±17.25 和 133.94±16.61)、UIV+1 椎体HU值(123.14±16.03 和 138.27±13.69)、UIV+2椎体 HU值(121.00±15.91和134.47±15.53)的差异均有统计学意义(P＜0.05),最佳截断值分别为120.72、127.51、121.50;两组rFCSA(156.87±48.06和204.87±50.16)、FMFI(0.31±0.10和0.23±0.09)的差异均有统计学意义(P＜0.05),最佳截断值分别为175.43 和 0.24.logistic 回归分析显示术后 SVA[OR=1.049,95％CI(1.003,1.097),P=0.037]、UIV 椎体 HU 值[OR=0.938,95％CI(0.887,0.991),P=0.024]及椎旁肌rFCSA[OR=0.883,95％CI(0.792,0.983),P=0.023]为PJK 的独立危险因素.结论 合并骨质疏松症的脊柱畸形长节段融合术后矢状面序列恢复不佳、UIV椎体HU值降低、腰椎椎旁肌rFCSA降低会导致PJK发生风险增加.
Abstract
Objective To investigate the risk factors for proximal junctional kyphosis(PJK)in adult spinal deformity pa-tients with concomitant osteoporosis undergoing long-segment spinal fusion surgery.Methods A retrospective analysis was con-ducted on 76 adults spinal deformity patients with osteoporosis who underwent long-segment spinal fusion surgery at the Depart-ment of Orthopaedics,Beijing Chaoyang Hospital,between June 2013 and December 2019.The cohort included 19 males and 57 females,with a mean age of 66.26±6.10 years(range,54-78 years).Patients were categorized into two groups based on the occur-rence of PJK within a 2-year postoperative follow-up:the PJK group(21 cases)and the non-PJK group(55 cases).Comparative analyses were performed on baseline characteristics,surgical details,preoperative and postoperative spinal-pelvic parameters,Hounsfield Units(HU)of the vertebral bodies,and paraspinal muscle morphology between the groups.Spinal-pelvic parameters in-cluded the main Cobb angle,lumbar lordosis(LL),lumbosacral lordosis(LSL),sagittal vertical axis(SVA),T,pelvic angle(TPA),pelvic tilt(PT),sacral slope(SS),and pelvic incidence(PI).Preoperative CT was used to measure HU values at the upper instru-mented vertebra(UIV),UIV+1,and UIV+2.Paraspinal muscle morphology,including the relative functional cross-sectional area(rFCSA)and functional muscle-fat index(FMFI)at the L4 lower endplate level,was assessed using preoperative MRI.Optimal cut-off values for HU and paraspinal muscle parameters were determined using receiver operating characteristic curve analysis.Multi-variable logistic regression was employed to identify independent risk factors for PJK.Results Significant differences were ob-served between the PJK and non-PJK groups in preoperative PT(17.60°±8.39° vs.24.12°±9.37°),postoperative LL(35.61°±10.62° vs.42.22°±13.11°),LSL(30.24°±10.10° vs.35.87°±11.12°),and SVA(37.82°±20.46° vs.21.37°±17.35°).The differences were statistically significant(P＜0.05).The HU values of UIV(113.62±17.25 vs.133.94±16.61),UIV+1(123.14±16.03 vs.138.27±13.69),and UIV+2(121.00±15.91 vs.134.47±15.53)were significantly lower in the PJK group(P＜0.05).Optimal cutoff values for HU at UIV,UIV+1,and UIV+2 were identified as 120.72,127.51,and 121.50,respectively.Significant differences were also found in rFCSA(156.87±48.06 vs.204.87±50.16)and FMFI(0.31±0.10 vs.0.23±0.09).The differences were statistically signifi-cant(P＜0.05),with optimal cutoff values of 175.43 for rFCSA and 0.24 for FMFI.Multivariable logistic regression analysis indicat-ed that postoperative SVA[OR=1.049,95％CI(1.003,1.097),P=0.037],HU of UIV[0R=0.938,95％CI(0.887,0.991),P=0.024],and rFCSA of paraspinal muscles[OR=0.883,95％CI(0.792,0.983),P=0.023]were independent risk factors for PJK.Conclu-sion Reduced HU values of the UIV,decreased rFCSA of lumbar paraspinal muscles,and inadequate sagittal alignment correc-tion are independent risk factors for PJK in adult spinal deformity patients with osteoporosis undergoing long-segment spinal fu-sion surgery.
NETL
NSTL
万方数据