Amara Dominic, Mummaneni Praveen V, Burch Shane, Deviren Vedat, Ames Christopher P, Tay Bobby, Berven Sigurd H, Chou Dean
Departments of1Neurosurgery and.
2Orthopedic Surgery, UCSF Spine Center, University of California, San Francisco, California.
J Neurosurg Spine. 2020 Nov 13;34(3):430-439. doi: 10.3171/2020.6.SPINE20256. Print 2021 Mar 1.
Radiculopathy from the fractional curve, usually from L3 to S1, can create severe disability. However, treatment methods of the curve vary. The authors evaluated the effect of adding more levels of interbody fusion during treatment of the fractional curve.
A single-institution retrospective review of adult patients treated for scoliosis between 2006 and 2016 was performed. Inclusion criteria were as follows: fractional curves from L3 to S1 > 10°, ipsilateral radicular symptoms concordant on the fractional curve concavity side, patients who underwent at least 1 interbody fusion at the level of the fractional curve, and a minimum 1-year follow-up. Primary outcomes included changes in fractional curve correction, lumbar lordosis change, pelvic incidence - lumbar lordosis mismatch change, scoliosis major curve correction, and rates of revision surgery and postoperative complications. Secondary analysis compared the same outcomes among patients undergoing posterior, anterior, and lateral approaches for their interbody fusion.
A total of 78 patients were included. There were no significant differences in age, sex, BMI, prior surgery, fractional curve degree, pelvic tilt, pelvic incidence, pelvic incidence - lumbar lordosis mismatch, sagittal vertical axis, coronal balance, scoliotic curve magnitude, proportion of patients undergoing an osteotomy, or average number of levels fused among the groups. The mean follow-up was 35.8 months (range 12-150 months). Patients undergoing more levels of interbody fusion had more fractional curve correction (7.4° vs 12.3° vs 12.1° for 1, 2, and 3 levels; p = 0.009); greater increase in lumbar lordosis (-1.8° vs 6.2° vs 13.7°, p = 0.003); and more scoliosis major curve correction (13.0° vs 13.7° vs 24.4°, p = 0.01). There were no statistically significant differences among the groups with regard to postoperative complications (overall rate 47.4%, p = 0.85) or need for revision surgery (overall rate 30.7%, p = 0.25). In the secondary analysis, patients undergoing anterior lumbar interbody fusion (ALIF) had a greater increase in lumbar lordosis (9.1° vs -0.87° for ALIF vs transforaminal lumbar interbody fusion [TLIF], p = 0.028), but also higher revision surgery rates unrelated to adjacent-segment pathology (25% vs 4.3%, p = 0.046). Higher ALIF revision surgery rates were driven by rod fracture in the majority (55%) of cases.
More levels of interbody fusion resulted in increased lordosis, scoliosis curve correction, and fractional curve correction. However, additional levels of interbody fusion up to 3 levels did not result in more postoperative complications or morbidity. ALIF resulted in a greater lumbar lordosis increase than TLIF, but ALIF had higher revision surgery rates.
节段性脊柱侧凸（通常从L3至S1）导致的神经根病可造成严重残疾。然而，针对该脊柱侧凸的治疗方法各异。作者评估了在节段性脊柱侧凸治疗中增加更多节段椎间融合的效果。
对2006年至2016年间在单一机构接受脊柱侧凸治疗的成年患者进行回顾性研究。纳入标准如下：L3至S1的节段性脊柱侧凸>10°，节段性脊柱侧凸凹侧存在同侧神经根症状，患者在节段性脊柱侧凸节段至少接受1次椎间融合，且随访至少1年。主要结局包括节段性脊柱侧凸矫正的变化、腰椎前凸的变化、骨盆入射角-腰椎前凸失配的变化、脊柱侧凸主弯的矫正以及翻修手术率和术后并发症发生率。二次分析比较了接受后路、前路和侧路椎间融合患者的相同结局。
共纳入78例患者。各组在年龄、性别、体重指数、既往手术史、节段性脊柱侧凸度数、骨盆倾斜度、骨盆入射角、骨盆入射角-腰椎前凸失配、矢状垂直轴、冠状面平衡、脊柱侧凸曲线大小、接受截骨术患者的比例或融合节段的平均数量方面无显著差异。平均随访时间为35.8个月（范围12 - 150个月）。接受更多节段椎间融合的患者节段性脊柱侧凸矫正更多（1个节段、2个节段和3个节段分别为7.4° vs 12.3° vs 12.1°；p = 0.009）；腰椎前凸增加更大（-1.8° vs 6.2° vs 13.7°，p = 0.003）；脊柱侧凸主弯矫正更多（13.0° vs 13.7° vs 24.4°，p = 0.01）。各组在术后并发症（总体发生率47.4%，p = 0.85）或翻修手术需求（总体发生率30.7%，p = 0.25）方面无统计学显著差异。在二次分析中，接受腰椎前路椎间融合（ALIF）的患者腰椎前凸增加更大（ALIF组为9.1°，经椎间孔腰椎椎间融合术[TLIF]组为-0.87°，p = 0.028），但与相邻节段病变无关的翻修手术率也更高（25% vs 4.3%，p = 0.046）。大多数（55%）ALIF翻修手术率较高的病例是由棒材断裂导致。结论：更多节段的椎间融合导致腰椎前凸增加、脊柱侧凸曲线矫正和节段性脊柱侧凸矫正增加。然而，额外增加至3个节段的椎间融合并未导致更多的术后并发症或发病率。ALIF导致的腰椎前凸增加比TLIF更大，但ALIF的翻修手术率更高。
