青少年特发性脊柱侧凸（AIS）中 L3-LIV 选择性融合术后冠状面失衡或翻修手术的风险因素。
Risk factors for persistent coronal imbalance or revision surgery following L3 LIV selection in adolescent idiopathic scoliosis (AIS).
机构信息
Department of Orthopaedic Surgery, Children's Hospital of Philadelphia, The University of Pennsylvania School of Medicine, Philadelphia, PA, USA.
Richard M. Armstrong, Jr., Endowed Chair, Department of Orthopaedic Surgery, Children's Hospital of Philadelphia, The University of Pennsylvania School of Medicine, Philadelphia, PA, USA.
出版信息
Spine Deform. 2021 Jul;9(4):1063-1072. doi: 10.1007/s43390-020-00277-0. Epub 2021 Jan 13.
STUDY DESIGN
Retrospective case-control.
OBJECTIVE
To identify a cohort of patients with persistent coronal imbalance (CIB) or revision surgery 5 years following fusion to an L3 lowest-instrumented-vertebra (LIV) and determine factors that make an L3 LIV high-risk. In surgical planning for AIS, L3 is chosen over L4 whenever possible to maximize motion segments below the LIV. Though fusion to an L3 LIV is common, the rate of failure and its risk factors have not been described.
METHODS
In this analysis of prospectively-collected multi-center data of AIS patients who underwent posterior spinal fusion (PSF) to an L3 LIV, we identified patients with CIB at 5 years and/or those who required revision surgery attributable to LIV selection. Patients who were balanced at 5 years and did not require revision surgery served as controls. Pre-operative patient and radiographic variables were compared between cases and controls to identify risk factors for CIB/revision surgery.
RESULTS
We identified 646 patients with 2-year follow-up and 225 patients with 5-year follow-up, of which 11 were found to have CIB and/or revision surgery attributable to selecting L3 as the LIV. There were statistically significant differences between cases and controls with respect to several pre-operative factors, including BMI (24.5 in cases vs. 20.1 in controls; p = 0.01), Lenke curve type (81.8% Lenke 5/6 vs. 44.4%; p = 0.03), lumbar curve magnitude (56 vs. 45°; p < 0.01), TL/L apical vertebral translation (AVT) (6.2 vs. 4.1 cm; p < 0.01), L3 angulation (30° vs. 22°; p < 0.01), L3 translation (4.3 vs. 2.9 cm; p < 0.01), thoracic rib hump (7° vs. 12°; p = 0.02), lumbar rib hump (16° vs. 10°; p < 0.01), and thoracolumbar (T10-L2) kyphosis (10.5° vs. 2°; p = 0.006). Multivariate logistic regression showed that pre-operative BMI, TL/L AVT, L3 angulation, L3 translation, lumbar rib hump, and thoracolumbar kyphosis were independent predictors of CIB/revision surgery.
CONCLUSIONS
An L3 LIV is frequently successful at 5 years post-operatively. Consider an L4 LIV when: pre-operative BMI ≥ 28, L3 angulation ≥ 25°, L3 translation ≥ 4 cm, TL/L AVT ≥ 6 cm, or the lumbar curve is large (≥ 55°) and rotated (≥ 10°).
LEVEL OF EVIDENCE
Level III.
研究设计
回顾性病例对照研究。
目的
确定一组在融合至 L3 最低固定椎体（LIV）后 5 年仍存在冠状面不平衡（CIB）或需行翻修手术的患者，并确定使 L3 LIV 成为高风险的因素。在 AIS 的手术规划中，只要有可能，L3 会被选作 L4 之上的节段以最大化 LIV 以下的运动节段。尽管融合至 L3 LIV 很常见，但尚未描述其失败率及其危险因素。
方法
在这项对接受后路脊柱融合术（PSF）至 L3 LIV 的 AIS 患者前瞻性收集的多中心数据的分析中，我们确定了在 5 年时存在 CIB 和/或归因于 LIV 选择而需行翻修手术的患者。5 年时平衡且无需行翻修手术的患者作为对照组。比较病例组和对照组的术前患者和影像学变量，以确定 CIB/翻修手术的危险因素。
结果
我们共纳入了 646 例患者，随访 2 年，225 例患者随访 5 年，其中 11 例患者因选择 L3 作为 LIV 而出现 CIB 和/或翻修手术。与对照组相比，病例组在以下几个术前因素方面存在统计学差异，包括 BMI（病例组为 24.5，对照组为 20.1；p=0.01）、Lenke 曲线类型（81.8% Lenke 5/6 型 vs. 44.4%；p=0.03）、腰椎曲度大小（56° vs. 45°；p<0.01）、TL/L 顶点椎体平移（6.2 vs. 4.1 cm；p<0.01）、L3 成角（30° vs. 22°；p<0.01）、L3 平移（4.3 vs. 2.9 cm；p<0.01）、胸肋部后凸（7° vs. 12°；p=0.02）、腰肋部后凸（16° vs. 10°；p<0.01）和胸腰椎（T10-L2）后凸（10.5° vs. 2°；p=0.006）。多变量逻辑回归显示，术前 BMI、TL/L 顶点椎体平移、L3 成角、L3 平移、腰肋部后凸和胸腰椎后凸是 CIB/翻修手术的独立预测因素。
结论
L3 LIV 在术后 5 年通常是成功的。当术前 BMI≥28、L3 成角≥25°、L3 平移≥4 cm、TL/L 顶点椎体平移≥6 cm 或腰椎曲度较大（≥55°）和旋转（≥10°）时，应考虑选择 L4 LIV。
证据等级
III 级。
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