University of Rochester Medical Center, Rochester, New York.
Maimonides Medical Center, Brooklyn, New York.
J Bone Joint Surg Am. 2022 Jun 1;104(11):995-1003. doi: 10.2106/JBJS.21.00763. Epub 2022 Apr 22.
Despite its importance for clinical decisions, the long-term consequences of posterior spinal instrumentation and fusion (PSIF) for adolescent idiopathic scoliosis (AIS), particularly in the lower lumbar spine, remain unclear. This study evaluates the long-term health-related quality of life and the need for a further surgical procedure in patients treated with Harrington instrumentation from 1961 to 1977 according to the lowest instrumented vertebra (LIV) and in comparison with age-matched norms.
A search was performed to identify and contact the 314 identified patients with AIS treated with PSIF by Dr. L.A. Goldstein. The assessment included identified subsequent spine surgery, the Oswestry Disability Index (ODI), Scoliosis Research Society-7 (SRS-7), EuroQol-5 Dimensions (EQ-5D), and Patient-Reported Outcomes Measurement Information System-29 (PROMIS-29). The health-related quality of life was compared with U.S. norms and, within the cohort, was compared by patient factors, LIV, and subsequent spine surgery.
In this study, 134 patients (42.7%) were identified; 24 (7.6%) had died, 81 (25.8%) consented to participate in the study, and 29 (9.2%) declined participation. The mean follow-up was 45.4 years (range, 40 to 56 years). There were 81 patients who completed the surveys, 77 patients who completed the SRS-7, 77 patients who completed the ODI, and 76 patients who completed the PROMIS-29 and EQ-5D. There were 12.8% of patients with LIV L3 or proximal and 36.4% with LIV L4 or distal who had an additional surgical procedure (odds ratio, 3.98). Comparing the ODI of patients who had undergone an additional surgical procedure with those who had not showed 42% and 73% minimal disability, 53% and 23% moderate disability, and 5% and 2% severe disability. Of the patients who had not undergone an additional surgical procedure, those with LIV L3 or proximal had mean scores of 14.12 points for the ODI and 23.3 points for the SRS-7 and those with LIV L4 or distal had mean scores of 17.9 points for the ODI and 22.7 points for the SRS-7; these differences were not significant. The mean PROMIS-29 and EQ-5D scores were not different from normal U.S. age-based means.
Patients with AIS treated with PSIF at a mean 45-year follow-up and LIV L4 or distal had a higher rate of undergoing an additional surgical procedure than those with LIV L3 or proximal. Patients undergoing an additional surgical procedure had lower health-related quality of life than those who did not. Despite this, there was no difference in health-related quality of life for patients with LIV L4 or distal compared with patients with LIV L3 or proximal. This cohort of patients with AIS treated with PSIF demonstrates normal self-reported health-related quality of life compared with the age-matched general population. These long-term outcomes of PSIF for AIS are encouraging.
Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.
尽管脊柱后路内固定融合术（PSIF）对青少年特发性脊柱侧凸（AIS）的长期后果，特别是在腰椎下部，非常重要，但仍不清楚。本研究根据最低固定椎（LIV）评估了 1961 年至 1977 年接受哈林顿器械治疗的 AIS 患者的长期健康相关生活质量和进一步手术的需求，并与年龄匹配的正常人群进行了比较。
通过搜索，我们找到了 L.A. Goldstein 博士治疗的 314 名接受 PSIF 的 AIS 患者，并联系了他们。评估包括识别出的后续脊柱手术、Oswestry 残疾指数（ODI）、脊柱侧凸研究协会 7 项（SRS-7）、EuroQol-5 维度（EQ-5D）和患者报告的结果测量信息系统 29 项（PROMIS-29）。与美国的正常标准进行了比较，并在队列内，根据患者因素、LIV 和后续脊柱手术进行了比较。
在这项研究中，确定了 134 名患者（42.7%）；24 名（7.6%）患者死亡，81 名（25.8%）同意参与研究，29 名（9.2%）拒绝参与。平均随访时间为 45.4 年（范围，40 至 56 年）。有 81 名患者完成了调查，77 名患者完成了 SRS-7，77 名患者完成了 ODI，76 名患者完成了 PROMIS-29 和 EQ-5D。有 12.8%的患者 LIV 为 L3 或近端，36.4%的患者 LIV 为 L4 或远端，需要进行额外的手术（优势比，3.98）。比较接受额外手术和未接受手术的患者的 ODI 发现，前者有 42%和 73%的患者为轻度残疾，53%和 23%的患者为中度残疾，5%和 2%的患者为重度残疾。在未接受额外手术的患者中，LIV 为 L3 或近端的患者 ODI 平均得分为 14.12 分，SRS-7 平均得分为 23.3 分，LIV 为 L4 或远端的患者 ODI 平均得分为 17.9 分，SRS-7 平均得分为 22.7 分；这些差异没有统计学意义。PROMIS-29 和 EQ-5D 的平均得分与美国正常年龄相关的平均得分没有差异。
在平均 45 年的随访中，接受 PSIF 治疗的 AIS 患者的 LIV 为 L4 或远端，需要进行额外手术的比例高于 LIV 为 L3 或近端的患者。需要进行额外手术的患者的健康相关生活质量低于未进行手术的患者。尽管如此，LIV 为 L4 或远端的患者与 LIV 为 L3 或近端的患者相比，健康相关生活质量没有差异。本队列接受 PSIF 治疗的 AIS 患者与年龄匹配的普通人群相比，自我报告的健康相关生活质量正常。这些 AIS 患者接受 PSIF 的长期结果令人鼓舞。
治疗学四级。有关证据水平的完整描述，请参见作者说明。
