Department of Orthopaedic Surgery, College of Medicine, Kyung Hee University Hospital at Gangdong, Kyung Hee University, 892 Dongnam-ro, Gangdong-gu, 05278, Seoul, Korea.
Department of Orthopaedic Surgery, Graduate School of Medicine, Kyung Hee University, Kyungheedae-ro, Dongdaemun-gu, Seoul, Korea.
BMC Musculoskelet Disord. 2022 Nov 22;23(1):1004. doi: 10.1186/s12891-022-05915-4.
We hypothesized that posterior osteotomy prior to ACR (Anterior column realignment) through P-A-P surgical sequence would permit a greater correction for deformity corrective surgery than the traditional A-P sequence without posterior osteotomy. This study aimed to determine the impact of the P-A-P sequence on the restoration of lumbar lordosis (LL) compared to the A-P sequence in deformity corrective surgery for adult spinal deformity (ASD) patients and to identify the characteristics of patients who require this sequence. METHODS: Between 2017 and 2019, 260 ASD patients who had undergone combined corrective surgery were reviewed retrospectively. This study included 178 patients who underwent posterior osteotomy before the ACR (P-A group) and 82 patients who underwent the A-P sequence (A-P group). Sagittal spinopelvic parameters were determined from pre- and postoperative whole-spine radiographs and compared between the groups. To find better indications for the P-A-P sequence, we conducted additional analysis on postoperative outcomes of patients in the A-P group. RESULTS: The P-A group showed a significantly higher change in LL (53.7° vs. 44.3°, p < 0.001), C7 sagittal vertical axis (C7 SVA: 197.4 mm vs. 146.1 mm, p = 0.021), segmental lordosis (SL) L2/3 (16.2° vs. 14.4°, p = 0.043), SL L3/4 (16.2° vs. 13.8°, p = 0.004), and SL L4/5 (15.1° vs. 11.3°, p = 0.001) compared to the A-P group. At the final follow-up, pelvic incidence (PI) minus LL mismatch (PI - LL mismatch) was significantly higher in the A-P group (13.4° vs. 2.9°, p < 0.001). Stepwise logistic regression analysis showed that age ≥ 75 years (odds ratio [OR] = 2.151; 95% confidence interval [CI], 1.414-3.272; p < 0.001), severe osteoporosis (OR = 2.824; 95% CI, 1.481-5.381; p = 0.002), rigid lumbar curve with dynamic changes in LL < 10° (OR = 5.150; 95% CI, 2.296-11.548; p < 0.001), and severe facet joint osteoarthritis (OR = 4.513; 95% CI, 1.958-10.402; p < 0.001) were independent risk factors for PI - LL mismatch ≥ 10° after A-P surgery.
P-A-P sequence for deformity corrective surgery in ASD offers greater LL correction than the A-P sequence. Indications for the procedure include patients aged ≥ 75 years, severe osteoporosis, rigid lumbar curve with dynamic change in LL < 10°, or more than four facet joints of Pathria grade 3 in the lumbar region.
我们假设在 ACR（前柱矫正）之前通过 P-A-P 手术序列进行后路截骨术，将比传统的 A-P 序列不进行后路截骨术更能矫正畸形矫正手术。本研究旨在确定与传统 A-P 序列相比，P-A-P 序列对成人脊柱畸形（ASD）患者畸形矫正手术中腰椎前凸（LL）恢复的影响，并确定需要该序列的患者的特征。
回顾性分析 2017 年至 2019 年期间接受联合矫正手术的 260 例 ASD 患者。本研究包括 178 例在 ACR 前进行后路截骨术的患者（P-A 组）和 82 例进行 A-P 序列的患者（A-P 组）。从术前和术后全脊柱 X 线片确定矢状位脊柱骨盆参数，并对两组进行比较。为了找到更好的 P-A-P 序列适应证，我们对 A-P 组患者的术后结果进行了额外分析。
P-A 组的 LL（53.7° vs. 44.3°，p < 0.001）、C7 矢状垂直轴（C7 SVA：197.4mm vs. 146.1mm，p = 0.021）、节段性前凸 L2/3（16.2° vs. 14.4°，p = 0.043）、节段性前凸 L3/4（16.2° vs. 13.8°，p = 0.004）和节段性前凸 L4/5（15.1° vs. 11.3°，p = 0.001）的变化明显更高。在最终随访时，A-P 组的骨盆入射角（PI）减去 LL 不匹配（PI-LL 不匹配）明显更高（13.4° vs. 2.9°，p < 0.001）。逐步逻辑回归分析显示，年龄≥75 岁（比值比[OR] = 2.151；95%置信区间[CI]，1.414-3.272；p < 0.001）、严重骨质疏松症（OR = 2.824；95%CI，1.481-5.381；p = 0.002）、LL 动态变化<10°的僵硬腰椎曲线（OR = 5.150；95%CI，2.296-11.548；p < 0.001）和严重关节突关节炎（OR = 4.513；95%CI，1.958-10.402；p < 0.001）是 A-P 手术后 PI-LL 不匹配≥10°的独立危险因素。
ASD 畸形矫正手术中的 P-A-P 序列比 A-P 序列提供更大的 LL 矫正。该手术的适应证包括年龄≥75 岁、严重骨质疏松症、LL 动态变化<10°的僵硬腰椎曲线或腰椎区 4 个以上 Pathria 3 级关节突关节。
