成人脊柱畸形患者近端交界性后凸或初次融合至胸上段与胸下段失败后的疗效比较分析
Comparative Analysis of Outcomes in Adult Spinal Deformity Patients with Proximal Junctional Kyphosis or Failure Initially Fused to Upper Versus Lower Thoracic Spine.
作者信息
Onafowokan Oluwatobi O, Lafage Renaud, Tretiakov Peter, Smith Justin S, Line Breton G, Diebo Bassel G, Daniels Alan H, Gum Jeffrey L, Protopsaltis Themistocles S, Hamilton David Kojo, Buell Thomas, Soroceanu Alex, Scheer Justin, Eastlack Robert K, Mullin Jeffrey P, Mundis Gregory, Hosogane Naobumi, Yagi Mitsuru, Anand Neel, Okonkwo David O, Wang Michael Y, Klineberg Eric O, Kebaish Khaled M, Lewis Stephen, Hostin Richard, Gupta Munish Chandra, Lenke Lawrence G, Kim Han Jo, Ames Christopher P, Shaffrey Christopher I, Bess Shay, Schwab Frank J, Lafage Virginie, Burton Douglas, Passias Peter G
机构信息
Duke Spine Division, Departments of Neurological and Orthopaedic Surgery, Duke School of Medicine, Durham, NC 27710, USA.
Department of Orthopedics, Lenox Hill Hospital, New York, NY 10075, USA.
出版信息
J Clin Med. 2024 Dec 18;13(24):7722. doi: 10.3390/jcm13247722.
Patients with proximal junctional kyphosis (PJK) or failure (PJF) may demonstrate disparate outcomes and recovery when fused to the upper (UT) versus lower (LT) thoracic spine. Few studies have distinguished the reoperation and recovery abilities of patients with PJK or PJF when fused to the upper (UT) versus lower (LT) thoracic spine. Adult spine deformity patients ≥ 18 yrs with preoperative and 5-year (5Y) data fused to the sacrum/pelvis were included. The rates of PJK, PJK revision, and radiographic PJF were compared between patients with upper instrumented vertebra (UIV) in the upper thoracic spine (UT; T1-T7) and lower thoracic spine (LT; T8-L1). Mean differences were assessed via analyses of covariance, factoring in any differences between cohorts at baseline and any use of PJF prophylaxis. Backstep logistic regressions assessed predictors of achieving Smith et al.'s Best Clinical Outcomes (BCOs) and complications, controlling for similar covariates. A total of 232 ASD patients were included (64.2 ± 10.2 years, 78% female); 36.3% were UT and 63.7% were LT. Postoperatively, the rates of PJK for UT were lower than LT at 1Y (34.6 vs. 50.4%, = 0.024), 2Y (29.5 vs. 49.6% ( = 0.003), and 5Y (48.7 vs. 62.8%, = 0.048), with comparable rates of PJF. In total, 4.0% of UT patients underwent subsequent reoperation, compared to 13.0% of LT patients ( = 0.025). A total of 6.0% of patients had recurrent PJK, and 3.9% had recurrent PJF (both > 0.05). After reoperation, UT patients reported higher rates of improvement in the minimum clinically important difference for ODI by 2Y ( = 0.007) and last follow-up ( < 0.001). While adjusted regression revealed that, for UT patients, the minimization of construct extension was predictive of achieving BCOs by last follow-up (model < 0.001), no such relationship was identified in LT patients. Patients initially fused to the lower thoracic spine demonstrate an increased incidence of PJK and lower rates of disability improvement, but are at a lessened risk of neurologic complications if reoperation is required.
近端交界性后凸畸形（PJK）或近端交界性失败（PJF）患者在融合至上段胸椎（UT）与下段胸椎（LT）时，可能会表现出不同的结果和恢复情况。很少有研究区分PJK或PJF患者融合至上段胸椎（UT）与下段胸椎（LT）时的再次手术及恢复能力。纳入年龄≥18岁、术前及有5年（5Y）骶骨/骨盆融合数据的成人脊柱畸形患者。比较上段胸椎（UT；T1-T7）和下段胸椎（LT；T8-L1）中具有上位固定椎体（UIV）的患者之间的PJK、PJK翻修及影像学PJF发生率。通过协方差分析评估平均差异，考虑队列在基线时的任何差异以及PJF预防措施的任何使用情况。逐步逻辑回归评估实现Smith等人的最佳临床结果（BCOs）和并发症的预测因素，控制相似的协变量。共纳入232例成人脊柱畸形患者（64.2±10.2岁，78%为女性）；36.3%为UT组，63.7%为LT组。术后，UT组1年时的PJK发生率低于LT组（34.6%对50.4%，P = 0.024），2年时（29.5%对49.6%，P = 0.003），5年时（48.7%对62.8%，P = 0.048），PJF发生率相当。总体而言，4.0%的UT组患者接受了后续再次手术，而LT组为13.0%（P = 0.025）。共有6.0%的患者出现复发性PJK，3.9%出现复发性PJF（均P>0.05）。再次手术后，UT组患者在2年时（P = 0.007）和末次随访时（P<0.001）报告的ODI最小临床重要差异改善率更高。虽然调整后的回归显示，对于UT组患者，构建物延伸的最小化可预测末次随访时实现BCOs（模型P<0.001），但在LT组患者中未发现这种关系。最初融合至下段胸椎的患者PJK发生率增加，残疾改善率较低，但如果需要再次手术，神经并发症风险降低。
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