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目的:探讨强直性脊柱炎(ankylosing spondylitis,AS)胸腰段后凸畸形截骨矫形手术时近端固定椎(upper instrumented vertebra,UIV)的选择。方法:回顾性分析2010年1月~2013年5月于解放军总医院骨科行单节段或双节段经椎弓根截骨或脊椎去松质骨截骨治疗AS胸腰段后凸畸形患者123例,其中男110例,女13例;年龄21~56岁(36.1±6.1岁),截骨椎(osteotomied vertebra,OV)均分布于T11~L4。根据UIV与近端OV的位置关系将患者分组:A组,UIV为近端OV头侧第3个椎体(n=64);B组,UIV为近端OV头侧第4个或更多椎体(n=59)。分别对两组患者的基本情况、手术前后脊柱矢状面参数[全脊柱后凸角(global kyphosis,GK),胸后凸角(thoracic kyphosis,TK),胸腰段后凸角(thoracolumbar kyphosis,TLK),腰前凸角(lumbar lordosis,LL)及矢状面偏移(sagittal vertical axis,SVA)]、Oswestry功能障碍指数(Oswestry disability index,ODI)及并发症发生率进行比较。根据UIV是否跨过后凸顶椎(apical vertebra,AV),将患者分为AV组(n=34)和Non-AV组(n=89),同样比较两组患者的上述参数。结果:随访24~60个月(29.3±3.2个月),随访期内所有病例均未发生内固定失败。A组患者年龄、性别构成与B组比较均无显著性差异(P>0.05),A组平均固定节段明显少于B组(7.2±1.0 vs.8.2±1.5,P<0.05);两组矢状面参数及ODI在术前、末次随访时以及末次随访时的改善率均无显著性差异(P>0.05)。A组患者末次随访时胸背部疼痛或异物感的发生率(10/64)明显低于B组患者(25/59)(P<0.05)。A组交界性后凸(proximal junctional kyphosis,PJK)发生率与B组比较无显著性差异(1/64 vs.2/59,P>0.05)。AV组和Non-AV组比较,AV组平均固定节段明显多于Non-AV组(P<0.05),两组矢状面参数及ODI在术前、末次随访时及末次随访时的改善率比较均无显著性差异(P>0.05),末次随访时AV组的胸背部疼痛或异物感发生率明显高于Non-AV组(P<0.05),两组PJK发生率无显著性差异(1/34 vs.2/89,P>0.05)。结论:AS胸腰段后凸畸形行截骨矫形时,UIV选择近端OV头侧端第3个椎体矫形与固定融合的效果满意,且患者出现胸背部疼痛或异物感的发生率更低;UIV跨过后凸顶椎时,易出现胸背部疼痛或异物突出感的情况。
Objective: To investigate the selection of upper instrumented vertebra (UIV) in ankylosing spondylitis (AS) with thoracolumbar kyphosis. Methods: From January 2010 to May 2013, patients with AS thoracolumbar kyphosis were treated by single or double segmental pedicle osteotomy or spondylolisthesis cancellous osteotomy in orthopedic department of General Hospital of PLA from January 2010 to May 2013. 123 cases, including 110 males and 13 females. The age ranged from 21 to 56 years old (36.1 ± 6.1 years). The osteotomied vertebra (OV) were all located in T11 ~ L4. According to the relationship between UIV and proximal OV, the patients were divided into group A, UIV as the third vertebrae of the proximal OV head (n = 64), group B, UIV as the fourth or more Vertebral body (n = 59). The basic situation of the two groups of patients, the sagittal parameters of the spine before and after surgery [total kyphosis (GK), thoracic kyphosis (TK), thoracolumbar kyphosis (thoracolumbar kyphosis, TLK, lumbar lordosis (LL) and sagittal vertical axis (SVA)], Oswestry disability index (ODI) and complication rates were compared. Patients were also divided into AV group (n = 34) and Non-AV group (n = 89) according to whether the UIV crossed the apical vertebra (AV), and the above parameters were also compared between the two groups. Results: All patients were followed up for 24 to 60 months (29.3 ± 3.2 months). All cases failed to undergo internal fixation during the follow-up period. There was no significant difference in age and sex between group A and group B (P> 0.05). The average number of fixed segments in group A was significantly less than that in group B (7.2 ± 1.0 vs.8.2 ± 1.5, P <0.05) There was no significant difference in the sagittal parameters and ODI between preoperative, final follow-up and final follow-up (P> 0.05). The incidence of thoracolumbar pain or foreign body sensation at the last follow-up in group A (10/64) was significantly lower than that in group B (25/59) (P <0.05). There was no significant difference in the incidence of proximal junctional kyphosis (PJK) between group A and group B (1/64 vs 2./59, P> 0.05). AV group and Non-AV group, AV group, the average fixed segment was significantly more than Non-AV group (P <0.05), two sets of sagittal parameters and ODI in the preoperative and final follow-up and the last follow-up improvement rate (P> 0.05). The incidence of thoracolumbar pain or foreign body sensation in AV group was significantly higher than that in Non-AV group (P <0.05) at the last follow-up, there was no significant difference in the incidence of PJK between the two groups / 34 vs 2/89, P> 0.05). CONCLUSIONS: In the AS thoracolumbar kyphotic deformity osteotomy, the effect of orthopedic fixation and fixation fusion of the third vertebra on the proximal end of the OV head in the UIV is satisfactory, and the incidence of thoracolumbar pain or foreign body sensation is lower ; UIV over the kyphosis, prone to chest and back pain or foreign body prominent sense of the situation.