后柱截骨术与腰椎减压术在改善术前运动障碍的成人脊柱畸形患者下肢运动力量中的作用。

IF 2.9 2区 医学 Q2 CLINICAL NEUROLOGY
Fthimnir M Hassan, Lawrence G Lenke, Erik Lewerenz, Peter G Passias, Eric O Klineberg, Virginie Lafage, Justin S Smith, D Kojo Hamilton, Jeffrey L Gum, Renaud Lafage, Jeffrey Mullin, Michael P Kelly, Bassel G Diebo, Thomas J Buell, Han Jo Kim, Khaled Kebaish, Robert Eastlack, Alan H Daniels, Gregory Mundis, Themistocles S Protopsaltis, Munish C Gupta, Frank J Schwab, Christopher I Shaffrey, Christopher P Ames, Shay Bess
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引用次数: 0

摘要

目的:本研究的目的是确定在接受手术矫正的成人脊柱畸形(ASD)和基线LEMS异常的患者中,是否有任何特定的手术、人口统计学和/或影像学因素与术后下肢(LE)运动评分(LEMS)改善相关。方法:对2018年至2023年在北美13个脊柱畸形中心参加一项观察性前瞻性研究的ASD患者进行调查。符合条件的参与者至少满足以下影像学和/或手术纳入标准中的一项:骨盆发生率减去腰椎前凸失配≥25°,T1骨盆角≥30°,SVA≥15 cm,胸部脊柱侧凸≥70°,胸腰椎侧凸≥50°,整体冠状面不对齐≥7 cm,接受3柱截骨术(3CO),脊柱融合≥12节段,和/或年龄≥65岁,内固定≥7节段。基线LEMS异常的患者根据LEMS在术后6周就诊时较基线改善或恶化进行二分类。与基线相比,LEMS维持6周的患者被排除在外。通过双变量分析比较患者和手术特征,以评估治疗差异。在控制潜在混杂因素的同时,建立了一个多变量逻辑回归模型来识别与改进LEMS相关的独立因素。结果:纳入研究的121例患者(77例女性,平均年龄62.9岁)中,109例(90.1%)改善,12例(9.9%)从基线到6周进一步恶化。两组的侧边度和每根神经的LEMS基线相似。两组在年龄、性别、合并症、基线LEMS、BMI、手术指征、器械水平数量、估计失血量、手术室时间和住院时间方面相似(p < 0.05)。基线和6周时,除了评分恶化的患者L1骨盆角(∆L1PA)变化较大(-8.0°±8.3°vs -1.6°±7.6°,p = 0.0413),影像学参数无差异。尽管在相似的水平上进行腰椎减压的频率相似,但在6周时病情恶化的患者进行腰椎后柱截骨术(PCOs)的次数较少(50%对82.6%,p = 0.0169)。在进行3COs的频率和数量上没有观察到差异。评分恶化的患者术中神经生理监测(IONM)变化更大(41.7% vs 8.3%, p = 0.0050),均为运动障碍。控制∆L1PA和IONM的变化显示腰椎PCOs是LEMS改善的独立驱动因素(OR 4.99 [95% CI 1.05-23.70]),具有优异的模型性能(p = 0.0031,受试者工作特征曲线下面积为0.77,Hosmer-Lemeshow拟合优度检验p = 0.3017)。结论:单独进行腰椎减压可能不足以改善ASD患者的LE无力和术前运动障碍,而使用PCO有利于改善。因此,在该患者群体中,应考虑通过腰椎PCOs联合入路和减压提供更积极和彻底的减压,以优化术后运动力量。
本文章由计算机程序翻译,如有差异,请以英文原文为准。
The role of posterior column osteotomies versus lumbar decompressions in improving lower extremity motor strength in adult spinal deformity patients with preoperative motor impairment.

Objective: The aim of this study was to determine if there are any specific procedural, demographic, and/or radiographic factors that are associated with an improved postoperative lower extremity (LE) motor score (LEMS) among patients with adult spinal deformity (ASD) and abnormal baseline LEMS undergoing surgical correction.

Methods: Patients with ASD enrolled in an observational prospective study from 2018 to 2023 at 13 spinal deformity centers in North America were queried. Eligible participants met at least one of the following radiographic and/or procedural inclusion criteria: pelvic incidence minus lumbar lordosis mismatch ≥ 25°, T1 pelvic angle ≥ 30°, SVA ≥ 15 cm, thoracic scoliosis ≥ 70°, thoracolumbar scoliosis ≥ 50°, global coronal malalignment ≥ 7 cm, underwent 3-column osteotomy (3CO), spinal fusion ≥ 12 levels, and/or age ≥ 65 years with ≥ 7 levels of instrumentation. Patients with a baseline abnormal LEMS were dichotomized based on whether the LEMS improved or deteriorated from baseline by the 6-week postoperative visit. Patients with a maintained LEMS by 6 weeks compared with baseline were excluded. Patient and operative characteristics were compared through bivariate analyses to assess differences in treatment. A multivariable logistic regression model was built to discern independent factors associated with improved LEMS while controlling for potential confounders.

Results: Of 121 patients (77 female, mean age 62.9 years) included in the study, 109 (90.1%) improved and 12 (9.9%) experienced further deterioration from baseline to 6 weeks. Both groups had similar baseline LEMS by laterality and per nerve root. The groups were similar in age, sex, comorbidities, baseline LEMS, BMI, surgical indication, number of instrumented levels, estimated blood loss, operating room time, and hospital length of stay (p > 0.05). No differences in radiographic parameters at baseline and 6 weeks were observed aside from patients whose score had deteriorated experiencing greater change in the L1 pelvic angle (∆L1PA) (-8.0° ± 8.3° vs -1.6° ± 7.6°, p = 0.0413). Despite having similar frequencies of lumbar decompressions performed across a similar number of levels, patients whose conditions had deteriorated at 6 weeks had fewer lumbar posterior column osteotomies (PCOs) performed (50% vs 82.6%, p = 0.0169). No differences in in the frequency and number of 3COs performed were observed. Patients whose score had deteriorated experienced greater intraoperative neurophysiological monitoring (IONM) changes (41.7% vs 8.3%, p = 0.0050), all of which were motor deficits. Controlling for ∆L1PA and IONM changes revealed lumbar PCOs to be an independent driver of improved LEMS (OR 4.99 [95% CI 1.05-23.70]), with excellent model performance (p = 0.0031, area under the receiver operating characteristic curve of 0.77, Hosmer-Lemeshow goodness-of-fit test p = 0.3017).

Conclusions: Performing lumbar decompressions alone might not be enough to improve LE weakness in patients with ASD and preoperative motor impairment, while the use of PCO was beneficial for improvement. Thus, more aggressive and thorough decompressions afforded by a combined approach of lumbar PCOs and decompression should be considered in this patient population to optimize postoperative motor strength.

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来源期刊
Journal of neurosurgery. Spine
Journal of neurosurgery. Spine 医学-临床神经学
CiteScore
5.10
自引率
10.70%
发文量
396
审稿时长
6 months
期刊介绍: Primarily publish original works in neurosurgery but also include studies in clinical neurophysiology, organic neurology, ophthalmology, radiology, pathology, and molecular biology.
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