【作者】 陈家瑜；

【导师】 李明；

【作者基本信息】 第二军医大学 ， 骨外科学（专业学位）， 2013， 博士

【摘要】 【研究目的】成人特发性脊柱侧凸（AdultIdiopathicScoliosis，AS）是常见的脊柱疾患，主要来源于两大人群：一类发病于骨骼成熟以后，另一类发病于骨骼成熟之前（婴幼儿、青少年等）未进行正规诊治迁延至成人。治疗目的：在获得良的平衡基础上，防止畸形进展并尽可能大程度地矫正畸形、改善外观。其中，获得良好的平衡是治疗成功的前提和首要目的。越来越多的研究表明，脊柱-骨盆矢状位失平衡是脊柱畸形患者疼痛、躯体功能丧失、生活质量下降的重要原因。由于脊柱-骨盆解剖学、病理学、影像学和临床表现等较为复杂，矢状位序列紊乱的临床治疗十分困难，序列重建手术存在复杂性和较高风险。目前主要通过脊柱后路截骨矫形改变脊柱矢状位某些弯曲（胸椎后凸、腰椎前凸）进而重建整体矢状位平衡。然而究竟术中重建矢状位到何种程度才能有效地恢复脊柱-骨盆矢状位序列平衡，是脊柱外科医师制定个体化、最优化手术决策首选需要解决的问题。目前国内外关于脊柱-骨盆矢状位研究现状主要包括：1）虽然提出并验证大量矢状位参数的重要性，但并没有研究探讨众多参数中究竟哪些对于人体矢状位平衡的维持起到关键的作用；2）缺少脊柱-骨盆矢状位全参数的汇总、统一分析；3）尚无学者明确将腰椎、骶骨、骨盆统一为整体（即本研究提出的腰骶椎-骨盆复合体，lumbosacral-pelviccomplex，LSPC）进行描述，更缺少LSPC冠状位-矢状位联合探讨研究；4）虽有研究提出一些参数关系或公式指导矢状位序列重建手术决策，但研究适用性差、结果过于简单、缺少某些关键矢状位参数的纳入、不能统筹兼顾整体和局部平衡；5）绝大部分研究集中在黑、白两个人种患者人群进行，缺少黄种人群矢状位平衡领域的深入研究。本课题针对上述问题进行探讨研究，并尝试建立一种能够联系脊柱-骨盆矢状位整体和局部平衡、初步预测矢状位截骨术后平衡关键参数的指导性模型，采用多病种验证的方式，尝试探讨拓展预测模型的病种适用范围，以期对临床矢状位重建手术最优化决策具有一定指导意义。【研究方法】1、研究对象：1)脊柱-骨盆矢状位参数分析病例：收集自2009年-2011年在同一脊柱畸形专科中心确诊并进行脊柱后路三维矫形植骨融合内固定术的成人特发性脊柱侧凸患者，共计63例符合纳入标准。2)脊柱-骨盆矢状位平衡状态预测建模及多病种验证病例：收集自2008年-2012年在同一脊柱畸形专科中心就诊的成人特发性脊柱侧凸患者进行建模，共计156例，随机分为两组：a、基础建模组，131例，用于脊柱-骨盆矢状位平衡状态预测模型的建立；b、初步验证组，25例，用于矢状位平衡预测模型的初步验证；另外收集自2008年-2012年在同一脊柱畸形专科中心行单纯后路截骨手术的成人脊柱畸形患者进行临床多病种验证，共计63例，其中成人特发性脊柱侧凸24例，先天性脊柱侧凸21例，强制性脊柱炎性脊柱后凸畸形18例。2、实验方法：1)影像学资料获得及测量：所有患者行术前、术后至少1年站立位脊柱-骨盆全长正侧位X线片检查，包括双侧股骨头。2名脊柱外科医生在脊柱-骨盆全长X线片上分别测量1次，取平均值。测量参数包括：TK、TotalTK、TJK、LL、TotalLL、SVA、PI、PT、SS、PA、SSA、ST、C7ratio、T1SPI、T9SPI、PR-S1、PR-L1、SPT等（详见英文缩略语表及第一部分测量方法）；2)数据处理软件及统计学方法：所有数据以均数±标准误来表示，数据处理软件包括MicrosoftExcel2007、Matlab软件7.8.0(R2009a)、SPSS软件(Chineseversion19.0)等，数据处理方法包括Pearson相关性分析、主成分分析、T检验、多元线性回归等。选取P<0.05作为显著性差异的界限。【结果】（一）成人特发性脊柱侧凸脊柱-骨盆矢状位参数分析1、AS人群，脊柱-骨盆矢状位平衡关键参数包括：TotalTK、TotalLL、PI、SS、PT、PA、PR-L1、SPT、SVA。2、脊柱-骨盆矢状位参数横向之间存在错综复杂的相关联系网络（详见第二部分相关性矩阵和相关性网络图），分析发现矢状位横向相关性主要集中在骨盆两套评测系统参数内部以及对外的延伸，可能与骨盆作为矢状位平衡主要的代偿机制有关；相关性更多可能归因于解剖学的毗邻；TotalTK和TotalLL相比于常规TK和LL可能能够更好地描述脊柱矢状位曲线。3、脊柱后路三维矫形植骨融合内固定手术对AS矢状位平衡的影响主要表现为：术后脊柱生理弯曲（TotalTK和TotalLL）角度显著减小（P<0.01）；PT、SPT术后显著增高（P<0.05），SS、PR-L1术后显著降低（P<0.05）；单纯脊柱后路选择性胸弯或腰弯融合AS未融合脊柱矢状位弯曲（TotalLL或TotalTK）手术前后无显著性差异。（二）LSPC冠状位-矢状位联合研究1、腰椎冠状位侧凸畸形导致骨盆矢状位高代偿状态（高PT和高PA）；2、发病于LSPC矢状位序列发育成熟之后冠状位腰椎侧凸畸形对骨盆矢状位解剖学序列无显著影响；发病于LSPC矢状位序列发育成熟之前的冠状位腰弯畸形存在增高PI和PR-S1的趋势和降低SPT的趋势，进一步的研究需要通过扩大病例数或进行大型流行病学调查。（三）脊柱-骨盆矢状位平衡预测建模及临床多病种验证1、初步建立成人脊柱畸形脊柱-骨盆矢状位平衡预测模型：YPT=-46.21+0.26XtotalTK-0.65XtotalLL+0.25XPI-0.59XPRSI（R2=0.82806,平均误差为3.8357°）YSVA=-27.06+2.02XtotalTK-3.39XtotalLL+3.49XPI-2.69XPTpredict（R2=0.50548,平均误差为21.8166mm）经初步验证，模型具有较好的预测能力（R2>0.5）。2、经临床多病种初步验证，脊柱-骨盆矢状位平衡预测模型适用于成人特发性脊柱侧后凸畸形、成人先天性脊柱畸形单纯后路截骨矫形/半椎体切除植骨融合内固定手术术后矢状位平衡状态预测；不适用于成人强直性脊柱炎伴脊柱后凸畸形脊柱后路截骨矫形术后矢状位平衡状态预测。【结论】脊柱-骨盆矢状位平衡是各解剖单元之间互相关联、互相作用的动态平衡，众多矢状位参数中存在某些关键参数对平衡的维持意义重大，在此基础上建立的脊柱-骨盆矢状位平衡预测模型可以初步预测成人特发性或先天性脊柱侧后凸畸形单纯后路截骨/半椎体切除矫形矢状位序列重建手术术后平衡状态，对临床矢状位重建手术最优化决策具有一定指导意义。更多还原

【Abstract】 Purpose:Adult Idiopathic Scoliosis(AS) is a kind of common spinal diseases, including two groups of patients, one is occurred after skeletal maturity, the other is occurred before growing up and continues until skeletal maturity without timely treatments. The treatment goals of AS are rebuilding and maintaining the spino-pelvic balance, which is the first target of the AS treatment, as well as preventing the increase of the scoliosis and correcting the cure as much as possible. More and more researches indicate that the spino-pelvic sagittal imbalance is the significant cause of pain, disability and the decline of the health related quality of life(HRQL). As the anatomy, the Pathology, the imaging and the clinical manifestation of the spino-pelvis are complex, the clinical treatment of sagittal imbalance is difficult and the realignment surgery is complex and high-risk. The way of surgery now is reconstruct certain sagittal cure by using posterior spinal osteotomy in order to rebuild the right sagittal alignment. However, in order to successfully regain the spino-pelvic sagittal balance after surgery, how much degree should the sagittal cure be reconstruct to? This is also a question which influences the surgeons making the optimize individualized treating strategies.In recent years, researches around the sagittal balance can be described as below:1) A lot of important parameters were put forward and certified their significance, however, no research has analyzed and point out the key parameters (as described in our research) which are mostly contribute to maintaining spino-pelvic sagittal balance.2) Little researches have collected and analyzed all the sagittal parameters being raised before.3) No research has clearly combined the lumbar, the sacrum and the pelvis into one research unit (lumbosacral-pelvic complex, LSPC, as described in this research). More over, no coronal-sagittal joint research in LSPC.4) Several researches have raised certain relationships or formulas used to guid the surgical strategy, however, some defects exist: poor applicability, simple results, lacking some key parameters, lack the co-ordination of the global and the partial parameters.5) As most researches focus on the black and the white races, more and in-depth studies are needed in the field of sagittal balance of the yellow race.This research is based on the questions above. Moreover, we try to establish certain models, which could combine the global and the partial sagittal balance, and could preliminary predict certain key sagittal parameters after the spinal realignment surgery. Finally, different clinical cases was retrospectively studied, trying to expand their applicabilities. These results may be helpful to guide the optimize individualized surgical strategies for the adult spinal deformity.Material and Methods:1. Study Patients:1) patients for spino-pelvic sagittal analysis:63AS patients were collected, who are diagnosed in the same spinal deformity research center and received the same posterior spinal orthopedic surgery from2009to2011.2) patients for establishing the spino-pelvic sagittal models and clinical validation:156AS patients, diagnosed in the same spinal deformity research center from2008-2012, were collected, which randomly divided into2groups:a) modeling group,131patients, used for establishing the spino-pelvic sagittal models. b) preliminary validation group,25patients, used for preliminary validation of the models. Moreover,63ASD(adult sagittal deformity) patients who have received the purely posterior spinal osteotomy, were collected for the clinical validation from2008to2012, including24AS,21adult Congenital scoliosis,18mandatory spondylitis with kyphosis deformity, respectively.2. Methods:1) images acquisition and radiographic evaluation:all patients took preoperative and postoperative long-cassette standing upright posterior-anterior(PA) and lateral X-rays radiographs of the spine and pelvis.2surgeons measures the parameters and take the average value. Sagittal parameters includes:TK, Total TK, TJK, LL, Total LL, SVA, PI, PT, SS, PA, SSA, ST, C7ratio, T1SPI, T9SPI, PR-S1, R-L1, SPT,etc.(see details in the English List of Abbreviations).2) Data processing softwares and:all data were expressed as mean±standard error (SE). Data processing softwares include: Microsoft Excel2007、Matlab software7.8.0(R2009a)、SPSS (Chinese version19.0). Statistical methods include Pearson correlation analysis, Principal component analysis, T test, Multiple linear regression analysis etc. P<0.05was considered statistically significant.Results:1. The analysis of AS spino-pelvic sagittal parameters(1) The key parameters of AS sagittal plane include Total TK、Total LL、PI、SS、PT、PA、 PR-L1、SPT、SVA.(2) There is a complex correlation network among the sagittal parameters, which is indicates as follow. Firstly, the correlations mainly focus on parameters of pelvis, which is probably due to compensatory role of pelvis. Secondly, correlations may mainly due to the anatomy adjacent relationship. Thirdly, total TK and total LL may describe the spinal sagittal curves better than conventional TK and LL.(3) The influence of spinal posterior three-dimensional orthopedic surgery to the AS sagittal balance include, decreasing the spine curves(total TK and total LL) greatly (P<0.01), increasing PT and SPT significantly (P<0.05), decreasing SS and PR-L1significantly (P<0.05). There is no significant difference between pre and postoperative Total LL or Total TK in posterior thoracic or lumbar selective fusion surgery.2. The coronal-sagittal joint analysis of LSPC(1) The lumbar coronal deformity leads to pelvic sagittal higher compensatory status(2) The lumbar coronal deformity, beginning before skeletal maturity, has no influence on pelvic sagittal morphologic parameters; but this, beginning after that, leads to increasing tendency of PR-S1and decreasing trend of SPT. Larger sample sizes are needed for further research.3. Modeling the forecasting system of spino-pelvic sagittal balance and clinical validation using different cases1) Modeling the preliminary forecasting system of spino-pelvic sagittal balance. YPT=-46.21+0.26XtotalTK-0.65XtotalLL+0.25XPI-0.59XPR-SI(R2=0.82806, Average error:3.8357°) YSVA=-27.06+2.02XtotalTK-3.39XtotalLL+3.49XPI-2.69XPTpredict(R2=0.50548, Average error:21.8166mm)The models has good predictive ability (R2>0.5)2) Through clinical validation using different kinds of cases, we find that the forecasting models are suitable for the AS or adult congenital scoliosis with kyphosis deformity, who underwent pure posterior spinal osteotomy or hemivertebra excision surgery. But the forecasting system is not suitable for the mandatory spondylitis with kyphosis deformity.Conclusion:The sagittal balance is due to the connection and interaction between anatomic units of the spino-pelvis, and there are several key parameters which contribute mostly to the sagittal balance, among multitudinous parameters. On this basis, the forecasting system of spino-pelvic sagittal balance is set up and is suitable for the AS or adult congenital scoliosis with kyphosis deformity, who underwent pure posterior spinal osteotomy or hemivertebra excision surgery, but not for the he mandatory spondylitis with kyphosis deformity.更多还原