doktorska disertacija
Matevž Kuhta (Author), Rok Vengust (Mentor), Matjaž Vogrin (Co-mentor)

Abstract

NAMEN Preučiti vpliv vzpostavitve ustrezne segmentne lordoze in repozicije listetičnega segmenta med operativnim posegom na kratko- in srednjeročne klinične rezultate pri zdravljenju degenerativne spondilolisteze ledvene hrbtenice. Raziskava je hkrati prva analiza spinopelvičnih parametrov in kliničnega stanja v odvisnosti od pelvične incidence (PI). METODE V prospektivno študijo je bilo vključenih 57 bolnikov, zdravljenih s spondilodezo enega nivoja ledvene hrbtenice po metodi TLIF. Radiološka analiza merjenih spinopelvičnih parametrov sagitalnega ravnovesja pred in po posegu je obsegala: sagitalno vertikalno os – SVA, segmentno lordozo – SL, ledveno lordozo - LL, lordozo nivojev nad (LLa) in pod posegom (LLb) ter repozicijo segmentne listeze. Klinično stanje je bilo ocenjeno s pomočjo vprašalnika ODI pred, leto dni in pet let po posegu. Za oceno zadostnosti intraoperativne korekcije ledvene lordoze v odvisnosti od PI je bil vpeljan parameter indeks deficita ledvene lordoze (R:def). REZULTATI Operativni poseg je privedel do izboljšanja kliničnega stanja bolnikov, kar se je pokazalo tako eno kot pet let po posegu (p<0,001) SVA se je izkazala kot edini parameter, ki korelira z izboljšanjem tako kratkoročnih kot srednjeročnih kliničnih rezultatov (p=0,005); bolniki s posteriornim pomikom SVA so poročali o večjem izboljšanju kliničnega stanja (∆ODI5: 29±15 vs. 11±16; p=0,001). Izboljšanje je bilo večje tudi, kadar je bila dosežena korekcija LL (∆ODI5: 23±4 vs. 12±3, p=0,035p=0,035). Korekcija SL sicer ni korelirala z izboljšanjem kliničnih rezultatov, temveč s korekcijo SVA (p=0,044) in z izboljšanjem LL (p<0,001); pri korekciji SL je bilo zaslediti manjši anteriorni pomik SVA (+3±7mm vs. +27±6mm; p=0,014), pa tudi zmanjšanje lordoze diskusa L5/S1 (p=0,011). Zmožnost korekcije SL (p=0,050) in LL (0,017) z naraščanjem PI upada. Izboljšanje kliničnega stanja bolnikov v skupini s PI<56⁰ korelira z izboljšanjem vrednosti LL (p=0,005). Po korekciji LL so bili klinični rezultati pet let po posegu izboljšani (26±19 vs. 9±15, p=0,017); neuspela korekcija LL se odraža s kompenzatornim porastom vrednosti PT (p<0,001) ter s pomikom SVA navzpred (p=0,045). V skupini s PI>56⁰ je bila korekcija LL slabša, vpliva na izboljšanje kliničnih rezultatov ni bilo moč zaslediti; prisotna pa je bila povezava med potekom SVA in izboljšanjem vrednosti ODI tako leto dni (18±13 vs. 34±15, p=0,014) kot tudi pet let po posegu (20±14 vs. 41, p=0,009). Na novo vpeljani R:def ne korelira le z normalizacijo spinopelvičnih parametrov, temveč, v skupini PI<56⁰ tudi s posteriornim pomikom težiščnice (r=0,380, p=0,038) in izboljšanjem kliničnih rezultatov po petih letih (p=0,02). Repozicija zdrsa, starost bolnikov in BMI niso vplivali neposredno na klinične rezultate. ZAKLJUČEK SVA se je izkazala kot parameter, ki najbolje korelira s kliničnimi rezultati po enonivojski spondilodezi zaradi degenerativne spondilolisteze. Neustrezna korekcija SL povzroči pomik SVA navzpred, kar se odraža v slabših kratko- in srednjeročnih kliničnih rezultatih. Korekcija SL pomembno vpliva na korekcijo LL, slednja pa na izboljšanje srednjeročnega kliničnega rezultata. V skupini s PI<56⁰ je vpliv korekcije LL na klinično sliko bolnikov opazen šele po petih letih in ne prej, kar potrjuje pomen in vpliv korekcije SL na zadovoljstvo bolnikov v daljšem časovnem obdobju. Po drugi strani pa je korekcija ledvene lordoze pri bolnikih z višjo vrednostjo PI pogosto neustrezna, vendar imajo ti bolniki na voljo več kompenzacijskih mehanizmov ki omogočajo ugoden pooperativni klinični rezultat. Repozicija listetičnega segmenta se ni izkazala kot pomemben dejavnik vpliva na srednjeročne klinične rezultate, vendar vpliva na korekcijo spinopelvičnih parametrov. Novo vpeljani indeks deficita ledvene lordoze (R:def) se je izkazal kot primeren parameter za oceno korekcije LL, s pomočjo katerega lahko ocenimo srednjeročno izboljšanje klinične slike, še posebej pri bolnikih z nižjo vrednostjo PI.

Keywords

sagitalno ravnovesje;segmentna lordoza;repozicija;TLIF;klinični rezultat;

Data

Language: Slovenian
Year of publishing:
Typology: 2.08 - Doctoral Dissertation
Organization: UM MF - Faculty of Medicine
Publisher: M. Kuhta]
UDC: 616.711/.72-007.53-089:615.8(043.3)
COBISS: 169565699 Link will open in a new window
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Other data

Secondary language: English
Secondary title: The impact of sagittal balance on clinical outcome in patients with degenerative spondylolisthesis after single-segment lumbar fusion
Secondary abstract: AIM To investigate whether achieving adequate segmental lordosis and reduction of vertebral slip during surgery for degenerative spondylolisthesis affects short- and medium-term clinical outcomes, and to analyze spinopelvic parameters and clinical outcomes according to pelvic incidence (PI). METHODS In prospective study 57 patients underwent single-level TLIF surgery for degenerative spondylolisthesis and were analyzed for radiographic spinopelvic sagittal parameters pre- and post-operatively, as well as ODI scores one, and five years postoperatively. The measured parameters included: sagittal vertical axis – SVA, segmental lordosis – SL, lumbar lordosis – LL, lordosis of the levels above (LLa) and below (LLb) the operated segment, and reduction of vertebral slip. A parameter of lumbar lordosis deficit index (R:def) was introduced to assess the adequacy of intraoperative correction of lumbar lordosis in relation to PI. The impact of BMI and age on clinical outcomes was identified. RESULTS Significant improvement in clinical outcome was noted at one and five years after the procedure (p<0,001). SVA was identified as the only parameter that correlated with both short- and medium-term clinical outcomes (p=0,005). Patients with a posterior shift of SVA reported greater improvement in ODI scores than patients with anterior SVA shift (∆ODI5: 29±15 vs. 11±16; p=0,001). ODI scores improved more when lumbar lordosis (LL) correction was achieved (∆ODI5: 23±4 vs. 12±3, p=0,035). Although segmental lordosis (SL) correction did not correlate with improvement in clinical outcomes directly, it correlated with correction of SVA (p=0,044) and improvement in LL (p<0,001). Correction of SL resulted in a significantly smaller anterior shift of SVA (+3±7mm vs. +27±6mm; p=0,014) and in reduction in lordosis of disc L5/S1 (p=0,011). The ability to correct SL (p=0,050) and LL (p=0,017) decreased with increasing value of PI. In patients with PI<56⁰, the correction of LL correlated ODI scores (p=0,005), change in PT (p<0,001) and position of SVA (p=0,045). In patients with PI>56⁰, the correction of LL was less pronounced, and the impact of LL correction on clinical outcomes could not be observed. However, improvement in SVA was associated with lower ODI values at one year (18±13 vs. 34±15, p=0,014) and five years after the surgery (20±14 vs. 41, p=0,009). Lumbar lordosis deficit index (R.def) correlated with improvement of spinopelvic parameters, especially in group with PI<56⁰ with the posterior shift of SVA (r=0,380, p=0,038) and improvement in ODI scores five years after the procedure (p=0,02) . Patients age, BMI or intraoperative reduction of the lytic segment did not correlate with clinical results. CONCLUSION SVA was found to be the only parameter that correlated directly with clinical outcomes. Results showed that inadequate correction of SL causes an anterior shift of SVA, which correlates with poorer short- and medium-term clinical outcomes. Correction of SL significantly affects the correction of LL, which in turn improves mid-term clinical outcomes. Awareness that the correlation between operative lordosis correction and clinical outcome, especially in patients with low PI, could be demonstrated only five years after surgery but not one year after the procedure underlines the importance of surgical correction of SL. On the other hand, patients with high PI are frequently under-corrected, but have on the other hand several compensation mechanisms that do not preclude good postsurgical clinical outcome. Patients age, BMI, or reduction of listhetic segment do not influence midterm clinical outcomes. Newly introduced lumbar deficit index (R:def) turned out to be an appropriate parameter for evaluation of lumbar lordosis correction and prediction of midterm clinical results, especially in patents with lower PI.
Secondary keywords: sagittal balance;segmental lordosis;reposition;TLIF;clinical outcome;
Type (COBISS): Dissertation
Thesis comment: Univ. v Mariboru, Medicinska fak.
Pages: XIV, 92 str..
ID: 13611137