Postoperative quality of life in patients with ankylosing spondylitis and thoracolumbar kyphosis: risk factors and personalized sagittal reconstruction strategy

Xin Lv Department of Orthopaedics, Sun Yat-sen Memorial Hospital, Sun Yat-sen University; and

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Renyuan Huang Department of Orthopaedics, Sun Yat-sen Memorial Hospital, Sun Yat-sen University; and

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Ziliang Zeng Department of Orthopaedics, Sun Yat-sen Memorial Hospital, Sun Yat-sen University; and

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Di Zhang Department of Orthopaedics, Sun Yat-sen Memorial Hospital, Sun Yat-sen University; and

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Bo Li Department of Orthopaedics, Sun Yat-sen Memorial Hospital, Sun Yat-sen University; and

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Yuhong Lin Faculty of Forensic Medicine, Zhongshan School of Medicine, Sun Yat-sen University, Guangzhou, Guangdong, China

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Zhilei Zhang Department of Orthopaedics, Sun Yat-sen Memorial Hospital, Sun Yat-sen University; and

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Qiwei Wang Department of Orthopaedics, Sun Yat-sen Memorial Hospital, Sun Yat-sen University; and

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Yelidana Nuertai Department of Orthopaedics, Sun Yat-sen Memorial Hospital, Sun Yat-sen University; and

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Zhihao Huang Department of Orthopaedics, Sun Yat-sen Memorial Hospital, Sun Yat-sen University; and

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Zheyu Wang Department of Orthopaedics, Sun Yat-sen Memorial Hospital, Sun Yat-sen University; and

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Canchun Yang Department of Orthopaedics, Sun Yat-sen Memorial Hospital, Sun Yat-sen University; and

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Haolin Yan Department of Orthopaedics, Sun Yat-sen Memorial Hospital, Sun Yat-sen University; and

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Xiaoshuai Peng Department of Orthopaedics, Sun Yat-sen Memorial Hospital, Sun Yat-sen University; and

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Qiancheng Zhao Department of Orthopaedics, Sun Yat-sen Memorial Hospital, Sun Yat-sen University; and

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Wenpeng Li Department of Orthopaedics, Sun Yat-sen Memorial Hospital, Sun Yat-sen University; and

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Xu Jiang Department of Orthopaedics, Sun Yat-sen Memorial Hospital, Sun Yat-sen University; and

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Xumin Hu Department of Orthopaedics, Sun Yat-sen Memorial Hospital, Sun Yat-sen University; and

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Liangbin Gao Department of Orthopaedics, Sun Yat-sen Memorial Hospital, Sun Yat-sen University; and

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OBJECTIVE

The aim of this study was to investigate the factors affecting postoperative quality of life in patients with ankylosing spondylitis (AS) and thoracolumbar kyphosis (TLK), and establish a personalized sagittal reconstruction strategy.

METHODS

Patients with AS and TLK who underwent pedicle subtraction osteotomy (PSO) from February 2009 to May 2019 were retrospectively included. Quality of life and spinal sagittal radiographic parameters were collected before surgery and at the last follow-up. Patients were divided into two groups based on the attainment of minimal clinically important difference (MCID) on the Bath Ankylosing Spondylitis Functional Index and Oswestry Disability Index. Comparisons of radiographic parameters and clinical outcomes were conducted between and within groups. Regression analysis was used to identify the risk factors within the missing MCID cohort. Sagittal reconstruction equations were established using the pelvic incidence (PI) and thoracic inlet angle (TIA) in the reached MCID cohort.

RESULTS

The study comprised 82 participants. Significant improvements were observed in most radiographic parameters and all quality-of-life indicators during the final follow-up compared with the preoperative measures (p < 0.05). Factors including cervical lordosis (CL) ≥ 18° (OR 9.75, 95% CI 2.26–58.01, p = 0.005), chin-brow vertical angle (CBVA) ≥ 25° (OR 14.7, 95% CI 3.29–91.21, p = 0.001), and pelvic tilt (PT) ≥ 33° (OR 21.77, 95% CI 5.92–103.44, p < 0.001) independently correlated with a failure to attain MCID (p < 0.05). Sagittal realignment targets were constructed as follows: sacral slope (SS) = 0.84 PI − 17.4° (R2 = 0.81, p < 0.001), thoracic kyphosis (TK) = 0.51 PI + 10.8° (R2 = 0.46, p = 0.002), neck tilt (NT) = 0.52 TIA − 5.8° (R2 = 0.49, p < 0.001), and T1 slope (T1S) = 0.48 TIA + 5.8° (R2 = 0.45, p = 0.002).

CONCLUSIONS

PSO proved efficacious in treating AS complicated by TLK, yielding favorable outcomes. CBVA ≥ 25°, CL ≥ 18°, and PT ≥ 33° were the primary factors affecting postoperative quality of life in patients with AS. The personalized sagittal reconstruction strategy in this study focused on the subjective sensations and daily needs of patients with AS, which were delineated by the equations SS = 0.84 PI − 17.4°, TK = 0.51 PI + 10.8°, NT = 0.52 TIA − 5.8°, and T1S = 0.48 TIA + 5.8°.

ABBREVIATIONS

AS = ankylosing spondylitis; ASQoL = Ankylosing Spondylitis Quality of Life; AUC = area under the ROC curve; BASFI = Bath Ankylosing Spondylitis Functional Index; CBVA = chin-brow vertical angle; CL = cervical lordosis; cSVA = cervical SVA; GK = global kyphosis; IQR = interquartile range; JSEQ = Jenkins Sleep Evaluation Questionnaire; LASSO = least absolute shrinkage and selection operator; LL = lumbar lordosis; LPA = L1 pelvic angle; MCID = minimal clinically important difference; MCS = mental component summary; mMCID = missing MCID; NT = neck tilt; OC2 = occiput-C2; ODI = Oswestry Disability Index; PCS = physical component summary; PI = pelvic incidence; PI-LL = PI-LL mismatch; PJK = proximal junction kyphosis; PROM = patient-reported outcome measure; PSO = pedicle subtraction osteotomy; PT = pelvic tilt; rMCID = reached MCID; ROC = receiver operating characteristic; SF-36 = 36-Item Short-Form Health Survey; SS = sacral slope; SSA = spino-sacral angle; SVA = sagittal vertical axis; T1S = T1 slope; TIA = thoracic inlet angle; TI-CL = difference between TIA and CL; TK = thoracic kyphosis; TLK = thoracolumbar kyphosis; TPA = transverse pedicle angle.
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Images from Özer and Demirtaş (pp 351–358).
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