李鹏志，王 冰，吕国华，李亚伟，李 磊，戴瑜亮，卿亚龙，吴鹏飞，徐洁涛 （中南大学湘雅二医院脊柱外科 410011 湖南省长沙市） 基金项目：国家自然科学基金面上项目（81871748）；国家自然科学基金青年项目（81601868）第一作者简介：男（1987-），博士研究生在读，研究方向：脊柱外科电话：（0731）85295125 E-mail：spine_lipengzhi@126.com通讯作者：王冰 E-mail：bingwang20021972@aliyun.com 【摘要】目的：应用数字化X线摄影（digital radiography，DR）系统构建新型人体全长X线片，并分析其评价人体整体矢状面平衡的可靠性和准确性。方法：2018年10月~2019年10 月，采用DR系统对30例志愿患者一次性连续曝光采集影像数据，运用医学图像处理软件全自动拼接获取人体全长X线片，其中男13例，女17例，年龄45～65岁（56.5±6.1岁）。同时接受全脊柱和下肢X线片检查。利用Surgimap软件由两名脊柱外科医师和一名影像科医师分别在人体矢状面全长X线片、全脊柱和下肢侧位X线片上分别独立测量：胸椎后凸角（thoracic kyphosis，TK）、腰椎前凸角（lumbar lordosis， LL）、骨盆入射角（pelvic incidence，PI）、骨盆倾斜角（pelvic tilt，PT）、骶骨倾斜角（sacral slop，SS）、矢状面垂直轴偏距（sagittal vertical axis，SVA）、骶股角（sacrofemoral angle，KFA）、膝关节角（knee angle，KA）、踝关节角（ankle angle，AA）、骨盆位移（pelvic shift，P.Shift）。通过独立样本t检验验证相关参数在不同摄片方式中的一致性，通过组内相关系数（ICC）分析观察者内以及观察者间参数值的一致性。结果：人体矢状面全长X线片与全脊柱和下肢侧位X线片上测量的脊柱-骨盆-下肢参数比较的P值为0.782～0.969，均无统计学差异，具有一致性。人体矢状面全长X线片测量的TK、LL、PI、PT、SS、SVA值与全脊柱侧位X线片上测量值的观察者内ICCs分别为0.696～0.857、0.724～0.873、0.672～0.943、0.691～0.851、0.648～0.852、0.645～0.867；观察者间的ICCs为0.678～0.822、0.704～0.872、0.772～0.904、0.763～0.936、0.665～0.824、0.541～0.665；人体矢状面全长X线片上测量的PI、PT、SS、KFA、KA、AA、P.shift值与下肢侧位X线片上测量值的观察者内ICCs分别为0.673～0.932、0.623～0.828、0.634～0.861、0.701～0.873、0.645～0.867、0.679～0.855、0.592～0.827；观察者间的ICCs为0.665～0.914、0.631～0.811、0.625～0.843、0.541～0.765、0.591～0.753、0.613～0.798、0.543～0.762。结论：采用DR系统一次性连续曝光成像构建人体全长X线片可行，脊柱-骨盆-下肢矢状面参数与全脊柱和下肢侧位X线片上测量结果一致率高，且具有良好的可靠性和准确性。【关键词】 人体全长X线片；矢状面平衡；脊柱－骨盆－下肢矢状面参数；可靠性；准确性doi：10.3969/j.issn.1004-406X.2020.08.07中图分类号：R816 文献标识码：A 文章编号：1004-406X（2020）-08-0710-08Theestablishment of full body splicing radiograph and study on its accuracy andreliability of global sagittal balance/LI Pengzhi, WANG Bing, L Guohua, et al//ChineseJournal of Spine and Spinal Cord, 2020, 30(8): 710-717【Abstract】 Objectives: To construct a newfull body splicing radiograph through digital radiography(DR) system, and to discussthe reliability and accuracy in its evaluation of overall sagittal balance.Methods: From October 2018 to October 2019, the DR system was applied tocollect the image data of 30 volunteers at one time continuous exposure, andthe medical image processing software was used to automatically stitch togetherand obtain clear and accurate full body splicing radiograph. There were 13 menand 17 women with an age of 45-65 years(mean age 56.5±6.1years). The volunteers were also subjected to an examination of whole spinelateral radiographic and lateral scanogram of the normal DR radiography system.The parameters of thoracic kyphosis(TK), lumbar lordosis(LL), pelvicincidence(PI), pelvic tilt(PT), sacral slop(SS), sagittal vertical axis(SVA),sacrofemoral angle(KFA), knee flexion angle(KA), ankle angle(AA), and pelvicshift(P.shift) were measured. Two spine surgeons and an imaging physicianperformed imaging measurements by using Surgimap software at three differentoccasions. The correlation coefficients were validated by independent samplet-test. The consistency of parameter values within and between the observerswas analyzed by the intragroup correlation coefficient(ICC). Results: Theindependent sample t-test of the full-body sagittal splicing radiograph and thewhole spine radiograph and lower limbs extremity had no statisticaldifference(independent sample t-test, 0.782-0.969 P>0.05). The full-bodysagittal splicing radiograph was compared to the whole-spine lateralradiograph, and the intraobserver ICCs of TK, LL, PI, PT, SS, SVA were0.696-0.857, 0.724-0.873, 0.672-0.943, 0.691-0.851, 0.648-0.852, and0.645-0.867, respectively. The interobserver correlation coefficients were0.678-0.822, 0.704-0.872, 0.772-0.904, 0.763-0.936, 0.665-0.824, and 0.541-0.665.The full-body sagittal splicing radiograph was compared to the lateralscanogram, and the intraobserver ICCs of PI, PT, SS, KFA, KA, AA, and P.shiftwere 0.673-0.932, 0.623-0.828, 0.634-0.861, 0.701-0.873, 0.645-0.867,0.679-0.855, and 0.592-0.827, respectively. The interobserver correlationcoefficients were 0.665-0.914, 0.631-0.811, 0.625-0.843, 0.541-0.765,0.591-0.753, 0.613-0.798, and 0.543-0.762. Intraobserver and interobserverreproducibility for both modalities were good to excellent. Conclusions: It isfeasible to construct the full body splicing radiograph by digital radiographysystem. The sagittal parameters of the spine-pelvis-lower extremity measured byit are similar to the measurement results on the whole-spine lateral radiographand the lateral scanogram, and have good reliability and repeatability.【Key words】 Full-body splicing radiograph;Global sagittal balance; Pelvic sagittal parameters; Reproducibility of results【Author′s address】Spine Surgery, the Second Xiangya Hospital, Central South University, Changsha,410008,China
图1 X线片拍摄站姿 a 正位片：患者直立以自然姿势站立，两眼向前方平视，两下肢并拢，足尖向前，两上肢下垂至躯干两侧 b 侧位片：患者直立以自然姿势站立，眼睛平视前方，身体无外在支撑物且右侧紧贴全脊柱摄影架。双脚分开与肩同宽，双肩放松，双臂屈肘与身体中垂线呈30°举于胸前，手腕放松，每一个指尖都并拢置于同侧锁骨上窝中Figure 1 X-ray shooting position requirements a Upright position: The patient stands upright in a natural posture, with two eyes looking straight ahead, two lower limbs close together, toes forward, two upper limbs hanging down to both sides of the trunk b Lateral position: The patient stands upright in a natural posture, the eyes look straight ahead, the body has no external supports and the right side clings to the full spine photography frame. The feet should be the same width as the shoulders, the shoulders should be relaxed, the elbows should be bent at 30° with the vertical line of the body in front of the chest, and the wrist should be relaxed. Each fingertip should be placed in the supraclavicular fossa
图2 脊柱-骨盆-下肢矢状位参数测量示意图：胸椎后凸角（thoracic kyphosis，TK），T4椎体上终板与T12 椎体上终板之间的角度；腰椎前凸角（lumbar lordosis，LL），L1椎体上终板与S1椎体上终板之间的角度；骨盆入射角（pelvic incidence，PI），S1上缘中点至股骨头中心点连线与S1上缘中垂线的夹角，骨盆倾斜角（pelvic tilt，PT），S1上缘中点至股骨头中心点连线与铅垂线的夹角；骶骨倾斜角（sacral slop，SS），S1上缘与水平线的夹角；矢状面垂直轴偏距（sagittal vertical axis, SVA），C7铅垂线至S1终板后上角的垂直距离；脊柱股骨角（spine femoral angle，KFA），S1上缘中点至股骨中点连线与双股骨轴之间的夹角；膝关节角（knee angle，KA），股骨的机械轴与胫骨的机械轴之间的角度；踝关节角（ankle angle，AA），胫骨的机械轴与铅垂线的角度；骨盆位移（pelvic shift, P.shift），S1终板后上角铅垂线至胫骨远端前皮质之间的垂直距离 图3 46岁女性患者，腰椎管狭窄症 a 人体全长X线片示TK 44.5°、LL 42.2°、PI 54.8°、PT 15.5°、SS 39.4°、SVA 3.5cm、KFA 198.1°、KA 14.1°、AA 21.4°、P.shift 153.7mm b 全脊柱侧位X线片示TK 39.3°、LL 39.1°、PI 57.9°、PT 17.7°、SS 40.2°、SVA 4.4cm c 下肢侧位X线片示PI 57.6°、PT 15.4°、SS 42.1°、KFA 197.3°、KA 15.3°、AA 22.5°、P.shift 147.9mmFigure 2 Schematic diagram of spinal-pelvic-lower limb parameter measurement. Thoracic kyphosis(TK) measured from T4-T12. Lumbar lordosis(LL) measured from L1-S1. Pelvic incidence(PI) is measured by the angle formed between the centre of femoral head to the midpoint of the S1 endplate and a perpendicular vertical line from the horizontal. Pelvic tilt(PT) measured by the angle between a line connecting the center of the femoral heads with the center of the S1 endplate and the vertical. Sacral slope(SS) is measured by the angle of the S1 endplate with the horizontal. Sagittal vertical axis(SVA) is measured by the distance between a C7 vertical plumb line with the superior posterior corner of S1. Sacrofemoral angle(KFA) is measured by the middle of the S1 endplate and the bicoxofemoral axis and the line between the bicoxofemoral axis and the femoral axis. Knee angle(KA) is defined as the angle between the mechanical axis of the femur and the mechanical axis of the tibia. Ankle angle(AA) is defined as the angle between the mechanical axis of the tibia and the plumb line. Pelvic shift(P.shift) is measured by the sagittal offset between the posterosuperior corner of sacrum and the anterior cortex of distal tibia Figure 3 A 46-year-old female, with lumbar spinal stenosis a Full-body sagittal splicing radiograph: TK 44.5°, LL 42.2°, PI 54.8°, PT 15.5°, SS 39.4°, SVA 3.5cm, KFA 198.1°, KA 14.1°, AA 21.4°, and P.shift 153.7mm b Whole-spine lateral radiograph: TK 39.3°, LL 39.1°, PI 57.9°, PT 17.7°, SS 40.2°, and SVA 4.4cm c Lateral scanogram: PI 57.6°, PT 15.4°, SS 42.1°, KFA 197.3°, KA 15.3°, AA 22.5°, and P.shift 147.9mm 图4 a 人体矢状面全长片与全脊柱侧位片上观察者内的可重复性 b 人体矢状面全长片与全脊柱侧位片上观察者间的可重复性 c 人体矢状面全长片与下肢侧位片上观察者内的可重复性 d 人体矢状面全长片与下肢侧位片上观察者间的可重复性Figure 4 a Intraobserver reproducibility of the full-body sagittal splicing radiograph and the whole-spine lateral radiograph b Interobserver reproducibility of the full-body sagittal splicing radiograph and the whole-spine lateral radiograph c Intraobserver reproducibility of the full-body sagittal splicing radiograph and the lateral scanogram d Interobserver reproducibility of the full-body sagittal splicing radiograph and the lateral scanogram 本文为删节版，原文见《中国脊柱脊髓杂志》2020年8月刊