儿童及青年漏斗胸患者Nuss术后发生脊柱侧弯的风险预测模型建立及验证

doi:10.19723/j.issn.1671-167X.2025.05.019

摘要/Abstract

摘要： 目的: 明确儿童及青年漏斗胸患者接受Nuss术后发生脊柱侧弯的风险因素, 并建立相关预测模型。方法: 回顾性分析2018年1月至2023年2月于北京积水潭医院胸外科行Nuss手术治疗的漏斗胸患者, 收集患者的人口学资料(年龄、性别、身高、体重、体重指数)及超声心动图、胸部CT、脊柱全长X线、胸部正侧位X线检查结果, 同时收集Haller指数、不对称指数、胸骨扭转角(sternal torsion angle, STA)指数及Cobb角变化, 评估Nuss术后脊柱侧弯的发生风险。通过Cox回归分析明确影响漏斗胸患者Nuss术后脊柱侧弯的独立危险因素, 建立风险预测模型, 通过内部交叉验证明确模型的具体预测效能。结果: 符合纳入排除标准的患者共59例, 中位随访6.84个月, 随访结果显示术后Haller指数、STA指数、不对称指数均较术前显著改善, 术后3个月12例(20.3%)患者发生脊柱侧弯。Cox回归分析显示, 术前肺动脉高压和不对称指数是影响Nuss术后脊柱侧弯的独立影响因素。基于术前肺动脉高压、不对称指数绘制列线图建立预测模型, 整体预测模型的受试者工作特征(receiver operating characteristic, ROC)曲线下面积为0.995, 校准曲线显示模型预测值与实际值重合度良好。结论: Nuss手术临床疗效显著, 但术后脊柱侧弯并发症发生比例较高; 术前肺动脉高压和不对称指数高是影响Nuss术后脊柱侧弯的独立影响因素, 预测模型能够有效预测患者术后脊柱侧弯的发生概率。

关键词: 漏斗胸, Nuss手术, 脊柱侧弯, 危险因素, 列线图

Abstract: Objective: To identify the risk factors associated with the development of post-Nuss procedure scoliosis in pectus excavatum patients and to establish a relevant predictive model. Methods: A retro-spective review was conducted on pectus excavatum patients who underwent Nuss procedure in Department of Thoracic Surgery at Beijing Jishuitan Hospital between January 2018 and February 2023. We gathered the patient demographic information (including age, sex, height, weight, and body mass index) and diagnostic imaging results (echocardiogram, chest CT scan, full-spine radiography, and PA/lateral chest X-rays), and measurements of Haller index, asymmetry index, sternal torsion angle (STA) index, and Cobb angle changes. The risk of post-Nuss procedure scoliosis was assessed. Cox regression analysis was performed to identify independent risk factors for scoliosis development in the pectus excavatum patients. Based on the results of the Cox regression analysis, a risk prediction model was established, and its specific predictive performance was assessed through internal cross-validation. Results: A total of 59 pectus excavatum patients who underwent Nuss procedure were included after applying inclusion and exclusion criteria. The median follow-up duration was 6.84 months, and the follow-up results showed significant improvements in Haller index, STA index, and asymmetry index postoperatively. Twelve patients developed scoliosis 3 months after Nuss procedure, while 47 patients did not, the incidence of scoliosis was 20.3%. Cox regression analysis identified preoperative pulmonary artery hypertension and preoperative asymmetry index as independent risk factors for post-Nuss procedure scoliosis. A predictive model was constructed based on single-factor Cox regression analysis results, incorporating age, height, weight, body mass index, preoperative pulmonary artery hypertension, preoperative Haller index, STA index, asymmetry index, and Cobb angle. The receiver operating characteristic (ROC) curve was plotted, and the area under the curve (AUC) for the overall predictive model was calculated to be 0.995. A calibration curve demonstrated good alignment between predicted values and actual values. Conclusion: Nuss procedure achieved favorable clinical outcomes. However, postoperative scoliosis emerged as a significant complication with a high incidence rate. Pulmonary artery hypertension and asymmetry index were independent predictors of post-Nuss procedure scoliosis. The predictive model developed in this study demonstrated robust performance in estimating the risk of postoperative scoliosis.

Key words: Pectus excavatum, Nuss surgery, Scoliosis, Risk factors, Nomograms

中图分类号:

R655

李博闻, 张强, 孙益鑫. 儿童及青年漏斗胸患者Nuss术后发生脊柱侧弯的风险预测模型建立及验证[J]. 北京大学学报（医学版）, 2025, 57(5): 941-946.

Bowen LI, Qiang ZHANG, Yixin SUN. Establishment and validation of a risk prediction model for scoliosis after Nuss procedure in children and young adults with pectus excavatum[J]. Journal of Peking University (Health Sciences), 2025, 57(5): 941-946.

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Characteristics	Values
Age/years, ${\bar x}$±s	16.0±3.99
Gender, n(%)
Male	52 (88.1)
Female	7 (11.9)
Height/cm, ${\bar x}$±s	134±8.71
Weight/kg, ${\bar x}$±s	38.3±8.15
Body mass index/(kg/m²), ${\bar x}$±s	20.0±2.36
Mitral valve prolapse, n(%)	3 (5.08)
Mitral regurgitation, n(%)	6 (10.2)
Tricuspid regurgitation, n(%)	1 (1.69)
Pulmonary artery hypertension, n(%)	4 (6.78)

Radiographic parameters	Before Nuss	3 months after Nuss	P
Haller index, median (P₂₅, P₇₅)	3.20 (0.47, 5.35)	1.32 (0.18, 2.53)	< 0.000 1
Sternal torsion angle index, median (P₂₅, P₇₅)	16.0 (5.75, 29.8)	11.8 (1.78, 21.6)	< 0.000 1
Asymmetry index, median (P₂₅, P₇₅)	0.59 (0.33, 0.89)	0.32 (0.12, 0.48)	< 0.000 1
Cobb angel, ${\bar x}$±s	7.16±2.45	8.86±3.20	0.001 6

Variable	HR (95%CI)	β	SE	P
Age	1.19 (1.05-1.36)	0.18	0.07	0.010
Gender	0.00 (0.00-Infinity)	-18.20	6 900.00	1.000
Height	1.07 (1.01-1.14)	0.07	0.03	0.040
Weight	1.10 (1.02-1.19)	0.10	0.04	0.020
BMI	0.67 (0.49-0.90)	-0.40	0.15	0.010
Mitral valve prolapse	4.75 (0.54-41.64)	1.56	1.11	0.160
Mitral regurgitation	1.54 (0.34-7.04)	0.43	0.78	0.580
Pulmonary artery hypertension	17.08 (4.66-62.62)	2.84	0.66	< 0.001
Haller index	0.25 (0.14-0.43)	-1.40	0.29	< 0.001
STA index	0.68 (0.58-0.80)	-0.39	0.08	< 0.001
Asymmetry index	0.00 (0.00-0.00)	-19.70	4.30	< 0.001
Cobb angle	0.41 (0.28-0.61)	-0.89	0.20	< 0.001

Variable	HR (95%CI)	β	SE	P
Age	1.19 (0.96-1.48)	0.176	0.110	0.111
Height	1.09 (0.94-1.25)	0.083	0.073	0.259
Weight	1.04 (0.87-1.25)	0.040	0.092	0.664
BMI	1.13 (0.61-2.08)	0.119	0.313	0.704
Pulmonary artery hypertension	20.80 (1.37-314.00)	3.030	1.390	0.029
Haller index	39.9 (0.19-8 380)	3.690	2.730	0.177
STA index	0.47 (0.06-3.55)	-0.749	1.030	0.466
Asymmetry index	1.8×10^-54 (3.6×10^-96-9.1×10^-13)	-124.000	49.000	0.011
Cobb angle	54.4 (0.31-9 650)	4.000	2.640	0.131