后路闭合-张开式截骨治疗儿童静止期胸腰椎结核后凸畸形

Closing-opening wedge osteotomy for correction of the thoracic and lumbar kyphosis in pediatric static tuberculosis

中文关键词:  脊柱结核  后路  截骨术  后凸畸形  儿童

英文关键词:Spinal tuberculosis  Posterior surgical approach  Osteotomy  Kyphosis  Pediatric patient

中文摘要:

  【摘要】 目的：探讨后路闭合-张开式截骨治疗儿童静止期胸腰椎结核后凸畸形的临床疗效。方法：2010年1月~2012年12月，采用后路闭合-张开式截骨矫形治疗静止期胸腰椎结核所致后凸畸形的儿童患者21例，男14例，女7例。年龄11.6±2.7（6~14岁）。脊柱结核病程86.3±33.1个月（58~142个月）。病变部位分布在T2~L3，其中累及2个椎体4例，3个椎体11例，4个椎体6例。6例伴有神经损害，其中Frankel C级2例，Frankel D级4例。术前局部后凸Cobb角为68.4°±18.2°（40°~110°）。均采用后路闭合-张开式截骨矫形、椎管减压、椎弓根螺钉内固定植骨融合术治疗，术后3个月、6个月、12个月及其后每年门诊随访，通过脊柱正侧位X线片评价内固定位置及畸形矫正效果。结果：手术均顺利完成，术中失血800~1600ml（1100±244ml）；手术耗时270±74min（210~410min）。手术固定节段6.8±1.6个（5~10个）。1例T2~T5侧后凸畸形伴双下肢不全瘫、Frankel C级患者术后脊髓功能Frankel评级下降至B级；未发生脑脊液漏、伤口感染等并发症。随访28.8±8.1个月（14~38个月），1例发生术中脊髓损伤患者末次随访时神经功能恢复至Frankel D级，另5例伴神经功能损害者恢复至正常。术后局部后凸Cobb角为24.6°±15.1°（4°~59°）；末次随访时局部后凸Cobb角为25.9°±15.0°（4°~61°），矫正丢失1.3°±0.3°（0°~4°）。术前与术后、末次随访时比较差异有统计学意义（P<0.05）；术后与末次随访时比较差异无统计学意义（P>0.05）。患者腰背痛VAS评分由术前4.3±1.1分（2~7分）降至随访时的0.8±0.6分（0~2分），差异有统计学意义。所有患者植骨均融合良好，无假关节形成及内固定失败。结论：后路闭合-张开式截骨矫形治疗儿童静止期胸腰椎结核后凸畸形可取得较满意的临床疗效。

英文摘要:

  【Abstract】 Objectives: To investigate the effect of closing-opening wedge osteotomy in correction of thoracic and lumbar kyphosis of pediatric static tuberculosis. Methods: From January 2010 to November 2012, a total of 21 pediatric patients with clear thoracic or lumbar kyphosis was treated in our hospital by using closing-opening wedge osteotomy. There were 14 males and 7 females, with the age ranging from 6 years to 14 years（mean 11.6±2.67 years）. The mean course of disease was 86.3±33.1 months(range, 58-142 months). The location of the tuberculosis distributed from T2 to L3, with 2 vertebrae affected in 4 cases, 3 vertebrae affected in 11 cases, and 4 vertebrae affected in 6 cases. Six cases presented with neurological compromise: Frankel C in 2 cases, and Frankel D in 4. The preoperative Cobb angle of kyphosis was 40°-110° (mean 68.4°±18.2°). Patients received closing-opening osteotomy, decompression, internal fixation and circumferential fusion in a posterior approach. Follow-up was performed at 3 months, 6 months, 12 months and each year thereafter. X-rays were used to evaluate the instrumentation′s status and the deformity correction. Results: All surgeries were carried out as planned, with a mean blood loss of 1100±244ml, ranging from 800ml to 1600ml, operation time ranged from 210min to 410min(mean, 270±74min). The number of instrumentation and fusion segments was 5 to 10 vertebrae(mean 6.8±1.6 vertebrae). One patient with T2-T5 scoliokyphosis and incomplete paraplegia presented neurofunction deterioration(Frankle grade C to B). No other complication such as cerebrospinal fluid leakage or wound infection was noted. The mean follow-up was 28.8±8.1 months(from 14 months to 38 months). The patient experiencing spinal injury during the operation improved from Frankle grade B to D at final follow-up. Another 5 patients with neurological deficit recovered completely. Cobb angle of kyphosis decreased to 4°-59° after operation(mean 24.6°±15.1°). At final follow-up, kyphosis angle was 4°-61°(25.9°±15.0°), with a loss of 0°-4°(mean 1.3°±0.3°). The differences of kyphotic angle between pre-operation and post-operation and between pre-operation and final follow-up were significant(P<0.05), while there was no significant difference between post-operation and the final follow-up. VAS score of back pain decreased from 4.3±1.1(2 to 7) at admission to 0.8±0.6(0 to 2) at final follow-up. The difference was also significant(P<0.05). Bone fusion was achieved in all cases, and no implant related complication was noted. Conclusions: Closing-opening wedge osteotomy is an effective way for the correction of kyphosis caused by static tuberculosis, and the clinical outcomes are good.