先天性半椎体切除术后新发侧凸畸形的临床分析

The clinical feature analysis for the emerging scoliosis following resection of congenital hemivertebra

中文关键词:  先天性脊柱侧凸  半椎体  新发侧凸畸形  半椎体切除术  并发症  短节段融合术

英文关键词:Congenital scoliosis  Hemivertebra  Emerging scoliosis  Hemivertebra resection  Complications  Short fusion

中文摘要:

  【摘要】 目的：分析后路半椎体切除、短节段融合术后新发侧凸畸形（emerging scoliosis，ES）的临床特征以及处理策略。方法：2008年1月~2017年1月，168例单发半椎体畸形的患者在我科接受单纯后路半椎体切除、短节段椎弓根螺钉内固定植骨融合术治疗，其中12例发生ES。ES诊断标准：①新发弯Cobb角较术前同节段Cobb角进展≥20°；②同时新发弯主弯顶椎距离融合节段端椎的节段≥2（近端融合椎以上或远端融合椎以下）；③排除半椎体切除不完全、融合内固定失败等因素。男4例，女8例；年龄11.8±3.2岁（5～15岁，其中10岁以下2例，10～15岁10例），融合节段数为2.7±1.0节（2～5节），随访34.0±10.0个月（18～50个月）。收集并测量患者术前、术后站立位全脊柱正侧位X线片等影像资料，对比分析患者主弯Cobb角、代偿弯Cobb角、新发侧凸Cobb角、节段后凸角度、术后融合交界区后凸角度等指标。结果：12例ES患者术前半椎体所在节段为胸腰段8例，胸段4例。经初次手术，患者半椎体节段侧凸Cobb角由术前36.1°±14.4°（21.8°～69.0°）显著减少至末次随访时的8.9°±8.5°（0°～19.5°）（P=0.000），平均矫正率为75.3%；节段后凸角从术前25.9°±12.8°（15.5°～40.2°）显著改善至末次随访时的9.5°±4.3°（4.0°～14.7°）（P=0.014）。术后ES出现时间：术后3个月5例，6个月7例。7例患者术后ES的节段与术前代偿弯节段一致。5例患者接受观察，其中1例ES进展接受翻修手术治疗，其他4例患者平均随访至术后25个月（18～36个月），ES角度无明显进展（平均25°→32°）；7例患者接受支具治疗，其中4例支具治疗效果满意，支具治疗后平均随访36个月（24～42个月），ES角度有所改善（平均34°→23°）。4例患者在观察或支具治疗失败后（ES角度＞45°且发展为结构弯），接受翻修手术治疗，翻修术后随访平均22.5个月（12～36个月），ES角度由平均52°（45°～64.2°）矫正至末次随访时平均13°（0°～25°），且均未出现其他继发畸形。结论：后路半椎体切除短节段融合术后ES的发生率约为7%，胸腰段半椎体（T11～L1）及初次手术患者年龄偏大（青春期）为其可能风险因素，其发生和进展较为迅速（3～6个月内），针对该并发症的治疗策略应采用“观察—支具—手术”的阶梯性治疗策略。

英文摘要:

  【Abstract】 Objectives: To analyze the clinical feature and treatment principle of emerging scoliosis(ES) after posterior hemivertebra resection and short segmental fusion. Methods: From January 2008 to January 2017, 168 patients with single-hemivertebra congenital scoliosis had received posterior hemivertebra resection and short segmental fusion in our department. 12 cases in these patients were found the ES occurred in the follow-up, and the diagnostic criteria were: (1)the Cobb angle increased more than 20° after operation; (2)the apical vertebra was far away from the fusion level[more than 2 levels above the upper instrumented vertebra(UIV) or below the lower instrumented vertebra(LIV)]; (3)without hemivertebra incomplete resection or fixation failure. There were 4 males and 8 females in these 12 cases of ES, with the mean age of 11.8±3.2 years(5-15 years, 2 patients under 10 years old while 10 patients between 10 to 15 years old), mean follow-up time of 34.0±10.0 months(18-50 months), mean fusion levels of 2.7±1.0(2-5). Their general and radiographic data, such as standing full spine AP and lateral X-films, were collected and measured in the study. The parameters included main curve Cobb angle, compensatory curve Cobb angle, ES Cobb angle, segmental kyphosis angle, and proximal junction kyphosis angle. Results: Eight of the twelve patients with ES had a hemivertebra in thoracolumbar spine while the other four in thoracic spine. After initial correction, the mean scoliosis Cobb angle significantly decreased from 36.1°±14.4°(21.8°-69.0°) to 8.9°±8.5°(0°-19.5°)(P=0.000), with a correction rate of 75.3%. The mean kyphosis angle significantly decreased from 25.9°±12.8°(15.5°-40.2°) to 9.5°±4.3°(4.0°-14.7°)(P=0.014). ES was found in 5 patients at 3 months after operation, while in 7 cases at 6 months after operation. The levels of ES were the same as preoperative compensatory scoliosis in 7 of the 12 patients. For the treatment, 5 of the 12 patients received observation: 1 case with progression of ES received revision, 4 cases had no marked progression(from average 25° to 32°) in 25 months(18-36 months) follow-up; 7 of the 12 patients received brace therapy: 3 cases with scoliosis progression received revision surgery, 4 cases with improvement of ES(from average 34° to 23°) in follow-up of 36 months(24-42 months). 4 of the 12 patients received revision operation after failure of observation or brace therapy(Cobb angle >45° and became structural). In an average of 22.5 months(12-36 months) follow-up, their ES had been corrected from 52°(45°-64.2°) to 13°(0°-25°). None of the 4 cases developed secondary deformity. Conclusions: The incidence of ES is about 7% after posterior hemivertebra resection and short segmental fusion. The thoracolumbar hemivertebra(T11-L1) and patient′s age at the time of surgery(adolescence) may be the risk factor for ES. ES progresses relatively fast and should obey the step by step treatment principle as observation, brace and corrective operation.