儿童及青少年颈胸段/上胸段先天性脊柱侧后凸畸形手术治疗的疗效与并发症

The efficacy and complications of surgical treatment of congenital deformities cervicothoracic and upper thoracic spine

中文关键词:  先天性脊柱畸形  颈胸段  上胸段  截骨术

英文关键词:Congenital kyphoscoliosis  Cervicothoracic spine  Upper thoracic spine  Osteotomy

中文摘要:

  【摘要】 目的：评估儿童及青少年颈胸段/上胸段先天性脊柱侧后凸畸形手术治疗的疗效和并发症。方法：回顾性研究2005年4月~2018年1月于我科接受手术治疗的颈胸段及上胸段先天性脊柱侧后凸畸形患者45例，男27例，女18例；年龄10.9±3.1岁（5~15）岁。术前所有患者均存在双肩不等高以及斜颈，2例患者存在脊髓受压及神经功能障碍（均为ASIA D级）。术前均行全脊柱CT平扫及三维重建，畸形顶点位于颈椎12例，位于胸椎33例；形成障碍型24例，分节障碍型5例，混合型16例；28例患者存在代偿性胸弯/胸腰弯；23例患者伴发其他部位的脊柱畸形。所有患者术前均行全脊柱MRI明确椎管内病变情况。对于计划进行颈胸段（C7/T1）截骨或颈椎固定的患者，行双侧椎动脉CT造影（CTA）检查。所有患者均行三柱截骨侧后凸矫形内固定植骨融合术，其中44例患者为单纯后路手术，1例接受C6-7半椎体切除患者行前后路联合手术。截骨水平位于颈椎12例，位于胸椎33例；半椎体切除术32例，全脊椎切除术10例，经椎弓根截骨术3例。6例患者代偿弯行手术治疗，其中4例接受后路融合术，2例接受双生长棒手术。于术后3个月、6个月及1年随访，此后每年进行随访。术前、术后及随访时均摄站立位全脊柱正侧位X线片，对原发侧凸、代偿侧凸及节段性后凸Cobb角与锁骨角、斜颈角度及矢状面平衡（sagittal vertical axis，SVA）进行测量。统计手术时间、术中出血量和手术并发症情况。结果：手术时间为269.1±65.3min（150~310min），术中出血量为987±157ml（500~2700ml）。45例患者均获1年以上随访，随访时间2.8±0.6（1~13）年。原发侧凸Cobb角术前为51.3°±13.9°，术后10.3°±6.4°，末次随访时12.4°±7.5°；代偿侧凸术前为32.1°±23.0°，术后11.1°±21.0°，末次随访时16.3°±23.1°；节段性后凸Cobb角术前为24.2°±15.2°，术后9.2°±8.7°，末次随访时10.4°±9.4°；斜颈术前为19.3°±5.0°，术后4.6°±3.0°，末次随访时5.7°±4.1°；锁骨角术前为7.5°±3.1°，术后2.7°±1.9°，末次随访时2.1°±1.2°；SVA术前为-9.1±16.1mm，术后-12.3±11.2mm，末次随访时-7.5±15.2mm。术后的原发侧凸Cobb角、代偿性侧凸Cobb角、斜颈角度、锁骨角及节段性后凸Cobb角与术前比较均有统计学差异（P＜0.05），末次随访时的原发侧凸、代偿性侧凸及节段性后凸Cobb角与术后比较有统计学差异（P＜0.05）；SVA术前、术后及末次随访时均在正常范围内，无统计学差异（P＞0.05）。2例术前存在神经功能障碍者术后完全恢复正常。22例患者发生24例次并发症，其中一过性脊髓损伤伴C8神经根损伤1例，一过性神经根损伤14例，Horner综合征1例，内固定失败2例，血胸3例，切口延迟愈合1例，肺不张1例。结论：三柱截骨术治疗颈胸段及上胸段先天性脊柱侧后凸畸形矫形效果良好，但手术相关并发症风险较高，一过性神经根损伤较为常见，需引起外科医生充分的重视。

英文摘要:

  【Abstract】 Objectives: To evaluate the outcomes of surgical treatment of congenital deformities in the cervicothoracic and upper thoracic spine. Methods: 45 patients (28males, 17 females) undergoing surgery for congenital deformities in cervicothoracic and upper thoracic spine in our hospital from April 2005 to January 2018 were included. The mean age at surgery was 10.9±3.1（5-15） years. Standing anteroposterior and lateral radiographs were obtained at the post-operation and follow-up. CT and MRI scan of spine were taken for every patient. 12 patients had deformity with apex in cervical spine and others in thoracic spine. There were 24 formation failures, 5 segmentation failures and 16 mixed types. The average follow-up was 2.8±0.6（1-13）years. Twenty-eight patients had compensatory thoracic or thoracolumbar curve and 23 patients had congenital deformities in other parts of spine. All of them were treated with 3-column osteotomy in cervicothoracic spine or upper thoracic curve: 32 with hemivertebra resection, 10 with vertebral column resection and 3 with pedicle subtraction osteotomy. 12 patients received osteotomy in cervical spine and 33 in thoracic spine. One stage anterior and posterior approach was used in 1 patient with C6 resection and posterior-only approach was chosen for other patients. All patients were followed up for 3 months, 6 months and 1 year after surgery and whole spine X ray was taken at the time of follow-up. Radiographic measurement and chats review were taken to record the results and complications. Results: The average operation time was 269.1±65.3 minutes and the mean blood loss was 987±157ml. The cervicothoracic curve was 51.3°±13.9° before surgery, 10.3°±6.4° after surgery, and 12.4°±7.5° at final follow-up. The compensatory curve was 32.1°±23.0° before surgery, 11.1°±21.0° after surgery, and 16.3°±23.1° at final follow-up. The segmental kyphosis was 24.2°±15.2° before surgery, 9.2°±8.7° after surgery, and 10.4°±9.4° at final follow-up. The head tilting was 19.3°±5.0° before surgery, 4.6°±3.0° after surgery, and 5.7°±4.1° at final follow-up. The clavicle angle was 7.5°±3.1° before surgery, 2.7°±1.9° after surgery, and 2.1°±1.2° at final follow-up. Sagittal vertical axis was -9.1±16.1mm before surgery, -12.3±11.2mm after surgery, and -7.5±15.2mm at final follow-up. Two patients with preoperative neurological deformity totally recovered after surgery. Twenty-four complications occurred in 22 patients: 1 transient cord injury together with permanent C8 root injury, 14 transient root injuries, 1 transient Horner syndrome, 2 implant failures, 3 hemothorax, 1 wound delayed union and 1 atelectasis. Conclusions: Most congenital deformities in cervicothoracic and thoracic spine are fixed and 3-column osteotomy may be mandatory for this kind of rigid deformity to improve the correction. However, 3-column osteotomy in cervicothoracic spine(C7/T1) is technical demanding with high risk of root injury, although most of them are transient.