伴发Chiari Ⅰ型畸形和脊髓空洞脊柱侧凸患者一期后路脊柱矫形术后5年以上随访结果

The follow-up outcomes of more than 5 years after one-stage posterior correction of scoliosis with Chiari Ⅰ malformation and syringomyelia

中文关键词:  脊柱侧凸  Chiari畸形  脊髓空洞  外科矫形  随访结果

英文关键词:Scoliosis  Chiari malformation  Syringomyelia  Surgical correction  Follow-up outcomes

中文摘要:

  【摘要】 目的：分析一期后路脊柱矫形术治疗伴发Chiari Ⅰ型畸形（Chiari Ⅰ malformation，CM1）和脊髓空洞（syringomyelia，SM）脊柱侧凸患者的5年以上随访结果。方法：2007年1月~2015年6月收治23例伴发CM1和SM的脊柱侧凸患者，男19例，女4例，年龄10～39岁（16.0±5.9岁）。均行一期后路脊柱矫形术，其中10例行后路全脊椎截骨矫形术（posterior vertebral column resection，PVCR），13例行单纯脊柱矫形而未行短缩截骨术。所有患者手术前后和随访时行全脊柱X线片、CT及MRI检查，在全脊柱X线片上评价患者的矢状位和冠状位矫形率，在MRI上测量SM的大小及变化。根据MRI结果，取颈脊髓空洞张力指数（cervical syrinx tension ratio，CSTR）平均值作为描述颈段SM大小及变化的指标，将末次随访时CSTR下降≥20%定义为SM改善，并将患者分为颈段SM改善组和无改善组；再根据术中是否行脊柱短缩截骨术，将患者分为PVCR组和非PVCR组。记录患者性别、手术年龄、顶椎节段、冠状位主弯角度、矢状位后凸角度、畸形角度比（deformity angular ratio，DAR）、SM长度、平均CSTR、术前牵引情况、融合节段数量、末次随访时冠状面矫形率与矢状面矫形率、SM改善情况、随访时间等，并进行统计学分析。两组间定量变量的差异采用独立样本t检验的方法进行比较，定性变量差异采用χ2检验。结果：随访时间为6.2±1.1年（5～9年）。术前冠状位主弯角度为77.1°±28.0°（33°～122°），术后减少至27.8°±18.4°，末次随访时为29.5°±21.2°，冠状面侧凸矫正率为（65.7±13.0）%。术前矢状面后凸角度为57.2°±31.9°（8°～155°），术后减少至29.3°±15.2°，末次随访时为32.4°±16.5°，矢状面后凸矫正率为（48.4±22.6）%。所有病例未见内固定螺钉松动、断裂，骨性融合均良好，无术后神经功能损害。CSTR改善率为47.8%（11/23），SM改善组11例，SM无改善组12例。SM改善组患者的平均手术年龄（18.6±7.5岁vs. 13.7±2.4岁，P=0.040）、接受PVCR术治疗的比例（81.8% vs. 16.7%，P=0.012）和融合节段数（14.2±0.9 vs. 12.3±2.9，P=0.044）均高于SM无改善组患者；而性别、顶椎节段、冠状位主弯角度、矢状位后凸角度、DAR、SM长度、平均CSTR、术前牵引运用、畸形矫正率和随访时间两组间比较均无统计学差异（P>0.05）。PVCR组患者较非PVCR组有更严重的侧凸畸形（98.8°±13.8° vs. 60.5°±24.5°，P=0.000）和后凸畸形（74.8°±37.5° vs. 43.6°±18.6°，P=0.032）、有更大的冠状面DAR（15.6°±4.2°/节段 vs. 10.2°±4.2°/节段，P=0.006）和矢状面DAR（12.0°±7.6°/节段 vs. 6.7°±3.9°/节段，P=0.040）、总DAR（26.8°±11.4°/节段 vs. 15.3°±6.5°/节段，P=0.006）及更常接受术前牵引治疗（70.0% vs. 23.1%，P=0.024）、有更长的融合节段数（14.2±1.2节段 vs. 12.4±2.7节段，P=0.045）和SM获得更高的改善率（80.0% vs. 23.1%，P=0.007）；而性别、平均手术年龄、顶椎节段、SM长度、平均CSTR、畸形矫正率和随访时间两组间比较均无统计学差异（P>0.05）。结论：一期后路脊柱矫形术是治疗术前无明显神经功能受损表现的伴发CMⅠ和SM脊柱侧凸患者的一种选择，可以在无需先行神经外科减压手术的前提下实现一期安全、有效的脊柱矫形，稳定和持续性改善大多数患者的SM。

英文摘要:

  【Abstract】 Objectives: To analyze the more than 5 years′ follow-up outcomes of scoliosis with Chiari Ⅰ malformation(CM1) and syringomyelia(SM) treated by one-stage spinal correction. Methods: A retrospective study was performed on 23 patients with CM1 and SM associated scoliosis treated from January 2007 to June 2015. The patients had complete clinical data and were followed up for more than 5 years after one-stage spinal correction. There were 19 males and 4 females with an average age of 16.0±5.9(range, 10-39) years old. The one-stage spinal correction was performed on all the patients, including 10 patients with posterior vertebral column resection (PVCR), 13 patients with simple spinal correction without shortening osteotomy. The spinal radiographs were obtained from all patients preoperatively, postoperatively and at final follow-up． Syringomyelia size and change were measured based on the results of MRI. According to full-spine standing radiographs, the spine sagittal and coronal correction rate were evaluated. According to the results of MRI, the average cervical syrinx tension ratio(CSTR) was used as an indicator of syrinx size and change, and a ≥20% decline was set as a boundary of syrinx improvement at the final follow-up. According to the degree of CSTR decline, all the cases were divided into two groups: with or without cervical SM improvement. And the cases were also divided into with or without PVCR based on whether the spinal shortening osteotomy was performed intraoperatively. Then gender, age at surgery, apical level, main scoliosis, kyphosis, deformity angular ratio (DAR), length of syrinx, average CSTR, preop traction, No. of fusion segments, coronal correction rate, sagittal correction rate, syrinx improvement, and period of the follow-up were compared separately. Differences between two groups were assessed by independent t test, and categorical variables were compared using Chi-square test. Results: The average follow-up period of all patients was 6.2±1.1 years(range, 5-9 years). The average scoliosis angle reduced from 77.1°±28.0° before surgery to 27.8°±18.4° after surgery and 29.5°±21.2° at the final follow-up, with a correction ?????慯湦搠?卣??慩獯獳潩捳椠慯瑦攠搨?猵挮漷沱椱漳献椰猩??眠桔楨捥栠?湶潥瑲?潧湥氠祫?慰捨桯楳敩癳攠獡?獧慬晥攠?獥灤極湣慥汤?捦潲牯牭攠挵琷椮漲溰?眳椱琮根澰甠瑴?渠攲甹爮漳沰澱朱椵挮愲沰?楡湦瑴敥牲瘠敳湵瑲楧潥湲??扡畮瑤?愳氲献漴?玱琱收愮搵榰氠祡?椠浦灩牮潡癬攠獦?慬湬摯?猭瑵慰戬椠汷楩穴敨猠?匠??楲湲?浣潴獩瑯?瀠慲瑡楴敥渠瑯獦?kyphosis of (48.4±22.6)%. At final follow-up, the spinal correction and fusion were satisfied, and no patient experienced deterioration of neurological function. In all patients, the improvement rate of CSTR was 47.8%. There were 11 patients in the syrinx improvement group and 12 patients in the without syrinx improvement group. Of patients with syrinx improvement, the mean age at surgery was bigger(18.6±7.5 years vs. 13.7±2.4 years, P=0.040), the frequency of undergoing PVCR was more (81.8% vs. 16.7%, P=0.012), and the number of fusion segments was bigger(14.2±0.9 vs. 12.3±2.9, P=0.044) than those in the group without syrinx improvement. However, there was no significant difference in gender, apical level, main scoliosis, kyphosis, DAR, length of syrinx, average CSTR, preop traction, coronal correction rate, sagittal correction rate, and the follow-up period(P>0.05). The patients who underwent PVCR had severer scoliosis (98.8°±13.8° vs. 60.5°±24.5°, P=0.000) and kyphosis(74.8°±37.5° vs 43.6°±18.6°, P=0.032), as well as greater coronal DAR(15.6°±4.2° per level vs. 10.2°±4.2° per level, P=0.006), sagittal DAR(12.0°±7.6° per level vs. 6.7°±3.9° per level, P=0.040) and total DAR (26.8°±11.4° per level vs. 15.3°±6.5° per level, P=0.006) than those without PVCR. There were more frequent uses of preoperative traction(70.0% vs. 23.1%, P=0.024), longer fusion segments (14.2±1.2 levels vs. 12.4±2.7 levels, P=0.045), and higher syrinx improvement rate (80.0% vs. 23.1%, P=0.007) in the patients with PVCR. However, there was no significant difference in gender, age at surgery, apical level, length of syrinx, averaging CSTR, coronal correction rate, sagittal correction rate, and the follow-up period(P>0.05). Conclusions: One-stage spinal correction can be another good choice in selected patients without preoperative clinically detectable neurologic deficit of