后路三柱截骨长节段与短节段固定术治疗胸腰段先天性脊柱后凸畸形的临床疗效对比

Posterior three-column osteotomy for the treatment of congenital thoracolumbar kyphosis: a comparison of long and short segment instrumentation

中文关键词:  先天畸形  脊柱后凸  截骨术  远端固定椎

英文关键词:Congenital abnormalities  Kyphosis  Osteotomy  Distal fusion level

中文摘要:

  【摘要】 目的：比较后路三柱截骨联合长节段与短节段固定治疗胸腰段先天性脊柱后凸（congenital kyphosis，CK）的临床疗效。方法：回顾性分析2014年1月~2018年12月在我院行后路三柱截骨后凸矫形椎弓根螺钉内固定术的26例CK患者资料，男13例，女13例，年龄3~18岁（11.5±4.5岁）。患者后凸Cobb角50°~80°。根据远端固定椎选择的节段将患者分组：长节段组（n=12），远端固定椎位于截骨椎下方3个椎体；短节段组（n=14），远端固定椎位于截骨椎下方2个椎体。两组患者年龄、性别、截骨术式、节段均无统计学差异（P＞0.05）。所有患者随访2年以上，随访时间37.1±10.3个月（24~81个月）。术前、术后1周及末次随访时拍摄站立位全脊柱正侧位X线片，测量患者最大后凸Cobb角（global kyphosis，GK）、腰椎前凸角（lumbar lordosis，LL）、矢状面平衡（sagittal vertical axis，SVA）、骨盆入射角（pelvic incidence，PI）、骨盆倾斜角（pelvic tilt，PT）、骶骨倾斜角（sacral slope，SS）。记录患者术中电生理监测及术后随访期间并发症发生情况。术前及末次随访时填写SRS-22量表以评估临床疗效。结果：所有患者手术顺利完成。两组患者术前、术后及末次随访时GK、LL、SVA均无显著性差异（P>0.05），术后均较术前显著性改善（P<0.05），且末次随访时维持稳定（P>0.05）。两组患者PI、PT和SS在术前、术后和末次随访时均无统计学差异（P>0.05），且在术后维持稳定（P>0.05）。术中神经电生理监测显示两组中各有1例患者截骨时诱发电位发生异常，术后均无明显神经损害表现。所有患者随访期间未出现内固定相关并发症。两组患者术前SRS-22评分无统计学差异（P＞0.05），末次随访时短节段组患者SRS-22量表功能维度和疼痛维度评分分别为4.3±0.6分和4.3±0.4分，明显高于长节段组患者（3.8±0.7分和3.8±0.6分）（P＜0.05），余各维度评分的差异无统计学意义（P>0.05）。结论：对于后凸角度范围在50°~80°的胸腰段CK，三柱截骨联合后路长节段或短节段固定均可有效矫正矢状面畸形，短节段固定可提升患者术后的生活质量。

英文摘要:

  【Abstract】 Objectives: To compare the clinical outcomes of long and short segment fixation following three-column osteotomies for congenital kyphosis(CK) in thoracolumbar spine. Methods: From January 2014 to December 2018, a consecutive cohort of 26 patients with kyphotic Cobb angle ranging from 50° to 80° who were treated with three-column osteotomies and pedicle screw fixation were retrospectively reviewed. 13 males and 13 females with a mean age of 11.5±4.5 years(range, 3-18 years) were included. According to the distal fusion level, the patients were divided into 2 groups. Long segment fixation group(n=12), included patients whose lowest instrumented vertebra(LIV) was 3 levels below osteotomy level; Short segment fixation group(n=14), included patients whose LIV was 2 levels below osteotomy level. There were no significant differences between the two groups in terms of age, sex, osteotomy technique, or osteotomy level(P>0.05). The patients were followed up for 37.1±10.3 months(24-81 months). On standing whole-spine X-rays preoperatively, 1 week postoperatively and at final follow-up, global kyphosis(GK), lumbar lordosis(LL), sagittal vertical axis(SVA), pelvic incidence(PI), pelvic tilt(PT), and sacral slope(SS) were measured. Intraoperative and postoperative complications were recorded. The Scoliosis Research Society-22 questionnaire(SRS-22) score was recorded at pre-operation and final follow-up to evaluate the clinical outcomes. Results: All surgeries were successfully completed. There were no significant differences in GK, LL, and SVA between the two groups preoperatively, postoperatively, and at the final follow-up(P>0.05). All three parameters showed significant improvement after surgery(P<0.05), and remained stable at the final follow-up(P>0.05). There were no significant differences in PI, PT, and SS between the two groups at any time point(P>0.05), and these parameters remained stable postoperatively(P>0.05). Intraoperative neurophysiological monitoring showed that one patient in each group had abnormal evoked potentials during osteotomy, while no neurological defect was observed during follow-up. There were no implant-related complications during follow-up. No significant difference was observed between groups in SRS-22 scores preoperatively(P>0.05). At the final follow-up, the function score(4.3±0.6) and pain score(4.3±0.4) of SRS-22 in short segment fixation group were significantly higher than those in long segment fixation group(3.8±0.7 and 3.8±0.6)(P<0.05). There was no significant difference in the rest of the domain(P>0.05). Conclusions: For CK patients with a cobb angle of 50°-80°, both long and short segment fixation after three-column osteotomies can effectively achieve satisfying curve correction, while short segment fixation could improve patients′ quality of life.