后路松解楔形截骨矫治先天性胸腰段半椎体并重度僵硬性脊柱侧后凸畸形

Posterior release and spinal wedge osteotomy for congenital thoracolumbar hemivertebra with severe rigid kyphoscoliosis deformity

中文关键词:  脊柱畸形  半椎体  重度脊柱侧后凸  后路松解  楔形截骨  融合节段选择

英文关键词:Spinal deformity  Hemivertebra  Severe kyphoscoliosis  Posterior release  Spinal wedge osteotomy  Fusion level selection

中文摘要:

  【摘要】 目的：评价经后路松解楔形截骨矫治先天性胸腰段半椎体并重度僵硬性脊柱侧后凸畸形的安全性和临床初步效果，并探讨其融合固定节段的选择。方法：2007年4月～2010年3月收治先天性胸腰段半椎体并重度僵硬性脊柱侧后凸畸形患者11例，男4例，女7例，年龄14～22岁，平均17.1岁；半椎体均为单个完全分节型，T11 3例，T12 4例，L1 1例，L2 3例；术前侧凸Cobb角82°～125°，平均94.4°，侧凸柔韧性为17.4%～28.9%，平均24.8%；后凸Cobb角72°～145°，平均101.1°；C7铅垂线与骶正中线距离1.5～5.5cm，平均2.9cm。均行经后路松解楔形截骨矫形手术，以触及椎（touched vertebrae，TV）（指站立前后位像上被骶正中线触及的最近端椎体）作为融合固定下端椎；1例合并脊髓拴系和脊髓纵裂者，术中一期行骨嵴切除，解除拴系。结果：均顺利完成手术。平均松解3.0个椎间隙。手术时间5.5～10.0h，平均7.7h；术中出血量1000～7000ml，平均3500ml。无脊髓神经损伤。1例术中切除肋骨小头时引起左侧胸膜撕裂，发生血气胸，行胸腔闭式引流，2周后痊愈；1例术后出现螺钉穿破背部皮肤，1枚螺钉钉尾外露，术后3个月取出该枚螺钉。术后侧凸Cobb角7°～54°，平均28.0°，平均矫正率为70.9%；后凸Cobb角20°～36°，平均27.8°，平均矫正率为71.7%；C7铅垂线与骶正中线距离0.1～2.3cm，平均0.6cm，冠状位平衡平均矫正率为78.1%。随访14～35个月，平均23.4个月，末次随访侧凸Cobb角8°～57°，平均29.7°，丢失率为7.3%；后凸Cobb角22°～38°，平均29.9°，丢失率为7.7%；C7铅垂线与骶正中线距离0.2～2.5cm，平均0.7cm；随访X线片证实植骨均融合，内固定物无松动、断裂。选择TV作为远端融合椎（lowest instrumented vertebrae，LIV）比选择稳定椎（stable vertebrae，SV）平均节省了1.09个椎体，未发现失代偿现象。结论：经后路松解楔形截骨矫治先天性胸腰段半椎体并重度僵硬性脊柱侧后凸畸形安全有效，选择TV作为LIV可以减少融合节段。

英文摘要:

  【Abstract】 Objective：To evaluate the early clinical outcome of posterior release and spinal wedge osteotomy for congenital thoracolumbar hemivertebra with severe rigid kyphoscoliosis deformity and to discuss the selection of fusion and fixation.Method：From April 2007 to March 2010，11 patients suffering from congenital thoracolumbar hemivertebra complicated with severe rigid kyphoscoliosis were reviewed retrospectively.There were 4 males and 7 females with an average age of 17.1 years（range，14-22 years）．All hemivertebrae were single fully segmented，which were sited in T11 in 3 cases，T12 in 4 cases，L1 in 1 case and L2 in 3 cases.The mean preoperative scoliosis Cobb angle was 94.4°（range，82°-125°）.The mean scoliosis flexibility was 24.8%（range，17.4%-28.9%）.The mean preoperative kyphosis Cobb angle was 101.1°（range，72°-145°）.The mean distance from C7 plumb line to middle sacral line was 2.9cm（range，1.5-5.5cm）.All cases underwent posterior release and spinal wedge osteotomy，and the touched vertebrae（TV）（defined as the most cephalad vertebrae touched by central sacrum vertical line） were regarded as the lowest instrumented vertebrae（LIV）.1 case with tethered spinal cord and diastematomyelia underwent tethered spinal cord release plus the above-mentioned procedure.Result：All the patients underwent the operation successfully.An average of 3.0 thoracic vertebra release was performed.The average surgical time was 7.7 hours（5.5-10.0 hours），and the average blood loss was 3500ml（1000-7000ml）.There was no neurological deficit.1 patient suffered from left pleura tearing during capitulum costae resection complicated with hemopneumothoraxes who was treated by chest cavity closed drainage alone and recovered completely after 2 weeks.1 patient suffered from screw perforating back skin，that was resolved by taking out the screw 3 months later.Immediately after operation，the mean scoliosis Cobb angle was 28.0°（7°-54°），with a correction rate of 70.9%；and the mean kyphosis Cobb angle was 27.8°（20°-36°），with a correction rate of 71.7%.The average distance from C7 plumb line to middle sacral line was 0.6cm（0.1-2.3cm），with coronal imbalance correction rate of 78.1%.All patients were followed up for an average of 23.4 months（14-35 months）.At final follow-up，the mean scoliosis Cobb angle was 29.7°（8°-57°），with loss of correction rate of 7.3%.The mean kyphosis deformity had Cobb angle of 29.9°（22°-38°），with kyphosis loss of correction rate of 7.7%.The average distance from C7 plumb line to middle sacral line was 0.7cm（0.2-2.5cm）.Bony fusion was achieved in all patients，and no instrument complications as well as significant loss of correction were documented.Compared with the procedure of fusion to stable vertebrae（SV），fusion to TV saved 1.09 mobile segments.Conclusion：Posterior release and wedge osteotomy is reliable and effective for congenital thoracolumbar hemivertabra with severe rigid kyphoscoliosis.Selecting TV rather than LIV can decrease fusion segments as more as possible.