单纯前路与前后联合入路矫形手术治疗重度颈椎后凸畸形

Single anterior via combined anterior-posterior correction for severe cervical spine kyphosis

中文关键词:  颈椎后凸畸形  重度  矫形手术  前入路  前后联合入路  疗效

英文关键词:Cervical kyphosis  Severe  Corrective surgery  Anterior approach  Combined anterior-posterior approach  Outcome

中文摘要:

  【摘要】 目的：探讨单纯前路与前后联合入路矫形手术治疗重度颈椎后凸畸形的适应证及疗效。方法：我院2005年7月~2008年12月收治重度颈椎后凸畸形（Cobb角>40°）患者12例，男8例，女4例，年龄13~69岁，平均28.75岁。引起颈椎后凸的病因为：先天性发育畸形4例，神经纤维瘤病3例，退变性后凸2例，创伤性畸形2例，因颈脊膜瘤行后路C2～C5椎板切除术后颈椎后凸1例。术前JOA评分7~16分，平均11.6分；后凸Cobb角41°~113°，平均69.7°。均行颈椎矫形手术，其中8例（Cobb角41°～86°，平均58.9°，后凸节段无明显后方骨性融合，JOA评分平均11.9分）行前路手术；4例（3例Cobb角>90°，1例前后方均有明显的骨性融合，Cobb角48°～113°，平均91.3°，JOA评分平均11.0分）行前后路联合手术，一期完成1例，二期完成3例。记录患者手术时间、术中出血量，观察术后Cobb角及随访时的JOA评分、Cobb角变化。结果：8例单纯前路手术患者的平均手术时间为196min，平均术中失血量为520ml；术后2例患者出现肢体肌力下降，其中1例因术后5d内固定松动行手术重置内固定，再手术后肌力恢复到术前，另1例患者经甲强龙冲击治疗后肌力恢复到术前；术后Cobb角平均24.1°，畸形矫正率为59.1%；随访8~60个月，平均27.3个月，末次随访时Cobb角平均为36.9°，矫形丢失率为36.8%；末次随访时JOA评分为11~17分，平均15.1分，改善率为62.7%。4例前后联合入路患者的平均手术时间为420min，平均术中失血量为1088ml；1例患者术后出现肢体肌力下降，经甲强龙冲击治疗后肱二头肌、三角肌肌力仍较术前减弱，其余肌力恢复至术前；术后Cobb角平均32°，畸形矫正率为65.0%；随访6~45个月，平均24.8个月，末次随访时Cobb角平均为45.5°，矫形丢失率为22.8%；末次随访时JOA评分为9~16分，平均13.5分，改善率为41.7%。结论：重度颈椎后凸畸形患者Cobb角40°～90°且无明显后方骨性融合时采用单纯前路矫形手术治疗，Cobb角>90°或前后方结构均有明显的骨性融合时行前后路联合矫形手术治疗，近期疗效均较好。

英文摘要:

  【Abstract】 Objectives： To evaluate the indications and surgical outcome of single anterior and combined anterior-posterior correction for severe cervical spine kyphosis. Methods: Twelve patients(8 males and 4 females ) with severe cervical spine kyphosis(Cobb angle >40°) treated surgically in our hospital from July 2005 to December 2008 were analyzed retrospectively. The average age was 28.75 years(range: 13-69 years). According to the etiology, 4 patients had congenital deformity, 3 had neurofibromatosis, 2 had degenerative kyphosis, 2 had posttraumatic deformity and 1 had C2-C5 post-laminectomy cervical kyphosis due to meningioma. The average preoperative JOA score was 11.6(range: 7-16). The average preoperative Cobb angle was 69.7°(range: 41°-113°). All the patients underwent corrective surgery: single anterior approach for 8 patients（the preoperative Cobb angle was 58.9°, range: 41°-86°; average JOA score was 11.9 without posterior bony union in the kyphotic segment） and combined anterior-posterior for 4 patients(3 cases with Cobb angle >90°,1 case with circumferential bony union, the preoperative Cobb angle was 91.3°, range: 48°-113°, average JOA score was 11.0). Of the 4 cases undergoing combined surgery, 1 had one-stage and 3 had two-stage surgery. The operation time, blood loss, post-operative Cobb angle, JOA score and Cobb angle at follow-up were collected and compared. Results: For single anterior approach group, the average operation time was 196min and blood loss was 520ml. Two cases suffered from limb weakness after operation; one of them experienced revision surgery due to instrument failure 5 days after operation, while the other one experienced methylprednisolone(MP) intervention. Both of them had symptom relieved completely. The average post-operative Cobb angle was 24.1° with the correction ratio of 59.1%, and the average Cobb angle at final follow-up(27.3 months in average, range: 8-60 months) was 36.9°, with the loss of correction of 36.8%. The JOA score at final follow-up was 15.1(range: 11-17), with the improving ratio of 62.7%. While for the combined anterior-posterior surgery group, the average operation time was 420min and blood loss was 1088ml. One case suffered from limb weakness after operation, who experienced MP intervention and had symptom relieved completely except the weakness in deltoids and biceps. The average post-operative Cobb angle was 32° with the correction ratio of 65.0%. The average Cobb angle at final follow-up(24.8 months in average, range: 6-45 months) was 45.5° with the loss of correction of 22.8%. The JOA score at final follow-up was 13.5(range: 9-16), with the improving ratio of 41.7%. Conclusions: For severe cervical spine kyphosis, single anterior correction is indicated for cases with Cobb angle of 40°-90° and without posterior bony union; while for cases with Cobb angle >90° or having circumferential bony union, combined anterior-posterior correction is indicated. The short-term outcome of both strategies was fairly.