不对称经椎弓根截骨矫治成人先天性脊柱侧后凸畸形

Asymmetrical pedicle subtraction osteotomy for the treatment of adult congenital kyphoscoliosis

中文关键词:  先天性脊柱侧凸  先天性脊柱后凸  截骨术  成人

英文关键词:Congenital scoliosis  Congenital kyphosis  Osteotomy  Adult

中文摘要:

  【摘要】 目的：分析应用不对称经椎弓根截骨技术矫治成人先天性脊柱侧后凸畸形的临床疗效。方法：2009年9月~2013年10月采用不对称经椎弓根截骨矫治成人先天性脊柱侧后凸畸形患者16例，男9例，女7例。年龄18～42岁，平均23.6岁。均有腰背痛，无神经受压症状。16例患者脊柱侧凸Cobb角43°~97°，后凸Cobb角15°~70°。侧凸畸形和后凸畸形顶椎均位于同一节段，其中顶椎位于胸椎10例、腰椎6例。于术前、术后及末次随访时在X线片上测量脊柱冠状面主弯Cobb角、矢状面后凸角、冠状面平衡及矢状面平衡，比较术前、术后及末次随访时影像学参数评估手术矫形效果。于术前、末次随访时填写SRS-22问卷量表，评估患者术后的生活质量变化。结果：手术融合节段5~12个，平均7.23个节段。手术时间3~7h，平均4.26h。术中出血量700～2500ml，平均1265ml。1例L1部位截骨患者术后出现双下肢痛觉过敏，急诊手术探查发现截骨部位硬脊膜皱褶，脊髓受压，对截骨部位椎板切开减压，术后症状明显好转，术后3个月随访神经症状消失。2例患者术后出现一侧胸腔积血，紧急行胸腔闭式引流术，1周后拔除引流管。15例患者获得6～48个月（平均13.4个月）随访。获得随访的15例患者冠状位主弯Cobb角术前为58.67°±20.36°（43°～97°），术后为20.32°±8.76°（8°～37°），末次随访时为21.76°±8.34°（10°～41°），术后与术前比较差异有统计学意义（P<0.01），矫正率为50.76%~82.36%，平均为65.36%，末次随访时与术后比较丢失率为2.45%。术前矢状位后凸角度为45.62°±16.26°（15°～70°），术后为16.35°±16.87°（-20°～40°），末次随访时为18.27°±13.92°（-15°～40°），术后与术前比较差异有统计学意义（P<0.01），矫正率为50.97%~79.32%，平均为64.16%，末次随访时与术后比较丢失率为4.2%。15例患者中，6例术前存在冠状面失平衡，术后均恢复平衡；4例术前存在矢状面失平衡，术后3例恢复平衡，1例仍为失平衡。SRS-22问卷量表总得分由术前66.47±12.35分（49～79分）提高至末次随访时的84.13±6.42分（76～92分）（P<0.01）。15例患者均获得骨性融合，无假关节形成或内固定断裂。结论：应用不对称经椎弓根截骨技术矫治先天性脊柱侧后凸畸形，可获得较好的矫形效果，显著改善患者躯体外观及躯体平衡，同时明显改善患者的生活质量。

英文摘要:

  【Abstract】 Objectives: To evaluate the outcome of asymmetrical pedicle subtraction osteotomy(APSO) for the treatment of adult congenital kyphoscoliosis. Methods: From September 2009 to October 2013, 16 patients with adult congenital kyphoscoliosis underwent APSO. There were 9 males and 7 females. The average age was 23.6 years(range, 18-42 yrs). All patients presented with back pain but no neurologic deficit. The preoperative average Cobb angle of the major curve of 16 patients was 43°-97°, and the preoperative average Cobb angle of kyphosis was 15°-70°. The apex of major curve in coronal plane and the apex of kyphosis were the same in all patients. The apex of the curve located at the thoracic spine in 10 patients and lumbar spine in 6 patients. The scoliosis, kyphosis, coronal balance and sagittal balance were measured in the X-ray films preoperatively, postoperatively and at the final follow-up to evaluate the effects of APSO. All patients filled out the SRS-22 questionnaire before surgery and during follow-up to evaluate the life quality changes after APSO. Results: The average fused vertebra was 7.23(range, 5-12), the average operation time was 4.26 hours(range, 3-7 hours), the average blood loss in the operation was 1265ml(range, 700-2500ml). 1 patient with L1 osteotomy presented with leg pain after the operation. The spinal cord compression was found at the osteotomy site during the emergency operation. Decompression and laminectomy was performed at the osteotomy site. Neurologic symptom was relieved after the operation and disappeared 3 months after operation. 2 patients suffered from hemothoraxs after the operation. Closed thoracic drainage was performed and removed 1 week later. 15 patients were followed up, the average followed-up time was 13.4 months. The major curve averaged 58.67°±20.36°(43°-97°) preoperatively, 20.32°±8.76°(8°-37°) postoperatively and 21.76°±8.34°(10°-41°) at the final follow-up. The curve improved significantly after the operation(P<0.01). The correction rate was 50.76%-82.36%, averaged 65.36%. The loss of correction was 2.45% at the final follow-up. The kyphosis averaged 45.62°±16.26°(15°-70°) preoperatively, 16.35°±16.87°[(-20°)-40°] postoperatively, and 18.27°±13.92°[(-15°)-40°] at the final follow-up. The curve improved significantly after the operation(P<0.01). The correction rate was 50.97%-79.32%, averaged 64.16%. The loss of correction was 4.2% at the latest follow-up. 6 patients had preoperative coronal imbalance, and all of them restored coronal balance after the operation. 4 patients had sagittal imbalance, 3 patients restored sagittal balance and 1 patient still had sagittal imbalance after the operation. The SRS-22 score increased from 66.47±12.35(49-79) preoperatively to 84.13±6.42(76-92) during the follow-up(P<0.01). Complications included 1 neural injury and 2 hemothoraxs. All the patients got fusion at the final follow-up. There was no pseudarthrosis and instrument breakage. Conclusions: APSO can improve the coronal and sagittal spinal deformity for adult congenital kyphoscoliosis, as well as the body appearance and the body balance, which can improve the life quality of the patients.