脊柱截骨术治疗合并脊髓纵裂伴脊髓拴系综合征的先天性脊柱侧凸

Spinal osteotomy for longitudinal split spinal cord malformation associated with tethered cord syndrome of congenital scoliosis

中文关键词:  脊柱侧凸  脊髓纵裂  脊髓拴系综合征  截骨术

英文关键词:Scoliosis  Split spinal cord malformation  Tethered cord syndrome  Osteotomy

中文摘要:

  【摘要】 目的：探讨脊柱截骨术治疗合并脊髓纵裂伴脊髓拴系综合征的先天性脊柱侧凸的安全性和有效性。方法：回顾性分析2007年6月~2013年6月在我院采用脊柱截骨手术治疗的23例合并脊髓纵裂伴脊髓拴系综合征的先天性脊柱侧凸患者。其中男6例，女17例；手术时年龄16.9±3.4岁（10~23岁）。腰骶部疼痛8例，其中5例仅表现为腰骶部疼痛，神经功能损害18例。术前冠状位Cobb角95.4°±25.2°（65°~156°）。Ⅰ型脊髓纵裂9例，Ⅱ型脊髓纵裂14例。脊髓圆锥位置均在L3水平以下。对合并Ⅰ型脊髓纵裂伴脊髓拴系的患者，采用骨性纵隔切除、一期脊柱截骨矫形；合并Ⅱ型脊髓纵裂伴脊髓拴系的患者单纯行一期脊柱截骨矫形（未处理纤维纵隔）。其中行全脊椎截骨13例，经椎弓根截骨10例。术前、术后3个月和末次随访时分别测量患者侧凸Cobb角，并按脊柱裂神经功能评分（SBNS）分级评估神经功能恢复情况。结果：手术时间571.1±136．5min（310~835min）；术中失血量4888.3±2482.3ml（500~9600ml）。随访38.9±18.3个月（24~79个月）。术后冠状面Cobb角33.7°±15.9°（3°~73°），较术前明显改善（P＜0.05），矫正率平均为（62.3±14.1）％；末次随访时冠状面Cobb角37.4°±17.2°（5°~82°），矫正率平均为（58.1±14.7）％，较术后平均丢失4.2°±2.3°，与术后比较无明显矫形丢失（P＞0.05），但与术前相比有明显改善（P＜0.05）。末次随访时，18例患者神经损害症状获得不同程度改善，其中13例术前SBNS神经功能分级为Ⅱ级者术后恢复至Ⅰ级；2例Ⅲ级恢复至Ⅱ级；另外3例神经损害评分提高，SBNS分级维持不变，脊柱侧凸畸形及局部疼痛明显好转。围手术期出现并发症5例，其中2例术后出现单侧下肢肌力下降，1例术后2周下肢肌力恢复至4级，另1例于术后3个月恢复至术前水平，术后2年随访肌力基本恢复正常；术中发现胸膜破裂1例，术后脑脊液漏1例、泌尿系感染1例。所有病例术后无伤口感染、假关节形成、内固定松动/断裂及永久性神经损害并发症。结论：脊柱截骨术治疗合并脊髓纵裂伴脊髓拴系综合征的先天性脊柱侧凸患者安全有效，且对神经功能恢复有促进作用。

英文摘要:

  【Abstract】 Objectives: To study the safety of spinal osteotomy for congenital scoliosis associated with longitudinal split spinal cord malformation(SSCM) and tethered cord syndrome(TCS). Methods: From June 2007 to June 2013, a total of 23 patients underwent spinal osteotomies for longitudinal SSCM associated with TCS in our hospital. 6 of them were male, and 17 cases were female with an average age of 16.9 years(range, 10 to 23 years). 8 patients presented with lumbosacral pain, including 5 patients with only lumbosacral pain. 18 patients had neurological deficit. There were 9 patients with type Ⅰ SSCM and 14 patients with type Ⅱ SSCM. During surgery, bony spurs were resected in patients with type Ⅰ SSCM, while nothing was done for type Ⅱ SSCM; pedicle subtraction osteotomy(PSO) was performed in 10 patients and vertebral column resection(VCR) in 13; posterior fusion surgery was performed following the correction. The local of conus medullaris of all patients were below L3. Preoperative average coronal Cobb angle was 94.5°±25.4°(65°-156°). All coronal Cobb angle and SBNS grade were measured before operation, after operation and at final follow-up. Results: All patients were followed up for a minimum of 24 months after initial surgical treatment with an average follow-up of 38.9±18.3 months(range, 24-79 months). The average operation time was 571.1±136．5min(range, 310-835min), and the average intraoperative blood loss was 4888.3±2482.3ml(range, 500-9600ml). Postoperative coronal Cobb angle ranged from 3° to 73°(average, 33.7°±15.9°). Compared with preoperative Cobb angle, postoperative Cobb angle showed significant decrease(P<0.05). The immediate postoperative correction rate was (62.3±14.1)%. At the final follow-up, the coronal Cobb angle ranged from 5° to 82°(average, 37.4°±17.2°), with a correction loss 4.2°±2.3°. The final correction rate was （58.1±14.7）％, Compared with preoperation, these indexes showed significant differences(P<0.05). The neurological function was improved in 18 cases. 13 patients improved from preoperative SBNS grade Ⅱ to grade Ⅰ. 2 patients from preoperative SBNS grade Ⅲ to grade Ⅱ. Although neurological function scores of the other 3 cases improved, SBNS grading remained unchanged. The coronal deformity and the local back pain relieved very well. The overall perioperative complications were noted in 5 cases. Postoperative unilateral lower limb neurological deterioration was noted in 2 cases, which recovered at 2 weeks and 3 months respectively. Cerebrospinal fluid leakage was noted in 1 case, pleural rupture in 1 case and urinary infection in 1 case. No infection surgical site, nonunion, pseudarthrosis, implant failure and permanent neurological deterioration were noted in all cases. Conclusions: The spinal osteotomy for SSCM associated with TCS is safe , effective and of well recovery of neurological function.