后路半椎体切除短节段融合固定术治疗儿童腰骶段半椎体畸形及近端代偿侧凸自发矫正的影响因素

Correlation factors analysis for spontaneous correction of proximal compensated curve after posterior lumbosacral hemivertebra resection and short-segment fusion in children

中文关键词:  先天性脊柱侧凸  腰骶椎半椎体  代偿弯  半椎体切除术  自发矫正

英文关键词:Congenital scoliosis  Lumbosacral hemivertebra  Compensated curve  Hemivertebra resection  Spontaneous correction

中文摘要:

  【摘要】 目的：评价后路半椎体切除、短节段融合固定术治疗儿童先天性腰骶部半椎体畸形的效果，探讨术后近端代偿侧凸（PCC）自发矫正的影响因素。方法：回顾性分析2012年1月~2018年12月我院诊治的25例腰骶部半椎体患儿的临床资料，其中男14例，女11例，年龄3.3～13.0岁（6.74±2.81岁），L4~S1半椎体10例，L5~S1半椎体13例，L6~S1半椎体2例。均行腰骶部一期后路半椎体切除、短节段固定融合术，随访至少24个月。术前、术后及末次随访时所有患儿均行站立位全脊柱正侧位X线检查。测量并对比术前、术后及末次随访时畸形部位侧凸Cobb角、PCC、骶骨冠状面倾斜（SSA）、近端固定椎倾斜度（PVO）、畸形部位前凸、胸椎后凸、腰椎前凸、躯干冠状面偏移（TS）、矢状面平衡（STS）及骨盆入射角（PI）、骨盆倾斜角（PT）、矢状位骨盆倾斜角（SS）。分析末次随访PCC及PCC矫正率与年龄、畸形部位侧凸、畸形侧凸矫正率、术前PCC、末次随访PVO、末次随访SSA等因素的相关性。依据末次随访PVO将患者分为近端固定椎倾斜组（≥5°）与近端固定椎水平组（＜5°），比较两组间各脊柱参数的差异。结果：融合固定2～4个椎体（2.58±0.77个椎体），手术时间120～300min（167.60±42.45min），术中出血量100～1000ml（362.00±215.50ml）。术后2例患者出现一过性下肢疼痛，术后两周恢复正常。术后随访24～70个月（37.72±14.90个月）。畸形部位侧凸Cobb角由术前的28.8°±5.8°降至术后的5.8°±3.5°（P<0.01），末次随访为7.8°±3.2°（矫正率72.9%，P<0.01）。PCC由术前的25.8°±10.9°自发性矫正为末次随访时的13.1°±8.0°（P<0.01），矫正率为49.2%。TS从术前的13.5±11.7mm降至末次随访5.5±4.5mm（P<0.01），STS从术前的16.1±9.6mm降至末次随访的7.0±5.0mm（P<0.01）。所有病例术前、末次随访骨盆矢状面均保持平衡，末次随访PI、PT、SS、胸椎后凸及腰椎前凸较术前均无明显改变。末次随访PCC与术前PCC和末次随访PVO存在相关性（P<0.01，P<0.05），末次随访PCC矫正率与末次随访PVO 存在相关性（P<0.01)。近端固定椎水平组14例，倾斜组11例，两组间年龄、术前畸形侧凸、融合节段、术前PCC及术前SSA均无统计学差异，末次随访PCC有显著性差异（9.8° vs 17.4°，P<0.05）。结论：一期后路半椎体切除、短节段融合固定术治疗儿童腰骶部半椎体畸形可以获得良好的侧凸矫正并改善躯干偏移。为更好地达到近端代偿侧凸自发矫正，应在术前评估已有的近端代偿侧凸角度，术中应尽可能实现近端固定椎水平化。

英文摘要:

  【Abstract】 Objectives: To evaluate the surgical outcomes and correlation factors for spontaneous correction of proximal compensated curve (PCC) after posterior lumbosacral hemivertebra resection with short-segment fusion in children. Methods: The clinical data of 25 congenital scoliosis children with lumbosacral hemivertebra treated from Jan 2012 to Dec 2018 were reviewed retrospectively. There were 14 boys and 11 girls with an average age of 6.74±2.81 (3.3-13.00) years. The hemivertebra conditions included: 10 cases located at L4-S1 level, 13 cases located at L5-S1, and 2 cases located at L6-S1. All the patients underwent one-stage posterior-only hemivertebra resection with short-segment internal fixation and fusion, with at least a 24-month follow-up. Standing anteroposterior and lateral radiographs of full spine pre-operatively, post-operatively, and at the last follow-up were acquired and compared. Radiographic evaluation included measured changes in deformity segmental scoliosis and lordosis, sacral slanting angle(SSA), proximal fused vertebral obliquity(PVO), thoracic kyphosis, lumbar lordosis, trunk shift(TS), sagittal trunk shift(STS) and pelvic incidence(PI), pelvic tilt (PT), and sacral slope(SS). The correlations between the PCC at the final follow-up and multiple factors including age, deformity segmental scoliosis, congenital segmental scoliosis correction rate, PCC at pre-operation, and SSA and PVO at the latest follow-up were analyzed. Based on the PVO (≥5° or <5°), patients were divided into oblique group and horizontal group. The spinal parameters were compared between groups. Results: The mean follow-up period was 37.72±14.90(24-70) months. The mean fusion level was 2.58±0.77(2-4) segments. The mean operation time was 167.60±42.45(120-300) minutes with the average blood loss of 362.00±215.50ml(100-1000ml). 2 cases had a lower limb transient pain after operation which alleviated within two weeks. The mean segmental scoliosis was 28.8°±5.8° preoperatively, 5.8°±3.5° postoperatively (correction rate 79.7%, P<0.01), and 7.8°±3.2° at the latest follow-up(correction rate 72.9%, P<0.01). The PCC was spontaneously corrected from 25.8°±10.9° preoperatively to 13.1°±8.0° at the latest follow-up(correction rate 49.2%, P<0.01). TS was significantly improved on both coronal (13.5±11.7mm vs 5.5±4.5mm, P<0.01) and STS(16.1±9.6mm vs 7.0±5.0mm, P<0.01) planes at the latest follow-up. There was no difference of the values of PI, PT, and SS between that preoperatively and at the last follow-up, respectivley. PCC at the latest follow-up was correlated with preoperative PCC and PVO(P<0.01, P<0.05). There was no difference between the oblique group(14 cases) and the horizontal group(11 cases) in terms of age, congenital segmental scoliosis, PCC, sacral slanting, preoperatively and fused segments. But the horizontal group had a better PCC spontaneous correction over the oblique group(9.8° vs 17.4°, P<0.05). Conclusions: One-stage posterior lumbosacral hemivertebra resection with short-segment fusion in children can offer excellent scoliosis correction and trunk shift improvement. Take preoperative PCC as a predict factor and horizontalize the proximal fused vertebral during-operation could be helpful for PCC spontaneous correction.