后路凸侧椎板楔形截骨经肋椎关节松解胸椎间隙治疗青少年重度脊柱侧后凸

Posterior convex lamina wedge osteotomy and thoracic intervertebral disc space release through costovertebral joints for severe and rigid kyphoscoliosis in adolescents

中文关键词:  重度脊柱侧后凸  青少年  凸侧椎板楔形截骨  肋椎关节  胸椎间隙松解

英文关键词:Severe kyphoscoliosis  Adolescent  Convex lamina wedge osteotomy  Costovertebral joints  Thoracic intervertebral space release

中文摘要:

  【摘要】 目的：评价经后路凸侧椎板楔形截骨经肋椎关节松解胸椎间隙矫形治疗青少年重度脊柱侧后凸畸形的安全性和早期临床效果。方法：2014年5月~2016年12月对我院15例青少年重度脊柱侧后凸患者行经后路凸侧椎板楔形截骨经肋椎关节松解胸椎间隙手术治疗，术前仅1例严重脊柱侧后凸患者行头盆环牵引。男6例，女9例，年龄13～18岁（16.1±1.6岁）。其中先天性脊柱侧后凸3例，特发性11例，神经纤维瘤病性1例。术前侧凸Cobb角82°～144°（102.5°±17.6°），侧凸的柔韧性为6.4％～28.5％[（21.56±5.70）%]；后凸50°～95°（68.1°±15.3°），冠状位躯干偏移距离（C7中垂线与骶骨中垂线距离）2.0～6.8cm（3.40±1.37cm）。术前四肢肌力及感觉均正常。观察治疗效果。结果：椎板楔形截骨5.20±0.56个（4~6个），松解椎间隙5.20±0.56个（4~6个），手术时间6.1～7.9h（7.00±0.51h），术中出血量1050～2500ml（1450.0±521.3ml）。术后侧凸Cobb角18°～40°（28.0°±6.6°），矫正率72.5%；后凸22°～42°（27.8°±6.1°），矫正率58.4%；冠状位躯干偏移距离0～2cm（0.85±0.74cm），矫正率72.8%。随访25～41个月（33.1±5.4个月）。末次随访时侧凸Cobb角19°～43°（30.0°±6.9°），矫正率70.6%；后凸22°～42°（28.6°±6.5°），矫正率57.2%；冠状位躯干偏移距离0.2～2.3cm（1.10±0.72cm），矫正率71.3%。无胸膜破裂，无假关节形成，无内固定断裂及松动，矫正度无显著丢失。1例患者术前骨盆牵引发生钉道感染，经局部换药及抗生素应用，2周后感染控制；1例术后第3天发生十二指肠系膜上动脉综合征，采取禁食水、持续胃肠减压、维持水电解质平衡、左侧卧位，术后2周痊愈；1例T4左侧椎弓根螺钉侵入椎管压迫神经，术后5h发生左下肢不完全性瘫痪，术后8h去除T4左侧椎弓根螺钉，术后5个月左下肢功能完全恢复。结论：采用后路凸侧椎板楔形截骨经肋椎关节松解胸椎间隙治疗青少年重度脊柱侧后凸畸形，不需要剥离椎体侧方胸膜，手术解剖层次表浅和创伤小，不仅有助于增加脊柱柔韧性，而且可提供足够的压缩和闭合空间来矫正脊柱侧后凸，能获得良好的脊柱三维矫正。

英文摘要:

  【Abstract】 Objectives: To evaluate the early clinical efficacy and safety of posterior convex lamina wedge osteotomy and thoracic intervertebral disc space release through costovertebral joints for severe and rigid kyphoscoliosis in adolescents. Methods: From May 2014 to December 2016, 15 patients with severe rigid kyphoscoliosis were treated with posterior convex lamina wedge osteotomy and thoracic intervertebral space release through costovertebral joints at our hospital, and only one of them underwent halo-pelvic traction before operation. There were 6 males and 9 females, aged 13 to 18 years, with a mean age of 16.1±1.6 years. Among them, 3 patients were of congenital vertebral deformity, 11 were of neglected idiopathic scoliosis, and 1 was of type I neurofibromatosis. The mean preoperative scoliosis Cobb angle was 102.5°±17.6°(ranged 82° to 144°). The mean flexibility was (21.56±5.70)%(range, 6.4% to 28.5%). And the mean preoperative sagittal kyphosis angle was 68.1°±15.3°(ranged 50° to 95°). The coronal balance(distance between coronal C7 centroid plumb line and the central sacral vertical line) was 2.0 to 6.8cm, with a mean distance of 3.40±1.37cm. The muscle strength and sensation of extremities of all the patients were normal before operation. Results: The average number of wedge osteotomy of convex vertebral lamina was 5.20±0.56 and the release space was 5.20±0.56． The operative time ranged from 6.1 to 7.9 hours, which was averaged 7.00±0.51 hours. Intraoperative blood loss was 1050ml to 2500ml, with a mean of 1450.0±521.3ml. The mean postoperative scoliosis Cobb angle was 28.0°±6.6°(range, 18° to 40°), and the correction rate was 72.5%. The mean postoperative sagittal kyphosis angle was 27.8°±6.1°(ranged 22° to 42°), and the correction rate was 58.4%. The mean coronal balance was 0.85±0.74cm(range, 0 to 2cm), and the correction rate was 72.8%. The mean follow up period was 33.1±5.4 months(range, 25 to 41 months). At the most recent follow-up, the scoliosis Cobb angle was 30.0°±6.9°(range, 19° to 43°), and the correction rate was 70.6%. The sagittal kyphosis angle was 28.6°±6.5°(range, 22° to 42°), and the correction rate was 57.2%. The mean coronal balance was 1.10±0.72cm (range, 0.2 to 2.3cm), and the correction rate was 71.3%. No pleural rupture was recognized during surgery. There were no definite pseudarthrosis, no breakage or loosening of internal fixation. Besides, no definite loss of correction was observed at the final follow up. One patient had pelvic traction nail tract infection before operation. After 2 weeks, the infection was controlled after local wound dressing change and antibiotic application. One patient experienced superior mesenteric artery syndrome at the third day postoperatively, which was resolved after 2 weeks by nutrilization via nasogastrie tube, electrolytic balance and appropriate position． One case developed incomplete paralysis of the left lower limb 5 hours after operation and gradually aggravated. CT examination showed that the left pedicle screw of T4 invaded the spinal canal and compressed the spinal cord. The operation was repeated 8 hours after operation, which removed the left pedicle screw of T4, and the function of the left lower limb recovered completely 5 months after operation. Conclusions: Posterior convex lamina wedge osteotomy and thoracic intervertebral disc space release through the costovertebral joints for treating severe and rigid kyphoscoliosis in adolescents does not require that the parietal pleura be detached off the lateral side of the vertebra. There is less deep dissection and trauma is less. The operation not only serves to increase the flexibility of the spine, but also provides enough space for compression and closure to correct the kyphoscoliosis. It can obtain excellent three-dimensional correction of spine.