后路经椎弓根截骨矫形术治疗合并食管裂孔疝的强直性脊柱炎胸腰椎后凸畸形的疗效评估

Evaluation of pedicle subtraction osteotomy in the treatment of ankylosing spondylitis patients with thoracolumbar kyphosis and hiatus hernia

中文关键词:  强直性脊柱炎  胸腰椎后凸畸形  食管裂孔疝  经椎弓根截骨矫形术  麻醉评估

英文关键词:Ankylosing spondylitis  Thoracolumbar kyphosis  Hiatus hernia  Pedicle subtrction osteotomy  Anesthesia evaluation

中文摘要:

  【摘要】 目的：分析合并食管裂孔疝（hiatus hernia）的强直性脊柱炎（ankylosing spondylitis，AS）胸腰椎后凸畸形患者的临床特点和影像学表现，评估后路经椎弓根截骨矫形术（pedicle subtraction osteotomy，PSO）对此类患者的疗效。方法：回顾性分析2014年1月~2020年7月于我院行PSO治疗的301例AS胸腰椎后凸畸形患者的资料，其中5例合并食管裂孔疝，男2例，女3例，年龄54.6±7.2岁（48~67岁），2例患者存在术前吞咽困难，术前通过肺功能检查评估患者呼吸功能，发现4例患者存在轻度呼吸功能受限，1例患者合并重度呼吸功能不全伴肺动脉高压。PSO术中未对患者食管裂孔疝进行特殊处理。术前、术后及末次随访时在患者全脊柱X线片上测量全脊柱最大后凸角（global kyphosis，GK）和矢状位平衡（sagittal vertical axis，SVA），术前和术后在矢状位CT上测量食管裂孔疝入物高度、在横断面CT上测量食管裂孔疝面积，记录术后并发症情况。应用配对秩和检验比较术前术后影像学参数。结果：5例患者随访3~24个月（12.6±7.5个月）。术前GK为103.2°±19.9°，术后改善至48.2°±15.0°，末次随访时45.0°±11.9°；术前SVA为213.4±90.6mm，术后改善至68.2±36.0mm，末次随访为63.0±50.3mm，术后GK、SVA与术前比较有均显著性差异（P>0.05），而末次随访时GK、SVA与术后比较无显著性差异（P<0.05）。术前疝入物高度为9.1±1.7cm，面积为73.0±39.3cm2，术后分别降至6.4±0.9cm和42.4±19.5cm2，术后疝入物高度和面积与术前比较均有显著性差异（P<0.05）。所有患者均未发生神经并发症及浅表或深部感染，且无断钉、断棒等内固定并发症。结论：对于合并食管裂孔疝的AS胸腰椎后凸畸形患者，在PSO术后脊柱畸形得以矫正的同时，食管裂孔疝也能获得一定程度改善。

英文摘要:

  【Abstract】 Objectives: To explore the clinical characteristics and imaging features of ankylosing spondylitis(AS) patients with thoracolumbar kyphosis and hiatus hernia, and to evaluate the outcomes of pedicle subtraction osteotomy(PSO) in such patients. Methods: The medical records of 301 AS patients with thoracolumbar kyphosis underwent PSO between January 2014 and July 2020 were reviewed. Among them, 5 were found with hiatus hernia(2 males and 3 females), averaged 54.6±7.2 years (48-67 years), and 2 of them were reported with dysphagia. And the preoperative pulmonary function examination was performed reporting 4 patients with mild respiratory function limitation and 1 with severe respiratory insufficiency and pulmonary hypertension. Hiatus hernia tissue was not treated specially during PSO. Global kyphosis(GK) and sagittal vertical axis(SVA) were measured in X-ray preoperatively, postoperatively and at the last follow-up, while the height and size of hiatus hernia were measured in CT scan before and after surgery. Complications were recorded after surgery. Rank-sum test was used to compare the preoperative and postoperative radiographic parameters. Results: All the 5 patients had a follow-up of 12.6±7.5 months(3-24 months). GK was corrected from 103.2°±19.9° to 48.2°±15.0°, and it was 45.0°±11.9° at the last follow-up. SVA was corrected from to 213.4±90.6mm to 68.2±36.0mm, and it was 63.0±50.3mm at the last follow-up. Significant differences were found in pre- and postoperative GK and SVA(P<0.05), while there was no statistical significance between those postoperatively and at the last follow-up(P>0.05). The height and size of hiatus hernia before operation were 9.1±1.7cm and 73.0±39.3cm2, and they decreased to 6.4±0.9cm and 42.4±19.5cm2 respectively after surgery. Significant difference swere found in preoperative and postoperative height and size of hiatus hernia(P<0.05). No neurological complications, superficial or deep infection, or implant related complications including screw breakage and rod fracture were found after surgery. Conclusions: Hiatal hernia can be ameliorated at the same time as the spinal deformity is corrected in AS patients with hiatus hernia after PSO.