术前Halo重力牵引对Ⅰ型神经纤维瘤病伴严重脊柱侧后凸畸形截骨等级的影响

The influence of preoperative Halo-gravity traction on the selection of osteotomy grades in the treatment of severe kyphoscoliosis secondary to neurofibromatosis type Ⅰ

中文关键词:  Ⅰ型神经纤维瘤病  脊柱侧后凸畸形  Halo重力牵引  截骨

英文关键词:Neurofibromatosis  Scoliosis  Kyphosis  Halo-gravity traction  Osteotomy

中文摘要:

  【摘要】 目的：探讨术前Halo重力牵引（Halo-gravity traction，HGT）对Ⅰ型神经纤维瘤病（neurofibromatosis type Ⅰ，NF1）伴严重脊柱侧后凸患者截骨等级的影响。方法：回顾性分析2011年1月~2018年12月在我院治疗的19例NF1合并严重脊柱侧后凸畸形患者的临床及影像学资料，其中男11例，女8例，年龄15.8±7.1岁（6~41岁）。根据术前是否行HGT分为两组：A组术前先行HGT治疗，再行后路矫形手术（13例）；B组术前未行HGT治疗，直接行后路截骨矫形手术（6例）。记录并比较两组患者术中截骨方案、手术情况及并发症发生情况。在牵引前（术前）、牵引后及术后的X线片上分别测量冠状面侧凸Cobb角、冠状面侧凸角度比值（coronal deformity angular ratio，c-DAR）、最大后凸Cobb角（global kyphosis，GK）及矢状面后凸角度比值（sagittal deformity angular ratio，s-DAR）并进行比较。结果：两组患者一般资料、肺功能相关指标及牵引前（术前）各影像学参数差异无统计学意义（P>0.05）。A组患者最大牵引重量为13.0±2.1kg（9~16kg），牵引时间9.9±3.8周（6.5~19周）；牵引前冠状面主弯Cobb角和最大后凸Cobb角分别为109.9°±23.2°和84.2°±16.2°，牵引治疗后分别为81.4°±21.0°和68.0°±15.2°，牵引后侧、后凸矫正率分别为（26.3±9.1）%和（18.9±11.7）%；冠状面侧凸角度比值与矢状面后凸角度比值分别由牵引前的17.5±4.1和13.0±3.6减小至12.8±3.5和10.9±2.7，差异均有统计学意义（P＜0.05）；A组8例患者最终未行三柱截骨（8/13，61.5%），仅行Ponte截骨，B组6例患者均行三柱截骨；术后主弯Cobb角为60.8°±19.8°，矢状面后凸Cobb角矫正至46.2°±16.1°，术后侧、后凸畸形矫正率分别为（45.2±10.9）%和（45.5±15.7）%。B组患者术前冠状面Cobb角、最大后凸Cobb角分别为101.7°±14.5°和75.5°±9.9°，术后分别改善至60.8°±19.8°和39.0°±5.0°，术后侧、后凸畸形矫正率分别为（49.9±10.8）%和（47.9±7.2）%。两组患者畸形矫正率比较无统计学差异（P>0.05）。与B组相比，A组患者手术时间明显缩短、术中出血量明显减少，差异有统计学意义（P<0.05）。A组有1例患者在牵引3周时出现右侧臂丛神经麻痹，减轻牵引重量后逐渐恢复。两组中各有1例患者在术中截骨过程中出现神经电生理监护异常，术后均无明显神经损害表现。结论：对于NF1伴严重脊柱侧后凸患者，术前HGT是一种安全可靠的术前干预策略，不仅能够在一定程度上改善患者术前侧后凸畸形，还能够降低术中截骨等级，缩短手术时间、减少术中出血量。

英文摘要:

  【Abstract】 Objectives: To evaluate the effects of preoperative Halo-gravity (HGT) traction on the osteotomy grades selection plan in the treatment of severe kyphoscoliosis secondary to neurofibromatosis type Ⅰ(NF1). Methods: From January 2011 to December 2018, a consecutive cohort of 19 NF1 patients with severe kyphoscoliosis who underwent surgery in our institute were retrospectively reviewed, including 11 males and 8 females with an average age of 15.8±7.1(6-41) years old. According to the treatment methods, patients were divided into 2 groups: 13 patients in group A were treated with preoperative HGT followed by posterior surgery; 6 patients in group B underwent one-stage posterior surgery with spinal osteotomies. The osteotomy grades, operation data and perioperative complications were recorded. Radiographic parameters including the Cobb angle of coronal curve, coronal deformity angular ratio(c-DAR), global kyphosis(GK) and sagittal deformity angular ratio (s-DAR) were measured and compared before traction, after traction and immediately after surgery. Results: No significant difference was observed between the two groups in terms of the demographic data, pulmonary function and the preoperative radiographic parameters. For patients in group A, the average maximum traction weight of HGT was 13.0±2.1kg(9-16kg) and the traction duration was 9.9±3.8(6.5-19) weeks. Before traction, the coronal Cobb angle and sagittal Cobb angle was 109.9°±23.2° and 84.2°±16.2° respectively, and they decreased to 81.4°±21.0° and 68.0°±15.2° after traction. The coronal and sagittal correction rates of deformity were (26.3±9.1)% and (18.9±11.7)% respectively. The c-DAR and s-DAR was significantly decreased from 17.5±4.1 and 13.0±3.6 to 12.8±3.5 and 10.9±2.7, respectively. 8 patients(8/13, 61.5%) in group A needed not undergo three-column osteotomies after traction treatment, only Ponte osteotomies were performed, while all the 6 patients in group B underwent three-column osteotomies. After surgery, the coronal Cobb angle further improved to 60.8°±19.8° and GK decreased to 46.2°±16.1°, with a correction rates of (45.2±10.9)% and (45.5±15.7)% respectively. For patients in group B, the coronal Cobb angle and sagittal Cobb angle was 101.7°±14.5° and 75.5°±9.9° respectively, and they decreased to 60.8°±19.8° and 39.0°±5.0° after surgery. The coronal and sagittal correction rates of deformity were (49.9±10.8)% and (47.9±7.2)% respectively. There was no significant difference with respect to the deformity correction rates between both groups(P>0.05). The operation time was significantly shorter and the intraoperative blood loss was significantly less in group A than in group B(P<0.05). 1 patient in group A had transient brachial plexus palsy which resolved completely after reducing the traction weight. Each group had 1 patient occurring abnormal intraoperative monitoring during the osteotomies period. No neurological defects were observed postoperatively. Conclusions: For NF1 patients with severe kyphoscoliosis, preoperative Halo-gravity traction is an effective and safe strategy, which can improve spinal deformity to some extent. In addition, it could increase the safety of surgery through reducing the osteotomy grades, shortening the operation time, and reducing blood loss.