术前牵引一期后路截骨矫形术治疗重度脊柱侧凸伴脊髓空洞的疗效分析

Efficacy analysis of preoperative traction combined with posterior approach one-stage osteotomy correction in treating severe scoliosis accompanied with syringomyelia

中文关键词:  脊柱侧凸  脊髓空洞症  牵引  外科矫形

英文关键词:Scoliosis  Syringomyelia  Traction  Surgical correction

中文摘要:

  【摘要】 目的：分析重度脊柱侧凸（severe scoliosis，SS）伴脊髓空洞（syringomyelia，SM）患者术前牵引和手术截骨矫形的效果，探讨术前牵引一期后路截骨矫形手术治疗SS伴SM（SS-SM）患者的安全性和有效性。方法：回顾2007年1月~2023年10月我院行术前牵引一期后路截骨矫形手术的40例SS-SM病例，男19例，女21例，年龄11~41岁（18.28±6.66岁）。所有患者既往无神经外科手术治疗史，术前均行全脊柱X线片、CT及MRI检查，测量冠状面主弯角度、矢状面后凸角度、SM的大小[最大脊髓空洞/脊髓比值（maximal syrinx/cord ratio，S/C）]和长度，观察是否合并Chiari畸形，计算畸形角度比（deformity angular ratio，DAR），牵引过程中及术后均适时复查全脊柱X线片，评估患者脊柱畸形矫正情况。根据SM是否合并Chiari Ⅰ型畸形（Chiari Ⅰ malformation，CMⅠ）分为合并CMI SM组（CMⅠ-related SM，CS组）与特发性SM组（idiopathic SM，IS组）；根据SM的大小分为大空洞组（big syrinx，S/C>0.6，BS组）与小空洞组（little syrinx，S/C≤0.6，LS组），统计分析不同组患者术前牵引与手术对矫形的贡献率并进行比较（CS组vs IS组、BS组vs LS组）。结果：40例患者SM的S/C为0.59±0.18，长度为9.43±5.50个节段。36例术前行颅-股骨牵引（skull-femoral traction，SFT），4例行颅重力牵引（halo-gravity traction，HGT），牵引过程中5例出现暂时性局部麻木，2例出现暂时性局部肌力减退，5例发生牵引钉道感染。29例（72.5%）行低级别截骨，11例（27.5%）行高级别截骨脊柱短缩融合术，脊柱融合节段数平均为13.48±1.34节段。术后躯干局部麻木2例，肺部感染4例，浅部术口感染3例，均未发生运动功能障碍。术前冠状面主弯角度、矢状面后凸角度、术前总畸形角度比（total DAR，T-DAR）分别为104.80°±18.58°、66.57°±31.21°、25.73°±8.30°/节段，牵引后分别为65.55°±19.00°、44.95°±23.32°、16.73°±7.24°/节段，矫形术后侧凸和后凸角分别为37.78°±14.91°、29.95°±14.14°，主弯柔韧性为（20.79±11.02）%。术后冠状面侧凸和矢状面后凸的总矫形率分别为（64.44±9.44）%和（51.74±18.40）%，牵引和手术对冠状面侧凸、矢状面后凸矫形的平均贡献率分别为（59.90±17.67）%和（40.10±17.67）%、（59.21±27.51）%和（40.79±27.51）%。CS组与IS组、BS组与LS组组间侧凸及后凸总矫形率、牵引与手术对侧凸及后凸矫形的贡献率之间无显著性差异，术前牵引均改善34%以上的DAR，实现50%以上的矫形贡献率。CS组男性比例较高，IS组中女性比例较高（P=0.027）；两组患者年龄、术前主弯Cobb角和柔韧性、脊柱后凸角、DAR值、 S/C和SM长度、牵引改善效果和术后总矫形率、融合节段、截骨等级、手术失血和手术时间、牵引与手术对脊柱矫形的贡献均无统计学差异（P>0.05）。BS组平均S/C比值明显高于LS组（0.74 vs 0.45，P<0.001），融合节段数少于LS组（13.00 vs 13.90，P=0.031），高级别截骨比例高于LS组（8/19 vs 3/21，P=0.049）；两组患者年龄、术前主弯Cobb 角及柔韧性、脊柱后凸角、DAR值、SM长度、牵引改善效果和术后总矫形率、手术失血和手术时间、牵引与手术对脊柱矫形的贡献率均无统计学差异（P>0.05）。结论：术前牵引可在一定程度上改善脊柱畸形，减小术中矫形难度及神经损伤风险；对于SS-SM患者，无论其否合并CMⅠ、SM大小如何，术前牵引均能为冠状面侧凸矫形及矢状面后凸矫形贡献一半以上的畸形矫正率；术前牵引一期后路截骨矫形手术治疗未行预防性神经外科干预的SS-SM是一种安全有效的治疗策略。

英文摘要:

  【Abstract】 Objectives: To analyze the effects of preoperative traction and surgical osteotomy correction in patients with severe scoliosis(SS) accompanied by syringomyelia(SM), and explore the safety and efficacy of one-stage posterior osteotomy surgery following preoperative traction in treating patients with SS accompanied with SM(SS-SM). Methods: A retrospective study was conducted on 40 cases of SS-SM patients who underwent one-stage posterior osteotomy surgery following preoperative traction in our department from January 2007 to October 2023. There were 19 males and 21 females, aged 11 to 41 years(18.28±6.66 years). All the patients had no history of neurosurgical operational treatment and underwent full-spine X-rays, CT, and MRI examinations before surgery to measure the major curve angle on coronal plane, kyphosis angle on sagittal plane, length of SM, to evaluate whether combined with Chiari malformation, and to calculate the size of SM(maximal syrinx/cord ratio, S/C) and deformity angular ratio(DAR). During traction and after operation, full-spine X-rays were re-examined in a timely manner to assess the correction conditions of deformity. According to whether SM was accompanied with Chiari Ⅰ malformation(CMⅠ), the patients were divided into the CMⅠ-related SM group(CS group) and the idiopathic SM group(IS group); According to the size of SM, the patients were also divided into the big syrinx group(BS group, S/C>0.6) and the little syrinx group(LS group, S/C≤0.6). The contribution rates of preoperative traction and surgery to correction were statistically analyzed and compared between different groups(CS group vs IS group, BS group vs LS group). Results: The S/C ratio of SM in 40 patients was 0.59±0.18, with a length of 9.43±5.50 segments. Preoperative skull-femoral traction(SFT) was performed in 36 cases, and halo-gravity traction(HGT) in 4 cases. During traction, 5 cases experienced temporary local numbness, 2 cases had temporary local muscle weakness, and 5 cases developed traction nail tract infections. Low-grade osteotomy was performed in 29 cases(72.5%), and high-grade osteotomy with spinal shortening and fusion was performed in 11 cases(27.5%), with an average of 13.48±1.34 fusion segments. Postoperative complications included local trunk numbness in 2 cases, pulmonary infection in 4 cases, and superficial wound infection in 3 cases, with no motor dysfunction observed. The coronal main curve angle, sagittal kyphosis angle, and total DAR(T-DAR) before operation were 104.80°±18.58°, 66.57°±31.21° and 25.73°±8.30°/segment, respectively, which were 65.55°±19.00°, 44.95°±23.32° and 16.73°±7.24°/segment, respectively after traction. After correction operation, the scoliosis and kyphosis angles were 37.78°±14.91° and 29.95°±14.14°, respectively, with a main curve flexibility of (20.79±11.02)%. The total correction rates for coronal scoliosis and sagittal kyphosis were (64.44±9.44)% and (51.74±18.40)%, respectively. The average contribution rates of traction and surgery to the correction of coronal scoliosis and sagittal kyphosis were (59.90±17.67)% and (40.10±17.67)%, and (59.21±27.51)% and (40.79±27.51)%, respectively. There were no significant differences in the total correction rates of scoliosis and kyphosis, or the contribution rates of traction and surgery to the correction of scoliosis and kyphosis between the CS and IS groups, and between the BS and LS groups. Preoperative traction improved the DAR by more than 34% and achieved a correction contribution rate of over 50%. The proportion of males was higher in the CS group, while the proportion of females was higher in the IS group(P=0.027). There were no statistical differences between the CS and IS groups in terms of age, preoperative main curve Cobb angle and flexibility, spinal kyphosis angle, DAR value, S/C ratio and SM length, traction improvement effect, total postoperative correction rate, number of fusion segments, osteotomy grade, blood loss, operational duration, or the contribution rates of traction and surgery to spinal correction(P>0.05). The average S/C ratio in the BS group was significantly higher than that in the LS group(0.74 vs 0.45, P<0.001), the number of fusion segments was lower in the BS group than in the LS group(13.00 vs 13.90, P=0.031), and the proportion of high-grade osteotomy was higher in the BS group than in the LS group(8/19 vs 3/21, P=0.049). There were no statistical differences between the BS and LS groups in terms of age, preoperative main curve Cobb angle and flexibility, spinal kyphosis angle, DAR value, SM length, traction improvement effect, total postoperative correction rate, blood loss, operational duration, or the contribution rates of traction and surgery to spinal correction(P>0.05). Conclusions: Preoperative traction can improve spinal deformity to a certain extent, reducing the difficulty of intraoperative correction and risks of neurological injury. For SS-SM patients, regardless of whether they are accompanied with CMⅠ or the size of SM, preoperative traction can contribute more than half of the deformity correction rate for coronal scoliosis and sagittal kyphosis. One-stage posterior osteotomy correction surgery following preoperative traction is a safe and effective treatment strategy for SS-SM patients who have not undergone preventive neurosurgical intervention.