术中导航校准技术辅助下青少年特发性脊柱侧凸顶椎区置钉精确性研究

【摘要】 目的：比较青少年特发性脊柱侧凸（adolescent idiopathic scoliosis,AIS）顶椎区相同椎弓根类型在导航及导航校准技术辅助下置钉的精确性及偏出方向,并分析影响导航置钉偏移的相关因素及导航校准技术的临床意义。方法：回顾性分析自2017年10月～2020年10月,在我院明确诊断为AIS并在导航辅助下行经后路脊柱侧凸矫形内固定术治疗的41例患者,依据术中是否使用导航校准技术,将41例患者分为两组：导航组（n=22）和校准组（n=19）。收集两组患者基本信息,记录两组患者Risser征,术前、术后Cobb角,术后1年时矫形率,根据付长峰椎弓根分型系统对两组患者顶椎区椎弓根分型（A、B、C、D、E型）,依据Rao分型评估两组相同椎弓根类型的置钉精确性。结果：校准组A、B、C型椎弓根优良置钉率（96.4%、87.8%、84.0%）显著高于导航组（79.2%、70.5%、56.7%）,且凹凸双侧0级钉率显著高于导航组,同时校准组B型椎弓根及其凹凸双侧3级钉率（4.1%、2.0%、6.3%）及C型椎弓根凸侧2级钉置钉率（11.1%）显著低于导航组（12.4%、11.1%、13.7%、50.0%）,两组间差异均具有统计学意义（P＜0.05）。此外,校准组A、B、C型椎弓根外侧皮质破壁率（33.3%、33.3%、60.0%）显著低于导航组（64.0%、38.6%、73.1%）,同时校准组A型椎弓根椎体前壁穿破率（0.0%）及C型椎弓根凹侧外侧皮质破壁率（66.7%）显著低于导航组（24.0%、77.8%）,而B型椎弓根内侧皮质穿破率（41.7%）高于导航组（40.9%）,但其凹侧内侧皮质穿破率（36.4%）显著低于导航组（33.3%）,两组间差异均具有统计学意义（P＜0.05）。两组间均未发生脊髓、神经血管损伤等严重并发症。结论：与传统导航相比,导航校准技术在术中能够有效地预防导航偏移,显著提高AIS顶椎区A、B、C型椎弓根置钉精确性,降低误置螺钉外侧壁穿孔率及B型椎弓根凹侧内侧壁穿孔率,提高手术的安全性。     

应用三维矫形系统矫治脊柱侧凸

DⅡRODUCⅡ0NScol-08i8 i8 a complex three dimensional deformity induding lateralbentinfrontal dimension,increase or decreasein anterior or p08te.fiorphy~eal curvature and rotation deformi~inaxialdimension.The~adifionaltze.atment,indudingHazlJngton哩Btemwhichmainly cor-蛐det'ormi~in frontal dimomi~a.iB easy to c肌8e plane-back小,f砌ty and easy蛔10聃correction.We have eorroeted 52 C.a~fl ofseo~osis bythree dimensional apparatus andthrough~nowing-upfor1—4 years,W6 have obaerved excellent eff…     

A randomised controlled trial of fibrinogen concentrate during scoliosis surgery

Bleeding and blood transfusion are common after scoliosis surgery. Fibrinogen is essential for blood clot formation and depletes quickly during haemorrhage. We randomly allocated 102 children 12–18 years old having surgery for idiopathic scoliosis, 51 to intra-operative fibrinogen concentrate 30 mg.kg⁻¹ (maximum 2 g) and 51 to saline placebo. Fibrinogen reduced peri-operative blood loss by a median (95%CI) volume of 155 (5–320) ml, from a median (IQR [range]) of 1035 (818–1420 [400–3030]) ml to 885 (755–1155 [270–2645]) ml, p = 0.04. Seven and four children received allogeneic red blood cell transfusion after fibrinogen and placebo, respectively, p = 0.34. There were no side-effects.     

Scoliosis in childhood

Scoliosis is the most frequently encountered spinal deformity of childhood. It is a three-dimensional deformity with lateral curvature in the coronal plane and associated rotation. Scoliosis is classified according to its a etiopathogenesis; it can be idiopathic (80%), congenital, neuromuscular or syndromic. Treatment depends on the etiology, age and maturity at presentation and magnitude of the deformity. The mainstay of treatment for significant scoliosis is surgery by way of spinal instrumentation, correction and bone grafting to achieve a selective fusion of the spine. Surgical aims vary depending on aetiology; late onset idiopathic -improve cosmesis, neuromuscular optimize function and early onset optimize lung development and growth.     

基于X线片的十二等分法评估全椎弓根螺钉固定矫形术治疗青少年特发性脊柱侧凸的置钉准确性

目的 :利用基于X线片的十二等分法评估单纯后路全椎弓根螺钉固定矫形术治疗青少年特发性脊柱侧凸(adolescent idiopathic scoliosis,AIS)的置钉准确性。方法:回顾性分析我科行单纯后路全椎弓根螺钉固定矫形术治疗的AIS患者40例(女性34例,男性6例),年龄15.2±1.9岁(11～18岁),分别采用传统方法和十二等分法在X线片上评估椎弓根螺钉置钉准确性,并通过CT平扫验证。传统方法:A级,螺钉钉尖在椎弓根内壁和椎体中线之间,且与相邻螺钉相比无明显偏内或偏外;B级,螺钉钉尖超越椎体中线或与相邻螺钉相比明显偏内;C级,螺钉钉尖在椎弓根内壁以外或与相邻螺钉相比明显偏外。十二等分法:将椎体由凹侧外侧缘及凸侧外侧缘向分别正中线画等分线分12等份,并根据螺钉钉尖在所在椎体上的位置和椎体旋转的程度确定相应的安全范围。A级,螺钉钉尖在安全范围内;B级,螺钉钉尖超出安全范围内界或与相邻螺钉相比明显偏内;C级,螺钉钉尖超出安全范围外界或与相邻螺钉相比明显偏外。CT平扫:A级,螺钉全部在椎弓根内;B级,螺钉有任何部分超出椎弓根内壁;C级,螺钉有任何部分超出椎弓根外壁。通过卡方检验和诊断试验结果法对比两种X线片评估方法的准确性。结果:CT平扫评估,638枚螺钉中595枚(93.3%)A级,9枚(1.4%)B级,34枚(5.3%)C级;十二等分法,589枚(92.3%)A级,10枚(1.6%)B级,39枚(6.1%)C级;传统方法 ,582枚(91.2%)A级,19枚(3.0%)B级,37枚(5.8%)C级。使用传统方法误判螺钉49枚(7.7%)枚,十二等分法误判螺钉14枚(2.2%)枚,二者有显著差异(P0.001),其中B级误判的螺钉分别为25枚(3.9%)和5枚(0.8%)(P0.001),C级误判的螺钉分别为24枚(3.8%)和9枚(1.4%)(P=0.006)。此外,使用传统方法和十二等分法,评估凹侧椎弓根置钉的误判率高于凸侧,评估旋转较大椎体置钉的误判率高于旋转较小的椎体。结论:在X线片上采用十二等分法评估AIS患者的置钉情况简便、可靠,可以提高评估螺钉置钉的准确性。     

成人退行性脊柱侧凸患者椎旁肌肉退变与顶椎旋转的关系

目的 :分析成人退行性脊柱侧凸(adult degenerative scoliosis,ADS)患者多裂肌、竖脊肌和腰大肌的退变与顶椎旋转的关系。方法:收集2017年1月～2019年7月在我院门诊就诊的ADS患者的临床资料,在顶椎层面MRI影像上测量并计算患者多裂肌、竖脊肌和腰大肌的横截面积(cross-sectional area,CSA)、脂肪化比例(fat saturation fraction,FSF)、凹侧与凸侧横截面积之比(rCSA)、凹侧与凸侧脂肪化比例之比(rFSF)和顶椎旋转度(apical vertebra rotation,AVR)。采用配对样本t检验分析顶椎层面凹凸两侧多裂肌、竖脊肌和腰大肌CSA和FSF的差异,Pearson相关分析分析肌肉影像学参数与AVR之间的相关性。结果:共纳入96例ADS患者,男18例,女78例;年龄64.64±7.18岁;腰椎前凸角20.19°±17.61°;Cobb角24.70°±10.41°;AVR 10.94°±6.47°,旋转方向均偏向侧凸凸侧。在顶椎层面,多裂肌、竖脊肌、腰大肌凹侧CSA均显著性大于凸侧(P0.05),多裂肌凹侧FSF显著性大于凸侧(P0.01),竖脊肌凸侧FSF显著性大于凹侧(P0.05),腰大肌两侧FSF差异无统计学意义(P0.05)。AVR与多裂肌凸侧CSA、腰大肌凸侧FSF呈显著性负相关(r=-0.225、-0.292,P0.05),与多裂肌rCSA、竖脊肌r FSF呈显著性正相关(r=0.396、0.215,P0.05)。结论:ADS患者脊柱侧凸顶椎两侧多裂肌、竖脊肌和腰大肌的退变与AVR显著相关,多裂肌、竖脊肌的退变可能参与顶椎的旋转。     

Posterior hemivertebra resection and monosegmental fusion in the treatment of congenital scoliosis

INTRODUCTION

Posterior hemivertebra resection combined with multisegmental or bisegmental fusion has been applied successfully for congenital scoliosis. However, there are several immature bones and their growth can be influenced by long segmental fusion in congenital patients. Posterior hemivertebra resection and monosegmental fusion was therefore suggested for treatment of congenital scoliosis caused by hemivertebra.

METHODS

Between June 2001 and June 2010, 60 congenital scoliosis patients (aged 2–18 years) who underwent posterior hemivertebra resection and monosegmental fusion were enrolled in our study. A standing anteroposterior x-ray of the whole spine was obtained preoperatively, postoperatively and at the last follow-up appointment to analyse the Cobb angle in the coronal and sagittal planes as well as the trunk shift.

RESULTS

The mean preoperative coronal plane Cobb angle was 41.6º. This was corrected to 5.1º postoperatively and 5.3º at the last follow-up visit (correction 87.3%). The compensatory cranial curve was improved from 18.1º preoperatively to 7.1º postoperatively and 6.5º at the last follow-up visit while the compensatory caudal curve was improved from 21.5º to 6.1º after surgery and 5.6º at the last follow-up visit. The mean sagittal plane Cobb angle was 23.3º before surgery, 7.3º after surgery and 6.8º at the last follow-up visit (correction 70.1%). The trunk shift of 18.5mm was improved to 15.2mm.

CONCLUSIONS

Posterior hemivertebra resection and monosegmental fusion seems to be an effective approach for treatment of congenital scoliosis caused by hemivertebra, allowing for excellent correction in both the frontal and sagittal planes.