全脊柱截骨联合前方钛网支撑治疗重度先天性脊柱畸形

目的：探讨全脊柱截骨矫形联合前方钛网支撑治疗重度先天性脊柱畸形的治疗效果。方法：2008年4月至2012年4月采用经顶椎全脊柱截骨矫形内固定、前方钛网植骨支撑治疗21例重度先天性脊柱畸形患者，男8例，女13例；年龄10～35岁，平均19．4岁；胸椎6例，胸腰段13例，腰椎2例；合并Chairs畸形2例，脊髓纵裂6例，脊髓空洞4例，神经纤维瘤病1例。术前Frankel分级：C级3例，D级5例，E级13例。记录术中出血量、手术时间及围手术期并发症，对术前、术后2d及末次随访时冠状面和矢状面Cobb角、顶椎偏移距离、矢状面偏移距离、双肩相对高度、剃刀背畸形高度等影像学数据进行测量，并对术后矫正率进行评估。结果：21例患者手术时间3．5-6．5h，平均5．2h；术中出血量1400—4900ml，平均2500ml。术后2d患者主弯冠状面Cobb角、矢状面Cobb角、顶椎偏距、矢状面偏移距离、剃刀背高度及双肩高度差与术前比较均有统计学意义（P〈0．05），与末次随访比较均无统计学意义（P〉0．05）。术后冠状面矫正率为（62．24±5．82）％，矢状面矫正率为（60．97±6．30）％。术后第1天2例Frankel分级由E级加重为D级，保守治疗2周后恢复；1例术后苏醒后查体Frankel分级由D级加重为C级，及时行翻修调整手术后恢复；左眼永久性失明1例，术中脑脊液漏2例，胸膜损伤1例。21例均获随访，时间9~31个月，平均18．6个月。末次随访时FrankelD级4例，E级17例，所有患者获得骨性愈合，无矫正角度丢失及内固定松动。结论：全脊柱截骨术联合应用前方钛网支撑治疗重度先天性脊柱畸形，可有效矫正和恢复冠状面及矢状面平衡，避免了脊柱短缩所造成的脊髓折皱，但仍应重视术中体位及神经系统损伤的并发症。

Total vertebral column resection combined with anterior mesh cage support for the treatment of severe congenital kyphoscoliosis

Objective: To explore the clinical effects of total vertebral column resection combined with anterior mesh cage support in treating severe congenital kyphoscoliosis. Methods: From April 2008 to April 2012,21 patients with severe congenital kyphoscoliosis were treated with total vertebral column resection and internal fixation through posterior approach combined with anterior mesh cage support. There were 8 males and 13 females with an average age of 19.4 years old (ranged from 10 to 35). And 6 cases were thoracic segments deformity,13 cases were thoracolumbar segments and 2 cases were lumbar segments,of them,2 cases were accompanied with Chairs deformity,6 cases with diastematomyelia,4 cases with syringomyelia,and 1 case with neurofibromatosis. According to the Frankel grade system,3 cases were grade C,5 cases grade D and 13 cases grade E. Blood loss,operative time,and perioperative complications were recorded. Coronal and sagittal Cobb angle,apical vertebral offset distance,sagittal offset,the relative height of shoulders,razor back deformities were measured and analyzed before and after operation. Results: The average operative time was 5.2 h (3.5 to 6.5 h) and blood loss was 2 500 ml (1 400 to 4 900 ml). The 2nd day after operation,apical vertebral offset distance,sagittal offset,the relative height of shoulders,razor back deformities had obviously improved than preoperative(P<0.05). There was no significant difference in above items between postoperative on the 2nd day and final follow-up(P>0.05). The corrective rate of kyphosis and scoliosis were (60.97±6.30)% and (62.24±5.82)%,respectively. On the first day after surgery,2 cases of Frankel grade E aggravated to grade D,and obtained recovery at 2 week after conservative treatment. And 1 case palinesthesia later,grade D aggravated to grade C and obtained recovery after revision surgery in time. One case complicated with permanent blindness of left eye,1 case occurred injury of pleura and 2 cases had cerebrospinal fluid leak during operation. All patients were followed up from 9 to 31 months with an average of 18.6 months. At final follow-up,all patients obtained bone union,Frankel grade D in 4 cases and grade E in 17 cases,no correction loss and internal fixation loosening was found. Conclusion: Total vertebral column resection combined with anterior mesh cage support can effectively correct kyphosis and scoliosis in severe congenital kyphoscoliosis and can avoid injury of spine cord by spinal crispation,but intraoperative position and neurologic complications should still be considered.