青少年先天性分节不全型脊柱侧凸治疗探讨

背景:先天性脊柱侧凸分为形成障碍型、分节不全型及混合型三型。目前国内外对先天性脊柱侧凸的治疗研究主要集中于形成障碍型脊柱侧凸,而对于分节不全型脊柱侧凸的治疗研究较少。目的:评价经后路凹侧肋椎关节松解联合单极或双极楔形截骨治疗青少年先天性分节不全型脊柱侧凸畸形的安全性和初步临床效果。方法:2004年11月至2009年12月经后路凹侧肋椎关节松解联合单极或双极楔形截骨治疗青少年先天性分节不全型脊柱侧凸患者24例(单极截骨10例,双极楔形截骨14例),男女各12例,年龄13～22岁,平均16.7岁;侧凸Cobb角50°～139°,平均84.1°;侧凸柔韧性5.1%～30.0%,平均17.0%;C7中垂线与骶骨中垂线距离0.8～6.3cm,平均2.54cm;1处分节不全18例,2处分节不全3例,3处分节不全3例。结果:手术时间5.3～11.2h,平均7.9h;术中出血1500～4500ml,平均2980ml。无1例因截骨间隙加压闭合而致脊髓剪切损伤。1例术中发生胸膜破裂,术后行胸腔闭式引流术,2周后痊愈。1例因T5椎弓根螺钉侵入椎管压迫脊髓出现左下肢不全瘫,术后4h拔出该螺钉,3个月后左下肢不全瘫完全恢复。术后侧凸Cobb角6°～51°,平均26.8°;术后C7中垂线与骶骨中垂线距离0.3～2.5cm,平均0.76cm。平均随访32.2个月,末次随访患者侧凸Cobb角9°～53°,平均28.6°,平均矫正率66.7%,矫正率平均丢失2.1%;冠状面C7中垂线与骶骨中垂线垂直距离0.3～2.6cm,平均0.81cm,平均矫正率63.3%,矫正率平均丢失2.4%。所有患者均达骨性愈合,内固定无松动、断裂,矫形无明显丢失,术后未发生失代偿现象。结论:经后路凹侧肋椎关节松解联合单极或双极楔形截骨技术治疗中、重度青少年分节不全型脊柱侧凸能较好改善脊柱柔韧性,增加截骨面加压闭合的安全性。

Treatment of congenital scoliosis with failure of segmentation in adolescent

Background： Congenital scoliosis is classified into three types： failure of formation, failure of segmentation and mixed defects. The researches on treatment of congenital scoliosis have been mainly focused on the failure of formation at present and very few on the failure of segmentation. Objective： To evaluate early clinical outcomes and safety of concave costovertebral joint release （CCJR） with single-end wedge osteotomy （SEWO） or both-ends wedge osteotomy （BEWO） via posterior approach for congenital scoliosis with failure of segmentation. Methods： From November 2004 to December 2009, 24 patients due to congenital scoliosis with failure of segmentation underwent a CCJR with SEWO （10 cases） or BEWO （14 cases） via posterior approach. There were 12 males and 12 females with an average age of 16.7 years （range, 13-22 years）. The mean Cobb angle was 84.1°（range, 50°-139°） . The mean spinal flexibility of scoliosis was 17.0% （range, 5.1%-30.0%）. The mean coronal imbalance was 2.54 cm （range, 0.8-6.3 cm）. Eighteen patients had an unsegmented bar at one site, 3 at two sites and 3 at three sites. Results： The operation time was 7.9 h （range, 5.3-11.2 h） and blood loss was 2980 ml （range, 1500-4500 ml）. There was no case of neurological defict as the osteotomy gap was closed by compression. One patient had hemopneumothoraxes intraoperatively and was treated with chest cavity closed type drainage with complete recovery after 2 weeks. Another one had incomplete left lower limb paralysis due to the pedicle screw, which invaded the T5 spinal canals and compressed the spine cord. The screw was removed 4 h postoperatively and the fimction of the left limb recovered completely 3 months later. At immediate assessment after surgery, the mean Cobb angle was 26.8°（range, 6°-51°）. The coronal imbalance improved to 0.76 cm （range, 0.3-2.5 cm）. The mean follow-up period was 32.2 months. At the final follow up, the mean Cobb angle was 28.6° （range, 9°-53°） with scoliosis correction of 66.7% and the correction loss rate of 2.1% on average. The coronal imbalance was 0.81 cm （range, 0.3-2.6 cm） and the correction loss rate was 2.4% on average. Bony fusion was achieved in all patients, and no instrument complication as well as no significant correction loss was documented. Conclusions： CCJR with SEWO or BEWO via posterior approach can improve the spinal flexibility and safety as the osteotomy gap is closed by compression. It is a reliable and effective method to achieve a good capability of correction for congenital scoliosis with failure of segmentation.