后路一期全脊椎截骨在脊柱侧后凸畸形中的应用

近年来,一期后路全脊椎截骨术被应用于矫正严重的先天性脊柱侧后凸畸形,此技术具有治疗时间短,单一人路和矫正率高的优点。然而,手术内在的危险、并发症和对术者和医院软硬件等要求高限制了该技术的推广应用。现就我院近年来采用后路一期全脊椎截骨术治疗脊柱侧后凸25例,获得满意效果,报告如下。     

35例后路脊椎切除术治疗严重脊柱侧后凸畸形

目的 探讨严重脊柱侧后凸畸形行后路脊椎全切除术(vertebral column resection,VCR)的可行性和临床意义.方法 回顾性分析35例严重脊柱侧凸或后凸Cobb角大于100°的重度脊柱侧后畸形的患者资料;术前患者侧凸主弯冠状面Cobb角平均为(124.8±27.4)°,胸腰段矢状位后凸角平均为(95.8±30.2)°.结果 平均手术用时为(5.9 ±1.2)h,术中平均出血量为(1855±1200)ml,术后未出现神经系统症状加重的患者,且无伤口感染等并发症.术后平均下床时间为(11±5)d;术后侧凸主弯冠状面Cobb角平均为(45.7±6.2)°,胸腰段后凸为(38.6±10.1)°,矫正率达到79%,患者的躯干和双肩失平衡均得到了显著的改善.结论 后路全脊椎切除术可使神经充分的减压,矫正侧后凸畸形效果满意,是治疗严重脊柱侧后凸畸形安全有效的方法.     

后路360°脊椎截骨术治疗重度脊柱侧后凸

目的探讨重度脊柱侧后凸进行后路全脊椎截骨矫正术的效果并评价其安全性。方法1998年1月~2005年1月,31例重度脊柱侧后凸患者在我院接受手术治疗,其中男14例,女17例;平均年龄16.7岁(9~37岁);先天性脊柱侧后凸16例,特发性脊柱侧后凸9例,脊柱侧凸术后翻修6例。术前:侧凸平均95°(76°~159°),后凸103°(90°~153°),躯干偏移3.9 cm(2~8.1 cm)。其中5例存在不同程度下肢神经症状,24例存在中、重度限制性呼吸功能障碍。所有患者均接受后路一期经顶椎全脊椎截骨、经椎弓根固定、植骨融合术。结果所有患者安全接受手术,平均手术时间4.6 h(3.5~6.2 h),平均出血量1170 ml(920~2300 ml)。术后1周左右戴支具下地活动,5例术前神经损害者有不同程度恢复。无严重并发症(神经损伤等)发生。矫正效果:术后侧凸平均51.2°(11°~79°),矫正率63.7%;后凸平均53.3°(39°~86°),矫正率54.9%;躯干偏移1.3 cm(0~1.9 cm),矫正率72%;身高平均增长7.1 cm(6~11.5 cm)。所有患者随访1年以上(1~5.2年),其中1例术后9个月发现假关节以及固定棒断裂,经过再次手术换棒、植骨后融合。最终随访时97%患者对治疗结果表示满意。结论后路360°脊椎截骨术治疗重度脊柱侧后凸,安全性好,矫正效果良好。     

顶椎不对称截骨治疗重度脊柱侧后凸畸形

重度僵硬性脊柱侧凸是指Cobb角＞80°、凸侧bending位X线片矫正率＜30％的侧凸畸形,同时伴有明显后凸者称为侧后凸畸形[1]。重度脊柱侧后凸畸形患者往往在冠状面和矢状面均有明显失平衡,患者常有心肺功能受损、胸背部疼痛、易疲劳以及社会心理障碍,甚至还存在神经功能缺陷[2]。常规矫形手术难以取得满意的矫正效果。     

后路一期全椎体切除加重建治疗严重脊柱后凸畸形

目的探讨严重脊柱后凸畸形行后路一期全椎体切除加重建手术的可行性和临床意义。方法回顾性分析了2003年1月～2007年7月在我科接受后路一期全锥体切除加重建术治疗的12例严重脊柱后凸畸形患者的临床资料。结果平均手术用时5.0h(4.0～7.8h),术中平均出血量1800ml(800～3000ml),未出现神经系统症状加重的患者,无伤口感染等并发症。术后平均下床时间8d(6～15)d;术后后凸平均为38°,矫正率达63%。5例患者术前有神经系统症状,1例术前Frankel分级为A级,4例为D级;术后所有5例患者的Frankel分级均恢复到E级。结论后路一期全椎体切除加重建术是治疗严重脊柱后凸畸形安全有效的手术方法,可使神经充分减压,矫正后凸畸形效果满意,早期恢复负重,在避免神经付损伤方面尤为重要。     

后路脊柱截骨矫形治疗重度僵硬后凸型脊柱侧凸

目的:评价应用后路脊柱截骨矫形治疗重度僵硬后凸型脊柱侧凸的效果 .方法:回顾性分析北京大学第一医院骨科自2005年3月至2006年9月应用后路脊柱截骨矫形治疗重度脊柱僵硬后凸型侧凸11例(平均年龄11.2岁),其中神经纤维瘤病3例,先天性脊柱侧弯5例,脊髓灰质炎1例,特发性脊柱侧凸2例.11例患者的Bending像脊柱活动度均小于25%.平均随访时间1.3年(0.5～2年).结果:术中1节段后柱楔形截骨3例,2节段后柱楔形截骨2例,3节段后柱楔形截骨2例,经椎弓根截骨2例,椎体切除+后柱切除2例.术前后凸畸形平均108°(87°～135°),侧凸畸形平均97°(65°～135°),术后后凸畸形平均矫正至49°(改善率55%),侧凸平均矫正至37°(改善率66%).术后身高平均增加4.7 cm.11例矫形手术无神经系统并发症发生. 结论:应用后路脊柱截骨矫形治疗重度僵硬后凸型脊柱侧凸是一种较为有效的手术方法.     

腰椎后路楔形截骨术治疗重度脊柱侧后凸畸形的疗效分析及术后康复

目的分析腰椎后路楔形截骨术对重度脊柱侧后凸畸形的临床疗效及术后康复影响。方法选取80例重度脊柱侧后凸畸形病人作为研究对象,随机分为观察组和对照组,各40例。对照组实施经椎弓根椎体截骨治疗,观察组实施腰椎后路楔形截骨治疗及术后康复训练。观察2组术前、术后的Cobb角矫正、Oswestry功能障碍指数（ODI）、日常生活活动能力（ADL）评分、脊髓神经功能Frankle分级和并发症发生情况,以及手术时间、术中出血量、术后住院时间、平均固定节段数等临床手术指标资料。结果2组组内术前、术后Cobb角差异均有统计学意义（P < 0.01）,术后Cobb角明显低于术前（P < 0.01）;但术前和术后2组间Cobb角差异均无统计学意义（P>0.05）。2组组内术前、术后ODI和ADL评分差异均有统计学意义（P < 0.01）,2组间术后6个月、12个月的ODI和ADL评分差异均有统计学意义（P < 0.05~P < 0.01）。术前2组间Frankle分级差异无统计学意义（P>0.05）,术后12个月2组间Frankle分级差异有统计学意义（P < 0.01）。观察组术中出血量和术后住院时间均明显低于对照组（P < 0.01）,2组间手术时间和平均固定节段数差异均无统计学意义（P>0.05）。结论腰椎后路楔形截骨术创伤小,结合术后康复训练可改善病人腰椎功能和脊髓神经功能障碍,提高病人生活质量,值得临床推广应用。     

全脊椎截骨治疗陈旧性胸腰椎骨折伴侧后凸畸形

目的探讨经后路全脊椎截骨术在治疗陈旧性胸腰椎骨折伴侧后凸畸形的应用。方法2007年3月-2009年3月应用经后路全脊椎截骨方法治疗陈旧性胸腰椎骨折伴侧后凸畸形6例。结果术中平均失血2450ml（1100-2900ml）;脊柱短缩平均1.3cm（1-1.5cm）。术后随防时间4-18个月,平均9个月。术后后凸角-5-20°,平均11.7°,矫正率67%;侧凸角1-5°,平均2°,矫正率89%。神经功能FrankelE级2例未损害;D级3例改善为E级2例,1例无变化;C级1例改善为D级。植骨愈合。随访无矫正角度丢失。结论后路全脊椎截骨术是治疗陈旧性胸腰椎骨折伴侧后凸畸形的有效方法,具有单一入路创伤小、减压彻底、容易矫形等优点。     

全脊椎截骨治疗先天性僵硬型脊柱侧后凸

自1989年以来,作者用全脊椎截骨术治疗先天性僵硬型脊柱侧后凸4例,其中胸椎侧后凸1例,胸腰椎侧后凸1例,腰椎侧后凸2例。4例共有后方半椎体5椎,后方楔状椎体7椎,椎体发育不全2椎。侧凸Cobb's角平均为52.5°(10～96°),后凸平均为80.25°(65～105°)。手术采用全麻,顶椎处梯形十楔形截骨,椎弓根钉+钢丝拉拢闭合截骨面,双哈灵顿撑开棒或双鲁格氏棒内固定,进一步矫正侧后凸畸形,术后侧凸平均矫正率为60.42％(12.5％～100％),后凸平均矫正率为49.88％(7％～96.5％)。1例术后发生脊髓前动脉缺血综合征,经使用血管扩张剂和抗凝剂后肌力全恢复。本手术的优点是一次完成全脊椎截骨,且矫正率高于二期手术病例(32％)。     

后路顶点经椎弓根截骨术治疗重度僵硬性脊柱侧后凸畸形

目的 评价后路顶点经椎弓根截骨术治疗重度僵硬性脊柱侧后凸畸形的安全性和早期临床治疗效果.方法 回顾性分析12例行后路顶点经椎弓根截骨术治疗重度僵硬性脊柱侧后凸畸形患者的术前、术后及随访时的X光像,对侧凸Cobb角、后凸Cobb角、躯干平衡等进行测量和分析.复习手术记录和病历,记录围手术期并发症.结果 本组患者12例,男4例,女8例,平均年龄20.1(9～57)岁,其中成人脊柱侧凸2例,先天性脊柱侧后凸畸形10例.平均随访9.2个月.融合固定节段平均12个节段.手术时间平均5.0 h,术中出血量平均1517 ml,回输自体血平均780 ml,异体输血平均1109 ml.手术前后主弯冠状面Cobb角分别为100.9°和48.8°,平均矫正率51.8%(P=0.000).节段性后凸Cobb角分别为81.7°和42.2°,平均矫正率为49.8%(P=0.000).随访时主弯冠状面Cobb角及节段性后凸Cobb角分别为50.7°和46.0°,矫形无明显丢失(P=0.763,P=0.698).手术前、后及随访时冠状面躯干平衡分别为16.3、14.7和12.0mm,随访时仅1例发生冠状面躯干失平衡(22 mm).2例患者出现一过性的下肢单侧肢体麻木、无力,获完全恢复.所有患者均无脊髓损伤.结论 后路顶点经椎弓根截骨术是矫正重度僵硬性脊柱侧后凸畸形的安全方法 ,早期结果 令人满意.     

一期后路VCR技术治疗活动期胸腰段脊柱结核伴严重后凸畸形

目的:评估一期后路全脊椎截骨(VCR)技术治疗活动期胸腰段脊柱结核伴严重后凸畸形的疗效.方法:自1998至2006年活动期胸腰椎结核伴严重僵硬角状后凸畸形患者36例,均应用VCR技术行一期后路全脊椎截骨矫形脊髓减压术,术后外支具制动3个月.所有病例随访至少2年,随访期间每6个月进行l临床评估和放射学检查.结果:无围手术期死亡发生,平均手术时间208(145～385)min,后凸Cobb角从术前平均57.2°(17°～86°)矫治到术后平均为8.9°(-6°～27°),C7-S1水平距离术前平均为13.6(8～19)mm,术后平均为3.6(-11～9)mm.术前有神经症状功能障碍者19例,术后神经功能改善率89.5%(17/19).围手术期并发症发生率为8.3%(3/36),包括肺炎和表层伤口感染,随访期并发症发生率为5.5%(2/36),表现为内固定植入物松动,25例(69.4%)获得良好的骨性融合.随访期间,25%(9/36)的患者对治疗结果非常满意,66.7%(24/36)的患者对治疗结果满意,2例一般,1例不满意.结论:一期后路VCR技术是一种治疗活动期胸腰段脊柱结核伴严重后凸畸形安全有效的外科手术方法,该手术技术要求高,外科医师必须熟练病理解剖并谨慎实施.     

后路全脊椎切除治疗胸腰椎陈旧性骨折角状后凸畸形的疗效观察

目的探讨后路全脊椎切除治疗胸腰椎陈旧性骨折角状后凸畸形的手术方法及临床疗效。方法15例胸腰椎陈旧性骨折角状后凸畸形患者采用后路全脊椎切除术,术后随访6～36个月,观察其临床症状缓解、手术前后后凸Cobb角度变化及Frankel分级情况。结果术后患者临床症状均得到明显缓解,术前后凸Cobb角为（51．2±4．9）度,术后经随访恢复为（11．2±1．7）度,术后后凸Cobb角度〈术前（P〈0．01）,且术后Frankel分级明显降低。结论后路全脊椎切除结合椎弓根内固定与椎板减压治疗胸腰椎陈旧性骨折角状后凸畸形效果显著。     

Surgical strategy of one stage surgery of anterior release combined with posterior correction in treatment of severe scoliosis

Objective: Severe scoliosis refers to scoliosis with serious and stiff curve. It always combins with trunk imbalance in coronal and sagittal contour. Besides complex pathological changes, cardiopulmonary deficits and other concomitant diseases increase treatmental difficulties. So the treatment of severe scoliosis is always a great challenge to spine surgeon. Methods :Thirty-six patients with severe scoliosis received one stage posterior correction followed by anterior release during July 1997 to January 2003, including 9 males and 27 females. Mean age was 17.2 years. Of them, 33 was idiopathic scoliosis and 3 was neurofibromatosis scoliosis( Cobb angle: 85-116 degree); 20 cases were abnormal in sagital plane. Three-dimensional devised instrumentation were applied such as CD, CD-Horizon, TSRH or Isola in posterior procedure followed by anterior release during the same anesthesia. 31 cases of this group received thorac icplasty. Results: The correction in the frontal plane achieved an average of 48.5%. In the sagittal plane, the pathological shape of the spine was reduced and distinctly ameliorated. 80. 6% of the patients maintained or achieved balance of sagittal plane. There were no complications of severe neurological deficit, hook displacement, rod broken, and deep infection at follow-up. One case occurred traumatic pleurisy after operation and another appeared pseudarthrosis 2 years later. One case demonstrated imbalance 11 months after operation. One patient was presented loss of correction more than 10 degree at one year follow-up and 5.2 degree in average. Conclusion:The study indicates that the one stage posterior correction combined with anterior release in treatment of severe scoliosis can achieve satisfactory correction. Appropriate choice of cases, preoperational detailed assessment and application of SEP and wake-up test during operation can possibly reduce severe complication. The long-term outcomes still need further observation.     

先天性胸腰段半椎体并重度僵硬性脊柱侧后凸畸形的后路松解楔形截骨矫治

目的探讨先天性胸腰段半椎体并重度僵硬性脊柱侧后凸畸形患者采用经后路松解楔形截骨治疗的安全性和临床初步效果,并探讨其融合固定节段（LIV）的选择。方法选择我院2006年7月～2011年10月收治的先天性胸腰段半椎体并重度僵硬性脊柱侧后凸畸形患者10例临床资料,均行经后路松解楔形截骨矫形手术,以触及椎（touched vertebrae,TV）（指站立前后位像上被骶正中线触及的最近端椎体）作为融合固定下端椎。结果本组10例患者均顺利完成手术。平均松解3.0个椎间隙;手术时间4.5～9.4 h,平均6.3 h;术中出血量680～10 000 mL,平均985 mL;术后侧凸Cobb角6°～32°,平均18.7°,平均矫正率为27.2%;后凸Cobb角-8°～22°,平均8.3°,平均矫正率为88.6%;C7铅垂线与骶正中线距离0.1～2.3 cm,平均0.6 cm,冠状位平衡平均矫正率为78.1%。随访14～35个月,平均23.4个月,末次随访侧凸Cobb角8°～57°,平均29.7°,丢失率为7.3%;后凸Cobb角22°～38°,平均29.9°,丢失率为7.7%。结论经后路松解楔形截骨矫治先天性胸腰段半椎体并重度僵硬性脊柱侧后凸畸形安全有效,选择TV作为LIV可以减少融合节段。     

后路椎体切除置入椎弓根钉棒系统内固定治疗先天性脊柱后侧凸畸形

目的 探讨后路半椎体切除加椎弓根钉棒系统内固定治疗先天性脊柱侧凸的临床效果.方法 选择2008年12月～2011年12月收治的先天性脊柱侧凸患者15例,均为完全分节性半椎体畸形.患者均采用后路半椎体切除加椎弓根钉棒系统内固定治疗.术后随访,摄脊柱正侧位X线片,比较手术前后冠状面Cobb角及后凸角度矫正情况.结果 本组15例患者术前胸弯Cobb角为（52.4±10.6）°,末次随访为（14.6±6.4）°,矫正率为72.1％;术前腰弯Cobb角为（43.7±9.8）°,末次随访为（12.1±4.7）°,矫正率为72.3％;术前C7-CSVL为（6.3±4.6）cm,末次随访为（2.7±1.3）cm,矫正率为57.1％;各指标治疗前与末次随访比较差异均有统计学意义（P＜0.05）;所有患者术后均无脊髓损伤,术后均无感染,无内固定松动,无假关节形成无骨不连及植骨吸收等并发症发生.结论 后路半椎体切除加椎弓根钉棒系统内固定治疗半椎体畸形所致先天性脊柱侧凸安全、有效,矫正效果满意.     

Surgical treatment of severe scoliosis and kyphoscoliosis by stages

Background  Although previous reports had reported the use of temporary internal distraction as an aid to correct severe scoliosis, two-stage surgery strategy (less invasive internal distraction followed by posterior correction and instrumentation) has never been reported in the treatment of patients with severe spinal deformity. This study aimed to report the results of the surgical treatment of severe scoliosis and kyphoscoliosis by two-stage and analyse the safety and efficacy of this surgical strategy in the treatment of severe spinal deformities.

Methods  A total of 15 patients with severe scoliosis, kyphoscoliosis or kyphosis who underwent two-stage surgeries (less invasive internal distraction followed by posterior correction and instrumentation) were studied based on hospital records. Pretreatment radiographs and radiographs taken after first surgery (internal distraction by two small incisions), before second surgery (posterior correction, instrumentation and fusion), one week after second surgery and final follow-up were measured. Subjects were analyzed by age, gender, major coronal curve magnitude, flexibility of major curve, major sagittal curve magnitude before first surgery, after first surgery, before second surgery, after second surgery and at final follow-up. Complications related to two-stage surgeries were noted in each case.

Results  The average major curve magnitude was 129.4° (range, 95° to 175°), reduced 58.9° or 45.4% after first stage surgery and reduced 30.6° or 24.6% after second stage surgery. The loss of correction during the interval between two surgeries was 7.1%. The total major coronal curve correction was 81.4°or 62.9%. At the final follow up, the average loss of correction of major coronal curve was 3.9° and the final average correction rate was 59.7%. The average major sagittal curve magnitude was 80.3° (range, 30° to 170°), and the total major sagittal curve correction was 48.2°. Loss of correction averaged 4.0° for major sagittal curve and the final correction averaged 42.2°. Clinical complications were noted in the peri-operative and long-term periods.

Conclusions  Two-stage surgery was a safe and effective surgical strategy in this difficult population. Using two-small-incision technique, the first stage surgery was less invasive. No permanent neurologic deficit was noted in this series.

     

经皮椎体后凸成形术治疗骨质疏松性胸腰椎压缩性骨折的临床观察

目的探讨经皮椎体后凸成形术治疗骨质疏松性胸腰椎压缩性骨折的疗效。方法我院采用经皮椎体后凸成形术治疗骨质疏松性胸腰椎压缩性骨折69例。结果术后随访不同时间其VAS评分较术前明显改善。术后疗效评价:治愈18例,显效30例,有效19例,无效2例。结论采用采用经皮椎体后凸成形术治疗骨质疏松性胸腰椎压缩性骨折的临床疗效确切,值得临床推广应用。     

后交叉韧带替代型与保留型全膝关节置换术的早期疗效比较

目的 探讨后交叉韧带替代型与保留型全膝关节置换术的早期疗效。方法 回顾性分析2015年8月至2018年7月期间,因膝骨性关节炎行全膝关节置换术的67例患者。其中35例为后交叉韧带保留型（posterior cruciate-retaining,CR）假体,32例为后交叉韧带替代型（posterior cruciate-substituting,PS）假体。观察比较两组患者的手术时间、术后引流量、住院时间、关节活动度、美国特种外科医院膝关节评分（Hospital for Special Surgery knee score,HSS）。结果 PS组患者手术时间（91.77±6.53） min大于CR组（87.48±5.83） min,差异有统计学意义（P<0.05）。PS组术后引流量（315.81±18.34） mL明显大于CR组（203.67±14.59） mL,差异有统计学意义（P<0.05）。在住院时间方面,两组患者间差异无统计学意义（P>0.05）。两组患者术后1、3、6个月的膝关节活动度及HSS差异无统计学意义（P>0.05）。结论 CR及PS假体在膝关节置换术后早期均获得良好的效果。在临床中,应根据患者膝关节的情况和术者的个人经验来选择假体。     

Early posterior spinal canal decompression and circumferential reconstruction of rotationally unstable thoracolumbar burst fractures with neurological deficit

Background Among the various treatments of neurologically involved unstable thoracolumbar burst fractures, the combination of anterior and posterior instrumentation provides the most stable reconstruction. However, the use of both approaches on a trauma patient may increase the morbidity. This study is a retrospective matched cohort study to evaluate the advantages of a single stage posterior approach for spinal canal decompression in combination with circumferential reconstruction by comparing the clinical and radiographic results.

Methods From March 2005 to September 2009, patients with matched type spinal fracture, ages at surgery, and involved levels in our institute underwent either a single stage posterior approach (group one, n=12) or traditional combined approach (group two, n=14) for spinal canal decompression and circumferential reconstruction were reviewed. Pre- and post-operative X-ray films were reviewed and changes in Cobb angle of thoracolumbar spine were documented. Intra-operative, post-operative, and general complications were registered.

Results The mean follow-up was (27.7±9.6) months (range, 14 to 56 months) in group one and (29.2±7.4) months (range, 20 to 60 months) in group two (P >0.05). The mean operation time was 214 minutes (range, 186–327 minutes) in group one and 284 minutes (range, 219–423 minutes) in group two (P <0.05). The average volume of intraoperative blood loss was 1856 ml (range, 1250–3480 ml) in group one and 2453 ml (range, 1600–3680 ml) in group two (P <0.05). There was no statistical difference between the groups one and two in average vertebral body height loss at the injured level and the average Cobb angle in sagittal plane before and immediately after surgery. Postoperatively, there was an epidural hematoma in one patient in group one and two patients in group two. Bony union after stabilization was obtained in all patients, without loosening or breakage of screws. Loss of correction (5°) was seen in 1 patient in group one at the 6th month owing to the subsidence of the Titanium mesh cages into the vertebra. In group two, totally four patients suffered respiratory-related complication, including pneumonia in two, severe atelectasis in one and pleural effusions in one. Importantly, there were no intraoperative or postoperative deaths in any group. All patients with incomplete neurologic deficits improved at least 1 Frankel grade.

Conclusion Single-stage posterior vertebra resection in combination with circumferential reconstruction is a new option to manage severe thoracolumbar burst fractures.