胸腰椎后凸畸形经后路截骨矫形术的进展

胸腰椎严重后凸畸形都需要脊柱的截骨矫形术,对于前后路的选择一直有争论.有作者[1]采用前路松解切除半椎体治疗胸椎畸形,发现创伤大、技术要求高、出血量很大,且易引起休克等并发症,认为该术式不太实际.自上世纪70年代以来,一些作者[2～4]报道了采取后路截骨矫形治疗胸腰椎后凸畸形,积累了不少经验,也获得了良好的手术效果,本文将后路截骨矫形方法及手术相关问题综述如下.     

一期头盆环牵引二期后路截骨矫正重度脊柱后凸侧后凸的临床效果评价

[目的]探讨一期头盆环牵引,二期后路截骨矫正重度脊柱后凸、侧后凸治疗的临床效果。[方法]回顾分析本院2006年1月²013年12月收治的80例重度脊柱后凸、侧后凸患者,均行一期头盆环牵引、二期后路截骨矫正的手术方案,对患者治疗效果进行评价。[结果]对于重度的脊柱后凸、侧后凸患者采用一期头盆环牵引后,脊柱后凸角明显减小,二期后路截骨矫正治疗后有效的避免了直接矫正时损伤脊髓及神经的并发症的发生,同时保证了矫形效果的最大化。[结论]通过选择一期头盆环牵引、二期后路截骨矫正治疗重度脊柱后凸、侧后凸畸形,可通过一期牵引使畸形部分松弛,从而保证矫形的最大化,是一种安全、有效、具有良好耐受性的治疗方法,矫形效果明显。     

应用头颅-骨盆环牵引辅助后路截骨治疗重度脊柱侧后凸畸形的临床效果

目的探讨应用头颅-骨盆环牵引辅助后路截骨矫形治疗重度脊柱侧后凸畸形的临床效果。方法回顾分析2014年3月至2018年3月贵州省骨科医院脊柱外科收治的重度脊柱侧后凸畸形患者32例的临床资料。其中男14例,女18例,年龄(17.5±4.8)(14~23)岁。均行Halo骨盆牵引后后路截骨矫形手术治疗。牵引力取患者可承受的极限,牵引时间为(3.2±0.6)(3~4)周,后行后路截骨内固定融合术。对患者治疗前左右侧屈位、牵引后和术后的侧后凸矫正率进行比较。采用SPSS 24.0软件对数据进行统计学处理。结果32例患者均顺利完成手术。行经椎弓根椎体截骨(pedicle subtraction osteotomy,PSO)或邻椎截骨12例、Smith-Petersen截骨(Smith-Petersen osteotomy,SPO)或Ponte截骨20例。未见脊髓与神经损伤并发症发生。治疗前脊柱冠状面Cobb角为(136.8±38.0)°(96°~172°),矢状面Cobb角为(90.4±24.0)°(45°~125°)。患者平卧左右侧屈位侧凸矫正率为(8.9±3.2)%,Halo骨盆牵引后侧凸矫正率为(37.6±4.3)%,后路截骨矫形术后侧凸矫正率为(68.7±4.8)%;牵引后矢状面侧凸矫正率为(30.7±5.6)%,后路矫形术后矢状面侧凸矫正率(60.6±4.3)%;各时间点差异均有统计学意义(均P<0.05)。结论应用Halo头颅-骨盆牵引辅助后路截骨矫形治疗重度脊柱侧后凸畸形患者,可预测矫形效果,简化手术,降低操作难度,提高畸形矫正率,安全有效。     

后路全脊椎截骨术治疗先天性脊柱侧后凸畸形

目的评价后路全脊椎截骨术治疗先天性脊柱侧后凸畸形的临床效果。方法 2007年8月至2009年12月,采用后路全脊椎截骨术治疗先天性脊柱侧后凸畸形病例21例,男7例,女14例;年龄7～32岁,平均16.3岁;胸段19例,腰段2例;伴发脊髓纵裂7例,脊髓空洞1例,不全瘫3例。所有病例均行后路一期全脊椎截骨、矫形植骨融合固定术。测量术前、术后及随访时站立位全脊柱正侧位X线片,记录冠状面和矢状面Cobb角、顶椎偏移;记录术中出血量、手术时间及围手术期并发症。结果所有患者切口均一期愈合,随访时间16～38个月,平均22.4个月。本组病例手术时间平均为694.5min,术中出血量平均2429ml,冠状面Cobb角由82.9°矫正到36.0°,平均矫形率56.6%,矢状Cobb角由82.5°矫正到39.8°,平均矫形率51.8%,顶椎偏移由27.1mm矫正到11.1mm,矫正率59.0%。1例术后神经诱发电位示右胫后神经SEP降低,2周后恢复,无其他神经系统并发症,椎体间植骨病例随访时均获得融合,无内固定松动、断裂等并发症。结论后路全脊椎截骨椎体切除可直接去除致畸原因,在冠状面和矢状面上均可获得良好的矫形,并可获360°减压,是目前治疗先天性脊柱侧后凸畸形较为有效的方法。     

后路脊柱截骨矫形术的临床应用进展

在脊柱截骨矫形术中,后路截骨应用最为普遍,可应用于多种常见的脊柱侧后凸畸形,如强直性脊柱炎、先天性脊柱侧凸、青少年特发性脊柱侧凸以及严重的后凸畸形等。本文就近年来后路截骨矫形治疗重度脊柱畸形的临床应用进展进行综述。     

脊柱结核角状后凸畸形手术治疗现状

目的 综述脊柱结核角状后凸畸形手术治疗现状,以期为临床提供参考。方法 广泛查阅国内外近年关于脊柱结核角状后凸畸形手术治疗文献,从手术指征、手术禁忌证、手术入路及截骨术式选择、围术期管理等方面进行总结。结果 脊柱角状后凸畸形是脊柱结核患者常见并发症,后凸畸形如逐步进展,易造成神经功能损害、恶化以及迟发性瘫痪等严重后果,需要手术干预。目前脊柱结核角状后凸畸形矫形手术入路包括前路、后路以及前后联合入路。对于脊髓受压严重、后凸畸形程度轻的患者,可以采用前路手术;后凸畸形严重但神经功能受损不严重患者,可以采用后路手术;若要兼顾椎管减压和矫形则可以选择前后联合入路。后凸畸形截骨矫形术式包括Smith-Peterson截骨（Smith-Peterson osteotomy,SPO）、经椎弓根截骨（pedicle subtraction osteotomy,PSO）、全脊柱切除（vertebral column resection,VCR）、脊柱去松质骨截骨（vertebral column decancellation,VCD）、后路脊柱切除（posterior vertebral column r...     

半椎体切除术与后路松解截骨矫形术治疗小儿先天性脊柱侧凸的疗效比较

目的比较半椎体切除术与后路松解截骨矫形术治疗小儿先天性脊柱侧凸的临床疗效。方法回顾性分析自2015-03—2017-12诊治的96例小儿先天性脊柱侧凸,48例采用后路松解骨矫形术治疗(截骨矫形组),48例采用半椎体切除术治疗(半椎体切除组)。比较2组手术时间、术中出血量、术后脊柱Cobb角及并发症发生率。结果 96例均获得随访,随访时间平均15.6(12～24)个月。与截骨矫形组比较,半椎体切除组手术时间更短,术中出血量更少,并发症发生率更低,术后Cobb角更小,差异有统计学意义(P 0.05)。结论与后路松解骨矫形术比较,半椎体切除术治疗小儿先天性脊柱侧凸疗效更为确切,术后并发症发生更少,具有较高的安全性。     

对后路全脊椎切除术治疗严重脊柱侧后凸畸形的体会

重度僵硬性脊柱侧后凸是严重的脊柱三维畸形。广泛前后柱结构的僵硬，以及脊柱冠状面和矢状面的严重失衡。使得单纯传统后路内固定矫形或前路松解联合后路矫形技术不能获得满意矫正效果，并具有较高的脊髓神经损伤风险。虽然常用于强直性脊柱炎胸腰椎后凸畸形治疗的后路脊椎截骨术（spinal osteotomy）（经关节突“V”型截骨或经椎弓根椎体截骨）在轻、中度成人僵硬侧凸或脊柱侧凸翻修手术中取得成功，但对于重度、僵硬的脊柱侧后凸畸形，由于截骨范围有限，该两种方法均不能取得畸形的满意矫正和躯干平衡恢复。基于先天性脊柱侧凸半椎体切除和脊柱恶性肿瘤后路全脊椎切除的经验，全脊椎切除术（vertebral column resection，VCR）主要适应证为：     

三种脊柱截骨方法治疗脊柱后凸畸形的比较

由Smith Reterson(1945)首先报告应用脊柱后方截骨术治疗脊柱后凸畸形,后La-chapell(1946),Brigge(1947)做了改进,Wilson(1949)应用多节段楔形截骨使手术矫形更加满意。国内刘润田(1958)首先开始脊柱后方截骨术,吴之康(1987)行脊柱后方截骨哈氏加压棍固定手术获得满意疗效。我院自1985年至1991年采用单节段椎板、双节段椎板及经椎弓根椎体截骨三种方法治疗驼背患者共420例。本文通过对用三种不同截骨方法治疗的96例患者进行了回顾性研究分析,从矫正效果、并发症等方面比较了三种方法的优劣,并从截骨方法与矫形的生物力学、矫正角度及并发…     

脊柱后路截骨术治疗局部严重后凸畸形的研究进展

正随着脊柱外科技术的发展,脊柱后路截骨矫形术在临床逐渐广泛开展,可用于矫正强直性脊柱炎、先天性椎体发育异常、陈旧性骨折、脊柱结核及椎体肿瘤等相关疾病所致的局部严重后凸畸形,亦可用来完成重度脊柱侧凸畸形的治疗。目前临床常用的后路截骨技术大致可分为闭合截骨术(SPO),经椎弓根截骨术(PSO),全椎体切除术(VCR)。以上3种术式各有侧重点,手术效果亦存在差别。现就脊柱后路截骨技术治疗局部严重后凸     

单一后路半椎体切除结合椎间融合器治疗先天性脊柱畸形

目的探讨经单纯后路半椎体切除结合椎间融合器在先天性脊柱畸形治疗中的应用及疗效。方法 2009年6月至2010年12月,6例先天性脊柱畸形患者行单纯后路半椎体切除,切除区域植入椎体间融合器,以此为支点,行后路椎弓根钉棒系统矫形,矫形区域行椎体间及后外侧融合。术后经过平均近12个月的随访。对术中出血、围手术期并发症、术后患者的影像学表现、临床症状等进行随访和评价。结果所有患者围手术期中均未发生血管、神经损伤等严重并发症。术后即刻影像学检查见半椎体切除彻底,脊柱侧后凸畸形矫正满意。随访中未见内固定失败及矫形丢失现象。结论后路切除半椎体畸形后,在缺损区域植入椎体间融合器,既可以帮助术中矫形,又可促进手术区域的融合和矫形的保持,减少假关节的发生和内固定的失败。     

Pain after adult deformity surgery

Adult spinal deformity is a broad spectrum of disorders that are becoming more prevalent with an ageing population. In those with moderate to severe deformity, surgical correction of spinal alignment is an increasingly common treatment and has demonstrated improvement in patients’ quality of life. Whilst continued research in risk stratification, advances in surgical techniques, and preoperative optimization has taken place, rates of adverse outcomes following surgery for adult spinal deformity are still frequent. Pain is a common complaint after spinal deformity correction; however, whether this pain is deemed a ‘normal’ amount, or a ‘pathological’ pain has not been well characterized in the literature. This paper aims to provide a framework for evaluating pain after spinal deformity correction surgery in order to guide clinical decision making.     

Isolated thoracolumbar and lumbar hyperlordosis in a patient with cerebral palsy

A severe isolated thoracolumbar and lumbar hyperlordosis spinal deformity occurring in a patient with cerebral palsy is rare and has not been reported before. The authors describe the presentation, operative considerations, and treatment of patients with this unusual hyperlordotic spinal deformity, particularly those with cerebral palsy. A multiple-stage surgical reconstruction was required to correct this complex spinal deformity. The patient underwent bilateral femoral extension osteotomies along with spinal extensor myotomies to ensure proper prone positioning for his anticipated spinal surgery. Then he had staged anterior releases and spinal fusion from T8 to the sacrum followed by 2 weeks of "90-90" femoral skeletal traction. Finally, a posterior spinal fusion with instrumentation from T2 to the pelvis definitively corrected his deformity. The patient responded well to surgical intervention without complications and continues to have stable correction of his hyperlordosis deformity 2 years after surgery. Severe lordotic sagittal plane spinal deformities can be treated with anterior and posterior spinal fusion and instrumentation with intervening traction in the properly selected and prepared patient who has cerebral palsy.     

Severe kyphoscoliosis associated with osteomalacia.

BACKGROUND CONTEXT: Kyphoscoliosis is one of the most frequent complications of osteomalacia, which only rarely results in severe deformity requiring surgery. To the best of our knowledge, there has been only one previous report of a spinal deformity as a complication of osteomalacia that was sufficiently severe so as to require surgical treatment. PURPOSE: To report here the case of a 27-year-old woman who experienced back pain of gradual onset accompanied by progressive scoliosis resulting in severe dyspnea. STUDY DESIGN: A case report. METHODS: She was diagnosed with hypophosphatemic osteomalacia and secondary hyperparathyroidism. She underwent posterior surgical correction and fusion from Th4-L1 using the ISOLA spinal system. RESULTS: At the last follow-up (3 year and 9 months postoperatively), her body balance was good and the dyspnea had disappeared. Plain radiographs demonstrated no loss of correction and also showed no evidence of instrumentation failure. CONCLUSIONS: We present a unique instance of a young woman with severe kyphoscoliosis who underwent posterior surgical correction/fusion with spinal instrumentation.     

Treatment of Spinal Tuberculosis by Debridement,Interbody Fusion and Internal Fixation via Posterior Approach Only

Surgical treatment for spinal tuberculosis includes focal tuberculosis debridement, segmental stability reconstruction, neural decompression and kyphotic deformity correction. For the lesions mainly involved anterior and middle column of the spine, anterior operation of debridement and fusion with internal fixation has been becoming the most frequently used surgical technique for the spinal tuberculosis. However, high risk of structural damage might relate with anterior surgery, such as damage in lungs, heart, kidney, ureter and bowel, and the deformity correction is also limited. Due to the organs are in the front of spine, there are less complications in posterior approach. Spinal pedicle screw passes through the spinal three‐column structure, which provides more powerful orthopedic forces compared with the vertebral body screw, and the kyphotic deformity correction effect is better in posterior approach. In this paper, we report a 68‐year‐old male patient with thoracic tuberculosis who underwent surgical treatment by debridement, interbody fusion and internal fixation via posterior approach only. The patient was placed in prone position under general anesthesia. Posterior midline incision was performed, and the posterior spinal construction was exposed. Then place pedicle screw, and fix one side rod temporarily. Make the side of more bone destruction and larger abscess as lesion debridement side. Resect the unilateral facet joint, and retain contralateral structure integrity. Protect the spinal cord, nerve root. Clear sequestrum, necrotic tissue, abscess of paravertebral and intervertebral space. Specially designed titanium mesh cages or bone blocks were implanted into interbody. Fix both side rods and compress both sides to make the mesh cages and bone blocks tight. Reconstruct posterior column structure with allogeneic bone and autologous bone. Using this technique, the procedures of debridement, spinal cord decompression, deformity correction, bone grafting, and internal fixation can be completed with only one incision and surgical position, and the deformity correction efficiency is higher than anterior surgery.     

Surgical treatment of advanced congenital scoliosis with the C-D method]

The paper presents the results of surgical treatment of 15 cases of congenital scolisios with CD instrumentation. Progression of the deformity was most often seen in cases with combined deformities (according to the McMaster classification). Indications for surgical treatment were progression of the curvature and trunk and thorax deformity progression, particularly during the growth spurt. The age at the time of surgery ranged from 10.3 to 16 years (average: 13.8 years). Follow-up period ranged from 2 to 8 years (average: 4 years). Intraoperative deformity correction ranged from 0 to 60% (average 32%). Loss of correction during follow up ranged from 0 to 3%. The overall silhouette improvement was a result of correction of the spine curvature, correction of thoracic hyperkiphosis and a decrease of trunk decompensation. The only complications noted were 3 cases of transient neurological symptoms from the lower extremities. Preoperative MRI allows detection of congenital deformities of the spinal canal, a contraindication for surgical correction of the deformity with spinal implants.     

单纯后路全椎弓根螺钉技术矫正Wilms瘤综合治疗后并发脊柱畸形

目的探讨单纯后路全椎弓根螺钉技术矫正Wilms瘤综合治疗后并发脊柱畸形的安全性及其疗效。方法回顾分析2010年8月~2012年3月单纯后路全椎弓根螺钉技术矫正Wilms瘤综合治疗后并发脊柱畸形患者3例。分析术后畸形矫正率、并发症、融合情况及患者腰痛视觉模拟量表(visual analog scale,VAS)评分。结果术后脊柱侧凸、胸腰段后凸均显著改善。腰痛VAS评分也显著提高。均随访>2年,3例患者均无畸形明显进展,无假关节形成、感染等并发症,无疼痛症状复发。结论对于Wilms瘤综合治疗后并发脊柱畸形的患者,单纯后路全椎弓根螺钉矫形技术可取得良好的手术效果。     

Tubercular spondylitis in children

Spine of the child has unique anatomy and growth potential to grow to adult size. Tuberculosis (TB) spine results in bone loss as well as disturbed growth potential, hence spinal deformities may progress as the child grows. The growth potential is also disturbed when the disease focus is surgically intervened. Surgery is indicated for complications such as deformity, neurological deficit, instability, huge abscess, diagnostic dilemma and in suspected drug resistance to mycobacterium tuberculosis. The child on antitubercular treatment needs to be periodically evaluated for weight gain and drug dosages need to be adjusted accordingly. The severe progressive kyphotic deformity should be surgically corrected. Mild to moderate cases should be followed up until maturity to observe progression/improvement of spinal deformity. The surgical correction of kyphotic deformity in active disease is less hazardous than in a healed kyphosis. The internal kyphectomy by extra pleural approach allows adequate removal of internal salient in paraplegic patients with healed kyphotic deformity.     

Surgical treatment of tumors of the spine

Indications for the surgical treatment of spinal tumors are intractable pain, spinal instability and deformity, and impending or present significant neurologic complications. The best results are obtained by thorough decompression, adequate correction of deformity, and proper stabilization of the spine. The decompressive laminectomy alone is rarely indicated for neoplastic diseases of the spine. In general, the principles of surgical treatment for spinal tumors are: anterior approach for the anterior lesion and posterior approach for the posterior lesion, a one-stage combined anterior and posterior approach for extensive lesions, and adequate stabilization with the use of various internal fixation devices, bone graft, or bone cement. The results of surgical treatments of 20 patients in this series based on these guidelines are satisfactory (7 excellent, 6 good, and 7 fair). None was rated as poor.     

Transpedicular wedge osteotomy for correction of thoracolumbar kyphosis in ankylosing spondylitis: experience with 78 patients

STUDY DESIGN: This is a retrospective study of surgical correction of thoracolumbar kyphosis caused by ankylosing spondylitis. OBJECTIVE: To report the surgical results of thoracolumbar kyphosis deformity corrected with transpedicular wedge osteotomy performed by a single surgeon at a university hospital. SUMMARY OF BACKGROUND DATA: There has not been a large series in the literature reporting on results of the Thomasen-type closing wedge osteotomy for correction of kyphosis deformity secondary to ankylosing spondylitis, nor has two-level osteotomy of this type in one patient ever been described. METHODS: From 1991 through 1998, 92 transpedicular wedge osteotomies were performed in 78 patients with ankylosing spondylitis for correction of fixed flexion deformity of the thoracolumbar spine. RESULTS: The mean amount of correction for each level of osteotomy was 34.5 degrees (range, 15 degrees -60 degrees ). The largest amount of overall correction for a single patient was 100 degrees. Most of the osteotomies (64 of 92) were done at L2 and L3. Fourteen patients with severe deformity required staged two-level osteotomy. Excellent and good results were obtained in 77 patients (98.7%) at the final follow-up. There was no mortality, nor were there any major neurological complications. CONCLUSIONS: Transpedicular wedge osteotomy can effectively and safely correct kyphotic deformity of the thoracolumbar spine caused by ankylosing spondylitis, regardless of rigidity of the spinal curves. Two-level osteotomy can provide sufficient correction for severe cases.