重视强直性脊柱炎颈胸段后凸畸形的截骨方案设计及并发症的预防

<正>强直性脊柱炎(ankylosing spondylitis,AS)是一种主要累及中轴骨与关节的慢性炎症性疾病~([1]),疾病中晚期可造成颈胸段的后凸或侧后凸畸形,即"颌触胸"或"耳触肩"畸形,影响患者的平视功能,严重者因下颌内收甚至会影响正常的吞咽和呼吸,甚至出现脊髓压迫症状~([2])。对于外观功能受损严重、畸形进行性进展或伴发神经损害的颈胸段畸形,矫形手术是必要的。1958     

颈椎截骨矫形手术治疗颈胸段后凸畸形的研究进展

正颈胸段后凸畸形(cervicothoracic kyphosis deformity,CKD)多由强直性脊柱炎引起,也可见于先天性或医源性因素,常导致患者视野严重受限、吞咽困难以及神经根压迫症状~([1])。颈椎截骨矫形手术(cervical osteotomy,CO)的目的是通过在颈椎部位截骨以恢复颈椎矢状位及冠状位平衡,缓解患者临床症状,其适应证包括~([2、3]):(1)重度CKD致平视功能受限;(2)脊柱后凸畸形经胸腰椎截骨术后平视功能仍受限;(3)脊柱畸形矫形术后颈胸段近端交界性后     

强直性脊柱炎胸腰椎后凸畸形患者困难气道的影像学预测因素分析

目的探讨强直性脊柱炎(ankylosing spondylitis,AS)胸腰椎后凸畸形气管插管困难患者的影像学测量。方法本组21例AS胸腰椎后凸畸形患者,其中男20例,女1例,年龄18~63岁。收集患者的影像学资料,包括:颈椎活动度(cervical range of motion,CROM)、胸腰椎后凸Cobb角、颈椎曲度及C2~C7矢状垂直轴(sagittal vertical axis,SVA)。麻醉过程中,应用直接喉镜进行气管插管,根据气管插管声门暴露的难易程度分为两组:易暴露组(A组,13例)、不易暴露组(B组,8例),比较两组间影像学资料的差异性,对于有差异的参数采用Logisic回归分析其与困难气道之间的相关性,寻找AS患者气管插管困难的影像学的预测因素。结果 B组的颈椎曲度显著小于A组(P0.05),C2~C7SVA显著大于A组(P0.05);而两组CROM、胸腰椎后凸Cobb角差异无统计学意义。Logistic回归分析显示,颈椎曲度(OR=1.445,P=0.039)及C2~C7SVA(OR=1.240,P=0.032)的改变是AS胸腰椎后凸畸形患者困难气道的危险因素。结论 AS胸腰椎后凸畸形困难气道患者的颈椎影像学有特征性改变,患者颈椎曲度及C2~C7SVA可作为有效的定量预测指标。     

强直性脊柱炎后凸畸形的301分型

目的 :建立强直性脊柱炎(ankylosing spondylitis,AS)后凸畸形新的分型方法———301分型,并对其可信度和可重复性进行检验分析。方法:根据后凸顶点位置不同将AS后凸畸形分为4种类型:腰椎型(Ⅰ型)、胸腰椎型(Ⅱ型)、胸椎型(Ⅲ型)及颈椎或颈胸交界型(Ⅳ型),除Ⅰ型外其他各型分为2个亚型:腰椎尚存在前凸为A亚型,腰椎出现后凸为B亚型。依据该分型方法对309例在我院接受脊柱截骨术治疗的AS后凸畸形患者进行分型,统计各型所占比例。由5位脊柱外科医生分别根据该分型标准对随机抽取的30例AS后凸畸形患者的影像资料进行分型,2周后此5位医生对打乱秩序的相同资料再次进行分型,收集分型结果,计算Kappa值检验一致性。结果:按照301分型方法将AS后凸畸形分为4型共7个亚型,309例患者中,Ⅰ型52例(16.8%);Ⅱ型223例(72.2%),其中ⅡA型153例,ⅡB型70例;Ⅲ型33例(10.7%),其中ⅢA型25例,ⅢB型8例;Ⅳ型1例(0.3%),为ⅣB型。观察者间可信度为73.3%~86.7%,Kappa系数为0.761~0.847,可重复性为83.3%~93.3%,Kappa系数为0.821~0.925。结论 :应用301分型方法对AS后凸畸形分型简单易行,其可信度和可重复性较好。     

强直性脊柱炎颈胸段后凸畸形截骨矫形手术进展

强直性脊柱炎（ankylosing spondylitis,AS）是一种以关节韧带骨化为特征的慢性炎症疾病;主要侵犯中轴骨,病变常从骶髂关节开始逐渐向上蔓延至脊柱。广泛的脊柱关节和韧带骨化最终导致脊柱的完全融合僵直。在骨化过程中,患者逐渐发展成严重的脊柱后凸畸形,胸腰段是最常受影响的部位,但颈椎和上胸段也不可避免的受到累及,导致颈胸段后凸畸形,表现为视野显著受限,平视功能丧失;严重者出现张口困难,呈“颌触胸”畸形,甚至出现吞咽困难和发作性窒息[1、2]。截骨矫形手术被认为是唯一有效的干预措施[1]。现就AS颈胸段后凸畸形截骨矫形手术的进展进行综述。     

强直性脊柱炎胸腰椎后凸畸形患者生存质量与矢状面参数的相关性

 目的 探讨强直性脊柱炎（ankylosing spondylitis,AS）胸腰椎后凸畸形患者生存质量与矢状面参数的相关性。方法 2011年6月至2013年8月,门诊AS患者30例、行经椎弓根椎体截骨矫形术的住院AS患者34例纳入研究。以SF-36量表评估患者生存质量;在站立位全脊柱X线侧位片上测量脊柱-骨盆矢状面参数;评估AS疾病活动性指数、AS功能指数和Oswestry下腰痛评分。依据胸腰椎最大后凸角将患者分为轻度后凸组（＜60°,29例）和重度后凸组（≥60°,35例）,比较两组患者的生存质量及矢状面参数,分析生存质量与矢状面参数的相关性。结果 重度后凸组患者在生理职能、一般健康状况、社会功能和情感职能四个维度的得分低于轻度后凸组。两组患者C7倾斜角、胸腰椎最大后凸角、矢状面躯干偏移、骨盆倾斜角、腰椎前凸角和骶骨倾斜角的差异有统计学意义。C7倾斜角和腰椎前凸角减小致生理职能评分减少;胸腰椎最大后凸角增加致情感职能评分降低;矢状面躯干偏移增大致社会功能评分减低。手术治疗患者随访6~36个月,平均16个月。末次随访时除胸椎后凸角和骨盆入射角外其他矢状面参数均较术前改善,一般健康状况、社会功能和情感职能评分均提高。结论 重度胸腰椎后凸畸形AS患者的生理职能、一般健康状况、社会功能和情感职能较轻度后凸患者降低。C7倾斜角、胸腰椎最大后凸角、腰椎前凸角和矢状面躯干偏移改变是AS患者生存质量降低的重要因素。经椎弓根椎体截骨术矫正胸腰椎后凸畸形矢状面参数的同时可提高患者生存质量。     

经椎弓根截骨术治疗强直性脊柱炎继发颈胸段后凸畸形

目的评估后路经椎弓根截骨术(PSO)治疗强直性脊柱炎(AS)继发颈胸段后凸畸形的临床疗效。方法2009年1月—2015年3月,本院采用PSO治疗AS继发颈胸段后凸畸形患者7例。患者翻身至手术床之前,先放置石膏床于患者腹侧,并在患者颈胸段与石膏床的空隙处填充数个长方形棉垫。术中C6~T1后方截骨及经C7椎弓根椎体截骨完成后,由台下助手缓慢逐个抽取垫于患者和石膏床之间的长方形棉垫。待棉垫抽取完毕后,患者颈胸段的曲度在重力的作用下恢复至近似直线。然后采用体内弯棒技术进一步增加颈胸段前凸曲度。记录手术时间及术中出血量,用颈胸段(C_2~T_1)后凸Cobb角、颏眉角(CBVA)、C_2~T_1矢状面偏移距离(SVA)、疼痛视觉模拟量表(VAS)和健康调查量表(SF-36)评估临床疗效。结果 7例患者平均手术时间260 min,术中平均出血量1 571 m L,平均随访24.4个月,术前C_2~T_1 Cobb角平均为26.2°,末次随访时为-5.4°。术前CVBA平均为43.1°,术后改善至-0.9°。术前C_2~T_1 SVA平均为6.7 cm,术后改善至3.0 cm。末次随访时,患者的VAS评分由术前的85.0分改善至17.1分;SF-36躯体机能评分(PCS)由术前的20.7分改善至79.3分;SF-36精神机能评分(MCS)由术前的12.8分改善至81.6分。结论 PSO治疗AS继发颈胸段后凸畸形可以有效地恢复颈胸段的矢状位平衡,较好地改善患者前方视野受限、颏-胸畸形等症状,采用术中体内原位弯棒技术安全可靠。     

胸腰椎后凸畸形的后路矫形手术

<正>胸腰椎后凸俗称驼背,常见于先天椎体发育畸形、脊柱陈旧结核、脊柱陈旧创伤、强直性脊柱炎和Scheuermann病等疾病;该病病程较长,多持续进展,常因脊髓受压而引发截瘫,还可由于代偿性腰椎过度前凸而引发下腰痛;该后凸畸形同时也会给患者带来严重的心理障碍。因此,胸腰椎后凸畸形的手术治疗需要解除神经压迫并矫正畸形。脊柱截骨矫形手术是治疗胸腰椎后凸畸形的有     

强直性脊柱炎重度胸腰段后凸畸形患者的双节段截骨设计

目的设计强直性脊柱炎(AS)重度胸腰段后凸畸形患者的双节段截骨方法,并进行评估。方法回顾性分析2011年1月—2012年12月于本院接受双节段截骨设计及手术矫形的10例AS重度胸腰段后凸畸形合并腰椎前凸角度减小患者临床资料,包括手术前后包含骨盆的自然站立位脊柱全长X线片,手术前后及末次随访时的T_5~S_1 Cobb角、胸腰段后凸角(TLK)、腰椎前凸角(LL)、骨盆入射角(PI)、骨盆倾斜角(PT)、骶骨倾斜角(SS)及矢状面偏移(SVA)等相关影像学参数,以及术前及术后1年随访时患者生活质量,使用健康相关生活质量(HRQoL)量表评估,通过对比评价双节段截骨手术矫形效果。结果与术前相比,术后T_5~S_1 Cobb角、PT、TLK及SVA均减小,差异有统计学意义(P0.05);LL及SS增大,差异有统计学意义(P0.05);PI无明显改变。术后1年随访时HRQoL得分较术前明显改善,差异有统计学意义(P0.05)。结论双节段截骨设计为AS胸腰段后凸畸形合并腰椎前凸角度减小患者的矫形提供了精确且可重复的方法,可使患者获得满意的矫形效果及生活质量。     

跳跃式双节段经椎弓根截骨长节段融合治疗强直性脊柱炎胸腰椎后凸畸形

目的 :探讨跳跃式双节段经椎弓根截骨长节段融合治疗强直性脊柱炎(AS)胸腰椎后凸畸形的安全性及有效性。方法:2011年10月~2015年10月采用跳跃式双节段经椎弓根截骨长节段融合内固定治疗25例AS胸腰椎后凸畸形患者,均为男性,年龄39.0±7.2岁,记录手术时间,术中出血量,术前、术后患者胸腰椎后凸Cobb角、腰椎前凸Cobb角、颌眉角、脊柱矢状面偏移(SVA)、骨盆入射角(PI)、骨盆倾斜角(PT)、骶骨倾斜角(SS)及Oswestry功能障碍指数(ODI),观察术后相关并发症的发生情况等。结果 :患者均顺利完成手术,手术时间396.4±51.5min,术中出血量1612.0±490.2ml,2例患者术中硬脊膜破裂,及时修补,术后未出现脑脊液漏;无其他严重并发症发生。所有患者均得到有效随访,随访时间19.0±6.6个月,患者活动能力及生活质量明显提高,ODI由术前33.9±6.5分降至术后6个月8.5±3.6分,末次随访时为6.8±5.0分,术后6个月及末次随访时与术前比较均有统计学差异(P0.05);末次随访时与术后6个月亦有统计学差异(P0.05)。术后2周及末次随访时的颌眉角、胸腰椎后凸Cobb角、腰椎前凸Cobb角、SVA、PT、SS与术前比较差异均有统计学意义(P0.05),PI无统计学差异;末次随访时颌眉角、胸腰椎后凸Cobb角、腰椎前凸Cobb角、SVA、PT与术后2周比较有统计学差异(P0.05);SS、PI与术后2周时比较无统计学差异(P0.05)。末次随访时均未见内固定物松动、脱出及断裂,植骨均骨性融合。结论:跳跃式双节段经椎弓根截骨长节段融合术治疗AS胸腰椎后凸畸形安全、有效。     

Cervicothoracic kyphosis

Cervicothoracic kyphotic deformity may inhibit horizontal gaze function, impede activities of daily living, and induce disabling pain. Eventually, some patients develop a chin-on-chest deformity that limits their ability to eat and drink; in the end stage, a few patients also may have difficulty breathing. Progressive kyphosis can stretch the spinal cord leading to myelopathy with progressive lower extremity spasticity and weakness.Indications for surgery include myelopathy, pain, dysphagia or dyspnea owing to kyphosis, and difficulty maintaining a functional horizontal gaze. Patients with unstable cervicothoracic fractures also require surgical fixation. For these patients, surgical goals include deformity correction with restoration of an acceptable forward gaze, re-establishment of sagittal balance, decompression of the spinal cord (if myelopathic), and stable fixation.     

Scheuermann's kyphosis

Scheuermann's disease is the most common cause of structural kyphosis in adolescents. The kyphotic deformity is frequently attributed to "poor posture," resulting in delayed diagnosis and treatment. Indications for treatment remain somewhat debated, because the true natural history of the disease has not been clearly defined. Brace treatment is almost always successful in patients with kyphosis between 55 degrees and 80 degrees if the diagnosis is made before skeletal maturity. Kyphosis greater than 80 degrees in the thoracic spine or 65 degrees in the thoracolumbar spine is almost never treated successfully without surgery in symptomatic patients. Surgical treatment in adolescents and young adults should be considered if there is documented progression, refractory pain, loss of sagittal balance, or neurologic deficit. The major postoperative complication after surgical treatment is junctional kyphosis proximally or distally, which is usually related to not including all levels of the kyphosis or overcorrection of the deformity (>50%). With proper patient selection, excellent outcomes can be expected with nonoperative or operative treatment in patients with Scheuermann's disease.     

Congenital kyphosis

Congenital kyphosis is an uncommon, but potentially devastating anomaly of the spine. Without treatment, the tendency is for severe, and sometimes catastrophic deformity. It is the most common etiology for spinal cord compression due to spine deformity, excluding tuberculosis. Few patients have nonprogressive benign lesions. Late treatment is difficult and dangerous. Braces and other forms of non-operative treatment do not work. The best treatment is early posterior fusion, before the curve reaches 50 degrees and before age 5 years. For curves over 60 degrees and over age 5, both posterior and anterior fusion are necessary. If cord compression exists, laminectomy is contraindicated. Anterior cord decompression and fusion are required.     

Juvenile kyphosis

Scheuermann's disease is a common cause of kyphosis developing in the juvenile period. Untreated, the deformity may progress, producing significant pain and, rarely, neurologic signs and symptoms. Successful treatment is possible with the Milwaukee brace, provided that the child has not reached skeletal maturity. Bracing will produce a superior result in terms of correcting the deformity and reversing vertebral wedging. Surgery may occasionally be necessary for severe kyphosis, especially in the adult who presents with pain and/or neurologic problems. Combined anterior and posterior approach is the preferred surgical procedure.     

Post-laminectomy kyphosis

Post-laminectomy spinal deformity occurs in 50% of children undergoing laminectomies for cord tumors. Kyphosis is the most frequent deformity found. The integrity of the facet joints appears to be one of the most important factors in the development of this kyphosis. More children are surviving after treatment of these tumors and a pessimistic attitude is not warranted. Observation of a progressing deformity is not acceptable treatment. When kyphosis develops, early prompt bracing must be started. For a progressive or severe kyphosis, an anterior spine fusion is indicated. This is reinforced by a posterior fusion with Harrington instrumentation. Surgical reconstruction is indicated in children recovering from extensive laminectomies but with a good prognosis.