脊柱前方垫高-后方闭合截骨矫形术治疗胸腰段脊柱后凸畸形的初步报告

目的探讨采用以脊柱前方垫高后方闭合为技术特征的新型脊柱截骨矫形术治疗胸腰段脊柱后凸畸形的可行性、安全性和有效性。方法自2003年以来,采用新型脊柱截骨矫形术治疗不同病因所致的胸腰段脊柱后凸畸形8例。其中男、女各4例,年龄14～58岁,平均35岁。术前脊柱后凸Cobb角平均为73°(42°～90°),3例合并脊柱侧凸的Cobb角平均为25.7°。术前Frankel分级:C级2例、D级2例、E级4例。8例均伴有较为严重的胸腰背部疼痛,3例伴有膀胱括约肌功能障碍。手术方式均为:单纯后路经双侧关节突关节、椎间隙楔性截骨,切断前纵韧带,先行脊柱前方撑开垫高(将椎间融合器植入椎间截骨面),再行脊柱后方加压闭合及椎弓根螺钉器械固定。结果平均手术时间4.5h(3.5～6.0h),平均术中出血量2280ml(700～4200ml)。术中有1例血压曾一度偏低,术后脑脊液漏1例,此外无其他手术并发症发生。术后脊柱后凸Cobb角平均为8.3°、平均矫正度数为64.7°、平均矫正率为88.6%;术后脊柱侧凸Cobb角平均为18.7°、平均矫正度数为7°、平均矫正率为27.2%。术后平均随访12.8个月(5～23个月),X线片可见原截骨平面均已发生骨性融合,胸腰背部疼痛症状完全消失。术后Frankel分级:C级1例、D级2例、E级5例;3例膀胱括约肌功能障碍者中2例术后症状有改善。结论与现行常用的单纯闭合楔形截骨术式相比,新型脊柱截骨矫形术可有效地避免脊柱过度短缩和脊髓扭曲、折皱的发生,提高了脊柱闭合截骨的安全性;同时也明显地提高了单一节段脊柱后凸畸形的安全截骨矫正度数。可适用于40°～90°的胸腰段脊柱后凸畸形的手术治疗。

New type spinal osteotomy with cage inserting anteriorly and closing posteriorly to correct thoracolumbar kyphosis by a single posterior approach

OBJECTIVE: To evaluate the feasibility, safety and efficacy of surgical correction of thoracolumbar kyphosis, using the new type spinal osteotomy with cage inserting into the intervertebral gap anteriorly and closing posteriorly by a single posterior approach. METHODS: Since 2003, eight consecutive patients with thoracolumbar kyphosis were treated surgically. There were 4 male and 4 female with the mean age of 35 years old (from 14 to 58 years old). There were 3 cases of congenital kyphosis with scoliosis, 1 case of old spinal tuberculosis kyphosis, 2 cases of post-traumatic kyphosis, 1 case of ankylosing spondylitic kyphosis with old stress fracture and 1 case of iatrogenic kyphosis post-op of laminectomy due to the removal of ependymoma from cauda equina. The apex level of kyphosis was T(11) in 1 case, T(12) in 2 cases, L(1) in 3 cases and L(2) in 2 cases. The average preoperative Cobb angle of kyphosis was 73 degrees (range from 42 degrees to 90 degrees), there were 3 cases associated with scoliosis, with the mean preoperative Cobb angle of scoliosis was 25.7 degrees (range from 20 degrees to 36 degrees). According to the Frankel grading system, 2 cases were classified as Grade C, 2 cases as Grading D and 4 cases as Grading E preoperatively. All the patients had severe thoracolumbar dorsum pain with difficulty of sitting. The bladder sphincter function disturbance were also found in 3 cases. The main procedures of the new type spinal osteotomy consisted of temporary rod installation, trans-intervertebral spinal osteotomy, circumferential decompression of the spinal cord, dissection and complete cut of the anterior longitudinal ligament, spreading the intervertebral gap with the distraction forceps during the instrumentation correction maneuver and replaced by the cage filled with autograft bone inserting into the intervertebral gap, then the closing maneuver followed. RESULTS: The average operation time was 4.5h (range from 3.5 to 6 h), and the mean blood loss volume during the operation was 2280 ml (range from 700 to 4200 ml). All patients underwent surgery safely and there were no major complications related to the surgical procedures, apart from CSF leakage of 1 case postoperatively and transient low blood pressure of 1 case intraoperatively. Localized kyphosis, scoliosis were reduced from an average of 73 degrees to 8.3 degrees and 25.7 degrees to 18.7 degrees respectively with an average 12.8 months follow-up. Bony fusion were achieved in all patients and there was no correction loss. Neurologic improvement occurred in 1 case from Frankel Grade C to Grade D, and 1 case from Frankel Grade D to Grade E after the surgery. The bladder sphincter function were also found improved in 2 cases postoperatively. CONCLUSIONS: The new type spinal osteotomy with cage inserting anteriorly and closing posteriorly by a single posterior approach was a safe, reliable and effective surgical procedure for the treatment of the thoracolumbar kyphosis with the Cobb angle from 40 degrees to 90 degrees. Compared with the other common spinal wedge osteotomies, the deformation danger, such as hanging down, kinking or dural buckling could be effectively prevented, a better correction rate is also achieved significantly with this new type procedure.