重度僵硬性脊柱畸形后路三柱截骨矫形67例疗效及并发症分析

目的探讨重度僵硬性脊柱畸形三柱截骨矫形术的疗效、神经并发症及其防治。方法2006年1月至2017年9月采用脊柱后路三柱截骨矫形术治疗重度僵硬性脊柱畸形患者67例,其中男39例,女28例;年龄9~62岁,平均47.6岁。神经肌肉性脊柱侧凸畸形2例,先天性脊柱侧凸和侧后凸畸形5例,特发性脊柱侧凸畸形8例,强直性脊柱炎后凸和侧后凸畸形10例,脊柱结核后凸与侧后凸畸形22例,陈旧性胸腰椎骨折后凸和侧后凸畸形20例。术前脊柱后凸畸形46例,侧凸畸形14例,侧后凸畸形7例;其中主弯侧凸畸形16例,Cobb’s角平均(75.9±13.5)°;主弯后凸畸形51例,Coob’s角平均(118.6±28.8)°。术前已有脊髓功能损害者24例(35.8%);行经后路椎弓根椎体楔形截骨术(pedicle subtraction osteotomy,PSO)17例,经椎弓根椎体椎间盘截骨术(bone-disc-bone osteotomy,BDBO)13例,全脊椎切除术(ertebral column resection,PVCR)22例,多节段椎体截骨术(posterior multilevel vertebral osteotomy,PMVO)15例,联合椎弓根螺钉钉棒系统矫形固定植骨融合,唤醒试验监测截骨术中脊髓神经功能。结果术后随访24~98个月,平均32个月,主弯侧凸畸形Cobb’s角(26.1±10.5)°,矫正率65.2%,冠状位垂直轴距(coronal vertical axis,CVA)由术前平均12.1 cm矫至术后4.8 cm,P<0.01;主弯后凸畸形Cobb’s角(32.8±9.1)°,矫正率67.67%,矢状位垂直轴距(sagittal vertical axis,SVA)由术前平均18.9 cm矫至术后6.4 cm,P<0.01;术后末次随访较术后1年主弯侧凸畸形与后凸畸形矫正Cobb’s角丢失平均值分别为2.1°和1.6°。术后并发症共16例20种,发生率23.9%;神经并发症9例(13.45%),其中2例不全性截瘫行手术探查后大部恢复,余7例非手术治疗神经功能恢复正常。24例术前已有脊髓神经根损害者术后美国脊髓损伤协会(American spinal injury association,ASIA)脊髓功能分级较术前平均提高2个级别。结论后路三柱截骨矫形术是治疗严重僵硬性脊柱畸形最有效的方法,可达显著的脊柱三维矫形效果,但手术难度高、风险大,截骨矫形疗效受多种因素影响,特别是神经系统并发症发生率高是影响疗效最严重的问题。针对这些因素采取严密的术前设计、个体化截骨方式、规范的手术操作和脊髓神经根的保护,维持正常有效循环血容量和早期发现与处理脊髓神经等并发症是保证手术疗效的关键。

An analysis of effects and complications after posterior three-columniation-osteotomy in 67 patients with severe rigid spinal deformity

Objective To investigate effects,neurological complication and its prevention following posterior three-columniation-osteotomy in patients with severe rigid spinal deformity.Methods A retrospective analysis of 67 patients(39 males;28 females)was conducted from January 2006 to September 2017.The mean age was 47.6 years(range:9-62 years).There were 2 patients of neuromuscular scoliosis,5 of congenital scoliosis,8 of idiopathic scoliosis,10 of ankylosing spondylitis with kyphosis,22 of kyphosis with spinal tuberculosis,and 20 of old thoracolumbar fracture with kyphosis.Forty-six patients of spinal kyphosis,14 patients of scoliosis and 7 patients of kyphoscoliosis were included.The preoperative average Cobb’s angle of main scoliosis was(75.9±13.5)°,while kyphosis(118.6±28.8)°.Spinal nerve injury was noted before operation in 24 patients(35.8%).PSO was performed on 17 patients,BDBO on 13 patients,PVCR on 22 patients,and PMVO on 15 patients.Pedicle screw and rod system fixation,bone graft fusion,wake-up test were combined during the osteotomy.Results Postoperative follow-up ranged 24-98 months(average:32 months).The average postoperative Cobb’s angle of the main scoliosis was(26.1±10.5)°with a corrective rate of 65.2%.CVA reduced from 12.1 cm preoperatively to 4.8 cm postoperatively(P<0.01).The average postoperative Cobb’s angle of the kyphosis was(32.8±9.1)°with a corrective rate of 67.67%.SVA reduced from 18.9 cm preoperatively to 6.4 cm postoperatively(P<0.01).The average lost of main scoliosis and kyphosis was 2.1°,1.6°respectively 1 year after surgery.There were 20 postoperative complications in 16 patients with an incidence of 23.9%.Neurological complications were observed in 9 patients(13.45%):2 patients of incomplete paraplegia recovered mostly after surgical exploration;7 patients returned to normal after non-surgical treatment.ASIA improved by 2 grades on average in 24 patients with spinal nerve root injury after surgery.Conclusions Three-columniation-osteotomy is the most effective method in the treatment of severe rigid deformity of the spine.Strict preoperative evaluation,individualized surgical design,standard operation,protection of the spinal nerve root,normal effective circulating blood volume,early detection and treatment of complications are required to ensure good clinical outcomes.