经椎弓根椎体截骨术矫正AS伴胸腰椎后凸畸形的临床分析

发布时间：2018-06-05 10:57

本文选题：强直性脊柱炎 + 椎间盘退变性疾病　；参考：《南京医科大学》2017年博士论文

【摘要】：第一章强直性脊柱炎伴胸腰椎后凸畸形腰椎及骶1椎弓根的解剖特征及临床意义目的:通过对强直性脊柱炎伴胸腰椎后凸畸形(ankylosing spondylitis,AS)和椎间盘退变性疾病(disc degenerative disease,DDD)患者腰1-骶1椎弓根CT扫描相关参数的测量,研究两者间椎弓根解剖参数差异,为临床手术中置钉提供参考依据。方法:选取2012年3月～2014年11月行截骨矫形手术治疗并有完整术前临床及影像学资料的男性AS伴后凸畸形患者30例,平均年龄(35.7±9.5)岁(23岁～51岁),同时选取行手术治疗具有完整术前全腰椎及骶椎CT扫描全部附件结构影像清晰易辩的男性DDD患者30例,平均年龄(52.4±8.9)岁(39岁～64岁)。分别测量腰1～骶1节段椎弓根内聚角(pedicle transverse angle,EA),椎弓根矢状角(pedicle inclined angle,FA),椎弓根宽度(pedicle width,PW),椎弓根钉道长度(pedicle screw path length,PL),椎弓根高度(pedicle height,PH),统计比较是否存在差异。结果:AS组和DDD组椎弓根宽度(PW)从L1～S1均是逐渐增大的,AS组PW在L5、S1 均显著大于DDD组,(16.47±2.66)mmvs.(14.51±2.11)mm、(21.76±2.97)mm vs.(18.87±2.14)mm,P0.05;椎弓根钉道长度(PL)自L1～S1在AS组均大于DDD组,P0.05;PL两组最大值均在L3节段;AS病人椎弓根内聚角(EA)在L1～S1均较DDD组小;AS矢状角(FA)在L3～S1显著小于DDD组,(-2.88±10.24)°,(-7.88±10.22)°,(-7.70±10.40)°,(-5.15±10.25)° vs.(4.05±2.21)°,(7.79±4.38)°,(7.07±3.21)°,(12.62±3.21)°,P0.05。结论:在AS伴后凸畸形患者腰椎及骶1椎弓根置钉时可选用更粗更长螺钉来增加内固定强度,需注意适当减小内聚角,并根据矢状面形态调整头尾向。第二章强直性脊柱炎伴严重胸腰椎后凸畸形截骨矫形术后臂丛神经麻痹的发生率、危险因素及预后目的:探讨经椎弓根椎体截骨术(Pedicle Subtraction Osteotomy PSO)和Smith-Peterson截骨术(SPO)治疗强直性脊柱炎伴严重胸腰椎后凸畸形患者术后臂丛神经麻痹的发生率、危险因素及预后。方法:回顾性分析2000.4-2013.10在南京鼓楼医院骨科行SPO或PSO矫形治疗的强直性脊柱炎(Ankylosing spondylitis AS)患者。通过对后凸角度,围手术期记录资料及术后神经功能的评价分析来研究术后臂丛神经麻痹的发生率及危险因素。结果:本研究228例患者中有6例发生了术后臂丛神经麻痹。发现臂丛神经麻痹有四个危险因素:(1)胸腰椎后凸畸形角度大于100度;(2)手术时间超过4个小时;(3)术中摆放体位时上肢肩关节外展超过90度;(4)肩关节软垫的应用。所有6例患者术后平均5周(2-16周)神经运动及感觉功能均完全恢复。结论:截骨矫形治疗强直性脊柱炎伴严重胸腰椎后凸畸形患者术后臂丛神经麻痹的发生率较低,而且预后较好。手术时间较长,术中体位摆放不当是引起臂丛神经损伤的重要原因。因此,外科医师在截骨治疗强直伴后凸畸形患者需想到臂丛神经损伤的可能性。术中摆放体位时需注意上肢外展不要超过90度以减轻对臂丛神经的牵拉,术中电生理监护及定时调整双上肢位置能有效预防臂丛神经损伤的发生。第三章PSO截骨椎椎间盘前纵韧带骨化对强直性脊柱炎伴胸腰椎后凸畸形后凸矫正的影响目的:评估PSO(pedicle subtraction osteotomy)截骨椎临近椎间盘水平前纵韧带骨化对强直性脊柱炎伴胸腰椎后凸畸形后凸矫正的影响。方法:回顾性分析2006年3月到2014年2月在我院行胸腰椎单节段PSO截骨矫形的71例AS(Ankylosing spondylitis)后凸并随访满2年的患者资料。根据PSO截骨椎临近椎间盘前纵韧带骨化与否分为骨化组和非骨化组。分析比较两组间单节段PSO截骨矫形角度以及椎体和椎间盘的贡献是否存在差异。另分析比较两组间远期脊柱骨盆矢状面形态的矫形丢失是否存在差异。结果:本研究组总共纳入71例强直患者,其中骨化组为32例,患者年龄及PI值明显大于非骨化组(40.31±8.44 岁 vs.30.97士8.28 岁,和 49.36±9.75°vs.43.03±10.6°,p0.05)单节段PSO截骨矫形角度显著小于非骨化组(36.3±6.9vs.41.5±6.9°,p0.001)。椎间盘楔形变对截骨角度的贡献在非骨化组中显著大于骨化组(8.10±6.19°,18.5%vs.1.09±2.88°,2.7%,p0.001)。统计比较两组间 2 年以上随访的脊柱矢状面参数显示矢状面平衡(sagittal vertical axis,SVA),骨盆倾斜角(pelvic tilt,PT),胸 1 骨盆角(T1 pelvic angle,TPA),胸椎后凸角(thoracic kyphosis,TK)和骶骨倾斜角(sacral slope,SS)的矫正丢失在非骨化组明显较大(p0.05)。非骨化组的椎间盘楔形变的矫正丢失也稍大,有统计学差异(1.41 士3.27°vs.0.22±1.49°,p0.05)。结论:对AS伴胸腰段后凸患者行PSO截骨矫形时选择邻近节段椎间盘前纵韧带未骨化的椎体可获得相对更多的单节段后凸矫形效果,但远期随访时其发生矫正丢失的概率更大。
[Abstract]:Chapter 1 anatomical characteristics and clinical significance of lumbar and sacral 1 pedicle in ankylosing spondylitis with thoracolumbar kyphosis: measurement of CT scanning parameters of lumbar 1- sacral 1 pedicle in patients with ankylosing spondylitis (ankylosing spondylitis, AS) and intervertebral disc degeneration disease (disc degenerative disease, DDD) The difference between the anatomical parameters of the pedicle of the two vertebral pedicles was studied. Methods: 30 cases of male AS with protruding malformation were selected from March 2012 to November 2014 with a complete orthopedic surgery and complete preoperative clinical and imaging data. The average age was (35.7 + 9.5) years (23 years to 51 years), and the surgical treatment was selected at the same time. A total of 30 male DDD patients with complete CT scan of all lumbar vertebrae and sacral spine before the complete operation were treated with an average age of (52.4 + 8.9) years (39 years to 64 years old). The Shiumi Ne cohesion angle (pedicle transverse angle, EA), Shiumi Ne sagittal angle (pedicle inclined angle, FA), and Shiumi Ne width (pedicle wid) were measured respectively. Th, PW), the length of the pedicle nail channel (pedicle screw path length, PL), the height of the pedicle of the vertebral arch (pedicle height, PH). 4) mm, P0.05; the length of pedicle screw (PL) from L1 to S1 in group AS was greater than that in group DDD, P0.05 and PL two were all in L3 segment, and AS patient's pedicle angle (EA) was smaller than that of the group; (7.07 + 3.21) degrees, (7.07 + 3.21) degrees, (12.62 + 3.21) degrees, P0.05. conclusion: in AS with protruding deformity of the lumbar and sacral pedicle screws can be used to increase the internal fixation strength, should pay attention to appropriately reduce the cohesion angle, and adjust the head and tail according to the shape of the sagittal plane. Second chapter ankylosing spondylitis with severe thoracolumbar kyphosis osteotomy. The incidence, risk factors and prognosis of brachial plexus paralysis after orthopedics: To explore the incidence, risk factors and prognosis of brachial plexus paralysis in patients with ankylosing spondylitis with severe thoracolumbar kyphosis (Pedicle Subtraction Osteotomy PSO) and Smith-Peterson osteotomy (SPO). The incidence and risk factors of postoperatively brachial plexus paralysis were studied by 2000.4-2013.10 in Department of orthopedics, Nanjing Gulou Hospital, with SPO or PSO orthopedic spondylitis (Ankylosing spondylitis AS) in the Department of orthopedics of Nanjing Gulou Hospital. The incidence and risk factors of postoperatively brachial plexus paralysis were studied through the evaluation and analysis of the kyphosis angle, the perioperative records and the postoperative nerve function. Results: 228 cases of this study were studied. 6 patients had postoperative brachial plexus paralysis. There were four risk factors for brachial plexus paralysis: (1) the angle of the thoracolumbar kyphosis was greater than 100 degrees; (2) the operation time was more than 4 hours; (3) the abduction of the upper limb of the upper limb was over 90 degrees in the operation (3); (4) the application of the shoulder joint cushion. The average of all 6 patients was 5 weeks after operation (2-16 weeks). Conclusion: the incidence of brachial plexus paralysis in patients with ankylosing spondylitis with severe thoracolumbar kyphosis is lower and the prognosis is better. The operation time is longer, and the improper placement of the body position is an important cause of the brachial plexus injury. Therefore, surgeons are in the osteotomy. Patients with tetanus with kyphosis need to think of the possibility of brachial plexus injury. During the operation, attention should be paid to the abduction of the upper limb not more than 90 degrees to reduce the traction of the brachial plexus. Intraoperative electrophysiological monitoring and timing adjustment of the position of the double upper limbs can effectively prevent the occurrence of brachial plexus injury. Third chapter PSO the anterior longitudinal toughening of the intervertebral disc of the osteotomy vertebra Effect of ossification on ankylosing spondylitis with kyphosis correction of thoracolumbar kyphosis. Objective: To evaluate the effect of PSO (pedicle subtraction osteotomy) osteotomy on the anterior longitudinal ligament ossification of the intervertebral disc on ankylosing spondylitis with thoracolumbar kyphosis correction. 71 cases of AS (Ankylosing spondylitis) protruding in single segment of lumbar vertebra were followed up for 2 years. According to the ossification of the anterior longitudinal ligament of the intervertebral disc, the osteotomy was divided into the ossification group and the non ossification group. The difference between the single segment PSO osteotomy angle of the two groups and the contribution of the vertebral body and intervertebral disc was analyzed and compared between the two groups. The difference was also divided between the two groups. Analysis and comparison of the difference in orthopedic loss between the two groups of forward Spina pelvic sagittal surfaces. Results: 71 cases of ankylosis were included in this study group, of which 32 cases were ossification group, and the age and PI value of the patients were significantly greater than those in the non ossification group (40.31 + 8.44 years old, 8.28 years old, and 49.36 + 9.75 vs.43.03 + 10.6 degrees, P0.05) single segment PSO osteotomy. The orthopedic angle was significantly smaller than the non ossification group (36.3 + 6.9vs.41.5 + 6.9 degrees, p0.001). The contribution of the intervertebral disc wedge change to the osteotomy angle was significantly greater in the non ossification group than in the ossification group (8.10 + 6.19 degrees, 18.5%vs.1.09 + 2.88 degrees, 2.7%, p0.001). The sagittal plane parameters of the spinal sagittal plane (sagittal vertica) were compared between the two groups for more than 2 years. L axis, SVA), pelvic inclination (pelvic tilt, PT), the 1 pelvic angle of the chest (T1 pelvic angle, TPA), the correction loss of the posterior convex angle of the thoracic vertebra (thoracic kyphosis) and the sacral inclination in the non ossification group. The correction loss of the disc wedge deformation in the non ossification group is also slightly larger, with a statistically significant difference (1.41 and 3.27 degrees). It is 22 + 1.49 degrees, P0.05). Conclusion: in patients with AS and thoracolumbar kyphosis, more single segment kyphosis can be obtained by selecting the non ossification of the anterior longitudinal ligaments of the adjacent segment of the intervertebral disc when PSO osteotomy is performed, but the probability of correction loss is greater in the long term follow-up.
【学位授予单位】：南京医科大学
【学位级别】：博士
【学位授予年份】：2017
【分类号】：R687.3

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