脊柱缩短截骨术治疗合并脊髓栓系的先天性脊柱侧弯的安全性和有效性研究
发布时间：2019-07-10 09:01
【摘要】：研究背景 脊髓栓系是指由于终丝肥厚等原因，将脊髓圆锥固定于脊柱下端而无法相对移动。由于脊髓受到牵拉导致张力增加，造成脊髓缺血、缺氧和变性，在临床上，一部分病人会出现下肢的无力、麻木、肢体细小、足部畸形以及大小便障碍等神经损害症状。如果不及时得到手术治疗，患者的神经症状将有可能加重。因此，通过及时有效的手术治疗防止神经功能的进一步损伤，是脊髓栓系患者治疗的关键。 先天性脊柱侧弯常合并椎管内脊髓畸形，其中，约13%～29%的患者合并脊髓栓系，增大了脊柱侧弯的手术难度，增加了手术风险。一方面：肥厚的终丝，将脊髓圆锥牵拉固定于脊柱尾端，限制了脊髓与脊柱骨性结构之间的相对移动，终丝牵拉脊髓，导致脊髓缺血、变性。而另一方面，对脊柱侧弯进行矫形时，脊髓与脊柱会产生相对移动，可能会加重栓系对脊髓的牵拉，加重神经症状。因此，对于合并脊髓栓系的脊柱侧弯，如何解决侧弯矫形与脊髓栓系这一矛盾，是手术治疗的难点和重点。 传统的治疗方法是先行栓系松解术，解除肥厚终丝对脊髓的牵拉固定,减轻脊髓张力，3～6个月后再行侧弯矫形手术，该方法虽然取得了一定的治疗效果，但大量实践表明，该治疗方法并发症发生率高，栓系松解不彻底比例高，发生再栓系几率高，而且需要二次手术、二次麻醉，增加了患者的痛苦和手术风险。因此，需要探索更加安全有效的新的手术方案。 1995年，Kokubun介绍了应用脊柱缩短截骨术治疗单纯脊髓栓系的手术方法。该方法主要考虑到肥厚的终丝向下牵拉脊髓，导致脊髓张力增加，是引起临床症状的主要病因。因此，他们采用截骨手术缩短脊柱的骨性结构，以间接减少终丝对脊髓的牵拉，应用该方法治疗6例单纯栓系的患者，取得了满意的治疗效果。此外，截骨术已经广泛应用于脊柱侧弯，特别是重度僵硬性脊柱侧弯患者的手术治疗。因此，，对于合并脊髓栓系的脊柱侧弯，是否能够不进行传统的栓系松解术，而是单纯采用脊柱截骨术，在纠正脊柱侧弯的同时，达到缓解脊髓张力的目的呢？本研究回顾性分析了我院应用脊柱缩短截骨术治疗合并脊髓栓系的脊柱侧弯患者的有效性和安全性。 第一部分全脊椎截骨术（VCR）治疗合并脊髓栓系的重度先天性脊柱侧弯的安全性及有效性研究 1.材料和方法 2007年4月～2011年8月，于我院行全脊椎截骨（vertebrate columun resection,VCR）治疗合并脊髓栓系的重度脊柱侧弯患者13例，其中男性患者6例、女性患者7例，平均年龄15.8岁。所有患者脊髓末端均在L4椎体平面或平面以下。患者于顶椎部位行VCR截骨。截骨完成矫形。记录手术时间、失血量、输血量；比较手术前、后、随访过程中患者脊柱侧弯和神经症状的改变。通过脊柱侧弯研究会问卷(SRS-22Questionnaire)及改良日本骨科学会评分（mJOA-Score)对患者生活质量等进行评估，所有患者平均随访时间44.4个月。 2.结果 平均手术时间619.6±80.9min、平均失血量3061.5±1367.8ml、平均输血量3068.3±1586.1ml ml。平均截骨长度25.5±3.1mm，平均融合14.3±1.1个椎体。术前患者冠状位Cobb角平均102.8°±17.0°，术后矫正为42.8°±10.8°，矫正率59.0%±7%，末次随访时，平均Cobb角为42.8°±10.8°(矫正率57±7%)；术前矢状面Cobb角平均81.0°±17.6°，术后矫正为34.3°±9.5°，末次随访为35.6°±7.9°。在末次随访中，下肢感觉减退患者症状改善率75%(3/4)，4例下肢肌力下降及5例腰背部疼痛患者症状均得到了缓解，1例术前小便障碍患者，症状消失。本组病例总体并发症为2例，其中1例脑脊液漏患者，经保守治疗一周后痊愈，1例术后即刻出现神经并发症患者，在出院后3个月随访时症状消失。 3.结论 对于合并脊髓栓系的重度先天性脊柱侧弯患者，VCR在有效矫正脊柱侧弯的同时，间接减少了脊髓张力，可有效缓解因栓系引起的神经症状，且未明显增加术后并发症的发生。尽管该手术耗时相对较长，患者出血量相对较多，对患者的手术耐受性是一种考验，但是我们的研究证明，该手术方式是一种相对安全有效的手术方式，为合并脊髓栓系的重度脊柱侧弯患者的治疗提供了治疗选择。 第二部分经椎弓根截骨术（PSO）治疗合并脊髓栓系的轻中度先天性脊柱侧弯的安全性及有效性研究 1.材料和方法 2007年4月～2011年8月，于我院行脊柱缩短截骨术治疗合并脊髓栓系的轻中度脊柱侧弯患者共8例，其中男性患者1例、女性患者7例，平均年龄14.8岁。所有患者脊髓末端均在L4椎体平面或平面以下。患者于顶椎部位行截骨手术，手术方式为经椎弓根脊柱截骨术（pedicle substraction osteotomy, PSO)。截骨完成行矫形手术。记录手术时间、失血量、输血量；比较手术前后，及随访过程中患者脊柱畸形和神经症状的改变。 通过SRS-22Questionnaire及mJOA-Score对患者生活质量等进行评估，所有患者平均随访时间46.7个月。 2.结果 平均手术时间449.4±73.1min、平均失血量2293.8±1060.5ml、平均输血量2500±1109.5ml。平均截骨长度22.8±5.0mm，平均融合12±2.2个椎体。术前患者冠状位Cobb角平均68.8°±7.6°，术后矫正为23.1°±5.8°，矫正率65.8±9.7%，末次随访时，平均Cobb角为24.4°±5.9°；术前矢状面Cobb角平均58.2°±9.1°，术后矫正为25.8°±9.0°，末次随访为27.6°±8.0°。在末次随访中，下肢肌力减弱患者症状改善率83.3%(5/6)，3例腰骶部或下肢疼痛患者及1例下肢感觉减退患者症状均得到改善，2例术前大小便障碍患者，症状均消失。本组病例总体并发症为2例，其中1例脑脊液漏患者，经保守治疗一周后痊愈，1例术后即刻出现神经并发症患者，在出院后3个月随访时症状消失。 3.结论 PSO治疗合并脊髓栓系的轻中度先天性脊柱侧弯患者，在达到预期的侧弯矫形效果的同时，能够通过经椎弓根截骨术间接减少脊髓张力，进而改善患者的神经功能状态，避免了传统的椎管内栓系松解手术可能对脊髓造成的损伤，且未增加手术并发症的发生率，是一种相对安全有效的手术方式。
[Abstract]:Study Background The cord of the spinal cord refers to the fixation of the spinal cord to the lower end of the spine due to the end-wire hypertrophy and the like and cannot be moved relative to each other. The spinal cord is induced to increase in tension, resulting in spinal cord ischemia, hypoxia, and degeneration. In the clinical part, a part of the patient will have the weakness of the lower limbs, the numbness, the fine limbs, the deformity of the foot, and the disorder of the bowels and the like. Form. If surgical treatment is not available in time, the patient's neurological symptoms will be possible. Heavy. Therefore, the prevention of further damage to the neurological function by timely and effective surgical treatment is the effect of the treatment of the spinal cord patient. Key. The congenital scoliosis of the spine is often combined with the spinal cord deformity in the spinal canal, in which about 13% to 29% of the patients are combined with the spinal cord, which increases the difficulty of operation of the scoliosis and increases the hand On the one hand, the end of the spinal cord is fixed at the tail end of the spinal column, the relative movement between the spinal cord and the bony structure of the spinal column is limited, the spinal cord is pulled by the end wire, and the spinal cord ischemia is caused. and on the other hand, when the scoliosis is orthopedic, the spinal cord and the spinal column produce relative movement, which may increase the tension of the tethered cord to the spinal cord, As a result, it is difficult to solve the contradiction between the lateral bending and the tethered cord of the spinal cord of the spinal cord of the combined spinal cord, and it is the difficult point of the surgical treatment. And a large number of practice shows that the treatment method is concurrent. The incidence of the disease is high, the rate of the release of the bolt is high, the probability of rebolting is high, the secondary operation is required, the secondary anesthesia is required, and the pain of the patient is increased. and surgical risk. Therefore, it is necessary to explore new and more safe and effective new In 1995, Kokubun described the use of a spinal-shortening osteotomy for the treatment of pure spinal cord The method of the invention mainly takes into account that the end wire of the hypertrophy pulls the spinal cord down, resulting in an increase of the tension of the spinal cord, which is caused by the fact that the tension of the spinal cord is increased, The main cause of the symptoms is that they use the osteotomy to shorten the bony structure of the spine to indirectly reduce the tension of the end wire to the spinal cord. satisfactory therapeutic effects. In addition, the osteotomy has been widely used for scoliosis, especially in the case of severe, stiff, scoliosis Surgical treatment of the patient. Therefore, for the scoliosis of the spinal cord of the combined spinal cord, it is possible to use a spinal osteotomy instead of a conventional bolt-based approach, and to achieve the relief of the spine while correcting the scoliosis. What is the purpose of the cord tension? This study is a retrospective analysis of the application of the spinal-reduction osteotomy in our hospital to treat the scoliosis patients with the spinal cord. Efficacy and safety. The first partial total-spine osteotomy (VCR) was used to treat the severe congenital scoliosis of the combined spinal cord Safety and effectiveness Sex study 1. Materials and methods in our hospital from April 2007 to August 2011. 13 cases of severe scoliosis in the combined spinal cord,6 of which were male and female, respectively. 7 of the patients with an average age of 15.8 years. The end of the spinal cord in all patients All below the plane or plane of the l4 vertebral body. The patient is at the position of the top vertebra The cutting of the VCR was performed. The osteotomy was completed. The time of operation, the amount of blood loss, the amount of blood transfusion were recorded, and the patients with the pre-operative, post-operative, follow-up The changes in the lateral and neurological symptoms of the spinal column were assessed by the SRS-22 Questionnaire and the modified Japanese Orthopaedic Association (mJOA-Score) to assess the quality of life of the patient. average of persons with The mean operative time was 619.6-80.9 min, the mean blood loss was 3061.5-1367.8 ml, and the mean blood transfusion volume was 3061.5-1367.8 ml. 3068.3 to 1586.1 ml. The average cut length is 25.5 to 3.1m The average Cobb angle was 102.8 掳 and 17.0 掳, the post-operative correction was 42.8 掳 and 10.8 掳, the correction rate was 59.0% and the correction rate was 59.0%. The mean Cobb angle was 42.8 掳 and 10.8 掳 (the correction rate was 57%7%) at the last follow-up; the average Cobb angle was 81.0 掳 and 17.6 in the pre-operative sagittal plane. 掳, post-operative correction of 34.3 掳 to 9.5 The last follow-up was 35.6 掳-7.9 掳. In the last follow-up, the symptoms of lower limb hypoesthesia were 75% (3/4),4 lower limb muscle strength and 5 cases of pain in the back of the waist. The total complications were 2 cases,1 case of cerebrospinal fluid leakage, one week after conservative treatment and 1 case of neurological complications immediately after operation. Patient, in 3. Conclusion For patients with severe congenital scoliosis, VCR can reduce the tension of the spinal cord and effectively relieve the risk of spinal cord. The neurological symptoms of the patient and the occurrence of postoperative complications were not significantly increased. Although the procedure is relatively long and the amount of blood loss of the patient is relatively large, the patient's surgical tolerance is a test, but our study The surgical method is a relatively safe and effective way of operation, in order to consolidate the spinal cord. The treatment of the severe scoliosis patients with the tether provides a treatment option. The second part is treated with a pedicle osteotomy (PSO) for the treatment of the combined ridge. The mild and moderate of the tethered cord. Study on the safety and effectiveness of scoliosis in the patients with congenital scoliosis 1. Materials and Methods From April 2007 to August 2011, a total of 8 patients with mild and moderate scoliosis combined with the tethered cord of the spinal cord were treated with a reduction osteotomy of the spine in our hospital. Example: One of the male patients,7 female patients, mean age 14.8 years of age. The end of the spinal cord of all patients was below the plane or plane of the L4 vertebral body. The patient underwent an osteotomy at the position of the apex, and the procedure was a pedicle spinal osteotomy (Pedicl e substract The operation time, blood loss and the amount of blood transfusion were recorded. The changes in the patient's spinal deformities and neurological symptoms were compared before and after the procedure and in the follow-up procedure. SRS-22 Questionnaire and mJOA-Score to be born to the patient The average follow-up time of all patients was 46.7 months.2. The mean operative time was 449.4 to 73.1 min and the mean blood loss was 2. 293.8-1060.5 ml, mean blood transfusion amount of 2500-1109.5 Ml. The average cut length was 22.8-5.0 mm, with an average fusion of 12-2.2 vertebral bodies. The preoperative coronal Cobb angle was 68.8 掳-7.6 掳, the post-operative correction was 23.1 掳-5.8 掳, the correction rate was 65.8-9.7%, the mean Cobb angle was 24.4 掳-5.9 掳 at the last follow-up, and the preoperative sagittal Cobb angle was 58.2 掳-5.9 掳. The post-operative correction was 25.8 掳 to 9.0 掳 and the last follow-up was 27.6 掳 to 8.0 掳. In the last follow-up, the symptoms of the lower limb muscle strength were 83.3% (5/6),3 cases of low-limb pain and 1 case The symptoms of the patients with lower limb hypoesthesia were improved, and the symptoms disappeared in 2 cases. The total complications in this group were 2 cases, of which 1 case of cerebrospinal fluid leakage was treated by conservative treatment for a week. Recovered,1 3. Conclusion PSO is used to treat the patients with mild and moderate congenital scoliosis and to achieve the desired side-bending effect. At the same time, the spinal cord tension can be indirectly reduced through the transpedicular osteotomy, so that the neurological function state of the patient can be improved,
【学位授予单位】：第四军医大学
【学位级别】：硕士
【学位授予年份】：2014
【分类号】：R687.3
本文编号：2512495
[Abstract]:Study Background The cord of the spinal cord refers to the fixation of the spinal cord to the lower end of the spine due to the end-wire hypertrophy and the like and cannot be moved relative to each other. The spinal cord is induced to increase in tension, resulting in spinal cord ischemia, hypoxia, and degeneration. In the clinical part, a part of the patient will have the weakness of the lower limbs, the numbness, the fine limbs, the deformity of the foot, and the disorder of the bowels and the like. Form. If surgical treatment is not available in time, the patient's neurological symptoms will be possible. Heavy. Therefore, the prevention of further damage to the neurological function by timely and effective surgical treatment is the effect of the treatment of the spinal cord patient. Key. The congenital scoliosis of the spine is often combined with the spinal cord deformity in the spinal canal, in which about 13% to 29% of the patients are combined with the spinal cord, which increases the difficulty of operation of the scoliosis and increases the hand On the one hand, the end of the spinal cord is fixed at the tail end of the spinal column, the relative movement between the spinal cord and the bony structure of the spinal column is limited, the spinal cord is pulled by the end wire, and the spinal cord ischemia is caused. and on the other hand, when the scoliosis is orthopedic, the spinal cord and the spinal column produce relative movement, which may increase the tension of the tethered cord to the spinal cord, As a result, it is difficult to solve the contradiction between the lateral bending and the tethered cord of the spinal cord of the spinal cord of the combined spinal cord, and it is the difficult point of the surgical treatment. And a large number of practice shows that the treatment method is concurrent. The incidence of the disease is high, the rate of the release of the bolt is high, the probability of rebolting is high, the secondary operation is required, the secondary anesthesia is required, and the pain of the patient is increased. and surgical risk. Therefore, it is necessary to explore new and more safe and effective new In 1995, Kokubun described the use of a spinal-shortening osteotomy for the treatment of pure spinal cord The method of the invention mainly takes into account that the end wire of the hypertrophy pulls the spinal cord down, resulting in an increase of the tension of the spinal cord, which is caused by the fact that the tension of the spinal cord is increased, The main cause of the symptoms is that they use the osteotomy to shorten the bony structure of the spine to indirectly reduce the tension of the end wire to the spinal cord. satisfactory therapeutic effects. In addition, the osteotomy has been widely used for scoliosis, especially in the case of severe, stiff, scoliosis Surgical treatment of the patient. Therefore, for the scoliosis of the spinal cord of the combined spinal cord, it is possible to use a spinal osteotomy instead of a conventional bolt-based approach, and to achieve the relief of the spine while correcting the scoliosis. What is the purpose of the cord tension? This study is a retrospective analysis of the application of the spinal-reduction osteotomy in our hospital to treat the scoliosis patients with the spinal cord. Efficacy and safety. The first partial total-spine osteotomy (VCR) was used to treat the severe congenital scoliosis of the combined spinal cord Safety and effectiveness Sex study 1. Materials and methods in our hospital from April 2007 to August 2011. 13 cases of severe scoliosis in the combined spinal cord,6 of which were male and female, respectively. 7 of the patients with an average age of 15.8 years. The end of the spinal cord in all patients All below the plane or plane of the l4 vertebral body. The patient is at the position of the top vertebra The cutting of the VCR was performed. The osteotomy was completed. The time of operation, the amount of blood loss, the amount of blood transfusion were recorded, and the patients with the pre-operative, post-operative, follow-up The changes in the lateral and neurological symptoms of the spinal column were assessed by the SRS-22 Questionnaire and the modified Japanese Orthopaedic Association (mJOA-Score) to assess the quality of life of the patient. average of persons with The mean operative time was 619.6-80.9 min, the mean blood loss was 3061.5-1367.8 ml, and the mean blood transfusion volume was 3061.5-1367.8 ml. 3068.3 to 1586.1 ml. The average cut length is 25.5 to 3.1m The average Cobb angle was 102.8 掳 and 17.0 掳, the post-operative correction was 42.8 掳 and 10.8 掳, the correction rate was 59.0% and the correction rate was 59.0%. The mean Cobb angle was 42.8 掳 and 10.8 掳 (the correction rate was 57%7%) at the last follow-up; the average Cobb angle was 81.0 掳 and 17.6 in the pre-operative sagittal plane. 掳, post-operative correction of 34.3 掳 to 9.5 The last follow-up was 35.6 掳-7.9 掳. In the last follow-up, the symptoms of lower limb hypoesthesia were 75% (3/4),4 lower limb muscle strength and 5 cases of pain in the back of the waist. The total complications were 2 cases,1 case of cerebrospinal fluid leakage, one week after conservative treatment and 1 case of neurological complications immediately after operation. Patient, in 3. Conclusion For patients with severe congenital scoliosis, VCR can reduce the tension of the spinal cord and effectively relieve the risk of spinal cord. The neurological symptoms of the patient and the occurrence of postoperative complications were not significantly increased. Although the procedure is relatively long and the amount of blood loss of the patient is relatively large, the patient's surgical tolerance is a test, but our study The surgical method is a relatively safe and effective way of operation, in order to consolidate the spinal cord. The treatment of the severe scoliosis patients with the tether provides a treatment option. The second part is treated with a pedicle osteotomy (PSO) for the treatment of the combined ridge. The mild and moderate of the tethered cord. Study on the safety and effectiveness of scoliosis in the patients with congenital scoliosis 1. Materials and Methods From April 2007 to August 2011, a total of 8 patients with mild and moderate scoliosis combined with the tethered cord of the spinal cord were treated with a reduction osteotomy of the spine in our hospital. Example: One of the male patients,7 female patients, mean age 14.8 years of age. The end of the spinal cord of all patients was below the plane or plane of the L4 vertebral body. The patient underwent an osteotomy at the position of the apex, and the procedure was a pedicle spinal osteotomy (Pedicl e substract The operation time, blood loss and the amount of blood transfusion were recorded. The changes in the patient's spinal deformities and neurological symptoms were compared before and after the procedure and in the follow-up procedure. SRS-22 Questionnaire and mJOA-Score to be born to the patient The average follow-up time of all patients was 46.7 months.2. The mean operative time was 449.4 to 73.1 min and the mean blood loss was 2. 293.8-1060.5 ml, mean blood transfusion amount of 2500-1109.5 Ml. The average cut length was 22.8-5.0 mm, with an average fusion of 12-2.2 vertebral bodies. The preoperative coronal Cobb angle was 68.8 掳-7.6 掳, the post-operative correction was 23.1 掳-5.8 掳, the correction rate was 65.8-9.7%, the mean Cobb angle was 24.4 掳-5.9 掳 at the last follow-up, and the preoperative sagittal Cobb angle was 58.2 掳-5.9 掳. The post-operative correction was 25.8 掳 to 9.0 掳 and the last follow-up was 27.6 掳 to 8.0 掳. In the last follow-up, the symptoms of the lower limb muscle strength were 83.3% (5/6),3 cases of low-limb pain and 1 case The symptoms of the patients with lower limb hypoesthesia were improved, and the symptoms disappeared in 2 cases. The total complications in this group were 2 cases, of which 1 case of cerebrospinal fluid leakage was treated by conservative treatment for a week. Recovered,1 3. Conclusion PSO is used to treat the patients with mild and moderate congenital scoliosis and to achieve the desired side-bending effect. At the same time, the spinal cord tension can be indirectly reduced through the transpedicular osteotomy, so that the neurological function state of the patient can be improved,
【学位授予单位】：第四军医大学
【学位级别】：硕士
【学位授予年份】：2014
【分类号】：R687.3
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