三柱截骨术治疗合并脊髓畸形的脊柱侧凸的安全性及有效性研究

发布时间：2018-01-25 23:50

  本文关键词： 脊柱侧凸 三柱截骨术 脊髓纵裂 脊髓空洞 脊髓栓系 安全性 有效性　出处：《北京协和医学院》2017年博士论文　论文类型：学位论文

【摘要】：研究背景:随着现代脊柱外科矫形技术的发展,脊柱截骨手术已经成为先天性脊柱侧凸、重度僵硬型脊柱侧凸以及强直性脊柱炎后凸畸形等疾病的治疗中广泛应用的一种术式。三柱截骨术是在传统的后柱截骨术的基础上发展而来,截骨范围涉及整个脊柱的前、中、后柱,可获得更好的矫形效果,包括全脊椎截骨(vertebrate columun resection,VCR)、半椎体切除(hemivertebra resection,HR)、三明治截骨(sandwich osteotomy,SO)及经椎;弓根椎体截骨术(pedicle subtraction osteotomy,PSO)等。另一方面,脊柱侧凸的患者往往伴发有脊髓畸形,如脊髓纵裂(split spinal cord malformation,SSCM)、脊髓空洞、脊髓栓系(tethered spinal cord syndrome,TCS)、Chiari畸形等。目前对于合并此类畸形的脊柱畸形患者接受三柱截骨矫形术的安全以及有效性尚无定论,相关研究报道也较少。合并脊髓畸形的脊柱侧后凸患者传统的治疗策略是先行神经外科手术处理脊髓畸形,择期再行侧弯矫形手术,以减少可能的神经系统并发症,目前已有研究采用脊柱截骨缩短术治疗脊髓栓系综合征获得了良好的效果。对于合并脊髓畸形的侧凸患者是否可在不处理脊髓畸形的情况下直接进行三柱截骨矫形术?随着技术的发展和经验的积累,我们尝试在不处理脊髓畸形的情况下通过三柱截骨对此类患者进行直接矫形,以避免预防性的神经外科手术。本研究针对我院应用一期三柱截骨术治疗伴发常见脊髓畸形的脊柱侧凸患者进行回顾性研究,对手术的有效性及安全性进行了分析。第一部分三柱截骨术治疗合并脊髓纵裂的脊柱侧凸1、研究对象与方法回顾性分析27例(女16例,男11例)合并脊髓纵裂的脊柱侧凸患者,其中Ⅰ型纵裂患者10例,Ⅱ型17例,均行一期三柱截骨矫形。Ⅰ型纵裂患者骨嵴位于截骨范围内7例,6例截骨前予以切除;其余患者未对纵裂畸形进行处理。随访3-67个月,平均随访时间20.1个月。术前、术后及随访时均摄站立位全脊柱正侧位X线片,对冠状面和矢状面Cobb角、躯干偏移进行测量分析。同时复习病历,统计手术时间、出血量、神经系统症状体征以及其他并发症情况。2、结果手术时间3-7.5 h,、平均为5.4 h,术中出血量200-4500ml,平均1300nml,固定椎体4-15个,平均10.1个。冠状面侧凸Cobb角术前平均60.4°,术后26.8°,末次随访29.3°,矫形率为62.7%;节段性后凸Cobb角术前平均60.4°,术后21.4°,末次随访24.3°,矫形率为63.4%;躯干偏移术前平均2.7cm,术后1.7cm,末次随访1.4 cm。3例患者术中MEP下降超过50%,手术结束前恢复正常。1例术中MEP消失,术后出现一过性肌力下降、二便障碍,随访好转。术后另有1例患者下肢麻木胀痛,调整螺钉位置后好转,1例患者出现血气胸。术后随访期间无神经并发症及内固定并发症发生。术前伴有神经症状者7例,术后及随访过程中症状无加重。3、结论一期三柱截骨手术治疗合并脊髓纵裂的脊柱侧凸病人,在达到满意的矫形效果的同时不会增加并发症的发生率。对于合并Ⅰ型脊髓纵裂的脊柱侧凸患者,若骨性纵裂位于截骨范围内,可在截骨过程中先对骨嵴进行切除,再进行截骨矫形;对于骨性纵裂范围与截骨节段不重合的患者以及Ⅱ型纵裂患者,则不需对脊髓畸形进行处理。同时术中脊髓监测对于评估脊髓状态,及时发现及预防神经损伤意义重大,在此类手术中不可或缺。第二部分三柱截骨手术治疗合并脊髓栓系的脊柱侧凸1、研究对象与方法回顾性分析16例(女9例,男7例)合并脊髓栓系的脊柱侧凸患者,均行一期三柱截骨矫形。随访3-72月,平均随访时间22.8个月。术前、术后及随访时均摄站立位全脊柱正侧位X线片,对冠状面和矢状面Cobb角、躯干偏移进行测量分析。同时复习病历,统计手术时间、出血量、神经系统症状体征以及其他并发症情况。2、结果手术时间3-8.5 h,平均为5.8h,术中出血量300-4500ml,平均1096ml,固定椎体5-15个,平均8.5个。冠状面侧凸Cobb角术前平均55.9°,术后18.8°,末次随访22.1°,矫形率为69.1%;节段性后凸Cobb角术前平均70.2°,术后28.3°,末次随访30.6°,矫形率为56.7%;躯干偏移术前平均2.7 cm,术后2.2 cm,末次随访2.3 cm。2例患者术中MEP下降超过50%,手术结束前恢复正常。1例术中MEP消失,术后出现一过性肌力下降、二便障碍,随访好转。另有1例患者术后出现血气胸。1例随访期间出现内固定感染。术前伴有神经症状者7例,术后及随访过程中症状均有改善。3、结论根据本研究的结果,对于合并脊髓栓系的脊柱畸形患者可以直接进行三柱截骨矫形,畸形矫正效果良好,并可改善患者的神经症状,且不会增加其并发症的发生率。在截骨过程中,脊髓监测信号异常提示存在脊髓损伤的可能,需要引起足够的重视。第三部分三柱截骨手术治疗合并脊髓空洞的脊柱侧凸1、研究对象与方法回顾性分析15例(女7例,男8例)合并脊髓空洞的脊柱侧凸患者,均行一期三柱截骨矫形。空洞范围位于矫形区内者6人,术前伴有神经症状者6人。随访3-71月,平均随访时间19.7个月。术前、术后及随访时均摄站立位全脊柱正侧位X线片,对冠状面和矢状面Cobb角、躯干偏移进行测量分析。同时复习病历,统计手术时间、出血量、神经系统症状体征以及其他并发症情况。2、结果手术时间3.5-8 h,平均为5.7h,术中出血量300-3000ml,平均1393ml,固定椎体6-14个,平均11.1个。冠状面侧凸Cobb角术前平均83.6°,术后31.4°,末次随访33.3°,矫形率为62.7%;节段性后凸Cobb角术前平均70.0°,术后20.9°,末次随访22.7°,矫形率为72.1%;躯干偏移术前平均2.6 cm,术后1.7 cm,末次随访1.65cm。1例术中MEP消失,术后出现双下肢肌力下降,影像学检查确认螺钉移位,突入椎管,压迫脊髓,急诊调整螺钉位置后好转。另有1例患者术后出现一过性肌力下降、感觉减退;1例出现血气胸。术后随访期间无神经并发症及内固定并发症发生。术前伴有神经症状者6例,术后及随访过程中症状无加重。3、结论根据本研究,一期三柱截骨手术治疗合并无症状的脊髓空洞的脊柱畸形患者是安全的,可以达到良好的矫形效果;无需矫形术前预防性脊髓空洞引流但是仍需注意其潜在的神经系统并发症风险,术中精细操作以及术中持续脊髓监测有助于降低神经系统并发症风险。
[Abstract]:Background: with the development of modern technology of orthopedic spine surgery, spine surgery has become the congenital scoliosis, a technique widely used for the treatment of severe rigid scoliosis and kyphosis of ankylosing spondylitis and other diseases. The three column osteotomy is developed based on the traditional posterior column osteotomy on the scope of the whole spine osteotomy before and after column, can obtain better correction effect, including total vertebral osteotomy (vertebrate columun resection VCR (hemivertebra), hemivertebra resection resection, HR three), Meiji osteotomy (sandwich osteotomy, SO) and vertebral pedicle vertebral osteotomy; (pedicle subtraction osteotomy, PSO). On the other hand, scoliosis patients often associated with spinal deformities, such as diplomyelia (split spinal cord malformation, SSCM), spinal cord hole, tethered cord (tethered spinal cord syndrome TCS, Chiari, etc.). The deformity of spinal deformity in patients with such deformity received three column osteotomy of the safety and effectiveness of inconclusive, related research is seldom reported. Treatment strategies combined with spinal kyphoscoliosis deformity is the traditional first Department of Neurosurgery surgical treatment of spinal deformities, and elective scoliosis the operation, in order to reduce the complications of the nervous system may be the current study used spinal osteotomy shortening treatment of tethered cord syndrome has good effect. Whether combined with spinal deformity of scoliosis can be directly carried out three column osteotomy in treatment of spinal cord malformation under? With the development of technology and experience we try to direct the accumulation of correction for such patients through three column osteotomy in treatment of spinal cord malformation by surgical prophylaxis to avoid Department of neurosurgery. This study According to the application in our hospital for a period of three column osteotomy for the treatment of concomitant common spinal deformity in patients with scoliosis were retrospectively studied, the efficacy and safety of surgery were analyzed. The first part of the three column osteotomy for the treatment of scoliosis with diastematomyelia 1, review the research objects and methods of analysis of 27 cases (16 female cases. 11 male patients with diastematomyelia) patients with scoliosis, including 10 cases of patients with type I fracture, 17 cases of type II, underwent a three column osteotomy. Bone fracture in patients with type 1 crest osteotomy range in 7 cases, 6 cases of osteotomy before resection; the rest patients without treatment of fracture deformity. The follow-up of 3-67 months, the average follow-up time was 20.1 months. The preoperative, postoperative and follow-up were taken standing full spine lateral X-ray of coronal and sagittal Cobb angle, trunk shift were measured and analyzed. At the same time to review the medical records, statistics of the operation time, bleeding volume, God The symptoms and other complications of.2, the operation time was 3-7.5 h, average 5.4 h, bleeding 200-4500ml, average 1300nml, fixation and 4-15, with an average of 10.1. The coronal scoliosis Cobb angle 60.4 degree preoperatively, postoperative 26.8 degrees, 29.3 degrees at the end of the follow-up, correction rate 62.7%; segmental kyphosis Cobb angle 60.4 degree preoperatively, postoperative 21.4 degrees, 24.3 degrees at the end of the follow-up, the correction rate is 63.4%; the average 2.7cm trunk shift before operation, 1.7cm after operation, at the end of the follow-up 1.4 cm.3 patients in MEP fell by more than 50%, normal.1 cases of MEP disappeared recovery before the end of surgery, postoperative transient decreased muscle strength, two improved. Postoperative follow-up, another 1 cases lower extremity numbness pain, adjust the screw position after improvement, 1 cases of patients with hemopneumothorax. No neurological complications and internal fixation complications during the postoperative follow-up period. All of the 7 cases with neurological symptoms operation. The symptoms and follow-up process aggravate.3, conclusion a three column osteotomy for treatment of scoliosis patients with diastematomyelia, complication rate will not increase to achieve satisfactory correction effect at the same time. The combined with type of diastematomyelia in patients with scoliosis, if myeloschisis osteotomy can be located within the scope of the the osteotomy procedure first resection of bone crest, then osteotomy; for myeloschisis and osteotomized segment does not coincide with and type II fracture patients without treatment of malformations of the spinal cord. Spinal cord monitoring for evaluation of spinal cord state at the same time in operation, timely detection and prevention of nerve damage is significant and indispensable in this kind of operation. The second part of the three column osteotomy for treatment of scoliosis with tethered spinal cord 1, review the research objects and methods of analysis of 16 cases (female 9 cases, male 7 cases) scoliosis with tethered cord. 鍑告偅鑰，

本文编号：1464047