前路半椎体切除截骨后路矫形固定治疗严重先天性脊柱侧凸

Resection of hemivertebra and anterior intervertebral osteotomy combined with posterior correction in treating serious congenital scoliosis

目的探讨分期前路半椎体切除截骨后路矫形手术治疗严重先天性脊柱侧凸的临床疗效。方法严重先天性脊柱侧凸14例,男4例,女10例;年龄8～13岁,平均11.2岁。其中形成缺陷2例,分节缺陷6例,混合型6例。半椎体位于T53例,T2、T8、T10、T11、L1、L4各1例。胸弯12例,胸腰弯2例。术前冠状面Cobb角63°～95°,平均72.1°。胸椎后凸减小或前凸8例,胸腰段后凸4例。一期采用前路半椎体切除、多节段椎体间楔形截骨及分节不全松解;二期采用后路椎弓根钉棒系统三维矫形固定。前后路手术均植骨,平均截骨5.5个节段。结果一期前路术后冠状面Cobb角48°～60°,平均51.5°;矫正率19.6%～37.8%,平均28.6%。二期术后冠状面Cobb角5°～45°,平均30.5°;矫正率52.6%～87.5%,平均62.5%。8例存在胸椎后凸减小或前凸的患者均恢复生理性后凸,4例胸腰段后凸患者3例达到矢状面矫正。全部病例随访8～30个月,平均12.1个月。无断钉、断棒及明显的矫正度丢失,植骨融合良好。发生并发症2例,椎弓根钉帽松动1例,T1神经根激惹1例。结论一期前路半椎体切除、多节段椎体间楔形截骨、分节不全松解,二期后路矫形固定及前后路植骨治疗先天性脊柱侧凸能够达到较满意的矫形效果,适合于8～12岁的青春期前患者。

Objective To discuss the clinical outcomes of two-stage anterior osteotomy and posterior correction to serious congenital scoliosis in children. Methods 14 patients with serious congenital scoliosis was typeⅠin 2 cases, type Ⅱin 6 cases, and combination of type Ⅰ and Ⅱ in 6 cases according to MacEwen's classification. There were 4 boys and 10 girls, and the age was ranged from 8 to 13 years with a mean of 11.2 years. The preoperative coronal Cobb's angle was ranged from 63° to 95° with an average of 72.1°. The hemivertebra ranging from T2 to L4. All cases were treated by anterior osteotomy, resection of hemivertebrae, and release of unilateral unsegmented bar, combined with posterior correction, and fusion with bone graft. The average range of osteotomy was 5.5 segments in anterior procedure, and all the patients were instrumented with pedicle screws in posterior procedure. Results In this group, the blood loss was 300 to 500 ml in first stage and 700 to 1200 ml in second stage respectively. After the first-stage surgery, the coronal Cobb's angle was ranged from 48° to 60° with a mean of 51.5°, and the correction rate ranged from 19.6% to 37.8% with an average of 28.6%. After the second-stage surgery, the Cobb's angle was ranged from 5° to 45° with a mean of 30.5° and the correction rate was from 52.6% to 87.5% with an average of 62.5%. All cases were followed up for 8 to 30 months (mean, 12.1 months). There were no loss of correction and major complications of the fixations, and the spinal fusions were excellent. Complications were observed in 2 cases, one was the loosening of the screw cap, and another was the T1 radicular pain after operations. Conclusion The combined anterior and posterior approach is an effective technique for serious congenital scoliosis in children of 8 to 12 years.