特发性脊柱侧凸的前路矫形手术

Anterior instrumentation and fusion for adolescent idiopathic scoliosis

目的评价前路矫形手术对特发性脊柱侧凸的治疗效果。方法回顾性分析术后随访时间超过1年的特发性脊柱侧凸34例,男5例,女29例;年龄8～17.5岁,平均15.7岁。侧凸类型包括PUMCⅠa型1例、Ⅰb型8例、Ⅰc型6例、Ⅱc1型4例、Ⅱd1型15例。采用前路三维矫形手术,内固定器械包括TSRH16例、MossMiami8例、CDH10例。术前、术后及随访时摄X线片,测量冠状面及矢状面Cobb角、躯干偏移、顶椎及下融合椎的旋转度、下融合椎与骶骨夹角,并观察有无假关节形成。结果全部病例随访12～63个月,平均21个月。术中出血量200～1200ml,平均255ml。融合3～7节椎体,平均4.42节。融合弯冠状面畸形矫正率平均为73.4%,矢状面手术前后Cobb角差异无显著性。7例胸腰段或腰椎后凸患者术前后凸平均11.9°,术后矫正为前凸6.8°。19例双弯患者术后上弯冠状面自动矫正率为39.5%(P<0.01);融合弯顶椎旋转改善率32%(P<0.01),下融合椎旋转亦有明显改善(P<0.05),上弯顶椎旋转无明显改善。凸侧Bending像融合弯Cobb角与术后比较差异有显著性(P<0.01)。单弯(PUMCⅠb型、Ⅰc型)者术后即刻躯干偏移增加7.3mm,1年后较术前改善7.5mm;双弯者术后躯干偏移持续改善。凹侧Bending像下融合椎与骶骨的夹角与术后比较差异无显著性。

Objective To evaluate the clinical results of anterior spinal fusion(ASF) with three-dimensional (3-D) instrumentations. Methods 34 cases receiving ASF with instrumentations over 1 year follow-up were reviewed. The coronal and sagittal Cobb's angles, trunk shifts, apical rotation, end fused vertebra rotation, and the lower end fused vertebra tilt-angle were measured on the standing AP and lateral radiographs before, after surgery and at the final follow-up. Results There were 5 males and 29 females with an average age of 15.7 years, the average follow-up was 21 months (range, 12-63 months). The types of curve covered PUMCⅠa in 1, Ⅰb in 8, Ⅰc in 6, Ⅱc1 in 4, Ⅱd1 in 15. All of them underwent anterior thoracolumbar or lumbar fusion. The average intra-operative bleeding was 255 ml (range, 200-1200 ml). The average fused vertebrae was 4.42 segments (range, 3-7 segments). The coronal correction rate of the fused curve was 73.4%, no significant change in the sagittal plane. In 7 cases with thoracolumbar or lumbar kyphosis, was corrected from 11.9° to lordosis 6.8°. The spontaneous correction rate of the upper curve was 39.5% (P<0.01) in 19 cases with double curve. An average correction rate of 32% of rotation was noted at the fused apical vertebra (P<0.01). There was significant improvement of rotation at the end fusion vertebra (P<0.05), while no significant change at the upper apical vertebra. There was significant difference between the Cobb's angle of the fused curve on the convex bending and post-operative films (P<0.01). Trunk shift deteriorated after surgery and balance recovered at one-year follow-up in the single curve, while continuous improvement was noted in the double curve. The lower end fused vertebra tilt-angle at the final follow-up was similar as that on the concave bending before surgery. Conclusion ASF with 3-D instrumentation shows excellent correction of the coronal curvature and sagittal kyphosis, and is capable to correct highly of rotational deformities with a shorter fusion. It is indicated to lower thoracic, thoracolumbar, lumbar and some double curve.