青少年先天性上胸椎侧弯的治疗

Treatment for congenital upper thoracic curve in adolescence

目的本文报道青少年先天性上胸椎脊柱侧弯病理变化特点、改进治疗方法和结果。方法本组先天性上胸椎脊柱侧弯14例,男5例,女9例;年龄9～15岁,平均11岁;左侧弯、右侧弯各7例;Cobb角40°～55°,平均47°;锁骨角18°～23°,平均21°。畸形原因主要为上胸椎单侧分节不良、骨桥形成或半椎体或并肋等引起。临床表现为两肩不平衡,凸侧肩部高起,肩胛骨上移,胸背后凸畸形加重,T1椎体倾斜。14例均手术矫形治疗俯卧位,凹侧有并肋、骨桥或手术区有骨性脊髓纵裂者,先予切除或松解。以侧弯顶椎为中心作纵切口,显露两侧椎板。先在凹侧下终末椎处,安装抱钩;然后在上终末椎处安装椎弓根钩;再在凸侧下终末椎处,安装椎弓根钩,在上终末椎处安装抱钩或两个横突钩(用椎板钩代替横突专用钩);随后预弯凸、凹侧金属杠,先安上凹侧金属杠,适当旋转以维持胸椎生理后凸弧度,再逐渐撑开至矫形满意后锁定凹侧金属杠;最后安上凸侧金属杠,给予加压固定。根据局部软组织决定安装1～2根横向DDT装置。唤醒试验后,取髂骨植骨。2周后拆线,下地行走。本组病例,最高上胸椎的椎弓根钩安放在C7处2例,其余在T1或T2处,最高上胸椎的横突钩安放在T2处。最下椎弓根钩、横突钩安放在中胸段。结果本组病例手术后随访1～3年,平均2年。双肩不等高明显改进。

Objective To review the pathological characteristics and modified surgical procedure on congenital upper thoracic curve in adolescence and its results.Methods There were 14 patients (5 males and 9 females) with congenital upper thoracic curve and their mean age was 11 years (range: 9～15 yrs). 7 patients had left convex and 7 had right. The mean Cobb angle was 47° (range: 40°～55°). The clavicle angle ranged from 18° to 23° with the mean of 21°. The main signs were unbalance of both shoulders,a high scapula at the convex side,kyphoscoliosis at upper back and a tilt of the first thoracic vertebra. The modified surgical procedure was a posterior approach. Firstly, the fused ribs or bone bridge was resected at the concave side or diastematomyelia in the curve of spine exposing all laminae and transverses of the main curve. Secondly, at the concave side a transversal hook and a pedicular hook were inserted respectively at the inferior terminal vertebra (called hugging hooks)and a pedicular hook was inserted at an upper terminal vertebra. At the convex side,the similar procedure was performed just like at concave side but the hugging hooks should be at an upper terminal vertebra.Then a short rod was debentnt, fixed and rotated at the concave side hugging the two hooks and distracting the rod properly. At the convex side,the same procedure was done as at the concave side but compressing the rod instead. Finally, DDT was put up. After the wake up test,bone graft was taken from ilium. Two weeks after the surgery, the patients were allowed to walk.Results They were followed up for a period of 1～3 years with the mean being 2 years. Their shoulders were nearly balanced. The Cobb angles were 20°～25° with an average of 23° and improvement of 53%.The clavicle angle was 3°～10°,with an average of 8°. There was no craftshank phenomenon.Conclusions Congenital upper thoracic curve is quite different pathologically from upper thoracic curve of idiopathic scoliosis. Early surgery of instrumentation outside the spinal canal is a safe, simple and effective procedure. From the aspect of growth, this method has little effect on the spinal canal. It is therefore advocated for mild to moderate scoliosis in patient at the age of 8 or more.