退变性腰椎侧后凸畸形的手术治疗

Surgical treatment of degenerative lumbar kyphoscoliosis

目的:探讨依据术前制作的腰骶曲线模板经后路神经减压、非对称性闭合-开放式楔形截骨术(asym-metric closing-opening wedge osteotomy)矫正治疗退变性腰椎侧后凸畸形的手术方法与疗效。方法:31例退变性腰椎侧后凸畸形患者,年龄65～78岁,平均72.3岁,因难以忍受的疼痛接受手术矫治,平均随诊4.1年,以术前、术后2个月及末次随访时的X线片、问卷及并发症进行评估。结果:术中没有并发症发生,术后所有患者疼痛感明显及持续减轻。末次随访时的X线片显示L1～S1前凸角度由后凸11.3°矫正至前凸50.5°(矫正61.8°),后凸畸形由64.3°矫正至前凸14.1°,侧凸畸形由48.9°矫正至8.3°,矢状面平衡由68.8mm矫正至27.1mm,骶股距(sacrofemoral distance)由59.3mm减至-5.1mm,骶椎倾斜角度(sacral inclination angle)由9.7°增至34.3°。大部分病例都可维持良好的矫正及临床结果,有8例(26%)发生交界后凸(junctional kyphosis)。结论:闭合-开放式楔形截骨手术的三柱松解(3-column release),彻底的神经减压,尽可能的矫正畸形,以及重建脊柱、骨盆和身体重心(center of gravity)的良好关系是治疗退变性腰椎侧后凸畸形成功的关键因素,单一后路手术可减少手术的危险,交界后凸仍是一个尚未解决的难题。

Objective：Degenerative lumbar kyphoscoliosis（DLKS） causes sagittal and coronal imbalance,posterior sacral migration away from the center of gravity line,and compromises the mechanical advantage of erector spinal musculature. The result is muscle fatigue and activity-related pain.We review radiographic and clinical results of patients with DLKS treated with neurologic decompression,asymmetric closing-opening wedge osteotomy （COWO）,instrumentation-assisted correction according to a preoperatively made template through a posterior-only approach.Method：Thirty-one patients with DLKS （mean age 72.3 years,range,65-78 years） treated for intractable pain were followed up for a mean of 4.1 years.We assessed their preoperative,2 month postoperative,and final follow-up radiographs and administered a questionnaire to measure changes in pain, function,self-image,patient satisfaction with surgery,and postoperative complications.Result：Final radiographs showed increased LI-SI lordosis from 11.3° to -50.5°（increase of 61.8°）,correction of kyphotic deformity from 64.3°to -14.1°,and correction of scoliotic deformity from 48.9°to 8.3°.Sagittal imbalance significantly improved from 68.8mm to 27.1mm,whereas the sacrofemoral distance decreased from 59.3mm to -5.1mm,and the sacral inclination angle increased from 9.7° to 34.3°.Subjective pain was significantly and persistently reduced.Most patients maintained good correction and had good clinical resuhs.No major complication occurred. Eight patients （26%） developed junctional kyphosis.Conclusion：Through neurologic decompression,the best possible correction and restoration of sound associations among the spine ,the pelvis ,and the center of gravity, are crucial in the surgical treatment of DLKS to obtain satisfactory clinical resuhs.The 3-column release procedure,COWO,and procedures of neurologic decompression and circumferential fusion at LS-SI make DLKS flexible enough to be manipulated adequately from behind.A posterior-only approach minimizes the risk of surgery.Junctional kyphosis remains a significant problem.