单一半椎体型先天性脊柱侧后凸初次手术失败的原因分析及翻修方法选择

Reasons for failed primary operation and selection of revision methods for congenital kyphoscoliosis caused by a single hemivertebra

目的：探讨单一半椎体所致先天性脊柱侧后凸初次手术失败的原因及翻修方法选择。方法：对2000年5月~2008年3月收治的因初次手术失败而行翻修术且临床资料完整的11例单一半椎体所致先天性脊柱侧后凸患者进行回顾性分析。男5例,女6例。入院时年龄2~19岁,平均11.5岁。术前侧凸Cobb角15°～97°,平均52.2°;后凸Cobb角25°～105°,平均63.5°;C7铅垂线距骶骨中线距离为1.2～5.6cm,平均2.7cm。结果：初次手术失败的原因：（1）初次手术术式本身的局限性（3例）;（2）内固定选择不当或固定范围选择不当,同时未行半椎体切除和植骨融合术（4例）;（3）初次手术未切除致畸形的半椎体且未植骨（2例）;（4）术中操作不当（1例）;（5）内固定范围选择不当合并半椎体切除不彻底（1例）。根据每例患者的初次手术方式及手术失败原因的不同,采用个体化的翻修方法。翻修手术无大血管损伤、感染、死亡等并发症,1例术后出现短暂性原神经症状加重。术后侧凸Cobb角2°～66°（平均22.3°）,平均矫正率为64%;后凸Cobb角2°～61°（平均26.1°）,平均矫正率为59.6%;C7铅垂线距骶中线距离为0.7～2.5cm,平均1.4cm。随访1~5年,平均2.3年,末次随访时,侧凸Cobb角4°～63°,平均23.8°;后凸Cobb角0°～59°,平均29.9°;C7铅垂线距骶中线距离为0.3～3.1cm,平均1.2cm。术后1年X线片证实植骨均融合,内固定物无松动、断裂,未发现失代偿现象。结论：初次手术方法选择不当是单一半椎体所致先天性脊柱侧后凸初次手术失败的主要原因,正确选择合适的翻修方案可以获得较满意的临床疗效。

Objective：To investigate the reasons for failed primary operation and selection of revision methods for congenital kyphoscoliosis due to a single hemivertebra.Method：From May 2000 to March 2008,11 patients with congenital kyphoscoliosis caused by a single hemivertebra undergoing revision surgery were enrolled.There were 5 males and 6 females,with the mean age of 11.5 years（ranged,2 to 19 years）.The preoperative scoliosis Cobb angle was 15°-97°（mean,52.2°）,with the kyphotic Cobb angle of 25°-105°（mean,63.5°）.The horizontal distance between C7 plumb line（C7PL） and the central sacral vertical line（CSVL） was 1.2-5.6cm（mean,2.7cm） preoperatively.Result：Reasons for failed primary operation were as follows：inappropriate surgical procedure in 3 patients,poor instrumentation and meanwhile without hemivertebra resection and bone graft in 4,fixation without hemivertebra resection and bone graft in 2,improper intraoperative manipulation in 1,and poor instrumentation associated with incomplete hemivertebra excision in 1.The revision methods were individualized according to the primary surgical procedures and the reasons for revision.No major vascular injury,infection or death was noted.1 case had transient deterioration of previous neurological deficit.The mean postoperative Cobb angle of scoliosis was 22.3°（2°-66°）,with a mean correction rate of 64%.The kyphotic Cobb angle averaged 26.1°（2°-61°）,with an average correction rate of 59.6%.The postoperative horizontal distance between C7PL and CSVL averaged 1.4cm（0.7-2.5cm）.The final follow-up time varied between 1 year and 5 years after surgery（mean,2.3 years）.At final follow-up,the mean Cobb angle of scoliosis was 23.8°（4°-63°）;the kyphotic Cobb angle averaged 29.9°（0°-59°）;the horizontal distance between C7PL and CSVL averaged 1.2cm（0.3-3.1cm）.The one-year postoperative X-rays showed solid bony fusion without hardware failure in all the patients.Conclusion：Inappropriate selection of primary surgery remains the main reason for failed primary operation in congenital kyphoscoliosis caused by a single hemivertebra,and revision surgery should be individualized.