跳跃式双节段经椎弓根椎体截骨治疗重度强直性脊柱炎胸腰椎后凸畸形

Osteotomy for severe thoracolumbar kyphosis in advanced ankylosing spondylitis： skipping two-level pedicle subtraction osteotomy

目的探讨一期跳跃式双节段经椎弓根椎体截骨术（PSO）治疗重度（Cobb〉1000）强直性脊柱炎（As）胸腰椎后凸畸形的可行性。方法回顾性分析2007年7月至2009年7月行跳跃式双节段PSO矫形内固定术的10例As胸腰椎后凸畸形患者，截骨节段分布为IJl、14（7例），T12、13（2例），L2、IJ5（1例），患者均为男性，年龄17—47岁（28．54-9．1）岁。所有患者术前术后均摄站立位全脊柱正侧位片。测量所有患者的术前、术后2周x线片的胸椎后凸（TK）、腰椎前凸（LL）、全脊柱最大后凸Cobb角（GK）、上截骨椎局部后凸角（LKl）、下截骨椎局部后凸角（LK2）、矢状面平衡（sagittalverticalaxis，SVA）°结果TK由术前平均（70．9±13）°（47～85°）矫正至术后（66．4±12．3）°（43-8l°）（P〉0．05），LL由术前平均（41．9±6．3）°（32—52°）矫正至术后（-44．1±9．5）°（-3l--59°）（P〈0．01），GK由术前（113．4±9．2）°（102～132°）矫正至术后（71．6±11．1）°（60-90°）（P〈0．01），LKl由术前平均（40．5±11．1）°（22～56°）矫正至术后（-13．5±9．2）°（-1-27°）（P〈0．01），LK2由术前（-0．3±13．9）°（-18—23°）矫正至术后（-26．8±11．1）°（-10-51°）（P〈0．01），SVA由术前平均25．2am（11．5-31．5am）矫正至术后5．8cm（1．5-9cm）（P〈0．01）°手术时间290—420rain，平均370min；术中出血量1700～3800ml，平均2600ml。1例术中硬脊膜破裂，术后脑脊液漏；1例术后右上肢暂时f生臂丛麻痹，1周内神经功能完全恢复。1例右大腿外侧疼痛，左踝关节内侧浅感觉减退，术后3周恢复。结论对于重度（Cobb〉100°）AS胸腰椎后凸畸形患者，跳跃式双节段经椎弓根椎体截骨可以获得更大的矫正角度（LL平均可获86。的矫正）及满意的矢状面重建，是一种安全有效的术式。

Objective To explore the feasibility of single-stage skipping two-level pedicle subtraction osteotomy （PSO） for severe thoracolumbar kyphosis （ Cobb 〉 100°） in advanced ankylosing spondylitis （AS）. Methods Ten AS patients with thoracolumbar kyphosis undergoing skipping two-level PSO were retrospectively reviewed. The most frequent levels of osteotomy was L1 and IA （ n = 7 ）, followed by T12 and L3 （ n = 2） and IX and L5 （ n = 1 ）. All patients were males with a mean age of 28.5 ±9. 1 years （ range： 17 - 47 ）. The preand post-operative values of thoracic kyphosis （ TK）, lumbar lordosis （ LL）, globe kyphosis （GK）, local kyphosis of osteotomized vertebra （LK1, LK2） and sagittal imbalance （SVA） were measured. Results Significant differences were observed with respects to the improvements of LL, GK, LK1, LK2 and SVA （P 〈 0. 01 ）. LL, GK, LK1, LK2 and SVA improved from 41.9°, 113.4°, 40.5°, -0.3° and 25.2 cm preoperatively to -44.1°, 71.6°, 13.5°, -26.8° and 5.8 cm postoperatively respectively. The mean operative duration was 370 minutes （range： 290 -420 ） and the estimated volume of blood loss 2600 ml （ range ： 1700 - 3800 ）. Dural tear occurred intra-operatively in1 patient. One had a transient brachial plexus paralysis and resolved after 1 week postoperatively. One had transient raiculopathy in right lower extremity and recovered completely 3 weeks postoperatively. Conclusion As a safe and effective technique for correction of severe thoracolumbar kyphosis （ Cobb 〉 100° ） secondary to AS, single-stage skipping two-level PSO osteotomy can achieve larger correction and better sagittal alignment with a mean correction of 86°in terms of LL.