重度僵硬型脊柱侧凸分期手术矫形不同撑开次数的效果及意义

The influence of distraction times on the surgical outcome in severe rigid scoliosis

目的：探讨分期前路松解、后路撑开联合后路固定融合治疗重度僵硬型脊柱侧凸患者侧弯及躯干平衡的改善情况,通过对不同撑开次数的手术效果及卫生经济学指标对比来评价第二次撑开的意义。方法：2010年1月-2014年1月共收治重度僵硬型脊柱侧凸（Cobb角〉90°,柔韧度〈30%）患者23例,根据后路撑开次数分为一次撑开组及两次撑开组。所有患者一期手术均为前路松解和第一次撑开,两次撑开组患者第二次撑开在第一次撑开后10d进行,两组患者均在撑开术后2周行后路融合固定术。分析比较两组患者术前、术后影像学躯干平衡参数;同时对两组患者并发症发生率、手术时间、手术出血量、住院时间、住院花费等卫生经济学指标进行对比。结果：总共有23例患者纳入研究,一次撑开组11例,两次撑开组12例。术前两组患者主弯Cobb角、主弯柔韧度、冠状位平衡、矢状位平衡、胸椎后凸、腰椎前凸差异无显著性（P〉0.05）。融合术后,两组患者主弯Cobb角、冠状位平衡、矢状位平衡较术前均有明显改善,差异有显著性（P〈0.05）;但两组间比较差异无显著性（P〉0.05）。两次撑开组中第一次与第二次撑开后除主弯Cobb角有明显改善外（P〈0.05）,其他指标间差异均无显著性（P〉0.05）。一次撑开组手术失血量、平均手术时间、住院时间、住院总费用均显著少于两次撑开组（P〈0.05）。两次撑开组围术期共有2例手术并发症发生（1例胸腔大量积液,1例术后下肢麻木,均通过相应治疗后恢复）,一次撑开组无相关并发症发生。结论：前路松解、后路撑开联合后路固定融合是一种治疗重度僵硬型脊柱侧凸有效安全的方法,两次撑开次能有限增加的躯干平衡的矫形效果,但可能会带来较高的手术费用及增加并发症发生率;从卫生经济学角度出发,临床上对于第二次的撑开应慎重进行。

Objectives： To investigate the improvement in the trunk balance following staged anterior release,internal distraction, posterior fusion in the treatment of severe and rigid scoliosis, and to compare the economic costs between the one-time distraction group and two-time distraction group. Methods： From January2010 to January 2014, 23 patients with severe and rigid scoliosis（Cobb angle90°, flexibility30%） were included in this study and devided into one-time distraction or two-time distraction group. For all patients, the primary surgery included anterior release and the first distraction, in the two-times distraction group, the second distraction was conducted 10 days after the first distraction, both groups had the final fusion surgery 2weeks after the distraction procedure. Radiographs on trunk balance, clinical records on health economic results（including complications, blood loss, operation time, hospital stay and hospital costs） were reviewed to e-valuate the surgical result; and compared between two groups. Results： A total of 23 patients was included in the study, 11 in the one-time distraction group, 12 in the two-time distraction group, there was no significant difference in preoperative major curve Cobb angle, flexibility of major curve, coronary imbalance, sagittal imbalance, thoracic kyphosis, and lumbar lordosis between two groups. After the surgery, the Cobb angle of major curve, coronary balance, sagittal balance improved significantly in both groups compared with the preoperative ones（P〈0.05）, but no statistical difference was noted between two groups（P〉0.05）. After the second distraction in the two-time distraction group, apart from major curve Cobb angle, there was no significant improvement of the balance parameters compared with those after the first distraction（P〈0.05）. In the one-time distraction group, the average total blood loss, the mean operation time, the total hospital stay and the mean hospital cost were significantly less than those of the two-time distraction group. Two cases in the two-time distraction groups were noted complications（1 case with pleura effusion, 1 with lower extremity numbness, both were fully recovered after appropriate treatment）, while none in the one-time distraction group. Conclusions：Anterior release, internal distraction and posterior fusion surgery can effectively correct the scoliosis and guarantee the level of trunk balance. Two-time distraction can further increase the correction of trunk balance to a limit degree, but considering the risk of complications and cost necessitated, a second distraction should be considered cautiously.