后路全脊椎切除与松解治疗先天性重度脊柱角状后凸

Posterior vertebral colunm resection and release in treatment of congenital severe angular kyphosis

目的探讨后路全脊椎切除与松解治疗先天性重度脊柱角状后凸的临床效果及其安全性。方法2004年2月-2012年2月,采用后路全脊椎切除与松解治疗先天性重度脊柱角状后凸畸形患者14例。其中男5例,女9例；年龄6~42岁,平均20.6岁。先天性分节不全型3例,先天性半椎体型8例和混合型3例。术前脊柱后凸 Cobb 角91°~155°,平均109.4°；术前矢状面偏移-0.1~5.5 cm ,平均0.9 cm。13例合并脊柱侧凸,Cobb角11°~128°,平均67.5°；术前冠状面偏移0~6.5 cm,平均2.6 cm。8例半椎体畸形中有2例合并神经损害,Frankel分级C级和D级各1例。术前Oswestry功能障碍指数（ODI）评分0~45分,平均16.8分。结果手术时间为5.6~10.7 h,平均6.9 h；术中出血1400~5100 ml,平均3160 ml；脊髓短缩为1.9~2.9 cm,平均缩短2.4 cm。融合固定节段为6~14节椎体,平均10.4节。14例患者均得到随访,随访24~96个月,平均44.9个月。末次随访结果：脊柱后凸 Cobb 角9°~44°,平均26.4°,后凸矫正率75.8%；矢状面偏移矫正到-0.8~0.5 cm,平均0.09 cm,矫正率89.8%；脊柱侧凸Cobb角0°~55°,平均17.2°,侧凸矫正率74.6%；冠状位偏移矫正到0~2.7 cm,平均0.5 cm,冠状位不平衡矫正率81.3%。术前2例神经损害者,术后Frankel分级恢复到E级。术后ODI评分0~2分,平均0.2分,改善率为98.8%。所有患者获得良好的骨质愈合,无脊髓损伤。结论后路全脊椎切除与松解治疗先天性重度脊柱角状后凸能有效改善脊柱的柔韧性,可获得极好的畸形矫正,且安全有效。

Objective To examine the efficacy of posterior vertebral column resection and release in treatment of severe congenital angular kyphosis. Methods From February 2004 to February 2012, 14 patients with severe congenital angular kyphosis deformity were treated surgically by posterior vertebral column resection and release. There were 5 males and 9 females with an average age of 20. 6 years （ range from 14 to 42 years old） . There were 3 cases of anterior failure of vertebral body segmentation, 8 cases of anterior failure of formation and 3 cases of combination of anterior failure of formation and segmentation. The local deformity was assessed by the Cobb method. The preoperative kyphosis angle was from 91° to 155°, with an average of 109. 4°. The average preoperative sagittal imbalance was 0. 9 cm, ranging from -0. 1 to 5. 5 cm. Thirteen patients also had scoliosis and the mean Cobb angle was mean 67. 5° （ range from 11° to 128°）. The coronal imbalance ranged from 0 to 6. 5 cm, average of 2. 6 cm. There were 2 cases who had neurologic deficits in the 8 patients with hemivertebrae. According to Frankel grading system, one patient was classified as grade C and the other grade D. The preoperative score of the Oswestry disability index （ODI） was 0-45 points, average of 16. 8. Results The average surgery time was 6. 9 hours （5. 6-10. 7 hours） with average blood loss 3 160 ml （1 400-5 100 ml） . The average spinal shortening was 2. 4 cm （range from 1. 9 to 2. 9 cm）. The average fusion segments were 10. 4, ranging from 6 to 14 segments. All patients were followed up for 24 -96 months, average of 44. 9 months. At the most recent follow-up, the kyphosis Cobb angle was corrected to 26. 4°（range from 9° to 44°）,with a correction rate of 75. 8%. The sagittal imbalance was corrected to 0. 09 cm（range from -0. 8 to 0. 5 cm）, with a correction rate of 89. 8%. The scoliosis Cobb angle was corrected to 17. 2°（range from 0° to 55°）, with a correction rate of 74. 6%. The coronal imbalance was corrected to 0. 5 cm （range from 0 to 2. 7 cm）, with a correction rate of 81. 3%. Two cases with preoperative neurologic deficits were recovered from grade C and D to grade E according to Franckel classification system. Bony fusion was achieved in all patients. There was no spinal cord injury. The ODI was improved to 0. 2 （range from 0 to 2）, with a 98. 8% improvement rate. Conclusions The technique of posterior release and vertebral column resection effectively improves the spinal flexibility. Excellent deformity correction can be achieved. The technique is a safe and effective alternative for severe congenital angular kyphosis.