136例脊柱畸形诊治中的失误与手术并发症分析

Analysis of pitfall and complication in the treatment of 136 spinal deformities

[目的]总结脊柱畸形诊治中的失误与手术并发症。[方法]回顾性分析2005年8月~2011年12月诊治且随访≥1年的脊柱畸形患者136例,男46例,女90例;年龄8~76岁,平均37.8岁。青少年特发性侧凸（adolesent idiopathic scoliosis,AIS）63例,采取观察11例、支具40例、手术12例;先天性侧后凸19例,观察10例、手术9例;神经肌肉型侧凸2例,观察1例、支具1例;成人特发性侧凸6例,观察3例、手术3例;退变性侧凸（de novo degenerative scoliosis,DDS）46例,观察24例、手术22例。随访期12~60个月,平均24.6个月,分析诊治中的失误和手术并发症。[结果]观察的49例患者中1例AIS随访不及时侧凸Cobb角由25°进展为62°。支具治疗41例,早期11例AIS存在过度治疗（8例Cobb角〈25°,7例Risser征≥4°）;1例T7、8分节不全先天性侧凸误诊为AIS,由胸椎侧凸30°发展为胸弯80°和腰弯80°。手术治疗的46例患者中,3例AIS存在失误,包括适应证选择不当1例、融合节段错误2例,其中1例椎弓根螺钉侵入椎管但未造成神经症状;4例先天性畸形存在失误,包括畸形残留1例、假关节形成1例、脊柱切除术缺乏前侧支撑1例、植骨排斥反应1例;4例DDS存在失误,包括内固定困难1例、椎弓根螺钉侵入椎管1例但未引起神经症状、硬膜囊撕裂1例、切口感染1例。[结论]脊柱畸形的诊治存在学习曲线,月经初潮期和Risser征〈2度的AIS、先天性侧凸可能快速进展,须及时诊治;Cobb角〈25°、Risser征≥4度的AIS一般不需支具治疗;矫形手术需严格掌握指征并采取正确的方案才能取得良好的效果。

[ Objective] To analyze the pitfall and complication in deal with spinal deformities. [ Methods] Total 136 pa- tients of spinal deformities admitted from August 2005 to December 2011 were followed for more than 1 year （range, 12 -60 months, average 24. 6 months）, including 46 men and 90 women, with a mean age of 37.8 years （range, 8 - 76 years old）. The diagnosis was adolescent idiopathic scoliosis （AIS） in 63 patients, congenital seoliosis and/or kyphosis in 19 cases, neuromuscular scoliosis in 2 cases, adult idiopathic scoliosis in 6 cases, and de novo degenerative scoliosis （DDS） in 46 cases. The treatment measures included observation in 49 patients, brace in 41 cases, and surgery in 46 cases. The pitfall and complication were retrospectively analyzed. [ Results] For the patients treated with observation, one 13 -years -old AIS was not followed timely, and her scoliosis progressed from 25° to 62°. For the patients treated with brace, 12 AIS at early stage had overtreat- ment, including 9 patients with 〈 25° scoliosis and 8 with ≥4 Risser sign. One 12 -years -old congenital thoracic scoliosis with TT,8 malsegmentation was misdiaguosed with AIS, her scoliosis progressed from 30° to thoracic and lumbar scoliosis of 80°respectively. For the 46 patients treated surgically, 3 patients of AIS had mistake, including wrong indication in 1 immature AIS, error in instrument segment in 2 cases, and one of them had real position of pedicle screws. Error occurred in 4 congenital deformities, including residual deformity, pseudarthrosis, lack of anterior support during posterior vertebral column resection, and rejection of graft. Four DDS had pitfall, including difficulty in instrumentation, real position of pedicle screws, dural tear, and incision infection. [ Conclusion] There are pitfalls and learning curve in deal with spinal deformities. AIS at menarche or with 〈 2 Risser sign, congenital scoliosis with malsegmentation or hemivertebrae may progress rapidly. Brace is unnecessary forAIS with 〈 25° scoliosis and ≥4 Risser sign. Good indication and suitable measurement are indispensable in the correction of spinal deformities.