脊柱截骨矫形技术治疗成人复杂脊柱侧后凸畸形的疗效及安全性的前瞻性观察

The efficacy and safety of spinal column osteotomies in complicated adult kyphoscoliosis: a prospective study

目的：探讨应用脊柱截骨矫形技术治疗成人复杂脊柱侧后凸矫形术的安全性,并评估其临床应用价值。方法：选择2011年9月~2012年9月期间应用截骨技术治疗的成人复杂脊柱侧后凸畸形患者进行前瞻性研究。所有入选患者均于手术前后及末次随访时测量侧凸Cobb角、最大后凸Cobb角、冠状面平衡（distance between C7 plumbline and center sacral vertical line C7PL-CSVL）和矢状面平衡（sagittal vertical axis,SVA）等影像学相关参数。同时采用SF-36量表、疼痛视觉模拟评分（VAS）、Oswestry功能障碍指数（ODI）、SRS-22量表等评估其临床疗效,并使用AISA评分法评价患者手术前后及末次随访时神经功能情况。结果：共17例患者最终纳入本次研究,其中男7例,女10例;年龄18~55岁（34.6±10.9）岁,术前侧凸Cobb角51°~97°（78.5°±13.1°）,后凸Cobb角50°~112°（71.8°±19.8°）,C7PL-CSVL为58.4±21.3mm,SVA为56.4±51.2mm。手术时间200~540min（406.1±82.2min）;术中出血量1000~12000ml（4088.9±2546.9ml）。术后侧凸Cobb角为37.7°±17.7°,后凸Cobb角为25.0°±16.4°,矫正率分别为51.9%±18.7%和67.2%±20.3%;C7PL-CSVL为18.0±9.4mm,SVA为27.6±16.9mm,均较术前明显改善。随访24.3±1.8个月,末次随访时侧、后凸Cobb角分别为39.5°±16.6°和26.2°±17.6°,C7PL-CSVL为22.1±15.4mm,SVA为30.4±17.1mm,随访期间无明显矫正丢失。术中监测均无诱发电位异常改变,无死亡、瘫痪等严重并发症,术后5例患者出现肢体远端一过性感觉功能减退,1例患者椎体前壁骨折,1例患者螺钉置钉不良,2例患者随访期间发生内固定并发症,总体并发症发生率为52.9%。术后和末次随访时的SF-36、VAS、ODI、SRS-22与术前比较均有明显改善,术后和末次随访时无显著性差异,ASIA运动和感觉评分与术前比较无显著性差异。结论：经后路脊柱截骨术治疗成人复杂脊柱侧后凸畸形矫正角度大,术后三维矫形效果满意,可显著改善患者临床症状和生活质量,但存在手术时间长、出血量大、并发症多等风险。

Objectives： To evaluate the safety and clinical outcomes of spinal column osteotomies in complicated adult kyphoscoliosis. Methods： A prospective study was conducted for the complicated adult kyphoscoliosis, who underwent spinal osteotomies from September 2011 to September 2012. All the radiographic pa- rameters were measured pre-operatively, post-operatively and at last follow-up. The spinal coronal parameters included： Cobb angle, distance between C7 plumb line and center sacral vertical line（C7PL-CSVL）. The sagit- tal spinal parameters included： global kyphosis（GK） and sagittal vertical axis（SVA）. The Seoliosis Research So- ciety-22 questionnaire（SRS-22）, the MOS item short-from health survey（SF-36）, visual analogue scale（VAS）, Oswestry disability index（ODI） and American Spinal Injury Association score（ASIA） were fullfilled at pre-oper- ation and each follow-up. The paired t-test was used to analyze the differences among pre-operation, post- operation and last follow-up. Results： 17 patients（7 males and 10 females） with an average age of 34.6±10.9 years（18-55 yrs） were finally included in this study. The average follow-up period was 24.3-＋1.8 months. The pre-operative average Cobb angle and GK angle were 78.5°±13.1°（51°-97°） and 71.8°±19.8°（50°-112°）. The post-operative average Cobb angle and GK angle were 37.7°±17.7° and 25.0°±16.4° The correction rate of Cobb angle and GK angle were （51.9±18.7）% and （67.2±20.3）%. At last follow-up, the average Cobb angle and GK angle were 39.5°±16.6° and 26.2°±17.6° with no significant loss of correction. The pre-operative, post-operative and last follow-up C7PL-CSVL were 58.4±21.3mm, 18.0±9.4mm and 22.1 ±15.4mm, respectively. Significant post-operative improvement was observed while there was no change at last follow-up. SVA decreased significantly from 56.4±51.2mm to 27.6±16.9mm. The average SVA at last follow-up was 30.4±17.1mm and no loss of correction was found. In addition, significant post-operative improvement was observed in SF-36, VAS, ODI, SRS-22 and there was no change at last follow-up. Compared with pre- operative baseline, no significant reduction in AISA scale was found in these patients. Moreover, no death or paralysis was observed in this study. The incidence of complications was 52.9%, including temporarily hypoaesthesia in 5 cases, anterior vertebral body fracture in 1 case, pediele screw malposition in 1 case, implant complications in 2 cases. Conclusions： The spinal column osteotomy is a safe and effect surgical technique for managing complicated kyphoscoliosis in adult patients, although the procedure is exhaustingly lengthy with blood loss, and is associated with a variety of complications.