经后路全脊椎切除术治疗严重僵硬性脊柱畸形的手术策略

Surgical strategy of posterior vertebral column resection to correct severe rigid spinal deformity

背景：严重僵硬性脊柱畸形曾被认为是外科治疗的禁区,其手术治疗充满挑战与风险。目的：分析总结本中心经后路全脊椎切除术（posterior vertebral column resection,PVCR）治疗严重僵硬性脊柱畸形的手术策略。方法：回顾分析2004年10月至2013年12月来自单中心连续的105例采用PVCR治疗的严重僵硬性脊柱畸形患者的病例资料。男47例,女58例,年龄10~45岁,平均年龄18.9岁。所有患者主弯柔韧度〈10%。12例冠状面和（或）矢状面畸形〉150°,术前接受4周持续颅-股骨牵引治疗。对患者的一般资料及手术相关信息,术前、术后及末次随访的影像学资料,围手术期并发症进行统计分析。结果：平均手术时间（602±132）min,术中失血量（4694±1794）ml。主弯侧凸：术前站立位108.9°±25.5°,术后36.6°±15.7°。节段性后凸：术前88.8°±31.1°,术后29.9°±14.1°。12例冠状面和（或）矢状面畸形〉150°患者,术前站立位主弯侧凸为152.5°±14.3°,牵引术前仰卧位141.8°±16.3°,牵引4周时仰卧位93.4°±14.0°,牵引4周时较牵引前仰卧位主弯侧凸有明显改善（P〈0.05）,术后为47.2°±7.2°。节段性后凸：术前站立位109.3°±42.3°,牵引术前仰卧位98.9°±40.0°,牵引满4周仰卧位67.3°±22.2°,牵引满4周较牵引前仰卧位有明显改善（P〈0.05）,术后站立位32.2°±9.5°。7例患者发生暂时性神经并发症,及时处理后均恢复正常,无永久性神经功能损害病例。24例患者发生了31项主要非神经并发症事件。所有患者均获得随访,5年以上随访49例,患者满意度高,生活质量显著提高。结论：PVCR术是治疗严重僵硬脊柱畸形有效手段之一,但因其应用过程面临着诸多风险,不应作为大多数脊柱畸形治疗的首选。PVCR是对术者手术技巧的全面考验和患者生命安全的严重挑战,有赖于有效的围手术期处理、严密的手术策略及紧密协作的团队。

Background： It was considered that the surgical treatment for severe rigid spinal deformity was a restricted zone, which would face huge challenges and risks. Objective：To summarize the surgical strategy of posterior vertebral column resection （PVCR） to correct severe rigid spinal deformity in our center. Methods：A total of 105 consecutive patients undergoing PVCR for severe rigid deformity from October 2004 to December 2013 were reviewed. There were 47 males and 58 females with an average age of 18.9 years （range, 10-45 years）. The flexi-bility of major curve of scoliosis was less than 10%in all patients. The major curve of scoliosis was larger than 150° in 12 patients who were treated with skull-femoral traction in supine position for 4 weeks before surgery. Demographic data, med-ical and surgical histories, perioperative and final follow-up radiographic measurements, and prevalence of perioperative complications were reviewed. Results：The mean operating time was （602×132） min and intraoperative blood loss was （4694×1794） ml. The mean major curve of scoliosis was 108.9° × 25.5° and 36.6° × 15.7° before and after PVCR, respectively, and the mean kyphosis was 88.8° × 31.1° and 29.9° × 14.1° . In the 12 patients with the curve greater than 150° , the mean major curve of scoliosis was 152.5°×14.3°, 141.8°×16.3°, 93.4°×14.0°, 47.2°×7.2° in standing position before surgery, in supine position before traction, at 4 weeks after traction in supine position and in standing position after surgery, respectively; the kyphosis was 109.3° × 42.3°, 98.9°×40.0°, 67.3°×22.2°, and 32.2°×9.5°, respectively. The major curve of scoliosis and kyphosis after 4-week trac-tion in supine position were significantly improved when compared with before traction （P〈0.05）. Transient neurological complications occurred in 7 cases and nerve function recovered soon after prompt management. There were 31 non-neuro-logical complications in 24 patients. All the 105 patients were followed up and 49 of them got more than 5-year follow-up. The patients were satisfactory and the quality of life was greatly improved. Conclusions： PVCR is an effective method to treat severe rigid spinal deformity. But it cannot be advocated as the first choice for common deformities because of lots of difficulties and risks during PVCR. PVCR is a challenge for surgeon skills and patient life. Its success depends on effective perioperative management, a rigorous scientific operation strategy and a collaborative team.