严重脊柱角状后凸畸形矫形策略及并发症分析

Vertebral column resection for severe kyphosis and related complications

[目的]探讨经后路治疗严重脊柱后凸畸形的矫形策略及并发症。[方法]2007年3月~2015年6月,采用经后路顶椎切除、前柱支撑植骨、矫形固定手术(顶椎切除+重建术)治疗严重脊柱后凸畸形28例,男18例,女10例;年龄8~56岁,平均24.6岁。病程21~38个月,平均25个月。颈胸椎7例,胸椎10例,胸腰椎4例,腰椎5例,腰骶椎2例。先天性15例,结核10例,翻修3例。术前Cobb角80°~135°,平均103°;术前Frankel分级:B级4例,C级11例,D级13例。术后及末次随访时测量后凸Cobb角。[结果]所有手术顺利完成。手术平均时间250 min。术中出血量850 ml^3 000 ml,平均1 430 ml。2个椎体切除8例,3个椎体切除11例,4个椎体切除6例,5个椎体切除3例。2例硬脊膜锐性撕裂,予以修复,已痊愈。术中唤醒试验发现:4例出现脊髓功能损伤加重情况,予静滴甲基强的松龙0.4 g^0.5 g处理后,术后2~4周脊髓功能逐渐恢复至术前。手术早期并发症:腹壁疼痛11例,术后早期痉挛性抽搐2例,伤口感染1例,脑积液漏1例,呼吸功能不全1例,无尿潴留、腹胀、十二指肠上动脉综合征。25例患者获术后随访,随访时间2~72个月,平均16个月。均无断钉、断棒等现象。患者症状及外形均明显改善。后凸Cobb角由术前(103.14±12.27)°(80°~135°)矫正至术后2周(31.28±8.13)°(12°~43°),矫正率69.67%,末次随访(34.84±9.04)°(13°~53°),矫正率为66.22%,矫正丢失率为11.38%。术后2周与末次随访的后凸Cobb角与术前相比,差异具有统计学意义(P<0.05)。术后2周Frankel分级B级1例,C级11例,D级13例,E级3例。末次随访D级2例,E级23例。与术前相比frankle分级均有改善,差异具有统计学意义(P<0.05)。所有病例均达到骨性融合。融合时间6~8个月,平均7个月。[结论]采用经后路顶椎切除、前柱支撑植骨、矫形固定手术(顶椎切除+重建术)治疗严重脊柱后凸畸形可取得较好效果。

[Objective] To discuss the surgical strategies and complications for severe kyphosis through posterior approach. [Methods] From March 2007 to June 2015,28 patients with severe kyphosis were treated with veterbral column resection and bone grafting for anterior column support through posterior approach. There were 18 males and 10 females,with an average age of 24. 6 years（ range,8 - 56）. The course of disease was 21 - 38 months（ mean,25 months）. Kyphosis located in cervical in 7 cases,thoracic in 10 cases,thoracolumbar in 4 cases,lumbar in 5 cases,and lumbar sacral vertebrae in 2 cases. Congenital kyphosis was found in 15 cases,and 10 cases were combined with tuberculosis,meanwhile,3 cases were second- time revision. Cobb angle ranged from 80° to 135°（ mean,103°）. According to Frankel classification,4 cases were grade B,11 cases were grade C,13 cases were grade D. The Cobb＇s angle were recorded before surgery,immediately after surgery and at last follow- up. [Results] All the operations were completed successfully. Operation time averaged 250 min. Intraoperative blood loss was 850 - 3 000 ml（ mean,1 430 ml）. In 8 cases,2 verterbrae were resected,besides,3verterbrae in 11 cases,4 verterbrae in 6 cases,and 5 verterbrae in 3 cases. Dural tear was found in two cases and cured after treatment. Intraoperative wake- up test revealed 4 cases of spinal cord function deterioration. After injection of methyl predniso-lone of 0. 4 - 0. 5 g,the spinal cord function gradually recovered to preoperative standard or improved at 2 to 4 weeks postoperatively. Early complications included abdominal pain in 11 cases,postoperative early spastic convulsions in 2 cases,wound infection in 1 case,cerebrospinal fluid leakage in 1 cases,as well asrespiratory insufficienc in 1 cases. No urinary retention,abdominal distension,spastic convulsions,duodenal artery syndrome was noticed. Except for the lost follow- up cases,25 patients were followed up for 2 - 72 months（ mean,16 months）. No loosen of nails or rod was found during follow up period. Symptoms were relieved significantly. The kyphtic angle was corrected from average（ 103. 14 ± 12. 27） °（ range,80° - 135°） to（ 31. 28 ± 8. 13） °（ range,12° - 43°）,the overall correction rate was 69. 67%. At the last follow- up,the average cobb angle was（ 34. 84 ± 9. 04） °,（ range,13° - 53°）,the overall correction rate was 66. 22%,and the lost rate was 11. 3%. At two weeks postoperatively and at the last follow- up,the Cobb angle was significantly improved compared with the preoperative one（ P〈0. 05）. At two weeks after operation,Frankle classification scale was grade B in 1 patient,grade C in 11,grade D in 13,and grade E in 3,showing significant difference compared with preoperative one（ P〈0. 05）. At the last follow- up,the scale improved to grade D in 2 cases,as well as grade E in 23 cases,also with significant difference compared with preoperative one（ P〈0. 05）. Bony fusion was achieved in all cases,with the fusion period of 6- 8 months（ mean,7 months）. [Conclusion] Severe kyphosis can be corrected successfully by using veterbral column resection and bone grafting for anterior column support through posterior approach.