“O”型臂三维CT导航辅助下Wiltse入路治疗Lenke 5C型特发性脊柱侧凸

Wiltse approach assisted by O-arm three-dimensional CT navigation in treatment of Lenke 5C Idiopathic Scoliosis

目的探讨后路微创矫形手术治疗Lenke分型5C型青少年特发性脊柱侧凸（adolescent idiopath icscoliosis，AIS）的可行性及临床疗效。方法2012年11月至2014年3月16例行“O”型臂三维CT导航技术后路微创矫形术治疗的Lenke分型5C型AIS患者纳入本研究，其中男2例，女14例；年龄14-18岁，平均年龄（16．7±1．6）岁。16例的冠状面腰弯平均Cobb角48．7°±5．6°，胸弯平均Cobb角24．1°±5．40°结果16例均顺利完成手术，手术时间平均为（246±89）min，术中出血量平均（192±105）ml；平均固定节段（4．9±0．5）个，共置入椎弓根螺钉155枚，平均植入密度98．9％±4．9％；16例均获得随访，平均随访（26．4±3．9）个月。测量术前、术后即刻及末次随访时的影像学指标：侧凸角度、顶椎偏移、顶椎旋转和冠状面平衡；矢状面胸椎后凸角、胸腰段后凸角、腰椎前凸角及躯干偏移。随访中根据术后CT图像评估置钉精确性和融合疗效，同时记录SRS-22评分及并发症。术后即刻腰弯矫正率为80．1％±8．3％，胸弯自发矫正率为59．3％±8．7％。与术前相比，术后即刻除胸椎后凸、腰椎前凸和矢状面躯干偏移无统计学差异外，侧凸角度、顶椎偏移、顶椎旋转、冠状面平衡和胸腰椎后凸均显著减小。至末次随访，矢状面躯干偏移由术后（-27．6±19．5）mm改善至（-12．3±6．6）mm，其他影像学参数维持稳定。术后CT扫描显示椎弓根螺钉置入满意率94．2％，破壁率5．8％（9枚）；所有患者椎间关节融合牢固。SRS-22评估中功能、疼痛、自我形象、精神状态和满意度平均评分分别为（4．3±0.5）分、（4．7-0．6）分、（4．2±0．7）分、（4．2±0．5）分和（4．4-0．6）分。本组病例术中术后无一例发生瘫痪，无切口感染、内固定松动断裂等并发症。结论“O”型臂三维CT导航技术辅助Wihse入路具有损伤小、出血少、置钉精确和患者自我满意度高的特点，是治疗Lenke分型5C型AIS的可行、安全有效的手术方式。

Objective To explore the feasibility and efficacy of posterior minimally invasive scoliosis surgery in Lenke 5C adolescent idiopathic scoliosis （AIS）. Methods From November 2012 to March 2014, a total of 16 patients underwent posteri- or minimally invasive scoliosis surgery assisted by O-arm three-dimensional CT navigation were included. There were 14 female and 2 male, with an average age of （16.7± 1.6） years （ranged from 14 to 18 years）. The mean Cobb angles of lumbar and thoracic curve were 48.7°±5.6°and 24.1°±5.4°, respectively. Results 16 patients were successfully completed the operation, the average operation time was （246±89） min, the average intraoperative blood loss was （192±105） ml, and the fusion level was 4.9±0.5 on average. A total of 155 screws were inserted in the 16 patients, with a mean implant density of 98.9%±4.9%. All the patients were followed up for （26.4±3.9） months on average. The following radiographic parameters were evaluated before surgery, immediately af- ter surgery and at the last follow-up： curve magnitude, apical vertebral translation （AVT）, apical vertebral rotation （AVR）, trunk shift, thoracic kyphosis （TK）, thoraeolumbar kyphosis （TLK）, lumbar lordosis （LL） and sagittal vertical axis （SVA）. The accuracy of pedicle screw placement was assessed according to postoperative CT scans. SRS-22 scores and complications were also recorded during the follow-up. Immediately after surgery, the correction rate of main lumbar curve was 80.1%±8.3%, and thoracic curve was 59.3%±8.7%, and a obvious improvement was noted in terms of AVT, AVR, trunk shift and TLK. At the last follow-up, except the increase of SVA from （-27.6± 19.5） mm to （-12.3±6.6） mm, no obvious changes of AVT, AVR, trunk shift, TK, TLK and LL were observed during the follow-up. According to CT evaluation, the satisfactory rate of pedicle screw placement was 94.2%, while the perforation rate was 5.8% （9/155）. Fusion across the facet joint were satisfactory. In SRS-22 assessment, the mean scores of functional, pain, self-image, mental state and satisfaction were （4.3 ± 0.5） points, （4.7 ± 0.6） points, （4.2 ± 0.7） points, （4.2 ± 0.5） points and （4.4 ± 0.6） points. No wound infection, implant failure and neurologie eomplieations were found after surgery. Conclusion Wihse approach assisted by O-ann three-dimensional CT navigation has the characteristics of small injury, less bleeding, high accuracy placement of pediele screws and high self-satisfaction of patients. It is a feasible, safe and effective way to treat Len- ke 5C AIS.