同步多平面手术治疗痉挛性脑瘫后遗复杂肢体畸形的队列研究

Cohort study of complicated limb malformation sequelae of spastic cerebral palsy by simultaneous multilevel surgery

目的 探讨同步多平面手术治疗痉挛性脑瘫后遗复杂肢体畸形的手术方法和临床疗效。方法 对比分析2001年6月至2015年10月行同步多平面手术一次矫治（观察组，43例）与分步手术（对照组，31例）矫治痉挛性脑瘫后遗复杂肢体畸形患儿的临床资料。分别在手术前、后行肌张力、痉挛状态、运动功能、步态特征及手功能评估，对术后疗效进行统计学分析。结果 两组均随访1～2年，两组患儿性别、年龄、肌张力、痉挛状态、运动功能、脑瘫类型、累关节数及随访时间统计，差异均无统计学意义（P〉0.05）。观察组肌张力、痉挛状态、运动功能及手功能评分治疗前分别为（1.47±0.74）级、（1.53±0.70）级、（58.19±5.82）分和（0.88±0.60）分，治疗后分别为（2.23±0.65）级、（2.14±0.80）级、（72.95±4.87）分和（3.32±0.56）分。对照组肌张力、痉挛状态、运动功能及手功能评分治疗前分别为（1.61±0.67）级、（1.45±0.72）级、（55.81±6.96）分和（0.83±0.62）分，治疗后分别为（1.94±0.25）级、（1.65±0.80）级、（68.74±4.25）分和（2.778±0.65）分。治疗前、后两组肌张力、痉挛状态、运动功能及手功能评分较术前提高，且观察组优于对照组，差异有统计学意义（P〈0.05）。观察组步态特征PRS评分从术前（8.81±1.53）分提高至术后（16.51±1.47）分，对照组从术前（8.13±1.57）分提高至术后（16.03±1.49）分，两组均较术前升高，但观察组与对照组间差异无统计学意义（P〉0.05）。观察组平均住院时间为（15.84±0.87）d，平均住院费用为（9 232.2±1 587.5）元；对照组分别为（37.58±7.04）d和（21 573.0±4 876.7）元，两组平均住院时间与平均住院费用比较，差异均有统计学意义（P〈0.05）。结论 痉挛性脑瘫后遗复杂肢体畸形采取分步手术矫治，手术周期长，易复发。同步多平面手术从机体的整体功能考虑，在行显微神经微缩术降低肌张力的同时，一次纠正多肢体多平面的畸形，缩短手术疗程，为康复治疗创造更多的时间，且有助于提高患儿的整体功能。术前对患儿进行多学科全面的评估，制定个性化的手术方案，术后进行系统化的康复治疗，同时配合适当的支具固定，提高治疗效果。

Objective To explore the surgical method and its clinical efficacy on complicated limb malformation sequelae of spastic cerebral palsy by simultaneous multilevel surgery.Methods A total of 74 cases of complicated limb malformation sequelae of spastic cerebral palsy from June 2001 to October 2001 by one time or step-by-step simultaneous multilevel surgery were compared. They were divided into observation （n=43） and control （n=31） groups. Observation group adopted synchronous more graphic operation while control group undergoing step-by-step operation. Muscle tone, postoperative spasticity, motor function, gait characteristics and hand function were evaluated before and after surgery and curative effect was statistically analyzed.Results During a follow-up period of 1-2 years, no significant inter-group statistical differences existed in gender, age, muscle tension, spasticity, motor function, types of cerebral palsy, accumulate joints or follow-up time （P〉0.05）. In observation group, pre-treatment scores of dystonia, spasticity, motor function and hand function were （1.47±0.74）, （1.53±0.70）, （58.19±5.82） and （0.88±0.60） while post-treatment scores （2.23±0.65）, （2.14±0.80）, （72.95±4.87） and （3.32±0.56） respectively. In control group, pre-treatment scores of muscle tension, spasticity, motor function and hand function were （1.61±0.67）, （1.45±0.72）, （55.81±6.96） and （0.83±0.62） while post-treatment scores （1.94±0.25）, （1.65±0.80）, （68.74±4.25） and （2.778±0.65） respectively. Muscle tension, spasticity and score of motor function significantly improved in observation group than those in control group （P〈0.05）. Average hospitalization time and expenses were （15.84±0.87） days and （9 232.2±1 587.5） yuan in observation group and （37.58±7.04） days and （21 573.0±4 876.7） yuan in control group respectively. Significant inter-group differences existed in average time and average expenses of hospitalization （P〈0.05）.Conclusions Operative cycle is long and prone to relapse during step-by-step surgery for complicated limb malformation sequelae of spastic cerebral palsy. Simultaneous multilevel surgery takes into consideration of the overall function of body. Miniatures undergoing microsurgery may reduce muscle tension, correct multiplanar limb deformities, shorten surgical procedures, allow more time for rehabilitation and improve allomeric function. Multidisciplinary comprehensive evaluations should be made and individualized surgical plan formulated preoperatively. Also systematic rehabilitation and appropriate supports should be offered postoperatively. It will improve the efficacies of treatment.