重度神经肌源性脊柱侧凸伴骨盆倾斜三种内固定模式的比较研究

The comparison of clinical outcomes among neuromuscular scoliosis with pelvic obliquity who utilized iliac, second sacral alar-iliac and iliosacral screw fixation

目的 比较髂骨钉（iliac screw,IS）、经第2骶椎骶髂螺钉（second sacral alar-iliac,S2AI）及髂骶螺钉（iliac sacral screw,ISS）固定技术治疗伴骨盆倾斜的重度神经肌源性脊柱侧凸患者的临床疗效。方法 回顾性分析2010年1月至2016年1月接受后路IS、S2AI或ISS固定技术治疗伴骨盆倾斜的神经肌源性脊柱侧凸患者（20例）的病历资料,男6例,女14例;中位年龄为21.5岁（17.3,26.3）岁。脊髓灰质炎伴脊柱侧凸14例,脊肌萎缩症伴脊柱侧凸4例,肌营养不良伴脊柱侧凸2例。按骨盆固定方式分为IS组（11例）、 S2AI组（6例）和ISS组（3例）。所有患者在术前、术后及末次随访时测量侧凸Cobb角、骨盆倾斜角、局部后凸Cobb角,记录患者术后及随访期间的并发症发生情况。在术前及末次随访时采用Oswestry功能障碍指数（Oswestry disability index,ODI）、健康调查简表（the MOS item short from health survey,SRS-22）评估疗效。结果 三组患者年龄、术前侧凸Cobb角及局部后凸角、骨盆倾斜角的差异均无统计学意义。ISS组患者随访时间较IS组与S2AI组短（H=15.183,P〈0.01）。IS组患者术前、术后及末次随访时中位侧凸Cobb角分别为70°、35°和40°,中位骨盆倾斜角分别为24°、11°和12°,中位局部后凸角分别为36°、12°和14°。S2AI组患者术前、术后及末次随访时中位侧凸Cobb角分别为70.5°、25.0°和26.5°,中位骨盆倾斜角分别为20°、10°和11.5°,中位局部后凸角分别为37°、12°和12.5°。ISS组患者术前、术后及末次随访时中位侧凸Cobb角分别为64°、25°和27°,中位骨盆倾斜角分别为24°、9°和11°,中位局部后凸角分别为53°、8°和8°。ISS组和S2AI组术后侧凸Cobb角、骨盆倾斜角、局部后凸角较术前均有明显改善;ISS组术后侧凸Cobb角、骨盆倾斜角、局部后凸角较术前减小,但差异无统计学意义,考虑为样本量较小所致。三组患者末次随访时侧凸矫正均无明显丢失,且术后和末次随访时三组间的差异均无统计学意义。IS组、S2AI组术前中位ODI分别为42%、45%,末次随访时分别改善至26%、25.5%,差异均有统计学意义（ZIS=-2.943, ZS2AI=-2.207,P〈0.05）;ISS组术前ODI为36%,末次随访时改善至24%,差异无统计学意义（Z=-1.826,P=0.068）。IS组、S2AI组末次随访时SRS-22总分较术前明显减小;ISS组末次随访时SRS-22总分虽较术前减小,但无统计学意义。IS组1例患者术后出现断棒,行翻修手术;1例出现深部感染。S2AI组1例患者出现右侧S2AI螺钉位置不良。结论 伴骨盆倾斜的重度神经肌源性脊柱侧凸患者采用IS、S2AI及ISS固定技术均可获得良好的矫形效果,改善生活质量;与IS相比, S2AI与ISS可明显降低内固定相关并发症的发生率。

Objective To compare the clinical outcomes of neuromuscular scoliosis （NMS） patients with pelvic obliquity who underwent spino-pelvic fixation utilized traditional iliac screw（IS）, second sacral alar-iliac（S2AI）screw or iliac sacral screw. Methods All of 20 patients who met the inclusion were included in this study, with 14 cases of poliomyelitis, 4 cases of spinal muscular atrophy, 2 cases of muscular dystrophy, with 11 patients utilizing IS, 6 patients utilizing S2AI, and 3 patients utilizing ISS. The radiographic parameters measured pre- and post-operation and at last follow up included coronal Cobb angle, pelvic obliquity, and regional kyphosis. The SRS-22 questionnaires and the Oswestry disability index （ODI） and complications were collected. Results There were no significant difference in age, Cobb angle,pelvic obliquity and regional kyphosis among three groups, the follow up times was significantly shorter in the ISS group（H=15.183,P〈0.01）. In the IS group, the Cobb angle at pre- or post-operation and at last follow up measured 70°, 35° and 40°, the pelvic obliquity measured 24°, 11° and 12°, the regional kyphosis measured 36°, 12° and 14°. In S2AI group, the Cobb angle measured 70.5°, 25.0° and 26.5°,the pelvic obliquity measured 20°, 10° and 11.5°, the regional kyphosis measured 37°, 12° and 12.5°, showing significant improvement compared to pre-operation（P〈0.05）. In the ISS group, the Cobb angle at pre or post operation and at last follow up measured 64°, 25° and 27°, the pelvic obliquity measured 24°, 9° and 11°, the regional kyphosis measured 53°, 8° and 8°, showing a decrease after surgery with P〉0.05, which may attribute to the small sample size in ISS group. The pre-operative ODI score was 42%, 45% in IS and S2AI group, improving significantly to 26%, 25.5% at last follow up. The ODI score in ISS group improved from 36% to 24% after surgery（P=0.068）. The SRS-22 score improved significantly in three groups, with P〈0.05 in IS and S2AI group and P= 0.066 in ISS group. In the IS group, one patient had rod breakage and underwent revision surgery, one patient had deep infection and recovered with conservative treatment. In the S2AI group, one patient had S2AI screw misplacement on the right side. Conclusion In the surgical management of neuromuscular scoliosis （NMS） patients with pelvic obliquity, the utilization of either iliac screw, S2AI screw or ISS fixation can obtain satisfied deformity correction and improvement in health-related quality of life, however, the utilization of S2AI and ISS could reduce the implant related complications.