伴有骶骨倾斜的腰椎先天性脊柱侧凸患儿的手术治疗策略研究

Surgical strategy for sacral slanting in early-onset congenital scoliosis with lumbar hemivertebra

背景:在先天性脊柱侧凸患儿中,骶骨倾斜的发生率较高,但既往相关的文献报道较少。对此类患儿行半椎体切除联合短节段融合后,维持冠状面平衡对脊柱外科医师来说仍是一个巨大挑战。目的:探讨早发性先天性脊柱侧凸患儿中骶骨倾斜的定义、病因及手术策略。方法:回顾性分析2004年7月至2014年12月于我院就诊的早发性先天性脊柱侧凸患儿的病例和影像学资料,测量其冠状及矢状面参数、骶骨倾斜角及近端融合椎-骨盆角。骶骨倾斜的定义为骶骨倾斜角>5°,严重骶骨倾斜的定义为>10°。对相关数据进行统计学分析。结果:本研究共纳入42个病例。平均年龄为(4.0±2.0)岁,平均随访(51.7±30.7)个月。节段侧凸Cobb角术前平均(34.9°±9.6°),术后(4.7°±6.0°),最终随访时(8.7°±8.5°)。术前躯干偏移(15.4±13.9)mm,术后(16.9±12.6)mm,末次随访时(12.1±10.3)mm。骶骨倾斜角度术前(7.2°±5.7°)。26例患儿伴有明显骶骨倾斜,骶骨倾斜发生率为61.9%。半椎体位于L3及以下的患儿中骶骨倾斜的发生率明显高于半椎体位于L3以上的患儿。11例患儿伴有严重骶骨倾斜,发生率为26.2%。术后即刻骶骨倾斜角度为(5.1°±4.1°),末次随访时(4.5°±4.7°)。术后近端融合椎-骨盆角(3.9°±3.5°)。术后近端融合椎偏距与术后躯干偏移呈正相关。结论:骶骨倾斜的发生率较高,需要引起脊柱外科医师的注意,其病因可能是先天性畸形。治疗严重骶骨倾斜的有效策略是使近端融合椎尽可能位于水平中立位。

Background： Literatures about sacral slanting in congenital scoliosis are rare despite of its high incidence. Great challenge remains in restoring coronal balance after hemivertebra resection with short segment fusion in children with sacral slanting. Objective： To clarify the definition, etiology and surgical strategy of sacral slanting in children with early-onset congenital scoliosis. Methods： From July 2004 to December 2014, clinical and imaging data of children with early-onset congenital scoliosis who underwent posterior hemivertebra resection with short fusion were reviewed. Coronal and sagittal parameters, as well as sacral slanted angle and upper instrumented vertebra-pelvis angle, were measured and calculated.Sacral slanting was defined as the angle of more than 5° and severe sacral slanting was thought to be more than 10°. Statistical analyses were performed. Results： A total of 42 consecutive children were identified. The mean age was（4.0±2.0） years old with an average follow-up of（51.7±30.7） months. The mean segmental curve was corrected from（34.9°±9.6°） to（4.7°±6.0°）, and（8.7°±8.5°） at final follow-up. Trunk shift was（15.4±13.9） mm preoperatively,（16.9±12.6） mm after surgery and（12.1±10.3） mm at final follow-up. Sacral slanted angle was measured as（7.2°±5.7°） before surgery. It could be noticed in26 patients with an incidence of 61.9%. Children with hemivertebrae at or below L3 had higher incidence of sacral slanting than those with hemivertebrae above L3. Severe sacral slanting was noted in 11 children with an incidence of 26.2%. Postoperative sacral slanted angle was（5.1°±4.1°） and（4.5°±4.7°） at final follow up. Postoperative upper instrumented vertebrapelvis angle was（3.9°±3.5°）. Postoperative upper instrumented vertebra translation was correlated positively with postoperative trunk shift. Two independent risk factors were identified for postoperative proximal adding-on： larger postoperative sacral slanted angle and larger postoperative upper instrumented vertebra-pelvis angle. Conclusions： Attentions must be paid to sacral slanting for its high incidence. The etiology may be congenital malformation. Placing a more central and even upper instrumented vertebra is a wise strategy for congenital early-onset scoliosis with severe sacral slanting.