八岁以内的儿童不同时机行后路单纯半椎体切除术后疗效分析

Postoperative efficacy of different surgical timing inpreschoolers aged under 8 years after single posterior hemivertebral resection

目的探讨小于8岁儿童不同手术时机行后路单纯半椎体切除术后疗效对比。方法回顾性分析中国人民解放军第306医院骨科2009年1月至2015年8月诊治的临床、手术及影像学资料完整的小于8岁儿童单纯半椎体致脊柱畸形患者共33例,全部行后路半椎体切除椎弓根螺钉内固定植骨融合术治疗。其中,男13例,女20例。年龄26~94个月,平均57.6个月,4例合并心脏畸形,4例合并脊髓畸形。因为出生后至5岁前是脊柱的第一个生长高峰期,按年龄将病例分为A、B两组,A组为26~60个月龄患儿,B组为61~94个月龄患儿。测量术前、术后及末次随访时全脊柱正侧位X线片,对比两组术后及术后末次随访(随访大于2年)疗效,并记录并发症。结果出血量占总血量的百分比、住院时间、术后随访时间等临床资料的差异均无统计学意义,B组手术时间大于A组(P<0.05)。手术前后冠状位主弯侧凸角、矢状位平衡、近端代偿弯及矢状位节段性后凸角比较差异有统计学意义(P<0.05),两组间比较差异无统计学意义(P>0.05)。术前冠状面主弯侧凸Cobb角:(41.37±12.51)°;A组:(41.25±13.11)°;B组:(41.54±12.05)°。术后即刻Cobb角:(16.18±10.68)°;A组:(15.85±11.78)°;B组:(16.69±9.18)°。冠状位平衡、远端代偿弯以及胸段后凸手术前后对比及组间对比差异均无统计学意义(P>0.05)。冠状面主弯侧凸术后即刻矫正率为(62.30±19.18)%;A组:(64.29±18.58)%;B组:(59.23±20.43)%。末次随访(41.41±33.32)%;A组:(47.35±37.90)%;B组:(32.28±23.19)%。围手术期及随访过程中发生了4例并发症(12.12%),其中A组3例:1例术后62个月背部肿物,1例内固定棒断裂,1例术后伤口愈合不良。B组1例术后出现肌力下降,随访2个月后恢复正常。结论后路半椎体切除术治疗小于8岁儿童因半椎体畸形导致的先天性脊柱侧凸是一种安全有效的手术方式,早期手术可以达到短节段融合。手术时机选择椎体终板发育成形前后,术后即刻及2年以上随访效果无明显差异,对于婴幼儿单纯半椎体畸形可观察随访侧弯进展情况,5岁以后再考虑半椎体切除手术,并不影响对手术效果及固定节段,降低内固定相关并发症及围手术期风险。

Objective To explore the postoperative efficacy in preschoolers after single hemivertebrectomy and to make comparison among different surgical timings.Methods A retrospective study was performed for a total of 33 preschoolers with spinal deformity due to hemivertebra from January 2009 to August 2015.There were 13 boys and 20 girls with a mean age of 57.6 (26-94) months.All children underwent posterior hemivertebra resection with pedicle screw fixation and interbody fusion.The concurrent conditions were cardiac malformations (n=4) and spinal deformities (n=4).Complete clinical and radiological data were reviewed and long-cassette-standing spinal radiographs measured at preoperation,postoperation and final follow-up for comparing the corrections and complications of two groups (group A,n=20,age: 26-60 months;group B,n=13,age: 61-94 months).Results No inter-group statistical differences existed in percentage of blood loss of total blood volume,length of hospital stay or postoperative follow-up period.Operative duration was longer in group B than that in group >A (P<0.05).Cobb’s angles of major curves,sagittal balance,proximal compensatory Cobb’s and sagittal segmental Cobb’s angles before and after operation were significanly different (P<0.05).However,there were no inter-group statistical differences (P>0.05).The Cobb’s angles of major curves pre-operation (°): 41.37±12.51(A∶B =41.25±13.11∶41.54±12.05),post-operaion: 16.18±10.68 (A∶B=15.85±11.78∶16.69±9.18),segmental kyphosis pre-operation (°): 33±17.20(A∶B =26±17.13∶41±14.42) and post-operation: 18.93±16.73 (A∶B =15.63±15.69∶22.71±18.30).Coronal balance,distal compensatory curve and thoracic kyphosis,differences between before and after operation and comparison among groups were insignificant.The immediate correction rate of Cobb’s angles of major coronal curves was (62.30±19.18)%(group A∶group B=64.29±18.58∶59.23±20.43)% and the final follow-up correction rate (41.41±33.32)%(group A∶group B=47.35±37.90∶32.28±23.19)%;The immediate correction rate of segmental kyphosis was (46.73±30)%(group A∶group B=45.88±33.15∶47.71±28.57)%and the final follow-up correction rate (50.05±33.36)%(group A∶group B=47.31±39.54∶53.17±27.42)%.During perioperative period and follow-ups,complications occurred in 4 patients (12.12%),including 3 cases in group A,hematoma 4 years post-operation (n=1),rod breakage (n=1) and poor wound healing (n=1);1 case in Group B had a decrease of muscle strength,yet recovered after 2-month follow-ups.Conclusions Posterior hemivertebral resection is both safe and effective for preschoolers with congenital scoliosis.Short-segment fusion is feasible.Immediate and >2 years follow-up outcomes between before and after vertebral endplate forming have no significant difference.For neonates with single hemivertebra,the progress of Cobb’s may be tracked until an age of 5 years old.Fixation-related complications and perioperative risks can be lowered without effect on operative outcomes or fusion segments.