生长棒治疗伴椎管内异常的早发性脊柱侧凸的疗效及安全性分析

Efficiency and safety of growing rod in early-onset scoliosis with co-existing intraspinal anomalies

目的:探讨生长棒治疗伴椎管内异常的早发性脊柱侧凸(early-onset scoliosis,EOS)的疗效及安全性。方法:2009年11月~2016年8月共73例EOS患儿于我院行生长棒治疗,其中伴椎管内异常的患儿中符合纳入标准的共11例,男2例,女9例,初次就诊年龄为8.2±1.3岁(6~10岁)。先天性脊柱侧凸9例,神经肌源性脊柱侧凸2例。伴单纯脊髓空洞3例,单纯脊髓拴系1例,单纯脊髓纵裂3例,脊髓空洞合并脊髓拴系2例,脊髓拴系合并脊髓纵裂1例,脊髓纵裂合并脊髓空洞、脊髓拴系1例。术前2例患儿存在神经系统症状,包括Honor综合征1例和神经源性膀胱伴会阴部麻木1例,其余患儿无神经系统损害表现。记录生长棒置入手术前后和末次随访时患儿站立位主弯Cobb角和T1-S1高度,采用配对t检验比较术前、术后及末次随访时的差异。记录术中及随访期间的神经及内固定并发症。结果:11例患儿共进行45次手术治疗,其中包括生长棒置入11次、生长棒撑开34次。平均撑棒间隔时间为11.2±1.1个月(8~12个月),总随访时长为39.7±11.6个月(24~72个月)。11例患儿生长棒置入术前主弯Cobb角为85.2°±23.4°,生长棒置入术后为51.4°±18.9°,末次随访时为52.8°±19.4°;生长棒置入术前站立位T1-S1高度为24.6±3.9cm,初次术后和末次随访时分别为28.9±3.4cm和31.9±3.4cm。初次术后和末次随访时主弯Cobb角和T1-S1高度与初次术前比较均有统计学差异(P<0.001)。11例患儿中,共3例患儿出现5次并发症。1例患者在第3次撑开时发现冠状面失衡伴骨盆倾斜和钉棒松动,撑开同时行翻修术;1例第3次撑开后随访中发现下端椎螺钉松动合并矢状面失衡,10个月后行终末期融合手术;1例第2次撑开后发现近端交界性后凸,随访中无明显进展。所有患儿在生长棒置入和后续多次撑开及随访过程中均未观察到新发神经并发症。结论:对于伴有椎管内异常的EOS患儿,若无明显神经损害或神经损害相对稳定,行生长棒置入及多次撑开是相对安全有效的。

Objectives:To investigate the efficiency and safety of growing rod in early-onset scoliosis(EOS)with co-existing intraspinal anomalies.Methods:A total of 73 EOS patients undergoing growing rod at our center between November 2009 and August 2016 was retrospectively reviewed,of whom 11 patients including 2 males and 9 females were enrolled in the study.The average age at initial surgery was 8.2±1.3 years(6-10 years).The etiologies were congenital scoliosis in 9 patients and neuromuscular scoliosis in 2 patients.16 intraspinal anomalies were identified in 11 patients,including syringomyelia in 3 patients,tethered cord malformation in 1 patient,split cord malformation in 3 patients,syringomyelia with tethered cord syndrome in 2 patients,tethered cord syndrome with split cord malformation in 1 patient,syringomyelia with split cord malformation and tethered cord syndrome in 1 patient.Two patients were found to have neurological deficit before index surgery,one with Honor syndrome and the other with neurogenic bladder and perineum numb.No neurological symptom was found in the other patients.The Cobb angle and T1-S1 height before and after the implant of growing rod and at last visit were documented and compared by paired t test.The peri-operative and post-operative neurological and implant-related complications were noted for each patient.Results:A total of 45 operations was conducted including 11 rod fixation and 34 lengthening procedures.The average interval of distractions was 11.2±1.1(8-12)months.The average follow-up was 39.7±11.6(24-72)months.The mean Cobb angle was 85.2°±23.4°preoperatively,51.4°±18.9°after index surgery and 52.8°±19.4°at last visit.The mean T1-S1 height was 24.6±3.9cm preoperatively,28.9±3.4cm after index surgery and 31.9±3.4cm at last visit.Compared with the measurements before index surgery,the Cobb angle and T1-S1 height after the implant of growing rod and at last visit were significantly different(P<0.001).Five complications were identified in 3 patients.Loosening of instruments combined with coronal imbalance and pelvic obliquity was detected in 1 patient before the third distraction,and revision surgery was conducted during distraction simultaneously.Loosening of lower instrumented screw combined with sagittal imbalance was found in 1 patient after the third distraction,and the final fusion surgery was performed 10 months after third distraction.Proximal junctional kyphosis was observed after the second distraction in 1 patient,and no significant progression was found till the last visit.For all 11 patients,no neurological complication was found during follow-up.Conclusions:For EOS patients with asymptomatic or stably-symptomatic intraspinal anomalies,growing rod is relatively safe and effective in clinical practice.