经骶2骶髂螺钉固定治疗伴严重骨盆倾斜的成人神经肌源性脊柱侧后凸畸形的中期疗效

Midterm clinical outcomes of second sacral alar-iliac screw fixation technique utilized in neuromuscular scoliosis with severe pelvic obliquity

目的探讨经第2骶椎骶髂螺钉(second sacral alar-iliac,S2AI)固定治疗伴严重骨盆倾斜的成人神经肌源性脊柱侧后凸的临床疗效和并发症发生情况,以及对患者生活质量的影响。方法回顾性分析2014年1月至2016年12月共11例接受S2AI固定技术治疗伴严重骨盆倾斜的成人神经肌源性脊柱侧凸患者的病历资料,男6例,女5例;年龄为(39.6±12.7)岁(范围18~55岁)。脊髓灰质炎8例,脊肌萎缩症2例,肌营养不良1例。均接受后路脊柱矫形内固定术治疗,术中均采用S2AI螺钉进行骨盆固定。主要的影像学观察指标为侧凸Cobb角、脊柱骨盆倾斜角(spinal pelvic obliquity,SPO)、局部后凸角(regional kyphosis,RK)、矢状面平衡(sagittal vertical axis,SVA)。初诊及末次随访时均采用脊柱侧凸研究学会问卷(Scoliosis Research Society,SRS-22)及Oswestry功能障碍指数(Oswestry disability index,ODI)评估生活质量,并记录并发症发生情况。计量资料(11例患者总体的侧凸Cobb角、SPO、RK和SVA)术前、术后、术后1年及末次随访时的比较采用方差分析(Friedman检验),差异有统计学意义者采用配对样本非参数检验(Wilcoxon检验)进行两两比较。SRS-22评分和ODI的比较采用重复测量t检验。结果11例患者随访时间为(62.4±10.8)个月(范围48~83个月)。术前侧凸Cobb角为98.0°±24.0°,术后改善至60.7°±20.8°,较术前有明显改善(Z=3.015,P=0.003),矫正率为57.2%±17.7%;术后1年Cobb角为62.8°±23.6°,末次随访时为61.6°±21.7°,与术后的差异均无统计学意义(Z=0.294,P=0.797;Z=0.603,P=0.594),随访期间未见明显矫形丢失。SPO术前为37.0°±11.8°,术后纠正至21.5°±11.6°,与术前的差异有统计学意义(Z=2.934,P=0.003);术后1年为23.2°±10.1°,末次随访时为21.1°±8.6°,与术后的差异均无统计学意义(Z=0.690,P=0.519;Z=0.000,P=1.000),随访期间无明显矫正丢失。RK术前为46.8°±23.6°,术后矫正至18.6°±10.6°,差异有统计学意义(Z=4.364,P<0.001);术后1年为18.9°±11.4°,末次随访时为19.5°±9.8°,与术后的差异均无统计学意义(Z=0.074,P=0.945;Z=0.271,P=0.838),随访期间维持良好。SVA手术前后及末次随访时的差异均无统计学意义。所有患者术中均无神经电生理监护信号的改变或丢失。1例患者发生切口感染,行清创手术后好转;1例患者发生腰背部剧烈疼痛,保守治疗后好转;随访期间1例患者因断棒行翻修手术。结论S2AI固定技术治疗伴严重骨盆倾斜的成人神经肌源性脊柱侧凸可获得满意的矫形效果,中期随访矫形效果维持良好,且并发症发生率较低。

Objective To evaluate the clinical outcomes and complications of second sacral alar-iliac(S2AI)technique utilized in adult patients with neuromuscular scoliosis,and to evaluate the impact on patients'quality of life.Methods All of 11 patients(6 males and 5 females)applying S2AI technique from January 2014 to December 2016 were retrospectively reviewed.The average age of the patients was 39.6±12.7 years.Among them,8 cases were poliomyelitis,2 cases were spinal muscular atrophy and 1 case was muscular dystrophy.All of 11 patients underwent posterior spinal fusion and utilized S2AI screws for pelvic fixation.All patients were taken anteroposterior and lateral radiographs of the entire spine.Cobb's angle,spinal pelvic obliquity(SPO),regional kyphosis(RK),sagittal vertical axis(SVA)were recorded at pre-operation,post-operation and last follow-up.The Scoliosis Research Society(SRS)-22 questionnaires and Oswestry disability index(ODI)were utilized to evaluate the patient-reported outcomes.All complications were also recorded.Repeated measurement analysis of variance,t-test or non-parametric test was used to analyzed the data,respectively.Results The average follow-up period was 62.4±10.8 months.The pre-operative Cobb angle was 98.0°±24.0°,and the post-operative Cobb angle was 60.7°±20.8°,of which difference was significant(Z=3.015,P=0.003).The correction rate of Cobb angles was 57.2%±17.7%.1-year after operation,the Cobb angle was 62.8°±23.6°,no loss of correction was found(Z=0.294,P=0.797).And at last follow-up,the Cobb angle was 61.6°±21.7°,the correction maintained well(Z=0.603,P=0.594).The pre-operative,post-operative,1-year post-operative and last follow-up spinal pelvic obliquity were 37.0°±11.8°,21.5°±11.6°,23.2°±10.1°and 21.1°±8.6°.The significant improvement was obtained(Z=2.934,P=0.003)and no loss of correction was found(Z=0.690,P=0.519;Z=0.000,P=1.000).The pre-operative,post-operative,1-year post-operative and last follow-up regional kyphosis were 46.8°±23.6°,18.6°±10.6°,18.9°±11.4°and 19.5°±9.8°.The significant improvement was obtained postoperatively(Z=4.364,P<0.001)and remained stable at the last follow-up(Z=0.074,P=0.945;Z=0.271,P=0.838).When compared the pre-and post-operative sagittal vertical axis,no significant difference was detected.In these patients,one patient had rod breakage and underwent revision,one patient suffered deep infection,and recovered by debridement surgery,one patient suffered from severe pain in the lower back and relieved with conservative treatment.Conclusion The S2AI technique utilized in patients with neuromuscular scoliosis could obtain satisfying clinical outcomes and provides safe,durable fixation with low rates of complications.