重度僵硬脊柱侧后凸截骨策略量化标准的探讨

Discussion on quantitative criteria for osteotomy strategy in treatment of severe scoliosis

目的探讨重度僵硬脊柱侧后凸截骨策略的量化标准。方法对2012年5月至2020年5月贵州省骨科医院脊柱外科采取牵引后手术治疗的重度脊柱侧凸患者63例的临床资料进行回顾性分析。其中男30例,女33例,年龄(19.8±5.0)(13~34)岁。主弯顶椎位于胸段43例,胸腰段9例,腰段11例;主弯冠状面Cobb角(117.4±17.2)°(91°~176°),矢状面Cobb角(92.5±11.6)°(62°~132°)。对全部病例行充分牵引后手术治疗,其中行Smith-Peterson截骨术(SPO)20例,经椎弓根截骨术(PSO)36例,全脊椎截骨术(VCR)7例。将全部患者依据牵引后冠状面和矢状面楔形变程度主弯凸侧与凹侧边椎体高度差(H_(1)-H_(2))与正常椎体高度(h)比值各分为H_(1)-H_(2)<1.5 h组、H_(1)-H_(2)=1.5 h~2.0 h组和H_(1)-H_(2)>2.0 h组3组,按牵引后冠状面和矢状面主弯椎间盘总开角(牵引后主弯各椎间盘角度之和α_(1)-牵引前主弯各椎间盘角度之和α_(2))各分为α_(1)-α_(2)<20°组、α_(1)-α_(2)=20°~30°组和α_(1)-α_(2)>30°组3组。记录12组病例术前与术后主弯冠状面和矢状面Cobb角、术后冠状面和矢状面Cobb角矫正率、手术时间和术中出血量并对3种术式进行比较。使用单因素ANOVA检验,组间使用事后检验多重比较。结果全部患者牵引时间为(31.13±9.26)(19~49)d。牵引过程中未见神经并发症以及钉道松动、感染和钉道皮肤不愈合等并发症。术后未出现神经损伤、大血管损伤、脑脊液漏、感染和病死病例。固定融合节段为(10.12±2.37)(8~14)个椎体。矫形术后主弯冠状面、矢状面Cobb角较术前矫正率分别为(58.54±8.87)%(31%~76%)和(52.55±12.69)%(38%~59%),手术时间(325.55±118.36)(250~480)min,术中出血量(954.76±443.55)(860~2400)ml。末次随访时主弯冠状面、矢状面Cobb角矫正率分别为(57.66±5.12)%(31%~78%)和(51.65±6.43)%(38%~59%)。SPO在冠状面与矢状面H_(1)-H_(2)<1.5 h组和α_(1)-α_(2)>30°组的畸形矫正率均超过50%;PSO在冠状面与矢状面H_(1)-H_(2)<1.5 h组,H_(1)-H_(2)=1.5 h~2.0 h组,α_(1)-α_(2)>30°组和α_(1)-α_(2)=20°~30°组的畸形矫正率均超过50%;VCR在冠状面与矢状面H_(1)-H_(2)=1.5 h~2.0 h组,H_(1)-H_(2)>2.0 h组,α_(1)-α_(2)=20°~30°组和α_(1)-α_(2)<20°组的畸形矫正率均超过50%。结论以主弯椎体楔形变程度及牵引后主弯椎间盘总开角为依据的截骨策略,对重度僵硬脊柱侧后凸的截骨方式选择具有一定指导意义,既可避免因截骨等级不足而影响矫形效果,又可避免患者承受截骨等级过高的风险。

Objective To explore the quantitative criteria for osteotomy strategy in treatment of severe scoliosis.Methods Clinical data of 63 patients with severe scoliosis underwent osteotomy in Department of Spine Surgery,Guizhou Orthopedic Hospital from May 2012 to may 2020 were analyzed retrospectively.Thirty males and 33 females,aged(19.8±5.0)(range:13 to 34),were included.Forty-three cases were located in thoracic segment,9 in thoracolumbar segment and 11 in lumbar segment.The Cobb angle of main curve on the coronal plane and the sagittal plane were(117.4±17.2)°(range:91°to 176°)and(92.5±11.6)°(range:62°to 132°),respectively.Smith-Peterson osteotomy(SPO)in 20 cases,pedicle subtraction osteotomy(PSO)in 36 cases and vertebral column resection(VCR)in 7 cases were performed after traction.All the patients were divided into 3 groups according to the degree of cuneiform change in scoliosis(the ratio of the difference between the length of the convex side(H_(1))and the concave side(H_(2))of the main curve and the normal vertebral body height(h))on the coronal plane and the sagittal plane,and the total open angle of the main curve disc in scoliosis(the difference between the sum of intervertebral disc angles in the main curve after traction(α_(1))and that before traction(α_(1)))on the coronal plane and the sagittal plane,respectively.So there were 12 groups including group of H_(1)-H_(2)<1.5 h,H_(1)-H_(2)=1.5 h-2.0 h and H_(1)-H_(2)>2.0 h on the coronal plane and the sagittal plane,and group ofα_(1)-α_(2)<20°,α_(1)-α_(2)=20°-30°andα_(1)-α_(2)>30°on the coronal plane and the sagittal plane.The correction rate,operation time and intraoperative blood loss of 12 groups were recorded and the indice of the 3 kinds of surgery were compared.Results The traction duration was(35.2±8.3)(range:20-49).No neurological complications and no loosening,infection,skin nonunion and other complications were found during traction.No postoperative complication of nerve injury,macrovascular injury,cerebrospinal fluid leakage,infection or death occrred.The range of fixation and fusion was(10.12±2.37)(range:8-14)vertebrae.The correction rates of coronal and sagittal Cobb angles were(58.54±8.87)%(range:31%-76%)and(52.55±12.69)%(range:38%-59%),respectively.The operation time was(325.55±118.36)(range:250-480)min.The intraoperative blood loss was(954.76±443.55)(range:860-2400)ml.All patients were followed up for(20.33±11)(range:12-36)months.At the last follow-up,the correction rates of coronal and sagittal Cobb angles were(57.66±5.12)%(range:31%-78%)and(51.65±6.43)%(range:38%-59%),respectively.SPO achieved 50%correction rate in coronal and saggital H_(1)-H_(2)<1.5 h andα_(1)-α_(2)>30°group;PSO achieved 50%correction rate in coronal and saggital H_(1)-H_(2)<1.5 h,H_(1)-H_(2)=1.5 h-2.0 h,α_(1)-α_(2)>30°andα_(1)-α_(2)=20°-30°group;VCR achieved 50%correction rate in coronal and saggital H_(1)-H_(2)=1.5 h-2.0 h,H_(1)-H_(2)>2.0 h,α_(1)-α_(2)=20°-30°andα_(1)-α_(2)<20°group.Conclusion The osteotomy strategy based on the degree of cuneiform change and the total open angle of the main curve intervertebral disc in scoliosis after traction has a certain guiding significance for the selection of osteotomy methods for severe rigid scoliosis.It can not only avoid the orthopedic effect affected by insufficient osteotomy grade,but also avoid the risk of patients suffering from too high osteotomy grade.