后路复位固定联合经椎弓根截骨矫形术治疗强直性脊柱炎后凸畸形合并上颈椎损伤的疗效

Efficacy of posterior reduction and fixation combined with pedicle subtraction osteotomy in the treatment of ankylosing spondylitis kyphotic deformity complicated by upper cervical spine injury

目的探讨后路复位固定联合经椎弓根截骨矫形术(PSO)治疗强直性脊柱炎(AS)后凸畸形合并上颈椎损伤的疗效。方法采用回顾性病例系列研究分析2010年10月至2022年12月新疆医科大学第一附属医院收治的8例AS后凸畸形合并上颈椎损伤患者的临床资料,均为男性;年龄32~58岁[(46.9±8.7)岁]。急性损伤1例,陈旧性损伤7例。3例颈胸椎后凸畸形,5例胸腰椎后凸畸形。合并齿状突骨折5例,C_(2~3)骨折1例,寰枢椎脱位2例。美国脊髓损伤学会(ASIA)分级:C级2例,D级3例,E级3例。根据畸形位置不同,行后路上颈椎损伤复位固定联合颈胸椎或胸腰椎PSO。记录手术时间及术中出血量。比较术前,术后1周、3个月、6个月、12个月及末次随访时颈椎功能障碍指数(NDI)、视觉模拟评分(VAS)、C_(0)~C_(2)角、C_(1)~C_(2)角、颈椎前凸角(CL)、头部倾斜角(HT)、颌眉角(CBVA)、颈椎矢状偏移距离(CSVA)、躯干矢状偏移距离(SVA)。术后12个月观察骨折愈合、截骨区融合情况。末次随访时观察神经功能恢复情况。观察并发症发生情况。结果患者均获随访12~24个月[(17.0±5.4)个月]。手术时间5.5~7.2 h[(6.2±0.6)h],术中出血量480~800 ml[(629.4±124.0)ml]。术后1周,3、6、12个月及末次随访时,NDI分别为(14.6±2.6)分、(13.6±2.8)分、(12.8±2.4)分、(12.8±2.7)分、(12.8±2.6)分,均低于术前的(29.6±8.5)分(P<0.01),术后各时间点NDI差异均无统计学意义(P>0.05);VAS分别为2.0(1.0,3.0)分、1.5(1.0,2.0)分、0.5(0.0,1.8)分、0.5(0.0,1.7)分、0.5(0.0,1.8)分,均低于术前的3.5(3.0,4.8)分(P<0.01);术后3个月VAS低于术后1周(P<0.05),术后6个月VAS低于术后3个月(P<0.05),术后6、12个月及末次随访时VAS差异均无统计学意义(P>0.05)。术前、术后各时间点C_(0)~C_(2)角、C_(1)~C_(2)角差异均无统计学意义(P>0.05)。术后1周,3、6、12个月及末次随访时,CL分别为-8.5(-5.3,-11.9)°、-8.6(-5.5,-11.9)°、-8.4(5.2,-12.1)°、-8.8(-5.6,-12.4)°、-8.7(-5.3,-12.5)°,均大于术前的1.2(9.5,-4.8)°(P<0.01);HT分别为6.1(4.5,9.6)°、6.1(4.3,9.4)°、6.0(4.2,8.9)°、6.0(4.2,9.2)°、6.1(4.3,9.2)°,均小于术前的17.0(10.3,22.0)°(P<0.01);CBVA分别为(23.2±5.0)°、(23.1±4.8)°、(23.0±4.7)°、(23.1±4.7)°、(23.1±4.9)°,均小于术前的(44.1±9.8)°(P<0.01);CSVA分别为5.2(4.2,7.5)cm、5.4(4.1,7.1)cm、4.7(4.0,7.4)cm、5.4(4.1,7.0)cm、5.1(4.3,6.5)cm,均短于术前的9.0(7.8,9.3)cm(P<0.01);SVA分别为7.7(6.2,13.7)cm、7.5(6.0,13.4)cm、7.6(6.2,13.2)cm、7.4(6.3,13.1)cm、7.5(6.2,13.2)cm,均短于术前的16.8(8.2,27.2)cm(P<0.05)。术后各时间点CL、HT、CBVA、CSVA、SVA差异均无统计学意义(P>0.05)。术后12个月骨折均愈合;截骨区均达BridwellⅠ级融合。末次随访时患者ASIA分级均为E级,较术前显著改善(P<0.01)。1例术后出现短暂性C8神经麻痹,治疗4周后恢复。患者均未发生感染或断钉、断棒、螺钉松动等内固定相关并发症。结论对于AS后凸畸形合并上颈椎损伤,后路复位固定联合颈胸椎或胸腰椎PSO可有效促进颈椎功能恢复、减轻疼痛、恢复整体躯干平衡、改善神经症状并减少并发症。

Objective To investigate the efficacy of posterior reduction and fixation combined with pedicle subtraction osteotomy(PSO)in the treatment of ankylosing spondylitis(AS)kyphotic deformity complicated by upper cervical spine injury.Methods A retrospective case series study was conducted to analyze the clinical data of 8 patients with AS kyphotic deformity complicated by upper cervical spine injury,who were admitted to First Affiliated Hospital of Xinjiang Medical University from October 2010 to December 2022.All were males,aged 32-58 years[(46.9±8.7)years].Acute injury was found in 1 patient and chronic injuries in 7 patients,including 3 with cervicothoracic kyphotic deformity and 5 with thoracolumbar kyphotic deformity.Five patients were complicated by odontoid fractures,1 by C_(2)-C_(3)fracture and 2 by atlantoaxial dislocation.According to American Spinal Injury Association(ASIA)scale,2 patients were with grade C,3 with grade D,and 3 with grade E.The patients were treated with posterior upper cervical reduction and fixation combined with cervicothoracic PSO or thoracolumbar PSO respectively according to the location of the deformity.The operation time and intraoperative blood loss were recorded.Neck disability index(NDI),visual analogue scale(VAS),C_(0)-C_(2)angle,C_(1)-C_(2)angle,cervical lordosis angle(CL),head tilt angle(HT),chin-brow vertical angle(CBVA),cervical sagittal vertical axis(CSVA),and sagittal vertical axis(SVA)were compared before surgery,at 1 week and 3,6,12 months after surgery,and at the last follow-up.The healing of fractures and fusion of osteotomy site were recorded at 12 months after surgery.Recovery of neurological function was observed at the last follow-up.Incidence of complications was observed.Results Patients were all followed up for 12-24 months[(17.0±5.4)months].The operation time was 5.5-7.2 hours[(6.2±0.6)hours]and the intraoperative blood loss was 480-800 ml[(629.4±124.0)ml].The NDI scores at 1 week and 3,6,12 months after surgery,and at the last follow-up were(14.6±2.6)points,(13.6±2.8)points,(12.8±2.4)points,(12.8±2.7)points,and(12.8±2.6)points respectively,significantly lower than(29.6±8.5)points preoperatively(P<0.01).There were no significant differences in NDI scores at various time points after surgery(P>0.05).The VAS scores were 2.0(1.0,3.0)points,1.5(1.0,2.0)points,0.5(0.0,1.8)points,0.5(0.0,1.7)points,and 0.5(0.0,1.8)points respectively,significantly lower than 3.5(3.0,4.8)points preoperatively(P<0.01).The VAS score at 3 months postoperatively was lower than that at 1 week postoperatively(P<0.05),and the VAS score at 6 months postoperatively was lower than that at 3 months postoperatively(P<0.05).There were no statistically significant differences in VAS scores at 6,12 months postoperatively,and at the last follow-up(P>0.05).There were no statistically significant differences between C_(0)-C_(2)angle and C_(1)-C_(2)angle preoperatively and at different time points postoperatively(P>0.05).At 1 week and 3,6,12 months postoperatively and at the last follow-up,the CL values were-8.5(-5.3,-11.9)°,-8.6(-5.5,-11.9)°,-8.4(5.2,-12.1)°,-8.8(-5.6,-12.4)°,and-8.7(-5.3,-12.5)°respectively,significantly higher than 1.2(9.5,-4.8)°preoperatively(P<0.01);the HT values were 6.1(4.5,9.6)°,6.1(4.3,9.4)°,6.0(4.2,8.9)°,6.0(4.2,9.2)°,and 6.1(4.3,9.2)°respectively,significantly lower than 17.0(10.3,22.0)°preoperatively(P<0.01);the CBVA values were(23.2±5.0)°,(23.1±4.8)°,(23.0±4.7)°,(23.1±4.7)°,and(23.1±4.9)°respectively,significantly lower than(44.1±9.8)°preoperatively(P<0.01);the CSVA values were 5.2(4.2,7.5)cm,5.4(4.1,7.1)cm,4.7(4.0,7.4)cm,5.4(4.1,7.0)cm,and 5.1(4.3,6.5)cm respectively,significantly shorter than 9.0(7.8,9.3)cm preoperatively(P<0.01);the SVA values were 7.7(6.2,13.7)cm,7.5(6.0,13.4)cm,7.6(6.2,13.2)cm,7.4(6.3,13.1)cm,and 7.5(6.2,13.2)cm respectively,significantly shorter than 16.8(8.2,27.2)cm preoperatively(P<0.05).There were no statistically significant differences among CL,HT,CBVA,CSVA,and SVA values at different time points after surgery(P>0.05).All the fractures healed at 12 months after surgery and Bridwell grade I healing was achieved at all the osteotomy sites.At the last follow-up,all the patients were classified as ASIA grade E,significantly improved compared with preoperatively(P<0.01).One patient had transient C8 nerve paralysis after surgery and recovered after 4 weeks′treatment.The remaining patients did not develop any infection or internal fixation-related complications,such as broken rods,broken screws,or loose screws.Conclusion For AS kyphosis deformity complicated with upper cervical injury,posterior reduction and fixation combined with cervicothoracic or thoracolumbar PSO can effectively promote functional recovery,relieve pain,maintain overall trunk balance,improve neurological symptoms,and reduce the incidence of complications.