单纯后路截骨矫形治疗僵硬性颈椎畸形

Single posterior osteotomy for the treatment of rigid cervical spine deformities

目的探讨单纯后路截骨矫形治疗僵硬性颈椎畸形的安全性和有效性、手术适应证及关键技术。方法回顾性分析2012年6月至2023年6月新疆医科大学第一附属医院采取单纯后路截骨矫形治疗僵硬性颈椎畸形的患者9例,男4例、女5例;年龄(19.8±27.2)岁(范围7~48岁)。先天性颈椎畸形5例,治愈型结核3例,医源性颈椎畸形1例。测量C1,2角、颈椎前凸角(cervical lordosis,CL)、颈椎侧凸角(structural scoliosis angle,SSA)、颈椎后凸角(structural kyphosis angle,SKA)、头部倾斜角(head tilt,HT)、颈椎矢状偏移距离(C2~C7 sagittal vertical axis,CSVA)、躯干矢状偏移距离(sagittal vertical axis,SVA)、冠状面偏移距离(coronal balance distance,CBD)、T1倾斜角(T1 Slope,T1S)及T1S与颈椎前凸角的差值(T1S-CL)。采用颈椎功能障碍指数(neck disability index,NDI)、疼痛视觉模拟评分(visual analogue scale,VAS)及脊柱侧凸研究学会-22(Scoliosis Research Society-22,SRS-22)简明量表评估颈椎畸形患者的生活质量。结果手术时间(273.9±76.1)min,出血量(472.2±128.8)ml。9例患者均获随访,随访时间(45.2±41.8)个月(范围12~116个月)。单节段截骨7例(C3、C6、C7各1例,C54例),双节段截骨2例(C2和C7,C3和C4)。经椎弓根截骨4节段,全脊椎截骨7节段。上固定椎(upper instrumented vertebrae,UIV)位于枕骨1例、颈椎8例,下固定椎(lower instrumented vertebrae,LIV)位于上胸椎6例、颈椎3例,其中UIV和LIV均位于颈椎2例。融合固定节段(7.6±4.4)个(范围2~12个)。术后(8.8±3.2)个月(范围6~12个月)患者均获得良好的植骨融合。9例患者术前CL、SSA、SKA、HT、CBD分别为19.8°(17.2°,30.5°)、27.4°(23.3°,30.4°)、28.4°(25.6°,30.1°)、9.0°(6.2°,12.3°)、18.5(12.3,23.6)mm;术后改善至-11.1°(-8.8°,-14.4)、1.3°(0.8°,1.6°)、-11.1°(-8.6°,-14.5°)、1.6°(0.5°,2.2°)、9.4(4.8,13.5)mm;末次随访时分别为-11.0°(-8.8°,-14.3°)、1.2°(0.8°,1.5°)、-11.0°(-8.6°,-14.3°)、1.5°(0.5°,2.2°)、9.4(4.8,13.4)mm,手术前后的差异均有统计学意义(P<0.05);而手术前后C1,2角、CSVA、SVA、T1S、T1S-CL的差异均无统计学意义(P>0.05)。术后NDI和SRS-22评分升高,手术前后的差异均有统计学意义(P<0.05),而VAS评分差异无统计学意义(P>0.05)。术后发生短暂性神经损伤2例、右侧视网膜中央动脉闭塞和椎动脉损伤各1例。结论采取单纯后路截骨矫形治疗颈椎不同原因所致僵硬性颈椎畸形安全、有效。颈椎畸形以后凸为主者可采用标准经椎弓根截骨及改良技术进行截骨矫形,而先天性颈椎侧凸或侧后凸畸形可采用半椎体切除和凹侧撑开技术。

Objective To evaluate the safety and effectiveness of single posterior osteotomy in the correction of rigid cervical spine deformities(CSD)and to explore the indications and key surgical techniques involved.Methods A retrospective analysis was conducted on the clinical data of 9 patients with rigid CSD who underwent single posterior osteotomy correction between June 2012 and June 2023 in the Department of Spine Surgery at the First Affiliated Hospital of Xinjiang Medical University.The cohort comprised 4 males and 5 females,with a mean age of 19.8±27.2 years(range,7-48 years).Among these,5 cases were congenital CSD,3 were post-tuberculosis deformities,and 1 was iatrogenic.Various coronal and sagittal alignment parameters were measured,including C,2 angle,cervical lordosis(CL),structural scoliosis angle(SSA),structural kyphosis angle(SKA),head tilt(HT),C2-C sagttal vertical axis(CSVA),sagittal vertical axis(SVA),coronal balance distance(CBD),T,slope(T,S),and the difference between T,tilt and cervical lordosis(TS-CL).Clinical outcomes were assessed using the neck disability index(NDI),visual analogue scale(VAS),and Scoliosis Research Society-22questionnaire(SRS-22).ResultsThe average operation time was 273.9±76.1 min,with an average blood loss of 472.2±128.8 ml.All 9 patients were followed up for an average of 45.2±41.8 months(range,12-116 months).A total of 7 patients underwent single-segment osteotomies(C3,C,and C:1 case each;Cs:4 cases),and 2 patients underwent double-segment osteotomies(C:and C7,Csand C4).Four cases involved pedicle subtraction osteotomy(PSO),while 7 cases required vertebral column resection.The upper instrumented vertebra(UIV)was located at the occiput in 1 case and in the cervical spine in 8 cases.The lower instrumented vertebra(LIV)was located in the upper thoracic spine in 6 cases and in the cervical spine in 3 cases,with 2 of the latter cases having both UIV and LIV in the cervical spine.The average number of fused segments was 7.6±4.4 segments(range,2-12 segments).All patients achieved successful bone fusion within an average of 8.8±3.2 months(range,6-12 months).Preoperatively,the mean values for CL,SSA,SKA,HT,and CBD were 19.8°(17.2°,30.5°),27.4°(23.3°,30.4°),28.4°(25.6°,30.1°),9.0°(6.2°,12.3°),and 18.5(12.3,23.6)mm,respectively.Postoperative improvements were not-ed with values of-11.1(-8.8°,-14.4°),1.3°(0.8°,1.6°),-11.1(-8.6°,-14.5°),1.6°(0.5°,2.2°),and 9.4(4.8-13.5)mm,respec-tively.At the final follow-up,these parameters were maintained,with values of-11.0(-8.8°,-14.3°),1.2°(0.8°,1.5°),-11.0°(-8.6°,-14.3°),1.5°(0.5°,2.2°),and 9.4(4.8,13.4)mm,respectively.Statistically significant improvements were observed between preop-erative and postoperative measurements(P<0.05),except for Cr.:angle,CSVA,SVA,TS,and T,S-CL(P>0.05).NDIand SRS-22 scores showed significant improvements postoperatively(P<0.05),while VAS scores did not show a significant change(P>0.05).Postoperative complications included transient nerve injury in two patients,one case of right central retinal artery occlusion,and one case of vertebral artery injury.Conclusion This study confirms the safety and efficacy of single posterior osteotomy for treat-ing rigid CSD of various etiologies.Standard PSO or modified techniques are effective for correcting cervical kyphosis,while hemi-vertebra resection and concave-side distraction are recommended for congenital scoliosis or kyphoscoliosis.