青少年Chiari畸形伴胸椎侧凸远端融合范围的选择及疗效比较

摘要

目的 探讨青少年Chiari畸形伴胸椎侧凸不同远端固定节段的选择对手术疗效的影响.方法 后路选择性胸椎融合术且随访超过2年的青少年共27例,男11例,女16例；年龄为12～18岁,平均15.2岁.记录术前、术后以及末次随访时的临床资料及影像学指标:冠状面侧凸Cobb角、侧凸柔韧性、顶椎偏移(apical vertebral translation,AVT)、顶椎旋转(apical vertebral rotation,AVR)及躯干偏移；矢状面胸椎后凸角(thoracic kyphosis,TK)、胸腰段Cobb角(thoracolumbar kyphosis,TLK)、腰椎前凸角(lumbar lordosis,LL)及躯干偏移(sagittal vertical axis,SVA),并进行统计学分析.结果 随访时间2～7年,平均3.4年.末次随访时的胸弯矫正率为55.9％,矫正丢失率2.3％,腰弯自发矫正率为59.2％.术前腰弯修正为A型与B型两组患者末次随访时各项影像学指标的差异均无统计学意义.除腰弯修正为B型且远端固定椎为L1的病例末次随访时的平均LL(59.8°)明显大于L2者(40.8°)外,A型及B型病例中远端固定椎位于L1或L2者其他各项影像学指标的差异均无统计学意义.结论 术前腰弯修正为A型及B型的青少年Chiari畸形伴胸椎侧凸患者采用后路选择性胸椎融合术治疗,可获得满意的胸弯矫正及腰弯的自发性矫正.%Objective To investigate the effect of lowest instrumented vertebrae (LIV) selection on clinical outcome of posterior thoracic fusion in adolescents with thoracic scoliosis secondary to Chiari malformation.Methods A total of 27 adolescents with Chiari malformation-associated scoliosis,who had undergone posterior thoracic fusion and been followed up for at least 2 years,were enrolled in this study.There were 11 males and 16 females,with an average age of 15.2 years (range,12 to 18 years).The following radiographic parameters:coronal Cobb angle,curve flexibility,apical vertebral translation (AVT),apical vertebral rotation (AVR),trunk shift (C7PL-CSVL distance),thoracic kyphosis (TK),lumbar lordosis (LL),thoracolumbar kyphosis,and sagittal vertical axis (SVA) were recorded preoperatively,immediately after surgery and at the last follow-up.Results All the patients received a followed-up from 2 to 7 years (average,3.4years).At the last follow-up,the average correction rate of thoracic curve was 55.9％ with an average correction loss rate of 2.3％.The spontaneous correction rate of lumbar curve was 59.2％ on average.At the last follow-up,no significant difference in terms of the radiographic parameters was found between patients with lumbar modifier "A" and "B".In patients having the lumbar modifier "A",the LIV was at L1 in 6 cases and at L2 in 7 cases.As for those with lumbar modifier "B",the LIV located at L1 in 6 cases,L2 in 4 cases,and T12 in 1 case.Among patients with lumbar modifier "B",the LL was significantly higher in cases with LIV at L1 when compared with those with LIV at L2.Conclusion Selective thoracic fusion can provide a satisfactory outcome in adolescents with Chiari malformation-associated scoliosis with lumbar modifier "A" and "B".