伴脊髓拴系脊柱侧凸的手术治疗

摘要

目的 评估伴脊髓拴系的脊柱侧凸直接进行侧弯矫形手术而不对拴系进行松解的安全性和有效性.方法 回顾性分析2005年12月至2011年1月收治的脊柱侧凸合并脊髓拴系22例的患者资料,其中男性8例,女性14例；年龄6～51岁,平均17.7岁.7例患者术前存在临床症状.全部病例术前均未行脊髓拴系松解而直接进行侧弯矫形手术.手术采用一期后路椎弓根钉棒系统进行矫形固定融合,术中均应用脊髓电生理监测.分别测量术前及术后冠状面主弯Cobb角、矢状面胸后凸Cobb角、主弯顶椎偏距、顶椎旋转度及躯干偏移,并记录围手术期并发症的发生情况.结果 术后20例患者获得随访,随访时间6～52个月,平均23.5个月.术前冠状面主弯Cobb角平均为68°±20°,术后矫正至38°±21°,平均矫形率为48.1％,术后与术前相比,差异具有统计学意义(t=13.9,P＜0.05)；术前胸后凸平均为65°±18°,术后为28°±11°,平均矫形率为56.7％,术后与术前相比,差异亦具有统计学意义(t=8.81,P＜0.05).术前主弯顶椎偏距、顶椎旋转度及躯干偏移分别为(5.4±2.5) cm、2.3°±0.6°、(2.0±1.8)cm,术后分别矫正至(3.2±1.8)cm、1.2°±0.5°、(1.5±1.1)cm.冠状面主弯顶椎偏距及主弯顶椎旋转度,术后与术前相比,差异均具有统计学意义(t=5.69和10.07,P＜0.05).术后冠状面躯干偏移较术前差异无统计学意义.术后3例患者发生并发症,1例为一过性下肢麻木,另2例为胸腔积液,经治疗后均好转出院.术后随访期间无神经并发症及内固定并发症发生.术前伴有临床症状的患者,术后及随访过程中其症状无加重.结论 伴脊髓拴系的脊柱侧凸如果拴系症状不明显,在矫形过程中注意加强脊髓监护,术前不对拴系进行松解而直接进行侧弯矫形可能仍然是安全、有效的,不过尚需积累更多的病例以进一步证实.%Objective To evaluate the safety and effectiveness of correction of scoliosis associated with tethered cord without releasing it.Methods Twenty-two cases diagnozed as scoliosis with tethered cord between December 2005 and January 2011 were investigated retrospectively in the study.There were 8 males and 14 females.The age was from 6 to 51 years,averaged 17.7 years.There were 7 patients with clinical symptoms before surgery.All the patients underwent posterior deformity correction and instrumentation by pedicle screws directly without releasing the tethered cord.Spinal cord monitoring was conducted in all the cases.The preoperative and postoperative Cobb angle of the coronal main curve and thoracic kyphosis were measured.Also,the preoperative and postoperative values of the apical vertebra translation,apical vertebra rotation and trunk shift were measured by the same person.The incidence of perioperative complications were recorded.Results A total of 20 patients were followed up.The follow-up time was from 6 to 52 months,mean 23.5 months.The average Cobb angle of the coronal main curve were 68° ± 20° before surgery and 38° ± 21 ° after surgery with a mean correction of 48.1％.The difference was significant (t =13.9,P ＜0.05 ).The mean kyphosis was 65 ° ± 18 ° preoperatively and 28° ± 11 ° postoperatively,with a correction of 56.7％.The difference was also significant(t =8.81,P ＜ 0.05).The preoperative values of the apical vertebra translation,apical vertebra rotation and trunk shift were (5.4 ± 2.5 ) cm,2.3 ° ± 0.6 ° and ( 2.0 ±1.8 )cm,respectively,which were corrected to (3.2 ± 1.8 ) cm,1.2 ° ± 0.5 ° and ( 1.5 ± 1.1 ) cm after the surgcry. Compared to the preoperative values, the difference were significant in the apical vertebra translation( t =5.69,P ＜ 0.05 ) and apical vertebra rotation ( t =10.07,P ＜ 0.05 ).However,there was no difference in trunk shift.Postoperativc complications occurred in 3 patients,including transient numbness of the lower extremity in 1 patient and hydrothorax in 2 patients. No neurological and instrumentation complications occurred during the follow-ups.Patients with clinical symptoms before surgery got no serious during the surgery and follow-ups.Conclusions If there are no symptoms of tethering in scoliosis patients with tethered cord,the corrective surgeries may be safe and effective when spinal cord monitoring conducted without spinal cord untethering.But more eases are needed to confirm it.