双侧钉棒梯次紧凑闭合脊髓短缩联合植入物内固定矫正僵硬性脊柱角状后凸

摘要

背景：胸腰椎角状后凸手术的治疗难点在于矫正率低，矢状面重建难，易发生神经并发症，术后失平衡、假关节发生率高及术后矫正度丢失。　　目的：探讨改良经后路全脊椎切除截骨端双侧钉棒梯次紧凑闭合脊髓逐步短缩联合植入物内固定治疗严重脊柱角状后凸畸形的安全性和有效性。　　方法：选择2006年1月至2013年12月解放军第306医院骨科收治的严重脊柱角状后凸畸形患者87例，男36例，女51例，采用经后路全脊椎切除截骨、双侧钉棒联合梯次紧凑闭合脊髓逐步短缩、植入物内固定方法治疗，对患者治疗前、后的后凸角、脊柱矢状位失平衡、躯干侧方偏移率、手术时间及术中失血量进行观察分析。　　结果与结论：患者治疗前的后凸角为31°-138°，平均90.1°；治疗后为15°-57°，平均27.9°，改善率为76%。躯干矢状位偏移的改善率为76%。术中失血量为800-3000 mL，平均失血量为2300 mL；手术时间为5-7 h，平均手术时间5.9 h；治疗前2例患者伴有双下肢神经症状，Frankel分型C级，治疗后恢复至E级。治疗后随访9-57个月，所有患者的截骨节段均获得骨性融合，无脊髓损伤并发症出现，无矫形角度丢失。提示经后路全脊椎切除截骨治疗重度僵硬性胸椎角状后凸畸形，术中可对血管最大限度的保留，避免血管损伤导致脊髓的缺血性改变以及缺血再灌注损伤等，低体质量患者手术过程中减少出血、以及保障有效血容量是治疗后早期恢复的有效保障；双侧钉棒联合梯次紧凑闭合脊髓逐步短缩脊柱矫形技术在胸腰椎角状后凸畸形的矫正过程中能够最大限度保护脊髓细胞不受损伤，应注意对神经根的保护和松解，避免术后出现相应的神经根刺激症状；充分的植骨融合程度是保证后凸畸形矫正、避免脊柱侧方偏移，同时又是脊柱功能和术后矫形效果的有效保障。%BACKGROUND:The treatment difficulties of thoracolumbar angular kyphosis surgery are:low correction rate, hard to rebuild sagittal plane, easily induce neurological complications, postoperative loss of balance, high incidence of pseudarthrosis and postoperative loss of correction degree. OBJECTIVE:To explore the safety and efficacy of modified posterior vertebral column resection osteotomy and bilateral pedicle screw combined with echelon tight closure spinal cord technique and implant fixation for severe spinal angular kyphosis. METHODS:A total of 87 severe spinal angular kyphosis patients, 36 males and 51 females, who were treated in the Department of Orthopedics, the 306 Hospital of Chinese PLA from January 2006 to December 2013, were enrol ed in this study. They underwent posterior vertebral column resection, bilateral pedicle screw combined with echelon tight closure spinal cord, and implant fixation. Kyphosis, spinal sagittal imbalance, offset rate towards trunk side, operation time and intraoperative blood loss were observed before and after treatment. RESULTS AND CONCLUSION:The preoperative average kyphosis was 90.1° (31°-138°). The postoperative average kyphosis was 27.9° (15°-57°). The improvement rate was 76%. The improvement rate of trunk sagittal offset was 76%. Intraoperative blood loss was 800-3 000 mL, and average blood loss was 2 300 mL. The operation time was 5-7 hours, averagely 5.9 hours. Before treatment, two patients affected neurologic symptoms in double lower extremity, and their Frankel classification was grade C and became grade E after treatment. Al patients were fol owed up for 9-57 months. Bony fusion was achieved in al patients. No complications of spinal cord injury appeared, and no orthopedic angle missing occurred. These results indicate that during posterior vertebral column resection for treating severe angular stiffness of the thoracic kyphosis, blood vessels could be maintained greatly. Blood vessel injury-induced ischemic changes in spinal cord and ischemic reperfusion injury could be avoided. To reduce hemorrhage and to keep effective blood volume in patients with low body mass are effective for early recovery after treatment. Bilateral pedicle screw combined with echelon tight closure spinal cord technique greatly protected spinal cord cells against injury. We should pay attention to the protection and loose of nerve root to avoid postoperative nerve root irritation. Sufficient bone fusion ensures kyphosis correction, avoids spine lateral offset, and plays a key role in spinal function and postoperative orthopedic effect.