全脊椎截骨梯次矫形治疗重度脊柱角状后凸畸形

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摘要目的评价后路全脊椎截骨梯次矫形治疗重度脊柱角状后凸畸形的安全性和有效性。方法 2015年1月至2016年12月，前瞻性采取后路全脊椎截骨梯次矫形技术治疗重度脊柱角状后凸畸形患者37例，男16例，女21例；年龄11~58岁，平均28.6岁。所有入选患者均于手术前、后及末次随访时测量后凸Cobb角、侧凸Cobb角、冠状位躯干偏移(trunk shift，TS)和矢状面平衡(sagittal vertical axis，SVA)等影像学相关参数。同时采用疼痛视觉模拟评分(visual analogue scale，VAS)、SF-36评分，Oswestry功能障碍指数((The oswestry disability index，ODI)评估其临床疗效，使用Frankel分级法评价患者手术前后及末次随访时神经功能情况，并对围手术期并发症进行分析。结果手术时间平均(468.9±108.3)min(312～723 min)，术中出血量平均(2 173.7±1 226.6)mL(800～5 100 mL)，随访时间平均22.5个月(12~40个月)，术前后凸Cobb角平均(124±20.4)°(91°~160°)，侧凸Cobb角平均(87.2±45.2)°(0°~156°)；术后后凸角平均(46.8±21.5)°(10°～120°)，侧凸角平均(49.1±26.9)°(0°～109°)，矫正率分别为62.3％和45.2％；末次随访时后凸、侧凸Cobb角有轻度丢失，但与术后比较，差异无统计学意义。TS由术前的(38.6±17.2)mm减少至(11.5±11.2)mm，SVA由术前(33.5±11.4)mm减少到术后(9.6±7.2)mm，差异有统计学意义。术后和末次随访时的SF-36、VAS、ODI与术前比较均有明显改善。14例次(37.8％)患者发生围手术期并发症，其中发生神经系统并发症4例(10.8％)，包括完全性脊髓损伤1例，一过性神经功能障碍3例；非神经系统并发症10例次(27％)，包括胸腔积液2例，切口愈合不良3例，消化系统并发症3例；螺钉松动拔出1例，螺帽脱落1例。结论后路全脊椎截骨梯次矫形是治疗重度脊柱角状后凸畸形的有效手术方法，但手术时间长，出血量多，应充分重视围手术期并发症。

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关键词 ：角状后凸畸形, 侧后凸畸形, 后路全脊椎截骨, 并发症

Abstract：Objective To evaluate the safety and clinical outcomes of posterior vertebral column resection (PVCR) combined with stepwise correction technique in the treatment of patients with severe angular kyphosis.Methods A prospective study was designed on patients.From January 2015 to December 2016，37 patients with severe angular kyphosis underwent PVCR combined with stepwise correction technique，including16 males and 21 females with an average age of 28.6 years old (range 11～58 years).Relevant radiographic parameters were recorded pre-operatively，post-operatively and at last follow-up，included Cobb angle，global kyphosis(GK)，Trunk shift(TS) and sagittal vertical axis(SVA). The clinical outcomes were evaluated by MOS item short-form health survey(SF-36)，visual analogue scale(VAS) and Oswestry disability index(ODI)，while neurological function was evaluated by Frankel classification.Perioperative complications were analyzed as well.Results The average operation time was (468.9±108.3)min (range 312～723 min)with an average blood loss of (2 173.7±1 226.6)mL (range 800～5 100 mL).The average follow-up time was 22.5 months (12~40 months).The pre-operative average GK angle and Cobb angle were (124±20.4)°(range 91°~160°)and (87.2±45.2)°(range 0°~156°).The post-operative average GK angle and Cobb angle were (46.8±21.5)°(range 10°～120°)and (49.1±26.9)°(range 0°～109°).The correction rate of GK angle and Cobb angle were 62.3% and 45.2%，respectively.At last follow-up，no significant loss of correction was observed in the GK angle and Cobb’s angle.The pre-operative and post-operative TS were (38.6±17.2)mm，(11.5±11.2)mm，respectively，SVA decreased from pre-operative (33.5±11.4)mm to (9.6±7.2)mm post-operatively，significant improvement of TS and SVA were observed.In addition，compared with SF-36，VAS，ODI values in pre-operation，the values in both post-operation and the last follow-up have significant improvement.The incidence of perioperative complications was 37.8% (n＝14)including complete paralysis (n＝1)，transient neurological deficit (n＝3)，hemothorax (n＝2)，poor wound healing (n＝3)，the digestive system complications (n＝3)，screw pull-out (n＝1)and screw cap dislodgement(n＝1).Conclusion Posterior vertebral column resection combined with stepwise correction technique can achieve satisfactory correction for severe angular kyphosis.However，more blood loss，longer operative time needed in these procedures，and high incidence of perioperative complications must be attentioned.

Key words： angular kyphosis kyphoscoliosis posterior vertebral column resection complications

基金资助:首都临床特色应用研究与成果推广(Z151100004015018)

通讯作者: 马华松

作者简介: 陈志明(1974－ )，男，副主任医师，解放军306医院骨科，全军脊柱外科中心，100101。

引用本文:

陈志明，马华松 *，吴继功，谭荣，赵福江，沙鑫，赵浩. 全脊椎截骨梯次矫形治疗重度脊柱角状后凸畸形[J]. 实用骨科杂志, 2018, 24(10): 865-869.
Chen Zhiming，Ma Huasong，Wu Jigong，et al. Posterior Vertebral Column Resection Combined with Stepwise Correction for Patients with Severe Angular Kyphosis. sygkzz, 2018, 24(10): 865-869.

链接本文:

http://www.sygkzz.com/CN/ 或 http://www.sygkzz.com/CN/Y2018/V24/I10/865

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