本文選題：強直性脊柱炎 + 椎間盤退變性疾病��； 參考：《南京醫(yī)科大學》2017年博士論文

【摘要】：第一章強直性脊柱炎伴胸腰椎后凸畸形腰椎及骶1椎弓根的解剖特征及臨床意義目的:通過對強直性脊柱炎伴胸腰椎后凸畸形(ankylosing spondylitis,AS)和椎間盤退變性疾病(disc degenerative disease,DDD)患者腰1-骶1椎弓根CT掃描相關參數(shù)的測量,研究兩者間椎弓根解剖參數(shù)差異,為臨床手術中置釘提供參考依據(jù)。方法:選取2012年3月～2014年11月行截骨矯形手術治療并有完整術前臨床及影像學資料的男性AS伴后凸畸形患者30例,平均年齡(35.7±9.5)歲(23歲～51歲),同時選取行手術治療具有完整術前全腰椎及骶椎CT掃描全部附件結構影像清晰易辯的男性DDD患者30例,平均年齡(52.4±8.9)歲(39歲～64歲)。分別測量腰1～骶1節(jié)段椎弓根內(nèi)聚角(pedicle transverse angle,EA),椎弓根矢狀角(pedicle inclined angle,FA),椎弓根寬度(pedicle width,PW),椎弓根釘?shù)篱L度(pedicle screw path length,PL),椎弓根高度(pedicle height,PH),統(tǒng)計比較是否存在差異。結果:AS組和DDD組椎弓根寬度(PW)從L1～S1均是逐漸增大的,AS組PW在L5、S1 均顯著大于DDD組,(16.47±2.66)mmvs.(14.51±2.11)mm、(21.76±2.97)mm vs.(18.87±2.14)mm,P0.05;椎弓根釘?shù)篱L度(PL)自L1～S1在AS組均大于DDD組,P0.05;PL兩組最大值均在L3節(jié)段;AS病人椎弓根內(nèi)聚角(EA)在L1～S1均較DDD組小;AS矢狀角(FA)在L3～S1顯著小于DDD組,(-2.88±10.24)°,(-7.88±10.22)°,(-7.70±10.40)°,(-5.15±10.25)° vs.(4.05±2.21)°,(7.79±4.38)°,(7.07±3.21)°,(12.62±3.21)°,P0.05。結論:在AS伴后凸畸形患者腰椎及骶1椎弓根置釘時可選用更粗更長螺釘來增加內(nèi)固定強度,需注意適當減小內(nèi)聚角,并根據(jù)矢狀面形態(tài)調整頭尾向。第二章強直性脊柱炎伴嚴重胸腰椎后凸畸形截骨矯形術后臂叢神經(jīng)麻痹的發(fā)生率、危險因素及預后目的:探討經(jīng)椎弓根椎體截骨術(Pedicle Subtraction Osteotomy PSO)和Smith-Peterson截骨術(SPO)治療強直性脊柱炎伴嚴重胸腰椎后凸畸形患者術后臂叢神經(jīng)麻痹的發(fā)生率、危險因素及預后。方法:回顧性分析2000.4-2013.10在南京鼓樓醫(yī)院骨科行SPO或PSO矯形治療的強直性脊柱炎(Ankylosing spondylitis AS)患者。通過對后凸角度,圍手術期記錄資料及術后神經(jīng)功能的評價分析來研究術后臂叢神經(jīng)麻痹的發(fā)生率及危險因素。結果:本研究228例患者中有6例發(fā)生了術后臂叢神經(jīng)麻痹。發(fā)現(xiàn)臂叢神經(jīng)麻痹有四個危險因素:(1)胸腰椎后凸畸形角度大于100度;(2)手術時間超過4個小時;(3)術中擺放體位時上肢肩關節(jié)外展超過90度;(4)肩關節(jié)軟墊的應用。所有6例患者術后平均5周(2-16周)神經(jīng)運動及感覺功能均完全恢復。結論:截骨矯形治療強直性脊柱炎伴嚴重胸腰椎后凸畸形患者術后臂叢神經(jīng)麻痹的發(fā)生率較低,而且預后較好。手術時間較長,術中體位擺放不當是引起臂叢神經(jīng)損傷的重要原因。因此,外科醫(yī)師在截骨治療強直伴后凸畸形患者需想到臂叢神經(jīng)損傷的可能性。術中擺放體位時需注意上肢外展不要超過90度以減輕對臂叢神經(jīng)的牽拉,術中電生理監(jiān)護及定時調整雙上肢位置能有效預防臂叢神經(jīng)損傷的發(fā)生。第三章PSO截骨椎椎間盤前縱韌帶骨化對強直性脊柱炎伴胸腰椎后凸畸形后凸矯正的影響目的:評估PSO(pedicle subtraction osteotomy)截骨椎臨近椎間盤水平前縱韌帶骨化對強直性脊柱炎伴胸腰椎后凸畸形后凸矯正的影響。方法:回顧性分析2006年3月到2014年2月在我院行胸腰椎單節(jié)段PSO截骨矯形的71例AS(Ankylosing spondylitis)后凸并隨訪滿2年的患者資料。根據(jù)PSO截骨椎臨近椎間盤前縱韌帶骨化與否分為骨化組和非骨化組。分析比較兩組間單節(jié)段PSO截骨矯形角度以及椎體和椎間盤的貢獻是否存在差異。另分析比較兩組間遠期脊柱骨盆矢狀面形態(tài)的矯形丟失是否存在差異。結果:本研究組總共納入71例強直患者,其中骨化組為32例,患者年齡及PI值明顯大于非骨化組(40.31±8.44 歲 vs.30.97士8.28 歲,和 49.36±9.75°vs.43.03±10.6°,p0.05)單節(jié)段PSO截骨矯形角度顯著小于非骨化組(36.3±6.9vs.41.5±6.9°,p0.001)。椎間盤楔形變對截骨角度的貢獻在非骨化組中顯著大于骨化組(8.10±6.19°,18.5%vs.1.09±2.88°,2.7%,p0.001)。統(tǒng)計比較兩組間 2 年以上隨訪的脊柱矢狀面參數(shù)顯示矢狀面平衡(sagittal vertical axis,SVA),骨盆傾斜角(pelvic tilt,PT),胸 1 骨盆角(T1 pelvic angle,TPA),胸椎后凸角(thoracic kyphosis,TK)和骶骨傾斜角(sacral slope,SS)的矯正丟失在非骨化組明顯較大(p0.05)。非骨化組的椎間盤楔形變的矯正丟失也稍大,有統(tǒng)計學差異(1.41 士3.27°vs.0.22±1.49°,p0.05)。結論:對AS伴胸腰段后凸患者行PSO截骨矯形時選擇鄰近節(jié)段椎間盤前縱韌帶未骨化的椎體可獲得相對更多的單節(jié)段后凸矯形效果,但遠期隨訪時其發(fā)生矯正丟失的概率更大。
[Abstract]:Chapter 1 anatomical characteristics and clinical significance of lumbar and sacral 1 pedicle in ankylosing spondylitis with thoracolumbar kyphosis: measurement of CT scanning parameters of lumbar 1- sacral 1 pedicle in patients with ankylosing spondylitis (ankylosing spondylitis, AS) and intervertebral disc degeneration disease (disc degenerative disease, DDD) The difference between the anatomical parameters of the pedicle of the two vertebral pedicles was studied. Methods: 30 cases of male AS with protruding malformation were selected from March 2012 to November 2014 with a complete orthopedic surgery and complete preoperative clinical and imaging data. The average age was (35.7 + 9.5) years (23 years to 51 years), and the surgical treatment was selected at the same time. A total of 30 male DDD patients with complete CT scan of all lumbar vertebrae and sacral spine before the complete operation were treated with an average age of (52.4 + 8.9) years (39 years to 64 years old). The Shiumi Ne cohesion angle (pedicle transverse angle, EA), Shiumi Ne sagittal angle (pedicle inclined angle, FA), and Shiumi Ne width (pedicle wid) were measured respectively. Th, PW), the length of the pedicle nail channel (pedicle screw path length, PL), the height of the pedicle of the vertebral arch (pedicle height, PH). 4) mm, P0.05; the length of pedicle screw (PL) from L1 to S1 in group AS was greater than that in group DDD, P0.05 and PL two were all in L3 segment, and AS patient's pedicle angle (EA) was smaller than that of the group; (7.07 + 3.21) degrees, (7.07 + 3.21) degrees, (12.62 + 3.21) degrees, P0.05. conclusion: in AS with protruding deformity of the lumbar and sacral pedicle screws can be used to increase the internal fixation strength, should pay attention to appropriately reduce the cohesion angle, and adjust the head and tail according to the shape of the sagittal plane. Second chapter ankylosing spondylitis with severe thoracolumbar kyphosis osteotomy. The incidence, risk factors and prognosis of brachial plexus paralysis after orthopedics: To explore the incidence, risk factors and prognosis of brachial plexus paralysis in patients with ankylosing spondylitis with severe thoracolumbar kyphosis (Pedicle Subtraction Osteotomy PSO) and Smith-Peterson osteotomy (SPO). The incidence and risk factors of postoperatively brachial plexus paralysis were studied by 2000.4-2013.10 in Department of orthopedics, Nanjing Gulou Hospital, with SPO or PSO orthopedic spondylitis (Ankylosing spondylitis AS) in the Department of orthopedics of Nanjing Gulou Hospital. The incidence and risk factors of postoperatively brachial plexus paralysis were studied through the evaluation and analysis of the kyphosis angle, the perioperative records and the postoperative nerve function. Results: 228 cases of this study were studied. 6 patients had postoperative brachial plexus paralysis. There were four risk factors for brachial plexus paralysis: (1) the angle of the thoracolumbar kyphosis was greater than 100 degrees; (2) the operation time was more than 4 hours; (3) the abduction of the upper limb of the upper limb was over 90 degrees in the operation (3); (4) the application of the shoulder joint cushion. The average of all 6 patients was 5 weeks after operation (2-16 weeks). Conclusion: the incidence of brachial plexus paralysis in patients with ankylosing spondylitis with severe thoracolumbar kyphosis is lower and the prognosis is better. The operation time is longer, and the improper placement of the body position is an important cause of the brachial plexus injury. Therefore, surgeons are in the osteotomy. Patients with tetanus with kyphosis need to think of the possibility of brachial plexus injury. During the operation, attention should be paid to the abduction of the upper limb not more than 90 degrees to reduce the traction of the brachial plexus. Intraoperative electrophysiological monitoring and timing adjustment of the position of the double upper limbs can effectively prevent the occurrence of brachial plexus injury. Third chapter PSO the anterior longitudinal toughening of the intervertebral disc of the osteotomy vertebra Effect of ossification on ankylosing spondylitis with kyphosis correction of thoracolumbar kyphosis. Objective: To evaluate the effect of PSO (pedicle subtraction osteotomy) osteotomy on the anterior longitudinal ligament ossification of the intervertebral disc on ankylosing spondylitis with thoracolumbar kyphosis correction. 71 cases of AS (Ankylosing spondylitis) protruding in single segment of lumbar vertebra were followed up for 2 years. According to the ossification of the anterior longitudinal ligament of the intervertebral disc, the osteotomy was divided into the ossification group and the non ossification group. The difference between the single segment PSO osteotomy angle of the two groups and the contribution of the vertebral body and intervertebral disc was analyzed and compared between the two groups. The difference was also divided between the two groups. Analysis and comparison of the difference in orthopedic loss between the two groups of forward Spina pelvic sagittal surfaces. Results: 71 cases of ankylosis were included in this study group, of which 32 cases were ossification group, and the age and PI value of the patients were significantly greater than those in the non ossification group (40.31 + 8.44 years old, 8.28 years old, and 49.36 + 9.75 vs.43.03 + 10.6 degrees, P0.05) single segment PSO osteotomy. The orthopedic angle was significantly smaller than the non ossification group (36.3 + 6.9vs.41.5 + 6.9 degrees, p0.001). The contribution of the intervertebral disc wedge change to the osteotomy angle was significantly greater in the non ossification group than in the ossification group (8.10 + 6.19 degrees, 18.5%vs.1.09 + 2.88 degrees, 2.7%, p0.001). The sagittal plane parameters of the spinal sagittal plane (sagittal vertica) were compared between the two groups for more than 2 years. L axis, SVA), pelvic inclination (pelvic tilt, PT), the 1 pelvic angle of the chest (T1 pelvic angle, TPA), the correction loss of the posterior convex angle of the thoracic vertebra (thoracic kyphosis) and the sacral inclination in the non ossification group. The correction loss of the disc wedge deformation in the non ossification group is also slightly larger, with a statistically significant difference (1.41 and 3.27 degrees). It is 22 + 1.49 degrees, P0.05). Conclusion: in patients with AS and thoracolumbar kyphosis, more single segment kyphosis can be obtained by selecting the non ossification of the anterior longitudinal ligaments of the adjacent segment of the intervertebral disc when PSO osteotomy is performed, but the probability of correction loss is greater in the long term follow-up.
【學位授予單位】：南京醫(yī)科大學
【學位級別】：博士
【學位授予年份】：2017
【分類號】：R687.3

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