【摘要】：研究背景 脊髓栓系是指由于終絲肥厚等原因，將脊髓圓錐固定于脊柱下端而無法相對移動。由于脊髓受到牽拉導(dǎo)致張力增加，造成脊髓缺血、缺氧和變性，在臨床上，一部分病人會出現(xiàn)下肢的無力、麻木、肢體細小、足部畸形以及大小便障礙等神經(jīng)損害癥狀。如果不及時得到手術(shù)治療，患者的神經(jīng)癥狀將有可能加重。因此，通過及時有效的手術(shù)治療防止神經(jīng)功能的進一步損傷，是脊髓栓系患者治療的關(guān)鍵。 先天性脊柱側(cè)彎常合并椎管內(nèi)脊髓畸形，其中，約13%～29%的患者合并脊髓栓系，增大了脊柱側(cè)彎的手術(shù)難度，增加了手術(shù)風(fēng)險。一方面：肥厚的終絲，將脊髓圓錐牽拉固定于脊柱尾端，限制了脊髓與脊柱骨性結(jié)構(gòu)之間的相對移動，終絲牽拉脊髓，導(dǎo)致脊髓缺血、變性。而另一方面，對脊柱側(cè)彎進行矯形時，脊髓與脊柱會產(chǎn)生相對移動，可能會加重栓系對脊髓的牽拉，加重神經(jīng)癥狀。因此，對于合并脊髓栓系的脊柱側(cè)彎，如何解決側(cè)彎矯形與脊髓栓系這一矛盾，是手術(shù)治療的難點和重點。 傳統(tǒng)的治療方法是先行栓系松解術(shù)，解除肥厚終絲對脊髓的牽拉固定,減輕脊髓張力，3～6個月后再行側(cè)彎矯形手術(shù)，該方法雖然取得了一定的治療效果，但大量實踐表明，該治療方法并發(fā)癥發(fā)生率高，栓系松解不徹底比例高，發(fā)生再栓系幾率高，而且需要二次手術(shù)、二次麻醉，增加了患者的痛苦和手術(shù)風(fēng)險。因此，需要探索更加安全有效的新的手術(shù)方案。 1995年，Kokubun介紹了應(yīng)用脊柱縮短截骨術(shù)治療單純脊髓栓系的手術(shù)方法。該方法主要考慮到肥厚的終絲向下牽拉脊髓，導(dǎo)致脊髓張力增加，是引起臨床癥狀的主要病因。因此，他們采用截骨手術(shù)縮短脊柱的骨性結(jié)構(gòu)，以間接減少終絲對脊髓的牽拉，應(yīng)用該方法治療6例單純栓系的患者，取得了滿意的治療效果。此外，截骨術(shù)已經(jīng)廣泛應(yīng)用于脊柱側(cè)彎，特別是重度僵硬性脊柱側(cè)彎患者的手術(shù)治療。因此，，對于合并脊髓栓系的脊柱側(cè)彎，是否能夠不進行傳統(tǒng)的栓系松解術(shù)，而是單純采用脊柱截骨術(shù)，在糾正脊柱側(cè)彎的同時，達到緩解脊髓張力的目的呢？本研究回顧性分析了我院應(yīng)用脊柱縮短截骨術(shù)治療合并脊髓栓系的脊柱側(cè)彎患者的有效性和安全性。 第一部分全脊椎截骨術(shù)（VCR）治療合并脊髓栓系的重度先天性脊柱側(cè)彎的安全性及有效性研究 1.材料和方法 2007年4月～2011年8月，于我院行全脊椎截骨（vertebrate columun resection,VCR）治療合并脊髓栓系的重度脊柱側(cè)彎患者13例，其中男性患者6例、女性患者7例，平均年齡15.8歲。所有患者脊髓末端均在L4椎體平面或平面以下�；颊哂陧斪挡课恍蠽CR截骨。截骨完成矯形。記錄手術(shù)時間、失血量、輸血量；比較手術(shù)前、后、隨訪過程中患者脊柱側(cè)彎和神經(jīng)癥狀的改變。通過脊柱側(cè)彎研究會問卷(SRS-22Questionnaire)及改良日本骨科學(xué)會評分（mJOA-Score)對患者生活質(zhì)量等進行評估，所有患者平均隨訪時間44.4個月。 2.結(jié)果 平均手術(shù)時間619.6±80.9min、平均失血量3061.5±1367.8ml、平均輸血量3068.3±1586.1ml ml。平均截骨長度25.5±3.1mm，平均融合14.3±1.1個椎體。術(shù)前患者冠狀位Cobb角平均102.8°±17.0°，術(shù)后矯正為42.8°±10.8°，矯正率59.0%±7%，末次隨訪時，平均Cobb角為42.8°±10.8°(矯正率57±7%)；術(shù)前矢狀面Cobb角平均81.0°±17.6°，術(shù)后矯正為34.3°±9.5°，末次隨訪為35.6°±7.9°。在末次隨訪中，下肢感覺減退患者癥狀改善率75%(3/4)，4例下肢肌力下降及5例腰背部疼痛患者癥狀均得到了緩解，1例術(shù)前小便障礙患者，癥狀消失。本組病例總體并發(fā)癥為2例，其中1例腦脊液漏患者，經(jīng)保守治療一周后痊愈，1例術(shù)后即刻出現(xiàn)神經(jīng)并發(fā)癥患者，在出院后3個月隨訪時癥狀消失。 3.結(jié)論 對于合并脊髓栓系的重度先天性脊柱側(cè)彎患者，VCR在有效矯正脊柱側(cè)彎的同時，間接減少了脊髓張力，可有效緩解因栓系引起的神經(jīng)癥狀，且未明顯增加術(shù)后并發(fā)癥的發(fā)生。盡管該手術(shù)耗時相對較長，患者出血量相對較多，對患者的手術(shù)耐受性是一種考驗，但是我們的研究證明，該手術(shù)方式是一種相對安全有效的手術(shù)方式，為合并脊髓栓系的重度脊柱側(cè)彎患者的治療提供了治療選擇。 第二部分經(jīng)椎弓根截骨術(shù)（PSO）治療合并脊髓栓系的輕中度先天性脊柱側(cè)彎的安全性及有效性研究 1.材料和方法 2007年4月～2011年8月，于我院行脊柱縮短截骨術(shù)治療合并脊髓栓系的輕中度脊柱側(cè)彎患者共8例，其中男性患者1例、女性患者7例，平均年齡14.8歲。所有患者脊髓末端均在L4椎體平面或平面以下�；颊哂陧斪挡课恍薪毓鞘中g(shù)，手術(shù)方式為經(jīng)椎弓根脊柱截骨術(shù)（pedicle substraction osteotomy, PSO)。截骨完成行矯形手術(shù)。記錄手術(shù)時間、失血量、輸血量；比較手術(shù)前后，及隨訪過程中患者脊柱畸形和神經(jīng)癥狀的改變。 通過SRS-22Questionnaire及mJOA-Score對患者生活質(zhì)量等進行評估，所有患者平均隨訪時間46.7個月。 2.結(jié)果 平均手術(shù)時間449.4±73.1min、平均失血量2293.8±1060.5ml、平均輸血量2500±1109.5ml。平均截骨長度22.8±5.0mm，平均融合12±2.2個椎體。術(shù)前患者冠狀位Cobb角平均68.8°±7.6°，術(shù)后矯正為23.1°±5.8°，矯正率65.8±9.7%，末次隨訪時，平均Cobb角為24.4°±5.9°；術(shù)前矢狀面Cobb角平均58.2°±9.1°，術(shù)后矯正為25.8°±9.0°，末次隨訪為27.6°±8.0°。在末次隨訪中，下肢肌力減弱患者癥狀改善率83.3%(5/6)，3例腰骶部或下肢疼痛患者及1例下肢感覺減退患者癥狀均得到改善，2例術(shù)前大小便障礙患者，癥狀均消失。本組病例總體并發(fā)癥為2例，其中1例腦脊液漏患者，經(jīng)保守治療一周后痊愈，1例術(shù)后即刻出現(xiàn)神經(jīng)并發(fā)癥患者，在出院后3個月隨訪時癥狀消失。 3.結(jié)論 PSO治療合并脊髓栓系的輕中度先天性脊柱側(cè)彎患者，在達到預(yù)期的側(cè)彎矯形效果的同時，能夠通過經(jīng)椎弓根截骨術(shù)間接減少脊髓張力，進而改善患者的神經(jīng)功能狀態(tài)，避免了傳統(tǒng)的椎管內(nèi)栓系松解手術(shù)可能對脊髓造成的損傷，且未增加手術(shù)并發(fā)癥的發(fā)生率，是一種相對安全有效的手術(shù)方式。
[Abstract]:Study Background The cord of the spinal cord refers to the fixation of the spinal cord to the lower end of the spine due to the end-wire hypertrophy and the like and cannot be moved relative to each other. The spinal cord is induced to increase in tension, resulting in spinal cord ischemia, hypoxia, and degeneration. In the clinical part, a part of the patient will have the weakness of the lower limbs, the numbness, the fine limbs, the deformity of the foot, and the disorder of the bowels and the like. Form. If surgical treatment is not available in time, the patient's neurological symptoms will be possible. Heavy. Therefore, the prevention of further damage to the neurological function by timely and effective surgical treatment is the effect of the treatment of the spinal cord patient. Key. The congenital scoliosis of the spine is often combined with the spinal cord deformity in the spinal canal, in which about 13% to 29% of the patients are combined with the spinal cord, which increases the difficulty of operation of the scoliosis and increases the hand On the one hand, the end of the spinal cord is fixed at the tail end of the spinal column, the relative movement between the spinal cord and the bony structure of the spinal column is limited, the spinal cord is pulled by the end wire, and the spinal cord ischemia is caused. and on the other hand, when the scoliosis is orthopedic, the spinal cord and the spinal column produce relative movement, which may increase the tension of the tethered cord to the spinal cord, As a result, it is difficult to solve the contradiction between the lateral bending and the tethered cord of the spinal cord of the spinal cord of the combined spinal cord, and it is the difficult point of the surgical treatment. And a large number of practice shows that the treatment method is concurrent. The incidence of the disease is high, the rate of the release of the bolt is high, the probability of rebolting is high, the secondary operation is required, the secondary anesthesia is required, and the pain of the patient is increased. and surgical risk. Therefore, it is necessary to explore new and more safe and effective new In 1995, Kokubun described the use of a spinal-shortening osteotomy for the treatment of pure spinal cord The method of the invention mainly takes into account that the end wire of the hypertrophy pulls the spinal cord down, resulting in an increase of the tension of the spinal cord, which is caused by the fact that the tension of the spinal cord is increased, The main cause of the symptoms is that they use the osteotomy to shorten the bony structure of the spine to indirectly reduce the tension of the end wire to the spinal cord. satisfactory therapeutic effects. In addition, the osteotomy has been widely used for scoliosis, especially in the case of severe, stiff, scoliosis Surgical treatment of the patient. Therefore, for the scoliosis of the spinal cord of the combined spinal cord, it is possible to use a spinal osteotomy instead of a conventional bolt-based approach, and to achieve the relief of the spine while correcting the scoliosis. What is the purpose of the cord tension? This study is a retrospective analysis of the application of the spinal-reduction osteotomy in our hospital to treat the scoliosis patients with the spinal cord. Efficacy and safety. The first partial total-spine osteotomy (VCR) was used to treat the severe congenital scoliosis of the combined spinal cord Safety and effectiveness Sex study 1. Materials and methods in our hospital from April 2007 to August 2011. 13 cases of severe scoliosis in the combined spinal cord,6 of which were male and female, respectively. 7 of the patients with an average age of 15.8 years. The end of the spinal cord in all patients All below the plane or plane of the l4 vertebral body. The patient is at the position of the top vertebra The cutting of the VCR was performed. The osteotomy was completed. The time of operation, the amount of blood loss, the amount of blood transfusion were recorded, and the patients with the pre-operative, post-operative, follow-up The changes in the lateral and neurological symptoms of the spinal column were assessed by the SRS-22 Questionnaire and the modified Japanese Orthopaedic Association (mJOA-Score) to assess the quality of life of the patient. average of persons with The mean operative time was 619.6-80.9 min, the mean blood loss was 3061.5-1367.8 ml, and the mean blood transfusion volume was 3061.5-1367.8 ml. 3068.3 to 1586.1 ml. The average cut length is 25.5 to 3.1m The average Cobb angle was 102.8 擄 and 17.0 擄, the post-operative correction was 42.8 擄 and 10.8 擄, the correction rate was 59.0% and the correction rate was 59.0%. The mean Cobb angle was 42.8 擄 and 10.8 擄 (the correction rate was 57%7%) at the last follow-up; the average Cobb angle was 81.0 擄 and 17.6 in the pre-operative sagittal plane. 擄, post-operative correction of 34.3 擄 to 9.5 The last follow-up was 35.6 擄-7.9 擄. In the last follow-up, the symptoms of lower limb hypoesthesia were 75% (3/4),4 lower limb muscle strength and 5 cases of pain in the back of the waist. The total complications were 2 cases,1 case of cerebrospinal fluid leakage, one week after conservative treatment and 1 case of neurological complications immediately after operation. Patient, in 3. Conclusion For patients with severe congenital scoliosis, VCR can reduce the tension of the spinal cord and effectively relieve the risk of spinal cord. The neurological symptoms of the patient and the occurrence of postoperative complications were not significantly increased. Although the procedure is relatively long and the amount of blood loss of the patient is relatively large, the patient's surgical tolerance is a test, but our study The surgical method is a relatively safe and effective way of operation, in order to consolidate the spinal cord. The treatment of the severe scoliosis patients with the tether provides a treatment option. The second part is treated with a pedicle osteotomy (PSO) for the treatment of the combined ridge. The mild and moderate of the tethered cord. Study on the safety and effectiveness of scoliosis in the patients with congenital scoliosis 1. Materials and Methods From April 2007 to August 2011, a total of 8 patients with mild and moderate scoliosis combined with the tethered cord of the spinal cord were treated with a reduction osteotomy of the spine in our hospital. Example: One of the male patients,7 female patients, mean age 14.8 years of age. The end of the spinal cord of all patients was below the plane or plane of the L4 vertebral body. The patient underwent an osteotomy at the position of the apex, and the procedure was a pedicle spinal osteotomy (Pedicl e substract The operation time, blood loss and the amount of blood transfusion were recorded. The changes in the patient's spinal deformities and neurological symptoms were compared before and after the procedure and in the follow-up procedure. SRS-22 Questionnaire and mJOA-Score to be born to the patient The average follow-up time of all patients was 46.7 months.2. The mean operative time was 449.4 to 73.1 min and the mean blood loss was 2. 293.8-1060.5 ml, mean blood transfusion amount of 2500-1109.5 Ml. The average cut length was 22.8-5.0 mm, with an average fusion of 12-2.2 vertebral bodies. The preoperative coronal Cobb angle was 68.8 擄-7.6 擄, the post-operative correction was 23.1 擄-5.8 擄, the correction rate was 65.8-9.7%, the mean Cobb angle was 24.4 擄-5.9 擄 at the last follow-up, and the preoperative sagittal Cobb angle was 58.2 擄-5.9 擄. The post-operative correction was 25.8 擄 to 9.0 擄 and the last follow-up was 27.6 擄 to 8.0 擄. In the last follow-up, the symptoms of the lower limb muscle strength were 83.3% (5/6),3 cases of low-limb pain and 1 case The symptoms of the patients with lower limb hypoesthesia were improved, and the symptoms disappeared in 2 cases. The total complications in this group were 2 cases, of which 1 case of cerebrospinal fluid leakage was treated by conservative treatment for a week. Recovered,1 3. Conclusion PSO is used to treat the patients with mild and moderate congenital scoliosis and to achieve the desired side-bending effect. At the same time, the spinal cord tension can be indirectly reduced through the transpedicular osteotomy, so that the neurological function state of the patient can be improved,
【學(xué)位授予單位】：第四軍醫(yī)大學(xué)
【學(xué)位級別】：碩士
【學(xué)位授予年份】：2014
【分類號】：R687.3

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