本文關(guān)鍵詞： 脊柱側(cè)凸 三柱截骨術(shù) 脊髓縱裂 脊髓空洞 脊髓栓系 安全性 有效性　出處：《北京協(xié)和醫(yī)學(xué)院》2017年博士論文　論文類型：學(xué)位論文

【摘要】：研究背景:隨著現(xiàn)代脊柱外科矯形技術(shù)的發(fā)展,脊柱截骨手術(shù)已經(jīng)成為先天性脊柱側(cè)凸、重度僵硬型脊柱側(cè)凸以及強直性脊柱炎后凸畸形等疾病的治療中廣泛應(yīng)用的一種術(shù)式。三柱截骨術(shù)是在傳統(tǒng)的后柱截骨術(shù)的基礎(chǔ)上發(fā)展而來,截骨范圍涉及整個脊柱的前、中、后柱,可獲得更好的矯形效果,包括全脊椎截骨(vertebrate columun resection,VCR)、半椎體切除(hemivertebra resection,HR)、三明治截骨(sandwich osteotomy,SO)及經(jīng)椎;弓根椎體截骨術(shù)(pedicle subtraction osteotomy,PSO)等。另一方面,脊柱側(cè)凸的患者往往伴發(fā)有脊髓畸形,如脊髓縱裂(split spinal cord malformation,SSCM)、脊髓空洞、脊髓栓系(tethered spinal cord syndrome,TCS)、Chiari畸形等。目前對于合并此類畸形的脊柱畸形患者接受三柱截骨矯形術(shù)的安全以及有效性尚無定論,相關(guān)研究報道也較少。合并脊髓畸形的脊柱側(cè)后凸患者傳統(tǒng)的治療策略是先行神經(jīng)外科手術(shù)處理脊髓畸形,擇期再行側(cè)彎矯形手術(shù),以減少可能的神經(jīng)系統(tǒng)并發(fā)癥,目前已有研究采用脊柱截骨縮短術(shù)治療脊髓栓系綜合征獲得了良好的效果。對于合并脊髓畸形的側(cè)凸患者是否可在不處理脊髓畸形的情況下直接進行三柱截骨矯形術(shù)?隨著技術(shù)的發(fā)展和經(jīng)驗的積累,我們嘗試在不處理脊髓畸形的情況下通過三柱截骨對此類患者進行直接矯形,以避免預(yù)防性的神經(jīng)外科手術(shù)。本研究針對我院應(yīng)用一期三柱截骨術(shù)治療伴發(fā)常見脊髓畸形的脊柱側(cè)凸患者進行回顧性研究,對手術(shù)的有效性及安全性進行了分析。第一部分三柱截骨術(shù)治療合并脊髓縱裂的脊柱側(cè)凸1、研究對象與方法回顧性分析27例(女16例,男11例)合并脊髓縱裂的脊柱側(cè)凸患者,其中Ⅰ型縱裂患者10例,Ⅱ型17例,均行一期三柱截骨矯形。Ⅰ型縱裂患者骨嵴位于截骨范圍內(nèi)7例,6例截骨前予以切除;其余患者未對縱裂畸形進行處理。隨訪3-67個月,平均隨訪時間20.1個月。術(shù)前、術(shù)后及隨訪時均攝站立位全脊柱正側(cè)位X線片,對冠狀面和矢狀面Cobb角、軀干偏移進行測量分析。同時復(fù)習(xí)病歷,統(tǒng)計手術(shù)時間、出血量、神經(jīng)系統(tǒng)癥狀體征以及其他并發(fā)癥情況。2、結(jié)果手術(shù)時間3-7.5 h,、平均為5.4 h,術(shù)中出血量200-4500ml,平均1300nml,固定椎體4-15個,平均10.1個。冠狀面?zhèn)韧笴obb角術(shù)前平均60.4°,術(shù)后26.8°,末次隨訪29.3°,矯形率為62.7%;節(jié)段性后凸Cobb角術(shù)前平均60.4°,術(shù)后21.4°,末次隨訪24.3°,矯形率為63.4%;軀干偏移術(shù)前平均2.7cm,術(shù)后1.7cm,末次隨訪1.4 cm。3例患者術(shù)中MEP下降超過50%,手術(shù)結(jié)束前恢復(fù)正常。1例術(shù)中MEP消失,術(shù)后出現(xiàn)一過性肌力下降、二便障礙,隨訪好轉(zhuǎn)。術(shù)后另有1例患者下肢麻木脹痛,調(diào)整螺釘位置后好轉(zhuǎn),1例患者出現(xiàn)血氣胸。術(shù)后隨訪期間無神經(jīng)并發(fā)癥及內(nèi)固定并發(fā)癥發(fā)生。術(shù)前伴有神經(jīng)癥狀者7例,術(shù)后及隨訪過程中癥狀無加重。3、結(jié)論一期三柱截骨手術(shù)治療合并脊髓縱裂的脊柱側(cè)凸病人,在達(dá)到滿意的矯形效果的同時不會增加并發(fā)癥的發(fā)生率。對于合并Ⅰ型脊髓縱裂的脊柱側(cè)凸患者,若骨性縱裂位于截骨范圍內(nèi),可在截骨過程中先對骨嵴進行切除,再進行截骨矯形;對于骨性縱裂范圍與截骨節(jié)段不重合的患者以及Ⅱ型縱裂患者,則不需對脊髓畸形進行處理。同時術(shù)中脊髓監(jiān)測對于評估脊髓狀態(tài),及時發(fā)現(xiàn)及預(yù)防神經(jīng)損傷意義重大,在此類手術(shù)中不可或缺。第二部分三柱截骨手術(shù)治療合并脊髓栓系的脊柱側(cè)凸1、研究對象與方法回顧性分析16例(女9例,男7例)合并脊髓栓系的脊柱側(cè)凸患者,均行一期三柱截骨矯形。隨訪3-72月,平均隨訪時間22.8個月。術(shù)前、術(shù)后及隨訪時均攝站立位全脊柱正側(cè)位X線片,對冠狀面和矢狀面Cobb角、軀干偏移進行測量分析。同時復(fù)習(xí)病歷,統(tǒng)計手術(shù)時間、出血量、神經(jīng)系統(tǒng)癥狀體征以及其他并發(fā)癥情況。2、結(jié)果手術(shù)時間3-8.5 h,平均為5.8h,術(shù)中出血量300-4500ml,平均1096ml,固定椎體5-15個,平均8.5個。冠狀面?zhèn)韧笴obb角術(shù)前平均55.9°,術(shù)后18.8°,末次隨訪22.1°,矯形率為69.1%;節(jié)段性后凸Cobb角術(shù)前平均70.2°,術(shù)后28.3°,末次隨訪30.6°,矯形率為56.7%;軀干偏移術(shù)前平均2.7 cm,術(shù)后2.2 cm,末次隨訪2.3 cm。2例患者術(shù)中MEP下降超過50%,手術(shù)結(jié)束前恢復(fù)正常。1例術(shù)中MEP消失,術(shù)后出現(xiàn)一過性肌力下降、二便障礙,隨訪好轉(zhuǎn)。另有1例患者術(shù)后出現(xiàn)血氣胸。1例隨訪期間出現(xiàn)內(nèi)固定感染。術(shù)前伴有神經(jīng)癥狀者7例,術(shù)后及隨訪過程中癥狀均有改善。3、結(jié)論根據(jù)本研究的結(jié)果,對于合并脊髓栓系的脊柱畸形患者可以直接進行三柱截骨矯形,畸形矯正效果良好,并可改善患者的神經(jīng)癥狀,且不會增加其并發(fā)癥的發(fā)生率。在截骨過程中,脊髓監(jiān)測信號異常提示存在脊髓損傷的可能,需要引起足夠的重視。第三部分三柱截骨手術(shù)治療合并脊髓空洞的脊柱側(cè)凸1、研究對象與方法回顧性分析15例(女7例,男8例)合并脊髓空洞的脊柱側(cè)凸患者,均行一期三柱截骨矯形�？斩捶秶挥诔C形區(qū)內(nèi)者6人,術(shù)前伴有神經(jīng)癥狀者6人。隨訪3-71月,平均隨訪時間19.7個月。術(shù)前、術(shù)后及隨訪時均攝站立位全脊柱正側(cè)位X線片,對冠狀面和矢狀面Cobb角、軀干偏移進行測量分析。同時復(fù)習(xí)病歷,統(tǒng)計手術(shù)時間、出血量、神經(jīng)系統(tǒng)癥狀體征以及其他并發(fā)癥情況。2、結(jié)果手術(shù)時間3.5-8 h,平均為5.7h,術(shù)中出血量300-3000ml,平均1393ml,固定椎體6-14個,平均11.1個。冠狀面?zhèn)韧笴obb角術(shù)前平均83.6°,術(shù)后31.4°,末次隨訪33.3°,矯形率為62.7%;節(jié)段性后凸Cobb角術(shù)前平均70.0°,術(shù)后20.9°,末次隨訪22.7°,矯形率為72.1%;軀干偏移術(shù)前平均2.6 cm,術(shù)后1.7 cm,末次隨訪1.65cm。1例術(shù)中MEP消失,術(shù)后出現(xiàn)雙下肢肌力下降,影像學(xué)檢查確認(rèn)螺釘移位,突入椎管,壓迫脊髓,急診調(diào)整螺釘位置后好轉(zhuǎn)。另有1例患者術(shù)后出現(xiàn)一過性肌力下降、感覺減退;1例出現(xiàn)血氣胸。術(shù)后隨訪期間無神經(jīng)并發(fā)癥及內(nèi)固定并發(fā)癥發(fā)生。術(shù)前伴有神經(jīng)癥狀者6例,術(shù)后及隨訪過程中癥狀無加重。3、結(jié)論根據(jù)本研究,一期三柱截骨手術(shù)治療合并無癥狀的脊髓空洞的脊柱畸形患者是安全的,可以達(dá)到良好的矯形效果;無需矯形術(shù)前預(yù)防性脊髓空洞引流但是仍需注意其潛在的神經(jīng)系統(tǒng)并發(fā)癥風(fēng)險,術(shù)中精細(xì)操作以及術(shù)中持續(xù)脊髓監(jiān)測有助于降低神經(jīng)系統(tǒng)并發(fā)癥風(fēng)險。
[Abstract]:Background: with the development of modern technology of orthopedic spine surgery, spine surgery has become the congenital scoliosis, a technique widely used for the treatment of severe rigid scoliosis and kyphosis of ankylosing spondylitis and other diseases. The three column osteotomy is developed based on the traditional posterior column osteotomy on the scope of the whole spine osteotomy before and after column, can obtain better correction effect, including total vertebral osteotomy (vertebrate columun resection VCR (hemivertebra), hemivertebra resection resection, HR three), Meiji osteotomy (sandwich osteotomy, SO) and vertebral pedicle vertebral osteotomy; (pedicle subtraction osteotomy, PSO). On the other hand, scoliosis patients often associated with spinal deformities, such as diplomyelia (split spinal cord malformation, SSCM), spinal cord hole, tethered cord (tethered spinal cord syndrome TCS, Chiari, etc.). The deformity of spinal deformity in patients with such deformity received three column osteotomy of the safety and effectiveness of inconclusive, related research is seldom reported. Treatment strategies combined with spinal kyphoscoliosis deformity is the traditional first Department of Neurosurgery surgical treatment of spinal deformities, and elective scoliosis the operation, in order to reduce the complications of the nervous system may be the current study used spinal osteotomy shortening treatment of tethered cord syndrome has good effect. Whether combined with spinal deformity of scoliosis can be directly carried out three column osteotomy in treatment of spinal cord malformation under? With the development of technology and experience we try to direct the accumulation of correction for such patients through three column osteotomy in treatment of spinal cord malformation by surgical prophylaxis to avoid Department of neurosurgery. This study According to the application in our hospital for a period of three column osteotomy for the treatment of concomitant common spinal deformity in patients with scoliosis were retrospectively studied, the efficacy and safety of surgery were analyzed. The first part of the three column osteotomy for the treatment of scoliosis with diastematomyelia 1, review the research objects and methods of analysis of 27 cases (16 female cases. 11 male patients with diastematomyelia) patients with scoliosis, including 10 cases of patients with type I fracture, 17 cases of type II, underwent a three column osteotomy. Bone fracture in patients with type 1 crest osteotomy range in 7 cases, 6 cases of osteotomy before resection; the rest patients without treatment of fracture deformity. The follow-up of 3-67 months, the average follow-up time was 20.1 months. The preoperative, postoperative and follow-up were taken standing full spine lateral X-ray of coronal and sagittal Cobb angle, trunk shift were measured and analyzed. At the same time to review the medical records, statistics of the operation time, bleeding volume, God The symptoms and other complications of.2, the operation time was 3-7.5 h, average 5.4 h, bleeding 200-4500ml, average 1300nml, fixation and 4-15, with an average of 10.1. The coronal scoliosis Cobb angle 60.4 degree preoperatively, postoperative 26.8 degrees, 29.3 degrees at the end of the follow-up, correction rate 62.7%; segmental kyphosis Cobb angle 60.4 degree preoperatively, postoperative 21.4 degrees, 24.3 degrees at the end of the follow-up, the correction rate is 63.4%; the average 2.7cm trunk shift before operation, 1.7cm after operation, at the end of the follow-up 1.4 cm.3 patients in MEP fell by more than 50%, normal.1 cases of MEP disappeared recovery before the end of surgery, postoperative transient decreased muscle strength, two improved. Postoperative follow-up, another 1 cases lower extremity numbness pain, adjust the screw position after improvement, 1 cases of patients with hemopneumothorax. No neurological complications and internal fixation complications during the postoperative follow-up period. All of the 7 cases with neurological symptoms operation. The symptoms and follow-up process aggravate.3, conclusion a three column osteotomy for treatment of scoliosis patients with diastematomyelia, complication rate will not increase to achieve satisfactory correction effect at the same time. The combined with type of diastematomyelia in patients with scoliosis, if myeloschisis osteotomy can be located within the scope of the the osteotomy procedure first resection of bone crest, then osteotomy; for myeloschisis and osteotomized segment does not coincide with and type II fracture patients without treatment of malformations of the spinal cord. Spinal cord monitoring for evaluation of spinal cord state at the same time in operation, timely detection and prevention of nerve damage is significant and indispensable in this kind of operation. The second part of the three column osteotomy for treatment of scoliosis with tethered spinal cord 1, review the research objects and methods of analysis of 16 cases (female 9 cases, male 7 cases) scoliosis with tethered cord. 鍑告?zhèn)ｈ�，

本文編號：1464047