成俊遙+王征
【摘要】 僵硬性脊柱畸形的矯形治療是脊柱外科領(lǐng)域的世界性難題,畸形的種類(lèi)、部位及畸形與神經(jīng)的空間關(guān)系均與矯形治療密切相關(guān)。術(shù)前針對(duì)畸形特點(diǎn)深入分析,設(shè)計(jì)合理手術(shù)方案,選擇適當(dāng)?shù)慕毓羌夹g(shù),對(duì)于優(yōu)化矯形效果及減少手術(shù)并發(fā)癥均有重要意義。本文就僵硬性脊柱畸形矯形治療的臨床研究進(jìn)展做一綜述。
【關(guān)鍵詞】 僵硬性脊柱畸形; 矯形治療; 截骨術(shù); 并發(fā)癥
doi:10.14033/j.cnki.cfmr.2017.13.080 文獻(xiàn)標(biāo)識(shí)碼 A 文章編號(hào) 1674-6805(2017)13-0151-03
【Abstract】 Rigid deformities of the spine pose a significant challenge to the even the most experienced spine surgeon.The type of deformity,location of deformity,presence of cord compression are all closely related to orthopedic treatment.Understanding the character of the curve can help surgeons choose the most appropriate surgical corrective.Preoperative planning and advisable option of osteotomies are crucial to operation result as well asavoiding complications.The orthopedic treatment for rigid spinal deformities are reviewed in this article.
【Key words】 Rigid spinal deformities; Orthopedic treatment; Osteotomy; Complications
僵硬性脊柱畸形是指在脊柱屈伸位或Bending像上修正度小于50%的脊柱畸形,可為脊柱原發(fā)性疾病引起,亦可由外傷、手術(shù)或其他疾病繼發(fā)產(chǎn)生,即便對(duì)于最有經(jīng)驗(yàn)的脊柱外科醫(yī)生來(lái)說(shuō),對(duì)僵硬性脊柱畸形的矯形治療也是十分嚴(yán)峻的挑戰(zhàn)。這一類(lèi)畸形使得脊柱僵硬的同時(shí),還常合并有矢狀面或冠狀面的嚴(yán)重彎曲,可造成脊髓(馬尾)、神經(jīng)根及胸腹腔臟器的病理性壓迫從而對(duì)患者生理及心理健康造成巨大影響。目前對(duì)于僵硬性脊柱畸形最有效的治療即為脊柱截骨矯形,通過(guò)不同截骨技術(shù)矯正僵硬的脊柱從而盡可能恢復(fù)其序列并糾正冠狀位及矢狀位的平衡[1-3]。
1 術(shù)前設(shè)計(jì)
僵硬性脊柱畸形患者的脊柱矯形更難且復(fù)雜,手術(shù)前對(duì)截骨方案進(jìn)行預(yù)先設(shè)計(jì)十分必要。肖連平等[4]曾提出通過(guò)“剪紙法”對(duì)術(shù)中截骨進(jìn)行模擬,即按照原比例大小將患者術(shù)前站立側(cè)位X線(xiàn)片復(fù)制在紙樣上,根據(jù)矢狀位參數(shù)值及患者畸形特點(diǎn)選取適當(dāng)截骨部位,測(cè)量頜眉角,剪裁紙樣進(jìn)行模擬截骨,從而計(jì)算截骨角度[5]?!凹艏埛ā崩没颊哂跋褓Y料的復(fù)制可直觀地展示截骨效果并得到精確的擬截骨角度,在截骨技術(shù)成熟早期起到了重要作用,但該方法的實(shí)施較為繁瑣,且只考慮到局部的脊柱序列恢復(fù),而未將脊柱-骨盆平衡代償機(jī)制考慮在內(nèi),難于使患者矢狀位的整體平衡得到恢復(fù)。Min等[6]則從畸形患者的外觀照入手,以正常站立姿勢(shì)為參考,通過(guò)使患者恢復(fù)至軀干、下肢成一線(xiàn)并于地面垂直的方法計(jì)算截骨所需角度。該方法同樣利用患者外觀照直觀地預(yù)設(shè)計(jì)截骨角度,但不同于“剪紙法”,其不僅僅考慮局部的脊柱畸形因素,還同時(shí)將下肢代償情況納入到設(shè)計(jì)之中,但由于外觀照無(wú)法準(zhǔn)確評(píng)估髖、膝關(guān)節(jié)屈伸情況,因而對(duì)于關(guān)節(jié)的代償機(jī)制有所忽略。
隨著脊柱-骨盆整體平衡理念的發(fā)展,越來(lái)越多的學(xué)者將骨盆代償納入脊柱畸形矯正的考慮范疇。LeHuec等[7]提出的FBI法以截骨椎前方鉸鏈點(diǎn)為中心旋轉(zhuǎn)近端脊柱,將C7恢復(fù)至骶骨上方,并將股骨傾斜角及骨盆傾斜追加角計(jì)算入截骨度數(shù)之中。該方法充分考慮了脊柱-骨盆作為調(diào)節(jié)矢狀面平衡整體的因素,并根據(jù)髖、膝關(guān)節(jié)對(duì)于矢狀面平衡的貢獻(xiàn)對(duì)截骨角度的計(jì)算分別進(jìn)行了修正。VanRoyen等[8]在提出截骨設(shè)計(jì)時(shí)充分考慮了骨盆的旋轉(zhuǎn)情況對(duì)矢狀面平衡的影響,其預(yù)先設(shè)定了骶骨傾斜角為40°且矢狀面平衡距離為7.5 cm的矢狀面平衡重建標(biāo)準(zhǔn),同樣以截骨椎前緣為中心旋轉(zhuǎn)脊柱恢復(fù)平衡,VanRoyen等[9]還為此方法設(shè)計(jì)了專(zhuān)門(mén)的計(jì)算機(jī)軟件。該方法在恢復(fù)骨盆中立位的同時(shí),亦可使下肢關(guān)節(jié)恢復(fù)正常狀態(tài),且相較于FBI法分別考慮髖、膝關(guān)節(jié)的代償,該方法僅通過(guò)糾正骨盆旋轉(zhuǎn)調(diào)節(jié)矢狀面平衡,不僅簡(jiǎn)單便捷而且更為精確,唯一的不足在于骨盆中立位的恢復(fù)較為機(jī)械化,采用40°的骶骨傾斜角而非更能反映個(gè)性化差異的指標(biāo)。Song等[10-11]論證了肺門(mén)可作為人體軀干重心,通過(guò)公式計(jì)算患者的理論骨盆傾斜角(theoretical Pelvic Tilt,tPT)后,過(guò)髖軸畫(huà)出tPT線(xiàn),以截骨處為中心旋轉(zhuǎn)脊柱近端使肺門(mén)落于tPT線(xiàn)上,從而恢復(fù)脊柱-骨盆矢狀位平衡。此方法充分考慮骨盆因素的同時(shí),亦將不同患者骨盆特征通過(guò)計(jì)算進(jìn)行評(píng)估,從而實(shí)現(xiàn)了個(gè)性化截骨設(shè)計(jì),此外,將肺門(mén)作為人體重心亦屬首次。
現(xiàn)階段伴隨輔助技術(shù)的發(fā)展,依托計(jì)算機(jī)軟件展開(kāi)的截骨設(shè)計(jì),無(wú)論模擬效果、精確程度以及操作便利程度較以往均有明顯提高。
2 截骨技術(shù)
矯正僵硬的脊柱畸形困難且復(fù)雜,需要在冠狀位及矢狀位上盡可能恢復(fù)脊柱序列及整體平衡,又不可矯枉過(guò)正給患者帶來(lái)不必要的損傷風(fēng)險(xiǎn),因此在合理設(shè)計(jì)之后選擇適當(dāng)?shù)慕毓羌夹g(shù)至關(guān)重要,針對(duì)這一類(lèi)患者的矯形,多節(jié)段截骨及多種截骨方式聯(lián)合應(yīng)用較為常見(jiàn)。
1945年Smith-Petersen截骨術(shù)(Smith—Petersenosteotomy,SPO)被首次報(bào)道用于矯正已發(fā)生融合的脊柱矢狀面失衡[12],此后該技術(shù)被多次改良,例如附加經(jīng)皮椎間孔成形術(shù)及后路內(nèi)固定術(shù)[13]。SPO依賴(lài)于可活動(dòng)的椎間盤(pán),后方結(jié)構(gòu)切除并閉合后,依靠前方張開(kāi)獲取角度,若脊柱前方融合,則需經(jīng)椎間或椎體終板進(jìn)行分離,曾有報(bào)道指出此分離過(guò)程易損傷前方動(dòng)脈從而造成生命危險(xiǎn)[14],與此相比,多階段SPO的應(yīng)用則更為廣泛,每一節(jié)段的SPO大約可獲得 10°的矯正,且應(yīng)將SPO節(jié)段數(shù)控制在4節(jié)以下[15]。2007年P(guān)onte截骨術(shù)被報(bào)道用于矯正休門(mén)氏病引起的脊柱后凸畸形[16],同樣利用多階段操作使后柱縮短從而矯正后凸畸形,但不同于SPO,尚未有報(bào)道指出Ponte截骨術(shù)可用于已發(fā)生融合的脊柱畸形。
經(jīng)椎弓根截骨術(shù)(pedicle subtraction osteotomy,PSO)自1985年被提出之后[17],得到了越來(lái)越廣泛的重視及應(yīng)用。椎弓根的切除早期多見(jiàn)于脊柱翻修手術(shù),而目前PSO技術(shù)則成為了脊柱畸形翻修手術(shù)的主要選擇[18-19],此外,PSO早期主要應(yīng)用于矢狀面失衡的矯正,而隨著該技術(shù)的發(fā)展其適應(yīng)癥越加廣泛,目前亦用于矯正冠狀位失衡且收效較好。相對(duì)于SPO使得脊柱前柱張開(kāi)并延長(zhǎng),PSO所面臨的則是前柱短縮帶來(lái)的脊髓皺縮及神經(jīng)根卡壓等問(wèn)題,并且所截角度越大,越容易導(dǎo)致脊柱失穩(wěn)及并發(fā)癥的發(fā)生,目前單節(jié)段PSO可提供最大約40°的矯正[20],這尚不能滿(mǎn)足某些較重畸形的矯形要求。Zheng等[21]于2014年報(bào)道了雙節(jié)段PSO截骨矯形在強(qiáng)直性脊柱炎所致后凸畸形當(dāng)中的應(yīng)用,并提出雙節(jié)段PSO在獲得更大截骨角度的同時(shí),可分別將胸腰段及腰段后凸恢復(fù)至近似生理曲度,從而提供更好的矯形效果及預(yù)后。
全椎體切除術(shù)(vertebralcolumnresection,VCR)首次應(yīng)用于半錐體切除的病例[22],通過(guò)前后路聯(lián)合的方式進(jìn)行,但手術(shù)明顯提高了并發(fā)癥發(fā)生率且未達(dá)到預(yù)期效果。Suk等[23]報(bào)道了單純后路實(shí)施VCR治療僵硬性脊柱后凸獲得了更大的單節(jié)段截骨角度并取得了良好療效。VCR可將畸形椎體完全切除,可根據(jù)需要進(jìn)行脊柱三柱的重建,同時(shí)對(duì)冠狀面及矢狀面的失衡進(jìn)行矯正,但該技術(shù)同時(shí)也面臨并發(fā)癥發(fā)生率的增加,且對(duì)截骨節(jié)段的固定、支撐及融合有更高的要求。去松質(zhì)骨截骨術(shù)(vertebralcolumndecancellation,VCD)由Wang等[24]在VCR的基礎(chǔ)上演變而來(lái),可獲得更好的矯形效果且使得并發(fā)癥明顯減少。
3 截骨手術(shù)并發(fā)癥
并發(fā)癥的出現(xiàn)與術(shù)者手術(shù)經(jīng)驗(yàn)及操作水平密切相關(guān),加之患者個(gè)體差異,因此不同報(bào)道之間相差較大??傮w并發(fā)癥發(fā)生率,Auerbach等[25]報(bào)道SPO為35%,Lenke等[26]報(bào)道PSO為38%,Kim等[27]報(bào)道VCR及VCD分別為39.5%和42%。截骨手術(shù)并發(fā)癥主要涉及切口感染、神經(jīng)并發(fā)癥、血管損傷、血腫形成、畸形加重及內(nèi)固定失敗等,神經(jīng)并發(fā)癥的發(fā)生率中,暫時(shí)性神經(jīng)并發(fā)癥發(fā)生率為9.2%~11.1%,而長(zhǎng)期神經(jīng)并發(fā)癥發(fā)生率為2.8%~5.7%[23,28]。
對(duì)于僵硬性脊柱畸形的矯治,已不僅僅局限于截骨手術(shù)的實(shí)施,術(shù)前設(shè)計(jì)及并發(fā)癥的防治同樣意義重大,截骨矯形已演變?yōu)閺?fù)雜且綜合的整體診療過(guò)程。而對(duì)于截骨技術(shù)的研究,脊柱外科醫(yī)生從未停止探索的腳步,當(dāng)代截骨技術(shù)的發(fā)展已收獲了階段性成效,但如何在恢復(fù)理想脊柱序列的同時(shí)盡量減少并發(fā)癥的發(fā)生,仍需不斷的探索和研究。
參考文獻(xiàn)
[1] Lonstein J E.Congenitalspinedeformities:scoliosis,kyphosis,andlordosis[J].Orthop Clin North Am,1999,30(3):387-405.
[2] Shelton Y A.Scoliosis and kyphosis in adolescents:diagnosis and management[J].Adolesc Med State Art Rev,2007,18(1):121-139.
[3] Korovessis P,Zacharatos S,Koureas G,et al.Comparative multifactorial analysis of the effects of idiopathic adolescent scoliosis and Scheuermann kyphosis on the self-perceived health status of adolescents treated with brace[J].Eur Spine J,2007,16(4):537-546.
[4]肖聯(lián)平,江毅,劉智,等.強(qiáng)直性脊柱炎后凸畸形的外科治療[J].中國(guó)脊柱脊髓雜志,2004,14(9):527-530.
[5] Van R B J,De G A.Lumbar osteotomy for correction of thoracolumbar kyphotic deformity in ankylosing spondylitis.A structured review of three methods of treatment[J].Ann Rheum Dis,1999,58(7):399-406.
[6] Min K,Hahn F,Leonardi M.Lumbar spinal osteotomy for kyphosis in ankylosing spondylitis:The significance of the whole body kyphosis angle[J].JSpinalDisordTech,2007,20(2):l49-153.
[7] LeHuec J C,Leijssen P,Duarte M,et al.Thoracolumbar imbalance analysis for osteotomy planification using a new method:FBItechnique[J].Eur Spine J,2011,20(S5):669-680.
[8] VanRoyen B J,De G A,Smit T H.Defomity planning for sagittal plane corrective osteotomies of the spine in ankylosing spondylitis[J].Eur Spine J,2000,9(6):492-498.
[9] VanRoyen B J,Scheerder F J,Jansen E,et al.ASKyphoplan:a program for deformity planning in ankylosing spondylitis[J].Eur Spine J,2007,16(9):1445-1449.
[10] Song K,Zheng G Q,Zhang Y G,et al.A new method for calculating the exact angle required for spinal osteotomy[J].Spine(Phila Pa 1976),2013,38(10):616-620.
[11] Song K,Zheng G,Zhang Y,et al.Hilus pulmonis as the center of gravity for AS thoracolumbar kyphosis[J].Eur Spine J,2014,23(12):2743-2750.
[12] Smith-Petersen M N, Larson C B, Aufranc O E.Osteotomy of the spine for correction of flexion deformity inrheumatoid arthritis[J].Clin Orthop Relat Res,1969,66(1):6.
[13] Briggs H,Keats S,Schlesinger P T.Wedge osteotomy of the spine with bilateral, intervertebral foraminotomy:correction of flexion deformity in fivecases of ankylosing arthritis of spine[J].J Bone JointSurg Am,1947,29(4):1075-1982.
[14] Weatherley C,JaVray D,Terry A.Vascular complications associated with osteotomy in ankylosing spondylitis:a report of two cases[J].Spine,1988,13(1):43-46.
[15] Aurouer N,Obeid I,Gille O,et al.Computerized preoperative planning for correction of sagittal deformity of the spine[J].Surg Radiol Anat,2009,31(10):781-792.
[16] Geck M J,Macagno A,Ponte A,et al.The Ponteprocedure:posterior only treatment of Scheuermanns kyphosis using segmental posterior shortening and pedicle screw instrumentation [J].Spinal Disord Tech 2007,20(8):586-593.
[17] Thomasen E. Vertebral osteotomy for correction of kyphosis in ankylosing spondylitis[J].Clin Orthop Relat Res,1985,194(194):142-152.
[18] Cho K J,Bridwell K H,Lenke L G,et al.Comparison ofSmith-Petersen versus pedicle subtraction osteotomy for the correction of fixed sagittal imbalance[J].Spine (Phila Pa 1976) 2005,30(18):2030-2037.
[19] Colomina M J,Bago J,F(xiàn)uentes I.Efficacy and safetyof prophylactic large dose of tranexamic acid inspine surgery:a prospective,randomized,doubleblind,placebo-controlled study[J].Spine (Phila Pa 1976) 2009;34(16):1740-1741.
[20] Debarge R,Demey G,Roussouly P.Sagittal balance analysis after pedicle subtraction osteotomy in ankylosing spondylitis[J].Eur Spine J,2011,20(5):619-625.
[21] Zheng G Q,Song K,Zhang Y G,et al.Two-level spinal osteotomy for severe thoracolumbar kyphosis in ankylosing spondylitis[J] [J].Spine,2014,39(13):1055-1058.
[22] Leatherman K,Dickson R.Two stage correctivesurgery for congenital deformities of the spine[J].Bone Joint Surg Br 1979,61-B(3):324-328.
[23] Suk S I,Chung E R,Kim J H,et al.Posterior vertebralcolumn resection for severe rigid scoliosis[J].Spine,2005,30(14):1682-1687.
[24] Wang Y,Lenke L G.Vertebral column decancellation for the management of sharp angular spinal deformity[J].Eur Spine J,2011,20(10):1703-1710.
[25] Auerbach J D,Lenke L G,Bridwell K H,et al.Major complications and comparison between 3-columnosteotomy techniques in 105 consecutive spinaldeformity procedures[J]. Spine(Phila Pa 1976),2012,37(14):1198-1210.
[26] Lenke L G,Sides B A,Koester L A,et al.Vertebralcolumn resection for the treatment of severe spinal deformity[J].Clin Orthop Relat Res,2010,468(3):687-699.
[27] Kim S S,Cho B C,Kim J H,et al.Complications of posterior vertebral resection for spinal deformity[J].Asian Spine J,2012, 6(4):257-265.
[28] Buchowski J M,Bridwell K H,Lenke L G,et al.Neurologic complications of lumbar pedicle subtractionosteotomy:a 10-year assessment[J].Spine (Phila Pa1976),2007,32(20):2245-2252.
(收稿日期:2017-01-02)