摘要
目的 探讨先天性颈胸段侧凸患者在接受后路半椎体切除短节段内固定术后发生远端侧凸严重进展的危险因素及翻修方法.方法 回顾性分析2012年8月至2021年8月于南京鼓楼医院55例接受后路颈胸段半椎体切除短节段固定术治疗的先天性颈胸段侧凸患者的临床和影像学资料,男28例、女27例,初次手术年龄(8.5±3.6)岁(范围3～15岁),Risser征为(0.7±1.4)级(范围0～4级),融合节段为(6.9±1.6)个(范围4～10个),初次手术后随访时间为(38.7±18.9)个月(范围9～94个月).根据术后远端侧凸进展的严重程度分为未进展、轻度进展与严重进展,后两者统称为进展.统计术前合并Klippel-Feil综合征的比例,手术前后及末次随访时测量颈胸段侧凸Cobb角、T1倾斜角、冠状面平衡、颈部倾斜角、锁骨角、头部倾斜角、头部偏移及术后上端固定椎倾斜角和下端固定椎倾斜角,在CT三维重建图像测量并计算术后截骨区Cobb角改善率.比较进展组与未进展组患者影像学测量参数的差异,将差异有统计学意义的因素纳入二分类变量lo-gistic 回归分析,确定影响远端侧凸进展的危险因素.结果 远端侧凸未进展组38例、轻度进展组11例、严重进展组6例.进展组相较于未进展组术前冠状面失平衡更严重,冠状面平衡分别为(35.6±22.3)mm和(11.6±7.1)mm;颈部倾斜和头部偏移更大,颈部倾斜角分别为17.4°±8.3°和12.4°±6.9°、头部偏移分别为(22.8±17.7)mm和(13.9±9.8)mm;合并Klippel-Feil综合征的比例更大,分别为65％(11/17)和34％(13/38),差异均有统计学意义(P＜0.05).术后进展组相较于未进展组表现为更严重的冠状面失平衡,分别为(17.3±12.7)mm和(9.6±8.1)mm;更明显的残留畸形,颈部倾斜角分别为9.4°±4.6°和6.4°±5.3°,头部偏移分别为(14.7±7.4)mm和(9.1±5.9)mm;更小的截骨区Cobb角改善率,分别为40.1％±15.2％和50.3％±19.9％;更明显的上、下固定椎倾斜,上端固定椎倾斜角分别为14.3°±7.4°和9.8°±5.3°、下端固定椎倾斜角分别为8.1°±5.5°和4.5°±3.6°,差异均有统计学意义(P＜0.05).严重进展组相较于轻度进展组仅在术前表现为更严重的冠状面失平衡[分别为(50.7±31.3)mm和(27.3±9.6)mm]和头部偏移[分别为(33.5±25.0)mm和(16.9±11.0)mm].Logistic 回归分析结果显示术前存在冠状面失平衡是影响术后远端侧凸进展的独立危险因素[OR=1.299,95％CI(1.101,1.531),P=0.002].5例严重进展组的患者在术后平均25个月(范围9～42个月)接受了翻修手术,延长下端固定椎至稳定区.结论 术前合并Klippel-Feil综合征、术后残留畸形、上端及下端固定椎倾斜均为术后远端侧凸再进展的重要原因,术前存在明显的冠状面失平衡是独立的危险因素.
Abstract
Objective To investigate the risk factors for severe distal curve progression after posterior hemivertebra(HV)resection and short-segment fixation in patients with congenital cervicothoracic scoliosis(CTS),and to analyze the surgical revision strategy.Methods Imaging and clinical data of patients who underwent posterior HV resection and short-segment fixation for CTS between August 2012 and August 2021 at Nanjing Drum Tower Hospital were retrospectively analyzed.A total of 55 patients were recruited,including 27 females and 28 males with an average age of 8.5±3.6 years(range 3-15 years)at surgery and an aver-age Risser grade of 0.7±1.4(range 0-4).The number of fused segments averaged 6.9±1.6(range 4-10),and the mean follow-up was 38.7±18.9 months(range 9-94 months).According to the severity of distal curve progression,the recruited patients were divid-ed into three groups:non-progression group(NPG),mild progression group(MPG),and severe progression group(SPG).The latter two groups were collectively called the progression group(PG).The cervicothoracic Cobb angle,T1 tilt angle,coronal balance dis-tance(CBD),neck tilt angle,clavicular angle,head tilt angle,head shift,and upper(UIV)and lower instrument vertebra(LIV)tilt angle on the standing whole spine X-ray were measured before and after surgery and at the last follow-up.The correction rate of the Cobb angle in the osteotomy area was measured and calculated on CT three-dimensional reconstruction,and the proportion of patients with Klippel-Feil syndrome(KFS)was recorded.Statistical analysis was conducted on the various parameters between the two groups.For factors with statistical significance in the single-factor analysis,binary logistic regression analysis was performed to identify the high-risk factors for distal curve progression.Results There were 38 cases in the NPG,11 in the MPG,and 6 in the SPG.Compared to the NPG,the PG showed more severe coronal imbalance preoperatively,with CBD of 35.6±22.3 mm and 11.6±7.1 mm respectively;more severe neck tilt and head shift,with neck tilt angle of 17.4°±8.3° and 12.4°±6.9° respectively,and head shift of 22.8±17.7 mm and 13.9±9.8 mm respectively;and a higher proportion of KFS,65％(11/17)and 34％(13/38)re-spectively,all with statistical significance(P＜0.05).Postoperatively,the PG showed more severe coronal imbalance compared with the NPG,with 17.3±12.7 mm and 9.6±8.1 mm respectively;more evident residual deformity,with cervical tilt angles of 9.4°±4.6° and 6.4°±5.3° respectively,and head shift of 14.7±7.4 mm and 9.1±5.9 mm respectively;lower correction of Cobb angle in the api-cal osteotomy region,with rates of 40.1％±15.2％and 50.3％±19.9％respectively;more significant UIV and LIV tilt,with UIV tilt angles of 14.3°±7.4° and 9.8°±5.3° respectively,and LIV tilt angles of 8.1°±5.5° and 4.5°±3.6° respectively,all with statistical significance(P＜0.05).SPG showed only more severe coronal imbalance preoperatively compared with the MPG,with 50.7±31.3 mm and 27.3±9.6 mm respectively;and head shift,with 33.5±25.0 mm and 16.9±11.0 mm respectively,all with statistical signifi-cance(P＜0.05).Logistic regression analysis demonstrated a significant correlation between significant preoperative coronal imbal-ance and postoperative distal scoliosis progression[OR=1.299,95％CI(1.101,1.531),P=0.002].Five cases(83.3％)in SPG un-derwent revision surgery with an average follow-up of 25 months,and selecting the LIV down to the stable region was the major re-vision strategy.Conclusion Combined KFS,residual cervicothoracic deformities,and tilting of UIV and LIV are key causes,whereas significant preoperative coronal imbalance is an independent risk factor predisposing to the distal curve progression.
基金项目
江苏省骨科医学创新中心项目(CXZX202214)
南京鼓楼医院新技术发展项目(XJSFZLX202108)
NETL
NSTL
万方数据