临床小儿外科杂志  2018, Vol. 17 Issue (11): 830-834
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生长棒撑开后最终融合手术治疗早发性脊柱侧凸的临床效果
祁新禹 , 姚子明 , 郭东 , 白云松 , 李承鑫 , 孙保胜 , 张学军     
国家儿童医学中心,首都医科大学附属北京儿童医院骨科(北京市,100045)
摘要目的 评估经生长棒撑开术治疗早发性脊柱侧凸(early-onset scoliosis, EOS)后行最终矫形融合手术患儿的临床效果。方法 回顾性分析2007年7月至2014年6月于北京儿童医院接受生长棒撑开技术治疗并行最终融合手术的26例EOS患儿临床资料(男15例, 女11例);初次手术平均年龄(5.2±2.6)岁。对病因、最终融合手术年龄、撑开次数、固定节段数及并发症等临床资料进行记录;同时对影像学资料(Cobb角、胸椎高度、脊柱高度)进行测量分析。结果 26例均行最终矫形融合手术,平均年龄为(13.2±2.3)岁。26例患儿中,17例为先天性脊柱侧凸,6例I型神经纤维瘤病脊柱侧凸,3例幼儿特发性脊柱侧凸;畸形顶椎位于胸段患儿15例,胸腰段8例,腰段3例;平均每例患儿经历8.2次撑开术,平均撑开时间间隔为(11.7±2.6)个月。术前冠状面主弯Cobb角为(69.3±30.8)°, 末次撑开术后为(49.4±22.9)°, 最终融合术后为(34.7±14.6)°。T1至T12距离从术前的(15.4±2.7)cm增至末次撑开术后的(22.5±3.6)cm, 最终融合术后达(22.9±3.5)cm;T1至S1距离从术前的(24.8±4.2)cm增至末次撑开术后的(32.5±4.8)cm, 最终融合术后达(33.6±5.2)cm。12例(46%)患儿共出现并发症14例次,主要为内固定相关并发症(12例次,85.71%), 均在撑开手术同时进行翻修;无一例出现神经系统并发症。结论 利用生长棒撑开技术治疗EOS患儿可有效控制其脊柱畸形的进展,并保留脊柱及胸廓的生长潜能。最终矫形融合手术的侧凸矫正率约为30%,适用于10岁以上骨骼发育相对成熟、反复出现内固定失败及畸形难以控制的患儿。
关键词早发性脊柱侧凸; 外科手术; 治疗; 并发症
Outcome of definitive fusion after growing-rod treatment of early-onset scoliosis
Qi Xinyu , Yao Ziming , Guo Dong , Bai Yunsong , Li Chengxin , Sun Baosheng , Zhang Xuejun     
Department of Orthopedics, Affiliated Beijing Children's Hospital, Capital Medical University & National Center for Children's Health, Beijing 100045, China
Abstract: Objective To explore the clinical efficacy and complications of definitive fusion after growing-rod treatment of early-onset scoliosis (EOS). Methods From July 2007 to June 2014, 26 EOS children (15 boys and 11 girls) underwent growing-rod and definitive fusion at our department were selected.The age at initial surgery was (5.2±2.6) years. Etiology, age at definitive fusion, number of distraction, instrumented segments and complications were recorded and reviewed. And radiographic data including Cobb angle of major curve, T1-T12 height and T1-S1 height were measured.The changes of these parameters were analyzed. Results All of them underwent definitive fusion at an average age of (13.2±2.1) years. The diagnoses were congenital scoliosis (n=17), neurofibromatosis type I scoliosis (n=6) and idiopathic scoliosis (n=3). And the curves were thoracic (n=15), thoracolumbar (n=8) and lumbar (n=3). All of them were operated for 240 times and 188 had distractive options with a mean of 8.2 distractions for each. The mean distractive interval was 11.7±2.6 months. The Cobb angle improved from (69.3±30.8)° to (49.4±22.9)° after the last distractive surgery and 34.7° ±14.6° after definitive fusion. The T1-T12 height improved from (15.4±2.7) cm to (22.5±3.6) cm after the last distractive option and (22.9±3.5) cm after final fusion. Similarly, T1-S1 height improved from (24.8±4.2) cm to (32.5±4.8) cm after the last distractive option and (33.6±5.2) cm after final fusion. In 12 children (46%), 14 complications occurred. And instrumentation-related complication was the most frequent and there was no neurological complications. Conclusion With an incidence of complication at 46%, growing-rod technique is effective for EOS. It may control curve progression and preserve spinal and thoracic growth ability. Definitive fusion is appropriate for children aged over 10 years with unacceptable or progressive major curve deformity or complications with previous implants.
Key words: Early Onset Scoliosis; Surgical Procedures, Operative; Therapy; Complication

早发性脊柱侧凸(early-onset scoliosis, EOS)是指发生于10岁之前的脊柱侧凸[1, 2]。由于EOS发病年龄小、侧凸进展快,对患儿肺功能发育可造成较为严重的影响[3]。当非手术治疗失败或患儿存在非手术治疗禁忌证时需考虑手术治疗。生长棒撑开延长技术通过对侧凸近端和远端行短节段固定,并定期行撑开手术,可在控制畸形进展的同时保留脊柱和胸廓的生长发育潜能[4, 5]

目前,关于生长棒撑开技术治疗EOS患儿的相关临床报道虽数量较多,但多数研究的随访时间相对较短,明确随访至终止生长棒撑开并进行最终矫形融合时期的报道更是罕见[6, 7]。因此,本研究回顾性分析了接受生长棒治疗并随访至行最终矫形融合手术的EOS患儿的临床和影像学资料,旨在评估生长棒撑开技术治疗EOS患儿的临床效果,并探讨行最终矫形融合手术的最佳时机。

材料与方法 一、临床资料

于2007年7月至2014年6月采用定群抽样法选取北京儿童医院收治的EOS患儿。纳入标准:①接受生长棒撑开治疗者;②已终止撑开并行最终融合手术者;③最终融合术后随访时间≥1年者;④影像学资料完整者。排除标准:①10岁之前行“截骨+生长棒手术”者;②撑开次数≤3次者;③未行最终融合手术者;④资料不全或失访者。最终共纳入26例,其中男15例,女11例,均接受生长棒撑开技术治疗并已行最终融合手术;初次手术平均年龄(5.2±2.6)岁。26例患儿中,17例诊断为先天性脊柱侧凸,6例Ⅰ型神经纤维瘤病脊柱侧凸,3例幼儿特发性脊柱侧凸。末次融合手术中,行经椎弓根截骨17例,行Ponte截骨术7例,行全脊椎截骨术2例。

记录并分析患儿初次及末次手术年龄、性别、病因及弯型(顶椎位于T2-T9为胸弯,T10-L2为胸腰弯,L3-L4为腰弯);同时记录患儿内固定方式、撑开次数、手术次数、固定节段数及手术相关并发症。固定节段数为内固定上端固定椎至下端固定椎的数量。生长棒治疗期间,患儿每6个月进行1次病情评估,身高增长超过2 cm或侧凸进展≥10°则每6个月撑开1次,否则每年撑开1次。出现下列情况之一即行最终融合手术:①年龄≥10岁且上次撑开距离≤0.5 cm;②反复内固定失败,畸形持续进展;③Risser征达4级。治疗过程中,单侧生长棒出现内固定并发症翻修时均改为双侧生长棒,本组病例中,2011年10月之前均采用单侧生长棒,2011年11月之后均采用双侧生长棒。

影像学指标包括:冠状面主弯Cobb角、胸椎高度(T1上终板至T12下终板垂直距离)、脊柱高度(T1上终板至S1上终板垂直距离),患儿取站立位,均于脊柱全长正侧位拍摄X线片。

二、统计学处理

采用SPSS 18.0进行统计分析。采用F检验及SNK事后比较法对比初次手术前、末次撑开后及最终融合术后主弯Cobb角、胸椎高度及脊柱高度变化。计算平均撑开次数、撑开时间间隔及撑开期间脊柱高度平均年增长率。以P<0.05为差异有统计学意义。

结  果

26例患儿中畸形顶椎位于胸段15例,胸腰段8例,腰段3例;所有患儿共接受240次手术,其中188次为撑开术,平均每例患儿经历8.2次撑开,平均撑开时间间隔为(11.7±2.6)个月。治疗过程中,10例患儿采用双侧生长棒,16例患儿行单侧(凹侧)生长棒,其中6例患儿撑开过程中改为双侧生长棒。因反复内固定失败,畸形持续进展行最终矫形融合手术的患儿2例,年龄≥10岁且末次撑开距离较小(≤0.5 cm)行最终矫形融合手术患儿15例(57.7%),骨骼发育成熟(Risser征达到4级)行最终融合术患儿9例。生长棒平均内固定节段数为(11.7±2.8),融合术后平均内固定节段数为(13.5±3.1)。

术前冠状面主弯Cobb角为(69.3±30.8)°,末次撑开术后为(49.4±22.9)°,最终融合术后为(34.7±14.6)°,末次撑开后Cobb角较术前显著减小(P=0.011),融合术后Cobb角较末次撑开术后显著减小(P=0.008);胸椎高度从术前(15.4±2.7)cm增至末次撑开术后(22.5 ±3.6)cm,差异有统计学意义(P < 0.001),最终融合术后胸椎高度为(22.9±3.5)cm,较末次撑开术后无明显增加(P=0.686);脊柱高度从术前的(24.8±4.2)cm增至末次撑开术后的(32.5 ±4.8)cm,差异有统计学意义(P < 0.001),最终融合术后脊柱高度为(33.6±5.2)cm,较末次撑开术后无明显增加(P=0.432)。手术矫形效果参数见表 1,影像资料变化见图 1

表 1 手术矫形效果参数(n=26, x±s) Table 1 Outcome parameters of surgical correction(n=26, x±s)

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图 1 胸椎高度、脊柱高度及Cobb角变化趋势 Fig. 1 Changing trends of thoracic height, spinal height and Cobb angle

本组中由12例患儿出现并发症,共14例次,其中畸形进展5例,断钉/棒4例,螺钉松动3例,皮肤破损感染2例。均在撑开或末次融合手术时进行翻修,无一例出现神经系统并发症。典型病例影像学资料见图 2

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图 2 典型神经纤维瘤病非营养不良型脊柱侧凸病例照片。图A、图B:术前右侧弯曲相及脊柱前后位相显示柔韧胸弯;图C:术前CT未见椎体异常;图D、图E:行双侧生长棒治疗,图F为第三次撑开术后;图G:第六次撑开术后;图H:第七次撑开术后;图I、图J:14岁时行最终融合手术 Fig. 2 A typical case with neurofibromatosis type1 nondystrophic scoliosis underwent dual growing-rod with definitive fusion.Analysis of preoperative right-leaning and anteroposterior radiograph showed flexible thoracic curve (A, B).Preoperative CT showed no vertebra deformity (C).He underwent dual growing-rod (D, E) and 7th distractions (F for 3rd distraction, G for 6th and H for 7th).Final fusion (I and J) was performed at an age of 14 years
讨  论

生长棒技术近年来常用于EOS患儿的治疗。一般认为,主弯Cobb角>50°、侧凸进行性加重、石膏或支具治疗不能控制、脊柱柔韧性好且纵向生长潜力大(Risser征≤Ⅰ级)是EOS生长棒治疗的适应证[4]。由于8岁儿童肺泡及胸廓发育水平可达到成年人的50%,而10岁之后脊柱生长进入第2个高峰期,患儿侧凸进展加快[8],因此,国内外学者目前倾向于10岁之前对EOS患儿进行生长棒内固定手术[9, 10]。Akbarnia等[4]发现采用双侧生长棒治疗EOS,主弯角度从术前的82°可改善至初次手术后的38°,该矫形效果可维持至末次随访,脊柱高度从术前的23.01 cm增加至末次随访时的32.65 cm。本研究中,患儿平均初次生长棒手术年龄为(5.2±2.6)岁,符合生长棒技术的治疗指征。至末次撑开后侧凸矫正率为29.8%,尽管矫正效果有限,但还是较好地控制了畸形的进展。本研究中畸形矫正效果较其他文献报道略差,可能与部分病例使用单侧生长棒有关。脊柱高度从术前的24.8 cm增加至末次撑开后的32.5 cm,证实了患儿的脊柱在接受生长棒治疗期间很好地保持了生长潜能。

尽管采用生长棒治疗EOS达到了一定的矫形效果,但该技术的并发症发生率较高,主要包括内固定相关并发症、近端交界性后凸、自发性融合、切口感染等。其中内固定相关并发症(如螺钉松动、断棒、断钉、脱钩等)最为常见。据文献报道内固定相关并发症的发生率为15% ~53.1%不等[11, 12]。Akbarnia等[4]报道了23例接受双侧生长棒治疗的EOS患儿,有11例(47.8%)出现手术相关并发症,其中5例为内固定相关并发症,占并发症总数的45.5%。本研究中手术相关并发症的发生率为46%,主要为断钉/断棒与螺钉松动。因生长棒技术需定期进行撑开,故可在行撑开手术的同时更换出现问题的内固定系统,然后继续撑开,避免不必要的翻修手术。作者认为,适当增加远近端的锚定点(近端固定尽量3个椎体,远端固定2~3个椎体)可减少内固定并发症,且需要保证足够的融合范围,术后患儿严格佩戴支具,每次撑开手术避免过分延长,以避免内固定相关并发症的发生。

关于终止生长棒的继续撑开并行最终融合手术最佳时机的报道较少。理论上,生长棒治疗过程应持续到骨骼发育成熟。2013年Flynn等[13]报道指出,接受撑开技术治疗的EOS患儿中,93%需要进行最终融合手术,并认为行最终融合的指征为:残余生长潜能较小、末次撑开后畸形持续进展、内固定失败及感染;同时该报道指出,为更好地矫正近端交界性后凸及冠状面畸形,最终融合手术的节段可较生长棒固定范围多出1~2个节段。作者认为,对于尚未达到骨骼发育成熟,但已发生自发融合且撑开能力较小的患儿,可考虑提前进行融合,因为多次撑开对于患儿脊柱高度的增加或侧弯的矫正意义不大。此外,对于反复发生内固定失败且畸形持续进展的患儿,年龄10岁以上时也可尽早融合。最终融合手术的目的一方面在于更好的矫正畸形,另一方面在于进行彻底融合固定。文献报道最终融合手术的矫形效果往往并不显著。主弯矫正率<50%[14, 15],本研究中末次融合手术的主弯矫正率平均为30%,一方面可能由于生长棒放置时间较长,自发性融合的发生率较高;另一方面,病因分类中先天性与神经纤维瘤病型脊柱侧凸较多,其矫正难度比特发性脊柱侧凸更大。

尽管本研究基本达到了预期的研究目的,但仍存在如下几点不足。首先,本研究纳入的EOS患儿病因不同,而侧凸矫形效果与脊柱增加高度都与病因存在相关性,故从某种程度上限制了该结果对某一类型EOS治疗的指导意义;其次,由于部分年龄较小患儿难以在术前对其肺功能进行准确评估,而患儿在接受手术前后肺功能的改善情况对治疗方案的实施及术后个性化干预方案的制定具有指导意义,因此在后续研究中可进一步完善肺功能评估的有关内容。

参考文献
1
Yang S, Andras LM, Redding GJ, et al. Early-onset scoliosis:a review of history, current treatment, and future directions[J]. Pediatrics, 2016, 137(1). DOI:10.1542/peds.2015-0709.
2
Williams BA, Matsumoto H, McCalla DJ, et al. Development and initial validation of the Classification of Early-Onset Scoliosis (C-EOS)[J]. J Bone Joint Surg Am, 2014, 96(16): 1359-1367. DOI:10.2106/JBJS.M.00253.
3
Redding G, Mayer OH, White K, et al. Maximal respiratory muscle strength and vital capacity in children with early onset scoliosis[J]. Spine, 2017, 42(23): 1799-1804. DOI:10.1097/BRS.0000000000002351.
4
Akbarnia BA, Marks DS, Boachie-Adjei O, et al. Dual growing rod technique for the treatment of progressive early-onset scoliosis:a multicenter study[J]. Spine, 2005, 30(17 Suppl): S46-57. DOI:10.1016/j.spinee.2017.06.027.
5
Wong CKH, Cheung JPY, Cheung PWH, et al. Traditional growing rod versus magnetically controlled growing rod for treatment of early onset scoliosis:Cost analysis from implantation till skeletal maturity[J]. J Orthop Surg (Hong Kong), 2017, 25(2): 2309499017705022. DOI:10.1177/2309499017705022.
6
Helenius IJ, Oksanen HM, McClung A, et al. Outcomes of growing rod surgery for severe compared with moderate early-onset scoliosis[J]. Bone Joint J, 2018, 100- B(6): 772-779. DOI:10.1302/0301-620X.100B6.BJJ-2017-1490.R1.
7
Jain A, Sponseller PD, Flynn JM, et al. Avoidance of "final" surgical fusion after growing-rod treatment for early-onset scoliosis[J]. J Bone Joint Surg Am, 2016, 98(13): 1073-1078. DOI:10.2106/JBJS.15.01241.
8
Dimeglio A, Canavese F. The growing spine:how spinal deformities influence normal spine and thoracic cage growth[J]. Eur Spine J, 2012, 21(1): 64-70. DOI:10.1007/s00586-011-1983-3.
9
王云生, 海涌, 孟祥龙, 等. 双生长棒固定治疗重度早发型脊柱侧凸的疗效分析[J]. 中国脊柱脊髓杂志, 2017, 27(6): 506-511. DOI:10.3969/j.issn.1004-406X.2017.06.06.
Wang YS, Hai Y, Meng XL, et al. Efficacy of dual growing rod in the treatment of severe early onset scoliosis[J]. Chinese Journal of Spine and Spinal Cord, 2017, 27(6): 506-511. DOI:10.3969/j.issn.1004-406X.2017.06.06.
10
孙旭, 徐亮, 陈忠辉, 等. 传统双侧生长棒对早发性脊柱侧凸患儿顶椎旋转的治疗效果[J]. 中华外科杂志, 2018, 56(3): 206-211. DOI:10.3760/cma.j.issn.0529-5815.2018.03.008.
Sun X, Xu L, Chen ZH, et al. Efficacy of traditional bilateral growing rods for correcting apical vertebra rotation in early-onset scoliosis[J]. Chinese Journal of Surgery, 2018, 56(3): 206-211. DOI:10.3760/cma.j.issn.0529-5815.2018.03.008.
11
Yang JS, Sponseller PD, Thompson GH, et al. Growing rod fractures:risk factors and opportunities for prevention[J]. Spine, 2011, 36(20): 1639-1644. DOI:10.1097/BRS.0b013e31822a982f.
12
Bess S, Akbarnia BA, Thompson GH, et al. Complications of growing-rod treatment for early-onset scoliosis:analysis of one hundred and forty patients[J]. J Bone Joint Surg Am, 2010, 92(15): 2533-2543. DOI:10.2106/JBJS.I.01471.
13
Flynn JM, Tomlinson LA, Pawelek J, et al. Growing-rod graduates:lessons learned from ninety-nine patients who completed lengthening[J]. J Bone Joint Surg Am, 2013, 95(19): 1745-1750. DOI:10.2106/JBJS.L.01386.
14
Jain A, Sponseller PD, Flynn JM, et al. Avoidance of "final" surgical fusion after growing-rod treatment for early-onset scoliosis[J]. J Bone Joint Surg Am, 2016, 98(13): 1073-1078. DOI:10.2106/JBJS.15.01241.
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Pizones J, Martín-Buitrago MP, Sánchez Márquez JM, et al. Decision making of graduation in patients with early-onset scoliosis at the end of distraction-based programs:risks and benefits of definitive fusion[J]. Spine Deform, 2018, 6(3): 308-313. DOI:10.1016/j.jspd.2017.10.005.