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前后联合入路治疗先天性颈椎半椎体畸形并上胸椎重度脊柱侧凸1例

2019-01-11 张珂 尹佳 马骁 脊柱外科杂志

先天性脊柱畸形是由于脊柱发育缺陷导致的脊柱形态及结构功能异常,在婴儿中其发生率约为1/1000。颈椎半椎体畸形是先天性脊柱畸形的一种,常见于Klippel-Feil综合征,与胸腰椎畸形相比,此类畸形在临床上更为罕见。Deburge等和Winter等分别于1981年首次报道颈椎半椎体畸形及其治疗方法,Ruf等在2005年对其进行详细阐述。近年来,临床报道了多例颈椎半椎体畸形病例,治疗方法各有不同。本

先天性脊柱畸形是由于脊柱发育缺陷导致的脊柱形态及结构功能异常,在婴儿中其发生率约为1/1000。颈椎半椎体畸形是先天性脊柱畸形的一种,常见于Klippel-Feil综合征,与胸腰椎畸形相比,此类畸形在临床上更为罕见。Deburge等和Winter等分别于1981年首次报道颈椎半椎体畸形及其治疗方法,Ruf等在2005年对其进行详细阐述。近年来,临床报道了多例颈椎半椎体畸形病例,治疗方法各有不同。本院2015年收治C5半椎体畸形并上胸椎重度脊柱侧凸1例,现将诊疗过程报告如下。

病例资料

患者,男,18岁,因“颈胸段脊柱向右弯曲10年余”收住院。随患者年龄增长,脊柱向右侧弯曲逐渐加重,无明显感觉运动异常,无气喘、呼吸困难等伴随症状。查体:背面观脊柱颈胸段向右侧弯曲,两侧髂嵴基本等高,右侧肩胛区明显“剃刀背”畸形,躯干整体平衡可,略向左偏。血和尿粪常规、肝肾功能、凝血功能等实验室检查及腹部B超、心电图、心脏彩超检查结果基本正常。肺功能提示第1秒用力呼气末容积/用力肺活量(FEV1/FVC)为54%。在全脊柱X线片上测量Cobb角为81°(图1a,b);颈椎CT三维重建示椎动脉和颈动脉位置基本正常(图1c,d),寰椎后弓缺如,C5半椎体畸形,C4,5椎体及附件部分融合(图1e,f);颈椎MRI检查未见明显脊髓压迫。



治疗方法及结果

患者入院后完善常规检查评估病情,先天性颈椎半椎体畸形诊断明确,肺功能差,不能耐受手术,行颅骨头环牵引3个月(牵引质量20kg)。牵引后复查全脊柱X线片,测量Cobb角为57°(图1g),肺功能FEV1/FVC提高至65%。再次评估病情后拟行前后联合入路颈椎半椎体切除术。

患者气管插管全身麻醉,取仰卧位,导尿,建立深静脉通道,术中应用电生理监测和自体血回输。常规颈前路右横切口进入椎前间隙,显露C4~7椎体及椎间盘前部,确定C5半椎体位置后予以前部切除,放置引流管后逐层缝合。颈托保护下患者改为俯卧位,同时水平方向颅骨牵引(牵引质量5kg),作C2~T9后正中纵行切口,咬除C2~T9棘突,分别在C2、C4、C6、T1~3、T5~6、T8~9右侧,C2、C4~7、T1、T5~9左侧置入椎弓根螺钉,处理T1~9两侧小关节,行后路松解,预弯钛棒并固定于两侧螺钉上,旋棒后予以凸侧加压、凹侧撑开,矫形满意后螺帽固定。手术总时长245min,术中出血量约1400mL,回输自体浓缩红细胞300mL,输注异体红细胞400mL,血浆200mL。

术后给予心电、血氧监护及对症支持治疗。术后5d拔除负压引流管,14d在颈胸支具保护下下床活动。分别于术后第1天、术后3个月和术后24个月复查全脊柱正侧位X线片(图1h~m),提示内固定位置良好,术后各随访时间点Cobb角基本无变化(分别为37°、37°、39°)。术后3个月复查颈椎CT三维重建,示后路植骨融合良好(图1n,o),随访过程中无感觉运动异常及其他并发症发生。

讨论

先天性颈椎畸形大部分是无症状的,其发生率难以准确统计,有研究报道先天性颈椎畸形的发生率为1/42000~1/40000,女性发生率略高于男性,其包含了颈椎枕骨畸形、上颈椎畸形和下颈椎畸形,其中由于椎体发育不良引起的颈椎半椎体畸形常因导致脊柱侧凸可获得早期诊治。

颅骨头环牵引是中重度脊柱畸形围手术期辅助治疗技术之一。有研究表明,儿童重度脊柱畸形术前行颅骨头环牵引在改善肺功能和Cobb角方面均效果良好,但对成人重度脊柱畸形牵引效果却不甚满意,可能与骨骼成熟、脊柱僵硬程度有关。研究表明,在矫形手术完成后,成人重度脊柱畸形患者的肺功能改善有限,甚至下降,这与脊柱畸形本身引起肺功能和肺容积损失有密切关系。对成人重度脊柱侧凸行术前颅骨牵引治疗的有效性仍需进一步探讨。本例患者虽已成年(18岁),颅骨头环牵引使患者Cobb角较术前改善29.7%,效果较为满意。

经过数十年的外科技术发展,多种手术方式被应用于半椎体畸形的治疗中,包括前后联合入路内固定技术、凹侧松解前后联合入路矫形内固定技术、前后联合入路半椎体切除术以及单纯后路半椎体切除术等。在成人和儿童患者中,后路椎弓根螺钉的安全性和有效性均被证实,但对颈椎半椎体畸形的固定效果尚无定论。2005年,Ruf等提出,由于颈椎区域解剖结构的复杂性,应采取前后联合入路半椎体完全切除以获得最大程度的矫形效果。本例患者亦采取前后联合入路半椎体完全切除的方式,并进行了长节段的融合固定,以防止患者在术后出现脊柱整体失衡或局部代偿弯形成,术前对椎动脉位置也作了充分评估,减少了手术误伤。颈椎半椎体畸形在临床中较为罕见,手术治疗可矫正畸形,并防止代偿弯进展。本例患者的治疗结果证实了前后联合入路半椎体切除的有效性和安全性,为临床相似病例的诊治提供一定借鉴。

原始出处:

张珂,尹佳,马骁,李唐波,高瑞,周许辉*.前后联合入路治疗先天性颈椎半椎体畸形并上胸椎重度脊柱侧凸1例报告[J].脊柱外科杂志,2018,16(6):384-386.

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    2019-01-13 dingxiaobo
  4. [GetPortalCommentsPageByObjectIdResponse(id=1776602, encodeId=c5da1e766025b, content=<a href='/topic/show?id=cd5884511ca' target=_blank style='color:#2F92EE;'>#脊柱侧凸#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=76, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=84511, encryptionId=cd5884511ca, topicName=脊柱侧凸)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=d38138982152, createdName=swallow, createdTime=Sun Feb 17 02:04:00 CST 2019, time=2019-02-17, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1362261, encodeId=d39c136226183, content=<a href='/topic/show?id=9857e03444b' target=_blank style='color:#2F92EE;'>#畸形#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=81, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=70344, encryptionId=9857e03444b, topicName=畸形)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=395f25, createdName=爆笑小医, createdTime=Sun Jan 13 06:04:00 CST 2019, time=2019-01-13, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1366854, encodeId=839d136685451, content=<a href='/topic/show?id=708a6283509' target=_blank style='color:#2F92EE;'>#椎体#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=96, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=62835, encryptionId=708a6283509, topicName=椎体)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=930e243, createdName=dingxiaobo, createdTime=Sun Jan 13 06:04:00 CST 2019, time=2019-01-13, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1369418, encodeId=17f113694185e, content=<a href='/topic/show?id=bc9f28589d0' target=_blank style='color:#2F92EE;'>#先天性#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=88, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=28589, encryptionId=bc9f28589d0, topicName=先天性)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=a435298, createdName=huirong, createdTime=Sun Jan 13 06:04:00 CST 2019, time=2019-01-13, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1489972, encodeId=a59514899e265, content=<a href='/topic/show?id=2d258411ea9' target=_blank style='color:#2F92EE;'>#胸椎#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=96, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=84117, encryptionId=2d258411ea9, topicName=胸椎)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=6d688662973, createdName=yyj065, createdTime=Sun Jan 13 06:04:00 CST 2019, time=2019-01-13, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=357846, encodeId=ca9535e84633, content=好文,值得点赞!认真学习,应用于实践!谢谢分享给广大同好!, beContent=null, objectType=article, channel=null, level=null, likeNumber=105, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=eb131638261, createdName=lietome24, createdTime=Fri Jan 11 15:15:19 CST 2019, time=2019-01-11, status=1, ipAttribution=)]
    2019-01-13 huirong
  5. [GetPortalCommentsPageByObjectIdResponse(id=1776602, encodeId=c5da1e766025b, content=<a href='/topic/show?id=cd5884511ca' target=_blank style='color:#2F92EE;'>#脊柱侧凸#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=76, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=84511, encryptionId=cd5884511ca, topicName=脊柱侧凸)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=d38138982152, createdName=swallow, createdTime=Sun Feb 17 02:04:00 CST 2019, time=2019-02-17, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1362261, encodeId=d39c136226183, content=<a href='/topic/show?id=9857e03444b' target=_blank style='color:#2F92EE;'>#畸形#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=81, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=70344, encryptionId=9857e03444b, topicName=畸形)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=395f25, createdName=爆笑小医, createdTime=Sun Jan 13 06:04:00 CST 2019, time=2019-01-13, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1366854, encodeId=839d136685451, content=<a href='/topic/show?id=708a6283509' target=_blank style='color:#2F92EE;'>#椎体#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=96, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=62835, encryptionId=708a6283509, topicName=椎体)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=930e243, createdName=dingxiaobo, createdTime=Sun Jan 13 06:04:00 CST 2019, time=2019-01-13, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1369418, encodeId=17f113694185e, content=<a href='/topic/show?id=bc9f28589d0' target=_blank style='color:#2F92EE;'>#先天性#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=88, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=28589, encryptionId=bc9f28589d0, topicName=先天性)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=a435298, createdName=huirong, createdTime=Sun Jan 13 06:04:00 CST 2019, time=2019-01-13, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1489972, encodeId=a59514899e265, content=<a href='/topic/show?id=2d258411ea9' target=_blank style='color:#2F92EE;'>#胸椎#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=96, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=84117, encryptionId=2d258411ea9, topicName=胸椎)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=6d688662973, createdName=yyj065, createdTime=Sun Jan 13 06:04:00 CST 2019, time=2019-01-13, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=357846, encodeId=ca9535e84633, content=好文,值得点赞!认真学习,应用于实践!谢谢分享给广大同好!, beContent=null, objectType=article, channel=null, level=null, likeNumber=105, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=eb131638261, createdName=lietome24, createdTime=Fri Jan 11 15:15:19 CST 2019, time=2019-01-11, status=1, ipAttribution=)]
    2019-01-13 yyj065
  6. [GetPortalCommentsPageByObjectIdResponse(id=1776602, encodeId=c5da1e766025b, content=<a href='/topic/show?id=cd5884511ca' target=_blank style='color:#2F92EE;'>#脊柱侧凸#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=76, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=84511, encryptionId=cd5884511ca, topicName=脊柱侧凸)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=d38138982152, createdName=swallow, createdTime=Sun Feb 17 02:04:00 CST 2019, time=2019-02-17, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1362261, encodeId=d39c136226183, content=<a href='/topic/show?id=9857e03444b' target=_blank style='color:#2F92EE;'>#畸形#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=81, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=70344, encryptionId=9857e03444b, topicName=畸形)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=395f25, createdName=爆笑小医, createdTime=Sun Jan 13 06:04:00 CST 2019, time=2019-01-13, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1366854, encodeId=839d136685451, content=<a href='/topic/show?id=708a6283509' target=_blank style='color:#2F92EE;'>#椎体#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=96, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=62835, encryptionId=708a6283509, topicName=椎体)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=930e243, createdName=dingxiaobo, createdTime=Sun Jan 13 06:04:00 CST 2019, time=2019-01-13, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1369418, encodeId=17f113694185e, content=<a href='/topic/show?id=bc9f28589d0' target=_blank style='color:#2F92EE;'>#先天性#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=88, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=28589, encryptionId=bc9f28589d0, topicName=先天性)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=a435298, createdName=huirong, createdTime=Sun Jan 13 06:04:00 CST 2019, time=2019-01-13, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1489972, encodeId=a59514899e265, content=<a href='/topic/show?id=2d258411ea9' target=_blank style='color:#2F92EE;'>#胸椎#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=96, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=84117, encryptionId=2d258411ea9, topicName=胸椎)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=6d688662973, createdName=yyj065, createdTime=Sun Jan 13 06:04:00 CST 2019, time=2019-01-13, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=357846, encodeId=ca9535e84633, content=好文,值得点赞!认真学习,应用于实践!谢谢分享给广大同好!, beContent=null, objectType=article, channel=null, level=null, likeNumber=105, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=eb131638261, createdName=lietome24, createdTime=Fri Jan 11 15:15:19 CST 2019, time=2019-01-11, status=1, ipAttribution=)]
    2019-01-11 lietome24

    好文,值得点赞!认真学习,应用于实践!谢谢分享给广大同好!

    0

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