全椎弓根螺钉与钉钩联合系统治疗青少年Chiari畸形伴胸椎侧凸的疗效比较  

Hybrid constructs versus all pedicle screw instrumentation for treatment of thoracic scoliosis secondary to Chiari mal-formation in adolescents

作　　者：江龙[1] 朱泽章[1] 邱勇[1] 钱邦平[1] 刘臻[1] 沙士甫[1] 闫煌[1] 

机构地区：[1]南京医科大学鼓楼临床医学院脊柱外科,210008

出　　处：《中华骨科杂志》2014年第5期516-524,共9页Chinese Journal of Orthopaedics

摘　　要：目的评估青少年Chiari畸形伴胸椎侧凸不同内固定模式的选择对手术疗效的影响。方法回顾性分析2001年3月至2011年3月期间，接受后路胸椎融合术的75例Chiari畸形伴脊柱侧凸患者的病历资料，根据内固定方式分为全椎弓根螺钉组（44例）和钉钩联合组（31例）。分别测量术前、术后以及末次随访时的影像学指标：冠状面侧凸Cobb角、侧凸柔韧性、顶椎偏移、顶椎旋转及躯干偏移；矢状面胸椎后凸角、腰椎前凸角、躯干偏移及近端与远端交界区Cobb角。比较两组术前、术后及末次随访时上述影像学指标的改变。根据术前不同程度胸椎后凸进一步分组，比较两种内固定模式的手术疗效。结果全椎弓根螺钉组术后胸弯平均矫正率为60．2％，明显著高于钉钩联合组（51．3％，t=2．372，P=0．023）。末次随访时全椎弓根螺钉组及钉钩联合组胸弯矫正丢失率分别为0-3％及1．7％（t=-0．468，P〉0．05）。术后腰弯平均矫正率在全椎弓根螺钉组为61．7％，明显优于钉钩联合组51．1％（t=2．431，P=0．020）。术前全椎弓根螺钉组与钉钩联合组的胸弯顶椎偏移分别平均为25．0mm和24．1mm，术后减小至6．9mm和7．4mm，两组术后的胸弯顶椎偏移均获得明显改善。术前胸椎后凸〉400的病例中，全椎弓根螺钉组末次随访时矢状面近端交界区Cobb角为10．0°，高于钉钩联合组（4．50，t=-2．031，P=0．052）。而且全椎弓根螺钉组近端交界性后凸发生率（20％）高于钉钩联合组（9％）。结论对继发于青少年Chiari畸形的胸椎侧凸行后路内固定矫形，全椎弓根螺钉具有更好的畸形矫正率，但是，与钉钩联合固定相比，术前胸椎过度后凸的患者在胸椎全椎弓根螺钉固定术后远期发生近端交界性后凸的风险增高。Objective To compare the clinical and radiological outcomes between hybrid and total pedicle screw in- strumentation in adolescents undergone posterior spinal fusion （PSF） for thoracic scoliosis secondary to Chiari malformation.. Methods A total of 75 patients undergone PSF were included and divided into two groups： the all pedicle screw group （Group A, n=44） and the hybrid group （Group B, n=31）. Patients were evaluated before surgery, immediately after surgery, and at the 2- year follow-up in radiographic changes in curve magnitude, apical vertebral translation （AVT）, apical vertebral rotation （AVR）, trunk shift, thoracic kyphosis （TK）, lumbar lordosis （LL）, and sagittal vertical axis （SVA）. These parameters were further analyzed with respect to preoperative TK in both groups. Results After surgery, the average correction of the thoracic curve was 60.2% and 51.3% in Group A and B, respectively （t=2.372, P=0.023）. The average lumbar curve correction was 61.7% in Group A, repre- senting a significant increase compared to Group B （51.1%, t=2.431, P=O.020）. At the final follow-up, loss of the thoracic curve correction was less in Group A （0.3%） than in Group B （1.7%）, however, there was no statistical significance （t=-0.468, P〉0.05）. AVT of the thoracic curve improved in Group A from 25.0 mm to 6.9 mm, while in Group B it changed from 24.1 mm to 7.4 mm. For patients with a preoperative TK greater than 40°, the proximal junctional angle was found to be significantly larger in Group A （10.0 degrees versus 4.5 degrees, t=-2.031, P=0.052） by the final follow-up, along with a significantly increased incidence of proxi- mal junctional kyphosis （20% versus 9%）. Conclusion Total pedicle screw instrumentation provided a significantly better cor- rection of the major and minor curves than hybrid constructs for the operative treatment of thoracic scoliosis secondary to Chiari malformation. However, for patients with thoracic hyperkyphosis, all-screw instrumentati

关 键 词：ARNOLD-CHIARI畸形 胸椎 脊柱侧凸 脊柱融合术 内固定器 

分 类 号：R726.8[医药卫生—儿科]