强直性脊柱炎矫形术中截骨椎脱位的危险因素、预防及远期预后研究进展  

Research progress on the risk factors,prevention and long-term prognosis of intraoperative sagittaltranslation secondary to ankylosing spondylitis

作　　者：陈旭 钱邦平[1] 王斌[1] 邱勇[1] Chen Xu;Qian Bangping;Wang Bin;Qiu Yong(Division of Spine Surgery,Department of Orthopedic Surgery,Nanjing Drum Tower Hospital,The Affiliated Hospital of Nanjing University Medical School,Nanjing 210008,China)

机构地区：[1]南京大学医学院附属鼓楼医院骨科、脊柱外科,210008

出　　处：《中华骨科杂志》2022年第3期188-194,共7页Chinese Journal of Orthopaedics

摘　　要：截骨椎脱位(sagittal translation,ST)指截骨椎近端椎体的后下缘与远端椎体的后上缘之间的矢状面偏移>5 mm。强直性脊柱炎(ankylosing spondylitis,AS)是一种以附着点炎和异位骨化为特征的慢性进行性炎症性疾病,主要破坏脊柱、骶髂关节。晚期出现胸腰段后凸畸形导致患者平视及平卧困难,需实施截骨矫形手术改善生活质量。AS后凸畸形截骨矫形术中截骨椎脱位在一定程度上可改善矢状面偏移(sagittal vertical axis,SVA),但严重的脱位易引起神经损伤、血管损伤、脑脊液漏等相关并发症。既往研究表明术中截骨椎脱位与术中操作不当、脊柱的骨化程度、后凸畸形曲线模式及矫正度、截骨椎前壁过早骨折、截骨量过多或不足、矫形棒铰链点与截骨闭合铰链点不在同一水平、不恰当地使用悬梁臂技术等有明显的相关性。防脱位器械的使用、术中透视及神经电生理监护可有效预防术中脱位的发生;对于术中已经出现脱位的患者,可根据神经功能情况采取相应的补救措施尝试复位或扩大椎板切除减压预防神经损害。AS患者较强的成骨能力使得脱位椎体可能发生重塑,随访期间可见良好的骨质重建、骨性融合。了解截骨椎脱位的发生机制和危险因素可使脊柱外科医生进一步认识截骨椎脱位,从而有助于减少术中截骨椎脱位及其并发症的发生,改善预后。Sagittal translation(ST)was defined as any measurable sagittal displacement more than 5 mm between the posterior inferior edge of the cranial vertebral body and the posterior superior edge of the caudal body at the osteotomized vertebrae(OV).Ankylosing spondylitis(AS)is a chronic inflammatory disease characterized by enthesitis and heterotopic ossification affecting sacroiliac joints and vertebral column.In the late stage,the poor quality of life caused by inability to lie supine or look straight ahead were the chief reasons for spinal osteotomy.Intraoperative ST secondary to AS thoracolumbar kyphosis contributed to improvement of sagittal vertical axis(SVA)partly.However,severe ST leaded to a huge bony step in front of dura,which was prone to vascular injury,neurologic deficit and cerebrospinal fluid leakage,thus affecting surgical outcomes.Prior research indicated there were significant correlations between intraoperative ST and inappropriate maneuver,the degree of ankylosis,the kyphosis curve pattern and correction,early fracture of the anterior cortex of the OV,excessive or insufficient decancellation of the OV,mismatch between the center of correcting forces and the center of rotation,incorrect application of cantilever technique.The use of anti-ST appliances,intraoperative fluoroscopy and nerve monitoring could prevent the occurrence of ST effectively.For AS patients with ST,relevant measures or decompressive laminectomies could be taken on the basis of neurological function to prevent neurologic deficit.Due to the strong osteogenic ability in AS patients,favorable bony reconstruction and fusion could be available during follow-up after adopting corresponding treatment involving ST.A thorough understanding of mechanism and risk factors of sagittal translation was essentially instructional to spinal surgeons thereby the incidence of intraoperative ST and complications could be decreased.

关 键 词：强直性脊柱炎 骶髂关节 神经损害 后凸畸形 截骨矫形 异位骨化 矫形术 矫正度 

分 类 号：R687.3[医药卫生—骨科学]