摘要
目的探讨腰骶段半椎体(lumbosacral hemivertebra,LSHV)合并胸腰段或腰段半椎体(thoracolumbar hemivertebra/lumbar hemivertebra,TLHV/LHV)平衡型双发半椎体畸形的选择性切除策略。方法回顾性分析2009年5月至2022年10月于南京鼓楼医院接受矫形手术治疗且年龄超过10岁的LSHV合并TLHV/LHV平衡型双发半椎体畸形的21例患者的资料,男7例、女14例,手术时年龄为(21.5±10.9)岁(范围12~55岁),随访时间为(32.8±15.9)个月(范围24~74个月)。根据术前冠状面平衡(coronal balance distance,CBD)分为平衡组(A型)及失衡组(C型)。测量手术前后及末次随访时主弯Cobb角、腰骶起飞角、后凸Cobb角、CBD和上端固定椎偏移距离,并记录并发症发生情况。结果术前失衡组10例、平衡组11例。平衡组TLHV/LHV与LSHV的畸形角率比值明显大于失衡组(0.9±0.3和0.6±0.2,t=2.143,P=0.045)。平衡组和失衡组术前主弯Cobb角分别为71.3°±22.3°和58.6°±8.2°,术后1周减小至38.4°±17.6°和31.3°±5.6°,末次随访维持在40.0°±18.1°和32.6°±5.6°,差异均有统计学意义(P<0.05);术前腰骶起飞角分别为37.5°±9.1°和36.7°±7.7°,术后1周减小至18.4°±9.4°和19.2°±5.5°,末次随访维持在19.4°±10.1°和19.6°±5.8°,差异均有统计学意义(P<0.05)。平衡组上端固定椎倾斜角、失衡组CBD及上端固定椎偏移距离较术前减小(P<0.05)。21例患者中LSHV切除15例,TLHV/LHV切除7例。15例后凸患者中TLHV/LHV切除6例。平衡组11例,LSHV切除4例、TLHV/LHV切除2例、均切除2例、均未切除1例术后维持A型,TLHV/LHV切除2例术后加重为C型。失衡组10例,LSHV切除8例术后改善为A型,LSHV切除1例、均不切除1例术后维持C型。切除LSHV的15例患者CBD由(29.8±15.2)mm矫正至(13.9±5.7)mm,末次随访时为(14.6±8.6)mm,CBD加重1例;而未切除LSHV的6例患者CBD由(17.2±8.7)mm加重至(19.7±12.1)mm,末次随访时进展至(20.5±13.0)mm,CBD加重3例,其中2例需行翻修手术。术后发生内固定断裂、近端交界性后凸和急性切口感染分别为3例、1例和1例。结论有效切除LSHV是腰骶段半椎体选择性切除策略的首选,对术前冠状面失衡的患者可降低冠状面失衡加重和内固定并发症的风险;而平衡型患者切除TLHV或LHV而保留LSHV的选择性切除策略存在较高的冠状面失衡风险。
ObjectiveTo explore a selective resection strategy for combined lumbosacral hemivertebra(LSHV)and thoracolumbar hemivertebra/lumbar hemivertebra(TLHV/LHV)double-balanced hemivertebra deformities.MethodsA retrospective analysis was conducted on 21 patients aged over 10 years with lumbosacral and thoracolumbar or lumbar combined hemimetameric segmental shift(HMMS)deformities who underwent surgery at Nanjing Drum Tower Hospital between May 2009 and October 2022.The cohort included 7 males and 14 females,with a mean surgical age of 21.5±10.9 years(range:12-55 years)and a mean follow-up duration of 32.8±15.9 months(range:24-74 months).Patients were divided into two groups based on preoperative coronal balance:the balanced group(Type A)and the unbalanced group(Type C).Radiographic parameters,including the major Cobb angle,lumbosacral take-off angle,kyphotic angle,coronal balance distance(CBD),and the deviation of the upper instrumented vertebra(UIV),were measured preoperatively,postoperatively,and at the final follow-up.Surgical complications were also recorded.ResultsOf the 21 patients,11 were classified as preoperatively balanced,and 10 as unbalanced.The deformity angular ratio of thoracolumbar to lumbosacral curves was significantly higher in the balanced group than in the unbalanced group(0.9±0.3 vs.0.6±0.2;t=2.143,P=0.045).The preoperative main curve Cobb angles in the balanced and imbalanced groups were 71.3°±22.3°and 58.6°±8.2°,respectively.One week postoperatively,these angles were reduced to 38.4°±17.6°and 31.3°±5.6°,and were maintained at 40.0°±18.1°and 32.6°±5.6°at the final follow-up,all differences were statistically significant(P<0.05).The preoperative lumbosacral take-off angles were 37.5°±9.1°in the balanced group and 36.7°±7.7°in the imbalanced group,which decreased to 18.4°±9.4°and 19.2°±5.5°at 1 week postoperatively,and remained at 19.4°±10.1°and 19.6°±5.8°at the final follow-up.These changes were also statistically significant(P<0.05).In the balanced group,the UIV tilt angle,the CBD and the deviation of the UIV,were all significantly reduced compared to preoperative values(P<0.05).Among the 21 patients,LSHV resection was performed in 15 cases,and TLHV/LHV resection was performed in 7 cases.Among the 15 patients with kyphosis,TLHV/LHV resection was performed in 6 cases.In the balanced group,9 patients maintained type A postoperatively,including 4 patients with LSHV resection,2 with TLHV/LHV resection,2 with both LSHV and TLHV/LHV resection,1 without resection of both hemivertebra.Two patients in the balanced group who underwent TLHV/LHV resection experienced postoperative deterioration to type C.In the unbalanced group,8 cases with LSHV resection improved to type A,while 1 case with LSHV resection and 1 case with neither resection maintained C-type.In the LSHV resection group,CBD improved from 29.8±15.2 mm to 13.9±5.7 mm postoperatively and remained stable at 14.6±8.6 mm at final follow-up.Only 1 patient in this group experienced worsened coronal imbalance.In contrast,in the non-LSHV resection group,CBD worsened from 17.2±8.7 mm to 19.7±12.1 mm postoperatively,progressing further to 20.5±13.0 mm at follow-up.Three patients in this group had worsening coronal imbalance,and 2 required revision surgery.Reported complications included 3 cases of internal fixation fracture,1 case of proximal junctional kyphosis,and 1 case of acute incision infection.ConclusionsEffective resection of lumbosacral hemivertebrae is the preferred selective strategy,particularly for patients with preoperative coronal imbalance,as it significantly reduces the risk of worsening coronal imbalance and internal fixation-related complications.However,selective resection involving only TLHV or LHV without addressing LSHV in preoperatively balanced patients may increase the risk of postoperative coronal imbalance.
作者
周杰
李松
孙凯
刘臻
邱勇
朱泽章
毛赛虎
Zhou Jie;Li Song;Sun Kai;Liu Zhen;Qiu Yong;Zhu Zezhang;Mao Saihu(Department of Orthopaedic and Spine Surgery,Drum Tower Clinical Medical College,Nanjing Medical University,Nanjing 210008,China)
出处
《中华骨科杂志》
北大核心
2025年第9期542-551,共10页
Chinese Journal of Orthopaedics
基金
江苏省骨科医学创新中心(CXZX202214)
南京鼓楼医院新技术发展项目(XJSFZLX202108)。
关键词
脊柱侧凸
先天畸形
腰骶部
椎体
平衡型半椎体
选择性半椎体切除
Scoliosis
Congenital abnormalities
Lumbosacral region
Vertebral body
Hemimetameric segmental shift
Selective hemivertebrae resection
