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双枚经第2骶椎骶髂螺钉固定技术在严重脊柱侧后凸畸形中的应用

Application of unilateral/bilateral dual second sacral alar-iliac technique for spinoplevic fixation in patients with severe kyphoscoliosis

摘要:

目的:探讨在严重脊柱侧后凸畸形患者后路矫形术中,采取单侧或双侧双枚经第2骶椎骶髂螺钉(second sacral alar-iliac,S2AI)固定技术的适应证,并且探究此技术的可行性并评估其临床疗效及并发症情况。方法:收集2014年1月至2019年12月共11例应用双S2AI固定技术进行后路脊柱矫形融合术的患者的病例资料,男5例,女6例;年龄(28.8±16.8)岁(范围12~60岁)。所有患者术前、术后均拍摄全脊柱正位、侧位X线片以及全脊柱CT,根据Gertzbein & Robbins评分法评价螺钉置入的精确性,测量术前、术后以及末次随访时的侧凸Cobb角,冠状面平衡(coronal balance,CB),脊柱骨盆倾斜角(spinal pelvic obliquity,SPO),局部后凸角(regional kyphosis,RK),探究描述患者采取双S2AI固定技术的原因,并且比较患者术前、术后及末次随访时的影像学差异及疗效评价差异。结果:11例中9例患严重脊柱侧后凸畸形伴骨盆倾斜,另外2例为既往脊柱术后医源性后凸畸形患者。11例患者术后随访(11.6±8.5)个月(范围6~30个月)。7例患者单侧置入双S2AI螺钉,4例双侧置入双S2AI螺钉,3例患者联合置入髂骨螺钉(iliac screw,IS)或髂骶螺钉(iliac sacral screw,ISS)。共置入35枚螺钉,术后CT示30枚为A级,5枚为B级,螺钉位置均良好,术前侧凸Cobb角87.2°(5.3°,150.5°),CB为13.6 mm(2.2 mm,91.7 mm),SPO为30.7°(0.6°,57.5°),RK为27.6°(14.2°,128.3°);术后即刻侧凸Cobb角25.4°(4.9°,84.1°),CB为8.2 mm(3.1 mm,63.2 mm),SPO为12.1°(0.9°,27.0°),RK为8.4°(4.1°,57.8°)。术后矢状面和冠状面的失衡均得到改善;末次随访矢状面以及冠状面的形态有较好的维持。11例术中均无SEP以及MEP信号改变或者丢失,随访中1例患者出现伤口深部感染,伤口愈合不良。余患者术后以及随访过程中无明显断棒断钉,螺钉松动等。结论:需行骨盆固定的患者若存在以下三种情况:①胸腰椎大段椎体无法置钉,但需保持植入物密度;②行序贯矫形的手术策略时单枚S2AI螺钉的置入无法有效的分散腰骶部的应力;③行复杂腰骶部畸形翻修手术时需要获取牢固内固定时,运用同侧双枚S2AI固定技术是一种好的选择,可提供坚强固定,有效地矫正畸形,并且并发症发生率较低。

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abstracts:

Objective:To investigate when to apply unilateral/bilateral dual second sacral alar-iliac technique for spinoplevic fixation in patients with severe kyphoscoliosis, and evaluate the feasibilityand clinical outcome.Methods:11patients (5 males and 6 females) applying unilateral/bilateral dual second sacral alar-iliac screws from January 2014 to December 2019 were retrospectively reviewed. The average age of the cohort was 28.8±16.8 years (range, 18-60 years). All patients were taken anteroposterior and lateral radiographs of the entire spine. Cobb's angle, coronal balance (CB), spinal pievic obliquity (SPO), regional kyphosis (RK) were recorded at pre-operation, post-operation and last follow up.Results:In these 11 patients, 9 patients suffered from severe scoliosis or kyphoscoliosis, 2 patients suffered from severe kyphosis and had underwent multiple operations. The average follow-up period was 11.6±8.5 months. 7 patients had unilateral dual S2AI screws placement and 4 patients had bilateral dual S2AI screws placement. Three patients had iliac screws or iliac sacral screws placement. The pre-operative Cobb angles were 87.2° (5.3°, 150.5°), CB were 13.6 mm (2.2 mm, 91.7mm), SPO were 30.7° (0.6°, 57.5°), RK were 27.6° (14.2°, 128.3°). The post-operative Cobb angles were 25.4° (4.9°, 84.1°), CB were 8.2 mm (3.1 mm, 63.2 mm), SPO were 12.1° (0.9°, 27.0°), RK were 8.4° (4.1°, 57.8°),showing significant improvement compared to pre-operation. In these patients, one patient had deep infection and recovered with debridement surgery, other patients didn't have any complications.Conclusion:Patients who need pelvic fixation have the following three conditions: the large segment of the thoracolumbarvertebral bodies cannot provide enough place for screws, but the implant density should be maintained; the placement of a single S2AI screw could not effectively disperse the stress in the lumbosacral region during the sequential correction strategy; when a firm internal fixation is needed for complex revision surgery. Unilateral/bilateral dual second sacral alar-iliac technique could produce excellent correction of kyphoscoliosis and obtain satisfied clinical outcomes with fewer complications.

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