摘要目的 探讨重度脊柱畸形经脊柱融合区域三柱截骨翻修的安全性及临床疗效.方法 回顾性分析2010年10月至2014年5月通过经融合区域三柱截骨翻修矫形治疗的重度脊柱畸形患者12例,男7例,女5例;年龄18～30岁,平均(21.8±3.8)岁;距初次脊柱后路融合矫形手术时间为3～17年,平均(10.2±4.8)年.翻修原因:畸形加重7例,神经损害2例,内固定断裂1例,假关节形成2例.分别测量翻修手术前后及末次随访时的冠状面主弯侧凸Cobb角、矢状面最大后凸Cobb角、冠状面平衡(distance between C7plumb line and center sacral vertical line,C7PL-CSVL)和矢状面平衡(sagittal verti-cal axis,SVA),并记录手术时间、出血量及并发症情况.翻修手术前后及末次随访时的侧凸Cobb角、后凸Cobb角、冠状面和矢状面躯干平衡比较采用配对t检验.结果 手术时间320～600 min,平均(451.7±83.1) min;术中出血量2 700～6000 ml,平均(4 016.7±1 080.0) ml.随访时间24～49个月,平均(35.4±9.8)个月.翻修术前冠状面主弯侧凸Cobb角平均为83.8°±23.3°,术后为34.6°±13.7°,平均矫正率为60.1％±8.8％;末次随访平均为34.9°±13.8°,随访期间未见明显矫正丢失.翻修术前后凸Cobb角为99.1°±13.3°,术后为38.7°±7.8°,平均矫正率为60.8％±6.7％;末次随访平均为39.3°±7.5°,亦未见明显丢失.C7PL-CSVL和SVA分别由翻修术前平均(30.3±17.1)mm、(40.1±31.1) mm改善至术后(14.3±7.6) mm、(19.1±12.3)mm,末次随访时分别为(14.1±7.6) mm、(19.6±12.1)mm,无明显矫正丢失.2例术前合并神经损害患者均由Frankel C级恢复至E级.5例患者出现围手术期并发症(41.7％),包括术中皮层体感诱发电位信号改变1例(8.3％)、术后一侧下肢神经根刺激症状1例(8.3％)、脑脊液漏例1例(8.3％)及胸腔积液2例(16.7％).随访期间无假关节形成、内固定物失败及感染等并发症.结论 既往接受后路脊柱矫形融合手术干预的重度脊柱畸形患者,经脊柱融合区域三柱截骨翻修可以安全实施,翻修矫形效果良好,但是手术时间长,出血量多,应充分重视围手术期并发症.

abstractsObjective To investigate the safety and efficacy of three column osteotomy (3-CO) procedures through previous spinal fusion site for the revision surgical treatment in severe spinal deformity patients.Methods From Oct.2010 to May 2014 in our hospital,a total of 12 severe spinal deformity patients underwent 3-CO for the revision surgical treatment.There were 7 males and 5 females with the average age of (21.8±3.8) years,ranging from 18 to 30 years.The mean time from the initial operation to the revision surgery was (10.2±4.8) years (ranging from 3 to 17 years).The reasons for revision were:curve progression in 7 patients,neurologic deficit in 2 cases,implant failure in 1 patient and pseudarthrosis in 2 patients.The coronal parameters including major Cobb angle and distance between C7 plumb line and center sacral vertical line (C7PL-CSVL),and the sagittal parameters including global kyphosis curve and sagittal vertical axis (SVA) were measured pre-operatively,post-operatively and at last followup,respectively.The operation time,intraoperative blood loss and complications were recorded.The paired t test was used to evaluate the difference among pre-revision,post-revision and last follow-up.Results The average operation time was (451.7±83.1) min (range,320-600 min) and the average blood loss was (4 016.7± 1 080.0) ml (range,2 700-6 000 ml).The average follow-up time after revision operation was (35.4±9.8) months (range,24-49 months).The coronal Cobb angles of pre-revision and post-revision were 83.8°±23.3°and 34.6°± 13.7°.The average correction rate was 60.1％ ±8.8％.At last follow-up,the average coronal Cobb angle was 34.9°±13.8°,there was no significant loss of correction.The pre-revision and post-revision values of global kyphosis were 99.1°±13.3°and 38.7°±7.8° with a mean correction rate of 60.8％ ±6.7％.At the last follow-up,the average global kyphosis was 39.3°±7.5°and no loss of correction was found.For the C7PL-CSVL and SVA,pre-revision (30.3± 17.1) mm and (40.1±31.1) mm were corrected to (14.3 ±7.6) mm and (19.1± 12.3) mm immediately after revision operation,respectively.At final follow-up,the average C7PL-CSVL and SVA were(14.1 ± 7.6) mm and (19.6± 12.1) mm,the correction was well maintained.Obviously,two patient's neurological status improved from Frankel C before revision surgery to Frankel E.Complications were encountered in five patients (41.7％),including SEP signal changed in 1 patient (8.3％),transient neurologic deficit after revision surgery in 1 patient (8.3％),cerebrospinal fluid leak in 1 patient (8.3％),and pleural effusion in 2 patients (16.7％).During the follow-up time,there was no patient experienced pseudarthrosis,implant failure,infection or significant loss of correction.Conclusion Based on results of this study,it was concluded that 3-CO procedures through previous spinal fusion sites could obtain satisfactory and safety results in severe spinal deformity revision surgery.However,it is a technique-demanding procedure with more blood loss,longer operative time and higher risk of perioperative complications.