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后路全脊椎切除术治疗儿童脊柱后凸畸形(附10例报告)曹光彪;李明;刘传康;康权;罗聪;郑超;杨琼【摘要】目的总结采用后路全脊椎切除术治疗儿童脊柱后凸畸形的临床经验、技术要点和疗效.方法回顾性分析2010年7月-2011年8月在重庆医科大学附属儿童医院骨科接受后路一期全椎体切除+重建治疗的10例脊柱后凸畸形患儿的病例资料,其中男3例,女7例,年龄6～15岁,平均11岁,术前脊柱后凸Cobb角76°～112°,平均97.8°.2例术前有神经系统症状,Frankel分级C级1例、D级1例.所有患儿均行后路一期全脊椎切除、经椎弓根固定、植骨融合术.结果所有患儿手术顺利,手术时间240～560min,平均373min;出血量550 ～ 2200ml,平均1115ml;术后后凸Cobb角10°～43°,平均29.3°,矫正率70.0％；患儿的躯干和双肩失平衡均得到显著改善,腰背部疼痛有明显缓解；术前有神经系统症状的2例患儿术后Frankel分级均恢复到E级.结论后路全脊椎切除+椎弓根钉-棒系统内固定术矫正儿童脊柱后凸畸形安全有效,并可达到稳定的短节段内固定及优良的融合效果.%Objective To summarize the experience, technique and curative effect of vertebral column resection via posterior approach for kyphotic deformity in children. Methods The clinical data of 10 children (3 males and 7 females; aged 6-15 years with average of 11 years) who suffered from kyphotic deformity and undergone one-stage posterior vertebral column resection and reconstruction from Jul. 2010 to Aug. 2011 were retrospectively analyzed. The pre-operative Cobb angle of kyphosis was 76°-112° with an mean of 97.8°. Nervous system symptoms were found in 2 children, of them one was of Frankel C class and another one was of Frankel D. All the children underwent one-stage posterior vertebral columnresection, pedicle fixation combined with bone graft. Results The operation was successfully in all the patients. The average surgery time was 373min (240-560min), the intraoperative blood loss was 1115ml (550-2200ml), the average post-operative Cobb angle of kyphosis was 29.3°(l0°-43°), and the correction rate was 70.0%. The torso and shoulder imbalance in all the 10 children was significantly improved, and dorsolumbar pain was markedly relieved. The Frankel classification of 2 children having preoperative nervous system symptoms were both ameliorated to class E after operation. Conclusions Posterior vertebral column resection with pedicle screw-rod fixation is an effective and safe surgical method for the treatment of kyphotic deformity in children. Satisfactory stability of short segment fixation and bone graft fusion can be accomplished.【期刊名称】《解放军医学杂志》【年(卷),期】2013(038)004【总页数】5页(P297-301)【关键词】脊柱后凸,儿童;后路全脊椎切除术;植骨融合【作者】曹光彪;李明;刘传康;康权;罗聪;郑超;杨琼【作者单位】400014 重庆儿童发育疾病研究教育部重点实验室、儿科学重庆市重点实验室、重庆市儿童发育重大疾病诊治与预防国际科技合作基地、重庆医科大学附属儿童医院骨科【正文语种】中文【中图分类】R726.873.7儿童脊柱后凸畸形临床并不少见，对于严重的脊柱后凸畸形，常需要采用截骨术进行矫形，国内外文献报道的截骨方式大致可分为Smith-Petersen截骨术(SPO)、经椎弓根截骨术(PSO)和全脊椎切除术(VCR)3种类型。
说明了此观点。
本组49例患者取材阳性率94%，较孙芳等［1］报道的采用钝头钩针胸膜活检取材阳性率63.2%明显增高。
同田攀文等［3］报道的采用切割针胸膜活检取材阳性率基本一致。
但与国外Dole 等［4］报道的经内科胸腔镜胸膜活检相比，取材阳性率95%基本接近，并发症的发生率却恰恰大幅降低，充分说明采用软组织切割针经皮胸膜活检具有明显优势。
成功取材的46例中，取材标本均良好，病理阳性率100%，高于既往研究［5，6］。
分析原因考虑：①本研究采用的软组织切割针几乎不影响标本的完整性，而传统钩针对组织完整性破坏较大；②既往采用软组织切割针胸膜活检的研究中，部分选择了较细的20G 切割针，虽成功取材，但获取组织标本细小，对病理结果判断的影响较大。
最终确诊病例中，结核性胸膜炎占56%；恶性占33%，慢性炎性11%，综合多项文献［1⁃7］发现，疾病百分比各家报道不一，考虑与病源不同所致。
本组病例中结核性胸膜炎占最大比例，考虑原因我院为结核专科医院，就诊病源已于综合医院大致排查，基本均为首要考虑结核者。
然而要警惕的是，恶性胸膜炎比例不断上升，需注意排查。
失败病例分析，2例获取组织为横纹肌、脂肪等胸壁残留组织。
2例病史均<1个月，考虑与病史短，影像所见病变可能反应性胸膜增生，难以留取实性组织有关。
1例为肺组织，同时该病例也为本组1例并发症病例（少量气胸）。
术后分析，考虑与穿刺角度有关，可能穿刺点胸膜增厚不明显，而穿刺针角度过于垂直，直接刺入肺组织，不仅导致穿刺失败，而且引起气胸并发症。
综合以上所述，笔者体会到，穿刺过程中的细节和熟练程度对取材成功率、诊断阳性率及并发症发生率有直接影响。
穿刺过程需注意以下几点：①穿刺前最好依据增强CT 判断胸膜增厚情况，确定穿刺点、穿刺方向及深度，对病变部位密度的准确识别，必要时可于彩超、CT 引导下穿刺，增加取材成功率。
②穿刺局部充分麻醉，减少胸膜反应、增加患者耐受力。
③垂直进针穿过肋骨后，可改斜角50°~60°进针至胸膜边缘，斜向取材，不仅可增加取材数量及阳性率（尤其对于胸膜增厚在1~2cm 者），而且可有效减少并发症（垂直进针易引起气胸，斜角进针易过多穿透胸壁引起肋间动静脉出血）。
经后路全脊柱截骨治疗胸腰椎骨折晚期后凸畸形作者：邹庆，杨永宏，楼肃亮，叶虹，张冬生，钱金黔，郑洁【关键词】截骨摘要：［目的］评价经后路全脊柱截骨治疗胸腰椎骨折晚期后凸畸形的效果及探讨其手术指征。
［方法］28例胸腰椎骨折晚期后凸畸形患者，22例腰背部疼痛剧烈，平卧困难、后凸畸形进行性加重，6例伴有不同程度神经损害症状(Frankel 分级：C级2例，D级4例)；术前后凸Cobb′s角32°～60°，平均475°。
均采用经后路全脊柱截骨术式纠正后凸畸形、植骨内固定稳定脊柱，重建脊柱矢状面平衡。
［结果］术后Cobb′s角平均68°，胸腰椎后凸畸形纠正率857％，重建脊柱矢状面平衡，神经损害症状恢复(Frankel分级C、D级5例神经功能恢复正常，1例C级恢复至D级)，外观满意；无神经并发症。
术后平均随访18个月，平均矫正丢失度数为28°。
［结论］对于胸腰椎骨折晚期后凸畸形僵硬、度数<50°的中老年患者经后路全脊柱截骨术式是理想选择。
关键词：胸腰椎；创伤后后凸；椎体截骨术；脊柱重建Posterior transvertebral osteotomy for posttraumatic thoracolumbar kyphosisAbstract：［Objective］To evaluate the curative effect of posterior transvertebral osteotomy for posttraumaticthoracolumbar kyphosis and discuss its indication.［Method］There were 28 cases in which posttraumatic thoracolumbar kyphosis were corrected by osteotomy with spine shortening through posterior approach.The reduction was fixed by a pedicular instrument.Successful treatment aimed at achieving satisfactory balance in both of the sagittal and coronal planes.The goals of surgery were to obtain a solid fusion with a balance spine,to relieve pain and to prevent further deformity.A secondary goal is to correct the thoracolumbar curvatures,and in so doing to improve the cosmetic appearece.［Result］The spinal balance was well maintained or restored and the cosmetic appcarccc was improved obviously.The average rate of kyphosis correction was 85.7%.All palients had no nerve compilations. Average 18 months followup were done,the clinical result was excellent with significant correction of kyphosis and solid vertebral fusion.［Conclusion］Following the surgical indication, posterior transvertebral osteotomy is demonstrated to be a safe and effective technique for the treatment of posttraumatic thoracolumbar kyphosis.Key words:Thoracolumbar; Posttraumatic kyphosis; Transvertebral osteotomy; Spinal reconstruction胸腰椎骨折早期治疗不当或延误治疗，晚期易出现腰背部疼痛、后凸畸形和神经功能障碍，治疗相当困难。
