【作者】 陈建文；

【导师】 王义生；

【作者基本信息】 郑州大学 ， 骨外科， 2004， 硕士

【摘要】 麻痹性脊柱侧凸(Paralytic Scoliosis PS)，主要是由脊神经系统病损致脊柱周围肌力的失平衡，从而引起进行性的脊柱冠状面的畸形。在我国最常见的是由于小儿麻痹所致，此外还可见于先天或后天因素所致脊髓、神经的病变及损伤。可发生于任何年龄，由于脊柱肌肉软弱，其结构和体位不平衡而造成形式繁多的脊柱侧弯。PS的角度取决于肌力大小，肌肉麻痹引起不平衡的范围及继发的挛缩。由于肌肉麻痹无法维持躯干的平衡，加上此类患者多合并有骨盆及下肢的畸形、功能障碍，以及全身条件和营养状况差、心肺功能不良，给手术矫治带来了许多困难。既往常使用Harrington器械矫正，很容易发生断棍和脱钩，随着节段性脊柱器械(Segmental Spinal Instrumentation SSI)的发展，后多采用Luque和C-D器械，取得了较好的手术效果。特别是近年来，生物力学的重大进步，椎弓根螺钉系统的出现，使得脊柱畸形能够得到三维的矫正；坚强的固定，更好地维持脊柱的平衡，已被广泛地应用于特发性脊柱侧凸的矫治，并且取得了许多成功经验。但对神经肌肉型脊柱侧凸，尤其是PS的临床应用相对较少，而且有关PS治疗问题仍存在很多的争议，至今仍未找到一种理想的治疗程序。本研究总结了自2000年5月至2003年11月期间，应用钛质椎弓根螺钉-棒系统治疗的14例PS病例，就相关的一些治疗问题进行了较详细的探讨。 材料与方法 本组14例，男7例，女7例，年龄11-26岁，平均16.5岁。其中脊髓灰质炎后遗症11例，先天性脊髓发育不良(Myelodysplasia MS)3例(2例为二次矫正)。术前脊柱侧凸cobb角55-125°，平均85°，牵引下30-105°，平均51°。合并腰后凸畸形9例(15-42°)，平均32°，3例为腰前凸，2例无法测量；均合并骨盆倾斜，平均24°(3-55°)；10例合并髋脱位，其中左侧4例，右侧3例，郑州大学2004年硕士学位毕业论文椎弓根螺钉一棒系统矫治麻痹性脊柱侧凸的临床研究双侧3例;均有不同程度的下肢畸形或/和肌力减退，下肢畸形主要为:屈骸、屈膝挛缩、肢体不等长、马蹄足、仰趾足、高弓足、足内翻等。MS病例均合并椎体及椎管的畸形，下肢功能障碍，感觉异常，但大小便功能正常，未发现其他脏器的先天异常。固定范围上界一般以上端椎的上1一2个椎体;下界一般为下端椎的下1个椎体，或为下端椎。应用器械Scofix器械11例，中华长城3例，PRSSI例。融合节段，最短的为6个，最长15个;所用螺钉数最多16个，最少6个。进钉技术要求:预先显露需要固定的各椎体的解剖标记，依据各椎体在空间上的不同排列，选择进钉点及方向。术中出血最多为2600ml，最少为sooml，平均1386ml。输血采用自体血、异体血及自体血回输等多项措施。 麻醉:本组均采用气管插管全身麻醉，体位为俯卧位，置于脊柱手术架上腹部悬空，术中做唤醒试验，并采取控制性低血压，持续监测中心静脉血及有创动脉压，血氧饱和度及心电监护等。 术前对患者的营养状况进行总体评价;要求患者术前进行心、肺功能训练;对身体状况欠佳者，术前应给予蛋白质及维生素的补充，以增加对手术创伤的耐受;准备充足的血源;术前半小时常规静滴广谱抗菌素。 术后所有病例均进行重点监护。记录伤口引流量，最少为300ml，最多为107Oml，平均792ml。对出血较多者，要及时补充新鲜冰冻血浆以补充凝血成份，并注意DIC的预防。两周左右伤口愈合后，配腰背支具，即可坐起或下床活动。 疗效评定:运动功能评定，采用修改的Rancho Los Amigos医院分类系统，畸形角度测量均采用Cobb法。骨盆倾斜测量，先标记出两侧骼峭的顶点，然后在两顶点之间画一条线，与胶片底边的平行线相交角即为骨盆倾斜角。测定脊柱、骨盆的柔韧性及纠正率。 统计学分析:1、比较术前与术后的角度，以确定手术的疗效;将术后3个月、1年的角度分别与术后角度相比较，以确认固定的可靠性及手术远期疗效。2、比较术前与出院时的红细胞与血红蛋白以一定程度上确认手术对患者身体状况的影响。3、比较术前与术后运动功能以确定手术对运动功能的改善情况。4、对脊柱、骨盆柔韧度与纠正率进行相关性评价。5、分析年龄与脊柱、骨盆畸形情况的相关性，以确定年龄与畸形的关系。6、统计处理采用SPSS10.O软件包。 结果郑州大学2004年硕士学位毕业论文椎弓根螺钉·棒系统矫治麻痹性脊柱侧凸的临床研究 本组无一例感染及神经症状加重，无死亡，伤口均一期愈合。手术时患者的平均年龄是16.5岁(11一26岁)。12例得到临床随访，随访时间最短3个月，最长3年，平均21个月。术后所有病例脊柱侧凸畸形得到明显改善(P<0.001)，侧弯角度平均减少了370，。obb角平均为48“(10一800)，矫正率平均46% (26一81%)。9例半年内的随访记录，显示与术后无明显改变(P>0.05);7例有1年左右的随访情况，显示畸形无明显发展(P>0.05)。腰后凸畸形术后得到明显矫正6例，3例无明显变化，3例术前术后均为腰前凸，2例无法测量;8例随访1年左右的，显示无明显变化(P>0.05)。骨盆倾斜明显矫正的有7例，无1例加重;7例随访1年左右，l例较术后有明显加重，更多还原

【Abstract】 Paralytic Scoliosis(PS) pertains to coronal plane deformity of the spine in patients with abnormalities of the spinal cord and neural pathways of the body. The disorders which cause this type of deformity mainly comprise the poliomyelitis in our country,others comprise congenital or acquired trouble and injury of spinal cord and peripheral nerve.PS is found at every age group and shows diverse scoliosis deformities,because of spinal flaccidity and inbalance of spinal constitution and posture.Paralytic scoliosis curve patterns are due to compromise in the muscular function of dynamic support for vertebral column stability and muscular flaccidity with inbalance and secondary contractures. There are many diffculty in the operative treatment of patients with paralytic scoliosis because of a number of additional factors,the muscular flaccidity can’t keep balance of the trunk;the patients are commonly in a debilitated state of health and poor nutritional status,comprise cardial and respiratory function, which manifest dysfunction and deformities of the pelvis and the lower extremity.In the past, Harrington instrumentation was usually used to correct the curves,but the breakage of rods and dislodgement of hooks were encountered easily.With advancement of Segmental Spinal Instrumentation(SSI), Luque and C-D instrumentations were applied in clinic and has gotten better efficacy.More recently,great advances in biomechanics,and particularly in the pedicle screw system,have contributed to a three-dimensional correction for spinal deformities.Stiff fixation and better maintaining spinal contours have been widely applied to the treatment of idiopathic scoliosis and have obtained lots of successfulexperiences.But for neuromuscular scoliosis,especially for paralytic scoliosis,the literature is little.There are many controversy as to the treatment of PS still without finding an ideal operative procedure to now.The study concludes and analyzes 14 patients with the treatment of pedicle screw-rod system implants which were made of titanium alloy from May,2000 to November,2003,and discusses some questions of surgical management in detail.Materials and MethodsOf the 14 patients,seven were males,seven were females,with a mean age of 16.5 years(ranged from 11 to 26 years). 11 poliomyelitis patients and 3 myelodysplasia(MS) patients(2cases for second correction) had scoliosis of an average 85 Cobb angle( range,55-125 ),and an average tractive angle 51 (range,30-105 ).There were lumbar kyphosis in 9 patients with an average 32 curve(range, 15-42 ), lumbar lodorsis in 3 patients, non-available mesurement in 2 patients.The pelvic oblity was found in all patients with an average 24 angle(range,3-55 ).The dislocation of hip was found in 10 patients,the left were 4 cases,the right were 3 cases,the double were 3 cases.All patients followed deformities and/or decline of muscular forces of the lower extremity on different extents,such as: hip flexion and dislocation,flexion contracture of the knee,unequal leg length,talipes equinus,talipes calcaneus,talipes cavus,talipes varus,etc.All patients of MS had congenital vertebral anomalies,leg malfunction and disesthesia,but no gatism and other congenital organ abnormalities.Spinal fixation levels:the upper limit is commonly 1-2 vertebra above the upper terminal vertebra;the lower limit is the lower terminal vertebra or 1 vertebra under the lower terminal vertebra.Fixation devices: 11 sets of Scofix Instrumentations,3 sets of Chinese Great Wall Spinal System,1 set of Plate-Rod System of Scoliosis.Fusion segment:the shortest is 6 section,the longest is 15 section. Applied screw numbenthe most is 16,the fewest is 6.Technique of implanting pedicle screw:appearing anatomical sign of the vertebra in advance which need to be fixed,based on the different arrange of each vertebra,the location and director of inserted screw can be selected.The average blood loss was 1386 ml(500-2600ml)during the operation.Blood transfusion included autologous andallogeneic transfusion,the use of a cell-sav更多还原