Management of Severe Spinal Deformity Scoliosis and Kyphosis
Management of Severe Spinal Deformity Scoliosis and Kyphosis
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DOI：
10.1097/brs.0b013e3181feab19
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发表时间：
2010-12-01
期刊：
影响因子：
3
通讯作者：
Sucato, Daniel J.
中科院分区：
文献类型：
--
作者：
Sucato, Daniel J.
研究设计。文献综述和作者治疗严重脊柱畸形的经验。目的。明确治疗严重脊柱畸形的解剖学和生理学挑战，并描述实现最佳安全结果的术前、术中和术后策略。背景数据摘要。严重的小儿脊柱畸形是一种相对罕见的疾病，通常在早发性脊柱侧凸治疗后出现。患者最常出现严重的临床和影像学畸形以及肺功能差。与更常见的青少年特发性脊柱侧凸（原发性脊柱畸形）相比，严重脊柱畸形的患者还存在胸壁畸形，可能需要在治疗时解决。先前的文献已经确定了这些患者的治疗面临的挑战以及较高的并发症风险。方法。对作者治疗这些患者的个人经历进行了文献综述和回顾。分析并报告了导致最佳结果的术前、术中和术后因素的评估。结果。早期评估应包括整形外科医生、肺科医生、麻醉师，或许还包括神经科医生的多学科方法，以提供基线评估。使用计算机断层扫描对脊柱进行高级成像非常有用，尤其是在之前已进行过手术和/或普通放射线摄影受到限制的情况下。脊髓和脑干的磁共振成像对于确保不存在神经轴异常并可以确定是否存在脊髓压迫非常重要。严重的脊柱畸形应与更常见的青少年特发性脊柱侧弯畸形区分开来，因为脊柱和胸壁都受到影响。术前光环重力牵引是改善脊柱和胸部灵活性、改善肺功能、在患者清醒时对脊髓施加压力并提供神经系统评估反馈的宝贵工具。手术治疗应分为3个阶段。首先，锚定放置应主要是以节段方式放置的椎弓根螺钉，并且在进行脊柱切除时也使用复位螺钉。其次，应采取措施增加脊柱和胸部的灵活性，从简单的后软组织松解到后小关节切除，再到针对最严重畸形的脊柱切除，逐步松解。第三阶段是脊柱和胸壁畸形的矫正。许多策略可用于矫正这些畸形，并依赖于良好的锚定点固定以及脊柱和胸壁的良好释放。在进行脊柱切除以安全矫正畸形时，临时杆固定至关重要。临床和放射学外观、肺功能和自我形象的改善往往是显着的。结论。严重脊柱畸形的治疗具有挑战性，需要整形外科医生、麻醉师、肺科医生和神经科医生对患者进行仔细评估，尤其是当存在神经功能缺损时。外科医生正确规划和执行正确的手术程序可以为这些患者带来显着的改变生活的结果。
Study Design. Review of the literature and author's experience with the treatment of severe spinal deformity.Objective. To define the anatomic and physiologic challenges in treating severe spinal deformity and to describe the preoperative, intraoperative, and postoperative strategies to achieve the optimal safe result.Summary of Background Data. Severe pediatric spinal deformity is a relatively uncommon condition that often arises following treatment of early onset scoliosis. Patients most often present with severe clinical and radiographic deformity with poor pulmonary function. In contrast to the more common adolescent idiopathic scoliosis which is a primary spinal deformity, patients with severe spine deformity have the added chest wall deformity which may need to be addressed at the time of treatment. Previous literature has identified the challenges in the treatment of these patients and the higher risk for complications.Methods. A literature review and review of the author's personal experience in the treatment of these patients was performed. An assessment of the preoperative, intraoperative, and postoperative factors leading to an optimal result was analyzed and reported.Results. The early evaluation should include a multi-disciplinary approach from the orthopaedic surgeon, pulmonologist, anesthesiologist, and perhaps the neurologist to provide a baseline assessment. Advanced imaging of the spine with computed tomography is useful especially when previous surgery has been performed and/or when plain radiography is limited. Magnetic resonance imaging of the spinal cord and brain stem is important to ensure that no neural axis abnormalities are present and can determine if spinal cord compression is present. Severe spinal deformity should be distinguished from the more common adolescent idiopathic scoliosis deformity in that both the spine and the chest wall are affected. Preoperative halo-gravity traction is an invaluable tool to improve the flexibility of the spine and chest, to improve pulmonary function, and to stress the spinal cord while the patient is awake and provides feedback as to the neurologic assessment. Surgical treatment should be divided into 3 phases. First, anchor placement which should be predominantly pedicle screws placed in a segmental fashion and also use of reduction screws when performing vertebral column resections. Second, steps should be performed to increase the flexibility of the spine and chest with incremental releases from simple posterior soft tissue releases to posterior facet resections, to vertebral column resections for the most severe deformity. The third phase is the correction of the spine and chest wall deformity. Many strategies can be used to correct these deformities and relies on good anchor point fixation and good releases of the spine and chest wall. Provisional rod fixation is critical when performing resection of the spine to allow for safe correction of the deformity. Improvements in the clinical and radiographic appearance, pulmonary function, and self image are often dramatic.Conclusion. The treatment of severe spinal deformity is challenging and requires careful assessment of the patient by the orthopaedic surgeon, anesthesiologist, pulmonologist, and neurologist especially when neurologic deficits are present. Proper planning and execution of the correct surgical procedure for the surgeon provides an outstanding life-changing result in these patients.