术中不同重量颅骨牵引对青少年特发性脊柱侧凸矫治的影响.pdf

收稿日期:2011-11-04;修订日期:2022-05-09作者简介:王秀萍(1972-),女,河南籍,副主任医师研究方向:骨科电子邮箱:临床论著术中不同重量颅骨牵引对青少年特发性脊柱侧凸矫治的影响王秀萍1,张婧2,王田田2(河南省洛阳正骨医院(河南省骨科医院),1.骨科;2.手术室,河南洛阳 471002)摘要:目的 探讨术中不同重量颅骨牵引对青少年特发性脊柱侧凸(adolescent idiopathic scoliosis,AIS)矫治的影响。方法 选择 2016 年 1 月 2020 年 6 月在本院接受手术治疗的 87 例 AIS 患儿资料进行回顾性分析,根据术中颅骨牵引重量的不同分为 A、B、C 三组,A 组 26 例接受高重量术中颅骨牵引(intraoperative skull-skeletal traction,ISST),B 组 33 例接受常规 ISST,C组 28 例不接受 ISST。观察三组患者术前、术中、术后资料,采用多因素 Logistic 分析观察不同重量 ISST 对末次随访矫正度和运动诱发电位(motor evoked potential,MEP)变化率的影响。结果 A 组和 C 组主弯 Cobb 角差异存在统计学意义(P0.05)。A 牵引重量、牵引后主弯 Cobb 角、牵引矫正率均显著高于 B组(P0.05);B 组手术时间显著长于 A 组和 C 组(P0.05),C 组融合节段数显著少于 A 组和 C 组(P0.05);A 组 MEP 变化显著高于 B 组和 C 组(P0.05)。所有患儿体感诱发电位均无变化。A 组和 B 组末次随访 Cobb 角均显著高于 C 组(P0.05),A 组矫正角度显著高于 B 组和 C 组(P0.05)。逐步多元 Logistic 回归分析提示,高重量 ISST 是矫正角度和 MEP 事件的影响因素(P0.05)。结论 高重量 ISST 与术中和最终侧凸矫正增加相关,但高重量 ISST 可增加术中 MEP 发生风险,AIS 矫正术术中进行 ISST,可采用 MEP 进行神经监测,以提高手术安全性。关键词:青少年特发性脊柱侧凸;术中颅骨牵引;运动诱发电位;神经生理学监测;重量中图分类号:R682.1+3 文献标识码:A 文章编号:1005-7234(2023)04-0544-04DOI:10.3969/j.issn.1005-7234.2023.04.011Effect of intraoperative skull traction with different weight on correction of adolescent idiopathic scoliosisWANG Xiu-ping1,ZHANG Jing2,WANG Tian-tian2(1.Department of Orthopedics;2.Operating Room,Henan Province Luoyang Orthopedics Hospital(Henan Provincial OrthopaedicHospital),Luoyang,Henan 471002,China)Abstract:Objective To investigate the effect of intraoperative skull traction with different weight on the correction of adolescentidiopathic scoliosis.Methods The data of 87 children with AIS who underwent surgery in our hospital from January 2016 to June 2020were retrospectively analyzed.The children were divided into groups A,B and C according to the surgical methods.A total of26 patientsin group A received high-weight ISST,33 patients in group B received conventional ISST,and 28 patients in group C did not receiveISST.The preoperative,intraoperative and postoperative data of the three groups were observed.The effects of different weight of ISSTon the degree of correction and the changing rate of motor evoked potential(MEP)were observed by multivariate logistic analysis.Results Further analysis showed that there was significant difference in Cobb angle between group A and group C(P0.05).The traction weight,Cobbangle and traction correction rate of group A were higher than those of group B(P0.05).The operation time in group B was higherthan that in group A and C(P0.05).The fusion segments in group C were lower than those in group A and group C(P0.05).The change of MEP in group A was higherthan that in group B and group C(P0.05).There was no change in somatosensory evoked potential in all children.The last Cobb angleof group A and group B were both higher than group C,and the difference was statistically significant(P0.05),and the correctionangle in group A was significantly higher than that in group B and C(P0.05).Stepwise multivariate logistic analysis showed that thecorrection angle of high weight ISST was an influencing factor of MEP(P50;经同一医师完成手术治疗;初次行手术治疗,既往无脊柱手术史;患儿病历资料完整,可供分析。排除标准:合并先天性脊柱侧凸,神经肌肉疾病,或其他疾病继发的脊柱侧凸者;翻修手术患儿;具有手术禁忌证的患儿;临床资料缺乏,无法完成分析者。根据术中颅骨牵引重量将患儿分为 A、B、C 三组,A 组26 例接受高重量 ISST,B 组 33 例接受常规 ISST,C 组 28例不接受 ISST。1.2 研究方法所有患儿均接受气管插管全身麻醉,麻醉成功后,A 组和 B 组患儿行术中颅骨和双侧股骨牵引。患儿取俯卧位,头部置于手术台上,置入 Gardner-Wells 颅骨钳,双侧平滑牵引针置入股骨远端,获得基线运动诱发电位(motor evoked potential,MEP)后开始牵引。使用 Digitimer D185 电刺激仪,刺激电极诱发经颅电刺激的 MEP,于左右腹直肌、髂腰肌、内收肌、股直肌、胫骨前肌和拇展肌记录下肢 MEP,于肩胛骨背侧肌肉双侧记录上肢 MEP。A 组牵引重量约为患儿体重的 50%,B 组牵引重量约为体重的30%,C 组不予牵引。术中通过 C 型臂 X 线机分析矫正情况。牵引过程中,所有患儿均接受 MEP 监测,振幅降低超过基线的 50%作为预警阈值。所有患儿均由同一医师完成脊柱后路融合手术。术毕移除牵引和导针。1.3 观察指标观察三组患儿性别、年龄、美国麻醉医师协会(American Society of Anesthesiologists,ASA)分级、侧凸类型,以及 ISST 术前、术中、术后 X 线片测量的Cobb 角。观察 MEP 和体感诱发电位记录的电生理监测事件发生率,比较三组患儿神经生理学变化频率、术中矫正角度和术中矫正率,末次随访 Cobb 角、末次随访矫正角度和末次随访矫正率。1.4 统计学方法采用 SPSS 23.0 统计学软件包进行数据分析,符合正态分布计量资料采用“xs”表示,组间比较采用单因素方差分析,;不符合正态分布资料表示为“中位值(四分位数值)”,采用非参数检验;计数资料采用率或百分比表示,组间比较采用卡方检验;多因素分析采用 Logistic 回归分析,P0.05);三组间主弯 Cobb 角比较,差异存在统计学意义(P 0.05)。进一步分析显示,A 组和 C 组主弯 Cobb 角差异存在统计学意义(P0.05)。见表 1。表 1 三组患儿术前资料比较组别n性别(男/女,例)年龄(岁)ASA 分级(/,例)分型主胸弯/(胸腰弯/腰弯),例主弯 Cobb 角()柔韧指数(%)A 组2620/615.032.86(11 18)15/1124/277.4829.03(51 123)23.1418.09(3 54)B 组3327/614.382.41(10 18)17/1629/469.0431.83(46 109)29.2521.37(3 57)C 组2821/715.142.54(11 18)14/1423/557.2525.32(42 103)25.5417.06(4 58)F0.4460.4400.3601.2895.9340.901P0.8000.6460.8350.5250.0040.410545颈腰痛杂志 2023 年第 44 卷第 4 期 The Journal of Cervicodynia and Lumbodynia 2023,Vol.44 No.42.2 三组患儿术中资料比较A 组牵引重量、牵引后主弯 Cobb 角、牵引矫正率均显著高于 B 组(P0.05);B 组手术时间显著长于 A 组和 C 组(P0.05),C 组融合节段数显著少于 A 组和 B 组(P0.05);A 组 MEP 变化的发生率显著高于 B 组和 C 组(P0.05)。所有患儿体感诱发电位均无变化。见表 2。表 2 三组患儿术中资料比较组别n牵引重量(%体重)牵引后主弯Cobb 角()牵引矫正率(%)手术时间(h)术中出血量(mL)融合节段(段)MEP 变化(例)A 组2644.145.42(34 54)35.439.14(24 53)46.2310.23(28 63)5.431.54(3.3 7.8)2140720(1273 3655)11.452.35(9 15)13(50.00)B 组3325.833.29(17 40)26.838.23(15 37)37.8211.54(22 56)6.391.23(3.8 8.2)2580640(1300 3874)11.872.10(9 15)8(24.24)C 组284.351.36(2.4 6.2)1960480(1008 2927)9.642.26(6 13)0(0.00)t/F/29.0422.3722.5956.6013.6054.31620.440P0.0010.0140.0120.0020.0320.0170.05);A 组和 B 组末次随访 Cobb 角均显著高于 C 组(P0.05);A 组矫正角度显著高于 B 组和 C 组(P0.05)。见表 3。表 3 三组患儿随访资料比较组别n随访时间(月)末次随访 Cobb 角()矫正角度()矫正率(%)A 组2621.215.22(14 36)25.3211.73(10 39)51.4815.08(32 73)68.0325.43(33 90)B 组3323.329.15(12 41)26.3612.03(11 40)42.3612.37(28 64)61.2823.46(32 88)C 组2821.358.15(11 37)18.4510.23(8 33)39.0810.27(22 53)66.2321.67(29 88)x2/F0.5957.3759.0582.505P0.7430.00165=1)和 MEP 事件(无=0,有=1)为应变量,将患儿的年龄(连续变量)、性别(女=0,男=1)、术前侧弯分型(主胸弯=0,胸腰弯/腰弯=1)、主弯 Cobb 角(连续变量)、柔韧指数(连续变量)、牵引重量(无=0,常规 ISST=1,高重量 ISST=2)等作为自变量,引入逐步多元 Logistic 回归分析,结果提示,高重量 ISST 是矫正角度和术中 MEP 事件的影响因素(P120):A 2-yearfollow-up review of 62 patientsJ.Spine(Phila Pa 1976),2021,46(2):E95-E104.8 Lewis SJ,Gray R,Holmes LM,et al.Neurophysiological changesin deformity correction of adolescent idiopathic scoliosis with intrao-perative skull-femoral traction J.Spine(Phila Pa 1976),2011,36:1627 1638.9 Chiu CK,Bashir ES,Chan CYW,et al.Cervical supine side-bending versus cervical supine traction radiographs:Which is betterin predicting proximal thoracic flexibility for lenke 1 and 2 adoles-cent idiopathic scoliosis?J.Asian Spine J,2018,12(4):669-677.10 Peiro-Garcia A,Brown GE,Earp MA,et al.Sagittal balance inadolescent idiopathic scoliosis managed with intraoperative skullfemoral traction J.Clin Spine Surg,2019,32(10):E474-E478.11 Bourget-Murray J,Brown GE,Peiro-Garcia A,et al.Quality,safety,and value of innovating classic operative techniques inscoliosis surgery:Intraoperative traction and navigated sequentialdrillingJ.Spine Deform,2019,7(4):588-595.12 ONeill CJ,Brennan SA,Quinn C,et al.Standardized tractionversus side-bending radiographs in adolescent idiopathic scoliosis:a preliminary studyJ.J Pediatr Orthop B,2019,28(1):17-21.745颈腰痛杂志 2023 年第 44 卷第 4 期 The Journal of Cervicodynia and Lumbodynia 2023,Vol.44 No.4