【摘要】目的 探讨伴有脊髓空洞的脊柱侧凸的临床特征及手术策略，并评价其手术治疗的有效性和安全性。方法 回顾总结2003年1月至2010年11月我院收治的脊柱侧凸合并脊髓空洞患者50例，按手术方案分为两组：A组，脊柱矫形手术前先行外科手术处理脊髓空洞，之后再行侧凸矫形术；B组，直接进行脊柱侧凸矫形术。分别测量术前、术后及末次随访时冠状面主弯Cobb角、矢状面胸后凸Cobb角，术前及术后主弯顶椎偏距、顶椎旋转度及躯干偏移，分析冠状面主弯的矫形率、矫形丢失率，并比较A、B两组的矫形效果和术后并发症的发生情况。结果 两组患者均采用后路椎弓根钉棒系统进行侧弯矫形固定融合术，术后全部病例获得随访，平均随访时间为32.1个月。术前42例患者存在不同程度的临床症状或体征，术后3例患者肌力或腱反射得到改善。术后冠状面主弯平均矫形率为65.7%，末次随访时丢失2.6°，平均矫形丢失率为6.4%。术后主弯顶椎偏距、顶椎旋转度平均改善63.0%、60.0%，而躯干偏移较术前平均增加0.4cm。对比A、B两组治疗效果，其术后矫形率及并发症发生率均无统计学差异（P＞0.05）。结论 伴脊髓空洞的脊柱侧凸手术矫形风险较高，但只要手术操作得当，术中注意加强脊髓监护，同样可以获得满意的矫形效果；且术前不对脊髓空洞进行预防性外科处理，并不一定增加其术后并发症的发生率。

【关键词】脊柱侧凸；脊髓空洞；Chiari畸形；矫形

The surgical Treatment of Scoliosis Associated with Syringomyelia

LIU Jia-ming, SHEN Jian-xiong, ZHAN Jian-guo, ZHAO Hong, ZHAO Yu, LI Shu-gang, ZHAO Li-juan, WANG Yi-peng, Qiu Guixing. Department of Orthopaedics, Peking Union Medical College Hospital, Beijing 100730, China

Corresponding author: SHEN Jia-nxiong, E-mail: sjxpumch@yahoo.com

【Abstract】-ive To investigate the clinical manifestation and surgical strategy of the scoliosis associated with syringomyelia, and to evaluate the effectiveness and safety of the surgery. Methods A total of 50 cases diagnosed as scoliosis with syringomyelia between January 2003 and November 2010 were included in this study. The patients were divided into 2 groups according to the surgical strategy: Group A, underwent neurosurgery before scoliosis correction, including suboccipital decompression and syrinx shunting; Group B, underwent one-staged posterior correction and instrumentation without previously neurosurgery. The preoperative, postoperative and the last follow-ups of the Cobb angle of the coronal main curve and thoracic kyphosis were measured. Also, the preoperative and postoperative of the apical vertebra translation, apical vertebra rotation and trunk shift were measured by the same person. The surgical effective and complications of the correction between 2 groups were compared. Results All patients were underwent posterior pedicle screw instrumentation. All the cases were followed up with a mean time of 32.1 months. 42 patients had clinical symptoms or signs preoperatively and 3 patients’ improved postoperatively. The average correction of coronal curve was 65.7% and average lost of was 6.4% after the follow-ups. The mean correction of the apical vertebra translation and apical vertebra rotation were 63.0%、60.0%, respectively. However, the trunk shift was increased 0.4cm. There were no statistically significant differences for the correction efficacy and complications between the 2 groups（P＞0.05）. Conclusions Scoliosis associated with syringomyelia can be effectively treated if the surgeon manipulated carefully during the surgery and perioperative spinal monitoring was performed. Moreover, the syrinx wouldn’t increase the incidence of the postoperative complications without prophylactic neurosurgery.

【Key words】Scoliosis; syringomyelia; Chiari malformation; correction

脊柱侧凸合并脊髓空洞在临床中并不少见，文献报道脊柱侧凸中脊髓空洞的发病率在4%-8%[1-3]。早期由于检查手段有限，大部分脊髓空洞被漏诊，导致其检出率极低。目前，由于MRI的广泛应用，脊柱侧凸伴发的颅底或脊髓畸形越来越多的得到诊断，有效的指导了临床治疗。然而，脊柱侧凸矫形本来就属高风险、高难度的手术，合并脊髓空洞更增加了手术的风险和困难。在行脊柱侧凸矫形手术之前，是否需要对脊髓空洞进行外科干预，目前一直存在争议，而国内在这方面的临床报道不多。现对我院近10年来收治的病例进行回顾总结。

资料与方法

一、一般资料

2003年1月至2010年11月，我院收治的伴有脊髓空洞的脊柱侧凸且资料完整的患者50例。全部病例均以脊柱侧凸为首诊原因，其中男21例，女29例，年龄11-56岁，平均18.2岁。全部病例均经MRI证实存在脊髓空洞，其中合并Chiari畸形35例（70%）。Chiari畸形中Ⅰ型31例（88.6%），Ⅱ型4例（11.4%）。2例同时合并脊髓拴系，4例合并脊髓纵裂，1例合并脊髓脊膜膨出，1例合并椎管狭窄。其中42例（84%）患者术前存在不同程度的临床症状或体征。伴随症状为胸背痛或腰背痛者13例（26%），四肢皮肤感觉减弱者9例（18%），肢体无力者5例（10%），肌肉萎缩者4例（8%）。伴随体征为躯干或四肢浅感觉减退者22例（44%），四肢肌力减弱者9例（18%），双侧腹壁反射不对称或减弱、消失者28例（56%），肌腱反射异常者22例（44%），下肢病理征阳性者12例（24%）。脊柱侧弯类型为胸弯16例，胸腰弯2例，双胸弯2例，胸腰双弯29例，三弯1例。其中侧弯中存在右胸弯者33例，左胸弯17例。胸弯为后凸型者12例（即胸后凸>40°）。

二、手术方法

全部病例均采用一期后路椎弓根钉棒系统进行侧凸矫形固定融合术。按手术方案分为两组：A组（10例），矫形术前先行外科手术处理脊髓空洞或合并的Chiari畸形，包括空洞引流术、寰枕减压术。术后间隔一段时间再行脊柱侧凸矫形术。所有患者术前均存在神经损害的症状或体征，其中2例下肢病理征阳性。B组（40例），直接行脊柱侧凸矫形术。其中32例患者术前存在神经损害的症状或体征，10例下肢病理征阳性。全部手术均在脊髓电生理监护下进行，采用体感诱发电位(Somatosensory Evoked Potentials，SEP)和/或运动诱发电位(Motor Evoked Potential，MEP)监测，以判断术中是否发生脊髓、神经损伤。手术采用的内固定器械包括：Moss 14例，CDH 13例，Sino 9例，USS 6例，TSRH 4例，Isola 4例。

三、测量指标及方法

于脊柱全长正侧位X线片上，分别测量术前、术后及末次随访时冠状面主弯Cobb角、矢状面胸后凸Cobb角；测量术前及术后主弯顶椎偏距（apical vertebra translation, AVT）、顶椎旋转度（apical vertebra rotation，AVR）（Nash-Moe法）及躯干偏移（trunk shift，TS）。计算冠状面主弯的矫形率、矫形丢失率及矢状面胸后凸的矫形率。其中矫形率=（术前Cobb角-术后Cobb角）/术前Cobb角，矫形丢失率=（末次随访Cobb角-术后Cobb角）/术后Cobb角。同时比较A、B两组的患者的矫形效果和术后并发症的发生情况。所有测量均由同一医生在同一时期完成。

四、统计方法

采用SPSS 13.0统计软件进行数据分析，统计结果以均数±标准差表示。统计方法采用t检验，当P