Chinese Journal of Tissue Engineering Research ›› 2017, Vol. 21 ›› Issue (3): 433-439.doi: 10.3969/j.issn.2095-4344.2017.03.020
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Wu Min-hao, Sun Wen-chao, Yan Fei-fei, Xie Yuan-long, Hou Zhi-qiang, Feng Fan, Cai Lin
Online:
2017-01-28
Published:
2017-03-14
Contact:
Cai Lin, M.D., Chief physician, Doctoral supervisor, Fourth Department of Orthopedics, Zhongnan Hospital of Wuhan University, Wuhan 430071, Hubei Province, China
About author:
Wu Min-hao, Studying for master’s degree, Physician, Fourth Department of Orthopedics, Zhongnan Hospital of Wuhan University, Wuhan 430071, Hubei Province, China
CLC Number:
Wu Min-hao, Sun Wen-chao, Yan Fei-fei, Xie Yuan-long, Hou Zhi-qiang, Feng Fan, Cai Lin . Treatment research and new progress of early-onset scoliosis[J]. Chinese Journal of Tissue Engineering Research, 2017, 21(3): 433-439.
2.1 早发型脊柱侧弯对幼儿生长发育的影响 这个时期的幼儿正处于生长发育的高峰期,脊柱侧弯无疑会对患儿的骨骼以及心肺等重要脏器的发育造成严重的负面影响[3],近年来相关研究还表明,婴儿出生后至5岁前,是脊柱纵向生长发育的第一个高峰期(以每年约2 cm的速度稳定增长)[4-5]。在此期间,若患儿的脊柱畸形持续进展,最终会压迫胸腔脏器,使胸腔容积减小,从而压迫肺实质,减小肺容积。倘若患儿得不到及时治疗或者治疗不当,会对幼儿产生严重的身体畸形和心肺发育受限,影响患儿的生活质量,甚至可引起心肺功能衰竭乃至死亡[6]。脊柱侧弯发病年龄越小,对肺的生长发育影响越大,治疗起来越是困难,最终很有可能导致永久性肺功能的损害[7]。Cahill等[8]通过调查发现,脊柱侧弯在婴幼儿和学龄前儿童有迅速和严重恶化的可能性,10岁以前95%患儿的侧弯会随年龄增长而加重。因此,对于早发型脊柱侧弯患儿往往需要早期进行干预,其治疗的重点:①矫正侧弯畸形的脊柱;②控制脊柱侧弯畸形的继续发展,维持脊柱正常的生长曲线,防止病情恶化;③更重要的是保证胸腔脏器,如心肺等重要器官的良好发育,这才是其治疗的最终目标[9]。因此,作者认为这对于早发型脊柱侧弯的治疗带来了巨大的挑战。 2.2 早发型脊柱侧弯的治疗方式 2.2.1 保守治疗 对于早发型脊柱侧弯,尤其是特发型婴幼儿脊柱侧弯,传统的治疗方式主要有定期观察、 支具或石膏治疗等,这其中又以支具及石膏治疗最为广泛。Dong等[10]报道了关于应用石膏夹克治疗13名早发型脊柱侧弯患儿和10名特发性脊柱侧弯的初步结果,通过平均4.5年的随访表明:石膏夹克的矫正的效果较为满意,其中1例患儿经过治疗后,其主弯的 Cobbs角由74°变至3°,最大矫正率为97.3%。Stefano等[11]认为石膏夹克在早发型脊柱侧弯患儿的早期治疗中,能够有效的逆转脊柱畸形的进展,并且对于患儿正常的呼吸功能起到了一定维持作用。Negrini[12]通过归纳文献后指出:支具虽然不是治疗脊柱侧弯的最好方式,但在大多情况下它是除手术治疗之外的一个无法替代的治疗方式。通过这种支具或石膏治疗,甚至最终可以推迟脊柱融合的手术时间,因此,作者认为保守治疗在早发型脊柱侧弯的治疗上起到了一个过渡的作用。 保守治疗的禁忌证包括:严重的脊柱侧弯、先天性脊柱侧弯或神经肌肉型脊柱侧弯,此类早发型脊柱侧弯的治疗效果往往不佳[13]。此外,早发型脊柱侧弯采用支具、石膏治疗的患儿依从性较差。最终会因胸廓受压引起胸廓及肺脏的生长发育受限[14]。因此,对于严重的脊柱侧弯畸形,尤其是快速进展的早发型脊柱侧弯和经保守治疗无效的患者,手术治疗是最合适的选择[13]。手术治疗的目的一般包括两个方面:一方面是在保留脊柱生长能力的同时控制、矫正脊柱畸形;另一方面是减小脊柱及胸廓畸形对心、肺等重要脏器发育的影响。作者认为手术治疗已经成为目前治疗早发型脊柱侧弯的最重要手段之一。 2.2.2 手术治疗 目前,随着科学技术的发展以及国内外众多学者对早发型脊柱侧弯治疗上的日益关注和研究,越来越来的手术方式及新技术被应用到该疾病疗上,其中最主要的方式包括:脊柱融合术和脊柱非融合术[15-16]。 脊柱融合术(spinal fusion surgery):近40年来,借助节段内全椎弓根螺钉技术的三维矫形术的大力发展,利用各种新型的三维矫形内固定器械,综合应用各种脊柱矫形方法,如凹侧撑开凸侧压缩技术、转棒技术、平移技术、悬臂梁技术、脊柱侧凸节段内全椎弓根钉技术、直接去旋转技术等,使得现阶段对于脊柱侧弯的三维矫形效果有了明显的提高[17]。然而,这些矫形内固定植入物的主要目的是维持脊柱矫形的作用,并不进行脊柱融合。其初衷是当脊柱侧弯的畸形生长曲线重获平衡、侧弯矫正后便立即取出内固定矫形植入物,最终,保留脊柱的生长、活动功能,使之不受影响。但大量研究及随访表明[18-26]:如果不进行脊柱融合,脊柱很难获得长期稳定,很多患儿甚至出现断棒、脊柱生长功能丧失至躯干缩短和心肺功能发育受限等并发症[19]。最终将导致脊柱矫正丢失,这不仅对患儿的身心造成了巨大的阴影和打击,还无形当中增加了家庭和社会的经济负担。随后,国内外一些学者及专家提出:对内固定植入物的区域进行植骨以增强内固定之后的稳定性[25-26],防止脊柱畸形矫正后的丢失。但融合后一些相应并发症又是不得不面临的问题。特别是早发型脊柱侧弯的患儿,过早及长节段的脊柱融合,势必将导致正处于生长发育高峰时期的脊柱生长功能丧失,从而致使躯干缩短和心肺功能发育受限[20]。2008年Hoh等[21]通过对脊柱融合术后的患儿进行随访发现:长节段的脊柱融合可影响早发型脊柱侧弯患儿身高发育最多达12.5 cm。Karol等[22]通过对28名早发型脊柱侧弯患儿(年龄在5-9岁间)进行呼吸功能的测试及评估表明:8岁前进行胸椎融合的患儿,有超过60%患儿的肺容量下降了50%以上。同时,术后产生的附加现象和曲轴现象也是面临的主要问题之一[23],相关研究认为:患儿年龄越小,行大范围的脊柱融合术后曲轴现象发生的危险性就越大[24]。因此应采用内固定植入物矫正脊柱畸形、稳定脊柱而尽量避免行脊柱融合术,以保持脊柱的正常生长。 脊柱非融合术( non-fusion surgery):由于脊柱的融合阻止了发育期幼儿的脊柱生长,人们开始把目光投向各种非融合手术[27-34]。目前,非融合技术被认为是早发型脊柱侧弯治疗的重要手段[25],主要包括:生长棒技术、纵向可撑开型人工钛肋技术( Vertical Expandable Prosthetic Titanium Rib,VEPTR)、椎体U形钉侧凸矫形技术、椎弓根螺钉栓系技术及椎体楔形截骨术等,均有优缺点及相应的适应证,治疗效果有待进一步的随访。其中生长棒技术:单棒技术及双棒技术是目前早发型脊柱侧弯治疗中应用最为广泛的非融合技术之一。其治疗早期脊柱侧弯的疗效已被大多数学者证实[31,33-34]。 2.2.3 传统生长棒技术(conventional growing rod CGR) 大量研究及随访表明,应用生长棒技术后,患儿的脊柱畸形和胸廓畸形在一定程度上得到纠正[26],相应的胸腔容积和肺容量也增大,缓解了早发型脊柱侧弯对患儿肺部功能的影响;同时缓解了脊柱和纵隔对膈肌的压迫,改善了胸壁和膈肌的运动;另外,在也一定程度上也改善了肺的通气功能。早在20世纪60年代,Harrington[27]即报道了应用非融合手术治疗脊柱侧弯,并认为对年龄< 10岁的患儿不应施行最终的脊柱融合术。Moe等[28]认为只要能够严格控制手术适应征, 生长棒矫形植入物配合定期延长手术可以有效的治疗早发型脊柱侧弯。但是,Minerio等[29]对生长棒技术的价值提出了质疑。他们报道了一组采用单棒技术对11例平均年龄5岁的早发型脊柱侧弯患儿进行治疗后的得到数据,其结果表明,早发型脊柱侧患儿术前侧凸 Cobb 角为 74°(53°-100°) , 随访中有1例患儿术后未见明显变化,平均矫正率约为54%,最大矫正度为18°,脊柱的平均生长高度为2 cm。11例患者中共发生14例次并发症:其中8例患儿术后发生断棒;2例患儿发生脱钩;发生术后感染的2例、脑脊液渗1例及椎板骨折1例。没有发生神经系统等并发症。有8例患者在随访中发生了脊柱自发性融合。由于早发型脊柱侧弯患儿脊柱的柔韧性较高,生长棒植入后长期替代脊柱正常的负重功能,且术后患儿需要长时间佩戴支具等因素,故而很容易造成相关的术后并发症,包括脱钩、断棒、脱棒等,且随着延长手术次数的增加,矫形效果会呈一个逐渐下降的趋势。并且“单棒”的稳定性有待进一步研究。 目前对于应用单棒技术及双棒技术治疗早发型脊柱侧弯的疗效出现了一些争议。双棒技术最早由Akbarina等[4]报道,其目的是利用两根生长棒之间的连接杆增强矫形整体的稳定性。2008年Akbarina等[30]进行了一项回顾性分析,对1990至2003年间,13例接受了生长棒,双棒技术治疗的早发型脊柱侧弯患儿平均年龄为(6.6±2.9)岁,随访时间3-11个月,直至最终的融合手术期间。这个期间主要观察并记录;延长手术的频率,延长的长度,及Cobb角的变化等指标,最终结果表明同单棒技术相比,双棒技术能够在维持脊柱生长能力的同时更好的矫正畸形,更重要的是能够降低相关内固定并发症的发生率。Thompson等[31]将 28例早发型脊柱侧弯患儿分为3组,分别采用不同的方式进行治疗,以比较单棒和双棒的疗效,3组数据中,在维持脊柱生长力方面第3组的效果最令人满意。这可能是因为双棒技术更为稳固, 可以提供更强大的把持力和控制力, 并且建议每隔半年进行一次延长而不必考虑弯曲的进展程度。孙志坚等[32]通过评价单侧与双侧生长棒治疗早发型脊柱侧弯的效果及并发症发生率方面的差异,认为双侧生长棒治疗早发型脊柱侧弯在矫形效果和维持脊柱生长方面均优于单侧生长棒,而两者总并发症发生率无明显差异,单侧组内固定物相关并发症发生率可能高于双侧组。然而Farooq等[33]认为单侧生长棒相比双侧生长棒同样可以获得较好的矫形效果和脊柱生长。 但无论是单棒还是双棒技术都需要定期每隔6-9个月对患儿行延长手术,重复多次的手术,对患儿的生理、心理还有家庭的经济均造成了巨大的负担[34]。同时,反复多次的手术会促进脊柱后路自发融合及肋椎关节的自发融合,增加了脊柱侧弯的僵硬度,两三年后大部分病例无法继续撑开。其他并发症如感染、钩端拔出、固定上端交界处的后凸畸形等的发生率也较高[35-37]。 后期,人们通过不断的改进和研究,研制出一种半限制型生长棒[38],并认为这种新型生长棒比传统双生长棒对早发型脊柱侧弯的治疗能起到更好的矫形和维持脊柱及胸腔内脏器生长的功能,并且具有更好的生物力学效应。作者认为无论是单棒还是双棒技术,只要掌握了手术的适应症及相关并发症的预防,其在早发型脊柱侧弯的治疗上都具有一定的价值和意义,并且在一定程度上都能够较好的矫正早发型脊柱侧弯患儿的畸形,维持心肺等重要脏器的功能稳定。 2.2.4 磁控生长棒技术(magnetically controlled growing rod MCGR) 近年来众多的学者及专家通过不断的努力及研究,克服传统的生长棒技术的限制[20],力求研制出了一种微创,非融合的治疗方式来治疗早发型脊柱侧弯,以求达到最大限度地维持患儿脊柱生长潜能,并尽可能保护患儿肺功能的目的。终于,在2012年,Akbarnia等[39-40]设计了磁控生长棒(magnetically controlled growing rod MCGR)。Ridderbusch等[41]认为这种微创,非融合的治疗方式避免了繁琐的麻醉及延长手术,开创早发型脊柱侧弯手术治疗的新时代。随后,大量的研究及测试开始投入到对磁控生长棒技术的试验中[42]。此装置包括一个带有可延长撑开器的生长棒,在撑开器内有一个小的磁铁延长装置(图2),通过体外磁力遥控装置(图3),可撑开延长或回缩矫形棒,借此实现畸形的矫型及外科医生的偏好,棒的粗细根据患者体质量定制。在头侧、尾侧固定点作局部植骨,术后佩戴支具3-6个月。"
MCGR的优势及研究进展:磁控生长棒技术相比传统的生长棒技术而言,避免了传统生长棒技术每隔6个月的手术撑开延长[43],减少了反复多次手术带来的麻醉风险,术后感染和呼吸道并发症等的发生率。显著的减轻了患儿的身体及心理负担,并且这种新技术可在门诊进行的非侵入性撑开延长治疗,减少了手术的创伤[44]。2012年Cheung等[45]进行了一项回顾性研究,他们应用磁控生长棒技术治疗两名早发型脊柱侧弯患儿,在随访的24个月中,2例患者均无疼痛,平均矫正率为56.7%,功能预后良好,对该治疗满意,未发现磁控生长棒的相关的并发症。Hickey等[46]通过对8名早发型脊柱侧弯患儿使用磁控生长棒技术治疗的术前,术后Cobb角进行记录,随访23-26个月后发现,磁控生长棒系统(magnetically controlled growing rod system MAGEC)能够有效的控制发病早期脊柱的侧弯畸形,减少手术时间及术中出血。虽然植入相关的并发症并不少见,但与传统生长棒系统相比避免了多次重复性的手术操作。La Rosa等[47]对2012至2013年间,10名早发型脊柱侧弯的患儿(包括5名男孩和5名女孩)采用磁控生长棒技术治疗,并且术前所有患儿的Cobb角均大于45°,术后进行了14-41个月的随访,其结果均表明:磁控生长棒技术能够有效的矫正早发型脊柱侧弯患儿的脊柱畸形,并且磁控生长棒的术后并发症发生率(约为30%)与传统生长棒术后并发症(约为58%)相比大大降低。随后,Cheung等[48]报道了一例关于磁控生长棒技术矫正严重脊柱侧弯的案例,患者术前未经任何手术及保守治疗,侧弯集中在T6-T11节段,术后定期在门诊复查并接受体外电磁延长治疗,随访期间患者能平稳行走并且没有任何神经系统的并发症,2.5个月后患者Cobb角由术前109°变至66°,直至最后行脊柱融合术。因此,他们认为磁控生长棒技术对于严重脊柱侧弯的患儿是一种安全、持续有效的方式。不仅如此,Daniel等[49]通过对磁控生长棒技术与传统生长棒技术对早发型脊柱侧弯患儿住院期间及后续治疗费用进行比较,发现磁控生长棒技术不仅降低了反复多次的侵入手术,更重要的是磁控生长棒技术相比生长棒技术生长棒节约了更多的医疗资源并且明显降低了治疗的费用。 有关MCGR的争论:但是,一些学者通过分析欧洲和美国的一些病例及随访表明,包括翻修手术和并发症的处理费用[49-51],磁控生长棒的总成本与传统生长棒相比几乎是差不多的。Kai等[52]对11只幼羊模型植入磁控生长棒,并通过影像学(CT及X射线)观察幼羊脊柱的生长,4个月后其结果表明:这种新型技术能够适应羊脊柱的正常生长曲线,并且为治疗早发型脊柱侧弯提供了一种更为有效,安全和非侵入性的方式。近段时间有不少科学家对磁控生长棒技术提出了一些质疑:如此种手术的适应症,每次延长的间隔时间,长度及单棒,双棒的选择,还有是否会有相关并发症的发生,这些尚无一个统一的标准。Kar H Teoh等[53]做了一项关于磁控生长棒的中期随访,对2011年左右接受过磁控生长棒治疗早发型脊柱侧弯患儿的Cobb角,脊柱生长速度和相关并发症等进行研究,随访时间大约4年,其结果令人们大跌眼球:磁控生长棒技术治疗的中期随访结果并没有如早期报道的那么理想,他建议医生应该谨慎选择磁控生长棒技术。并且该团队在随后的研究中还发现,虽然磁控生长棒系统相比传统生长棒(conventional growing rod CGR)系统无论是在深部组织还是浅部组织感染的几率均较低,但它并不能像之前报道的那样完全避免反复侵入性的手术,并且存在较高的断棒,弯棒的风险,最终不得不进行翻修[54]。目前对于磁控生长棒技术还有很多问题需要去探索和解决。作者认为无论哪一种治疗方式都必须根据患者的自身情况并且充分告知其相关风险后再来决定。 磁控生长棒技术做为一种治疗早发型脊柱侧弯的新手段充满了无限的潜能及广泛的应用前景,但由于缺少大量的中,长期的随访病例和动物实验,使得这项新技术的有效性受到了质疑,同时也缺少磁控生长棒技术相关的生物力学研究及晚期并发症等方面的研究。即使如此,La Rosa等[47]仍坚持认为磁控生长棒技术能够作为一种有效、可靠的手段来治疗早发型脊柱侧弯。"
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