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摘要: 加速康复临床路径(enhanced recovery pathways, ERPs)的引入促使围手术期医疗模式发生了巨大转变, 现已广泛应用于各外科中, 并取得了不俗成效。加速康复的原则为促进正常功能恢复、全面的围手术期干预、多学科参与和教育以及基于循证医学证据的干预。ERPs最先应用于结直肠和心脏手术, 现已被整形外科、泌尿外科和妇产科等各外科专业广泛采用, 但其在高龄、衰弱或急诊手术患者中的应用仍存在局限性, 可针对这些患者的实际情况进行改良。本文就ERPs的基本原则、应用现状及未来发展方向展开讨论。Abstract: The introduction of enhanced recovery pathways has led to a considerable shift in the paradigm of perioperative care, which are now widely implemented in a variety of surgical specialties with large positive results. The principles of enhanced recovery are promoting recovery of normal functions, comprehensive perioperative interventions, multidisciplinary involvement and education, and evidence-based intervention. Enhanced recovery pathways were initially introduced in colorectal and cardiac surgery, and have been adopted amongst orthopedics, urology, obstetrics and gynecology, and other surgical specialties. Limitations for older or more frail patients, or patients undergoing emergent surgeries should be considered, and the pathways could be modified for those patients. In this review, we discussed the principles and status of enhanced recovery pathways as well as the room for further development.
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Keywords:
- enhanced recovery /
- principle /
- development
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腰骶段半椎体是指半椎体位于腰骶交界部, 上方为腰椎, 下方紧邻骶骨[1]。临床上, 胸腰段半椎体比较多见, 可导致局部后凸, 引起明显的矢状面失衡; 而腰骶段半椎体则以冠状面失衡、躯干偏斜为特点。由于腰骶段半椎体相对少见, 有关其临床特点和手术治疗策略的研究也相对较少。本院2001年1月至2010年1月共收治了8例腰骶段半椎体所致先天性脊柱侧凸(congenital scoliosis, CS)患者, 现回顾性分析其临床特点及手术治疗策略。
对象和方法
对象
本院2001年1月至2010年1月共收治了877例CS患者, 其中8例为腰骶段半椎体所致CS。8例患者中男性2例, 女性6例; 手术时年龄2~17岁, 平均11岁。所有患者术前均行站立位全脊柱正侧位、左右支点弯曲(Bending)位X线片、脊髓造影+脊髓造影CT (computed tomography myelography, CTM)或脊柱脊髓核磁共振(magnetic resonance imaging, MRI)检查, 明确是否伴发椎管内畸形, 确定半椎体的位置及其与相邻椎体的解剖关系。
测量方法与疗效评价
每半年随访1次。随访时摄站立位全脊柱正侧位X线片, 观察内固定物位置和矫形维持情况, 测量冠状面、矢状面Cobb角、腰骶间隙椎间角、躯干偏移。矢状面Cobb角定义为半椎体上一椎体的上终板和S1椎体的上终板间的夹角, 腰椎矢状面Cobb角定义为T12上终板和S1上终板间的夹角, 其中负值为前凸, 正值为后凸。顶椎偏距定义为侧凸顶点经C棘突垂线(胸弯)或骶正中线(腰弯或胸腰弯)的垂直距离。冠状面躯干偏移指骶骨中点至C7铅垂线的垂直距离(cm), 矢状面躯干偏移指S1终板后上角至C 7铅垂线的垂直距离(cm), 其中在S1终板后上角前方者为正值, 在其后方者为负值。术后躯干失平衡指在冠状面上躯干偏移 > 2 cm, 在矢状面上躯干偏移绝对值> 2 cm。
结果
8例腰骶段半椎体所致先天性脊柱侧凸患者完全分节型半椎体5例, 部分分节型半椎体3例; 1例患者合并脊髓栓系, 1例患者合并胸段脊髓空洞(表 1)。
表 1 8例腰骶段半椎体患者术前影像学特点
8例患者中采用一期前后路半椎体切除1例, 一期后路半椎体切除7例。手术出血量200~2300 ml, 平均692 ml; 手术时间平均6.5 h。短节段固定6例, 长节段固定2例。内固定器械包括CDH (CD Horizon) 4例、TSRH (Texas Scottish Rite Hospital) 1例, Moss-miami 3例, 其中2例联合应用Meshcage。
8例患者手术前后及末次随访时腰骶弯冠状面Cobb角分别平均为33.1°、9.8°和14.0°, 术后即刻矫正率为70.4%, 最终矫形率为57.7%。手术前后和末次随访时近端腰弯冠状面Cobb角分别平均为32.5°、12.6°和14.2°, 术后即刻矫正率为61.2%, 最终矫形率为56.3%;其中6例患者近端腰弯未融合, 术后自发矫形率为57.4%。T12-S1矢状面Cobb角术前平均为-31.6°, 术后为-39.2° (图 1)。术前腰骶间隙椎间角平均为- (11.9±3.5) ° (-18~0°), 局部无明显后凸。
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图 1 13岁先天性脊柱侧凸女性患者的影像学特点A, B.术前X线片示冠状位腰骶弯Cobb角34°, 腰弯Cobb角30°; C.术前三维CT重建显示L5-S1间完全分节半椎体, L4为部分分节半椎体, 与L3椎体融合在一起; D, E.行一期后路L5-S1间半椎体切除+上下各一个节段固定, 术后X线片示腰骶弯矫正至16°, 腰弯自发矫正至27°; F, G.术后34个月随访, X线片示矫形维持良好, 冠状面躯干偏移改善, 平衡良好全部病例随访12~82个月, 平均30.9个月。手术并发症包括伤口裂开1例, 一过性神经根损伤1例。椎弓根螺钉位置不良2例, 其中1例行翻修手术。术前4例患者有冠状面躯干失平衡, 最终随访时7例患者冠状面躯干偏移较术前改善(图 1), 躯干偏移 < 2 cm; 1例加重, 冠状面躯干失衡, 躯干偏移2.4 cm, 矢状面无失平衡发生。
讨论
腰骶段半椎体的临床特点
正常人冠状面躯干中心位于骶骨正中, 脊柱保持平衡状态。由于腰骶段半椎体紧邻骶骨, 基底的倾斜可引起上方脊柱偏斜, 从而导致明显的冠状面躯干失平衡。而在矢状面上, 腰骶段半椎体是否也同胸腰段半椎体一样, 形成以半椎体为顶点的局部后凸畸形, 通过本组病例观察, 笔者发现腰骶段半椎体并没有伴发明显的腰骶段后凸。本组腰骶椎间隙的前凸角为11.9°±3.5°, 而Bollini等[1]研究结果则为13.6°±6.9°, 两者结果相类似, 说明单纯的腰骶半椎体并没有引起局部后凸畸形。分析可能的原因: (1)腰骶段半椎体位于脊柱基底部, 离正常脊柱前后凸交界处较远, 并有强大的腰骶韧带维持前凸, 与胸腰段比较, 相对不容易形成局部后凸; (2)腰骶椎间隙有较明显前凸, 即使有轻度的局部致后凸效应, 但对腰骶间隙前凸角和整体的腰前凸影响不大。然上述解释只是一种假说, 仍需要更多的病例观察进一步验证上述观点。
腰骶段半椎体手术治疗策略
手术治疗指征:由于腰骶段半椎体可引起冠状面明显的躯干偏移, 而支具等保守治疗往往难以控制其进展, 因此多需手术治疗。McMaster等[2]报道完全分节的腰骶段半椎体平均每年可进展1.5°。笔者的初步经验是如果侧弯每年进展超过5°或冠状面躯干已出现失平衡, 则需要考虑手术治疗。手术年龄以3~5岁为宜, 此时患者的代偿弯柔韧性较好, 可行短节段融合, 保留更多活动节段, 且患儿的骨质条件也可较好地耐受内固定[3]。
手术方法:半椎体切除, 直接去除病因, 是理想的手术方式[3], 已逐渐成为腰骶段半椎体畸形的主要治疗方法。从腰骶段半椎体解剖部位讲, 一期后路半椎体切除相对前后路半椎体切除更具优势[4], 关键在于彻底切除半椎体及其终板。本组最早的1个病例采取前后路联合入路半椎体切除, 此后的病例均采取后路半椎体切除。文献报道腰骶段半椎体矫形率为35.2%~67.6%[5-6], 本组矫形率为57.7%, 接近胸腰段半椎体[7-8]。笔者的体会是一期后路腰骶段半椎体切除可以取得良好的临床效果, 且胸腰段以下为马尾神经, 相对较安全, 是比较理想的术式。
融合范围与固定方式选择:笔者的初步体会是若近端代偿腰弯较轻, 柔韧性好, 应尽可能采取短节段融合, 多数可上下固定各一个节段, 如果半椎体上方相邻椎体明显偏离中线, 则可考虑近端融合2个椎体, 以保持冠状面平衡。而若近端代偿腰弯 > 40°或腰段合并有半椎体致明显侧弯, 则需要考虑融合双弯, 需要长节段固定融合。
内固定材料首选椎弓根螺钉, 以利于凸侧的加压。目前有直径3.5 mm椎弓根螺钉, 可满足幼儿的固定要求。术前应采取CT评估椎弓根发育情况, 以确定是否能行椎弓根螺钉固定。如果椎弓根螺钉固定困难, 儿童椎板钩也是一种选择。如果一般的内固定困难, 则可以考虑Hosalkar等[9]推荐的钛缆+骶骨、髂骨螺钉固定或术后Risser石膏固定6个月。由于腰骶间隙没有明显的节段性后凸, 使用Meshcage的必要性不如胸腰段半椎体, 但使用Meshcage有利于凸侧加压和分散椎弓根螺钉应力。如果使用Meshcage, 一定要注意放到腰骶间隙的凹侧前方, 这样在凸侧加压时可以进一步改善冠状面和矢状面畸形。
并发症:后路半椎体切除的主要并发症是椎弓根螺钉切割, 尤其是短节段固定者, 主要原因是应力集中和患儿骨质较软。本组有2例椎弓根螺钉位置不良, 其中1例在加压过程中发生椎弓根螺钉切割, 术后出现一过性神经根损伤, 行翻修手术更换椎弓根螺钉后神经功能恢复。防止椎弓根螺钉切割的关键是要做到以下两点:完全切除半椎体, 加压时无明显阻力; 3岁以下或术后无法配合的患者, 可术后石膏外固定, 防止扭动身体时发生椎弓根螺钉切割[3]。
如何保持或重建冠状面的平衡是腰骶段半椎体手术的关键所在, 也是手术的难点, 尤其是合并腰段半椎体者或近端腰段代偿弯较严重者。如果单纯融合腰骶弯, 则需要术前通过仰卧位侧方弯曲位X线片了解近端腰弯的代偿能力, 避免过矫腰骶弯使其失代偿; 如果同时融合腰弯, 则需掌握好腰骶弯和近端腰弯各自矫形之间的平衡。笔者的体会是要尽量摆平底座, 在凸侧半椎体切除+加压的基础上同时行凹侧关节突截骨+撑开, 有助于冠状面保持平衡。另外, 必要时应在冠状面上对内固定棒作一定程度预弯, 以防止躯干在加压后向凸侧偏斜。如有疑问, 需术中透视, 必要时在术中拍摄X线片, 以防止术后冠状面躯干偏斜加重。
综上, 腰骶段半椎体可引起严重脊柱畸形, 并可伴有明显的躯干失平衡, 应及早手术治疗。早期病例往往畸形较轻, 可采用半椎体切除+短节段固定融合术。如果畸形较重并且代偿弯较明显则需要延长融合范围。本研究为回顾性研究, 病例数较少, 仅是一种对腰骶段半椎体手术治疗的初步探索, 今后还需要长时间随访和更多病例的积累以获取更为成熟的治疗经验。
利益冲突 无翻译: 赵梦芸, 裴丽坚 (北京协和医院麻醉科)审校: 黄宇光 (北京协和医院麻醉科) -
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