Please use this identifier to cite or link to this item: http://hdl.handle.net/11455/35618
標題: 開合式截骨術治療矢狀面失衡或駝背畸型
Closing-opening wedge osteotomy for the treatment of sagittal imbalance or kyphotic deformity
作者: 張國華
Chang, Kao-Wha
關鍵字: kyphotic deformity;駝背畸型;osteotomy;sagittal imbalance;sagittal malalignment;截骨術;矢狀面失衡;矢狀面排列不正
出版社: 生物產業機電工程學系所
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[29] White AA, Panjabi MM, Thomas CL. The clinical biomechanics of kyphotic deformities. Clin Orthop 1977; 8-17. [30] Chang KW, Chen YY, Lin CC, Hsu HL, Pai KC. Closing wedge osteotomy versus opening wedge osteotomy in ankylosing spondylitis with thoracolumbar kyphotic deformity. Spine 2005;30:1584-93. [31] Gertzbein SD, Harris MB. Wedge osteotomy for the correction of posttraumatic kyphosis. Spine 1992;17:374-9. [32] Kawaharu H, Tomita K. Influence of acute shortening on the spinal cord: an experimental study. Spine 2005:30;613-20. [33] Lehmer SM, Keppler L, Buscup RS, Enker P, Miller SD, Steffee AD. Posterior transvertebral osteotomy for adult thoracolumbar kyphosis. Spine 1994;19:2060-7. [34] Berven SH, Deviren V, Smith JA, Emami A, Hu SS, Bradford DS. Management of fixed sagittal plane deformities. Spine 2001;26:2036-43. [35] Chang KW, Chen YY, Lin CC, Hsu HL, Pai KC. Apical lordosating osteotomy and minimal segment fixation for the treatment of thoracic or thoracolumbar osteoporotic kyphosis. Spine 2005;30:1674-81. [36] Chen TC, Tu MY, Wu CM, Fu CY. Risk of aorta injury in patients treated by accomplishing an anterior open wedge and lengthening of anterior column for sagittal imbalance or kyphosis. Jorthop Surg Taiwan 2008;25:72-78. [37] Bradford DS. Adult scoliosis. Current concepts of treatment. Clin Orthop 1988;229:70-87. [38] Byrd JA III, Scoles PV, Winter RB, Bradford DS, Lonstein JE, Moe JH. Adult idiopathic scoliosis treated by anterior and posterior spinal fusion. J Bone Joint Surg Am 1987;69:843-50. [39] Johnson JR, Holt RT. Combined use of anterior and posterior surgery for adult scoliosis. Orthop Clin North Am 1988;19:361-70. [40] Winter RB, Lonstein JE. Adult idiopathic scoliosis treated with Luque or Harrington rods and sublaminar wiring. J Bone Joint Surg Am 1989;71:1308-13. 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摘要: 
Kyphotic deformity can produce sagittal malalignment and imbalance. Patients can not move or stand erect without overwork of musculature because of compromising the biomechanical advantage. The result is muscle fatigue and activity-related pain. During reconstructive surgery, restoration of the best possible sagittal balance is crucial for obtaining satisfactory clinical results. However, there are two problems for this. The first, there is no way to control and predict the quality or outcomes of the reconstructed sagittal balance before or during operation. The second, there is no an osteotomy through posterior-only approach for the large and rigid kyphosis to allow three-column release and large range of correction.
A method was developed to determine the lumbosacral curve which theoretically would bring spinal sagittal balance to an ideal state by calculation and simulation for each patient preoperatively and a template and blueprint was made accordingly for operative procedures to follow. Also a new osteotomy, closing-opening wedge osteotomy(COWO), to provide three-column release through a posterior-only approach was developed and could make rigid kyphotic deformity flexible enough to be adequately manipulated to match the template and to obtain optimal correction of sagittal imbalance.
The objective of this study is to investigate the feasibility of controlling quality of reconstructed sagittal balance for sagittal imbalance and to evaluate the safety and efficacy of the new method and surgical procedures to reconstruct an optimal sagittal balance for patients with sagittal imbalance or kyphotic deformity.
The report contained two studies. In study 1, thirty-one patients with degenerative lumbar kyphoscoliosis (mean age, 72.3 years; range, 65-78 years) treated with the method and COWO were followed up for a mean of 4.1 years. Their preoperative, 2-month postoperative, and final follow-up radiographs were assessed and a questionnaire to measure changes in pain, function, self-image, patient satisfaction with surgery administered was. Postoperative complications was analyzed. In study 2, eighty-three consecutive patients treated for sagittal imbalance with the method and COWO with a minimum follow-up of two years were analyzed. Radiographic analysis included assessment of thoracic kyphosis, lumbar lordosis, lordosis through COWO site, and sagittal balance. Outcomes analysis utilized the Scoliosis Research Society questionnaire. Complications and radiographic findings were analyzed.
In study 1, final radiographs showed increased L1-S1 lordosis from 11.3° to -50.5° (increase of 61.8°), correction of kyphotic deformity from 64.3° to -14.1°, and correction of scoliotic deformity from 48.9° to 8.3°. Sagittal imbalance significantly improved from 68.8 to 27.1 mm, whereas the sacrofemoral distance decreased from 59.3 to -5.1 mm, and the sacral inclination angle increased from 9.7° to 34.3°. Subjective pain was significantly and persistently reduced. Most patients maintained good correction and had good clinical results. No major complication occurred. Eight patients (26%) developed junctional kyphosis. In study 2, the average increased in lordosis and improved sagittal balance were 81.9o and 17.1 cm. Mean correction through the osteotomy site was 42.2o (range 31-55o). No vascular injury occurred. While three patients developed lumbosacral pseudarthrosis, the COWO area was unaffected in all patients. Nine patients developed cephalad junctional kyphosis and two patients developed caudad junctional kyphosis. Most patients reported improvement in terms of pain, self-image, and function as well as overall satisfaction with the procedure.
Analysis of all radiographic datas showed the mean estimated values of L1-S1 lordosis, sacral inclination angle (SIA), sacrofemoral distance (SFD), and distribution of L1-S1 lordosis at the closing-opening wedge osteotomy (COWO) site and L4-S1 segments were -30.8o, 24.6o, 0 mm, 16.1% (-5o), and 62% (-19o), respectively. The mean reconstructed values were -41.1o, 23.3o, 3.9 mm, 41% (-17o), and 46% (-19o), respectively. There were significant differences between estimated and reconstructed values of L1-S1 lordosis and percent of distributions, however, there was no significant difference between the estimated and reconstructed magnitude of L4-S1 lordosis, SIA, and SFD. A properly oriented pelvis can be brought nearly directly above the hip axis. The mean sagittal global balance, represented by the distance between the vertical line through the hip axis and sacral promontory, improved from 61.4 mm before surgery to 3.9 mm 2 months after surgery. Normal sagittal global balance was reconstructed. The mean sagittal spinal balance measured as the horizontal distance between the C7 sagittal plumb line and the posterior superior corner of S1 improved from 97.4 mm before surgery to 11 mm 2 months after surgery. Normal sagittal spinal balance was reconstructed.
Quality control of the reconstructed sagittal balance for sagittal imbalance is possible. Correctly orienting the pelvis reconstructed by restoration of enough L1-S1 lordosis with adequate distribution at L4-S1 segments is a matter of critical importance for optimizing reconstructed sagittal balance. Preventing junctional fracture and persistent rehabilitation of surgically injured lumbar extensor musculature are crucial for maintaining the reconstructed sagittal balance. COWO is a safe and useful procedure for patients with sagittal imbalance the level of patient satisfaction was high after more than two years of follow-up, with most patients having improved resolution of pain, increased self-image, and greater function. A worse clinical result is associated with increasing patient comorbidities, pseudarthrosis in lumbosacral fusion, and junctional kyphosis.

駝背畸型會造成脊椎矢狀面排列不正及失衡,病患喪失生物力學的優勢而必需過度使用肌力以維持行動及站立,結果導致肌肉疲憊及疼痛,在重建手術中回復良好的矢狀面平衡,對獲得令人滿意的臨床結果而言是至關重要的,可是,目前有二大困難,其一是無法在手術前預測或手術中控制所重建矢狀面平衡的結果與品質,其二是沒有一種截骨術可經由後路單一路徑,針對大而堅硬的駝背畸型提供脊椎三柱鬆解及大幅度的矯正。
本研究設計出一種方法,可在手術前藉由計算及模擬出理論上可帶動脊椎並達到理想矢狀面平衡的腰薦椎曲線,並製作成模型及手術藍圖以供手術遵循,並研發一種新的截骨術,即開合式截骨術,可經由後路提供脊椎三柱鬆解,可使堅硬的駝背畸型得到足夠的柔軟度以便操控脊椎排列以符合模型曲線而達到脊椎失衡的良好矯正。
研究的目的是要評估在臨床上使用這個方法及手術步驟治療駝背畸型及矢狀面失衡以重建良好矢狀面平衡的安全性及有效性。
以二組病患群為研究材料。第一組:31例腰椎駝背側彎病患,平均年齡72.3歲(65-78歲),因難以忍受的疼痛接受前上述方法治療,平均追蹤4.1年,以術前,術後二個月,及最終隨訪之X光片,問卷及併發症進行評估探討。第二組:83例因矢狀面失衡或駝背畸型以前述方法治療的病患進行分析,所有病例追蹤期最少二年,放射線學分析包括胸椎駝背角度,腰椎前曲角度,開合截骨節段之前曲角,及脊椎矢狀面平衡,結果分析是根據SRS問卷,併發症及放射線學數據。
研究結果兩組病患x光資料分析顯示第一組病患最終隨訪的x光片顯示腰1至薦1前曲角度由後凸11.3度矯正至前曲50.5度(矯正61.8度),後凸畸型由64.3度矯正至前曲14.1度,側凸畸型由48.9度矯正至8.3度,矢狀面平衡由68.8㎜,矯正至27.1㎜,薦股距(sacrofemoral distance)由59.3㎜減至-5.1㎜,薦椎傾斜角度(sacral inclination angle)由9.7度增至34.3度,疼痛感明顯及持續的減輕,大部份病例都可維持良好的矯正及臨床結果,沒有大的併發症發生,有8例(26%)的病例發生交界後凸(junctional kyphosis)。第二組病患最終隨訪的x光片顯示,平均前曲角度之增加為81.9度,矢狀面平衡改善17.1公分,截骨節段平均矯正度為42.2度(範圍:31~55度),沒有血管損傷發生,在截骨節段沒有假關節形成,有三例在腰薦節段有假關節形成,有11例產生交界處駝背畸型,大部分的病患在疼痛,自體形象感,功能及滿意度均改善。
分析兩組病患x光資料顯示,術前預估第一腰椎與第一薦椎之腰椎前曲角,薦椎前傾角,薦椎股骨間距,截骨部份角度及佔比,第四腰椎與第一薦椎間之前曲角及佔比分別為-30.8度、24.6度、0毫米、16.1%(-5度)和62%(-19度)。重建值分別為-41.1度、23.3度、3.9毫米、41%(-17度)及46%(-19度)。第一腰椎與第一薦椎前曲角度及部位佔率值之預估值和重建值有意義的差異,而第四腰椎與第一薦值前曲角度,薦椎前傾角度和薦椎股骨間距均無有意義的差異,一個適當前傾的骨盆可被矯正到股骨軸的正上方,平均整體矢狀面平衡由術前61.4mm矯正至術後二個月的3.9mm。重建了正常的整體矢狀面平衡,平均矢狀面脊椎平衡由術前97.4mm矯正至術後二個月11mm,重建了正常的矢狀面脊椎平衡。
研究結論證明重建矢狀面平衡的品質控管是可行的,其關鍵在於重建足夠的第一腰椎與第一薦椎間前曲度及適當的分配第四腰椎與第一薦椎間前曲角以重建正確的骨盆前傾,預防交界骨折及持續復健腰伸肌對於維持矢狀面平衡是至關重要的。開合式截骨矯正術治療腰椎駝背畸型導致矢狀面失衡是一安全有效的方法。
URI: http://hdl.handle.net/11455/35618
其他識別: U0005-1104201017071000
Appears in Collections:生物產業機電工程學系

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