Ravindra Vijay M, Christensen Michael T, Onwuzulike Kaine, Smith John T, Halvorson Kyle, Brockmeyer Douglas L, Walker Marion L, Bollo Robert J
Division of Pediatric Neurosurgery, Department of Neurosurgery; and.
Division of Pediatric Orthopedic Surgery, Department of Orthopedic Surgery, University of Utah School of Medicine, Salt Lake City, Utah.
J Neurosurg Pediatr. 2017 Nov;20(5):456-463. doi: 10.3171/2017.5.PEDS16630. Epub 2017 Sep 8.
OBJECTIVE Selective dorsal rhizotomy (SDR) via limited laminectomy is an effective treatment of lower-extremity spasticity in the pediatric population. Children with spasticity are also at risk for neuromuscular scoliosis; however, specific risk factors for progressive spinal deformity requiring posterior spinal fusion (PSF) after SDR are unknown. The authors' goal was to identify potential risk factors. METHODS The authors performed a retrospective cohort study of patients who underwent SDR via limited laminectomy between 2003 and 2014 and who had at least 1 year of follow-up. They analyzed demographic, clinical, and radiographic variables to elucidate risk factors for progressive neuromuscular scoliosis. The primary outcome was need for PSF. RESULTS One hundred thirty-four patients underwent SDR and had at least 12 months of follow-up (mean 65 months); 48 patients (36%) had detailed pre- and postoperative radiographic data available. The mean age at surgery was 10 years (SD 5.1 years). Eighty-four patients (63%) were ambulatory before SDR, 109 (82%) underwent a single-level laminectomy, and a mean of 53% of the dorsal rootlets from L-1 to S-1 were sectioned. Fifteen patients (11.2%) subsequently required PSF for progressive deformity. Nonambulatory status (p < 0.001) and a preoperative Cobb angle > 30° (p = 0.003) were significantly associated with PSF on univariate analysis, but no statistically significant correlation was found with any clinical or radiographic variable and PSF after SDR on multivariate regression analysis. CONCLUSIONS Patients with preoperative nonambulatory status and Cobb angle > 30° may be at risk for progressive spinal deformity requiring PSF after SDR. These are well-known risk factors for progressive deformity in children with spasticity in general. Although our analysis suggests SDR via limited laminectomy may not significantly accelerate the development of neuromuscular scoliosis, further case-control studies are critical to elucidate the impact of SDR on spinal deformity.
目的 通过有限椎板切除术进行选择性背根切断术（SDR）是治疗小儿下肢痉挛的有效方法。痉挛患儿也有发生神经肌肉型脊柱侧弯的风险；然而，SDR后需要后路脊柱融合术（PSF）的进行性脊柱畸形的具体危险因素尚不清楚。作者的目标是确定潜在的危险因素。方法 作者对2003年至2014年间通过有限椎板切除术接受SDR且至少随访1年的患者进行了一项回顾性队列研究。他们分析了人口统计学、临床和影像学变量，以阐明进行性神经肌肉型脊柱侧弯的危险因素。主要结局是是否需要PSF。结果 134例患者接受了SDR并至少随访了12个月（平均65个月）；48例患者（36%）有详细的术前和术后影像学数据。手术时的平均年龄为10岁（标准差5.1岁）。84例患者（63%）在SDR前可独立行走，109例（82%）接受了单节段椎板切除术，L-1至S-1平均53%的背根小束被切断。15例患者（11.2%）随后因进行性畸形需要PSF。单因素分析显示，不能独立行走状态（p<0.001）和术前Cobb角>30°（p=0.003）与PSF显著相关，但多因素回归分析未发现任何临床或影像学变量与SDR后PSF有统计学意义的相关性。结论 术前不能独立行走且Cobb角>30°的患者在SDR后可能有发生需要PSF的进行性脊柱畸形的风险。这些是一般痉挛患儿进行性畸形的众所周知的危险因素。虽然我们的分析表明通过有限椎板切除术进行SDR可能不会显著加速神经肌肉型脊柱侧弯的发展，但进一步的病例对照研究对于阐明SDR对脊柱畸形的影响至关重要。
