| Split cord malformation (SCM) is thought to be rare abnormalities, representing 3.8-5% of all spinal cord anomalies[1]. SCM can be divided into type I and type Ⅱ according to contained osseous and cartilaginous septum or not, and the two types of SCM might be accompanies with congenital scoliosis.Whether osseous septum resection priors to corrective surgery or not was controversial all the time because of unknown effects of osseous septum on spinal cord. At the present, surgical treatment of type I SCM associated with CS have two different opinions, first opinion considers that corrective surgery of CS is carried out in the most appropriate time after the resection of the osseous septum[2,3,23], the second opinion reckons that corrective surgery of CS can be conducted directly regardless of osseous septum[19,24].Hence surgeon have to understand the spilt cord, osseous septum and the their relationships thoroughly, and we conduct the measurements of the split cord and the osseous septum on the MR imaging based on this in order to search for the potential regularity.Part one:Image study on type I split cord malformationObjective The purpose of this study was to investigate the characteristics of split cord malformation(SCM) and the relationships of osseous septum and split cord in type I split cord malformation associated with congenital scoliosis(CS).Methods On the magnetic resonance imaging(MRI), we conducted measurement of split cord. The parameters included the transverse diameters of split cord(TD), the sagittal diameters of split cord(SD), osseous septum and convex side of the split cord transverse diameters(TDconvex), osseous septum and concave side of the split cord transverse diameters(TDconcave), osseous septum and cranial side of the split cord sagittal diameters(SDcranial), osseous septum and cranial side of the split cord sagittal diameters(SDcaudal). All the patients were divided into two groups according to SCM with or without osseous septum, that was type Ⅰ and Ⅱ SCM groups, and type Ⅰ SCM were divided into two groups according to type Ⅰ SCM with or without congenital scoliosis. Type Ⅰ SCM associated with CS were divided into three groups according to the relative position of osseous septum and apical verterbrae, they were respectively the group of apical vertebrae(Gav), the group of above apical vertebrae(Gaav) and the group of inferior apical vertebrae(Giav). Statistical comparison was performed within and between the groups.Results Total numbers of 36 patients were measured in this present study. TD(range,0.16 to 1.31cm) in type Ⅰ SCM was bigger than it(range,0.12 to 0.3cm) in type Ⅱ SCM (P<0.05). There was no significant difference about SD between type Ⅰ SCM and type Ⅱ SCM. TD of split cord in type Ⅰ SCM with CS was significantly greater than in type Ⅰ SCM without CS(P<0.05), but the difference of SD between type Ⅰ SCM with CS and type Ⅰ SCM without CS was no statistically significant(P>0.05). There was no statistically significant about TD, SD, TDconvex, TDconcave, SDcranial and SDcaudal between the Gaav, Gav and Giav. Overall, there was statistically significant difference between TDconvex and TDconcave in type Ⅰ SCM with CS(P<0.05), but there was no statistically significant difference between SDcranial and SDcaudal in type Ⅰ SCM with CS(P>0.05).Conclusion This study has demonstrated that both spine and spinal cord presented the bowstring shape, and spinal cord always shifted to the opposite directions of scoliosis in order to alleviate neurological impairment resulted from traction. The relationship of osseous septum and split cord was extremely complicated, and osseous septum is not always located in the lower end of the split cord, but it has greater influence on the transverse diameter. To enchance the safety correction, we suggest to measure the parameters of the relationship split cord and osseous septum in order to determine safety distance around the osseous septum.Part two:Corrective surgery without resection of ossseus septum for the treatment of congeital scoliosis associated with type I split cord malformationObjective To evaluate and analyze the safety and the efficacy of one stage osteotomy without resection of osseus septum for the treatment of congenital scoliosis with type I split cord malformation.Methods Clinical data of 10 cases of congenital scoliosis with type I split cord malformation in our department from March 2005 to September 2015 were retrospective analyzed. All of them were treated by the methods of osteotomy correction without resection of bony septum. The operative time, bleeding volume and confusion volume were recorded in order to evaluate the safety of corrective surgery. Measured and recorded the changes of Cobb angles in coronal plane, the apical vertebral translation, the trunk shift and the trunk balance in order to evaluate the efficacy of corrective surgery.Results All patients were followed up for 14.2 months(range from 3 months to 36 months), and none was lost to follow-up, among of them, males 3 cases, and female 7 cases. Average bleeding volume and confusion volume were sepratetly 4005.7ml and 2800ml, and the average operative time was 275.4min. The average corrective rate of Cobb angle of postoperation was 57.6%, and the average corrective rate of the apical veterbral translatioon of postoperation was 58.33%, and the average corrective rate of trunk shift of postoperation was 60.33%, and the average corrective rate of coronal and saggital trunk balance was seperately 58.8% and 76.9%.Conclusion Only spinal osteotomies without resection of bony septum is relative safe and effective for the congenital scoliosis with type I SCM.Part three:Image study on type I split cord malformationObjective The purpose of this study is to investigate and summarize the clinical results of one stage and two-stage osteotomy for the treatment of congenital scoliosis with type I split cord malformation.Methods Clinical data of 23 cases of congenital scoliosis with type I split cord malformation in our department from March 2006 to September 2014 were retrospectively analyzed. All of them were treated by the methods of the resection of bony septum and osteotomy correction, and they were divided two groups, one-stage group and two-stage group. Reviewed the medical records and roentgenograms of these patients and recorded the changes of the symptoms and signs. The operative time, bleeding volume and confusion volume were recorded and compared. Measured and recorded the changes of Cobb angles in coronal plane, the apical vertebral translation.Results All patients were followed up in the two groups.for 14.6 months, among of them, males 8 cases, and female 15 cases. Bleeding volume and confusion volume in the one-stage group were more than the two-stage group, but the operative time in the one-stage group was less than the two-stage group. There was significant difference between the groups in the Cobb angles, but there was no significant difference between the groups about the spinal balance in after-operation and final follow-up periods. In the two-stage group, the complications about spinal cord and nerve root was more seriously in the pei-operative time than of in the one-stage group. The overall prevalence incidence of complications was 30.4%, and we found the changes of the potential in 9 cases during the surgical periods.Conclusion One stage spinal osteotomies is safe and effective for the congenital scoliosis with type I SCM, but it increase complication rate peri-operative periods, addition, one stage resulting in longer operative time and greater blood loss. |
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