青少年特发性胸椎侧凸患者胸椎横断面上的发育特征及其意义

目的:探讨青少年特发性脊柱侧凸(adolescent idiopathic scoliosis,AIS)患者青春期胸椎横断面上的发育特征及其意义。方法:收集30例AIS患者(A组)和30例相应年龄无脊柱畸形的青少年(N组)的胸椎CT片,每组根据研究对象年龄组成再分为两个亚组,每个亚组均为15例。低龄AIS组(A1组)和高龄AIS组(A2组)平均年龄分别为10.6岁和16.8岁;低龄对照组(N1组)和高龄对照组(N2组)平均年龄分别为10.8岁和17.3岁。在AIS患者侧凸区(T5～T12)及对照组相应椎体横断面CT上分别测量椎体的横径和纵径、椎管的横径和纵径、椎弓根长度和直径、椎板长度和直径。对相同年龄段的AIS和对照组、同一组内的两个亚组以及每个亚组患者左右侧(凹凸侧)的各个相应参数进行比较分析。结果:每组内高龄亚组的椎体均较低龄组增大,但同年龄层的两亚组无明显差异;N组两个亚组间椎管大小无明显差异,而A2组椎管横径明显大于A1组以及N2组。高龄亚组的椎弓根长度、直径及椎板长度和相应低龄亚组相比均无明显差异,但A2组凸侧以及N2组的椎板直径明显大于相应低年龄组。N组内左右侧后弓测量参数无明显差异,A1组和A2组凹侧椎弓根较凸侧长,但差异无显著性。同年龄层两亚组的椎弓根、椎板的直径、长度均无明显差异。结论:在青春期,AIS患者脊椎后弓可能存在膜内成骨异常,而神经中央软骨对AIS脊椎发育没有明显的影响。     

The development of adolescent idiopathic scoliosis

There are many conflicting actiological theories for adolescent idiopathic scoliosis. We present a simple new model of scoliosis and a mechanism by which it is initiated and progresses. This mechanism provides a final common pathway for the multiple aetiological factors. A simple model of the spine, incorporating its fundamental mechanical features, was constructed. The model consisted of interconnected anterior compression and posterior tension columns. It allowed normal spinal movements, with flexion limited by the posterior column and rotation centred around the anterior column. It also allowed deformities to develop. The ends of the model were fixed in the position of the vertebrae they represented. Overgrowth of the anterior column relative to the posterior column caused the model to take up the shape of an idiopathic scoliosis. The greater the overgrowth, the more marked the deformity. Normally anterior and posterior column growth are coupled. During the growth spurt the thoracic kyphosis flattens indicating that anterior growth temporarily exceeds posterior growth. If this overgrowth is marked a scoliosis will develop, as demonstrated by the model. Once this occurs the coupling is lost, anterior growth further outstrips posterior growth and the deformity progresses. Not all scolioses worsen, as the tendency to progress is balanced by neuromuscular factors and remodelling. Factors that increase the growth rate, induce asymmetry or decrease the inherent stability of the spine all encourage the development and progression of a scoliosis. This explains the complex biomechanics of scoliosis and provides a final common pathway by which the multiple aetiological factors can induce idiopathic scoliosis. It has important implications for the understanding and treatment of this condition.     

Spinal growth and progression of adolescent idiopathic scoliosis

Summary The spinal growth in scoliotic segments (T4-L4) of 110 girls with untreated idiopathic scoliosis was measured from two successive radiographs taken at a mean interval of 1.1 years. At the first visit the mean age of the patients was 14 years (range 11–16 years), the mean magnitude of the major curves 24° (range 9°–38°) and that of the minor curves 14° (range 2°–38°). Spinal growth was most rapid at the age of 11–12 years. The progression of the curves (major plus minor) correlated with the spinal growth (r=0.384). The greater the initial curves were, the stronger the correlation was between the spinal growth and the progression of the curves (r=0.046–0.639), and the correlation was more significant in thoracic scoliosis (r=0.560) than in thoracolumbar and lumbar scoliosis (r=0.152).     

青少年特发性脊柱侧凸的治疗进展

青少年特发性脊柱侧凸(adolescent idiopathic scoliosis,AIS)是指年龄在10¹8岁,冠状面上Cobb角>10°伴有椎体的旋转而无其他器质性病变的一种常见病。该疾病能够导致身体外观畸形、疼痛,甚至心肺功能受损,严重影响了患者的身心健康及生活质量。在治疗上,对于轻中度的AIS患者常用定期观察、支具等保守治疗方法,能够有效的延缓侧凸的进展;对于保守治疗无效,达到手术阈值的AIS患者,则建议手术治疗,目前较为常用的手术方法是以椎弓根螺钉内固定系统为代表的后路椎体融合术,往往能够达到较好的临床疗效。近年来,由于物理治疗性脊柱侧凸特异性运动(PSSE)疗法安全有效,越来越受欢迎。目前对于AIS患者治疗的具体适应证正逐渐完善,治疗理念与技术在不断更新,临床疗效也不断得到改善。本文将从保守治疗和手术治疗两方面展开,主要阐述常用的治疗方法在临床上的进展和应用以及所面临的问题,为临床治疗的选择提供参考。     

SSEP analysis in surgery of idiopathic scoliosis: the influence of spine deformity and surgical approach

The study was conducted to assess the possible impact of spine deformity in patients with idiopathic scoliosis (IS) on tibial nerve somatosensory evoked potentials (t-SSEPs) and the influence of spine correction upon postoperative SSEP recordings. In 61 consecutive patients undergoing 64 spinal instrumentations, 129 pre- and postoperative SSEPs were analyzed. The degree of spine deformity was assessed by the pre-operative Cobb angle of the major scoliotic curve. In a control group, reference values of t-SSEP latencies were established with respect to body height. In a cohort study, IS patients were compared with healthy controls with respect to t-SSEP latency, amplitude, configuration and interside difference. The results of the analysis showed that preoperative-body-height-corrected t-SSEP latencies were prolonged in 61% of patients, with a pathological interside difference in 23.4% of them. The impairment of t-SSEPs was not related to the extent of spine deformity as assessed by the Cobb angle. Even without occurrence of postoperative neurological deficits, postoperative t-SSEPs showed significantly increased latencies without changes in t-SSEP configuration. The prolongation of t-SSEP latencies was related to the surgical procedure (combined ventro-dorsal approach), but not to the extent of spine correction, level of instrumentation, or number of fused segments.The analysis of preoperative t-SSEPs was of no predictive value for intra- or postoperative neurological complications. t-SSEPs are significantly affected in IS patients, although these patients show no obvious clinical neurological deficits. The extent of t-SSEP impairment is not related to the severity of scoliosis. Even in clinically uneventful surgery, the postoperative t-SSEPs can be deteriorated depending on the surgical approach. This indicates a subclinical impact of spine surgery upon spinal cord function.     

Rib-vertebral angle asymmetry in idiopathic, neuromuscular and experimentally induced scoliosis

The concave and convex rib-vertebral angle (RVA) at levels T2–T12 was measured on AP radiographs of 19 patients with right convex idiopathic thoracic scoliosis and 10 patients with major thoracic right convex neuromuscular scoliosis. The difference between the angles on the concave and the convex sides, the RVAD, was calculated. The RVAs were also measured on radiographs from three animal groups in which spinal curves had been induced experimentally in a variety of ways. Group 1 comprised 16 rabbits that had been subjected to selective electrostimulation of the latissimus dorsi, the erector spinae and the intercostal muscles. Group 2 comprised four dead rabbits whose spines had been subjected to manual bending. Group 3 comprised eight rabbits that had undergone mechanical elongation of one rib. In both the idiopathic and the neuromuscular group, the convex RVA was smaller than the concave RVA between levels T2 and T8, with a maximal difference between T4 to T5. From T9 to T12 the concave RVA was smaller than the convex. The RVA in relation to the scoliotic segment, i.e. the apex level of the curve and the two neighbouring vertebrae above and below this level, showed similar results. With increasing Cobb angle the RVADs increased linearly with the greatest difference at the second vertebra above the apex. In the three experimental groups the pattern of the RVADs between T6 to T12 was basically similar to the findings of the clinical study. From the results of these clinical and experimental studies, it is concluded that the typical pattern of the RVAs on the concave and convex sides seems to be independent of the underlying cause of the spinal curvature. It is likely that the RVADs result from a passive mechanical adaptation of the ribs to the lateral curvature of the spine.     

特发性脊柱侧凸患者骨组织中唾液酸蛋白的表达

目的:检测青少年特发性脊柱侧凸(AIS)患者脊柱不同部位和髂骨松质骨骨唾液酸蛋白(bone sialo-protein,BSP)的表达量,并与先天性脊柱侧凸(CS)患者比较,探讨非胶原结构蛋白与AIS患者骨代谢异常的关系。方法:从12例平均年龄为13.8岁的AIS患者取7块髂骨(7例患者)、12对关节突和17个棘突,从10例平均年龄为11.2岁的CS患者中收集10块髂骨。骨组织块固定脱钙处理,石蜡包埋切片,片厚5!m,免疫组织化学染色,观察骨基质中BSP阳性面积比、骨基质总光密度/骨面积和阳性细胞比率。结果:BSP在骨细胞和骨基质中均有表达,AIS组和CS组患者髂骨骨基质总体光密度/骨面积(total OD/bone area)为0.0678±0.0003和0.0803±0.0013,差异有显著性(P<0.05),AIS患者顶椎区凹、凸侧关节突的骨基质BSP阳性面积比和骨基质BSP面积×平均光密度/骨面积分别为0.7363±0.0632、0.5552±0.0259和0.0761±0.0079、0.0632±0.0058,差异有显著性(P<0.05)。AIS患者上胸椎棘突与胸腰段棘突骨基质BSP染色阳性率分别为63.2%和65.5%,阳性细胞表达率分别为58.7%和61.2%,差异无显著性(P>0.05)。结论:BSP对AIS患者骨异常代谢及骨量降低的影响不大,非胶原结构蛋白可能不是AIS患者骨代谢研究的首要考虑对象;脊柱侧凸异常应力影响脊椎骨骼塑型和代谢,脊柱侧凸畸形对脊椎各结构的影响是多方面的。     

Joint flexibilities in structurally normal girls and girls with idiopathic scoliosis

Seven clinical measurements of joint flexibilities were made in 51 girls with untreated mild idiopathic scoliosis and 65 girls with structurally normal spines. Subject ages ranged from 10 to 16 years. Abilities to have the index finger passively extended, the wrist bent, and the elbow and the knee hyperextended, along with abilities to bend the trunk voluntarily forward and to the right and left sides, were measured. The girls with scoliosis in the mean either had the same flexibilities or were less flexible than the normal girls. The study provided no evidence that untreated mild idiopathic scoliosis occurs or progresses because of increased joint flexibilities.     

Melatonin and adolescent idiopathic scoliosis: The present evidence

IntroductionAdolescent idiopathic scoliosis (AIS) is a multifactorial condition with genetic predisposing factors, and several causes have been put forward for its aetiopathogenesis, including possible hormonal dysfunction. Melatonin seems to play significant role in AIS.MethodsA systematic search in different database, to July 2021, was performed to define the role of melatonin in the pathophysiology of adolescent idiopathic scoliosis. Eight suitable studies were identified.ResultsThe concentration and rhythm of melatonin secretion can play an important role by influencing the pathogenesis of adolescent idiopathic scoliosis.ConclusionsAlthough there are many alterations of melatonin in subjects with adolescent idiopathic scoliosis, the many variables present do not allow to establish a direct cause–effect relationship.Level of evidenceLevel IV.     

对青少年特发性脊柱侧弯患者的体感诱发电位检查

本体感觉神经传导异常被认为与青少年特发性脊柱侧弯有关。用体感诱发电位检查在青少年特发性脊柱侧弯患者中是否合并存在本体感觉传导通道的功能异常。研究包括147例青少年特发性脊柱侧弯患者及31位同年龄分布正常对照。对每一位受试者检查胜后神经体感皮质诱发电位，电信号缺失、传导时间延长或双侧传导时间不对称为本体感觉传导通道结构性异常诊断指标。在脊柱侧弯患者中有7人电信号单或双侧缺失，其余140例脊柱侧弯患者中10例传导时间延长，其中4例双侧延长，6例单侧延长。结果证实，部分青少年特发性脊柱侧弯患者同时有本体感觉传导异常，提示青少年特发性脊柱侧弯可进一步分为有本体感觉传导异常及无异常两组。     

低角度青少年特发性脊柱侧凸女性患者的骨密度分析

目的分析低角度青少年特发性脊柱侧凸(adolescent idiopathic scoliosis,AIS)女性患者的骨密度(BMD)和骨矿含量(BMC),探讨其与年龄、生长发育、人体测量学和侧凸角度等的相关性。方法研究对象为218例Cobb角15～40°的女性AIS患者。运用双能X线骨密度吸收仪测定非优势侧股骨颈和腰椎的BMC/BMD。探讨这两个部位的BMC/BMD与患者的年龄、生长发育、人体测量学和侧凸角度等的相关性。结果所有患者的年龄平均为(13.4±1.4)岁,Cobb角平均为(28.3±6.2)°。股骨颈BMD平均为(0.827±0.103)g/cm2,腰椎BMD平均为(0.887±0.124)g/cm2,显著低于同龄健康女性儿童;股骨颈BMC平均为(3.49±0.56)g,腰椎BMC平均为(29.78±7.37)g。患者的BMC/BMD与Cobb角无显著相关,而与体重、身高、Risser征、月经状况、BMI和年龄显著相关。逐步回归分析显示,体重和年龄是影响患者BMD的主要因素。结论低角度女性AIS患者存在全身性的骨量减低,且与Cobb角无显著相关,而与生长发育和人体测量学相关指标显著相关。这提示AIS患者的骨量减低与生长发育和低体重有关。     

Biomechanical comparison of alternative densities of pedicle screws for the treatment of adolescent idiopathic scoliosis

Purpose

The objective of this computational study was to compare the biomechanical effects of different implant densities in terms of curve reduction and the force levels at the implant–vertebra interface and on the intervertebral elements.

Methods

Eight cases were randomly picked among patients who have undergone a posterior spinal instrumentation for adolescent idiopathic scoliosis (AIS). For each case, two computer simulations were performed, one with the actual surgery implant pattern and another with the same fusion levels but an alternative implant pattern proposed by an experienced surgeon. The two implant patterns for each case were respectively put into higher and lower implant density group. The spinal correction and the force levels at bone–implant interface and on the intervertebral elements were analyzed and compared between the two groups.

Results

There were on average 13% more pedicle screws and 30% more bilaterally placed pedicle screws in the higher versus lower density group. The difference in the density of screws (92% vs. 79%) did not lead to significant difference in terms of the resulting main thoracic (MT) Cobb angle, and the MT apical axial vertebral rotation. The average and maximum implant-vertebra force levels were about 50 and 65%, respectively higher in the higher versus lower density group, but without consistent distribution patterns. The average intervertebral forces did not significantly differ between the two groups.

Conclusions

With the same fusion levels, lower density screws allowed achieving similar deformity correction and it was more likely to have lower screw–vertebra loads.     

Dorsal instrumentation for idiopathic adolescent thoracic scoliosis: rod rotation versus translation

The radiographic and clinical outcomes and complications among two groups of adolescent patients treated for idiopathic thoracic scoliosis with dorsal instrumentation using a unified implantation system (Universal Spinal System) were compared retrospectively. A total of 69 patients were included in the study. In 30 patients an intraoperative correction of the scoliosis was performed by translation and segmental correction (translation group, Helsinki). In 39 patients the correction was achieved according to the Cotrel-Dubousset rod rotation maneuver (rod rotation group, Berlin). The goal of the present study is to investigate whether one of the operative procedures leads to a better correction of idiopathic adolescent thoracic scoliosis than the other. The mean follow-up interval was 30 months, with a minimum of 12 months. There were no significant preoperative differences in age (15 ± 2 years in both groups), gender, or type of scoliosis (King types 2, 3, and 4). The preoperative radiographic measurements showed no significant differences between the two groups. In both patient groups, the thoracic primary curve, the lumbar secondary curve and the thoracic apical rotation were improved by the operation. Lumbar apical rotation and the sagittal profile were unchanged in both groups. The thoracic primary curve was corrected from 50°± 6° to 24°± 7° in the translation group and from 54°± 11° to 22°± 11° in the rod rotation group. The extent of the correction of the thoracic curve was significantly greater in the rod rotation group than in the translation group (59% vs 52% correction). In contrast, the translation procedure seems to have a more beneficial effect on spinal balance than rod rotation. Neurological complications did not occur. In both patient groups an increase in the non-instrumented lumbar curve was noted, in two cases each. In three patients from the rod rotation group the instrumentation had to be removed due to a late infection with negative microbiological results. Received: 6 June 1998 Revised: 18 December 1998 Accepted: 18 December 1998     

In vivo three-dimensional segmental analysis of adolescent idiopathic scoliosis

Introduction  

An accurate assessment of three-dimensional (3D) intervertebral deviation is crucial to the better surgical correction of adolescent idiopathic scoliosis (AIS). However, a precise 3D study of intervertebral deviation has not been previously reported.     

Surgical assessment of the proximal thoracic curve in adolescent idiopathic scoliosis

Existing predictive signs as available in current literature may miss potential proximal thoracic (PT) curve deterioration and shoulder imbalance, following selective main thoracic (MT) curve correction in adolescent idiopathic scoliosis (AIS). The present study is an attempt to evaluate and complement these signs, through a retrospective study of 56 AIS patients who underwent correction and fusion from 1986 till 2003 with follow-up 4–16 years. Forty-nine had fusion of MT curve, 7 of MT and PT. Cotrel–Dubousset instrumentation in 45, Luque in 12. Preoperative data: MT 50° (40°–80°), PT 25° (0°–50°), shoulder elevation from −4 cm (right) to 2 cm (left), clavicle angle from −14° to 5°, PT bending correction from 0 to 100% and T1 tilt from −15° to 14°. We introduced the first rib index (FRI), i.e., the difference between the diameter of right and left first rib arch as a percentage of the sum of both diameters, averaging from −22.7 to 14.3%. (Minus signs refer to or predict right, while positive left shoulder elevation.) Evaluation included all predictive parameters as related principally to postoperative left shoulder elevation ≥1 cm, patient satisfaction and surgeon fulfillment. Postoperative correction MT curve 53% (23–83%) and PT 35% (0–100%). One progressive paraplegic started 40 min following normal wake-up test. Immediate decompression, full recovery. Three cases with wound infection recovered after late removal of instrumentation. Loss of correction ≥10° in five. Fifteen had postoperative persisting left shoulder elevation ≥1 cm. Seven of these expressed dissatisfaction. Statistically FRI proved valuable predictive factor always in combination with previously described signs. We concluded that a postoperative left shoulder elevation ≥2 cm is a potential cause of dissatisfaction and may be prevented with thorough validation of all predictive signs, principally the FRI. Part of this paper was presented at the 62nd annual meeting of the Hellenique Orthop. Society (October 2006) and received the 1st award for best clinical paper.     

女性青少年特发性脊柱侧凸患者生长高峰预测因素的组织学评价

目的通过组织学研究来评价青少年特发性脊柱侧凸女性患者生长高峰预测因素的价值。方法收集青少年特发性脊柱侧凸女性患者的髂软骨标本,垂直钙化层进行切片染色,并对其增殖活性进行分级。将患者年龄、月经、腕骨骨龄、肘关节骨龄、指骨骨龄及Risser征进行分级,比较各级间患者髂软骨增殖活性的差异。结果共收集53例患者骨标本,平均年龄14．0岁。通过组织学分析发现年龄〉13．0岁、月经来潮、腕骨骨龄〉14．0岁及Risser征Ⅲ级的患者增殖活性下降。结论年龄〉13．0岁、月经来潮、腕骨骨龄〉14．0及Risser征Ⅲ级均可用于判定青春期生长高峰结束;年龄11．0岁、乳房开始发育、腕骨骨龄12岁可用于预测PHV的开始。     

脊柱生长速率对行支具治疗的特发性脊柱侧凸患儿侧凸进展的预测价值

【摘要】 目的：分析行支具治疗的特发性脊柱侧凸（idiopathic scoliosis,IS）患儿侧凸进展速率（Cobb velocity,CV）的相关因素,并探讨脊柱生长速率（spine length velocity,SLV）对IS患儿侧凸进展的预测价值。方法：于我院门诊行正规支具治疗的女性IS患儿23例,初诊时Risser征为0,无神经系统异常。其中胸主弯19例,胸腰弯4例,平均随访3.3年。患儿每次随访均拍摄站立位全脊柱正位片及左手掌正位片,测量主弯的Cobb角、Risser征、脊柱长度及骨龄（digital skeletal age,DSA）评分。另外记录患儿每次随访时的实足年龄、月经状态及身高等资料,计算患儿每次随访时的CV、SLV及身高生长速率（height velocity,HV）。采用Spearman相关系数分析IS患儿SLV及CV的相关因素。结果：本组患儿平均初诊年龄10.8±1.3岁;月经年龄12.2±2.0岁;初诊DSA评分384.6±51.9;初诊脊柱长度311.6±23.6mm;平均初诊身高145.5±7.8cm;平均初诊Cobb角23.0°±6.9°。随访时患儿平均SLV为19.1±17.1mm/年;平均HV为5.4±4.1cm/年;平均CV为5.7°±8.1°/年。另外,SLV高峰期（大于20mm/年）与CV高峰期（大于5°/年）均发生于实足年龄10～13岁之间。Spearman相关性分析表明,SLV与实足年龄、Risser征、DSA评分、HV及CV呈显著相关（r=-0.337、-0.292、-0.199、0.374和0.456,P<0.05）;CV与实足年龄、DSA评分及HV呈显著相关（r=-0.192、-0.188和0.281,P<0.05）。结论：IS患儿侧凸进展速率与年龄、DSA评分、HV及SLV显著相关。SLV与年龄、Risser征、DSA评分及HV显著相关,是较好的评估IS患儿生长潜能和侧凸进展的指标。SLV大于20mm/年时提示较高的侧凸进展风险。     

Preoperative radiological and electrophysiological evaluation in 100 adolescent idiopathic scoliosis patients

This is a prospective study of spinal magnetic resonance imaging (MRI), electrophysiological recordings, and neurological examinations of 100 patients admitted for surgery for adolescent idiopathic scoliosis (AIS), which was conducted to assess the prevalence of structural and functional abnormalities within the spinal cord in patients with clinically normal neurologic condition. In all patients the clinical diagnosis and intact neurological condition was ascertained by a spinal orthopedic surgeon. Full-length spinal axis MRI studies (T1/T2 sequences) and somato-sensory evoked potentials of the tibial nerves (tSSEPs) were preoperatively assessed by independent evaluators blinded to the patients' medical histories. Structural spinal cord abnormalities were found in three of 100 AIS patients on MR imaging. In one patient a Chiari malformation type 1 with an accompanying syringomyelia was diagnosed, which required a suboccipital decompression. In the other two patients small thoracic syringomyelias were diagnosed. Abnormalities of spinal cord function were detected in 68% of the 100 patients: tSSEP latencies corrected for body height were increased in 56% of the patients; pathological differences between tSSEPs on the left and right sides were present in 17% (12% in combination with a prolongation of the latency). The findings of this study indicate that MRI and electrophysiological examinations are essential to assess spinal cord abnormalities that are clinically not detectable in AIS patients. Even in patients with intact neurologic condition and clinically typical right-curved thoracic scoliosis, the possibility of intraspinal pathologies should be ruled out by MRI. It is especially important to detect structural pathologies like syringomyelia and Chiari malformation before proceeding with scoliosis surgery, as these conditions are associated with a higher neurological risk during scoliosis surgery. The electrophysiological recordings made in the present study, with the high number of pathological tSSEPs, are indicative of functional abnormalities with a subclinical involvement of the recorded neuronal pathways. The relevance of the latter findings is not yet clear, but pre-operative tSSEP examinations offer the possibility of assessing alterations in spinal cord function that are undetectable by clinical examination.     

Neurophysiological mechanism of the unloading reflex as a prognostic factor in the early stages of idiopathic adolescent scoliosis

This paper presents a new neurophysiological method of evaluating the risk of progression in idiopathic scoliosis in the early stages of the disease, by investigating the unloading reflex in paraspinal muscles. The study included 394 patients with scoliosis and 70 healthy children. Latency of the unloading reflex and repeatability of the rebound and silent period were analysed for each reflex evoked. Prolonged latency and minimal number of cycles are the most important factors in the evaluation of progressive idiopathic scoliosis. The method can be used to detect progressive idiopathic scoliosis in the early stages of the disease. The high sensitivity of the method means it can be used as a basis on which to take an early decision to perform surgery.