儿童下腰椎和腰骶段半椎体畸形冠状面平衡状况与外科矫形选择

目的:评估儿童下腰椎及腰骶段半椎体畸形冠状面平衡情况,分析不同外科矫形方式的选择和临床疗效。方法:回顾分析2005年1月~2013年12月我院收治的14例先天性脊柱侧凸患者,平均年龄7.8±3.3岁(3~10岁)。L4半椎体4例,L5半椎体7例,S1半椎体3例。根据术前冠状面平衡情况分为3组:A组冠状面平衡,C7铅垂线偏离骶骨正中平分线(CSVL)≤2cm;B组为C7铅垂线位于半椎体的对侧(偏离CSVL2cm);C组为C7铅垂线位于半椎体的同侧(偏离CSVL2cm)。所有患者均采用一期后路半椎体切除联合椎弓根螺钉内固定矫形植骨融合术式。矫形方式:A组中凸侧与凹侧撑开、压缩力均等;B组半椎体侧单纯压缩;C组增加L5/S1节段"反向"凸侧撑开、凹侧压缩的矫形操作。随访观察各组患者畸形矫正情况。结果:所有病例随访24~68个月,平均33±12个月。术前冠状面排列中平衡4例(29%),失平衡10例(71%)。术前冠状面Cobb角平均36.8°,末次随访时平均12.1°±8.0°(P=0.000),最终矫正率67.1%。术前的冠状面平衡为6~53mm,平均30.6±14.9mm,末次随访时冠状面平衡为0~44mm,平均10.7±10.9mm(P=0.001)。其中,A组患者4例,术前与术后均维持了冠状面平衡;B组患者6例,术后有1例患者冠状面仍然失平衡;C组患者4例,术后均恢复了冠状面平衡。结论:儿童下腰椎和腰骶段的半椎体畸形冠状面失平衡发生率较高,一期后路半椎体切除联合椎弓根内固定、结合不同冠状面排列情况采取恰当矫形方式,可能获得满意的冠状面平衡和临床疗效。     

后路半椎体全切钉棒固定治疗幼儿先天性脊柱侧凸畸形

目的：评价后路半椎体切除钉棒固定治疗幼儿先天性脊柱侧后凸畸形的临床效果。方法采用后路一期半椎体切除、椎弓根螺钉固定治疗16例完全性半椎体畸形患儿,手术时年龄12～27（15．56±3．79）个月。术前侧凸 Cobb 角为32°～45°（38．35°±3．44°）,Bending 位侧凸26°～72°（53．26°±7．28°）。结果手术时间145～210（185±25）min,术中出血量220～580（375±58）ml,输血量300～480（450±38）ml;固定节段4～6（5．12±0．75）个椎体。患儿均获随访,时间13～26（18．5±3．2）个月。术后患儿站立位全脊柱正、侧位 X线片示侧凸 Cobb 角9°～15°（12．26°±2．06°）,平均矫正率68．4％;末次随访时侧凸 Cobb 角12°～20°（17°±1．56°）,丢失约5°,平均矫正率55．3％。术后伤口愈合不良1例,无神经系统并发症。结论采用一期后路半椎体切除、钉棒固定治疗幼儿先天性脊柱侧凸畸形,可直接去除致畸因素,在幼儿可获得良好的临床效果。     

Do Current Recommendations for Upper Instrumented Vertebra Predict Shoulder Imbalance? An Attempted Validation of Level Selection for Adolescent Idiopathic Scoliosis

Background

Shoulder balance for adolescent idiopathic scoliosis (AIS) patients is associated with patient satisfaction and self-image. However, few validated systems exist for selecting the upper instrumented vertebra (UIV) post-surgical shoulder balance.

Questions/Purposes

The purpose is to examine the existing UIV selection criteria and correlate with post-surgical shoulder balance in AIS patients.

Methods

Patients who underwent spinal fusion at age 10–18 years for AIS over a 6-year period were reviewed. All patients with a minimum of 1-year radiographic follow-up were included. Imbalance was determined to be radiographic shoulder height |RSH| ≥ 15 mm at latest follow-up. Three UIV selection methods were considered: Lenke, Ilharreborde, and Trobisch. A recommended UIV was determined using each method from pre-surgical radiographs. The recommended UIV for each method was compared to the actual UIV instrumented for all three methods; concordance between these levels was defined as “Correct” UIV selection, and discordance was defined as “Incorrect” selection.

Results

One hundred seventy-one patients were included with 2.3 ± 1.1 year follow-up. For all methods, “Correct” UIV selection resulted in more shoulder imbalance than “Incorrect” UIV selection. Overall shoulder imbalance incidence was improved from 31.0% (53/171) to 15.2% (26/171). New shoulder imbalance incidence for patients with previously level shoulders was 8.8%.

Conclusions

We could not identify a set of UIV selection criteria that accurately predicted post-surgical shoulder balance. Further validated measures are needed in this area. The complexity of proximal thoracic curve correction is underscored in a case example, where shoulder imbalance occurred despite “Correct” UIV selection by all methods.

Electronic supplementary material

The online version of this article (doi:10.1007/s11420-015-9451-y) contains supplementary material, which is available to authorized users.     

三亚市青少年脊柱侧凸畸形患病率调查

目的：了解三亚市中小学生特发型脊柱侧凸畸形(AIS)的患病情况。方法采用横断面研究方法,随机抽查三亚市城乡10所中学10~16岁中学生6952名,其中男生3750名,女生3202名。首先通过观察体检者的肩部和肩胛骨的对称性以及Adams试验筛选出疑似患者。对于AIS疑似患者,进一步采用全脊柱正侧位X射线摄片来明确脊柱侧凸诊断。结果6952名中小学生中共检筛出AIS疑似患者375名(男性191名,女性184名),其中358名疑似患者接受进一步检查,最终明确AIS患者88名(1.27%),男性42名(0.60%),女性46名(0.66%),男、女比率为1：0.91,但二者患病率比较差异无统计学意义(χ2=1.39,P>0.05)。结论三亚市公立学校中小学生AIS患病率为1.27%,男女患病率相当。     

成人脊柱侧凸患者长时间行走后矢状面失平衡的动态评估

目的 评估成人脊柱侧凸患者长时间步行前后整体和局部的矢状面影像学参数。方法 回顾性纳入2016年1月至2018年6月于海军军医大学（第二军医大学）长征医院就诊的98例成人脊柱侧凸患者,根据行走前矢状面参数将患者分为两组：代偿组（行走前矢状面平衡,矢状面躯干偏移<40 mm且骨盆倾斜角>20°）和失代偿组（行走前矢状面失平衡,矢状面躯干偏移≥ 40 mm且骨盆倾斜角>20°）。步行15 min前后拍摄站立位全脊柱正侧位X线片,测量脊柱矢状面参数,包括矢状面躯干偏移、胸椎后凸角、腰椎前凸角、骨盆入射角、骨盆倾斜角、骶骨倾斜角。比较两组步行15 min前后脊柱矢状面参数,并对每组步行15 min前后矢状面躯干偏移变化值与其余矢状面参数变化值进行相关性分析。结果 代偿组19例,其中女16例、男3例,平均年龄为（64.1±5.9）岁,BMI为（24.2±4.6）kg/m²;失代偿组79例,其中女67例、男12例,平均年龄为（66.7±7.2）岁,BMI为（24.9±5.1）kg/m²,两组患者性别构成比、年龄、BMI差异均无统计学意义（P均>0.05）。步行前,代偿组患者腰椎前凸角大于失代偿组（Z=2.784,P=0.003）,骨盆入射角-腰椎前凸角和矢状面躯干偏移均小于失代偿组（Z=1.953,P=0.028;Z=3.815,P<0.01）;两组间骨盆倾斜角、骶骨倾斜角、胸椎后凸角差异均无统计学意义（P均>0.05）。步行15 min后,两组间骨盆倾斜角、骶骨倾斜角、腰椎前凸角、胸椎后凸角、骨盆入射角-腰椎前凸角、矢状面躯干偏移差异均无统计学意义（P均>0.05）。与步行前比较,代偿组和失代偿组患者步行15 min后骶骨倾斜角、骨盆入射角-腰椎前凸角、矢状面躯干偏移均增大（代偿组Z=1.718、P=0.043,Z=2.198、P=0.015,Z=3.875、P<0.01;失代偿组Z=1.842、P=0.031,Z=1.943、P=0.021,Z=2.917、P=0.002）,骨盆倾斜角和腰椎前凸角均减小（代偿组Z=1.639、P=0.047,Z=3.624、P<0.01;失代偿组Z=1.812、P=0.039,Z=3.893、P<0.01）;失代偿组患者步行15 min后胸椎后凸角也较步行前增大（Z=2.287,P=0.012）。代偿组、失代偿组患者步行15 min前后矢状面躯干偏移变化值均与骨盆倾斜角变化值呈负相关（r_s=-0.519、-0.625,P=0.024、0.001）,与骶骨倾斜角变化值、腰椎前凸角变化值、骨盆入射角-腰椎前凸角变化值均呈正相关（代偿组r_s=0.519、0.645、0.645,P均<0.05;失代偿组r_s=0.625、0.407、0.407,P均<0.01）。结论 成人脊柱侧凸患者长时间行走后矢状面平衡的代偿机制逐渐减弱或消失,骨盆及脊柱伸肌肌群的疲劳可能是代偿机制消失的原因。对于初次就诊时矢状面躯干偏移<40 mm、骨盆倾斜角>20°的患者,建议在行走15 min后再次拍摄X线片重新评估是否存在潜在的矢状面失平衡。     

青少年特发性脊柱侧凸术前柔韧性影响因素及评估方法研究进展

脊柱侧凸柔韧性评估是青少年特发性脊柱侧凸患者术前常规检查,其对确定融合节段、选择手术入路、预测术后矫形效果等方面都有重要意义。随着矫形理念的革新和内固定矫形器械不断发展,作为以往脊柱侧凸柔韧性评估“金标准”—仰卧位侧屈位法逐渐暴露出重复性差、术后预测准确性低等的缺点。因此,许多学者开始提出新的脊柱柔韧性评估方法。本文主要就青少年特发性脊柱侧凸柔韧性的的影响因素、不同脊柱柔韧性评估方法及评价作一综述,以便更多的脊柱外科医生对其有充分的认识了解,并指导在以后的临床工作中选择合适的评估方法对青少年特发性脊柱侧凸进行柔韧性评估。     

脊柱均匀短缩脊髓轴性减压术治疗脊髓栓系综合征合并脊柱侧凸的疗效分析

目的 探讨脊柱均匀短缩脊髓轴性减压术（HSAD）对脊髓栓系综合征（TCS）合并脊柱侧凸的治疗效果。方法 回顾性纳入2015年4月至2018年1月在海军军医大学（第二军医大学）长征医院骨科因TCS合并脊柱侧凸行HSAD治疗的6例患者,记录手术时间、术中失血量、并发症等资料。并于术前、术后行尿动力学检查评估逼尿肌反射、括约肌功能、功能膀胱容量和最大尿流率。结果 男3例、女3例,年龄为7~23岁,平均年龄为（15.7±6.9）岁,平均随访时间为（28±9）个月。其中5例患者伴大小便失禁,3例伴足下垂,4例伴下肢肌力下降,1例存在腰痛,1例合并髋关节脱位。6例患者手术时间为180~320 min,平均（261±63）min;术中失血量为650~1 100 mL,平均（925±167）mL。1例腰痛患者术后腰痛症状完全缓解,4例伴下肢肌力下降患者术后下肢肌力均有改善。1例患者因术后未行尿动力学检查未予统计;其余5例患者于术前、术后均接受尿动力学检查,其中4例术前尿道外括约肌过动、1例失调,术后2例尿道外括约肌协调、1例改善、2例过动。术前、术后功能膀胱容量分别为195.0（127.5,233.5）mL、213.0（188.5,251.5）mL,差异无统计学意义（Z=-0.4,P=0.70）。术前最大尿流率、残余尿量分别为7.3（1.4,10.3）mL/s、130（106,200）mL,与术后[10.3（5.6,16.2）mL/s、30（6,174）mL]相比差异均有统计学意义（Z均=-2.0,P均=0.04）。5例患者术后膀胱逼尿肌肌力得到不同程度改善,最大尿流率增加,残余尿减少。结论 TCS合并脊柱侧凸可以通过HSAD一期手术治疗,该手术可同时缓解脊髓轴向张力、矫正脊柱畸形、恢复脊柱和脊髓的协调性。患者术后下肢症状和膀胱功能均得以有效改善,同时避免了脑脊液漏、出血多和神经功能恶化等并发症。     

The Prevalence of Idiopathic Scoliosis in Eleven Year-Old Korean Adolescents: A 3 Year Epidemiological Study

Purpose

School screening allows for early detection and early treatment of scoliosis, with the purpose of reducing the number of patients requiring surgical treatment. Children between 10 and 14 years old are considered as good candidates for school screening tests of scoliosis. The purpose of the present study was to assess the epidemiological findings of idiopathic scoliosis in 11-year-old Korean adolescents.

Materials and Methods

A total of 37856 11-year-old adolescents were screened for scoliosis. There were 17110 girls and 20746 boys. Adolescents who were abnormal by Moiré topography were subsequently assessed by standardized clinical and radiological examinations. A scoliotic curve was defined as 10° or more.

Results

The prevalence of scoliosis was 0.19% and most of the curves were small (10° to 19°). The ratio of boys to girls was 1:5.5 overall. Sixty adolescents (84.5%) exhibited single curvature. Thoracolumbar curves were the most common type of curve identified, followed by thoracic and lumbar curves.

Conclusion

The prevalence of idiopathic scoliosis among 11-year-old Korean adolescents was 0.19%.     

Conservative treatment for adolescent idiopathic scoliosis: can it reduce the incidence of surgical treatment?

Since 1986, the authors have been conducting conservative treatment for idiopathic scoliosis with the combination of brace treatment and physical treatment (side shift exercise and hitch exercise). A total of 328 female patients with adolescent idiopathic scoliosis who were at least 10 years of age at the first visit, with Cobb angle of 10° at the minimum and followed until after 15 years of age or skeletal maturity were included. The average Cobb angle was 32.4° and the average age was 13.8 years at the first visit. Surgery was recommended when curvature progressed to >50°. Twenty of 328 patients (6.1%) with more severe curves to begin with (mean Cobb angle at admission of 48.5?±?9.3°) progressed to 62.2?±?8.5° and were treated with spinal fusion by the age of 16.0?±?2.6 years. The remaining 308 patients, of comparable age at inception of treatment but with a smaller original mean Cobb angle (32.4?±?11.1°), showed no significant increase in magnitude of curvature (mean 33.6?±?11.5°) by the time of discharge (18.6?±?3.1 years). The fact that curvature magnitude was maintained at <35° means that these patients will have a good prognosis for avoiding dramatic progression during adulthood.     

Neurofibromatosis Type 1 and Primary Hyperparathyroidism with Spinal Deformity and Osteoporosis

The association of Neurofibromatosis type 1(NF1) and primary hyperparathyroidism (PHPT) is a well described but very rare entity. This association supports the hypothesis of a variant of multi-endocrine neoplasia syndrome. We report a 52-year-old woman with NF1, PHPT and spinal deformity. She had cutaneous lesions of neurofibromatosis. X-ray imaging has shown severe kyphoscoliosis and bone mineral density measurement has revealed severe osteoporosis. Significant increases in blood calcium and parathormon level were measured. Parathyroid adenoma was determined by ultrasound and MIBI scan. Hyperparathyroidism and hypercalcaemia resolved after surgical removal of adenoma. The general condition of the patient was improved significantly after two months of medical and physical therapy. All NF1 patients who have severe skeletal deformities, osteoporosis, and motor activity loss should be investigated for the concurrence of PHPT.