青少年特发性脊柱侧凸与神经源性脊柱侧凸患者椎体和椎间盘的楔形变及其临床意义

目的:观察青少年特发性脊柱侧凸(adolescent idiopathic scoliosis,AIS)与神经源性脊柱侧凸(neurological scoliosis,NS)患者的椎体和椎间盘的楔形变情况,探讨其临床意义。方法:对35例AIS患者和31例NS患者(继发于Chiari畸形)应用Cobb法测量胸椎和腰椎每个侧凸范围内顶椎及其上、下各两个椎体和相应椎间盘的楔变角,计算其占整个侧凸角度的百分比(楔变率),得出侧凸范围内5个椎体的平均楔变率和4个椎间盘的平均楔变率。应用SPSS10.0统计软件进行统计分析,组间比较采用单因素方差分析。结果:相同病因、相同侧凸部位、相同Cobb角分组情况下,椎体与椎间盘的楔变率存在显著性差异(P0.05)。相同病因、相同侧凸部位,Cobb角60°组的椎体楔变率和椎间盘楔变率与Cobb角≥60°组比较均无显著性差异(P0.05)。相同侧凸部位、相同Cobb角分组,AIS组椎体和椎间盘的楔变率分别与NS组比较均无显著性差异(P0.05)。结论:AIS与NS患者椎体与椎间盘的相对楔形变方式相同,AIS患者的椎体楔形变可能是继发的。在治疗脊柱侧凸时,即便是较小角度的脊柱侧凸,都应该考虑到其存在椎体和椎间盘的楔形变。     

青少年特发性脊柱侧凸患者脊柱柔韧性的影响因素

目的:探讨青少年特发性脊柱侧凸(adolescent idiopathic scoliosis,AIS)患者脊柱柔韧性的可能影响因素.方法:选取2006年12月～2008年4月在我院脊柱外科手术治疗的204例AIS患者,男性36例,女性168例,平均年龄15.0岁;平均Cobb角50.1°;平均Risser征3.4度;主弯跨度平均6.8个椎体;主弯顶椎旋转度平均2.0度.摄站立位全脊柱正侧位及仰卧左右侧屈位X线片,计算主弯柔韧性.采用相关分析研究各临床指标与主弯柔韧性的相关性.结果:女性AIS患者的脊柱柔韧性明显高于男性(P<0.05);胸腰弯组和腰弯组AIS患者的脊柱柔韧性显著大于胸弯组(P<0.05),胸腰弯和腰弯组之间无显著性差异(P>0.05).女性AIS患者中的年龄及主弯Cobb角(站立位与侧屈位)均与脊柱柔韧性显著负相关(P<0.05),且胸弯女性AIS患者的月经初潮至手术时间及顶椎旋转度也与脊柱柔韧性显著负相关(P<0.05).男性胸弯AIS患者中侧屈位主弯Cobb角、胸腰弯/腰弯组中主弯Cobb角(站立位与侧屈位)均与脊柱柔韧性显著负相关(P<0.05).主弯跨度及Risser征与脊柱柔韧性均无明显相关性(P>0.05).结论:女性AIS患者脊住柔韧性受年龄、月经初潮至手术时间、主弯Cobb角(站立位与侧屈位)、弯型及顶椎旋转度等因素影响;男性AIS患者的脊柱侧凸柔韧性主要受主弯Cobb角及弯型影响.     

Spine slenderness and wedging in adolescent idiopathic scoliosis and in asymptomatic population: an observational retrospective study

The origin of the deformity due to adolescent idiopathic scoliosis (AIS) is not known, but mechanical instability of the spine could be involved in its progression. Spine slenderness (the ratio of vertebral height to transversal size) could facilitate this instability, thus playing a role in scoliosis progression. The purpose of this work was to investigate slenderness and wedging of vertebrae and intervertebral discs in AIS patients, relative to their curve topology and to the morphology of control subjects. A total of 321 AIS patients (272 girls, 14 ± 2 years old, median Risser sign 3, Cobb angle 35° ± 18°) and 83 controls were retrospectively included (56 girls, median Risser 2, 14 ± 3 years). Standing biplanar radiography and 3D reconstruction of the spine were performed. Geometrical features were computed: spinal length, vertebral and disc sizes, slenderness ratio, frontal and sagittal wedging angles. Measurement reproducibility was evaluated. AIS girls before 11 years of age had slightly longer spines than controls (p = 0.04, Mann–Whitney test). AIS vertebrae were significantly more slender than controls at almost all levels, almost independently of topology. Frontal wedging of apical vertebrae was higher in AIS, as expected, but also lower junctional discs showed higher wedging than controls. AIS patients showed more slender spines than the asymptomatic population. Analysis of wedging suggests that lower junctional discs and apex vertebra could be locations of mechanical instability. Numerical simulation and longitudinal clinical follow-up of patients could clarify the impact of wedging, slenderness and growth on the biomechanics of scoliosis progression. These slides can be retrieved under Electronic Supplementary Material.     

青少年特发性脊柱侧凸的选择性胸椎融合治疗

目的　探讨青少年特发性脊柱侧凸选择性胸椎融合治疗的适应证。方法　回顾性分析12例行选择性胸椎融合患者术前、术后及随访时的X光像 ,对侧凸类型、侧凸Cobb角、顶椎旋转度、顶椎偏距、侧凸柔韧性、躯干偏移及胸腰段矢状面Cobb角进行测量和分析。患者 12例中男 2例 ,女10例 ,平均年龄 15 1(13～ 18)岁。侧凸均为KingⅡ型 ,其中PUMCⅡb1型 9例 ,Ⅱc3型 3例。所有病例均行选择性胸椎融合 ,平均随访 3 5 (1～ 10 5 )年。结果　手术前后胸弯冠状面Cobb角分别为5 4 0°、19 0° ,平均矫正率 6 2 7% ;腰弯冠状面Cobb角分别为 34 6°、12 5° ,自动矫正率为 6 4 7%。最后随访时 ,胸、腰弯的冠状面Cobb角分别为 18 8°、15 9°;腰弯冠状面Cobb角、顶椎偏距及顶椎旋转度与术后相比无显著变化。术后发生胸腰段后凸 1例 ,最终随访时未见进一步加重。无躯干失平衡现象发生。选择性胸椎融合较后路融合双弯平均减少 3 5个融合节段。结论　对腰弯柔韧性好且度数较小的KingⅡ (PUMCⅡb1和部分Ⅱc3)型特发性脊柱侧凸 ,可安全有效地行选择性胸椎融合     

合并胸腰段后凸的青少年特发性脊柱侧凸的临床研究

目的 探讨合并胸腰段后凸的青少年特发性脊柱侧凸(AIS)的临床特点和手术治疗策略. 方法对2001年1月至2007年1月收治的413例AIS患者进行回顾性分析,合并胸腰段后凸者共10例,其中男2例,女8例;年龄12～18岁,平均14.3岁.侧凸类型包括PUMC Ⅱb2型3例,Ⅱc 3型4例,Ⅱd2型1例,Ⅲb型2例.单纯后路内固定术8例,前路松解+后路内固定术2例.术前、术后及随访时摄X线片,对侧凸类型、Cobb角、顶椎旋转度、顶椎偏距、侧凸柔韧性、胸腰段后凸、冠状面及矢状面躯干偏移进行评测和分析.结果 本组患者中双弯8例,三弯2例;胸腰弯/腰弯Cobb角≥45°者7例,柔韧性指数≤70%者6例,顶椎旋转度≥Ⅱ度者9例.所有病例的融合范围均符合PUMC分型原则.手术前后平均胸弯冠状面Cobb角分别为71.7°和37.4°,平均矫正率为47.8%;手术前后平均胸腰弯/腰弯冠状面Cobb角分别为65.0°和27.8°,平均矫正率为57.2%;手术前后平均胸腰段后凸分别为35.5°和4.2°,平均矫正率为88.2%.全部病例随访12～72个月,平均23.1个月;最终随访时无躯干失平衡发生. 结论 合并胸腰段后凸的AIS一般多为双弯或三弯,胸腰弯/腰弯畸形往往比较严重,并有明显的旋转畸形.对合并胸腰段后凸的AIS,应融合胸腰弯/腰弯以防止术后发生失代偿或后凸加重, PUMC分型可以有效识别病变类型并指导融合范围的选择.     

Vertebral column growth in children with early onset scoliosis treated with magnetically controlled growing rods – Effects of distraction on vertebral and disc morphology

ObjectivesTo report changes in vertebral and disc morphology following treatment of early onset scoliosis (EOS) with magnetically controlled growing rods (MCGR).Methods30 Patients, 21 girls and 9 boys, treated with MCGR for EOS were compared to a matched control group of 19 patients (12 girls, 7 boys) treated with bracing or observation. Age at surgery in the MCGR group was 8.75 (range: 4.6–11) years compared to 7.75 (range: 3.5–10.3) years in the control group at the time of onset of treatment. Mean follow-up was 45 (range: 24–65) months in the MCGR group vs 42 (range: 24–65) months in the control group.Calibrated radiographs were used to digitally measure disc height, vertebral body height, depth and width after surgery and at latest follow-up. Height, width and depth of lumbar and thoracic vertebrae and discs under distraction were compared to the control group and to vertebrae below instrumentation. T1-T12, T1-S1 length and Cobb angles were also measured.Results(1) There is a significant increase of lumbar vertebral height under distraction. (2) Lumbar disc height as well as lumbar vertebral width within distraction is significantly reduced. (3) Depth of lumbar vertebrae is not significantly affected by distraction. (4) Morphology of thoracic vertebrae and adjacent discs is not significantly changed with distraction. (5) T1-T12 distance did not show any significant changes between surgical and control group, while T1-S1 growth was significantly reduced compared to the control group.ConclusionsSignificant changes of morphology of lumbar vertebra and discs are observed under distraction with MCGR compared to segments below instrumentation and the control group.Level of evidenceLevel III – retrospective comparative series.     

退变性腰椎侧凸形成和发展的相关因素分析

目的 探讨退变性腰椎侧凸患者椎问盘的不对称指数、腰椎间盘退变程度以及骨密度降低对侧凸角度的影响.方法 采用回顾性研究的方法,选取2002年1月至2010年8月,共96例退变性腰椎侧凸患者为研究对象(侧凸组);2002年1月至2010年8月确诊为腰椎管狭窄症并且资料齐全的患者96例为对照组;两组间性别、年龄、体质量指数匹配.侧凸组:在腰椎正位X线片上测量凸凹侧顶椎间盘及其上下椎间盘的高度和顶椎及其上下椎体的高度,利用Adobe Photoshop 6.0软件,测量MRI图像T2WI顶椎及其上下椎间盘内髓核与脑脊液的相对信号强度.对照组:取2～3、L3-4、L4-5这3个椎间盘为研究对象测定上述指标.应用双能X线吸收法测定两组患者腰椎(L2-4)及股骨颈、股骨粗隆和Ward's三角的T值.结果 侧凸组凸侧椎间盘高度和为(40±7)mm高于凹侧的(28±7)mm(P<0.01),凸侧椎体高度和为(76±12)mm高于凹侧的(72±10)mm(P=0.016):两组之间的椎间盘退变程度差异有统计学差异(P=0.003);两组之间骨密度T值的平均值和骨质疏松的发生率差异有统计学意义(均P<0.01).通过多元线性回归分析结果 显示患者椎间盘的不对称指数、椎间盘的退变程度、骨密度T值影响退变性腰椎侧凸角度.结论 退变性腰椎侧凸常伴有凸凹两侧椎间盘高度以及椎体高度不对称.侧凸角度与椎间盘的不对称指数、椎间盘的退变程度呈正相关,与骨密度值T值呈负相关.

Abstract：

Objectives To investigate the correlation between scoliosis angle and the asymmetric index of degenerative lumbar scoliosis, the degree of intervertebral disc degeneration, decreased bone density. Methods As a retrospectively study, a total of 96 patients with degenerative lumbar scoliosis were retrospectively enrolled from January 2002 to August 2010 as scoliosis group, meanwhile % patients with lumbar spinal stenosis matched in gender, age and body mass index (BMI) were selected as control group.All patients were studied with plain radiographs, MRI and dual energy X-ray absorptiometry at presentation. Radiographic measurements include Cobb angle, the height of the convex and concave side of the apical disc and the contiguous disc superiorly and inferiorly, the height of the convex and concave side of the apical and the contiguous vertebral body superiorly and inferiorly in scoliosis group, the height of L2-3, L3-4, L4-5 discs and the height of L2-4 vertebral body in control group. The average relative signal intensity of lumbar intervertebral disc and cerebrospinal fluid in T2WI sagittal image was measured in apex intervertebral disc and adjacent discs by Adobe Photoshop 6.0 in scoliosis group, which was measured in L2-3, L3-4, L4-5 disc in control group. The bone density of lumbar, femoral neck, trochanter, and Ward's triangle regions were measured with dual-energy X-ray absorptiometry. Results The intervertebral disc height in convex side was greater than the height in the concave side [(40 ± 7) mm vs. (28 ± 7) mm, P < 0. 01] , the vertebral body height in convex side was greater than the height in the concave side [(76 ± 12) mm vs. (72 ± 10) mm, P =0.016] in scoliosis group. There was significant statistically difference in the degenerative degree of intervertebral discs between two groups (P = 0. 003). There was significant statistically difference of the average T-value and the rate of osteoporosis between two groups (P < 0. 01). Multiple linear regression analysis showed that the asymmetric disc index, the degenerative degree of intervertebral disc and osteoporosis were the predominant correlative factors, which affected the development of degenerative lumbar scoliosis. Conclusions Degenerative lumbar scoliosis is always accompanied by the height asymmetry of intervertebral discs and vertebral body from convex and concavity sides. There is positive correlation between the angle of scoliosis and the asymmetric disc index, the degeneration of intervertebral disc, and negative correlation between the angle of scoliosis and the bone density (T-value).     

选择性胸椎融合治疗脊柱侧凸合并脊髓空洞症

目的 评价选择性胸椎融合治疗脊柱侧凸并脊髓空洞症的效果.方法 对2001年1月至2009年1月收治的93例脊柱侧凸并脊髓空洞症患者进行回顾性分析,其中行选择性胸椎融合且术后随访超过2年的患者共11例,男性3例,女性8例;年龄9～21岁,平均14.9岁.侧凸类型包括双弯9例,三弯2例.术前、术后及随访时行X线片检查,对侧凸类型、侧凸Cobb角、顶椎旋转度、顶椎偏距、侧凸柔韧性、躯干偏移进行测量和分析.结果 术前胸腰凸或腰凸Lenke A型2例,LenkeB型7例,Lenke C型2例.手术前后胸凸Cobb角平均值分别为62.6°和19.0°,平均矫正率为69.6%;手术前后胸腰凸或腰凸Cobb角分别为36.1°和11.6°,自动矫正率为67.9%,随访时间24～48个月,平均29.5个月,胸凸矫正丢失率为6.8%.最终随访时有1例发生了冠状面躯干失平衡,有1例发生椎弓根螺钉螺帽脱出,行翻修手术,无神经系统并发症发生.结论 选择性胸椎融合可用于脊柱侧凸并脊髓空洞症患者的手术治疗,这类患者的胸腰凸或腰凸具有与特发性脊柱侧凸类似的自发矫形能力,参照特发性脊柱侧凸的选择性融合标准可获得良好效果.

Abstract：

Objective To evaluate the surgical results of selective thoracic fusion(STF)for scoliosis associated with syringomyelia Methods From January 2001 to January 2009,93 cases of scoliosis associated with syringomyelia were retrospectively reviewed.There were 11 cases who underwent STF and were followed up more than 2 years,which included 8 female and 3 male,the mean age was 14.9 years (9-21 years).Curve type,coronal and sagittal Cobb angle,apical vertebral rotation apical vertebral translation,flexibility,trunk shift were recorded and analyzed.Results There were 9 double curves and 2 triple curves,the Lenke type of thoracolumbar/lumbar curve included Lenke A in 2 cases,Lenke B in 7 cases and Lenke C in 2 cases.The average coronal Cobb angle of thoracic curve before and after surgery were 62.6°and 19.0° respectively,and the average correction rate was 69.6%.The average coronal Cobb angle of thoracolumbar/lumbar curve before and after surgery were 36.1° and 11.6° respectively,and the average spontaneous correction rate was 67.9%.The followed up time ranged from 24 to 48 months(mean 29.5 months),the average loss of correction rate was 6.8%.Only one trunk decompensation was noted at final follow-up.Pedicle screw nut loosening occurred in one patient and this patient underwent revision surgery,no neurological complication was noted at final follow-up.Conclusions STF could be safely performed in scoliosis associated with syringomyelia.Thoracolumbar/lumbar curve in these patients has similar spontaneous correction ability compared with idiopathic scoliosis patients.The satisfactory result could be achieved according to the STF criteria for IS.     

The role of spinal concave–convex biases in the progression of idiopathic scoliosis

Inadequate understanding of risk factors involved in the progression of idiopathic scoliosis restrains initial treatment to observation until the deformity shows signs of significant aggravation. The purpose of this analysis is to explore whether the concave–convex biases associated with scoliosis (local degeneration of the intervertebral discs, nucleus migration, and local increase in trabecular bone-mineral density of vertebral bodies) may be identified as progressive risk factors. Finite element models of a 26° right thoracic scoliotic spine were constructed based on experimental and clinical observations that included growth dynamics governed by mechanical stimulus. Stress distribution over the vertebral growth plates, progression of Cobb angles, and vertebral wedging were explored in models with and without the biases of concave–convex properties. The inclusion of the bias of concave–convex properties within the model both augmented the asymmetrical loading of the vertebral growth plates by up to 37% and further amplified the progression of Cobb angles and vertebral wedging by as much as 5.9° and 0.8°, respectively. Concave–convex biases are factors that influence the progression of scoliotic curves. Quantifying these parameters in a patient with scoliosis may further provide a better clinical assessment of the risk of progression.     

An analysis of the effect of the Zielke operation on S-shaped curves in idiopathic scoliosis. A follow-up study revealing some skeletal and soft tissue factors involved in curve progression

This article analyzes the fate of S-shaped idiopathic spinal curves during follow-up in 18 patients having the Zielke VDS operation. The spinal radiographs were evaluated by Cobb angle, end-vertebra angles (EVAs), vertebral rotation, and by a new method using the tilt of the surgically fused spinal block in the frontal plane. Spinal growth was measured. Using the conventional criterion for Cobb angle progression, 83% of the lower curves and 50% of the upper curves progress. The use of EVAs shows that progression occurs mainly in the middle (thoracolumbar) segment of the spine. Curve progression occurs in the frontal plane without any significant change in vertebral rotation. The progression of the upper curve Cobb angle is not related to the progression of the Cobb angle of the lower curve; but it is related to 1) tilt of the spinal block, 2) growth of the spine below the block and 3) overall linear spinal growth (T1-S1). Progression of the upper EVA of the upper curve is associated with skeletal immaturity. The key features leading to curve progression after the Zielke operation appear to be spinal asymmetry in the frontal plane, linear spinal growth, and concave lumbar muscle tether (myostatic contracture). The surgical implications of the findings are outlined.     

Prediction of curve progression in a goat scoliosis model

OBJECTIVES: Currently, prediction of progression in scoliosis is accomplished by analysis of several factors, which provide only a broad percentage chance, rather than an accurate risk assessment, of deformity progression. A model for prediction of scoliosis progression was investigated using an experimental scoliosis: A goat model was used to predict curve progression based on the percentage of vertebral body wedging in the region of maximal deformity. METHODS: Structural, lordoscoliotic curves of significant magnitude (> or = 30 degrees) convex to the right in the thoracic spine were created in 15 immature goats using a rigid posterior asymmetric tether in combination with convex rib resection and concave rib tethering. At 12 weeks, all posterior tethers were removed, and the goats were observed for an additional 4-week period. Serial radiographs were used to document progression (defined as > or = 5 degrees) and vertebral body wedging within the maximal scoliotic deformity. RESULTS: During the additional 4-week observation period following removal of the tether, seven goats developed progressive curves (mean progression: +10.1 degrees, range: +6 degrees to +17 degrees) and eight goats developed nonprogressive curves (mean: -1.6 degrees, range: -8 degrees to +4 degrees). At the beginning of the observation period, the percentage of vertebral body wedging was 60.4% versus 50.2% in the progressive versus nonprogressive groups (P = 0.002). Thus, at 55.3% vertebral body wedging, prediction of curve progression was possible for 85% of progressors and 88% of nonprogressors. CONCLUSIONS: Prediction of curve progression is often difficult when based on skeletal maturity and curve magnitude alone. In an immature goat scoliosis model, however, in which these two factors are relatively well controlled, curve progression can be predicted based on the percentage of vertebral body wedging in the region of maximal deformity.     

椎体和椎间盘矢状面形态学改变对退变性脊柱后凸畸形的影响

目的：探讨椎体楔形变和椎间盘退变（塌陷）等形态学改变对成人退变性胸腰椎/腰椎后凸畸形的影响。方法：回顾性分析2015年8月至2020年12月收治的32例脊柱退变性胸腰椎/腰椎后凸畸形患者,其中男8例,女24例,年龄48~75（60.3±12.4）岁。在站立位全脊柱正侧位X线片上测量脊柱冠状面侧凸Cobb角和矢状面胸腰椎/腰椎后凸角（kyphosis angle,KA）,评估顶椎（apex vertebral,AV）及顶椎上下各2个椎体（AV-1,AV-2,AV+1,AV+2）与椎间盘（AV-1D,AV-2D,AV+1D,AV+2D）的高度及楔变参数,包括椎体前缘高度（anterior vertebral body height,AVH）,椎体后缘高度（posterior vertebral body height,PVH）,椎体楔变角（vertebral wedge angle,VWA）,椎体楔变率（ratio of vertebral wedging,RVW）;椎间盘前缘高度（anterior disc height,ADH）,椎间盘后缘高度（posterior disc height,PDH）,椎间盘楔变角（disc wedge angle,DWA）,椎间盘楔变率（ratio of disc wedging,RDW）,椎间盘贡献率（DWA/KA）。结果：所纳入患者KA为（44.2±19.1）°,后凸节段内椎体前缘高度均显著低于椎体后缘高度（P<0.05）,提示椎体发生不同程度楔形变;而后凸节段内椎间盘前后缘高度差异无统计学意义。后凸节段内椎体楔变率/贡献率分别为AV-2（14.98±10.95）%/（14.21±8.08）%,AV-1（21.08±12.39）%/（18.09±7.38）%,AV （26.94±11.94）%/（25.52±8.64）%,AV+1（24.19±8.42）%/（20.82±8.69）%,AV+2（20.56±7.80）%/（15.60±9.71）%,椎体总贡献率为（94.23±22.25）%;后凸节段内椎间盘楔变率/贡献率分别为AV-2D （2.88±2.57）%/（5.27±4.11）%,AV-1D （1.98±1.41）%/（2.29±2.16）%,AV+1D （-5.54±3.75）%/（-0.57±0.46）%,AV+2D （-8.27±4.62）%/（-1.22±1.11）%,椎间盘总贡献率（5.77±4.79）%,且顶椎贡献率明显大于邻近椎体贡献率（P<0.05）。结论：椎体楔形变及椎间盘塌陷共同构成了成人退变性胸腰椎/腰椎后凸畸形状态。就对后凸贡献率而言,椎体形态改变对后凸的贡献要远超椎间盘的贡献,且顶椎的楔形变对胸腰椎/腰椎后凸的贡献尤为明显。     

The modulation of spinal growth with nitinol intervertebral stapling in an established swine model

Purpose

Anterior spinal stapling for the treatment of adolescent idiopathic scoliosis has been shown to slow progression in small curves; however, its role in larger curves remains unclear. The purpose of this study was to evaluate the effectiveness of nitinol staples to modulate spinal growth by evaluating the two-dimensional and three-dimensional morphological and histological effects of this method in a well-established porcine model.

Methods

Three immature Yucatan miniature pigs underwent intervertebral stapling. Two staples spanned each of three consecutive mid-thoracic discs and epiphyses. Monthly radiographs were obtained. Computed tomography (CT) was conducted at harvest after 6 months of growth. Measurements of wedging and height for each disc and vertebral body were conducted. Micro CT was used to compare physeal closure between stapled and non-stapled levels. Histology of the growth plate also compared the hypertrophic zone thickness for control and stapled vertebrae.

Results

After 6 months of stapled growth, the average coronal Cobb angle of the stapled segments increased by 7.7 ± 2.0° and kyphosis increased by 3.3 ± 0.6° compared to preoperative curves. Increased vertebral wedging and decreased disc height (p < 0.001) were noted in stapled regions. Overall, 26 ± 23 % of each growth plate was closed in the stapled segments, with 6 ± 8 % closure in the unstapled levels. No difference was observed regarding the hypertrophic zone height when comparing instrumented to uninstrumented levels, nor was a difference recognized when comparing right versus left regions within stapled levels alone.

Conclusions

Six months of nitinol intervertebral stapling created a mild coronal and sagittal deformity associated with reduced vertebral and disc height, and increased coronal vertebral and sagittal disc wedging.     

神经纤维瘤病性脊柱侧凸的治疗

目的回顾性研究45例神经纤维瘤病性脊柱侧凸患者的外科治疗结果,分析侧凸分类与手术效果的关系。方法45例神经纤维瘤病性脊柱侧凸患者,平均年龄14.2岁,平均随访时间6.8年。其中6例为非营养不良型侧凸,39例为营养不良型侧凸。后者按照顶椎位置分为3组:胸弯组、胸腰弯组、单纯腰弯组。根据侧凸类型和位置选择后路脊柱融合或前后路脊柱融合。所有病例行完整的影像学检查,并进行侧弯角度与手术效果之间关系的评估。结果术中平均出血600 m l,平均输血670 m l。在非营养不良组冠状面和矢状面的矫正率分别为61.77%和40.19%,随访平均Cobb角丢失分别为2.9°和5.2°。营养不良组冠状面和矢状面的矫正率胸弯组分别为48.91%和47.74%,随访平均Cobb角丢失分别为4.8°和3.6°;胸腰弯组分别为58.40%和52.00%,随访平均Cobb角丢失分别为6.3°和5.0°。腰弯组冠状面矫正率为65.10%,随访平均Cobb角丢失为12.8°。在45例患者中有6例随访时出现大于10°的角度丢失,3例出现内固定失败,6例进行了共7次翻修手术。结论神经纤维瘤病性脊柱侧凸治疗较为复杂,难度较大。早期积极的手术治疗,是治疗此类侧凸尤其是营养不良型NF-1型侧凸的关键。     

Prospective comparison of flexibility radiographs in adolescent idiopathic scoliosis

STUDY DESIGN: A prospective evaluation of radiographs in patients undergoing anterior spinal fusion or posterior spinal fusion for adolescent idiopathic scoliosis. OBJECTIVE: To determine the most effective preoperative radiographic method for evaluating coronal plane flexibility by comparing preoperative and postoperative correction. SUMMARY OF BACKGROUND DATA: Curve flexibility is traditionally evaluated with side-bending radiographs. Recently, the fulcrum-bending radiograph was shown to provide better correction of thoracic curves undergoing posterior spinal fusion but was not evaluated in thoracolumbar/lumbar curves or in patients undergoing anterior spinal fusion. METHODS: Preoperative coronal radiographs of 46 consecutive patients undergoing spinal fusion for adolescent idiopathic scoliosis obtained while standing, lying supine, side-bending (maximally bending while supine), push-prone (padded bolsters applied to chest wall while prone), and fulcrum-bending (curve apex suspended over a radiolucent fulcrum while lateral) were compared with standing postoperative radiographs. Cobb angles were determined and evaluated for statistical significance. RESULTS: The fulcrum-bending radiograph demonstrated statistically better correction than other preoperative methods for main thoracic curves (P < 0.01) but fell short of demonstrating the correction obtained surgically. There was no statistical difference between side-bending, fulcrum-bending, or postoperative correction for thoracolumbar/lumbar curves (all P values > 0.07). The left side-bending was the most effective method for reducing upper thoracic curves (P < 0.001). There was no difference in the results obtained for curves corrected by anterior spinal fusion or anterior spinal fusion. CONCLUSION: To achieve maximal preoperative correction, thoracic fulcrum-bending radiographs should be obtained for evaluating main thoracic curves, whereas side-bending radiographs should continue to be used for evaluating both upper thoracic and thoracolumbar/lumbar curves.     

Differential rod contouring on thoracolumbar/lumbar curvature in patients with adolescent idiopathic scoliosis: An analysis with intraoperative acquisition of three-dimensional imaging

BackgroundDifferential rod contouring (DRC) is useful for periapical vertebral derotation and decreasing rib hump in patients with thoracic adolescent idiopathic scoliosis (AIS). However, it is unknown whether DRC in the thoracolumbar/lumbar spine also contributes to derotation. We assessed the contributions of rod contouring and of DRC to the reduction of apical axial vertebral body rotation in patients with AIS with thoracolumbar/lumbar curvatures.MethodsForty-five (Lenke type 3 or 4, 17; Lenke type 5 or 6, 28) were analyzed for the contribution of DRC to thoracolumbar/lumbar spinal derotation. Rod contouring was assessed by comparing the preinsertion x-ray with the post-operative CT images. Intraoperative C-arm fluoroscopic scans of the periapical vertebrae of the thoracolumbar/lumbar curve of the scoliosis (135 vertebrae) were taken post-rod rotation (RR) and post-DRC in all patients. Three-dimensional images were automatically reconstructed from the taken x-ray images. The angle of vertebral body rotation in these apical vertebrae was measured, and the contribution of DRC to apical vertebral body derotation and rib hump index (RHi) for lumbar prominence was analyzed.ResultsThe pre-implantation convex rod curvatures of both Lenke 3/4 and 5/6 groups decreased after surgery. The mean further reductions in vertebral rotation with post-RR DRC were 3.7° for Lenke 3/4 and 4.4° for Lenke 5/6 (P < 0.01). Both changes in apical vertebral rotation and in RHi for evaluating lumbar prominence were significantly correlated with the difference between concave and convex rod curvature in preimplantation. Vertebral derotation was significantly higher in curves with a difference >20° (P < 0.05).ConclusionsDRC following rod rotation contributed substantial additional benefit to reducing vertebral rotation and decreasing lumbar prominence in thoracolumbar/lumbar scoliosis.     

Spontaneous regression of curve in immature idiopathic scoliosis - does spinal column play a role to balance? An observation with literature review

Background  

Child with mild scoliosis is always a subject of interest for most orthopaedic surgeons regarding progression. Literature described Hueter-Volkmann theory regarding disc and vertebral wedging, and muscular imbalance for the progression of adolescent idiopathic scoliosis. However, many authors reported spontaneous resolution of curves also without any reason for that and the rate of resolution reported is almost 25%. Purpose of this study was to question the role of paraspinal muscle tuning/balancing mechanism, especially in patients with idiopathic scoliosis with early mild curve, for spontaneous regression or progression as well as changing pattern of curves.     

Annual changes in radiographic indices of the spine in cerebral palsy patients

Purpose

We estimated the annual changes in radiographic indices of the spine in cerebral palsy (CP) patients and analyzed the factors that influence its progression rate.

Methods

We included CP patients who had undergone whole-spine radiography more than twice and were followed for at least 1 year. The scoliosis Cobb angle, coronal balance, apical vertebral translation, apical rotation, and pelvic obliquity were measured on anteroposterior (AP) radiographs; thoracic kyphosis and lumbar lordosis angles, and sagittal balance was measured on lateral radiographs; and migration percentage was measured on AP hip radiographs to determine hip instability. For each gross motor function classification system (GMFCS) level, the Cobb angles, apical vertebral translation, coronal and sagittal balance, and pelvic obliquity were adjusted by multiple factors with a linear mixed model.

Results

A total of 184 patients (774 radiographs) were included in this study. There was no significant annual change in scoliosis Cobb, thoracic kyphosis, and lumbar lordosis angles in the GMFCS level I–II and III groups. In the GMFCS level IV–V group, there was an annual increase of 3.4° in the scoliosis Cobb angle (p = 0.020). The thoracic kyphosis angle increased by 2.2° (p = 0.018) annually in the GMFCS level IV–V group. Apical vertebral translation increased by 5.4 mm (p = 0.029) annually in the GMFCS level IV–V group. Progression of coronal and sagittal balance and pelvic obliquity with aging were not statistically significant. Sex, hip instability, hip surgery, and triradiate cartilage did not affect the progression of scoliosis and the balance of the spine and pelvis.

Conclusions

The scoliosis Cobb angle, thoracic kyphosis angle, and apical vertebral translation in the GMFCS level IV–V CP patients progressed with age. These findings can predict radiographic progression of scoliosis in CP patients.

     

Maintaining lumbar lordosis with anterior single solid-rod instrumentation in thoracolumbar and lumbar adolescent idiopathic scoliosis.

STUDY DESIGN: A prospective radiographic evaluation of 20 consecutive patients with primary lumbar or thoracolumbar adolescent idiopathic scoliosis who were treated with anterior convex compressive single solid-rod spinal instrumentation and structural titanium mesh (Harms) cages. OBJECTIVES: To evaluate a lordosis-preserving anterior single solid-rod instrumented fusion technique for these specific adolescent idiopathic curves. SUMMARY OF BACKGROUND DATA: Maintaining instrumented segmental lumbar lordosis after anterior fusion and instrumentation for thoracolumbar and lumbar curves has been difficult. Twenty consecutive patients who underwent anterior single solid-rod fusion, aged 18 or younger with a primary thoracolumbar or lumbar curve, were observed for preservation of lordosis for a minimum of 2 years. METHODS: All patients underwent an identical anterior surgical technique, involving discectomies and anulectomies of all convex discs, structural titanium mesh (Harms) cages placed in the anterior half of all disc spaces below T12, morselized rib autograft packed in all disc spaces to be fused and inside the cages, and anterior single solid-rod (5.0-mm or 5.5-mm diameter) convex compressive spinal instrumentation with appropriate lordotic rod contour and rod rotation as necessary. The anterior rod was placed just posterior to the cages to optimize lordotic contouring of the spine during compression. None of the patients was braced after surgery. The lowest instrumented vertebrae (LIV) were L2 (n = 3), L3 (n = 15), and L4 (n = 2), typically the lower end vertebra of the Cobb measurement. RESULTS: Measurements for the primary coronal Cobb before surgery, 1 week after surgery, and 2 years after surgery were 48 degrees, 11 degrees, and 12 degrees; for C7 plumb line deviation from the midline: 3.6 cm, 1.9 cm, and 1.2 cm; for lowest instrumented vertebra translation: 31 mm, 15 mm, and 15 mm; and for LIV tilt: 29 degrees, 6 degrees and 6 degrees, respectively. Sagittal measurements before surgery, 1 week after surgery, and 2 years after surgery were: T12-L2: -1 degree, -6 degrees, and -6 degrees; T12-LIV: -8 degrees, -13 degrees, -9 degrees; T12-S1: -61 degrees, -56 degrees, -60 degrees; and entire instrumented levels: -6 degrees, -9 degrees, and -6 degrees, respectively. Coronal plane correction improved: 75% in the primary Cobb, 66% in the plumb line, 50% in LIV translation, and 80% in LIV tilt. Sagittal plane alignment improved in T12-L2 lordosis (P < 0.01) with preservation of physiologic lordosis in the instrumented levels, T12-LIV, and T12-sacrum. There were no instrumentation failures, pseudarthroses, or reoperations. CONCLUSIONS: Coronal plane correction with preservation of thoracolumbar and lumbar lordosis 2 years after anterior convex compressive spinal instrumentation was accomplished using a lordotically contoured single solid rod with structural cages placed anteriorly in the disc spaces of patients with primary thoracolumbar or lumbar adolescent idiopathic scoliosis.     

Comparison of push-prone and lateral-bending radiographs for predicting postoperative coronal alignment in thoracolumbar and lumbar scoliotic curves

STUDY DESIGN: A comparative evaluation of supine right and left lateral-bending radiographs and push-prone radiographs in patients with thoracolumbar and lumbar scoliosis to determine postoperative correction of the curve. OBJECTIVES: To determine the difference in the ability of the push-prone radiograph and the supine lateral-bending radiograph to predict postoperative coronal alignment for primary thoracolumbar and lumbar curves managed with an anterior spinal instrumentation and fusion. SUMMARY OF BACKGROUND DATA: Right and left supine side-bending radiographs are the standard means of evaluating curve flexibility before surgery in idiopathic scoliosis. A push-prone radiograph also has been obtained at the authors' institution as a single dynamic radiographic assessment of forced correction of the primary curve and resultant effects on compensatory curves above and below the fusion. METHODS: Preoperative standing, supine right and left lateral-bending, and push-prone radiographs were performed in 40 patients who underwent anterior spinal instrumentation and fusion. Postoperative standing radiographs of the spine were obtained at 3 months after surgery. Measurements on all the radiographs included the coronal Cobb angle, the angle of the lowest instrumented vertebra to the horizontal, the rotation of the lowest instrumented vertebra, and the distance of the midpoint of the lowest instrumented vertebra from the center sacral line. RESULTS: The lateral-bending and the push-prone radiographs predicted less correction of the Cobb angle and the angle of the lowest instrumented vertebra to the horizontal than was achieved after surgery. However, the push-prone radiograph was superior to the lateral-bending radiograph in accurately predicting the postoperative correction of the rotation of the lowest instrumented vertebra as well as the translation of the lowest instrumented vertebra from the center sacral line. CONCLUSIONS: The push-prone and lateral-bending radiographs are similar in predicting less correction of the Cobb angle after anterior spinal surgery. The push-prone radiograph helps in determining the effects that correction of the primary curve has on the curves above and below the level of fusion by better predicting the translational correction of the lowest instrumented vertebra and the rotation of the lowest instrumented vertebra.