KASS内固定治疗胸腰段脊柱侧凸畸形

[目的]评价应用Kaneda脊柱前路矫形系统(Kaneda anterior scoliosis system,KASS)治疗胸腰椎侧凸畸形的临床疗效。[方法]回顾分析43例脊柱侧凸畸形通过前路椎间盘摘除、松解、椎间植骨融合及KASS内固定矫正侧凸畸形的临床资料,男性17例,女26例。年龄11~24岁(平均14.6岁)。侧弯病因:特发性35例,先天性8例。[结果]所有患者均达到满意矫正效果,平均随访时间为22个月(6个月~4年)。胸腰椎术前侧凸Cobb s角平均为66°(43°~98°),术后矫正至18°(0°~32°),畸形矫正率为91.7%。无明显并发症出现。术后随访3例出现矫正度部分丢失。[结论]KASS内固定系统治疗脊柱侧凸具有能早期矫正畸形,创伤小,融合固定节段少,矫形效果好,维持术后矫正度理想等优点,是一种值得推广的手术方法。     

King Ⅲ型特发性脊柱侧凸经胸侧前方椎体三维矫形术

[目的]探讨King Ⅲ型特发性脊柱侧凸经胸侧前方椎体三维矫形术的治疗效果。[方法]回顾本院2003年9月-2005年9月应用TSRH、CDH-M。等矫形器械对12例青少年King Ⅲ型特发性脊柱侧凸患者经凸侧胸腔于椎体侧前方行椎间松解、椎体三维矫形、植骨融合内固定术的临床资料，分析评价其手术并发症、侧凸矫正率及随访结果。[结果]术后出现肺部并发症2例，1例肺不张，1例呼吸道梗阻。经气管插管和呼吸机辅助呼吸后缓解。所有病例均未出现大血管损伤、脊髓损伤、肺炎和乳糜胸等并发症。术前胸椎Cobb’s角48^o～66^o，平均52．6^o。术后胸椎残余Cobb，s角平均15.2^o，矫正率77．8％。随访12～36个月，平均18．5个月。12例患者均获得了较好的节段性骨融合，矫正率无明显丢失，未发现假关节、内固定松动或断裂、失代偿等并发症。[结论]经胸椎体侧前方二维矫形手术是治疗King Ⅲ型特发性脊柱侧凸畸形的一种较安全、有效的内固定方式。     

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     

King Ⅱ型特发性脊柱侧凸的手术治疗

目的：探讨King Ⅱ型特发性脊柱侧凸患者三维矫形融合节段的选择。方法：1997年7月～2002年6月手术矫形治疗King Ⅱ型特发性脊柱侧凸患者79例，平均年龄14．3岁，其中King Ⅱ A型28例，均行选择性胸椎融合，平均融合椎体8．5个；King ⅡB型51例，均固定融合胸椎与腰椎，平均融合椎体11．8个。结果：术后平均随访35个月(12～57个月)，King ⅡA型胸弯矫正率为56％，King ⅡB型的胸弯矫正率为67％，腰弯矫正率为60％。共有5例躯干失平衡并发症，其余患者均获得较好的躯干平衡和矫形效果。结论：KingII型特发性脊柱侧凸进行选择性胸椎融合是可行的，但应慎重。     

全节段椎弓根螺钉固定矫形术治疗退变性腰椎侧凸

[目的]评价采用全节段椎弓根螺钉固定矫形术治疗退变性腰椎侧凸的临床疗效。[方法]回顾性分析本院从2001年1月～2005年1月收治的退变性腰椎侧凸患者54例。共计分为2组，甲组15例，乙组39例，甲组未行椎间融合单纯行PLF手术，乙组采用椎间融合行PLIF技术。其中男性23例，女性31例，对其临床资料进行比较，分析退变性腰椎侧凸的矫正效果、并发症和随访结果。[结果]全部病例都获得了临床随访，随访时间平均2．1年，疼痛缓解率为31％和75％，临床症状改善率75％和80％。术后并发症包括矫正效果丢失1例，但无椎间隙塌陷、椎间融合器移位、断钉断棒等发生。[结论]后路全节段椎弓根内固定矫形和椎间融合内固定术是治疗退变性腰椎侧凸的有效方法之一。     

退变性症状性腰椎侧凸的手术治疗

[目的]探讨后路椎管减压、椎弓根螺钉间断固定、椎间植骨融合、矢状位重建术式治疗退变性症状性腰椎侧凸的临床效果。[方法]1999年1月-2006年4月，采用经后路椎管减压、椎弓根螺钉间断固定、椎间植骨融合、矢状位重建术式治疗退变性症状性腰椎侧凸37例，男21例，女16例；年龄51—82岁，平均62．6岁。所有病例拍摄腰椎正侧位片及Bending片，常规备CT和MRI。根据患者下肢症状行全椎板或半椎板减压，神经根扩大，椎间植骨融合及椎弓根螺钉间断固定。[结果]本组病例均获随访（1—6年，平均2年零7个月），术后临床症状均明显缓解，按JOA评分，手术疗效优良率91．9％，侧凸平均矫正率54．8％。随访期间无明显矫正度数及椎间隙高度丢失，术后3个月、1年复查X片内置物无松动及断裂，植骨融合时间平均11．6周。[结论]对于退变性症状性腰椎侧凸患者：（1）采取个体化治疗，年龄不是绝对手术禁忌证，病程长短不是决定手术疗效的重要指标；（2）后路椎管减压、椎弓根螺钉间断固定、椎间植骨融合、矢状位重建术是安全有效的理想术式。     

King Ⅱ型脊柱侧凸的认识和融合区选择

目的：探讨选择性胸椎后融合术治疗ＫｉｎｇⅡ型侧凸的疗效。方法：对８０例特发性脊柱侧凸病例复习和对其中２２例ＫｉｎｇⅡ型侧凸患者治疗结果进行随访。２２例中８例实行了选择性胸椎后融合术，１４例实行了未经选择的脊柱后融合术，将二者做对比。结果：应用选择性胸椎后融合术治疗ＫｉｎｇⅡ型侧凸不仅减少融合范围，并可使腰段弯曲得到自然矫正同时又保留了腰椎的正常活动。结论：认为Ｋｉｎｇ分型对特发性脊柱侧凸中胸弯和胸腰双弯曲的融合区选择有指导意义，强调了ＫｉｎｇⅡ型侧凸融合区选择中对稳定椎识别的重要性     

全节段椎弓根螺钉系统矫治青少年特发性胸腰椎/腰椎侧凸的疗效

目的:探讨采用单纯后路广泛松解技术联合侧凸全节段椎弓根螺钉系统治疗青少年特发性胸腰椎和腰椎脊柱侧凸的疗效。方法:我院于2002年4月至2005年7月连续收治了114例(女86例,男28例)青少年特发性胸腰椎和腰椎脊柱侧凸患者,其中Lenke5型72例,Lenke6型32例,Lenke3C型10例。全部采用后路广泛松解技术联合椎弓根螺钉系统治疗。手术前后在X线正侧位片上测量冠状位Cobb角,矢状面胸椎后凸角和腰椎前凸角,最下端融合椎冠状面成角,骶骨中垂线与融合下端椎、顶椎及C7中垂线平均距离,并观察各种并发症情况。结果:共置入1460枚椎弓根螺钉,平均融合9.6个椎体(5～14个)。冠状面平均矫正率为78.6%(61°减少到13°),矢状面腰椎前凸角从36°(23°～67°)增加到42°(34°～55°)。最下端融合椎冠状面成角矫正率达79%,骶骨中垂线与融合下端椎距离从2.3cm减少到0.5cm,与顶椎距离从5.0cm缩短到1.6cm;C7中垂线与骶骨中垂线距离由2.7cm减少到0.8cm。术后平均随访时间为30个月(12～50个月),未发现假关节形成、深部感染,且无明显矫形丢失。结论:后路广泛松解联合全节段椎弓根螺钉系统治疗青少年特发性胸腰椎/腰椎侧凸效果满意。     

经后路多点锚定技术治疗Ⅰ型神经纤维瘤病伴营养不良性脊柱侧凸的临床疗效

[目的]探讨经后路多点锚定技术治疗Ⅰ型神经纤维瘤病伴营养不良性脊柱侧凸的临床疗效。[方法]回顾性研究2005年1月~2013年12月本科收治的Ⅰ型神经纤维瘤病伴营养不良性脊柱侧凸23例;年龄10~22岁,平均13.6岁;其中胸弯13例,胸腰双主弯4例,胸腰弯3例,双胸弯2例,腰弯1例;术前冠状面Cobb角48.9°~91.4°,平均68.3°;凸侧Bending相Cobb角40°~79.2°,平均57.4°;柔韧性8.3%~28.1%,平均15.7%;顶椎旋转度2°~3°,平均2.3°;矢状面胸椎后凸Cobb角46.4°~79.6°,平均58.2°,胸腰段后凸Cobb角21.1°~35.7°,平均28.3°。均采用经后路多点锚定技术进行矫形融合固定。[结果]随访12~96个月,平均52个月。术后冠状面Cobb角16.3°~46.7°,平均28.4°;顶椎旋转度1°~2°,平均1.2°;矢状面胸椎后凸Cobb角16.1°~38.3°,平均25.3°,胸腰段后凸Cobb角-4.3°~18.7°,平均8.9°;术后各指标均获得良好的矫正,侧凸矫正率为46.3%~74.1%,平均56.9%。末次随访时侧凸矫正丢失率仅3.1%,无神经系统并发症,仅1例假关节形成。[结论]经后路多点锚定技术治疗Ⅰ型神经纤维瘤病伴营养不良性脊柱侧凸可获得较满意的矫形融合效果。     

采用关键椎置钉及选择性融合治疗Lenke6型AIS可行性的有限元分析

[目的]通过有限元模型矫形手术模拟的方法探讨关键椎置钉技术的可行性及矫形效果,分析Lenke 6型脊柱侧凸是否适合采用选择性融合策略.[方法]通过CT图像建立1例Lenke 6型特发性脊柱侧凸三维有限元模型,并验证其有效性后,利用后路CD矫形手术模拟技术,分别模拟全节段椎弓根钉技术矫形工况、关键椎置钉技术矫形工况、胸腰弯选择性融合工况等.测量各种工况完成后双弯Cobb角度、计算矫形率,分析各种工况的矫形效果.[结果]全节段椎弓根钉技术(非选择性融合):胸腰弯矫形率47.8％,主胸弯矫形率43.9％;关键椎置钉技术:胸腰弯矫形率44.2％,主胸弯矫形率19.1％;胸腰弯选择性融合:胸腰弯矫形率43.5％,主胸弯矫形率14.3％.[结论]全节段椎弓根钉技术因矫形力施加点更多,矫形效果较关键椎置钉技术更佳;Lenke 6型脊柱侧凸采用选择性融合策略应慎重,非选择性融合策略能明显矫正双弯,纠正脊柱序列,更适合该类型病例.     

Radiographic evaluation of selective anterior thoracolumbar or lumbar fusion for adolescent idiopathic scoliosis

According to Lenke classification of adolescent idiopathic scoliosis (AIS), patients with type 5 curve in which the structural major curve is thoracolumbar or lumbar curve with nonstructural proximal thoracic and main thoracic curves, could be surgically treated with selective anterior thoracolumbar or lumbar (TL/L) fusion. This study retrospectively analyzed the radiographies of selective anterior TL/L fusion in 35 cases of AIS with Lenke type 5 curve. Segmental fixation with a single rigid rod through anterior thoracoabdominal approach was applied in all patients. Measurements of scoliosis curve in preoperative, immediate postoperative and follow-up radiographies were analyzed. The average follow up time was 36 months (24-42 months). The average preoperative Cobb angle of the TL/L curve was 45.6 degrees and improved into 9.7 degrees immediate postoperatively, with 79.7% curve correction. In addition, the minor thoracic curve decreased from 29.7 degrees preoperatively to 17.6 degrees postoperatively, with a spontaneous correction of 41.5%. During the follow-up, a loss of 4.6 degrees correction was found and the average Cobb angle of TL/L increased to 14.4 degrees . Also, the minor thoracic curve increased to average 20.1 degrees with a loss of 2.4 degrees correction. Trunk shift deteriorated slightly immediate postoperatively and improved at the follow-up. The lowest instrumented vertebra (LIV) tilt was improved significantly and maintained its results at the follow-up. During the follow-up, the coronal disc angle immediately above the upper instrumented vertebra (UIVDA) and below the LIV (LIVDA) aggravated, while the sagittal contours of T5-T12 and T10-L2 were well maintained. The lumbar lordosis of L1-S1 and the sagittal Cobb angle of the instrumented segments were reduced slightly postoperatively and at the follow-up. There were no major complications or pseudarthrosis. The outcomes of this study show that selective anterior thoracolumbar or lumbar fusion with solid rod instrumentation is effective for surgical correction of AIS with Lenke type 5 curve. The TL/L curve, minor thoracic curve, and LIV title can be improved significantly, with good maintenance of sagittal contour. However, the UIVDA and LIVDA aggravate postoperatively when the trunk rebalances itself during follow-up. The degeneration of LIV disc warrants longer-term follow-up.     

Short anterior correction of the thoracolumbar/lumbar curve in King 1 idiopathic scoliosis: the behaviour of the instrumented and non-instrumented curves and the trunk balance

This is a retrospective clinical, radiological and patient outcome assessment of 21 consecutive patients with King 1 idiopathic adolescent scoliosis treated by short anterior selective fusion of the major thoracolumbar/lumbar (TL/L) curve. Three-dimensional changes of both curves, changes in trunk balance and rib hump were evaluated. The minimal follow-up was 24 months (max. 83). The Cobb angle of the TL/L curve was 52 degrees (45-67 degrees) with a flexibility of 72% (40-100%). The average length of the main curve was 5 (3-8) segments. An average of 3 (2-4) segments was fused using rigid single rod implants with side-loading screws. The Cobb angle of the thoracic curve was 33 degrees (18-50 degrees) with a flexibility of 69% (29-100%). The thoracic curve in bending was less than 20 degrees in 17 patients, and 20-25 degrees in 4 patients. In the TL/L curve there was an improvement of the Cobb angle of 67%, of the apex vertebral rotation of 51% and of the apex vertebral translation of 74%. The Cobb angle of the thoracic curve improved 29% spontaneously. Shoulder balance improved significantly from an average preoperative imbalance of 14.5-3.1 mm at the last follow-up. Seventy-five percent of the patients with preoperative positive shoulder imbalance (higher on the side of the thoracic curve) had levelled shoulders at the last follow-up. C7 offset improved from a preoperative 19.8 (0-40) to 4.8 (0-18) mm at the last follow-up. There were no significant changes in rotation, translation of the thoracic curve and the clinical rib hump. There were no significant changes in thoracic kyphosis or lumbar lordosis. The average score of the SRS-24 questionnaire at the last follow-up was 91 points (max. 120). We conclude that short anterior selective fusion of the TL/L curve in King 1 scoliosis with a thoracic curve bending to 25 degrees or less (Type 5 according to Lenke classification) results in a satisfactory correction and a balanced spine. Short fusions leave enough mobile lumbar segments for the establishment of global spinal balance. A positive shoulder imbalance is not a contraindication for this procedure. Structural interbody grafts are not necessary to maintain lumbar lordosis.     

Coronal deformity correction in adolescent idiopathic scoliosis patients using the fulcrum-bending radiograph: a prospective comparative analysis of the proximal thoracic, main thoracic, and thoracolumbar/lumbar curves

The aim of the prospective, comparative radiographic analysis was to determine the role of the fulcrum-bending radiograph (FBR) for the assessment of the proximal thoracic (PT), main thoracic (MT), and the thoracolumbar/lumbar (TL/L) curves in patients undergoing posterior spinal pedicle screw fixation and fusion for adolescent idiopathic scoliosis (AIS). The FBR demonstrated statistically better correction than other preoperative methods for the assessment of frontal plane correction of the MT curves. The fulcrum-bending correction index (FBCI) has been considered a superior method than the correction rate for comparing curve correction undergoing posterior spinal fusion because it accounts for the curve flexibility. However, their applicability to assess the PT and TL/L curves in AIS patients remains speculative. The relation between FBR and correction obtained by pedicle screws fixation is still unknown. Thirty-eight consecutive AIS patients who underwent pedicle screw fixation and posterior fusion were included in this study. The assessment of preoperative radiographs included standing posterior–anterior (PA), FBR, supine side-bending, and postoperative standing PA and lateral plain radiographs. The flexibility of the curve, as well as the FBCI, was calculated for all patients. Postoperatively, radiographs were assessed at immediate (i.e. 1 week), 3-month, 6-month, 12-month, and 2-year follow-up. Cobb angles were obtained from the PT, MT, and TL/L curves. The study consisted of 9 PT, 37 MT, and 12 TL/L curves, with a mean age of 15.1 years. The mean FBR flexibility of the PT, MT, and the TL/L curves was 42.6, 61.1, and 66.2%, respectively. The mean operative correction rates in the PT, MT, and TL/L curves were 43.4, 69.3, and 73.9%, respectively, and the mean FBCI was 103.8, 117.0, and 114.8%, respectively. Fulcrum-bending flexibility was positively correlated with the operative correction rate in PT, MT, and TL/L curves. Although the correction rate in MT and TL/L curves was higher than PT curves, the FBCI in PT, MT, and TL/L curves was not significantly different (p < 0.05). The FBR can be used to assist in the assessment of PT, MT, and TL/L curve corrections in AIS patients. When curve flexibility is taken into account by FBR, the ability of pedicle screws to correct PT, MT, and TL/L curves is the same.     

Prognosis of spontaneous thoracic curve correction after the selective anterior fusion of thoracolumbar/lumbar (Lenke 5C) curves in idiopathic scoliosis

Background contextPrognosis of minor lumbar curve correction after selective thoracic fusion in idiopathic scoliosis is well defined. However, the prognosis of minor thoracic curve after isolated anterior fusion of the major lumbar curve has not been well described.PurposeTo define the prognosis of spontaneous thoracic curve correction after selective anterior fusion of the lumbar/thoracolumbar curve in idiopathic scoliosis.Study designA retrospective cohort study on the prognosis of the minor curve after selective anterior correction and fusion of the lumbar/thoracolumbar curve in idiopathic scoliosis.Patient sampleIdiopathic lumbar scoliosis patients treated with anterior spinal fusion.Outcome measuresThe Scoliosis Research Society 22 questionnaire was used as an outcome measure at the final follow-up.MethodsTwenty-eight patients were included in this study. Four patients were male, 24 patients were female, and average age at the time of surgery was 16 years. Mean follow-up was 48 months. According to the Lenke Classification, 22 patients were 5CN, 5 were 5C?, and 1 was 5C+. All operations were performed in the same institution. Standing long posterior-anterior and lateral radiographs were taken just before surgery, 1 week after surgery, and at final follow-up.ResultsThe mean preoperative Cobb angle of the lumbar (major) curve was 53° (standard deviation [SD]=8.6) and that of the thoracic (minor) curve was 38.4° (SD=6.24). The lumbar and thoracic curves were corrected to 10° (SD=7.6) and 25° (SD=8.3) postoperatively and measured 17° (SD=10.6) and 27° (SD=7.7), respectively, at the last follow-up. There was a significant difference between the preoperative and postoperative measurements of the minor curves (p<.05). However, there was no significant difference between the early postoperative and the final follow-up measurements (p>.05). Regarding the overall sagittal balance, there was no significant difference between preoperative, early, and late postoperative measurements (p>.05).ConclusionsSelective anterior fusion of the major thoracolumbar/lumbar curve was an effective method for the treatment of Lenke Type 5C curves. Minor thoracic curves did not progress after selective fusion of thoracolumbar/lumbar curves in minimum 2-year follow-up.     

Anterior surgery with short fusion using the Zielke procedure for thoracic scoliosis: focus on the correction of compensatory curves

Anterior instrumentation is recommended to correct idiopathic thoracolumbar or lumbar scoliosis through short fusion within the major curve. Only a few reports exist of anterior surgical correction for thoracic scoliosis. This study assessed the results of Zielke instrumentation for thoracic curve and analyzed the three-dimensional correction of deformity, especially correction of the uninstrumented compensatory curve. Seventeen patients, who had undergone selective thoracic correction and fusion using the Zielke procedure to treat thoracic scoliosis, had been followed for at least 3 years. Three-dimensional correction was evaluated radiographically. Furthermore, three-dimensional back deformities were evaluated using a topographic body scanner. Twelve patients with a single thoracic curve and five with a double curve were all female, with a mean age of 14.6 years. The preoperative main thoracic curve was 54.8 degrees +/- 10.5 degrees (range, 40-78 degrees), and it was 23.8 degrees +/- 10.5 degrees (range, 7-40 degrees) at the final follow-up examination (p < 0.0001). The average correction rate of the main curves was 56.6%. By correcting the thoracic curve, the upper and lower compensatory curves were corrected spontaneously without surgical instrumentation, with average correction rates of 45.1% and 50.2%, respectively. The average correction loss of the main curve was 2.3 degrees. The hump angle measured using a topographic body scanner decreased from 12.8 degrees +/- 4.5 degrees to 8.4 degrees +/- 4.3 degrees after surgery (p = 0.0001). Of the three patients in whom the rod broke up, only one showed a correction loss of 10 degrees; however, bony fusion was obtained. Anterior short fusion for thoracic scoliosis appears to offer significant correction, stabilization, and spontaneous correction of the compensatory lumbar curve without limiting lumbar motion.     

Selective ventral derotation spondylodesis in idiopathic thoracic scoliosis: a prospective study

AIM: Radiometric curve analysis of instrumented primary and spontaneous secondary curve correction after anterior correction and fusion of idiopathic thoracic scoliosis. METHOD: Sixty-four patients with idiopathic thoracic scoliosis were prospectively evaluated. All patients were operated either with the Zielke-VDS or with a primary stable double rod instrumentation with selective fusion of the thoracic curve from end-to end-vertebra. Follow-up averaged 29 months (24 - 52 months). RESULTS: The Cobb angle of the primary curve averaged 63.2 degrees preoperatively and was corrected to 21.4 degrees postoperatively with an average loss of correction of 5.3 degrees (58 % final curve correction). Apical thoracic vertebral rotation was corrected by 48 %. The secondary lumbar curve measured 38.2 degrees preoperatively (72 % correction on the bending films) and was spontaneously corrected by 57 % to 16.4 degrees without significant loss of correction in the final follow-up. Apical vertebral rotation averaged 11.3 degrees in the lumbar curve and was corrected spontaneously by 24 % to 8.6 degrees without significant loss of correction. Lumbar apex vertebra deviation showed no significant reduction. There was no case of lumbar curve decompensation in either frontal or sagittal plane. Implant related complications were observed in 7 patients (rod breakage), but no pseudarthrosis occurred. There were no neurological complications noted. CONCLUSION: Selective anterior correction and fusion in idiopathic thoracic scoliosis enables a satisfactory correction of both primary and lumbar secondary curves. The advantage of selective anterior correction and fusion of thoracic scoliosis is the short fusion length, better derotation and satisfactory correction of the secondary lumbar curve. The disadvantages of single threaded rod techniques in terms of lack of primary stability and a kyphogenic effect have been eliminated by the development of a primary stable, small size double rod instrumentation.     

Postoperative Trunk Shift in Lenke 1C Scoliosis: What Causes It? How Can It Be Prevented?

STUDY DESIGN.: A risk factor analysis study. OBJECTIVE.: To identify the causative factors for postoperative trunk shift in Lenke 1C scoliosis and investigate how to prevent it. SUMMARY OF BACKGROUND DATA.: When selective thoracic fusion is performed, postoperative trunk shift is a significant problem in the management of Lenke 1C scoliosis. It is often accompanied by unsatisfactory clinical outcomes and a risk of reoperation. METHODS.: We reviewed all the patients with adolescent idiopathic scoliosis (AIS) surgically treated in our institution from 2002 through 2008. Inclusion criteria were as follows: (1) patients with Lenke 1C curves who were treated with selective thoracic fusion using posterior pedicle screw-only constructs; (2) the lowest instrumented vertebra (LIV) ending at L1 level or above; and (3) 2-year radiographical follow-up. Eighteen radiographical parameters were chosen as potential risk factors. The 18 parameters measured (1) amount of correction obtained by surgery; (2) preoperative position of LIV; (3) magnitude of major thoracic and thoracolumbar/lumbar (MT and TL/L) curves and ratio of MT: TL/L curve; and (4) curve flexibility. Both comparative and correlation analyses were performed. Those parameters that had shown highest correlation with the 2-year thoracic apical vertebra-center sacral vertical line (AV-CSVL) distance were selected to form a linear regression model, by which the correlations were quantified. RESULTS.: Of the 278 patients reviewed, 44 met the inclusion criteria. The parameters that measured the preoperative position of LIV and ratio of MT: TL/L curve showed high correlation with the 2-year thoracic AV-CSVL distance. With regard to the parameters that measured the amount of correction obtained by surgery, only the correction of the thoracic AV-T1 distance showed low correlation. Among the 18 parameters, preoperative lowest instrumented vertebra-lower end vertebra (LIV-LEV) difference and ratio of MT: TL/L Cobb angle were selected to form a formula to help predict postoperative trunk shift. The formula was as follows: 2-year thoracic AV-CSVL distance = -26.6 + 22.7 (ratio of MT: TL/L Cobb angle) - 3.9 (preoperative LIV-LEV difference). The model R = 0.55. CONCLUSION.: Both LIV selection and ratio of MT: TL/L curve were found to be highly correlated with the onset of postoperative trunk shift in Lenke 1C scoliosis. Amount of correction obtained by surgery, however, did not seem to be an independent causative factor. Postoperative trunk shift is less likely to occur when selecting LEV as LIV and the ratio of MT: TL/L Cobb angle of 1.2° or more.     

选择性前路胸腰段或腰段融合治疗青少年特发性脊柱侧凸

目的 评价选择性前路胸腰段或腰段融合治疗PUMCⅡd1型(Lenke5型)青少年特发性脊柱侧凸(AIS)的临床效果. 方法回顾性分析35例行选择性前路胸腰段或腰段融合的PUMCⅡd1型(Lenke5型)AIS病例.所有病例均行前路单棒节段性固定融合,随访18～42个月,平均36个月.术前、术后及随访时均摄站立位全脊柱正侧位X线片,对躯干偏移、上下融合椎邻近椎间盘开角、下固定椎的倾斜、冠状面和矢状面Cobb角进行测量分析.测量数据使用SPSS 11.0统计学软件进行分析.结果 胸腰弯或腰弯冠状面Cobb角术前平均45.6°,术后9.7°,末次随访14.4°.胸弯冠状面Cobb角术前平均29.7°,术后17.6°,末次随访20.1°.躯干偏移术前平均14.0 mm,术后14.8 mm,末次随访5.1 mm.下端固定椎(LIV)倾斜术前平均-21.8°,术后-1.5°,末次随访-2.1°.冠状面上端固定椎(UIV)上位椎间盘开角(UIVDA)及LIV下位椎间盘开角(LIVDA)术前分别为0.5°和0.6°,术后为0.9°和4.9°,末次随访时均显著加重,为3.0°和7.8°.矢状面胸段(T5～12)及胸腰段(T10～L2)曲度术后及末次随访时均保持良好.矢状面腰前凸(L1～S1)及固定融合节段Cobb角在术后有所减小,末次随访时均保持良好.所有病例末次随访时均未见假关节形成及其他并发症. 结论 选择性前路胸腰段或腰段融合是治疗PUMCⅡd1型(Lenke 5型)AIS的安全、有效的方法,融合节段上、下椎间盘开角增加及部分病例残余胸弯过大现象需进一步随访评估.     

重度脊柱双侧凸的前后路手术治疗

目的: 通过前后路二次手术治疗重度脊柱双侧凸, 评价其治疗效果。方法: 1999年12月至今, 16例重度双侧凸患者, 采用前后路两次手术矫形, 矫正其在冠状面和矢状面的畸形。结果: 16例病例通过手术矫形, 胸段侧凸矫正率79%, 腰段83%, 腰椎后凸恢复成生理前凸, 椎体旋转度提高Ⅱ~Ⅲ度。结论: 通过前后路分次手术矫形, 可以对严重的、复杂的畸形进行有效的矫正, 彻底改变严重畸形的外观, 达到了良好的手术效果。     

Comparative analysis of pedicle screw and hook instrumentation in posterior correction and fusion of idiopathic thoracic scoliosis

Posterior correction and fusion with segmental hook instrumentation represent the gold standard in the surgical treatment of progressive idiopathic thoracic scoliosis. However, there is a debate over whether pedicle screws are safe in scoliosis surgery and whether their usage might enable a better curve correction and a shorter fusion length. The details of curve correction, fusion length and complication rate of 99 patients with idiopathic thoracic scoliosis treated with either hook or pedicle screw instrumentation were analyzed. Forty-nine patients had been operated with the Cotrel-Dubousset system using hooks exclusively ("hook group"). Fifty patients had been operated with either a combination of pedicle screws in the lumbar and lower thoracic and hooks in the upper thoracic spine or exclusive pedicle screw instrumentation using the Münster Posterior Double Rod System ("screw group"). The preoperative Cobb angle averaged 61.3 degrees (range 40 degrees-84 degrees ) in the hook group and 62.5 degrees (range 43 degrees-94 degrees ) in the screw group. Average primary curve correction was 51.7% in the hook group and 55.8% in the screw group ( P>0.05). However, at follow-up (2-12 years later) primary curve correction was significantly greater ( P=0.001) in the screw group (at 50.1%) compared to the hook group (at 41.1%). Secondary lumbar curve correction was significantly greater ( P=0.04) in the screw group (54.9%) compared to the hook group (46.9%). Correction of the apical vertebral rotation according to Perdriolle was minimal in both groups. Apical vertebral translation was corrected by 42.0% in the hook group and 55.6% in the screw group ( P=0.008). Correction of the tilt of the lowest instrumented vertebra averaged 48.1% in the hook group and 66.2% in the screw group ( P=0.0004). There were no differences concerning correction of the sagittal plane deformity between the two groups. Fusion length was, on average, 0.6 segments shorter in the screw group compared to the hook group ( P=0.03). With pedicle screws, the lowest instrumented vertebra was usually one below the lower end vertebra, whereas in the hook group it was between one and two vertebrae below the lower end vertebra. Both operative time and intraoperative blood loss were significantly higher in the hook group ( P<0.0001). One pedicle screw at T5 was exchanged due to the direct proximity to the aorta. There were no neurologic complications related to pedicle screw instrumentation. Pedicle screw instrumentation alone or in combination with proximal hook instrumentation offers a significantly better primary and secondary curve correction in idiopathic thoracic scoliosis and enables a significantly shorter fusion length.