特发性胸椎侧凸选择性融合术后远端叠加现象

【摘要】 目的：探讨主胸弯型青少年特发性脊柱侧凸（adolescent idiopathic scoliosis,AIS）单次前或后路胸弯融合术后远端叠加现象的发生率,并对其影响因素进行分析。方法：回顾性分析110例行单次前或后路主胸弯融合术的主胸弯型（Lenke 1A型）AIS患者。其中男20例,女90例;年龄10～18岁,平均14.2±2.0岁;主胸弯Cobb角40°～80°,平均为48.2°±7.8°。所有患者在术前、术后及术后随访时均摄站立位全脊柱正侧位X线片。测量侧凸Cobb角,记录患者的年龄、Risser征、Y软骨形态、手术方式、稳定椎及融合节段,统计术后远端叠加现象的发生率,分析其影响因素。结果：随访时间为12～46个月,平均21±5个月。术后Cobb角平均为16.7°±6.1°,末次随访时Cobb角平均为22.0°±8.5°。共有19例出现远端叠加现象,发生率为17.3%。与非叠加组相比,叠加组患者的Risser征较低（2.1±1.4∶3.1±1.3,P=0.002）,月经来潮后时间较短（11.2±14.2∶21.9±18.9个月,P=0.002）,代偿性腰弯柔软度较高[（97.0±9.1）%∶（90.5±15.5）%,P=0.017],远端融合椎（LIV）的位置约高出0.8个椎体。关于叠加现象发生率,低Risser征患者高于高Risser征患者,Y软骨开放组高于Y软骨闭合组,月经初潮未至和来潮小于1年组高于月经来潮大于1年组,腰弯高柔软度组高于低柔软度组,LIV高位置组[相对于稳定椎（SV）]高于低位置组。经过Logistic回归分析,LIV-SV≤-2、Y软骨开放和腰弯高柔软度是术后发生远端叠加现象的三个独立的危险因素。结论：部分主胸弯型AIS患者前或后路矫形术后可发生远端叠加现象。LIV的选择、患者的生长发育成熟度和代偿性腰弯的柔软度是影响远端叠加现象的重要因素。     

Lenke 5+型青少年特发性脊柱侧凸患者后路选择性融合术后胸弯的转归

目的:探讨Lenke 5+型脊柱侧凸患者不同融合策略疗效及选择性融合术后胸弯自发矫正情况.方法:回顾性分析2010年1月～2018年12月期间在我院接受手术治疗且随访2年以上Lenke 5+型青少年特发性脊柱侧凸(adolescent idiopathic scoliosis,AIS)患者资料,共80例,男13例,女6...     

Selective fusion in adolescent idiopathic scoliosis: a radiographic evaluation of risk factors for imbalance

ObjectivesTo report on the outcome and evaluate possible risk factors for postoperative complications following selective spinal fusion in patients with adolescent idiopathic scoliosis (AIS).ResultsDuring the 11-year study period, 157 patients with AIS underwent surgery for their progressive spinal deformity. Thirty patients (19 %) had a selective spinal fusion, with 16 patients (group A) having a selective thoracic, and 14 patients (group B) having a selective thoracolumbar/lumbar spinal arthrodesis. In both groups the main postoperative complications were adding-on (25 % group A, 36 % group B) and coronal decompensation (25 % group A, 29 % group B). In group A, no statistically significant risk factors for postoperative complications were identified. In group B, global coronal balance was identified as a significant risk factor for adding-on. Patients with adding-on had significantly higher coronal balance scores (mean 3.6) than those who did not experience adding-on (mean 1.9) (p = 0.03). In addition, those with adding-on had a significantly smaller bending lumbar Cobb angle (mean 15) than those without adding-on (mean 31.6) (p = 0.015). None of the patients who underwent selective spinal fusion required revision surgery.ConclusionAlthough the complication rate after performing a selective spinal fusion is high, the revision rate remains low and the debate whether or not to perform a selective spinal fusion will continue.     

Spontaneous correction of coronal imbalance after selective thoracolumbar-lumbar fusion in patients with Lenke-5C adolescent idiopathic scoliosis

Background Context

Coronal imbalance is a complication of corrective surgeries in adolescent idiopathic scoliosis (AIS). However, few studies about immediate coronal decompensation in Lenke-5C curves have reported its incidence, prognosis, and related factors.

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.     

Selective fusion for adolescent idiopathic scoliosis: a review of current operative strategy

Selective fusion of thoracic and thoracolumbar/lumbar curves in adolescent idiopathic scoliosis is a concept critically debated in the literature. While some surgeons strongly believe that a more rigid and straighter spine provides predictably excellent outcomes, some surgeons recommend a mobile and less straight spine. This topic is a crucial part of surgical treatment of idiopathic scoliosis, particularly in young patients who will deal with the stress of the fusion mass at the proximal and distal junctions over many years. This study will review the literature on various aspects of selective fusion.     

Lenke 3型青少年特发性脊柱侧凸后路矫形术后身高增长的相关影响因素分析

目的:探讨Lenke 3型青少年特发性脊柱侧凸(adolescent idiopathic scoliosis,AIS)患儿脊柱后路矫形术后身高增长(ΔSH)的相关影响因素。方法:选取2014年1月~2016年6月于我院行脊柱后路矫形手术的女性Lenke 3型AIS患儿90例,年龄15.0±2.6岁。于站立位全脊柱正侧位X线片上测量术前、术后的主弯侧凸Cobb角1(最大侧凸Cobb角)、侧凸Cobb角2(次之侧凸Cobb角)、脊柱高度(spinal height,SH)、胸椎后凸角(thoracic kyphosis,TK)及腰椎前凸角(lumbar lordosis,LL)。应用Pearson相关分析ΔSH与其他参数之间的相关性,应用线性回归探讨ΔSH的相关影响因素。结果:ΔSH为2.9±1.0cm。Pearson相关性分析示ΔSH与术前的侧凸Cobb角1(P=0.000)、侧凸Cobb角2(P=0.000)及TK(P=0.023)均呈显著相关性,与术后的侧凸Cobb角1(P=0.000)、侧凸Cobb角2(P=0.000)、LL(P=0.025)、侧凸Cobb角1变化(P=0.000)、侧凸Cobb角2变化(P=0.000)及TK变化(P=0.032)均呈显著相关性。线性回归分析示ΔSH与侧凸Cobb角1变化(P=0.017)、侧凸Cobb角2变化(P=0.001)均呈显著线性相关(R~2=0.333);另外,ΔSH与术前侧凸Cobb角1(P=0.006)、侧凸Cobb角2(P=0.007)、术前TK(P=0.038)亦呈显著线性相关(R~2=0.595)。结论:Lenke 3型AIS患儿脊柱后路矫形术后身高增长的相关影响因素包括术前、术后的主弯侧凸Cobb角、术前TK及其术后变化值。主弯Cobb角矫正是Lenke 3型AIS术后身高增加的最主要影响因素。Lenke 3型AIS患儿的术前侧凸Cobb角及术前TK可以较好地预测患儿术后身高恢复情况。     

Posterior fusion only for thoracic adolescent idiopathic scoliosis of more than 80°: pedicle screws versus hybrid instrumentation

The treatment of thoracic adolescent idiopathic scoliosis (AIS) of more than 80° traditionally consisted of a combined procedure, an anterior release performed through an open thoracotomy followed by a posterior fusion. Recently, some studies have reassessed the role of posterior fusion only as treatment for severe thoracic AIS; the correction rate of the thoracic curves was comparable to most series of combined anterior and posterior surgery, with shorter surgery time and without the negative effect on pulmonary function of anterior transthoracic exposure. Compared with other studies published so far on the use of posterior fusion alone for severe thoracic AIS, the present study examines a larger group of patients (52 cases) reviewed at a longer follow-up (average 6.7 years, range 4.5–8.5 years). The aim of the study was to evaluate the clinical and radiographic outcome of surgical treatment for severe thoracic (>80°) AIS treated with posterior spinal fusion alone, and compare comprehensively the results of posterior fusion with a hybrid construct (proximal hooks and distal pedicle screws) versus a pedicle screw instrumentation. All patients (n = 52) with main thoracic AIS curves greater than 80° (Lenke type 1, 2, 3, and 4), surgically treated between 1996 and 2000 at one institution, by posterior spinal fusion either with hybrid instrumentation (PSF–H group; n = 27 patients), or with pedicle screw-only construct (PSF–S group; n = 25 patients) were reviewed. There were no differences between the two groups in terms of age, Risser’s sign, Cobb preoperative main thoracic (MT) curve magnitude (PSF–H: 92° vs. PSF–S: 88°), or flexibility on bending films (PSF–H: 27% vs. PSF–S: 25%). Statistical analysis was performed using the t test (paired and unpaired), Wilcoxon test for non-parametric paired analysis, and the Mann–Whitney test for non-parametric unpaired analysis. At the last follow-up, the PSF–S group, when compared to the PSF–H group had a final MT correction rate of 52.4 versus 44.52% (P = 0.001), with a loss of −1.9° versus −11.3° (P = 0.0005), a TL/L correction of 50 versus 43% (ns), a greater correction of the lowest instrumented vertebra translation (−1.00 vs. −0.54 cm; P = 0.04), and tilt (−19° vs. −10°; P = 0.005) on the coronal plane. There were no statistically significant differences in sagittal and global coronal alignment between the two groups (C7-S1 offset: PSF–H = 0.5 cm vs. PSF–S = 0 cm). In the hybrid series (27 patients) surgery-related complications necessitated three revision surgeries, whereas in the screw group (25 patients) one revision surgery was performed. No neurological complications or deep wound infection occurred in this series. In conclusion, posterior spinal fusion for severe thoracic AIS with pedicle screws only, when compared to hybrid construct, allowed a greater coronal correction of both main thoracic and secondary lumbar curves, less loss of the postoperative correction achieved, and fewer revision surgeries. Posterior-only fusion with pedicle screws enabled a good and stable correction of severe scoliosis. However, severe curves may be amenable to hybrid instrumentation that produced analogous results to the screws-only constructs concerning patient satisfaction; at the latest follow-up, SRS-30 and SF-36 scores did not show any statistical differences between the two groups. Presented at 8th Annual Meeting of the Spine Society of Europe, October 2006, Istanbul, Turkey.     

Clinical and economic implications of early discharge following posterior spinal fusion for adolescent idiopathic scoliosis

Objective

To evaluate the clinical and economic impact of a novel postoperative pathway following posterior spinal fusion (PSF) in patients with adolescent idiopathic scoliosis (AIS).

Methods

Patient charts were reviewed for demographic data and to determine length of surgery, implant density, use of osteotomies, estimated blood loss, American Society of Anesthesiologists (ASA) score, length of hospital stay, and any subsequent complications. Hospital charges were divided by charge code to evaluate potential savings.

Results

Two hundred and seventy-nine of 365 patients (76.4 %) treated with PSF carried a diagnosis of AIS and had completed 6 months of clinical and radiologic follow-up, a period of time deemed adequate to assess early complications. There was no difference between groups in age at surgery, sex, number of levels fused, or length of follow-up. Patients managed under the accelerated discharge (AD) pathway averaged 1.36 (31.7 %) fewer days of inpatient stay. Operative time was associated with a shorter length of stay. There was no difference in complications between groups. Hospital charges for room and board were significantly less in the AD group ($1.885 vs. $2,779, p < 0.001).

Conclusions

A pathway aimed to expedite discharge following PSF for AIS decreased hospital stay by nearly one-third without any increase in early complication rate. A small but significant decrease in hospital charges was seen following early discharge. Early discharge following PSF for AIS may be achieved without increased risk of complications, while providing a small cost savings.     

Financial analysis of circumferential fusion versus posterior-only with thoracic pedicle screw constructs for main thoracic idiopathic curves between 70° and 100°

Purpose Reports on thoracic pedicle screw (TPS) constructs have demonstrated their safety and efficacy; however, concerns exist regarding their increased cost. This is a review of adolescents with main thoracic scoliosis surgically treated with anterior release and posterior fusion or posterior fusion only. The objectives were to compare the radiographic outcomes and financial data of two surgical treatments: anterior/posterior spinal fusion (APSF) versus posterior spinal fusion (PSF-TPS) alone with TPSs, in patients with large 70–100° main thoracic adolescent idiopathic scoliosis (AIS) curves. Methods We identified 43 patients with main thoracic Lenke type 1–4 AIS curves between 70 and 100° who had been treated with either APSF or PSF-TPS. Results Both groups had equivalent radiographic corrections postoperatively. The PSF-TPS group patients had higher implant charges, but the APSF group had higher surgeon procedural charges, operating room charges, anesthesia charges, and inpatient room charges. Total charges were $75,295 for the APSF group and $71,236 for the PSF-TPS group (P > 0.05). Analyses of two subgroups of the APSF group, anterior release via thoracotomy versus VATS and same-day versus staged surgeries, failed to change any of the above findings. Conclusion Based on this financial analysis, there was no statistically significant differences between the APSF and PSF-TPS groups, with equivalent radiographic corrections.     

后路选择性胸腰弯或腰弯融合治疗Lenke 5C型青少年特发性脊柱侧凸

目的:评价后路选择性胸腰弯或腰弯融合治疗青少年特发性脊柱侧凸(adolescent idiopathic scoliosis,AIS)的临床效果。方法:回顾性分析45例行后路选择性胸腰弯(20例)或腰弯(25例)融合的Lenke 5C型AIS病例,男4例,女41例,平均年龄14.9±2.1岁(12~20岁)。所有病例均行后路椎弓根螺钉内固定矫形融合,平均随访36±20个月(24~105个月)。术前、术后及末次随访时均摄站立位全脊柱正侧位X线片,对躯干偏移、融合节段邻近椎间盘开角、远端融合椎的倾斜、冠状面和矢状面Cobb角进行测量分析。测量数据使用SPSS 17.0统计学软件进行分析。结果:术前胸腰弯或腰弯Cobb角平均47.3°±7.2°,术后矫正至6.4°±4.6°,矫正率(84.8±11.6)%,末次随访时为9.1°±5.4°,矫形丢失2.7°±4.6°。胸弯术前25.7°±7.4°,凸侧Bending像Cobb角7.6°±5.8°,柔韧性(72.7±23.0)%,术后矫正至13.2°±6.7°,自动矫正率(48.5±29.4)%,末次随访14.2°±7.6°,矫形丢失1°±6°。躯干偏移:术前21.3±11.5mm,术后19.5±13.3mm,末次随访10.9±8.9mm。术后近端与远端融合椎邻近椎间盘开角较术后明显减小,且在随访过程中无明显加重。远端融合椎倾斜术后及末次随访时均显著改善。末次随访时,交界性后凸1例,躯干失衡3例,胸弯失代偿并行融合延长手术1例。所有病例末次随访时均未见假关节形成。结论:后路选择性胸腰弯或腰弯融合对Lenke 5C型特发性脊柱侧凸可获得满意矫形效果,胸弯可获得良好的自动矫正,有效缩短了融合节段。     

双侧椎弓根交叉间隔置钉矫形治疗Lenke 1型青少年特发性脊柱侧凸

目的:观察双侧椎弓根交叉间隔置钉矫形治疗Lenke 1型青少年特发性脊柱侧凸(AIS)的临床疗效。方法:2007年1月～2008年12月采用后路双侧椎弓根交叉间隔置钉矫形手术治疗Lenke 1型AIS患者36例,其中男7例,女29例,年龄11～18岁,平均15.3岁,术前胸椎侧凸角度均<75°,且侧凸柔韧性均>50%。测量术前和术后冠状面主胸弯Cobb角、胸椎矢状面Cobb角、C7铅垂线与骶骨正中线(CSVL)的距离、C7铅垂线与S1椎体后上角的垂直距离、双侧肋骨后凸的高度差(RH)、顶椎上下横突侧方5个肋间距总和的左右侧差值(ARSD)、胸弯顶椎椎体外侧缘至两侧胸壁距离的比值(AVB-R),分析临床疗效。结果:手术时间150～240min,平均176min;术中失血量460～1100ml,平均840ml。术中无脊髓、重要神经及血管损伤,1例患者术后出现左侧胸腔积液,2例患者术后2周出现伤口浅表感染。随访1.6～3.2年,平均2.06年。主胸弯冠状面Cobb角由术前56.7°±8.0°矫正为14.1°±6.0°(P<0.05),末次随访(17.2°±3.2°)与术后比较无显著性差异(P>0.05)。胸椎矢状面Cobb角由术前的28.9°±7.9°减小为21.9°±10.6°(P<0.05),末次随访(24.3°±5.1°)与术后比较无显著性差异(P>0.05)。矢状面C7铅垂线与S1椎体后上角的垂直距离由术前-11.7±12.1mm变为术后-1.4±9.4mm(P<0.05),末次随访(-2.7±4.7mm)与术后比较无显著性差异(P>0.05)。RH、ARSD、AVB-R术前分别为37.7±5.8mm、20.1±6.6mm和1.56±0.16,术后分别为19.3±6.9mm、8.1±4.7mm和1.22±0.20,差异有显著性(P<0.05)。C7铅垂线与CSVL的距离术前、术后及末次随访无显著性差异(P>0.05)。随访期间未发现内固定失败征象。结论:双侧椎弓根交叉间隔置钉矫形治疗柔韧性好的轻中度Lenke 1型AIS可以获得良好的三维矫形效果。     

Lenke 5型青少年特发性脊柱侧凸患者前路选择性融合术后腰椎后滑脱的发生率及危险因素分析

目的 ：分析Lenke 5型青少年特发性脊柱侧凸（AIS）患者行前路选择性融合术后腰椎后向滑脱的发生率及其危险因素。方法：回顾性分析2005年1月～2010年12月在我院接受前路选择性胸腰椎融合手术的49例Lenke 5型AIS患者的临床资料。在术前、术后3个月及末次随访时的站立位全脊柱正侧位X线片上测量胸腰弯Cobb角、胸弯Cobb角、腰椎前凸角（lumbar lordosis,LL）、胸椎后凸角（thoracic kyphosis,TK）、胸腰段后凸角（thoracolumbar junctional kyphosis,TJK）、骶骨倾斜角（sacral slope,SS）、骨盆倾斜角（pelvic tilt,PT）、骨盆入射角（pelvic incidence,PI）、C7矢状位垂直距离（C7 sagittal vertical axis,SVA）。统计患者性别、年龄、Risser征、随访时间、融合椎体数、下端固定椎位置。按照Roussouly分型对患者术前矢状面形态进行分型。根据末次随访时发生腰椎后滑脱与否将患者分为滑脱组与非滑脱组。对两组患者术前、术后3个月及末次随访时的各参...     

Anterior surgery for adolescent idiopathic scoliosis

Anterior open scoliosis surgery using the dual rod system is a safe and rather effective procedure for the correction of scoliosis (50–60 %). Thoracic hypokyphosis and rib hump correction with open anterior rather than posterior instrumentation appear to be the better approaches, although the latter is somewhat controversial with current posterior vertebral column derotation devices. In patients with Risser grade 0, hyperkyphosis and adding-on may occur with anterior thoracic spine instrumentation. Anterior thoracoscopic instrumentation provides a similar correction (65 %) with good cosmetic outcomes, but it is associated with a rather high risk of instrumentation (pull-out, pseudoarthrosis) and pulmonary complications. Approximately 80 % of patients with adolescent idiopathic scoliosis (AIS) curves of >70° have restrictive lung disease or smaller than normal lung volumes. AIS patients undergoing anterior thoracotomy or anteroposterior surgery will demonstrate a significant decrease in percentage of predicted lung volumes during follow-up. The thoracoabdominal approach and thoracoscopic approach without thoracoplasty do not produce similar changes in detrimental lung volume. In patients with severe AIS (>90°), posterior-only surgery with TPS provides similar radiographic correction of the deformity (44 %) with better pulmonary function outcomes than anteroposterior surgery. Vascular spinal cord malfunction after segmental vessel ligation during anterior scoliosis surgery has been reported. Based on the current literature, the main indication for open anterior scoliosis instrumentation is Lenke 5C thoracolumbar or lumbar AIS curve with anterior instrumentation typically between T11 and L3.     

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.     

轻中度胸弯型青少年特发性脊柱侧凸患者胸椎后凸角对上胸椎后凸角的影响

目的:探讨轻中度胸弯型青少年特发性脊柱侧凸(adolescent idiopathic scoliosis,AIS)患者胸椎后凸角与上胸椎后凸角的关系,并评估其临床意义。方法:选取在我院就诊的轻中度(Cobb角40°~60°)单胸弯型AIS患者50例、双胸弯型AIS患者50例,均摄站立位脊柱全长正位X线片及上肢抱胸体位下的站立位脊柱全长侧位X线片。测量主胸弯Cobb角、上胸椎(T2~T5)后凸角(upper thoracic kyphosis,UTK)及胸椎(T5~T12)后凸角(total kyphosis,TK)。两种弯型患者分别按TK大小分为两组:A组TK<10°,B组10°≤TK≤40°。分别将两种弯型的A组及B组的参数测量结果进行比较,并对相关参数指标进行Spearman相关分析。结果:在单胸弯型AIS患者中,A组UTK平均为6.9°,B组为9.8°,两组比较有统计学意义(P<0.05);单胸弯AIS患者TK与UTK存在显著性正相关(P<0.05)。在双胸弯型AIS患者中,A组的UTK平均为12.0°,B组为11.9°,两组比较无统计学差异(P>0.05),双胸弯型AIS患者的TK与UTK无显著性相关(P>0.05)。结论:双胸弯型AIS患者的TK对UTK无明显影响;而单胸弯型AIS患者的UTK会随着TK的减小而减小,在对单胸弯型AIS患者进行胸椎融合时,应考虑其对术后矢状面形态重建的影响。     

Current concepts and controversies on adolescent idiopathic scoliosis: Part II

A new era in the surgical treatment of adolescent idiopathic scoliosis (AIS) opened with the introduction of pedicle screw instrumentation, which provides 3-column vertebral fixation and allows major deformity correction on the coronal, sagittal, and axial planes. A steep learning curve can be expected for spinal surgeons to become familiar with pedicle screw placement and correction techniques. Potential complications including injury to adjacent neural, vascular, and visceral structures can occur due to screw misplacement or pull-out during correction maneuvers. These major complications are better recognized as pedicle screw techniques become more popular and may result in serious morbidity and mortality. Extensive laboratory and clinical training is mandatory before pedicle screw techniques in scoliosis surgery are put to practice. Wider application, especially in developing countries, is limited by the high cost of implants. Refined correction techniques are currently developed and these utilize a lesser number of pedicle anchors which are strategically positioned to allow optimum deformity correction while reducing the neurological risk, surgical time, and blood loss, as well as instrumentation cost. Such techniques can be particularly attractive at a time when cost has major implications on provision of health care as they can make scoliosis treatment available to a wider population of patients. Pedicle screw techniques are currently considered the gold standard for scoliosis correction due to their documented superior biomechanical properties and ability to produce improved clinical outcomes as reflected by health-related quality-of-life questionnaires. Ongoing research promises further advances with the future of AIS treatment incorporating genetic counseling and possibly fusionless techniques.     

Minimal invasive surgery techniques for patients with adolescent idiopathic and early onset scoliosis

ObjectiveProvide an update on minimal invasive surgery (MIS) techniques for surgical management of pediatric spine.MethodsMinimal Invasive surgery for pediatric spine deformity has evolved significantly over the past decade. We include updated information about the surgical management of patients with adolescent idiopathic and Early Onset Scoliosis through MIS techniques. We take into consideration the implementation of this technique in Low-to-Middle Income Countries (LMICs).ResultsAlthough MIS began as a technique in adult and degenerative spine, recent publications on MIS in pediatric spine cases report benefits of decreased blood loss and infection incidence, and cosmetic advantages from fewer incision numbers. Adoption of MIS techniques in pediatric spine can be facilitated with pre- and intraoperative use of pertinent medical systems.ConclusionWith appropriate considerations and training, MIS is a safe procedure for pediatric spine correction surgery and can be applicable in LMICs.     

Discrepancy between radiographic shoulder balance and cosmetic shoulder balance in adolescent idiopathic scoliosis patients with double thoracic curve

Shoulder balance is one of the key components to the body deformity in adolescent idiopathic scoliosis (AIS) patients with double thoracic curve and shoulder cosmesis plays an important role in patients’ satisfaction of surgical outcomes. Up to now, only radiographic parameters were used to evaluate the shoulder balance in literatures; no corresponding cosmetic parameters have been developed to evaluate the cosmetic shoulder balance. Meanwhile, we often confronted that perfect radiographic shoulder balance was achieved, but the patients complained about the residual cosmetic deformity. This phenomenon implied that discrepancy may exist between radiographic shoulder balance and cosmetic shoulder balance. The present study was carried out to investigate the correlation between radiographic and clinical cosmetic shoulder balance in AIS patients with double thoracic curve. Thirty-four AIS patients were recruited for this study. All the patients had a double thoracic curve. Six cosmetic parameters––inner shoulder height (SHi), outer shoulder height (SHo), shoulder area index 1 (SAI1), shoulder area index 2 (SAI2), shoulder angle (α1) and axilla angle (α2) were developed and measured on the standing photographs. Also, seven radiographic parameters––T1 tilting (T1), first rib angle (FRA), clavicle angle (CA), coracoid process height (CPH), clavicle-rib cage intersection (CRCI), first rib–clavicle height (FRCH), trapezius length (TL) were measured on the standing posterior–anterior radiographs. Correlation analysis was made between cosmetic parameters and radiographic parameters. SHi was found to be significantly correlated with T1, FRA, CA, CPH, CRCI (P < 0.05), among which FRA had the highest correlation coefficient. SHo was found to be significantly correlated with T1, FRA, CA, CPH, CRCI, FRCH (P < 0.05), among which CRCI had the highest correlation coefficient. However, none of the correlation coefficient was greater than 0.8. The correlation coefficients between radiographic parameters and SAI1, SAI2, α1, α2 were also below 0.8 that were similar with SH. The results indicated that radiographic parameters could only partially reflect the shoulder cosmetic appearances. However, none of the existing parameters can accurately reflect the shoulder cosmetic appearance. As cosmesis is critical important to patients’ satisfaction, spine surgeons should pay more attention to the cosmetic shoulder balance rather than radiographic shoulder balance.     

Lenke 5C型青少年特发性脊柱侧凸病人行后路脊柱融合术后持续性冠状面失衡的危险因素分析

目的 探讨Lenke 5C型青少年特发性脊柱侧凸（adolescent idiopathic scoliosis,AIS）病人行后路脊柱融合术后持续性冠状面失衡（persistent coronal imbalance,PCI）的危险因素。方法 回顾性分析2015年1月至2020年1月在西安交通大学附属红会医院行后路脊柱融合术且随访2年以上的112例Lenke 5C型AIS病人的临床资料。根据病人术后2年的冠状面平衡状态分为PCI组和非PCI组。PCI定义为术后冠状面失衡持续时间≥2年。测量并比较两组病人术前、术后即刻和术后2年的各项冠状面参数和矢状面参数;采用脊柱侧凸研究学会-22评分量表（Scoliosis Research Society-22,SRS-22）评估病人临床疗效。并进一步对上述相关因素进行多元二分类Logistic回归分析确定PCI的独立危险因素。结果 112例病人中,50例（44.6%）术后发生即刻冠状面失衡,其中12例（10.7%）冠状面失衡持续至术后2年。多元二分类Logistic回归分析显示,年龄较大［比值比（odds ratio,OR）=1.841,95%可信区间（confidence interval,CI）：1.147~2.132,P=0.001］、术前胸弯柔韧性较差（OR=1.308,95% CI：1.041~2.015,P=0.016）、术前胸腰弯/腰弯顶椎偏移较大（OR=2.291,95% CI：1.120~4.719,P=0.001）、术前下端固定椎（lowest instrumented vertebra,LIV）倾斜角较大（OR=2.141,95% CI：1.491~3.651,P=0.011）、术后即刻冠状面失衡（OR=5.512,95% CI：4.531~6.891,P=0.001）是发生PCI的独立危险因素。PCI组术后2年SRS-22量表满意度和总分均显著低于非PCI组（P＜0.05）。结论 年龄较大、术前胸弯柔韧性较差、术前胸腰弯/腰弯顶椎偏移较大、术前LIV倾斜角较大和术后即刻冠状面失衡是预测PCI的重要参数。PCI对Lenke 5C型AIS病人后路脊柱融合术后临床效果产生不良影响。