青少年特发性脊柱侧凸患者术后生活质量的影响因素分析

[目的]分析各因素对青少年特发性脊柱侧凸患者术后生活质量的综合影响,为提高患者生活质量提供参考。[方法]选择2011年1月~2015年1月在本院手术的青少年特发性脊柱侧凸患者79例,之前均未接受任何治疗,详细统计患者性别、年龄、居住地、胸弯Cobb角、腰弯Cobb角、冠状面C_7铅垂线与骶骨正中线距离、矢状面C_7铅垂线与骶骨后上角距离、顶椎旋转度、双肩平衡等,采用SRS-30生活质量问卷进行评估,而后用多重线性回归模型预测各因素与青少年特发性脊柱侧凸患者术后生活质量的相关性。[结果]患者术后均获得不同程度改善,术后胸弯Cobb角平均20.7°,腰弯Cobb角平均12.8°,双肩高度差平均6.8 mm,C_7PL-CSVL平均13.7 mm,SVA平均22.9 mm,术后患者生活质量总分128.3分,各维度平均得分分别为疼痛(4.53)、心理(4.46)、功能/活动(3.73)、自我形象(4.28)、满意度(4.45)。男性患者在功能/活动维度(P=0.05)及满意度(P=0.037)上得分显著高于女性患者,城乡患者间得分无明显差异。[结论]不同影响因素对SRS-30问卷各个维度的影响权重各异,青少年特发性脊柱侧凸患者术后的生活质量是各个因素综合作用的结果。     

先天性多发性关节挛缩症合并脊柱侧凸的临床特征及疗效评价

目的 探讨先天性多发性关节挛缩症(arthrogryposis multiplex congenital,AMC)合并脊柱侧凸的临床特征和手术方式并评估疗效.方法 回顾性分析2001年11月至2006年8月在我院接受脊柱三维矫形手术治疗的AMC合并脊柱侧凸患者14例,男7例,女7例;年龄11～20岁,平均14.3岁.对侧凸类型进行分析并对其手术前后侧凸冠状面和矢状面Cobb角、骨盆倾斜角进行评价.结果 12例为长"C"型胸腰弯,5例合并先天性脊柱侧凸.14例患者主弯冠状面Cobb角术前平均79.1°,术后平均35.9°,平均矫正率为54.6%;10例合并胸椎前凸畸形者矢状位术前胸椎前凸Cobb角平均43.0°,术后胸椎后凸Cobb角平均16.4°;2例合并胸椎后凸畸形者矢状位术前胸椎后凸Cobb角平均91.5°,术后胸椎后凸Cobb角平均54.5°;3例术前骨盆倾斜角平均22.1°,术后平均13.3°.术后随访2.0～4.5年,平均29个月,末次随访时冠状面矫正丢失率平均6.8%.3例发生术中和术后并发症:1例后路矫形时发生大出血(4000m1);1例术后出现短暂性呼吸困难;1例二期后路内同定完成后出现完全性截瘫,术后3个月恢复正常.结论 AMC合并脊柱侧凸弯型以麻痹性神经肌源性长"C"型胸腰弯为主,可合并有先天性脊柱侧凸.脊柱三维矫形可以对AMC合并脊柱侧凸进行有效的矫正,但易发生并发症.     

青少年特发性脊柱侧凸支具治疗结束后近期矫正丢失及影响因素

目的:观察青少年特发性脊柱侧凸(adolescent idiopathic scoliosis,AIS)支具治疗结束后短期内侧凸的矫正丢失情况,并探讨其影响因素。方法:选取2002年10月～2007年12月在我院完成规范化支具治疗后短期随访的AIS患者84例,其中男4例,女80例。初诊时年龄10～15岁,平均12.8岁;Risser征0～3级,平均1.6级;主弯Cobb角20°～43°,平均29.5°。胸腰双主弯36例,单胸弯22例,单胸腰弯或腰弯26例。所有患者在初诊、复查时均摄佩带支具前后站立位全脊柱正位X线片。分别测定不同时期侧凸Cobb角,记录侧凸类型、Risser征、患者的生理年龄及月经初潮时间,分析去除支具后侧凸的矫正丢失情况及影响因素。结果:AIS患者支具治疗后主弯Cobb角的平均矫正率为12.4%,其中14例(16.7%)患者在治疗期间出现脊柱侧凸进展,不同弯型脊柱侧凸的侧凸矫正率、进展率比较差异无显著性(P0.05)。支具治疗结束时主弯Cobb角10°～37°,平均25.5°,明显小于初诊时的29.5°(P0.05),停用支具后6～18个月主弯Cobb角为27.2°,与支具治疗结束时比较无显著性差异(P0.05)。停用支具后,有15例(17.6%)患者出现脊柱侧凸进展,不同弯型脊柱侧凸进展差异无统计学意义(P0.05);侧凸进展的患者在支具治疗时主弯Cobb角的平均矫正率为23.3%,明显高于未出现侧凸进展患者的10.6%,且差异具有统计学意义(P0.05)。停用支具时不同Cobb角组后期出现侧凸进展的概率无显著性差异(P0.05)。结论:支具治疗能够有效控制AIS患者侧凸的进展。在结束支具治疗后短期内随访侧凸矫正基本稳定,但仍有一小部分患者会出现侧凸进展,这种进展与弯型、侧凸的严重程度无关,可能与支具治疗期间侧凸的矫正率较大有关。     

青少年特发性脊柱侧凸支具治疗研究分析

[目的]探讨胸腰骶支具治疗青少年特发性脊柱侧凸的临床疗效,为开展青少年特发性脊柱侧凸的筛查和临床治疗提供参考依据。[方法]对2004年10月~2012年2月在云南部分地区筛查中确诊为青少年特发性脊柱侧凸的132例患者进行Lenke分型,并予胸腰骶支具治疗,比较治疗前后Cobb角。[结果]Lenke1型治疗前后Cobb角平均减小9°,差异具有统计学意义(P0.05),Lenke3型治疗前后胸弯Cobb角平均减小5.2°,胸腰弯Cobb角平均减小6.4°,差异均具有统计学意义(P0.05),Lenke5型治疗前后Cobb角平均减小12.7°,差异具有统计学意义(P0.05),Lenke6型治疗前后胸弯Cobb角平均减小2.0°,胸腰弯Cobb角平均减小6.8°,差异没有统计学意义(P0.05)。[结论]12~16岁是青少年特发性脊柱侧凸重点普查对象,胸腰骶支具对减缓或阻止Lenke1型、Lenke3型和Lenke5型畸形具有显著作用,而对Lenke6型没有明显效果,支具治疗对阻止或减缓病情发展不受年龄、性别和分型的影响。     

青少年特发性脊柱侧凸的支具治疗

目的探讨青少年特发性脊柱侧凸支具治疗的适应证,并评价其临床疗效。方法77例骨骼发育未成熟的青少年特发性脊柱侧凸患者接受Milwaukee支具或Boston支具矫正,男15例,女62例;年龄10～15岁,平均12.7岁。胸腰双主弯26例、单胸弯37例、单胸腰弯或腰弯14例。原发弯Cobb角22°～62°,平均35.9°;20°～35°者37例,>35°者40例。Risser征0度38例、Ⅰ度19例、Ⅱ度13例、Ⅲ度7例。每3～6个月定期复查,复查时均摄佩带支具前、后的站立位全脊柱正位X线片,测量初次就诊及末次随访时的Cobb角、顶椎旋转度及Risser征。结果全部病例随访24～60个月,平均30个月。29.9%的病例出现脊柱侧凸进展,不同类型脊柱侧凸中胸腰双主弯进展率最低,但与其他类型比较差异无显著性。Risser征越小,初诊支具矫正率越大、侧凸进展率越高,且Risser征Ⅰ度组(包括0度)与Ⅱ度组之间、Ⅰ度组与Ⅲ度组之间初诊支具矫正率的差异有显著性(P<0.05)。原发弯Cobb角20°～35°组的初诊支具矫正率大于Cobb角>35°组(P<0.05);而侧凸进展率低于Cobb角>35°组,但差异无显著性。21例因出现侧凸进展而采用手术矫形,支具治疗使其中13例的手术时间推迟了12～20个月。结论Risser征可作为预测青少年特发性脊柱侧凸支具矫正成功率的一个指标。不同类型脊柱侧凸中胸     

接受心脏手术的Marfan综合征患者合并脊柱侧凸的特点

目的:探讨接受心脏手术治疗的Marfan综合征患者合并脊柱侧凸的患病率、侧凸程度、类型及特点。方法:回顾性总结138例进行心脏外科手术的Marfan综合征患者的X线资料,测量冠状面和矢状面Cobb角,并对数据进行统计分析。结果:58例(42.03%)患者合并脊柱侧凸,男38例,女20例,男女患病率比例为1.18∶1,其中≤10岁6例,11～20岁12例,21～30岁19例,31～40岁11例,41～50岁7例,51～60岁3例;平均冠状面Cobb角为26.8°±27.8°;胸弯36例,胸腰弯11例,腰弯2例,双弯6例,三弯3例;单弯中顶椎凸向右侧38例,凸向左侧11例;矢状面胸椎后凸平均为14.3°±13.2°,其中胸椎前凸5例,胸椎后凸不足40例,胸椎正常后凸12例,仅1例胸椎后凸45°;11例患者冠状面Cobb角>40°,平均年龄15.9岁。结论:在接受心脏手术的Marfan综合征患者中脊柱侧凸患病率为42.03%;脊柱侧凸类型多样,冠状位畸形以胸弯和胸腰弯多见,胸椎凸向右侧发生率较高,矢状位畸形以胸椎后凸不足为主;在青少年表现较为严重,需要严密的随访及手术矫形。     

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.     

青少年发育不良性腰椎滑脱症合并脊柱侧凸的临床分析

目的:对青少年发育不良性腰椎滑脱症患者合并脊柱侧凸的情况进行调查并对侧凸情况做术后随访。方法:回顾性分析2007年3月~2017年10月于我院行滑脱复位固定融合手术治疗的28例青少年发育不良性腰椎滑脱症患者,滑脱节段均为L5,依据Meyerding滑脱分度将其分为重度滑脱(Ⅲ、Ⅳ、Ⅴ度)组与轻度滑脱(Ⅰ、Ⅱ度)组。以术前全脊柱正侧位X线片评估两组患者有无脊柱侧凸(Cobb角≥10°诊断为脊柱侧凸)、滑脱情况(滑脱程度、Dubousset腰骶角)以及脊柱-骨盆矢状位参数(骨盆入射角、骶骨倾斜角、骨盆倾斜角)。青少年腰椎滑脱合并的脊柱侧凸分为特发性侧凸和痉挛/疼痛性侧凸两大类,其中痉挛/疼痛性侧凸又分为单纯痉挛性侧凸和"滑脱性"侧凸两种,"滑脱性"侧凸主要由滑脱椎体的旋转造成。对有侧凸的患者测量其末次随访时的侧凸角度以了解侧凸改善情况。结果:发育不良性重度腰椎滑脱15例,年龄12.5±2.6岁,男2例,女13例;轻度滑脱者13例,年龄14.5±2.6岁,男6例,女7例,两组年龄、性别比例及各脊柱-骨盆矢状位参数均无统计学差异(P0.05)。重度滑脱组的Dubousset腰骶角明显小于轻度滑脱组(55.6°±17.0°vs.83.3°±18.4°,P0.05)。28例患者中合并脊柱侧凸者14例,其中重度滑脱组合并脊柱侧凸13例,轻度滑脱组中仅1例符合脊柱侧凸诊断,两组合并侧凸比例有统计学差异(86.7%vs.7.7%,P0.001)。重度滑脱患者术前冠状位平均Cobb角明显大于轻度滑脱患者(18.1°±13.0°vs.4.6°±3.7°,P=0.001)。重度滑脱组中脊柱侧凸的构成情况:特发性侧凸5例,Cobb角11.6°~52.6°,平均30.2°±17.0°;痉挛/疼痛性侧凸8例,其中单纯痉挛性侧凸4例(Cobb角12.5°~17.5°,平均14.8°±2.1°),"滑脱性"侧凸4例(Cobb角11.2°~12.6°,平均11.9°±0.6°)。对13例重度滑脱伴侧凸患者进行术后随访,其中12例获得随访,随访时间为1~100个月(23.8±28.7个月),末次随访时单纯痉挛性侧凸的平均矫正率为92%,特发性脊柱侧凸的平均矫正率为7.5%,"滑脱性"脊柱侧凸的平均矫正率为4%。结论:青少年发育不良性腰椎滑脱症患者中,重度滑脱患者合并脊柱侧凸的比例高于轻度滑脱者,发育不良性重度腰椎滑脱与脊柱侧凸可能具有相关性,其中单纯痉挛性侧凸在滑脱复位固定融合术后可大部分自发矫正。     

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.     

后路松解楔形截骨矫治先天性胸腰段半椎体并重度僵硬性脊柱侧后凸畸形

目的:评价经后路松解楔形截骨矫治先天性胸腰段半椎体并重度僵硬性脊柱侧后凸畸形的安全性和临床初步效果,并探讨其融合固定节段的选择。方法:2007年4月～2010年3月收治先天性胸腰段半椎体并重度僵硬性脊柱侧后凸畸形患者11例,男4例,女7例,年龄14～22岁,平均17.1岁;半椎体均为单个完全分节型,T11 3例,T12 4例,L1 1例,L2 3例;术前侧凸Cobb角82°～125°,平均94.4°,侧凸柔韧性为17.4%～28.9%,平均24.8%;后凸Cobb角72°～145°,平均101.1°;C7铅垂线与骶正中线距离1.5～5.5cm,平均2.9cm。均行经后路松解楔形截骨矫形手术,以触及椎(touched vertebrae,TV)(指站立前后位像上被骶正中线触及的最近端椎体)作为融合固定下端椎;1例合并脊髓拴系和脊髓纵裂者,术中一期行骨嵴切除,解除拴系。结果:均顺利完成手术。平均松解3.0个椎间隙。手术时间5.5～10.0h,平均7.7h;术中出血量1000～7000ml,平均3500ml。无脊髓神经损伤。1例术中切除肋骨小头时引起左侧胸膜撕裂,发生血气胸,行胸腔闭式引流,2周后痊愈;1例术后出现螺钉穿破背部皮肤,1枚螺钉钉尾外露,术后3个月取出该枚螺钉。术后侧凸Cobb角7°～54°,平均28.0°,平均矫正率为70.9%;后凸Cobb角20°～36°,平均27.8°,平均矫正率为71.7%;C7铅垂线与骶正中线距离0.1～2.3cm,平均0.6cm,冠状位平衡平均矫正率为78.1%。随访14～35个月,平均23.4个月,末次随访侧凸Cobb角8°～57°,平均29.7°,丢失率为7.3%;后凸Cobb角22°～38°,平均29.9°,丢失率为7.7%;C7铅垂线与骶正中线距离0.2～2.5cm,平均0.7cm;随访X线片证实植骨均融合,内固定物无松动、断裂。选择TV作为远端融合椎(lowest instrumented vertebrae,LIV)比选择稳定椎(stable vertebrae,SV)平均节省了1.09个椎体,未发现失代偿现象。结论:经后路松解楔形截骨矫治先天性胸腰段半椎体并重度僵硬性脊柱侧后凸畸形安全有效,选择TV作为LIV可以减少融合节段。     

退变性腰椎侧凸的冠状面失衡分型及对截骨矫形术式选择的意义

目的 探讨退变性腰椎侧凸冠状面躯干失衡的分犁及对截骨矫形术式选择的意义.方法 统计自2000年10月至2006年10月期间收治的退变性腰椎侧凸患者36例,均接受后路三维内固定截骨矫形术,男13例,女23例.年龄49～73岁,平均60.1岁.术前Cobb角33°～86°,平均48.3°.术前根据站立位全脊柱正位X线片冠状面失衡情况将患者分为3型:A型,C7铅垂线(C7plumb line,C,PL)偏距骶骨中垂线(center sacral vertical line,CSVL)<3 ca;B型,C7PL偏向腰椎主弯凹侧>3 cm;C型,C7PL偏向腰椎主弯凸侧>3 cm.结果 本组患者随访12个月～5年.平均28个月.根据分型标准,A型10例,B型20例,C型6例.手术策略根据分型选择,A型和B型采用单纯后路顶椎区凸侧入路截骨矫形术,术后Cobb角平均22°,矫正率平均为58%;C型采用后路矫形,后路截骨水平在主弯远端,术后Cobb角平均26°,矫正率平均为40%.两种截骨术后患者冠状面平衡均恢复良好,术后A、B、C 3组C7PL与CSVL的平均距离分别为0.6 cm、1.0 cm和1.2 cm,随访时矫正无明显丢失.无死亡,无感染等并发症.结论 冠状面失衡分型系统基于退变件腰椎侧凸冠状面失衡情况而设定,以此分型为依据有针对性选择不同截骨矫形策略可以使术后躯干平衡恢复更具预测性.     

Lumbosacral scoliotic list by lumbar disc herniation

STUDY DESIGN: A prospective study of 45 patients with lumbar disc herniation and scoliotic list who had undergone conventional open discectomy. OBJECTIVES: To determine the association between the location of the disc herniation and the direction of sciatic scoliotic list and to clarify the mechanism of sciatic scoliosis. SUMMARY OF BACKGROUND DATA: The association between the scoliotic list and lumbar disc herniation is well known. However, there have been few studies regarding the direction of scoliotic list and the location of the disc herniation observed during surgery. METHODS: The direction of scoliotic list, the preoperative and postoperative Cobb's angle, and the displacement of the first lumbar vertebra from the center sacral line were measured. The location, side, and degree of disc herniation were observed during surgery. RESULTS: There was no statistically significant association observed between the location or degree of nerve root compression and the direction or degree of sciatic scoliosis. Moreover, there was no statistically significant association observed between the location or degree of nerve root compression and the displacement of the first lumbar spine from the center sacral line. However, there was a significant association between the side of the disc herniation and the direction of sciatic scoliosis. Most of the sciatic scoliotic list disappeared after surgical decompression. CONCLUSION: The direction of sciatic scoliosis was not observed to be associated with the location of nerve root compression, although it was related to the side of disc herniation.     

Sagittal spinal alignment in patients with lumbar disc herniation

A retrospective cross-sectional study was designed to evaluate total sagittal spinal alignment in patients with lumbar disc herniation (LDH) and healthy subjects. Abnormal sagittal spinal alignment could cause persistent low back pain in lumbar disease. Previous studies analyzed sciatic scoliotic list in patients with lumbar disc herniation; but there is little or no information on the relationship between sagittal alignment and subjective findings. The study subjects were 61 LDH patients and 60 age-matched healthy subjects. Preoperative and 6-month postoperatively lateral whole-spine standing radiographs were assessed for the distance between C7 plumb line and posterior superior corner on the top margin of S1 sagittal vertical axis (SVA), lumbar lordotic angle between the top margin of the first lumbar vertebra and first sacral vertebra (L1S1), pelvic tilting angle (PA), and pelvic morphologic angle (PRS1). Subjective symptoms were evaluated by the Japanese Orthopedic Association (JOA) score for lower back pain (nine points). The mean SVA value of the LDH group (32.7 ± 46.5 mm, ± SD) was significantly larger than that of the control (2.5 ± 17.1 mm), while L1S1 was smaller (36.7 ± 14.5°) and PA was larger (25.1 ± 9.0°) in LDH than control group (49.0 ± 10.0° and 18.2 ± 6.0°, respectively). At 6 months after surgery, the malalignment recovered to almost the same level as the control group. SVA correlated with the subjective symptoms measured by the JOA score. Sagittal spinal alignment in LDH exhibits more anterior translation of the C7 plumb line, less lumbar lordosis, and a more vertical sacrum. Measurements of these spinal parameters allowed assessment of the pathophysiology of LDH.     

Relationship between low-back pain, muscle spasm and pressure pain thresholds in patients with lumbar disc herniation

It is not known whether or not muscle spasm of the back muscles presented in patients with sciatic scoliosis caused by lumbar disc herniation produces muscle pain and/or tenderness. Pressure pain thresholds (PPTs) of the lower back and low-back pain were examined in 52 patients (13 of 52 presenting sciatic scoliosis) with lumbar disc herniation who complained of radicular pain and in 15 normal subjects. PPTs were measured at five points bilaterally using an electronic pressure algometer. Low-back pain was evaluated using visual analogue scale (VAS) ratings. All patients complained of radicular leg pain and were divided into the following three groups according to the presence of and the region of low-back pain: no low-back pain group, low-back pain with no laterality group, and low-back pain dominantly on the herniation side group; the VAS rating on the side ipsilateral to the herniation side was higher than that on the contralateral side. In the normal subjects, there were no statistically significant differences between sides in mean PPTs at all sites examined. PPTs were not lower in the spasmodic side (concave side) than the convex side in patients with sciatic scoliosis. PPTs on the herniation side were significantly lower than those on the contralateral side in patients with low-back pain dominantly on the herniation side. Furthermore, the areas of low PPTs were beyond the innervation area of dorsal ramus of L5 and S1 nerve root. It was considered that not only the peripheral mechanisms but also the hyper excitability of the central nervous system might contribute in lowering PPTs of the lower back on the herniation side.     

Measurements of lumbopelvic lordosis using the pelvic radius technique as it correlates with sagittal spinal balance and sacral translation.

BACKGROUND CONTEXT: Maintenance of normal lumbar lordosis is important in the treatment of spinal disorders. Many attempts have been made to quantify normal sagittal spinal alignment and lordosis using a C7 plumb line and segmental angulations of the spinal vertebrae. Little attention has been given to pelvic compensation as it correlates to lumbar lordosis and overall sagittal spinal alignment. Better methods of measuring lordosis, which correlate with sagittal spinal balance and pelvic compensation, are needed in treating patients with spinal disorders. PURPOSE: To determine the correlation between lumbopelvic lordosis, pelvic rotation and sagittal spinal balance and standardize a method for measuring lumbopelvic lordosis, sacral translation, and sagittal spinal alignment. STUDY DESIGN: Sagittal alignments using the C7 plumb line, Cobb angles, sacral plumb line and the pelvic radius (PR) technique were used to measure standing 36-inch lateral radiographs of patients with various spinal disorders. PATIENT SAMPLE: A review of the records identified 62 patients with various spinal pathologies presenting to the (RGW) spine clinic that had standing lateral spine radiographs. Only radiographs that allowed positive identification of the C7 vertebral body, the entire thoracolumbar spine, the sacrum and both femoral heads were studied. These criteria allowed inclusion of 28 subjects in this study. The final population had 12 women and 16 men with an average age of 52 years (SD, 16.6 years; range, 20 to 84 years). OUTCOME MEASURES: No outcomes measures were used in this study. METHODS: Measurements for sagittal spinal balance and lumbopelvic lordosis were made on 36-inch standing lateral radiographs of adult patients. Measurements included the C7 plumb line, segmental angulations of spinal vertebrae (Cobb angles), sacral translation and the PR technique for lumbopelvic lordosis. Data were analyzed for significant correlation between lumbopelvic lordosis, sagittal spinal balance, sacral translation and total segmental lumbar lordosis using the Cobb method. RESULTS: Our population averaged 50 degrees of total segmental lumbar lordosis from L1 to S1 (SD, 14.3; maximum, 89.5; minimum, 17.9). Nearly 75% of total segmental lumbar lordosis measured from L1 to S1 can be accounted for through the L4 to S1 superior end plates and 47% through L5 to S1 superior end plates in our population. Total segmental lumbar lordosis correlated with total thoracic kyphosis (r=0.45, p=.008). Total segmental lumbar lordosis measured by the Cobb method significantly correlated with sagittal spinal balance (r=-0.35, p=.022) and sacral translation (r=0.41, p=.016). Measurements for lumbopelvic lordosis significantly correlated with sagittal spinal balance (r=-0.33, p=.042), sacral translation (r=-0.70, p=.00002) and total segmental lumbar lordosis (r=0.82, p<.000001). Measurements for sacral translation and sagittal spinal balance also correlated significantly (r=0.35, p=.034). CONCLUSIONS: Sacral translation, the C7 plumb line and lumbopelvic lordosis are useful measures for sagittal spinal balance. Lumbopelvic lordosis and sacral translation can be correlated to the sagittal spinal balance. Understanding these measurements and the range of lumbopelvic compensation can be extremely helpful in treating patients with spinal pathology and in avoidance of flatback deformity. Application of these measures would be especially helpful in the treatment of patients with spinal fusion, degenerative spondylosis, disc disease, fractures, and in the prevention of sagittal malalignment.     

不同上肢体位对正常人和青少年特发性脊柱侧凸患者站立位脊柱矢状面形态的影响

目的 探讨不同上肢体位时,脊柱侧位片上脊柱区域和整体的形态变化,并确定上肢何种体位能更正确地反映脊柱的矢状位形态.方法 研究对象包括特发性脊柱侧凸(adolescent idiopathic scoliosis,AIS)胸弯患者21例和正常青少年志愿者13名.均摄站立位脊柱全长正位X线片及上肢平举及上肢抱胸两种体位的侧位X线片.侧位X线片上测量的参数指标包括:(1)线性距离指标.T1与C-铅垂线(C7 plumb line,C7PL)的距离、胸椎后凸顶点与C7PL的距离、L1与C7PL的距离、腰椎前凸顶点与C7PL的距离、骶骨后上缘与C7PL的距离(SVA);(2)区域前凸及后凸角度的指标.T2～5、T5～12、T10～L2、T1～12、L1～S1、上胸椎后凸(T1上缘与水平线的夹角)、下胸椎后凸(T12下缘与水平线的夹角)、上腰椎前凸(L1上缘与水平线的夹角)、下腰椎前凸(S1上缘与水平线的夹角);(3)骨盆的形态参数:骨盆倾斜角(pelvic tilt,PT)、骶骨倾斜角(sacral slope,SS)、骨盆投射角(pelvic incidence,PI).分别对AIS组及正常组就不同上肢体位时参数的测量结果进行配对t检验.结果 当上肢平举时,AIS组及正常组的腰椎前凸顶点与C7PL的距离、SVA及上胸椎后凸角度均小于上肢抱胸时的测量结果,下胸椎后凸角度及上腰椎前凸角度大于上肢抱胸时的测量结果;另外当上肢平举时,AIS组的腰椎前凸(L1-S1)较上肢抱胸时增大,胸椎后凸顶点与C7PL的距离、L1与C7PL的距离较上肢抱胸减小.结论 双上肢抱胸体位可以更好地反映生理状况下脊柱的矢状面形态.     

Differences in early sagittal plane alignment between thoracic and lumbar adolescent idiopathic scoliosis

Background contextIt has previously been shown that rotational stability of spinal segments is reduced by posteriorly directed shear loads that are the result of gravity and muscle tone. Posterior shear loads act on those segments of the spine that are posteriorly inclined, as determined by each individual's inherited sagittal spinal profile. Accordingly, it can be inferred that certain sagittal spinal profiles are more prone to develop a rotational deformity that may lead to idiopathic scoliosis; and lumbar scoliosis, on one end of the spectrum, develops from a different sagittal spinal profile than thoracic scoliosis on the other end.PurposeTo examine the role of sagittal spinopelvic alignment in the etiopathogenesis of different types of idiopathic scoliosis.Study design/settingMulticenter retrospective analysis of lateral radiographs of patients with small thoracic and lumbar adolescent idiopathic scoliotic curves.Patients sampleWe included 192 adolescent idiopathic scoliosis patients with either a thoracic (n=128) or lumbar (n=64) structural curve with a Cobb angle of less than 20° were studied. Children with other spinal pathology or with more severe idiopathic scoliosis were excluded, because this disturbs their original sagittal profile. Subjects who underwent scoliosis screening and had a normal spine were included in the control cohort (n=95).Outcome measuresThoracic kyphosis, lumbar lordosis, T9 sagittal offset, C7 and T4 sagittal plumb lines, pelvic incidence, pelvic tilt, and sacral slope, as well as parameters describing orientation in space of each individual vertebra between C7 and L5 and length of the posteriorly inclined segment.MethodsOn standardized lateral radiographs of the spine, a systematic, semi-automatic measurement of the different sagittal spinopelvic parameters was performed for each subject using in-house developed computer software.ResultsEarly thoracic scoliosis showed a significantly different sagittal plane from lumbar scoliosis. Furthermore, both scoliotic curve patterns were different from controls, but in a different sense. Thoracic kyphosis was significantly decreased in thoracic scoliosis compared with both lumbar scoliosis patients and controls. For thoracic scoliosis, a significantly longer posteriorly inclined segment, and steeper posterior inclination of C7–T8 was observed compared with both lumbar scoliosis and controls. In lumbar scoliosis, the posteriorly inclined segment was shorter and located lower in the spine, and T12–L4 was more posteriorly inclined than in the thoracic group. The lumbar scoliosis cohort had a posteriorly inclined segment of the same length as controls, but T12–L2 showed steeper posterior inclination. Lumbar lordosis, pelvic incidence, pelvic tilt, and sacral slope, however, were similar for the two scoliotic subgroups as well as the controls.ConclusionsThis study demonstrates that even at an early stage in the condition, the sagittal profile of thoracic adolescent idiopathic scoliosis differs significantly from lumbar scoliosis, and both types of scoliosis differ from controls, but in different aspects. This supports the theory that differences in underlying sagittal profile play a role in the development of different types of idiopathic scoliosis.     

Sagittal balance of the pelvis-spine complex and lumbar degenerative diseases. A comparative study about 85 cases

Retrospective analysis of the spino-pelvic alignment in a population of 85 patients with a lumbar degenerative disease. Several previous publications reported the analysis of spino-pelvic alignment in the normal and low back pain population. Data suggested that patients with lumbar diseases have variations of sagittal alignment such as less distal lordosis, more proximal lumbar lordosis and a more vertical sacrum. Nevertheless most of these variations have been reported without reference to the pelvis shape which is well-known to strongly influence spino-pelvic alignment. The objective of this study was to analyse spino-pelvic parameters, including pelvis shape, in a population of 85 patients with a lumbar degenerative disease and compare these patients with a control group of normal volunteers. We analysed three different lumbar degenerative diseases: disc herniation (DH), n = 25; degenerative disc disease (DDD), n = 32; degenerative spondylolisthesis (DSPL), n = 28. Spino-pelvic alignment was analysed pre-operatively on full spine radiographs. Spino-pelvic parameters were measured as following: pelvic incidence, sacral slope, pelvic tilt, lumbar lordosis, thoracic kyphosis, spino-sacral angle and positioning of C7 plumb line. For each group of patients the sagittal profile was compared with a control population of 154 asymptomatic adults that was the subject of a previous study. In order to understand variations of spino-pelvic parameters in the patients’ population a stratification (matching) according to the pelvic incidence was done between the control group and each group of patients. Concerning first the pelvis shape, patients with DH and those with DDD demonstrated to have a mean pelvic incidence equal to 49.8° and 51.6°, respectively, versus 52° for the control group (no significant difference). Only young patients, less than 45 years old, with a disc disease (DH or DDD) demonstrated to have a pelvic incidence significantly lower (48.3°) than the control group, P < 0.05. On the contrary, in the DSPL group the pelvic incidence was significantly greater (60°) than the control group (52°), P < 0.0005. Secondly the three groups of patients were characterized by significant variations in spino-pelvic alignment: anterior translation of the C7 plumb line (P < 0.005 for DH, P < 0.05 for DDD and P < 0.05 for DSPL); loss of lumbar lordosis after matching according to pelvic incidence (P < 0.0005 for DH, DDD and DSPL); decrease of sacral slope after matching according to pelvic incidence (P = 0.001 for DH, P < 0.0005 for DDD and P < 0.0005 for DSPL). Measurement of the pelvic incidence and matching according to this parameter between each group of patients and the control group permitted to understand variations of spino-pelvic parameters in a population of patients.     

Pain and disability correlated with disc degeneration via magnetic resonance imaging in scoliosis patients

Prior imaging studies of scoliosis patients attempted to demonstrate a relationship between plain radiographic curve patterns and curve progression and pain, or used magnetic resonance imaging (MRI) to focus on spinal cord abnormalities. Pain in scoliosis patients may differ from nondeformity patients, yet may still be discogenic. The purpose of this study was to assess the possible relationship of degenerative disc findings on MRI to scoliosis patients’ pain. This prospective study enrolled scoliosis and control patients, all of whom had assessment for back pain (visual analog scale) and disability (Oswestry Index) and spinal MRI to identify prevalence and distribution of degenerative disc findings. Specifically, we assessed 60 consecutive pediatric and adult idiopathic scoliosis patients who had progressed to surgical treatment, 60 age- and gender-matched asymptomatic controls, and 172 nondeformity symptomatic degenerative disc disease patients who had progressed to surgical treatment. All subjects had independent analysis of their preoperative MRI for disc degeneration, disc herniation, Schmorl’s nodes, and inflammatory end plate changes. Imaging findings of the scoliosis patients were compared to those from asymptomatic and symptomatic control groups. Our results found that both pediatric and adult scoliosis patients had significantly more pain and disability than did asymptomatic controls (P < 0.001). The adult idiopathic scoliosis patients had pain and disability similar to those of surgical degenerative disc disease control groups. Disc degeneration and herniation (contained) were not related to pain. However, in the pediatric scoliosis patients, those with Schmorl’s nodes often had greater pain than those without (P = 0.01). Adults with painful scoliosis, typically occurring at the apex of the scoliosis or at the lumbosacral junction, had a significantly higher frequency of inflammatory end plate changes on MRI than did controls (P < 0.001). Prior studies have demonstrated a correlation of inflammatory end plate changes to lumbar discogenic pain. In conclusions, scoliosis patients who have progressed to surgical intervention, pediatric patients have varying degrees of pain, and those with Schmorl’s nodes may be at greater risk for pain. Adult scoliosis patients have multifactorial pain of which one component may be related to degeneration of the lower lumbar discs similar to that in nondeformity patients. Additionally, adult scoliosis patients may have MRI findings consistent with discogenic pain at the apex of their curvature, most commonly at the proximal lumbar levels.     

骶管注射配合牵引治疗腰椎间盘突出症的临床观察

目的评价骶管注射配合牵引理疗治疗腰椎间盘突出症的疗效和安全性。方法将136例腰椎间盘突出症患者随机分为治疗组、对照组，每组各68例。治疗组给予骶管注射、腰椎牵引及理疗，对照组仅给予腰椎牵引和理疗。结果对总体疗效而言，意向性分析（intention—to—treat，ITT）结果显示两组总有效率分别为89．70％、77．94％，方案数据分析（per-protocol population，PP）结果显示两组总有效率分别为93．76％、85．00％，疗效差异均有统计学意义，P〈0．05，治疗组具有临床上的优效性，P〈0．05。ITT分析与PP分析结果一致。结论 骶管注射配合牵引理疗治疗腰椎间盘突出症操作简单、疗效肯定、安全性高，值得在临床上推广应用。