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.     

Biomechanical comparison of alternative densities of pedicle screws for the treatment of adolescent idiopathic scoliosis

Purpose

The objective of this computational study was to compare the biomechanical effects of different implant densities in terms of curve reduction and the force levels at the implant–vertebra interface and on the intervertebral elements.

Methods

Eight cases were randomly picked among patients who have undergone a posterior spinal instrumentation for adolescent idiopathic scoliosis (AIS). For each case, two computer simulations were performed, one with the actual surgery implant pattern and another with the same fusion levels but an alternative implant pattern proposed by an experienced surgeon. The two implant patterns for each case were respectively put into higher and lower implant density group. The spinal correction and the force levels at bone–implant interface and on the intervertebral elements were analyzed and compared between the two groups.

Results

There were on average 13% more pedicle screws and 30% more bilaterally placed pedicle screws in the higher versus lower density group. The difference in the density of screws (92% vs. 79%) did not lead to significant difference in terms of the resulting main thoracic (MT) Cobb angle, and the MT apical axial vertebral rotation. The average and maximum implant-vertebra force levels were about 50 and 65%, respectively higher in the higher versus lower density group, but without consistent distribution patterns. The average intervertebral forces did not significantly differ between the two groups.

Conclusions

With the same fusion levels, lower density screws allowed achieving similar deformity correction and it was more likely to have lower screw–vertebra loads.     

青少年脊柱侧凸患者胸椎椎弓根螺钉置入的准确性和安全性评价

目的：探讨青少年脊柱侧凸患者胸椎椎弓根螺钉置入的准确性和安全性，以减少相关手术并发症。方法：32例青少年脊柱侧凸患者术前均对畸形脊柱进行标准俯卧位CT加密扫描，测量进钉点至椎体前缘的深度、进针角度、椎弓根直径和椎体的旋转角度，根据测得数据确定椎弓根螺钉置入的深度和方向，置入螺钉后再行脊柱全长X线片及CT扫描评价置钉的准确性和安全性。结果：32例共置入226枚胸椎椎弓根螺钉，术后CT加密和X线片观察到205枚螺钉（90．7％）完全在椎弓根皮质骨内。10例21枚螺钉（9.3％）发生错置，7枚螺钉（3．1％）偏外，5枚螺钉（2．2％）偏前外侧（其中2枚螺钉靠近节段血管），4枚螺钉（1．8％）偏下，4枚螺钉（1．8％）直径过大导致椎弓根内壁膨胀内移，1枚螺钉（0．4％）误入椎管导致完全性脊髓损伤。T1～T4错置12枚（18．2％），T5～T12错置9枚（6．1％）；凸侧椎根螺钉置入的准确率为93．8％，凹侧为83．1％。结论：脊柱畸形患者术前应常规采用标准俯卧位CT加密扫描，根据扫描图像测得的相关数据可为术中准确置入椎弓根螺钉提供重要参考依据。在青少年脊柱侧凸患者胸椎椎弓根螺钉置入有一定的误置率，螺钉发生错置多见于上胸椎和凹侧．术中应高度重视。     

特发性脊柱侧凸后路矫形中尾侧椎应用椎弓根螺钉与椎板钩固定的效果比较

目的:评价特发性脊柱侧凸矫形中,尾侧椎应用椎板钩和椎弓根螺钉固定的临床效果及安全性。方法:对收治的34例后路矫形内固定且随访1年以上的特发性脊柱侧凸(KingⅡA和Ⅲ型)患者,根据尾侧椎固定方式的不同,分为A组(椎板钩固定组)和B组(椎弓根螺钉固定组)。A组14例,男4例,女10例,平均年龄13.6岁(12～17岁)。B组20例,男6例,女14例,平均年龄14.1岁(13～17岁)。比较两组患者术前侧凸角度、矢状面曲度及矫正率、随诊丢失角度、手术时间、出血量、融合节段等方面的差异。结果:两组患者术前侧凸角度、矢状面曲度及矫正率、手术时间、手术出血量没有明显的统计学差异。A组侧凸角度丢失大于B组(P<0.05),且A组中有3例在融合节段与下方非融合节段交界处出现后凸。A组平均融合11个节段,B组平均为10个节段。结论:在特发性脊柱侧凸后路矫形中,以椎弓根螺钉替代椎板钩内固定尾侧椎可较好地维持术后矫形效果,预防融合节段与未融合节段交界处后凸,保留更多的远端活动节段并具有较好的安全性。     

全节段与选择性节段椎弓根螺钉固定治疗重度僵硬型青少年特发性脊柱侧凸比较

目的 比较全节段椎弓根螺钉(all segmental pedicle screws,ASPS)固定与选择性节段椎弓根螺钉(selective segmental pedicle screws,SSPS)固定治疗重度僵硬型青少年特发性脊柱侧凸(adoles-cent idiopathic scoliosis,AIS)的疗效.方法 回顾性分析我院2003年3月至2008年12月期间单纯行后路椎弓根螺钉固定融合治疗的重度僵硬型AIS患者.站立前后位主胸弯Cobb角>70°和柔韧度<30%者为筛选对象,从327例AIS患者中筛选出符合标准的48例,22例行SSPS同定,26例行ASPS固定.统计并比较两组患者手术时的年龄、术前冠状面主胸弯Cobb角、脊柞柔韧度、术中出血量、术后1周及末次随访时的矫正率.结果 ASPS组和SSPS组的平均年龄分别为15.65岁和17.32岁,术前冠状面主胸弯Cobb角分别为86.77°±11.71°(71.31°～107.51°)和87.56°±14.88°(70.10°～117.83°),柔韧度分别为15.82%±7.37%(6.82%～29.74%)和19.30%±9.19%(0.89%～29.71%),手术时间分别为(280.69±35.92)min和(275.10±33.91)min,术中出血量分别为(988.50±287.80)ml和(800.98±360.47)ml(t=2.004,P=0.051),术后1周冠状面主胸弯畸形矫正率分别为60.07%±8.80%和46.79%±14.90%(u=3.280,P=0.001).ASPS组有1例因凸侧断棒而明显丢失畸形矫正率,余患者无明显丢失.结论 对于重度僵硬型AIS,ASPS治疗的患者术后冠状面主胸弯矫正率明显高于SSPS治疗的患者.     

同种异体骨加自体肋骨治疗特发性胸椎侧凸的疗效分析

目的通过与自体髂骨植骨融合术进行比较,探讨以同种异体骨加用自体肋骨取代自体髂骨在特发性胸椎侧凸后路矫形术中的应用效果。方法对1999～2000年间收治的有完整资料的84例特发性胸椎侧凸患者进行回顾性分析。A组(自体髂骨融合组)34例,年龄12～20岁,平均14.5岁;Cobb角40°～82°(平均56°),未行胸廓成形术,King分型Ⅱ型8例,Ⅲ型22例,Ⅴ型4例。B组(同种异体骨加自体肋骨融合组)50例,年龄13～19岁,平均15.4岁;Cobb角38°～80°(平均54°),King Ⅱ型14例,Ⅲ型30例,Ⅴ型6例。均采用后路CD、CDH 或TSRH固定。术后定期随访并进行影像学和临床融合状态评估。结果术后随访2～5年,平均3.4年。A组患者术后Cobb角平均矫形率为73.2%。随访2年时矫形丢失率为10%,假关节发生率为3%。取骨处的总体并发症发生率为26%,包括取髂骨处深部感染、血肿,伤口浅层愈合不佳,取髂骨处疼痛等。B组术后Cobb角矫形率为70.4%,随访2年时矫形丢失率为9%,假关节发生率为2%,TSRH钩-棒固定松动2例。胸廓成形术取肋骨的总体并发症发生率为20%,包括术中胸膜破裂,术后局部反常呼吸,渗出性胸膜炎,深吸气性疼痛等。结论同种异体骨加自体肋骨植骨若适应证选择恰当是一种安全、可靠、有效、经济的植骨方法,从融合率、矫形丢失、术后并发症等因素考     

特发性脊柱侧凸远端融合椎的选择

目的 探讨青少年特发性脊柱侧凸(adolescent idiopathic scoliosis,AIS)远端融合椎(low-est instrumented vertebra,LIV)的选择标准.方法 前瞻性分析按LIV标准进行融合的随访2年以上(24～36个月,平均29个月)的AIS患者共33例,男4例,女29例.按照北京协和医学院(Peking Union Medical College Hospital)分型Ⅰ b 2例,Ⅰ c 2例,Ⅱa 3例,Ⅱb2 3例,Ⅱc1 3例,Ⅱd1 17例和Ⅲb 3例.患者手术时年龄11～16岁,平均14.2岁.LIV的选择标准:术前站立前后位像上被骶正中线触及的最近端椎体,即触及椎体,其旋转范围在Ⅰ度以内,并在凹侧Bending像上2/3以上椎体落在Harrington稳定区内,不伴腰段或胸腰段后凸畸形.所有患者均采用椎弓根螺钉固定.观测指标包括躯干偏移、LIV倾斜度和LIV尾侧椎间盘开角,并分析LIV与稳定椎之间的关系.结果 术前和末次随访时躯干偏移由(1.87±1.18)cm矫正至(0.97±0.69)cm(t=3.24,P=0.004);术前和末次随访时LIV倾斜度由20.95°±7.51°矫正至4.57°±2.80°(矫正率为76.2%,t=10.10,P<0.001);术前和末次随访时的LIV尾侧椎间盘开角分别为4.90°±3.83°和5.43°±2.23°(t=0.14,P=0.626).选择触及椎体作为LIV比选择稳定椎平均节省(1.14±0.73)个椎体.结论 按此触及椎体标准选择LIV可获得良好的矫形效果并可保留更多的运动节段.     

特发性脊柱侧凸的前路矫形手术

目的评价前路矫形手术对特发性脊柱侧凸的治疗效果。方法回顾性分析术后随访时间超过1年的特发性脊柱侧凸34例,男5例,女29例;年龄8～17.5岁,平均15.7岁。侧凸类型包括PUMCⅠa型1例、Ⅰb型8例、Ⅰc型6例、Ⅱc1型4例、Ⅱd1型15例。采用前路三维矫形手术,内固定器械包括TSRH16例、MossMiami8例、CDH10例。术前、术后及随访时摄X线片,测量冠状面及矢状面Cobb角、躯干偏移、顶椎及下融合椎的旋转度、下融合椎与骶骨夹角,并观察有无假关节形成。结果全部病例随访12～63个月,平均21个月。术中出血量200～1200ml,平均255ml。融合3～7节椎体,平均4.42节。融合弯冠状面畸形矫正率平均为73.4%,矢状面手术前后Cobb角差异无显著性。7例胸腰段或腰椎后凸患者术前后凸平均11.9°,术后矫正为前凸6.8°。19例双弯患者术后上弯冠状面自动矫正率为39.5%(P<0.01);融合弯顶椎旋转改善率32%(P<0.01),下融合椎旋转亦有明显改善(P<0.05),上弯顶椎旋转无明显改善。凸侧Bending像融合弯Cobb角与术后比较差异有显著性(P<0.01)。单弯(PUMCⅠb型、Ⅰc型)者术后即刻躯干偏移增加7.3mm,1年后较术前改善7.5mm;双弯者术后躯干偏移持续改善。凹侧Bending像下融合椎与骶骨的夹角与术后比较差异无显著性。结论前路矫形融合术具有较强的冠状面     

Lenke 5型脊柱侧凸前路选择性融合术后胸弯的转归及其影响因素

目的 探讨Lenke 5型脊柱侧凸前路选择性融合术后胸弯的转归及其可能的影响因素.方法 回顾性分析伴有胸弯的29例女性Lenke 5型脊柱侧凸患者,年龄12～20岁,平均(15.3±2.0)岁;Risser征0～5级,平均(3.8±0.8)级.所有患者均行前路选择性融合术,随访24～58个月,平均33个月,分析术后胸弯的转归及其与术前相关指标的关系.结果所有患者行前路选择性融合术后,主弯Cobb角减小至11.9°±7.3°(矫正率为74.7%±15.3%),胸弯Cobb角减小至16.7°±7.5°(矫正率为40.4%±21.8%).胸弯Cobb角矫正丢失2°以上的9例患者术前胸弯Bending相矫正率较低(F=5.408,P=0.028).在发生显著胸弯矫正丢失的3例患者中,2例术前胸弯Cobb角均达35°以上,2例胸弯柔软度低于50%,1例主弯和胸弯Cobb角比值低于1.25,1例Risser征为0级.末次随访时,胸弯Cobb角与术前胸弯Cobb角、胸弯Bending相Cobb角以及胸弯和主弯Cobb角比值均正相关(分别为r=0.664,19<0.001;r=0.555,P=0.001;r=0.515,P=0.002).而末次随访时胸弯矫正率则与术前胸弯Bending相矫正率正相关(r=0.495,P=0.006).结论 Lenke 5型患者行前路选择性融合术后胸弯的自发性矫正可能与术前胸弯Cobb角、柔软度以及生长潜能等密切相关,但术前胸弯柔软度小能完全反映术后自发性矫正的程度.     

胸椎侧凸胸腔镜下和开放小切口前路矫形术椎间融合面积研究

目的 比较特发性胸椎侧凸胸腔镜下前路矫形术与胸腔镜辅助下开放小切口前路矫形术的椎间植骨和融合效果。方法 将34例特发性胸椎右侧凸患者分为两组，A组10例患者接受胸腔镜下胸椎侧凸前路矫形术，平均年龄14．4岁，平均Cobb角52．9°。B组24例患者接受开放小切口前路矫形手术，平均年龄14．5岁，平均Cobb角45．4°。两组患者均采用自体肋骨作为移植骨。所有患者术后均行固定节段的CT扫描并获得完整的随访资料。通过测量术后CT片以及不同随访时间的X线片，对两组病例的椎间植骨面积百分比、矫形效果以及矫正丢失进行分析。结果两组患者在年龄、侧凸柔软性和固定节段等方面差异均无统计学意义，A组术前胸弯大于B组。两组患者术后平均椎间植骨面积百分比均超过40％，且组间差异无统计学意义（P〉0．05）。A组术后早期矫正丢失明显高于B组，差异有统计学意义（P〈0．05）。但两组在术后6个月后均无明显矫正丢失。结论 胸腔镜下胸椎侧凸前路矫形手术能够获得与开放小切口前路矫形手术同样满意的椎间植骨和融合效果，前者早期矫正丢失明显可能与固定的棒较细有关。     

脊柱侧凸前路矫形固定术后椎间角的变化及下融合椎后滑移

目的探讨特发性脊柱侧凸前路矫形内固定术后椎间角的变化及下融合椎后滑移的发生情况。方法回顾性分析近4年来我院青少年特发性脊柱侧凸患者接受前路矫形内固定手术前后及随访时的X线片,对侧凸Cobb角、侧凸矫形率、躯干偏移、下融合椎旋转度、下融合椎相对于骨盆的倾斜度、椎间角及下融合椎后滑移等参数进行测量分析。结果50例患者符合入选标准,主侧凸位于胸腰段或腰段。手术前后主弯冠状面Cobb角分别为47.78°±9.39°和10.32°±8.50°,侧凸矫形率平均79.05%。手术前后下融合椎旋转度分别为1.54°±0.58°及1.06°±0.47°。手术前后下融合椎相对于骨盆的倾斜度分别为23.80°±7.91°和9.16°±9.46°。椎间角术前平均为3.72°±3.05°,Bending相上为-2.22°±5.85°,术后即刻为1.56°±5.97°,较术前明显改善(P=0.029);末次随访时为4.87°±7.95°,与术后即刻相比差异有统计学意义(P=0.038)。术后19例(38%)患者发生下融合椎后滑移,平均滑移距离(4.79±1.75)mm。发生与未发生后滑移的患者在术前顶椎旋转度及Bending相椎间角的差异均有统计学意义(P=0.047,0.033)。结论特发性脊柱侧凸前路矫形内固定术后椎间角较术前明显改善,但在随访时椎间角又逐渐增大。下融合椎后滑移的发生可能与术前顶椎旋转度及B     

内固定方式对青少年特发性脊柱侧凸选择性胸椎融合矢状面重建的影响

目的 探讨胸弯型青少年特发性脊柱侧凸患者行后路选择性胸椎融合术时采用不同内固定方式对胸椎矢状面形态及远端腰椎代偿模式的影响.方法 行胸弯后路矫形内同定术且有2年以上(2～3年)完整随访资料的lenke 1、2型青少年特发性脊柱侧凸患者51例,按内固定方式分为A组(全钩组)、B组(钩钉混合组)和C组(全钉组).测量术前及术后随访的胸弯Cobb角、腰弯Cobb角、胸椎后凸角、腰椎前凸角、远端交界性后凸、胸腰段交界性后凸及C7铅垂线偏离S1后上缘的距离.结果 三组患者主弯矫正率均大于60%,继发弯也获得较满意的自发性矫正.三组患者术前及随访中腰椎前凸角、C7铅垂线偏离S1后上缘的距离均保持正常.随访2年时,A组远端交界性后凸、胸椎后凸角、胸腰段交界性后凸分别达3.6°、23.0°、6.4°,其中远端交界性后凸与术前比较差异有统计学意义(P<0.05).B组和C组各项指标与术前比较差异均无统计学意义.结论 全钩型同定可以获得良好的冠状面矫形,且在随访中能保持腰椎前凸和欠状面平衡.但钩的固定不如椎弓根螺钉牢固,全钩型固定患者胸椎后凸角有增大趋势,胸腰椎交界区有失代偿的可能.     

青少年特发性脊柱侧凸后路矫形后远端交界区变化

目的:探讨青少年特发性脊柱侧凸(AIS)患者后路矫形术后远端交界区(LIV+2)在冠状面、矢状面和轴位上的变化。方法:2005年6月～2007年6月手术治疗AIS患者32例,男6例,女26例,年龄10～19岁,平均14.4岁。按PUMC分型,Ⅰc1例,Ⅱa4例,Ⅱb19例,Ⅱb21例,Ⅱc11例,Ⅱc35例,Ⅱd15例,Ⅲa5例,Ⅲb1例。均采用后路全节段椎弓根螺钉系统矫形固定,其中远端融合椎(LIV)与稳定椎(SV)为同一椎体(A组)15例,LIV与SV非同一椎体(B组)17例。术前和末次随访时摄站立位全脊柱正侧位X线片,测量冠状面上躯干偏移(TS),LIV的倾斜度(LIVT),LIV尾侧椎间盘开角(LIVA),冠状面和矢状面上远端交界区的Cobb角和椎体的旋转度(LIV+1VR和LIV+2VR)。结果:随访24～36个月,平均29个月。两组末次随访时的TS与术前比较均无显著性差异(P0.05)。A组LIVT由术前20.2°±5.9°下降到末次随访时的4.7°±3.8°(P0.001),B组由17.2°±5.5°下降到4.4°±2.7°(P0.001);A组术前和末次随访时LIVA分别为7.5°±4.7°和3.9°±3.1°(P=0.056);B组分别为4.5°±3.4°和5.4°±3.2°(P=0.492);Pearson′s相关分析显示两组远端融合椎倾斜度变化和其尾侧椎间盘开角变化之间相关性不显著(A组r=-0.067,P=0.813;B组r=0.362,P=0.154)。A组远端交界区(LIV+2)冠状面上Cobb角由术前20.5°±9.6°矫正至末次随访时9.4°±7.3°(P0.001);B组由13.8°±6.7°矫正至8.1°±4.7°(P=0.013);A、B组末次随访时远端交界区矢状面上Cobb角与术前比较均无显著性差异(分别为P=0.464,P=0.598);Pearson′s相关分析显示A组末次随访时矢状面Cobb角和术前矢状面Cobb角之间相关性不显著(r=0.076,P=0.788),B组的相关性显著(r=0.803,P0.001)。两组末次随访时LIV+1VR和LIV+2VR与术前比较均无显著性差异(P0.05)。结论:AIS患者应用后路全节段椎弓根螺钉系统矫正后远端交界区在冠状面上矫形明显,矢状面和轴位上矫形不明显,且远端融合椎倾斜度减小。     

Adolescent idiopathic thoracic scoliosis: apical correction with specialized pedicle hooks

Forty-one patients with thoracic adolescent idiopathic scoliosis (AIS) treated with only a posterior spine fusion using specialized pedicle hooks (SPH) (hooks augmented with 3.2-mm screws) at the apex of the curve were reviewed in order to assess the effectiveness of this correction method. Inclusion in the study group required a minimum of 2 years’ follow-up and the same strategy of correction where the apical vertebrae (3 or 4 vertebrae on the concave side) were instrumented with SPH. The mean preoperative Cobb angle was corrected from 55° (42°–80°) to 18° (67%) postoperatively and to 23° (58%) at the last follow-up (28–50 months) for a flexibility index of 46%. Apical vertebral translation was corrected to 70% at the last follow-up. Thoracic kyphosis remained unchanged, from 23° to 26°, and the lumbar lordosis went from –53° to –59°. The lumbar curve was corrected from 38° to 18°. Coronal balance improved from 10 to 1 mm; shoulder balance was improved from 15 to 5 mm. The rib hump was improved from an average of 30 mm preoperatively to 15 mm postoperatively, but only to 25 mm at the last follow-up (17% of correction). One case of a spastic bladder was observed postoperatively, which resolved completely after 8 months. Three patients had to have their instrumentation removed because of pain. There was no complication related to the use of the SPH. The authors conclude that apical correction with SPH allows effective scoliosis correction without spinal distraction and does not require supra- or infralaminar hook in the spinal canal. Received: 1 July 1998 Revised: 25 March 1999 Accepted: 21 April 1999     

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.     

青少年特发性脊柱侧凸术后住院时间延长的危险因素

青少年特发性脊柱侧凸(AIS)是一种常见的脊柱畸形,发生率为1.0％ ～ 5.2％[1-2].大部分AIS患者可以进行非手术治疗,对于畸形角度大、进展速度快的患者,则需要手术矫形[3].近年来,随着手术技术的发展和内固定器械的改良,越来越多的医师掌握了后路脊柱侧凸矫形技术,手术量迅速扩大,随之而来的是住院费用的增长.有...     

椎弓根螺钉联合经椎板螺钉治疗胸腰椎骨折的实验研究及临床初步应用

目的探讨椎弓根螺钉联合经椎板螺钉(TLS)治疗胸腰椎骨折的价值。方法6具腰椎标本,模拟三柱不稳定骨折模型,以椎弓根螺钉固定(CD)或椎弓根螺钉联合经TLS固定(CD+TLS),测量脊柱运动范围(ROM),比较两种方法的稳定性。31例胸腰椎骨折椎体前缘平均压缩至59%,椎体后缘压缩至88%,采用椎弓根螺钉联合TLS治疗,20例同时行后路或前后路植骨。结果“CD+TLS”组较CD组前屈、侧弯和轴向旋转分别减少5·38%、4·91%和11·85%,两种方法间ROM经t检验,除后伸压缩外,差异均有显著性意义(P<0·05)。术后椎体前缘恢复到97%,椎体后缘恢复到98%,随访4~34个月,平均13个月,椎体前缘矫正丢失5·0%,其中植骨组20例均融合,平均融合时间4·3个月,矫正丢失3·8%。结论TLS联合椎弓根螺钉治疗胸腰椎骨折,增加了固定器稳定性,TLS主要起抗旋转和抗后柱分离作用,可以提高后路植骨融合率,减少矫正丢失。     

选择性前路和后路手术治疗胸腰段或腰段脊柱侧凸的疗效分析

目的 比较选择性前路和后路手术治疗胸腰段或腰段青少年特发性脊柱侧凸的疗效.方法 1998年3月～2004年9月,共64例胸腰段或腰段特发性脊柱侧凸患者接受手术,其中36例采用选择性前路手术(A组),28例采用选择性后路手术(B组),随访时间为2～4 年.结果 A组术前胸腰段或腰段弯曲角度平均 42°,术后平均 18°;B组术前平均46°,术后平均18°.2 组患者术后弯曲都得到了明显改善,且2组患者改善率差异无统计学意义(P>0.05),术中的出血量差异也无统计学意义(P>0.05),而B组手术时间(179 min) 相似文献   

前后路矫形融合术治疗胸腰段/腰段青少年特发性脊柱侧凸(PUMC Ⅰb/Ⅰc/Ⅱd1型)

目的比较前后两种入路及手术方法治疗特发性胸腰段／腰段脊柱侧凸的疗效。方法青少年特发性脊柱胸腰段／腰段侧凸（PUMC Ⅰb，Ⅰc，Ⅱd1型）患者28例，分为两组。A组16例，平均14．88岁，行前路短节段矫形融合术；B组12例，平均15．50岁，行后路、椎弓根系统矫形融合术。两组均采用第三代坚强矫形内固定器械。比较两组术前一般资料和术中情况，并通过X线参数，比较两种手术的矫形效果和躯干平衡的矫正情况。结果两组术前资料无显著差异，术后均无严重手术并发症，融合效果满意。A组手术时问、术中出血及输血量、内固定材料花费明显少于B组；A组平均融合4．25个节段，B组平均融合5．95个节段。随访时间12-47个月，A组术后冠状面矫正率是82％，随访时72％；B组术后冠状面矫正率是74％，随访时70％。矢状面矫形效果均满意，两组无显著性差异；A组术后即刻躯干偏移矫正不如B组，但随访时，两组无差异。两组在矫正顶椎旋转和顶椎偏移方面无显著差异。结论前路矫形和后路椎弓根系统矫形融合术治疗轻中度胸腰段／腰段青少年特发性脊柱侧凸，均可获得满意的矫形效果，但前路融合可缩短手术时间和减少术中出血、输血量，并能保留较多运动节段。     

Gait in adolescent idiopathic scoliosis: energy cost analysis

Walking is a very common activity for the human body. It is so common that the musculoskeletal and cardiovascular systems are optimized to have the minimum energetic cost at 4 km/h (spontaneous speed). A previous study showed that lumbar and thoracolumbar adolescent idiopathic scoliosis (AIS) patients exhibit a reduction of shoulder, pelvic, and hip frontal mobility during gait. A longer contraction duration of the spinal and pelvic muscles was also noted. The energetic cost (C) of walking is normally linked to the actual mechanical work muscles have to perform. This total mechanical work (W _tot) can be divided in two parts: the work needed to move the shoulders and lower limbs relative to the center of mass of the body (COM_b) is known as the internal work (W _int), whereas additional work, known as external work (W _ext), is needed to accelerate and lift up the COM_b relative to the ground. Normally, the COM_b goes up and down by 3 cm with every step. Pathological walking usually leads to an increase in W _tot (often because of increased vertical displacement of the COM_b), and consequently, it increases the energetic cost. The goal of this study is to investigate the effects of scoliosis and scoliosis severity on the mechanical work and energetic cost of walking. Fifty-four female subjects aged 12 to 17 were used in this study. Thirteen healthy girls were in the control group, 12 were in scoliosis group 1 (Cobb angle [Cb] ≤ 20°), 13 were in scoliosis group 2 (20° < Cb < 40°), and 16 were in scoliosis group 3 (Cb ≥ 40°). They were assessed by physical examination and gait analysis. The 41 scoliotic patients had an untreated progressive left thoracolumbar or lumbar AIS. During gait analysis, the subject was asked to walk on a treadmill at 4 km h⁻¹. Movements of the limbs were followed by six infrared cameras, which tracked markers fixed on the body. W _int was calculated from the kinematics. The movements of the COM_b were derived from the ground reaction forces, and W _ext was calculated from the force signal. W _tot was equal to W _int + W _ext. Oxygen consumption ( [(V)\dot]\textO₂ ) \left( {\dot{V}{\text{O}}_{2} } \right) was measured with a mask to calculate energetic cost (C) and muscular efficiency (W _tot/C). Statistical comparisons between the groups were performed using an analysis of variance (ANOVA). The external work (W _ext) and internal work (W _int) were both reduced from 7 to 22% as a function of the severity of the scoliosis curve. Overall, the total muscular mechanical work (W _tot) was reduced from 7% to 13% in the scoliosis patients. Within scoliosis groups, the W _ext for the group 1 (Cb ≥ 20°) and 2 (20 ≤ Cb ≤ 40°) was significantly different from group 3 (Cb ≥ 40°). No significant differences were observed between scoliosis groups for the W _int. The W _tot did not showed any significant difference between scoliosis groups except between group 1 and 3. The energy cost and [(V)\dot]\textO₂ \dot{V}{\text{O}}_{2} were increased by around 30%. As a result Muscle efficiency was significantly decreased by 23% to 32%, but no significant differences related to the severity of the scoliosis were noted. This study shows that scoliosis patients have inefficient muscles during walking. Muscle efficiency was so severely decreased that it could be used as a diagnostic tool, since every scoliosis patient had an average muscle efficiency below 27%, whereas every control had an average muscle efficiency above 27%. The reduction of mechanical work found in scoliotic patients has never been observed in any pathological gait, but it is interpreted as a long term adaptation to economize energy and face poor muscle efficiency. With a relatively stiff gait, scoliosis patients also limit vertical movement of the COM_b (smoothing the gait) and consequently, reduce W _ext and W _int. Inefficiency of scoliosis muscles was obvious even in mild scoliosis (group 1, Cb < 20°) and could be related to the prolonged muscle contraction time observed in a previous study (muscle co-contraction).