特发性脊柱侧凸患者肩部失平衡的临床分析及其意义

目的：对不同类型特发性脊柱侧凸（idiopathic scoliosis,IS）患者肩部失平衡情况进行观察,探讨避免肩部失平衡的融合节段选择方案.方法：对137例随访2年以上资料完整的IS患者进行回顾性分析.对术前及术后的肩部平衡进行影像学评价.根据可能影响肩部平衡的因素（上胸椎侧凸情况、各个侧凸间相互平衡情况及主侧凸角度大小）将患者的Lenke分型进一步分为不同类型.分析各因素及手术融合方式对肩部平衡产生的影响.结果：术前肩部失平衡的病例71例;其中显著肩部失平衡22例;重度肩部失平衡10例,均为Lenke 1型及Lenke 2型.这些患者均存在较大角度的上胸椎侧凸（非结构性或结构性）.术后6例显著肩部失平衡.其中Lenke 1型第一类型1例,Lenke 2型第一类型1例,Lenke 2型第三类型4例,手术方式均为选择性融合.对Lenke 2型第二类型进行双侧凸融合,术后肩部失平衡改善.结论：术前肩部不平衡主要为Lenke 1型及Lenke 2型患者.上胸椎侧凸畸形对肩部平衡产生关键性影响.对Lenke 2型第二及第三类型不建议行选择性融合,对Lenke 2型第一类型进行选择性融合时应避免过度矫正.

Evaluation and surgical management of shoulder imbalance of idiopathic scoliosis patients

Objective:To evaluate the preoperative shoulder imbalance of idiopathic scoliosis(IS) patients with the purpose of determining fusion level to avoid postoperative shoulder imbalance.Method:137 IS patients with over 2 years follow-up were reviewed.The shoulder height difference was evaluated pre-,post-operatively.The patients were classified into subtypes of Lenke classification based on the factors influencing the shoulder balance including the upper thoracic curve,the balance between the curves and the Cobb angle of the main curve. The impact of all the factors and fusion levels were evaluated.Result:71 of the 137 patients had shoulder imbalance preoperatively while 22 had significant and 10 had severe imbalance.All the patients had significant upper thoracic curves while 6 patients had significant imbalance after operation.The shoulder imbalance of 1(Lenke 2 subtype 1) and 4(subtype 3) patients aggravated after selective lower thoracic curve fusion.The shoulder imbalance of the Lenke 2 subtype 2 patients improved after both thoracic curve fusion.Conclusion:The most significant shoulder imbalance before operation is occured in the Lenke 1 and Lenke 2.The proximal thoracic curve has critical influence on the shoulder balance.The selective lower curve fusion is not suggested for Lenke 2 subtype 2 and subtype 3.For Lenke 2 subtype 1,over-correction of main thoracic curve might result in shoulder imbalance.