Lenke 1型青少年特发性脊柱侧凸患者不同上端融合椎对术后双肩平衡的影响

Influence of upper fused vertebra on postoperative shoulder balance for Lenke type 1 adolescent idiopathic scoliosis

目的：探讨不同上端融合椎对术前双肩水平的Lenke1型青少年特发性脊柱侧凸（adolescent idiopath-ic scoliosis,AIS ）患者术后双肩平衡的影响。方法：选取2006年6月-2009年6月在我院行后路主胸弯融合术并有2年以上完整影像学随访资料的32例Lenke1型AIS患者。所有患者术前均表现为双肩水平，其中男6例，女26例，手术时年龄13-19岁，平均14．9岁，上胸弯Cobb角平均为23．7°±8．0°（10°-36°），主胸弯Cobb角平均47．5°±6．9°（40°-62°）。按照上端融合椎不同将AIS患者分为两组：A组，上端融合椎为T3，19例；B组，上端融合椎为T4，13例。A组患者的手术时年龄、Risser征、上胸弯及主胸弯柔韧度与B组比较均无统计学差异（P〉0．05）。采用方差分析比较两组患者术前、术后1年和末次随访时的上胸弯及主胸弯Cobb角、顶椎及躯干偏移距离、影像学肩关节高度差（radiographic shoulder height, RSH）、喙突高度差（CPH）和锁骨角（CA）。结果：A组随访时间2-4．5年，平均3．6±1．3年；B组随访时间2-4．8年，平均3．1±2．1年，两组比较无统计学差异（P〉0．05）。术前、术后1年和末次随访时，A组患者的上胸弯Cobb角、主胸弯Cobb角、顶椎及躯干偏移距离、RSH、CPH及CA与B组比较均无统计学差异（P〉0．05）。A、B两组患者术后1年和末次随访时的上胸弯Cobb角、主胸弯Cobb角、顶椎及躯干偏移距离、RSH、CPH、CA分别与术前比较均有显著性改善（P〈0．05）；末次随访时，两组患者的上胸弯Cobb角及RSH、CPH、CA较术后1年均显著减小（P〈0．05），均获得较满意的双肩平衡。结论：对于术前双肩水平的Lenke1型AIS患者，上端融合椎为T3或T4对重建术后双肩平衡的疗效无明显差别；对此类患者上端融合至T4即可获得良好的矫形效果和满意的双肩平衡。

Objectives： To analyze the influence of upper fused vertebra on postoperative shoulder balance in Lenke type 1 adolescent idiopathic scoliosis（AIS） patients with preoperative leveled shoulders. Methods： A to- tal of 32 Lenke type 1 AIS patients with preoperative leveled shoulders was included in the study. There were 6 boys and 26 girls with an average age of 14.9 years old（range, 13-19 years）. The average preopera- tive proximal thoracic curve was 23.7°±8.0°（range 10°-36°）, and the average preoperative main thoracic curve was 47.5°±6.9°（range 40°-62°）. Thirty-two patients undergoing posterior thoracic fusion were divided into two groups： group A（n=19） included those who had a proximal fusion to T3; group 2（n=13） included those who had a proximal fusion to T4. There was no significant difference in demographics or baseline characteristics between group A and B including age at operation, Risser stage, flexibility of proximal and main thoracic （PT and MT） curves（P〉0.05）. Based on analysis of variance, radiographic parameters were compared among preoperation, 1 year follow-up and the final follow-up including PT and MT curve Cobb angle, apical verte- bral translation（AVT）, trunk shift, radiographic shoulder height（RSH）, coracoids process beight（CPH） and clavi-cle angle（CA）. Results： In group A, the follow-up time ranged from 2 to 4.5 years with an average time of 3.6±1.3 years; while in group B, the follow-up time ranged from 2 to 4.8 years with a mean time of 3.1±2.1 years, which showed no difference between two groups（P〉0.05）. At preoperation, 1 year follow-up and the fi- nal follow-up, there were no significant differences in radiographic outcomes between group A and B includ- ing PT and MT curve Cobb angle, AVT, trunk shift, RSH, CPH and CA（P〉0.05）. For all patients, PT and MT curve Cobb angle, AVT, trunk shift, RSH, CPH and CA at 1 year follow-up and the final follow-up were both better than those before surgery（all P〈0.05）; while the values of RSH, CPH and CA at final fol- low-up were lower than those at 1 year follow-up（P〈0.05）. All patients obtained the balanced shoulders after surgery. Conclusion： For the Lenke type 1 AIS patient with leveled shoulder, proximal fusion to T4 can pro- duce equivalent correction of scoliosis and shoulder balance.