青少年特发性脊柱侧弯肩平衡相关参数评价及术后肩失衡危险因素研究进展

Evaluation of related parameters and risk factors of shoulder balance in adolescent idiopathic scoliosis

青少年特发性脊柱侧弯(adolescent idiopathic scoliosis,AIS)是最常见的脊柱畸形之一,术后肩失衡(postoperative shoulder imbalance,PSI)是医生和患者重点关注的问题之一,也是目前研究的热点。对于AIS患者肩部平衡的定义目前尚无统一共识,这导致各研究设置的标准不同,最终结论也可能相反。目前大多数研究以影像学肩高(radiographic shoulder height,RSH)>10 mm,喙突高度差(coracoid height difference,CHD)>9 mm,锁骨角(clavicle angle,CA)>2°或锁骨倾斜角度差(clavicle tilt angle difference,CTAD)>4.5°定义为患者肩失衡。为了更好地描述肩部情况,学者们提出了很多影像学参数,此外美学参数也被引入到肩平衡的研究中。然而两种参数都有自己的局限性,没有单一参数能够完全真实准确反映患者肩部平衡情况,美学参数虽然评价结果较为真实,但是临床上最易获得,应用最广泛的是影像学参数。然而影像学参数和美学参数间的相关性并不高,无法用影像学参数去完全替代美学参数。PSI发生的危险因素有Risser征分级,近端椎体倾斜角大小,术后上胸弯/主胸弯比值大小,术前CA的大小或T 1倾斜角大小、PTC僵硬度、MTC矫正率、上端固定椎体(upper instrumented vertebrae,UIV)选择等,但都不是独立危险因素。近年来锁骨胸腔角度差被认为是一个良好的预测因素,但除了在Lenke1型和5型AIS患者中结果较可靠外,其他类型中暂无相关报道。既往对PSI预防措施研究最多的是UIV选择,近来发现畸形的矫正程度对术后肩平衡的影响也很重要。该文针对青少年特发性脊柱侧弯患者肩平衡的目前研究现状进行综述,为青少年特发性脊柱侧弯肩平衡的进一步研究提供思路。

Adolescent idiopathic scoliosis(AIS)is one of the most common spinal deformities.Postoperative shoulder imbalance(PSI)is one of the issues that doctors and patients focus on,and it is also the focus of current research.At present,there is no unified consensus on the definition of shoulder balance in patients with AIS,which leads to different standards set in some studies,and the final conclusion may be the opposite.Now,most studies define shoulder imbalance as radiographic shoulder height(RSH)>10 mm,coracoid height difference(CHD)>9 mm,clavicle angle(CA)>2°or clavicle tilt angle difference(CTAD)>4.5°.In order to better describe the shoulder balance,scholars have proposed a lot of imaging parameters,in addition,aesthetic parameters have also been introduced into the study of shoulder balance.However,the two parameters have their own limitations,no single parameter can truly and accurately reflect the shoulder balance of patients.Although the evaluation results of aesthetic parameters are more real,they are the most easily obtained in clinic,and imaging parameters are the most widely used.Then,the correlation between imaging parameters and aesthetic parameters is not high,imaging parameters can not be used to completely replace aesthetic parameters.The risk factors of PSI are Risser sign grade,proximal wedge angle(PWA)size,postoperative proximal thoracic curve(PTC)/main thoracic curve(MTC)ratio,preoperative CA size or T1 tilt angle,PTC stiffness,MTC correction rate,upper instrumented vertebrae(UIV)selection and so on,but they are not independent risk factors.Recently,CCAD has been considered as a good predictor,but it has not been reported in other types of AIS except in patients with Lenke type 1 and 5.In the past,the most research on the preventive measures of PSI is the choice of upper fixation of vertebral body(UIV).Recently,it has been found that the degree of correction of deformity has an important effect on shoulder balance after operation.This article reviews the current research status of shoulder balance in adolescent idiopathic scoliosis,in order to provide ideas for further study of shoulder balance in adolescent idiopathic scoliosis.