青少年特发性脊柱侧凸术后失代偿原因分析及处理

Causes and strategies on decompensation after operation for adolescent idiopathic scoliosis

目的探讨青少年特发性脊柱侧凸(AIS)术后失代偿的原因及治疗对策。方法回顾性分析自1997年7月～2001年12月间AIS手术后失代偿病例14例。术后失代偿的诊断标准:躯干偏移距离>20mm,肩部不等高,远侧腰椎的旋转加重为冠状面失平衡;C7棘突垂线偏离S1后缘,胸腰段后凸>10°为矢状位失平衡。结果病例失代偿的原因包括初次手术时的分型错误、融合节段选择不当、胸弯过度矫正及腰骶弯认识不足。根据患者的主观症状及失代偿的类型选择再手术10例,其中3例取出内固定后重新融合固定,6例延长融合节段,1例去除主胸弯内固定、融合上胸弯;采用支具治疗4例。随访除1例为6个月外,其余随访1～3年,平均18.9个月,12例随访时脊柱冠状面躯干偏移均<20mm,所有患者矢状面平衡良好。结论AIS手术治疗时应根据不同的侧凸类型,自重力悬吊牵引位、反向弯曲位X线片了解躯干的平衡、侧凸的柔韧性,以选择适当的融合水平和手术方式来减少术后失代偿的发生,当术后发生失代偿时,应根据患者的主观症状及失代偿的类型选择不同的治疗方法。

Objective The study was to probe into the causes and strategies of decompensation after operation in adolescent idiopathic scoliosis in order to reduce the operative mistakes and be aware of pitfalls in scoliosis surgery.Methods From July1997to December2001,174patients underwent the operation of three-dimensional correction of adolescent idiopathic scoliosis,ten of them developed postoperative decom-pensation.Other four patients with postoperative decompensation were referred to our hospital,who received the primary operation for idiopathic scoliosis at the local hospital.In all,fourteen patients with decompensa-tion were retrospectively reviewed including3male and11female cases aging from12to23years(range,15.7years).The criteria of postoperative decompensation was defined as trunk shift more than2mm,shoul-der tilting,aggravated distal lumbar rotation in coronal plane,the plumb line of center of C 7 deviating the from the posterior edge of S 1 and kyphosis of thoracic-lumbar junction more than10degree in sagittal plane.Results The analysis was made depending on preoperative and postoperative X-ray films,the causes of de-compensation after surgery included classification error,inappropriate fusion level,over correction for tho-racic curve and insufficient knowledge of lumbosacral hemicurve in this group.According to the patientssubjective symptoms and decompensation conditions,ten of the patients were treated surgically,which in-cluded re-fusion and fixation for3patients,fusion level extension for6patients and fusion of the upper tho-racic curve after removing major thoracic curve instrumentation for one patient.The other four patients re-ceived conservative therapy with brace.The patients were followed up from1to3years(average,18.9months),except one case followed up to6months.Twelve patients regained spinal balance;two patients re-mained more than20mm trunk shift.Conclusion Although operative treatment is frequently used for idio-pathic scoliosis,it is important to recognize the necessity for operative intervention,indication for surgery.The adolescent idiopathic scoliosis should be operated according to the curve type and flexibility,the appro-priate fusion level and operative procedures can contribute to lessen the postoperative decompensation.If postoperative decompensation occurs,therapeutic decision should be made according to subjective symptoms and the decompensation type of the patients.