合并胸腰段后凸的青少年特发性脊柱侧凸的临床研究

Clinical features of adolescent idiopathic scoliosis with thoracolumbar kyphosis and its surgical treatment

目的探讨合并胸腰段后凸的青少年特发性脊柱侧凸（AIS）的临床特点和手术治疗策略。方法对2001年1月至2007年1月收治的413例AIS患者进行回顾性分析，合并胸腰段后凸者共10例，其中男2例，女8例；年龄12～18岁，平均14．3岁。侧凸类型包括PUMCⅡb2型3例，Ⅱc3型4例，Ⅱd2型1例，Ⅱb型2例。单纯后路内固定术8例，前路松解＋后路内固定术2例。术前、术后及随访时摄X线片，对侧凸类型、Cobb角、顶椎旋转度、顶椎偏距、侧凸柔韧性、胸腰段后凸、冠状面及矢状面躯干偏移进行评测和分析。结果本组患者中双弯8例，三弯2例；胸腰弯／腰弯Cobb角≥45。者7例，柔韧性指数≤70％者6例，顶椎旋转度≥Ⅱ度者9例。所有病例的融合范围均符合PUMC分型原则。手术前后平均胸弯冠状面Cobb角分别为71．7°和37．4°，平均矫正率为47．8％；手术前后平均胸腰弯／腰弯冠状面Cobb角分别为65．0°和27．8°，平均矫正率为57．2％；手术前后平均胸腰段后凸分别为35．5°和4．2°，平均矫正率为88．2％。全部病例随访12～72个月，平均23．1个月；最终随访时无躯干失平衡发生。结论合并胸腰段后凸的AIS一般多为双弯或三弯，胸腰弯／腰弯畸形往往比较严重，并有明显的旋转畸形。对合并胸腰段后凸的AIS，应融合胸腰弯／腰弯以防止术后发生失代偿或后凸加重，PUMC分型可以有效识别病变类型并指导融合范围的选择。

Objective To summarize the clinical features and evaluate the surgical results of adolescent idiopathic scoliosis （AIS） with thoracolumbar kyphosis. Methods Four hundred and thirteen AIS patients were retrospectively reviewed between January 2001 and January 2007. Among them, 10 patients had thoracolumbar kyphosis, including 2 males and 8 females. The average age at surgery was 14. 3 years old. There were 3 PUMC type Ⅱ b2, 4 PUMC Ⅱ c3, 1 PUMC Ⅱ d2, 2 PUMC m b Eight patients underwent posterior correction and spinal fusion with instrumentation, 2 patients underwent anterior release, posterior correction and spinal fusion with instrumentation. By reviewing the roentgenograms of patients, the curve type, Cobb angle, flexibility, apical rotation and translation, coronal and sagittal trunk shift and thoracolumbar kyphosis were measured and analyzed. Results Eight patients had double curves and 2 patients had triple curves. Among them, the Cobb angles of thoracolumbar or lumbar curve were larger than 45°in 7 patients, the flexibility index was less than 70% in 6 patients, the apical vertebral rotation was larger than Ⅱ° in 9 patients and the apical vertebral translation was larger than 2 cm in all patients. All the surgical treatment strategy and fusion level followed the criteria of PUMC classification. The coronal Cobb angles of thoracic curve before and after surgery were 71.7° and 37.4° respectively, and the average correction rate was 47.8%. The coronal Cobb angles of thoracolumbar or lumbar curve before and after surgery were 65.0° and 27.8° respectively, and the average correction rate was 57. 2%. The Cobb angles of thoracolumbar kyphosis before and after surgery were 35.5° and 4. 2° respectively, and the average correction rate was 8 8. 2 % . No trunk decompensation was noted at final follow - up. All patients were followed-up from 12 to 72 months; the average follow up was 23.1 months. Conclusions AIS patients with thoracolumbar kyphosis usually have double or triple curves. In these patients, thoracolumbar curves or lumbar curves are severe and have obvious rotatory deformity. Thoracolumbar curve or lumbar curve should be fused in idiopathic scoliosis patients with thoracolumbar kyphosis to avoid trunk decompensation or junctional kyphosis. By using criteria of PUMC classification, these patients can be well identified and corresponding fusion level can be followed as well.