青少年特发性脊柱侧凸选择性胸弯融合的策略

The strategy for the selective fusion of thoracic curve in adolescent idiopathic scoliosis

目的:探讨青少年特发性脊柱侧凸(AIS)手术矫形时胸弯选择性融合的策略。方法:回顾分析手术矫形治疗的46例Lenke1B和1C型AIS患者,男12例,女34例,手术时年龄12～18岁,平均15.4岁,Risser指数0～Ⅳ级。Lenke1B型29例,Lenke1C型17例。胸弯Cobb角43°～82°,平均58°,腰弯Cobb角16°～64°,平均45°。采用单纯后路手术,其中CD技术19例,全椎弓根螺钉固定技术27例。手术融合范围的选择依据腰弯的结构特征,包括弯曲大小、柔韧度、顶椎旋转度以及C7重力垂线偏离骶骨中线的距离等,兼顾双肩和腰部外观以及躯干平衡情况。结果:25例1B型和9例1C型融合单胸弯,其余12例融合双弯。随访12～38个月,平均15个月,术后胸弯Cobb角平均18.9°,矫正率64%,末次随访时角度丢失平均2.2°;术后腰弯Cobb角平均11.8°,矫正率70%,末次随访时角度丢失平均2.7°。术后躯干和双肩平衡满意(躯干侧方移位和双肩高度差均在2cm以内)。2例随访时出现明显矫形丢失,均为选择性胸弯融合的病例,1例发生"曲轴现象",1例发生腰弯失代偿。结论:在确定青少年特发性脊柱侧凸手术融合范围时,应充分评价腰弯的结构特征以及外观和平衡等因素,尽量保留腰椎活动度,以取得满意的矫形效果。

Objective：To investigate the rules on the selective fusion of thoracic curve in the surgical treatment of adolescent idiopathic seoliosis （AIS） for Lenke type 1B and 1C curves.Method：46 AIS patients（34 females and 12 males） with Lenke type 1B and 1C curves were included.Their average age was 15.4 years （12-18 years） and Risser signs were 0 to Ⅳ at operation.Lenke type 1B was in 29 cases and 1C in 17 cases.Before operation,the average Cobb angle of the thoracic curve was 58°（43°-82°） and the lumbar curve was 45°（16°-64°）.All patients were operated with posterior approach among whom 19 were corrected by CD technique and 27 by whole segmental pedicle screw technique.The fusion region of each patient was decided based on the structural feature of the lumbar curve including the curve magnitude,flexibility,the rotation of the apex vertebrae,and the distance between the central sacral vertical line （CSVL） and the C7 plumb line. And the appearance of the shoulders and the back and the tunk balance were also considered.Result：25 patients with 1B curves and 9 with 1C curves were fused selectively.12 were fused in double curves.With a follow-up of 12-38 months （mean 15 rnonths）,the thoracic curves were corrected to an average of 18.9°（correetion rate 64% ） and the correction loss was in an average of 2.2° at the final follow-up.The lumbar curves were corrected to an average of 11.8°（correetion rate 70%） and the correction loss was in an average of 2.7° at the final follow-up.The balance were well rebuilt.The trunk translation and the shoulders difference in height were all within 2cm.2 patients treated with selective curve fusion were found with obviously correction loss.One was crank-shaft phenomenon and other was lumbar discompensation.Conclusion：When deciding the fusion levels of the AIS patients,the struetral characteristics of the lumbar curves,the apperance of the patients and the trunk banlance should be carefully evaluated ,more mobilizable lumbar segments should he retained as far as possible to get a good eorrecting result.