青少年特发性脊柱侧凸术后肩部外观可塑性与融合策略

Spontaneous shoulder correction and instrumentation strategy of upper thoracic curve in adolescent idiopathic scoliosis

目的：本研究旨在探讨青少年特发性脊柱侧凸（adolescent idiopathic scoliosis，AIS）术后肩部外观可塑性，分析基于该现象的胸弯融合上端椎选择策略。方法：对56例Lenke Ⅰ型AIS患者进行回顾性研究，术后随访2～5年。术前Cobb角主胸弯57.65°±12.28°、上胸弯20.34°±9.52°。根据术前肩部平衡、上胸弯柔韧度情况，主胸弯融合上端椎选择方案为：术前右肩抬高非僵硬性上胸弯（柔韧度＞30%）患者10例，选择端椎下位椎（端椎－1）；僵硬性上胸弯（柔韧度≤30%）患者7例，选择端椎。术前双肩平衡非僵硬性上胸弯患者，7例选择端椎上位椎（端椎＋1），7例选择T3；僵硬性上胸弯患者，5例选择T4，6例选择T3。术前左肩抬高非僵硬性上胸弯患者4例，选择端椎上位椎（端椎＋1）；僵硬性上胸弯患者，1例选择T4，9例选择T3。配对t检验比较术后即刻、末次随访外观肩高（CSD），评估术后肩部外观可塑性。并对术后肩部平衡进行主观评价，其中患者和家属一方或双方认为肩部外观未恢复平衡，为主观评价不满意。通过分析外观CSD变化，影像学冠状面平衡及T2～T5后凸角，患者及家属主观评价，总结基于肩部外观可塑性的上端椎选择策略。结果：末次随访Cobb角主胸弯19.16°±10.34°、上胸弯11.83°±8.65°，冠状面平衡0.67±0.56cm，T2～T5后凸角17.23°±7.28°。1例患者2年内随访主观评价左肩抬高，其余患者无并发症发生。术前、术后即刻、末次随访时，CSD值：1.04±0.24cm、0.92±0.22cm、0.63±0.16cm；CSD≥1cm患者例数：31例、23例、5例。术后即刻与末次随访CSD存在显著差异（t=7.98，P＜0.001），最大肩部外观可塑值ΔCSD为1.69cm。随访中肩部恢复平衡的上端椎选择方案：术前右肩抬高非僵硬性上胸弯患者选择端椎－1，右肩抬高僵硬性上胸弯患者选择端椎，双肩平衡非僵硬性上胸弯患者选择端椎＋1或T3，双肩平衡僵硬性上胸弯患者选择T3后，患者末次随访CSD均＜1cm，主观评价满意；术前左肩抬高非僵硬性上胸弯患者选择端椎＋1后1例末次随访CSD为1.06cm，左肩抬高僵硬性上胸弯患者选择T3后1例末次随访CSD为1.02cm，主观评价满意。随访中肩部未恢复平衡的上端椎选择方案：术前双肩平衡僵硬性上胸弯患者选择T4后，2例CSD分别为1.45cm、1.54cm，其中1例随访2年内主观评价左肩抬高；术前左肩高僵硬性上胸弯患者选择T4，1例CSD较大为1.52cm。结论：AIS患者术后肩部外观存在可塑性，基于该特性Lenke Ⅰ型AIS患者胸弯融合上端椎策略为：术前右肩抬高非僵硬性上胸弯患者选择端椎－1，僵硬性上胸弯患者选择端椎；双肩平衡非僵硬性上胸弯患者选择端椎＋1，僵硬性上胸弯患者选择T3；左肩抬高非僵硬性上胸弯患者选择端椎＋1，僵硬性上胸弯患者选择T3。

Objectives： To evaluate the spontaneous correction of shoulder cosmetic difference（SCSC） in adolescent idiopathic scoliosis（AIS） and the strategy of choosing upper instrumented vertebra（UIV）. Methods： 56 consecutive Lenke Ⅰ AIS patients followed up for 2 to 5 years were enrolled, the preoperative main thoracic（MT） Cobb angle was 57.65°±12.28° and proximal thoracic（PT） Cobb angle was 20.34°±9.52°. Preoperative shoulder balance, flexibility of PT, and UIV were defined as following, when lifting right shoulder, 10 patients with non-rigid PT were chosen the vertebra just below the end vertebra（EV-1）; 7 patients with rigid PT were chosen the end vertebra（EV）. When encountering shoulder balance and non-rigid PT, 7 patients were chosen the vertebra just above end vertebra（EV＋1）, 7 patients were chosen T3. For patients with rigid PT, 5 of them were chosen T4, 6 of them were chosen T3. When lifting left shoulder, 4 patients with non-rigid PT were chosen EV＋1; Patients with rigid PT, 1 of them was chosen T4, 9 of them were chosen T3. T-test was used to evaluate the difference of shoulder cosmetic difference（SCD） after surgery immediately and at final follow-up. The subjective evaluations of shoulder balance from patients and parents were also recorded. Poor subjective evaluation was got when patient or parent considered shoulder unbalanced. Photographs, radiographic images and subjective evaluation were assessed to summarize the strategy to choose UIV based on SCCS. Results： The correction rate was （66.76±10.21）% at final follow-up. Coronal balance improved to 0.67±0.56cm, and T2-T5 kyphosis was 17.23°±7.28°. 1 patient had the subjective perception of left shoulder lifted in two years of follow-up, all the other patients were satisfied with their shoulder balance and had no experience of other complication. At preoperation, postoperation immediately and final follow-up, the SCD was 1.04±0.24cm, 0.92±0.22cm and 0.63±0.16cm respectively, number of patients with SCD≥1cm was 31, 23 and 5 respectively. There was significant difference between SCD after surgery immediately and that at final follow-up（t=7.98, P〈0.001）. The maximum correction of shoulder cosmetic（SCD） was 1.69cm. Patients with successful results and the strategies to choose UIV： patients with preoperative right shoulder lifted and non-rigid PT when choosing EV-1, patients with preoperative right shoulder lifted and rigid PT when choosing EV, patients with preoperative balanced shoulder and non-rigid PT when choosing EV＋1 or T3, patients with preoperative balanced shoulder and rigid PT when choosing T3, all got CSD〈1cm and subjective satisfaction of shoulder balance. Patients with preoperative left shoulder lifted and non-rigid PT when choosing EV＋1, 1 of whom had CSD as 1.06cm, but gained subjective satisfaction. Patients with preoperative left shoulder lifted and rigid PT when choosing T3, 1 of whom had CSD as 1.02cm, gained subjective satisfaction. Patients with unsuccessful results and the strategies to choose UIV： Patients with preoperative balanced shoulder and rigid PT when choosing T4, 2 of whom had CSD as 1.45cm and 1.54cm, 1 of the two considered left shoulder lifted in two years follow-up. Patients with preoperative left shoulder lifted and rigid PT when choosing T4 had CSD as 1.52cm at final follow-up. Conclusions： Cosmetic shoulder balance maybe developed in most patients after surgery. The strategy to choose UIV based on SCSC is as follow, when lifting right shoulder, patients with non-rigid PT should choose EV-1, while rigid PT choosing EV. When encountering shoulder balance, patients with non-rigid PT should choose EV＋1, while rigid PT choosing T3. When lifting left shoulder, patients with non-rigid PT choose EV＋1, while rigid PT choosing T3.