不同分型系统对AIS单胸弯融合和下端融合椎选择的影响
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摘要
目的:研究不同分型系统对青少年特发性脊柱侧凸(adolescent idiopathicscoliosis,AIS)实际手术中融合弯和下端融合椎(lowest instrumentedvertebra,LIV)选择的影响,探讨Lenke 1型病例的融合原则。
方法:回顾分析我院2002～2007年收治的共52例Lenke 1型AIS患者的手术治疗,其中男11例,女41例,手术时年龄为11～18岁,平均15.5岁。胸弯Cobb角平均53°,柔韧度平均40%;腰弯Cobb角平均35°,柔韧度平均84%。腰弯腰骶角范围0°～20°,所有患者颈7重力垂线不同程度地偏离骶骨中线。手术均采用单纯后路,其中采用CD矫形技术23例,采用全椎弓根钉矫形技术29例。参照King和Lenke分型系统相关的融合原则,首先就是否行选择性胸弯融合进行评估,选择性胸弯融合的病例LIV选择在胸弯的NV或NV+1,非选择性融合的病例LIV选择在尾端基椎(caudal foundation vertebra,CFV)。实际LIV的选择是在综合考虑了腰弯角度的大小、腰弯的柔韧度、旋转中立椎、稳定椎以及患者的外观、平衡等因素后确定的。对所选病例分别用King分型理论和Lenke分型理论确定融合范围并选定下端融合椎,与实际手术中的融合范围进行对比分析。
结果:所有病例随访12～38个月,平均15个月,术后胸弯矫正至平均20°,矫正率为64%,最后随访时与术后即刻比较Cobb角平均丢失2.7°;术后腰弯矫正至平均11°,矫正率为70%,最后随访时与术后即刻比较Cobb角平均丢失2.4°。术后均未出现明显的躯干侧方移位和双肩失衡。与实际LIV比较,相差3个节段以上(包括3个节段)的病例,King分型系统有8例,Lenke分型系统有4例,Lenke分型系统的融合原则似乎与实际手术更加相符,但符合该原则的病例的主胸弯和腰弯的矫正率及末次随访时的角度丢失与符合King分型原则的病例无明显差异;对于Lenke 1A(KingⅢ、Ⅳ型)单胸弯患者,两种分型系统的原则无明显差异,实际手术中LIV的选择与Suk原则建议的LIV比较,相差均在1个节段以内;全椎弓根螺钉技术的主胸弯矫正率及末次随访时角度丢失优于CD技术。手术效果不满意的病例有2个,均为实际行选择性胸弯融合的病例,其中1例发生“曲轴现象”,1例发生腰弯失代偿,角度丢失15°。
结论:Lenke分型系统的融合原则与实际手术更相符,但符合两种分型原则的病例的手术效果无明显差异;Lenke 1型患者融合弯和下端融合椎的选择按照本文所用原则,手术效果较好;全椎弓根螺钉技术的矫形效果优于CD技术。
Objective:To evaluate the effects of classification systems on the selection of thoracic curve fusion and lowest instrumented vertebrae(LIV) in the surgical treatment of adolescent idiopathic scoliosis(AIS) for Lenke type 1 curves.
Methods:Fifty-two AIS patients with Lenke type 1 curves operated between 2002 and 2007 were included and classified retrospectively according to the King and Lenke classification systems among whom 41 were female and 11 were male.Their average age was 15.5 years(11-18 years) at operation.Preoperative standing posteroanterior(PA) and lateral radiographs,preoperative right and left supine bending radiographs,and the instant and latest postoperative standing PA and lateral radiographs were reviewed.Before operation,the Cobb angle of the thoracic curve was averaged 53°and the curve flexibility was averaged 40%.The Cobb angle of lumbar curve was averaged 35°and the curve flexibility was averaged 84%.All patients were operated with posterior-only approach among whom 23 curves were corrected by CD technique and 29 curves were corrected by thoracic pedicle screw technique.The LIV of each patient was identified with King and Lenke classification systems respectively.
Results:With a follow-up of 12-38 months,the thoracic curves were corrected to an average of 20°(correction rate 64%) and the correction loss was an average of 2.7°at the final follow-up.The lumbar curves were corrected automatically to an average of 11°(correction rate 70%) and the correction loss was an average of 2.4°at the final follow-up.Compared with the King system,the LIVs recommended by Lenke system were more consistent with our actual LIVs.No spinal imbalance was clinically observed in all the patients.
Conclusion:The rules recommended by Lenke system for selective fusion are more reliable.The rules used in this article for the selection of LIVs in Lenke type 1 patients help to obtain good results in the clinical operations.
方法:回顾分析我院2002～2007年收治的共52例Lenke 1型AIS患者的手术治疗,其中男11例,女41例,手术时年龄为11～18岁,平均15.5岁。胸弯Cobb角平均53°,柔韧度平均40%;腰弯Cobb角平均35°,柔韧度平均84%。腰弯腰骶角范围0°～20°,所有患者颈7重力垂线不同程度地偏离骶骨中线。手术均采用单纯后路,其中采用CD矫形技术23例,采用全椎弓根钉矫形技术29例。参照King和Lenke分型系统相关的融合原则,首先就是否行选择性胸弯融合进行评估,选择性胸弯融合的病例LIV选择在胸弯的NV或NV+1,非选择性融合的病例LIV选择在尾端基椎(caudal foundation vertebra,CFV)。实际LIV的选择是在综合考虑了腰弯角度的大小、腰弯的柔韧度、旋转中立椎、稳定椎以及患者的外观、平衡等因素后确定的。对所选病例分别用King分型理论和Lenke分型理论确定融合范围并选定下端融合椎,与实际手术中的融合范围进行对比分析。
结果:所有病例随访12～38个月,平均15个月,术后胸弯矫正至平均20°,矫正率为64%,最后随访时与术后即刻比较Cobb角平均丢失2.7°;术后腰弯矫正至平均11°,矫正率为70%,最后随访时与术后即刻比较Cobb角平均丢失2.4°。术后均未出现明显的躯干侧方移位和双肩失衡。与实际LIV比较,相差3个节段以上(包括3个节段)的病例,King分型系统有8例,Lenke分型系统有4例,Lenke分型系统的融合原则似乎与实际手术更加相符,但符合该原则的病例的主胸弯和腰弯的矫正率及末次随访时的角度丢失与符合King分型原则的病例无明显差异;对于Lenke 1A(KingⅢ、Ⅳ型)单胸弯患者,两种分型系统的原则无明显差异,实际手术中LIV的选择与Suk原则建议的LIV比较,相差均在1个节段以内;全椎弓根螺钉技术的主胸弯矫正率及末次随访时角度丢失优于CD技术。手术效果不满意的病例有2个,均为实际行选择性胸弯融合的病例,其中1例发生“曲轴现象”,1例发生腰弯失代偿,角度丢失15°。
结论:Lenke分型系统的融合原则与实际手术更相符,但符合两种分型原则的病例的手术效果无明显差异;Lenke 1型患者融合弯和下端融合椎的选择按照本文所用原则,手术效果较好;全椎弓根螺钉技术的矫形效果优于CD技术。
Objective:To evaluate the effects of classification systems on the selection of thoracic curve fusion and lowest instrumented vertebrae(LIV) in the surgical treatment of adolescent idiopathic scoliosis(AIS) for Lenke type 1 curves.
Methods:Fifty-two AIS patients with Lenke type 1 curves operated between 2002 and 2007 were included and classified retrospectively according to the King and Lenke classification systems among whom 41 were female and 11 were male.Their average age was 15.5 years(11-18 years) at operation.Preoperative standing posteroanterior(PA) and lateral radiographs,preoperative right and left supine bending radiographs,and the instant and latest postoperative standing PA and lateral radiographs were reviewed.Before operation,the Cobb angle of the thoracic curve was averaged 53°and the curve flexibility was averaged 40%.The Cobb angle of lumbar curve was averaged 35°and the curve flexibility was averaged 84%.All patients were operated with posterior-only approach among whom 23 curves were corrected by CD technique and 29 curves were corrected by thoracic pedicle screw technique.The LIV of each patient was identified with King and Lenke classification systems respectively.
Results:With a follow-up of 12-38 months,the thoracic curves were corrected to an average of 20°(correction rate 64%) and the correction loss was an average of 2.7°at the final follow-up.The lumbar curves were corrected automatically to an average of 11°(correction rate 70%) and the correction loss was an average of 2.4°at the final follow-up.Compared with the King system,the LIVs recommended by Lenke system were more consistent with our actual LIVs.No spinal imbalance was clinically observed in all the patients.
Conclusion:The rules recommended by Lenke system for selective fusion are more reliable.The rules used in this article for the selection of LIVs in Lenke type 1 patients help to obtain good results in the clinical operations.
引文
1.Bunnell WP.The natural history of idiopathic scoliosis[J].Clin Orthop Relat Res,1988,20(2):229.
2.King HA,Moe JH,Bradford DS,et al.The selection of fusion levels in thoracic idiopathic scoliosis [J].J Bone Joint Surg (Am),1983,65(9):1302-1313.
3.Lenke LG,Edwards CC Ⅱ,Bridwell KH.The Lenke classification of adolescent idiopathic scoliosis:how it organizes curve patterns as a template to perform selective fusions of the spine [J].Spine,2003,28 (20s):S199-S207.
4.Suk S,Lee SM,Chung ER,et al.Determination of Distal Fusion Level With Segmental Pedicle Screw Fixation in Single Thoracic Idiopathic Scoliosis[J].Spine,2003,28(5):484-491.
5.Ibrahim K,Benson L.Cotrel-Dubousset instrumemation for double major right thoracic left lumbar scoliosis,the relation between frontal balance,hook configuration and fusion level[J].Orthop Trans,1991,15(1):114.
6.Douglas CB,Marc AA,Lee SM,et al.The Selection of Fusion Levels Using Torsional Correction Techniques in the Surgical Treatment of Idiopathic Scoliosis[J].Spine,1999,24(16):1728-1739.
7.Potter BK,Rosner MK,Lehman RA,et al.Reliability of End,Neutral,and Stable Vertebrae Identification in Adolescent Idiopathic Scoliosis[J].Spine,2005,30(14):1658-1663.
8.Satake K,Lenke LG,Kim YJ,et al.Analysis of the Lowest Instrumented Vertebra Following Anterior Spinal Fusion of Thoracolumbar/Lumbar Adolescent Idiopathic Scoliosis:Can We Predict Postoperative Disc Wedging? [J]Spine,2005,30(4):418-426.
9.Lenke LG,Betz RR,Haher TR,et al.Multisurgeon Assessment of Surgical Decision-MaKing in Adolescent Idiopathic Scoliosis:Curve Classification,Operative Approach,and Fusion Levels [J].Spine,2001,26(21):2347-2353.
10.Burton DC,Asher MA,Lai SM,et al.Patient-Based Outcomes Analysis of Patients With Single Torsion Thoracolumbar-Lumbar Scoliosis Treated With Anterior or Posterior Instrumentation:An Average 5-to 9-Year Follow-up Study[J].Spine,2002,27(21):2363-2367.
11.Engsberg JR,Lenke LG,Uhrich ML,et al.Prospective Comparison of Gait and Trunk Range of Motion in Adolescents With Idiopathic Thoracic Scoliosis Undergoing Anterior or Posterior Spinal Fusion[J].Spine,2003,28(17):1993-2000.
12.Kim YJ,Lenke LG,Kim J,et al.Comparative Analysis of Pedicle Screw Versus Hybrid Instrumentation in Posterior Spinal Fusion of Adolescent Idiopathic Scoliosis[J].Spine,2006,31(3):291-298.
1.Douglas CB,Marc AA,Lee SM,et al.The Selection of Fusion Levels Using Torsional Correction Techniques in the Surgical Treatment of Idiopathic Scoliosis[J].Spine,1999,24(16):1728-1739.
2.Suk S,Lee SM,Chung ER,et al.Determination of Distal Fusion Level With Segmental Pedicle Screw Fixation in Single Thoracic Idiopathic Scoliosis [J].Spine,2003,28(5):484-491.
3.Satake K,Lenke LG,Kim YJ,et al.Analysis of the Lowest Instrumented Vertebra Following Anterior Spinal Fusion of Thoracolumbar/Lumbar Adolescent Idiopathic Scoliosis:Can We Predict Postoperative Disc Wedging? [J]Spine,2005,30(4):418-426.
4.Nault ML,Labelle H,Aubin CE,et al.The Use of Fuzzy Logic to Select Which Curves Need to be Instrumented and Fused in Adolescent Idiopathic Scoliosis:A Feasibility Study[J].Journal of Spinal Disorders & Techniques,2007,20(8):594-603.
5.Potter BK,Rosner MK,Lehman RA,et al.Reliability of End,Neutral,and Stable Vertebrae Identification in Adolescent Idiopathic Scoliosis[J].Spine,2005,30(14):1658-1663.
6.Lenke LG,Betz RR,Haher TR,et al.Multisurgeon Assessment of Surgical Decision-MaKing in Adolescent Idiopathic Scoliosis:Curve Classification,Operative Approach,and Fusion Levels [J].Spine,2001,26(21):2347-2353.
7.Ibrahim K,Benson L.Cotrel-Dubousset instrumemation for double major right thoracic left lumbar scoliosis,the relation between frontal balance,hook configuration and fusion level[J].Orthop Trans,1991,15(1):114.
13.Aaro S,Dahlborn M.Estimation of vertebral rotation and the spinal rib cage deformity in scoliosis by computer tomography [J].Spine,1981,6(5):460-7.
14.Lenke LG,Edwards CC Ⅱ,Bridwell KH.The Lenke classification of adolescent idiopathic scoliosis:how it organizes curve patterns as a template to perform selective fusions of the spine [J].Spine,2003,28 (20s):S199-S207.
15.Lenke LG,Bridwell KH,Baldus C,et al.Preventing decompensation in King type Ⅱ curves treated with Cotrel-Dubousset instrumentation.Strict guidelines for selective thoracic fusion[J].Spine,1992,17 (8s):S274-S281.
16.Cil A,Pekmezci M,Yazici M,et al.The Validity of Lenke Criteria for Defining Structural Proximal Thoracic Curves in Patients with Adolescent Idiopathic Scoliosis[J].Spine,2005,30(22):2550-2555.
17.Sanders AE,Baumann R,Brown H,et al.Selective Anterior Fusion of Thoracolumbar/Lumbar Curves in Adolescents:When Can the Associated Thoracic Curve Be Left Unfused? [J]Spine,2003,28(7):706-713.
18.Newton PO,Faro FD,Lenke LG,et al.Factors Involved in the Decision to Perform a Selective Versus Nonselective Fusion of Lenke IB and 1C (King-Moe Ⅱ)Curves in Adolescent Idiopathic Scoliosis[J].Spine,2003,28(20s):S217-S223.
19.Ward WT,Rihn JA,Solic J,et al.A Comparison of the Lenke and King Classification Systems in the Surgical Treatment of Idiopathic Thoracic Scoliosis[J].Spine,2008,33(1):52-60.
20.Suk S,Lee SM,Chung ER,et al.Selective Thoracic Fusion With Segmental Pedicle Screw Fixation in the Treatment of Thoracic Idiopathic Scoliosis:More than 5-Year Follow-Up[J].Spine,2005,30(14):1602-1609.
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29.Engsberg JR,Lenke LG,et al.Prospective Evaluation of Trunk Range of Motion in Adolescents With Idiopathic Scoliosis Undergoing Spinal Fusion Surgery[J].Spine,2002,27(12):1346-1354.
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34.Engsberg JR,Lenke LG,Uhrich ML,et al.Prospective Comparison of Gait and Trunk Range of Motion in Adolescents With Idiopathic Thoracic Scoliosis Undergoing Anterior or Posterior Spinal Fusion[J].Spine,2003,28(17):1993-2000.
35.张永刚,王岩,张雪松,等.特发性脊柱侧凸KingⅢ型和Ⅳ型远端融合椎的选择[J].中国修复重建外科杂志,2006,20(4):387-390.
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38.王岩,张永刚,张雪松,等.侧弯全节段椎弓根螺钉固定矫治单胸弯特发性脊柱侧凸的下固定融合椎选择[J].中国脊柱脊髓杂志,2005,14(4):203-206.
2.King HA,Moe JH,Bradford DS,et al.The selection of fusion levels in thoracic idiopathic scoliosis [J].J Bone Joint Surg (Am),1983,65(9):1302-1313.
3.Lenke LG,Edwards CC Ⅱ,Bridwell KH.The Lenke classification of adolescent idiopathic scoliosis:how it organizes curve patterns as a template to perform selective fusions of the spine [J].Spine,2003,28 (20s):S199-S207.
4.Suk S,Lee SM,Chung ER,et al.Determination of Distal Fusion Level With Segmental Pedicle Screw Fixation in Single Thoracic Idiopathic Scoliosis[J].Spine,2003,28(5):484-491.
5.Ibrahim K,Benson L.Cotrel-Dubousset instrumemation for double major right thoracic left lumbar scoliosis,the relation between frontal balance,hook configuration and fusion level[J].Orthop Trans,1991,15(1):114.
6.Douglas CB,Marc AA,Lee SM,et al.The Selection of Fusion Levels Using Torsional Correction Techniques in the Surgical Treatment of Idiopathic Scoliosis[J].Spine,1999,24(16):1728-1739.
7.Potter BK,Rosner MK,Lehman RA,et al.Reliability of End,Neutral,and Stable Vertebrae Identification in Adolescent Idiopathic Scoliosis[J].Spine,2005,30(14):1658-1663.
8.Satake K,Lenke LG,Kim YJ,et al.Analysis of the Lowest Instrumented Vertebra Following Anterior Spinal Fusion of Thoracolumbar/Lumbar Adolescent Idiopathic Scoliosis:Can We Predict Postoperative Disc Wedging? [J]Spine,2005,30(4):418-426.
9.Lenke LG,Betz RR,Haher TR,et al.Multisurgeon Assessment of Surgical Decision-MaKing in Adolescent Idiopathic Scoliosis:Curve Classification,Operative Approach,and Fusion Levels [J].Spine,2001,26(21):2347-2353.
10.Burton DC,Asher MA,Lai SM,et al.Patient-Based Outcomes Analysis of Patients With Single Torsion Thoracolumbar-Lumbar Scoliosis Treated With Anterior or Posterior Instrumentation:An Average 5-to 9-Year Follow-up Study[J].Spine,2002,27(21):2363-2367.
11.Engsberg JR,Lenke LG,Uhrich ML,et al.Prospective Comparison of Gait and Trunk Range of Motion in Adolescents With Idiopathic Thoracic Scoliosis Undergoing Anterior or Posterior Spinal Fusion[J].Spine,2003,28(17):1993-2000.
12.Kim YJ,Lenke LG,Kim J,et al.Comparative Analysis of Pedicle Screw Versus Hybrid Instrumentation in Posterior Spinal Fusion of Adolescent Idiopathic Scoliosis[J].Spine,2006,31(3):291-298.
1.Douglas CB,Marc AA,Lee SM,et al.The Selection of Fusion Levels Using Torsional Correction Techniques in the Surgical Treatment of Idiopathic Scoliosis[J].Spine,1999,24(16):1728-1739.
2.Suk S,Lee SM,Chung ER,et al.Determination of Distal Fusion Level With Segmental Pedicle Screw Fixation in Single Thoracic Idiopathic Scoliosis [J].Spine,2003,28(5):484-491.
3.Satake K,Lenke LG,Kim YJ,et al.Analysis of the Lowest Instrumented Vertebra Following Anterior Spinal Fusion of Thoracolumbar/Lumbar Adolescent Idiopathic Scoliosis:Can We Predict Postoperative Disc Wedging? [J]Spine,2005,30(4):418-426.
4.Nault ML,Labelle H,Aubin CE,et al.The Use of Fuzzy Logic to Select Which Curves Need to be Instrumented and Fused in Adolescent Idiopathic Scoliosis:A Feasibility Study[J].Journal of Spinal Disorders & Techniques,2007,20(8):594-603.
5.Potter BK,Rosner MK,Lehman RA,et al.Reliability of End,Neutral,and Stable Vertebrae Identification in Adolescent Idiopathic Scoliosis[J].Spine,2005,30(14):1658-1663.
6.Lenke LG,Betz RR,Haher TR,et al.Multisurgeon Assessment of Surgical Decision-MaKing in Adolescent Idiopathic Scoliosis:Curve Classification,Operative Approach,and Fusion Levels [J].Spine,2001,26(21):2347-2353.
7.Ibrahim K,Benson L.Cotrel-Dubousset instrumemation for double major right thoracic left lumbar scoliosis,the relation between frontal balance,hook configuration and fusion level[J].Orthop Trans,1991,15(1):114.
13.Aaro S,Dahlborn M.Estimation of vertebral rotation and the spinal rib cage deformity in scoliosis by computer tomography [J].Spine,1981,6(5):460-7.
14.Lenke LG,Edwards CC Ⅱ,Bridwell KH.The Lenke classification of adolescent idiopathic scoliosis:how it organizes curve patterns as a template to perform selective fusions of the spine [J].Spine,2003,28 (20s):S199-S207.
15.Lenke LG,Bridwell KH,Baldus C,et al.Preventing decompensation in King type Ⅱ curves treated with Cotrel-Dubousset instrumentation.Strict guidelines for selective thoracic fusion[J].Spine,1992,17 (8s):S274-S281.
16.Cil A,Pekmezci M,Yazici M,et al.The Validity of Lenke Criteria for Defining Structural Proximal Thoracic Curves in Patients with Adolescent Idiopathic Scoliosis[J].Spine,2005,30(22):2550-2555.
17.Sanders AE,Baumann R,Brown H,et al.Selective Anterior Fusion of Thoracolumbar/Lumbar Curves in Adolescents:When Can the Associated Thoracic Curve Be Left Unfused? [J]Spine,2003,28(7):706-713.
18.Newton PO,Faro FD,Lenke LG,et al.Factors Involved in the Decision to Perform a Selective Versus Nonselective Fusion of Lenke IB and 1C (King-Moe Ⅱ)Curves in Adolescent Idiopathic Scoliosis[J].Spine,2003,28(20s):S217-S223.
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