【作者】 陈庆贺；

【导师】 周跃；

【作者基本信息】 第三军医大学 ， 外科学， 2008， 博士

【摘要】 研究背景及研究目的特发性脊柱侧凸对青少年的身心健康造成重大危害,随年龄增加畸形加剧,引起外观畸形、心肺功能障碍及残疾,严重影响以后的劳动能力和生活质量,有针对性地治疗此种脊柱畸形的系统研究,将完善和加强我国青少年的保健工作,有利于提高国民整体素质和促进经济建设发展。由于青少年特发性脊柱侧凸的发病机理复杂,近百年来对其治疗仍在不断探索之中,本领域是脊柱畸形治疗的难点,尽管国内外的治疗方式方法多种多样,但根本目的是减少病残,使患儿重返社会。要取得较为理想和肯定的治疗效果,其关键措施则是早期治疗、有效控制和正确手术矫形。特发性脊柱侧凸的弯度进展与性别、弯度大小、骨骼成熟度等多项因素相关。现在临床上有许多种术前摄片方法,哪一种能更准确地反映青少年特发性脊柱侧凸术后的矫正效果还不清楚,采用三种术前摄片方法,对脊柱后路椎弓根钉固定系统的矫正结果进行预测,找出一种更接近真实矫正效果的术前摄片预测方法,为临床手术治疗提供依据。脊柱侧凸Cobb角在10°~40°之间的患者,必须进行以支具为主的非手术治疗。支具治疗是目前公认有效的非手术治疗方法,其他方法的疗效不确切,只能作为辅助治疗手段。支具治疗的目的是矫正或控制脊柱弯曲,改善平衡及外观,防止弯曲增加,并使脊柱稳定。支具对脊柱侧凸的早期治疗,其社会效益很大,如能广泛地被采用,可使许多患有脊柱侧凸的少年儿童得到及时纠正,或将弯度控制在轻度范围内,使这些少年儿童不致成残废。为探讨青少年特发性脊柱侧凸支具治疗的适应症、禁忌症和疗效情况,并评价其临床效果,需要进行较大样本的总结,当前用热塑矫形支具治疗青少年特发性脊柱侧凸尚无系统报道,我们对青少年特发性脊柱侧凸106例进行规范化的支具矫正治疗,以期获得较为满意的效果。脊柱侧凸Cobb角大于40°时,应进行手术矫形固定与融合,在决定是否手术及手术的方式选择时需对患者的骨龄、生长发育状态、侧凸类型、结构特征、脊柱的旋转、累及的椎体数、顶椎与中线的距离、特别是外观畸形和躯干平衡等因素加以综合考虑。目前国内外在三维矫形手术方面取得了很大进展,内固定器材仍在不断改进和完善之中。研制一种能够滑动的椎弓根钉内固定系统在临床手术治疗中很有必要,既矫治了脊柱侧凸,又不影响或少影响脊柱的生长,这是一种手术治疗脊柱侧凸的理想方法。目前临床上矫正脊柱侧凸的常用手术方法是采用椎弓根钉内固定系统,但该系统因椎弓根钉呈锁定状态,阻止了处于生长发育期青少年脊柱的纵向生长,更为严重的还可能导致医源性躯干短缩和曲轴现象。为此,我们分析了现有国内外常用椎弓根钉内固定系统的结构特点,自行研制了一种滑动椎弓根钉内固定系统(Sliding Instrumentation of Pedicle Screw System, SIPSS),能够减少或避免上述可能出现的不良问题。作者还应用生物力学测试方法,对滑动椎弓根钉系统与锁定椎弓根钉系统固定脊椎的力学性能指标和固定强度及刚度进行比较。因为青少年特发性脊柱侧凸的治疗还有许多尚未解决和需要探索的问题,所以选定本课题进行系统研究。研究方法1.对63例青少年特发性脊柱侧凸患者的79个结构性侧凸摄术前站立位、支点弯曲位、重力悬吊牵引位和仰卧侧屈位X线片,将其与术后的站立位X线片比较,测量全部Cobb角后进行统计学处理,并评估其价值。2.对106例未做过治疗的生长发育期青少年特发性脊柱侧凸患者,给予热塑矫形支具治疗。男21例,女85例,年龄8~19岁,平均13.1岁。单胸凸49例,双胸凸8例,胸和腰双凸37例,胸腰段或腰凸12例。原发Cobb角20°~42°(平均29. 5°)。Risser征0°51例,Ⅰ°33例,Ⅱ°19例,Ⅲ°3例。每3~6个月复查1次,摄站立位全脊柱正侧位X线片。3.将椎弓根钉与矫形棒之间的连接设计为滑动式,使之可随脊柱生长而延长。采用12具新鲜猪脊柱标本,随机分成两组(滑动组和锁定组),应用实验力学分析手段进行测试。研究结果1.三种摄片方法中,结构性胸凸组与结构性腰凸组重力悬吊牵引位片Cobb角分别是40°和21°,仰卧侧屈位片Cobb角分别是41°和23°,支点弯曲位片Cobb角分别是35°和19°,术后站立位片Cobb角分别是36°和18°;重度组(大于或等于60°)与中度组(小于60°)重力悬吊牵引位片Cobb角分别是52°和23°,仰卧侧屈位片Cobb角分别是53°和24°,支点弯曲位片Cobb角分别是47°和20°,术后站立位片Cobb角分别是44°和19°;僵硬组与柔软组重力悬吊牵引位片Cobb角分别是51°和22°,仰卧侧屈位片Cobb角分别是52°和22°,支点弯曲位片Cobb角分别是48°和18°,术后站立位片Cobb角分别是45°和17°;前路手术组与后路手术组重力悬吊牵引位片Cobb角分别是47°和15°,仰卧侧屈位片Cobb角分别是49°和16°,支点弯曲位片Cobb角分别是43°和11°,术后站立位片Cobb角分别是42°和10°,以上角度均为平均值。平均随访时间是1.5年(11~37个月)。2.全部106例进行热塑矫形支具治疗的患者,随访24~72个月,平均36个月,79例(74.5%)治疗有效,27例(25.5%)出现脊柱侧凸进展,治疗无效。柔软性侧凸的矫正效果优于僵硬性侧凸,两组比较差异显著(P<0.05),脊柱侧凸Cobb角度数越小,则矫正效果越好,Cobb角20°~30°组的矫正效果优于Cobb角30°~40°组,两组比较有显著差异(P<0.05)。3.滑动椎弓根钉棒系统生物力学测试中,滑动组和锁定组在屈伸、侧屈、轴向压缩情况下,其主应变、位移变化及固定强度、刚度均无显著性差异(P>0.05)。全文结论1.支点弯曲位X线片比重力悬吊牵引位和仰卧侧屈位X线片能更准确地预测术后矫正效果,并能为选择前路或后路术式,以及融合节段提供依据。2.热塑矫形支具治疗青少年特发性脊柱侧凸能够取得良好疗效,侧凸柔软性好,Cobb角较小,则矫正效果好。3.支点弯曲位时的矫正率可以预测支具矫正效果。4.滑动椎弓根钉棒系统可以获得与锁定椎弓根钉棒系统相同的生物力学稳定性。更多还原

【Abstract】 Background and objectivePhysical and mental health of juvenile was deeply affected by idiopathic scoliosis. Aggravated malformation, which was paralleled with age, induced deformity of appearance, dysfunction of heart and lung, and seriously impacted on the future of the workforce capacity and quality of life. Special and systematical treatment of spinal deformities not only improve and strengthen juveniles’ health, but also enhance quality of nation and promote national economic development. Although treatment of idiopathic scoliosis had been explored over 100 years, it was still regarded as a problem in correction of spinal deformity for its complex pathogenesis. To reduce the invalidity, variety of methods of treatment had been suggested and applied in domestic and international. Some satisfactory and positive treatment methods had been summarized as follows: early treatment, effective control and effective orthopaedic surgery. Progression of idiopathic scoliosis correlated to sex, Cobb’s angle, maturity of bone and other related factors. At present, many kinds of preoperative radiography methods had been designed and used clinically. But there was not a special method which could accurately forecast correction ratio. To find a more accurate preoperative forecasting method for clinical treatment, three preoperative radiography methods had been applied in forecasting the correction ratio of juveniles’patients who were treated with pedicle screw fixation systems.When Cobb angle 10°~ 40°, non-surgical treatment, such as brace treatment must be carried out. At present, brace treatment was generally regarded as effective non-surgical treatment. Although as a complementary treatment, effect of treatment with other non-surgical methods was not widely accepted. Objective of brace treatment were as follows: correct or control curved spine, improve balance and appearance, prevent deformity progression, and enhance spinal stability. The method would bring great social effect if it was widely adopted in early stage. Such as prompt correction in time for those suffering from scoliosis, controlling of bending in the mild range, reducing disabilities. To explore indications and contraindications of brace treatment for adolescent idiopathic scoliosis and to evaluate its clinical effect, large numbers of samples need to be summarized, Currently, treatment of adolescent idiopathic scoliosis with thermosetting plastic brace (TPB) had not been reported. To observe clinical results, 106 cases with adolescent idiopathic scoliosis were normative treated with thermosetting plastic brace (TPB) .Orthopaedic correction and fusion should be applied when Cobb angle was more than 40°. whether to correct or how to correct depended on skeletal age, development, type of scoliosis, structural characteristics, spinal rotation, number of involved vertebrae, distance between middle line and apical vertebra, malformation of appearance, imbalance of trunk. and other factors. So far, 3-D correction were deeply developed in domestic and abroad. Infixating instrumentations are still being developed continuously. It is necessary for patients to design a new kind of sliding pedicle screw fixation system. Correcting spinal deformity and not restraining spinal growth could be the characteristic of the idealist instrumentation. At present, scoliosis clinically corrected with pedicle screw fixation system. Locking state between pedicles and rods usually restrained spinal growth, more seriously induced shot trunks and crankshaft phenomena. To this end, we analyzed characteristic of the previous instrumentation and designed a sliding pedicle screw system (Sliding Instrumentation of Pedicle Screw System, SIPSS), which could reduce or avoid complications stated above. The author also compared biomechanical index between traditional pedicle screw system and the SIPSS.There are still many problems in treatment of idiopathic idiopathic scoliosis. So we devote ourselves on this topic.Research Method1. sixty-three cases of adolescent idiopathic scoliosis(AIS) with 79 structural curves were studied, Preoperative X-films of standing , gravity-suspendig traction , supine bending and fulcrum bending were compared with postoperative standing X-films one week after surgery, Cobb angle of all X-films were measured and statistical significance was evaluated.2. All 106 immatured skeleton patients suffered from adolescent idiopathic scoliosis with no history of prior treatment . They were treated with Thermosetting plastic brace. 21 cases were male and 85 cases were female with the mean age being 13.1 years(range from 8 to 19 years). 49 cases had single thoracic curve, 8 cases had double thoracic curve, 37 cases had thoracic and lumbar double major curve, 12 cases had either single thoraco-lumbar or single lumbar curve. The mean primary curve was 29.5°(range, 20°~42°). Risser sign was 0°in 51 cases, I°in 33 cases, II°in 19 cases, andШ°in 3 cases. The standing AP X-ray films were obtained at intervals of 3 to 6 months.3. Sliding pattern was designed between pedicle screws and rods to accommodate spinal growth. 12 new spinal columns of pigs were random divided into 2 groups (sliding group and locking group). Testing biomechanical methods was used to analyze corresponding results.Research Result1. In structural thoracic group and lumbar group the mean Cobb angle was 40°and 21°in gravity-suspendig traction X-film, 41°and 23°in supine bending X-film, 35°and 19°in fulcrum bending X-film, 36°and 18°in postoperative standing X-film respectively. In severe group and moderate group the mean Cobb angle was 52°and 23°in gravity-suspendig traction X-film, 53°and 24°in supine bending X-film, 47°and 20°in fulcrum bending X-film, 44°and 19°in postoperative standing X-film respectively. In rigid group and flexible group the mean Cobb angle was 51°and 22°in gravity-suspendig traction X-film, 52°and 22°in supine bending X-film, 48°and 18°in fulcrum bending X-film, 45°and 17°in postoperative standing X-film respectively. In anterior approach group and posterior approach group the mean Cobb angle was 47°and 15°in gravity-suspendig traction X-film, 49°and 16°in supine bending X-film, 43°and 11°in fulcrum bending X-film, 42°and 10°in postoperative standing X-film respectively. Above all Cobb angle are mean numerical value,The mean follow-up period was 1.5years (range:1years~3years).2. 79 cases (74.5%) with the brace showed a good effectiveness, 27 cases (25.5%) were judged as curve progression ,All patients with a follow-up of 24 to 72 months (mean, 36 months). The difference of the initial brace correction rate was significant(P<0.05) between flexible scoliosis and rigid scoliosis.The lower the Cobb’s angle , the higher the brace correction rate . The initial brace correcting effectiveness in patients with a Cobb’s angle between 20°to 30°were higher than with a Cobb’s angle between 30°to 40°(P<0.05).3. samples of sliding group and locking group were tested in sagittal and coronal plane bending and axial compression. No statistical difference (P>0.05) was detected in main stress, deviation of apical vertebrae and strength of fixation.Conclusion1. The fulcrum bending X-films are more predicting of correctability of AIS patients than the gravity-suspendig traction and supine bending X-films, It can provide reference for chosing anterior or posterior approach and chosing fusion levels.2. Thermosetting plastic brace had a good treatment effectiveness, flexible scoliosis and lower Cobb’s angle , correcting result is better.The focrum bending film can predict correcting effectiveness.3. Compared with traditional pedicle screw system, same stability could be got in correction with sliding instrumentation of pedicle screw system.更多还原