【作者】 张国莹；

【导师】 张永刚；

【作者基本信息】 中国人民解放军军医进修学院 ， 骨科， 2009， 硕士

【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。更多还原

【Abstract】 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.更多还原