特發(fā)性脊柱側(cè)彎畸形的分型與治療ppt課件

1、Adolescent Scoliosis Classification and Treatment特發(fā)性脊柱側(cè)彎畸形的分型與治療Jane S. Hoashi, MD, MPH, Patrick J. Cahill, MD,James T. Bennett, MD, Amer F. Samdani, MD*Neurosurg Clin N Am 24 (2021) 173183.KEYWORDS Adolescent idiopathic scoliosis Lenke classification Scoliosis Pediatric spine deformity Pedicle scre

2、ws 青少年特發(fā)性脊柱側(cè)彎Lenke分型弓根螺釘矯形.KEY POINTS Adolescent idiopathic scoliosis (AIS) can be classified according to the Lenke classification system, which incorporates curve magnitude, flexibility, the lumbar modifier, and the sagittal plane. 青少年特發(fā)性脊柱側(cè)凸AIS可根據(jù)Lenke分類系統(tǒng)進(jìn)展分類，該系統(tǒng)包括曲線大小，柔韌性。 The Lenke classificat

3、ion serves as a guide with respect to level selection in patients with AIS. Lenke分類可作為AIS患者交融程度選擇的指南。 The widespread use of pedicle screws has resulted in most AIS being treated through a posterior approach. 椎弓根螺釘?shù)膹V泛使大多數(shù)AIS可以用后路治療。.INTRODUCTION Adolescent idiopathic scoliosis (AIS) is a spinal condi

4、tion causing deformity of the spine in 3 dimensions: the coronal, sagittal, and axial planes. AIS is defined as any curve equal to or greater than 10 in the coronal plane1,2 in patients 10 to 18 years old.3 It is a diagnosis of exclusion after congenital, neuromuscular, neural, or syndromic causes o

5、f scoliosis have been ruled out. Preoperative mag-netic resonance imaging is useful for ruling out neural causes of scoliosis, such as syringomyelia or Chiari malformation, although its use as a preop-erative screening tool is controversial.4,5 A genetic component has been described regarding the ca

6、use of AIS.611 With an incidence of 11% among first-degree relatives,12 it is not uncommon for a health care provider to manage multiple mem-bers of a family with scoliosis. 青少年特發(fā)性脊柱側(cè)凸AIS是一種脊柱疾病，在三維方面引起脊柱畸形：冠狀面，矢狀面和軸面。 AIS被定義為10-18歲患者冠狀面等于或大于10。排除先天性，神經(jīng)肌肉，神經(jīng)或綜合征引起的脊柱側(cè)凸緣由。 術(shù)前磁共振成像對于排除脊柱側(cè)凸的神經(jīng)緣由，如脊髓空洞癥

7、或Chiari畸形是有用的，雖然其作為術(shù)前篩查工具的運用還存在爭議.曾經(jīng)報道了AIS的緣由 .在一級親屬中，發(fā)生率為11，醫(yī)療保健提供者報道一個家庭有多個脊柱側(cè)彎患者的情況并不少見。. AIS affects approximately 2% to 3% of the adolescent population, but fewer than 10% of patients with AIS need treatment.13 The higher the curve magnitude, the lower the prevalence and the higher the female/m

8、ale ratio. Curves greater than 30 have a 0.1% to 0.3% prevalence and affect females 10 times more than males. AIS對青春期人群的影響約為23，而AIS患者中只需不到10需求治療。曲度越重，患病率越低，女性比例越高。曲度大于30的患病率為0.10.3，女性患病率是男性的10倍以上。. For years, the King-Moe classification was the most widely used system for guiding treatment in AIS. I

9、ts shortcomings included classifying curves based only on the coronal plane and showing low interobserver reliability.15 Also, only variants of the thoracic curve were described, leaving some other curve types such as thoracolumbar or lumbar curves unable to be classified by this system. The Lenke c

10、lassification16 addresses these shortcomings and is now considered the gold standard for classifying AIS and guiding treatment. In this article, the Lenke classification is used to describe the AIS types and the treat-ment options. 多年來，King-Moe分類是用于指點AIS治療的最廣泛運用的系統(tǒng)。 其缺陷是包括僅僅根據(jù)冠狀面分型，并顯示出較低的察看者間的可靠性。另

11、外，僅描畫了胸彎的變體，殘留了一些其他曲線類型，如胸腰彎或腰椎彎無法經(jīng)過該系統(tǒng)進(jìn)展分類。Lenke分類處理了這些缺陷，如今以為是AIS分類和指點治療的金規(guī)范。在本文中，Lenke分類用于AIS類型和治療選擇。. Treatment of scoliosis includes nonoperative management such as bracing of curves measuring 20 to 40 or progressing more than 5 per year. Larger curve magnitude, younger chronologic age, and Ris

12、ser sign are associated with curve progression.17 The literature has shown bracing to be more effective in patients with earlier Risser scores (01) and open triradiate cartilages.1820 The goal of bracing is to maintain curve magnitude throughout a patients growth period, although conflicting evidenc

13、e of its effectiveness have been reported. 治療脊柱側(cè)彎包括非手術(shù)治療：20至40度的曲度或每年5度以上的曲度進(jìn)展。 較大的曲度，較小的年齡和Risser征與曲度進(jìn)展有關(guān)。文獻(xiàn)顯示早期Risser評分0-1和開放性Y軟骨患者的支具更有效。支具的目的是堅持患者在整個生長期中堅持目前曲度的幅度，雖然目前的報道對其有效性的報道是相互矛盾的。. Surgery is indicated when a curve is progressive despite bracing and generally when the curve rea-ches 45 to

14、50 . The main goal is to stop the curve from progressing, leading to potentially severe complications from an untreated curve, including pulmonary function and back pain. Other goals driven by the patients themselves are improvement of cosmesis. Quality of life studies as measured by the SRS-22 (Sco

15、liosis Research Society 22) ques-tionnaire have shown that patients with AIS have lower self-image and are more self-conscious about their general appearance than the general population.21,22 This finding can be related to a shoulder imbalance, rib prominence, or trunk asymmetry. Thus, the psycholog

16、ical impact of the deformity must also be taken into account when considering surgery. 雖然有支具，曲度依然是進(jìn)展性開展的，通常曲度大于45到50之間時表示需求手術(shù)。 手術(shù)的主要目的是阻止曲度繼續(xù)進(jìn)展，導(dǎo)致包括肺功能和背部疼痛在內(nèi)的潛在的嚴(yán)重并發(fā)癥。 患者本人的目的是改善外觀。根據(jù)SRS-22的調(diào)查詢卷所丈量的生活質(zhì)量研討顯示，AIS患者的自我籠統(tǒng)評價較低. 能夠與肩部不平衡，肋骨突出或軀干不對稱有關(guān)。 因此，在思索手術(shù)時也必需思索到畸形的心思影響。.The goals of surgery are to r

17、estore coronal and sagittal balance, reduce the rib prominence, and achieve shoulder balance. However, another important goal is to leave as many unfused seg-ments as possible to preserve motion in the lumbar spine. The specific treatment options are discussed further in this article.手術(shù)的目的是恢復(fù)冠狀和矢狀平衡

18、，減少肋骨突出，到達(dá)肩部平衡。 然而，另一個重要的目的是盡能夠多的保管未交融的部分以堅持腰椎運動。 本文將進(jìn)一步討論詳細(xì)的處置措施。. Two approaches to AIS surgery exist: the anterior approach and the posterior approach; a combina-tion of the 2 is also used. Some potential advan-tages to the anterior approach are saving fusion levels,23,24 decreased prominence of

19、instrumenta-tion, and decreased risk of crankshaft phenom-enon in a skeletally immature adolescent.16,25 However, some studies have indicated morbidity related to decreased pulmonary function,26,27 which seems to improve at 2-year follow-up.28 The anterior approach can be used to fuse simple thoraci

20、c curves and can also be used to perform anterior release and fusion combined with posterior spinal fusion in stiffer and larger (90 ) curves, although similar curve correction can be achieved in these larger curves by the posterior approach alone. AIS手術(shù)有兩種方法：前路手術(shù)和后路手術(shù);兩種手術(shù)的組合也被運用。 前路手術(shù)的一些潛在優(yōu)勢是節(jié)約交融程

21、度，降低青少年骨骼不成熟的曲軸景象的風(fēng)險。然而，一些研討闡明發(fā)病率與 肺功能下降26,27，在2年的隨訪中似乎有所改善。前路手術(shù)可用于交融簡單的胸彎，也可用于前路松解后路脊柱交融。. Since the development of pedicle screws, the posterior-only approach has become the mainstay of treatment of AIS. Pedicle screws provide a 3-column fixation that permits greater curve correction and improved

22、derotation.30 Even in the more severe (90 ) and stiffer curves, pedicle screw constructs with osteotomies render good correction,29 thereby reducing the need for combined anterior and posterior approaches. The crankshaft phenomenon may also be reduced by using pedicle screws. 自從椎弓根螺釘開展以來，后路手術(shù)已成為AIS治

23、療的主要手段。 即使在嚴(yán)重的 90和生硬的側(cè)彎治療中，用截骨加椎弓根螺釘能得到良好的效果，從而減少對前后結(jié)合手術(shù)的依賴。 曲軸景象也可以經(jīng)過運用椎弓根螺釘減少。. However, pedicle screw placement has a learning curve, especially with the free hand technique.32 With surgeon experience, the accuracy of pedicle screw placement improves, and the medial breach rate decreases.33,34 Re

24、ported breach rates range from 1.6% to as high as 58%.3338 However, rates for neurologic and visceral injuries despite these breaches are low. Although hypokyphosis has been observed with posterior-only pedicle screw constructs,39,40 long-term follow-up has shown good maintenance of correction and c

25、oronal and sagittal alignment. 然而，椎弓根螺釘置釘需求有學(xué)習(xí)曲線特別是徒手置釘技術(shù)。隨著外科醫(yī)生的閱歷提高，椎弓根螺釘置入的準(zhǔn)確性提高，內(nèi)側(cè)破口率降低。報告的破口率從1.6到58。神經(jīng)和內(nèi)臟損傷的發(fā)生率很低。 只需后路椎弓根螺釘矯形才會出現(xiàn)交界后凸，但長期隨訪顯示良好的矯正和冠狀位及矢狀位序列。.LENKE CLASSIFICATIONOverview The Lenke classification for AIS was developed as a tool to help surgeons classify curve types and guide t

26、hem in operative treatment.16 The curve type (the major curve), lumbar modifier (A, B, and C, depending on the location of the center sacral vertical line CSVL in relation to the apical lumbar vertebra), and the sagittal profile (, N, 1) is used to determine a specific curve pattern. Although there

27、are 6 Lenke curve types, a total of 42 curve patterns can be observed. 對于AIS的Lenke分型是為了協(xié)助外科醫(yī)生對側(cè)彎的曲線類型分類并指點他們進(jìn)展手術(shù)治療而開發(fā)的.側(cè)彎類型主彎，腰椎修正型A，B和C，CSVL相對于腰椎頂椎的位置和后凸 - ，N，1用于確定特定的側(cè)彎方式。 雖然有6個Lenke主彎類型，但總共可以察看到42個側(cè)彎方式。. The basis of surgical treatment is to fuse only the structural curves. The curve with the lar

28、gest Cobb magnitude is defined as the major curve, which, by definition, is structural. Curves with lesser magni-tude (minor curves) can be structural or nonstruc-tural, depending on the degree of their flexibility seen on bending films. Generally, minor curves are not considered part of the arthrod

29、esis if they bend out to less than 25 . Focal kyphosis is also a criterion for considering a curve to be structural. 手術(shù)治療的根底是只交融構(gòu)造彎。 COBB最大的彎曲被定義為主彎，根據(jù)定義它是構(gòu)造性的。 曲度較小的彎曲次彎可以是構(gòu)造性的或非構(gòu)造性的，這取決于它們在 bending 上看到的柔韌程度。 普通來說，假設(shè) bending 小于25，次彎不交融。 后凸也是思索曲線構(gòu)造的規(guī)范。. The Lenke classification differentiates King-M

30、oe type 2 curves into Lenke types 1 and 3, helping surgeons select which curves are amenable to selective fusions (Lenke type 1) and those that require an extended fusion in the lumbar spine (Lenke type 3). Unlike the King-Moe classification, which considers only the coronal plane, the Lenke classif

31、ication accounts for both coronal and sag-ittal planes and has been shown to have good interobserver reliability. However, the axial plane (a reflection of vertebral body rotation) is still not included in the Lenke classification. Moreover, some curve types such as curves with C lumbar modifiers ar

32、e subject to controversy regarding selective versus nonselective fusion. The following section on the specific Lenke curve types includes some of the controversies and current recommen-dations for treatment. Lenke分類將King-Moe 2型曲線區(qū)分為Lenke 1型和3型，協(xié)助外科醫(yī)生選擇適宜選擇性交融Lenke 1型和需求在腰椎Lenke 3型中進(jìn)展交融。 與僅思索冠狀面的King

33、-Moe分類不同，Lenke分類既包括冠狀平面也包括矢狀平面，并且已被證明具有良好的察看者間可靠性。 然而，Lenke分類仍不包括軸面椎體旋轉(zhuǎn)的反映。 此外，某些曲線類型如帶有腰彎修正型的曲線在選擇性與非選擇性交融方面存在爭議。 以下關(guān)于特定Lenke曲線類型的部分包括一些爭議和當(dāng)前的治療建議。.Treatment of Lenke Curve TypesLenke 1: single thoracic curve For single thoracic curves (Fig. 1), it is generally accepted to perform selective fusions

34、 of the main thoracic curve, unless there is a kyphosis of more than 20 in the thoracolumbar area, in which case, the lumbar curve is also included in the fusion.16 The unfused lumbar curve is nonstruc-tural and usually spontaneously corrects itself after thoracic fusion.4246 It is important to note

35、 any preoperative shoulder height discrepancy, be-cause this often determines the upper fusion levels. Shoulder height can be determined clini-cally as well as radiographically using the clavicle angle or T1 tilt. 對于單胸彎圖1，普通以為胸彎選擇性交融是可行的，除非在胸腰段有超越20的后凸畸形，這種情況下，腰彎也需求交融16。腰椎不交融，通常在胸椎交融術(shù)后自行矯正。重要的是要留意術(shù)前

36、肩高的差別，由于這通常決議了交融的高度。 可以臨床確定肩高，也可以運用鎖骨角或T1傾斜進(jìn)展放射學(xué)檢查。. Three different scenarios exist regarding shoulder height. The first and most common scenario is a right main thoracic curve, with the right shoulder being higher than the left. In this case, correction of the thoracic spine also brings down the r

37、ight shoulder, usually achieving equal shoulder height. In these cases, the upper instru-mented level is usually T4 or T5.48 If the left shoulder is elevated, the compensatory proximal thoracic curve is usually included in the fusion (to T2) to oppose the corrective forces being placed on the main t

38、horacic curve, which would otherwise continue to drive the left shoulder up. If both shoul-ders are equal in height preoperatively, T3 is usually the upper level of fusion. 關(guān)于肩高有三種不同的情況。 第一種也是最常見的情況是右側(cè)主胸彎，右肩高于左側(cè)。 在這種情況下，矯正胸彎也會使右肩下垂，通常到達(dá)肩高相等。 在這些情況下，UIV通常為T4或T5.假設(shè)左肩高，那么補償性近端胸椎交融通常交融T2，否那么會繼續(xù)向左。 假設(shè)術(shù)前雙

39、方肩高相等，T3通常是UIV。. For single thoracic curves with minor flexible lumbar curves (Lenke 1A and 1B), selective thoracic fusions are generally indicated. For distal fusion levels, it is important to choose the appropriate lowest instrumented vertebra (LIV) so as to leave good coronal balance and avoid lu

40、mbar decom-pensation or progression of the primary curve (adding-on). Conventional guidelines have used the stable vertebra, or the most proximal vertebra with pedicles most closely bisected by the CSVL as the LIV.15 However, this guideline was based on Harrington instrumentation, in which the corre

41、c-tive forces were uniplanar. With 3-column fixation using pedicle screws, an additional 1 or 2 distal motion segments can be saved, instead of fusing to the stable vertebra. 對于具有較小腰彎的單胸彎Lenke 1A和1B，普通選擇性胸椎交融。 對于遠(yuǎn)端交融程度，重要的是選擇適宜的LIV，以堅持良好的冠狀平衡并防止腰椎退化或附加景象。 常規(guī)的指南運用了穩(wěn)定椎。然而，這個指南是基于Harrington，其矯正力是單平面的。

42、經(jīng)過運用椎弓根螺釘可以進(jìn)展三柱固定，可以節(jié)省額外的1或2個遠(yuǎn)端運動節(jié)段，而不是交融到穩(wěn)定的椎骨上。.Adding-on附加景象 2000年由Suk最先報道 發(fā)生率：2-21% 再次手術(shù)率為 7.3% .Adding-on附加景象定義：末次隨訪時主彎的LEV向LIV遠(yuǎn)端挪動并且冠狀面 Cobb角添加5；LIV遠(yuǎn)端臨近椎間盤成角添加5；LIV偏離CSVL添加10mm以上。. The neutral vertebra is also used to determine the distal fusion level.49,50 The relation between the neutral ver

43、tebra and the end vertebra can be used to ascertain the LIV. If there is no more than 1 level between the end vertebra and the neutral vertebra, then fusion to the neutral vertebra is suffi-cient. This level corresponds to 1 level proximal to the stable vertebra. However, if the neutral vertebra is

44、2 or more levels distal to the end vertebra, then the LIV is NV-1. If the neutral vertebra is the end vertebra, then it is adequate to fuse to the distal end vertebra. A 2-year follow-up by Suk and colleagues49 in patients treated using these guide-lines showed satisfactory results with good coronal

45、 balance, compensatory lumbar straightening, and no adding-on. 中立椎也用于確定遠(yuǎn)端交融。中立椎和端椎之間的關(guān)系可以用來確定LIV。 假設(shè)端椎和中立椎之間的間隔不超越1個椎體，那么交融到中立椎是足夠的。 當(dāng)術(shù)前NV與EV間隔為兩個椎體以上時,LIV選擇在NV-1。 假設(shè)中性椎骨是端椎骨，那么足以交融到端椎。 Suk及其同事對運用這些指南治療的患者進(jìn)展為期2年的隨訪，結(jié)果令人稱心，具有良好的冠狀平衡，腰椎矯正，無附加功能。. With regard to adding-on, Miyanji and colleagues51 diff

46、erentiated 2 types of Lenke 1 curves, depending on the L4 tilt: 1A-L (tilted to the left) and 1A-R (tilted to the right). 1A-R curves have been shown to have a higher risk of adding-on because of the overhanging curve pattern, requiring a more distal fusion, approximately 2 levels more distal than a

47、 1A-L curve. 關(guān)于附加景象，Miyanji和他的同事根據(jù)L4傾斜：1A-L向左傾斜和1A-R向右傾斜區(qū)分了2種類型的Lenke 1曲線。 曾經(jīng)顯示1A-R曲線具有較高的附加風(fēng)險，需求更遠(yuǎn)端的交融，比1A-L曲線更遠(yuǎn)2個節(jié)段。. Lenke 1C curves have been subject to ongoing controversy regarding their fusion levels because often they behave like double major curves. In the 1C pattern, the nonstructural lumb

48、ar curve is flexible (side-bending to 25 ), in which the apex completely crosses the midline. A study by Lenke and colleagues53 showed that selective thoracic fusion was performed in 62% of patients with 1C curves, implying that the remaining 38% had nonselective fusions. Newton and colleagues repor

49、ted that larger preoperative lumbar curve magnitude, greater lumbar apical vertebra dis-placement from the CSVL, and smaller thoracic/ lumbar magnitude ratio were factors associated with nonselective fusion. Lenke and colleagues55 reported that for a selective fusion to be success-ful for 1B and 1C

50、curves, the thoracic/lumbar ratios for Cobb magnitude, apical vertebral trans-lation, and apical vertebral rotation should be greater than 1.2。 Lenke 1C曲線因其交融程度而遭到繼續(xù)的爭議，由于它們通常表現(xiàn)為兩個大彎。 在1C方式中，非構(gòu)造性腰部曲線是柔性的side-bending25，其中頂點完全穿過中線。 Lenke等的一項研討顯示62的1C曲線患者進(jìn)展了選擇性胸段交融，這意味著剩下的38是非選擇性交融。 Newton及其同事報道，較大的術(shù)前腰

51、彎曲度，較大的腰椎頂椎椎體位移與較小的胸椎/腰椎大小比例是非選擇性交融的相關(guān)要素。 Lenke等報道，對于1B和1C曲線的選擇性交融是勝利的，Cobb大小，頂椎旋轉(zhuǎn)和頂椎偏移的胸/腰比應(yīng)大于1.2.Lenke 2: double thoracic curves In treating double thoracic curves (Fig. 2), it is important to not overlook a structural proximal thoracic curve. Both the main thoracic and the structural proximal tho

52、racic curves must be included in the fusion, according to the Lenke criteria for structural curves. Inappropriate distinc-tion of a structural proximal thoracic curve leading to exclusion of the proximal curve from the fusion, especially in the context of a preoperative elevated left shoulder, can l

53、ead to severe worsening of shoulder imbalance and patient dissatisfaction. Suk and colleagues56 reported improved results when both proximal and main thoracic curves were fused in patients with level shoulders or a higher shoulder on the side of the proximal thoracic curve. In patients with an eleva

54、ted left shoulder, fusing to T2 as the upper instrumented level is usually sufficient to gain good correction of the proximal thoracic curve and achieve adequate shoulder alignment. In patients with level shoulders preoperatively, the upper level of fusion can be T2 or T3, depending on the correctio

55、n and shoulder balance achieved intraoperatively. In general, fusion of both proximal and main thoracic curves is recommended for Lenke type 2 curves. Suk and colleagues56 found that the proximal thoracic curve can be left unfused if the left shoulder is lower than the right by a difference greater

56、than 12 mm. 在治療雙胸彎時，重要的是不要忽視構(gòu)造性近端胸彎。根據(jù)構(gòu)造曲線的Lenke規(guī)范，主胸椎和構(gòu)造性近端胸彎都必需納入交融。不恰當(dāng)?shù)膮^(qū)分構(gòu)造性近側(cè)胸彎導(dǎo)致近端曲線從交融中排除，特別是在術(shù)前左肩背部高的情況下，可導(dǎo)致肩部不平衡嚴(yán)重加重和患者不滿。 Suk及其同事報道，近端和主胸彎交融在肩部程度較高的患者或近端胸彎一側(cè)肩部較高的，結(jié)果改善。在左肩抬高的患者中，UIV將T2交融通常足以獲得對近端胸彎的良好矯正并實現(xiàn)肩膀程度。術(shù)前平肩患者，根據(jù)術(shù)中矯正和肩關(guān)節(jié)平衡，上位交融可以是T2或T3。普通而言，Lenke 2型曲線引薦交融近端和主胸彎。 Suk及其同事發(fā)現(xiàn)，假設(shè)左肩低于右側(cè)大于1

57、2mm，那么近端胸彎可以堅持不交融。. To select the LIV, the distal fusion rules used for Lenke 1 curves can be applied to Lenke 2 curves. Using the NV and EV as landmarks, the LIV is generally the stable vertebra (the most proximal vertebra intersected by the CSVL).4850 Recom-mendations for selective fusions for t y

58、 p e 2 C a re t h e s a m e fo r 1 C c u r ve s , w h e re t h e rat i o o f t h e m a i n thoracic/thoracolumbar/lumbar curves for Cobb magnitude, apical vertebral translation (AVT), and apical vertebral rotation (AVR) must be 1.2 or greater in curves lacking a focal thoraco-lumbar kyphosis 10 or g

59、reater. 為了選擇LIV，用于Lenke 1曲線的遠(yuǎn)端交融規(guī)那么可以運用于Lenke 2曲線。 運用NV和EV作為標(biāo)志，LIV通常是穩(wěn)定的椎骨與CSVL相交的最近的椎骨。對于2C型的選擇性交融的引薦方法與1C曲線一樣，其中 在缺乏局灶性胸腰椎后凸10或更高的曲線中，Cobb大小，頂椎平移AVT和頂椎旋轉(zhuǎn)AVR的主胸椎/胸腰椎/腰椎曲線必需為1.2或更高。.Lenke 3: double major curves Lenke type 3 curves (Fig. 3) are those in which both thoracic and lumbar curves are struc

60、tural, so both curves are generally included in the fusion. Some confusion exists between Lenke 1C and Lenke 3 curves, because they can behave simi-larly, especially Lenke 1C curves with lumbar curves with a borderline nonstructural criterion (bending to slightly 25 ). Lenke 3型的胸彎和腰彎都是構(gòu)造性的，所以胸彎和腰彎普通