成人脊柱側(cè)凸的的治療課件整理

成人脊柱側(cè)凸的的治療南京大學(xué)醫(yī)學(xué)院附屬鼓樓醫(yī)院脊柱外優(yōu)選成人脊柱側(cè)凸的的治療南京大學(xué)醫(yī)學(xué)院附屬鼓樓醫(yī)院脊柱外1398成人在頂椎區(qū)凹側(cè)關(guān)節(jié)突退變椎間盤退變不明顯Case5在繼發(fā)彎區(qū)

可長期保持其柔軟性1416在交界區(qū)

—早期椎間盤退變

—進(jìn)展性旋轉(zhuǎn)半脫位

—終椎離心性移位加重及僵硬化可發(fā)生在主彎或次彎F,32yrs56-80Radicularpain加重及僵硬化可發(fā)生在主彎或次彎預(yù)后：旋轉(zhuǎn)、退變、矢狀面手術(shù)結(jié)果分析（南京鼓樓）感染率1％－5％神經(jīng)并發(fā)癥1％－5％ResidualpainArthrodesistothesacrum-indication所有這些指征在成人中很難證明死亡率1％－2％Lumbarcurvaturefixeddeformityand/orpreviousfusion手術(shù)效果不如青少年脊柱側(cè)凸患者Lossoflordosis1yrpost-opSignificantcurvatureOperativetreatment后松解－Halo－后路Eggshellprocedure腰彎進(jìn)展，L2－3脫位Pseudarthrosis解剖上的加重

胸彎50－80°腰彎進(jìn)展，L2－3脫位終椎下移F,14yrs50-65F,24yrs54-75F,32yrs56-805yrspost-op手術(shù)效果不如青少年脊柱側(cè)凸患者2~5%1.死亡率1％－2％AIS在成年期的自然史手術(shù)效果不如青少年脊柱側(cè)凸患者緩解疼痛60％－90％,Residualpain加重及僵硬化可發(fā)生在主彎或次彎冠狀面平衡（n=79）腰彎進(jìn)展，L2－3脫位EggshellprocedureEggshellprocedure向后凸性側(cè)凸進(jìn)展（頂椎一致）Eggshellprocedure2~5%1.SpinalstenosissymptomsPseudarthrosis優(yōu)選成人脊柱側(cè)凸的的治療南京大學(xué)醫(yī)學(xué)院附屬鼓樓醫(yī)院脊柱外Radicularpain所有這些指征在成人中很難證明Ifdeformityassociatedwithtranslation,andcoronalimbalance,osteotomieswithresectionpreferable.胸腰彎

最易進(jìn)展

L3－4脫位旋轉(zhuǎn)加重70yrs腰彎

向后凸性側(cè)凸進(jìn)展（頂椎一致）腰4－5脫位預(yù)后：旋轉(zhuǎn)、退變、矢狀面705-711雙大彎

長期保持平衡進(jìn)展發(fā)生遲腰彎進(jìn)展>胸彎

L3、L4或L4、5脫位交界性后凸1004-1024椎管狹窄或根痛18（23％）—早期椎間盤退變Ifdeformityassociatedwithtranslation,andcoronalimbalance,osteotomieswithresectionpreferable.ReferenceGulouResidualpainComplicationIncludes成人脊柱側(cè)凸的的治療南京大學(xué)醫(yī)學(xué)院附屬鼓樓醫(yī)院脊柱外加重及僵硬化可發(fā)生在主彎或次彎手術(shù)效果不如青少年脊柱側(cè)凸患者F,24yrs54-75進(jìn)行性軀干塌陷6（8％）6yrsPost-op交界性不穩(wěn)定＋節(jié)段性不穩(wěn)定#2489ChiYHF36yrs5~16%2.Spinalstenosissymptoms發(fā)生遲，45－50歲后TakeintraoperativeAPX-raytoinsurecoronalalignmentwhileonthetable－－－Key度數(shù)矯正30％－50％AIS在成年期的自然史繼續(xù)進(jìn)展!43yrs65yrs自然史規(guī)律胸腰彎和腰彎進(jìn)展加重及僵硬化可發(fā)生在主彎或次彎加重機(jī)理：關(guān)節(jié)突退變，交界性椎間盤病每年進(jìn)展0.5－1°?脊柱側(cè)凸的分型成為困難退變性脊柱側(cè)凸

發(fā)生遲，45－50歲后椎間盤關(guān)節(jié)突退變?yōu)槭紕涌墒加谛匮?、腰或腰骶部為后突性，并發(fā)生脫位退變的其他特征!1082-1091牽引下加重及僵硬化可發(fā)生在主彎或次彎5~16%2.ProgressionofcurveF,24yrs54-75#2489ChiYHF36yrs6yrsPost-opIffixedcoronaldeformity,resectionmaybenecessarytoachievebalance.Spinalstenosissymptoms交界性不穩(wěn)定＋節(jié)段性不穩(wěn)定椎管狹窄或根痛18（23％）向后凸性側(cè)凸進(jìn)展（頂椎一致）感染率1％－5％Arthrodesistothesacrum-indicationEggshellprocedureAIS在成年期的自然史矢狀面平衡（n=79）5~15%1.手術(shù)適應(yīng)證(鼓樓醫(yī)院79例)Pseudarthrosis術(shù)前Halo——后路Indicationforsurgery所有這些指征在成人中很難證明退變性側(cè)凸與特發(fā)性側(cè)凸的區(qū)別

難!鑒別線索

初診時見頂椎區(qū)椎間盤退變交界性不穩(wěn)定＋節(jié)段性不穩(wěn)定節(jié)段性畸形呈不規(guī)則神經(jīng)壓迫癥狀嚴(yán)重雙平面失償椎間盤關(guān)節(jié)突退變?yōu)槭紕邮笭蠲嫫胶猓╪=79）Lossoflordosis感染率1％－5％Lumbarobliquetake-off椎管狹窄或根痛18（23％）5~15%1.手術(shù)適應(yīng)證(鼓樓醫(yī)院79例)神經(jīng)并發(fā)癥1％－5％手術(shù)適應(yīng)證(鼓樓醫(yī)院79例)冠狀面平衡（n=79）脊柱側(cè)凸的分型成為困難F,24yrs54-75手術(shù)結(jié)果分析（南京鼓樓）感染率1％－5％EggshellprocedureSpinalstenosissymptomsProgressionofcurveLumbarcurvature腰椎前突角（n=58）5~15%1.OperativetreatmentUnderstandRisk/BenefitRates！IndicationforsurgerySignificantcurvatureBackpainRadicularpainSpinalstenosissymptomsProgressionofcurveProgressivelossofpulmonaryfunctiondecompensation所有這些指征在成人中很難證明手術(shù)適應(yīng)證(鼓樓醫(yī)院79例)

力學(xué)性疼痛71（90％）雙平面失償69（87％）畸形加重56（70％）椎管狹窄或根痛18（23％）進(jìn)行性軀干塌陷6（8％）手術(shù)結(jié)果分析（南京鼓樓）評價指標(biāo)術(shù)前術(shù)后一年隨訪最后一次隨訪冠狀面平衡（n=79）3.8cm0.8cm1.0cm1.0cm雙肩水平度（n=79）-2.5cm-0.9cm-0.9cm-0.9cm矢狀面平衡（n=79）+6cm+1.8cm+2.0cm+2.0cm腰椎前突角（n=58）37°56°56°53°疼痛（n=65）手術(shù)治療手術(shù)效果不如青少年脊柱側(cè)凸患者緩解疼痛60％－90％, 度數(shù)矯正30％－50％ 肺功能略有增加 融合率70％－90％ 神經(jīng)并發(fā)癥1％－5％ 死亡率1％－2％ 感染率1％－5％ ComplicationIncludesPseudarthrosisResidualpainMortalityNeurologicInfectionPulmonaryembolicLossoflordosisImplantfailureReferenceGulou<5~27%8%5~15%1.4%<1~5%0.2~5%1.4%1~20%2.9%5~16%2.9%手術(shù)策略

一期后路術(shù)前Halo——后路后松解－Halo－后路前松解－Halo－后路一期前后路聯(lián)合1yrpost-op#624F46yrs雙主彎<70°后路融合內(nèi)固定>70°先前路融合，通常融合腰椎后路雙彎融合內(nèi)固定750-7546yrsPost-opPost-op胸腰彎<70°前路融合內(nèi)固定>70°聯(lián)合前后路手術(shù)伴有椎管狹窄減壓使用cage或others胸椎后突時固定至近端胸椎550-56136yrs56yrs緩解疼痛60％－90％,死亡率1％－2％PseudarthrosisLossoflordosisProgressionofcurveResidualpainResidualpain5~16%2.椎間盤關(guān)節(jié)突退變?yōu)槭紕蛹怪鶄?cè)凸的分型成為困難可長期保持其柔軟性TakeintraoperativeAPX-raytoinsurecoronalalignmentwhileonthetable－－－KeyLumbarcurvaturefixeddeformityand/orpreviousfusion發(fā)生遲，45－50歲后1yrpost-op5~16%2.先前路融合，通常融合腰椎預(yù)后：旋轉(zhuǎn)、退變、矢狀面前松解－Halo－后路腰彎進(jìn)展，L2－3脫位RadicularpainComplicationIncludesLumbarcurvatureSingleanteriororposteriorapproachInsomepatientpossible!Case3Lumbarcurvaturefixeddeformityand/orpreviousfusionifarthrodesissolid,anddeformitysecondarytoangulationAnteriorsupportEggshellprocedure#2489ChiYHF36yrsCase8Ifdeformityassociatedwithtranslation,andcoronalimbalance,osteotomieswithresectionpreferable.Lumbarcurvaturefixeddeformityand/orpreviousfusionCase1Iffixedcoronaldeformity,resectionmaybenecessarytoachievebalance.6yrsPost-opOperativetreatment手術(shù)適應(yīng)證(鼓樓醫(yī)院79例)成人脊柱側(cè)凸的的治療南京大學(xué)醫(yī)學(xué)院附屬鼓樓醫(yī)院脊柱外Lossoflordosis椎管狹窄或根痛18（23％）交界性不穩(wěn)定＋節(jié)段性不穩(wěn)定Fixationtopelvis---L-rod/TSRH/IsolaPseudarthrosis手術(shù)適應(yīng)證(鼓樓醫(yī)院79例)脊柱側(cè)凸的分型成為困難所有這些指征在成人中很難證明脊柱側(cè)凸的分型成為困難緩解疼痛60％－90％,進(jìn)行性軀干塌陷6（8％）L/Spainbelowlumbarcurve交界性不穩(wěn)定＋節(jié)段性不穩(wěn)定椎間盤關(guān)節(jié)突退變?yōu)槭紕覮umbarcurvaturefixeddeformityand/orpreviousfusionArthrodesistothesacrum-indicationLumbarobliquetake-offUnbalancedL/ScurvewithlumbarscoliosisL/SpainbelowlumbarcurveRecommendatwo-stageapproach+screwfixationFixationtopelvis---L