特发性脊柱侧弯畸形的分型与治疗ppt课件

1、Adolescent Scoliosis Classification and Treatment特发性脊柱侧弯畸形的分型与治疗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 青少年特发性脊柱侧弯Lenke分型弓根螺钉矫形.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. 青少年特发性脊柱侧凸AIS可根据Lenke分类系统进展分类，该系统包括曲线大小，柔韧性。 The Lenke classificat

3、ion serves as a guide with respect to level selection in patients with AIS. Lenke分类可作为AIS患者交融程度选择的指南。 The widespread use of pedicle screws has resulted in most AIS being treated through a posterior approach. 椎弓根螺钉的广泛使大多数AIS可以用后路治疗。.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. 青少年特发性脊柱侧凸AIS是一种脊柱疾病，在三维方面引起脊柱畸形：冠状面，矢状面和轴面。 AIS被定义为10-18岁患者冠状面等于或大于10。排除先天性，神经肌肉，神经或综合征引起的脊柱侧凸缘由。 术前磁共振成像对于排除脊柱侧凸的神经缘由，如脊髓空洞症

7、或Chiari畸形是有用的，虽然其作为术前筛查工具的运用还存在争议.曾经报道了AIS的缘由 .在一级亲属中，发生率为11，医疗保健提供者报道一个家庭有多个脊柱侧弯患者的情况并不少见。. 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对青春期人群的影响约为23，而AIS患者中只需不到10需求治疗。曲度越重，患病率越低，女性比例越高。曲度大于30的患病率为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. 多年来，King-Moe分类是用于指点AIS治疗的最广泛运用的系统。 其缺陷是包括仅仅根据冠状面分型，并显示出较低的察看者间的可靠性。另

11、外，仅描画了胸弯的变体，残留了一些其他曲线类型，如胸腰弯或腰椎弯无法经过该系统进展分类。Lenke分类处理了这些缺陷，如今以为是AIS分类和指点治疗的金规范。在本文中，Lenke分类用于AIS类型和治疗选择。. 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. 治疗脊柱侧弯包括非手术治疗：20至40度的曲度或每年5度以上的曲度进展。 较大的曲度，较小的年龄和Risser征与曲度进展有关。文献显示早期Risser评分0-1和开放性Y软骨患者的支具更有效。支具的目的是坚持患者在整个生长期中坚持目前曲度的幅度，虽然目前的报道对其有效性的报道是相互矛盾的。. 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. 虽然有支具，曲度依然是进展性开展的，通常曲度大于45到50之间时表示需求手术。 手术的主要目的是阻止曲度继续进展，导致包括肺功能和背部疼痛在内的潜在的严重并发症。 患者本人的目的是改善外观。根据SRS-22的调查询卷所丈量的生活质量研讨显示，AIS患者的自我笼统评价较低. 能够与肩部不平衡，肋骨突出或躯干不对称有关。 因此，在思索手术时也必需思索到畸形的心思影响。.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.手术的目的是恢复冠状和矢状平衡

18、，减少肋骨突出，到达肩部平衡。 然而，另一个重要的目的是尽能够多的保管未交融的部分以坚持腰椎运动。 本文将进一步讨论详细的处置措施。. 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手术有两种方法：前路手术和后路手术;两种手术的组合也被运用。 前路手术的一些潜在优势是节约交融程

21、度，降低青少年骨骼不成熟的曲轴景象的风险。然而，一些研讨阐明发病率与 肺功能下降26,27，在2年的随访中似乎有所改善。前路手术可用于交融简单的胸弯，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. 自从椎弓根螺钉开展以来，后路手术已成为AIS治

23、疗的主要手段。 即使在严重的 90和生硬的侧弯治疗中，用截骨加椎弓根螺钉能得到良好的效果，从而减少对前后结合手术的依赖。 曲轴景象也可以经过运用椎弓根螺钉减少。. 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，椎弓根螺钉置钉需求有学习曲线特别是徒手置钉技术。随着外科医生的阅历提高，椎弓根螺钉置入的准确性提高，内侧破口率降低。报告的破口率从1.6到58。神经和内脏损伤的发生率很低。 只需后路椎弓根螺钉矫形才会出现交界后凸，但长期随访显示良好的矫正和冠状位及矢状位序列。.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. 对于AIS的Lenke分型是为了协助外科医生对侧弯的曲线类型分类并指点他们进展手术治疗而开发的.侧弯类型主弯，腰椎修正型A，B和C，CSVL相对于腰椎顶椎的位置和后凸 - ，N，1用于确定特定的侧弯方式。 虽然有6个Lenke主弯类型，但总共可以察看到42个侧弯方式。. 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. 手术治疗的根底是只交融构造弯。 COBB最大的弯曲被定义为主弯，根据定义它是构造性的。 曲度较小的弯曲次弯可以是构造性的或非构造性的，这取决于它们在 bending 上看到的柔韧程度。 普通来说，假设 bending 小于25，次弯不交融。 后凸也是思索曲线构造的规范。. 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分类将King-Moe 2型曲线区分为Lenke 1型和3型，协助外科医生选择适宜选择性交融Lenke 1型和需求在腰椎Lenke 3型中进展交融。 与仅思索冠状面的King

33、-Moe分类不同，Lenke分类既包括冠状平面也包括矢状平面，并且已被证明具有良好的察看者间可靠性。 然而，Lenke分类仍不包括轴面椎体旋转的反映。 此外，某些曲线类型如带有腰弯修正型的曲线在选择性与非选择性交融方面存在争议。 以下关于特定Lenke曲线类型的部分包括一些争议和当前的治疗建议。.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. 对于单胸弯图1，普通以为胸弯选择性交融是可行的，除非在胸腰段有超越20的后凸畸形，这种情况下，腰弯也需求交融16。腰椎不交融，通常在胸椎交融术后自行矫正。重要的是要留意术前

36、肩高的差别，由于这通常决议了交融的高度。 可以临床确定肩高，也可以运用锁骨角或T1倾斜进展放射学检查。. 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. 关于肩高有三种不同的情况。 第一种也是最常见的情况是右侧主胸弯，右肩高于左侧。 在这种情况下，矫正胸弯也会使右肩下垂，通常到达肩高相等。 在这些情况下，UIV通常为T4或T5.假设左肩高，那么补偿性近端胸椎交融通常交融T2，否那么会继续向左。 假设术前双

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. 对于具有较小腰弯的单胸弯Lenke 1A和1B，普通选择性胸椎交融。 对于远端交融程度，重要的是选择适宜的LIV，以坚持良好的冠状平衡并防止腰椎退化或附加景象。 常规的指南运用了稳定椎。然而，这个指南是基于Harrington，其矫正力是单平面的。

42、经过运用椎弓根螺钉可以进展三柱固定，可以节省额外的1或2个远端运动节段，而不是交融到稳定的椎骨上。.Adding-on附加景象 2000年由Suk最先报道 发生率：2-21% 再次手术率为 7.3% .Adding-on附加景象定义：末次随访时主弯的LEV向LIV远端挪动并且冠状面 Cobb角添加5；LIV远端临近椎间盘成角添加5；LIV偏离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. 中立椎也用于确定远端交融。中立椎和端椎之间的关系可以用来确定LIV。 假设端椎和中立椎之间的间隔不超越1个椎体，那么交融到中立椎是足够的。 当术前NV与EV间隔为两个椎体以上时,LIV选择在NV-1。 假设中性椎骨是端椎骨，那么足以交融到端椎。 Suk及其同事对运用这些指南治疗的患者进展为期2年的随访，结果令人称心，具有良好的冠状平衡，腰椎矫正，无附加功能。. 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. 关于附加景象，Miyanji和他的同事根据L4倾斜：1A-L向左倾斜和1A-R向右倾斜区分了2种类型的Lenke 1曲线。 曾经显示1A-R曲线具有较高的附加风险，需求更远端的交融，比1A-L曲线更远2个节段。. 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曲线因其交融程度而遭到继续的争议，由于它们通常表现为两个大弯。 在1C方式中，非构造性腰部曲线是柔性的side-bending25，其中顶点完全穿过中线。 Lenke等的一项研讨显示62的1C曲线患者进展了选择性胸段交融，这意味着剩下的38是非选择性交融。 Newton及其同事报道，较大的术前腰

51、弯曲度，较大的腰椎顶椎椎体位移与较小的胸椎/腰椎大小比例是非选择性交融的相关要素。 Lenke等报道，对于1B和1C曲线的选择性交融是胜利的，Cobb大小，顶椎旋转和顶椎偏移的胸/腰比应大于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. 在治疗双胸弯时，重要的是不要忽视构造性近端胸弯。根据构造曲线的Lenke规范，主胸椎和构造性近端胸弯都必需纳入交融。不恰当的区分构造性近侧胸弯导致近端曲线从交融中排除，特别是在术前左肩背部高的情况下，可导致肩部不平衡严重加重和患者不满。 Suk及其同事报道，近端和主胸弯交融在肩部程度较高的患者或近端胸弯一侧肩部较高的，结果改善。在左肩抬高的患者中，UIV将T2交融通常足以获得对近端胸弯的良好矫正并实现肩膀程度。术前平肩患者，根据术中矫正和肩关节平衡，上位交融可以是T2或T3。普通而言，Lenke 2型曲线引荐交融近端和主胸弯。 Suk及其同事发现，假设左肩低于右侧大于1

57、2mm，那么近端胸弯可以坚持不交融。. 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. 为了选择LIV，用于Lenke 1曲线的远端交融规那么可以运用于Lenke 2曲线。 运用NV和EV作为标志，LIV通常是稳定的椎骨与CSVL相交的最近的椎骨。对于2C型的选择性交融的引荐方法与1C曲线一样，其中 在缺乏局灶性胸腰椎后凸10或更高的曲线中，Cobb大小，顶椎平移AVT和顶椎旋转AVR的主胸椎/胸腰椎/腰椎曲线必需为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型的胸弯和腰弯都是构造性的，所以胸弯和腰弯普通