特發(fā)性脊柱側(cè)彎畸形的分型與治療幻燈片

AdolescentScoliosis

ClassificationandTreatment

特發(fā)性脊柱側(cè)彎畸形的分型與治療JaneS.Hoashi,MD,MPH,PatrickJ.Cahill,MD,JamesT.Bennett,MD,AmerF.Samdani,MD*NeurosurgClinNAm24(2021)173–183精品文檔KEYWORDSAdolescentidiopathicscoliosisLenkeclassificationScoliosisPediatricspinedeformityPediclescrews青少年特發(fā)性脊柱側(cè)彎Lenke分型弓根螺釘矯形精品文檔KEYPOINTSAdolescentidiopathicscoliosis(AIS)canbeclassifiedaccordingtotheLenkeclassificationsystem,whichincorporatescurvemagnitude,flexibility,thelumbarmodifier,andthesagittalplane.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。TheLenkeclassificationservesasaguidewithrespecttolevelselectioninpatientswithAIS.Lenke分類可作為AIS患者融合水平選擇的指南。ThewidespreaduseofpediclescrewshasresultedinmostAISbeingtreatedthroughaposteriorapproach.椎弓根螺釘?shù)膹V泛使大多數(shù)AIS可以用后路治療。精品文檔INTRODUCTIONAdolescentidiopathicscoliosis(AIS)isaspinalconditioncausingdeformityofthespinein3dimensions:thecoronal,sagittal,andaxialplanes.AISisdefinedasanycurveequaltoorgreaterthan10inthecoronalplane1,2inpatients10to18yearsold.3Itisadiagnosisofexclusionaftercongenital,neuromuscular,neural,orsyndromiccausesofscoliosishavebeenruledout.Preoperativemag-neticresonanceimagingisusefulforrulingoutneuralcausesofscoliosis,suchassyringomyeliaorChiarimalformation,althoughitsuseasapreop-erativescreeningtooliscontroversial.4,5AgeneticcomponenthasbeendescribedregardingthecauseofAIS.6–11Withanincidenceof11%amongfirst-degreerelatives,12itisnotuncommonforahealthcareprovidertomanagemultiplemem-bersofafamilywithscoliosis.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)凸原因。術(shù)前磁共振成像對于排除脊柱側(cè)凸的神經(jīng)原因，如脊髓空洞癥或Chiari畸形是有用的，盡管其作為術(shù)前篩查工具的使用還存在爭議.已經(jīng)報道了AIS的原因.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。精品文檔AISaffectsapproximately2%to3%oftheadolescentpopulation,butfewerthan10%ofpatientswithAISneedtreatment.13Thehigherthecurvemagnitude,thelowertheprevalenceandthehigherthefemale/maleratio.Curvesgreaterthan30havea0.1%to0.3%prevalenceandaffectfemales10timesmorethanmales.AIS對青春期人群的影響約為2％?3％，而AIS患者中只有不到10％需要治療。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0.1％?0.3％，女性患病率是男性的10倍以上。精品文檔Foryears,theKing-MoeclassificationwasthemostwidelyusedsystemforguidingtreatmentinAIS.Itsshortcomingsincludedclassifyingcurvesbasedonlyonthecoronalplaneandshowinglowinterobserverreliability.15Also,onlyvariantsofthethoraciccurveweredescribed,leavingsomeothercurvetypessuchasthoracolumbarorlumbarcurvesunabletobeclassifiedbythissystem.TheLenkeclassification16addressestheseshortcomingsandisnowconsideredthegoldstandardforclassifyingAISandguidingtreatment.Inthisarticle,theLenkeclassificationisusedtodescribetheAIStypesandthetreat-mentoptions.多年來，King-Moe分類是用于指導(dǎo)AIS治療的最廣泛使用的系統(tǒng)。其缺點是包括僅僅根據(jù)冠狀面分型，并顯示出較低的觀察者間的可靠性。另外，僅描述了胸彎的變體，殘留了一些其他曲線類型，如胸腰彎或腰椎彎無法通過該系統(tǒng)進(jìn)展分類。Lenke分類解決了這些缺點，現(xiàn)在認(rèn)為是AIS分類和指導(dǎo)治療的金標(biāo)準(zhǔn)。在本文中，Lenke分類用于AIS類型和治療選擇。精品文檔Treatmentofscoliosisincludesnonoperativemanagementsuchasbracingofcurvesmeasuring20to40orprogressingmorethan5peryear.Largercurvemagnitude,youngerchronologicage,andRissersignareassociatedwithcurveprogression.17TheliteraturehasshownbracingtobemoreeffectiveinpatientswithearlierRisserscores(0–1)andopentriradiatecartilages.18–20Thegoalofbracingistomaintaincurvemagnitudethroughoutapatient’sgrowthperiod,althoughconflictingevidenceofitseffectivenesshavebeenreported.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。支具的目標(biāo)是保持患者在整個生長期中保持目前曲度的幅度，盡管目前的報道對其有效性的報道是相互矛盾的。精品文檔Surgeryisindicatedwhenacurveisprogressivedespitebracingandgenerallywhenthecurverea-ches45to50.Themaingoalistostopthecurvefromprogressing,leadingtopotentiallyseverecomplicationsfromanuntreatedcurve,includingpulmonaryfunctionandbackpain.Othergoalsdrivenbythepatientsthemselvesareimprovementofcosmesis.QualityoflifestudiesasmeasuredbytheSRS-22(ScoliosisResearchSociety22)ques-tionnairehaveshownthatpatientswithAIShavelowerself-imageandaremoreself-consciousabouttheirgeneralappearancethanthegeneralpopulation.21,22Thisfindingcanberelatedtoashoulderimbalance,ribprominence,ortrunkasymmetry.Thus,thepsychologicalimpactofthedeformitymustalsobetakenintoaccountwhenconsideringsurgery.盡管有支具，曲度仍然是進(jìn)展性開展的，通常曲度大于45到50之間時表示需要手術(shù)。手術(shù)的主要目標(biāo)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?；颊咦约旱哪繕?biāo)是改善外觀。根據(jù)SRS-22的調(diào)查問卷所測量的生活質(zhì)量研究顯示，AIS患者的自我形象評價較低.可能與肩部不平衡，肋骨突出或軀干不對稱有關(guān)。因此，在考慮手術(shù)時也必須考慮到畸形的心理影響。精品文檔Thegoalsofsurgeryaretorestorecoronalandsagittalbalance,reducetheribprominence,andachieveshoulderbalance.However,anotherimportantgoalistoleaveasmanyunfusedseg-mentsaspossibletopreservemotioninthelumbarspine.Thespecifictreatmentoptionsarediscussedfurtherinthisarticle.手術(shù)的目標(biāo)是恢復(fù)冠狀和矢狀平衡，減少肋骨突出，到達(dá)肩部平衡。然而，另一個重要的目標(biāo)是盡可能多的保存未融合的局部以保持腰椎運(yùn)動。本文將進(jìn)一步討論具體的處理措施。精品文檔TwoapproachestoAISsurgeryexist:theanteriorapproachandtheposteriorapproach;acombina-tionofthe2isalsoused.Somepotentialadvan-tagestotheanteriorapproacharesavingfusionlevels,23,24decreasedprominenceofinstrumenta-tion,anddecreasedriskofcrankshaftphenom-enoninaskeletallyimmatureadolescent.16,25However,somestudieshaveindicatedmorbidityrelatedtodecreasedpulmonaryfunction,26,27whichseemstoimproveat2-yearfollow-up.28Theanteriorapproachcanbeusedtofusesimplethoraciccurvesandcanalsobeusedtoperformanteriorreleaseandfusioncombinedwithposteriorspinalfusioninstifferandlarger(>90)curves,althoughsimilarcurvecorrectioncanbeachievedintheselargercurvesbytheposteriorapproachalone.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)的組合也被使用。前路手術(shù)的一些潛在優(yōu)勢是節(jié)約融合水平，降低青少年骨骼不成熟的曲軸現(xiàn)象的風(fēng)險。然而，一些研究說明發(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)可用于融合簡單的胸彎，也可用于前路松解后路脊柱融合。精品文檔Sincethedevelopmentofpediclescrews,theposterior-onlyapproachhasbecomethemainstayoftreatmentofAIS.Pediclescrewsprovidea3-columnfixationthatpermitsgreatercurvecorrectionandimprovedderotation.30Eveninthemoresevere(>90)andstiffercurves,pediclescrewconstructswithosteotomiesrendergoodcorrection,29therebyreducingtheneedforcombinedanteriorandposteriorapproaches.Thecrankshaftphenomenonmayalsobereducedbyusingpediclescrews.自從椎弓根螺釘開展以來，后路手術(shù)已成為AIS治療的主要手段。即使在嚴(yán)重的〔>90〕和僵硬的側(cè)彎治療中，用截骨加椎弓根螺釘能得到良好的效果，從而減少對前后聯(lián)合手術(shù)的依賴。曲軸現(xiàn)象也可以通過使用椎弓根螺釘減少。精品文檔However,pediclescrewplacementhasalearningcurve,especiallywiththefreehandtechnique.32Withsurgeonexperience,theaccuracyofpediclescrewplacementimproves,andthemedialbreachratedecreases.33,34Reportedbreachratesrangefrom1.6%toashighas58%.33–38However,ratesforneurologicandvisceralinjuriesdespitethesebreachesarelow.Althoughhypokyphosishasbeenobservedwithposterior-onlypediclescrewconstructs,39,40long-termfollow-uphasshowngoodmaintenanceofcorrectionandcoronalandsagittalalignment.然而，椎弓根螺釘置釘需要有學(xué)習(xí)曲線特別是徒手置釘技術(shù)。隨著外科醫(yī)生的經(jīng)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。只有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。精品文檔LENKECLASSIFICATION

OverviewTheLenkeclassificationforAISwasdevelopedasatooltohelpsurgeonsclassifycurvetypesandguidetheminoperativetreatment.16Thecurvetype(themajorcurve),lumbarmodifier(A,B,andC,dependingonthelocationofthecentersacralverticalline[CSVL]inrelationtotheapicallumbarvertebra),andthesagittalprofile(–,N,1)isusedtodetermineaspecificcurvepattern.Althoughthereare6Lenkecurvetypes,atotalof42curvepatternscanbeobserved.對于AIS的Lenke分型是為了幫助外科醫(yī)生對側(cè)彎的曲線類型分類并指導(dǎo)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)彎模式。雖然有6個Lenke主彎類型，但總共可以觀察到42個側(cè)彎模式。精品文檔Thebasisofsurgicaltreatmentistofuseonlythestructuralcurves.ThecurvewiththelargestCobbmagnitudeisdefinedasthemajorcurve,which,bydefinition,isstructural.Curveswithlessermagni-tude(minorcurves)canbestructuralornonstruc-tural,dependingonthedegreeoftheirflexibilityseenonbendingfilms.Generally,minorcurvesarenotconsideredpartofthearthrodesisiftheybendouttolessthan25.Focalkyphosisisalsoacriterionforconsideringacurvetobestructural.手術(shù)治療的根底是只融合構(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。一般來說，如果bending小于25°，次彎不融合。后凸也是考慮曲線構(gòu)造的標(biāo)準(zhǔn)。精品文檔TheLenkeclassificationdifferentiatesKing-Moetype2curvesintoLenketypes1and3,helpingsurgeonsselectwhichcurvesareamenabletoselectivefusions(Lenketype1)andthosethatrequireanextendedfusioninthelumbarspine(Lenketype3).UnliketheKing-Moeclassification,whichconsidersonlythecoronalplane,theLenkeclassificationaccountsforbothcoronalandsag-ittalplanesandhasbeenshowntohavegoodinterobserverreliability.However,theaxialplane(areflectionofvertebralbodyrotation)isstillnotincludedintheLenkeclassification.Moreover,somecurvetypessuchascurveswithClumbarmodifiersaresubjecttocontroversyregardingselectiveversusnonselectivefusion.ThefollowingsectiononthespecificLenkecurvetypesincludessomeofthecontroversiesandcurrentrecommen-dationsfortreatment.Lenke分類將King-Moe2型曲線區(qū)分為Lenke1型和3型，幫助外科醫(yī)生選擇適合選擇性融合〔Lenke1型〕和需要在腰椎〔Lenke3型〕中進(jìn)展融合。與僅考慮冠狀面的King-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觀察者間可靠性。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融合方面存在爭議。以下關(guān)于特定Lenke曲線類型的局部包括一些爭議和當(dāng)前的治療建議。精品文檔精品文檔TreatmentofLenkeCurveTypes

Lenke1:singlethoraciccurveForsinglethoraciccurves(Fig.1),itisgenerallyacceptedtoperformselectivefusionsofthemainthoraciccurve,unlessthereisakyphosisofmorethan20inthethoracolumbararea,inwhichcase,thelumbarcurveisalsoincludedinthefusion.16Theunfusedlumbarcurveisnonstruc-turalandusuallyspontaneouslycorrectsitselfafterthoracicfusion.42–46Itisimportanttonoteanypreoperativeshoulderheightdiscrepancy,be-causethisoftendeterminestheupperfusionlevels.Shoulderheightcanbedeterminedclini-callyaswellasradiographicallyusingtheclavicleangleorT1tilt.對于單胸彎〔圖1〕，一般認(rèn)為胸彎選擇性融合是可行的，除非在胸腰段有超過20的后凸畸形，這種情況下，腰彎也需要融合[16]。腰椎不融合，通常在胸椎融合術(shù)后自行矯正。重要的是要注意術(shù)前肩高的差異，因為這通常決定了融合的高度?？梢耘R床確定肩高，也可以使用鎖骨角或T1傾斜進(jìn)展放射學(xué)檢查。精品文檔Threedifferentscenariosexistregardingshoulderheight.Thefirstandmostcommonscenarioisarightmainthoraciccurve,withtherightshoulderbeinghigherthantheleft.Inthiscase,correctionofthethoracicspinealsobringsdowntherightshoulder,usuallyachievingequalshoulderheight.Inthesecases,theupperinstru-mentedlevelisusuallyT4orT5.48Iftheleftshoulderiselevated,thecompensatoryproximalthoraciccurveisusuallyincludedinthefusion(toT2)toopposethecorrectiveforcesbeingplacedonthemainthoraciccurve,whichwouldotherwisecontinuetodrivetheleftshoulderup.Ifbothshoul-dersareequalinheightpreoperatively,T3isusuallytheupperleveloffusion.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.如果左肩高，那么補(bǔ)償性近端胸椎融合通常融合T2，否那么會繼續(xù)向左。如果術(shù)前雙方肩高相等，T3通常是UIV。精品文檔Forsinglethoraciccurveswithminorflexiblelumbarcurves(Lenke1Aand1B),selectivethoracicfusionsaregenerallyindicated.Fordistalfusionlevels,itisimportanttochoosetheappropriatelowestinstrumentedvertebra(LIV)soastoleavegoodcoronalbalanceandavoidlumbardecom-pensationorprogressionoftheprimarycurve(adding-on).Conventionalguidelineshaveusedthestablevertebra,orthemostproximalvertebrawithpediclesmostcloselybisectedbytheCSVLastheLIV.15However,thisguidelinewasbasedonHarringtoninstrumentation,inwhichthecorrec-tiveforceswereuniplanar.With3-columnfixationusingpediclescrews,anadditional1or2distalmotionsegmentscanbesaved,insteadoffusingtothestablevertebra.對于具有較小腰彎的單胸彎〔Lenke1A和1B〕，一般選擇性胸椎融合。對于遠(yuǎn)端融合水平，重要的是選擇適宜的LIV，以保持良好的冠狀平衡并防止腰椎退化或附加現(xiàn)象。常規(guī)的指南使用了穩(wěn)定椎。然而，這個指南是基于Harrington，其矯正力是單平面的。通過使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(yùn)動節(jié)段，而不是融合到穩(wěn)定的椎骨上。精品文檔Adding-on〔附加現(xiàn)象〕2000年由Suk最先報道發(fā)生率：2-21%再次手術(shù)率為7.3%精品文檔Adding-on〔附加現(xiàn)象〕定義：末次隨訪時主彎的LEV向LIV遠(yuǎn)端移動并且冠狀面Cobb角增加＞5°；LIV遠(yuǎn)端鄰近椎間盤成角增加＞5°；LIV偏離CSVL增加10mm以上。精品文檔Theneutralvertebraisalsousedtodeterminethedistalfusionlevel.49,50TherelationbetweentheneutralvertebraandtheendvertebracanbeusedtoascertaintheLIV.Ifthereisnomorethan1levelbetweentheendvertebraandtheneutralvertebra,thenfusiontotheneutralvertebraissuffi-cient.Thislevelcorrespondsto1levelproximaltothestablevertebra.However,iftheneutralvertebrais2ormorelevelsdistaltotheendvertebra,thentheLIVisNV-1.Iftheneutralvertebraistheendvertebra,thenitisadequatetofusetothedistalendvertebra.A2-yearfollow-upbySukandcolleagues49inpatientstreatedusingtheseguide-linesshowedsatisfactoryresultswithgoodcoronalbalance,compensatorylumbarstraightening,andnoadding-on.中立椎也用于確定遠(yuǎn)端融合。中立椎和端椎之間的關(guān)系可以用來確定LIV。如果端椎和中立椎之間的距離不超過1個椎體，那么融合到中立椎是足夠的。當(dāng)術(shù)前NV與EV距離為兩個椎體以上時,LIV選擇在NV-1。如果中性椎骨是端椎骨，那么足以融合到端椎。Suk及其同事對使用這些指南治療的患者進(jìn)展為期2年的隨訪，結(jié)果令人滿意，具有良好的冠狀平衡，腰椎矯正，無附加功能。精品文檔Withregardtoadding-on,Miyanjiandcolleagues51differentiated2typesofLenke1curves,dependingontheL4tilt:1A-L(tiltedtotheleft)and1A-R(tiltedtotheright).1A-Rcurveshavebeenshowntohaveahigherriskofadding-onbecauseoftheoverhangingcurvepattern,requiringamoredistalfusion,approximately2levelsmoredistalthana1A-Lcurve.關(guān)于附加現(xiàn)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Lenke1曲線。已經(jīng)顯示1A-R曲線具有較高的附加風(fēng)險，需要更遠(yuǎn)端的融合，比1A-L曲線更遠(yuǎn)2個節(jié)段。精品文檔Lenke1Ccurveshavebeensubjecttoongoingcontroversyregardingtheirfusionlevelsbecauseoftentheybehavelikedoublemajorcurves.Inthe1Cpattern,thenonstructurallumbarcurveisflexible(side-bendingto<25),inwhichtheapexcompletelycrossesthemidline.AstudybyLenkeandcolleagues53showedthatselectivethoracicfusionwasperformedin62%ofpatientswith1Ccurves,implyingthattheremaining38%hadnonselectivefusions.Newtonandcolleaguesreportedthatlargerpreoperativelumbarcurvemagnitude,greaterlumbarapicalvertebradis-placementfromtheCSVL,andsmallerthoracic/lumbarmagnituderatiowerefactorsassociatedwithnonselectivefusion.Lenkeandcolleagues55reportedthatforaselectivefusiontobesuccess-fulfor1Band1Ccurves,thethoracic/lumbarratiosforCobbmagnitude,apicalvertebraltrans-lation,andapicalvertebralrotationshouldbegreaterthan1.2。Lenke1C曲線因其融合程度而受到持續(xù)的爭議，因為它們通常表現(xiàn)為兩個大彎。在1C模式中，非構(gòu)造性腰部曲線是柔性的〔side-bending<25〕，其中頂點完全穿過中線。Lenke等的一項研究顯示62％的1C曲線患者進(jìn)展了選擇性胸段融合，這意味著剩下的38％是非選擇性融合。Newton及其同事報道，較大的術(shù)前腰彎曲度，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融合的相關(guān)因素。Lenke等報道，對于1B和1C曲線的選擇性融合是成功的，Cobb大小，頂椎旋轉(zhuǎn)和頂椎偏移的胸/腰比應(yīng)大于1.2精品文檔Lenke2:doublethoraciccurvesIntreatingdoublethoraciccurves(Fig.2),itisimportanttonotoverlookastructuralproximalthoraciccurve.Boththemainthoracicandthestructuralproximalthoraciccurvesmustbeincludedinthefusion,accordingtotheLenkecriteriaforstructuralcurves.Inappropriatedistinc-tionofastructuralproximalthoraciccurveleadingtoexclusionoftheproximalcurvefromthefusion,especiallyinthecontextofapreoperativeelevatedleftshoulder,canleadtosevereworseningofshoulderimbalanceandpatientdissatisfaction.Sukandcolleagues56reportedimprovedresultswhenbothproximalandmainthoraciccurveswerefusedinpatientswithlevelshouldersorahighershoulderonthesideoftheproximalthoraciccurve.Inpatientswithanelevatedleftshoulder,fusingtoT2astheupperinstrumentedlevelisusuallysufficienttogaingoodcorrectionoftheproximalthoraciccurveandachieveadequateshoulderalignment.Inpatientswithlevelshoulderspreoperatively,theupperleveloffusioncanbeT2orT3,dependingonthecorrectionandshoulderbalanceachievedintraoperatively.Ingeneral,fusionofbothproximalandmainthoraciccurvesisrecommendedforLenketype2curves.Sukandcolleagues56foundthattheproximalthoraciccurvecanbeleftunfusediftheleftshoulderislowerthantherightbyadifferencegreaterthan12mm.在治療雙胸彎時，重要的是不要無視構(gòu)造性近端胸彎。根據(jù)構(gòu)造曲線的Lenke標(biāo)準(zhǔn)，主胸椎和構(gòu)造性近端胸彎都必須納入融合。不恰當(dāng)?shù)膮^(qū)分構(gòu)造性近側(cè)胸彎導(dǎo)致近端曲線從融合中排除，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，近端和主胸彎融合在肩部水平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融合通常足以獲得對近端胸彎的良好矯正并實現(xiàn)肩膀水平。術(shù)前平肩患者，根據(jù)術(shù)中矯正和肩關(guān)節(jié)平衡，上位融合可以是T2或T3。一般而言，Lenke2型曲線推薦融合近端和主胸彎。Suk及其同事發(fā)現(xiàn)，如果左肩低于右側(cè)大于12mm，那么近端胸彎可以保持不融合。精品文檔ToselecttheLIV,thedistalfusionrulesusedforLenke1curvescanbeappliedtoLenke2curves.UsingtheNVandEVaslandmarks,theLIVisgenerallythestablevertebra(themostproximalvertebraintersectedbytheCSVL).48–50Recom-mendationsforselectivefusionsfortype2Carethesamefor1Ccurves,wheretheratioofthemainthoracic/thoracolumbar/lumbarcurvesforCobbmagnitude,apicalvertebraltranslation(AVT),andapicalvertebralrotation(AVR)mustbe1.2orgreaterincurveslackingafocalthoraco-lumbarkyphosis10orgreater.為了選擇LIV，用于Lenke1曲線的遠(yuǎn)端融合規(guī)那么可以應(yīng)用于Lenke2曲線。使用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型的選擇性融合的推薦方法與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/腰椎曲線必須為1.2或更高。精品文檔Lenke3:doublemajorcurvesLenketype3curves(Fig.3)arethoseinwhichboththoracicandlumbarcurvesarestructural,sobothcurvesaregenerallyincludedinthefusion.SomeconfusionexistsbetweenLenke1CandLenke3curves,becausetheycanbehavesimi-larly,especiallyLenke1Ccurveswithlumbarcurveswithaborderlinenonstructuralcriterion(bendingtoslightly<25).Lenke3型的胸彎和腰彎都是構(gòu)造性的，所以胸彎和腰彎一般都要融合。Lenke1C和Lenke3之間存在一些混淆，因為它們可以表現(xiàn)得相似，特別是Lenke1C具有邊緣的非構(gòu)造性標(biāo)準(zhǔn)〔bending略小于25〕的腰部曲線。精品文檔Thegoalsfordoublemajorcurvesincludeob-tainingadequatecorrectionandbalanceofbothcurves.Preoperatively,itisimportanttonoteanywaistasymmetryortrunkshiftinthesepatients,becausethegoalistorestorecoronalbalance.ThisbalanceisattainedbycentralizingandneutralizingtheLIV.AlsocrucialinachievingcoronalbalanceismakingtheLIVdiskashori-zontalaspossible.Itisalsonotuncommontofindhyperkyphosisinthethoracolumbararea(T10-L2),whichshouldbecorrectedtoachievenormalsagittalalignment.Theupperinstrumentedvertebra(UIV)isdeterminedfirstbythemagnitudeandcharacteristicsofthethoraciccurve,butshoulderasymmetryandcharacteristicsoftheproximalnonstructuralthoraciccurvemustalsobeconsideredbeforedecidingtheproximalleveloffusion.ThislevelusuallycorrespondstoT3toT5.雙主彎的目標(biāo)包括獲得適當(dāng)?shù)男Ｕ蛢蓷l曲線的平衡。在術(shù)前，重要的是要注意這些患者的腰部不對稱或軀干移位，因為目標(biāo)是恢復(fù)冠狀平衡。這種平衡是通過LIV來到達(dá)的。實現(xiàn)冠狀平衡的關(guān)鍵還在于使LIV椎間盤盡可能地水平。在胸腰段〔T10-L2〕發(fā)現(xiàn)椎管內(nèi)病變并不罕見，應(yīng)該糾正以到達(dá)正常的矢狀對齊。UIV首先由胸彎大小和特征決定，但在決定近端融合水平之前，還必須考慮肩部不對稱性和近端非構(gòu)造性胸彎的特征。這個水平通常對應(yīng)于T3到T5。精品文檔Asageneralguidelineforthedistalfusionlevel,themostproximallumbarvertebraintersectedbytheCSVLisusuallytheLIV,48eitherL3orL4.Onposteroanteriorstandingfilms,iftheapexofthethoracolumbar/lumbarcurveisL2ordistal,theL3toL4diskspaceopensontheconvexity,andiftherotationofL4isNash-MoegradeIorgreater,57thenthefusionshouldextendtoL4.However,iftheapexistheL1to2diskorproximal,theL3toL4diskspaceclosesorisneutralontheconvexity,andtherotationofL3isgrade1.5orless,thenthefusioncanstopatL3.57Side-bendingfilmscanalsobeusefulfordecidingwhethertofusetoL3orL4.Foratypicalright-sidedthoracicandleft-sidedlumbarcurve,Sukandcolleagues49,50recommendfusingtoL3,ifL3crossestheCSVLintheleftbendingradiograph,oriftherotationofL3intherightbendingradiographislessthanNash-MoegradeII。FusiontoL4isrecommendedifL3doesnotcrosstheCSVLonleftbendingfilms,orifL3rota-tionisgradeIIorhigherontherightbendingfilms.作為遠(yuǎn)端融合水平的一般指導(dǎo)原那么，CSVL相交的最近側(cè)腰椎通常是LIV，L3或L4。在前后立位片上，如果胸腰彎的頂點是L2或遠(yuǎn)端，那么L3到L4的椎間盤在凸面上翻開，如果L4的旋轉(zhuǎn)是Nash-Moe大于I級，那么融合應(yīng)該延伸到L4。但是，如果頂點是L1到2椎間盤或近端，那么L3到L4椎間盤在凸側(cè)上閉合或水平，并且L3的旋轉(zhuǎn)等于或小于1.5，那么融合可以在L3停頓。bending也可用于決定是否融合到L3或L4。對于典型的右側(cè)胸彎和左側(cè)腰彎，Suk和同事建議融合到L3，如果L3在左側(cè)bending中穿過CSVL，或者如果右側(cè)bending中L3的旋轉(zhuǎn)小于Nash-MoeII級。如果L3沒有穿過左彎bending上的CSVL，或者如果右bending上的L3旋轉(zhuǎn)等級為II級或更高，那么推薦使用融合到L4。精品文檔Selectivethoracicfusioncanbeconsideredinsome3Ccurvesinwhichthemainthoraciccurveislargerthanthethoracolumbar/lumbarcurveandthereisanabsenceofthoracolumbarkyphosisfromT10toL2of10orgreater.Thesamemainthoracic/thoracolumbar/lumbarratiocriteriaofmorethan1.2describedfor1Cand2Ccurvesamenabletoselectivethoracicfusionsisusedfor3Ccurvesaswell.T10?L2胸腰椎后凸畸形不超過10°，胸彎大于胸腰彎/腰彎的3C可考慮選擇性胸椎融合。3C也采用了同樣的主胸椎/胸腰椎/腰椎比率標(biāo)準(zhǔn)，對于1C和2C所描述的超過1.2的比率適用于選擇性胸椎融合。精品文檔Lenke4:triplemajorcurvesLenke4curvesarethoseinwhichtheproximalthoracic,mainthoracic,andthoracolumbar/lumbarcurvesareallstructural.All3curvesshouldbeincludedinthearthrodesisbymeansofaposteriorspinalfusion.ThechoiceoftheUIVisthesameasfordoublethoraciccurves,andisT2orT3,dependingoncurveflexibilityandshoulderheightdiscrepancy.SelectionofLIVisinaccor-dancewiththerulesfordoublemajorcurves.Lenke4是那些近端胸彎，主胸椎和胸腰彎/腰彎都是構(gòu)造性的側(cè)彎。所有3彎均應(yīng)通過后路脊柱融合術(shù)進(jìn)展融合。UIV的選擇與雙胸彎一樣，是T2或T3，取決于曲度的柔韌性和肩高差異。LIV的選擇符合雙主彎的規(guī)那么。精品文檔Lenke5:thoracolumbar/lumbarForLenke5curves(Fig.4),generally,onlythemajorthoracolumbar/lumbarcurveisfusedusingananteriororposteriorapproach.Traditionally,theanteriorapproachwasoftenusedbecauseofitsabilitytosavefusionlevelscomparedwiththeposteriorapproachusinghooksandrods.58–64Thefusionlevelsfortheanteriorapproachincludedonlythethoracolumbar/lumbarcurvefromtheproximalendvertebratothedistalendvertebra.Withtheuseofpediclescrews,studieshaveshownthatfusionlevelsthroughtheposte-riorapproachcanbeequivalenttothoseusingtheanteriorapproach,aswellastheabilitytoachievecorrectionwithouthavingtoviolatethethoraciccavity.對于Lenke5，通常用前路或后路手術(shù)融合胸腰彎或腰彎。傳統(tǒng)上，常用前路手術(shù)，因為與CD后路手術(shù)相比它能夠節(jié)省融合水平。前路手術(shù)的融合水平僅包括從近端椎到遠(yuǎn)端椎。研究說明通過使用椎弓根螺釘后路手術(shù)的融合水平可以等同于前路手術(shù)的融合水平，以及在不必暴露胸腔的情況下實現(xiàn)矯形。精品文檔Similartoreco