【脊柱侧弯 精】6.2 退行性脊柱侧凸Fusion Levels

• 无法直立
• lumbar stenosis symptoms
• 间歇性跛行
• Root compression on the Concave
• 凹侧神经根压迫
• Root Stretching on the Convex
Wang, et al. Medicine, 2016
成人退行性脊柱侧凸ADS
Risk Factor for Progression
• 每年平均增加3度 • 主弯曲大于30度 • > 20%椎间隙不对称 • 椎体骨刺> 5 mm • > 6 mm侧方滑移 • 旋转大于II度 (Nash-Moe) • 髂棘连线穿过或低于 L45 椎间隙
Risk Factors
Age>65y Gender F Osteoporosis
PROS and CONS
Risk
Life Quality
非手术治疗NS 手术风险高 全身情况差 合并其他系统疾病 较高的并发症发生率 保守治疗进展
平衡
手术治疗S 麻醉技术进步 手术技术进步 内固定器械进步 术中监护的应用
详细的治疗选择期望评值估增高
• How much pain relief 疼痛缓解程度 • How much deformity correction 畸形矫正程度
How to avoid PJK?
Osteotomy
Lee, et al. Contemporary Spine Surgery, 2010 Russo, et al. Current Orthopedic Practice, 2008
Tribus C.B. JAAOS 2003; 11:174 -183 Jeong & Bendo CORR 2004; 425:110 - 125
Complex Spinal Deformity
Lee, et al. Contemporary Spine Surgery, 2010 Russo, et al. Current Orthopedic Practice, 2008
• 20R1i6sskysFteamcattioc rrevfoiewr Progression
3-Dimensional Coronal Sagittal Axial
Sagittal Local Regional Global
4th Dimension: Time 四维畸形 Disco-ligamentous structures Bone density Muscle mass and tone Neural control mechanisms
• Asymmetric degeneration: disc, facet joints不对称退变导致不对称 畸形
• Asymmetric deformity: scoliosis , kyphosis or axial plane deformity • 常见于T11或T12到L5或S1
• Spinal imbalance symptoms • 腰痛
• 充分证据： • 椎间盘退变 • 髂棘连线通过L5（而不是L4以上） • 顶椎横向滑移≥6mm • 中等证据： • 顶椎旋转度 II / III
手术指征和治疗目的
严重疼痛
侧凸进展
神经压迫
• 缓解疼痛 • Pain Relief
• 矫正稳定
• Correction and Stabilization
• 减压松解 • Decompression
Technical Challenges
How high? How Low?
MIS or Open?
Anterior or Posterior?
脊柱失衡
• 恢复平衡 • Restore Balance
How Extensive?
How much to correct?
• How much risk acceptable 风险承担
Selection of Fusion Levels
• Principles 原则 • Symptoms 症状 • Stability 稳定性 • Balance 平衡 • Degeneration 退变情况 • Algorithm 流程 • Decompression or not 减压部位 • UIV from upper thoracic vs. thoracolumbar Junction上位 椎 • L5 or S1 or pelvis?下位椎
Ames, et al. Spine Deformity, 2016 Lee, et al. Contemporary Spine Surgery, 2010 Russo, et al. Current Orthopedic Practice, 2008
成人退行性脊柱侧凸ADS
• 继发于椎间盘及椎间关节退变的成人结构性侧凸
退行性脊柱侧凸之融合节段选择Degenerative Scoliosis：Where to Stop?
ቤተ መጻሕፍቲ ባይዱ
成人退行性脊柱侧凸ADS
• ADS成人退行性脊柱侧凸 • 在骨骼发育成熟后(大于20岁)出现的
脊柱侧凸(Cobb角>10°) • Aging population is increasing • Age 50-60s, Prevalence 6%发病率 • Co-morbidity in elderly patients • Poor bone quality • the complexity of surgical approaches
手术可以这么做吗？
• 手201术5年并IS发SG症回顾与成再人手脊术柱畸形并发症率
• 11,318 patients→3,615 complications, complications rate 55%. • 围术期并发症(18.5%) • 神经损伤、伤口感染、内固定/植骨失败、失血过多 • 短期术后并发症(15.7%) • 脑脊液漏、胃肠道并发症、短暂性神经损伤、伤口感 染等 • 长期并发症(20.5%) • 假关节、内固定/植骨失败、PJK、ASD、新发症状取 钉 • 2015年Glassman等报道成人脊柱畸形再手术率为18%