Nanjing Gulou Hospital成人脊柱側(cè)凸的治療成人脊柱側(cè)凸的治療Nanjing Gulou Hospital1398成人Nanjing Gulou HospitalNanjing Gulou Hospital在頂椎區(qū)在頂椎區(qū)凹側(cè)關(guān)節(jié)突退變凹側(cè)關(guān)節(jié)突退變椎間盤退變不明顯椎間盤退變不明顯Nanjing Gulou HospitalNanjing Gulou HospitalNanjing Gulou HospitalCase 5Nanjing Gulou Hospital在繼發(fā)彎區(qū)在繼發(fā)彎區(qū) 可長期保持其柔軟性可長期保持其柔軟性Nanjing Gulou Hospital1416Nanjing Gulou HospitalNanjing Gulou Hospital在交界區(qū)在交界區(qū) 早期椎間盤退變早期椎間盤退變 進(jìn)展性旋轉(zhuǎn)半脫位進(jìn)展性旋轉(zhuǎn)半脫位 終椎離心性移位終椎離心性移位Nanjing Gulou HospitalNanjing Gulou Hospital解剖上的加重解剖上的加重胸彎胸彎5080腰彎進(jìn)展，腰彎進(jìn)展，L23脫位脫位終椎下移終椎下移Nanjing Gulou HospitalF, 14yrs 50-65F, 24yrs 54-75F, 32yrs 56-80Nanjing Gulou Hospital5yrs post-opNanjing Gulou Hospital胸腰彎胸腰彎 最易進(jìn)展最易進(jìn)展 L34脫位脫位 旋轉(zhuǎn)加重旋轉(zhuǎn)加重Nanjing Gulou HospitalNanjing Gulou Hospital70yrsNanjing Gulou Hospital腰彎 向后凸性側(cè)凸進(jìn)展（頂椎一致）向后凸性側(cè)凸進(jìn)展（頂椎一致） 腰腰45脫位脫位 預(yù)后：旋轉(zhuǎn)、退變、矢狀面預(yù)后：旋轉(zhuǎn)、退變、矢狀面Nanjing Gulou HospitalNanjing Gulou Hospital705-711Nanjing Gulou Hospital雙大彎雙大彎 長期保持平衡長期保持平衡 進(jìn)展發(fā)生遲進(jìn)展發(fā)生遲 腰彎進(jìn)展腰彎進(jìn)展胸彎胸彎 L3、L4或或L4、5脫位脫位 交界性后凸交界性后凸Nanjing Gulou Hospital1004-1024Nanjing Gulou HospitalNanjing Gulou HospitalNanjing Gulou HospitalAIS在成年期的自然史在成年期的自然史繼續(xù)進(jìn)展繼續(xù)進(jìn)展!43yrs65yrsNanjing Gulou Hospital自然史規(guī)律自然史規(guī)律胸腰彎和腰彎進(jìn)展胸腰彎和腰彎進(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，交界性椎間盤病加重機(jī)理：關(guān)節(jié)突退變，交界性椎間盤病每年進(jìn)展每年進(jìn)展0.51?脊柱側(cè)凸的分型成為困難脊柱側(cè)凸的分型成為困難Nanjing Gulou Hospital退變性脊柱側(cè)凸退變性脊柱側(cè)凸 發(fā)生遲，發(fā)生遲，4550歲后歲后 椎間盤關(guān)節(jié)突退變?yōu)槭紕幼甸g盤關(guān)節(jié)突退變?yōu)槭紕?可始于胸腰、腰或腰骶部可始于胸腰、腰或腰骶部 為后突性，并發(fā)生脫位為后突性，并發(fā)生脫位 退變的其他特征退變的其他特征!Nanjing Gulou Hospital1082-1091Nanjing Gulou Hospital牽引下牽引下Nanjing Gulou HospitalNanjing Gulou HospitalNanjing Gulou HospitalNanjing Gulou HospitalNanjing Gulou Hospital退變性側(cè)凸與特發(fā)性退變性側(cè)凸與特發(fā)性側(cè)凸的區(qū)別側(cè)凸的區(qū)別 難難 !Nanjing Gulou Hospital鑒別線索鑒別線索 初診時(shí)見頂椎區(qū)椎間盤退變初診時(shí)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)則節(jié)段性畸形呈不規(guī)則 神經(jīng)壓迫癥狀神經(jīng)壓迫癥狀 嚴(yán)重雙平面失償嚴(yán)重雙平面失償Nanjing Gulou HospitalNanjing Gulou HospitalNanjing Gulou HospitalNanjing Gulou HospitalNanjing Gulou HospitalOperative treatment Understand Risk/Benefit Rates！Nanjing Gulou HospitalIndication for surgerySignificant curvature Back pain Radicular pain Spinal stenosis symptomsProgression of curveProgressive loss of pulmonary function decompensation 所有這些指征在成人中很難證明Nanjing Gulou Hospital手術(shù)適應(yīng)證手術(shù)適應(yīng)證(鼓樓醫(yī)院鼓樓醫(yī)院 79 例例) 力學(xué)性疼痛力學(xué)性疼痛 71 （90） 雙平面失償雙平面失償 69 （87） 畸形加重畸形加重 56 （70） 椎管狹窄或根痛椎管狹窄或根痛 18 （23） 進(jìn)行性軀干塌陷進(jìn)行性軀干塌陷 6 （ 8 ） Nanjing Gulou Hospital手術(shù)結(jié)果分析（南京鼓樓）評價(jià)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）37565653疼痛（n=65）7.54.34.5Nanjing Gulou Hospital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 6090, 度數(shù)矯正 3050 肺功能 略有增加 融合率 7090 神經(jīng)并發(fā)癥 15 死亡率 12 感染率 15Nanjing Gulou HospitalComplication IncludesPseudarthrosis Residual painMortalityNeurologicInfectionPulmonary embolicLoss of lordosisImplant failureReference Gulou527% 8%515% 1.4%15%0.25% 1.4%120% 2.9%516% 2.9%Nanjing Gulou Hospital手術(shù)策略手術(shù)策略 一期后路一期后路 術(shù)前術(shù)前Halo后路后路 后松解后松解Halo后路后路 前松解前松解Halo后路后路 一期前后路聯(lián)合一期前后路聯(lián)合Nanjing Gulou Hospital1yr post-op#624 F 46 yrsNanjing Gulou Hospital雙主彎70 先前路融合，通常融合腰椎 后路雙彎融合內(nèi)固定Nanjing Gulou Hospital750-754Nanjing Gulou Hospital6 yrs Post-opPost-opNanjing Gulou Hospital胸腰彎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(shí) 固定至近端胸椎Nanjing Gulou Hospital550-56136 yrs56 yrsNanjing Gulou HospitalNanjing Gulou HospitalLumbar curvatureSingle anterior or posterior approach In some patient possible!Nanjing Gulou HospitalCase 3Nanjing Gulou HospitalNanjing Gulou HospitalLumbar curvature fixed deformity and/or previous fusionif arthrodesis solid, and deformity secondary to angulation Anterior support Eggshell procedureNanjing Gulou Hospital#2489 Chi YH F 36yrsNanjing Gulou HospitalCase 8Nanjing Gulou HospitalNanjing Gulou HospitalNanjing Gulou HospitalIf deformity associated with translation, and coronal imbalance, osteotomies with resection preferable.Lumbar curvature fixed deformity and/or previous fusionNanjing Gulou HospitalCase 1Nanjing Gulou HospitalNanjing Gulou HospitalNanjing Gulou HospitalNanjing Gulou HospitalArthrodesis to the sacrum-indicationLumbar oblique take-offUnbalanced L/S curve with lumbar scoliosisL/S pain below lumbar curveRecommend a two-stage approach +screw fixationFixation to pelvis-L-rod/TSRH/IsolaTake intraoperative AP X-ray to insure coronal alignment while on the table KeyIf fixed coronal deformity, resection may be necessary to achieve balance.Nanjing Gulou HospitalNanjing Gulou Hospital忠心感謝本文的合作者！馬薇薇馬薇薇錢邦平錢邦平王王 斌斌邱邱 勇勇朱澤章朱澤章朱朱 鋒鋒俞俞 楊楊Nanjing Gulou HospitalThank You！Nanjing Gulou HospitalTHANKSTHANKSTHANKSTHANKSTHANKSTHANKSTHANKSTHANKSTHANKSTHANKSTHANKSTHANKSTHANKSTHANKSTHANKSTHANKSTHANKSTHANKSTHANKSTHANKSTHANKSTHANKSTHANKSTHANKSTHANKSTHANKSTHANKSTHANKSTHANKSTHANKSTHANKSTHANKSTHANKSTHANKSTHANKSTHANKSTHANKSTHANKSTHANKSTHANKSTHANKSTHANKSTHANKSTHANKSTHANKSTHANKSTHANKSTHANKS