ADS的外科治疗 ppt课件

成人退行性脊柱侧凸的外科治疗,Surgical Treatment for Adult Degenerative Scoliosis,1,成人退行性脊柱侧凸,定义：退行性脊柱侧凸是指骨骼成熟以后由于椎间盘及椎间小关节的退行性改变而导致的原发性脊柱侧凸, 侧凸冠状面上 Cobb 角 10,Simmons 分型Aebi 分型Ploumis 分型Faldini 分型脊柱侧凸研究协会分型（SRS分型）Schwab 分型,Simmons ED. Surgical treatment of patients with lumbar spinal stenosis with associated scolios is J . Clin Orthop Relat Res , 2001, 3( 384): 45-53Ploumis A, Transfledt EE, Denis F. Degenerat ive lumbar s colios is associated with spinal stenosis J . Spine J, 2007, 7( 4) : 428 -436Schwab F, Farcy J P, Bridwell K, et al. A clinical impact classific ation of scolios is in the adult J . Spine ( Phila Pa 1976 ) , 2006, 31( 18) : 2109-2114,2,脊柱畸形分型目的,使类似疾病系统化预测疾病的自然进程及治疗结果 与健康状态或畸形程度关联 理想地指导治疗,目前尚无一种理想的分型方法,3,ADS病理生理变化,椎间盘与椎小关节的非对称性退变脊柱力学负荷不均衡导致ADS绝经后的骨质疏松50岁以上女性多见,Aebi M. The adult scoliosis. Eur Spine J 2005;14:925-48,4,疾病自然进程,通常50岁以后发病发病率及侧凸角度随年龄增加侧凸进行性发展的危险因素Cobb角30顶椎上下间盘不对称顶椎侧方滑移6mmL5椎体高于双侧髂嵴连线,Pritchett JW, Bortel DT. Degenerative symptomatic lumbar scoliosis. Spine (Phila Pa 1976) 1993;18:700-3,5,临床表现,一、腰背痛间盘和小关节的退变脊柱失衡导致的肌肉劳损疼痛与曲度大小无直接相关旋转半脱位及矢状位失衡可加剧疼痛,Weinstein SL, Dolan LA, Cheng JC, Danielsson A,Morcuende JA. Adolescent idiopathic scoliosis. Lancet 2008;371:1527-37Glassman SD, Bridwell K, Dimar JR, Horton W, Berven S, Schwab F. The impact of positive sagittal balance in adult spinal deformity. Spine (Phila Pa 1976) 2005;30:2024-9,6,临床表现,二、下肢神经症状椎管狭窄导致的间歇性跛行和放射性腿痛椎管狭窄发生率90%侧隐窝狭窄较中央椎管狭窄常见，且多见于凹侧小关节肥大和半脱位与椎管狭窄有关三、畸形冠状位和矢状位失衡,引发腰背痛,Simmons ED. Surgical treatment of patients with lumbar spinal stenosis with associated scoliosis. Clin Orthop Relat Res 2001;(384):45-53Glassman SD, Bridwell K, Dimar JR, Horton W, Berven S, Schwab F. The impact of positive sagittal balance in adult spinal deformity. Spine (Phila Pa 1976) 2005;30:2024-9,7,手术治疗需注意的地方,一般情况，伴发疾病老年患者伴发疾病多,围术期并发症发生率高骨质疏松症减弱内固定强度，矫形丢失，假关节等冠状面和矢状面失衡ADS患者常见重建平衡较矫形更重要,Glassman SD, Bridwell K, Dimar JR, Horton W, Berven S, Schwab F. The impact of positive sagittal balance in adult spinal deformity. Spine (Phila Pa 1976) 005;30:2024-9,8,手术治疗,手术目的缓解腰痛；改善神经症状；矫正畸形手术适应症下肢放射痛间歇性跛行单纯腰痛作为手术依据不够充分,Kyu-Jung Cho1, Young-Tae KimSurgical treatment of adult degenerative scoliosis. Asian Spine J 2014;8(3):371-381,9,手术策略,一、单纯椎管减压通常不推荐此术式适用人群：全身条件差，伴发疾病多，预期并发症发生率高的老年人。侧弯曲度小，无半脱位者可酌情考虑缺点：无法恢复间盘高度；加重畸形和不稳，椎管狭窄易复发,Vaccaro AR, Ball ST. Indications for instrumentation in degenerative lumbar spinal disorders. Orthopedics 2000;23:260-71.Kyu-Jung Cho1, Young-Tae KimSurgical treatment of adult degenerative scoliosis. Asian Spine J 2014;8(3):371-381,10,手术策略,二、椎管减压+短节段固定仅处理需减压的节段适用于“侧凸曲度小，半脱位轻”的患者邻近节段病变常见三、椎管减压+长节段固定矫形侧凸曲度大，半脱位严重的患者可缓解疼痛，改善畸形，恢复腰椎前凸及脊柱平衡,11,矫形固定节段范围的选择,固定阶段应跨过顶椎交界性后凸部位应在固定范围内严重的半脱位应被固定滑脱部位应在固定范围内上固定节段应处于水平而不是倾斜,Aebi M. The adult scoliosis. Eur Spine J 2005;14:925-48Gupta MC. Degenerative scoliosis. Options for surgical management. Orthop Clin North Am 2003;34:269-79,12,近端融合椎的选择,近端融合椎体选择L1或胸10仍存在较大争议选择L1可能引起胸腰段相邻节段病变，而选择T10可祈祷预防作用，因为T10更稳定（肋骨的存在）一些学者认为：融合至T10无法起到预防作用；更高围术期并发症发生率Cho等报导：若固定范围跨过上端椎，可以选择T11/T12,Shufflebarger H, Suk SI, Mardjetko S. Debate: determining the upper instrumented vertebra in the management of adult degenerative scoliosis: stopping at T10 versus L1. Spine (Phila Pa 1976) 2006;31(19 Suppl):S185-94Cho KJ, Suk SI, Park SR, Kim JH, Jung JH. Selection of proximal fusion level for adult degenerative lumbar scoliosis. Eur Spine J 2013;22:394-401,13,远端融合椎的选择,L5/S1存在病变时选择S1当L5/S1完好时，选择L5或S1仍存在争议选择L5手术创伤较小可能导致L5/S1退变Edwards等报导：约61%固定于L5的患者出现L5/S1退变，导致矢状位失衡,增加再次手术风险选择S1矢状位矫形效果更佳较高的并发症发生率(假关节,S1 42% vs L5 4%)需行髂骨固定以预防并发症,Edwards CC 2nd, Bridwell KH, Patel A, et al. Thoracolumbar deformity arthrodesis to L5 in adults: the fate of the L5-S1 disc. Spine (Phila Pa 1976) 2003; 28:2122-31Cho KJ, Suk SI, Park SR, et al. Arthrodesis to L5 ver-Surgical treatment of adult degenerative scoliosis Asian Spine Journal 381sus S1 in long instrumentation and fusion for degenerative lumbar scoliosis. Eur Spine J 2009;18:531-7,14,术后并发症,大量失血及与其相关的硬膜外血肿、肺栓塞、呼吸衰竭术前自体血捐献、抗纤溶管理、自体血回收远期并发症：邻近节段病变假关节形成内植物失败,15,术后并发症,邻近节段病变椎管狭窄近端交界性后凸（PJK）假关节形成（常发生于L5/S1）危险因素：高龄；胸腰段后凸20；腰前凸减小；矢状位失衡内植物失败螺钉松动、拔出危险因素：长节段固定；矢状位失衡预防：骨水泥，髂骨固定,Kim YJ, Bridwell KH, Lenke LG, Cho KJ, Edwards CC 2nd, Rinella AS. Pseudarthrosis in adult spinaldeformity following multisegmental instrumentation and arthrodesis. J Bone Joint Surg Am 2006;88:721-8Emami A, Deviren V, Berven S, Smi