成人脊柱侧凸的治疗课件.ppt

1、NanjingNanjingNanjing Gulou Hospital Gulou Hospital Gulou Hospital成人脊柱侧凸的治疗成人脊柱侧凸的治疗NanjingNanjingNanjing Gulou Hospital Gulou Hospital Gulou Hospital1398成人NanjingNanjingNanjing Gulou Hospital Gulou Hospital Gulou HospitalNanjingNanjingNanjing Gulou Hospital Gulou Hospital Gulou Hospital在顶椎区在顶椎区凹侧关节

2、突退变凹侧关节突退变椎间盘退变不明显椎间盘退变不明显NanjingNanjingNanjing Gulou Hospital Gulou Hospital Gulou HospitalNanjingNanjingNanjing Gulou Hospital Gulou Hospital Gulou HospitalNanjingNanjingNanjing Gulou Hospital Gulou Hospital Gulou HospitalCase 5NanjingNanjingNanjing Gulou Hospital Gulou Hospital Gulou Hospital在继发弯

3、区在继发弯区 可长期保持其柔软性可长期保持其柔软性NanjingNanjingNanjing Gulou Hospital Gulou Hospital Gulou Hospital1416NanjingNanjingNanjing Gulou Hospital Gulou Hospital Gulou HospitalNanjingNanjingNanjing Gulou Hospital Gulou Hospital Gulou Hospital在交界区在交界区 早期椎间盘退变早期椎间盘退变 进展性旋转半脱位进展性旋转半脱位 终椎离心性移位终椎离心性移位NanjingNanjingNanj

4、ing Gulou Hospital Gulou Hospital Gulou HospitalNanjingNanjingNanjing Gulou Hospital Gulou Hospital Gulou Hospital解剖上的加重解剖上的加重胸弯胸弯5080腰弯进展，腰弯进展，L23脱位脱位终椎下移终椎下移NanjingNanjingNanjing Gulou Hospital Gulou Hospital Gulou HospitalF,14yrs 50-65F,24yrs 54-75F,32yrs 56-80NanjingNanjingNanjing Gulou Hospital

5、 Gulou Hospital Gulou Hospital5yrs post-opNanjingNanjingNanjing Gulou Hospital Gulou Hospital Gulou Hospital胸腰弯胸腰弯 最易进展最易进展 L34脱位脱位 旋转加重旋转加重NanjingNanjingNanjing Gulou Hospital Gulou Hospital Gulou HospitalNanjingNanjingNanjing Gulou Hospital Gulou Hospital Gulou Hospital70yrsNanjingNanjingNanjing G

6、ulou Hospital Gulou Hospital Gulou Hospital腰弯 向后凸性侧凸进展（顶椎一致）向后凸性侧凸进展（顶椎一致）腰腰45脱位脱位 预后：旋转、退变、矢状面预后：旋转、退变、矢状面NanjingNanjingNanjing Gulou Hospital Gulou Hospital Gulou HospitalNanjingNanjingNanjing Gulou Hospital Gulou Hospital Gulou Hospital705-711NanjingNanjingNanjing Gulou Hospital Gulou Hospital Gu

7、lou Hospital双大弯双大弯 长期保持平衡长期保持平衡 进展发生迟进展发生迟 腰弯进展腰弯进展胸弯胸弯 L3、L4或或L4、5脱位脱位 交界性后凸交界性后凸NanjingNanjingNanjing Gulou Hospital Gulou Hospital Gulou Hospital1004-1024NanjingNanjingNanjing Gulou Hospital Gulou Hospital Gulou HospitalNanjingNanjingNanjing Gulou Hospital Gulou Hospital Gulou HospitalNanjingNanj

8、ingNanjing Gulou Hospital Gulou Hospital Gulou HospitalAIS在成年期的自然史在成年期的自然史继续进展继续进展!43yrs65yrsNanjingNanjingNanjing Gulou Hospital Gulou Hospital Gulou Hospital自然史规律自然史规律胸腰弯和腰弯进展胸腰弯和腰弯进展加重及僵硬化可发生在主弯或次弯加重及僵硬化可发生在主弯或次弯加重机理：关节突退变，交界性椎间盘病加重机理：关节突退变，交界性椎间盘病每年进展每年进展0.51?脊柱侧凸的分型成为困难脊柱侧凸的分型成为困难NanjingNanjing

9、Nanjing Gulou Hospital Gulou Hospital Gulou Hospital退变性脊柱侧凸退变性脊柱侧凸 发生迟，发生迟，4550岁后岁后 椎间盘关节突退变为始动椎间盘关节突退变为始动 可始于胸腰、腰或腰骶部可始于胸腰、腰或腰骶部 为后突性，并发生脱位为后突性，并发生脱位 退变的其他特征退变的其他特征!NanjingNanjingNanjing Gulou Hospital Gulou Hospital Gulou Hospital1082-1091NanjingNanjingNanjing Gulou Hospital Gulou Hospital Gulou H

10、ospital牵引下牵引下NanjingNanjingNanjing Gulou Hospital Gulou Hospital Gulou HospitalNanjingNanjingNanjing Gulou Hospital Gulou Hospital Gulou HospitalNanjingNanjingNanjing Gulou Hospital Gulou Hospital Gulou HospitalNanjingNanjingNanjing Gulou Hospital Gulou Hospital Gulou HospitalNanjingNanjingNanjing G

11、ulou Hospital Gulou Hospital Gulou Hospital退变性侧凸与特发性退变性侧凸与特发性侧凸的区别侧凸的区别 难难!NanjingNanjingNanjing Gulou Hospital Gulou Hospital Gulou Hospital鉴别线索鉴别线索 初诊时见顶椎区椎间盘退变初诊时见顶椎区椎间盘退变 交界性不稳定节段性不稳定交界性不稳定节段性不稳定 节段性畸形呈不规则节段性畸形呈不规则 神经压迫症状神经压迫症状 严重双平面失偿严重双平面失偿NanjingNanjingNanjing Gulou Hospital Gulou Hospital Gu

12、lou HospitalNanjingNanjingNanjing Gulou Hospital Gulou Hospital Gulou HospitalNanjingNanjingNanjing Gulou Hospital Gulou Hospital Gulou HospitalNanjingNanjingNanjing Gulou Hospital Gulou Hospital Gulou HospitalNanjingNanjingNanjing Gulou Hospital Gulou Hospital Gulou HospitalOperative treatment Unde

13、rstand Risk/Benefit Rates！NanjingNanjingNanjing Gulou Hospital Gulou Hospital Gulou HospitalIndication for surgerySignificant curvature Back pain Radicular pain Spinal stenosis symptomsProgression of curveProgressive loss of pulmonary function decompensation 所有这些指征在成人中很难证明NanjingNanjingNanjing Gulou

14、 Hospital Gulou Hospital Gulou Hospital手术适应证手术适应证(鼓楼医院鼓楼医院 79 例例)力学性疼痛力学性疼痛 71 （90）双平面失偿双平面失偿 69 （87）畸形加重畸形加重 56 （70）椎管狭窄或根痛椎管狭窄或根痛 18 （23）进行性躯干塌陷进行性躯干塌陷 6 （8）NanjingNanjingNanjing Gulou Hospital Gulou Hospital Gulou Hospital手术结果分析（南京鼓楼）评价指标术前术后一年随访最后一次随访冠状面平衡（n=79）3.8cm0.8cm1.0cm1.0cm双肩水平度（n=79）-2.

15、5cm-0.9cm-0.9cm-0.9cm矢状面平衡（n=79）+6cm+1.8cm+2.0cm+2.0cm腰椎前突角（n=58）37565653疼痛（n=65）7.54.34.5NanjingNanjingNanjing Gulou Hospital Gulou Hospital Gulou Hospital手术治疗手术效果不如青少年脊柱侧凸患者 缓解疼痛 6090,度数矫正 3050 肺功能 略有增加 融合率 7090 神经并发症 15 死亡率 12 感染率 15NanjingNanjingNanjing Gulou Hospital Gulou Hospital Gulou Hospit

16、alComplication IncludesPseudarthrosis Residual painMortalityNeurologicInfectionPulmonary embolicLoss of lordosisImplant failureReference Gulou527%8%515%1.4%15%0.25%1.4%120%2.9%516%2.9%NanjingNanjingNanjing Gulou Hospital Gulou Hospital Gulou Hospital手术策略手术策略 一期后路一期后路 术前术前Halo后路后路 后松解后松解Halo后路后路 前松解前

17、松解Halo后路后路 一期前后路联合一期前后路联合NanjingNanjingNanjing Gulou Hospital Gulou Hospital Gulou Hospital1yr post-op#624 F 46 yrsNanjingNanjingNanjing Gulou Hospital Gulou Hospital Gulou Hospital双主弯70 先前路融合，通常融合腰椎 后路双弯融合内固定NanjingNanjingNanjing Gulou Hospital Gulou Hospital Gulou Hospital750-754NanjingNanjingNanj

18、ing Gulou Hospital Gulou Hospital Gulou Hospital6 yrs Post-opPost-opNanjingNanjingNanjing Gulou Hospital Gulou Hospital Gulou Hospital胸腰弯70 联合前后路手术伴有椎管狭窄 减压使用cage或 others胸椎后突时 固定至近端胸椎NanjingNanjingNanjing Gulou Hospital Gulou Hospital Gulou Hospital550-56136 yrs56 yrsNanjingNanjingNanjing Gulou Hosp

19、ital Gulou Hospital Gulou HospitalNanjingNanjingNanjing Gulou Hospital Gulou Hospital Gulou HospitalLumbar curvatureSingle anterior or posterior approach In some patient possible!NanjingNanjingNanjing Gulou Hospital Gulou Hospital Gulou HospitalCase 3NanjingNanjingNanjing Gulou Hospital Gulou Hospit

20、al Gulou HospitalNanjingNanjingNanjing Gulou Hospital Gulou Hospital Gulou HospitalLumbar curvature fixed deformity and/or previous fusionif arthrodesis solid,and deformity secondary to angulation Anterior support Eggshell procedureNanjingNanjingNanjing Gulou Hospital Gulou Hospital Gulou Hospital#2

21、489 Chi YH F 36yrsNanjingNanjingNanjing Gulou Hospital Gulou Hospital Gulou HospitalCase 8NanjingNanjingNanjing Gulou Hospital Gulou Hospital Gulou HospitalNanjingNanjingNanjing Gulou Hospital Gulou Hospital Gulou HospitalNanjingNanjingNanjing Gulou Hospital Gulou Hospital Gulou HospitalIf deformity

22、 associated with translation,and coronal imbalance,osteotomies with resection preferable.Lumbar curvature fixed deformity and/or previous fusionNanjingNanjingNanjing Gulou Hospital Gulou Hospital Gulou HospitalCase 1NanjingNanjingNanjing Gulou Hospital Gulou Hospital Gulou HospitalNanjingNanjingNanj

23、ing Gulou Hospital Gulou Hospital Gulou HospitalNanjingNanjingNanjing Gulou Hospital Gulou Hospital Gulou HospitalNanjingNanjingNanjing Gulou Hospital Gulou Hospital Gulou HospitalArthrodesis to the sacrum-indicationLumbar oblique take-offUnbalanced L/S curve with lumbar scoliosisL/S pain below lumb

24、ar 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.NanjingNanjingNanjing Gulou Hospital Gulou Hospital Gulou HospitalNanjingNanjingNanjing Gulou Hospital Gulou Hospital Gulou Hospital忠心感谢本文的合作者！马薇薇马薇薇钱邦平钱邦平王王 斌斌邱邱 勇勇朱泽章朱泽章朱朱 锋锋俞俞 杨杨NanjingNanjingNanjing Gulou Hospital Gulou Hospital Gulou HospitalThank You！