退变性成人脊柱侧凸长节段固定术近端固定椎的选择  

Selection of upper instrumented vertebra for long-segment fixation in adult degenerative scoliosis

作　　者：董军峰 李危石[1,2] 姜宇 孙卓然[1,2] DONG Junfeng;LI Weishi;JIANG Yu;SUN Zhuoran(Department of Orthopedics,Peking University Third Hospital,Beijing,100191,P.R.China;BeijingKey Laboratory of Spine Disease Research,Beijing,100191,P.R.China;Department of Orthopedics,the First Dongguan Affiliated Hospital of Guangdong Medical University,Dongguan Guangdong,523710,P.R.China)

机构地区：[1]北京大学第三医院骨科,北京100191 [2]脊柱疾病研究北京市重点实验室,北京100191 [3]广东医科大学附属东莞第一医院骨科,广东东莞523710

出　　处：《中国修复重建外科杂志》2022年第10期1305-1311,共7页Chinese Journal of Reparative and Reconstructive Surgery

基　　金：国家自然科学基金面上项目(81871807)。

摘　　要：目的 对退变性成人脊柱侧凸(adult degenerative scoliosis,ADS)长节段固定术(long-segment fixation,LSF)中近端固定椎(upper instrumented vertebra,UIV)选择的相关研究进行综述,以指导临床治疗。方法查阅近年国内外相关文献,就ADS患者LSF术中矢状面及冠状面UIV的选择策略、UIV选择与近端交界性后凸(proximal junctional kyphosis,PJK)及近端交界性失败(proximal junctional failure,PJF)之间的关系、微创脊柱外科手术对UIV选择策略的影响等方面进行总结。结果 LSF治疗ADS可恢复脊柱生物力学平衡,重建脊柱生理曲度。对侧弯严重、伴有椎体旋转、矢状面严重失平衡的ADS患者应选择LSF。一般情况较差者,可融合至胸腰椎,以减少手术时间和术中出血,有利于早期活动,减少并发症发生;一般情况较好者,必要时可考虑融合至上胸椎,以期获得满意远期疗效。但在矫形条件允许情况下,应尽量选择下胸椎区(T9、10),以减少PJK、PJF等术后并发症。近年,有学者提出了一种新的参考标志——冠状位第1反转椎来指导UIV选择,但还需要大样本量、多中心随机对照研究进一步验证其可靠性。研究表明,不同人种、不同生活习惯会导致脊柱-骨盆矢状位参数不同,进而影响UIV的选择。微创手术治疗ADS获得了满意疗效,但UIV选择策略还有待进一步深入研究。结论 LSF术中UIV选择策略目前尚未统一,UIV在矢状面上选择上胸椎、下胸椎还是胸腰椎,应综合考虑患者脊柱生物力学平衡、全身情况等,同时需要结合冠状面上水平椎、中立椎、上端椎关系,以制定科学、合理的个体化方案。Objective To review the research progress of upper instrumented vertebra(UIV) selection strategy for long-segment fixation(LSF) in adult degenerative scoliosis(ADS). Methods The relevant domestic and foreign literature in recent years was reviewed, and the selection strategy of sagittal and coronal UIV for LSF in ADS patients, the relationship between UIV selection and proximal junctional kyphosis(PJK) and proximal junctional failure(PJF), the impact of minimally invasive spine surgery on the selection strategy of UIV were summarized. Results LSF can restore the biomechanical balance of the spine and reconstruct the physiological curve of the spine for ADS patients. LSF should be selected for ADS patients with severe scoliosis, vertebral rotation, and severe sagittal imbalance. For patients with poor general condition, UIV can choose the thoracic and lumbar vertebrae to reduce the operation time and intraoperative bleeding, which is conducive to early mobilization and reduce complications;for patients with good general condition,the upper thoracic vertebrae can be considered if necessary, in order to achieve satisfactory long-term effectiveness.However, the lower thoracic vertebra(T9、10) should be selected as much as possible to reduce postoperative complications such as PJK and PJF. In recent years, a new reference marker, the first coronal reverse vertebra was proposed, to guide the selection of UIV. But a large-sample multicenter randomized controlled study is needed to further verify its reliability.Studies have shown that different races and different living habits would lead to different parameters of the spine and pelvis, which would affect the selection of UIV. Minimally invasive surgeries have achieved satisfactory results in the treatment of ADS, but the UIV selection strategy in specific applications needs to be further studied. Conclusion The selection strategy of UIV in LSF has not yet been unified. The selection of UIV in the sagittal plane of the upper thoracic spine, the lower thoracic spine, or

关 键 词：退变性成人脊柱侧凸 长节段固定术 近端固定椎 微创手术 

分 类 号：R687.3[医药卫生—骨科学]