MISS治疗成人退变性脊柱侧弯
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- Usually an equal thoracic curve -usually >40° - Rotation all spine
疼痛 :腰痛,根性疼痛 功能障碍 后凸畸形
≠AIS!
缓解神经根性疼痛
◦ 压迫部位
◦ 直接/间接减压
缓解腰痛
◦ 局部不稳定 (腰椎滑脱, 侧向滑移)
minimal
+ -
±
-
+
+ + -
+
+ + + -
+
+ + + + (flexible)
+
+ + + + (stiff) (<30% correction)
Surgical Treatment
No fusion
Fuse Levels decomp
Fuse all lumbar curve
Ant/Post fusion
less collateral tissue damage decrease in morbidity more rapid functional recovery
without differentiation in the intended surgical goal
McAfee PC. et al. Spine 2010:s271
上海交通大学医学院附属瑞金医院骨科 吴文坚 梁裕
De novo
- DJD
AIS Progression
- Curve progression - DJD
- Iatrogenic
- Fractures
- Lumbar curve apex L2-3 + compensatory fractional curve - Usually <40° - Usually thoracic curve is not structural - Rotation mainly lumbar
Post-2nd op
Cobb T: 6.8° Cobb L:4° PO:1.9° C7PL:3.4 cm TK: 22.4° LL:36° SVA:5.2 cm PT:19° SS: 24° PI:43° PI-LL:7
Cobb T:33° Cobb L:34° PO:1.6°
TK: 25° LL:15° SVA:2.1cm PT:22° SS: 18° PI:41° PI-LL:26 C7PL 5.0cm
◦ 脊柱整体不稳定
改善畸形 ◦ 矢状面失平衡 ◦ 冠状面失平衡
改善外观
Adding fusion to decompression gives better results than decompression alone
Correcting coronal deformity is not as important as correcting sagittal deformity and may not impact quality of life
drwuwenjian@
Yes
Mean ∆° Stand alone (DLIF) Circumferential (DLIF+Perc screws ± TLIF) Hybrid (DLIF + Open posterior ± osteotomies) 5 5.7 16.6
Ceiling∆° 23 34 55
PICs by M Wang
Sagittal Imbalance
Coronal Imbalance
<5cm
<0°
<20°
LL=PI+TK-45°
<4-5cm, within SI joints
Significant
• • • • • •
Sagittal alignment Thoracolumbar alignment Lumbar lordosis Spondylolisthesis Coronal imbalance >4-5cm Lateral listhesis >7mm
ClassIII SVA=14.3cm PT=25° LL-PI Mismatch=39° Cobb Angle=43°
DLIF
• • • •
ClassII SVA=8.9cm PT=20° LL-PI Mismatch=24° Cobb Angle=34°
pPSF
• • • •
Level I +
Level II +
Level III +
Level IV +
Level Vቤተ መጻሕፍቲ ባይዱ+
Level VI +
Back Pain
Ant Osteophytes, <2mm sublux Olisthesis ≥6mm Coronal Cobb >30° Lumbar Kyphosis Global Imbalance
12
Conclusions. Direct lateral interbody fusion significantly improves segmental, regional, and global coronal plane alignment in patients with degenerative lumbar disease. Although DLIF increases the segmental sagittal Cobb angle at the level of instrumentation, it does not improve regional lumbar lordosis or global sagittal alignment.
ClassIII SVA=12cm PT=29° LL-PI Mismatch=32.7° Cobb Angle=30°
L3/4
L4/5
Cobb T:8° Cobb L:11° PO:1.5° C7PL:3 cm
TK: 30° LL:30° SVA:5.6 cm PT:25.5° SS: 23° PI:48.5° PI-LL:18.5
Cobb T:16° Cobb L:19°
TK: 19° LL:21° SVA:4.1cm PT:-1° SS: 39° PI:38° PI-LL:17 C7PL 3.0cm
Cobb T:18° Cobb L:16°
TK: 18° LL:40° SVA:1.5cm PT:2° SS: 39° PI:41° PI-LL:1 C7PL 1.0cm
Fuse to upper thoracic
Osteotomy
成人退变性脊柱侧弯:问题与挑战
• 骨骼僵硬 • 骨质疏松 • 内科合并症 • 体质虚弱 • 其他关节疾病
29%
39%
42%
An MIS procedure is one that by virtue of the extent and means of surgical technique results in
POST SVA=5.5cm PT=15° LL-PI Mismatch=22° Cobb Angle=14°
Cobb T:19° Cobb L:30° PO:1.6° C7PL:1.8 cm
TK: 37.4° LL:21.3° SVA:12cm PT:29° SS: 25° PI:54° PI-LL:32.7
Aug. 2015
49
Case by Taha
对于适用的患者,MISS可以有效的改善退变性侧弯患者的 冠状面和矢状面平衡
分期MISS手术 (double MIS procedures)
◦ 缩短麻醉的时间
◦ 重新评估是否需要直接减压 ◦ 重新评估固定和融合的范围 ◦ 重新评估截骨问题
Thank you for your attention
Cobb T:6° Cobb L:46° C7PL:4.1 cm TK: 13.1° LL:23° SVA:14.3cm PT:25° SS: 37° PI:62° PI-LL:39 °
ClassIII SVA=14.3cm PT=25° LL-PI Mismatch=39° Cobb Angle=43°
1st most important
Sagittal
Coronal
2nd most important
Not significant
• Coronal cobb • Age • Adolescent vs. de-novo scoliosis
3rd most important
Symptom Radicular