摘要目的 统计主胸腰弯或腰弯型(Lenke 5型)青少年特发性脊柱侧凸(AIS)行前路选择性胸腰弯或腰弯融合术后胸弯失代偿或近端附加现象的发生率,并分析其危险因素.方法 选取2001年6月至2008年12月行手术治疗的Lenke 5型获得规律随访2年以上的AIS患者130例,男性16例,女性114例；年龄12 ～18岁,平均(14.8±1.6)岁；主弯Cobb角为40° ～73°,平均46°±6°；均接受前路选择性胸腰弯或腰弯融合术.分别根据手术时上端固定椎(LIV)与上端椎(UEV)的关系、Risser征及UIV偏离C7铅垂线(C7PL)情况进行分组,采用Fisher检验比较不同分组附加现象的发生情况,并采用t检验对附加现象组与非附加现象组病例一般资料进行比较.结果 术后随访共有11例(8.5％)患者发生近端附加现象.所有患者术前近端胸弯Cobb角为25°±7°,术后末次随访平均胸腰弯或腰弯Cobb角为9°±4°,胸弯Cobb角为11°±5°.附加现象的发生率:Risser征0～1级组(3/8)明显高于2～3级组(12.1％)和4～5级组(4.5％)；UIV选择UEV下2个及以下椎体组的附加现象发生率(2/3)明显高于UIV选择UEV下1个椎体组(16.1％)和UIV选择UEV组(4.7％)；术前C7PL完全偏离UIV组(19.5％)显著高于C7PL位于UIV椎弓根与外缘之间组(3.6％)和C7PL位于UIV双侧椎弓根之间组(3.0％).Fisher精确检验示不同分组内附加现象的发生率差异均具有统计学意义(P＜0.05).结论 Lenke 5型青少年AIS行前路选择性胸腰弯或腰弯融合术后有发生胸弯失代偿的风险,DIV的选择及患者骨骼成熟度均与术后胸弯失代偿的发生密切相关.

abstractsObjectives To investigate the incidence of thoracic curve decompensation or proximal adding-on phenomenon after anterior selective fusion of thoracolumbar or lumbar curve in Lenke type 5 adolescent idiopathic scoliosis (AIS),and to identify its risk factors. Methods From June 2001 to December 2008,1.30 Lenke type 5 AIS patients with a Cobb angle of 40°-73° treated with anterior selective thoracolumbar or lumbar fusion,and with a minimum 2-year postoperative regular follow-up were recruited in this study.The average age,Cobb angle and Risser sign of all patients was 14.8 ± 1.6 years,46° ±6° of major thoracolumbar or lumbar curve ( TL or L),25° ±7°of proximal thoracic curve and 0-5,respectively.The patients were grouped according to the relationship between the upper instrumented vertebrae (UIV) and the upper end vertebrae (UEV),the patients' Risser sign and the relationship between UIV and C7 plumb line (CTPL). The radiographic data of the patients were compared between patients with and without proximal adding-on by using t test,and the incidence of proximal adding-on was analyzed in terms of determination of UIV and Risser sign to identify the risk factors of this phenomenon by using Fisher's exact test.Results Eleven patients were identified with proximal adding-on,thus the incidence of it was 8.5％.At last follow-up postoperatively,the average Cobb angle of TL or L and proximal thoracic curve was 9° ± 4° and 11° ±5°,respectively.Moreover,the incidence of adding-on in Rissex sign grade 0 to 1 (3/8) was higher than that of gade 2 to 3 ( 12.1％ ) and gade 4 to 5 (4.5％ ).In addition,the incidence of addingon in UIV lower than UEV group (20.6％ ) was obviously higher than that of UIV higher than or equal to UEV group (4.2％ ).The incidence of adding-on for patients with C7PL falls away from UIV ( 19.5％ )were obviously higher than that of patients with C7 PL falls between the pedicle and lateral margin of UIV (3.6％ ) and between bilateral pedicles of UIV (3.0％).Each group showed significant difference for the incidence of adding-on by Fisher's exact test (P ＜ 0.05 ).Conclusions There exists the risk of proximal thoracic curve decompensation,with a not low rate,after anterior selective fusion for major TL or L curve AIS.The determination of UIV relative to UEV and the skeletal maturity of the patient are the two factors closely associated with the presence of such a phenomenon.