微創(chuàng)手術(shù)治療成人退變性脊柱側(cè)彎

--是否可以改善脊柱平衡上海交通大學(xué)醫(yī)學(xué)院附屬瑞金醫(yī)院骨科吳文堅(jiān)梁裕1.2019/11/1成人退變性脊柱側(cè)彎Denovo-DJD-Iatrogenic-Fractures-LumbarcurveapexL2-3+compensatoryfractionalcurve-Usually<40°-Usuallythoraciccurveisnotstructural-RotationmainlylumbarAISProgression-Curveprogression-DJD-Usuallyanequalthoraciccurve-usually>40°-Rotationallspine2.2019/11/1疼痛

：腰痛，根性疼痛功能障礙后凸畸形≠AIS！

成人退變性脊柱側(cè)彎3.2019/11/1緩解神經(jīng)根性疼痛壓迫部位直接/間接減壓緩解腰痛局部不穩(wěn)定(腰椎滑脫,側(cè)向滑移)脊柱整體不穩(wěn)定改善畸形矢狀面失平衡冠狀面失平衡改善外觀成人退變性脊柱側(cè)彎的治療目的4.2019/11/1AddingfusiontodecompressiongivesbetterresultsthandecompressionaloneCorrectingcoronaldeformityisnotasimportantascorrectingsagittaldeformityandmaynotimpactqualityoflife5.2019/11/1我們需要矯正多少?LL=PI+TK-45°<20°<5cm<0°<4-5cm,withinSIjointsSagittalImbalanceCoronalImbalance6.2019/11/11stmostimportant2ndmostimportant3rdmostimportantSignificantSagittalalignmentThoracolumbaralignmentLumbarlordosisSpondylolisthesisCoronalimbalance>4-5cmLaterallisthesis>7mmNotsignificantCoronalcobbAgeAdolescentvs.de-novoscoliosisSagittalCoronal那些是最需要糾正的問題?7.2019/11/1開放手術(shù)的治療路線圖SymptomLevelILevelIILevelIIILevelIVLevelVLevelVIRadicular++++++BackPainminimal±++++AntOsteophytes,<2mmsublux+-----Olisthesis≥6mm--++++CoronalCobb>30°--++++LumbarKyphosis---+++GlobalImbalance----+(flexible)+(stiff)(<30%correction)SurgicalTreatmentNofusionFuseLevelsdecompFusealllumbarcurveAnt/PostfusionFusetoupperthoracicOsteotomy8.2019/11/1成人退變性脊柱側(cè)彎：臨床結(jié)果9.2019/11/1成人退變性脊柱側(cè)彎：問題與挑戰(zhàn)骨骼僵硬骨質(zhì)疏松內(nèi)科合并癥體質(zhì)虛弱其他關(guān)節(jié)疾病10.2019/11/129%39%42%11.2019/11/1AnMISprocedureisonethatbyvirtueoftheextentandmeansofsurgicaltechniqueresultsinlesscollateraltissuedamagedecreaseinmorbiditymorerapidfunctionalrecovery

withoutdifferentiationintheintendedsurgicalgoal

McAfeePC.etal.Spine2010:s271MinimallyInvasiveSpineSurgery12.2019/11/1MIS能不能有效的治療成人脊柱側(cè)彎?13.2019/11/1側(cè)方入路治療成人退變性脊柱側(cè)彎的臨床療效Conclusions.Directlateralinterbodyfusionsignificantlyimprovessegmental,regional,andglobalcoronalplanealignmentinpatientswithdegenerativelumbardisease.AlthoughDLIFincreasesthesegmentalsagittalCobbangleatthelevelofinstrumentation,itdoesnotimproveregionallumbarlordosisorglobalsagittalalignment.14.2019/11/1MISDEF路線圖15.2019/11/1Case1TYF,F6416.2019/11/117.2019/11/118.2019/11/1EOS19.2019/11/1CobbT：6°CobbL：46°C7PL：4.1

cmTK:13.1°LL：23°SVA：14.3cmPT：25°SS:

37°PI：62°PI－LL：39°20.2019/11/1ClassIIISVA=14.3cmPT=25°LL-PIMismatch=39°CobbAngle=43°21.2019/11/1Stage1DLIF22.2019/11/1Stage1-DLIF23.2019/11/124.2019/11/125.2019/11/1Stage2

PPS+facetfusionRuijinSpine26.2019/11/1RuijinSpineRuijinSpine27.2019/11/128.2019/11/129.2019/11/1POSTSVA=5.5cmPT=15°LL-PIMismatch=22°CobbAngle=14°DLIFpPSFClassIIISVA=14.3cmPT=25°LL-PIMismatch=39°CobbAngle=43°ClassIISVA=8.9cmPT=20°LL-PIMismatch=24°CobbAngle=34°30.2019/11/112mfollow-up31.2019/11/1Case2YAMF6132.2019/11/1CobbT：19°CobbL：30°PO：1.6°C7PL：1.8

cmTK:37.4°LL：21.3°SVA：12cmPT：29°SS:

25°PI：54°PI－LL：32.733.2019/11/1ClassIIISVA=12cmPT=29°LL-PIMismatch=32.7°CobbAngle=30°34.2019/11/135.2019/11/1L3/4L4/536.2019/11/1CobbT：8°CobbL：11°PO：1.5°C7PL：3

cmTK:30°LL：30°SVA：5.6

cmPT：25.5°SS:

23°PI：48.5°PI－LL：18.537.2019/11/138.2019/11/1CobbT：6.8°CobbL：4°PO：1.9°C7PL：3.4

cmTK:22.4°LL：36°SVA：5.2

cmPT：19°SS:

24°PI：43°PI－LL：7Post-2nd

op39.2019/11/1Case3LJH,F7140.2019/11/141.2019/11/142.2019/11/1CobbT：33°CobbL：34°PO：1.6°TK:25°LL：15°SVA：2.1cmPT：22°SS:

18°PI：41°PI－LL：26C7PL5.0cm43.2019/11/1Stage1DLIF44.2019/11/1CobbT：16°CobbL：19°TK:19°LL：21°SVA：4.1cmPT：-1°SS:

39°PI：38°PI－LL：17C7PL3.0cm45.2019/11/146.2019/11/1CobbT：18°CobbL：16°TK:18°LL：40°SVA：1.5cmPT：2°SS:

39°PI：41°PI－LL：1C7PL1.0cm47.2019/11/1Mean?°Ceiling?°Standalone(DLIF)523Circumferential(DLIF+Percscrews±TLIF)5.734Hybrid(DLIF+Openposterior±osteotomies)16.655YesMIS與開放手術(shù)結(jié)合?(雜交手術(shù))48.2019/11/1PICsbyMWang50.2019/11/151.2019/11/