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单击此处编辑母版标题样式,单击此处编辑母版文本样式,第二级,第三级,第四级,第五级,*,李方才,退行性脊柱侧凸的分级治疗,退行性脊柱侧凸（,degenerative scoliosis,，,DS,）是指既往无脊柱侧凸病史、成年后继发于腰椎间盘及关节突关节退行性病变而出现的脊柱侧凸。,在腰椎间盘变性的基础上,;,发生腰椎侧凸,Cobb,s,角大于,10,度,且伴有症状者。,诊,断,标,准,临床症状,腰背痛,神经症状,腰部支撑功能障碍,特殊类型的腰椎管狭窄,手术技术,麻醉技术,内植入物,生活质量,手术治疗,而不是外形和美观。,手术治疗目标,缓解临床症状，改善生活质量,阻止病情进展,最小并发症,35,单纯减压？,减压融合？,畸形矫正？,如何矫正？,Lenke-Silva,治疗分级系统,（2010,年）,一、单纯减压,神经根痛,/,间歇性跛行,无或轻度腰痛,无不稳定,轻度侧凸，,Cobb,角,30,无滑移（侧方或前后）,无明显腰椎后凸,无冠状面和,/,或矢状面失平衡,典型椎管狭窄减压,男，,62,岁,单纯减压虽创伤小、风险小，但多数患者无效、甚至加重；,本组,3,例，均无效。,In the decompression alone group,6,(37%),of 16 patients developed recurrent stenosis at the previously decompressed level and,five,developed,二、减压、有限固定融合,神经根痛,/,间歇性跛行,无或有腰痛,不稳定,轻度侧凸，,Cobb,角,30,无滑移（侧方或前后）,无明显腰椎后凸,无冠状面和,/,或矢状面失平衡,复杂椎管狭窄减压,女性，,63,岁,短节段固定融合,不稳定节段融合,!,需遵循侧凸固定原则吗？,固定椎能终止在顶椎区吗？,尚不明确！,Conclusions:,The scoliotic angle after short segment decompression and fusion was not deteriorated seriously in degenerative lumbar scoliosis.,A larger scoliotic angle,and,fusion to the apical vertebra,are significant risk factors for the acceleration of degenerative lumbar scoliosis.,3,固定椎远离顶椎，,术后侧凸无进展,固定椎位于顶椎区域，,术后侧凸进展,三、减压、腰弯固定融合（,PLF,）,四、减压、前后融合固定（,LIF,）,畸形严重,腰椎后凸,-+,TLIF,有助于,腰椎移位,、,腰椎前凸,及,脊柱矢状位平衡恢复,；,对于术前腰椎前凸及脊柱矢状位平衡良好患者，,PLF,仍然是可选择的方法,腰椎无后凸，,PLF,腰椎后凸,TLIF,五、胸段固定广泛融合,脊柱失平衡,畸形柔软,脊柱矢状位失平衡，畸形柔软，,T10-L5,六、胸段固定广泛融合、加截骨,脊柱失平衡,畸形僵硬,矢状位严重失平衡，畸形僵硬，,T10-S1,，,PSO-L3,脊柱失平衡，畸形严重、僵硬，,T6-S1,，,VCR-L2,近端固定椎？,T10,？,远端固定椎？,L5 vs S1,？,骨盆形态？,LL=PI9,患者是否能耐受,并发症风险评估,手术室、麻醉科,The surgeon always must keep in mind that he or she is treating the entire patient and not just the patients spine.,If the patients physiology will not withstand large anterior and posterior combined procedures,then these should not be attempted.,谢谢！,
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