腰椎管狹窄癥合并退行性脊柱側(cè)彎治療策略

腰椎管狹窄癥合并腰椎管狹窄癥合并退行性脊柱側(cè)彎的治療策略朱澤章邱勇鮑虹達(dá)南京大學(xué)醫(yī)學(xué)院附屬鼓樓醫(yī)院Whatisdegenerativespine CoronalSagittalAxial44thDimension:BoneMusclemassandNeuralcontrol

Focal,Regional,Global 1yrs-ASDPatientsvs.otherProspectiveASDdatabasevs.ReferenceValues(Bess&ASDProspective497ASDReferenceGeneralHealthyDiseaseOnaverageOnaverageASD?Similartocancer,diabetes,heartdiseases,OnaverageASDSimilartocancer,diabetes,heartdiseases,SF-36AdultSpinalDeformity=Debilitating

Degenerative 30%（Robinetal60%（Schwabetal10%Incidenceper10（Robin/KobayashiPrevalenceincreaseswithElderlyPopulationChronicconditionDisco-ligamentousBoneMusclemassandMobilesegmentDegenerativefacetDJDdisccollapsediscdegen.MRIfacetDJDdisccollapsediscdegen.MRIchangesUnfavorableUnfavorable

AdultAdultYangXXFDegenerativeStable

UnderstandingtheClinicalimpactofAdolescentIdiopathic

AdultSpinalCurveseverityCobbangleKingCurveseverityCobbangleSkeletalSkeletalRisserClinicalkeyfactorintreatmentdecisionPatientChiefClinicalPastmedicalTreatmenttoImagingTreatmentdecisionPatientLikelihoodofsuccessTeamRisk/HistoryandPhysicalChiefProgressionintrunkNeuroPainNeurologicalPain/2separateaspectsimplicationontreatmentBaselineevaluationofDSassociatedwithstenosisAxialversusRadicularCommonFrequentlyco-existant:Cross-overDeformity,instability,rootAxialSofttissuefailure:discdegeneration,facetarthrosis,Cascadeof FailureofnaturalPaintransmitsbysurroundingfacets,ligaments,nerveroot,musclesBlackbox…non-optreatmentslimitedinRadicularInflammation,pressure,dysfunction,stretchofnerveDecompressionworksfairlywell(48%-89%successRe-occurrenceat10years:20-FindingtheresponsibleCanal??CanalForaminaForaminaForaminaMoreMoreprevalentatconcavesideoftheRotatoryTheradiographicInterestingDuralsaccross-sectionaldiameter(mm)andarea(mm2)aresignificantlyreducedatL3-L4subluxation#8132，♀，L1- L2- L3- L4-Duralsaccross-sectionalDuralsaccross-sectionaldiameterDuralsaccross-sectional

ForamenForamenareaandheightissmalleratconcavecross-sectionalarea

#7173，♀，L3-#7173，♀，L3- height heightConcave cross- - Concex cross- - #9494，♀，#9494，♀，Concave:Convex:Subarticular#8404X62yrsMoreMoreseverefacetdegenerationontheconcaveL3-L3-L4-L4-L4-#7168X66yrsPxscore5CorrelationCorrelationbetweendiscdegenerationandrotatoryL4-L4-Pxscore32y2yPost-TreatmentFL22yPost-Lenke-SilvaclassificationforadultIDecompressionInstrumentationlimitedtodecompressionInstrumentationatentirelumbarAnteriorandposteriorfusionoflumbarExtendinginstrumentationintothoracicOsteotomy成人退變性脊柱側(cè)凸手術(shù)治療分級(jí)Silva,Lenkeetal.Adultdegenerativescoliosis:evaluationandmanagement.[J]NeurosurgFouce28(3):El2010Silva,Lenkeetal.Adultdegenerativescoliosis:evaluationandmanagement.[J]NeurosurgFouce28(3):El2010I級(jí)：?jiǎn)渭儨p壓椎管狹窄，明顯下肢癥狀，輕度脊柱畸形：Cobb<30°，脫位<2mm，無腰痛，不伴軀干失平衡I級(jí)：?jiǎn)渭儨p壓 II級(jí)：短節(jié)段融合Cobb<30°，脫位>2mm，無腰痛，不伴軀干失平衡WithWithdiabetesandrelatedElderlywithmultipleco-#9113,F68Decompressionwith#9113,F682.3ypost-Relieve2.3ypost-IIIIII級(jí)：腰彎內(nèi)固定植骨融合Cobb>40°，脫位>2mm，存在明顯腰背痛，不伴軀干失平衡#9638F59Instrumentation#9638F59##9494FLargecurveInstrumentationatentirelumbar前后路聯(lián)合（腰彎）Anterio-posterior#4182,(rarelyusedinmy#4182,WhyWhyanteriorMIS+PSFMaybehelpfulincase#6777,F,48#6777,F,48#6777,#6777,5m-#8424#8424XXFV級(jí)：上延至胸彎的內(nèi)固定植骨融合胸段后凸，胸段失代償，或存在冠矢狀面失平衡V級(jí)：上延至胸彎的內(nèi)固定植骨融合#9119FKyphoscoliosis:L1#9119FF,52y #7900,61y,9ypost-op1y,post- L41yrs-3.5yrspost-

VCR:limitedplacein5.5yrspost-revisionL1VCR#6996,,F#6996,,FL21yPost-1yPost-P-(notcommonlyindicatedforDSinmypractice)#6996,#6996,,F1yPost-CARDIAC

RESPIRATORYSignificantlyassociatedwithdeathwithin2yearsRESPIRATORY

Leeetal.SpineJ. NEURO

UROLOGICAL HEMATOLOGICAL

GASTROINTESTINALRiskfactorfor-Nbofinstrumentedvertebrae-Fusiontothesacrum-PSO-BaselinePT(23vs26°-BaselineCobbangle(48vs

48%reop.RateatRevisionRateinour Thelargeststudyontherateofunanticipatedrevisionsurgery(involve815cases,uptoDec.2011)Revisionrateinourclinicalcenter:4949thSRSAnnualFactorsaffectingFactorsaffectingFactorsaffecting4m-10mHigh10mHigh2323Implantb