Dec 20-21, 20083rd Guangtong Orthopedic Congress 1

Principles of Management for Adult Spinal Deformity

Po-Quang Chen, MD., PhD台大骨科 陳博光 名譽教授敏盛醫院 副總裁www.taiwanspine.org.tw

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成人脊椎畸形治療之原則

Dec 20-21, 2008 3rd Guangtong Orthopedic Congress 2Oct. 24-25, 2008

Adult versus Adolescent ScoliosisAdult deformity

skeletally mature with relatively fixed curves,

Typically present with back pain and neurological concerns,

degenerated and osteoporotic

sagittal balance is lost co-morbidities

Adolescent skeletally immature with

flexible curves

present with cosmetic complaints.

have normal bone stock, no degenerative changes

Consider normal coronal and sagittal profile

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Adult Spinal Deformity ( 成人脊椎畸形 )

Adult scoliosis Degenerative scoliosis Flat back deformity Salvage procedure

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手術適應症 indications for operation

relief of back pain, radiating pain to the legs,

motor weakness due to root compression, curve progression or severe deformity and

truncal decompensation resulting in pulmonary compromise.

43rd Guangtong Orthopedic Congress

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手術路徑Surgical approaches

Anterior instrumentation and fusion Combined A/P instrumentation – long

instrumentation, Posterior pedicle screw fixation Fusion to sacrum inter-vertebral fixation with cages

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Case Presentations

病例介紹

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1.31Y/F. symptomatic scoliosis

71

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術前 術後 4+7 年

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2. Chao CM 37 Y/F severe LBP

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63

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術前 術後 2Yrs

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3. 36 Y/F Progressive symptomatic lumbar curve,

2000

2002

55

1999

27

9

2001

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PO 5YPO 5Y

OP: A/P with follow-up radiographs

PO

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PO 7Y PO 7Y

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we use posterior fixation & correction by pedicle screws

經後路 使用椎弓根釘 矯正方式

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4. 44 Y/F with severe LBP

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5. 66Y/F, symptomatic L scoliosis

3rd Guangtong Orthopedic Congress

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Post-operative 4M, painless

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7. Degenerative scoliosis 蔣 O 賢

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8. 先天性 Scoliosis T12 HemiV, 41 歲 女

T12 Hemivertebra Excision, Cobb angle 95° 50º

95

7750 58

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9. 61 yo woman, DLS FBS PO10Y

術後十年 背疼痛嚴重

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50

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No canal compromise

Op for LS

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Revision by extending screws upward to correct deformity

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PO 9M

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1.Surgical Approaches 2002 2007: 360º↓ vs. posterior↑ only

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SRS report 20083rd Guangtong Orthopedic Congress

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2. Bone graft substitutes, mainly BMP ↑ (29% →66%)

20第一屆首都高峰論壇

SRS report 2008

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3. Distal Fusion Level for Long Fusion: L5↓ vs. S1↑

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SRS report 2008

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4. Posterior Thoracic Fixation Type:

Screws ↑ vs. hooks vs. hybrid ↓

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SRS report 2008

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The Conclusions:

A posterior only approach provided the same deformity as A/P fusion

1. OR time, EBL, and LOS were significantly less2. Outcomes and complications were equivalent at over 2 years follow-up1. Pseudarthrosis was not seen in the Posterior only group 2008 SRS report

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1. 手術目的為矯正畸形及緩和背部疼痛 2. 從後路利用 all pedicle screw method 一次完成 .3. 有退化性之病人可考慮塞入椎籠 (Structural cages) 4. 矯正率 : young adults 與 adolescent 相同 72.7 vs. 70.6%5. 併發症 : all age>22 Y, 210 cases (ADIS 89 cases) paresis one, paraplegia one, deep wound infection one.

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Reported operative complications文獻報告之合併症

Neurologic injury – 1 to 5% Infection – 1 to 8 % Pseudarthrosis – 38% Pulmonary embolism – 1 to 20% Low lime thrombo-embolism Spinal decompensation

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Neurological deficits: analysis of 1373 cases at 南京鼓樓醫院 Total incidence 1.89%, serious 0.51%, mild ones was 1.38%,

risk factors

Congenital Scoliosis,

Scoliosis with hyperkyphosis,

Correction by combined procedures,

Scoliosis with a Cobb's angle > 90°,

Revision surgery. --- Qiu Y et al Spine. 2008 Mar 1;33(5):519-26

--- Qiu Y et al Spine. 2008 Mar 1;33(5):519-26

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complications in different scoliosis aetiologies

Complication NM AS ISCS

Mixed

Death 6,5% (3S) 2,5%

0,03%

Pseudarthrosis(7S)

13,1%(7S)

17,5%(5S) 5%

(4S) 23%

Deep wound infection

(3S) 13,2%

(S2) 3,1%

4,7%

Neurologic Complications

(2S) 7,5%

(3S) 1,5%

9%

(4S) 2,7%

Delayed Infection(2S)

2,9%

Pedicle screw mispl.(2S)

15,8%10,5%

Delayed Paraparesis

X

--Weiss HR & Godall D. Scoliosis 2008 3:927

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Thank you, 謝謝

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