Scoliosis, idiopathic, Adolescent

前一陣子在科裡為大家整理過這個題目，所以可以很方便貼出來。

這個題目是成因不明性的青少年脊柱側彎，所有可能會被問到的問題和身為骨科，不是，是身為脊柱外科的骨科醫師所必須知道的現今的觀念。是2002年美國骨科醫學會出的，到目前還沒改版，所以還算是目前的共識。

我會再把它翻譯為中文，希望這種大綱式的還能為大家理解（我看很難，但有版權問題，所以...）

Idiopathic Scoliosis
成因不明性脊柱側彎

Orthopaedic Knowledge Update 2002 （英文，中文對照）
Spine 2


Prevalence and Natural History
＃ Prevalence
＃ >10°, 0.5 to 3 per 100
＃ >30°, 1.5 to 3 per 1000
＃ Infantile, juvenile, adolescent
Adolescent idiopathic Scoliosis
＃ > 10 y/o, rapid growth associated
＃ scoliosis >10°: 2%
＃ 5% of these 2%: > 30°
M:F ratio
＃ Minor curve: equal
＃ Those requiring treatment: 1:8

盛行率和自然史
＃ 每一百人，有0.5到3人，脊柱側彎的角度大於十度
＃ 每一千人，有1.5到3人，脊柱側彎角度大於三十度
＃ 分為嬰兒型，少年型和青少年型脊（成因不明性）脊椎側彎

本篇專講青少年型（成因不明性）脊柱側彎
＃ 定義是大於十歲的患者，與此時期快速成長有關
＃ 此歲數所有人口角度大於十度的佔2%
＃ 此2%當中又有5%大於三十度
＃ 男比女之比例
＊ 小角度相同
＊ 大到需要治療的角度：一比八，女生多很多


Risk factors for scoliosis progression
＃ Gender, remaining skeletal growth, curve location, and curve magnitude
＃ Growth remaining
＃ Chronological age
＃ Bone age
＃ Menarche ( onset of menarche ---> rapid skeletal growth for 12 months)
＃ Closure of triradiate cartilage: time of peak growth velocity

脊柱側彎的病人角度變化的危險因子，亦即哪些病人容易角度增加
（hbrk55的附註： 骨骼生長快速，就幾乎等於角度增加快速。 身高增加，可以說角度就會增加，除非這患者的角度變化目前是靜止的，接下來的追蹤會講。）
＃ 性別，剩餘骨骼成長能力，曲線位置，曲度大小
＃ 還有幾年可以成長
＃生理年齡
＃骨骼年齡
＃初經年紀（初經來臨之後一年內，骨骼快速成長）
＃骨盆部位，三角軟骨生長板閉合與否：正是骨骼生長最快速的時候

Risk factors
＃ Curve pattern
＃ Apex at T12: more likely to progress than lumbar curves
＃ Curve magnitude : initial ---> to predict progression

角度增加的危險因子
＃要看側彎的形態
＃側彎的頂點在第十二胸椎，比在腰椎的容易變化
＃角度大小： 第一次來看醫師時的角度大小，可以預測變化的濳力

Nature Hx in Adulthood
＃ Not all stabilized after growth stops
＃ Uni. Of Iowa: 2/3 curve progression following skeletal maturity
成年之後的自然史（意即這些青少年在成年之後會有怎樣的變化）
＃並不是每個人成年之後角度都不在增加
＃小於三十度的角度，比較不會變化
＃角度在50度到75度的人，最容易變化（一年增加一度）

＃ < 30°: less tend to progress ＃ 50° to 75°: most marked progression(1°/yr)
＃ Increased mortality? Not confirmed
＃ back pain: slightly higher than control group
＃ Disability: higher or similar Treatment
＃ Nonsurgical treatment
＃ Most < 20°, most simply monitored ＃ <25°, f/u every 4 to 12 mo(age, gr. Rate)
＃ Rapid growth: 4-6 mo interval Indications for brace treatment
＃ Curve progression to 25°-30°: brace
＃ Brace: applying external force to modify spinal growth(Risser 2 to 3 or less)
＃ Upper limit for bracing: 45° To maintain curve at the onset of bracing ＃ <30°> f/u progression > 5° ---> bracing


Brace
＃ Underarm braces(eg, Boston and Wilmington) have replaced the Milwaukee brace
＃ Charleston night time bending brace
＃ Elastic strap brace

Effectiveness of bracing
＃ 1995 prospective controlled study of bracing, by Scoliosis Research Society
＃ 286 pt 10-15 yrs, initial 25 to 35 deg
＃ A. observation along(129 pt)
＃ B. underarm brace(111 pt)
＃ C. nighttime electrical stimulation(46pt)
＃ Curve progression at skeletal maturity, <5°>75deg), rigid(bend correction <> 45 to 50 deg.
＃ If selected fusion at T: just modest correction to avoid residual trunkal imbalance
＃ To both T- and L-
＃ Distal usually to L3 or L4
＃ To L3: limited remaining growth, minimal axial rotation




Surgery
＃ Double thoracic pattern
＃ Presence of an elevated left shoulder, not right shoulder as seen in an isolated right thoracic curve
＃ If side bending left upper T curve reduced to greater than 20 to 25 deg, than fusion extended up to T1 or T2
＃ If Rt T alone fused, Lt shoulder elevation is often worse following surgery
Left Lumbar or Thoracolumbar curve pattern
＃ Primary lumbar or TL: trunk shift to left
＃ Isolated fusion of L or TL adequate
＃ Correction with posterior hook: not successful
＃ Limited anterior fusion 3 or 4 veterbrae of the apex: becomes popular
＃ Posterior: pedicle screw fixation
Outcomes of Surgical Treatment
＃ Horrington instrumentation: 48% of coronal plane correction
＃ Late onset of back pain: conflicting results for the correlation between pain and caudal level of instrumentation
＃ CD: better correction, 61%
＃ Anterior correction for L and TL: 67% to 98%
＃ Loss of lumbar lordosis
＃ Suggest structural graft for interbody support
＃ Anterior instrumentation for T
＃ 3.2 or 4.0 mm threaded rod
＃ Comparable correction but 31% of rod breakage
＃ Greater spontaneous recovery of L curve
＃ Solid unthreaded rods better



Complications
＃ Continuous electrical spinal cord monitoring
＃ SSEPs, very reliable in detecting changes in spinal cord function
＃ Lag time between insult to the spinal cord and the changes: 10 to 20 minutes
＃ False positive: hypotension, hypothermia, dislodgment of the monitoring leads, technical malfunction
＃ Implanted loosened to remove corrective forces
＃ Methylprednisolone?