Ritzman Todd F, Upasani Vidyadhar V, Pawelek Jeff B, Betz Randal R, Newton Peter O
Department of Orthopaedic Surgery, Children's Hospital Medical Center of Akron, Akron, OH, USA.
Spine (Phila Pa 1976). 2008 Sep 15;33(20):2228-35. doi: 10.1097/BRS.0b013e31817c0445.
Multicenter, prospective, cohort study.
To compare minimum 2-year postoperative shoulder function after 3 different surgical approaches for the treatment of primary thoracic curves in patients with adolescent idiopathic scoliosis (AIS).
Thoracic spinal instrumentation and fusion can be performed via posterior (PSF), open anterior (OASF), or thoracoscopic anterior (TASF) techniques. Although the morbidity of these 3 surgical approaches is beginning to be understood, no reports have been published comparing 2-year postoperative shoulder strength and range of motion.
AIS patients who underwent selective fusion of primary thoracic curves were studied. Right-sided shoulder strength (flexion, abduction) and range of motion (flexion, extension, abduction) measurements were collected prospectively at selected intervals. An arbitrary threshold (80% of preoperative value) was defined as postoperative return of normal shoulder function. Univariate analysis of variance (P < 0.05) was used to compare differences in shoulder function for the 3 approaches at each postoperative time-point.
Ninety-two patients with minimum 2-year postoperative shoulder function data were included in this study (24 PSF, 32 OASF, and 36 TASF). On average, patients who had an OASF failed to reach the 80% threshold for right shoulder forward flexion and abduction strength until 1-year and 6-months after surgery, respectively; whereas patients that had a TASF or PSF returned to normal shoulder strength by the 3-month follow-up visit. With regards to ROM, patients in all 3 groups surpassed the 80% preoperative threshold for right shoulder active forward flexion and extension by the 6-week visit, with no clinically significant differences between the groups. However, for active abduction range of motion, patients that had an OASF required 3-months to regain 80% of their preoperative motion, compared to 6-weeks for patients in both the TASF and PSF groups.
Approach-related differences in shoulder morbidity do exist in the treatment of primary thoracic curves in AIS. Specifically, OASF imparts a significantly greater magnitude and duration of postoperative shoulder dysfunction than do the TASF or PSF approaches. Nonetheless, these negative effects are transient as shoulder function in those patients treated via an open thoracotomy normalized by the 1-year postoperative time-point at the latest. Accordingly, viewed in isolation, shoulder morbidity should not deter surgeons from using an open anterior approach in the surgical treatment of AIS.
多中心、前瞻性队列研究。
比较青少年特发性脊柱侧凸（AIS）患者原发性胸弯采用3种不同手术方式治疗后至少2年的肩部功能。
胸段脊柱内固定融合术可通过后路（PSF）、开放前路（OASF）或胸腔镜前路（TASF）技术进行。虽然这3种手术方式的发病率已开始为人所知，但尚未有比较术后2年肩部力量和活动范围的报道。
对接受原发性胸弯选择性融合术的AIS患者进行研究。前瞻性地在选定的时间间隔收集右侧肩部力量（前屈、外展）和活动范围（前屈、后伸、外展）的测量数据。将任意阈值（术前值的80%）定义为术后肩部功能恢复正常。采用单因素方差分析（P < 0.05）比较3种手术方式在每个术后时间点的肩部功能差异。
本研究纳入了92例术后至少2年有肩部功能数据的患者（24例PSF，32例OASF，36例TASF）。平均而言，接受OASF手术的患者直到术后1年和6个月才分别达到右肩前屈和外展力量的80%阈值；而接受TASF或PSF手术的患者在术后3个月随访时肩部力量恢复正常。关于活动范围，所有3组患者在术后6周时右肩主动前屈和后伸均超过术前阈值的80%，组间无临床显著差异。然而，对于主动外展活动范围，接受OASF手术的患者需要3个月才能恢复术前活动的80%，而TASF组和PSF组患者只需6周。
在AIS原发性胸弯的治疗中，确实存在与手术方式相关的肩部发病率差异。具体而言，与TASF或PSF手术方式相比，OASF术后肩部功能障碍的程度和持续时间明显更大。尽管如此，这些负面影响是短暂的，因为通过开胸手术治疗的患者肩部功能最迟在术后1年时恢复正常。因此，单独来看，肩部发病率不应阻碍外科医生在AIS手术治疗中采用开放前路手术方式。
