Eur Spine J. 2013 Mar;22 Suppl 2(Suppl 2):S149-63. doi: 10.1007/s00586-012-2343-7. Epub 2012 May 30.
OBJECTIVES/PURPOSE: The choice of anterior instrumentation in the treatment of lumbar scoliosis in adolescents and young adults is not a new topic for the authors. The first results achieved using the Dwyer surgical modality were reported by one of the authors followed by the results achieved using Zielke (VDS) instrumentation. Today, new techniques and new instrumentations have been developed that challenge the instrumentation choices. Here we describe how the new system of classification of scoliotic curves we developed has been used as a basis for treating idiopathic scoliosis in lumbar area in adolescents and young adults using an anterior approach.
A prospective study was carried out between 1998 and 2010 at two hospital centers on 33 adolescents and young adult with idiopathic lumbar scoliosis involving curves of three kinds, on whom surgical treatment was performed using a single solid rod. Topography of curves: our system of classification includes curves corresponding to the following three type of scoliosis: Type K I: double thoracic and lumbar curves (lumbar predominant) scoliosis (17 cases) mean age 16 years all female patients. Mean Cobb angle of lumbar curve 41°. Mean Cobb angle of thoracic curve 28°. The lumbar curve was left hand convex in 15 cases and right hand convex in 2 cases. Horizontal tilting of L4 mean value 22°. C7 offset mean value 3 cm. Type K IV A: unbalanced thoracolumbar scoliosis (13 cases) mean age 17 years, ten female patients and three male patients. Mean Cobb angle of thoracolumbar curve 39°. The thoracolumbar curve was left hand convex 4 times and right hand convex 9 times. Horizontal tilting of L4 mean value 18°. C 7 offset mean value 2.5 cm. Type K VI A: real lumbar (three cases). Age: 17, 15 and 13 years; all female patients. Cobb angle of the lumbar curve 66°, 29° and 70° (all LH convex). Horizontal tilting of L4: 40°, 20° and 46°. C 7 offset: 7 cm, 1 cm and 4 cm.
Surgical instrumentation: We used the EUROS AZUR anterior instrumentation for all the procedures. Cages have been used on five patients at the lower stages. Number of vertebrae instrumented: mean five vertebrae. The patients did not wear postoperative orthosis. Mean duration of procedure: 3 h 50 min. Mean blood loss: 350 cm(3).
Type K I scoliosis (17 cases): Mean follow-up: 6 years. Correction of the lumbar curve Cobb angle: the mean angle has been corrected from 41° to 21°. Number of vertebrae instrumented: 4:6 times and 5:11 times. Correction of the upper thoracic curve Cobb angle: mean angle corrected from 28° to 19°. Correction of L4 horizontal tilting: mean residual was 7°. Correction of C 7 offset: mean 0.7 cm. Type K IV A scoliosis (13 cases): mean follow-up: 4 years. Correction of the lumbar curve Cobb angle: the mean angle has been corrected from 39° to 16°. Mean number of instrumented vertebrae: 5 (4:4 times, 5:6 times and 6:3 times.) Correction of L4 horizontal tilting: mean residual 5°. Correction of C 7 offset: mean 0.7 cm. Type K VI A scoliosis (three cases): mean follow-up: 7, 2 and 4 years; Correction of the lumbar curve Cobb angle: the angles have been corrected from 66° to 15°, from 29° to 11° and from 70° to 28°. Number of instrumented vertebrae: 5, 4 and 6. Correction of L4 horizontal tilting: residual tilting of 8°, 7° and 17°. Correction of C 7 offset: 1 cm, 0 cm and 1 cm.
There has been no report early or late septic or vascular or neurological complications. Instrumentation failure: there were three cases of screw breakage, all occurred on the lowest implant. Revision surgery was undertaken in both cases, only the last plate needed to be replaced and the rod could be kept without any other modification of the construct. In both cases, fusion has been achieved without any loss of correction. The mean loss of correction of the main curve was 2.5° for the three series.
Anterior instrumentation of lumbar idiopathic scoliosis gives highly satisfactory morphological and functional results, since the lumbar musculature is spared and the instrumentation placed at the apex of the curvature has selective effects. Despite our preference and that of other surgeons throughout the world for anterior instrumentation, we are still a minority in comparison with the users of posterior instrumentation. There are several reasons for this reticence, including surgeons' training and ideas about pedicular screw fixation, but the main reason has been the lack of a sufficiently exact system of classification. Previous comparative studies between the anterior and posterior approaches have been biased by the use of an excessively restrictive mode of classification (lumbar/thoracolumbar) of the curves. Real lumbar scoliosis, unbalanced thoracolumbar scoliosis and thoracic and lumbar double curve (lumbar predominant) scoliosis should be properly defined before being compared.
目的/目的：青少年和年轻成人腰椎侧凸的前路器械选择不是作者的新话题。一位作者首先报道了使用 Dwyer 手术方式获得的最初结果，随后又报道了使用 Zielke（VDS）器械获得的结果。如今，已经开发出了新技术和新器械，这对器械选择提出了挑战。在这里，我们描述了我们开发的新的脊柱侧凸曲线分类系统如何被用作青少年和年轻成人腰椎特发性脊柱侧凸前路治疗的基础。
在两个医院中心，对 33 名青少年和年轻成人特发性腰椎侧凸患者进行了前瞻性研究，这些患者涉及三种类型的曲线，对他们均采用单一实心棒进行手术治疗。曲线的拓扑结构：我们的分类系统包括以下三种类型的脊柱侧凸曲线：K I 型：双胸腰（腰椎为主）侧凸（17 例），平均年龄 16 岁，均为女性患者。腰椎侧凸的 Cobb 角平均为 41°。胸椎侧凸的 Cobb 角平均为 28°。15 例腰椎曲线凸向左侧，2 例凸向右侧。L4 水平倾斜的平均值为 22°。C7 偏移的平均值为 3cm。K IV A 型：不平衡的胸腰脊柱侧凸（13 例），平均年龄 17 岁，10 例女性，3 例男性。胸腰段侧凸的 Cobb 角平均为 39°。胸腰段侧凸凸向左侧 4 次，凸向右侧 9 次。L4 水平倾斜的平均值为 18°。C7 偏移的平均值为 2.5cm。K VI A 型：真性腰椎（3 例）。年龄：17 岁、15 岁和 13 岁；均为女性患者。腰椎侧凸的 Cobb 角为 66°、29°和 70°（均为 LH 凸侧）。L4 水平倾斜：40°、20°和 46°。C7 偏移：7cm、1cm 和 4cm。
手术器械：我们使用 EUROS AZUR 前路器械进行所有手术。在 5 例患者的下阶段使用了笼。固定的椎体数量：平均 5 个椎体。患者术后不佩戴支具。手术时间：3 小时 50 分钟。平均失血量：350cm³。
K I 型脊柱侧凸（17 例）：平均随访时间：6 年。腰椎侧凸 Cobb 角的矫正：平均角度从 41°矫正至 21°。固定的椎体数量：4 次：6 次和 5 次：11 次。胸椎侧凸 Cobb 角的矫正：平均角度从 28°矫正至 19°。L4 水平倾斜的矫正：平均残余 7°。C7 偏移的矫正：平均 0.7cm。K IV A 型脊柱侧凸（13 例）：平均随访时间：4 年。腰椎侧凸 Cobb 角的矫正：平均角度从 39°矫正至 16°。固定的椎体数量：5 次（4 次：4 次，5 次：6 次，6 次：3 次）。L4 水平倾斜的矫正：平均残余 5°。C7 偏移的矫正：平均 0.7cm。K VI A 型脊柱侧凸（3 例）：平均随访时间：7、2 和 4 年；腰椎侧凸 Cobb 角的矫正：角度从 66°矫正至 15°，从 29°矫正至 11°，从 70°矫正至 28°。固定的椎体数量：5 次、4 次和 6 次。L4 水平倾斜的矫正：残余倾斜 8°、7°和 17°。C7 偏移的矫正：1cm、0cm 和 1cm。
无早期或晚期感染、血管或神经并发症报告。器械失败：有 3 例螺钉断裂，均发生在最低植入物处。两次手术均进行了翻修手术，仅更换了最后一块板，无需对结构进行任何其他修改即可保留棒。在这两种情况下，融合均无丢失矫正。三组患者的主要曲线矫正丢失平均值为 2.5°。
前路器械固定青少年特发性腰椎侧凸的形态学和功能结果非常满意，因为腰椎肌肉得以保留，且器械放置在曲率的顶点处具有选择性作用。尽管我们和世界各地的其他外科医生都更喜欢前路器械，但与后路器械的使用者相比，我们仍然是少数。这种保留的原因有很多，包括外科医生对椎弓根螺钉固定的训练和观念，但主要原因是缺乏足够精确的分类系统。以前前路和后路的比较研究因对曲线的分类（腰椎/胸腰段）使用了过于严格的模式而存在偏差。真正的腰椎侧凸、不平衡的胸腰段脊柱侧凸和胸腰椎双曲线（腰椎为主）脊柱侧凸应在进行比较之前进行适当的定义。
