Ilharreborde Brice
Department of Pediatric Orthopaedic Surgery, Robert Debré Hospital, AP-HP, Paris Diderot University, 48 Bd Sérurier, 75019, Paris, France.
Eur Spine J. 2018 Feb;27(Suppl 1):48-58. doi: 10.1007/s00586-018-5472-9. Epub 2018 Jan 24.
In the last decade, spine surgeons have been impacted by the "sagittal plane analysis revolution". Significant correlations have been found in adult spinal deformity (ASD) between sagittal lumbo-pelvic parameters and functional outcomes, but most of them do not apply in adolescent idiopathic scoliosis (AIS). Meanwhile, instrumentation and reduction strategies have considerably evolved. This paper aims to describe the preoperative sagittal alignment in AIS, and to report literature evidence regarding the influence of postoperative sagittal balance on complication rates, low back pain incidence and disc degeneration.
A bibliographic search in Medline and Google database from 1984 to May 2017 was performed. The keywords included 'adolescent idiopathic scoliosis', 'adult scoliosis', 'sagittal alignment', 'proximal junctional kyphosis', 'distal junctional kyphosis', 'outcomes', 'low back pain' and 'complication', used individually or in combination.
Algorithms of sagittal balance analysis and treatment decision have been reported in ASD, but the clinical situation is very different in children. Sagittal alignment greatly varies in AIS among the various Lenke types. Most patients are clinically balanced before surgery, but the spinal harmony is altered, with overgrowth of the anterior column and global sagittal flattening (undersestimated in 2D). The exact role of pelvic incidence and whether or not patients also use pelvic compensation to maintain balance still require further clarification. The incidence of radiological junctional failures remains highly variable, depending on definitions, cohort size and follow-up. Preoperative hyperkyphosis seems to be a consistent and relevant risk factor. Current literature does not support the recent trend to save motion segments (selective fusion), and no significant association was found between the distal level of fusion and the incidence of low back pain. Postoperative sagittal alignment seems to be more important than LIV selection to avoid disc degeneration at mid-term follow-up.
It is clear now that sagittal alignment plays a major role in clinical outcomes and should not be neglected in AIS. Seven key guidelines that should be considered for each patient before surgery are reported (Table 2). Personalized planning using 3D technology is gaining popularity and might help in the future reducing complications.
在过去十年中，脊柱外科医生受到了“矢状面分析革命”的影响。在成人脊柱畸形（ASD）中，矢状位腰骨盆参数与功能结果之间存在显著相关性，但其中大多数不适用于青少年特发性脊柱侧凸（AIS）。与此同时，内固定和矫正策略有了很大发展。本文旨在描述AIS患者术前的矢状位对线情况，并报告有关术后矢状位平衡对并发症发生率、下腰痛发生率和椎间盘退变影响的文献证据。
对1984年至2017年5月期间Medline和谷歌数据库进行文献检索。关键词包括“青少年特发性脊柱侧凸”“成人脊柱侧凸”“矢状位对线”“近端交界性后凸”“远端交界性后凸”“结果”“下腰痛”和“并发症”，单独或组合使用。
已有关于ASD矢状位平衡分析和治疗决策的算法报道，但儿童的临床情况差异很大。在不同的Lenke类型中，AIS的矢状位对线差异很大。大多数患者术前临床平衡，但脊柱协调性改变，前柱过度生长和整体矢状位变平（在二维中被低估）。骨盆倾斜度的确切作用以及患者是否也利用骨盆代偿来维持平衡仍需进一步阐明。根据定义、队列规模和随访情况，影像学交界性失败的发生率差异很大。术前过度后凸似乎是一个一致且相关的危险因素。目前的文献不支持近期保留运动节段（选择性融合）的趋势，并且未发现融合远端水平与下腰痛发生率之间存在显著关联。在中期随访中，术后矢状位对线似乎比选择腰椎内固定椎体更重要，以避免椎间盘退变。
现在很清楚，矢状位对线在临床结果中起主要作用，在AIS中不应被忽视。报告了术前针对每位患者应考虑的七条关键指导原则（表2）。使用3D技术进行个性化规划越来越受欢迎，可能有助于未来减少并发症。
