Department of Spinal Surgery with Scoliosis Centre, Schön Klinik Neustadt, Neustadt in Holstein, Germany.
Orthopaedics, Orthopädie Leonberg, Leonberg, Germany.
Z Orthop Unfall. 2022 Jun;160(3):307-316. doi: 10.1055/a-1337-3435. Epub 2021 Feb 18.
Postoperative shoulder imbalance is a common complication in adolescent idiopathic scoliosis and may impair patient satisfaction. The little data in the literature on the prediction and treatment of postoperative shoulder imbalance is incongruous. According to some studies, postoperative shoulder imbalance depends on the superior instrumented vertebral bodies, skeletal maturity, extent of correction and flexibility of the major curve.
Can preoperative radiological parameters from X-ray and traction films as well as correction of the curves be used to identify a factor impacting on postoperative shoulder imbalance?
Prospective data in adolescent idiopathic scoliosis with thoracic curve (Lenke type 1), operated on between 2015 and 2018 at a scoliosis centre, were analysed retrospectively based on full-length X-rays of the spine (pre-/postOP and follow-up (FU)) and preoperative-traction films: age; correction of proximal, main and lumbar curve; shoulder height [mm]; clavicle angle [°]; T1 tilt [°]; coronal plumb line deviation [mm]. The findings were expressed as means with standard deviation. Changes in parameters over time (postOP-FU) were compared by t test (significance level α = 0.05). The correlation between preOP parameters and extent of correction with postoperative shoulder imbalance (≥ 15 mm) was determined by Pearson correlation and regression classification analysis.
55 patients with adolescent idiopathic scoliosis, mean age of 15 ± 1.4 years. The FU-rate after a mean of 15 months was 80% (n = 44). Correction of proximal, main and lumbar curve: 47.0%, 75.8% and 68.8%, respectively, without statistically significant change (Δ) in FU (p > 0.05). Shoulder height was - 11.0 ± 12.7 mm (preOP), 15.5 ± 13.4 mm (postOP), 10.1 ± 10.6 mm (FU) (p < 0.05). 38% of those with adolescent idiopathic scoliosis had preOP right shoulder elevation; 55% (postOP) and 32% (FU) respectively had postoperative shoulder imbalance (left shoulder elevation). Strong statistical correlation was found for Δshoulder position (FU-preOP) with pre-OP shoulder position (r = - 0.7), and Δshoulder position (pre-OP traction films) (r = 0.5) with pre-OP clavicle angle (r = - 0.5). On regression classification analysis, 81.8% of cases did display postoperative shoulder imbalance if proximal curve correction was ≤ 64.4%; main and lumbar curve correction, Δshoulder elevation (preOP traction films) played a secondary role.
One common complication even in Lenke type 1 adolescent idiopathic scoliosis is postoperative shoulder imbalance. Preoperative planning should include traction films, preoperative shoulder position and clavicle angle to avoid postoperative shoulder imbalance. Moderate correction of proximal curve is critical for postoperative shoulder balance.
术后肩部失衡是青少年特发性脊柱侧凸的常见并发症，可能会降低患者满意度。文献中关于术后肩部失衡的预测和治疗的数据很少，且相互不一致。一些研究表明，术后肩部失衡取决于上置的器械椎体、骨骼成熟度、主要弯曲的矫正程度和柔韧性。
术前 X 线和牵引片的影像学参数以及曲线的矫正能否用于识别影响术后肩部失衡的因素？
回顾性分析了 2015 年至 2018 年在脊柱侧弯中心接受治疗的青少年特发性脊柱侧凸（Lenke 1 型）患者的前瞻性数据，基于脊柱全长 X 线片（术前/术后和随访（FU））和术前牵引片：年龄；近端、主要和腰椎曲度的矫正；肩高[mm]；锁骨角[°]；T1 倾斜[°]；冠状铅垂线偏差[mm]。结果表示为平均值±标准差。通过 t 检验（显著性水平α=0.05）比较各参数随时间（术后-FU）的变化。通过 Pearson 相关性和回归分类分析确定术前参数与术后肩部失衡（≥15mm）的矫正程度之间的相关性。
55 例青少年特发性脊柱侧凸患者，平均年龄 15±1.4 岁。平均随访 15 个月后，FU 率为 80%（n=44）。近端、主要和腰椎曲度的矫正率分别为 47.0%、75.8%和 68.8%，FU 无统计学显著变化（p>0.05）。肩高为-11.0±12.7mm（术前）、15.5±13.4mm（术后）、10.1±10.6mm（FU）（p<0.05）。38%的青少年特发性脊柱侧凸患者术前右侧肩高；55%（术后）和 32%（FU）分别出现术后肩部失衡（左肩高）。Δ肩部位置（FU-术前）与术前肩部位置（r=-0.7）和Δ肩部位置（术前牵引片）（r=0.5）与术前锁骨角（r=-0.5）之间存在很强的统计学相关性。回归分类分析显示，如果近端曲度矫正≤64.4%，81.8%的患者会出现术后肩部失衡；主要和腰椎曲度矫正、Δ肩部抬高（术前牵引片）起次要作用。
即使在 Lenke 1 型青少年特发性脊柱侧凸中，术后肩部失衡也是一种常见并发症。术前计划应包括牵引片、术前肩部位置和锁骨角，以避免术后肩部失衡。近端曲度的适度矫正对术后肩部平衡至关重要。
