【摘要】 评估术前站立位、支点弯曲位、重力悬吊牵引位和仰卧侧屈位X线片在预测青少年特发性脊柱侧凸三维矫形融合术效果的价值。［方法］对63例青少年特发性脊柱侧凸患者的79个结构性侧凸摄术前站立位、支点弯曲位、重力悬吊牵引位和仰卧侧屈位X线片，将其与术后的站立位X线片比较，测量全部Cobbs角后进行统计学处理，并评估其价值。［结果］结构性胸凸组与结构性腰凸组重力悬吊牵引位片Cobbs角分别是40°和21°，仰卧侧屈位片Cobbs角分别是41°和23°，支点弯曲位片Cobbs角分别是35°和19°，术后站立位片Cobbs角分别是36°和18°；重度组（≥60°）与中度组（＜60°）重力悬吊牵引位片Cobbs角分别是52°和23°，仰卧侧屈位片Cobbs角分别是53°和24°，支点弯曲位片Cobbs角分别是47°和20°，术后站立位片Cobbs角分别是44°和19°；僵硬组与柔软组重力悬吊牵引位片Cobbs角分别是51°和22°，仰卧侧屈位片Cobbs角分别是52°和22°，支点弯曲位片Cobbs角分别是48°和18°，术后站立位片Cobbs角分别是45°和17°；前路手术组与后路手术组重力悬吊牵引位片Cobbs角分别是47°和15°，仰卧侧屈位片Cobbs角分别是49°和16°，支点弯曲位片Cobbs角分别是43°和11°，术后站立位片Cobbs角分别是42°和10°，以上角度均为平均值。平均随访时间是1.5年（11~37个月）。［结论］支点弯曲位X线片比重力悬吊牵引位和仰卧侧屈位X线片能更准确地预测术后矫正效果，并能为选择前路或后路术式，以及融合节段提供依据。
【关键词】 青少年特发性脊柱侧凸 影像学 柔韧性 脊柱融合
Comparative analysis of three radiographic way in prediction of correction of adolescent idiopathic scoliosis∥CHEN Qinghe,ZHOU Yue,GAO Jichang,et al.The Orthopaedic Department of Xinqiao Hospital of the Third Military Medical University,Chongqing 400037,China
Abstract：［Objective］To evaluate the role of three radiographic ways in patients undergoing spinal threedimensional correction and fusion for adolescent idiopathic scoliosis.［Method］Sixtythree cases of adolescent idiopathic scoliosis（AIS）with 79 structural curves were studied.Preoperative Xray of standing,gravitysuspendig traction,supine bending and fulcrum bending were compared with postoperative standing Xray one week after surgery,Cobbs angle of all Xray were measured and statistical significance was evaluated.［Result］In structural thoracic group and lumbar group the mean Cobbs angle were 40°and 21°in gravitysuspendig traction Xray,41°and 23°in supine bending Xray,35°and 19°in fulcrum bending Xray,36°and 18°in postoperative standing Xray respectively.In severe group and moderate group the mean Cobbs angle were 52°and 23°in gravitysuspendig traction Xray,53°and 24°in supine bending Xray,47°and 20°in fulcrum bending Xray,44°and 19°in postoperative standing Xray respectively.In rigid group and flexible group the mean Cobbs angle were 51°and 22°in gravitysuspendig traction Xray,52°and 22°in supine bending Xray,48°and 18°in fulcrum bending Xray,45°and 17°in postoperative standing Xray respectively.In anterior approach group and posterior approach group the mean Cobbs angle were 47°and 15°in gravitysuspendig traction Xray,49°and 16°in supine bending Xray,43°and 11°in fulcrum bending Xray,42°and 10°in postoperative standing Xray respectively.All above Cobbs angle were mean numerical value,the mean followup period was 1.5 years（range:1~3 years）.［Conclusion］The fulcrum bending Xray are more predicting of correctability of AIS patients than the gravitysuspendig traction and supine bending Xray.It can provide reference for chosing anterior or posterior approach and chosing fusion levels.
Key words:adolescent idiopathic scoliosis（AIS）; radiography; flexibility; spinal fusion
青少年特发性脊柱侧凸手术治疗的目的是获得一个稳定平衡的脊柱。术前常常摄片评估其术后的矫形效果，所用方法有站立侧屈、仰卧侧屈、侧方按压、俯卧推压和牵引下摄X线片。以往这些方法对预测哈氏法和卢氏法手术的矫正效果确实有效，但均不能更好地预测目前应用的三维椎弓根钉棒矫形系统的矫正效果。为此作者采用支点弯曲位、重力悬吊牵引位和仰卧侧屈位X线片对青少年特发性脊柱侧凸进行术前评估，并和术后矫正效果比较，以探讨这3种方法预测矫正效果的准确性。
1 资料与方法
1.1 一般资料
63例青少年特发性脊柱侧凸患者中男18例，女45例；平均年龄为15.8岁（10~21岁）。按King分型，KingⅠ型9例，King Ⅱ型28例，King Ⅲ型16例，King Ⅳ型6例，King Ⅴ型4例。按Lenke分型，LenkeⅠ型19例，Lenke Ⅱ型4例，Lenke Ⅲ型9例，Lenke Ⅳ型15例，Lenke Ⅴ型11例。Lenke Ⅵ型5例。共有79个结构性侧凸，其中胸凸48个，腰凸31个；中度（小于60°）侧凸51个，重度（大于或等于60°）侧凸28个。用支点弯曲位时的矫正率表示脊柱侧凸的柔韧性，本组有柔软性侧凸48个（矫正率≥50%），僵硬性侧凸31个（矫正率＜50%）。行脊柱前路手术（Isola）7例，脊柱后路手术（USS）56例。
1.2 摄片方法和统计学分析
全部患者术前X线片包括站立位全脊柱正侧位片、支点弯曲位片、重力悬吊牵引位片和仰卧侧屈位片，术后一周时摄站立位全脊柱正侧位片。摄支点弯曲位片是将不透X线的塑料圆桶横放于放射台上，胸凸时将圆桶置于顶椎对应的肋骨下方，肩部离开放射台面，腰凸时圆桶放于腰凸顶椎下方，骨盆离开放射台面（图1~4）。摄重力悬吊牵引位片时嘱患者站立于悬吊牵引架下，双足尖着地，医生安置枕颌吊带，证实固定牢靠后，嘱患者背伸踝关节，使足尖离地，靠重力作用将脊柱被动拉直〔1〕。摄仰卧侧屈位片时嘱患者仰卧于放射台上，向左右两侧主动尽大力屈曲其脊柱，力争使同侧的第12肋与同侧髂骨翼接触。所测角度用Cobbs角表示，由同一名副主任医师用标准方法测量和记载，全部数据均经统计学分析，并进行t检验。
2 结 果
统计结果显示，术前支点弯曲位Cobbs角与术后Cobbs角比较无显著性差异，而术前重力悬吊牵引位和仰卧侧屈位Cobbs角与术后Cobbs角均有显著差异性（P＜0.05），说明术前支点弯曲位片能够较准确地预测术后矫正效果，而术前重力悬吊牵引位和仰卧侧屈位片预测术后矫正效果的准确性则不如支点弯曲位片。重力悬吊牵引位与仰卧侧屈位Cobbs角比较无显著性差异，两者的预测结果相类似（表1）。表1 术前不同体位Cobbs角与术后Cobbs角的比较（°）
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