行支具治疗的特发性脊柱侧凸患儿生长高峰期Cobb角进展速率变化及其对支具疗效的影响

Variation of angle velocity during the pubertal growth peak and its influence on bracing outcome in brace-wearing idiopathic scoliosis patients

中文关键词:  特发性脊柱侧凸  生长高峰  侧凸进展  支具疗效

英文关键词:Adolescent idiopathic scoliosis  Peak growth velocity  Curve progression  Bracing outcome

中文摘要:

  【摘要】 目的：评估行支具治疗的特发性脊柱侧凸（idiopathic scoliosis，IS）患儿青春期生长高峰参数及生长高峰时的脊柱侧凸Cobb角进展速率（angle velocity，AV）变化情况，评估正性和负性AV组之间支具疗效的差异及不同支具疗效组之间生长参数的差异。方法：选取初诊时Y三角软骨未闭、以3~6个月为周期随访至停止支具治疗或因侧凸进展而行手术治疗的女性IS患儿35例。随访时测量的指标包括实足年龄、Y三角软骨闭合状态、Risser征、身高、脊柱长度、主弯Cobb角和尺桡骨远端骨龄（digital radius and ulnar，DRU）分级。根据纵向数据判定身高和脊柱生长速率峰值（peak height growth velocity，PHGV；peak spinal growth velocity，PSGV）及相应年龄，分析AV在该阶段的变化情况及其对支具疗效的影响。支具治疗失败定义为主弯Cobb角进展≥5°或进展至超过40°需行手术治疗。结果：35例患儿初诊年龄为10.2±1.5岁（8~12.5岁），初诊Cobb角为26.5°±5.0°（20°~38°），20例主胸弯或胸腰双弯患儿接受Milwaukee支具治疗，15例胸腰弯及腰弯患儿接受Boston支具治疗。随访时间为5.1±2.1年（4.0~6.2年），末次随访年龄15.3±2.2岁（12~18岁），末次随访Cobb角为34.0°±12.6°（9°~59°）。支具治疗成功15例（42.9%）；支具治疗失败20例（57.1%），其中转为手术16例（45.7%）。支具治疗失败组患儿PHGV年龄、PSGV年龄均较治疗成功组患儿更小（P<0.05），而支具治疗失败组的末次随访Cobb角、胸弯百分率及PSGV时AV均高于成功组（P<0.05），PHGV和PSGV的值、初诊Cobb角两组之间无统计学差异（P>0.05）。PSGV时负性AV组19例（54.3%），正性AV组16例（45.7%），负性AV组的支具治疗失败率、手术率、PSGV时AV及末次随访Cobb角均显著低于正性AV组（P<0.05）。结论：行支具治疗的IS患儿生长高峰期时AV变化与支具疗效显著相关。处于生长加速期的IS患儿，其支具治疗失败率较高，尤其是脊柱生长高峰发生时间较早的胸弯型患儿。生长高峰时负性AV预示着更好的远期支具治疗效果。

英文摘要:

  【Abstract】 Objectives: To analyze the pubertal growth parameters and the variation of angle velocity(AV) during the pubertal growth peak in brace-wearing idiopathic scoliosis(IS) patients, and to analyze the difference in bracing outcome between patients with alleviative and positive AV as well as the difference in pubertal growth parameters between patients with successful and failed bracing outcomes. Methods: 35 physically immature braced IS girls with open triradiate cartilage were evaluated every three to six months through their growth spurt until brace wearing or surgery. Serial measurements of Cobb angle and multi-dimensional maturity indicators involving chorological age, triradiate cartilage, Risser sign, height, spinal length and distal radius and ulnar(DRU) classification were recorded. The timing and magnitude of peak height growth velocity(PHGV) and peak spinal growth velocity(PSGV) were identified and compared between the failed and successful brace group. The AV fluctuated by onset of PSGV was also defined as alleviative if the AV was negative, otherwise it was positive. The bracing outcome was defined as failed if curve progression ≥5° or needing surgical intervention(>40°). Results: The average age and Cobb angle at initial visit were 10.2±1.5 years(8-12.5 years) and 26.5°±5.0°(20°-38°), while the average values changed to 15.3±2.2 years(12-18 years) and 34.0°±12.6°(9°-59°) at last follow-up, respectively. There were 20 and 15 patients undergoing Milwaukee and Boston braces, respectively. The average follow-up period was 5.1±2.1 years(4.0-6.2 years). Bracing treatment through the pubertal growth spurt demonstrated the successful and failure rate of 42.9% and 57.1% respectively. Patients in the failed group had older PHGV and PSGV ages, greater Cobb angle at last follow-up, higher ratio of thoracic curve and AV at PSGV than patients in the successful group(P<0.05). No difference was found in the magnitude of PHGV and PSGV, or initial Cobb angle(P>0.05). Onset of PSGV triggered the occurrence of positive and alleviative AV in 45.7% and 54.3% of the patients. The alleviative AV group had lower incidence of failed brace treatment, surgical rate, AV at PSGV and Cobb angle at last follow-up as compared with the positive AV group(P<0.05). Conclusions: The AV at pubertal spurt is significantly correlated with bracing outcome. Bracing prescribed before pubertal spurt is associated with higher risk of failed brace treatment, especially for those with relatively advanced onset of growth spurt, positive AV by growth peak and curve pattern being major thoracic scoliosis.