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MINISTRY OF EDUCATION AND TRAINING - MINISTRY OF DEFENSE CLINICAL MEDICINE SCIENCE RESEARCH INSTITUTE 108 MILITARY CENTRAL HOSPITAL PHAM TRONG THOAN RESEARCH ON CLINICAL FEATURES, X-RAY IMAGE AND EVALUATION ON THE RESULTS OF ADOLESCENT IDIOPATHIC SCOLISIS CORRECTION SURGERY Major: Trauma Orthopedic Code: 62720129 A SUMMARY OF MEDICAL PH.D DISSERTATION HANOI, 2019 WORKS COMPLETED AT: CLINICAL MEDICINE SCIENCE RESEARCH INSTITUTE - 108 MILITARY CENTRAL HOSPITAL Supervisors: Ass Prof Pham Hoa Binh Ph.D Phan Trong Hau Reviewer 1:…………………………………… Reviewer 2…………………………………… Reviewer 3……………………………………… The dissertation will be defended in front of the Revewing Council at the Institute level at: …… day… month….year… Find out at: National Library Library of Clinical Medicine Science Research Institute – 108 Military Central Hospital BACKGROUND Adolescent idiopathic scoliosis accounts for the highest proportion (2-4% of adolescents) The characteristics of the disease are physical body deformities that cause the spine to curl to one side and rotate the vertebrae on three planes Spinal deformities occur on a normal healthy body, if severe and untreated, such deformities may lead to complications, sequelae: backache, cardiopulmonary function impairment, physical body deformities, psychological insecurity, patients lose confidence when they integrate into the community Scoliosis appears silently and become severe in puberty, continues to change until adulthood The complications and sequelae have a very different impact and effect for each individual Scoliosis correction surgery is often very difficult and complex with many risks, future results may change without meeting the expectations of patients and their families Decision on surgery, selection on surgical techniques must be carefully considered and accurately planned based on a process of monitoring, detailed assessment of clinical and x-ray characteristics as well as the evolution of curves, rate of growing and synthesizing prognostic factors Until now in Vietnamese medical literature, there has not been a study of in-depth analysis of reference data on Vietnamese people such as clinical features and x-ray images to serve as basis for the designation and selection of the most appropriate surgical techniques for each case of scoliosis in adolescents, no work has reported the application of direct rotation of vertebral body in scoliosis correction surgery We study the subject: “Research on clinical features, x-ray image and evaluation on the results of adolescent idiopathic scoliosis correction surgery”with objectives: Survey the clinical features and x-ray images of unknowncause scoliosis of the adolescence age as a basis for surgery designation Evaluate the results of scoliosis surgery by direct rotation of the vertebral body CHAPTER OVERVIEW 1.1 Outline of idiopathic scoliosis 1.1.1 Functional anatomy characteristics of the thoracic and lumbar spine The thoracic and lumbar spines are spinal segments from T1 to L5 with two opposite physiological curves With lumbar spine, spinal functional unit consists of two vertebral bodies, intervertebral disc connecting the two vertebral bodies and the soft parts that links them Biomechanical studies assessing the role of components in lumbar spinal function units by Abumi showed that supraspinous ligament and interspinous ligament did not affect the firmness and movement amplitude of the spinal unit However, the joints and intervertebral disc are important and directly affect the instability of the lumbar spinal movement unit For the thoracic spine surrounded by the rib cage, sternum and back muscles, the anatomical structure and the biomechanical role of the relevant factors have many differences from the lumbar spine The thoracic spine is connected to the rib through costa joints, including the transverse costal joint and articulation of head of rib (or cost central articulations) Costa joints are surrounded by ligaments such as transverse ligaments, wing ligaments and internaljoint ligaments Takeuchi's research on experiment showed that the costa joint and the intervertebral disc are important components in the thoracic spinal function unit 1.1.2 Clinical features of idiopathic scoliosis 1.1.2.1 Objective symptoms Objective symptoms of scoliosis patients depend on the location and magnitude of the curve The patient's age at onset is significant in assessing the flexibility of the spine and predicting the risk of progression of the curve Changing gait of scoliosis patients can be observed when the scoliosis angle is large or causing nerve damage For scoliosis in the chest if the top vertebrae rotate much, it will cause imbalance of the rib cage - convex side and concave side, the clinical examination may show that the posterior rib cage - convex side is higher than the concave side due to the protrusion of the ribs Scoliosis patients may have two disproportionate shoulders, the protrusion of the left or right shoulder is an important factor for determining the screw position and fixation for each type of curve 1.2.The role of X-ray imaging and CT scanning in scoliosis assessment 1.2.1 The role of X-ray imaging in scoliosis assessment To comprehensively assess scoliosis patients, the x-ray image of the entire spine plays an important role On animated X-ray films, it can be assessed the flexibility of each spinal curve, the film tilting into one side is important in assessing curves, the basis for determining the extent of bone welding and has an important role to for the high thoracic curves and lumbar thorax Films with deviated peak padding, neck pulls or deviated peak push-press contribute to analyzing and evaluating spinal flexibility, predicting correction ability, determining bone welding position None of the films has superior superiority in assessing factors related to location diagnosis, flexibility and determination of bone fixation location, so it is necessary to take enough films to serve as the basis for analyzing and evaluating the preparation before surgery 1.3 Surgical treatment for scoliosis patients 1.3.1.Scope, screwing position for curves according to Lenke's classification Lenke's classification system is designed for doctors to plan surgery based on the classification of curves The principle is that the main curves and the real curves need to be fixed to the bone, the offset curve can adjust itself after surgery 1.3.1.1 For the main thoracic curve, Lenke type Lenke’s type 1A curve at the position LIV may stop at the intermediate vertebrae, the position UIV depends on the shoulder balance and characteristics of the high thoracic curve When selecting the position LIV higher than the intermediate vertebrae, the risk of losing offset is very likely to occur 1.3.2 scoliosis surgery by direct rotation of the vertebral body A scoliosis correction system when applied in surgery needs to achieve factors such as creating the strongest correction force, max.correction of the spinal deformities with the number of vertebrae bolted and bone-welded is as few as possible Principles and techniques of direct rotation of the vertebral body have been studied, introduced and applied in clinical practice When implementing vertical rod derotation technique, scoliosis correction has two impact force vectors The first is the vector of vertical rod rotation force; this force element directly affects the back and side of the vertebrae This force corrects deformities on the plane of the forehead plane and the vertical plane but has no impact element on the horizontal plane At the same time, when rotating, the vertical rod itself also rotates around its axis 90 degrees which is the next force vector This can affect the vertebral body rotation of scoliosis patients For scoliosis patients with large Cobb angle and without the flexibility of the curve, there is a large friction force between the vertical rod and the pedicle screw during the vertical rod rotation In that case the rotating force of the vertical rod will increase the rotation degree of the curve deformity If there is no friction between the screw and the vertical rod, the screw will slide on the vertical rod In this situation, the rotational deformity correction depends on the angle of the pedicle screw and the vectors of the vertical rod rotation force Clinically, the effect of rotational deformity correction of vertical rod rotation technique is negligible because it always exists a large friction between the vertical rod and the screw during the vertical rod rotation The concept of direct vertebral rotation is to correct the deformity of the vertebral body by a direct force opposite the back of the curve deformity The pedicle screw is taken from the back of the vertebral body through the peduncle and to the front of the vertebral body; with this position of the pedicle screw, it can transmit force into the deformed vertebral body and perform the rotational correction Fixed tools such as steel wires, hooks not perform this transmission force because the means only lie behind the vertebra The direct rotation of the vertebral body is carried out on the opposite side of the rotational deformity, the opposite direct rotation force can correct the rotational deformity on the horizontal plane and correct the deformity in threedimensional space Directvertebral rotation Slide between screw and vertical rod Figure 1.1 The principle of direct rotation of the vertebral body CHAPTER SUBJECTS AND METHODS OF RESEARCH 2.1 Research subjects Subjects include 40 adolescent idiopathic scoliosis patients who are undergoing surgical treatment with Lenke's scoliosis correction method by a system of pedicle screws via peduncle in the Faculty of Trauma Orthopedic Spine, 108 Military Central Hospital from August 2009 to July 2016 2.1.1.Criteria for selecting patients (According to the recommendation of World Scoliosis Society) -Idiopathic scoliosis patient - Cobb angle > 40 degrees - Adolescence age - Eligible for anesthesia, resuscitation - Records of sufficient data and follow-up time 2.2 Research Method 2.2.1 Research Method A prospective study describes vertical clinical prospect, without a control group The study is based on examination for patients, analysis of subclinical test results (mainly conventional x-ray films), surgical treatment, and monitoring and evaluation of results 2.2.3.Clinical scoliosis research criteria - Iliac crest balance - Shoulder balance - Bodybalance - Balance the rib cage and bone… 2.2.4.Research criteria on x-ray film - Difference of spine rib angle - Balance the collarbone… 2.2.5 Surgical method 2.2.5.1 Pre-surgerical preparation Determine the tactic of screwing according to Lenke as following: Type 1: Main thoracic curve - The vertebrae position of the bottom screw is the intermediate vertebra for the 1A, 1B curve The vertebrae position of the top screw of the curve: patients with the right shoulder higher than the left shoulder will put the screw to T4, patients with the two shoulders balancing before the surgery will put the screw on T3, and patients with the left shoulder higher than the right shoulder will put the screw to T2 - Curve type 1C: the position of the bottom screw extends to the lumbar spine levels under intermediate vertebra Type 2: Double curve of the thoracic spine - Determine the vertebra to put the top screw on the top: if the left shoulder is higher, put the screw up to T2; if the right shoulder is higher, put the screw T3; if two shoulders are balanced, put the screw on T4 The vertebrae position to be put the bottom screw is as type 2.2.7.3 Criteria for evaluating treatment results Evaluating the treatment results is based on the following criteria - The effectiveness of correcting scoliosis according to Harrington - Evaluate according to SRS-24 criteria - Evaluate complications during and after surgery 2.2.8 Data processing methods Use the software SPSS 22.0 for medical statistics - Results of qualitative variables and quantitative variables with subgroups are presented in the form of frequency and percentage - Results of quantitative variables are presented as: average +/- standard deviation or the median (smallest-largest) - To compare the relationship between qualitative variables, percentages or quantitative variables with subgroups, we use ChiSquared tests - To compare the relationship among quantitative variables with normal distribution and qualitative variables with two values, we use the T test for two independent groups - The difference is considered statistically significant when the value of p is 18 10.0 Age Oldest: 21 Youngest: 08 Total 40 100% The oldest patient is 21 years old and the youngest is years old, of which the age of 10-18 years accounts for 85%, there are patients older than 18 years old These patients were examined and found out at adolescence age when monitoring periodically Due to objective and subjective conditions of patients, when she was older than 18 years, she could afford to carry out a surgery An 8-year-old patient underwent surgery because at the time of the examination, the patient had iliac crest ossification developed to Risser III, the patient had menstruation, deformity of the lumbar misalignment greater than 4.8 cm, large iliac crest imbalance, large rib cage deformity, comparing Cobb angles after one year, we see a rapid progression (Cobb angle after one year of follow-up from 25 degrees to 68 degrees) Considering the above factors of patients, we decided to make surgical intervention Figure 3.1 Picture of an 8-year-old patient before surgery, the arrow pointing her body curve 4.8cm to the side and rib cage difference of 16 degrees 11 3.3.1.2 Height change after surgery Table 3.17 Height change immediately after surgery (n = 40 patients)(unit: cm) Patient’s height Average Deflection P value Height before surgery 154.50 8.269 Height after surgery 159.92 8.160 p
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