青少年原發性脊椎側彎(Adolescent Idiopathic Scoliosis)

青少年原發性脊椎側彎 (Adolescent Idiopathic Scoliosis) Introduction- 簡介 : Scoliosis in patients between 10 and 18 years of age is termed adolescent scoliosis and can be due to many causes. By far the most common type of scoliosis in the adolescent period is one in which the cause is not known and is called idiopathic or adolescent idiopathic scoliosis (AIS). Although significant ongoing research continues in this area, including the genetic basis for AIS, there are no identifiable causes for this condition today. Despite this, we currently have accurate methods to determine the risk for curve progression of scoliosis and good methods of treatment. 青少年脊椎側彎 (Adolescent Scoliosis) 是指 10~18 歲的青少年被診斷出脊椎側彎的情況, 有很多的原因都會造成, 其中青少年原發性脊椎側彎 (Adolescent Idiopathic Scoliosis,AIS) 是目前最常見的類型, 雖然已有大量 積極的生醫研究如基因研究等投注在這領域, 但截至目前這類的病因以及詳細病況仍然不甚明朗 即便如此, 好消息是目前我們還是有一些有效的方法能夠分析病情惡化的危險因子, 也有一些好的治療計畫來改善患者的生活品質 Causes- 原因 : There are significant efforts being made toward identifying the cause of AIS, but to date there are no well accepted causes for this particular type of scoliosis. The vast majority of patients are otherwise healthy and have no previous medical history. There are though many theories about the cause of AIS including hormonal imbalance, asymmetric growth and muscle imbalance. Approximately 30% of AIS patients have some family history of scoliosis, and therefore there seems to be a genetic connection. Many Scoliosis Research Society members are working to identify the genes that cause AIS, and this knowledge continues to expand at a rapid pace. Most likely, there will be many genes associated with scoliosis and each may be helpful in detecting scoliosis and determining the risk for progression of the curve. 雖然現有大量的研究詴圖闡明青少年原發性脊椎側彎的原因, 但關於這方面的討論目前仍然沒有廣為大家所接受的共識 很大一部分的病人除了此疾病之外都是很健康的, 也沒有其他重大的個人病史, 所以目前沒有發現其與其他疾病的明顯關連性 此外, 目前有許多的假設像是內分泌失調 不對稱的生長 或是不

平衡的肌肉發育也都被認為是與脊椎側彎的病發有關 另外, 統計發現大約 30% 的病人有脊椎側彎的家族病史, 因此目前認為他跟基因是有一定程度的關聯性, 很多的研究都詴著找出與此疾病相關聯的基因, 而許多相關的發現也在迅速的進展中 目前大家都認為脊椎側彎的病發是與許多基因有關, 對於每個基因的了解都有助於我們去早期偵測 及預估病情惡化的風險 Symptoms- 症狀 : Adolescent idiopathic scoliosis generally does not result in pain or neurologic symptoms. The curve of the spine does not put pressure on organs, including the lung or heart, and symptoms such as shortness of breath are not seen with AIS. When scoliosis begins in adolescence patients often have some back pain, typically in the low back area. Although it is often associated with scoliosis, it is generally felt that the curvature does not result in pain. Low back pain is not uncommon in adolescents in general. Many teens experience back pain due to participating in a large number of activities without having good core abdominal and back strength, as well as flexibility of the hamstrings. Adolescent idiopathic scoliosis generally does not result in pain or neurologic problems. If these symptoms occur, further evaluation and testing may be necessary to include an MRI, CAT scan or Bone scan. 青少年原發性脊椎側彎一般來說不會造成疼痛或是其他的神經學症狀, 脊椎彎曲造成心 肺壓迫進而引發呼吸困難的情況也很少發生 雖然鮮少時候可以聽到此類的青少年抱怨背痛 ( 尤其是下背痛 ), 但這通常並不是脊椎彎曲所造成的痛, 更常是因為在沒有良好與足夠的腹背支持肌力 韌帶柔軟度的情況下從事大量運動所造成 也因為疼痛與神經學症狀並非常見的青少年原發性脊椎側彎症狀, 故當病人有這些表徵時需要再安排 MRI CAT scan 或是 Bone scan 來進一步檢查 Physical findings- 身體檢查 There are many visible symptoms associated with adolescent idiopathic scoliosis. Depending on the curve pattern and the size or magnitude of the curve, scoliosis may be barely seen or it may have significant visible symptoms. One of the most common is shoulder height asymmetry, in which one shoulder appears higher than the other (see figure 1). A shift of the body to the right or the left can occur especially when there is an single curve in the thoracic (chest-part) or the lumbar (lower back) of the spine without a second curve to help balance the patient. This is often seen as some waistline asymmetry in which one hip appears to be higher than the other and may

result in one leg appearing taller than the other (see figure 2). A prominence on the back or a rib hump secondary to the rotational aspect of the scoliosis is the most visible sign of scoliosis (see figure 3). Patients with AIS generally have a normal appearance when viewed from the side. In general, there are no neurologic abnormalities such as weakness or changes in a patients feeling in the upper or lower extremities(see figure 4). 青少年原發性脊椎側彎可藉由一些簡單的身體檢查即可發現一些徵狀, 雖然較輕微的病人肉眼是很難看得出來有什麼異常, 但嚴重的則可以明顯的看見一些易於正常的表徵 不對稱的肩膀高度是常見的表徵之一, 如下圖一中可明顯看見左側的肩膀高度高於右邊 其二, 若是脊椎側彎只有單一一個彎曲的話, 則往往可以看到身體有歪向左側或右側生長的情形 其三, 腰部高度不對稱的情況也是常常可見, 如下圖二可明顯看到左邊的髖關節高度高於右邊, 間接導致長短腳的情形 最後, 在背部看到左右不對稱的隆起是臨床上最容易發現的現象, 如下圖三 除了上述這些, 要知道的是, 青少年原發性脊椎側彎的病人是很難從側面觀去發現異常的, 如圖四, 通常也不會有四肢無力 感覺異常或是其他的神經學症狀, 這部分要特別留意 圖一 (Fig.1) 圖二 (Fig.2) 圖三 (Fig.3) 圖四 (Fig.4) Imaging studies- 影像檢查 : The typical radiographic images that are obtained to define scoliosis include a standing X-ray of the entire spine looking both from the back (AP radiograph), as well as from the side (lateral radiograph) (see figure 5). These radiographs are often done with lead shields to protect the patient while allowing for a clear view of the spine. Your physician will be able to measure the radiographs to determine your curves magnitude, which is measured in degrees using the Cobb method (see figure 6). A straight spine has a curve of 0 any curve greater than 10 is considered scoliosis. Between 0 and 10 is considered a curvature which is not true scoliosis. The way a patient stands at the time of an X-ray or many other factors can cause a slight

curvature. The lateral radiograph is used to determine the thoracic kyphosis (or roundback appearance) and the amount of lumbar lordosis (swayback). 脊椎側彎一般的影像學檢查是做涵蓋到整個脊椎的 AP view( 前後向 ) 與 lateral view( 側位相 ) 的站姿 X 光各一張, 如下圖五 藉由 AP view 的 X 光檢查醫生可以測量脊椎側彎的 Cobb's angle 來了解側彎的程度, 如下圖六 在 AP view 中, 正常人的脊椎是直立的, 其量測出來的 Cobb's angle 為 0 度 ; 當量測出來的 Cobb's angle 大於 10 度時, 我們就認定為有脊椎側彎的情況 ; 而介於 0 到 10 度之間的情況我們則很難認定為病理性的脊椎側彎, 還需要持續的追蹤觀察 lateral view 的 X 光檢查可以提供醫生關於胸椎後凸 (thoracic kyphosis) 與腰椎前凸 (lumbar lordosis) 的情況 如上所說 X 光檢查確實給予醫生很大的診斷幫助, 但還是有一些因素會引響到診斷的品質譬如病人的站姿或是一些其他的因素都會影響到脊椎彎曲的程度 圖五 (Fig.5):AP view lateral view 圖六 (Fig.6):Cobb's angle 的測量 Further radiographs can be performed to determine the flexibility of the curvature (how much it straightens). These flexibility radiographs can be done several ways. X-rays can be taken in which the patient lays on the table and bends to the right and then to the left (see figure 7). Traction films are taken with the patient's arms and legs pulled to stretch the spine out. A fulcrum- bend radiograph is taken with a padded roll placed at the apex of the curve to improve the curve correction. These radiographs are most often taken in the planning of surgical treatments. 還有一些其他的 X 光檢查方式可以幫助醫生了解病人脊椎彎曲的柔軟度, 這對於病情的了解也是很重要的一部分, 通常是在手術之前為了詳細了解病人情況時會安排的檢查 一種方法是 flexible radiograph 如圖七, 請病人躺在床上身體左側彎或是右側彎的姿勢下照相 ; 其二,Traction films 則是在請病人伸展四肢以牽拉脊椎的姿勢下照相 ; 其三,fulcrum- bend radiograph 則是放一個墊子在脊椎側彎最彎曲的地方 (apex) 以幫助脊椎側彎的修正

圖七 (Fig.7):flexible radiograph 圖八 (Fig.8): 以 X 光追蹤支架效果 When bracing treatment is started, radiographs are usually performed with the brace on to ensure that the brace is effective in achieving some correction of the curve(s) (see figure 8). When bracing is use to make a correction X-rays are often used to determine progress. These X-rays can be taken either in the brace or out of the brace depending on the preference of the physician. 當病人開始支架的治療時, 會以穿著支架時的 X 光片來觀察支架治療是否有效, 如圖八 但若是要追蹤脊椎側彎進展的程度時, 要以著支架的 X 光或是拆掉支架的 X 光片來追蹤則是取決於醫生的決定, 在臨床上都可以使用 Treatment- 治療 : Treatment of adolescent idiopathic scoliosis falls into three main categories (observation, bracing and surgery), and is based on the risk of curve progression. In general, AIS curves progress in two ways: 1. during the rapid growth period of the patient, and 2. into adulthood if the curves are relatively large. 青少年原發性脊椎側彎的治療主要分為三大類 : 觀察 支架 以及手術, 至於選擇哪一個治療方式端看病人脊椎側彎惡化的危險程度 一般來說, 青少年原發性脊椎側彎的病情進展有兩種模式, 其一是隨者病人的快速發育而惡化, 其二是角度比較大的病人在發育停滯的成人期時後仍繼續惡化, 而這兩點就是醫生在臨床分析時最重要的危險因子 Since scoliosis gets larger during rapid growth, the potential for growth is evaluated taking into consideration the patient's age, the status of whether females have had their first menstrual period, as well as radiographic parameters. In general, girls grow until 14 years of age, while boys grow until 16 years of age. Girls grow

very rapidly until their first menstrual period, and then their growth generally slows down, but they continue to grow until 18 months to 2 years after their first menstrual period. Radiographs of the spine and pelvis are also used to determine growth. The Risser grading system (Figure 8) is often used to determine a child's skeletal maturity (how much growth is left) on the pelvis, which correlates with how much spine growth is left. The Risser grading system rates a child's' skeletal maturity on a scale of 0 to 5. Patients who are Risser 0 and 1 are growing rapidly, while patients who are 4 and 5 have stopped growing (Figure 9). Generally patients who are being treated in a scoliosis clinic will have their height measured at each visit to help determine growth potential. 因為脊椎側彎的情況會隨著快速發育而惡化, 所以藉由年齡 女性初經 或是一些 X 光上的指標來了解病人發育可能性就顯得相當重要 一般來說, 女生會發育到 14 歲, 男生會發育到 16 歲 女生在開始發育到初經來潮前是發展最快速的時期, 初經來潮之後發展的速度會漸漸慢下來, 然後持續發育到初經後的 18 個月到 2 年 X 光檢查中的生長指標是看所謂的 Risser grading system, 如圖九, 是很普遍用來了解孩童骨頭發育成熟度的一個指標, 從這個指標我們可以了解骨盆還有多少的發育可能性, 也因此可以推斷脊椎還有多少的發育可能性 Risser grading system 是在 X 光下觀察腸骨生長板骨化的程度, 將孩童的骨頭成熟度分為 0~5 級,Risser 0 和 1 代表骨頭才剛開始發育, 還在快速發育的時期 ; 而 Risser 4 跟 5 則代表接近成熟的骨頭, 發育已經減緩甚至停止 除了上述這些, 脊椎側彎的病人在每次來門診時也應該記錄身高的情況, 這對於骨頭發育可能性的了解也是個有用的指標 Large curves are also more likely to progress or worsen. Curves greater than 45 in patients who are growing, or curves greater than 50 in patients who are done growing will continue to slowly progress over time. This is a general rule and there are exceptions based on multiple factors which your physician will determine. 除了骨頭成熟度, 臨床發現較大的脊椎側彎角度有比較大的可能會惡化 : 仍然在發育階段且 Cobb's angle 大於 45 度的病人以及已經停止發育且 Cobb's angle 大於 50 度的病人都會隨著時間逐漸惡化 所以持續追蹤病人的脊椎側彎角度對於治療及預後是很重要的一部分 除了骨頭成熟度與脊椎側彎角度這兩點主要評估脊椎側彎惡化的危險因子之外, 還有許多的因素會綜合著影像病人的病情 預後 以及治療方法, 這些都是臨床醫生會詳加了解的部分

圖九 (Fig.9): 觀察腸骨生長板 的骨化情形來訂出 Risser grading 治療個論 1: 觀察 (Observation) Observation is generally for patients whose curves are less than 25 who are still growing, or for curves less than 50 in patients who have completed their growth. 通常仍然在發育階段且 Cobb's angle 小於 25 度的病人以及已經停止發育且 Cobb's angle 小於 50 度的病人會選擇持續觀察追蹤的方式 治療個論 2: 附加療法 (Alternative treatment) Alternative treatments to prevent curve progression or prevent further curve progression such as chiropractic medicine, physical therapy, yoga, etc. have not demonstrated any scientific value in the treatment of scoliosis. However, these and other methods can be utilized if they provide some physical benefit to the patient such as core strengthening, symptom relief, etc. These should not, however, be utilized to formally treat the curvature in hopes of improving the scoliosis. 在前面說的三大類治療方法之外還有一些附加療法, 像是脊椎治療 物理治 療 瑜珈等等, 雖然目前都還沒有實證資料證明他們的療效, 但這些附加療法確 實能帶來某些好處譬如說加強核心肌力 症狀緩解等等 治療個論 3: 支架 (Bracing) Bracing is for patients with curves that measure between 25 and 40 during their growth phase. The goal of the brace is to prevent the curve from getting bigger. This is accomplished by correcting the curve while the patient is in the brace so that the curve does not progress with time. Once the brace is discontinued, the best one hopes for is to not have any curve progression, and to remain at the curve magnitude present when the brace was started. For example, a young girl who is 11 years of age who is a Risser 0, with a curve measuring 30 will be prescribed the brace and will wear the brace until growth of the spine has stopped (Risser 4 or 5, two years after the

menstrual period). For that particular patient the best he/she can hope for is to prevent progression and end treatment with a 30 degree curve. Even if slight curve progression occurs despite wearing the brace, surgical treatment is not necessary as long as the curve remains below 45 degrees at the end of growth. There are several types of braces available but all of them work in the same fashion. All braces are worn under the clothes and cannot be seen by others. 支架治療是供仍然在發育階段且 Cobb's angle 介於 25~40 度的病人在發育期的時候使用, 使用的目的是為了減少在快速發育期時脊椎側彎的惡化 目前有許多種支架可供挑選, 一般都是穿在衣服裡面能夠避免暴露在外直接被人看見, 而他們的原理跟作用方法基本上都是大同小異的 最佳的治療期望是希望在完成了療程脫掉支架後, 脊椎側彎的角度跟剛開始穿支架時一樣, 代表穿了支架後控制的效果非常好, 完全沒有惡化 舉例來說, 一個 11 歲 Risser 0 脊椎側彎 30 度的小女孩將會被建議穿支架直到他的脊椎停止發育 (Risser 4 or 5, 通常是初經後的兩年 ) 在療效完美的情況下我們可以看到她在脫掉支架後還是維持跟當初剛穿支架時一樣的 30 度, 不過一般情況還是多少會有一定程度的角度增加, 但即便角度有增加也不用急著開刀, 通常在病人停止發育以後, 脊椎側彎能控制在 45 度以下的病人是不需要開刀的 治療個論 4: 手術 (Surgery) Surgical treatment is used for patients whose curves are greater than 45 while still growing or greater than 50 when growth has stopped. The goal of surgical treatment is two-fold: First, to prevent curve progression and secondly to obtain some curve correction. Surgical treatment today utilizes metal implants which are attached to the spine, and then connected to a single rod or two rods. Implants are used to correct the spine and hold the spine in the corrected position until the spine segments which have been operated on are fused as one bone. The surgery can be performed from the back of the spine (posterior approach) (Figure 10) through a straight incision along the midline of the back or through the front of the spine (anterior approach) (Figure 11). Although there are advantages and disadvantages to both approaches, the posterior approach is utilized most often in the treatment of AIS and can be utilized for all curve types. The anterior approach is an option when a single thoracic curve or a single lumbar curve is being treated. Many factors go into the decision as to the surgical approach and your doctor will review the options and choose the best approach for you. 仍然在發育階段且 Cobb's angle 大於 45 度的病人以及已經停止發育且 Cobb's angle 大於 50 度的病人, 這時就需要考慮手術治療 手術治療有兩個目的, 一方面可

以減少脊椎側彎的惡化, 一方面能修正脊椎側彎的角度 現今手術常用的方式是在脊椎植入金屬器然後以 1~2 根的棒子將脊椎彼此接合起來, 達到將彎曲移位的脊椎矯正回接近正常的位置, 但如此的方法只是暫時性的矯正, 最後還是要用骨融合術把之前暫時固定在正常位置的脊椎融合成一塊骨頭 至於開刀的方式, 目前使用的是從背側進入的 posterior approach, 如圖十, 以及從脊椎前面著手的 anterior approach, 如圖十一 這兩種方法都有各自的好處,posterior approach 可以廣泛性的應用在各種彎曲類型的大部份青少年原發性脊椎側彎 ; 而 anterior approach 則適合在單一胸彎曲或單一腰彎曲的病人 其中還有很多因素會影響手術方式的選擇, 臨床醫師也會一一評估幫每一位病患選擇最適當的手術方式 圖十 (Fig.10): 手術治療的 posterior approach 圖十一 (Fig.11): 手術治療的 anterior approach Following surgical treatment, no external bracing or casts are used. The hospital stay is generally between 5 and 7 days. The patient can perform regular daily activities and generally returns to school in 3-4 weeks. Depending on the activities of the patient, full participation is allowed between 3 and 6 months after surgery.

手術之後不需要再穿戴支架固定, 只需要在醫院待個 5~7 天觀察狀況, 而之後大 約在 3~4 週內能恢復到一般的日常功能 返回學校, 而看術後活動的情形如何, 一般在 3~6 個月後就可以完全恢復正常的生活 Living with scoliosis- 長期生活影響 In general, AIS does not cause symptoms and should not restrict patients with respect to physical activities. For those patients who have mild scoliosis and who are being watched by their physician, all activities can be performed without any restriction or risk for injury. For those patients who are undergoing brace treatment, all physical activities are allowed while the brace is not being worn. For patients who have surgical treatment, your surgeon will provide you with information as to what activities are allowed following treatment. 一般來說, 輕度的青少年原發性脊椎側彎並不會有什麼症狀, 在定期回診追蹤下, 並不需限制, 可正常的從事任何活動而不會有比正常人高的危險 而對於穿戴支架的病患, 也可以在脫掉支架時正常的從事任何活動不需限制 而對於接受了手術治療的病患, 則必須在醫生的建議下避面一些特定的活動 Reference- 原文出處 Adolescent Idiopathic Scoliosis,Scoliosis Research Society http://www.srs.org/professionals/education/adolescent/idiopathic/treatment.php 譯者 : 台北榮民總醫院骨科部見習醫學生李承擇 / 陳晉瑋 in 2009-12