未治療原發性脊椎側彎不如想像那麼糟


  Feb. 4, 2003 - 二月5日出刊的「(Journal of the American Medical Association)」期刊中,一項具有指標性的試驗評估未治療的晚發作型原發性脊椎側彎(LIS)自然病史顯示,患者除了較少發生功能性缺損之外,還有背痛與整型的困擾,但較大的脊椎側彎角度則容易引起肺部的問題。
  
  愛荷華州立大學Stuart L. Weinstein博士表示,目前已完成了在1932 ~ 1948年間首次到愛荷華州立大學看診的未治療晚發作型原發性脊椎側彎(LIS)患者之自然病史研究,無論從任何可能引起脊椎側彎的一般原因或從心肺功能來看,我們都未發現任何會增加未治療晚發作型原發性脊椎側彎(LIS)死亡率的證據。
  
  這個追蹤50年的研究在開始時共有444位在1932 ~ 1948年間被診斷罹患LIS的患者參與,1992年開始,研究人員從這444位未治療的患者中選取117位與另外62位年齡與性別相當的志願者(未罹患LIS)做比較。
  
  這117位LIS患者中,有104位(89%)為女性,平均年齡66歲(54 ~ 80歲),自診斷確認後平均追蹤51年,存活率估計為0.55(95%信賴區間,0.47 - 0.63),而一般人的存活率約為0.57左右。
  
  當脊椎側彎角度大於80度且有胸廓尖點(thoracic apex)時,會增加每天日常活動時呼吸的困難。在98位LIS患者中有22位(22%),控制組的53位志願者中僅8位(15%)每天活動時會有呼吸急促、困難的現象(調整後的危險比,9.75;95%信賴區間,1.15 - 82.98);另外,109位LIS患者中有66位(61%),控制組的62位志願者中有22位(35%)發生慢性背痛,但71位LIS患者中有48位(68%),控制組的17位志願者中有12位(71%)為輕到中度的疼痛。
  
  在晚發作型原發性脊椎側彎(LIS)的病程中,只有側彎角度大於100度且有胸廓尖點才會增加因肺心症(cor pulmonale)或右心室衰竭致死的機率。在研究最後10年的36死亡個死亡病例中,只有3位可能是真正死於脊柱側彎,這表示過去估計的LIS致死率比實際來得高。
  
  在隨後的評論中,巴爾的摩Johns Hopkins 大學醫學院Paul D. Sponseller博士也同意這樣的看法,認為過去的研究是針對合併先天性與神經肌肉的早期發作型脊椎側彎所做,因此才會有較高的死亡率。
  
  這個由Weinstein等人所進行的研究提供了患者與政策制訂者一些重要的資訊,讓臨床醫師們可以根據這些架構來預測患者未來可能發生的狀況

Outlook Good in Untreated Idio

By Laurie Barclay, MD
Medscape Medical News

Feb. 4, 2003 — A landmark trial reported in the Feb. 5 issue of the Journal of the American Medical Association assessed the natural history of untreated late-onset idiopathic scoliosis (LIS) and showed that patients had little functional impairment, aside from back pain and cosmetic concerns. However, those with large Cobb angles may develop pulmonary problems.

"The current study completes the natural history study of untreated LIS patients first seen at the University of Iowa between 1932 and 1948," write Stuart L. Weinstein, MD, of the University of Iowa in Iowa City, and colleagues. "We did not find evidence to link untreated LIS with increased rates of mortality in general or from cardiac or pulmonary conditions potentially related to the curvature."

This 50-year follow-up study began with 444 patients diagnosed as having LIS between 1932 and 1948. Beginning in 1992, the investigators compared 117 of the original 444 patients with LIS who were untreated to 62 age- and sex-matched volunteers without LIS.

Of the 117 LIS patients, 104 (89%) were women; average age was 66 years (range, 54 - 80 years) and average follow-up since diagnosis was 51 years. Estimated probability of survival was approximately 0.55 (95% confidence interval [CI], 0.47 - 0.63), compared with 0.57 expected for the general population.

Shortness of breath during everyday activities was reported by 22 (22%) of 98 LIS patients and by eight (15%) of 53 controls. The combination of a Cobb angle greater than 80 degrees and a thoracic apex increased the risk of dyspnea during activities of daily living (adjusted odds ratio, 9.75; 95% CI, 1.15 - 82.98). Chronic back pain was reported by 66 (61%) of 109 LIS patients and by 22 (35%) of 62 controls. However, pain was minimal or moderate in 48 (68%) of 71 LIS patients and in 12 (71%) of 17 controls.

"In LIS, only patients with thoracic apices and curves of more than 100 degrees are at increased risk of death from cor pulmonale and right ventricular failure," the authors write. "Of the 36 deaths in the last 10 years, only three are possibly attributable to scoliosis. This points out the deficiency of previous research reporting a higher than expected mortality rate without properly controlling for the age at onset."

In an accompanying editorial, Paul D. Sponseller, MD, from Johns Hopkins University School of Medicine in Baltimore, Maryland, agrees that earlier studies of scoliosis combined patients with congenital, neuromuscular, and early onset forms, leading to conclusions about morbidity that were confounded by other factors.

"The studies by Weinstein et al provide important information for advising patients as well as for policy," he writes. "This series allows a framework for clinicians to predict future possibilities for patients."

JAMA. 2003;289:559-567, 608-609

Reviewed by Gary D. Vogin, MD

    
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