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The PUMCH Conservative Classification System for Young Idiopathic Scoliosis Patients
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摘要:目的 建立青少儿特发性脊柱侧凸(idiopathic scoliosis, IS)特定性训练分型新方法, 并评估其临床实用性。方法 本研究共包含两部分。第一部分为回顾性分析, 旨在建立青少儿IS保守治疗协和分型系统并对其可信度和可重复性进行评定, 研究对象为2013年1月至2020年6月北京协和医院确诊的青少儿IS患者。收集其站立位全脊柱正侧位X线片、背面及前屈位大体相等临床资料, 以PUMC手术分型系统为蓝本, 建立青少儿IS保守治疗协和分型系统, 并对观察者组间可信度和组内可重复性进行一致性检验。第二部分为双向性队列研究, 旨在验证该协和分型系统在指导青少儿IS临床治疗中的作用, 评估其临床实用性, 研究对象为2020年7月至2020年8月北京协和医院确诊IS且选择保守治疗的青少儿患者。根据患儿及家属意愿将其分为训练组和对照组。其中对照组仅定期复查, 不予临床干预, 训练组基于协和保守分型系统制订个体化特定性训练治疗方案(连续治疗1年)。比较两组1年后Cobb角变化和患者满意度。结果 (1) 回顾性研究共入选符合纳入和排除标准的IS青少儿899例。青少儿IS保守治疗协和分型系统将PUMC手术分型中的单弯(Ⅰ型)、双弯(Ⅱ型)、三弯(Ⅲ型)进行了精减, 并新增了一种微小弯型(0型), 共包括4种型别9个亚型。青少儿IS保守治疗协和分型的观察者组间可信度均值为88.23%, Kappa系数为0.862;组内可重复性均值为92.78%, Kappa系数为0.908。(2)双向性队列研究共入选符合纳入和排除标准的IS青少儿90例。其中训练组51例, 对照组39例。训练组治疗1年后Cobb角下降[(12.16±9.97)°比(16.61±2.88)°, P=0.002], 对照组1年后Cobb角增加[(17.64±5.60)°比(15.74±2.75)°, P=0.014], 且Cobb角变化组间比较存在临床意义(≥5°)。训练组治疗1年后满意度评分增高[5(3, 5)分比3(3, 3)分, P≤0.001], 对照组1年后满意度评分降低[3(1, 3)分比3(3, 3)分, P=0.004]。结论 本研究针对青少儿IS建立了一种新型评估与训练体系, 即青少儿IS保守治疗协和分型系统。该保守分型系统具有良好的可信度和可重复性, 可指导青少儿IS特定性训练治疗, 临床实用性强。Abstract:Objective To establish a new method of scoliosis specific exercise(SSE) classification foryoung idiopathic scoliosis(IS) patients and evaluate its clinical practicability.Methods This study consists of two parts, the first part, a retrospective analysis, aimed at establishing Peking Union Medical College Hospital(PUMCH) conservative classification system for young IS patients and evaluating its reliability and repeatability. The research subjects were young IS patients in PUMCH from January 2013 to June 2020. The standing X-ray(A-P and lateral) and clinical appearance (bending and standing) were analyzed. The PUMCH conservative classification system was established based on PUMC surgical classification system, and the consistency test was conducted for the inter group reliability and intra group repeatability of the observers. The second part, an ambispective cohort study, aimed at verifying the role of PUMCH conservative classification system in guiding clinical treatment and evaluating its clinical practicability. The research subjects were young IS patients(4 to 17 years old) who received conservative treatment in PUMCH from July 2020 to August 2020. According to the wishes of patients and their families, they were divided into training group and control group. The control group only had regular reexamination without clinical intervention, while the training group conducted SSE based on PUMCH conservative classification system (continuous treatment for 1 year). Cobb angle difference and patient satisfaction were compared between the two groups after 1 year.Results (1) A total of 899 young IS patients who met the inclusion and exclusion criteria were selected for the retrospective study. PUMCH conservative classification system finally included 4 types and 9 subtypes after revising the single-curve(type Ⅰ), double-curve(type Ⅱ) and triple-curve(type Ⅲ) in PUMC surgical classification, and adding a micro-curve (type 0). The mean inter-observer reliability was 88.23%, with Kappa coefficient 0.862, while mean intra-observer repeatability was 92.78%, with Kappa coefficient 0.908. (2) Ambispective cohort study included 90 young IS patients who met the inclusion and exclusion criteria. There were 51 cases in the training group and 39 cases in the control group. The Cobb angle of the training group decreased from (16.61±2.88)°to (12.16±9.97)° after 1 year of treatment(P=0.002), while the Cobb angle of the control group increased from (15.74±2.75)° to (17.64±5.60)° after 1 year(P=0.014). There was clinical significance between the two groups(Cobb angle difference≥5°). After 1 year, the satisfaction score of the training group increased from 3(3, 3) to 5(3, 5)(P≤0.001), while that of the control group decreased from 3(3, 3) to 3(1, 3) (P=0.004).Conclusions A new conservative classification system for young IS patients is established. The PUMCH conservative classification system not only has good reliability and repeatability, but also has clinical practicability in guiding SSE.
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作者贡献：袁望舒、石伟宏负责对患儿进行特定性训练，以及数据采集和论文撰写；张宇航和张厚强参与试验设计，并负责统计学分析；陈丽霞、沈建雄负责结果解读，并指导论文修订。利益冲突：所有作者均声明不存在利益冲突
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表 1 青少儿IS协和分型系统
型别 亚型 X线片特点 0 微小弯，Cobb角0~10° Ⅰ Ⅰ0 单上胸弯，顶椎位于T1椎体至T5、T6椎间盘 Ⅰa 单胸弯，顶椎位于T6椎体至T10椎体 Ⅰb 单胸腰弯，顶椎位于T10、T11椎间盘至L1椎体 Ⅰc 单腰弯，顶椎位于L1、L2椎间盘至L4、L5椎间盘 Ⅱ Ⅱa 双胸弯(上胸弯+胸弯) Ⅱb 胸弯+胸腰弯或腰弯 Ⅱc 上胸弯+胸腰弯或腰弯 Ⅲ 三弯(上胸弯+胸弯+胸腰弯或腰弯) IS：特发性脊柱侧凸 
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表 2 青少儿IS协和分型系统的组间可信度分析
康复治疗师序号 分型相同例数(n) 分型相同患儿所占比例(%) Kappa系数 1-2 26 86.67 0.844 1-3 28 93.33 0.921 1-4 27 90.00 0.883 1-5 26 86.67 0.844 1-6 26 86.67 0.844 2-3 24 80.00 0.767 2-4 29 96.67 0.961 2-5 26 86.67 0.845 2-6 26 86.67 0.843 3-4 25 83.33 0.805 3-5 28 93.33 0.922 3-6 28 93.33 0.921 4-5 27 90.00 0.884 4-6 25 83.33 0.804 5-6 26 86.67 0.844 均值 26.47 88.23 0.862 IS：同表 1
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