Impalement injuries involving the spinal canal

Two cases of impalement injury involving the spinal canal are presented. In the first patient septic bacteria were carried into the spinal canal along the track of the impaling rod. This patient died of sepsis. In the second patient a steel rod penetrated the patient's trunk on the right side, traversing his body obliquely, impaling the L1 vertebral body and coming to lie in the left retroperitoneal space. This injury was not complicated by infection and the patient recovered without any neurological deficit. The principles of managing these injuries and factors influencing their outcomes are discussed. Received: January 6, 2000 / Accepted: June 23, 2000     

影像学参数与胸腰段PLC及神经损伤的相关性分析

目的分析胸腰段损伤椎体压缩、平移、椎管侵及、后凸畸形等骨性影像学参数与后方韧带复合体及神经损伤的相关性。方法回顾分析2012年1月至12月间的胸腰段损伤(T11~L2)患者48例,排除骨质疏松性压缩骨折和病理性骨折患者。所有患者均具备X线片、CT平扫及矢状位重建、MRI检查。CT正中矢状位片上测量局部后凸角、伤椎楔变角、伤椎前后壁高度、伤椎压缩率、棘突间距、椎体间平移距离、椎管前后径;轴位CT测量后壁骨折块突入椎管的距离,除以椎管前后径计算为椎管侵及率。根据MRI的表现将后方韧带复合体(posterior ligamentous complex,PLC)状态分为无损伤、不完全损伤、完全断裂。记录ASIA运动评分及ASIA残损分级。使用Spearman相关系数评估影像学参数、韧带损伤、神经损伤间的相关性。结果 3例患者局部后凸角大于30°,4例患者椎体楔变角大于30°,6例局部后凸角大于20°,11例椎体楔变角大于20°。10例椎体压缩率大于50%,29例椎体间平移大于3.5 mm,6例棘突间距增大大于7mm,12例椎管侵及率大于50%。根据MRI评估,17例患者存在PLC损伤。局部后凸角大于30°、椎体间平移大于3.5mm、棘突间距增大大于7 mm时,与PLC损伤存在有统计学意义的正相关性,而当椎体间平移大于2.5 mm、椎管侵及率大于50%时,与AISA残损分级和ASIA运动评分存在有统计学意义的负相关性。其他未见明显相关性。结论椎体间平移大于3.5 mm、局部后凸角大于30°、棘突间距增宽大于7 mm通常合并PLC损伤,椎管侵及率大于50%及椎体间平移大于2.5 mm时倾向于合并神经损伤。PLC和神经组织的状态应直接通过MRI进行评估。     

前路病灶清除椎管减压及一期椎间植骨内固定治疗胸、腰椎结核

目的 分析前路病灶清除椎管减压一期椎间植骨内固定治疗胸腰椎结核的疗效。方法 回顾2002年3月以后的病例中对17例胸腰段、腰椎结核病者，行前路病灶清除椎管减压一期椎间植骨钛质钉-板、钉-棒系统内固定治疗。本组患者术前均有椎旁或腰大肌脓肿，椎体破坏塌陷，椎管内占位，脊柱畸形，不同程度神经功能受损。结果 术中无脊髓、神经及大血管损伤；术后随访1～3年，脊髓神经功能恢复良好。椎间植骨全部融合，脊柱畸形被矫正，无病灶复发。结论 前路病灶清除椎管减压一期椎间植骨内固治疗胸、腰椎结核具有安全．疗效可靠、恢复快，卧床时间短，护理简单等优点。     

Management of lumbar translocation injuries: case reports

Lumbar translocation (complete lumbar dislocation) injuries constitute a severe and highly unstable form of thoraco-lumbar spinal injury and are uncommon. Adequate management of such injuries includes removing the neural tissue compression and realigning and stabilizing the spine. Computerized axial tomographic scans of the spine are very dramatic in demonstrating encroachment on the spinal canal by bony fragments. We report two cases of lumbar translocation injuries with favorable outcomes. The patients were initially managed with halo-femoral traction, resulting in spinal reduction and eliminating the need for acute surgical intervention, and subsequently underwent posterior fusion for stability. Anterior decompression was done at a later date as computed tomography showed retropulsed intracanalicular bone fragments. The use of Harrington rod instrumentation and realignment of the spine did not free the canal of bony fragments and, hence, decompression was required.     

An unconventional indication for open kyphoplasty

BACKGROUND CONTEXT: Kyphoplasty is a means of treatment for painful osteoporotic vertebral body compression fractures. Its efficacy has not yet been totally proven. Even though the conventional percutaneous kyphoplasty is a relatively safe procedure, it is not routinely recommended for use in vertebral body fractures that involve posterior cortical compromise/retropulsion or in fractures associated with neurological deficit. PURPOSE: To see whether the open kyphoplasty procedure can be used in patients with painful vertebral body compression fractures who also have bony retropulsion into the spinal canal. STUDY DESIGN/SETTING: This technical report is based on the experience of one patient. METHODS: A 79-year-old woman with a history of osteoporosis presented with a painful vertebral body compression fracture at T12. Magnetic resonance imaging of her lumbar spine demonstrated an acute compression fracture at T12 with significant decrease in vertebral body height and retropulsion of bone resulting in one-third reduction in canal width. She was not considered a candidate for percutaneous kyphoplasty. Three months after the injury, an open kyphoplasty was performed after a decompression laminectomy at T12. RESULTS: The fractured vertebral body was successfully reduced, and there was no leakage of polymethylmethacrylate into the spinal canal through the fractured posterior cortex using the open kyphoplasty procedure. One month after the operation, the patient was free from mid-back pain and was again able to walk. CONCLUSION: Open kyphoplasty procedure allows direct visualization to the spinal canal. It can be performed safely and effectively in selected vertebral body compression fractures with retropulsed bone associated with neurological deficit.     

钛网椎管成形植骨脊柱融合的实验研究

目的 观察以犬作为实验动物,进行钛合金网为支撑物的脊柱椎管重建及植骨融合情况,并探讨其临床可行性。方法对6只蒙古犬进行静脉全麻,暴露T_(10)～L_3椎板,行全椎板减压,用钛丝将“Ω”形钛合金网固定并覆盖于减压区,上填自体骨及异种脱蛋白松质骨,逐层闭合伤口。于术后,6周、12周分别摄手术部位X线正侧位片及CT扫描,对比观察骨质愈合情况,钛网位置及椎管成形情况。同时宰杀3只动物,对实验部位行大体观察。结果 所有伤口均一期愈合。12周X线提示异种骨与钛网融合成片,形成椎板样结构,椎板与异种骨相接处骨质融合。CT扫描示椎管成形良好,硬膜囊未见骨性压迫。结论 应用钛网支撑植骨脊柱后路融合,可以在保护脊髓,神经根免于受压,维持减压效果的同时,有效的进行脊柱后路融合,在临床上有广阔的应用前景。     

Vertebral artery injury--diagnosis and management

The literature on vascular trauma contains little information on the management of vertebral artery injuries. We have reviewed our experience consisting of 23 patients with vertebral artery injuries caused by 19 gunshot wounds, two stab wounds, one shotgun wound, and one blunt injury. Twelve patients sustained unilateral vertebral artery thrombosis, seven patients had vertebral AV fistulae (three jugular vein, four vertebral vein) and four patients sustained mural injury without thrombosis. Six patients (26.1%) developed major neurologic deficits of which five could be directly attributed to CNS missile injury. One patient had transient vertebrobasilar ischemia on the basis of a vertebral AV fistula. Four of the seven vertebral AV fistulae were managed solely by therapeutic embolization and two patients early in the series underwent surgical management alone. One patient had therapeutic embolization of the proximal vertebral artery and operative distal vertebral artery ligation for an AV fistula. The four patients who died (17.4%) did so as a direct result of their CNS missile injury. We conclude that: 1) unilateral vertebral artery occlusion seldom results in a neurologic deficit if there is a normal contralateral vertebral artery and PICA (posterior inferior cerebellar artery) blood supply is preserved; 2) accurate assessment of a vertebral artery injury requires contralateral vertebral arteriogram; 3) management of vertebral artery injury is simplified by proximal, and if possible distal, therapeutic embolization; 4) an anterior approach to the C1-2 vertebral artery is a satisfactory method of obtaining distal surgical control, obviating the need to unroof the bony canal of the vertebral artery; 5) angiography is necessary in penetrating neck trauma to identify occult vascular injuries.     

Production of a reproducible spinal burst fracture for use in biomechanical testing

We have developed a technique to create a reproducible spinal burst fracture of the 12th vertebral body using 6-8-week-old calf spines with ribs, muscles, and vessels resected. We used the entire thoracolumbar segment of 20 calf spines with a standardized 5-mm-deep slice placed onto the body of T12 and the T11-12 disc. We then delivered a proximal-axial impact to the vertically mounted spine, preflexed to 15 degrees of forward flexion, by dropping a 32-kg weight, guided by a 1.55-m steel rod (potential energy = 487 J). Motion was limited to anterior flexion only, at the T12-13 disc, by splinting the rest of the spinal segments. Fractures were documented with the use of radiographs and computed tomography (CT) scans. We noted disruption of the vertebral column and end plates, fracture of the posterior body wall, fracture of the pedicles, and retropulsion of bony fragments into the neural canal. With the production of a reproducible spinal burst fracture model, various spinal fixation devices can be applied and tested.     

Impalement injury of the lumbar spine

Impalement is an uncommon injury, which combines aspects of both blunt and penetrating trauma. Particularly, reported cases of impalement injury of the lumbar spine are very rare. We present a case of impalement in which a steel rod penetrated the back into the vertebral body of the lumbar spine as the result of a fall. This injury was treated successfully with irrigation, debridement, and removal of the foreign body in the operating room. Thereafter, a secondary posterolateral interbody fusion (PLIF) procedure was performed due to instability of the lumbar spine. After 1 year, the patient had regained good functional results.     

螺旋CT对脊椎结核的诊断价值

目的分析总结脊柱结核的CT影像表现。方法分析经手术病理、穿刺活检及临床证实的脊柱结核31例的多层螺旋CT表现。结果椎骨的溶骨性、虫蚀样、斑片状碎骨片样的骨质破坏部分伴有硬化,椎旁软组织中见砂粒状钙化寒性脓肿的形成,椎间隙变窄,累及椎管,韧带下型等是脊柱结核的常见影像学表现。结论脊柱结核CT诊断优于X平片,可直观显示椎旁脓肿及椎间盘等改变。脊椎骨质破坏形态多样,但仍有其典型CT影像特征,须与脊柱其他病变鉴别诊断。     

Spinal injury and computerized tomography: a review of fracture pathology and a new approach to canal decompression

The plain X-rays and CT scans of 23 cases of thoracolumbar and 18 cases of lower cervical (below C2) spinal compression fractures were compared. A new picture of the fracture pathology has emerged as several features consistently appeared and are described: a midline or slightly oblique split of the vertebral body; posterolateral fractures of the body in the region of the developmental neurocentral joint; fragments of the body displaced backwards into the canal at the level of the pedicles; oblique laminal fractures; and separation of the zygapophyseal rim in thoracolumbar fractures. With this more complete picture of the bony injury, in particular canal encroachment, a new method of anterolateral canal decompression has been tried and is described.     

短节段C—D棒椎弓根螺钉治疗胸腰椎骨折疗效分析

目的探讨短节段C-D棒椎弓根螺钉治疗胸腰椎骨折的临床意义.方法采用短节段C-D棒折弯后对抗脊柱后凸畸形,产生过伸、撑开复位内固定,同时开窗减压和植骨.结果完成61例,随访1～6年,平均3.5年.术前椎体前、后缘平均高度分别为50.8%和72.1%,术后一周分别为93.7%和98.2%,术后一年分别为89.7%和92.3%.cobb角术前平均23.6°,术后平均6°,腰椎生理前凸术后平均18°.结论C-D系统结构简单,操作方便,固定牢固,使三柱产生均匀的前凸撑开,降低了前、中柱对螺钉的压缩负荷,防止椎体高度的远期丢失.对突入椎管内的骨折块及伤椎高度的矫正满意.     

髂部火器伤并椎管内枪弹异物存留

目的 探讨髂部火器伤并椎管内枪弹异物存留的诊治及临床疗效。方法 对收治的1例髂部火器伤并椎管内枪弹异物存留患者行急诊腰椎管内金属异物摘除术，并随访疗效。结果术后伤口甲级愈合，经3年随访，患者双下肢肌力及感觉均恢复正常。结论 火器伤所致的脊髓损伤致残率高，伤后宜急诊手术解除弹丸对脊髓的压迫，利于损伤神经的恢复。     

钉棒及钩棒系统治疗胸腰椎多节段脊柱骨折

目的评价钉棒及钩棒系统治疗胸腰椎多节段脊柱骨折的临床疗效。方法23例多节段胸腰椎骨折患者，后路切开复位，选择性椎管减压．钉棒或钩棒系统内固定及后外侧植骨融合进行手术治疗。其中相邻多节段型13例，非相邻多节段型8例，混合型2例。结果全组病例平均随访14个月，未发现内固定物松动、断离，无继发性脊柱后凸畸形加重。椎体高度由术前平均48．4％恢复至术后平均92．4%。2例完全性及11例不完全性脊髓损伤者．脊髓神经功能获改善。结论在椎管进行充分减压的基础上．钉棒及钩棒系统能有效复位椎体骨折，重建脊柱稳定性，是多节段胸腰椎不稳定性骨折合并脊髓神经损伤后路手术的理想选择。     

Herniated intervertebral disc associated with a lumbar spine dislocation as a cause of Cauda Equina syndrome: a case report

To report a case of Cauda Equina syndrome with the completion of the paralysis after the reduction of a L4L5 dislocation due to a herniated disc. Although several articles have described a post-traumatic disc herniation in the cervical spinal canal, this is not well known in the lumbar region. A 30-year-old man was admitted to the emergency room with blunt trauma to the chest and abdomen with multiple contusions plus a dislocation of L4-L5 with an incomplete neurological injury. After an emergency open reduction and instrumentation of the dislocation, the patient developed a complete cauda equina syndrome that has resulted from an additional compression of the dural sac by a herniated disc. In a dislocation of the lumbar spine, MRI study is mandatory to check the state of the spinal canal prior to surgical reduction. A posterior approach is sufficient for reduction of the vertebral displacement, however an intra-canal exploration for bony or disc material should be systematically done.     

后入路固定侧前减压治疗胸腰椎爆裂骨折

目的介绍后入路固定侧前减压治疗胸腰椎爆裂骨折的方法。方法 对53例胸腰椎爆裂骨折的患者采取后入路AF固定后，探查并侧前减压。结果 37例AF固定、撑开恢复脊柱序列后脊髓仍受压，患者伤椎椎体前高与正常椎体前高比值为术前0．49、术后0．95、随诊0．81，伤椎椎体后高与正常椎体后高比值为术前0．89、术后0．98、随诊0．95，Cobb’s角术前26．2^。、术后3．4^。、随诊8．7^。。结论 单纯后路固定、撑开借助后纵韧带张力使骨块间接复位，起到椎管减压作用是不彻底的，常需手术探查直接减压，并采用骨块按压复位数术，可减少并发症     

腰椎椎体后缘离断合并椎间盘突出症

目的 分析腰椎椎体后缘离断合并椎间盘突出症的发病机理，探讨手术治疗方法。方法 回顾总结10例腰椎后缘离断合并椎间盘突出症患的临床表现、影像学资料及手术方法选择。结果 10例患中，6例表现为单侧腰腿痛，4例为双侧；4例合并间歇性跛行，其中2例伴有马尾神经受压。CT检查显示全部病例腰椎椎体后缘形成突向椎管内的骨块，其相应的椎体后角骨缺损区为椎间盘髓核组织，其中7例椎间盘突出物超过椎体后缘骨。10例均行手术切除突出的椎间盘组织，其中6例同时行离断骨块切除。全部病例经3～36个月随访取得满意效果。结论 本病发病机理主要还是由于青少年时期椎体后缘环状骨骺变异或损伤逐步引起椎间盘突出的继发改变，最终造成神经根和硬膜囊的压迫。椎体后缘骨块仅部分参与神经根压迫。椎管内神经根及硬膜囊的彻底减压才能达到满意效果。     

Bow hunter's stroke associated with an aberrant course of the vertebral artery--case report

A 53-year-old male presented with repeated vertebrobasilar insufficiency on turning the head to the left. Angiography revealed severe stenosis of the dominant right vertebral artery at the atlantoaxial level in this position. Decompression surgery for the affected vertebral artery at the transverse foramen of the atlas was planned. However, surgery revealed an aberrant course of the artery, turning at the orifice of the transverse foramen of the atlas and perforating the dura at the occipitoatlantal level after passing through the bony canal of the atlas. Therefore, decompression was performed at the bony canal, which was the contributing site, and the symptoms improved. Bow hunter's stroke may be caused by atlantoaxial arterial anomalies, so accurate preoperative evaluation of the region is necessary to avoid anatomical confusion at surgery.     

Spinal canal restoration by posterior distraction or anterior decompression in thoracolumbar spinal fractures and its influence on neurological outcome

Summary Thirty consecutive patients who had suffered unstable fractures and dislocations of the thoracolumbar spine mostly associated with neurologic impairment and bony encroachment on the spinal canal were treated either with Harrington distraction rods combined with sublaminar wires or with the Zielke-VDS device. These patients were subsequently assessed for neurologic outcome, spinal canal clearance, sagittal and coronal spinal deformity correction preoperatively and postoperatively with a minimum follow-up of 26 months. In the follow-up evaluation, the patients who underwent surgery with Harrington rods showed an overall improvement of their neurologic function of 90.9%, whereas all patients who underwent the Zielke operation improved. Preoperatively, positive correlations were found between the level of injury and Frankel grades; the cord lesion tended to demonstrate more severe neurologic deficit when compared with cauda equina ones (P < 0.001). Furthermore, dislocation accompanying the injury resulted in a more severe neurological deficit (P < 0.05). Harrington rods and Zielke device offer sufficient initial correction of the frontal spinal deformity but did not significantly either restore or maintain sagittal plane alignment. The Harrington series showed an overallimprovement of the segmental kyphosis of 26% (NS), with a subsequent loss of correction of 7.38% (NS) on the follow-up observation. The Zielke device produced an immediate, much better correction of the segmental posttraumatic kyphosis of 45% (NS), but a loss of correction of 22.9% (NS) was measured in the follow-up evaluation. Correction of the anterior and posterior vertebral height was shown to be better for the Zielke patient group. The coronal deformity was completely corrected equally well by the Harrington and Zielke devices. There was no statistically significant correlation between the degree of bony encroachment of the spinal canal and the initial Frankel grade. Additionally, no statistically significant correlation was found between correction of the sagittal deformity, restoration of anterior and posterior vertebral height, coronal deformity correction, and clearance of the vertebral canal. Concerning neurological status, no patient in either group was worse in the follow-up evaluation. A significant correlation was found between the age of the patient and the neurological improvement favoring young patients (P < 0.001).     

后侧入路重建脊柱前中柱技术的安全性及疗效分析

目的：探讨在腰椎爆裂骨折的治疗中应用经单一后侧入路植入钛网重建椎体前中柱技术的安全性及疗效。方法：自2005年7月至2007年1月,对22例腰椎爆裂骨折患者（男18例,女4例,年龄28-57岁,平均42．7岁）,采用单一后侧入路截除骨折椎一侧横突,从侧方对前中柱骨折碎块进行清理,行椎管扩大减压成形,然后置入填塞自体松质骨的钛网重建椎体前中柱。同时,采用后路短节段椎弓根螺钉系统固定骨折椎邻近上下节段椎体。记录手术时间、术中出血量、手术前后骨折椎椎体部位高度、脊柱后凸畸形程度、椎管内占位情况等。结果：手术时间平均3．5h（2．8—5．8h）,术中出血量平均820ml（650～2100ml）。所有患者均获随访,随访时间12-28个月,平均17．2个月。术后,骨折椎椎体高度由术前平均压缩至（23．70±9．31）％恢复至正常高度的（95．77±1．93）％（P〈0．05）,脊柱生理曲度恢复,椎管内压迫完全解除。术后3例发生短暂的神经根牵拉伤,1例术后3个月时发生椎弓根螺钉系统连接杆松动。结论：通过单一的后侧入路向前侧植入钛网重建腰椎爆裂骨折的前中柱技术安全性可靠,应用于腰椎爆裂骨折的治疗有良好的疗效。