颈椎后纵韧带骨化术后C5神经根麻痹

目的探讨颈椎后纵韧带骨化患者后路减压术后发生C5神经根麻痹的临床特点、病理机制及其危险因素。方法2000年1月至2005年8月，采用后路椎板切除减压及侧块钉棒（板）系统固定治疗颈椎后纵韧带骨化患者49例，男35例，女14例；年龄39-75岁，平均53．7岁。在术后6-64h，9例患者发生C5神经根麻痹，表现为患肢三角肌和（或）肱二头肌肌力下降，伴有肩部及上臂外侧感觉减退或消失。比较麻痹患者与非麻痹患者侧位X线片上颈椎前凸角度的变化、C4-5水平CT横断面上椎管狭窄率和MRI T2加权像脊髓高信号区改变的差异。结果9例C5神经根麻痹患者均接受保守治疗，治疗措施包括功能锻炼、口服药物及高压氧治疗。随访1-4年，平均2．2年，9例患者肌力均恢复至3-4级。麻痹患者颈椎曲度矫正值（12．5°±3．0°）大于非麻痹患者（1．9°±1．1°），差异有统计学意义（P=0．04）；麻痹患者椎管狭窄率（62．6％±6．8％）高于非麻痹患者（35．1％±5．4％），但差异无统计学意义（P=0．12）；麻痹患者术后仅有3例脊髓高信号区范围扩大而超过原椎间隙水平，与非麻痹患者脊髓高信号区改变的比例差异无统计学意义（P=0．32）。结论C5神经根麻痹在颈椎后纵韧带骨化患者中具有较高发生率，后路手术中应适度矫正颈椎前凸角度。     

颈椎术后C5神经根麻痹

颈椎术后C5神经根麻痹是指颈脊髓减压术后出现三角肌和／或肱二头肌的麻痹，而不伴有脊髓压迫症状加重的一种并发症。约半数患者有感觉缺失和／或肩部难以处理的疼痛，而另外半数患者只有C5神经根支配区的肌力减弱。大约92％的患者发生在单侧，8％的患者发生在双侧。C5神经根麻痹病例大多数在术后1周内出现，少部分在术后2～4周内出现。其他的颈神经根麻痹(C6、C7、C8)，可以与C5神经根麻痹合并存在，或单独出现，但其发生率较C5神经根麻痹低得多。多数情况下，颈椎术后的上肢麻痹都有C5神经根受累。     

颈椎后路减压术后C5神经根麻痹危险因素及预防措施的研究现状

正C5神经根麻痹是颈椎后路减压术后常见的并发症,1961年由Scoville~([1])和Stops~([2])首次报道,C5神经根麻痹的定义尚未统一,目前大部分学者将其定义为颈椎减压术后无脊髓症状加重情况下新发的三角肌和(或)肱二头肌麻痹,肌力下降超过1级~([3])。由于缺乏统一的诊断标准,对颈椎病减压术后C5神经根麻痹的发生率、危险因素、预防和治疗等方面研究尚无统一的认识。     

颈椎前路减压融合术后C5神经根麻痹

目的:观察和评估颈椎前路减压融合术后C5神经根麻痹的发生情况与预后.方法:2007年5月～2012年1月行颈椎前路减压植骨融合术且术前三角肌肌力正常、手术减压范围包含C4/5椎间隙的患者共121例,男65例,女56例,平均手术年龄64.2岁,其中脊髓型颈椎病45例,神经根型颈椎病32例,颈椎后纵韧带骨化症44例.观察术后患者肩及上臂的肌力、感觉情况,在术前CT上测量C4/5神经根管直径,观察术前MRI T2加权像上脊髓高信号区.C5神经根麻痹诊断标准为三角肌肌力降至3级或3级以下.结果:共6例患者术后出现C5神经根麻痹,其中三角肌肌力2级1例,3级5例;单侧三角肌及肱二头肌肌力下降5例,双侧1例,均伴有感觉障碍.1例为C4/5椎间隙减压,l例为C5椎体次全切,4例为2个节段以上减压.5例患者术前MRI T2像上观察到C5节段脊髓高信号区.6例患者随访1～4年,感觉恢复正常;其中2例(1例术前T2像脊髓高信号区范围较大、1例术后肌力下降至2级)肌力恢复至4级,4例恢复至5级,恢复时间为1～8个月,平均4个月.6例C5神经根麻痹患者颈椎JOA评分由术前10.8±1.1分改善至末次随访时16.2±1.3分,差异有统计学意义(P＜0.05),术后1年患者自我满意度评价为40％～70％,平均55％.6例C5神经根麻痹患者术前C4/5神经根管直径为2.86±0.28mm,115例无麻痹组为3.18±0.39mm.121例患者中,术前C4/5神经根管直径≤3.0mm者53例,发生C5神经根麻痹4例(7.5％);＞3.0mm者68例,发生C5神经根麻痹2例(2.9％),两组比较无统计学差异(P＞0.05).121例中,减压融合1～2个颈椎节段发生C5麻痹为2/82(2.4％),减压3个节段发生C5麻痹为4/39(10.2％),两组比较差异有统计学意义(P＜0.05).结论:颈椎前路减压融合术后可能出现C5神经根麻痹,但预后较好,保守治疗后肌力、感觉均可明显改善.     

颈椎多节段减压术后C_5神经根麻痹临床观察与分析

目的探讨颈椎多节段减压术后C5神经根麻痹的发生机制、临床特点及预后。方法对自2006-01—2013-12行颈椎多节段减压术的患者进行随访。颈椎多节段减压包括:颈前路多节段椎体次全切术、前路多节段椎体次全切除并后路融合术、颈椎椎板切除融合术、椎板成形术,排除减压节段不含C5、术前三角肌肌力异常、臂部感觉异常患者后,共132例。对比不同术式、疾病类型、性别及减压节段数目的 C5神经根麻痹发生率,明确统计学差异。结果 132例平均随访22.8个月(10~105个月)。共有13例出现术后C5神经根麻痹(9.8%),颈椎椎板切除融合术5/36例(13.9%),前路多节段椎体次全切除并后路融合术2/17例(11.8%),椎板成形术3/26例(11.5%),颈前路多节段椎体次全切术3/53例(5.7%),差异无统计学意义(P=0.16)。颈椎外伤组1/9例(11.1%),颈椎不稳组1/10例(10%),OPLL组4/17例(23.5%),颈椎管狭窄组3/32例(9.4%),颈椎病组4/64例(6.3%),差异有统计学意义(P0.05)。男/女为11/2例,差异有统计学意义(P0.05)。发生/未发生C5神经根麻痹患者平均55.8/58.1岁,差异无统计学意义(P=0.23)。结论颈椎多节段减压术后可发生C5神经根麻痹,在不同术式间发生率存在差别。OPLL及男性为其发生的危险因素。     

颈椎病术后第5颈椎神经根麻痹的临床研究

目的探讨颈椎病术后第5颈椎(C5)神经根麻痹的临床表现、治疗及预后。方法我院骨科1994年3月至2003年10月手术治疗223例颈椎病,对术后出现C5神经根麻痹的7例患者的临床资料进行回顾性分析。结果223例患者7例术后发生C5神经根麻痹,表现为三角肌瘫痪,肩部感觉减退,牵扯痛等,发生率为3．1％。前路椎体次全切除术中发生2例;后路单开门颈椎管扩大成形术中发生5例(开门侧1例,铰链侧3例,双侧1例)。7例患者术后2周～6个月内逐渐恢复。结论颈椎病前、后路手术中均可能发生C5神经根麻痹,保守治疗即可痊愈,预后良好。     

两种颈后路术式治疗多节段脊髓型颈椎病术后C_5神经根麻痹分析

目的回顾分析两种颈后路手术术后C5神经根麻痹的发生与预后。方法回顾性分析自200-08-2011-01期间行手术治疗并获得随访的166例脊髓型颈椎病患者的临床资料,单纯行颈椎后路单开门椎管扩大成形术84例(A组):其中多节段椎间盘突出脊髓型颈椎病37例,发育性椎管狭窄28例,后纵韧带骨化19例。同期行颈椎后路全椎板切除、椎间孔扩大减压联合侧块螺钉内固定术82例(B组):其中多节段椎间盘突出脊髓型颈椎病39例,发育性椎管狭窄24例,后纵韧带骨化19例。记录术后C5神经根麻痹的发生情况,其诊断标准为:在无脊髓原有症状加重的情况下,颈椎管减压术后出现三角肌和/或肱二头肌肌力下降,伴或不伴肩部感觉减退或消失。结果两组术后神经功能改善率方面组间比较差异无统计学意义(P0.05)。两组术后颈椎曲度改变率以及术后C5神经麻痹发生率方面组间比较差异有统计学意义(P0.05)。结论颈椎后路全椎板切除联合侧块螺钉内固定术中,对椎间孔的减压降低了术后C5神经根麻痹的发生率。     

不同颈椎后路减压术后C_5神经根麻痹及其预防措施

[目的]分析不同颈椎后路减压术后C5神经根麻痹的发生率及其可能的原因,探讨C4、5椎间孔减压对C5神经根麻痹的预防作用。[方法]将2005年6月~2012年5月行颈椎后路减压术的131例颈椎疾病患者纳入研究,男86例,女45例;平均年龄(58.3±10.9)岁。其中行椎管扩大成形术63例,行椎板切除减压术68例;此外,67例患者行单纯颈椎后路减压术(A组),64例患者接受颈椎后路减压术并双侧椎间孔减压术(B组)。对行椎管扩大成形术患者与行椎板切除减压内固定术患者术前术后的临床资料、术前影像学资料和C5神经根麻痹发生率进行评估,同时对A、B组术前术后的临床资料、影像学资料和C5神经根麻痹发生率进行统计学分析。[结果]随访12~54个月,平均(23.4±8.8)个月,131例患者中共有9例发生术后C5神经根麻痹,总体发生率为6.9%。行椎管扩大成形术患者中,3例发生C5神经根麻痹(4.8%);行椎板切除减压内固定术的患者中有6例发生C5神经根麻痹(8.8%)。两种术式C5神经根麻痹的发生率差异无统计学意义(P>0.05)。A组有8例患者发生C5神经根麻痹(11.9%),B组有1例患者发生C5神经根麻痹(1.6%),两组差异有统计学意义(P<0.05),B组发生率显著低于A组。[结论]颈椎后路减压术后C5神经根麻痹有一定的发生率,椎板切除减压内固定术发生率相对较高,但两种方法并无统计学差异;加行C4、5椎间孔减压术可降低颈椎后路减压术后C5神经根麻痹的发生率。     

颈椎手术后C5神经根麻痹的临床观察与分析

背景：颈椎手术后C5神经根麻痹是颈椎疾病减压术后常见的并发症,严重影响术后近期疗效的判断和患者对手术疗效的满意度。目的：探讨C5神经根麻痹的临床特点、发生机制、预防治疗措施及预后。方法：回顾性分析2004年1月至2010年12月由同一术者（通信作者）行单纯后路手术治疗的106例颈椎疾病患者,男77例,女29例;年龄22～78岁,平均59岁。手术方法包括颈椎后路椎板切除术、后路单开门手术、双开门椎管成形术。患者术后均佩戴颈托3个月。结果：共有4例患者出现术后C5神经根麻痹。麻痹出现时间均在术后1周内,均为单纯三角肌肌力减退。2例伴随C5神经支配区的皮肤痛觉减退。经治疗均得到不同程度缓解。结论：C5神经根麻痹的发生是由多种原因共同作用造成的。发生机制尚不明确。应采取必要的治疗措施缩短病程、改善预后、预防继发疾病的发生。     

合并骨质疏松颈椎病后路减压术颈5神经损伤的MEP监测研究

目的 评估应用经颅电刺激运动诱发电位行术中脊髓监测在预测颈椎后路减压术后部分节段运动麻痹的价值。方法64例患者，男47例、女17例，平均年龄64岁，合并骨质疏松，在本中心行经颅电刺激运动诱发电位术中脊髓监测下颈椎后路减压术。经颅电刺激经针型电极进行传送，胸髓及双侧三角肌、肱二头肌、肱三头肌的诱发电位被完整记录。结果 术中诱发电位在57例患者的上述 所有肌群被成功记录，在其余的7例患者中诱发电位未被完整记录。在57例患者中无一例出现诱发电位波幅的明显降低。所有患者的临床症状在术后均有明显的改善；然而,有3例患者出现短暂的术后颈5神经。结论 在经颅电刺激运动诱发电位的监测中无异常出现，即使在合并有短暂的术后颈5神经麻痹的患者。这些结果提示颈椎后路减压手术后颈5神经麻痹与术中神经根或者脊髓的 损伤无明显的关联,虽然其确切的机制尚不清楚。术者应清楚颈椎后路减压手术后颈5神经麻痹是 一可能的并发症，即使术中无明显的神经损伤。     

寰椎后弓螺钉在寰枢椎后路固定融合手术中的应用

<正>目前对于治疗寰枢椎不稳或脱位的手术方法有多种,常用术式为后路钉棒系统固定融合术,其中寰椎安全顺利置钉为手术成败的关键,若术中寰椎置钉不成功或不顺利,可能导致手术时间增加,手术风险加大,临床需要一种安全、可靠、操作相对简单的手术补救措施。我科2013年12月~2015年1月收治的寰枢椎不稳患者均行寰枢椎后路固定融合手术,其中4例因术中置入寰椎椎弓根螺钉     

后方入路治疗胫骨平台后髁冠状位骨折的疗效分析

目的探讨后方入路治疗胫骨平台后髁冠状位骨折的临床疗效,分析该类骨折形态、手术入路的选择以及对Schatzker分型的再认识。方法回顾分析2003年6月-2009年6月23例采用后方入路治疗胫骨平台后髁冠状位骨折患者的临床资料。男15例,女8例;年龄32～56岁,平均38岁。均为闭合性骨折。致伤原因:高处坠落伤5例,交通事故伤15例,运动损伤3例。骨折按Moore分型:Ⅰ型10例,Ⅱ型9例,Ⅳ型4例。常规行膝关节正侧位X线片、CT扫描及三维重建。患者受伤至手术时间为3～14d,平均6d。结果骨折获解剖复位17例,一般复位6例。术后切口均Ⅰ期愈合。23例均获随访,随访时间12～36个月,平均24个月。骨折于术后6～9个月达临床愈合,平均7.6个月。无神经、血管损伤、内固定失效、关节僵硬、创伤性骨关节炎、畸形愈合等并发症发生。末次随访时根据Rasmussen评分系统评定膝关节功能,获优14例,良7例,可2例,优良率为91.3%。结论胫骨平台后髁冠状位骨折少见,有其独特的形态特点,Schatzker分型不能完全涵盖该类骨折。采用后方入路可在直视下复位关节面,固定牢靠,术后可早期行功能锻炼,并发症少,是较好的手术治疗方案。     

Fixation of posterior pelvic ring disruptions through a posterior approach

Objective  Stable internal screw fixation of posterior pelvic ring disruptions through a posterior approach. Indications  Complete, unstable sacroiliac dislocations with incompetence of anterior and posterior sacroiliac ligaments. Sacroiliac fracture dislocations. Displaced vertical sacral fractures. Contraindications  Damage to posterior soft tissues. Acceptable closed reduction of sacrum or sacroiliac joint. Ipsilateral acetabular fractures treated through an anterior approach. Inadequate intraoperative fluoroscopic visualization of posterior pelvis. Surgical Technique  Vertical paramedian incision overlying the sacroiliac joint. Release of origin of gluteus maximus. Inspection and reduction of sacroiliac joint. Stabilization with iliosacral screws under image intensification. Secure repair of gluteal fascia. Results  107 patients with unstable pelvic ring fractures were treated with open reduction and internal fixation of which 83 had an open reduction of posterior ring injuries. Accuracy of reduction: more than 95% of patients had residual displacement of less than 10 mm. Two patients had a deep wound infection postoperatively. Two-thirds of the patients were able to resume their previous occupation. Pain was either absent or occurred only with strenuous activities. 63% had a normal gait.     

髋臼后柱骨折与后柱伴后壁骨折的诊断和治疗

目的探讨髋臼后柱骨折、后柱伴后壁骨折的诊断和治疗方法。方法15例A2型髋臼骨折均采用手术治疗。手术入路：Kocher-Langenbeck入路6例，改良Kocher-Langenbeck入路9例。结果15例中达到解剖复位13例，复位欠佳2例。获得随访11例，随访时间1～4年，平均2年。关节功能按改良d-Aubigne和Postel功能评定标准，优良10例，可1例。术后异位骨化Brookel Ⅰ度1例、Ⅱ度2例。原发坐骨神经损伤2例，1例在1年后恢复，另1例未恢复。结论只有把患髋前后位片、闭孔斜位片、髂骨斜位片、CT平扫图像、SSD重建图像、MPR图像和VRT重建图像结合起来，才能做出髋臼后柱骨折或后柱伴后壁骨折的诊断。绝大多数髋臼后柱骨折和后柱伴后壁骨折需行玎放复位内固定，复位后柱骨折的最好方法是联合使用Schanz螺钉与Farabeuf钳，术中根据具体情况选择1块或2块后柱重建钢板固定。     

Open posterior stabilization for recurrent posterior glenohumeral instability

Open posterior capsular shift is used for posterior glenohumeral instability that has failed nonoperative treatment. Few series have fully evaluated the outcome after open posterior stabilization. The purpose of this series was to evaluate the clinical and radiographic outcome after open posterior stabilization of the shoulder. Preoperative and intraoperative factors were analyzed with regard to their impact on results. Forty-eight consecutive shoulders were identified that had undergone primary open shoulder stabilization by use of open posterior capsular shift. Of the shoulders, 4 were lost to follow-up, resulting in a study group of 44 shoulders in 41 patients. Shoulders were evaluated at a range of 1.8 to 22.5 years after surgery by use of the L'Insalata shoulder form, Short Form-36 (SF-36), and a subjective shoulder rating in 44 shoulders. Thirty-nine shoulders were evaluated by physical examination, and thirty-seven underwent radiographic examination. A recurrence of posterior instability occurred in 8 shoulders (19%). Of the patients, 84% were satisfied with the current status of their shoulder. The mean L'Insalata score was 81.25+/-17.8 points, the mean SF-36 physical component score was 50.81+/-7.87, and the mean mental component score was 53.82+/-7.55. Significantly poorer satisfaction and outcome scores were seen in shoulders found to have a chondral defect at the time of stabilization and in patients aged greater than 37 years at the time of surgery. No progressive radiographic signs of glenohumeral arthritis were seen up to 22 years after surgery. Open posterior shoulder stabilization is a reliable procedure for treating significant posterior instability without causing arthritic changes. Patients found to have chondral damage within the shoulder and older patients were found to have less success after stabilization.     

膝后内侧入路治疗后交叉韧带胫骨止点撕脱骨折

2003年1月～2007年12月,我科应用膝后内侧入路对21例后交叉韧带胫骨止点撕脱骨折患者行手术治疗,疗效满意。     

后侧入路内固定治疗胫骨平台后侧骨折

目的 探讨后侧入路内固定治疗胫骨平台后侧骨折的近期疗效.方法 对2008年6月至2010年6月采用后侧入路内固定治疗且随访资料完整的11例胫骨平台后侧骨折患者进行回顾性分析.男7例,女4例;年龄33～60岁,平均47.8岁.AO/OTA分型:41-B2.2.4型2例,41-B3.1.2型3例,41-B3.3.2型3例,41-B3.1.2型+41-B3.3.2型2例,41-C3.3型1例.5例后外侧骨折采用膝关节Carlson后外侧入路;3例后内侧骨折采用Carlson后内侧入路;3例累及胫骨平台前、后侧及胫骨髁间嵴骨折者采用Carlson后内和(或)后外入路,辅以前侧入路行钢板螺钉内固定.关节面塌陷者采用自体髂骨植骨.结果 随访3个月至2年,平均1.6年.全部病例均获得影像学上的骨性愈合,愈合时间12～16周.Rasmussen放射学评分15～18分,平均16.7分.骨折愈合后美国特种外科医院(the Hospital for Special Surgery,HSS)膝关节评分75～96分,平均86.2分.后外侧入路5例膝关节活动范围平均0°-135°,后内侧入路3例0°-130°,混合入路3例-10°-125°.结论 胫骨平台骨折表现为以后侧为主时,应选择后外或后内侧手术入路,于直视下进行复位及固定,便于操作,术后近期疗效满意.

Abstract：

Objective To evaluate the clinical results of operative treatments for the complex posterior tibial plateau fractures via posterior approach. Methods Eleven cases with complex posterior tibial plateau fracture from June 2008 through June 2010 were reviewed retrospectively. There were 7 males and 4females, with age from 33 years to 60 years (average, 47.8 years). According to AO classification, there were 41-B2.2.4 type in 2 cases, 41-B3.1.2 type in 3, 41-B3.3.2 type in 3, 41-B3.1.2 type combined 41-B3.3.2 type in 2, 41-C3.3 type in 1. Carlson posterior lateral approach were used in 5 cases, posterior medial approach were used in 3 cases, and posterior medial and/or lateral approach combined with anterior approach were used in 3 cases. All fractures were fixed with plates. Autogenous ilium grafts were used if necessary.Results All cases were followed up. The average follow-up time was 1.6 years (range, 3-24 months). At the final follow-up visit, bone union was obtained in all cases. The mean Rasmussen score was 16.7 (range, 15-18), and the mean HSS was 86.2 (range, 75-96). The postoperative knee range of motion were 0°-135°, 0°-130° and -10°-125° in 5 cases with posterior lateral plateau fractures, 3 cases with posterior medial plateau fractures and 3 cases with anterior and posterior plateau and intercondylar fractures respectively. There was no vascular and nerve injuries. Loosing or breaking of hardware's was not found. Conclusion The Carlson posterior lateral and/or medial approach is preferred for the complex posterior plateau fractures, with the advantages of direct reduction and stabilization.     

Sacrocolpopexy without concomitant posterior repair improves posterior compartment defects

The aim of this study is to determine posterior compartment topography 1-year after sacrocolpopexy (SC). Women who had SC without concomitant anterior or posterior repairs for symptomatic pelvic organ prolapse (POP) were included. Vaginal topography was assessed at baseline and 1-year postoperatively using POP quantification (POPQ). At baseline, 24% had stage IV POP, 68% stage III, and 8% stage II. One year after surgery, 75% had stage 0/I POP, 24% stage II, and 1% stage III. 112 (75%) were objectively cured (stage 0 or I POP). Anterior compartment was the most common site of POP persistence or recurrence (Ba >/= stage II in 23 women) followed by posterior compartment (Bp >/= stage II in 12 women) and apex (C >/= stage II in 2 women). In 1-year follow-up, SC without concomitant posterior repair restores posterior vaginal topography in the majority of women with undergoing SC.