椎体后缘切除治疗陈旧性胸腰段脊柱脊髓损伤

胸腰段脊柱骨折伴脊髓损伤的病理变化多数是由于脊髓前方受压而表现出脊髓缺血缺氧临床症状和体征。根据这一病理特征，自1995年起，采用椎体后缘切除减压术治疗陈旧性胸腰段脊柱脊髓损伤22例，现总结报道如下。     

合理治疗脊髓损伤

在过去的30年中,我国脊柱脊髓损伤的治疗经历了从闭合复位、保守处理到积极手术治疗（包括开放复位、减压、内固定等）的过程。特别是近10年来脊柱外科的快速发展,为脊髓损伤的治疗带来了积极的影响。现根据我们迄今30年间救治脊柱脊髓损伤及施行康复治疗的经验,对合理治疗脊髓损伤的若干原则和方法进行探讨。     

多节段脊柱损伤128例分析

目的 提出一种多节段脊柱损伤的分类方法，以提高诊断意识与治疗水平。方法 对128例多节段脊柱损伤进行回顾性分析，平均随访8．2年。按自行设计的分类方法进行分类。结果 相邻型82例(占64．1％)，非相邻型46例(占35．9％)；损伤部位以胸腰段为主；脊髓功能：Frankel A级60例，B级12例，C、D级27例，E级29例。手术治疗69例(其中减压内固定42例)，保守治疗59例。随访94例，改善1级者30例，改善2级者29例，无改善者35例。结论 类型不同其患病率、致伤因素、脊髓损伤严重度及诊断失误率均不同，诊断必须正确，必要时摄脊柱全长X线片。     

脊柱脊髓损伤患者低钠血症的临床研究

目的：探讨脊柱脊髓损伤患者低钠血症的临床发病情况、发生机制及治疗措施。方法：回顾性分析543例急性脊柱脊髓损伤患者的临床资料。结果：543例患者中发生低钠者202例，占全部病例的37．2％。脊柱脊髓损伤患者低钠血症的发生率与患者脊髓损伤平面和程度有关。202例低钠者中13例出现神经精神症状。结论：脊柱脊髓损伤患者低钠血症的发生与钠盐摄入量减少、过量水负荷、脊髓损伤后肾脏排水保钠能力下降等原因有关。ASIA运动评分与脊柱脊髓损伤患者低钠血症的发生有相关性。     

脊柱脊髓损伤的综合治疗及存在的问题

近20年来,CT、MRI等新技术的应用与脊柱内固定器械的进步使脊柱脊髓损伤的分类、诊断和治疗水平有了明显提高,但在脊柱脊髓损伤治疗的一些基本问题上仍存在争议,如药物治疗、外科治疗的适应证、手术入路选择、椎管减压的必要性及减压方式、神经移植及髓内细胞移植的应用与功能重建等问题均有待进一步探讨。手术仅是脊柱脊髓损伤治疗的重要环节,而非全部。其主要目的是重建脊柱的稳定性,椎管减压以促进脊髓功能的恢复,为早期康复训练创造条件。外科治疗应根据脊柱脊髓损伤的类型、患者的全身情况及医院或术者的具体条件确定治疗方式,而不应…     

脊髓损伤的手术治疗

手术治疗脊柱骨折脱位合并骨髓损伤300例，作认为在治疗脊髓损伤时．尽可能早期、恰当地对受累脊髓减压，坚强固定复位后不稳定的脊柱骨折脱位、降温，并给予类固醉、脱水剂与高压氧等治疗，时干不完全受损脊髓感觉和运动功能的恢复有重要的促进意义。     

陈旧性胸腰段脊柱骨折脱位伴脊髓不全损伤的手术治疗

目的探讨脊髓侧前方减压术治疗陈旧性胸腰段脊柱骨折脱位伴脊髓不全损伤的效果。方法1992至2002年采用脊髓侧前方减压术治疗陈旧性胸腰椎骨折21例，19例获得随访。结果随访时间平均18．7个月，总有效率为90％。结论脊髓侧前方减压术对陈旧性胸腰椎骨折脱位伴脊髓不全损伤具有良好效果。     

重视脊柱脊髓损伤的早期治疗

脊柱脊髓损伤诊断和治疗的手段及技术已有很大提高，但仍面临着很多问题。如何早期救治、如何降低伤残率和伤残程度等一系列问题，始终困扰着临床医生。本期刊登5篇脊柱脊髓损伤相关文章，多从外科治疗方面作临床研究。但必须指出，脊柱脊髓损伤的治疗是一项系统救治过程，尤其是早期的综合性治疗，作为脊柱外科医师，更容易忽视，从而影响了治疗结果。     

F-J系列U形钉治疗胸腰椎骨折合并脊髓损伤

短节段椎弓根内固定系统作为脊柱后路固定方法已被广泛应用，并取得较好效果。自2000年以来本院应用F-J系列U形钉治疗胸腰椎骨折伴脊髓损伤14例，取得满意疗效。     

关于脊髓损伤若干临床问题的专家意见

长期以来，脊髓损伤的诊治与康复一直是脊柱外科、神经外科及相关研究领域学者们的关注热点。对于脊髓损伤早期治疗和手术时机的选择、脊髓损伤评价方法、脊髓损伤并发症的预防和处理、脊髓损伤后的康复治疗等问题，既有共识，也有争议。[第一段]     

Roentgenographic and biomechanical analysis of lumbar fusions: a canine model

An animal model of anterior and posterior column instability was developed to allow in vivo observation of bone remodeling and arthrodesis after spinal instrumentation. Various combinations of spinal fusions and instrumentation procedures were performed after an initial anterior and posterior destabilizing lesion was created at the L5-L6 vertebral levels in 35 adult beagles. After 6 months of postoperative observation, there was improved probability of achieving a spinal fusion if spinal instrumentation had been used. All biomechanical testing was performed after removal of instrumentation to test the inherent stiffnesses and quality of the spinal fusions. The fusions performed in conjunction with instrumentation (group V = Harrington instrumentation and posterolateral fusion; group VI = Luque instrumentation and posterolateral fusion) demonstrated the greatest axial rotation stiffnesses (group V, p less than .05); axial compressive stiffness (group V, p less than .05); and flexural stiffness (group VI, p less than .05). The results show that a spinal fusion can be more reliably achieved and will be more rigid if it is accompanied by spinal instrumentation.     

多椎体结核内固定与非内固定疗效的比较

目的　探讨多椎体结核内固定与非内固定疗效的差异 ,比较二者的优缺点。方法　总结 1990年～ 2 0 0 1年采用脊柱前路病灶清除植骨术与同时用饶氏椎体钉、Ventrofix、Z -Plate钢板、USS等器械内固定治疗胸腰椎结核病人共 12 4例。其中非内固定 6 8例 ,内固定 5 6例。观察术后植骨融合、神经恢复、畸形纠正情况及治愈率。结果　经平均 2 5年的随访证实 ,内固定植骨融合速度快于非内固定组 ,有显著性差异 ;神经功能Frankel分级二组全部得到改善 ;畸形纠正内固定组后弓角较术前平均改进 2 9°、非内固定组平均改进 5°,有显著性差异。内固定组治愈率为 10 0 % ,非内固定组治愈率为 87% ,有显著性差异。结论　脊柱结核内固定可早期重建脊柱稳定性并加速植骨融合 ;有明显改善畸形的作用 ;减少结核复发 ,在治疗多椎体结核中有重要意义     

Comparison of sprotte and Quincke needles with respect to spinal fluid leakage using artificial spinal cord

Purpose This research investigated whether the Sprotte needle causes less leakage of CSF than the Quincke needle in the artificial spinal cord. Methods The changes in intradural pressure, extradural pressure, and leaked volume of CSF were evaluated following puncture with Sprotte and Quincke needles in the artificial spinal cord. Results The decrease in intradural pressure was 9.7±1.8 mm H₂O with the Sprotte needle and 20.5±2.7 mm H₂O with the Quincke needle (P<0.05). The volume of leakage of artificial CSF was 2.0±0.3 ml with the Sprotte needle and 3.3 ±0.3 ml with the Quincke needle (P<0.01). The extradural pressure increase was 166.1±8.2 mm H₂O with the Sprotte needle and 186.8±13.2 mm H₂O with the Quincke needle (P<0.05). Conclusion The Sprotte needle produces less CSF leakage than the Quincke needle.     

Post operative infections of the spine: technique,indications and results of the surgical treatment - A retrospective study of 90 cases

Post operative infection in spine surgery is a well known complication. The authors studied a series of 90 patients in accordance with an homogenous strategy based on the excision of necrotic and infected tissues, associated with appropriate antibiotics.The results are analyzed according to the degree of infection (which is based on the type of germs and their associations), and type of patients, the delay in diagnosis and the anatomical extension of the infected lesions.Making a difference between superficial and deep infection is of no therapeutic value and may lead to wrong and inadequate treatment.One must separate the common infections (which are due to germs as staphylococcus aureus or others from the urinary or digestive tract), and severe infections (which are either due to a per operative massive and deep contamination, or associated with patient's poor general condition).This series is mainly about posterior approaches to the spine, with or without osteosynthesis. Technical problems for treatment depend on the site of infection, particularly at the thoracic kyphosis level, or at the lumbar level where the muscle necrosis can be extensive. At the cervical level, the infection of an anterior approach mandates a check on the respiratory and digestive tracts.Removing the osteosynthesis is not mandatory in post operative spinal infections, as it may induce severe mechanical destabilization. An anterior approach is not necessarily required in the case of a posterior infection, except with massive contamination of an anterior graft. In some cases, posterior lumbar interbody fusion can lead to the indication for anterior cage removal.Pseudarthrosis of an infected spine, initially treated to obtain fusion, is still the worst complication. In case of previous posterior infection, even a severe one, fusion can still be obtained through a secondary anterior or posterior approach for grafting, with or without osteosynthesis.In this series, there was no neurological complication due to infection.However, eight diceases occured in weak patients with neurological involvement. This points out the importance of the general treatment associated with the surgery, and the necessity of a thorough assessment. a thorough assessment.Résumé Les infections post-opératoires représentent une complication largement documentée dans le domaine de la chirurgie du rachis. Les auteurs étudient une série de 90 patients traités selon une stratégie homogène basée sur l'excision des tissus nécrosés et infectés associée à l'utilisation d'un traitement antibiotique adapté. Les résultats sont analysés en fonction du degré d'infection (basé sur le type de germe et leurs associations) de l'état des patients, du délai pour le diagnostic et de l'étendue anatomique des lésions infectieuses. L'opposition entre infection superficielle et profonde semble sans intérêt sur le plan thérapeutique et peut conduire à un traitement insuffisant ou mal adapté.Il est important de séparer les infections classiques (qui sont dûes à des germes comme le staphylocoque doré ou d'autres germes provenant de la sphère urinaire ou digestive) et les infections sévères (qui sont soit dûes à une contamination per-opératoire massive et profonde ou associées à des patients dont létat général est déficient).Cette série est principalement basée sur les abord postérieurs du rachis avec ou sans ostéosynthèse. Les problèmes techniques pour le traitement dépendent du site de l'infection: aux niveaux thoracique et lombaire, la nécrose musculaire peut être très extensive. Au niveau cervical, l'infection d'un abord antérieur impose de vérifier l'intégrité du tractus aéro-digestif.L'ablation initiale du matériel n'est pas nécessaire dans beaucoup de cas d'infections post-opératoires car elle peut induire des destabilisations sévères et des complications mécaniques supplémentaires. Un abord antérieur n'est pas forcément nécessaire en cas d'infection postérieure mises à part les contaminations massives d'une greffe antérieure ou une infection d'une cage intervertébrale réalisée pour une fusion intersomatique par voie postérieure.La pseudarthrose des greffes sur un rachis infecté qui a été traité initialement pour obtenir une fusion reste encore la plus sévère des complications. Dans les cas d'infections postérieures même sévères, la fusion peut être encore obtenue secondairement grâce à un abord antérieur ultérieur ou même un abord postérieur pour des greffes complémentaires avec ou sans ostéosynthèse.Dans cette série, les auteurs ne signalent aucune complication neurologique dûe à l'infection. Néanmoins, 8 décès sont à déplorer chez des patients fragiles avec signes neurologiques initiaux. Ceci souligne l'importance du traitement général associé à la chirurgie et la nécessité d'un bilan complet de ces malades.EBJIS Congress, Leuven     

儿童无骨折脱位型胸腰髓损伤的临床分析

目的：通过对６例儿童无骨折脱位型胸腰段脊髓损伤的病例分析,进一步认识本病。方法：本组６例全部为胸腰段脊髓损伤。其中不完全脊髓损伤５例,完全性脊髓损伤１例,根据Ｆｒａｎｋｅｌ脊髓损伤分类法：Ａ级１例,Ｂ级２例,Ｃ级３例。保守治疗５例,手术治疗１例。结果：经６个月￣９年１０个月随访,４例完全恢复,１例参照Ｆｒａｎｋａｌ分级法,半年后由入院时的Ｂ级恢复至Ｅ级,１例完全性脊髓损伤病儿无恢复。结论：如何治疗     

Morphometric effects of acute shortening of the spine: the kinking and the sliding of the cord,response of the spinal nerves

Spinal shortening is performed for a wide spectrum of diseases. This study was designed to investigate the morphologic effects of shortening on the spinal cord, to enlighten the amount and direction of the sliding of the cord, the alteration of the angles of the roots, and to identify the appropriate laminectomy length. Total vertebrectomy of T12 was applied to ten sheep models after spinal instrumentation. Gradual shortening was applied to five sheep; then, the degree and direction of the sliding of the spinal cord and the angles of the adjacent roots were measured. On five other sheep, additional sagittal sectioning was performed via excision of the pedicles. Measurements were taken at different laminectomy lengths to record kinking of the spinal cord with gradual shortening. The mean sliding of the spinal cord was 9 mm cranially and 7.8 mm caudally. T11 spinal nerves became more vertical caudally, and T12 spinal nerves achieved an ascending position with gradual shortening. Both T11 and T12 spinal nerves were sharply bent in the foramen and on the pedicle of T13, respectively. In full-length shortening, the mean kink of the spine in the sagittal plane was 92.4° for two levels of hemi-laminectomies, 24.6° for complete laminectomy of T11 with hemilaminectomy of T13, and 20.2° for two levels of complete laminectomies. The slippage of the cord is dominant in the earlier stages and kinking is dominant in later stages of shortening. Increasing the laminectomy length by only a half or one level prevents excessive kinking and compressions at the upper and lower margins of the laminectomy. In the later stages of shortening, the spinal nerves near the vertebrectomy site are at risk because of the sharp bending of the nerves. This study describes the mechanism of the sliding and kinking of the cord due to gradual shortening of the spine, which might be useful in spinal surgery procedures. It also states that it is possible to avoid excessive kinking by planning the appropriate technique of laminectomy style in full-length shortening. This study has been approved by Institutional Review Board by sentence number 1150 on 26 April 2006.     

创伤性上升性脊髓缺血损伤

脊椎损伤后,脊髓损伤平面上升较为少见。作者报告了５例,其中Ｔ１０－１１骨折脱位２例：１例于伤后２周内,截竣平面上升至Ｃ２,呼吸麻痹死亡,１例上升至颈部脊髓,双上肢无力;另３例为Ｔ１２骨折２例,Ｌ３骨折１例：其中截竣平面上升至Ｔ９至１例,Ｔ８者２例。５例患者双下肢皆呈软竣,１例死亡患者尸检见脊髓完整,Ｔ９－１０段脊髓前后动静脉血栓,其向上至Ｃ３,向下至Ｓ１,脊髓前血管、中央血管、髓内小血管多处 栓,     

A thoracic and lumbar spine injury severity classification based on neurologic function grade, spinal canal deformity, and spinal biomechanical stability

BACKGROUND CONTEXT: Current well regarded thoracic and lumbar spine injury classifications use mechanistic and anatomical categories, which do not directly rely on quantifiable management parameters. Their clinical usefulness is not optimal. PURPOSE: Formulate an injury severity based classification. STUDY DESIGN/SETTING: This retrospective investigation studied patients who suffered thoracic and lumbar spine injuries, and examined the following three quantifiable parameters: 1) neurologic function grade; 2) spinal canal deformity; 3) biomechanical stability. These parameters are the primary clinical indications for management decisions. PATIENT SAMPLE: One hundred twenty-six consecutive patients with spinal trauma admitted to a level 1 tertiary trauma center from January 1997 to November 2005 were enrolled in this study. OUTCOME MEASURES: Spine injury severity was independently scored on three parameters: 1) neurologic function impairment grade according to the modified Frankel grading method and the American Spinal Injury Association (ASIA) function scale; 2) spinal canal deformity from translation and intrusion, measured as percent canal cross-sectional area compromise; 3) failure of five possible biomechanical functions in Denis's three anatomic columns, and a sixth group of unstable deformities. All three columns contribute to tensile function. Only the anterior and middle columns provide compression load-bearing function. A combination of three or more column biomechanical function failure or an unstable deformity renders the injury unstable. METHODS: Five fellowship-trained spine surgeons from one institution took part in the study. Hospital medical records, including admission history and physical examination, discharge summary, and operative report (if surgery was performed), were examined for neurologic deficit. Plain radiographs, computed tomographic scans and magnetic resonance imaging were assessed for canal compromise and biomechanical function status. RESULTS: Injuries were located from T3 to L5, 58% of which were at the thoracolumbar junction (T11-L2). Neurologic impairment occurred in 45% (57/126) of patients, with 19 complete paraplegias (Frankel grade A). The average spinal canal cross-sectional area compromise was 56.1% in neurologically impaired and 14.2% for patients who where neurologically intact. The number of tensile element failure patients in neurologically impaired versus intact are as follow: tri-columns 22/4; two columns 16/8; one column 11/17; all columns intact 8/40. Load-bearing element failed in 55/57 neurologically impaired and 63/69 intact patients. Sixty-seven patients had spinal reconstructive surgery. Their average instability profile score was 4.4 out of 6, and canal compromise score was 3.3 out of 5. CONCLUSIONS: A clinically useful thoracic and lumbar spine injury classification should be based on parameters that are the primary indications for management decisions. The same parameters should be injury severity quantifiable as to guide treatment. In this study we introduced spinal canal deformity and column biomechanical functions as quantifiable parameters in thoracic and lumbar injury severity classification. Validation of this method is beyond the scope of this preliminary study.     

Experimental determination of the effect of progressive sharp-angle spinal deformity on the spinal cord

Neurological deficit is a serious though not well-known complication associated with spinal deformity. Sharp-angle kyphosis may be congenital, traumatic, degenerative, infectious, or iatrogenic in origin. Many kyphotic deformities are underestimated, thus leading to severe neurological deficit. In order to determine exactly what procedures of angulation the patients should undergo to stabilize the spine, which are major operations, the authors analyzed in an experimental model the effects of progressive sharp angulation on the anatomy of spinal canal and cord. We found that sharp anterior angulation of 50° causes ante rior-posterior stenosis and the dura will touch the spinal cord. At 90° of angulation, the spinal cord will be squeezed and the pressure in the canal will be double what it was initially, probably leading to ischemia. The experimental confirmation (determination) of these angulations allows the physician in charge to define early in the treatment program when a surgical stabilization procedure should be included, before the angulation causes any neurological damage.     

Surgical decompression: a life-saving procedure for an extensive spinal epidural abscess

Extensive spinal epidural abscesses (SEAs) carry a high mortality rate. Traditionally they are treated non-operatively with longterm antibiotics and/or surgical decompression, but there is a continuing debate as to whether they should be managed by emergency surgical decompression. However, such decisions are made in the light of the clinical setting. We report the successful management of a female patient who presented with features of upper cervical cord compression and later developed septic shock and multisystem failure. Surgical decompression of the cervical spine and irrigation of the epidural space with a paediatric catheter was performed followed by tricortical strut grafting and plating. At review, 36 weeks after surgery, the patient remained asymptomatic, having made full neurological recovery. The purpose of this report is to highlight the importance of emergency surgical intervention for extensive SEA in the presence of progressive neurological loss associated with multisystem failure.