重度僵硬型脊柱侧凸的后路非全椎体截骨手术治疗

[目的]探讨重度僵硬型脊柱侧凸后路非全椎体截骨手术治疗的疗效。[方法]本组男18例,女24例,年龄13~32岁,平均19.2岁。术前冠状面Cobb角80°~135°,平均96.2°,矢状位Cobb角56°~102°,平均73.5°。均采用后路顶椎附近凹侧脊旁软组织、椎板间隙和小关节松解,再用直的短棒连接并强力撑开,矫正部份畸形,再分别在凹侧和凸侧进行双棒进一步矫形和固定。[结果]所有患者均安全完成手术,无神经脊髓损伤等严重并发症发生。术后随访12~60个月,平均36.5个月。术后冠状位Cobb角平均35.3°,矫正63.3%,最后一次随访时平均40.2°,矫正58.2%。术后矢状位Cobb角平均33.4,°矫正54.6%,最后一次随访时平均36.8°,矫正49.9%。[结论]对于椎体间无骨性融合的重度僵硬性脊柱侧凸,在充分松解的基础上,采用直的短棒强力撑开后再矫形,不需要全椎体截骨就能够获得满意的矫形效果,避免了截骨可能出现的并发症。     

经后路多点锚定技术治疗Ⅰ型神经纤维瘤病伴营养不良性脊柱侧凸的临床疗效

[目的]探讨经后路多点锚定技术治疗Ⅰ型神经纤维瘤病伴营养不良性脊柱侧凸的临床疗效。[方法]回顾性研究2005年1月~2013年12月本科收治的Ⅰ型神经纤维瘤病伴营养不良性脊柱侧凸23例;年龄10~22岁,平均13.6岁;其中胸弯13例,胸腰双主弯4例,胸腰弯3例,双胸弯2例,腰弯1例;术前冠状面Cobb角48.9°~91.4°,平均68.3°;凸侧Bending相Cobb角40°~79.2°,平均57.4°;柔韧性8.3%~28.1%,平均15.7%;顶椎旋转度2°~3°,平均2.3°;矢状面胸椎后凸Cobb角46.4°~79.6°,平均58.2°,胸腰段后凸Cobb角21.1°~35.7°,平均28.3°。均采用经后路多点锚定技术进行矫形融合固定。[结果]随访12~96个月,平均52个月。术后冠状面Cobb角16.3°~46.7°,平均28.4°;顶椎旋转度1°~2°,平均1.2°;矢状面胸椎后凸Cobb角16.1°~38.3°,平均25.3°,胸腰段后凸Cobb角-4.3°~18.7°,平均8.9°;术后各指标均获得良好的矫正,侧凸矫正率为46.3%~74.1%,平均56.9%。末次随访时侧凸矫正丢失率仅3.1%,无神经系统并发症,仅1例假关节形成。[结论]经后路多点锚定技术治疗Ⅰ型神经纤维瘤病伴营养不良性脊柱侧凸可获得较满意的矫形融合效果。     

僵硬性脊柱侧凸前、后路松解效果的比较

目的:比较前、后路松解在僵硬性脊柱侧凸分期治疗中的效果,分析前、后路松解的手术适应证。方法:79例僵硬性脊柱侧凸患者(均为先天性或特发性脊柱侧凸患者),分别一期行脊柱前路或后路松解,头颅骨盆环牵引2～5周,平均18d,二期行矫形内固定术。前路松解组40例,其中先天性脊柱侧凸18例,特发性脊柱侧凸22例。后路松解组39例,其中先天性脊柱侧凸19例,特发性脊柱侧凸20例。对两组患者松解术前、术后Cobb角及脊柱畸形改善率、手术时间和手术并发症进行分析比较。结果:前路松解组先天性脊柱侧凸患者的Cobb角由101°矫正至61°,特发性脊柱侧凸由96°矫正至53°;后路组先天性脊柱侧凸由106°矫正至78°,特发性脊柱侧凸由89°矫正至63°,脊柱畸形改善率前路松解优于后路松解(P<0.05)。两组的手术时间、手术并发症均无显著性差异。结论:前路松解的脊柱畸形改善率明显优于后路松解,前路松解更适合于僵硬性脊柱侧凸的一期松解,不适合行前路松解的患者可选择后路松解。     

前路松解联合后路矫形固定治疗重度脊柱侧凸

目的：评价前路松解联合后路矫形对重度脊柱侧凸的治疗效果。方法：2000年7月至2007年1月采用前路松解联合后路矫形固定治疗重度脊柱侧凸23例,男12例,女11例;年龄9～18岁,平均15.3岁。其中先天性半椎体脊柱侧凸9例,特发性脊柱侧凸13例,神经纤维瘤病性脊柱侧凸1例。冠状面上Cobb角81°～126°,平均97.4°。结果：术后侧凸Cobb角为10°～55°,平均37.4°,平均矫正率56.2%。身高增加0.5～7.5cm,平均5.2cm。全部病例均获随访,时间6～24个月,平均10个月,2例出现交界区＂附加＂现象,无断棒、脱钩等并发症。结论：脊柱前路松解安全、有效,联合后路矫形内固定治疗重度脊柱侧凸可获得满意治疗效果。     

胸腔镜下前路松解联合后路矫形治疗脊柱畸形

目的:评价胸腔镜下前路松解联合后路矫形对脊柱畸形的治疗效果。方法:回顾性分析我院收治的19例脊柱畸形行胸腔镜辅助前路松解及后路脊柱畸形矫形植骨融合术患者的临床资料及治疗结果。结果:胸腔镜手术时间平均120min,前路松解、阻滞椎间盘平均4.2个。术后14例特发性脊柱侧凸Cobb角平均被纠正到29.4°,4例神经纤维瘤病性脊柱侧凸Cobb角平均被纠正到28°,1例胸椎后凸Cobb角被纠正到58.5°。术后平均随访17.5个月,无矫正度的丢失和其它神经系统及血管损伤并发症。结论:胸腔镜辅助前路脊柱松解是安全、有效的微创手术,联合后路矫形治疗脊柱畸形可获得满意治疗效果。     

前路ADS联合后路PRSS应用治疗重度僵硬脊柱侧弯

[目的]研究前后路联合矫形治疗僵硬脊柱侧弯畸形。[方法]男6例,女12例;年龄11~18岁,平均15.2岁,先天性胸腰段侧凸8例,胸段侧凸 胸腰段侧凸9例,其中Luque氏棒后路矫形后翻修1例。均采用前路松解后,进行ADS(anterior derotation spondylodese,ADS)前路矫形,2周后再进行后路PRSS(plate-rod system forscoliosis)矫形。[结果]本组病例获得6个月~2年(平均18个月)随访,其矫形效果满意。术前平均Cobb s角99.4°(70°~110°),术后平均Cobb s角42.4°(30°~64°),平均矫正率57.4%。侧弯(冠状面畸形)矫正效果良好,平背或后凸畸形者与腰椎前凸术后基本达到正常的矢状重建。无明显并发症。仅内固定棒断裂1例。[结论]前后路联合矫形治疗重度脊柱侧弯畸形可取得较好的矫正结果。     

胸腰段骨折前路与后路手术对侧方成角的影响

[目的]探讨胸腰段骨折前路与后路手术纠正脊柱侧方成角的效果。[方法]回顾分析本院自2007年1月~2011年6月胸腰段骨折手术患者117例,行前路手术者42例,行后路手术者75例。术后随访时间3~19个月,平均11.5个月,随访率91.4%,行术前、术后早期、末次随访时冠状位Cobb角测量并比较。[结果]对于术前冠状面Cobb角5°病例,前路手术术后冠状面Cobb角减小值较后路手术大(t=5.94,P0.05);对于术前冠状面Cobb角5°病例,前路手术较后路手术术后侧方畸形发生率更高(x~2=4.88,P0.05);前或后路手术患者如术后冠状面Cobb角小于10°,当其骨性愈合时冠状面Cobb角并未明显进展(P0.05);如术后冠状面Cobb角≥10°,其骨性愈合时冠状面Cobb角较前有进展(P0.05)。[结论]胸腰椎前路手术较后路手术能更好矫正侧方成角畸形,但也增加发生医源性侧凸畸形的风险;胸腰椎骨折术后出现或存留轻度侧凸畸形通常不会导致畸形持续进展,亦不产生明显临床症状,可以保守观察。     

一期前路松解后路三维矫形治疗重度僵硬性脊柱侧凸

目的探讨一期前路松解后路三维矫形治疗重度僵硬性脊柱侧凸的手术策略,并评价其疗效。方法1997年7月～2003年1月应用一期前路松解后路三维矫形治疗重度脊柱侧凸36例,男9例,女27例;年龄13～39岁,平均17.2岁。其中特发性脊柱侧凸33例,神经纤维瘤病性脊柱侧凸3例。术前冠状面Cobb角85°～116°,平均96.2°;矢状面异常20例。前路行凸侧松解、椎间植骨后,同次麻醉下再行后路CD(4例)、CD-Horizon(5例)、TSRH(10例)或Isola(17例)脊柱内固定器械三维矫形内固定及植骨融合,其中31例行胸廓成形术。结果全部病例随访6～48个月,平均24个月。术后冠状面Cobb角30°～65°,平均47.6°,平均矫正率48.5%;80.6%的患者术后维持或达到矢状面平衡。未发生严重的神经系统并发症,无脱钩、断棒及深部感染。术后气胸2例,创伤性胸膜炎1例,术后2年假关节形成1例,术后11个月躯干失平衡1例。随访1年后矫正度丢失大于10°者2例,平均丢失5.2°。结论对重度僵硬性脊柱侧凸应用一期前路松解、后路三维矫形的方法矫形满意。正确选择病例、术前仔细评估、术中应用SEP及唤醒试验可减少神经系统并发症的发生。其远期疗效尚待进一步观察。     

青少年特发性胸椎侧凸胸腔镜辅助前路矫形的疗效

目的 介绍特发性胸椎侧凸胸腔镜辅助小切口前路矫形手术的技术要点和手术适应证选择,并对其临床结果进行分析.方法 2001年7月至2006年1月共进行胸椎侧凸小切口前路矫形手术37例,男4例,女33例,平均年龄14.1岁,冠状面Cobb角平均56°,Lenke分型Ⅰ A 14例,Ⅰ B14例,Ⅰ C 9例,均为胸椎右侧凸,Risser征++～++++,对手术时间、术中出血量、固定节段、矫正效果以及矫正丢失等进行分析.结果 平均手术时间220 min,术中出血量平均320 ml,平均固定节段7.8个,术后Cobb角平均16.8°,平均侧凸矫正率70%,随访18～36个月,平均矫正丢失4.6%,无内固定并发症发生.结论 胸椎侧凸前路胸腔镜辅助小切口矫形手术在减少手术创伤、降低麻醉要求、相对胸腔镜手术更为宽松的适应证选择基础上,可以达到传统开胸前路矫形或后路矫形手术的临床效果、且没有增加手术并发症.     

胸腔镜与开胸前方松解在脊柱侧凸后路矫形中的作用

目的比较胸腔镜与开胸前方松解对脊柱侧凸后路矫形的作用,评估胸腔镜脊柱侧凸前方松解手术的临床效果。方法2001年11月～2002年9月共施行14例胸腔镜脊柱侧凸前方松解手术和22例开胸前方松解手术,所有病例均为特发性脊柱侧凸。胸腔镜组男1例,女13例;平均年龄15.9岁;其中KingⅡ型9例,KingⅢ型5例;Cobb角88°±10.4°,柔软度(Bending片侧凸矫正率)25.5%±6.1%;松解节段5.8±0.9个。开胸组男5例,女17例;平均年龄15.5岁;其中KingⅡ型13例,KingⅢ型9例;Cobb角90°±15.2°,柔软度24.8%±7.8%;松解节段6.0±1.1个。两组患者均于前方松解后2周行后路TSRH矫形手术。对两组的术后侧凸矫正率以及半年后的矫正丢失率进行比较。结果胸腔镜组术后Cobb角39.6°±10.8°,侧凸矫正率54.7%±10.3%,半年后矫正丢失率2.9%±1.1%;开胸组术后Cobb角41.9°±13.2°,侧凸矫正率53.2%±12.5%,半年后矫正丢失率3.2%±1.3%。两组比较差异均无显著性(P >0.05)。结论胸腔镜脊柱侧凸前方松解手术能达到开胸前方松解手术的临床效果。     

Mini-open anterior spine surgery for anterior lumbar diseases

Minimally invasive surgeries including endoscopic surgery and mini-open surgery are current trend of spine surgery, and its main advantages are shorter recovery time and cosmetic benefits, etc. However, mini-open surgery is easier and less technique demanding than endoscopic surgery. Besides, anterior spinal fusion is better than posterior spinal fusion while considering the physiological loading, back muscle function, etc. Therefore, we aimed to introduce the modified “mini-open anterior spine surgery” (MOASS) and to evaluate the feasibility, effectiveness and safety in the treatment of various anterior lumbar diseases with this technique. A total of 61 consecutive patients (46 female, 15 male; mean age 58.2 years) from 1997 to 2004 were included in this study, with an average follow-up of 24–52 (mean 43) months. The disease entities included vertebral fracture (20), failed back surgery (13), segmental instability or spondylolisthesis (10), infection (8), herniated disc (5), undetermined lesion for biopsy (4), and hemivertebra (1). Lesions involved 13 cases at T12–L1, 18 at L1–L2, 18 at L2–L3, 22 at L3–L4 and 11 at L4–L5 levels. All patients received a single stage anterior-only procedure for their anterior lumbar disease. We used the subjective clinical results, Oswestry disability index, fusion rate, and complications to evaluate our clinical outcome. Most patients (91.8%) were subjectively satisfied with the surgery and had good-to-excellent outcomes. Mean operation time was 85 (62–124) minutes, and mean blood loss was 136 (minimal-250) ml in the past 6 years. Hospital stay ranged from 4–26 (mean 10.6) days. Nearly all cases had improved back pain (87%), physical function (90%) and life quality (85%). Most cases (95%) achieved solid or probable solid bony fusion. There were no major complications. Therefore, MOASS is feasible, effective and safe for patients with various anterior lumbar diseases.     

Revision anterior shoulder repair for recurrent anterior glenohumeral instability

Although the operative management of recurrent anterior glenohumeral instability has received significant attention in literature, the outcome of revision anterior shoulder repair is much less frequently reported. We report the results of our experience with this challenging problem. Retrospective chart review identified 29 patients who underwent revision anterior shoulder repair. Prior procedures included eight Bankart repairs, seven capsular shifts, 10 combined Bankart and capsular shift procedures, three Putti-Platt procedures, two staple capsulorrhaphies, two Bristow procedures, seven arthroscopie procedures, and one Magnuson-Stack. The average age of the patients was 31.6 years (range: 18 to 52 years) and the dominant extremity was involved in 69%. Findings at the time of revision anterior shoulder repair included 22 patients with capsulolabral detachment, 24 with capsular redundancy, and 14 with rotator interval defects. Twenty-three of the 29 patients were available for at least a two-year follow-up. Twenty-one (91%) remain stable. One patient was non-compliant with the postoperative immobilization and re-dislocated within the first month. The second patient, who had a prior Bankart procedure followed by a capsular shift two years later, underwent a capsular shift for significant capsular laxity. He re-dislocated approximately 15 months postoperatively. Our success rate of 91% in this small series approaches the results of primary open repair for recurrent glenohumeral instability. To achieve a successful outcome, it is essential to address all pathology at the time of revision repair.     

Microscopic anterior foraminal decompression combined with anterior lumbar interbody fusion

Background context

Anterior lumbar interbody fusion (ALIF) with percutaneous pedicle screw fixation (PPF) provides successful surgical outcomes to isthmic spondylolisthesis patients with indirect decompression through foraminal volume expansion. However, indirect decompression through ALIF followed by PPF may not obtain a successful surgical outcome in patients with isthmic spondylolisthesis accompanied by foraminal stenosis caused by a posterior osteophyte or foraminal sequestrated disc herniation. Thus far, there has been no report of foraminal decompression through anterior direct access in the lumbar spine.

Purpose

This study aims to describe the new surgical technique of microscopic anterior foraminal decompression and to analyze the clinical outcomes and radiologic results of the microscopic anterior decompression during ALIF followed by PPF.

Study design/Setting

We conducted a multisurgeon, retrospective, clinical series from a single institution.

Patient sample

This study was carried out from March 2007 to July 2010 and included 40 consecutive patients with isthmic spondylolisthesis accompanied by foraminal stenosis caused by posterior osteophyte or foraminal sequestrated disc herniation undergoing microscopic anterior foraminal decompression during ALIF followed by PPF.

Outcome measures

The visual analog scales (VAS) of back and leg pain and the Oswestry disability index were measured preoperatively and at the last follow-up.

Methods

Postoperative computed tomography and magnetic resonance imaging measured whether decompression of neural structure had been made and morphometric change of the foramen and the amount of resected bone. Moreover, segmental lordosis, whole lumbar lordosis, disc height, and degree of listhesis were measured through X-ray examination before the operation and at the last follow-up; we also verified whether fusion had been achieved.

Results

Successful decompression was confirmed in both patients with foraminal stenosis caused by posterior osteophyte and those with foraminal sequestrated disc herniation. Clinically, compared with before the surgery, the VAS (leg and back) and the Oswestry disability index significantly decreased at the last follow-up (p=.000). With regard to radiology, at the last follow-up all patients had bone fusion on X-ray examination, and an increase in disc height, a reduction in the degree of listhesis, an increase in segmental lordosis, and an increase in whole lumbar lordosis were significant in both groups (p=.000) compared with before the surgery. Foraminal volume, foraminal width, and foraminal height also significantly increased postoperatively compared with before the operation (p=.000). The height, width, and dimension of resected body were 4.61±1.05 mm, 7.92±1.42 mm, 17.15±4.96 mm², respectively, in patients with foraminal stenosis caused by a posterior osteophyte, and 3.88±0.92 mm, 6.8±1.29 mm, and 13.12±2.25 mm², respectively, in patients with foraminal sequestrated disc.

Conclusions

The microscopic anterior foraminal approach provides successful foraminal decompression. Combined with ALIF and PPF, this approach shows a good surgical outcome in patients with isthmic spondylolisthesis accompanied by foraminal stenosis caused by a posterior osteophyte or those with foraminal sequestrated disc herniation.     

Laparoscopic anterior gastroplasty

Background: The treatment of the morbidly obese patient is difficult because compliance with dietary regimens is poor. As a result, most weight reduction programs fail very quickly. Surgical treatment, on the other hand, provides a reliable method for sustained weight reduction. The most frequently performed procedure has been the vertical banded gastroplasty. Adaptation of the standard open procedure to laparoscopic techniques has been technically difficult and imprecise. We have developed, in the laboratory, an anterior wall banded gastroplasty that can be performed precisely and reproducibly using laparoscopic techniques. Methods: Five Yorkshire pigs were used in attempt to laparoscopically perform the standard vertical banded gastroplasty. The procedure was difficult and was associated with a risk of staple line leak and with bleeding along the lesser curvature of the stomach. Furthermore, a reproducible pouch of proper dimension could not be created reliably. Fifteen animals were then used to develop a new technique using a small gastric pouch based on the anterior gastric wall. Results: A reproducible pouch, 4 cm in length, was created over an 18-Fr nasogastric tube. A standard polyproylene band of 5.2 cm in length was utilized at the gastric pouch outlet. Conclusions: This operation can be reproduced accurately and has not demonstrated any leaks on postmortem examination. Received: 14 July 1997/Accepted: 4 February 1998     

Peripheral anterior synechiae formation with anterior chamber intraocular lenses.

In a cross-sectional study, 88 eyes with anterior chamber intraocular lenses (AC-IOLs) were evaluated by goniophotography by one masked observer for the presence of peripheral anterior synechiae (PAS) and by another masked observer for the length of the AC-IOL. Sixty-eight of the 88 lenses had PAS which were strongly correlated with the lens being oversized (P less than .001). However, differences in haptic style or lens rigidity were not associated with the presence of PAS.     

Meningocele sacralis anterior

Ohne Zusammenfassung Mit 3 Abbildungen.