选择性连续三节段椎间融合器置入对脊髓型颈椎病患者颈椎曲度的长期影响

目的:评价选择性颈椎前路三节段椎间融合术治疗脊髓型颈椎病对颈椎曲度的长期影响。方法:应用Solis融合器行选择性连续三节段颈前路手术治疗脊髓型颈椎病共25例,C3/4/52例,C4/5/6 8例,C5/6/714例,C6/7/T11例,共75个椎间隙。所有患者均随访2年以上。收集术前、术后6个月及术后2年的Borden法颈椎前曲度数据及颈椎Japan orthopedics association(JOA,17分法)评分予以统计学分析。结果:出血量20~80 ml,平均37 ml,手术时间100~175 min,平均118 min。平均随访31.3 ms,手术节段均骨性融合,无植入物移位或椎体塌陷。术前JOA评分(10.31±3.44)分,术后6个月(16.72±1.36)分,术后2年(15.59±1.71)分;术前颈椎曲度均值为(1.82±3.13)mm,术后6个月为(4.59±1.68)mm,术后2年为(4.38±2.25)mm。以上各组数据术前与术后6个月,术前与术后2年间差异均有统计学意义(P<0.05),术后6个月与术后2年间差异均无统计学意义(P>0.05)。结论:行颈椎前路连续三节段椎间融合器植术治疗脊髓型颈椎病可有效改善颈椎曲度并长期维持,有良好的临床疗效。     

术前Halo重力牵引辅助治疗青少年重度脊柱侧凸畸形的临床疗效

目的:探讨术前Halo重力牵引辅助治疗青少年重度脊柱侧凸畸形患者的临床疗效。方法:回顾性分析2009年1月至2014年12月第二军医大学长征医院脊柱外科收治的37例青少年重度脊柱侧凸患者的临床资料,所有患者术前均接受Halo重力牵引治疗,随访时间1~4个月。结果:与牵引前相比,牵引后冠状面Cobb角明显降低,差异有统计学意义[(99.5±14.4)°vs(73.2±9.3)°,P0.01]。与牵引前相比,牵引后患者用力肺活量(forced vital capacity,FVC)明显上升[(1.97±0.35)L vs(2.34±0.22)L],1秒用力呼气容积(forced expiratory volume in one second,FEV_1)明显上升[(1.75±0.28)L vs(2.08±0.15)L],血浆白蛋白明显上升[(33±9)g/L vs(38±3)g/L],差异均有统计学意义(P0.01)。牵引前后主弯变化量与FVC变化量正相关(r=0.230,P=0.004),与FEV_1变化量正相关(r=0.216,P=0.007)。牵引过程中1例患者出现左上肢麻木。结论:术前Halo重力牵引可缓慢矫正重度脊柱侧凸青少年患者脊柱畸形,增强肺功能水平,提高营养水平,但应避免牵引相关神经并发症的发生。     

伴有椎动脉优势的下颈椎椎弓根形态学的CT观察

目的 :观察存在椎动脉优势(一侧直径较对侧大0.8mm以上)的下颈椎椎弓根的形态学特点,探讨其对椎弓根螺钉置钉的影响。方法:回顾性分析我科2016年1月1日~2017年7月1日因颈椎疾患行椎动脉CT造影(CT angiography,CTA)患者的影像学资料。在CT三维重建上测量椎动脉直径(vertebral artery diameter,VAD),将存在椎动脉优势患者纳入研究,VAD较大的一侧为椎动脉优势侧,较小的一侧分为椎动脉非优势侧。共纳入存在椎动脉优势患者68例。其中男42例,女26例,年龄12~81岁,平均56.3±13.0岁。在CT三维重建上测量C3~C6椎体双侧的以下参数:VAD、椎弓根宽度(pedicle outer width,POW)、椎弓根外侧壁到椎动脉内侧距离(lateral pedicle border to vertebral artery,LPVA)、横突孔面积(area of transverse foramen,ATF),并计算:椎动脉横截面积(area of vertebral artery,AVA)=π×(VAD/2)2;横突孔占用率(occupation ratio of transverse foramen,ORTF)=AVA/ATF。比较优势侧与非优各参数的差异,分析与椎动脉优势的相关性;统计双侧POW4mm比例,并纵向比较优势侧各椎体参数差异,判断椎弓根螺钉置钉风险。结果 :存在椎动脉优势患者中,左侧优势占75%,右侧优势占25%。VAD优势侧平均为3.78±0.49mm,非优势侧为2.29±0.53mm;POW优势侧宽度为5.07±0.98mm,非优势侧为5.46±0.94mm,LPVA优势侧与非优势侧分别为1.04±0.50mm和1.18±0.56mm,ATF优势侧与非优势侧分别为29.00±6.87mm2和20.41±5.40mm2,ORTF优势侧与非优势侧分别为(40.5±8.5)%和(22.6±8.9)%。优势侧与非优势侧相比,POW、LPVA及ATF、ORTF存在统计学差异(P0.05)。POW4mm的比例优势侧与非优势侧分别为9.9%和4%。优势侧纵向对比,各参数在C3、C4较小,C5、C6较大。结论:椎动脉优势侧POW、LPVA小于非优势侧,POW4mm的比例及ORTF大于非优势侧,优势侧椎弓根螺钉置钉风险高于非优势侧。     

Axial Lumbar and Lumbosacral Interbody Fusion for Degenerative Spine and Adult Deformity: Surgical Technique and The Evidence

Axial lumbosacral interbody fusion (AXIALIF) is an interbody technique that may be performed as part of an anterior arthrodesis of L5-S1 or L4-S1. This minimally invasive, paracoccygeal approach utilizes the presacral space between the sacrum and rectum. Drilling, discectomy, and placement of an implant are all performed under fluoroscopic guidance through the anterior cortex of the sacrum and into the disc space(s). Although the research to date is still somewhat limited, AXIALIF may represent

Relevant anatomy

The AXIALIF procedure involves the placement of instruments along the anterior concavity of S1-S2 through the presacral space, which is bounded anteriorly by the fascia propria of the rectum and posteriorly by the parietal pelvic fascia. In this potential interval, there is a layer of presacral fat between the rectum and sacrum. Superiorly, the presacral space is contiguous with the retroperitoneum. An anatomic study published in 2012 further defined the anatomy of the presacral space.³ In the

Discussion

Several cadaver studies have established the feasibility of the AXIALIF procedure.5, 6 Since this technique spares the annulus and the supporting anterior /posterior longitudinal ligaments, there is increased spinal stability immediately after surgery secondary to ligamentotaxis. A retrospective investigation evaluating the postoperative radiographic outcomes of two-level AXIALIF constructs demonstrated that approximately 85% of patients maintained their preoperative lumbar segmental lordosis.⁷

Complications

The complication rates associated with the AXIALIF technique have varied in the literature, ranging from 1.3%¹⁵ to 26.5%¹⁶. With a reported incidence of up to 2.9%,¹⁶ one of the most serious adverse events is rectal injury necessitating long-term antibiotics and diverting colostomy.¹⁷ Using finger dissection to expose the anterior sacrum and taking care to ensure that no soft tissues structures are in close proximity to the entry point during drilling, discectomy, and insertion of the implant

Conclusion

The AXIALIF technique represents a novel minimally invasive approach for achieving a lumbosacral interbody arthrodesis, utilizing the presacral space. By preserving the integrity of the annulus and spinal ligaments, it may confer greater stability to the operative levels. It is certainly a reasonable treatment option to consider for patients who are not ideal candidates for conventional anterior or posterior lumbar interbody procedures. As with other minimally invasive spinal procedures, the

Disclosures

None.

     

腰椎关节突关节形态变化及其对腰椎退行滑脱的影响

目的：研究腰椎关节突关节形态变化及其对腰椎退行性变滑脱的影响。方法：随机抽取42例腰椎退行性变滑脱(LDS)、52例腰椎间盘突出症(LDH)的病人的X光、CT进行测量其椎间盘的高度比、关节突关节的角度以及关节突关节的横径数据进行统计处理与分析。结果：与LDH组相比，LDS组的关节突关节角偏矢状角，其椎间盘的高度比以及关节突关节的横径均较少。结论：腰椎关节突关节宽基部横径越小，该关节角度越趋于矢状位，腰椎滑移几率越高。     

Segmental cervical instability does not drive the loss of cervical lordosis after laminoplasty in patients with cervical spondylotic myelopathy

BACKGROUND/CONTEXTKyphotic deformity after cervical laminoplasty (CLP) often leads to unfavorable neurological recovery due to insufficient indirect decompression of the spinal cord. Existing literature has described that segmental cervical instability is a contraindication for CLP because it is a potential risk factor for kyphotic changes after surgery; however, this has never been confirmed in any clinical studies.PURPOSETo confirm whether segmental cervical instability was an independent risk factor for postoperative kyphotic change and to examine whether segmental cervical instability led to poor neurological outcomes after CLP for cervical spondylotic myelopathy (CSM).STUDY DESIGN/SETTINGA retrospective studyPATIENT SAMPLEPatients who underwent CLP for CSM between January 2013 and January 2021 with a follow-up period of ≥1 year were enrolled.OUTCOME MEASURESCervical radiographic measurements including C2–C7 lordosis (C2–7 angle), cervical sagittal vertical axis, C7 slope, flexion range of motion (fROM) and extension ROM (eROM) were assessed using neutral and flexion-extension views. Segmental cervical instability was classified into anterolisthesis (AL) of ≥2 mm displacement, retrolisthesis (RL) of ≥2 mm displacement, and translational instability (TI) of ≥3 mm translational motion. The amount of C2–7 angle loss at the follow-up period compared to the preoperative measurements was defined as cervical lordosis loss (CLL). Neurological outcomes were assessed using the recovery rate of the Japanese Orthopedic Association score (JOA-RR).METHODSCLL was compared among patients with and without segmental cervical instability. Further, multiple linear regression model for CLL was built for the evaluation with adjustment of the reported risks, including cervical sagittal vertical axis, C7 slope, fROM, eROM, and patient age together with AL, RL, and TI, as independent variables. The JOA-RR was also compared between patients with and without segmental cervical instability.RESULTSA total of 138 patients (mean age, 68.7 years; 65.9% male) were included in the analysis. AL, RL, and TI were found in 12 (8.7%), 33 (23.9%), and 16 (11.6%) patients, respectively. Comparisons among the groups showed that AL led to greater CLL; however, RL and TI did not. Multiple linear regression analysis revealed that greater CLL is significantly associated with greater fROM and smaller eROM (regression coefficient [β]=0.328, 95% confidence interval: 0.178 to 0.478, p<.001; β=?0.372, 95% confidence interval: ?0.591 to ?0.153, p=.001, respectively). However, there were no significant statistical associations in the AL, RL, and TI. Whereas, patients with AL tended to exhibit lower JOA-RR than those without AL (37.8% vs. 52.0%, p=.108).CONCLUSIONSSegmental cervical instability is not the definitive driver for loss of cervical lordosis after CLP in patients with CSM; thus, is not a contraindication in and of itself. However, it is necessary to consider the indications for CLP, according to individual cases of patients with AL on baseline radiograph, which is a sign of poor neurological recovery.     

Complications associated with cement augmentation techniques in spinal surgery

Metabolic conditions can compromise the integrity of the spine, placing patients at risk of pain, progressive spinal deformity, and failure of instrumentation used in treatment of spinal pathology. Vertebroplasty, kyphoplasty, sacroplasty, and augmented pedicle screws are frequently performed procedures developed to help combat these issues. These procedures are infrequently associated with significant issues, but serious complications from these surgeries can occur. Consequently, it is critical that treating surgeons be aware of the most common complications associated with cement augmentation procedures, as well as understand how to minimize their occurrence, diagnose them swiftly, and manage them appropriately when needed.     

不同侧凸方向的Lenke 5型脊柱侧凸前路矫形疗效的比较

【摘要】 目的：比较不同侧凸方向的Lenke 5型脊柱侧凸前路矫形内固定的手术疗效。方法：对2005年1月~2009年12月期间在我院手术治疗的Lenke 5型青少年特发性脊柱侧凸（AIS）患者进行回顾分析。按照侧凸方向分为左侧凸组（L组,n=38）和右侧凸组（R组,n=14）,在术前、术后及末次随访时的X线片上测量两组患者的如下参数：冠状面参数包括胸弯、胸腰弯/腰弯Cobb角及冠状面平衡等;矢状面参数有胸椎后凸角、胸腰段交界角、腰椎前凸角和整体矢状面平衡等。对两组病例的上述参数进行独立样本t检验,分析比较两组的矫形疗效。结果：两组术前主弯Cobb角、主弯累及节段及代偿胸弯Cobb角均无显著性差异（P＞0.05）。L组、R组平均随访时间分别为3.1±0.9年（2~4年）、2.7±0.8年（2~3年）。与L组相比,R组手术时间（208.8±41.4min vs. 225.6±39.6min）及出血量（236.5±159.6ml vs. 284.4±164.7ml）较多,但均无统计学差异（P=0.132和P=0.345）。L、R组腰弯平均矫正率分别为66.7%和64.4%（P=0.808）,末次随访平均矫正丢失率分别为4.6%和5.1%（P=0.992）;L、R组胸弯平均矫正率分别为49.8%和47.7%（P=0.886）,末次随访时平均矫正丢失率分别为13.4%和14.3%（P=0.759）。两组均无血管损伤及神经并发症,无1例发生内固定失败。L组术后2例患者发生远端Adding-on,1例患者发生近端交界性后凸;R组1例出现近端Adding-on。结论：前路胸腰弯/腰弯矫形融合术是治疗Lenke 5型脊柱侧凸的有效方法,且不同侧凸方向对矫形疗效无明显影响。     

Thoracic spinal cord compression by a tophus

We report a case of thoracic (T10) spinal cord compression by a tophus in a patient with known chronic gout. Spastic paraplegia developed gradually over 6 months in this 43-year-old man with hypertension, alcohol abuse, and chronic gouty arthritis with tophi. Magnetic resonance imaging and computed tomography visualized an intradural nodule measuring 1.5 cm in diameter at the level of T10, as well as geodes in the left T10 lamina and left T9–T10 articular processes. The nodule was removed surgically and shown by histological examination to be a tophus. The neurological impairments resolved rapidly and completely. We found about 60 similar cases in the literature. Spinal cord compression in a patient with chronic gout can be caused by a tophus.     

脊柱外科术后脑脊液漏的诊断及处理

目的探讨脊柱术后脑脊液漏的诊断及处理方法。方法回顾性分析2010年1月~2011年6月脊柱外科手术后出现脑脊液漏的7例病人资料,男4例,女3例,年龄34~64岁,平均48岁,发生于颈椎3例,其余4例均见于腰椎。结果 5例经修补硬脊膜、严密缝合、卧床休息、延长引流时间等愈合,1例拔管后出现脑脊液囊肿并发皮下感染,经伤口加压、抗炎、反复穿刺抽液治愈,1例术后1月复查时发现脑脊液囊肿并低颅压综合征,经再次置管引流治愈。结论术后引流液的量及颜色、术后症状的观察对诊断脑脊液漏至关重要,经积极的保守治疗均能治愈。