单纯后路多个全脊椎切除矫治严重脊柱侧、后凸畸形

目的评价严重脊柱侧、后凸畸形单纯后路多节段全脊椎切除,侧后凸畸形矫正技术的手术矫治效果和临床风险性。方法2003年1月~2001年1月,本院骨科收治38例严重脊柱侧、后凸畸形患者,全部病例均采用单纯后路多节段全脊椎切除的方法。全部病例手术前均行站立位X线脊柱全长片、核磁共振和三维CT重建等辅助检查,计算手术时间、出血量,观察手术前后侧后凸的矫正率、术中脊柱短缩,手术后整体平衡情况。结果本组患者均进行1.5~3个椎体的全脊椎切除,术中测量脊柱短缩42 mm(31~62 mm),手术平均用时348 m in(280~510 m in),手术中平均出血量2010 m l(1400~3200 m l)。全部病例经过1~2.5年的随访,侧凸畸形cobb角平均矫正率为56.3%(51.2%~64.2%);后凸畸形平均矫正率为75.6%(67.8%~81.4%)。所有患者躯干平衡良好,未发现失代偿现象。手术并发症包括3例出现一过性的脊髓损伤症状(1例一过性双侧下肢不全瘫、2例一过性单侧下肢不全瘫)和6例神经根性疼痛,未经特殊处理恢复正常,4例肠系膜上动脉综合症,经胃肠减压处理症愈。结论对于严重成人脊柱侧、后凸畸形患者,单纯后路顶椎附近多个椎体全脊椎切除技术三维矫正效果满意,安全有效。     

后路脊椎V型截骨术治疗创伤性脊柱后凸畸形

目的总结应用椎弓根钉-棒系统后路脊椎V型截骨术治疗创伤性脊柱后凸畸形的临床经验、技术要点及效果。方法将创伤性脊柱后凸畸形的病人分为两组，进行对比分析。治疗组：应用椎弓根钉-棒系统后路V型截骨内固定术29例；对照组：应用前路椎体骨折复位内固定融合术26例。结果与对照组相比，治疗组术后畸形复发率显著低于对照组（P〈0．05），断钉、松动等并发症发生率显著低于对照组（P〈0．05），骨折不融合、纠正后凸畸形度数对比无显著性差异（P〉0．05）。结论应用椎弓根钉-棒系统后路V型截骨术治疗的创伤性脊柱后凸畸形可有效防止手术后畸形再发生，矫正后凸畸形彻底、安全、可靠。     

Surgical treatment of symptomatic degenerative lumbar spondylolisthesis by decompression and instrumented fusion

Degenerative spondylolisthesis is characterized by the slippage of one vertebral body over the one below, with association of intervertebral disc degeneration and degenerative arthritis of the facet joints, which cause spinal stenosis. The aim of this study was to evaluate the clinical and radiographic results of 22 patients with symptomatic degenerative spondylolisthesis, operated on by decompressive laminectomy and instrumented posterolateral fusion associated with interbody fusion (PLIF). Mean age at surgery was 64 years (range, 57–72). Clinical results were evaluated on a questionnaire at the last follow-up visit concerning postoperative low back and leg pain, restriction of daily life activities, and resumption of sports activity. Lumbar spine radiographs were used to evaluate the status of fixation devices, the reduction of the spondylolisthesis, the lumbar sagittal balance and the presence of spinal fusion. No intraoperative or postoperative complications were encountered. There were no superficial or deep infections, fixation device loosening, or hardware removal. Mean follow-up time was 4 years (range, 3–6 years). Clinical outcome was excellent or good in 19 patients and fair in 3 patients. Preoperatively, mean forward vertebral slipping on neutral lateral radiographs was 5 mm, while postoperatively it decreased to 3 mm. Preoperatively, mean sagittal motion was 3 mm and angular motion was 8°, while postoperatively these values decreased to 1 mm and 1°, respectively. This study demonstrated that spinal decompression followed by transpedicular instrumentation associated with PLIF technique is a valid surgical option for the treatment of degenerative spondylolisthesis with symptomatic spinal stenosis. Clinical outcome, intended as relief of pain and resumption of activity, was improved significantly and fusion rate was high.     

Idiopathic scoliosis: biomechanics and biology

For whatever reason, right-left asymmetry has attracted an illogical proportion of research effort. Non-structural scoliosis, for example secondary to a leg length inequality, is indeed a problem of right-left asymmetry, but structural scoliosis is a complex three-dimensional deformity involving all planes. Biomechanical, biological and clinical evidence indicates clearly that the problem is one of front-back asymmetry and not right-left. The importanc of biological factors lies in their ability to bring the spinal column to and beyond its buckling threshold. Thus a taller and more slender spine is more liable to bend and, being stiffer in the sagittal plane, favours movement into other planes. This epitomises the spine of the scoliosis patient who is growing faster with a spinal template similar to other family members allowing idiopathic scoliosis to express itself genetically. It is the opposite condition to idiopathic hyperkyphosis (Scheuermann's disease), but this deformity is rotationally stable, thus remaining in the sagittal plane. The presence of an adjacent area of lordo-scoliosis below the region of hyperkyphosis testifies to the common nature of the pathogenesis of idiopathic scoliosis and Scheuermann's disease. It is the area of compensatory hyperlordosis below the Scheuermann's area that has obligatorily buckled and represents a human model supporting the lordosis theory, as does surgically tethering the back of the young growing human spine, which crankshafts accelerated progression. Similarly the only successful animal model of the formation of idopathic follows creation of a lordotic spinal segment in an otherwise kyphotic spine. For centuries, engineers have recognised that the mechanical behaviour of a column under load is influenced by geometry, as well as by material properties; it is clear that the spinal column also obeys these well-described laws.     

退行性腰椎管狭窄症相关指南的质量评价和推荐意见比较研究

背景 退行性腰椎管狭窄症（DLSS）是一种老年多发,严重影响患者正常生活且医疗费用负担较重的疾病。DLSS治疗方法较多,开发高质量的临床实践指南和临床医生应用高质量指南是提高DLSS诊疗水平的重要途径。目的 采用AGREEⅡ及RIGHT评价DLSS相关指南的方法学及报告质量,为DLSS指南制订及报告提供参考依据。方法 计算机检索中国生物医学文献数据库（CBM）、中国知网（CNKI）、万方数据知识服务平台（Wanfang Data）、维普网（VIP）、PubMed,补充检索医脉通数据库（Medlive）、世界卫生组织（WHO）、英国国家临床优化研究所（NICE）、国际指南协作网（GIN）、美国国立指南文库（NGC）和苏格兰院际间协作网（SIGN）等指南库中有关DLSS的临床实践指南、共识或规范,检索时限均为2010-01-01至2022-01-01。由两位评价员独立对纳入文献进行方法学质量及报告质量评价,并在文献中推荐意见等级统一前提下进行比较。结果 共纳入6篇文献,其中4篇指南,2篇共识;1篇指南为中医指南,3篇指南为循证指南。AGREEⅡ评价结果显示纳入6篇文献的实际总得分/总最高可...     

经皮脊柱内镜下可视化置钉在Endo-LIF椎弓根螺钉置钉中的应用价值

研究经皮内镜下可视化置钉在经皮内镜下后路腰椎融合术（End-PLIF）椎弓根螺钉置钉中的应用价值。方法 纳入2020年10月—2021年4月我院有腰椎融合手术指征的腰椎间盘源性腰痛、腰椎管狭窄症伴腰椎不稳、腰椎间盘突出症伴腰椎不稳、腰椎滑脱症（Meyerding分级I、II）患者共50例。50例患者随机分为甲、乙两组,每组25例。甲组的手术方式为经皮内镜下后路腰椎融合术+经皮脊柱内镜下可视化椎弓根螺钉置钉,乙组的手术方式为经皮内镜下后路腰椎融合术+传统X线透视下经皮椎弓根螺钉置钉。比较两组X线透视总次数、导丝置入时间、手术时间、术后住院时间;采用Gertzbein-Robbins标准评价置钉优良率;术前及术后24 h VAS评分和ODI指数、改良Macnab标准及术后并发症的发生率评价疗效。同时对经皮内镜下改进的置钉器械进行3D打印制造并验证其可行性、实用性。通过上述指标观察其医患X线辐射情况、微创性、置钉的优良率及手术效果。结果 全部患者均完成了手术和随访。甲组患者X线透视总次数、手术时间、导丝置入时间,均少于乙组（P＜0.05）,两组术后住院时间比较差异无统计学意义（P＞0.05）。两组术前、术后24 h VAS、ODI比较差异无统计学意义（P＞0.05）,但两组术后24 hVAS、ODI均较术前改善（P＜0.05）。末次随访时,两组患者改良Macnab标准的优良率比较差异无统计学意义（P＞0.05）。甲组经皮内镜置钉优良率优于乙组（P＜0.05）。两组患者术后并发症发生率比较差异无统计学意义（P＞0.05）。结论 经皮内镜下置钉能减少医患X线辐射次数,降低医患辐射暴露风险,且置钉的优良率较高;同时,3D打印的经皮内镜下置钉器械具有可行性和实用性     

骨水泥强化椎弓根螺钉固定治疗老年退行性腰椎疾病的疗效观察

目的评价骨水泥强化椎弓根螺钉固定治疗老年退行性腰椎疾病的近期临床疗效。方法回顾性分析2011年6月~2013年5月采用聚甲基丙烯酸甲酯(PMMA)骨水泥强化椎弓根螺钉固定结合后路椎体间植入聚醚醚酮(PEEK)材质椎间融合器治疗老年退行性腰椎疾病30例。所有患者术前骨密度检测均符合骨质疏松诊断(超声骨密度值测定-2.5)。结果 30例患者均顺利完成手术,术中无神经及硬膜损伤,骨水泥无严重渗漏,术后复查X线、CT显示骨水泥分布均匀。随访10~21个月,平均(16±2.11)个月,神经受压症状均得到改善。VAS评分术前(7.01±1.44)、术后6个月随访为(3.00±0.57)、末次随访为(2.23±1.19);JOA评分术前为(9.98±5.64)、术后6个月随访为(17.99±1.41)、末次随访为(18.42±1.47);ODI评分术前为(0.64±0.24)、术后6个月为(0.27±0.07)、末次随访为(0.22±0.09)。三项评分术后6个月、末次随访分别与术前对比差异有统计学意义;术后6个月和末次随访对比差异无统计学意义。末次随访时复查X线或CT显示椎弓根螺钉无松动,椎间融合器无下沉,椎间融合满意,融合率为86.7%。结论使用骨水泥强化椎弓根螺钉能够提高螺钉对伴有骨质疏松的椎体的握持力,防止椎弓根螺钉松动,保证较高的椎间融合率,是治疗老年退行性腰椎疾病一种安全而有效的手术方式。     

颈椎后路术后颈椎曲度不良与疗效的相关性

目的：探讨颈椎后路手术治疗颈椎退变性疾病后颈椎曲度不良与疗效的相关性。方法：采用颈椎后路减压术治疗颈椎退变性疾病患者85例,其中全椎板减压术26例、单开门椎管扩大成形术39例和单开门棘突重建扩大成形术20例,观察手术后颈椎后凸畸形对治疗效果的影响。结果：经6-72个月,平均18个月随访,颈椎后凸与否,各组之间神经功能改善率差异无统计学意义（P〉0.05）;单开门椎管扩大成形术与单开门棘突重建椎管扩大成形术,术后颈椎后凸发生率低于全椎板减压术（P〈0.05）;颈椎无后凸与轻度后凸（与A、B、C的对应关系）畸形之间的轴性症状发生率无差异,但与明显后凸组相比有差异性（P〈0.05）。结论：颈椎后路减压术是治疗颈椎退变性疾病常用的手术方法,具有椎管容积扩大明显等优点。但减少手术对后方肌肉韧带复合体损伤并对此复合体进行有效修复,可以减少颈后凸畸形和轴性症状发生,提高手术效果。     

多发颈椎不连综合征的影像学特点与外科诊疗策略

【摘要】 目的：分析多发颈椎不连综合征（multilevel cervical disconnection syndrome,MCDS）的影像学特点及外科诊疗策略。方法：2004年3月~2021年6月,我院收治MCDS患者共7例,男性3例,女性4例;年龄5~46岁（中位年龄12岁）。7例MCDS患者中,平均椎体发育不良节段数3.6±1.3个节段,平均椎弓不连节段数5.7±1.5个节段,局部后凸角平均-92.2°±20.2°,C2-7 Cobb角平均-68.6°±31.0°,T1倾斜角（T1 slope,T1S）平均-12.5°±12.5°,后凸顶点位于C4节段1例,C5节段5例,T1节段1例;术前改良日本骨科学会评分（mJOA评分）8.5~14分（平均12.6±2.1分）,其中1例患者伴有吞咽困难。记录患者预矫形方式及手术方式,入院时、预矫形后、术后及末次随访影像学参数,神经功能及并发症。结果：1例术前接受颅骨牵引,3例接受平衡悬吊牵引,3例接受联合牵引,经术前牵引预矫形后,局部后凸角矫正率为60.8%。1例接受手术松解、Halo-vest外固定治疗,1例接受前路矫形内固定手术,1例接受后路矫形固定融合术,4例接受前-后联合手术治疗,手术固定6.0±2.1个节段,2例患者出现术后神经系统并发症,接受翻修手术。术后随访时间6~84个月（41.2±32.0个月）,末次随访局部后凸角平均-27.9°±11.6°,矫正率69.7%,C2-7 Cobb角平均-13.3°±28.4°,T1S平均4.9°±17.9°;术后mJOA评分10.5~17分（15.7±2.3分）,改善率78.3%。对比手术前后临床及影像学指标,mJOA评分、C2-7后凸角、局部后凸角及T1S有统计学差异。结论：MCDS影像学上主要表现为前方椎体发育不良伴多节段椎弓不连,继发严重后凸畸形。治疗策略可采取术前牵引预矫形并前路多节段椎体切除重建、后路长节段固定融合。