Rib-vertebral angle asymmetry in idiopathic, neuromuscular and experimentally induced scoliosis

The concave and convex rib-vertebral angle (RVA) at levels T2–T12 was measured on AP radiographs of 19 patients with right convex idiopathic thoracic scoliosis and 10 patients with major thoracic right convex neuromuscular scoliosis. The difference between the angles on the concave and the convex sides, the RVAD, was calculated. The RVAs were also measured on radiographs from three animal groups in which spinal curves had been induced experimentally in a variety of ways. Group 1 comprised 16 rabbits that had been subjected to selective electrostimulation of the latissimus dorsi, the erector spinae and the intercostal muscles. Group 2 comprised four dead rabbits whose spines had been subjected to manual bending. Group 3 comprised eight rabbits that had undergone mechanical elongation of one rib. In both the idiopathic and the neuromuscular group, the convex RVA was smaller than the concave RVA between levels T2 and T8, with a maximal difference between T4 to T5. From T9 to T12 the concave RVA was smaller than the convex. The RVA in relation to the scoliotic segment, i.e. the apex level of the curve and the two neighbouring vertebrae above and below this level, showed similar results. With increasing Cobb angle the RVADs increased linearly with the greatest difference at the second vertebra above the apex. In the three experimental groups the pattern of the RVADs between T6 to T12 was basically similar to the findings of the clinical study. From the results of these clinical and experimental studies, it is concluded that the typical pattern of the RVAs on the concave and convex sides seems to be independent of the underlying cause of the spinal curvature. It is likely that the RVADs result from a passive mechanical adaptation of the ribs to the lateral curvature of the spine.     

Two cases of fatal air embolism in children undergoing scoliosis surgery

Venous air embolism during surgery is a rare but important complication and can be rapidly fatal. We present two cases of fatal air embolism in the prone position occurring in small children undergoing surgery for progressive scoliosis.
Venous air embolism is a rare complication in the prone position. This is thought to be because in this position there is virtually no gravitational gradient between the site of surgery and the right atrium.
The possible sites of entry of air and ways that this may be minimized are discussed.     

特发性脊柱侧凸King型和型远端融合椎的选择

目的回顾采用椎弓根钩和螺钉CD技术治疗特发性脊柱侧凸King型和型患者,分析选择性缩短融合节段的治疗效果。方法2000年3月~2003年1月,治疗58例特发性脊柱侧凸单胸弯患者,男17例,女41例,年龄12~18岁,平均14岁。其中King型40例,King型18例。胸弯Cobb角平均64°(50~83°),柔韧性62%;腰弯Cobb角平均37°(16~48°),柔韧性105%。腰弯腰骶角平均为17°(10~22°)。所有患者C7重力垂线均不同程度地偏离骶骨中线。采用椎弓根钩和螺钉CD技术矫形治疗,以中立椎为基础选择远端融合椎,所有远端融合节段均未超过中立椎。术后随访摄站立前后位和侧位X线片,观察各项指标的变化。结果患者均获随访1年8个月~3年2个月,平均2.4年,均未出现明显的躯干侧方移位和双肩不平衡。术后Cobb角平均丢失3.1°(-1~5°);最后随访时,胸弯矫正率68%;除2例C7重力垂线偏离骶骨中线1~2cm外,其余均通过骶骨中线;腰弯腰骶角减少至平均8°(2~13°),矫正率为53%;48例远端融合椎为非稳定椎者术后成为稳定椎。与Harrington远端融合椎选择原则相比,患者远端融合椎平均节省1.4个节段(1~2个节段)。结论采用三维节段性器械内固定系统治疗特发性单胸弯时,以中立椎为基础选择远端融合椎,可获得较好的临床效果。     

Penicillamine-Induced Degenerative Dermatoses: Report of a Case and Brief Review of Such Dermatoses

We describe a case of elastosis perforans serpiginosa with additional findings of degenerative skin changes. A 20-year-old man with hepatolenticular degeneration, under prolonged treatment with D-penicillamine, presented with a circular or serpiginous arrangement of nuchal papules. Histopathologically, transepidermal channels were accompanied by granulomatous reactions, with several giant cells engulfing elastic fibers. In addition to these findings of a typical elastosis perforans serpiginosa, we observed scar-like skin changes inside the circular arrangement of the papules. At the scar-like tissue, we found electron-microscopical evidence of randomly aggregated thin collagen fibers with no tendency toward systemic combined bundle formation, which is a characteristic feature of normal collagen fiber formation. Pseudoxanthoma-elasticum-like changes were observed on his neck. On his axillae and groin, slight skin thickening and wrinkling were detected. The diagnosis of elastosis perforans serpiginosa does not represent all of the manifestations or the pathological background described above. The skin manifestations described here represent not only an elastosis but also a total degenerative dermatosis with over-healed collagenosis. Thus, those dermatoses should be summarized as one entity, penicillamine-induced degenerative dermatosis. After considering the pathogenic background and clinical similarities, we further propose to simplify the penicillamine-induced skin manifestations to three categories: acute sensitivity reactions, bullous dermatoses, and degenerative dermatoses.     

低角度青少年特发性脊柱侧凸女性患者的骨密度分析

目的分析低角度青少年特发性脊柱侧凸(adolescent idiopathic scoliosis,AIS)女性患者的骨密度(BMD)和骨矿含量(BMC),探讨其与年龄、生长发育、人体测量学和侧凸角度等的相关性。方法研究对象为218例Cobb角15～40°的女性AIS患者。运用双能X线骨密度吸收仪测定非优势侧股骨颈和腰椎的BMC/BMD。探讨这两个部位的BMC/BMD与患者的年龄、生长发育、人体测量学和侧凸角度等的相关性。结果所有患者的年龄平均为(13.4±1.4)岁,Cobb角平均为(28.3±6.2)°。股骨颈BMD平均为(0.827±0.103)g/cm2,腰椎BMD平均为(0.887±0.124)g/cm2,显著低于同龄健康女性儿童;股骨颈BMC平均为(3.49±0.56)g,腰椎BMC平均为(29.78±7.37)g。患者的BMC/BMD与Cobb角无显著相关,而与体重、身高、Risser征、月经状况、BMI和年龄显著相关。逐步回归分析显示,体重和年龄是影响患者BMD的主要因素。结论低角度女性AIS患者存在全身性的骨量减低,且与Cobb角无显著相关,而与生长发育和人体测量学相关指标显著相关。这提示AIS患者的骨量减低与生长发育和低体重有关。     

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。     

特发性脊柱侧凸PUMC分型的可重复性及可信度研究

目的:探讨特发性脊柱侧凸PUMC(协和)分型系统的一致性,并对影响分型一致性的因素进行分析.方法:随机选取南京鼓楼医院2004年～2006年治疗的80例特发性脊柱侧凸患者,其中男性15例,女性65例,平均年龄14.6岁(10～18岁),均有完整的术前站立位正侧位X线片及仰卧位左右Bending片共四张.由4名脊柱外科专科医生分别根据PUMC(协和)分型标准进行分型,2周后此4位医生分别对这些患者的X线片再次进行分型,收集分型结果分别作可信度和可重复性分析,计算Kappa值检验一致性并对影响分型一致性的因素进行统计分析,结果:80例患者均可用PUMC分型,分型可信度平均Kappa值为0.801,可重复性Kappa值为0.878.PUMC分型不一致中包括上胸弯的界定18次;胸弯明显时,代偿性与结构性腰弯的界定15次;腰弯明显时,代偿性与结构性胸弯的界定18次;单弯顶点的判断20次;测量角度的差异18次.结论:PUMC(协和)分型学习曲线相对较短,易于掌握且具有良好的可信度和可重复性.     

青少年特发性胸椎侧凸后路凸侧胸廓成形术的并发症分析

目的:探讨青少年特发性胸椎侧凸患者后路凸侧胸廓成形术的并发症发生原因及预防措施。方法:自1999年1月～2006年9月,共有410例青少年特发性胸椎侧凸患者在我科施行脊柱侧凸后路矫形内固定术,同时行同一切口下的凸侧胸廓成形术,男86例,女324例。年龄11～18岁,平均14.7岁。术前剃刀背畸形15°～48°,平均32°。统计并发症发生情况。结果:凸侧胸廓成形的肋骨切除数平均4.2根,术后剃刀背畸形0°～14°,平均6°。无手术死亡病例。24例(5.8%)术中发生壁层胸膜穿孔,6例(1.5%)术后胸腔积液,3例(0.7%)术后气胸,1例(0.2%)术后呼吸困难需间歇性吸氧,34例(8.3%)术后有局部反常呼吸,17例(4.1%)术后诉不同程度的胸壁疼痛,9例(2.2%)诉局部皮肤麻木或感觉减退,3例(0.7%)早期手术的患者术后肋骨残端突出明显,1例(0.2%)皮下血肿,1例(0.2%)皮肤压疮。经相应处理后,患者大多恢复满意。319例平均随访28个月,仅4例仍残留有胸壁皮肤感觉减退。结论:凸侧胸廓成形术是一种安全、有效的改善"剃刀背"畸形的手段。提高手术技巧,术后积极处理,可以减少甚至避免相关并发症的发生。     

退变性症状性腰椎侧凸的手术治疗

[目的]探讨后路椎管减压、椎弓根螺钉间断固定、椎间植骨融合、矢状位重建术式治疗退变性症状性腰椎侧凸的临床效果。[方法]1999年1月-2006年4月，采用经后路椎管减压、椎弓根螺钉间断固定、椎间植骨融合、矢状位重建术式治疗退变性症状性腰椎侧凸37例，男21例，女16例；年龄51—82岁，平均62．6岁。所有病例拍摄腰椎正侧位片及Bending片，常规备CT和MRI。根据患者下肢症状行全椎板或半椎板减压，神经根扩大，椎间植骨融合及椎弓根螺钉间断固定。[结果]本组病例均获随访（1—6年，平均2年零7个月），术后临床症状均明显缓解，按JOA评分，手术疗效优良率91．9％，侧凸平均矫正率54．8％。随访期间无明显矫正度数及椎间隙高度丢失，术后3个月、1年复查X片内置物无松动及断裂，植骨融合时间平均11．6周。[结论]对于退变性症状性腰椎侧凸患者：（1）采取个体化治疗，年龄不是绝对手术禁忌证，病程长短不是决定手术疗效的重要指标；（2）后路椎管减压、椎弓根螺钉间断固定、椎间植骨融合、矢状位重建术是安全有效的理想术式。     

退变性腰椎侧凸的外科治疗

目的探讨退变性腰椎侧凸的特点、诊断与治疗。方法2001年7月至2004年1月手术治疗退变性脊柱侧凸患者15例,行后路彻底椎板减压、椎弓根钉棒矫形固定,椎间融合器融合12例,后外侧植骨融合3例,回顾性分析其临床特点、手术方法与效果。结果术后侧凸平均矫正率为42.8%,腰腿痛均消失,下肢麻木等症状减轻,随访6~36个月,植骨融合良好,无融合器移位,矫正度数与椎间隙高度无丢失。结论成人退变性腰椎侧凸发病年龄大,多合并腰椎管狭窄、失稳等,腰腿痛原因复杂,治疗的主要目的是彻底减压,通过矫形使脊柱重新获得稳定,椎弓根钉棒固定及椎间融合是有效的治疗方法。