三维导航技术在微创经椎间孔入路腰椎椎间融合术中的应用

目的 探讨术中三维导航技术在微创经椎间孔入路腰椎椎间融合术(MIS-TLIF)中的应用价值.方法 2016年1月—2017年12月采用MIS-TLIF治疗腰椎退行性疾病患者64例,其中32例术中应用三维导航(A组),另32例术中采用传统C形臂X线机透视(B组).记录并比较2组手术时间、术中出血量、术中辐射量、置钉准确率及每枚螺钉置入时间,采用疼痛视觉模拟量表(VAS)评分、Oswestry功能障碍指数(ODI)及日本骨科学会(JOA)评分评价临床疗效,记录并发症发生情况.结果 所有手术顺利完成.所有患者随访24～48个月,平均29.5个月.A组手术时间、术中出血量、置钉准确率及每枚螺钉置入时间优于B组,而术中辐射量则高于B组,差异均有统计学意义(P<0.05).2组术后VAS评分、ODI及JOA评分均较术前显著改善,差异有统计学意义(P<0.05);组间差异无统计学意义(P>0.05).所有患者术中、术后均无明显并发症发生.结论 MIS-TLIF术中应用三维导航技术可提高置钉准确率,缩短手术时间,提高手术的便利性和安全性.     

两种入路经皮内镜手术治疗稳定型退变性腰椎滑脱症

目的:评价两种入路经皮内镜手术治疗稳定型退变性腰椎滑脱症的疗效。方法:根据手术入路不同将2016年1月至2019年12月接受经皮内镜手术的64例稳定型退变性腰椎滑脱症患者分为椎间孔入路组(32例)和椎板间入路组(32例)。其中椎间孔入路组男16例,女16例;年龄52~84(66.03±9.60)岁;L2滑脱4例,L3滑脱5例,L4滑脱23例。椎板间入路组男17例,女15例;年龄46~81(61.38±9.88)岁;L3滑脱3例,L4滑脱15例,L5滑脱14例。比较两组患者手术时间、术中X线透视次数、术后卧床时间,测量两组患者术前和术后12个月动力位X线片上滑脱椎体间前后位移变化值、椎体间张开角度变化值、滑脱百分比,观察手术前后腰痛及下肢疼痛视觉模拟评分(visual analgue scale,VAS)和日本骨科协会(Japanese Orthopaedic Association,JOA)评分,并根据改良Macnab标准评定临床疗效。结果:所有手术顺利完成,两组患者术后均随访1年以上,随访期未见并发症。(1)手术时间组间比较差异无统计学意义(P>0.05),术中X线透视次数椎间孔入路组大于椎板间入路组(P<0.05),术后卧床时间椎间孔入路组小于椎板间入路组(P<0.05)。(2)两组患者术后12个月在动力位X线片上未见腰椎不稳,滑脱椎体间前后位移变化值、椎体间张开角度变化值、滑脱百分比与术前1 d比较差异均无统计学意义(P>0.05)。(3)两组患者术后3 d,术后1、12个月腰痛VAS和术前比较差异均无统计学意义(P>0.05),但下肢疼痛VAS与术前比较均明显改善(P<0.05);两组患者术后12个月JOA评分与术前比较均明显改善(P<0.05)。术后同时段腰痛及下肢疼痛VAS及JOA评分组间比较差异均无统计学意义(P>0.05)。术后12个月按照改良Macnab标准评定疗效,椎间孔入路组优21例,良7例,可3例,差1例;椎板间入路组优20例,良7例,可5例,差0例;组间疗效比较差异无统计学意义(P>0.05)。结论:椎板间入路手术可减少术中X线透视次数,椎间孔入路手术可缩短术后卧床时间,两种入路经皮内镜手术治疗稳定型退变性腰椎滑脱症均可获得满意疗效,并且短期内滑脱程度无进展。     

Axial back pain in the athlete: pathophysiology and approach to rehabilitation

Back pain in athletes is common. Proper management of an athlete with back pain who is trying to return to competition must take into account the probable biomechanical contributors and incorporate these into a comprehensive rehabilitation program that moves steadily forward towards defined goals. This study will attempt to discuss pathological commonalities of low-back pain in athletes and how these can be applied to an evidence-based rehabilitation approach.     

Direct repair of defect in lumbar spondylolysis and mild isthmic spondylolisthesis by bone grafting, with or without facet joint fusion

Forty-six patients with lumbar spondylolysis and mild isthmic spondylolisthesis were managed with direct repair of the defect with or without facet joint fusion in the affected segment. There were 24 males and 22 females, ranging in age from 15 to 56 years (average, 38.2 years). These patients had experienced clinical symptoms due to spondylolysis for between 4 months and 20 years (average, 5.3 years). Of 46 patients, 28 had no spondylolisthesis, 11 had Meyerding grade I vertebral slippage and 7 had grade II. Direct repair of 98 defects was performed on these patients. Twenty-six patients, in whom the disc adjacent to the defect was determined as degenerative by magnetic resonance imaging (MRI), simultaneously underwent facet joint fusion; 17 in one segment and 9 in two segments. The average period of follow-up was 50 months (24-92 months). Ninety-four defects achieved bony healing. As a result, 28 patients were graded as having an excellent outcome, 15 good, and 3 fair. Bone grafting in the defects achieves union between the loose lamina and the anterior element of lumbar vertebrae, and reconstructs the anatomic structure and physiologic functions of the lumbar vertebrae. There was no significant difference in outcome between the spondylolytic/spondylolisthetic patients with non-degenerative disc, who were treated with direct repair of defect only, and those with degenerative disc, who additionally underwent a fusion procedure (P > 0.05). The present series demonstrates a satisfactory result and a high rate of bony healing of the pars defect by this operative procedure in patients with lumbar spondylolysis and mild isthmic spondylolisthesis. Preoperative assessment of the disc degeneration with MRI is of great assistance in making the protocol choice of whether to opt for fusion.     

椎弓根内固定系统联合椎问融合器治疗峡部不连性腰椎滑脱症

目的探讨椎弓根内固定系统联合椎间融合器治疗峡部不连性腰椎滑脱症的疗效。方法自2008年1月-2012年1月本院收治峡部不连性腰椎滑脱症45例,所有患者均行椎弓根内固定系统复位滑脱,椎间融合器行椎间植骨融合固定。记录患者的手术情况,使用日本骨科学会腰痛评分标准（JOA评分,）及Oswestry功能障碍指数（OOI）分别对患者治疗前后躯体功能及疼痛状况进行评价。随访观察远期疗效。结果平均手术时间（217-95）min（165-291）min,术中平均出血量（813-307）mL（550～1250mL）。术后未发现脑脊液漏或脊神经根损伤等。随访1-5年,平均26个月。治疗后患者功能障碍指数001（25．7％±4．71％）显著低于治疗前（59．1±10．2％）,P〈0．001;JOA评分显著升高（25．9±2．1）分vs（15．2±1．3）分,（P〈0．001）。根据NaKai评分标准,优30例,良8例,可7例,优良率为84．44％。无滑脱复发、内固定松动及断钉发生。结论椎弓根内固定系统加椎间融合器治疗腰椎滑脱症手术安全、有效;能显著改善患者躯体功能,降低患者疼痛疼痛状况;术后优良率高、并发症少。     

后路椎弓根钉复位固定加自体减压椎板骨粒超大量植骨治疗腰椎滑脱

目的 探讨后路椎弓根螺钉复位固定加自体减压椎板骨粒超大量植骨治疗腰椎滑脱症的有效治疗方法. 方法 回顾性分析2005年6月-2010年6月收治的56例腰椎滑脱患者.根据Meyerding分类法:Ⅰ度滑脱35例,Ⅱ度滑脱21例.其中L4/5滑脱19例,L5 ～S1滑脱37例.采用后路椎弓根钉复位固定加自体减压椎板骨粒超大量植骨后,评价其手术疗效. 结果 所有患者植骨均融合,无断钉、损伤神经表现.根据Macrab评定标准评定:优53例,良3例.完全复位率及椎间融合率均达100％. 结论 后路椎弓根螺钉复位固定加自体减压椎板骨粒超大量植骨能够对滑脱的腰椎进行良好的固定、减压、复位和融合,是治疗腰椎滑脱症的理想方法之一.     

Prevalence of Spondylolysis and Its Relationship with Low Back Pain in Selected Population

Background

To determine the prevalence of spondylolysis in a selected population and evaluate the association of spondylolysis with low back pain (LBP). Spondylolysis is widespread in the general population but the prevalence of spondylolysis and its relationship with LBP in the Korean population is controversial.

Methods

A sample of 855 participants (age, 20 to 86 years) from our medical center who underwent multidetector computed tomography (CT) imaging to assess abdominal and urological lesions were enrolled in this study. The occurrence of LBP requiring medication in the preceding 12 months was evaluated using a self-report questionnaire (a modified Nordic Low Back Pain Questionnaire). The presence of spondylolysis was characterized by CT imaging. Multiple logistic regression models were used to examine the association between spondylolysis and LBP, while adjusting for gender and age.

Results

Seventy-eight study subjects (9%) demonstrated spondylolysis on CT imaging. There was no significant difference between the age groups (p = 0.177). The p-value of gender was 0.033 but this was not significant due to the selected population bias. Three hundred eleven study subjects (36%) had back pain. There was a significant difference between gender (p = 0.001). No significant association was identified between spondylolysis and the occurrence of LBP.

Conclusions

The prevalence of LBP was 36.37% and the prevalence of lumbar spondylolysis in a selected population, who visited hospital for abdominal or urological lesions except LBP, was 9.12% based on CT imaging. Males demonstrated a similar presence of LBP to females but a significantly higher incidence of spondylolysis (p = 0.033). The prevalence of spondylolysis was not associated with the presence of LBP and age in adulthood.     

经骶骨钛网原位融合与经椎间孔融合治疗成人Ⅱ度腰椎滑脱疗效对比

目的针对13例椎间隙塌陷合并骨质疏松的L5Ⅱ度滑脱患者采取后路减压经骶骨钛网原位融合固定治疗,并与后路减压复位内固定、经椎间孔融合（transforaminal lumbar interbody fusion,TLIF）的21例患者在临床和影像学预后等方面进行了对比研究。方法回顾性分析了共34例患者,其中13例接受后路减压经骶骨钛网原位融合术（A组）,另外21例接受后路减压复位内固定、TLIF术式（B组）。采用Oswestry功能障碍指数（Oswestry disabilityindex,ODI）和腰腿痛视觉模拟量表（visual analog scale,VAS）评分来评价临床疗效。影像学评估参数包括滑移率,全腰椎前凸角和腰骶角。同时记录了术中相关资料,融合率及围术期并发症。结果 A组平均手术时间和出血量显著低于B组,所有患者术后背部和腿部疼痛均显着减轻,2组间比较差异无统计学意义（P〉0.05）。两组患者术后腰骶角、腰椎前凸角、VAS评分和ODI差异无统计学意义（P〉0.05）。2组患者椎体融合率分别为92.3%和95.2%,A组中2例硬膜撕裂,2例一过性的S1感觉异常,踇长伸肌肌力下降1例;B组患者中有2例患者术后出现固定部位疼痛,1例表浅感染,1例螺钉松动。结论对于存在椎间隙塌陷和/或骨质疏松患者,经骶骨钛网原位融合固定术式可成为TLIF术式外的另一选择。经骶骨钛网原位融合固定与TLIF手术相比较,虽然具有相对较高的神经系统并发症发生率,但在短期临床预后和影像学结果方面并无明显差异。     

腰椎椎间融合术与动态固定术治疗腰椎退行性疾病的临床评价

目的通过比较分析腰椎椎间融合术与动态固定术治疗腰椎退行性疾病的临床疗效和术后并发症,探讨腰椎退行性疾病治疗方法的合理选择。方法 2009年1月～2010年12月,选择32例腰椎退行性疾病（L4/L5）患者,按配对设计分为对照组和治疗组,对照组16例患者均行椎弓根螺钉固定并单枚融合器置入;治疗组16例患者行常规椎板切除减压、髓核摘除和Isobar动态固定。比较观察2组病例的治疗效果、手术时间、出血量、手术并发症等。治疗效果评价采用Oswestry功能障碍指数（Oswestry disability index,ODI）及疼痛视觉模拟量表（visual analogue scale,VAS）评分,手术邻近节段（L3/L4和L5/S1）及腰椎（L2～S1）的活动度（range of motion,ROM）采用过伸过屈动力侧位X线片检查进行评价。结果所有患者均获6～24个月的随访,平均15.8个月。与术前相比,2组患者术后症状均有明显改善,术后ODI及VAS评分与术前相比差异有统计学意义（P〈0.01）;2组手术时间、出血量差异无统计学意义（P〉0.05）;2组均未出现内固定相关并发症;2组术后邻近节段（L3/L4和L5/S1）的ROM与术前相比差异无统计学意义（P〉0.05）。腰椎（L2～S1）的ROM,融合组较术前显著下降,差异有统计学意义（P〈0.05）;而动态固定组较术前有所增加,但差异无统计学意义（P﹥0.05）。结论腰椎椎间融合术与Isobar动态固定术治疗单节段腰椎退变性疾病均可取得满意的短期临床疗效,但理论上动态固定技术内固定失败的风险高于椎间融合术,故采用动态固定技术治疗腰椎退变性疾病应慎重。     

腰椎不稳和腰椎滑脱的相关问题

<正>腰椎不稳或腰椎滑脱是导致腰腿痛的常见病因之一。然而在临床上,有关不稳和滑脱的界定、两者之间的关系、影像学诊断、治疗方案的合理选择、滑脱的复位等