多裂肌间隙入路与经皮入路联合伤椎置钉治疗无神经损伤的胸腰段椎体骨折的对比研究

目的 探讨多裂肌间隙入路和经皮入路分别联合伤椎置钉治疗无神经损伤胸腰段椎体骨折的临床疗效。方法 回顾性分析苏州大学附属第一医院2015年1月-2018年1月采用多裂肌间隙入路和经皮入路分别联合伤椎置钉治疗无神经损伤的胸腰段椎体骨折的52例患者的临床资料。经多裂肌间隙入路患者25例(A组),男19例、女6例,年龄35~67 (49.84±9.11)岁;经皮入路患者27例(B组),男20例、女7例,年龄21~66(48.44±11.02)岁。比较两组患者一般资料,以及手术出血量、手术时间、术后镇痛药物使用率、术后下地时间及术后住院时间;手术前后不同时间点的腰背部疼痛视觉模拟评分(VAS);比较两组手术前、术后下地前及术后12个月时伤椎前缘高度比值和矢状位Cobb角变化。结果 两组患者一般资料比较差异均无统计学意义(P值均＞0.05)。均顺利完成手术,术后随访12个月。A组的手术时间、术后下地时间分别为120(90,136)min、2(1,3)d,均短于B组的144(110,220)min、4(2,5)d,差异均有统计学意义(P值均＜0.05);A组术后使用镇痛药物例数(2例)少于B组(15例),差异有统计学意义(P＜0.05);两组患者手术出血量、术后住院时间差异均无统计学意义(P值均＞0.05)。两组患者术后VAS评分均较术前有明显改善,差异均有统计学意义(P值均＜0.01);A、B组间术前、术后12个月VAS评分比较,差异均无统计学意义(P值均＞0.05),但术后第3天VAS评分比较,A组低于B组,差异有统计学意义(P＜0.05)。两组患者术后下地前及术后12个月伤椎前缘高度比值、矢状面Cobb角较术前改善明显,差异均有统计学意义(P值均＜0.05),但两组间同时间点伤椎前缘高度比值和矢状面Cobb角比较差异均无统计学意义(P值均＞0.05)。结论 多裂肌间隙入路和经皮入路分别联合伤椎置钉治疗无神经损伤的胸腰段椎体骨折均取得良好疗效,在改善骨折畸形及远期腰背部疼痛上无明显差异,但经皮入路手术时间更长、术后短期腰背部疼痛更严重、下地时间更晚,相较于多裂肌间隙入路手术并不具有明显优势。     

皮质骨轨迹螺钉固定在合并骨质疏松腰椎退行性疾病手术中应用的效果

【摘要】 目的：探讨皮质质骨轨迹（cortical bone trajectory，CBT）螺钉与椎弓根螺钉（pedicle screw，PS）固定在腰椎退行性疾病合并骨质疏松手术中应用的效果及并发症发生情况。方法：按照非劣性检验标准估算样本量，经伦理委员会批准，前瞻性纳入2019年3月~2020年6月我院收治的124例腰椎退行性疾病患者，并平均随机分配到CBT组与PS组，分别进行后路腰椎减压单节段CBT螺钉固定与PS固定椎间融合术，经过至少2年随访。主要观测指标为椎间融合率；次要观测指标为术前、术后3个月、术后1年及末次随访时腰背与下肢疼痛视觉模拟评分（visual analogue scale，VAS）、Oswestry残障指数（Oswestry disability index，ODI）和日本骨科协会（Janpanese Orthopedics Association，JOA）评分，手术相关参数（手术时间、切口长度、术中失血量和术后引流量）及术中、术后并发症发生率，对两组数据进行组间与组内对比分析。结果：最终CBT组共有58例、PS组56例完成随访。两组患者在年龄、性别、随访时间、吸烟状况、体重指数、骨密度及手术节段分布方面无显著性差异（P>0.05）。术后1年，CBT组45例（77.59%）、PS组42例（75.00%）患者实现了椎间融合，两组之间无显著性差异（P=0.745）。每组术后3个月、1年及末次随访时的VAS评分、ODI及JOA评分较术前均有明显改善（P<0.05）；术前VAS评分、ODI及JOA评分两组比较均无统计学差异，术后3个月CBT组的ODI及JOA评分均优于PS组（P<0.05），术后3个月、术后1年及末次随访时的VAS评分及术后1年、末次随访时的ODI及JOA评分两组间均无统计学差异（P>0.05）。CBT组的手术时间、术中出血量、切口长度和术后引流量均优于PS组（P<0.05）。两组硬膜撕裂、神经根损伤和手术部位感染发生率相似。术后CT显示螺钉误置，CBT组发生率为2.16%（5/232枚），PS组为1.34%（3/224枚），组间无统计学差异（P=0.724）。CBT组共有2枚螺钉（0.89%）出现松动并在CT扫描图像上出现移位，发生率低于PS组（10/224，4.46%）（P=0.034）。CBT组58例患者中共有3例（5.17%）出现并发症，PS组56例患者中共有9例（16.07%）出现并发症，PS组总体并发症发生率较高（P=0.041）。结论：CBT螺钉固定在合并骨质疏松腰椎退行性疾病患者行单节段固定融合手术时可获得较PS固定更加优秀的短期功能恢复，以及相似的临床效果和椎间融合。CBT螺钉固定用于合并骨质疏松的腰椎疾病人群的手术治疗是较PS内固定有效且更优的替代选择。     

Tratamiento endourológico de la litiasis ureteral lumbar. ¿Qué aporta la ureterorrenoscopia flexible?

Introduction and objectivesCurrently, there are no established criteria regarding treatment for lumbar ureteral stones. The objective of this work is to present our results in the endourological treatment of this pathology, analyzing the variables associated with the use of the flexible ureterorenoscope.Material and methodsRetrospective review of 103 patients who underwent retrograde URS with semi-rigid or flexible ureterorenoscope. Proximal location: L2-L3. Medial location: L4-L5. Semirigid URS was the initial treatment, with conversion to flexible URS when it was required to complete the procedure. Success was defined as absence of residual fragments (6 weeks). Demographic, surgical, immediate postoperative variables, and those related to the stone, were analyzed. Their correlation with the use of the flexible ureterorenoscope was evaluated.ResultsMean age: 57.2 years (SD 15.6); there were 73 men (70.9%). Stone size: 8 mm (range 4-30; IQR 4.5). Proximal location: 58 (56.3%). Previous JJ: 44.7%. Previous nephrostomy: 10.7%. Semirigid URS with conversion to flexible URS: 51 (49.5%). Impacted stones: 28.2%. Intraoperative complications: 2 (1.9%). Postoperative JJ: 84.5%. Immediate postoperative complications: 23 (22.3%) (Clavien-Dindo I-II: 91.3%). Postoperative ureteral stricture: 5.8%. Success: 88.4%. Residual fragments: 12 (11.7%). Spontaneous passage: 6 (50%). Greater performance of flexible URS in proximal ureteral stones (P = 0.001) of more than 11 mm (P = 0.02) in univariate analysis, and in proximal stones [OR 3.5; 1.5-8.1; P = 0.004] in multivariate analysis.ConclusionsEndourological treatment obtained a high success rate in our sample. Size greater than 11 mm and proximal ureteral location in univariate and multivariate analysis, respectively, behaved as predictors of flexible URS.     

腰穿持续外引流的护理及并发症观察

腰穿持续外引流是指用体外监测引流系统进行腰椎穿刺，接一次性脑室引流袋，通过调节引流袋的高度，脑脊液经腰大池缓慢、均匀引出体外的一种治疗方法［1 ］ 。目前，该方法具有损伤小、操作简便、带管时间长、感染率低、疗效明显、并发症小等优点，得到临床广泛推广。我院2012 年6 月－ 2014 年6月，对87 例神经外科患者进行腰穿持续外引流，现将护理体会总结如下。     

腰椎间盘突出症术后腰围使用的护理干预

目的：通过对腰椎间盘突出症术后佩戴腰围的护理干预随访，探讨患者术后合理使用腰围对康复的影响。方法选择我科2011－2014年收治的356例腰椎间盘突出症手术的患者；按入院前后分为两组，将2011－2012年收治的178例作为对照组，将2013－2014年收治的178例作为观察组。观察组进行护理随访干预，指导患者术后正确功能锻炼及使用腰围，对照组患者术后虽也进行功能锻炼指导及佩戴腰围护理，但未能追踪指导。于术后3个月比较两组患者疼痛度（JO A ）评分指数及腰功能改善情况。结果观察组JO A评分改善指数指标中优69例、良87例、可15例、差7例；对照组分别为：优61例、良76例、可28例、差13例。两组患者差异有统计学意义（ P＜0．05）。观察组疗效改善率为：优75％、良79％、可19％、差5％，对照组分别为：优63％、良72％、可31％、差12％，两组差异有统计学意义（ P＜0．05）。结论腰椎间盘突出症术后，指导并干预患者合理使用腰围，有利于患者术后顺利康复，提高患者的生活质量。     

The anatomy of the clavicle

The clavicle has a complex osteologic structure that makes morphological analysis extremely difficult. A three‐dimensional study was conducted to examine the anatomical variations and characteristics of the bone. Sixty‐eight human cadaver clavicles were dissected, CAT‐scanned, and reconstructed. An automated parameterization and correspondence shape analysis system was developed. A new length, designated as centerline (CL) length, was defined and measured. This length represents the true length of the clavicle. The endpoint length was measured as the distance between two endpoints. The width and curvature were measured in the axial (AX) and frontal (FR) plane and defined along the CL. Next gender and side characteristics and variations were examined. The mean CL length was 159.0 ± 11.0 mm. The mean endpoint length was 149.4 ± 10.3 mm, which was statistically significantly shorter than the CL. The male clavicle was significantly longer (166.8 ± 7.3 mm vs. 151.0 ± 8.2 mm), wider (14.6 ± 1.5 mm vs. 12.7 ± 1.3 mm lateral FR plane, 25.9 ± 4.1 mm vs. 23.5 ± 3.0 mm lateral AX plane and 24.7 ± 2.8 mm vs. 22.8 ± 2.8 mm medial AX plane), and more curved (10.8 ± 2.8 mm vs. 8.6 ± 2.3 mm medial and 10.5 ± 3.3 mm vs. 9.1 ± 2.5 mm lateral) than the female one. Left clavicles were significant longer (159.8 ± 10.9 mm vs. 158.0 ± 11.2 mm) than right clavicles. A novel three‐dimensional system was developed, used and tested in order to explore the anatomical variations and characteristics of the human clavicle. This information, together with the automated system, can be applied to future clavicle populations and to the design of fixation plates for clavicle fractures. Clin. Anat. 27:712–723, 2014. © 2013 Wiley Periodicals, Inc.     

Allograft alone versus allograft with bone marrow concentrate for the healing of the instrumented posterolateral lumbar fusion

Background contextSpondylodesis in the operative management of lumbar spine diseases has been the subject of numerous studies over several decades. The posterolateral fusion (PLF) with pedicle screw fixation is a commonly used procedure.PurposeTo determine whether the addition of bone marrow concentrate (BMC) to allograft bone increases fusion rate after instrumented posterior lumbar fusion.Study designThe study was prospective, randomized, controlled, and blinded.MethodsEighty patients with degenerative disease of the lumbar spine underwent instrumented lumbar or lumbosacral PLF (22 men, 58 women; body mass index less than 35 for a good visualization of the PLF in the X-rays). In 40 cases, the PLF was done with spongious allograft chips alone (Group I, age 62.7 years in average, range 47–77 years, level of fusion 1–2). In another 40 cases, spongious allograft chips were mixed with BMC (Group II, age 58.5 years in average, range 42–80, level of fusion 1–3), including the mesenchymal stem cells (MSCs). Patients were scheduled for anteroposterior and lateral radiographs 12 and 24 months after the surgery and for computed tomography scanning 24 months after the surgery. Fusion status and the degree of mineralization of the fusion mass were evaluated separately by two radiologists blinded to patient group affiliation. The bony mass was judged as fused if there was uninterrupted bridging of well-mineralized bone between the transverse processes or sacrum, with trabeculation indicating bone maturation on least at one side of the spines.ResultsIn Group I at 12 months, the bone graft mass was assessed in X-rays as fused in no cases (0%) and at 24 months in four cases (10%). In Group II, 6 cases (15%) achieved fusion at 12 months and 14 cases (35%) at 24 months. The statistically significant difference between both groups was proven for complete fusion at both 12 (p=.041) and 24 months (p=.011). Computed tomography scans showed that 16 cases (40%) in Group I and 32 cases (80%) in Group II had evidence of at least unilateral continuous bridging bone between neighboring vertebrae at 24 months (p<.05).ConclusionsWe have confirmed the hypothesis that the autologous BMC together with the allograft is a better alternative for PLF than the allograft alone. The use of autologous MSCs in form of BMC in combination with allograft is an effective option to enhance the PLF healing.