经皮椎体后凸成形术治疗椎体裂隙周围硬化的Kümmell病

目的探讨经皮椎体后凸成形术(percutaneous kyphoplasty,PKP)治疗椎体裂隙周围硬化的Kümmell病的安全性与疗效。方法 2011年1月~2013年6月,20例骨质疏松性椎体裂隙周围硬化的Kümmell病患者在本院接受PKP治疗。术前、术后2 d及末次随访时采用疼痛视觉模拟量表(visual analogue scale,VAS)评分及Oswestry功能障碍指数(Oswestry disability index,ODI)评估患者疼痛缓解和生活质量改善情况。测量并记录伤椎前缘相对高度和局部后凸Cobb角的矫正情况。结果本组病例随访12~36个月,平均16个月;无脊髓神经根损伤、肺栓塞等并发症发生。术前VAS评分、ODI、伤椎前缘相对高度和后凸角分别为(8.9±0.4)分、(87.5±3.5)%、(41.3±5.2)%、22.1°±1.8°,术后2 d分别为(2.2±0.6)分、(31.8±4.1)%、(71.2±4.9)%、12.6°±1.4°,末次随访时为(2.0±0.3)分、(26.1±1.3)%、(70.7±4.8)%、13.2°±1.8°,术后2 d与术前相比差异具有统计学意义(P0.05),末次随访与术后2 d相比差异无统计学意义(P0.05)。结论 PKP用于治疗椎体裂隙周围硬化的Kümmell病安全、有效,能缓解疼痛、恢复椎体高度、纠正脊柱后凸畸形,可改善患者生活质量。     

后路截骨矫形治疗低龄先天性脊柱后凸畸形的疗效分析

目的:评价经后路截骨内固定术治疗低龄(10岁以下)先天性脊柱后凸畸形的临床效果。方法:2009年10月~2013年5月采用经后路截骨椎弓根螺钉内固定治疗先天性脊柱后凸患者17例,男6例,女11例,手术时年龄64±21个月(37~109个月)。根据Winter分型:Ⅰ型8例,Ⅱ型4例,Ⅲ型5例。后凸顶椎均位于T10~L2之间。5例伴神经系统畸形。8例行后路椎体切除(PVCR),5例行经椎弓根截骨(PSO),4例行Ponte截骨,截骨后均采用后路自体骨或同种异体骨植骨椎弓根螺钉内固定。统计手术时间、术中出血量及手术并发症,观察矫形效果、内固定并发症、椎体融合情况等。结果:手术时间210±46min(130~300min),出血量650±330ml(200~1300ml);固定融合节段4.9±0.8个(4~6个)。随访34.7±10.4个月(24~51个月),矢状面节段性后凸Cobb角由术前61.5°±14.3°(42°~92°)矫正至术后20.7°±9.0(5°~42°),矫正率为(66.3±8.7)%,末次随访时为17.5°±9.5°(1°~36°),矫正率为(71.5±10.7)%,手术后Cobb角得到显著性改善(P0.01);矢状面平衡术前为-41.3±31.8mm,术后为-43.5±30.4mm,与术前比较无显著性变化(P0.05),末次随访时为-25.6±26.7mm,较术前明显改善(P0.05)。术后出现双下肢无力1例,排尿困难1例,术后2周恢复。术前腰背痛5例、排尿异常1例,术后6个月症状好转。1例患者术后7个月出现近端交界性后凸。随访期间未发现假关节及内固定相关并发症。结论:对低龄先天性脊柱后凸畸形患者早期行后路截骨、椎弓根螺钉内固定可显著改善后凸畸形,但术后不能立即达到脊柱矢状面平衡,而是在术后随生长发育逐渐恢复矢状面平衡。     

复位导向器在强直性脊柱炎胸腰椎后凸畸形截骨矫形术中的应用

目的 :探讨经椎弓根椎体截骨(pedicle subtraction osteotomy,PSO)治疗强直性脊柱炎(ankylosing spondylitis,AS)胸腰椎后凸畸形术中采用复位导向器预防截骨椎脱位的有效性。方法 :回顾性分析2014年4~12月在我院行单节段PSO矫形内固定术中应用复位导向器的27例AS胸腰椎后凸畸形患者。所有患者手术前后均摄站立位全脊柱正侧位X线片并在矢状面上测量胸椎后凸角(thoracic kyphosis,TK)、全脊柱最大后凸Cobb角(global kyphosis,GK)、腰椎前凸角(lumbar lordosis,LL)和矢状面平衡距离(sagittal vertical axis,SVA)。随访观察神经并发症及截骨椎脱位情况,以截骨水平的头侧与尾侧脊椎间,截骨椎在矢状面上移位(sagittal translation,ST)大于5mm定义为截骨椎脱位。结果:所有患者均顺利完成手术。平均随访5.2±2.4个月(3~12个月),术前TK为43.2°±10.6°,GK为72.6°±15.1°,LL为2.3°±13.5°,SVA为12.8±4.2cm;术后分别为42.9°±11.8°、38.2°±12.4°、-38.6°±13.0°和3.2±5.8cm;末次随访时分别为42.7°±10.5°、38.8°±15.2°、-38.4°±11.6°和3.3±6.4cm。除TK外,其余参数手术前后相比均有统计学意义(P0.01);末次随访时,TK、GK、LL及SVA的矫正丢失无统计学差异(P0.05)。无患者出现术中截骨椎脱位,除1例短暂性右下肢麻木外,无其他神经并发症发生。结论:采用PSO治疗强直性脊柱炎胸腰椎后凸畸形患者,术中应用复位导向器械能有效预防截骨椎脱位的发生。     

脊柱畸形截骨矫形的问题与思考

正目前,脊柱截骨矫形术作为一种有效的手术方式,在脊柱畸形,尤其是重度脊柱畸形的治疗中广泛应用。相比单纯的后路内固定术,截骨矫形术对矫正脊柱的畸形,重建脊柱的整体平衡具有更好的疗效。根据截骨的方式和范围,其主要包括Smith-Peterson截骨术(SmithPeterson osteotomy,SPO),经椎弓根截骨术(pedicle     

伴腰椎退变性后凸畸形的人工全髋关节置换安放髋臼假体前倾角的策略

目的：探讨伴腰椎退变性后凸畸形患者行人工全髋关节置换时如何更合理地安放髋臼假体的前倾角。方法：纳入2017年12月至2019年10月行人工全髋关节置换术的患者122例,均伴腰椎退变性后凸畸形,分为试验组和对照组,各61例。试验组男25例,女36例;年龄中位数67.0岁;病程中位数46.0个月;术中根据骨盆前平面支架,按不同类型,设置安装髋臼前倾角的功能性骨盆平面。对照组男27例,女34例;年龄中位数67.0岁;病程中位数42.0个月;对照组以传统的方法设定前倾角。术后随访3个月,记录两组患者手术时间、术中出血量,统计3个月内感染脱位发生,记录手术前和术后3个月Harris评分,测量术后3个月患者站立位功能性前倾角。结果：试验组和对照组手术时间、术中出血量比较差异无统计学意义（P=0.918,0.381）;术后3个月内两组均无感染;对照组1例髋关节脱位,试验组无脱位。手术前后Harris评分比较差异无统计学意义（P>0.05）。3个月后复查骨盆站立位X线片示：髋臼假体功能性前倾角在安全区外的患者数量试验组比对照组少（P=0.048）;并且试验组在15°~20°范围内更集中（P<0.001）。。结论：伴有腰椎退变性后凸畸形的人工髋关节置换,根据术前对患者的评估分类,可以借助骨盆前平面参考支架,获得更佳的髋臼假体功能性前倾角。     

后柱切除后伸压缩中柱矫治胸腰段骨质疏松性重度椎体压缩骨折伴后凸畸形

【摘要】 目的：评价后柱切除后伸压缩中柱矫治胸腰段骨质疏松性重度椎体压缩骨折伴后凸畸形的安全性和临床效果。方法：2009年7月～2012年1月经后入路行后柱切除后伸压缩中柱矫治胸腰段骨质疏松性重度椎体压缩骨折伴后凸畸形患者14例,男2例,女12例;年龄62～81岁,平均68岁。骨折均位于T11～L2,其中单椎体骨折12例,两个椎体骨折2例;椎体高度压缩78.5%～92.4%,平均82.5%。后凸畸形的顶椎均位于胸腰段,其中L1 7例,T12 5例,L2 2例。后凸畸形Cobb角39°～59°,平均45°;脊柱矢状位C7铅垂线偏移距离为0.4～2.8cm,平均1.6cm;腰椎前凸41°～62°,平均58.4°,9例出现腰椎前凸代偿性加大。均有腰背部疼痛及疲劳感,疼痛视觉模拟评分（VAS）8.5分（7.5～9分）。神经功能按Frankel分级：E级12例,D级2例。其中10例采用注射型聚甲基丙烯酸甲酯骨水泥强化钉道。结果：手术时间187～221min,平均190min;术中出血量372～463ml,平均420ml。1例术中硬脊膜破裂,予以修补,术后未发生脑脊液漏。术后胸腰椎后凸Cobb角0°～9°,平均5°,平均矫正率达88.9%;矢状位C7铅垂线偏移距离0～0.8cm,平均0.3cm;腰椎前凸角28°～43°,平均37°。随访12～33个月,平均21个月。末次随访时,胸腰椎后凸Cobb角0～11°,平均7°;矢状位C7铅垂线偏移距离为0～1.2cm,平均0.4cm;腰椎前凸29°～45°,平均39°;神经功能按Frankel分级均为E级;腰背疼痛消失11例,明显缓解3例,VAS为1.9（0~3.5）分,与术前比较差异有统计学意义（P<0.05）;均植骨融合及骨折愈合良好,内固定无松动及拔出,固定邻近节段无继发骨折。结论：后柱切除后伸压缩中柱矫治胸腰段骨质疏松性重度椎体压缩骨折伴后凸畸形,与经椎弓根截骨术比较手术操作简单、创伤小。当骨质疏松性重度椎体压缩骨折伴后凸难以施行椎体成形术时,此技术是一种安全有效的补充方法。     

强直性脊柱炎胸腰段后凸畸形矫形前后影像学参数分析

【摘要】 目的 通过对强直性脊柱炎（ankylosing spondylitis, AS）僵硬性胸腰段后凸畸形矫形前后影像学参数对比分析及相关性研究,探讨经椎弓根椎体截骨（pedicle subtraction osteotomy,PSO）矫形对矢状面脊柱骨盆序列的影响,进而探究AS后凸患者脊柱骨盆序列的代偿机制。 方法 2004年1月～2010年3月, 38例AS僵硬性胸腰段后凸畸形患者行后路单节段或双节段截骨矫形椎弓根螺钉内固定术。矫形前后拍摄全脊柱侧位X线片,测量AS患者全脊柱后凸角（Cobb T1~S1）、矢状面平衡距离（sagittal vertical axis,SVA）、骨盆入射角（pelvic incidence,PI）、骨盆倾斜角（pelvic tilt,PT）、骶骨倾斜角（sacral slope,SS）及截骨角度（PSO angle）。观察矫形前后影像学参数变化,控制影响患者个体差异的因素,将影像学参数做偏相关分析。 结果 矫形前,Cobb T1~S1=56°±28°,PI=45°±9°,PT=38°±13°,SS=7°±12°,SVA=21 cm±9 cm;矫形后,Cobb T1~S1=11°±22°,PI=46°±9°,PT=21°±10°,SS=24°±9°,SVA=9 cm±5 cm。矫形前,PT、SVA与Cobb T1~S1偏相关系数分别为r=0.81（P＜0.01）、0.64（P＜0.01）;矫形后,PT、SVA与Cobb T1S1偏相关系数分别为r=0.58（P＜0.05）、0.72（P＜0.01）。PSO angle与Cobb T1~S1、PT偏相关系数分别为r=－0.82（P＜0.01）、－0.56（P＜0.05）,PSO angle与SVA无相关性。 结论 矫形前后,AS患者通过后旋骨盆代偿全脊柱后凸所致的矢状面失平衡;骨盆后旋程度、矢状面平衡距离与全脊柱后凸程度呈正相关;人体自身代偿机制优先恢复骨盆的中立状态而非改善矢状面平衡距离。     

Postoperative spinal deformity after treatment of intracanal spine lesions

Background context

Surgical treatment of intracanal (both intramedullary and extramedullary) spine lesions requires posterior decompressive techniques in nearly all instances. Postoperative spinal deformities, most notably sagittal and coronal decompensation, are of significant concern for both the patient and the spinal surgeon.

Purpose

To review and define principles and features of spinal deformities after posterior spinal decompression for intracanal spinal lesions, and to define patients who may benefit from the concomitant spinal fusion.

Methods

A systematic review of MEDLINE was conducted, including articles published between 1980 and 2011. Articles related to spinal deformities after posterior decompression for the treatment of intracanal spine lesions were identified.

Results

Ten articles met all inclusion and exclusion criteria. All were case series with limited evidence (Level IV). Many risk factors to deformity were implied but with limited evidence. Young age was the most commonly identified risk in these articles.

Conclusions

Spinal deformity after posterior decompression is a common complication, most notably in children and young adults, after the removal of intramedullary tumors. Many risk factors have been implied to increase the postoperative development of spinal deformity, including young age, laminectomy extension, preoperative deformity, and extensive facet resection, among others. However, there is a lack of high-quality evidence to propose an algorithm for treatment or preventive measures. New studies with larger series of patients and standardized clinical outcomes are necessary to establish optimal treatment protocols.     

Post-laminectomy rotokyphoscoliosis causing paraplegia in long term: case report

CONTEXT: Childhood laminectomy can lead to spinal deformity. This is a report of a case of paraplegia caused by rotokyphoscoliosis, a late complication of laminectomy. FINDINGS: A 55-year-old woman developed paraplegia due to post-laminectomy kyphoscoliosis. She had surgery for a spinal tumor at age 13 years. She developed kyphosis 2 years after the laminectomy, which has been gradually progressing over the years. She experienced weakness of lower limbs that progressed to paraplegia. There was no evidence for tumor recurrence. To our knowledge, this is the first reported case of post-laminectomy kyphoscoliosis causing late-onset paraplegia. Conclusions/clinical relevance: This case highlights a possible long-term complication of laminectomy without stabilization or untreated kyphoscoliosis. Children should be followed closely after laminectomy because development of spinal deformity is very common. Without intervention, the kyphosis might progress and in the long term, serious neurological complications may result, including paraplegia.     

Kyphectomy for congenital kyphosis due to meningomyelocele: a case treated with a modified approach to skin healing

This study is a case report of a meningomyelocele patient with congenital kyphosis who was treated with kyphectomy and a special approach to soft tissue healing. The objective of this study is to show a step by step approach to surgical treatment and postoperative care of a meningomyelocele patient with congenital kyphosis. In meningomyelocele the incidence of kyphosis is around 12-20%. It may cause recurrent skin ulcerations, impaired sitting balance and respiratory compromise. Kyphectomy has first been described by Sharrard. This surgery is prone to complications including pseudoarthrosis, skin healing problems, recurrence of deformity and deep infections. A 15-year-old male presented with congenital kyphosis due to meningomyelocele. He had back pain, deformity and bedsores at the apex of the deformity. The wound cultures showed Staphylococcus epidermidis colonisation at the apex. He was given appropriate antibiotic prophylaxis. During surgery, the apex of the deformity was exposed through a spindle-shaped incision. After instrumentation and excision of the apex, correction was carried out by cantilever technique. Two screws were inserted to the bodies of L3 and T11. After the operation, the skin was closed in a reverse cross fashion. He was sent to hyperbaric oxygen treatment for prevention of a subsequent skin infection and for rapid healing of skin flaps post operation. The patient's deformity was corrected from a preoperative Cobb angle of 135°-15° postoperative. The skin healed without any problems. Preoperative culture and appropriate antibiotic prophylaxis, spindle-shaped incision, reverse cross-skin closure and postoperative hyperbaric oxygen treatment can be useful adjuncts to treatment in congenital kyphosis patients with myelomeningocele to prevent postoperative wound healing and infection problems. Reduction screws and intracorporeal compression screws help to reduce the amount of screws and aid in corection of the deformity.