Cranial fat dissemination following fat grafting for lumbar dural tear: First case report in the literature

Introduction and importanceDural tear and cerebrospinal fluid (CSF) leak is among the most common complications in lumbar spine surgery. Although primary dural suturing is the preferred method for repair, this is not always achievable specially with ventrolateral tears. Autologous fat grafting is one of the oldest and effective methods for dural repair which can also be used along with other methods of repair. This case report highlights a unique post spinal surgery complication with comment on how to avoid it. To our knowledge, this has not been previously reported in the literature.Case presentationThe authors report a sixty-seven-year-old male with lumbar pseudomeningocele and cranial fat dissemination following fat grafting for non suturable lumbar dural tear. This was demonstrated on magnetic resonance imaging (MRI) after her presented with low-pressure headache.Clinical discussionIntraoperative dural tear is one of the most common complications in spinal surgery. Methods for optimal dural repair including fat grafting have been described but the choice still heavily dependent on the surgeon’s preference and experience. Fat graft can migrate leading to potential undesirable further complications like hydrocephalus and aseptic meningitis.ConclusionCranial fat dissemination following fat grafting for lumbar dural tear should be recognized as a post-operative complication in lumbar spine surgery. It should be considered in case of hydrocephalus or aseptic meningitis post dural fat grafting. Surgeons should utilize adjunct methods to minimize its incidence.     

Laminar and Arch Fractures with Dural Tear and Nerve Root Entrapment in Patients Operated upon for Thoracic and Lumbar Spine Injuries

Summary Objective: To determine the neurological outcome in patients with laminar fractures associated with dural tears and nerve root entrapment, operated upon for thoracic and lumbar spine injuries. Patient population: Out of 103 patients operated upon consecutively for thoracic and lumbar spine injuries during the period 1990 to 1994 inclusive, 24 (23.3%) patients had laminar fractures out of whom 3 (2.9%) had an associated dural tear and an other 17 (16.5% or 70.8% of the total patients with laminar fractures) had an associated dural tear and nerve root entrapment. Results: Twelve (70.5%) patients had injury at the thoraculumbar junction, 13 (76.5%) had Magerl's type A3 or above, 10 (58.8) had a kyphotic angle deformity greater than 5°. Seven (41.1%) had their spinal canal's sagittal diameter reduced by at least 50% and two had dislocations. Nine (52.9%) had initial neurological deficits. Four (50%) out of 8 patients with no initial neurological deficits (Frankel E) worsened to Frankel D. However, one patient among the 3 with initial Frankel A improved to Frankel C while both patients with initial Frankel C usefully improved to final Frankel grades D and E respectively. Two of the four patients with initial Frankel D improved to Frankel E, the other 2 remaining unchanged. All in all five patients' neurological status improved, 4 worsened and 8 remained unchanged after neurosurgical treatment. Conclusions: Vertical laminar fractures with dural tears and nerve root entrapment represent a special group of thoracic and lumbar spine injuries that carry a poor prognosis. However, special operative precautions lead to significant improvement in some of them although a majority remain unchanged or even worsened.     

Subdural hematoma after microdiscectomy: a case report and review of the literature

Background contextSubdural hematomas (SDHs) have been described as a rare complication from durotomy after lumbar spine surgery. In half of the reported cases, the durotomy was unnoticed intraoperatively. The most common presenting symptom was persistent headache.PurposeTo report a case of SDH after routine microdiscectomy and to review the literature.Study designCase report and review of the literature.MethodsRetrospective review of patient's history and imaging studies.ResultsA 39-year-old female underwent routine microdiscectomy for L5–S1 herniated disc. There were no complications, and no dural tear was noted. Approximately 1 week postoperatively, the patient complained of severe headaches. Imaging revealed a right intracranial chronic SDH and a lumbar pseudomeningocele. Operative exploration of her lumbar wound revealed a dural tear, which was closed primarily. The patient had subsequent resolution of her SDH.ConclusionsThe authors present a case of a routine microdiscectomy complicated by delayed cerebrospinal leak causing a chronic SDH. This report illustrates the need for a comprehensive evaluation of headaches after spine surgery.     

Surgical treatment of an atlantoaxial fracture after a delayed diagnosis in a comatose patient

Study design

Case report.

Objective

To report a case of fractures of the right lateral atlantoaxial joint and C2 body diagnosed more than 5 months after injury.

Summary of background data

Misdiagnosis of an injury to the cervical spine has been reported frequently. For patients in whom cervical injury is suspected, the primary screening modality is axial CT from the occiput to T1 with sagittal and coronal reconstructions. The inadequacy of this radiological evaluation could delay diagnosis of fractures and lead to unnecessary surgical treatment of the cervical spine.

Methods

We report the case of a 74-year-old woman with an old, displaced combined fracture of the C1 and C2 right facet joint. In this case, CT of the brain was evaluated at the time of injury, but not CT of the cervical spine. As a consequence, diagnosis was delayed and surgical treatment was necessary.

Results

We performed posterior fusion surgery for C1 and C2. A pedicle screw was not inserted on both sides of C2, because of destruction of the insertional point on the right side and a high-riding VA on the left. Alternatively, a lamina screw and hook were used for C2, fixed with lateral mass screws on C1, with a bone graft harvested from the iliac crest.

Conclusions

To avoid unnecessary surgery, surgeons should recognize the possibility of cervical fractures that cannot be detected without CT, especially in patients who are comatose at injury. Atlantoaxial fixation with a hook and lamina screw in C2 is an option for old upper cervical fractures in cases where a pedicle screw cannot be inserted into C2.

     

Low lumbar burst fractures: a unique fracture mechanism sustained in our current overseas conflicts

Background contextThe most common location for burst fractures occurs at the thoracolumbar junction, where the stiff thoracic spine meets the more flexible lumbar spine. With our current military conflicts in Iraq and Afghanistan, we have seen a disproportionate number of low lumbar burst fractures.PurposeTo report our institutional experience in the management of low lumbar burst fractures.Study designRetrospective review.MethodsWe performed a retrospective review of medical records and radiographs for all patients treated at our institution with combat-related injuries and thoracolumbar fractures. We included all patients who had sustained a burst fracture from T12 to L5 and had at least 1-year clinical follow-up.ResultsThirty-two patients sustained burst fractures. Nineteen patients (59.4%) had low lumbar (L3–L5) burst fractures, and 12 patients (37.5%) had thoracolumbar junction (T12–L2) burst fractures as their primary injury. Additionally, seven patients sustained less severe burst fractures at an additional level. One patient sustained burst fractures at both upper and lower lumbar levels. Of the low lumbar fractures, 52.6% had evidence of neurologic injury, two of which were complete. Similarly, in the upper lumbar group, 58.2% sustained a neurologic injury, two of which were complete. Twenty-two patients underwent surgical intervention, complicated by infection in 18%. At most recent follow-up, all but one patient with presenting neurologic injury had persistent deficits.ConclusionLow lumbar burst fractures are the predominant combat-related spine injury in our current military conflicts. The rigidity offered by current body armor may effectively lower the transition zone that normally occurs at the thoracolumbar junction, thereby, transferring forces into the lower lumbar spine. Increased awareness of this fracture pattern is warranted by all surgeons because of unique clinical challenges associated with its treatment. Although the incidence is increased in the military population, other surgeons may be involved with long-term care of these patients on completion of their military service.     

Facet joint violation after open and percutaneous posterior instrumentation: a comparative study

Purpose

Posterior instrumentation is the state-of-the-art surgical treatment for fractures of the thoracic and lumbar spine. Options for pedicle screw placement comprise open or minimally invasive techniques. Open instrumentation causes large approach related muscle detachment, which minimally invasive techniques aim to reduce. However, concerns of accurate pedicle screw placement are still a matter of debate. Beside neurological complications due to pedicle screw malplacement, also affection of the facet joints and thus motion dependent pain is known as a complication. The aim of this study was to assess accuracy of pedicle screw placement concerning facet joint violation (FJV) after open- and minimally invasive posterior instrumentation.

Methods

A retrospective data analysis of postoperative computer tomographic scans of 219 patients (1124 pedicle screws) was conducted. A total of 116 patients underwent open screw insertion (634 screws) and 103 patients underwent minimally invasive, percutaneous screw insertion (490 screws).

Results

In the lumbar spine (segments L3, L4, L5), there were significantly more and higher grade (open = 0.55 vs. percutaneous = 1.2; p = 0.001) FJV’s after percutaneously compared to openly inserted screws. In the thoracic spine, no significant difference concerning rate and grade of FJV was found (p > 0.56).

Conclusion

FJV is more likely to occur in percutaneously placed pedicle screws. Additionally, higher grade FJV’s occur after percutaneous instrumentation. However, in the thoracic spine we didn’t find a significant difference between open and percutaneous technique. Our results suggest a precise consideration concerning surgical technique according to the fractured vertebrae in the light of the individual anatomic structures in the preop CT.

     

Dural tears associated with lumbar burst fractures

A retrospective review of 817 spinal fracture patients revealed a 7.7% (20 of 258) incidence of dural tears in surgically treated patients. Dural tears were most common in the lumbar burst fractures (10 of 85). Twenty-five percent of patients with lumbar spine burst fractures and a neurologic deficit had a dural tear requiring repair. Eighty-six percent of patients with lumbar burst injuries and dural tears had a neurologic deficit. An initial posterior approach with inspection of the dura and stabilization of the fracture is recommended when treating lumbar burst fractures with a neural deficit.     

老年腰椎椎管狭窄症患者术中硬膜囊撕裂位置及术中术后处理对策

目的探讨老年腰椎椎管狭窄症患者手术发生硬膜囊撕裂的解剖学机制,比较撕裂位置及术中、术后处理对策。方法回顾性分析2012年01月~2014年01月本院行腰椎后路手术的216例〉70岁老年患者,记录患者一般资料、病程时间、术前诊断、手术方式和节段、术中硬膜囊撕裂的位置、术后脑脊液漏情况和处理方法以及并发症等。结果共计151例患者入选,其中男89例,女62例,年龄70~93岁,平均78.12岁。术中发生硬膜囊撕裂共计34例,术后出现脑脊液漏23例,硬膜囊撕裂位置发生率硬膜囊后外侧〉根袖〉硬膜囊外侧〉硬膜囊腹侧。术中采取硬膜囊缝合修补、明胶海绵压迫、生物蛋白胶粘合等处理,术后常规给予预防感染、神经根脱水、补液等治疗,均于术后3~10 d拔管,3~4周切口愈合,全部患者未出现严重并发症。结论 〉70岁老年腰椎椎管狭窄症患者术中硬膜囊撕裂及术后脑脊液漏的发生率高于整体人群,且多位于硬膜囊后外侧及根袖,术中及时发现并仔细缝合或修补破损的硬膜、术后间断夹闭引流管、延长拔管时间能获得良好的效果。     

Intravertebral pseudomeningocele: an unusual complication after disc surgery

Background contextPseudomeningoceles are most commonly the result of dural tear during spine surgery. They may sometimes slowly enlarge but they generally develop inside the spinal canal, toward the foramina or toward the surgical incision.PurposeTo describe a late and exceptional complication of a surgical discectomy.Study designA case report.MethodsWe report a unique case of a large asymptomatic pseudomeningocele strictly developed in the L5 vertebra, discovered incidentally in a 38-year-old woman. Computed tomography and magnetic resonance imaging showed a large cystic lesion involving the vertebral body and the left pedicle of L5 without contrast enhancement. There was neither extension of the cyst toward the vertebral lamina nor toward the spinal canal. Consent to publish the data was obtained from our patient.ResultsDiagnosis was performed during transpedicular image-guided puncture, when opacification of the cyst revealed dural communication. Biochemical analysis and cytology confirmed the presence of cerebrospinal fluid and absence of tumoral cells.ConclusionsDural tear was considered as a neglected complication after surgical discectomy at the same level performed 18 years ago. Differential diagnoses of cystic spinal lesions are discussed.     

Bilateral pedicle stress fracture in a patient with osteoporotic compression fracture

A case of bilateral pedicle stress fracture of L4 in a patient with osteoporotic compression fracture of L5 and without a history of major trauma or surgery is reported, and the literature is reviewed. Bilateral pedicle fracture is a rare entity and few cases have been reported in the literature. All reported cases had some underlying causative factors like previous spine surgery or stress related activities. To the best of the authors’ knowledge, only one case of bilateral pedicle stress fracture without a history of trauma, previous spine surgery, or stress-related activities has been reported. A 77-year-old woman presented with severe low back pain and radiating pain in the right leg that was exacerbated after standing and walking. Plain radiograph showed pathological fracture at L5 level. Magnetic resonance imaging (MRI) revealed the compression of dural sac at L5 level. CT scan taken 3 months after admission revealed bilateral pedicle fractures through L4. The patient was treated with decompressive laminectomies of L4, followed by posterior spinal fusion with rigid pedicle screw fixation and autogenous bone graft mixed with hydroxyapatite. The patient achieved pain relief and returned to normal activity. Stress fracture of the pedicle within the proximal vertebra of an osteoporotic compression fracture of lumbar spine is an uncommon entity. It may, however, be an additional source of symptoms in patients with osteoporosis who present with further back pain. Surgeons caring for this group of patients should be aware of this condition.     

Adverse effects of surgeon performance after a night shift on the incidence of perioperative complications in elective thoracolumbar spine surgery

BackgroundDecline in cognitive function after night shift has been well described. However, in the field of spine surgery, the effect of surgeons’ sleeplessness on patient outcome is unclear. The purpose of this study was to investigate whether the risk of perioperative complications in elective thoracolumbar spine surgery could be higher if the surgeon had been on a night shift prior to the day of surgery.MethodsWe performed a retrospective review of patients who underwent elective posterior thoracolumbar spine surgery, as indicated in medical records, between March 2015 and September 2018. In total, 1189 patients were included and divided into two groups: the post-nighttime (n = 110) and control groups (n = 1079). A post-nighttime case was defined when the operating surgeon was on nighttime duty on the previous night, and other cases were defined as controls. We evaluated the incidence of perioperative complications (surgical site infection, postoperative hematoma, postoperative paralysis, nerve root injury, and dural tear) in both groups.ResultsOverall, we found no significant difference in the major or minor perioperative complication rates between the two groups, but according to the type of complication, the incidence rate of dural tear tended to be higher in the post-nighttime group (13.6% vs 8.2%, P = 0.074). Multivariate analysis showed that post-nighttime status was an independent risk factor of dural tear (adjusted odds ratio, 2.02; 95% confidence interval [CI], 1.10–3.70; P = 0.023). After stratification by surgical complexity, post-nighttime status was an independent risk factor of dural tear only in the surgeries of 3 levels or more (adjusted odds ratio, 2.81; 95% CI, 1.18–6.67; P = 0.019).ConclusionsPost-nighttime status was generally not a risk factor of perioperative complications in elective posterior thoracolumbar spine surgeries, but was an independent risk factor of dural tear, especially in complex cases.     

Pedicle fracture after instrumented posterolateral lumbar fusion: a case report

STUDY DESIGN: The case report of a 60-year-old man with late onset back pain after lumbar spine fusion is presented. OBJECTIVE: To report the rare complication of bilateral pedicle stress fractures after instrumented posterolateral lumbar fusion. SUMMARY OF BACKGROUND DATA: A 56-year-old man underwent revision spinal surgery for ongoing back pain secondary to pseudoarthroses. A posterolateral L4-S1 instrumented fusion using pedicle screws was performed. Autologous bone graft was applied to the decorticated lateral masses. The internal fixation was removed 2 years later, at which time plain radiographs showed that the fusion mass was solid. At the age of 60 years, the man presented with worsening back pain. Plain radiographs and computed tomographic scans demonstrated bilateral L4 pedicle stress fractures. A bone scan indicated that these were recent in origin. METHOD: The clinical assessment was undertaken by the senior author and surgeon. Investigations included plain radiography, computer tomography, and scintographic imaging. A systematic literature review of the relevant publications was performed. RESULTS: In the reported patient, bilateral pedicle stress fractures developed 2 years after pedicle screw removal from an L4-S1 instrumented posterolateral lumbar spine fusion. This occurred at the uppermost level of the fusion mass. CONCLUSIONS: The pedicle is the weakest point in the neural arch after posterolateral fusion. Although movement continues at the level of the disc space anteriorly, the pedicle is susceptible to fracture. Pedicle fracture is a rare late complication of posterolateral lumbar spine fusion.     

颈椎前路手术中硬膜损伤的预防与治疗

目的探讨如何预防与治疗颈椎前路手术中出现的硬膜损伤。方法回顾分析2011年10月—2015年10月在本院接受治疗的72例颈椎前路手术中硬膜损伤患者的临床资料。术中行明胶海绵、生物蛋白胶封堵30例,皮下筋膜组织覆盖缺损处加明胶海绵、生物蛋白胶黏合加固42例。其中32例术后48 h切口引流200 m L/d,后续采用持续常压引流加弹力绷带适度绕颈环形加压的方法治疗;40例术后48 h切口引流200 m L/d,后续采用腰大池引流结合弹力绷带适度绕颈环形加压的方法治疗。术后常规卧床,预防感染,营养支持治疗。结果 32例持续常压引流的患者恢复至脑脊液漏停止的平均时间为6.4 d,40例腰大池引流的患者平均恢复时间为11.2 d。所有患者术后神经功能均显著改善,切口愈合良好,无感染发生。仅1例发生颈前脑脊液假性囊肿,经反复穿刺抽吸加腰大池引流无效,于术后半年行颈椎前路囊肿切除修补术后痊愈。结论充分的术前评估及熟练的手术技巧对于减少颈椎前路手术中硬膜损伤至关重要。对于已经形成的硬膜损伤,术中采取明胶海绵、生物蛋白胶封堵或皮下筋膜组织覆盖缺损处结合明胶海绵、生物蛋白胶黏合加固,再辅以术后伤口引流、腰大池引流等措施,可以取得满意疗效。     

Posterior arch defects of the cervical spine: a comparison between absent pedicle syndrome and spondylolysis

Background contextAbnormalities of the posterior arch are rare entities that are usually found incidentally on neck radiographs. Their radiographic appearance may cause them to be confused with more serious entities such as fractures, locked facets, and tumor-induced bony erosions. It is important to distinguish these posterior arch abnormalities from the other entities because the treatment is very different.PurposePosterior arch defects of the cervical spine, including cervical spondylolysis and absent pedicle syndrome, occur rarely. In this case report, we describe three cases of posterior arch defects and present a review of the literature concerning the distinguishing features between spondylolysis and absent pedicle syndrome.Study designA case report and literature review of the posterior arch defects.MethodsTwo patients are presented who developed posterior neck pain after trauma. They had no neurologic deficits, but cervical radiographs suggested that they had a traumatic injury. Cervical spine computed tomography (CT) revealed absent pedicle syndrome and they were treated conservatively. Another patient is presented who developed worsening posterior neck pain and left shoulder pain. She had no history of significant neck injury. Cervical radiographs and CT showed bilateral spondylolysis of C6 vertebra and subluxation of C6 on C7. Because her symptoms were not relieved by conservative measures, we performed anterior cervical discectomy and fusion.ResultsWe treated two patients with absent pedicle syndrome by conservative measures and one patient with cervical spondylolyis by surgical treatment.ConclusionsPosterior arch defects were often confused with other disease entities. But, they have some distinctive features and such distinctive features may be helpful in confirming diagnosis and planning treatment. Furthermore, three-dimensional CT scan reconstruction provides comprehensive anatomic evaluation of the structures with an absent pedicle and the associated bony abnormalities.     

Simultaneous bilateral versus unilateral tibial tubercle fractures

PurposeTibial tubercle/tuberosity fractures are rare injuries in young patients accounting for less than one percent of physeal fractures. Bilateral simultaneous fractures are even rarer, with only a few case reports in literature. The purpose of our study was to describe the largest case series of bilateral simultaneous tibial tuberosity avulsion fractures and compare it with unilateral fractures. We also wanted to compare our bilateral fractures case series with all the cases reported in the last 65 years.MethodsIRB approved retrospective study involving patients under age 18 years with tibial tuberosity avulsion fractures. Bilateral simultaneous fractures were compared to a unilateral group including demographic data, mechanism of injury, clinical exam findings, complication rates, and outcomes including return to function. Statistical analysis was performed using Mann-Whitney and Fisher Exact tests to compare the different groups.Results138 patients (131 males, 7 females) from a tertiary children’s hospital between 2012 and 2019 with tibial tuberosity avulsion fractures were included. 11 bilateral simultaneous fractures (BL Group) were identified and compared to age matched cohort from the 127 unilateral fracture patients (UL group). There was no significant difference found in BMI, height, weight, age, sex, mechanism of injury, return to functional range of motion, and return to sports between the groups. 7/11 (63%) of the patients in the BL group who sustained simultaneous fractures had to be home bound and could not attend school for an average of 8.3 weeks. There was a higher rate of complications in the BL group (63.3%) compared to the UL group (21.1%), which was statistically significant. The most common complications in the bilateral group were hardware removal and wound dehiscence.ConclusionThis first case series comparing unilateral versus bilateral simultaneous tibial tuberosity avulsion fractures suggests that the final outcomes of the two groups are similar, however it shows a significantly higher complication rate and hardware removal rate in the BL group. This study is also the first to highlight the significant initial morbidity in the BL fracture group with issues with regards to early mobility and loss of school-days. Keeping in mind the profound initial impact the bilateral injury poses to the patient; surgeons can possibly plan for rigid fixation for early mobilization to better prepare bilateral fracture patients for the early post-operative recovery process.     

Biomechanical study of adjacent intervertebral motion after lumbar spinal fusion and flexible stabilization using polyethylene-terephthalate bands

Thirty fresh-frozen calf cadaveric spinal specimens (L3-L6) were used to investigate the effect of flexible stabilization and fixation on the adjacent intervertebral motion segment. The intact spine that had not been subjected to injury was used for comparison as control. The destabilized spine was made up of specimens from which the bilateral facet joints and the supraspinous and interspinous ligaments were removed. The flexible stabilized spine was applied with pedicle screws and polyethylene-terephthalate bands, and the fixed spine was applied with pedicle screws and rods at the L4-L5 segment. The range of motion (ROM) was measured under flexion, extension, and bilateral bending moments, and the ROM ratio (ROM of each model versus ROM of the comparison model) was calculated at L3-L4, L4-L5, and L5-L6 segments. In the flexible stabilized spine, the restriction of motion was high under flexion and bilateral bending moments, and the mobility of the adjacent intervertebral motion segments approximated the normal lumbar vertebra. In the fixed spine, the ROM ratio increased at the cranial and caudal adjacent segments.     

A rare case of low voltage electrical injury leading to bilateral femur fractures and vertebral body fractures: A case report and review of the literature

Introduction and importanceLow voltage electrical injuries (less than 1000 V) can produce enough tetany to cause fractures, usually of the upper extremities. Simultaneous bilateral fractures of the femoral neck are an extremely rare occurrence. It is even more uncommon for a young healthy male to suffer significant fractures from a low voltage injury.Case presentationA 25-year-old male attempted suicide by filling a bathtub with water and getting into it prior to dropping a blender into the water. He experienced full body convulsions but remained awake throughout the entire event. In the trauma bay his primary complaints were bilateral hip pain and back pain, without neurologic deficit. Radiological studies confirmed bilateral sub-capital femur fractures and thoracic vertebral fractures (compression fractures of T3, T4, T5, T6, T7, T9, and T11). The patient underwent bilateral open reduction and internal fixation (ORIF) of the femurs, while the spine fractures were treated with a thoracic-lumbar-sacral orthosis TLSO brace.Clinical discussionLow voltage electrical injury is more likely to lead to fractures in patients with chronic renal failure and metabolic conditions such as hypocalcemia, osetomalacia, and osteoporosis. Fractures after low voltage electrical injury are extremely uncommon and a high suspicion for these injuries should be maintained because if missed there is a high risk of morbidity and mortality.ConclusionWe present a rare case of low voltage electrical injury by 120 V from a domestic US power supply, amplified by water conduction resulting in bilateral femoral neck fractures and vertebral body fractures.     

肌间隙入路通道下固定融合治疗复发性腰椎间盘突出症

目的:探讨肌间隙入路通道下单侧椎弓根螺钉联合对侧椎板关节突螺钉固定并椎间融合器植骨治疗复发性腰椎间盘突出症的临床价值和安全性。方法:回顾性分析2012年6月至2017年12月收治的51例复发性腰椎间盘突出症的临床资料。男32例,女19例;年龄34~64(51.11±7.28)岁;L4,538例,L5S113例;均有腰痛病史,其中3例伴双下肢放射痛,48例伴一侧下肢放射痛。24例患者采用正中切口入路单侧椎弓根螺钉联合对侧椎板关节突螺钉固定并椎间融合器植骨治疗(正中切口组),27例采用肌间隙入路通道下单侧椎弓根螺钉联合对侧椎板关节突螺钉固定并椎间融合器植骨治疗(肌间隙组)。记录两组患者手术时间、术中出血量、术后引流量和切口长度;采用视觉模拟评分法(visual analogue scale,VAS)对术后72 h腰部切口疼痛进行评分,采用JOA下腰痛评分系统评定术前及末次随访时两组患者腰椎功能;通过影像学资料观察术前、术后3~5 d和末次随访时病变节段椎间隙高度的变化,术前和末次随访时腰椎冠状面和矢状面Cobb角变化,术前和术后12个月多裂肌面积和多裂肌脂肪组织沉积等级,术后椎弓根螺钉和椎板关节突螺钉位置,以及椎间融合情况;比较两组患者并发症发生情况。结果:两组患者手术时间比较差异无统计学意义(P>0.05)。肌间隙组在切口长度、术中出血量和术后引流量方面优于正中切口组(P<0.05)。术后72 h腰部切口疼痛VAS评分正中切口组1.61±0.54,肌间隙组0.76±0.28,两组比较差异有统计学意义(P<0.05)。所有患者获得随访,时间12~84(43.50±15.84)个月。末次随访时两组JOA评分均较术前明显改善(P<0.05)。椎弓根螺钉位置不良率:正中切口组6.25%(3/48),肌间隙组9.26%(5/54),两组差异无统计学意义(P>0.05)。椎板关节突螺钉位置不良率:正中切口组12.50%(3/24),肌间隙组18.52%(5/27),两组差异有统计学意义(P<0.05)。两组患者术后3~5 d椎间隙高度较术前均有明显恢复(P<0.05),而在末次随访时亦有较明显的丢失(P<0.05)。末次随访时两组患者冠状面和矢状面平衡获得了很好的改善(P<0.05)。两组术后12个月多裂肌面积和等级的对比显示:正中切口显露对多裂肌损害明显,而采用肌间隙入路通道下操作多裂肌损害较轻(P<0.05)。椎间融合率:正中切口组91.7%(22/24),肌间隙组92.6%(25/27),两组差异无统计学意义(P>0.05)。并发症方面:正中切口组术中椎弓根入点骨折1例,术中硬脊膜撕裂1例,术后神经根损伤1例;肌间隙组术中椎弓根入点骨折1例,术中硬脊膜撕裂2例,术后神经根损伤1例,切口表皮坏死2例,切口愈合不良1例。两组神经根损伤均为椎弓根螺钉位置不正确所致,发现后即予螺钉调整术,神经根症状分别于术后3、6个月完全恢复。两组均未发生切口感染,随访过程中无椎弓根螺钉与椎板关节突螺钉松动、移位、断裂或椎间融合器前后向移位。并发症发生率肌间隙组25.93%高于正中切口组的12.50%(P<0.05)。结论:采用肌间隙入路通道下单侧椎弓根螺钉联合对侧椎板关节突螺钉固定并椎间融合治疗复发性腰椎间盘突出症临床上具有可行性,而且效果良好,与正中切口显露相比,明显缩小了切口、减少了创伤和出血量,术后反应轻、恢复快,较好地保护了多裂肌,同时无严重并发症的发生,值得临床上选择应用。     

Management of an unstable lumbar fracture with a laminar split.

This is a case report describing the injury sustained by a 36-year-old man injured in a motorcycle crash who sustained a fracture dislocation of L2 upon L3, associated with a split in the lamina of L3. His neurologic lesion was T12 ASIA B: with a motor score of 52 but with preservation of sensory function (sensory score 96) in most parts of his lower extremities. He also suffered a lower extremity fracture. Imaging of the spine is presented showing a multiplanar fracture associated with translation and with a defect in the lamina that may be seen in certain AO type B or type C fractures, that may entrap the lumbar spinal nerve roots. Discussants of this case comment on the classification and clinical significance of this fracture pattern. and present their operative approaches, both for management of this particular fracture pattern and for any associated dural tear. The issues of steroid use and the place of rehabilitation are also discussed.