单纯前路与一期前后路手术治疗腰骶椎结核

目的探讨单纯前路与一期前后路病灶清除植骨内固定两种手术方式在治疗L5∕S1结核临床疗效。方法回顾性分析17例L5∕S1结核患者行手术治疗。男13例,女4例;年龄23~62岁,平均39岁。病程6~24个月。前路病灶清除植骨内固定术7例(A组),前路病灶彻底清除、植骨加后路器械固定、融合治疗腰骶段脊柱结核10例(B组),术后随访时间16~48个月,平均22个月,记录手术时间,术中出血量,住院时间,患者随访期间植骨融合时间,术前、术后及末次随访VAS评分和下腰痛JOA评分,比较组间差异。结果两组之间平均植骨融合时间,术前、术后及末次随访VAS评分和下腰痛JOA评分等指标无显著统计学意义(0.05),手术时间,术中出血量及住院时间有统计学意义(0.05)。两组所有患者均达到骨性融合,融合时间4~7个月,平均6个月。8例神经根受压症状术后消失。结论单纯前路与一期前后路病灶清除植骨内固定两种手术方式在治疗L5∕S1结核均达到满意疗效。单纯前路手术在手术时间、术中出血量及住院时间方面优于一期前后路手术。     

Anatomic bases for anterior spinal surgery: surgical anatomy of the cervical vertebral body and disc space

Twenty adult cadaveric cervical spines were sectioned longitudinally through the midline to display longitudinal sections of the vertebral bodies and disc spaces from C3 to T1. Computer-assisted anatomic images were obtained for measurements of the disc spaces and vertebral bodies. Anteroposterior (AP) depth gradually increased from 16.56 ± 2.21 mm at C3 to 19.32 ± 2.30 mm at C7. Greater values of AP depth at the inferior endplate were found at C5 (20.75 ± 2.87 mm) and C6 (20.56 ± 2.31 mm) compared with the values at C3 (18.26 ± 1.82 mm), C4 (19.27 ± 2.88 mm) and C7 (19.21 ± 3.22 mm). The AP depth at the superior endplate was greater than that at the inferior endplate. The height of the disc space was found to be lowest at the posterior disc space from C2-3 to C7-T1 (2.95 ± 0.86 mm at C2-3, 2.78 ± 0.93 mm at C3-4, 2.45 ± 0.79 mm at C4-5, 2.92 ± 0.64 mm at C5-6, 2.46 ± 0.59 mm at C6-7, 2.93 ± 1.05 mm at C7-T1), when compared to the height of the disc space at the anterior disc space from C2-3 to C7-T1 (4.07 ± 0.85 mm at C2-3, 4.34 ± 1.18 mm at C3-4, 3.95 ± 1.37 mm at C4-5, 3.55 ± 1.37 mm at C5-6, 3.55 ± 0.76 mm at C6-7, 3.67 ± 1.17 mm at C7-T1). The mid-axis of the disc space was situated at approximately 3 mm above the anterior midpoint of the annulus fibrosus at the level of the lower cervical spine. To reach the posterior portion of the disc space from the anterior midpoint of the annulus fibrosus, a 5° cephalad angulation of the drill relative to the mid-axis of the disc space is necessary. All these original data from cadavers may be helpful during anterior approach for discectomy, vertebrectomy and anterior screw-plate placement.     

Ligaments of the lumbar spine: a review

A thorough knowledge of the anatomy of the intervertebral ligaments is necessary to provide the basis for good clinical management of back injuries. This paper reviews the literature concerning the lumbar ligaments, including the zygoapophyseal joints. While general principles regarding the anatomy of the ligaments is relatively clear, areas of omission or discrepancy exist. There is very little substantiated information on: the dimensional characteristics of the ligaments; the fibre lengths of the facet capsule; the attachments of the anterior longitudinal ligament; the orientation of the interspinous ligament, and the extent of the supraspinous ligament.     

鼻前棘的解剖

目的探讨鼻前棘的出现率、解剖学形态与年龄及性别的关系。方法观察并统计1000例颅面部(包括上颌骨)横轴位电子计算机断层扫描(CT)中鼻前棘的出现率,观察其形态并进行分类,并对鼻前棘出现率、形态及其分别与性别、年龄的关系进行研究并做统计学分析。结果鼻前棘的总体出现率为98.20%(982/1000)。鼻前棘在男女性中的出现率分别为99.06%(629/635)、96.71%(353/365),男性高于女性(χ2=7.1970,P<0.05)。鼻前棘在儿童组(年龄≤7岁)、青少年组(年龄8~18岁)、成年组(年龄>18岁)的出现率分别为92.59%(75/81)、99.25%(133/134)、98.60%(774/785),鼻前棘在青少年组(99.25%)和成人组(98.60%)的出现率高于儿童组(92.59%)。鼻前棘不同形态中,三角型最多(64.66%)。三角型鼻前棘在女性中的出现率最高(74.22%),双杆型及单杆型在男性中的出现率最高(28.46%、8.90%),不规则型在男女中的出现率差异不明显(3.34%、1.98%)。双杆型在青少年中出现率最高(58.65%),三角型在儿童组(64.00%)和成人组中的出现率(71.32%)高于青少年组(26.32%),单杆型在青少年中出现率最高(12.78%),不规则型在各组年龄段(2.67%、2.56%、2.97%)的出现率差异不明显。结论绝大多数人(98.20%)有鼻前棘。鼻前棘的形态以三角型最多见。鼻前棘的出现率和形态与性别及年龄有关。     

The anatomical relationship of the aortic bifurcation to the lumbar vertebrae: a MRI study

The objective of this study was to determine the level of the aortic bifurcation in relation to the lumbar spine by MRI and the effect of lumbosacral anomalies on the aortic bifurcation. A prospective study of 441 patients was performed. Sagittal MR images of the entire spine were obtained along with the standard protocol for imaging of the lumbar spine. The vertebrae were counted caudally from C2 instead of cranially from the presumed L5 vertebra. The aortic bifurcation in relation to the lumbar vertebrae was determined. The aorta bifurcated at the L4 vertebral body in 67% of cases. In patients with sacralization of L5 the aortic bifurcation was at the L3 vertebral body in 59%. In those patients with lumbarization of S1 the aorta bifurcated at the level of the L4 vertebral body in 40% and at the L4/5 disc space in 33%. There was no demographic variation of the aortic bifurcation in relation to age or sex. The aorta bifurcated at L4 in two-thirds of cases and was variably located in the remaining third. The stability of this as a landmark is disturbed by the significant high incidence of lumbosacral transitional segments.     

Thoracoscopically assisted ligamentous release of the thoracic spine a cadaver study

The surgical treatment of thoracic kyphosis frequently requires an anterior release, which can be carried out by an open or endoscopic technique. This study concerns the reference points which are essential from the anatomic view for minimizing the operative risks. Furthermore we wanted to find the most convenient video-assisted thoracoscopic surgery (VATS) technique for transection of the anterior longitudinal ligament (ALL). Transection of the ALL, as well as discectomy, was performed using this technique. The extensive anatomic dissection of 12 fresh cadavers was performed to define possible technical errors and surgical complications. The development of new instruments has made the VATS approach to the ALL a viable alternative to open procedures. With the help of a standardized technique, the isolated thoracoscopic ligamentous transection required less time than the comparable open procedure. The anatomic study showed, that in no case was a ligation of the intercostal or segmental vessels necessary as part of the approach to the spine, once an adequate mobilization of the esophagus and azygos vein had been carried out. The risk of an ischemic lesion of the spinal cord was thereby reduced. The thoracoscopic, limited anterior release consisting of a multilevel transection of the ALL proved to be a rapid and reliable procedure. Our anatomic studies provides suitable the reference points.     

一期和分期前后路手术治疗下颈椎骨折脱位的疗效观察

目的观察应用一期和分期前后路内固定手术治疗下颈椎骨折脱位的临床疗效和风险。方法自1999年1月～2009年2月间对74例下颈椎骨折脱位的患者,一组采用一期前后路手术治疗54例,另一组采用分期前后路手术治疗20例。术后定期复查X线观察融合率和稳定性,以Frankel分级判定脊髓功能恢复情况。结果术后74例病例得随访,随访6～36个月。全体病例脱位均完全复位,植骨均获得融合,颈椎间隙高度及生理曲度恢复满意,未出现内固定断裂、松动及脱出。脊髓功能按Frankel分级平均有1级以上改善。两组患者术后6个月脊髓功能按Frankel分级情况经R×C卡方检验(2=4.14,﹥0.05),无统计学差异。结论一期或分期前后路治疗下颈椎骨折脱位,均能取得良好效果。应根据患者病情、体质的特点及术者手术技术的熟练程度,选择合适的手术方式。     

Biomechanical behaviour in vitro of the spine and lumbosacral junction

Summary Six fresh human specimens extending from the 9th thoracic vertebra (T9) to the pelvis were used to study the biomechanical behaviour of the long lumbopelvic segments, including mobility of the sacrum. The loads were applied at T9 using pure couples up to 5Nm. The displacements were measured by an optoelectronic method (VICON 140). Stress-displacement curves were obtained for the three angular components of the vertebra studied according to the plane of the principal stresses and of the two other planes corresponding to the coupled mobilities. Mobility decreased from T9 to the sacrum. There was mobility of the sacrum in relation to the pelvis in flexion, with a mean of 1.28° (0.5 to 2.8°); 3 sacrums showed a mobility of the order of one degree for torsional stresses. There was no sacral mobility during stresses in lateral flexion. The use of this experimental protocol with low mechanical stresses should allow the evaluation of long osteosyntheses extending to the sacrum.

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Comportement biomécaniquein vitro de la colonne vertébrale et de la charnière lombo-pelvienne

Résumé Six pièces anatomiques humaines fraîches, allant de la 9ème vertèbre thoracique (T9) au pelvis ont été utilisées pour étudier le comportement biomécanique de segments longs lombopelviens intégrant la mobilité du sacrum. Les charges étaient appliquées en T9 selon des couples purs jusqu'à 5Nm. Les déplacements étaient mesurés par un procédé optoélectronique (Vicon 140). Des courbes effort-déplacement ont été obtenues pour les trois composantes angulaires de la vertèbre étudiée selon le plan de sollicitations principales et selon les deux autres plans correspondant aux mobilités couplées. Les mobilités décroissaient de T9 au sacrum. Il existait une mobilité du sacrum par rapport au bassin en flexion avec une moyenne de 1.28° (0,5 à 2,8°); 3 sacrums présentaient une mobilité de l'ordre du degré pour des sollicitations en torsion. Il n'existait pas de mobilité sacrée lors des sollicitations en inflexion latérale. L'utilisation de ce protocole expérimental, avec des sollicitations mécaniques faibles, doit permettre l'évaluation d'ostéosynthèses longues étendues jusqu'au sacrum.

     

Biomechanical behaviour in vitro of the spine and lumbosacral junction

Six fresh human specimens extending from the 9th thoracic vertebra (T9) to the pelvis were used to study the biomechanical behaviour of the long lumbopelvic segments, including mobility of the sacrum. The loads were applied at T9 using pure couples up to 5Nm. The displacements were measured by an optoelectronic method (VICON 140). Stress-displacement curves were obtained for the three angular components of the vertebra studied according to the plane of the principal stresses and of the two other planes corresponding to the coupled mobilities. Mobility decreased from T9 to the sacrum. There was mobility of the sacrum in relation to the pelvis in flexion, with a mean of 1.28° (0.5 to 2.8°) 3 sacrums showed a mobility of the order of one degree for torsional stresses. There was no sacral mobility during stresses in lateral flexion. The use of this experimental protocol with low mechanical stresses should allow the evaluation of long osteosyntheses extending to the sacrum.     

Anatomical basis of the anterior cervical spine approach: topographic study of the nerve structure

Summary The results of the surgical anterior approach to the cervical spine are marked in a number of cases by dysphagia and dysphonia, especially when the approach is extensive or performed at the upper cervical spine. 35 cadaver dissections were performed to define the topography of the nerve structures during operative exposure at various vertebral levels : superior and recurrent laryngeal nerves, hypoglossal nerve and its superior root of the ansa cervicalis. The authors suggest some technical improvements, for each stage of surgical dissection.

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Bases anatomiques de l'abord antérieur du rachis cervical: étude topographie des structures nerveuses

Résumé Les suites de la chirurgie du rachis cervical par voie antérieure présternocléidomastoïdienne sont marquées dans un nombre de cas non négligeable par des troubles de la déglutition et de la phonation, et ce, d'autant que l'abord est étendu. 35 dissections sur cadavres ont été réalisées afin de préciser la topographie par rapport aux niveaux vertébraux, le trajet et les variations des éléments nerveux rencontrés lors de cet abord cervical : nerfs laryngés supérieur et récurrent, nerf hypoglosse et la racine supérieure de l'anse cervicale. A partir de cette étude morphologique, les auteurs suggèrent quelques points d' amélioration technique, à chacune des étapes de la dissection, en pratique chirurgicale.

     

The relationship between the lumbosacral enlargement and the conus medullaris during the period of fetal development and adulthood

The spinal cord is situated within the vertebral canal by the third month of intrauterine life. The spinal cord possesses two symmetrical enlargements, which constitute the segments of the plexuses the cervical enlargement for the brachial plexus and the lumbosacral enlargement for the lumbar and sacral plexus. In our study, we aimed to investigate the relationship between the termination level of the lumbosacral enlargement (TLLE) and that of the conus medullaris (TLCM) during the period of fetal development and adulthood. We used a total of 75 cases 25 fetuses (male 16, female 9) whose crown-rump length ranged between 90–190 mm, 25 premature and full-term neonates (male 17, female 8) whose post-menstrual ages ranged between 33–55 weeks, and 25 adults (male 12, female 13) aged between 22–72 years. The dissection technique for fetuses, ultrasonography for premature and full-term newborns, and magnetic resonance imaging (MRI) for adults were used to determine lumbosacral enlargement and TLCM. The differences between the TLCM and the termination level of the largest part of the transverse diameter of the lumbosacral enlargement were investigated. The differences between the TLLE and TLCM were found in different ratios from the period of fetal development to adulthood. Therefore, during medical treatment and surgical procedures this should be taken into account to avoid complications.     

下颈椎前方手术中预防颈交感干损伤的应用解剖

目的:探讨下颈椎前路手术中颈交感干易于损伤的部位及预防方法。方法:25具经防腐处理的颈椎标本,解剖观测颈交感干距前正中线、颈长肌内缘和横突前结节的距离,与前正中线及颈长肌内缘的交角。结果:颈交感干由外上行向内下,距前正中线和颈长肌内缘的距离从C3-C7依次减小,C3分别为(25.1±4.5)mm,(20.5±5.8)mm;C7分别为(19.4±2.9)mm,(12.9±3.7)mm。颈交感干在C5平面以上多位于颈椎横突前结节的外侧,在C6平面位于前结节的前方或内侧。颈交感干距前正中线最近点在C6.7,平面最多(56％)。颈交感干与中线及颈长肌内缘的交角分别为10.1°±4.6°和17.3±6.2°。结论:颈交感干与颈椎横突前结节关系紧密,在C6.7平面距前正中线及颈长肌内缘最近,在以上部位手术时颈交感干易于损伤。     

经胸骨上段显露颈胸段脊柱的应用解剖

目的:为临床经胸骨上段显露脊柱颈胸段提供解剖学基础。方法:对40具成人尸体模拟经胸骨上段显露颈胸段脊柱的入路进行解剖,并进行有关的数据测量。结果:甲状腺中静脉有48.8%的人一侧缺如。胸骨劈开后撑开的横径为(60.8±1.64)mm。两侧胸膜在前界中段之间有分离型、接近型、接触型和掩复型,后两者占50.4%。食管在T3椎体平面超出气管左缘(0.5±0.08)cm。胸导管由颈血管鞘后方到注入静脉的行程位于颈静脉角三角区。左、右侧喉返神经分别有94.5%、59.6%走行在气管食管沟内,并与甲状腺下动脉有复杂的关系。胸骨角正对T4/5椎间盘、T4下1/3和T5上1/3椎体(62.5%)水平,喉返神经左、右侧返折点分别平对T3/4椎间盘、T4椎体(75.6%)和T1/2椎间盘、T2椎体(82.0%),主动脉弓、右锁骨下动脉上缘分别对T3(73.7%)和T1椎体(70.0%)水平,经胸骨上段入路的颅侧和尾侧分别平对C3/4椎间盘、C4椎体(75.6%)和T3椎体、T3/4椎间盘(86.8%)。结论:经胸骨上段显露脊柱颈胸段具有暴露充分,操作方便,具有推广价值。     

Method of quantitative anatomical study of the dorsal neck muscles

Summary Biomechanical models of the cervical spine require knowledge of the position, size and orientation of the individual muscles that act on the cervical spine. We have developed a technique to stereometrically measure anatomical specimens. The apparatus is composed of three graduated metallic rods, which slide along a fixed support. This method is accurate to map the anatomy of individual muscles and provides quantitative data on their lines of action. Results are obtained from one specimen. The computer processing of the collected data allows formulation of a three-dimensional model of the neck muscles in man.

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Méthode d'étude anatomique quantitative des muscles de la nuqueEtude préliminaire

Résumé Pour élaborer un modèle biomécanique de la colonne cervicale, il faut connaître la position, la taille et l'orientation des différents muscles du cou. Nous avons mis au point une méthode de mesure stéréométrique sur des sujets anatomiques. L'appareil est composé de 3 axes métalliques gradués qui coulissent sur un support fixe. Cette technique permet une étude anatomique précise de chacun des muscles de la nuque, fournissant des données quantitatives sur les différents faisceaux ou lignes d'action. Les résultats sont obtenus sur un sujet. Leur traitement informatique permettra l'élaboration d'un modèle mathématique tridimensionnel des muscles du cou chez l'homme.

     

The phrenico-esophageal ligament: an anatomical study

The phrenico-esophageal ligament (PEL), which is claimed by some to be an important anti-reflux barrier, has been accepted as an important structure by some surgeons dealing with the surgical treatment of hiatal hernias. However, the characteristics of its anatomical structure and the physiological importance of this ligament is still a subject of discussion. The aim of this study was to define this anatomic structure and to point out the clinical importance of the PEL. This study has been carried out on samples taken from 2 fresh and 12 fixed cadavers. The PEL was observed to be derived from the transversalis and endothoracic fascia attaching the esophagus to the diaphragmatic crura at the region of the esophageal hiatus. While the transversalis fascia covered the inferior surface of the diaphragm, it was observed to divide into upper and lower leaflets when it approached the esophageal hiatus. The endothoracic fascia turned superiorly at the level of esophageal hiatus and attached on to the esophagus by uniting with the upper leaflet of the transversalis fascia in 11 of the specimens. In three of the specimens, it attached on the esophagus at a higher level than the transversalis fascia. The histologic sections of our study revealed that the PEL is formed by collagen and elastic fibers composed of fibroblasts and blood vessels. Since the PEL is a strong structure that firmly attached to the esophageal wall and surrounded the upper part of the distal esophagus like a skirt, it is reasonable that it may play an important role in the gastroesophageal sphincteric mechanism. Histological evidence for decrease in collagen fibers with age and the loose arrangement of the elastic fibers due to this decrement might decrease the resistance and the elasticity of the PEL. This situation may explain the predisposition to hiatal hernias seen with increased in age.     

Ⅰ型腰骶移行椎与正常第5腰椎的形态学比较及其临床意义

目的　探讨Ⅰ型腰骶移行椎与正常第5腰椎椎体的形态学差异,为临床应用提供形态学依据。 方法　选取Ⅰ型腰骶移行椎和正常第5腰椎标本各60例,观测：椎体上下终板前后径、横径;椎体前缘高度、后缘高度及其前/后高比值;椎弓根纵、横径。统计学分析并进行t检验。 结果　I型移行椎与正常第5腰椎相比,椎体上、下终板前后径及横径差异均有显著意义（P<0.01）;椎体的上、下前后径大1~2 mm,上、下横径大2~3 mm,前高大0.7~1.2 mm,后高大0.8~1 mm,统计均有显著意义;椎体的前/后高度比值及椎弓根纵横径I型移行椎与正常第5腰椎之间差异均无显著意义。 结论　I型腰骶移行椎椎体各径线较正常第5腰椎椎体稍大, 但形态相近; I型移行椎椎体与正常第5腰椎椎体无明显区别,I型腰骶移行椎椎弓根螺钉进钉可按正常第5腰椎方法进行。     

Fractures of the tibial spine: epidemiology and outcome

We documented functional outcome in 83 knees with tibial spine fractures. The mean age at injury was 35 years. There was a medial collateral ligament sprain in 17 knees and posterolateral corner injury in three knees. Twenty patients with displaced tibial spine fractures were treated with fixation of the tibial spine and 63 patients with undisplaced or minimally displaced fractures were treated non-operatively.

Fourteen (22%) non-operatively treated knees developed symptomatic instability, three of which underwent ACL reconstruction. Tibial spine fixation restored stability in 18 of 20 knees, but knee stiffness was more common in this group when compared to non-operatively treated knees (60% vs 19%, p < 0.0005). Patients with postoperative knee stiffness had a mean age of 28 years compared to 18 in patients with no knee stiffness (p < 0.05).

We concluded that tibial spine fracture in skeletally mature patients is associated with a significant risk of knee stiffness and instability.     

骶髂关节周围腰骶丛神经的解剖学研究及其临床意义

目的　对腹直肌外侧入路显露骶髂关节周围重要结构的位置关系进行测量及描述,探讨入路的安全性及安全操作空间。 方法 选取新鲜成人完整尸体标本,对每具骨盆标本经双侧腹直肌入路逐层解剖,观察腹膜、髂外血管、髂腰肌、闭孔神经等重要组织结构的位置关系,重点观测L4、L5、S1神经与闭孔神经位置,测量分析神经至骶髂关节的距离。 结果　腹直肌外侧入路可清楚显露骶髂关节、腰骶干、S1神经根、骶骨翼等结构。 L5神经前支出椎间孔处与骶髂关节距离左侧为(23.56±4.30)mm,右侧为(23.69±3.41)mm,L4神经前支与骶髂关节在L5神经前支出椎间孔处的距离左侧为(17.97±1.58)mm,右侧为(17.49±1.49)mm,腰骶干外缘在其形成汇合点平面与骶髂关节的水平距离左侧为(14.34±2.51)mm,右侧为(13.81±2.21)mm,平骶岬处腰骶干外缘与骶髂关节的水平距离左侧为(12.19±1.98)mm,右侧为(12.22±1.55)mm。 结论　腹直肌外侧入路可用于复位固定骶髂关节周围骨折脱位,具有安全的操作空间,且经该入路的操作为骶髂关节复合体损伤引起的神经损伤提供了探查松解的新思路。     

下颈椎的侧方外科入路解剖及其临床意义

目的：探讨下颈椎侧方外科入路。方法和结果：通过解剖研究和临床实际应用，对下颈椎入路的解剖层次及各种结构的外科处理要点作了描述。结论：本文所描绘的下颈椎侧方外科入路能兼顾半侧椎体及附件，在临床上尤合适作半侧脊椎切除术以治疗某些脊柱肿瘤