一期外科治疗颈椎结核的疗效评价

目的探讨颈椎前路一期手术行病灶清除,植骨融合联合前路和(或)后路内固定,联合支具、石膏等外固定对颈椎结核的疗效。方法前路或者后路手术治疗颈椎结核16例。采用颈椎前路病灶清除,自体髂骨植骨或钛网植骨融合,并行前路和(或)后路内固定;对于年幼患者则单纯采用病灶清除、植骨融合和石膏外固定术。术后患者行正规抗结核治疗。结果所有患者经2~5年随访,16例颈椎结核均治愈。所有患者在动态颈椎侧位片上均达到骨性融合,融合时间平均为5.8个月,后凸矫正角度平均32.4°。术后1个月内复查,JOA评分提高了2~10分,平均为5.7分。结论颈椎前路一期彻底病灶清除、椎管减压、联合后路和(或)前路内固定手术治疗颈椎结核,能避免经口咽入路等手术入路的并发症,同时能矫正颈椎后凸畸形或上颈椎脱位,进行颈椎稳定性重建,能增加植骨块的融合率,有利于患者早期活动和提高颈椎结核治愈率。     

前路病灶清除、植骨、内固定治疗脊柱结核

目的观察前路病灶清除、植骨、前路或后路内固定治疗脊柱结核的效果。方法总结1997年1月至2004年6月采用前路病灶清除、植骨、前路或后路内固定治疗脊柱结核41例,病变位于颈椎3例、胸椎3例、胸腰椎20例、腰椎14例、腰骶椎1例,术前有后凸成角畸形9~°71,°平均32°。Ⅰ期前路病灶清除、植骨、内固定31例,Ⅰ期前路病灶清除、植骨、后路内固定6例,Ⅱ期后路内固定4例。结果平均随访1.6 a,优良率为87.8%,植骨融合率为92.7%,平均矫正后凸角度15.3(°P<0.05),随访期间无1例复发。结论前路病灶清除、植骨、前路或后路内固定治疗脊柱结核有利于恢复脊柱的早期稳定性,融合率高,可预防及矫正脊柱后凸畸形。     

前路病灶清除自体髂骨植骨融合内固定术联合抗结核药物治疗下颈椎结核

目的 探讨前路病灶清除自体髂骨植骨融合内固定术联合抗结核药物治疗下颈椎结核.方法 回顾性分析2010年1月—2017年12月本院收治的25例下颈椎结核患者,所有患者术前采用抗结核药物治疗2周以上,均采用一期前路病灶清除自体髂骨植骨融合内固定术治疗,术后继续规范抗结核药物治疗12～18个月.随访观察记录颈部疼痛视觉模拟量...     

成人颈椎结核外科治疗的术式选择

目的 探讨成人颈椎结核外科治疗的术式选择.方法 2例枢椎结核患者,行前路经颈部病灶清除、自体髂骨植骨融合并Halo架外固定,其中1例1个月后再次行后路枕颈融合术.13例下颈椎结核患者, 9例采用经前路一期病灶切除、自体骼骨植骨融合并前路钛合金钢板内固定术,4例采用前路病灶清除并自体髂骨植骨及Halo架外固定.15例均接受9～12个月的规范抗结核药物治疗.结果 所有患者切口均一期愈合,随访1～6年,局部无复发,植骨均融合,平均融合时间为3.9个月(3.5～4.5个月).6例脊髓损害患者中,4例恢复至E级,2例C级仅感觉改善,肌力无恢复.结论 颈椎结核应积极采用手术治疗.彻底病灶清除及有效稳定性重建是治疗颈椎结核的关键环节.     

一期前路病灶清除植骨内固定治疗胸腰椎结核临床观察

[目的] 探讨经前路病灶清除植骨一期前路/后路内固定术治疗胸腰椎结核的临床疗效.[方法] 对24例胸腰椎结核患者,经3～4周正规抗结核治疗,行前路病灶清除、椎间大块自体髂骨/肋骨植骨、一期前路/后路内固定术,术后继续抗结核治疗18～24个月.[结果] 1例脊柱结核复发(3%).23例植骨融合,植骨融合率为96.9%,植骨愈合时间 4～8个月(平均6个月).无窦道形成.脊柱后凸畸形平均矫正80%.[结论] 经前路病灶清除植骨一期前路/后路内固定术治疗胸腰椎结核能彻底清除结核病灶,对脊髓及神经根进行彻底减压,促进脊髓及神经功能恢复,矫正脊柱后凸畸形,同时一期建立和恢复脊柱的连续性和稳定性,促进脊柱植骨融合,提高脊柱结核的治愈率.     

胸腰椎结核前路术后复发的原因及再手术治疗

目的探讨胸腰椎结核一期前路病灶清除、植骨融合及内固定术后复发的原因及再手术治疗的策略。方法对136例胸腰椎结核患者行一期经前路术病灶清除、植骨融合及内固定,对其中15例术后复发合并窦道形成并经过保守治疗无效患者的复发原因进行分析,并均采取一期前路病灶清除、内固定取出、植骨融合、后路植骨融合内固定的翻修术治疗。结果 15例均获得随访,时间12~48个月。14例治愈,影像学检查显示植骨融合;1例再次复发,再次复发率为6.67%(1/15),经抗结核及换药4个月治愈。结论胸腰椎结核一期前路术后复发的主要原因与病灶清除不彻底、耐药性结核菌株出现、非活性异物过多放置、内固定松动失效、长期营养不良及不正规化疗有关;前路病灶的彻底清除及良好的植骨支撑、后路坚强的内固定结合有效的化疗可明显减少翻修术后结核的复发率。     

前路内固定矫正结核性脊柱畸形

目的　总结前路病灶清除、椎体间植骨和前路内固定手术治疗结核性脊柱畸形的临床疗效 ,探讨前路内固定植入在脊柱结核外科治疗中的安全性和价值。　方法　 1997年 6月～ 2 0 0 1年5月 ,采用前路病灶清除、椎体间植骨和一期前路内固定手术治疗脊柱结核 18例 ,其中颈椎 1例 ,胸椎10例 ,胸腰段 2例 ,腰椎 5例。平均每例受累椎体 2 8个。脊柱后凸畸形角度 2 7 0°～ 75 5°,平均47 5°± 11 4°。均采用髂骨植骨。　结果　 18例病例均获得随访 ,平均随访时间 2 5个月。所有病例均未出现伤口深部感染或窦道形成 ,植骨均完全融合 ,平均融合时间为 3 6个月。后凸畸形矫正度数为 32 7°± 8 3°,后期矫正度丢失 3 2°± 2 8°。　结论　前路内固定手术在脊柱外科治疗中能有效地达到矫正后凸畸形、重建脊柱稳定性和促进椎体间植骨融合的目的 ,是一种安全和有效的治疗方法。     

前路病灶清除植骨内固定术治疗胸腰椎结核

目的探讨在胸、腰椎结核外科治疗中,前路病灶清除植骨内固定术对清除结核病灶,对脊髓神经的减压及重建脊柱稳定性的重要性。方法对2000年10月~2004年6月共收治的胸、腰椎结核患者46例,采用前路病灶清除自体髂骨植骨38例,异体深冻骨植骨并胸、腰椎前路钛钢板内固定8例。结果经过平均18个月的随访,长达1~1.5年的抗结核治疗,44例患者结核治愈,植骨融合时间平均为5.2个月。术前截瘫、不全瘫或伴有神经症状者均有不同程度的恢复;1例内固定松动、异体深冻骨植骨未融合;1例复发,但其异体深冻骨植骨块及内固定位置良好,经继续抗结核治疗6个月后结核治愈。结论前路病灶清除,自体髂骨植骨,钛钢板内固定对胸、腰椎结核疗效肯定,异体深冻骨植骨存在融合慢或不融合的问题。     

一期前路病灶清除植骨融合内固定治疗胸腰椎结核

目的总结一期前路病灶清除植骨融合内固定治疗胸腰椎结核的经验。方法采用一期前路病灶清除、自体植骨、前路内固定治疗胸腰椎结核19例。结果平均随访15个月,脊髓神经功能得到不同程度地恢复,术后平均5.2个月达满意植骨融合,无内固定失败和脊柱结核病灶复发,后凸畸形矫正满意,Cobb角平均23.4°,平均矫正21.3°。结论一期前路病灶清除植骨融合内固定术可使病变节段在术后即刻重建稳定性,为脊柱融合和结核病灶的静止提供良好的力学环境,是外科治疗脊柱结核安全、有效的方法。     

一期病灶清除并植骨内固定术治疗颈椎结核

目的探讨规范抗结核药物治疗基础上一期手术病灶清除术并植骨融合内固定治疗颈椎结核的临床疗效。方法回顾性分析2008年1月—2014年12月在本院接受规范抗结核治疗基础上一期手术行病灶清除并自体髂骨植骨融合内固定术治疗的26例颈椎结核患者资料,男17例,女9例;年龄26~75岁,平均45.4岁。其中累及颈椎单椎体7例、相邻双椎体12例、3椎体4例,合并脊柱其他部位结核病灶3例(包括T5 1例、T12 1例、L3 1例)。1例合并颈椎后纵韧带骨化症。术前颈部疼痛视觉模拟量表(VAS)评分4~9分,平均5.7分;日本骨科学会(JOA)评分7~12分,平均10.1分;术前病变节段Cobb角21.5°±6.1°;美国脊髓损伤协会(ASIA)分级C级2例,D级3例,E级21例。术前行规范的抗结核治疗,待红细胞沉降率(ESR)50 mm/h后行手术治疗。根据手术节段及病变情况选择颈椎前路、后路或联合入路进行手术。术后继续规范抗结核治疗12~18个月。结果术后随访13~49个月,平均25.3个月。术前症状均明显改善,骨性融合时间3~6个月,平均4.5个月。末次随访时,颈部VAS评分(1.1±2.7)分,JOA评分(15.1±3.9)分,病变节段Cobb角4.7°±6.1°。1例上颈椎结核患者术后出现取骨区皮下脂肪液化、切口不愈合,给予手术清创缝合后二期愈合。术后未发生颈椎结核复发。结论在术前规范抗结核治疗基础上,根据病变节段采用一期彻底病灶清除联合植骨融合内固定手术可有效治疗颈椎结核,术后规范的抗结核治疗是提高颈椎结核治愈率的关键。     

脊柱前路手术的适应证

脊柱外科手术入路的选择常常取决于脊柱外科医师的手术技能。随着脊柱生物力学研究的深入、影像诊断技术的发展以及脊柱融合与内固定技术的进步 ,脊柱前路手术已作为许多脊柱疾患的常规治疗方法而逐渐普及。掌握适应证对于脊柱外科手术的成功至关重要 ,笔者就脊柱前路手术适应证的选择作一讨论。1　前方减压与稳定包括椎体和椎间盘在内的脊柱前部结构担负着脊柱的大部分生物力学功能 ,因而多数脊柱伤病系以累及脊柱前部结构为主。1.1　 感染与肿瘤　脊柱感染和肿瘤最容易累及的是椎体和椎间盘 ,经前路施行病灶清除及椎管减压手术常常为病情…     

侧方途径切除胸腰椎肿瘤和脊柱重建

目的探讨侧方入路手术途径切除胸腰椎肿瘤和重建脊柱稳定性的临床疗效和意义。方法29例T3～T4肿瘤患者，Frankel神经功能分级：A级3例，B级5例，C级7例，D级6例，E级8例。经侧方入路手术途径显露病椎前方、侧方和后方，切除肿瘤以及上下相邻椎间盘，然后根据肿瘤的具体情况进行不同肜式的脊柱稳定性的重建。结果围手术期无死亡病例，患者出院时Frankel神经功能分级，A级2例，B级3例．C级4例，D级4例，E级16例。术后获访23例，随访时间13～58个月，死亡4例；神经功能情况，13例较出院时有改善，加重1例。结论侧方入路手术途径无需经胸／腹膜腔，患者容易耐受手术，适合于某些胸腰椎肿瘤的切除和脊柱稳定性的重建。     

Atypical forms of spinal tuberculosis

Summary Twenty-three patients with atypical forms of spinal tuberculosis treated between 1975 and 1985, are described.All presented with signs and symptoms of compression of the spinal cord or cauda equina, ranging from paraesthesiae and increasing weakness of extremities to paraplegia and loss of sphincter control. None of them showed visible or palpable spinal deformity nor the typical radiographic appearance of destruction of the intervertebral disc and the two adjoining vertebral bodies. These atypical forms constituted about 12 percent of all the cases of spinal tuberculosis seen (a total of 190 cases); and fell into three well-defined groups: those with the involvement of neural arch only; those with the inolvement of a single vertebral body; and, those without bony involvement. The correct surgical approach in these groups was found to be different: spinal cord compression caused by the tuberculous disease of the neural arch was best treated by laminectomy; whereas single vertebral body disease required an anterior or anterolateral approach. Spinal computerized tomography was helpful in defining the extent of disease and planning the surgical approach. Histological confirmation of tuberculosis was obtained in all the cases and acid fast bacilli (A.F.B.) were found in, and cultured from, the biopsy specimens of 18 cases.     

Incidence and significance of findings on spinal MRIs in a paediatric population with spinal column complaints

PurposeWe sought to identify correlations between working diagnosis, surgeon indication for obtaining spinal MRI and positive MRI findings in paediatric patients presenting with spinal disorders or complaints.MethodsSurgeons recorded their primary indication for ordering a spinal MRI in 385 consecutive patients. We compared radiologist-reported positive MRI findings with surgeon response, indication, working diagnosis and patient demographics.ResultsThe most common surgeon-stated indications were pain (70) and coronal curve characteristics (63). Radiologists reported 137 (36%) normal and 248 (64%) abnormal MRIs. In total, 58% of abnormal reports (145) did not elicit a therapeutic or investigative response, which we characterized as ‘clinically inconsequential’. In all, 42 of 268 (16%) presumed idiopathic scoliosis patients had intradural pathology noted on MRI.Younger age (10.3 years versus 12.0 years) was the only significant demographic difference between patients with or without intradural pathology. Surgeon indication ‘curve magnitude at presentation’ was associated with intradural abnormality identification. However, average Cobb angles between patients with or without an intradural abnormality was not significantly different (39° versus 37°, respectively). Back pain without neurological signs or symptoms was a negative predictor of intradural pathology.ConclusionRadiologists reported a high frequency of abnormalities on MRI (64%), but 58% of those were deemed clinically inconsequential. Patients with MRI abnormalities were two years’ younger than those with a normal or inconsequential MRI. ‘Curve magnitude at presentation’ in presumed idiopathic scoliosis patients was the only predictor of intrathecal pathology. ‘Pain’ was the only indication significantly associated with clinically inconsequential findings on MRI.Level of evidence:III     

椎管内肿瘤的诊断及手术治疗

探讨椎管内肿瘤的临床特点及手方法。方法１０３例椎管内肿瘤患者均经手术治疗,颈椎行单开门术暴露椎管,胸椎行全椎板切除,腰椎椎则行次全椎板切队鹘椎椎管内外哑铃型肿瘤分别采用颈前路和肋骨横突切除术入路。结果随访８２例平均随访时间３．５年,优良率为８１．７％。     

MR-imaging of chronic spinal cord injury. Association with neurologic function

Twenty-two para- and tetraplegic patients with chronic spinal cord injuries were examined with magnetic resonance imaging (MRI). The clinical course in the entire rehabilitation period was recorded and an attempt was made to associate the functional status of the patients with the morphologic findings on MRI. Small and large spinal cord cysts and syringomyelia, cord atrophy, and spinal stenosis were found. Additionally, in a number of patients regions of increased signal intensity within the cord, interpreted as myelomalacia, and obliteration of the intradural extramedullary space, interpreted as arachnopathy, were noted. The large number (13/22) of cystic lesions in our patients was unexpected. It was in contrast to the rate reported in autopsy studies of paraplegics which note only few cysts. Whereas a direct association of morphologic findings with neurologic symptoms and the clinical course was difficult, it was found that patients with large cysts and spinal cord atrophy generally showed no tendency to improve in spite of the measures taken during the rehabilitation period. It is difficult to decide whether the initial trauma with cord hemorrhage is limiting the chance of neurological improvement or if a sequence of events leading from hemorrhage to gliosis and cystic necrosis is the determining factor.     

椎体成形术治疗老年骨质疏松脊柱压缩骨折

目的探讨椎体成形术治疗老年骨质疏松脊柱压缩骨折的疗效和安全性.方法在C臂X线机监测下对20例36个椎体行椎体成形术(均为后壁完整疼痛剧烈老年骨质疏松脊柱压缩骨折).观察术后症状改善情况,分析并发症.结果20例椎体成形术术后均未出现肺栓塞、神经损伤等并发症,CT检查无椎管内或椎间孔渗漏.术后随访5～18个月,17例疼痛消失,2例明显减轻,1例缓解.结论椎体成形术是治疗老年骨质疏松脊柱压缩骨折安全有效的方法.     

Somatosensory evoked potential

Summary Somatosensory evoked potentials (SSEPs) have been used to help minimize neurologic morbidity during spinal surgery. While this is a sensory test it has been used as an inference of motor function. The failure to always achieve the latter goal has resulted in some pessimism regarding the value of this test. In this series of 161 operations in 150 patients, it was demonstrated that SSEPs were recordable under anesthesia in 87% of patients. Of these patients, 12% had their spinal surgery interrupted due to significant neurophysiologic changes; of these patients, 18% had new neurologic deficits postoperatively. There were no cases with new neurologic deficits who had no changes in their SSEPs. It was concluded that SSEP monitoring may be helpful in identifying potentially neurologically threatening surgical maneuvers in a significant number of patients.     

胸腰椎爆裂骨折损伤部位和椎管内占位程度与神经损伤的关系

目的探讨胸腰椎爆裂骨折骨折部位及椎管内骨块占位程度与神经损伤的关系。方法对213例胸腰椎爆裂骨折根据骨折部位及CT测出的椎管内骨折骨块占位程度与神经损伤进行分析评定。结果神经损伤组椎管骨折骨块占位程度明显高于无神经损伤组;在有神经损伤情况下,骨折部位椎管内骨块占位程度腰段大于胸腰段;神经损伤程度与椎管内骨块占位程度无显著相关。结论胸腰椎爆裂骨折椎管内骨块占位压迫是神经损伤的重要因素;神经损伤与骨折部位和椎管内骨块占位程度联合相关。     

胸椎管狭窄症术后脊髓缺血再灌注损伤的临床分析

目的 探讨胸椎管狭窄症患者手术后出现脊髓功能受损的原因,总结脊髓手术后缺血再灌注损伤(spinal cord ischemic reperfusion injury,SCII)[1]的预处理和早期治疗方法.方法 回顾性分析我科2年内收治的32例胸椎管狭窄症患者术后脊髓恢复情况,出现脊髓损伤患者的临床资料及处理方法,并对其预后进行客观评估.结果 2年内在收治并手术的胸椎管狭窄症患者中,手术减压前给予1克甲基强的松龙预防.5例患者于手术后出现不同程度的脊髓功能受损,即刻给予大剂量甲基强的松龙冲击治疗、脱水药及神经营养药,1例患者症状改善不理想,2例患者症状部分改善,生活可自理,2例患者基本恢复正常.结论 胸椎管狭窄症患者手术后出现的脊髓功能受损可能是脊髓缺血再灌注损伤引起,再灌注损伤在胸椎管狭窄症患者中较多见,但出现严重监床症状的少见,诊断有一定的困难.妥善的处理可望改善患者的生存质量.