借助胸腔镜技术的胸段、上腰段脊柱前路手术

目的探讨胸腔镜辅助胸椎、上腰椎前路手术的适应证 ,单肺或双肺通气的选择以及术中注意事项。方法　应用胸腔镜、骨科常规手术器械或自制的骨科器械 ,在胸腔镜辅助下行病灶清除、脊髓减压、植骨、钢板螺丝钉内固定术。结果　全部病例手术都顺利完成 ,切口均一期愈合 ,随访 3～ 10个月 ,影像学检查显示病灶清除彻底 ,脊髓减压充分 ,除 1例骨折复位、固定后仍有轻度侧方成角畸形外 ,其他病例复位满意、内固定可靠 ,位置良好。结论胸椎、上腰椎疾患 ,不论是否并发脊髓、马尾神经压迫 ,都能在胸腔镜辅助下完成病灶清除术 ,必要时还可进行脊髓减压、脊柱前路植骨、内固定手术。原则上可选择常规气管插管、双肺通气下完成手术。     

Percutaneous techniques in the thoracic and lumbar spine

Techniques of percutaneous spinal instrumentation have in the meantime become standard methods in many hospitals. While several indications have been established that are excellently suited to this technique, uncertainty prevails for other indications. This contribution intends to clarify the technical prerequisites for performing percutaneous instrumentation in the region of the thoracic and lumbar spine in addition to describing customary indications and various techniques of percutaneous instrumentation. This is combined with a critical assessment of what intrinsically cannot or cannot yet be achieved with a percutaneous approach to illustrate that the percutaneous procedure can by no means be considered a mere evolution of the previous classic open techniques.     

The lateral extracavitary approach to the thoracic and lumbar spine

The LECA is a technically challenging procedure with a steep learning curve. It is one of the most versatile approaches to the spine, however,with a logical sequence of maneuvers that can be combined to adapt the LECA for many different spinal procedures that need to be performed for decompression of the spinal cord and reconstruction of the spinal column in cancer patients.     

Percutaneous instrumentation of the thoracic and lumbar spine

The development of percutaneous instrumentation systems has been a significant milestone in the ability of surgeons to perform complex spinal procedures through minimally invasive approaches. These systems rely on cannulated screws or portal systems and using intraoperative imaging to allow accurate placement of the spinal implants without a full traditional exposure of the spine. This article reviews the operative concepts and techniques used to place percutaneous instrumentation in the thoracolumbar spine.     

Congenital abnormalities of the thoracic and lumbar spine

Congenital spinal anomalies entail a wide spectrum of conditions that share in common some form of error during embryogenesis. Congenital disorders of the spine may not always be readily apparent at birth; they can present as a deformity with growth or with clinical signs of neurologic dysfunction early or later as an adolescent or adult. In this article the authors briefly summarize the embryology of the spine, which provides a background for understanding the pathophysiology of congenital spinal lesions. The discussion entails spine embryology and the developmental abnormalities commonly seen in the thoracolumbar spine.     

Spiroid fractures of the thoracic and lumbar spine

The review of our observations of fractures of the thoracic and lumbar spine (588 files could be used from 1969 to 1989) allowed us to demonstrate fractures not included in the usual classification. In our opinion, the fracture line is spiral. The mechanism therefore includes a very likely axial rotation. The fracture line may be confined to the vertebral body (this is the type called S1) or extends to the posterior arch as well (S2 type). The fractures often cause nerve root lesions. However, no complications involving the cord were noted in our series, even in the few cases showing considerable displacement. Note the tendency to axial telescoping of the focus, which requires specific modalities of treatment.     

Burst fractures of the thoracic and lumbar spine

A burst fracture may be defined as an unstable compression fracture of the posterior wall of the vertebral body that allows fragments to be retropulsed into the spinal canal. Computerized axial tomography evaluation of these injuries often reveals posterior element fracture heretofore not stressed in the literature. In surgical treatment for these injuries four important considerations must be met; (1) the coronal and sagittal alignment of the spine; (2) patency of the neural canal; (3) the two-column concept of spinal stability; and (4) bony vertebral body reconstitution. An algorithm for treatment may be developed with the aid of these principles. Distraction and the creation of spinal lordosis are necessary for reduction.     

Rheumatoid arthritis of the thoracic and lumbar spine

We report seven cases of patients with seropositive rheumatoid arthritis in whom involvement of the thoracic and lumbar vertebrae occurred. Histological corroboration is presented in four. Pathological lesions comprised various combinations of paravertebral joint erosions, erosive discitis, anteroposterior and rotatory instability, major lumbar nerve root compression, and vertebral collapse. Specific radiological features are presented, enabling a distinction to be made between pure degenerative spondylosis and rheumatoid spondylitis. We submit that subcervical rheumatoid spondylitis is commoner than is generally believed, though less common than rheumatoid involvement of the cervical spine.     

Unilateral dislocations of the thoracic and lumbar spine

Unilateral dislocation is a trauma typical of the cervical spine. Case reports on unilateral dislocation of the thoracic or lumbar vertebrae can be found in the relevant literature only rarely and they often describe this condition associated with multiple trauma or combined injuries. Although unilateral dislocation is an unstable injury with rotation involved, injury to the spinal cord or spinal nerve roots is not common. Diagnosis is based on radiographic and CT examination. Therapy includes open reduction and instrumented spondylodesis of the injured segment. The cases of two patients with unilateral dislocations in the thoracic and the lumbar spine, respectively, treated at the Department of Spinal Surgery, Motol Teaching Hospital in Prague, are reported here.     

Burst fractures in the thoracic and lumbar spine. A clinico-neuropathologic analysis

Neuropathologic analysis of eight acute and 12 chronic burst fractures was performed. In the acute cases, the injury to the bony, ligamentous, and neural tissues was investigated. Serious Denis B or D fractures showed signs of pronounced instability, and all had a large bone fragment rotated into the spinal canal. The neural tissues were compressed in two cases and transected in one. The Denis A fractures had relatively well-restored ligamentous structures and the bone fragment in the spinal canal was narrowing the spinal canal less than 50% in all cases. Three of four had normal neural tissue macroscopically and microscopically. The majority of the patients with chronic burst fractures did not show any sign of bone fragment resorption. Six out of eight patients with thoracolumbar (T12 and L1) and lumbar (L3) fractures experienced intractable burning pain and/or rhizopathy. The pain seemed to be caused by entrapment of the nerve roots in adhesions.     

Neurological deficit in injuries of the thoracic and lumbar spine

Summary Seventy consecutive patients with injuries of the thoracic and lumbar spine accompanied by neurological deficit were prospectively studied and followed-up.In 40 of these patients with a burst fracture, the degree of involvement of the cross-sectional area of the spinal canal, as revealed on first CT after admission, was not correlated with the type and degree of initial neurological deficit.In patients with injuries of the lumbar spine, neurological deficit may be mild, although the sagittal diameter of the spinal canal may be reduced by as much as 90%.We cannot establish a difference in neurological recovery between those cases who were managed conservatively and those in whom a surgical decompression and stabilization procedure was performed.Surgical stabilizing procedures, however, result in immediate stabilization of the spine, they diminish pain, facilitate nursing care and allow more rapid mobilization and earlier active rehabilitation.If major extraspinal injuries form a relative contra-indication to surgical decompression of the cord and stabilization of the spine injury, the patient can quite well be treated conservatively without endangering neurological recovery.     

Fractures of the thoracic and lumbar spine in ankylosing spondylitis

Summary In the literature a total of 27 cases of thoracic and lumbar fractures in ankylosing Spondylitis have previously been reported in contrast to cervical fractures which are more common. Transvertebral fractures are relatively rare amounting to 8 cases. The majority of the fractures were transdiscal. Here three additional cases with four fractures are reported. Of these fractures two were transvertebral and two transdiscal. All reported fractures are reviewed regarding age, sex, trauma, fracture localization and type, neurologic complications and fracture healing. Compared to cervical fractures there are less neurological complications in thoracic and lumbar fractures (23%) in ankylosing spondylitis. These fractures mostly heal by moderate immobilisation. Attention should be paid to the possibility of fracture in ankylosing spondylitis even after minor trauma.

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Zusammenfassung In der Literatur sind bisher im ganzen 27 Fälle mit thorakalen oder lumbaren Frakturen bei Spondylitis Ankylopoetica rapportiert worden. Cervikale Frakturen sind dagegen weitaus gewöhnlicher. Transvertebrale Frakturen kommen verhältnismäßig selten vor (8 Fälle). Die Mehrzahl der Frakturen waren transdiskal. Hier werden drei neue Fälle mit vier Frakturen rapportiert. Von diesen Frakturen sind zwei transvertebral und zwei transdiskal. Alle rapportierten Frakturen sind mit Hinsicht auf Alter und Geschlechtszugehörigkeit des Patienten, Trauma, Lokalisation und Typ der Fraktur, neurologische Komplikationen und Frakturheilung rapportiert worden.Verglichen mit cervikalen Frakturen kommen bei Spondylitis Ankylopoetica weniger neurologische Komplikationen bei thorakalen und lumbaren Frakturen vor (23%). Diese Frakturen heilen meistens nach einer kürzeren Immobilisierung. Die Möglichkeit einer Fraktur bei Spondylitis Ankylopoetica sollte auch bei kleineren Schäden beachtet werden.

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This work was supported by the Swedish Medical Research Council (Project 17X-2031)     

Percutaneous computed-tomography-guided biopsy of the thoracic and lumbar spine

Axial computed tomographic scans were used to guide percutaneous needle biopsies in 76 patients with thoracic and lumbar spinal lesions. Prebiopsy evaluation included spine radiographs, radionuclide bone scans, computed tomographic scans, magnetic resonance imaging scans in some cases, and coagulation studies. Forty-five patients were diagnosed as having metastatic lesions, 11 infection, and 12 primary bone tumors. Of all patients, 34 had lytic vertebral lesions with significant collapse and questionable spinal stability. Six of those had a concomitant paravertebral mass. A clinical and pathologic correlation was completed for each of the cases studied. Histologic diagnosis confirming the clinical suspicion was obtained on the first biopsy attempt in 65 (86%) of the 76 cases.     

Lateral distraction injuries to the thoracic and lumbar spine. A report of three cases

Three patients sustained a lateral distraction injury to the thoracic or lumbar spine. These injuries were associated with multiple fractures of the ribs and extremities as well as with thoracic and abdominal visceral injuries. No patient had an injury to the spinal cord or cauda equina. The injuries to the spine were successfully treated with open reduction of the unilateral subluxation of the facet joint and with internal fixation with Harrington instrumentation. Fusion was achieved with the spine in anatomical alignment, without any complications, in all three patients.