椎体后凸成形与后伸体位恢复骨质疏松性压缩骨折椎体高度12例

2007-03/2008-12东莞市人民医院骨科行球囊扩张椎体后凸成形治疗椎体压缩骨折患者12例,平均年龄71岁,其中女性患者8例。共计19处椎体压缩性骨折。每例患者依次使用体位与球囊进行复位。手术前患者站立侧位骨折椎影像与患者过伸位X射线片相比较。随后患者进行单侧球囊后凸成形术。应用X射线片评估体位治疗与椎体后凸成形恢复椎体高度的百分比。在椎体中部所获得椎体高度恢复比,通过后伸体位是10.4%(中位数11.1%),而球囊后凸成形为57.0%(中位数62.2%),差异具有显著性意义(P < 0.001),球囊后凸成形获得额外46.6%的椎体高度恢复。通过手术体位复位,51.2%的椎体压缩性骨折有>10%的椎体中部高度恢复,而90.7%的骨折通过球囊后凸成形恢复至少10%的椎体高度(P < 0.002)。虽然试验结果支持通过体位治疗椎体压缩骨折,但在恢复椎体高度方面,球囊椎体后凸成形大于体位治疗4.5倍,并超过80%最终复位。如果恢复椎体高度是最终目的,球囊椎体后凸成形很明显优于单纯体位治疗。     

单侧与双侧入路脊柱行后凸成形治疗骨质疏松性椎体压缩骨折的Meta分析

背景：椎体后凸成形明显改善了骨质疏松性椎体压缩骨折的治疗过程,但临床上对于单侧入路还是双侧入路还存在一定争议。 目的：对比单侧与双侧入路脊柱后凸成形治疗骨质疏松性椎体压缩骨折的疗效。 方法：全面收集椎体单侧与双侧入路脊柱后凸成形治疗骨质疏松性椎体压缩骨折的随机对照研究,由两个研究者独立评价文献,并采集数据,在严格文献质量评价的基础上,进行Meta系统评价。 结果与结论：共纳入5篇文献,241例患者。在止痛及骨水泥渗漏方面,两种脊柱入路差异无显著性意义(P=0.99,P=0.56);在改善后凸角度方面,双侧入路优于单侧入路(P=0.05);在手术时间方面,单侧入路优于双侧入路(P < 0.000 01)。表明单侧入路与双侧入路均能明显减轻疼痛,二者差异无显著性意义;二者骨水泥渗漏率差异无显著性意义;双侧入路可更好地改善脊柱后凸角度,但手术时间较长;鉴于纳入的文献质量不高,结论尚需更多设计严谨的随机对照研究加以证实。     

注射型磷酸钙人工骨椎体后凸成形固化治疗骨质疏松性胸腰椎压缩骨折

背景：椎体后凸成形目前常用的注射型聚甲基丙烯酸甲酯骨水泥椎体增强剂可达到增加椎体强度、稳定椎体、止痛的目的,但其组织相容性差,无生物降解性,容易造成使临近椎间盘或椎体发生变性、甚至骨折。 目的：观察注射型磷酸钙人工骨椎体后凸成形固化治疗骨质疏松性椎体压缩骨折的效果。 方法：选择2007-12/2010-06哈尔滨医科大学附属第四医院骨外科收治的骨质疏松性胸腰椎压缩性骨折患者20例,均采用经双侧椎弓根球囊扩张注射型磷酸钙人工骨行椎体后凸成形固化治疗。手术前后行疼痛目测类比评分,胸(腰)椎正侧位X射线片及椎体前缘高度、Cobb角检测。 结果与结论：术后病椎前缘椎体平均高度较术前平均高度恢复(3.38±1.44) mm (P < 0.05)。术后Cobb角较术前平均恢复(7.63±2.52)° (P < 0.05),后凸矫正率为(38.90±11.28)%。术后3d及3周目测类比评分均较术前明显降低(P < 0.01)。说明经双侧椎弓根球囊扩张注射型磷酸钙人工骨行椎体后凸成形可以有效增加椎体强度、稳定椎体、明显缓解患者疼痛,是治疗骨质疏松性胸腰椎压缩骨折的有效方法。     

单侧穿刺经皮椎体注入骨水泥后凸成形治疗多椎体骨质疏松性压缩骨折

背景：经皮椎体成形和经皮椎体后凸成形是一种治疗骨质疏松症所致椎体压缩性骨折的新方法,目前已经在各大医院广泛开展,但是在临床上很多病例有多个椎体的骨折,采用经典的手术方法操作次数多,增加手术风险,射线暴露量大,医疗费用高。 目的：观察单侧穿刺经皮椎体后凸成形治疗老年多椎体骨质疏松压缩骨折的疗效。 方法：选择2007-06/2009-06巢湖市第一人民医院骨二科和皖南医学院附属弋矶山医院骨一科收治的多椎体骨质疏松压缩骨折患者12例(29椎),根据治疗前MRI信号改变判断疼痛性椎体并进行选择性单侧穿刺球囊扩张后凸成形的治疗。根据目测类比评分评价手术前后疼痛变化,观察治疗后症状改善、骨折复位情况及有无并发症发生。 结果与结论：12例穿刺均顺利完成,48 h内疼痛缓解,平均随访14个月。治疗后目测类比评分较治疗前降低(P < 0.01)。椎体前缘、中部、后缘平均高度治疗前低于治疗后,至末次随访椎体复位后前缘、中部、后缘平均高度未见明显丢失(P > 0.05)。治疗前穿刺侧与对侧椎体高度差距有显著性意义(P < 0.01),治疗后两侧差距无显著性意义(P > 0.05)。治疗前后同侧相比差异均有显著性意义(P < 0.01)。提示对多椎体压缩骨折采用选择性单侧穿刺后凸成形治疗,临床效果满意,能够缩短治疗时间、减少并发症、射线暴露和治疗费用,适于老年多椎体骨质疏松压缩骨折的治疗。 关键词：骨质疏松;脊柱;压缩骨折;后凸成形;骨水泥 doi:10.3969/j.issn.1673-8225.2010.25.025     

经皮椎体后凸成形术治疗严重骨质疏松性椎体压缩性骨折

目的 探讨经皮椎体后凸成形术治疗严重骨质疏松性椎体压缩性骨折的疗效。方法 2014年1月至2015年1月应用经皮椎体后凸成形术治疗严重骨质疏松性椎体压缩性骨折42例,分析手术前后Cobb's角、疼痛视觉模拟量表（VAS）评分、Oswestry功能障碍指数及骨折椎体高度变化。结果 术后椎体三柱高度显著大于术前（P<0.05）,而术后Cobb's角、VAS评分、Oswestry功能障碍指数均显著低于术前（P<0.05）。结论 经皮椎体后凸成形术治疗严重骨质疏松性椎体压缩性骨折,可以明显改善患者疼痛症状,恢复椎体高度,矫正后凸角度,有着较好的疗效。     

经皮椎体后凸成形治疗中骨水泥渗漏对椎体高度恢复的影响

摘要 背景：将经皮椎体后凸成形通过球囊加压扩张在椎体内形成周围有相对致密松质骨的空腔,可有效降低骨水泥渗漏率,同时扩张的球囊有助于塌陷椎体的复位,矫正脊柱后凸畸形。 目的：回顾性分析手法复位后将经皮椎体后凸成形注入骨水泥治疗骨质疏松性椎体压缩骨折渗漏情况及对椎体高度恢复的影响。 方法：选择2008-02/2010-06华北石油总医院骨科行经皮椎体后凸成形治疗骨质疏松性椎体压缩骨折患者31例,41椎体。平均年龄69(53~82)岁。并于术前手法按压使腰部过伸复位。观察患者术后疼痛缓解、椎体高度恢复以及骨水泥渗漏情况。 结果与结论: 所有患者术后随访8~13(11.0±1.6)个月。患者视觉模拟疼痛评分由术前6.7±1.9下降至术后1.3±1.2,差异有显著性意义(P < 0.05)。椎体高度由术前(15.7±5.2) mm恢复至(20.2±4.5) mm,椎体高度显著恢复(P < 0.05)。发生骨水泥渗漏3例,均无明显临床症状。说明术前手法复位后经皮椎体后凸成形将骨水泥注入骨质疏松性椎体压缩骨折可以显著恢复椎体高度,止痛效果良好且无严重渗漏发生。 关键词：经皮椎体后凸成形;骨质疏松;骨质疏松性椎体压缩骨折;骨水泥;生物材料 doi:10.3969/j.issn.1673-8225.2010.42.038     

骨水泥椎体强化椎弓根钉置入对骨质疏松脊柱生物力学稳定性的影响

背景：伴有骨质疏松患者的脊柱内固定松动、脱落是脊柱外科一个复杂而棘手的问题。用聚甲基丙烯酸甲酯骨水泥强化椎弓根螺钉可增加伴有骨质疏松患者的椎弓根螺钉防止椎弓根钉的松动及脱落。 目的：评价聚甲基丙烯酸甲酯骨水泥椎体强化后椎弓根钉固定对不稳定骨质疏松脊柱的生物力学稳定性影响。 设计、时间及地点：体外生物力学实验,于2008-03在上海大学生物力学实验室完成生物力学实验。 材料：12具新鲜老年女性尸体T10~L3椎体标本,制成T12、L1间的不稳定模型,采用椎弓根螺钉系统固定。 方法：将标本按照不同的处理方式分为4组。①对照组：为完整标本,只进行生物力学性能的测试。②一次固定组：对照组测试后随机选取6具不稳定模型,行T11~L2椎弓根钉固定。③二次固定组：一次固定组标本完成稳定性测试后,取出所有椎弓根螺钉,分别用注射器向T11~L2椎弓根钉道注入配制好的聚甲基丙烯酸甲酯骨水泥骨水泥2.0 mL后再次拧入螺钉固定。④强化固定组：将余下的6具标本于T11~L2双侧椎弓根分别以直径3.5 mm的钻头导孔,沿孔道插入直径3.5 mm的穿刺导管,插入深度为40 mm,用加压注射器经导管缓慢向椎体内加压注射配制好的聚甲基丙烯酸甲酯骨水泥3.5 mL后拧入螺钉固定。 主要观察指标：进行轴向压缩、前屈/后伸、左/右侧弯、左/右旋转7项非损伤性加载,比较上述4组不同状态下脊柱的相对运动范围变化。 结果：与一次固定组比较,二次固定组及强化固定组脊柱的相对运动范围增加(P < 0.05),强化固定组与二次固定组组间比较,差异无统计学意义(P > 0.05)。 结论：椎体成形强化椎弓根钉固定及钉道强化固定均可明显增强不稳定骨质疏松脊柱的稳定性。     

骨质疏松性椎体骨折经皮后凸成形术的护理

我科自2004-08～2008-01采用PKP治疗骨质疏松性椎体骨折患者38例共45节椎体,取得良好治疗效果.现将护理情况总结如下. 1资料与方法 1.1 一般资料     

骨质疏松性椎体压缩骨折患者经皮椎体成形注入黏丝期骨水泥后的再骨折

背景：目前经皮椎体成形术已成为治疗骨质疏松性椎体压缩骨折的首选方法,但其骨水泥注入后邻近椎体骨折并发症也在逐年增加,椎体成形过程中常采用黏丝期骨水泥注射,而骨水泥注射时状态可影响其在椎体内分布。 目的：回顾性分析骨质疏松性椎体压缩骨折经皮椎体成形注入黏丝期骨水泥后再骨折的原因。 方法：2006-07/2009-11对112例骨质疏松性椎体压缩骨折行经皮椎体成形术,术中DSA机透视引导下经单侧或双侧椎弓根入路,调配聚甲基丙烯酸甲酯骨水泥至黏丝期后经工作通道注入,并观察疗效。 结果与结论：每个椎体注入骨水泥2.4~6.0 mL,平均(3.40±1.02) mL。术中骨水泥渗漏至椎旁14例,椎间隙内15例。患者术后全部得到随访,随访时间6~15个月,平均(9.61±2.82)个月,未发现特殊的材料和宿主反应,29例患者疼痛再发,其中15例经MRI证实手术相邻椎体发生新鲜骨折,再次给予经皮椎体成形手术后疼痛症状缓解。结果提示经皮椎体成形注入黏丝期的骨水泥后应力集中、术中灌注剂渗漏椎间隙等综合因素增加了术后相邻椎体再次发生骨折的危险,寻找理想的骨水泥替代物将成为今后临床研究的方向。 关键词：骨水泥;骨质疏松性椎体压缩骨折;骨质疏松;经皮椎体成形术;生物材料 doi:10.3969/j.issn.1673-8225.2010.25.024     

球囊扩张椎体后凸成形术治疗椎体压缩性骨折

随着人口的老龄化,骨质疏松症的发生率日渐增加。椎体压缩性骨折是骨质疏松症的主要并发症之一,由此引起难以忍受的背痛病例也呈上升趋势。服用药物、佩戴支具等姑息治疗效果不确切,且长期卧床会导致骨质进一步丢失,形成恶性循环;传统外科手术治疗创伤大,老年患者往往难以接受。1984年Galibert首先采用X线透视下,经皮穿刺椎体内注射骨水泥治疗侵袭性血管瘤取得满意效果。1994年Reiley在此基础上设计了通过球囊扩张来纠正后凸畸形的技术,     

Kyphoplasty for the treatment of malignant vertebral compression fractures caused by metastases

Despite the literature supporting the efficacy of kyphoplasty for treatment of osteoporotic vertebral compression fractures in multiple myeloma, few reports exist documenting its use in the treatment of malignant vertebral compression fractures (MVCF) caused by metastases. Accordingly, we sought to evaluate the feasibility, efficacy and safety of kyphoplasty in the treatment of MVCF without epidural involvement. We performed a retrospective review of clinical outcome data for 48 patients with multiple spinal metastases treated with kyphoplasty. Outcome data (vertebral body height variation, degree of kyphosis, visual analog scale score for pain, Oswestry Disability Index score, the Short Form-36 [SF-36] questionnaire score for function) were collected preoperatively, postoperatively, and at 1 month, 6 months, 1 year, and 2 years after treatment. Significant improvements in all of the outcome measures were observed postoperatively and throughout the duration of follow-up. The mean anterior vertebral body height variation improved from 52.7 ± 16.8% preoperatively to 85.3% ± 13.2% postoperatively (p < 0.001). Kyphotic angle improved from 16.4° ± 4.7° preoperatively to 8.4° ± 2.5° postoperatively (p < 0.001). The mean visual analog scale score decreased significantly from presurgery to postsurgery (7.4 ± 2.1 to 3.8 ± 1.6; p < 0.001), as did the Oswestry Disability Index score (71.5 ± 16.7 to 32.4 ± 9.6; p < 0.001). The SF-36 scores for bodily pain, physical function, vitality, and social functioning all also showed significant improvement (p < 0.05). Kyphoplasty is an effective, minimally invasive procedure for the stabilization of pathological vertebral fractures caused by metastatic disease, even in levels with vertebral wall deficiency, leading to a statistically significant reduction in pain, improvement in function and prevention of further kyphotic deformity of the spine.     

经皮椎体成形术在椎体压缩骨折及椎体肿瘤治疗中的临床应用

目的 总结分析经皮椎体成形术(PVP)在骨质疏松性椎体压缩骨折及椎体肿瘤治疗中临床应用的疗效.方法 宣武医院神经外科2007年1月至2012年6月应用PVP治疗45例患者共62个病变椎体,随访时间点为术后24h、3、6、12、24及36个月,采用VAS、ODI评价其临床疗效,椎体前缘高度及Cobb角评估影像学结果.结果 平均随访时间(13.9±7.8)个月,术后24 h,患者VAS疼痛评分、ODI指数及Cobb角分别由术前(7.3±1.9)分、32.0±3.4和15.0°±2.3°降至术后(4.8±1.6)分、22.1±2.1和14.0°±1.9°(P＜0.05),椎体前缘高度由术前(16.0±1.8) mm升至(19.0±2.1)mm(P＜0.05).3～36个月随访期内,VAS评分、椎体前缘高度及Cobb角差异无统计学意义(P＞0.05).随访中约54％患者VAS评分维持在5分以内.结论 PVP是治疗骨折及肿瘤所致的椎体源性疼痛简单有效的微创疗法,临床疗效稳定.     

经半椎板入路并椎板复位治疗胸椎椎管内肿瘤（附16例报告）

目的探讨半椎板入路手术并椎板复位术在切除胸椎椎管内肿瘤显微手术中的应用价值。方法采用半椎板入路手术并椎板复位术治疗胸椎椎管内肿瘤16例。术前患者神经功能按Frankel分级,A级1例,B级2例,c级7例,D级5例,E级l例。术后随访12—30个月[平均（19．7±5．4）个月],随访内容包括Fankel分级,以及有无脊柱不稳或畸形。结果手术时间72—155min[平均（119．5±23．0）min]。术中铣开1个椎板2例,2个椎板12例,3个锥板2例。术后行CT三维成像检查均显示椎板固定良好,无脑脊液漏或皮下积液病例。随访时Frankel D、E级病人的比例由入院时的37．5％（6,16）上升到随访时的81．2％（13／16）,两者相差显著（P〈0．05）;随访时均未见脊柱畸形或脊柱不稳者。结论胸椎椎管内肿瘤手术较适合采用半椎板入路,术中同时行胸椎椎板复位能最大限度地保留脊柱的完整性和稳定性,减少术后并发症的发生。     

Comparison of unilateral and bilateral puncture percutaneous kyphoplasty in the treatment of osteoporotic vertebral compression fractures

Objectives:To compare the clinical efficacy of unilateral and bilateral puncture PKP in the treatment of OVCFs and explored whether there is a difference in the efficacy of unilateral and bilateral puncture PKP after surgery.Methods:A total of 98 patients with OVCFs treated by PKP from August 2016 to June 2018 were selected. There were 62 cases in the unilateral puncture group and 36 cases in the bilateral puncture group. The operation time, the amount of bone cement injection, the height of the anterior edge of the vertebral body and the visual analog scale (Visual Analog Scale, VAS) scores before and after the operation were analyzed, and whether the differences between the 2 groups were statistically significant was analyzed.Results:All patients were followed up completely. The operation time and the number of X-ray fluoroscopies of the unilateral puncture group were significantly reduced compared to those of the bilateral group, and the difference was statistically significant (p<0.05). In terms of the bone cement injection volume, the average injection volume of the bilateral group was greater than that of the unilateral group, and the difference was statistically significant (p<0.05); the postoperative VAS scores of the 2 groups of patients were significantly improved, and the difference was statistically significant compared with that before surgery (p<0.05) but that of the unilateral group was not statistically significant compared with that of the bilateral group (p>0.05). The height of the anterior edge of the vertebral body in both groups was significantly improved compared with that before the operation, and the difference was statistically significant (p<0.05).Conclusion:Unilateral and bilateral puncture PKP can achieve good clinical efficacy in the treatment of osteoporotic vertebral compression fractures, but unilateral PKP has the advantages of short operation time and low X-ray exposure.

Osteoporosis (OP) is caused by a decrease in bone mass for a variety of reasons, especially a decrease in the amount of cancellous bone in the vertebral body and damage to the microstructure of bone tissue, bone mineral composition and bone matrix per unit volume. Osteoporosis is one of the diseases with high morbidity and mortality in the world and has become an important disease that endangers the health of middle-aged and elderly people.¹ Osteoporotic vertebral compression fractures (OVCFs) are one of the major complications of osteoporosis, which often cause stubborn waist and back aches. Severe thoracolumbar osteoporotic vertebral body compression fractures may lead to cardiopulmonary and other multisystem dysfunctions, seriously affecting the patient’s quality of life.²For the treatment of OVCFs, the current recommendations are conservative treatment and surgical treatment. Conservative treatment may cause various complications due to long-term bed rest, including bedsores, delayed fracture healing, deformity healing or nonunion, respiratory and urinary tract infections, and lower extremity venous thrombosis, which can threaten the life of the patient.^3,4 Therefore, patients with OVCFs who have early out-of-bed activity requirements and surgical indications are more likely to undergo surgical treatment.The traditional surgical treatment for OVCFs is posterior laminectomy and decompression pedicle screw internal fixation, but due to the higher degree of osteoporosis in older patients, the long-term screw internal fixation effect is poor, and surgical trauma has a greater impact on patients; thus, the long-term efficacy is not ideal.⁵ In recent years, with the improvement of minimally invasive spine technology, percutaneous vertebralplasty (PVP) and percutaneous balloon dilatation kyphoplasty (Percutaneous kyphoplasty, PKP) have achieved satisfactory results in the treatment of OVCF. Compared with PVP, PKP uses a balloon or other expansion system to expand the compressed vertebral body to form a relatively low-pressure vertebral body space, followed by low-pressure injection of bone cement, which can better correct kyphosis and reduce the penetration of bone cement leakage.^6,7The PKP surgical puncture consists of a bilateral pedicle approach or a unilateral pedicle approach. While the advantages of the transdermal bilateral pedicle approach include better diffusion of bone cement and reduced risk of puncture, there are shortcomings, such as long operation time, large radiation exposure and high hospitalization costs.⁸ At present, there is no unified conclusion as to which PKP approach is better for use to treat OVCFs. Therefore, it is of great clinical significance to clarify the difference between unilateral and bilateral PKP in the treatment of OVCFs.The OVCFs are one of the common diseases that cause lumbago and kyphosis in the elderly. At present, PKP is one of the common methods for the treatment of OVCFs. Bilateral puncture of the pedicle approach is the classic operation method of PKP, but some scholars believe that unilateral puncture bone cement injection can achieve the same surgical effect. This record-based case–control study retrospectively analyzed patients with OVCFs treated in our hospital from August 2016 to June 2018, performed an in-depth analysis and comparison of the unilateral and bilateral PKP treatment of OVCFs, and provided a reference for the clinical approach to PKP treatment of OVCFs.     

Comparison of unilateral versus bilateral balloon kyphoplasty for the treatment of osteoporotic vertebral compression fractures

Thirty-one patients with osteoporotic vertebral compression fractures (OVCF) were treated with unilateral balloon kyphoplasty (BKP), and 31 patients were treated with bilateral BKP. The efficacy of unilateral and bilateral BKP was assessed by comparing operation time, X-ray exposure times, incidence of complications, vertebral height restoration, and improvement of the visual analogue scale (VAS) scores. The mean operative time and the exposure time to X-rays in the unilateral BKP group was less than that of the bilateral BKP group (p<0.05). No statistically significant differences were observed in the cement leakage rate, VAS score, or vertebral height restoration between the two groups (p>0.05). Unilateral and bilateral BKP are safe and effective treatments for OVCF. Compared with bilateral BKP, patients undergoing unilateral BKP have shorter operations and receive lower X-ray radiation doses.     

Compound osteosynthesis in the thoracic spine for treatment of vertebral metastases. Technical report

Metastases to vertebrae often cause bone destruction leading to instability and neural compression. Anterior surgical approaches allow tumor resection and direct neural decompression. For patients with a short life expectancy, vertebral body replacement with methyl-methacrylate polymerized in situ can be used for load sharing in the axial plane. Screws hung from the rod into the corpectomy site are incorporated into the acrylic cement. The technique described in this article allows for immediate spinal stabilization and provides a protective environment for the neural elements. All the patients tolerated the procedure well and were able to ambulation without an orthoses.     

颈椎后路椎弓根螺钉系统C2,3短节段固定材料置入治疗Hangman骨折

目的：分析椎弓根螺钉系统短节段内固定材料置入治疗枢椎椎弓根骨折（Hangman骨折）的临床疗效，评价其应用价值。 方法：回顾性分析四川省人民医院骨科自2004年以来收治的枢椎椎弓根骨折17例患者，按Levine-Edwards分型，其中Ⅱ型4例，ⅡA型6例，Ⅲ型7例，脊髓功能按Frankel分级，12例E级，5例D级；行颅骨牵引复位病情稳定后用椎弓根螺钉系统（美敦力枢法模产品）短节段置入材料固定C2，C3椎弓根。 结果：术中无椎动脉损伤及脊髓损伤，术后摄片及CT检查显示1例两侧椎弓根骨折未复位，其余均复位良好；1例出现脑脊液漏，经常规治疗痊愈。所有病例随访12~24个月，平均14.5个月，骨折均在6个月内愈合，颈椎活动无明显受限，神经功能4例D级恢复至E级。术中所用材料均为钛合金体内置入物，与人体组织的生物相容性好，到随访结束时，无血液、免疫、组织等反应；亦无钛合金腐蚀、磨损等材料反应的发生。 结论：椎弓根螺钉系统短节段固定材料置入治疗Hangman骨折，复位固定及骨折愈合良好，对颈椎功能影响小，神经功能恢复满意。     

Retropleural paraspinal approach in the treatment of anterolateral thoracic spinal diseases

The personal experience in the treatment of the spinal and paraspinal thoracic pathology using the paraspinal retropleural approach is presented. A total of 18 patients with neoplastic, traumatic and discal lesions were operated on. Improvement of neurological disturbances and pain was noted in all patients. The surgical technique for spinal cord and root decompression and also for anterior and/or posterior stabilization of the spine is described. The paraspinal retropleural approach is compared with the anterior transthoracic approach. The advantages of the paraspinal retropleural approach are: low rate of complications; allows a very wide decompression of the neurological elements as well as an anterior and/or posterior stabilization of the spine by a single approach; and it can be easily tailored for each lesion. These advantages are enhanced in the management of lesions located in the upper thoracic or thoracocervical levels.     

To keep the alcoholic in out-patient treatment. A differentiated approach through treatment contracts

Eighty-two alcoholics were offered a 2-year out-patient programme characterized by stressing the patients' own decisions both in joining the programme and in the choice of objectives and methods, by repeated feedbacks through treatment evaluations, and by relapse prevention. The 58 patients who accepted were more often married than the others. All but eight completed the programme. The most important treatment components were ranked by the patients. Individual counselling was ranked highest, followed by evaluations of contract with therapist, disulfiram and biofeedback by means of gamma-GT. Patients with alcohol dependence more often preferred instrumental components, such as disulfiram and gamma-GT, while the others more often preferred psychological components, such as individual counselling and contract evaluations. Preference of psychological components was not found to be related to degree of personality disturbances. It is suggested that to effectively keep the patients in treatment in the present programme depends on the combination of patients' active engagement, continuous feedback and individualized treatment objectives.