下颈椎前路椎弓根螺钉内固定的初步临床应用

目的 探讨颈椎前路椎弓根螺钉(anterior pedicle screw,APS)内固定技术临床应用的可行性和安全性. 方法 应用下颈椎APS内固定技术治疗下颈椎损伤患者10例.术前皆行颈椎CT扫描,Mimics软件重建三维模型,测量置钉参数(进钉点、置钉角度和螺钉长度与直径).采用常规颈前方入路术,显露椎体前壁致两侧外缘,辨清固定椎体上下终板.在X线透视引导下,严格按照术前的置钉参数置钉.术后复查颈椎正、侧位X线片、CT平扫和三维重建及MRI,由放射科医师与非术者骨科医师共同评价.术后1,3,6,12个月随访,并进行评价. 结果 术中除1枚C4和l枚C7螺钉未能成功置入外,共计置入C3～C7螺钉24枚.术后CT示4枚损伤椎弓根外侧壁.术后1例1周后死于急性心肌梗死,余9例均获随访.按Frankel分级,3例创伤患者中1例A级患者无恢复,但无加重,另2例有2～3级恢复;6例非创伤患者脊髓功能日本骨科学会(JOA)评分平均提高到13.4分,按Hirabayashi法计算,改善率为60.7％.所有受访患者,除2例发生吞咽困难外,余均无并发症发生.各例早期均有骨融合出现. 结论 下颈椎APS内固定技术可行.置钉成功的关键在于术前个体化置钉参数的测定及术中X线透视技术的运用.     

下颈椎椎弓根螺钉并发症分析

目的 分析下颈椎椎弓根螺钉的并发症,总结其手术技巧和经验.方法 回顾性分析2004年7月-2008年3月采用C3～7椎弓根螺钉治疗的各类颈椎损伤患者112例(共使用624枚螺钉).创伤患者66例均行后路I期复位,双侧椎弓根钉棒/板系统固定;非创伤患者46例,予椎管减压,后路钉棒/板系统矫形或重建稳定性.所有患者结合术中颈椎椎弓根四壁探查、术后手术节段椎弓根CT扫描及颈椎左、右斜位X线片,观察螺钉在椎弓根内的位置、角度以及与椎弓根壁的关系和距离.结果 椎弓根壁损伤77枚(12.3%),其中外侧壁损伤68枚(10.9%),包括Ⅰ度损伤56枚(9.0%),Ⅱ度损伤12枚(1.9%);下壁损伤9枚(1.4%).随访时间3～24个月(平均9.8个月).断钉2枚(0.3%),松动1枚(0.2%).未发现植骨不融合、假关节形成或节段不稳表现.结论 下颈椎椎弓根置钉的并发症发生率较低,是相对安全的操作方法.术前详细分析影像学资料、熟悉局部解剖特点、掌握合理的置钉技术,可以有效减少和避免并发症的发生.     

椎弓根螺钉技术在下颈椎不稳中的安全使用方法

目的探讨颈椎椎弓根技术在下颈椎疾病的安全使用方法。方法回顾性分析2001年10月-2006年3月76例下颈椎疾病行颈椎椎弓根固定患者,其中49例为颈椎骨折脱位, 23例为颈椎病,4例为椎管内肿瘤。患者术前均行X线和CT等检查,术中在C形臂X线监视下置钉,术后行X线和CT检查了解螺钉位置。结果76例螺钉均成功置入,术中无脊髓、椎动脉损伤。术后CT显示,342枚螺钉中有37枚(10.8%)螺钉穿破椎弓根,其中29枚螺钉穿破椎弓根外侧皮质,3枚螺钉穿破椎弓根上侧皮质,5枚螺钉穿破椎弓根下侧皮质。所有患者近期及远期随访未发现与椎弓根螺钉相关的神经血管及内脏器官损伤的并发症。有1枚螺钉断裂,但患者没有明显的临床症状,其余未发现螺钉松动或断钉及颈椎不稳症等。所有患者固定良好,并均已达骨性融合。术后随访脊髓神经功能均有不同程度改善。结论颈椎椎弓根固定提供了三柱的稳定和最坚强的后方固定,为了防止并发症的发生,熟悉颈椎椎弓根的解剖和手术操作技巧以及采用个体化综合置钉是决定手术成功的重要因素。     

寰枢椎椎弓根钉棒系统内固定融合术治疗上颈椎损伤

目的 探讨经后路寰枢椎椎弓根钉棒系统内固定融合术治疗上颈椎损伤的可行性、方法、疗效和适应证. 方法 对13例上颈椎损伤患者行后路寰枢椎椎弓根钉棒系统内固定融合术.其中陈旧性齿状突骨折不愈合4例,新鲜齿状突骨折(Aderson Ⅱ C型)2例,寰椎横韧带断裂3例,寰椎骨折4例.13例均采用美国强生Depuy公司生产的后路Summit钉棒系统和山东威高公司生产的PCF钉棒系统行后路寰枢椎椎弓根内同定(万向螺钉直径3.5 mm,寰椎螺钉长26～30 mm,平均28 mm,枢椎螺钉长24～28 mm,平均26 mm),术后不用外固定或用颈领保护1～3个月. 结果 13例共置入寰椎椎弓根螺钉26枚,枢椎椎弓根螺钉26枚.平均手术时间2.6 h,平均出血量470 ml.术中未发生椎动脉和脊髓损伤.全组患者获得4～25个月(平均13个月)随访.临床症状得到不同程度的改善,有神经损伤患者日本骨科协会(JOA)评分改善率为72%～91%,平均81%.X线、CT复查示螺钉位置良好,无钉棒断裂、变形、松动,1枚寰椎螺钉前端穿透侧块内上皮质约3 mm,但未影响寰枕关节活动,其余位置满意.3～6个月后所有患者均获植骨融合.1例寰椎骨折患者出现寰枕腹侧融合. 结论 经后路寰枢椎椎弓根钉棒系统内固定融合术治疗上颈椎损伤具有可行性,如果操作方法得当,疗效较好,适应证较广,应用前景广阔.     

高速磨钻辅助下椎弓根钉棒系统治疗颈椎交锁性脱位

目的 探讨应用高速磨钻辅助下颈椎椎弓根钉棒系统治疗下颈椎交锁性脱位的适应证、方法及疗效. 方法 回顾性分析2006年12月-2011年7月应用高速磨钻辅助椎弓根钉棒系统复位固定治疗的13例颈椎交锁性脱位患者临床资料.脱位部位:C3/43例,C4/55例,C55/64例,C6/71例.致伤原因:交通伤7例,高处坠落伤6例.2例无任何神经症状,7例合并中央管损伤综合征,4例截瘫.13例患者均在伤后7d内行高速磨钻辅助后路椎弓根螺钉复位内固定术,采用短节段固定,椎弓根钉置入上下相邻的椎弓根内,在复位撑开钳的配合下解除小关节交锁,并复位固定. 结果 所有患者均获良好复位,13例患者中8例解剖结构完全复位,5例有1～2 mm轻度滑脱.共置入52枚椎弓根螺钉,术中未出现脊髓、神经根或椎动脉损伤,术后X线片及CT显示除3枚螺钉偏移出椎弓根外,其余49枚螺钉完全位于椎弓根内.随访12-36个月,术后上肢感觉、运动功能明显改善.1例术后3个月断钉,但无神经症状. 结论 高速磨钻辅助椎弓根钉棒复位内固定适用于治疗颈椎交锁性脱位,复位过程符合生物力学,同时可行减压治疗.     

数字化导航模板在下颈椎椎弓根定位定向中的应用

目的 探讨数字化导航模板辅助下颈椎椎弓根螺钉置入的可行性和准确性.方法 采集15例下颈椎脱位患者的术前CT资料,利用逆向工程原理和快速成型技术制造出数字化导航模板,术中通过导航模板辅助颈椎椎弓根螺钉的置入.术后根据X片和CT 扫描评价椎弓根螺钉位置.结果 共设计制作54个导航模板,辅助置入108枚颈椎椎弓根螺钉,CT扫描发现所有螺钉均准确置入相应椎弓根内.结论 数字化导航模板辅助下颈椎椎弓根螺钉置钉准确性高,操作简单,为下颈椎椎弓根螺钉的准确置入提供了一种新方法.     

计算机导航辅助置入颈椎椎弓根螺钉的准确性探讨

目的：探讨计算机导航辅助置入颈椎椎弓根螺钉的准确性和产生偏差的原因。方法：30例下颈椎疾患手术患者,导航辅助下置入172枚颈椎（C3-C7）椎弓根螺钉,术后行X线和CT检查。横断位测量螺钉中线与椎弓根内壁的相对位置以及与椎体中线的角度;矢状位测量螺钉中线与椎弓根上壁的相对位置以及与椎体上缘的角度。对导航图像数据与术后CT数据进行回归分析。结果：2枚螺钉穿出椎弓根上壁,3枚螺钉穿出椎弓根外壁入椎动脉孔。导航图像数据与术后CT数据呈正直线相关。结论：计算机导航辅助置入颈椎椎弓根螺钉具有较高的准确性,术中漂移是置钉偏差的原因。     

下颈椎椎弓根螺钉置入有限开放技术的实验研究与初步临床应用

目的 评价有限开放技术在置入下颈椎椎弓根螺钉中的安全性和准确性.方法 新鲜尸体20具,利用有限开放技术对C_3～C_7椎弓根置入199枚螺钉,评价螺钉的位置;解剖观察C_3、C_4共40椎、80侧椎弓根管入口形状结构,并测量与钉道位置相关的参数.临床应用7例,在侧块外上限刮除有限松质骨开窗,暴露侧块和椎弓根内侧骨皮质移行部,确定进钉点.参照X线片和CT测量的角度,用自制单刃圆头探针准备钉道,置入螺钉29枚,术后通过X线和CT扫描评估螺钉位置.结果 C_3、C_4侧块深层皮质骨和椎弓根内侧皮质骨汇合成椎弓根入口内侧,形成向外突起的弧状面,骨质厚实坚硬,未发现有滋养血管孔.钉道入针点分布在侧块外上限,侧块表面的开口直径平均5.2 mm,椎弓根入口宽度平均7.5 mm,钉的内倾角为42°,上倾10°.置钉准确率在标本中为94.5%,临床为100%.结论 在侧块表面有限开窗,暴露侧块和椎弓根移行部,作为下颈椎椎弓根螺钉置入的标志,结合单刃圆头探针进行置钉,是一种安全性高、创伤小、准确率高的下颈椎椎弓根螺钉置入技术.     

枢椎前路椎弓根螺钉固定通道的安全因素分析

目的 探讨枢椎前路椎弓根螺钉通道的安全性和可行性,为经前路枢椎椎弓根螺钉固定提供理论依据.方法 对32具干燥枢椎标本行前路椎弓根螺钉置入,测量枢椎前路椎弓根螺钉的钉道长度.行加密薄层螺旋CT扫描和重建,然后在重建后的横断面和矢状面图像上运用软件测量枢椎前路椎弓根螺钉的外倾角度及尾倾角度.结果 枢椎椎弓根螺钉均位于椎弓根内.枢椎前路椎弓根螺钉的进钉点选择在枢椎椎体与上关节突之间凹陷的顶点,螺钉长度为(28.4±2.5)mm,外倾角度为(28.5±2.3)°,尾倾角度为(15.5±2.0)°.结论 枢椎前路椎弓根螺钉不仅具有可行性,而且可以避开横突孔、椎动脉沟、椎管等重要解剖结构,安全空间较大.

Abstract：

Objective To investigate feasibility and safety of anterior pedicle screw fixation tunnel in the axis so as to provide theoretic evidence for further clinical application.Methods Thirty-two dry axis specimens were used for anterior pedicle screw placement,and the length of pedicle crews tunnel was measured by a digital caliper.The extraversion angle and the downslope angle were determined by CT cross-sectional scanning and reconstruction.Results All the anterior pedicle screws were positioned well,with no perforation of the pedicle.The anchoring point was at the vertex between the vertebral body and the superior articular process,with axis pedicle length of(28.4 ± 2.5)mm,the extraversion angle of (28.5 ±2.3)°and the downslope angle of(15.5 ±2.0)°.Conclusions Anterior pedicle screw fixation tunnel is feasible in the axis and can keep away from some important anatomy structures including transverse foramen,vertebral artery groove and vertebral canal to provide large safety space.     

计算机辅助个体化导航模板在Hangman骨折中的临床应用

目的 利用计算机辅助个体化导航模板为Hangman骨折后路经椎弓根固定提供准确定位. 方法 Hangman骨折患者CT连续扫描,三维重建软件MIMICS 10.01建立Hangman骨折三维模型,以STL格式导出模型.在UG lmageware 12.0平台打开三维重建模型.利用逆向工程(RE)原理寻找椎弓根的最佳进钉钉道.提取椎板的表面解剖学形态,建立与椎板解剖学形态一致的模板.拟合模板和椎弓根孔道成定位模板,将椎体和定位模板通过激光快速成形技术生产出实物模板,手术时利用建立的定位模板与椎体的后部结构相吻合,通过导航孔进行C2椎弓根的定位,置入椎弓根螺钉.同法制作C3椎弓根钉导航模板,对需行C2,3后路固定时进行C3椎弓根钉的导航定位.术后根据X线片和CT扫描评价椎弓根螺钉的位置.结果 应用于4例患者,2例行C2,3椎弓根同定融合,2例行单纯C2椎弓根螺钉固定;共置入C2椎弓根螺钉8枚,C3椎弓根螺钉4枚.术中模板与暴露的椎板贴合紧密,稳定性好,所有椎弓根螺钉置入均顺利.所有患者术中和术后末出现血管和神经并发症. 结论利用逆向工程原理和快速成形技术生产出的导航模板具有较好的准确性,为Hangman骨折椎弓根的定位提供了一种新的方法,利用该方法可使Hangman骨折后路固定手术简单及安全化.     

Knee injury and Osteoarthritis Outcome Score (KOOS) - validation of a Swedish version

The Knee injury and Osteoarthritis Outcome Score (KOOS) is a self-administered instrument measuring outcome after knee injury at impairment, disability, and handicap level in five subscales. Reliability, validity, and responsiveness of a Swedish version was assessed in 142 patients who underwent arthroscopy because of injury to the menisci, anterior cruciate ligament, or cartilage of the knee. The clinimetric properties were found to be good and comparable to the American version of the KOOS. Comparison to the Short Form-36 and the Lysholm knee scoring scale revealed expected correlations and construct validity. Item by item, symptoms and functional limitations were compared between diagnostic groups. High responsiveness was found three months after arthroscopic partial meniscectomy for all subscales but Activities of Daily Living.     

Endovascular management of carotid-cavernous fistulas

Objective To investigate endovascular treatment of traumatic direct carotid-cavernous fistulas （CCF） and their complications such as pseudoaneurysms. Methods： Over a five-year period, 22 patients with traumatic direct CCFs were treated endovascularly in our institution. Thirteen patients were treated once with the result of CCF occluded, 8 twice and 1 three times. Treatment modalities included balloon occlusion of the CCF, sacrifice of the ipsilateral internal carotid artery with detachable balloon, coll embolization of the cavernous sinus and secondary pseudoaneurysms, and covered-stem management of the pseudoaneurysms. Results All the direct CCFs were successfully managed endovascularly. Four patients developed a pseudoaneurysm after the occlusion of the CCF with an incidence of pseudoaneurysm formation of 18.2% （4/22）. A total number of 8 patients experienced permanent occlusion of the ICA with a rate of ICA occlusion reaching 36.4% （8/22）. Followed up through telephone consultation from 6 months to 5 years, all did well with no recurrence of CCF symptoms and signs. Conclusion Traumatic direct CCFs can be successfully managed with endovascular means. The pseudoaneurysms secondary to the occlusion of the CCFs can be occluded with stent-assisted coiling and implantation of covered stents.     

The role of interventional radiology in trauma

Introduction Interventional Radiology has evolved into a specialty having enormous input into the care of the traumatized patient.In all hospitals,regardless of size,the Interventional Radiologist must consider their relationships with the trauma service in order to     

Diagnóstico ecográfico del neumotórax

The ultrasonographic diagnosis of pneumothorax is based on the analysis of artifacts. It is possible to confirm or rule out pneumothorax by combining the following signs: lung sliding, the A and B lines, and the lung point. One fundamental advantage of lung ultrasonography is its easy access in any critical situation, especially in patients in the intensive care unit. For this reason, chest ultrasonography can be used as an alternative to plain-film X-rays and computed tomography in critical patients and in patients with normal plain films in whom pneumothorax is strongly suspected, as well as to evaluate the extent of the pneumothorax and monitor its evolution.     

Carbohydrate Supplementation during Exercise: Does It Help? How Much is Too Much?

KEY POINTS· Carbohydrate intake during exercise can delay the onset of fatigue and improve performance of prolonged exercise as well as exercise of shorter duration and greater intensity (e.g., continuous exercise lasting about 1h and intermittent high-intensity exercise), but the mechanisms by which performance is improved are different.     

The acutely limping child

Acute limping may be the result of multiple pathologies in children. The differential diagnosis varies based on the age of the child. Irrespective of age, the initial imaging work-up includes AP and frog leg radiographs of the pelvis and ultrasound; MRI may sometimes be helpful. In children less than 3 years, infections and trauma are most frequent. MRI is the imaging modality of choice when osteomyelitis is clinically suspected. Between the ages of 3 and 10 years, transient synovitis of the hip and Legg-Calvé-Perthes disease are main considerations but infection, inflammation and focal bony lesions are also considered. In children over 10 years, slipped capital femoral epiphysis also is considered.