可膨胀椎间融合器治疗腰椎退变性疾病30例回顾性分析☆

摘要：回顾性分析2005-08/2008-02北京大学第一医院骨科收治的应用可膨胀椎间融合器(B-Twin)行后路开放腰椎椎间融合治疗30例,男14例,女16例;年龄28~72岁;椎间融合节段L1/2 1例,L2/3 1例,L3/4 1例,L4/5 14例,L5/S1 13例。单独应用B-Twin 8例(单枚1例,双枚7例),结合椎弓根螺钉22例(单枚17例,双枚5例);直径9.5/ 11.0 mm 28例,直径11.5/13.0 mm 2例。术前、术后及随访时采用JOA评分(29分法)、Oswestry功能障碍指数评分评价患者生活质量改善情况,通过腰椎X射线平片评价融合间隙高度变化及腰椎滑脱纠正情况。30例患者中28例获得随访,平均随访9个月。Oswestry功能障碍指数术后优良率97%,随访优良率100%。JOA评分术后优良率93%,随访优良率96%。融合间隙高度术前占上位椎体的0.29±0.09,术后占上位椎体的0.44±0.09,随访时占上位椎体的0.42±0.09。腰椎滑脱患者中,术前滑脱占上位椎体高度的10%~60%;术后滑脱占上位椎体高度的0%~40%;随访滑脱占上位椎体高度的0%~30%。无神经损伤、感染患者。减压过程中因粘连硬膜撕裂1例,术后融合器陷入终板1例,随访时融合器碎裂1例。提示可膨胀椎间融合器有手术时间短、 创伤小、对神经刺激少等优点,术后及随访效果满意。需注意根据术前及术中测得椎间高度选择匹配的融合器型号;如放置单枚椎间融合器偏椎间隙一侧有碎裂可能,为防止碎裂应充分植骨,并可应用2枚椎间融合器。     

腰椎后路椎弓根钉置入并自体颗粒骨打压植骨治疗下腰椎结核

背景：采用自体颗粒骨结合打压植骨技术,行单节段腰椎椎间融合治疗下腰椎结核具有可靠的融合率,但目前临床应用报道不多。 目的：探讨经腰椎后路椎弓根钉置入并自体颗粒骨打压植骨治疗单节段下腰椎结核的临床可行性。 方法：回顾性分析2003-07/2009-07广州医学院第三附属医院骨科收治的单节段下腰椎结核患者20例,均行后路一期病灶清除、自体颗粒骨打压植骨腰椎椎体间融合内固定。置入内固定后评价其神经功能障碍改善、疗效、椎体融合及畸形矫正情况。 结果与结论：所有患者均获得随访,随访时间9~20个月。采用Macnab标准评价临床结果优11例,良8例,中1例,优良率95%。椎间融合率约为90%。内固定未见松脱、断裂等并发症。置入后及末次随访时Cobb角、椎间高度均较置入前有明显改善,差异有显著性意义(P < 0.05)。表明后路一期病灶清除、自体颗粒骨打压植骨腰椎椎体间融合固定是治疗下腰椎结核的有效方法之一。     

两种椎间融合手术对腰椎退变性疾病术后神经功能恢复的影响

目的探讨椎间孔入路腰椎融合术(TLIF)与后路椎间融合术(PLIF)在腰椎退行性疾病治疗中对患者术后神经功能恢复的影响。方法 224例腰椎退行性疾病患者根据手术方式分为TLIF组(n=98)及PLIF组(n=126),对比2组临床效果、术后神经功能损伤及术后3个月时神经功能JOA评分。结果 2组有效率(TLIF组90.8%,PLIF组89.7%)比较差异无统计学意义(P0.05);TLIF组术后神经根损伤发生率5.1%,显著低于PLIF组的19.8%(P0.01);2组术前JOA评分比较差异无统计学意义(P0.05),术后均显著增高(P0.01),术后1周TLIF组显著高于PLIF组(P0.01),术后3个月2组比较差异无统计学意义(P0.05)。结论 TLIF与PLIF在腰椎退行性疾病的外科治疗中均具有良好效果,虽然手术方式不同,但术后远期神经功能恢复情况并无明显区别,应密切结合病人的病情选择合适的手术方式。     

椎间关节植骨加内固定治疗退变性腰椎管狭窄症

目的 介绍椎间关节植骨加内固定治疗退变性腰椎管狭窄症的疗效.方法 采用椎间关节植骨加内固定治疗退变性腰椎管狭窄症268例.结果 268例,平均随访36个月,优良率为89.6%,并发症2.3%.结论 椎间关节植骨加内固定治疗退变性腰椎管狭窄症疗效确切,融合率高.     

半椎板切除减压加对侧椎板、横突间植骨融合治疗椎管狭窄合并下腰椎失稳症

我院自2006—10～2007-10,采用半椎板切除减压加对侧椎板、横突问植骨融合治疗椎管狭窄合并下腰椎不稳症共21例,取得不错疗效,现报告如下。     

椎间植骨融合效果与腰椎前柱组织结构及生物力学的关系

背景：腰椎融合后,椎间植骨融合率低,是临床上亟待解决的问题。 目的：阐述椎间植骨融合效果与腰椎前柱的关系,分析其组织结构及生物力学发生改变后对椎体间植骨融合效果的影响。 方法：电子检索CBM/CNKI(2000/2010)和计算机Medline数据库(1995/2010)收录的腰椎椎间植骨融合的相关综述和论文报告,找出并分析其中与前柱结构及生物力学相关的研究进展。 结果与结论：腰椎前柱的完整性及生物力学的稳定性对椎间植骨融合的效果有显著的影响。在腰椎前路间盘切除及腰椎前柱爆裂骨折撑开内固定中,应该着重保护好椎体前柱结构及血运,尽量恢复腰椎前柱结构的完整性及稳定性,维持腰椎正常的生物力学环境,以期达到理想的椎间融合效果。     

Coflex棘突间动力重建系统治疗腰椎退变性疾病18例

背景：近年来脊柱非融合技术一直是脊柱外科研究与争论的热点。Coflex棘突间动力重建系统作为腰椎后路非融合器材,国外虽已应用较长时间,但国内尚处于试用阶段。 目的：探讨Coflex棘突间动力重建系统治疗腰椎退变性疾病的适应证,并对其早期临床疗效进行评价。 方法：2008-10/2010-06使用Coflex棘突间动力重建系统治疗腰椎退变性疾病31例,对其中随访超过1年的18例患者临床资料进行分析总结。治疗方式均为后路髓核摘除,椎管减压、Coflex棘突间动力重建系统置入;1例患者术中置入2枚Coflex。治疗前及各次随访时均对患者进行日本骨科学会下腰痛功能量表、中文版Oswestry功能障碍指数量表及目测类比评分法评估,并测量治疗前后、各次随访时腰椎前屈后伸位置入节段及其上下节段活动范围、Colfex上下极板夹角及置入节段椎间隙高度。 结果与结论：患者均获随访,随访时间12~20个月。末次随访时患者日本骨科学会下腰痛功能量表评分、中文版Oswestry功能障碍指数量表评分及目测类比评分均获显著改善;治疗前后置入节段椎间高度及其上下节段椎间活动度差异均无显著性意义(P > 0.05),末次随访时Coflex上下极板夹角在过伸位较中立位显著增大(P < 0.05)。提示Coflex棘突间动力重建系统对腰椎间盘突出症、椎管狭窄及腰椎不稳等腰椎退变性疾病安全有效,在腰椎后伸时能够有效分担载荷,同时对腰椎生理活动影响较小,有利于维护腰椎功能,早期临床疗效肯定。     

自体骨、异种骨及人工骨微创植入治疗骨不连、骨缺损11例

回顾性分析上海市交通大学医学院附属仁济医院骨科2004-01/2007-12收治的骨折术后骨折延迟愈合、骨不连、骨缺损进行微创植骨的患者11例，局部麻醉或连续硬膜外麻醉下，在电视透视引导下定位，做5~8 mm的切口。通过植骨器撑开软组织，切割、钳夹、取出纤维瘢痕组织，并打通硬化封闭的髓腔，形成新鲜植骨床。通过套筒将自体骨、异种骨或人工骨植入。植骨后每2周复查X射线片，观察植骨块吸收、骨再生以及骨折的愈合情况。10例患者植骨后一般情况好，无发热，伤口无明显肿胀、渗出等炎症反应，均为一期愈合。骨折延迟愈合或骨不连均在植骨后2~4个月(平均2.9个月)达到临床愈合，恢复正常负重。1例胫骨中下1/3开放性骨折骨不连患者3周内出现炎症反应，植骨后8个月仍未愈合。提示微创植骨术操作简便，创伤小，愈合较快，疗效较好。     

椎间融合器植入并双侧下关节突切除治疗退变性腰椎管狭窄症

背景：对退变性腰椎管狭窄治疗可行全椎板减压内固定置入、单侧或双侧开窗减压、后路全椎板减压等方法。但采取何种方式治疗中是否需行椎间融合器植入内固定目前还没有定论。 目的：评价以cage椎间植骨融合椎弓根内植入固定并腰后路全椎板及双侧下关节突切除减压、自体小关节骨质移植治疗退变性腰椎管狭窄症的效果。 方法：选择经3个月保守治疗无效的退变性腰椎管狭窄症患者41例,男23例,女18例,平均年龄60.3岁,行腰后路全椎板及双侧下关节突切除减压、自体小关节骨质及cage椎间植骨融合植入椎弓根内固定治疗,随访24个月,术前及术后随访时JOA评分评价患者疗效,放射学检查患者植骨融合情况及手术节段椎体稳定性。 结果与结论：随访时JOA评分较术前有明显提高(P < 0.01),临床优良率为90%;40例获得骨性融合,融合率98%,1例患者有腰椎不稳征象。术后均无内固定物松动、断裂等并发症发生,但有2例发生硬脊膜撕裂,1例发生椎弓根位置偏斜,1例假关节形成。结果提示腰后路全椎板及双侧下关节突切除减压、自体小关节骨质及cage椎间植骨融合植入椎弓根内固定治疗退变性腰椎管狭窄症具有良好的临床效果。     

JJXA钉棒脊柱内固定置入及椎间颗粒骨植骨治疗动力性腰椎不稳症46例

选择2003-03/2007-03南阳市第九人民医院和南阳市第二人民医院收治的动力性腰椎不稳患者46例，行后正中入路下的椎管减压手术，钛制JJXA椎弓根螺钉置入，并行椎间隙撑开，双侧切除椎间盘保留侧方以及前方的纤维环，刮除终板的软骨层，行椎间颗粒骨植骨，椎弓根螺钉系统加压固定。46例随访时间≥15个月，优良率91.3%。JJXA固定牢靠，无断钉断棒和螺钉松动现象，无复位丢失，无炎症及排异现象发生，植骨融合率为97.8%。提示JJXA钉棒内固定及椎间颗粒骨植骨治疗腰椎不稳，能够达到即刻腰椎稳定性重建以及长期骨性融合的治疗目的。     

Outcome of posterior lumbar interbody fusion versus posterolateral fusion in lumbar degenerative disease

Between March 2003 and September 2007, 170 consecutive patients with lumbar degenerative disease were studied retrospectively. Eighty patients underwent posterior lumbar interbody fusion (PLIF group) with pedicle screw (PS) fixation, and 82 patients underwent posterolateral fusion (PLF group) with PS fixation. Eight patients were lost to follow-up. The minimum follow-up period in each group was 2.0 years. The mean follow-up period for the PLIF group was 3.6 years, and for the PLF group, the mean follow-up was 3.4 years: there was no significant difference between the two groups for length of follow-up. The Pain Index (PI) improved from 66 to 27 in the PLF group (p < 0.001) and from 69 to 29 in the PLIF group (p < 0.001), but there was no significant difference between the two groups (p > 0.05). In the PLF group, the preoperative mean Oswestry Disability Index (ODI) score was 34.5, which reduced to 14.2 at the final follow-up. In the PLIF group, the mean preoperative ODI was 36.4, which reduced to 16.2 at the final follow-up. There was no significant statistical difference between the two groups for ODI (p > 0.05). Eighty-eight percent (n = 72) of patients in the PLF group and 91% (n = 73) in the PLIF group had radiologically confirmed union, with no significant difference in fusion percentage between the two groups (p > 0.05). Twenty-two of 162 patients (14%) underwent a second operation: 18 (22%) in the PLF group and four (5%) patients in the PLIF group (p < 0.001). The clinical and functional outcomes in both groups were similar, and no significant difference was found in the parameters tested. Both surgical procedures were effective, but patients in the PLF group showed more complications related to hardware biomechanics than patients in the PLIF group (p < 0.001).     

斜外侧腰椎间融合术治疗退行性腰椎疾病一例

正患者女性,48岁,主因反复腰腿痛3年,加重伴间歇性跛行3个月,于2015年8月12日入院。患者3年前无明显诱因出现间断性腰部胀痛伴双臀和双大腿疼痛,活动和行走无明显受限,劳累后加重、卧床休息后缓解,当地医院行腰椎CT检查显示,L4-5椎间盘突出,临床诊断为L4-5椎间盘突出症。予牵引、理疗、敷中药(具体药物不详)等治疗后好转,但上述症状反复发作,时轻时重。3个月前腰痛和双下肢放射痛加重,尤以右侧显著,伴间歇性跛行,当     

Posterolateral lumbar fusion versus transforaminal lumbar interbody fusion for the treatment of degenerative lumbar scoliosis

This study compares the safety and efficacy of posterolateral lumbar fusion (PLF) and transforaminal lumbar interbody fusion (TLIF) in the treatment of degenerative lumbar scoliosis (DLS). Forty DLS patients with Cobb angles of 20–60 degrees were randomized into either the PLF or TLIF treatment group, and were followed up for 2–5 years. Operating time, intraoperative blood loss, clinical outcomes, complications and imaging were compared between the two groups. There were significant differences between the PLF and TLIF treatment groups in operative time (187.8 ± 63.5 minutes and 253.2 ± 57.6 minutes, respectively; p = 0.002) and intraoperative blood loss (1166.7 ± 554.1 mL and 1673.7 ± 922.4 mL, respectively; p = 0.048). The occurrence rates of early complications in the two groups were 11.1% and 26.3%. The recovery rates of the lumbar lordotic angle and spinal sagittal balance were significantly different (36.7% versus 62.5% and 44.8% versus 64.1%, respectively). In various domains of the Scoliosis Research Society-22 (SRS-22) questionnaire, the scores for pain and satisfaction with the treatment showed significant differences between PLF and TLIF group (p = 0.033 and p = 0.006, for pain and satisfaction respectively), and the TLIF group showed better outcomes than the PLF group. There were no significant differences in the recovery rates in the Cobb angle and the spinal coronal balance, function, self-image, or mental health scores. Although TLIF increases the surgical trauma and occurrence of complications, it helps to improve lumbar lordosis and sagittal balance and shows better clinical outcomes. For patients without significant loss of lumbar lordosis and with good spinal sagittal balance preoperatively, PLF is still an option.     

MAST QUADRANT 可扩张管下单侧椎弓根钉置入与椎体间融合治疗腰椎退变性疾病**

背景：腰椎后路椎体间融合治疗腰椎退变性疾病,能够恢复椎间隙高度、维持腰椎生理前凸、提供腰椎的即刻稳定性及取得较高的椎间骨性融合率。目的：验证运用MAST QUADRANT 可扩张管通道微创系统行单侧椎弓根钉置入并椎体间融合治疗腰椎退变性疾病的适应证及有效性。方法：在3.0 cm的微创切口内放置MAST QUADRANT可扩张管,应用单侧椎弓根钉内固定加椎体间融合治疗腰椎退变性疾病患者32例。结果与结论：患者置入内固过程中未发生硬膜囊撕裂、神经根和大血管等副损伤。随访3个月以上。置入3个月后JOA评分明显高于置入前(P < 0.01),目测类比评分显著低于置入前(P < 0.01)。X射线片显示椎间隙骨密度均逐渐增加,未发现椎间融合器移位、假关节、内固定松脱或折断等并发症,亦无炎症、过敏等不良反应。     

Comparison of endoscopic spine surgery and minimally invasive transforaminal lumbar interbody fusion for degenerative lumbar disease: A meta-analysis

This study aimed to compare the clinical outcomes of endoscopic spinal surgery (ESS) and minimally invasive transforaminal lumbar interbody fusion (MIS-TLIF) for degenerative lumbar disease (DLD) through meta-analysis. The Medline (via PubMed), Cochrane, Scopus, and Embase databases were searched for studies that evaluated the outcomes of ESS and MIS-TLIF in DLD, including visual analog scale (VAS) score for low back pain, VAS score for leg pain, Oswestry Disability Index (ODI), and complications published between January 2000 and August 2020. Two authors extracted the data independently. Any discrepancies were resolved by a consensus. Four comparative studies were identified. No significant differences were found between the ESS and MIS-TLIF groups in terms of VAS score for back pain, VAS score for leg pain, and ODI, except for complication rate. The complication rate was higher in the ESS than in the MIS-TLIF group. A literature review identified four comparative studies reporting the clinical outcomes of ESS and MIS-TLIF for DLD. Despite the heterogeneity, a limited number of meta-analyses showed that the clinical outcomes between the two groups were not significantly different except for complication rate. Hence, further large-scale multicenter studies are required to validate our results.     

微创经椎间孔腰椎间融合术联合经皮螺钉内固定融合术治疗退行性腰椎滑脱

目的探讨微创经椎间孔腰椎间融合术(MIS-TLIF)联合经皮螺钉内固定融合术治疗退行性腰椎滑脱的临床疗效。方法采用MIS-TLIF联合经皮螺钉内固定融合术共治疗32例退行性腰椎滑脱患者,比较术前和术后1周、3个月、末次随访时视觉模拟评分(VAS)、Oswestry功能障碍指数(ODI)和36条简明健康状况调查表(SF-36)评分,以及X线测量腰椎前凸角、冠状位Cobb角、冠状位和矢状位躯干偏移、腰椎滑脱程度(Meyerding分度)并计算滑脱率,X线或CT判断椎体融合率,MRI评价减压程度。结果 32例患者平均手术时间160 min,术中出血量120 ml,住院时间7.22 d,术后随访10.83个月。手术融合41个椎体节段,范围覆盖L2~S1节段。与术前相比,术后1周、3个月和末次随访时VAS(均P=0.000)和ODI(均P=0.000)评分增加,SF-36评分减少(P=0.002,0.000,0.000),腰椎前凸角(均P=0.000)、冠状位Cobb角(均P=0.000)和滑脱率(均P=0.000)均减小。至末次随访时,ODI改善率为(80.51±6.02)%,椎体融合率达92.22%且螺钉位置均良好。32例患者中1例术后感染、2例脑脊液漏,经对症治疗均痊愈;无一例发生神经功能缺损等严重并发症、内固定失败、椎弓根螺钉和钛棒断裂或Cage移位,无一例死亡。结论 MIS-TLIF联合经皮螺钉内固定融合术创伤小、术中出血量少、并发症轻微、复位效果好、疗效确切,尽管存在手术时间较长、学习曲线较长、术中X线照射量较大等缺点,但仍是治疗退行性腰椎滑脱的有效方法。     

Evaluation of Coflex interspinous stabilization following decompression compared with decompression and posterior lumbar interbody fusion for the treatment of lumbar degenerative disease: A minimum 5-year follow-up study

Few studies have compared the clinical and radiological outcomes between Coflex interspinous stabilization and posterior lumbar interbody fusion (PLIF) for degenerative lumbar disease. We compared the at least 5-year clinical and radiological outcomes of Coflex stabilization and PLIF for lumbar degenerative disease. Eighty-seven consecutive patients with lumbar degenerative disease were retrospectively reviewed. Forty-two patients underwent decompression and Coflex interspinous stabilization (Coflex group), 45 patients underwent decompression and PLIF (PLIF group). Clinical and radiological outcomes were evaluated. Coflex subjects experienced less blood loss, shorter hospital stays and shorter operative time than PLIF (all p < 0.001). Both groups demonstrated significant improvement in Oswestry Disability Index and visual analogue scale back and leg pain at each follow-up time point. The Coflex group had significantly better clinical outcomes during early follow-up. At final follow-up, the superior and inferior adjacent segments motion had no significant change in the Coflex group, while the superior adjacent segment motion increased significantly in the PLIF group. At final follow-up, the operative level motion was significantly decreased in both groups, but was greater in the Coflex group. The reoperation rate for adjacent segment disease was higher in the PLIF group, but this did not achieve statistical significance (11.1% vs. 4.8%, p = 0.277). Both groups provided sustainable improved clinical outcomes for lumbar degenerative disease through at least 5-year follow-up. The Coflex group had significantly better early efficacy than the PLIF group. Coflex interspinous implantation after decompression is safe and effective for lumbar degenerative disease.     

Minimally invasive surgery compared to open spinal fusion for the treatment of degenerative lumbar spine pathologies

This clinical study prospectively compares the results of open surgery to minimally invasive fusion for degenerative lumbar spine pathologies. Eighty-two patients were studied (41 minimally invasive surgery [MIS] spinal fusion, 41 open surgical equivalent) under a single surgeon (R. J. Mobbs). The two groups were compared using the Oswestry Disability Index, the Short Form-12 version 1, the Visual Analogue Scale score, the Patient Satisfaction Index, length of hospital stay, time to mobilise, postoperative medication and complications. The MIS cohort was found to have significantly less postoperative pain, and to have met the expectations of a significantly greater proportion of patients than conventional open surgery. The patients who underwent the MIS approach also had significantly shorter length of stay, time to mobilisation, lower opioid use and total complication rates. In our study MIS provided similar efficacy to the conventional open technique, and proved to be superior with regard to patient satisfaction, length of hospital stay, time to mobilise and complication rates.