DR与MSCT检查诊断小儿寰枢椎病变的比较研究

目的比较寰枢椎X线DR(X-RayDigital Roentgenography)检查与螺旋CT(SpiralCT)检查对诊断小儿寰枢椎半脱位的临床应用价值。方法分别对12例小儿患者进行寰枢椎X线DR检查和螺旋CT检查及重建。结果 7例X线DR检查诊断为小儿寰枢椎半脱位,而通过CT检查和重建4例诊断为小儿寰枢关节半脱位,3例为正常;2例X线DR检查误诊为齿状突骨折、寰枢椎半脱位,CT重建清楚显示为寰枢椎畸形,分别为齿状突后弓缺如1例,齿状突发育不良1例;3例小儿在拍摄颈椎张口位时不配合,寰枢椎显示欠清,CT检查清晰显示为寰枢椎半脱位。结论螺旋CT检查和重建技术较X线DR检查更易显示小儿寰枢椎半脱位征象,有助于提高临床诊断率。     

枢椎椎弓根钉板结合对侧椎板钉棒固定在寰枢椎及枕颈固定中的应用

目的探讨后路单侧枢椎椎弓根钉板系统结合对侧枢椎椎板钉棒系统在寰枢关节及枕颈固定中的临床疗效。方法后路单侧椎弓根钉板系统结合对侧枢椎椎板钉棒系统寰枢椎固定及枕颈固定11例,新鲜Ⅱ型齿突骨折5例,陈旧性齿突骨折3例,寰椎枕骨化畸形2例,寰枢椎不稳1例。单侧椎弓根发育狭小者6例,单侧椎动脉优势型2例,一侧椎动脉高跨2例,寰椎枕骨化畸形寰枢关节脱位行钉板系统固定失效后再次手术1例。寰枢椎固定9例,枕颈固定2例,1例难复型寰枢关节脱位行经口咽前路松解+后路复位内固定融合术,术后内固定失效行翻修手术。全部患者行后路寰枢或枕颈固定植骨融合术。比较术前、术后JOA评分变化,术后随访X线片及CT,观察寰枢椎复位及融合情况。结果所有患者均得到随访,随访时间6~32个月,平均16个月。全组患者无一例发生脊髓或椎动脉损伤,寰枢椎得到解剖复位,临床症状得到不同程度改善。术后JOA评分13~16分,平均14.9分,术前、术后JOA评分改善率为76%~92%,平均83%,术后半年复查CT显示均获得骨性融合,未见寰枢椎失稳或复位丢失征象,固定螺钉位置良好。结论单侧枢椎椎弓根钉板系统结合对侧枢椎椎板钉棒系统行寰枢关节及枕颈固定临床疗效可靠,但缺少临床对比研究。     

高分辨CT在寰枢椎外伤中的诊断价值

目的分析高分辨CT在寰枢椎损伤中的影像学特点和对临床的应用价值。方法收集2011年12月至2013年5月寰枢椎外伤病例90例,均行普通x线检查及CT扫描,采用高分辨CT轴位扫描,并行MPR、VR后处理及3D重建,分别分析这几种成像方法对寰枢椎外伤性改变的灵敏度及特异性。结果90例寰枢椎外伤病例中,通过高分辨CT轴位检查、MPR、VR后处理及3D重建相结合,诊断为寰椎骨折10例,齿状突骨折40例,枢椎骨折25例,单纯性寰枢关节脱位15例。寰枢关节脱位合并寰枢椎骨折患者30例。行高分辨CT扫描及后处理后诊断全部正确,x线片正确诊断为54例,占60％,其余均为误诊或漏诊。高分辨CT对寰枢椎外伤性改变的灵敏度及特异性高于普通X线片。结论高分辨cT成像可以清楚显示寰枢椎各部位外伤性改变,特别是隐蔽性创伤,能对寰枢椎损伤作出全面而准确的评价,其独特的影像学特点可做为寰枢椎外伤的首选检查方法。     

多层螺旋CT薄层扫描重建对寰枢椎骨折脱位的诊断和临床应用

目的:采用多层螺旋CT薄层扫描及三维重建(3D)和多平面重建(MPR)技术诊断寰枢椎骨折脱位并进行术后效果评价.方法:回顾性分析69例寰枢椎骨折脱位患者的手术前后X线片与多层螺旋CT薄层扫描及3D和MPR重建图像,其中男54例,女15例,年龄17～73岁,平均46.5岁.结果:运用CT薄层扫描及重建技术诊断全部准确,其中齿状突骨折49例(Anderson Ⅱ型35例,Ⅲ型14例);C1,2联合骨折(Jeffson骨折联合Hangman骨折合并C1,2不稳)9例;寰椎爆裂骨折合并枕颈不稳6例;枢椎椎体骨折5例.而X线片诊断准确38例(38/69),漏诊23例,6例未能作出诊断,2例误诊.术后69例CT图像均清楚显示金属内固定的准确位置,其中2例螺钉螺纹轻微穿破寰枢椎侧块(椎弓根)外侧骨皮质,3例螺钉螺纹轻微穿破寰椎后弓上侧骨皮质.结论:多层螺旋CT薄层扫描及重建能够直观清晰地显示寰枢椎骨折脱位的部位、类型及术后金属内固定位置,为临床确定骨折分型、选择合适的治疗方案和术后疗效评价提供了可靠而直观的依据,可作为寰枢椎骨折脱位的诊断和术后评价的影像学首选检查方法,应该常规使用.     

双侧经寰枢关节螺钉及寰椎椎板钩内固定系统的三维有限元研究

目的 探讨双侧经寰枢关节螺钉及寰椎椎板钩内固定系统的生物力学性能.方法 健康男性志愿者,年龄28岁,身高172 cm ,体重60 kg ,X线检查排除枕颈部畸形;对志愿者进行枕骨底到第三颈椎(C0-3)薄层CT扫描,建立具有详细解剖结构的上颈椎(C0-3)有限元模型并验证其有效性.在寰枢椎不稳的上颈椎模型中模拟双侧经寰枢关节螺钉及寰椎椎板钩固定并进行三维有限元对比分析.结果 上颈椎三维非线性有限元模型的仿真性好,可以进行生物力学分析.双侧经寰枢关节螺钉及寰椎椎板钩内固定系统中螺钉在经过寰枢关节部位时应力最大,有良好的生物力学稳定性.结论 双侧经寰枢关节螺钉及寰椎椎板钩固定是一种实用、有效的寰枢椎融合方式.     

CT监测下经皮穿刺寰枢椎侧块关节植骨融合术

目的报告自行设计的CT监测下经皮穿刺寰枢椎侧块关节植骨融合术并探讨其临床应用。方法在对56具成人寰枢椎干燥骨标本行解剖学研究的基础上,1999年3月～2001年3月,9例寰枢椎脱位患者经牵引复位后,采用Halo-Vest外固定架固定4例,前路经枢椎体寰椎侧块螺钉内固定5例。在CT监测下,应用自行研制的手术器械,后外侧入路经皮穿刺将寰枢椎侧块关节后外侧的关节囊、关节软骨去除,做好植骨床并将用穿刺法钻取的髂骨松质骨骨柱植入。结果9例术后随访2～17个月,平均12.7个月,其中8例超过6个月。3例术后3个月去除了Halo-Vest架。8例均摄过伸、过屈及张口位X线片,显示寰枢椎稳定;其中6例在术后3～4个月行CT扫描及三维重建显示侧块关节达到植骨融合。结论此术式为创新设计,其创伤小,出血少,融合时间相对缩短,融合率高。     

前路经寰枢关节螺钉内固定生物力学性能的有限元分析

目的:通过有限元分析的方法评估前路经寰枢关节螺钉内固定的生物力学性能。方法:选择一名21岁健康男性志愿者,采用螺旋CT对枕骨底到C3椎体进行层厚1mm的薄层扫描,利用MIMICS 13.0软件、Freeform Plus软件及ANSYS 9.0软件,建立正常上颈椎有限元模型。去除模型中横韧带的所有单元模拟寰枢关节不稳,以枢椎前弓下缘与枢椎椎体侧缘交界点上方4mm处为进钉点,经寰枢关节分别向两寰椎侧块外上角中部置钉,最终建立前路经寰枢关节螺钉内固定治疗寰枢关节不稳的有限元模型。给予模型分别施加前屈、后伸、侧屈、旋转四种生理载荷,观察不同载荷下螺钉的三维运动范围与应力变化,分析前路经寰枢关节螺钉内固定的生物力学性能。结果:前路经寰枢关节螺钉内固定在不同载荷下三维运动范围均较小,但前屈、后伸状态下三维运动范围(0.72°,1.08°)明显大于侧屈、旋转状态(0.39°,0.32°)。不同状态下应力集中区域均为螺钉经寰枢关节部位,最大应力值为10.58×107Pa,出现在后伸状态。结论:前路经寰枢关节螺钉内固定具有可靠的生物力学性能,在侧屈、旋转状态下的力学性能优于前屈后伸状态,螺钉经寰枢关节部位易产生应力集中,为可能的断钉部位,临床应用时应采取有效预防措施。     

数字骨科技术在寰枢椎手术中的应用 寰枢椎脱位系列讲座(七)

正1概述寰枢椎位于颅脊交界区,解剖结构上具有独特性。寰椎由前后弓、侧块、横突构成,侧块上接枕骨髁、下邻枢椎关节突上关节面,形成寰枢外侧关节,而枢椎齿突与寰椎前弓构成寰齿关节,寰枢、寰枕之间由横韧带、翼状韧带和齿突尖韧带等多个韧带连接,这样就形成了一个复杂的三维复合结构;寰枢椎还毗邻诸多重要的血管和神经,因此治疗难度较大,风险较高[1-2]。寰枢椎脱位是各种上颈椎与颅脊交界疾患的病理转归,临床上并不少见,除了部分儿童自发性     

合并寰枢关节脱位的寰椎枕骨化手术治疗

[目的]分析后路减压枕颈融合内固定术治疗合并寰枢关节脱位的寰椎枕骨化临床疗效。[方法]2005年12月至2007年6月间，对8例合并寰枢关节脱位的寰椎枕骨化患者在行颅骨牵引治疗一段时间（12～16d，平均13．5d）后采用枕骨大孔后缘扩大，寰椎后弓切除减压取自体髂骨枕颈融合Cervifix系统内固定术，手术后采用日本骨科学会（JOA）神经功能评分分析临床疗效。[结果]8例患者随访6个月～2年，平均为15个月。8例患者无一例出现术后并发症，术前寰齿前间隙（ADI）为5～9mm，经颅骨牵引后为5～7mm，寰枢关节脱位未能完全复位。手术前后JOA评分示神经症状均有不同程度恢复，影像学检查示枕颈区减压充分植骨区获得骨性融合，无一例出现内固定松动或断裂。[结论]合并寰枢关节脱位的寰椎枕骨化患者术前仔细评估影像学改变，采用颅骨牵引一段时间后行后路减压枕颈融合内固定术的治疗方案是合理可行的，且临床效果满意。     

人工寰齿关节置换后各寰枢椎部件生物力学性能的有限元分析

目的通过有限元分析方法评估人工寰齿关节置换后寰枢椎各部件的生物力学性能,以便对其结构优化提供理论依据。方法对人体正常新鲜寰枢椎尸体标本和人工寰齿关节行薄层CT扫描,利用Mimics软件、Freeform Plus软件及Ansys软件,模拟临床前路减压术,将人工寰齿关节模型装配于寰枢椎模型上,构建人工寰齿关节置换后寰枢关节几何模型。对实体模型进行网格划分,并在网格模型基础上添加相关韧带结构,最终建立人工寰齿关节置换后寰枢关节的有限元网格模型。给予模型分别施加前屈、后伸、侧屈、旋转4种生理载荷,计算分析不同载荷下人工寰齿关节置换后寰枢椎各部件的应力分布情况。结果在前屈和后伸状态下,枢椎螺钉钉尾处表现高应力,而寰椎螺钉钉尾未出现高应力;在各种运动状态下,应力集中区分别为人工寰齿关节钢板钉孔处和两部件接触处,枢椎钢板与椎骨接触处也出现应力集中。结论人工寰齿关节钢板钉孔处、枢椎螺钉钉尾和寰枢椎部件接触处容易出现应力集中,人工寰齿关节表面需要涂层处理及其材料硬度和耐磨性有待进一步优化。     

Atlanto-axial arthrodesis by the wedge compression method.

Fifteen patients with atlanto-axial instability (secondary to os odontoideum in three, nonunion of an odontoid fracture in seven, acute odontoid fracture in three, and rheumatoid arthirtis in two) were treated by wedge compression arthrodesis of the atlanto-axial joint. One patient died at home eight weeks after fusion with the cause of death never established. Of the two patients with rheumatoid arthritis (ankylosing spondylitis), one had a non-union and in the other the posterior arch of the atlas fractured and the fusion had to be extended up to the occiput and down to the third cervical vertebra. The procedure is rarely indicated in patients with long-standing rheumatoid arthritis or severe osteopenia.     

Abnormal bone remodelling in inflammatory arthritis

Osteopenia is responsible for substantial comorbidity in patients suffering from rheumatoid arthritis and is an important factor in the surgical management of joint disease. In animal models of bone loss stimulated by inflammatory arthritis, increased bone remodelling and altered microstructure of bone have been documented. The subchondral bone plate near the joint surface is narrow and perforated by vascular inflammatory invasion, and in the shaft the thin cortices are weakened by giant resorption defects. Biomechanical tests and a mathematical model of bone strength suggest that cortical defects, much larger than those found in normal osteonal remodelling, are principally responsible for the experimentally observed loss of strength. Similarly, these defects may explain the increased femoral fracture risk in rheumatoid arthritis.The osteoclast, the cell resorbing bone, is demonstrated in increased number and activity in rheumatoid arthritis and in animal models. Bisphosphonates, drugs that inhibit osteoclast function, have been shown experimentally to reduce both focal and generalized osteopenia and to prevent loss of bone strength. Bisphosphonates also protect articular cartilage from damage characteristic of inflammatory arthritis. The mechanism of chondroprotection may be prevention of subchondral bone resorption by the osteoclast and also an altered distribution of bone marrow cells. Thus, bisphosphonates, currently in clinical use for other bone metabolic diseases, appear to have potential as prophylaxis and treatment for osteopenia and joint damage in inflammatory arthritis.     

The wrist joint

The wrist joint is involved in a great majority of cases of rheumatoid arthritis. Tenosynovitis and synovitis can lead to severe destruction of the joint and to spontaneous ruptures of the tendons. Therefore, early tenosynovectomy and wrist-joint synovectomy are required. At the advanced stage of the disease, arthroplasty is necessary. Arthrodesis is rarely indicated in the treatment of severe wrist destruction in rheumatoid arthritis.     

关节镜治疗膝关节早中期类风湿性关节炎

目的探讨膝关节类风湿性关节炎关节镜下滑膜切除术的治疗方法以及疗效评价。方法在关节镜下对33例（39个关节）膝关节类风湿性关节炎患者进行滑膜切除术,其中早期类风湿性关节炎7例,8个关节;中期类风湿性关节炎26例,31个关节。术后给予正规严格的抗类风湿药物治疗。术后随访分别按照Lysholm评分、ESR、CRP以及Ishikawa疗效评定标准进行评价。结果 33例患者平均随访时间为5.77年。采用Lysholm评分、ESR、CRP差异均具有统计学意义（P〈0.05）。Ishikawa评分：39个关节优良率为76.9%（30/39）,早期8个关节的优良率为87.5%（7/8）,中期31个关节的优良率为74.2%（23/31）,二者差异不具有统计学意义（P〉0.05）。结论膝关节早、中期类风湿性关节炎关节镜下滑膜切除术联合术后正规的抗类风湿药物治疗,均可以获得较满意的疗效。     

Principles of surgical treatment of the cervical spine in rheumatoid arthritis

Summary About 20% of patients with rheumatoid arthritis complain about neck problems based on instability and deformity. As a consequence, pain, myelopathy, and severe neurological deficit may occur. Results reported in the literature were not encouraging as regards surgical decompression and stabilization. However, new surgical techniques allow a more aggressive strategy towards the complex problem of the instable cervical spine in rheumatoid arthritis. The most frequent instability of C1/2 can be stabilized by a posterior atlantoaxial screw fixation, a three-dimensional multidirectional construct with few complications. For the inclusion of the occiput into the fusion and the extension of the fusion down to the lower cervical spine, a titanium Y-plate is presented as a successful implant. While through a posterior approach, stability may be achieved, decompression is preferably done by anterior diskectomy or vertebrectomy. Encouraging results with a significant recovery of neurological deficits justify an early intervention in cases of instability of the cervical spine in rheumatoid arthritis.     

Surgical treatment for rheumatoid neck arthritis bilateral occipitospinal fusion with plate fixation

The results of surgical treatment of 12 patients with rheumatoid cervical spine arthritis were reviewed. The Ranawat classification was as follows: 5 with Ranawat IIIB, 1 Ranawat IIIA and 6 Ranawat II. Decompression and fusion using autogenous iliac bone graft and double occipitospinal plate fixation was carried out on 11 of these patients; the remaining patient underwent upper cervical spine fusion using screw and wire fixation. The main indication for surgery was neurological deterioration. In three cases previous surgery had been carried out on the cervical spine. The results were assessed at a mean follow-up of 26.1 months. According to Frankel's grading the neurological recovery in patients with neurological compression was one grade. There was clinical and radiological evidence of fusion in all these patients. The following complications required further surgery: acute postoperative epidural hematoma (one patient) screw loosening (one patient) CONCLUSION: Fusion of the occiput and lateral mass of the involved cervical spine using a plate on each side provides a relatively stable fixation in patients with rheumatoid arthritis of the cervical spine. Laminectomy and adequate decompression of the neural elements can be carried out without compromising spinal stability. There is a relatively high complication rate associated with surgery for rheumatoid neck and the patient needs to be informed.     

Rapidly destructive arthropathy of the hip joint in patients with rheumatoid arthritis

This article describes 3 patients with rheumatoid arthritis in which hip joint conditions were similar to rapidly destructive arthropathy of the hip joint. The patients had the following additional characteristics: (1) age at diagnosis was comparatively older; (2) rheumatoid arthritis had an onset after age 40 years; (3) severe rheumatoid arthritis was present in >4 major joints; (4) long-term steroids and disease-modifying antirheumatic drugs were taken due to the high activity of rheumatoid arthritis; and (5) patients were underweight, with body mass indexes <20 kg/m(2).Rapidly destructive arthropathy of the hip joint rarely occurs in osteoarthritis, avascular necrosis of the femoral head, and rheumatoid arthritis. Clinically, rapidly destructive arthropathy of the hip joint occurs in elderly patients who report severe pain but have a relatively preserved range of motion. Typical radiologic changes in rapidly destructive arthropathy of the hip joint are rapid destruction, resorption, or subluxation of the femoral head, destruction of the acetabulum, and minimal spur formation developing 6 to 12 months after symptom onset. Destruction of the hip joint in rheumatoid arthritis occurs in the sequence of depression, flattening, and loss, and commonly progresses gradually. When patients with rheumatoid arthritis report persistent and severe pain in the hip joint with no specific cause, rapidly destructive arthropathy of the hip joint must be identified through repetitive follow-up radiographic observations.     

超声早期诊断类风湿关节炎

类风湿关节炎是一种以慢性破坏性关节病变为特征的自身免疫性疾病,临床、实验室检查与放射学检查对早期诊断的作用有限。高频灰阶超声软组织分辨力较高,能够区分渗出性和增殖性滑膜病变;能量多普勒超声有助于区分活动性和非活动性关节病变;CEUS可提高检出滑膜增厚、滑膜血管增生等病变的敏感性。超声检出骨侵蚀的能力优于放射学检查,还可随访和监测治疗效果。     

Posterior occipito-cervical fusion in rheumatoid arthritis

Summary The instability of atlanto-axial subluxation remains a challenging problem in patients with rheumatoid arthritis. In order to preserve as much function of the cervical spine as possible, inclusion of the occiput into the fusion should exclusively be performed when there is a radiologically or clinically manifest pathological condition of the atlanto-occipital joint or marked upward migration of the dens axis. In order to prevent irreversible damage to the spinal cord, an early indication of surgical stabilization is recommended. This article presents a retrospective analysis of the clinical and radiological results of occipito-cervical fusion in 26 patients with rheumatoid arthritis using a modified Brattström technique. The complications encountered were mainly due to the use of wire fixation, reinforcement using bone cement and insufficient reduction of atlanto-axial subluxation.