颈椎间盘置换与颈前路椎间盘切除减压植骨融合治疗退变性颈椎病的Meta分析

背景：颈前路减压植骨融合是目前治疗退变性颈椎病手术方案中的“金标准”。但是,随着颈前路减压植骨融合技术使用的增加和随访资料的不断丰富,一些不良结果开始暴露出来。近20年来,人工颈椎间盘置换技术在国外和国内逐步推广并广泛应用于临床,文献报道治疗效果令人满意。 目的：系统评价颈椎间盘置换与传统的颈前路减压植骨融合治疗退变性颈椎病治疗效果的差异。 方法：计算机检索Medline(1966/2009-06),荷兰医学文摘(EMbase1966/2009-06),Cochrane图书馆(2009年第2期)、Cochrane协作网背痛专业试验数据库、中国生物医学文献数据库(CBM截止2009-06),CNKI(截止2009-06),手工检索中文文献,收集颈椎间盘置换与颈前路减压植骨融合比较治疗退变性颈椎病的随机、半随机对照试验,进行严格的质量评价,利用RevMan4.2.2软件对纳入研究结果进行Meta分析。 结果与结论：共纳入15个研究,Meta分析结果显示：颈椎间盘置换与颈前路减压植骨融合术比较平均出血量、手术时间、住院时间及术后并发症差异无显著性意义;术后2年再手术率颈椎间盘置换组低于颈前路减压植骨融合组;手术满意率两组差异无显著性意义;颈椎间盘置换组术后颈部功能异常指数较颈前路减压植骨融合组明显改善,术后SF-36评分改善显著优于颈前路减压植骨融合组;术后手术节段运动幅度颈椎间盘置换组显著大于颈前路减压植骨融合组,术后邻近节段运动范围颈前路减压植骨融合组明显较颈椎间盘置换组增大。但上述结果可能存在各种偏倚,因此需要更多高质量的临床随机对照试验来得出更为可靠的结论。     

颈椎间盘置换与颈前路减压植骨融合术治疗单节段颈椎病疗效的系统评价

比较颈椎间盘置换与颈前路减压植骨融合术治疗单节段颈椎病的疗效及安全性。 资料来源：计算机检索PubMed(1966-01/2009-04)、Embase(1989-01/2009-04)、Cochrane图书馆(2009,Issue 2)临床对照试验资料库、中国生物医学文献数据库(CBM,1978-01/2009-04)、中国期刊全文数据库(CNKI,1994-01/2009-04)、维普中文科技期刊数据库(VIP,1989-01/2009-04)及所有相关文章的参考文献。 资料选择：纳入标准：①随机对照试验。②经CT或MRI证实为单一节段退行性椎间盘疾病所致的颈椎病患者,且经正规保守治疗无效者。排除标准：①患有严重骨质疏松症。②影像学上手术节段严重不稳定。③创伤。④感染。⑤肿瘤。⑥全身代谢性疾病。⑦金属过敏。⑧有颈椎解剖异常。⑨严重颈椎管狭窄或多节段病变的颈椎病。⑩颈椎曾经手术治疗或有严重器质性疾病。由2名评价者依据纳入排除标准独立筛选文献及提取资料,并按Cochrane Handbook 5.0.1对纳入研究进行偏倚风险评估及数据分析。 结局评价指标：制作统一资料提取表提取数据,内容包括研究的人口统计学资料、颈部活动范围、手术总成功率、颈部功能异常评分指数、上肢疼痛评分、平均手术时间、出血量、住院时间、不良反应及并发症,由2名评价者独立提取资料并填入表格。 结果：共纳入7个随机对照试验,包括1 400例患者。所有研究存在不同程度的选择性偏倚、实施偏倚、测量性偏倚及其他偏倚的可能性。7篇随机对照试验多数没有提供完整的原始数据且存在临床异质性,故未能进行Meta分析。4篇研究提示颈椎间盘置换优于颈前路减压植骨融合术;2篇研究肯定颈椎间盘置换近期临床疗效优于颈前路减压植骨融合术同时建议延长随访时间;1篇研究提示颈椎间盘置换对比颈前路减压植骨融合术疗效相似。 结论：颈椎间盘置换近期临床疗效优于颈前路减压植骨融合术;然而纳入研究均未报告长期随访的相关资料,所以尚不能肯定颈椎间盘置换能否防止毗邻节段的退变。     

腰椎间盘镜手术和显微手术治疗腰椎间盘突出症的系统评价

目的 系统评价腰椎间盘镜手术和显微手术治疗腰椎间盘突出症的疗效和安全性.方法 分别以椎间盘镜、显微镜、腰椎间盘突出等相关中英文关键词作为检索词,计算机检索PubMed、EMbase、Cochrane图书馆临床对照试验资料库、中国知网中国期刊全文数据库和万方数据知识服务平台学术期刊库,并对部分杂志进行手工检索,收集椎间盘镜手术和显微手术治疗腰椎间盘突出症的随机对照临床试验.采用Jadad 量表进行文献质量评价,数据提取和文献质量评价由两名评价员独立进行,RevMan 5.0.24 统计软件行Meta分析.结果 共纳入4 项临床研究计1069 例患者.Meta分析结果显示,术后Oswestry 功能障碍指数比较,两种术式间差异无统计学意义(MD = - 0.170,95%CI:- 3.590 ~ 3.260;P = 0.920).椎间盘镜手术患者术中硬脊膜撕裂(RR = 3.040,95%CI:1.170 ~ 7.890;P = 0.020)、神经根损伤(RR = 5.130,95%CI:0.890 ~ 29.420;P = 0.070)等并发症发生率和术后复发率(RR = 2.320,95%CI:0.970 ~ 5.520;P = 0.060)均高于显微手术;两种手术所用时间(MD = 10.780,95%CI:7.180 ~ 14.370;P =0.000)、手术切口长度(MD = - 0.950,95%CI:- 1.840 ~ 0.070;P = 0.030)和术后住院时间(MD = 0.210,95%CI:- 0.080 ~ 0.340;P = 0.002)具有统计学差异,但术中出血量比较差异无统计学意义(MD = 27.420,95%CI:- 8.840 ~ 63.680;P = 0.140).结论 椎间盘镜手术和显微手术治疗腰椎间盘突出症疗效相当,但椎间盘镜手术术后复发率和手术并发症发生率均高于显微手术.鉴于所纳入临床研究的整体质量较低且数量较少,应谨慎引用本研究结果,上述结论尚需更多高质量的随机对照临床试验加以验证.     

显微内窥镜下腰椎间盘摘除和传统开放手术治疗腰椎间盘突出症的

背景：显微内窥镜手术系统将传统开放手术和显微内镜技术相结合,将传统的髓核摘除内镜化、微创化。与传统开放手术相比,显微内窥镜腰椎间盘摘除可放大手术野、有良好的照明系统,术者视野更清晰,操作更为精细,对周围组织的损伤也较小。 目的：对显微内窥镜下腰椎间盘摘除和传统开放手术治疗腰椎间盘突出症的疗效及临床价值进行评价。 方法：按照Cochrane系统评价的方法,计算机检索Medline(1990-01/2010-03)、Embase(1990-01/2010-03)、Cochrane图书馆及中国生物医学数据库(1990-01/2010-03),并采用手工检索等方法收集会议文献。文献检索无语种限制。收集所有相关随机对照试验,采用Cochrane协作网提供的软件Revman 5.0进行Meta分析,以获得显微内窥镜下腰椎间盘摘除和开放手术治疗腰椎间盘突出症的疗效是否有差异的相关证据。 结果与结论：共纳入12个研究,包括1 748例腰椎间盘突出症患者。进行Meta分析结果显示,显微内窥镜手术的操作时间与传统开放手术无明显差异,但在术中出血量、术后卧床时间和住院时间上优于传统开放手术。提示显微内窥镜手术是一种治疗腰椎间盘突出症理想的微创手术方式。     

注入骨水泥椎体成形与非手术治疗骨质疏松性椎体压缩骨折的Meta分析

背景：注入骨水泥椎体成形或称经皮椎体成形术作为治疗骨质疏松性椎体压缩骨折的微创技术,一些病例报道及非随机对照研究揭示了椎体成形对骨质疏松性椎体压缩骨折引起的疼痛有效。然而,这些研究主要基于回顾性的病例分析,缺乏高质量的随机对照研究。 目的：通过系统评价Meta分析的方法对椎体成形术与非手术治疗骨质疏松性椎体压缩骨折的疗效进行评价。 方法：计算机检索Cochrane Library(2010年第4期) 、PubMed (1966/2010-11)、EMBASE(1974/2010-11)、CBM (1978/2010-11)、CNKI(1994/2010-11)、和万方数据库(1997/2010-11)。纳入椎体成形术与非手术治疗骨质疏松性椎体压缩骨折的随机对照试验,按照Cochrane Handbook 5.0 进行严格的质量评估,采用RevMan 5.0.1软件进行Meta分析。 结果与结论: 共纳入4个随机对照试验,共445例患者。Meta分析结果显示,与保守治疗比较,随访1,4,24,48 周时椎体成形术在缓解疼痛方面更明显,在新发骨折发生方面,两种治疗方法没有差别;与安慰剂相比,随访4周时椎体成形术在缓解疼痛、提高腰部功能活动及改善生活质量方面并无明显优势。受系统评价纳入研究数量以及质量的限制,上述结论尚需要更多高质量的随机对照试验进一步验证。     

后路椎间融合椎弓根钉系统内固定术的护理

对于退变性腰椎间盘疾病、腰椎滑脱及腰椎节段性不稳定等,在严格保守治疗无效的情况下,需行手术治疗,而后路椎间融合椎弓根钉系统内固定术以其能达到全椎间盘切除、恢复椎间高度、扩大椎间孔减压及植骨融合率高等优点,而成为目前治疗腰椎退行性疾病的主要手段。2004-01~2007-12     

单侧椎弓根螺钉置入并椎间融合对邻近椎间盘节段退变的影响

背景：坚强内固定和良好融合存在严重缺陷和不足。目前还未见临床应用单侧椎弓根螺钉固定结合椎间cage植骨融合治疗腰椎退变性疾病对邻近节段退变影响的相关报道。 目的：回顾分析单侧椎弓根螺钉固定结合椎间cage植骨融合治疗部分腰椎退变性疾病后对固定融合邻近上下节段退变的影响。 方法：2006-03/2009-12对收治的部分腰椎管狭窄症、腰椎失稳及腰椎间盘脱出症患者22例,进行了单侧椎弓根螺钉固定加椎间cage植骨融合,术中不显露对侧。在固定融合后3,6,12,20个月及取出内固定钉棒后3,6个月,随访X射线片及MRI。针对X射线片运用角平分线法测量固定融合邻近上位椎间隙高度变化,MRI测量椎间盘髓核退变情况。 结果与结论：所有病例获得随访,患者椎管狭窄症状及神经根性症状消失,并且在随访期间内没有新的临床症状出现。固定融合前、固定融合后3,6,12,20个月邻近节段上位椎间隙高度分别为(7.420±0.035 4),(7.426 6±0.036 9),(7.453 3±0.036 9),(7.516 6±0.036 9),(7.430 8±0.036 9) mm,结果表明,腰椎单侧固定融合后邻近节段椎间隙高度无明显变化(P > 0.05)。MRI测量结果显示,固定融合邻近上位椎间盘髓核信号在T2加权像无明显退变。提示单侧椎弓根螺钉固定结合椎间融合治疗部分腰椎退变性疾病能有效预防固定融合邻近上下节段退变。     

置入棘突间稳定系统Wallis治疗腰椎退变性疾病：与单纯腰椎管减压的比较☆

背景：在早期,腰椎间盘退变性疾病的治疗临床常用髓核摘除或髓核摘除加刚性内固定融合技术,但是随着非刚性固定技术的发展,棘突间稳定系统固定和全椎间盘置换在脊柱非融合治疗中逐渐受到人们的重视,其优点日益突出。 目的：与单纯腰椎管减压相比,评价腰椎管减压并棘突间稳定系统Wallis置入固定治疗腰椎退变性疾病的效果。 方法：选择2007-12/2008-12华中科技大学附属同济医院骨科收治的腰椎退变性疾病患者40例,随机选取20例行单纯髓核摘除(对照组),20例行突出髓核摘除加棘突间稳定系统Wallis固定(实验组)。分别于置入后1周,1年对两组患者分别进行JOA评分、目测类比评分。 结果与结论：两组患者置入后1周JOA评分及目测类比评分差异均无显著性意义(P > 0.05);术后1年JOA评分及目测类比评分差异均有显著性意义(P < 0.05)。提示两术式即刻效果无差异,均取得良好的效果,此效果主要依赖于手术有效的减压。实验组中期效果明显优于乙组,主要是棘突间稳定系统Wallis发挥良好的生物学作用,有效缓解了患者残余的慢性下腰痛。 关键词：腰椎退变性疾病;椎管减压;棘突间稳定系统;硬组织植入物     

脊柱非融合U型棘突间钛合金材料植入治疗早期腰椎间盘突出伴

背景：脊柱非融合技术是目前对于早期脊柱疾病进行干预的新技术,可以在保护脊柱运动功能的同时达到治疗患者病情的效果。U型棘突间钛合金材料植入物属于后路棘突间非融合新技术范畴,此方面的研究将是非融合技术的一个热点。 目的：观察腰椎后路动态腰椎管狭窄运动保留的非融合U型棘突间钛合金材料植入物的临床力学性能。 设计、时间及地点：对比观察,病例来自2006-06/2007-12上海长海医院骨科。 对象：选择退变性椎间盘突出伴有动态椎管狭窄的患者28例,男23例,女5例,年龄41~58岁。 方法：根据患者自愿的方式随机分为2组,单纯椎间盘摘除减压组(n=20)：单纯椎间盘摘除减压术摘除责任节段椎间盘;材料植入物组(n=8)：先摘除责任节段椎间盘后去除棘突间韧带,将2个翼状突起夹在头尾端棘突上,然后在棘突间植入U型棘突间钛合金材料植入物。 主要观察指标：术后及随访测量责任节段的椎间隙高度保护度、椎管面积以及患者的腰椎JOA评分。 结果：28例退变性椎间盘突出伴有动态椎管狭窄患者均进入结果分析。材料植入物组植入U型钛合金材料后椎间隙高度保护度和平均椎管面积较单纯椎间盘摘除减压组明显增加(P < 0.05)。患者腰椎手术前后的JOA评分均有明显改善,但是采用非融合技术材料植入物组的改善程度明显优于常规单纯椎间盘摘除减压组(P < 0.05)。 结论：脊柱非融合U型棘突间钛合金材料植入物对于早期椎间盘突出伴有动态腰椎管狭窄患者的腰椎力学性能有很好的保护作用。     

全髋与半髋关节置换治疗老年股骨颈骨折的Meta分析

背景：目前全髋关节置换和半髋关节置换是治疗老年移位股骨颈骨折的有效方法,但两种方案的选择在临床治疗仍存争议。 目的：对全髋关节置换与半髋关节置换治疗老年股骨颈骨折的疗效进行系统评价。 方法：计算机检索Cochrane协作网数据库(2009年第1期)、MEDLINE(1966-01/2009-05)、EMbase(1984-01/2009-05)、中国生物医学文献数据库(CBM,1979-01/2009-05)、中文期刊全文数据库(1979-01/2009-05)。收集所有相关随机对照试验及半随机对照试验,并评价纳入研究的方法学质量。统计软件用Cochrane协作网提供的RevMan5.0.18。 结果与结论：共纳入7个随机对照临床试验,包括648例患者。Meta分析结果显示,全髋与半髋关节置换的病死率、感染率差异均无显著性意义;全髋关节置换术中出血量多、手术时间长(P < 0.001);远期随访全髋置换翻修率低于半髋置换(RR=0.28,95%CI=0.12~0.66,P=0.003);全髋置换后脱位发生率高于半髋置换(RR=3.45,95%CI=1.29~9.19,P=0.01);全髋置换后疼痛发生率低于少于半髋置换(RR=0.12,95%CI=0.05~0.30,P < 0.000 01);全髋置换活动功能优于半髋置换(RR=1.32,95%CI=1.04~1.68,P=0.02)。提示短期随访全髋置换与半髋置换后病死率、翻修率、关节功能、脱位率、疼痛及感染率无明显差异;中期随访全髋置换的脱位发生率高于半髋置换;远期随访全髋置换后活动功能优于半髋置换,且翻修率和疼痛发生率明显低于半髋置换。     

Prosthetic lumbar disc replacement for degenerative disc disease

Mechanical articulated device to replace intervertebral disc as a treatment for low back pain secondary to disc degeneration has emerged as a promising tool for selected patients. The potential advantages are prevention of adjacent segment degeneration, maintenance of mobility as well as avoidance of all the complications associated with fusion. The short-term results have been comparable to that of fusion, a few mid-term results have shown mixed outcome, but information on long-term results and performance are not available at present. The rationale for lumbar disc arthroplasty, indications, contraindications, the various artificial devices in the market and the concepts intrinsic to each of them, basic technique of insertion, complications are discussed and a brief summary of our experience with one of the devices is presented.     

Optic disc edema

Optic disc edema is the end result of many pathological processes, some relatively benign, some with devastating visual and neurological consequences. Differentiating among the various etiologies depends on a thorough history and complete examination with careful attention to the optic disc. Papilledema implies disc swelling due to elevated intracranial pressure, and can be distinguished from other causes of disc edema by clinical features. Congenitally anomalous optic discs may appear swollen, and proper recognition may spare patients unnecessary testing. The pathogenesis of disc swelling remains subject to debate, but the ultimate mechanism is backflow of axoplasmic transport. The treatment strategy for disc edema highly depends on the underlying etiology.     

Childhood intervertebral disc calcification

Two cases of intervertebral disc calcification in children are reported. A 13-year-old boy presented with right subscapular pain radiating into the axilla with radiographic demonstration of multiple calcified intervertebral discs and a herniated fragment of calcified nucleus pulposus at T2–3. His condition improved with conservative therapy, and follow-up radiographic evaluation revealed resolution of the herniated calcified disc material. A second case of multiple intervertebral disc calcifications was observed incidentally in an asymptomatic 6-year-old boy. The clinical presentation of this condition, its incidence, natural history, proposed etiologies, treatment options, and outcome are reviewed.     

Clinical outcomes of percutaneous plasma disc coagulation therapy for lumbar herniated disc diseases

Objective

This is prospective study of clinical outcomes of percutaneous plasma disc coagulation Therapy (PDCT) in patients with herniated lumbar disc disease (HLD) to evaluate the safety and efficacy in its clinical application and usefulness as a reliable alternative to microscopic discectomy.

Methods

Forty-six patients were enrolled in this study from April 2006 to June 2010. All patients had one-level HLD. Disc degeneration was graded on routine T2-weighted magnetic resonance Image (MRI) using the Pfirrmann''s grading system and all index levels were grade 3 and grade 4. Indications for surgery were radiculopathy caused by disc protrusion with soft consistency. MRI was done at one month after the procedure in all patients to check post-PDCT change. The clinical outcomes were evaluated using Visual Analog Scales (VAS) score and MacNab''s criteria.

Results

This study was approved by the Institutional Review Board of our institution. The age of the study population ranged from 16 to 59 years with a mean age of 37.2 years. There were 29 males and 17 females in this study. The mean period of clinical follow-up was 21 months. The average preoperative VAS score for radiculopathy was 7.4±1.4, while the final follow-up VAS score was 1.4±0.7 (p<0.001). In MacNab''s criteria, 41 patients (89.1%) had achieved favorable improvement (excellent and good) until later follow-up. There were one patient from infection and two patients who needed to convert to open discectomy.

Conclusion

PDCT is a safe and efficient treatment modality in a selective patient with HLD.     

Intervertebral disc calcification in children

Calcification of cervical intervertebral discs in children is due to an uncommon, but distinct, disease of unknown etiology. Signs and symptoms of nerve root or spinal cord compression are unusual and acute symptoms are followed by a benign course and spontaneous recovery. We describe a 5-year-old patient with symptomatic cervical disc calcification and discuss the relevant clinical and radiographic features.     

Drusen of the optic disc

Optic disc drusen are acellular calcific deposits occurring in small, crowded optic discs with abnormal vasculature. Evidence suggests axoplasmic transport alteration and axonal degeneration are involved in disc drusen formation. In affected patients, the number and size of disc drusen are highly variable, and the drusen may be visible near the disc surface or buried within the disc, causing them to appear as pseudopapilledema. B-scan echography is the most sensitive method for detecting disc drusen. Most patients with disc drusen are asymptomatic, but progressive visual field loss and vascular complications, including anterior ischemic optic neuropathy and choroidal neovascularization, may occur. Optic disc drusen have no established effective treatment. Diagnosing disc drusen correctly is important to avoid unnecessary work-up and to avoid overlooking potential serious conditions such as true papilledema. Disc drusen patients with more-than-expected visual field defects or progressive visual loss should have work-up to exclude other causes.