单平面和多平面截骨术治疗脊柱后凸的生物力学特征

目的探讨单平面截骨Dick钉固定和多平面截骨Luque棒固定治疗脊柱后的生物力学特点。方法12具新鲜小牛胸腰段脊柱标本（T8-L5）随机分成完整组（INT组），单平面截骨Dick钉固定组（Dick组）和多平面截骨Luque棒固定组（Luque组），每组4具。进行生理负荷下的前屈、后伸、左右侧弯、顺逆时针轴向旋转6种运动范围（ROM）的测试，记录载荷值的变化，对ROM值进行统计学分析。结果在生理负荷下，两种术式的脊柱标本的屈伸和侧弯运动的稳定性均达到或超过完整组标本，其中多平面截骨Luque棒固定组的稳定性更好；在轴向旋转稳定性上，两种术式的标本稳定性均不能达到完整组水平。结论实验中多平面截骨Luque棒固定的稳定性稍优于单平面截骨Dick钉固定组，但不足以构成临床应用中决定取舍的依据。     

计算机辅助单一斜形旋转截骨矫正股骨多平面畸形

[目的]介绍斜形单平面旋转截骨术矫正股骨多平面畸形的手术技术和初步临床效果。[方法]对1例股骨骨折畸形愈合患者行上述手术治疗。进行术前设计，确定截骨角度和旋转角度，在Mimics软件上模拟手术，3D打印制作截骨导板，对该病例行斜形单平面旋转截骨手术治疗。取股骨外侧纵行切口，显露畸形部位，安放截骨导板，按术前设计完成截骨、旋转，截骨断端用髓内钉固定，断端取髂骨植骨。[结果]手术过程顺利，术后无不良并发症，术后6个月复查，无跛行，膝关节无疼痛，CT证实骨断端完全愈合。[结论]斜形单平面旋转截骨术切实可行，一次截骨同时矫正股骨在冠状面、矢状面和旋转畸形，短期可取得满意的临床疗效。     

对“脊柱截骨术”一词的商榷

读了《中国脊柱脊髓杂志》1991第1期20页姜洪和医师发表的《多节段全脊椎截骨术矫正脊柱后凸畸形》[1]一文之后收益甚大,但对其所用之“全脊柱截骨术”一词有不同的见解,特提出与同道商榷。 自1945年Smith-Petersen[2]对强直性脊柱炎所致脊柱后凸畸形采用脊柱截骨术(spinalosteotomy)的治疗方法以来,在很长一段时期内把单纯的椎板截骨矫正强直性脊柱后凸圆背畸形称之谓“脊柱截骨术(spinal osteotomy)”。由于近10年来脊柱外科学的不断发展,脊柱截骨术也产生了新的分类方法,在解剖上大体分为椎弓截骨术、椎体截骨术和椎弓椎体联合截骨术。…     

多节段全脊椎楔形截骨术

多节段全脊椎楔形截骨术姜洪和，王长纯，高吉昌，商广友我科在沿用Ｓｍｉｔｈ－ｐｅｔｅｒｓｏｎ所设计的椎弓楔形截骨术矫正脊柱后凸这一术式的基础上，于１９８５年６月开始应用自行研制的脊柱截骨器械及新术式──多节段全脊椎楔形截骨术矫正脊柱后凸畸形，至１９９３...     

椎弓椎体楔形截骨治疗腰椎后凸伴不全瘫

目的　观察经椎弓椎体楔形截骨治疗L1～ 3 后凸畸形伴不全瘫的疗效。方法　经椎弓椎体楔形截骨 ,行椎弓根螺钉加短Luque棒或Dick钉内固定。结果　平均随访 18个月 ,后凸角平均纠正42°。Frankel评分进步 1～ 2级 ,截骨处愈合。结论　该方法治疗L1～ 3 后凸畸形伴不全瘫 ,效果良好 ,但手术时间长 ,出血量大 ,易出现脊髓及大血管损伤 ,宜掌握好适应证。     

脊柱后路内固定器治疗胸腰段非稳定性骨折疗效分析

自1987年以来使用Harrington棒、Luque棒、Dick钉及Dick钉加后路植骨四种方法治疗非稳定性胸腰段脊柱骨折96例.随访2～7年,四个治疗组对脊髓损伤治疗效果类似,在矫正脊柱矢状面后凸畸形方面术后短期内均能获得满意效果.但术后2年,三组单纯内固定对脊柱矢状面后凸矫正度均有显著丢失,仅Dick钉加后路植骨组有效控制了后凸矫正度的丢失(P<0.001).作者认为,坚强的后路内固定加充分植骨可达到生物性固定,这对稳定脊柱有重要意义.     

USS应用于脊柱后凸全脊柱截骨内固定31例

目的　研究USS椎弓根内固定系统应用于脊柱后凸畸形截骨矫治内固定的疗效。方法　根据后凸角度采用一次性多平面全脊椎截骨 ,应用USS椎弓根内固定系统固定 ,对后凸角度矫正率 ,截骨融合率 ,内固定结构稳定性进行随访统计。结果　 31例得到术后平均 12个月随访 ,术前脊柱后凸角平均 73°,术后后凸角平均 12° ,截骨融合率 96 77% ;后凸角矫正率为 83 5 6 % ;无一例发生断钉、断棒及联接结构松脱。结论　采用USS椎弓根内固定系统固定 ,增加了脊椎融合率 ,提高了后凸角矫正率 ,脊柱基本呈流线型恢复生理曲度 ;可早期离床活动 ,无须外固定。     

多平面脊椎截骨矫正脊柱后凸畸形并发脊椎滑脱（附6例报告）

本文介绍我院１９８５年５月～１９９３年５月应用多平面脊椎截骨矫正脊柱后凸畸形３７６例中６例脊椎滑脱，其中两例瘫痪。滑脱多发生在畸形重、截骨矫正度数大病例。强大挛缩腹肌及椎旁软组织牵拉力；截骨面不稳；内固定不牢及松脱是发生椎体滑脱的主要原因。为予防其发生，我们体会是（１）多平面截骨中单一平面矫正最好不超过３０°，两平面不超过６０°，过多残留畸形可二次手术。（２）注意截骨面与椎体垂直、左右对称，保留椎前１／４骨质，增强合拢骨面稳定。（３）强调妥善保护下背部逐渐缓慢加压合拢法。（４）采用坚强有效内固定，遇有滑移倾向者可采用椎板下钢丝鲁氏法或弓根钉装置等固定。（５）适当切除截骨面上下椎板内壁，扩大椎管容积，以防滑脱脊髓受压。     

胸腰椎骨折内固定取出后严重脊柱后凸的再次手术矫治

目的　总结胸腰椎骨折内固定取出后发生严重脊柱后凸畸形患者再次行脊椎截骨和椎弓根钉内固定治疗的经验。方法　对 4例患者脊椎后凸发生的原因、脊椎截骨和再次椎弓根内固定的方法、手术适应证等进行分析。结果　Cobb角由术前 72°矫正到术后 8° ,无并发症发生。经 12个月以上随访 ,后凸无复发。结论　椎弓根钉内固定取出时间过早和脊柱后路融合术失败是胸腰椎骨折术后发生严重脊柱后凸的主要原因 ;再次行脊椎截骨、椎弓根钉内固定矫治手术设计合理 ,安全可靠     

脊椎截骨术治疗驼背畸形45例报告

自１９９１～１９９３年应用脊椎骨截骨术治疗驼背畸形４５例，畸形矫正最小２０°，最大８０°（Ｃｏｂｂ法），截骨平面为１～３处不等。４４例达到驼背畸形基本矫正的满意效果，１例并发不全截瘫。文中介绍了手术的适应证，手术方法及术后处理。脊椎骨截骨术，截骨面从棘突、椎板、椎弓根到椎体，不易损伤脊髓和神经根，不波及软骨面处理问题，不导致前纵韧带断裂，椎体前方崩开，截骨面对合好，愈合快，脊柱三柱稳定     

Stabilizing potential of anterior cervical plates in multilevel corpectomies

STUDY DESIGN: An in vitro investigation of three-dimensional kinematics of cervical spine models of one- and three-level corpectomy with anterior plate fixation. OBJECTIVES: To evaluate the capability of an anterior plate to stabilize the reconstructed cervical spine under simulated physiologic motions, and to study the effects of fatigue loading. SUMMARY OF BACKGROUND DATA: Clinical studies have found high failure rates of multilevel anterior cervical plate fusions, indicating suboptimal stabilization. However, no biomechanical studies have been done to investigate the stabilizing capabilities of long-plate instrumentations in corpectomy models. METHODS: Seven fresh human cadaveric cervical spine specimens (C2-T1) were used. Flexibility tests consisted of flexion, extension, and bilateral torsion, and lateral bending, each with a pure moment of 0.25, 0.5, 0.75, and 1.0 Nm. Stabilizing potential indices [(MotionIntact-MotionInstrumented)/MotionIntact] for ranges of motion and neutral zones obtained from the flexibility tests, were measured when the specimen was intact and after one-level (C5) and three-level (C4, C5, and C6) corpectomies and anterior plate stabilizations). The stabilizing potential indices were re-measured after a 1000-cycle fatigue loading (1 Nm flexion and extension moments at C5 vertebra at 0.14 Hz). RESULTS: The differences in stabilizing potential indices of range of motion and neutral zone between one-level and three-level plates were not significant before fatigue. However, after fatigue, the stabilizing potential indices significantly decreased (P < 0.05) for the three-level model, but not for the one-level plate model. CONCLUSIONS: The capability of an anterior cervical plate to stabilize the spine after three-level corpectomy was significantly reduced with fatigue loading.     

A comparative biomechanical study of spinal fixation using the combination spinal rod-plate and transpedicular screw fixation system

A biomechanical study was performed comparing the stiffness and stability of the three-level combination spinal rod-plate and transpedicular screw (CSRP-TPS) fixation system with those of three anterior stabilization constructs that spanned three vertebral levels: iliac strut grafting, polymethylmethacrylate and anterior Harrington rod instrumentation (technique of Siegal et al.), and the Kaneda anterior device. The CSRP-TPS fixation system was also compared with five posterior instrumentation systems that spanned five vertebral levels: Harrington distraction rod instrumentation, segmentally wired Luque rectangular instrumentation, Cotrel-Dubousset transpedicular instrumentation. Steffee transpedicular screws and plates, and R. Roy-Camille plates under conditions of single-level instability. The relative stability of each instrumentation system was compared by mounting the fixation systems on calf spine segments containing five motion segments destabilized by complete L3 anterior corpectomies and L2-L3 and L3-L4 anterior diskectomies to simulate the two-column instability found clinically in spine fractures. Mechanical nondestructive cyclical testing in rotation, axial compression, and flexion was performed on 12 spines. All biomechanical tests were performed on a biaxial servo-controlled MTS 858 Bionix hydraulic materials testing device with a biaxial load cell. Intervertebral displacements between L2 and L4 were continuously recorded utilizing an extensometer with the knife edges placed directly adjacent to the L3 corpectomy defect during testing. This biomechanical study showed that CSRP-TPS instrumentation spanning three vertebral levels could restore the torsional, compressive, and flexural rigidity of the destabilized calf spines to that of the intact calf spines and provided more in vitro stability than either the traditional five-level Harrington distraction rod or the segmentally wired Luque rectangular instrumentation. The greatest torsional rigidity occurred with the five-level Cotrel-Dubousset instrumentation, the five-level Steffee plate and screw system, and the three-level Kaneda anterior device. In axial compression and flexural testing, the three-level CSRP-TPS system provided fixation comparable with the five-level Cotrel-Dubousset instrumentation, the five-level Steffee transpedicular screw and plate system, the five-level R. Roy-Camille plate and screw system, and the three-level Kaneda anterior device. Satisfactory levels of rigidity can be restored by three-level CSRP-TPS instrumentation under conditions of single-level instability in unstable thoracolumbar and lumbar spine fractures.     

The role of bone graft force in stabilizing the multilevel anterior cervical spine plate system

STUDY DESIGN: The role of bone graft force in stabilizing an instrumented cervical spine was evaluated for one-level and three-level corpectomy models using in vitro experiments. OBJECTIVES: To investigate the role of bone graft force in enhancing stability of anterior cervical plate, and to study effects of fatigue loading. SUMMARY OF BACKGROUND DATA: The anterior cervical plate system is used widely in stabilizing the cervical spine after spinal corpectomy and grafting. Many factors such as applied screw torque, screw pullout force, plate strength, plate geometry, and type of bone graft have been studied. However, the role of bone graft in stabilizing the anterior plate system has not been explored. METHODS: Two models (one-level and three-level) incorporating corpectomy, strut graft, and anterior plate were constructed from eight human spine specimens (C2-T1). The flexibility of an intact specimen and two constructs with graft forces of 0 N and 100 N was determined. A flexibility test, simulating physiologic loads, consisted of pure moments of flexion, extension, lateral bending, and axial torques up to 1 Nm. For each moment, range of motion and neutral zone were determined. The stability potential index was defined as the decrease in motion caused by instrumentation, as compared with intact motion. A larger stability potential index indicates a more stable spinal construct. Repeated measures analysis of variance was used to determine the significant changes. RESULTS: In both models, bone graft force increased during extension, decreased during flexion, and showed minor changes during axial torsion and lateral bending. Higher bone graft force increased stability potential index-neutral zone and stability potential index-range of motion in the three-level model in all directions, but only in flexion-extension in the one-level model. Fatigue loading decreased bone graft force to a greater extent in the three-level model. CONCLUSIONS: In the corpectomy-graft-anterior-plate model, graft force decreased in flexion and increased in extension. Higher graft force increased and fatigue decreased stability of the spinal construct in the three-level model.     

Loosening at the screw-vertebra junction in multilevel anterior cervical plate constructs

STUDY DESIGN: An in vitro biomechanical study of one-level and three-level corpectomy and anterior cervical plate models. OBJECTIVE: To investigate the failure of the screw-vertebra interfaces in one- and three-level corpectomy models. SUMMARY AND BACKGROUND DATA: Although there are several biomechanical studies of strength and stability of anterior cervical plating, there has been no investigation into clinically observed failures. METHODS: One- and three-level models (corpectomy, strut graft, and anterior plate) were constructed from eight cadaveric specimens (C2-T1). Multidirectional flexibility tests (1.0 Nm moments) performed before and after fatigue (1000 cycles, 1.0 Nm flexion-extension, 0.14 Hz) documented the screw-vertebra motions at upper and lower ends. Ranges of motion and neutral zones were determined. Analysis of variance was used to evaluate significant differences between the upper and lower ends of the plates and changes caused by fatigue loading (P < 0.05). RESULTS: Extension motion at the lower ends was more than at the upper ends in both models. Fatigue increased three-level model ranges of motion at the lower end by 171% in flexion, 164% in extension, 153% in lateral bending, and 115% in axial rotation. Similar increases were observed in neutral zones. Fatigue loading produced no significant changes in one-level models. CONCLUSION: There was excessive screw-vertebra motion caused by fatigue at the lower end of the three-level corpectomy model. These findings of loosening may explain clinically observed failures at the caudal end of long anterior cervical plate constructs. Longer screws, larger diameter screws, and supplemental posterior fixation may decrease screw-vertebra loosening.     

Complications of buttress plate stabilization of cervical corpectomy

STUDY DESIGN: A retrospective analysis of 14 patients treated with cervical corpectomy and buttress plate fixation. OBJECTIVES: To determine the complications of buttress plate fixation following multilevel cervical corpectomies. SUMMARY OF BACKGROUND DATA: Buttress plate fixation of multilevel cervical corpectomy has recently been reported. Biomechanical data suggests that it is preferable to long plates spanning the entire corpectomy site. There are no clinical studies that have specifically addressed the complications of this type of plate fixation. METHODS: The records and radiographs of all patients who had undergone cervical buttress plate fixation following anterior cervical corpectomy for myelopathy were independently reviewed. Twelve of the patients had three-level corpectomies and two had two-level corpectomies. All patients had placement of a short plate at the inferior end of the construct with sufficient overhang to act as a buttress against graft extrusion. Three patients underwent posterior cervical fusion in addition to the anterior procedure. RESULTS: Graft extrusion. One patient had complete graft extrusion on the third post-operative night. A second patient who had undergone circumferential fusion had minimal plate dislodgement secondary to graft settling. Pseudarthrosis. Three patients had pseudarthroses. Two of these required revision posterior surgery. Neurologic. None of the patients suffered neurologic complications. With the exception of the one patient who died, the rest of the patients all improved by at least one Nurick grade. CONCLUSION: The most catastrophic complication in the present series was plate dislodgement causing airway compromise and eventually resulting in death. Surgeons who utilize these types of buttress plates without additional posterior instrumentation should be aware of the potential complications of buttress plate fixation.     

Anterior cervical allograft arthrodesis and instrumentation: Multilevel interbody grafting or strut graft reconstruction

This retrospective study evaluated a single surgeon's series of patients treated by multilevel cervical disc excision (two or three levels), allograft tricortical iliac crest arthrodesis, and anterior instrumentation. The objective of this retrospective study was to compare fusion success and clinical outcome between multilevel Smith-Robinson interbody grafting and tricortical iliac strut graft reconstruction, both supplemented with anterior instrumentation in the cervical spine. The incidence of nonunion for cervical discectomy and fusion varies widely depending on the number of disc levels involved, type of bone graft used, and whether the anterior grafting is supplemented with instrumentation. An alternative to multilevel interbody fusion is corpectomy and strut grafting, in which the incidence of nonunion has been reported to be 27% with autograft and 41% with allograft. Sixty-four consecutive patients who underwent allograft tricortical iliac crest reconstruction and anterior cervical plating were studied. The average follow-up was 39 months. There were 38 patients in the discectomy and interbody grafting group and 26 patients in the corpectomy and strut graft reconstruction group. Pseudoarthrosis occurred in 42% of the anterior cervical interbody fusion patients and 31% of the corpectomy patients. Nonunion in two-level interbody fusions occurred in 36% of the patients as compared to 10% for patients with one-level corpectomies; while 54% of patients with three-level interbody fusions and 44% of patients with two-level corpectomies were noted to have pseudoarthrosis. Higher percentages of nonunion were noted in multilevel interbody grafting than in corpectomy with strut grafting and when more vertebral levels were involved. These radiographic and clinical findings underscore the shortcomings of multilevel anterior cervical allograft reconstruction with plating. Corpectomy may be the preferred method when multiple disc levels are fused. In addition, anterior corpectomy affords decompression of significant osteophytes in a safer and quicker manner. In retrospective studies, there is a need for long-term follow-up before accurate statements can be made about the study population.     

The management of one-level anterior cervical corpectomy with fusion using Atlantis hybrid plates: preliminary experience

To limit high pseudarthrosis rates encountered after cervical procedures for adjacent two-level disease, one-level anterior corpectomy with fusion was performed using the newly available Atlantis hybrid plates (fixed screws placed superiorly and variable screws placed inferiorly). Eight one-level anterior corpectomies with fusion were performed using iliac autografts and Atlantis hybrid plates. Nurick and Medical Outcomes Trust Short Form 36 scores were recorded before operation (Nurick grade 2.3) and 6 months after operation. Fusion status was followed an average of 9 months (range, 8 to 11 months). Fusion was confirmed an average of 6 months after operation in seven patients, when the mean Nurick grade was 0.2 and all had improved on the eight Medical Outcomes Trust Short Form 36 health scales. Atlantis plates contributed to successful fusion in seven of eight patients undergoing one-level anterior corpectomy with fusion using Atlantis hybrid plates.     

一种新型植骨重建钛网的初步临床应用

目的评价新型植骨重建钛网在颈前路椎体次全切除减压植骨融合术中的临床应用及疗效。方法采用颈前路椎体次全切除减压、新型钛网植骨融合术治疗颈椎退行性疾病患者53例,其中男38例,女15例,年龄39～76岁,平均49.7岁。手术方式包括单节段椎体次全切除22例,单节段椎体次全切除联合椎间盘切除减压28例,双节段椎体次全切除3例。术后定期随访颈椎X线片,比较术后椎间高度及颈椎生理曲度变化。采用日本骨科学会的JOA评分系统进行神经功能评价。结果单节段手术患者椎间高度从术前22.3mm±0.8mm增加至术后24.5mm±0.6mm,双节段手术患者椎间高度从术前平均42.3mm增加至术后平均45.7mm,6个月随访两者均无明显丢失。单节段手术患者颈椎曲度从术前8.2°±1.4°增加至术后14.5°±1.6°,但双节段手术患者颈椎曲度术前平均6.3°,术后平均仅为7.0°,6个月随访两者均无明显丢失。全部患者临床神经功能均有改善,JOA评分从术前8.4±0.5分提高至术后12.2±0.4分,6个月随访提高至14.5±0.3分。结论新型钛网的外形设计更符合颈椎椎体终板形态学特点,可有效避免术后钛网沉陷,临床应用单节段手术能够较好的重建颈椎椎间高度和生理曲度,而双节段手术由于该新型钛网设计的不足之处对于颈椎生理曲度的重建作用有限,有待进一步改进。