Anterior versus posterior procedure for surgical treatment of thoracolumbar tuberculosis: A retrospective analysis

Background:

Approach for surgical treatment of thoracolumbar tuberculosis has been controversial. The aim of present study is to compare the clinical, radiological and functional outcome of anterior versus posterior debridement and spinal fixation for the surgical treatment of thoracic and thoracolumbar tuberculosis.

Materials and Methods:

70 patients with spinal tuberculosis treated surgically between Jan 2001 and Dec 2006 were included in the study. Thirty four patients (group I) with mean age 34.9 years underwent anterior debridement, decompression and instrumentation by anterior transthoracic, transpleural and/or retroperitoneal diaphragm cutting approach. Thirty six patients (group II) with mean age of 33.6 years were operated by posterolateral (extracavitary) decompression and posterior instrumentation. Various parameters like blood loss, surgical time, levels of instrumentation, neurological recovery, and kyphosis improvement were compared. Fusion assessment was done as per Bridwell criteria. Functional outcome was assessed using Prolo scale. Mean followup was 26 months.

Results:

Mean surgical time in group I was 5 h 10 min versus 4 h 50 min in group II (P>0.05). Average blood loss in group I was 900 ml compared to 1100 ml in group II (P>0.05). In group I, the percentage immediate correction in kyphosis was 52.27% versus 72.80% in group II. Satisfactory bony fusion (grades I and II) was seen in 100% patients in group I versus 97.22% in group II. Three patients in group I needed prolonged immediate postoperative ICU support compared to one in group II. Injury to lung parenchyma was seen in one patient in group I while the anterior procedure had to be abandoned in one case due to pleural adhesions. Functional outcome (Prolo scale) in group II was good in 94.4% patients compared to 88.23% patients in group I.

Conclusion:

Though the anterior approach is an equally good method for debridement and stabilization, kyphus correction is better with posterior instrumentation and the posterior approach is associated with less morbidity and complications.     

The results of anterior fusion and Cotrel-Dubousset-Hopf instrumentation in idiopathic scoliosis

Anterior instrumentation for the correction of scoliotic curves has recently been gaining in popularity. The problems of high mortality and morbidity that were associated with the employment of anterior instrumentation in the first years it was used have now been overcome. Efforts are now being concentrated on increasing the correction rates in the frontal plane and decreasing the kyphotic effect in the sagittal plane. The anterior Cotrel-Dubousset-Hopf (CDH) system is a recently developed instrumentation that has been claimed to decrease the kyphotic effect through the use of double rods. This study aimed to investigate the impact of the anterior CDH system on idiopathic scoliotic curves in frontal and sagittal planes. To this end, 26 idiopathic scoliosis patients treated with the CDH system were followed for a mean period of 32.8 ± 5.3 months. In the frontal plane, Cobb angles of major and secondary curves were measured, and postoperative and final correction rates determined. In the sagittal plane, sagittal contours of both the instrumented region and the thoracic and lumbar regions were measured, and their preoperative, postoperative and final control values were determined. In addition to clinical examination, lateral trunk shift (LT), shift of head (SH) and shift of stable vertebra (SS) were measured in vertebral units (VU), on the preoperative and postoperative radiographs in order to evaluate the effect of the system on trunk balance. It was established that in patients with single flexible thoracolumbar and lumbar curves and those with rigid thoracic curves, the correction rates obtained in the frontal plane were respectively 79.4 ± 14.8%, 68.0 ± 9.4% and 61.5 ± 8.0%, with statistical significance. Their final corrections at the last control were 76.3 ± 17.4%, 56.9 ± 9.1% and 52.3 ± 8.3%, respectively. Although the corrections in the lumbar rigid curves were relatively low, they were still statistically significant. Taking all the patients together, the mean preoperative Cobb angle of the major curves of 67.2°± 20.2° improved to a mean of 28.6°± 21.0°, which was a statistically significant difference (P < 0.05), giving a mean correction rate of 61.2 ± 20.3%. The mean correction loss of major curves in the frontal plane in all patients was 6.0°± 3.8° and the mean final correction rate was 52.6 ± 23.2%. In the sagittal plane, there was a favorable kyphotic effect on the thoracic region of patients with hypokyphosis and lordosis pattern, whilst in patients with kyphotic pattern, this effect was minimal. In patients with a single flexible lumbar curve, kyphotic effect was not observed except in two patients. In these two patients, it was thought that excessive compression force may have been used. As to the patients with a rigid lumbar curve, there was a slight decrease in lumbar lordosis. No postoperative complaints were made about imbalance, and the mean overall correction in LT values was 60.1 ± 21.7%. While preoperatively, the SH and SS values of all patients were over 0.5 VU, postoperatively, 12 patients (46.2%) were completely balanced (SH = 0 VU, SS = 0 VU) and 8 patients (30.8%) were balanced (0 VU < SH and SS < 0.5 VU). The remaining six patients, whose balance values were corrected with statistical significance but were still over 0.5 VU, were found to be the ones with rigid lumbar curves. Implant failure and systemic complications were not noted in the follow-up period. In view of these findings, it was determined that CDH instrumentation achieves significant correction rates in the frontal and sagittal planes, particularly in single flexible lumbar, thoracolumbar and thoracic rigid curves. It was found that the kyphotic effect was minimized with a double rod system. Significant clinical and radiological corrections were achieved in balance values, without any imbalance and decompensation problems. Received: 27 April 1999 Revised: 13 April 2000 Accepted: 2 May 2000     

一期前路病灶清除植骨融合结合后路内固定术治疗胸腰椎结核疗效分析

目的 探讨一期前路病灶清除植骨融合加后路内固定术治疗胸腰椎结核的可行性及疗效.方法 回顾性分析自2009-01-2011-06诊治的30例胸腰椎结核,术前正规抗结核治疗后行一期前路病灶清除植骨融合加后路内固定术.观察其手术时间、术中出血量、住院时间、植骨融合情况及手术前后的ASIA分级、Cobb角、血沉及CRP变化情况.结果 手术时间(229.8±32.1)min,术中出血量(707.3±75.6)ml,住院时间(24.2±5.5)d.30例获得随访4～36个月,平均18个月,无严重的并发症发生.结论 一期前路病灶清除植骨融合加后路内定固定术治疗脊柱结核疗效满意,尤其在矫正后凸畸形、防止术后Cobb角的丢失、恢复脊柱的生物力学稳定性方面更有优势.     

Anterior debridement,decompression, bone grafting,and instrumentation for lower cervical spine tuberculosis

Background contextCervical spine tuberculosis (TB) is uncommon, accounting for 3% to 5% of spinal TB. Although the development of anti-TB chemotherapy decreases the mortality rate significantly, it may not be applicable for all situations, especially for those with risk of instability, progression of neurologic deficit, and failure of medical treatment.PurposeTo evaluate the efficacy of anterior instrumentation after debridement and bone grafting in patients with lower cervical TB over a 5-year period at a single institution.Study designA retrospective study examining the results of anterior debridement, decompression, bone grafting, and instrumentation for lower cervical spine TB.Patient sampleThe procedure was performed in 25 patients.Outcome measuresThe clinical outcomes of infection activity, deformity, pain, and neurologic function were evaluated using erythrocyte sedimentation rate value and C-reactive protein value, kyphotic angle, visual analog scale pain score, and Frankel grade, respectively.MethodsBetween 2005 and 2010, 25 patients (18 males and seven females; average age, 39 years) with lower cervical spine tuberculosis (C3–C7) underwent anterior debridement, decompression, bone grafting, and instrumentation. The average follow-up period was 37.4 months (range 24–57 months). The medical records and radiographic findings of the patients were reviewed.ResultsThere were three patients who had involvement of one vertebra, 18 had two vertebrae of involvement, and four had three vertebrae of involvement. Before surgery, there were three patients with Frankel grade B, five with grade C, 12 with grade D, and five with grade E. During the last follow-up examination, in 20 patients with neurological deficit, 11 patients improved one grade, six patients improved two grades, one patient improved three grades, and the neurologic status remained unchanged in two patients. Stable bone union was observed in all cases and the average time required for fusion was 6.8 months. The kyphosis Cobb angle improved from the preoperative average of 15.48° (range 0°–55°) to a postoperative average of ?4.8° (range ?12° to 4°) and there was no significant correction loss during the follow-up period. During the follow-up period, there were no grafts or instrumentation-related stabilization problems. There was no other recurrence of TB infection.ConclusionsAnterior debridement, decompression, bone grafting, and instrumentation are safe and effective methods in the surgical management of lower cervical spine tuberculosis.     

Biomechanical study of anterior spinal instrumentation configurations

The biomechanical impact of the surgical instrumentation configuration for spine surgery is hard to evaluate by the surgeons in pre-operative situation. This study was performed to evaluate different configurations of the anterior instrumentation of the spine, with simulated post-operative conditions, to recommend configurations to the surgeons. Four biomechanical parameters of the anterior instrumentation with simulated post-operative conditions have been studied. They were the screw diameter (5.5–7.5 mm) and its angle (0°–22.5°), the bone grip of the screw (mono–bi cortical) and the amount of instrumented levels (5–8). Eight configurations were tested using an experimental plan with instrumented synthetic spinal models. A follower load was applied and the models were loaded in flexion, torsion and lateral bending. At 5 Nm, average final stiffness was greater in flexion (0.92 Nm/°) than in lateral bending (0.56 Nm/°) and than in torsion (0.26 Nm/°). The screw angle was the parameter influencing the most the final stiffness and the coupling behaviors. It has a significant effect (p ≤ 0.05) on increasing the final stiffness for a 22.5° screw angle in flexion and for a coronal screw angle (0°) in lateral bending. The bi-cortical bone grip of the screw significantly increased the initial stiffness in flexion and lateral bending. Mathematical models representing the behavior of an instrumented spinal model have been used to identify optimal instrumentation configurations. A variation of the angle of the screw from 22.5° to 0° gave a global final stiffness diminution of 13% and a global coupling diminution of 40%. The screw angle was the most important parameter affecting the stiffness and the coupling of the instrumented spine with simulated post-operative conditions. Information about the effect of four different biomechanical parameters will be helpful in preoperative situations to guide surgeons in their clinical choices.     

一期后路椎弓根螺钉固定联合前路经腹膜后病灶清除治疗腰骶段脊柱结核

目的:探讨一期后路椎弓根螺钉固定联合前路经腹膜后病灶清除治疗腰骶段脊柱结核的疗效。方法:2012年10月~2015年3月共收治12例腰骶段脊柱结核患者,其中男9例,女3例;年龄24~77岁(43.9±18.4岁);病变节段位于L4~S1。术前抗结核药物治疗2~4周,血沉下降及结核中毒症状改善后,行手术治疗。均为一期后前路手术,即后路微创置入椎弓根螺钉内固定系统后,前路经腹旁正中腹膜后入路行结核病灶清除植骨融合术。术后继续系统抗结核治疗12~18个月。记录手术时间、术中出血量、手术入路相关并发症、植骨融合情况,比较术前、术后疼痛视觉模拟评分(VAS)、美国脊髓损伤协会(ASIA)分级、红细胞沉降率(ESR)、腰椎局部前凸角(local lordotic angle,LLA)。结果:12例患者均顺利完成手术,术中切除的病灶组织行病理检查,均符合结核改变。手术时间165~380min(268.8±76.7min);出血量160~2500ml(627.5±640.3ml)。共有3例手术相关并发症,均发生于前路手术时,1例为静脉丛撕破,经压迫后止血;2例腹膜撕裂,术中进行修补。随访12~48个月(31.1±9.8个月),12例均获骨性融合,无结核复发征象,无内固定松动、断裂征象。8例术前神经功能损害者术后有不同程度的恢复。术前VAS评分为7.1±1.1分,末次随访时为2.1±1.0分;术前ESR为65.8±29.9mm/h,末次随访时为15.1±8.5mm/h;VAS和ESR均较术前显著降低(P0.05)。术前LLA为3.0°±8.3°,术后即刻矫正为11.0°±6.0°,末次随访时为10.4°±5.9°;与术前相比较,术后即刻LLA显著改善(P0.05),末次随访时LLA无明显丢失。结论:一期后路椎弓根螺钉固定联合前路经腹膜后病灶清除治疗腰骶段脊柱结核,可以显著矫正脊柱畸形并获得满意的临床疗效,但前路经腹膜后入路存在一定的并发症发生率,需谨慎操作。     

经脊柱前路病灶清除植骨一期前路内固定术治疗脊柱结核

目的探讨经前路病灶清除植骨一期前路内固定术治疗脊柱结核的临床疗效及经验。方法对123例脊柱结核患者,男71例,女52例;年龄20～86岁,平均39岁。经3～4周正规抗痨治疗后行病变椎体次全切除(或全切除)及周边脓肿、死骨、肉芽组织及干酪样物等结核病灶清除,椎间大块髂骨植骨,一期前路内固定术,术后继续抗结核治疗1～1.5年。结果123例术后除2例死亡外121例获随访8个月～5年,平均21个月。2例脊柱结核复发。9例植骨未愈合(包括感染、复发、死亡病例),植骨融合率为92.7%,植骨愈合时间3～8个月,平均5个月。脊柱后凸畸形较术前平均矫正70.1%,脊柱高度较术前增高15～30mm,平均19mm。94例有椎管狭窄者患椎椎管狭窄率较术前减少65.4%。术后并发手术切口感染形成慢性窦道、脊柱侧凸、内固定钢板松动各2例,气胸肺不张3例,并发ARDS、急性心肌梗死死亡各1例。其中34例多节段脊柱结核和10例既往术后结核复发者全部治愈,除前者1例植骨未愈合外,其余植骨全部融合。26例截瘫患者肢体神经功能术前FrankA级5例、B级11例、C级10例;术后FrankA级3例、B级3例、C级2例、D级8例、E级10例。结论经前路病灶清除植骨一期前路内固定术治疗脊柱结核能彻底清除结核病灶,对脊髓及神经根彻底进行减压,促进脊髓及神经功能恢复,矫正脊柱后凸畸形,同时一期建立和恢复脊柱的连续性和稳定性,促进脊柱植骨融合,提高了脊柱结核的治愈率。     

Anterior dual rod instrumentation in idiopathic thoracic scoliosis

For anterior correction and instrumentation of thoracic curves single rod techniques are widely used. Disadvantages of this technique include screw pullouts, rod fractures and limited control of kyphosis. This is a prospective study of 23 consecutive patients with idiopathic thoracic scoliosis treated with a new anterior dual rod system. Aim of the study was to evaluate the safety and efficacy of this new technique in the surgical treatment of idiopathic thoracic scoliosis. To the best knowledge of the authors, this is the largest series on dual rod dual screw instrumentation over the entire fusion length in thoracic scoliosis. Twenty-three patients with an average age of 15 years were surgically treated with a new anterior dual rod system through a standard open double thoracotomy approach. Average clinical and radiological follow-up was 28 months (24–46 months). Fusion was carried out mostly from end-to-end vertebra. The primary curve was corrected from 66.6° to 28.3° (57.5% correction) with an average loss of correction of 2.0° at Cobb levels and of 1.3° at fusion levels. Spontaneous correction of the secondary lumbar curve averaged 43.2% (preoperative Cobb angle 41.2°). The apical vertebral rotation was corrected by 41.1% with a consecutive correction of the rib hump of clinically 66.7%. The thoracic kyphosis measured 29.2° preoperatively and 33.6° at follow-up. In seven patients with a preoperative hyperkyphosis of on average 47.3° thoracic kyphosis was corrected to 41.0°. This new instrumentation enables an entire dual rod instrumentation over the whole thoracic fusion length. It offers primary stability without the need of postoperative bracing. Dual screw dual rod instrumentation offers the advantages of a high screw pullout resistance, an increased overall stability and satisfactory sagittal plane control.     

Follow-up of 146 spinal tuberculosis patients operated through an anterior approach

Summary From 1978 to 1995, 146 patients with spine tuberculosis were operated through an anterior approach. The mean age of the patients was 42, ranging from 18 to 74. Preoperative neurological deficit was present in 26% of cases. Paraplegia was present in 9 cases and paresis in 29 cases. The TB process was localized in cervical 2%, thoracic 64%, thoracolumbar 15%, lumbar 17% and lumbosacral in 2%. In 96% of the cases two vertebrae were affected with kyphosis and angulation (20–40° in 40%, 40–50° in 36% and over 50° in 24%). All patients had angulation and collapse of vertebral body more than a 1/4 of its height. There are no anamnestic data about smokers and non-smokers. Surgery consisted of anterior approach (thoracotomy, thoracophrenolumbotomy, lumbotomy), excision of the focus, decompression of spinal canal, solid interbody fusion with autogenous grafts (rib autograft in 62%, iliac crest in 18%, vascularised rib in 16%and fibula in 4%) and biopsy. All patients with neurological deficit improved after this type of treatment. Follow-up was possible in 110 patients. On follow-up after completion of treatment-operation, cast and drug, during 8 months none of the patients showed recurrence of disease, increase of deformity or any neurological deficit. Follow-up period was from 14 months up to 9 years. The authors believe that the anterior approach offers several advantages: wide exposure of the lesion, excellent opportunity for decompression and adequate solid body fusion with autografts.     

One-stage anterior debridement,bone grafting and posterior instrumentation vs. single posterior debridement,bone grafting,and instrumentation for the treatment of thoracic and lumbar spinal tuberculosis

Purpose

The aim of this study was to compare single posterior debridement, interbody fusion and instrumentation with one-stage anterior debridement, interbody fusion and posterior instrumentation for treating thoracic and lumbar spinal tuberculosis.

Method

From January 2006 to January 2010, we enrolled 115 spinal tuberculosis patients with obvious surgical indications. Overall, 55 patients had vertebral body destruction, accompanied by a flow injection abscess or a unilateral abscess volume greater than 500 ml. The patients underwent one-staged anterior debridement, bone grafting and posterior instrumentation (group A) or single posterior debridement, bone grafting and instrumentation (group B). Clinical and radiographic results for the two groups were analyzed and compared.

Results

Patients were followed 12–36 months (mean 21.3 months), Fusion occurred at 4–12 months (mean 7.8 months). There were significant differences between groups regarding the post-operative kyphosis angle, angle correction and angle correction rate, especially if pathology is present in thoracolumbar and lumbar regions. Operative complications affected five patients in group A, and one patient in group B. A unilateral psoas abscess was observed in three patients 12 months postoperatively. In one of them, interbody fusion did not occur, and there was fixation loosening and interbody absorption. All of them were cured by an anterior operation.

Conclusion

Anterior debridement and bone grafting with posterior instrumentation may not be the best choice for treating patients with spinal tuberculosis. Single posterior debridement/bone grafting/instrumentation for single-segment of thoracic or lumbar spine tuberculosis produced good clinical results, except in patients who had a psoas abscess.     

前路病灶清除植骨融合内固定治疗颈椎结核

目的 探讨前路病灶清除植骨融合内固定治疗颈椎结核的临床疗效.方法 采用前路病灶清除自体髂骨植骨融合内固定治疗18例颈椎结核患者.记录并发症情况.比较手术前后疼痛VAS评分、JOA评分.采用ECK融合分级标准评价植骨融合情况并观察颈椎融合节段高度.结果 患者均获得随访,时间12～38个月.围手术期无食管损伤、深静脉血栓等...     

一期前后路联合手术治疗下腰椎结核

[目的]评价一期前路经腹直肌旁腹膜后入路行病灶清除、自体髂骨植骨融合、后路椎弓根螺钉短节段固定融合治疗下腰椎单节段结核的手术疗效。[方法]2002年6月~2007年1月,本组采用该术式治疗下腰椎单节段结核27例。[结果]手术时间平均4.3 h,手术平均出血量438 ml。前路手术切口长度5~7 cm,前路显露时间平均21min,显露过程平均出血量48 ml。术后随访12~37个月,术前病变节段前凸角-2.1°±4.0°,术后4.9°±1.4°,最后随访时3.7°±3.0°。所有病例全部治愈,未发生结核复发,植骨融合率100%。[结论]前路经腹直肌旁腹膜后入路可满意显露病灶、操作简便、创伤小。后路椎弓根螺钉短节段固定融合使脊柱达到即刻稳定的同时减少正常运动节段的牺牲。该术式是治疗下腰椎结核安全、有效的方法。     

后路经椎弓根入路病灶清除椎弓根固定术治疗胸腰椎结核的疗效分析

背景：脊柱结核多采用前路病灶清除植骨融合手术,而后路经椎弓根入路行病灶清除的手术疗效少见报道。目的：探讨经后路椎弓根入路病灶清除和椎弓根固定治疗胸腰椎结核的疗效。方法：2006年1月至2010年12月采用后路经椎弓根入路病灶清除和椎弓根固定治疗胸腰椎结核16例,男11例,女5例,年龄19～80岁,平均47．2岁。病程6～11个月。根据结核破坏程度及手术对脊柱稳定性的影响,所有患者均采用一期后路椎弓根系统内固定。结果：16例患者切口均一期愈合,无慢性窦道形成。所有患者均获随访,随访时间11～58个月,平均37．6个月。术后脊柱结核均治愈,未出现复发病例。腰背疼痛VAS评分由术前平均8．0改善到术后2．2（F=17．6,P〈0．05）。后凸畸形由术前平均18．7。改善到术后12．5°（F=94．5,P〈0．05）。术后6个月植骨块骨性融合,未出现植骨块脱出、吸收。随访至植骨块融合时,角度丢失0°-8°,平均3．1O°结论：后路经椎弓根入路病灶清除和椎弓根固定术治疗胸腰椎结核能够达到有效清除病灶并且纠正脊柱畸形的目的。     

Anterior instrumentation for the treatment of pyogenic vertebral osteomyelitis of thoracic and lumbar spine

Anterior radical debridement and bone grafting is popular in the treatment of pyogenic infection of the spine, but there remains great concern of placing instrumentation in the presence of infection because of the potentiality of infection recurrence after surgery. The objective of this study was to prospectively evaluate the efficacy and safety of anterior instrumentation in patients who underwent simultaneous anterior debridement and autogenous bone grafting for the treatment of pyogenic vertebral osteomyelitis. The series consisted of 22 consecutive patients who were treated with anterior debridement, interbody fusion with autogenous bone grafting and anterior instrumentation for pyogenic vertebral osteomyelitis of thoracic and lumbar spine. The patients were prospectively followed up for a minimum of 3 years (average 46.1 months; range 36–74 months). Data were obtained for assessing clinically the neurological function and pain and radiologically the spinal alignment and fusion progress as well as recurrence of the infection. All the patients experienced complete or significant relief of back pain with rapid improvement of neurological function. Kyphosis was improved with an average correction rate of 93.1% (range 84–100%). Solid fusion and healing of the infection was achieved in all the patients without any evidence of recurrent or residual infection. The study shows that combined with perioperative antibiotic regimen, anterior instrumentation is effective and safe in the treatment of pyogenic vertebral osteomyelitis of thoracic and lumbar spine directly following radical debridement and autogenous bone grafting.     

Is there a role for selective anterior instrumentation in neuromuscular scoliosis?

Our objective was to report on the clinical and radiological outcome from a cohort of patients with neuromuscular scoliosis who underwent selective anterior single rod instrumentation for correction of thoraco-lumbar and lumbar scoliosis. Traditionally combined anterior release with long posterior instrumentation has been advocated for the treatment of neuromuscular scoliosis. Neuromuscular curves tend to be long and may have significant pelvic obliquity. However, certain neuromuscular curves with minimal pelvic obliquity may lend themselves to selective anterior correction thereby saving motion segments and allow continued ambulation for those patients. Nine patients with neuromuscular scoliosis underwent selective anterior instrumentation between 1994 and 2000. The mean follow up was 2 years and 9 months (range 24–55 months). The clinical outcome (including parent and caregiver satisfaction), radiological outcome (Cobb angle, apical vertebral translation, pelvic obliquity, truncal shift, thoracic kyphosis, lumbar lordosis, sagittal vertical axis) and complications are reported. Subjective outcome was excellent in six patients and good in three. All nine patients retained their ability to walk. There were no neurological or vascular complications. Supplementary posterior surgery was required in two patients. The mean pre-operative Cobb angle of 52° (range 44–60) improved to 20° (range 10–28) at 3 months, achieving Cobb angle correction of 61% and was 19° (range 7–28) at final follow-up. The mean pre-operative compensatory curve of 31° (range 20–42) spontaneously corrected to 18° (range 14–24) at 3 months and was maintained at 18° (range 10–26) at final follow up. The mean pre-operative pelvic obliquity of 7° (range 0–14) corrected to 4° (range 0–8) at 3 months and was 3° (range 0–8) at final follow up. Selective anterior instrumentation and fusion in carefully selected patients with neuromuscular scoliosis (short flexible curves, minimal pelvic obliquity, pre-operative walkers, slow or non-progressive pathology) appears to have satisfactory clinical and radiological outcome at least in the short-term.     

一期前路病灶清除植骨内固定治疗脊柱结核

目的探讨经前路病灶清除植骨一期前路内固定术治疗脊柱结核的临床效果。方法对43例脊柱结核患者,行前路病灶彻底清除、椎间植骨、一期前路内固定术。结果脊柱结核复发2例（4.7%）,植骨不融合3例（7.0%）。植骨融合时间3～8个月。脊柱后凸畸形平均矫正70.2%±11.4%。11例截瘫患者神经功能Frankel分级术后恢复情况：术前A级3例术后恢复至B级1例、2例无恢复;B级5例恢复至C级1例、D级2例、E级1例、1例无恢复;C级3例恢复至D级1例、E级2例。结论经前路病灶清除植骨一期前路内固定术治疗脊柱结核能彻底清除结核病灶,充分减压,矫正脊柱后凸畸形,提高脊柱结核的治愈率。     

Combined anterior and posterior instrumentation in severe and rigid idiopathic scoliosis

A prospective clinical and radiographic evaluation of 33 consecutive patients with severe and rigid idiopathic scoliosis (average Cobb angle 93°, flexibility on bending films 23%) were treated with combined anterior and posterior instrumentation with a minimum follow-up of 2 years. All patients underwent anterior release and VDS-Zielke Instrumentation of the primary curve. In highly rigid scoliosis, this was preceded by a posterior release. Finally, posterior correction and fusion with a multiple hook and pedicle screw construct was performed. Thirty patients were operated in one stage, three patients in two stages. Preoperative curves ranged from 80 to 122° Cobb angle. Frontal plane correction of the primary curve averaged 67% with an average loss of correction of 2°. The apical vertebral rotation of the primary curve was corrected by 49%. In all but three patients, sagittal alignment was restored. There were no neurological complications, deep wound infections or pseudarthrosis. Combined anterior and posterior instrumentation is safe and enables an effective three-dimensional curve correction in severe and rigid idiopathic scoliosis.     

Primary stable anterior instrumentation or dorsoventral spondylodesis in spondylodiscitis?: Results of a comparative study

The operative results of 23 patients with a specific or unspecific spondylodiscitis were documented over 2 years after the focus of the inflammation had been eradicated, bone chip had been interposed and a CDH instrumentation had been performed by an anterior approach only. These outcomes were compared with the results of 32 patients in whom the focus had been removed and the defect had been filled with bone graft from an anterior approach, followed by stabilisation with CD instrumentation through an additional dorsal approach. In the cases where CDH instrumentation was applied, the range of fusion averaged 1.3 segments. This was clearly less extensive than in dorsoventral stabilisation, in which on average 3.5 segments were fused. In 47 of 55 cases mobilisation was achieved without orthesis. Eight months after the operations bony fusion could be observed radiologically in all patients. The mean preoperative kyphotic angle of the affected segments was 14.4°, compared to 4° after the operation. The mean loss of reposition was measured to be about 2.7° in both groups. Average operation time and blood loss were about 50% higher in the patients treated dorsoventrally. We conclude that even in the case of florid spondylodiscitis, a short-range anterior fusion of the affected spinal segment may be performed by use of a stable-angle implant without an increased risk of infection-related loosening.     

Approach-related lesions of the sympathetic chain in anterior correction and instrumentation of idiopathic scoliosis

During anterior scoliosis instrumentation with a dual-rod system, the vertebrae are dissected anterolaterally. After surgery, some patients report a change in temperature perception and perspiration in the lower extremities. Sympathetic lesions might be an explanation for this. The aim of this clinical study was to investigate sympathetic function after anterior scoliosis instrumentation. A total of 24 female patients with idiopathic scoliosis (mean age at follow-up, 23.8 years) who had undergone anterior instrumentation on average 6.6 years earlier were included. Due to the suspected relevance of the sympathetic L2 ganglion, two groups were created: a T12 group, in which instrumentation down to T12 was carried out (n = 12), and an L3 group, in which instrumentation down to L3 was done (n = 12). Sympathetic function was assessed by measuring skin temperature at the back of the foot, a plantar ninhydrin sweat test and sympathetic skin responses (SSRs) following electrical stimulation. The side on which the surgical approach was carried out was compared with the contralateral, control side. Health-related quality of life was investigated using the Scoliosis Research Society SRS-22 patient questionnaire. In the T12 group, mean temperatures of 29.6°C on the side of the approach versus 29.5°C on the control side were measured (P > 0.05); in the L3 group, the mean temperatures were 33.2°C on the approach side versus 30.5°C on the control side (P = 0.001). A significant difference between the T12 group and the L3 group (P < 0.001) was observed on the approach side, but not on the control side (P = 0.15). The ninhydrin sweat test showed reduced perspiration in 11 of 12 patients in the L3 group on the approach side in comparison with the control side (P = 0.002). In the T12 group, no significant differences were noted between the left and right feet. SSRs differed significantly between the two groups (P = 0.005). They were detected in all nine analyzable patients in the T12 group on both sides. In the L3 group, they were found on the approach side only in 4 of 11 analyzable patients versus 11 patients on the control side. The results of the SRS-22 questionnaire did not show any significant differences between the two groups. In conclusion, anterior scoliosis instrumentation with a dual-rod system including vertebrae down to L3 regularly leads to lesions in the sympathetic trunk. These are detectable with an increase in temperature, reduced perspiration and reduced SSRs. The caudal level of instrumentation (T12 vs. L3) has an impact on the extent of impairment, supporting the suspected importance of the L2 ganglion. The clinical outcome does not seem to be significantly limited by sympathetic trunk lesions.     

应用Isola内固定系统矫治重度脊柱侧凸

目的:探讨Isola脊柱内固定系统矫治重度脊柱侧凸的方法并评价其疗效。方法:1998年6月至2003年1月应用Isola脊柱内固定系统治疗重度脊柱侧凸32例,其中特发性脊柱侧凸25例,神经纤维瘤病性脊柱侧凸3例,神经肌肉性脊柱侧凸4例。冠状面主弯Cobb角92.1°±11.4°(75°～116°)。根据不同的侧凸类型、侧凸角度、柔韧性等采用一期前后路联合矫形、分期前后路联合矫形或单纯后路矫形手术,术中运用悬臂技术产生的平移力进行矫形,同时应用椎板下钛缆固定。比较术前、术后冠状面和矢状面的畸形程度,并通过躯干侧移(LT)值分析躯干平衡的重建。结果:随访6~48个月,平均18个月,全组患者术后冠状面矫形效果明显,Cobb角术后与术前相比有显著性差异(P<0.01),主弯平均Cobb角矫正率为53.8%,末次随访冠状面Cobb角平均丢失3.3°±3.8°。矢状面上81.3%的患者恢复了胸椎生理性后凸(30°~50°),84.4%的患者恢复了腰前凸(40°~60°)。术后LT值矫正率为67.1%,与冠状面Cobb角的矫正率呈正相关。结论:应用Isola内固定系统矫治重度脊柱侧凸,利用悬臂技术产生的平移力尤其与椎板下钛缆矫形固定相结合,可获得冠状面上较高的矫正率,同时可获得矢状面的矫正并达到躯干平衡。