椎管内外沟通瘤的手术治疗（附98例分析）

目的 探讨椎管内外沟通瘤的临床特征和手术方法及疗效。方法 回顾性分析2012年4月至2018年4月手术治疗的98例椎管内外沟通瘤的临床资料。采取单纯后正中入路92例、颈外侧入路4例和前后联合入路2例;术中同期行脊椎固定术35例,其中椎板成形术25例,颈段侧块螺钉内固定术或胸腰段椎弓根螺钉内固定术10例。结果 肿瘤全切除85例,部分切除13例;经单纯后正中入路手术肿瘤全切除率为78.3%（72/92）,经颈外侧入路4例和前后联合入路2例肿瘤均全切除。术后病理证实神经鞘瘤77例,神经纤维瘤7例,脊膜瘤6例,节细胞神经瘤5例,海绵状血管瘤1例,孤立性纤维瘤1例,脂肪瘤1例。所有病人术后随访6~84个月,平均47.6个月。临床症状改善89例,肿瘤复发4例,发生并发症7例。未行任何维持脊柱稳定措施的病人脊柱畸形发生率（17.46%）明显高于颈段侧块或胸腰段椎弓根螺钉内固定术（0%,P<0.05）以及椎板成形术（4.00%,P<0.05）。结论 椎管内外沟通瘤可经不同手术入路手术全切肿瘤,其中骨质破坏严重者可通过椎板成形术或椎弓根及椎体内螺钉内固定植入术重建脊柱稳定性,可减少术后脊柱畸形发生率。     

半椎板入路显微手术切除椎管内髓外硬膜下肿瘤的效果分

目的 探讨半椎板入路显微手术切除椎管内髓外硬膜下肿瘤的方法及疗效。方法 回顾性分析2016年1月至2018年12月采用半椎板入路显微手术切除的38例椎管内髓外硬膜下肿瘤的临床资料。结果 肿瘤全切除35例,次全切除3例（肿瘤与周围神经组织粘连紧密）。术后病理示神经鞘瘤 29例、脊膜瘤6例、表皮样囊肿2例、副神经节瘤1例。术后随访6~36个月,平均19.3个月;MRI复查显示复发1例,未见椎体滑脱及脊柱畸形发生;术后6个月Frankel分级:改善34例,不变3例,恶化1例。结论 半椎板入路显微手术切除椎管内髓外硬膜下肿瘤,不但能够充分显露肿瘤,而且保留椎板后弓的完整性,脊柱稳定性良好。     

椎板切开复位术在成人椎管内肿瘤术中的应用

目的 评价椎板切开复位术在成人椎管内肿瘤切除术中的应用价值及术后椎管的稳定性变化.方法 经后正中入路行椎管内肿瘤切除72例,术中分开椎旁肌,取下相应病变节段椎板、棘突.在显微镜下切除椎管内肿瘤后,将取下的椎板用钛片-钛钉固定复位,将椎旁肌解剖复位.分析此术式对椎管内肿瘤的显露与切除效果,评价术后患者的神经功能.结果 72例病人中髓内室管膜瘤18例,血管网织细胞瘤6例,髓外硬膜下神经鞘瘤22例,脊膜瘤21例,先天性肿瘤5例.椎板切开复位节段2～6节段(平均3.8节段),肿瘤全切68例,全切率94.4%.共27例病人获得随访,随访率37.5%,术后随访时间6个月到2.5年(平均11个月).所有随访病例均在术后7 d到2.5年间检查MRI、X线片.结论 椎板切开对椎管内肿瘤的暴露及切除效果满意,可减少椎板切除术后脊柱畸形的发生,对脊柱的稳定件影响较小.     

半椎板入路显微手术切除椎管内髓外硬膜下肿瘤的效果分析

目的探讨半椎板入路显微手术切除椎管内髓外硬膜下肿瘤的方法及疗效。方法回顾性分析2016年1月至2018年12月采用半椎板入路显微手术切除的38例椎管内髓外硬膜下肿瘤的临床资料。结果肿瘤全切除35例,次全切除3例(肿瘤与周围神经组织粘连紧密)。术后病理示神经鞘瘤29例、脊膜瘤6例、表皮样囊肿2例、副神经节瘤1例。术后随访6～36个月,平均19.3个月;MRI复查显示复发1例,未见椎体滑脱及脊柱畸形发生;术后6个月Frankel分级:改善34例,不变3例,恶化1例。结论半椎板入路显微手术切除椎管内髓外硬膜下肿瘤,不但能够充分显露肿瘤,而且保留椎板后弓的完整性,脊柱稳定性良好。     

椎弓根螺钉置入内固定与单纯椎管减压治疗退行性腰椎滑脱的比较

背景：随着脊柱内固定和脊柱融合技术的发展,脊柱融合已成为腰椎退行性滑脱症毫无争议的“金标准”。同时,邻近节段退行性变的问题引起人们越来越多的关注。 目的：观察椎弓根螺钉内固定置入植骨融合治疗退行性腰椎滑脱的临床疗效、手术节段稳定性及其对相邻节段的影响,并与单纯椎管加压进行对比。 方法：选择天津医科大学总医院骨科收治的退行性腰椎滑脱患者38例,排除失访3例,余35例中采用椎弓根固定后外侧融合21例,单纯椎管减压14例。单纯椎管加压组用咬骨钳咬除黄韧带和椎板解除神经根后方的压迫,用骨凿凿除向前滑脱的椎体后缘与下位相邻椎体后缘形成的相对性突起;椎弓根螺钉固定植骨融合组按Wein-stein 法定位椎弓根钉进针,拧入椎弓根螺钉,根据受压情况进行椎板减压。按Oswestry功能障碍指数综合评价临床疗效,观察过伸、过屈位时的水平位移及角移位,采用UCLA系统来评价邻近节段退变情况。 结果与结论：35例患者随访时间1年。椎弓根螺钉固定植骨融合组优良率显著高于单纯椎管加压组(P < 0.05)。椎弓根螺钉固定植骨融合对腰椎稳定性影响不大,邻近节段退变置入前和置入后1年无明显变化。单纯椎管加压对腰椎稳定性影响显著,同时治疗前和治疗后1年邻近节段退变无明显变化。提示椎弓根螺钉内固定置入植骨融合治疗退行性腰椎滑脱疗效满意,对腰椎稳定性影响小,并且置入后早期对椎间盘的邻近节段影响不大。     

一期显微手术切除椎管内外沟通性哑铃型肿瘤(附13例分析)

目的探讨椎管内外沟通性哑铃型肿瘤的临床特点和外科治疗策略。方法回顾性分析13例椎管内外沟通性哑铃型肿瘤病人的临床资料。肿瘤位于颈椎8例,胸椎1例,腰椎4例。肿瘤分期：Ⅲ期12例,Ⅳ期1例。采用联合入路（后正中入路＋前外侧入路）8例,经后正中入路5例;均行半椎板切除。1例Ⅳ期病人切除肿瘤后采用后路钉棒系统固定融合病变节段。结果本组肿瘤均完全切除。肿瘤性质：神经鞘瘤11例,恶性神经鞘瘤1例,神经节细胞瘤1例。术后感觉麻木面积扩大5例,肢体运动功能改善8例。随访6个月～3年,平均18个月。无肿瘤复发,无脊柱畸形发生。结论采用一期显微手术可以切除大多数椎管内外沟通性哑铃型肿瘤,行半椎板切除可以减少对脊柱稳定性的影响,应用囊内分块切除技术可以减少对肿瘤邻近解剖结构的损伤。     

长节段椎板-棘突复合体回植进行椎管重建在长节段椎管内肿瘤手术中的应用

目的 探讨长节段（≥4个节段）椎板-棘突复合体回植进行椎管重建在长节段椎管内肿瘤手术中的应用效果。方法回顾性分析2014年1月至2020年12月显微手术治疗的6例长节段椎管内肿瘤的临床资料。术中采取长节段椎板-棘突复合体回植复位+钛板钛钉固定的方法进行椎管重建。结果 肿瘤位于颈胸段3例，胸腰段1例，腰段1例，腰骶段1例。肿瘤全切除5例，大部分切除1例。术后病理检查显示室管膜瘤3例，神经鞘瘤1例，脂肪瘤1例，畸胎瘤1例。术后随访2～7年，未见肿瘤复发，未见椎管狭窄，未见脊柱不稳及滑脱，部分椎板已骨性愈合。结论 对长节段椎管内肿瘤，采用长节段椎板-棘突复合体回植方法进行椎管重建，手术疗效肯定，术后并发症少，脊柱稳定性影响小。     

手术治疗椎管内神经鞘瘤58例

目的总结椎管内神经鞘瘤的手术经验。方法回顾性分析2002年3月2012年9月手术治疗的58例椎管内神经鞘瘤的临床资料,其中40例采用后正中全椎板入路,4例采用后正中半椎板入路,3例采用经后路半椎板+关节突入路部分切除,7例行经后路全椎板+关节突入路切除+内固定植骨融合术,2例行前外侧经胸+后路椎板入路切除,2例行后外侧经横突+椎板入路切除。结果肿瘤全切除55例,次全切除3例。55例术后随访6~34个月,平均18.5月;按照Frankle分级评定标准评判效果,改善50例,不变5例;肿瘤全切者无复发,肿瘤次全切除者2例复发。结论对于椎管内神经鞘瘤,手术入路的选择应根据肿瘤的位置、大小、肿瘤与脊髓之间的关系及椎管外有无侵润等综合考虑。     

劈开式椎板切开复位技术在多节段椎管内肿瘤手术的应用

目的探讨劈开式椎板切开复位技术在多节段椎管内肿瘤切除术中的有效性与可行性。方法回顾性分析3例累及多节段的椎管内肿瘤病例,男性2例,女性1例,MRI检查均为腰椎椎管内占位,分别累及2~4个节段。治疗方法采取劈开式椎板切开复位技术进行椎管内肿瘤切除。结果肿瘤均全切除,病理诊断:神经鞘瘤2例,转移性腺瘤1例。术后病人临床症状明显改善,无手术相关并发症发生。术后影像学检查显示:椎板骨质损失少,无椎板、椎弓根及椎体骨折发生。结论劈开式椎板切开复位技术具有微创、费用低等优点,在多节段椎管内肿瘤切除手术具有良好应用前景。     

显微切除+棘突椎板复合体原位回植椎管成形术治疗椎管内神经鞘瘤疗效分析(附18例报告)

目的 探讨显微切除+棘突椎板复合体原位回植椎管成形术治疗椎管内神经鞘瘤的疗效. 方法 蚌埠医学院第一附属医院神经外科自2011年9月至2014年6月采用显微切除+棘突椎板复合体原位回植椎管成形术治疗18例椎管内神经鞘瘤患者.回顾性分析患者的临床资料,采用椎管MRI检查评价肿瘤的切除情况,采用脊柱CT三维重建或脊柱X线检查观察椎管成形情况,术后3个月采用Frankel分级标准评价患者的脊髓功能恢复情况. 结果 本组18例肿瘤均在显微镜下全部切除,术中无硬脊膜破损及神经根损伤.术后无脑脊液漏及切口感染.患者症状和体征明显改善,无肿瘤复发,无椎管狭窄、脊柱失稳,术后3个月Frankel分级显示患者脊髓功能恢复D级4例,E级14例. 结论 显微切除+棘突椎板复合体原位回植椎管成形术治疗椎管内神经鞘瘤,可最大程度的切除肿瘤及减少脊髓损伤,术后椎管成形且脊柱稳定,效果良好.     

Percutaneous endoscopic lumbar discectomy for lumbar disc herniation

This study aims to compare the advantages and disadvantage of percutaneous endoscopic lumbar discectomy (PELD) and standard discectomy (SD) for the treatment of lumbar intervertebral disc herniation (LDH). We searched in MEDLINE, EMBASE, PubMed, Web of Science and Cochrane databases for relevant trials that compare PELD and SD for the treatment of LDH. The Cochrane Collaboration’s Revman 5.3 software was used for data analyses. This meta-analysis compiled 1301 cases from four random controlled trials and three retrospective studies. Compared with SD, PELD showed a shorter operative time (mean difference (MD) = −18.68, 95% confidence interval (CI): −24.92 to −12.43; p < 0.00001), less blood loss (MD = −64.88, 95% CI: −114.51 to −15.25, p < 0.0001), shorter hospital stay (MD = −3.51, 95% CI: −4.93 to −2.08, p < 0.00001), and shorter mean disability period (MD = −34.34, 95% CI: −53.90 to −14.77, p < 0.006). However, there were no significant differences in the visual analogue scale (VAS) scores at the final follow up (MD = −0.23, 95% CI: −0.53 to 0.07, p = 0.14), Macnab criteria at the final follow up (MD = 1.04, 95% CI: 0.72 to 1.50, p = 0.82), complications (RR = 0.76, 95% CI: 0.40 to 1.43, p = 0.39), recurrence rate (risk ratio (RR) = 1.00, 95% CI: 0.61 to 1.64, p = 1) and reoperation rate (RR = 1.40, 95% CI: 0.90 to 2.16, p = 0.13). In conclusion, despite PELD showing significant benefit in short term outcomes such as hospital course and mean disability period, similar clinical efficacy and long term outcomes were observed when compared to SD. Therefore, we suggest that PELD can be a feasible alternative to the conventional posterior approach for the LDH depending on surgeon preference and indication. High-quality randomized controlled trials with sufficient large sample sizes necessary further confirm these results.     

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.     

经皮腰椎间盘摘除术治疗腰椎间盘突出症62例探讨

目的探讨经皮腰椎间盘摘除术(PLD)在腰椎间盘突出症治疗中的临床应用。方法采用PLD技术在DSA监控下行经皮腰椎间盘摘除术。结果62例患者均达到了治疗效果,其中60例全愈,22例术后短期内出现症状“反跳”,经治疗后症状消失;结论PLD手术的有效率达90%以上,并发症发生率几乎为零,为一安全、有效的治疗手段。     

Juvenile lumbar discs

One hundred and two patients, ages 10–18 years, were operated upon for herniated lumbar discs. Until age 17, the male-to-female ratio was even. A significant relationship was found between traumatic etiology and the occurrence of free disc rupture. Disc material was found outside the annular ligament in more than half of the patients. Results of surgical excision have been excellent in 95% of cases. Same level recurrence remains below 3%.     

不同融合方式对腰椎生物力学的影响

背景：腰椎融合已广泛应用于腰椎疾患,但腰椎融合后对邻近节段的影响尚存争议,不同融合方式的节段稳定性及对邻近节段的影响尚不清楚。 目的：利用动物模型研究腰椎融合节段生物力学稳定性及相邻上节段的生物力学特点。 方法：将新西兰大白兔随机分为前路椎体间融合组(切除L5~6椎间盘,终板去皮质化,自体髂骨移植)、后外侧融合组(L5~6双侧横突去皮质化后自体髂骨移植)、环状融合组(先行前路椎体间融合,1周后作后外侧融合)、对照组(不作手术)。术后12周处取标本作影像学检查、手触测试、生物力学测试。对融合标本分别施加屈伸,左右侧弯,左右旋转6个方向的纯力矩,比较不同融合方式融合节段的稳定性及邻近节段运动范围。 结果与结论：与对照组比较,前路椎体间融合组、环状融合组、后外侧融合组L5~6节段屈曲活动度分别下降86.24%(P < 0.05),88.74%(P < 0.05),73.10%(P < 0.05),融合节段近上节段L4~5屈曲运动范围分别增加52.22%(P < 0.05),55.89%(P < 0.05),27.11%(P < 0.05)。说明3种融合方式均显著提高融合节段稳定性,环状融合提供的节段稳定性最高,后外侧融合提供的节段稳定性最低。3种融合方式均使融合节段邻近上节段运动范围显著增加。前路椎体间融合,360°融合使邻近上节段屈曲运动范围增加无统计学差异。后外侧融合使邻近上节段屈曲运动范围增加最少。     

Sex differences in lumbar spinal cord gene expression following experimental lumbar radiculopathy

Considerable evidence indicates that there are sex-related differences in clinical and experimental pain sensitivity. In the present study, we sought to determine what genes were expressed in the spinal cord in a sexually dimorphic manner. We first analyzed global gene expression in the lumbar spinal cord of uninjured male and female rats using the Affymetrix RAE230A GeneChip platform in order to identify genes that are selectively expressed in male and female rats at a basal level. We subsequently analyzed global gene expression in the lumbar spinal cord of male and female rats at two time points (7 days and 14 d) following a rodent model of lumbar radiculopathy (L5 nerve root ligation) in order to determine what genes were regulated in a sexually dimorphic manner following nerve root injury. We utilized a linear regression analysis method to identify genes that were significantly different from the corresponding sham surgical controls. The expression patterns of several genes of interest were subsequently confirmed using RT-PCR. Our findings demonstrate significant differences in lumbar spinal cord gene expression in both uninjured and injured (L5 nerve root ligation) male and female rats. Further confirmation of a subset of the genes identified Neuregulin 1 and its high affinity receptor, ErbB4, Tachykinin 1, and Metabotropic glutamate receptor 6 as female specific genes upregulated following L5 nerve root injury. These findings provide several target genes for further study that may elucidate the neurochemical mechanisms underlying sex differences in pain sensitivity and lead to improved treatments for chronic pain syndromes.     

显微镜下经管道与开放式腰椎间盘摘除术综合疗效对比分析

目的 探讨显微镜下经管道与开放式腰椎间盘摘除术的综合疗效。方法 回顾性分析2014年6月至2016年6月手术治疗的165例腰椎间盘突出症的临床资料，其中96例行显微镜下经管道腰椎间盘摘除术（观察组），60例行开放式腰椎间盘切除术（对照组）。所有病人术后平均随访（12.7±1.1）个月。采用视觉模拟量表（VAS）评分、Oswestry功能障碍指数（ODI）评估疗效。末次随访采用Macnab标准评定术后功能。结果 与对照组相比，观察组手术时间明显延长，住院时间明显缩短（P<0.05），术中出血量明显减少（P<0.05）。观察组术后并发症发生率（4.1%）与对照组（3.0%）无统计学差异（P>0.05）。两组术前VAS评分、ODI均无统计学差异（P>0.05）；两组术后1周、3个月、12个月VAS评分、ODI均较术前均明显降低（P<0.05）；而且，术后1周、3个月，观察组VAS评分均显著低于对照组（P<0.05）。末次随访两组Macnab功能无统计学差异（P>0.05）。结论 与开放式腰椎间盘切除术比，显微镜下经管道腰椎间盘摘除术治疗腰椎间盘突出症康复快、住院时间短。     

Intradural lumbar cystic schwannoma

Intradural lumbar cystic schwannomas are a very rare entity and only 10 case reports have been reported in the literature. The diagnosis and management remains a challenge for clinical physicians. Herein, we report a 51-year-old female presenting with lower back pain and radiating pain at the left upper thigh. Magnetic resonance images of lumbar spine demonstrated an intradural cystic mass approximately 18 x 17 x 35 mm in size occupying L4 to L5, which appeared as the same signal intensity as CSF. At operation, a well encapsulated cystic mass was found. The pathological examination confirmed a diagnosis of schwannoma. The relevant literature was also reviewed.