峡部植骨固定治疗腰椎椎弓峡部不连性下腰痛

目的研究腰椎椎弓峡部不连下腰痛峡部植骨固定的手术方法及应用价值。方法46例单纯峡部不连病人,采用椎弓根螺钉、椎板钩加峡部植骨固定治疗,术后进行随访,探讨此手术方式的峡部不连愈合及病人症状改善情况。结果本组46例病人经平均16个月随访,下腰部疼痛明显缓解,峡部不连愈合,功能恢复良好,优良率达93．5％：没有切口感染、内固定物断裂、神经根损伤等并发症：结论单节段峡部植骨椎板钩固定是治疗腰椎峡部不连性下腰痛的一种简单有效的方式。     

椎弓根钉、椎板钩加峡部植骨术治疗腰椎峡部不连

目的探讨椎弓根螺钉、椎板钩加峡部植骨术治疗腰椎峡部不连的手术方法及疗效。方法 8例腰椎峡部不连患者采用椎弓根螺钉、椎板钩加峡部植骨固定治疗,并对手术结果进行分析。结果术前及术后随访VAS评分分别为6.20±1.26和1.93±0.81,JOA评分分别为20.06±1.16、27.89±0.66,差异有明显统计学意义（P〈0.05）。患者术后X线片示峡部裂植骨均骨性愈合,优6例,良2例。结论椎弓根螺钉、椎板钩加峡部植骨术治疗腰椎峡部不连是单节段固定,对腰椎的正常生理活动范围干扰及手术创伤均较小,是一种简单、有效的术式。     

椎弓根钉钩系统加峡部植骨系统治疗单纯腰椎峡部不连5年疗效随访

目的：椎弓根螺钉、椎板钩加峡部植骨术治疗腰椎峡部不连手术5年疗效随访研究。方法2006-2008,我院收治20例单纯腰椎峡部不连患者采用椎弓根螺钉、椎板钩加峡部植骨固定治疗术后5年随访。结果术前及术后5年随访VAS评分有明显统计学意义（P〈0.05）;患者术后5年CT断扫峡部裂植骨均骨性愈合。20例患者均未发生脱钩及临近节段退变（椎间隙高度丢失）;2例诉腰椎活动度较术前轻度受限;6例出现腰椎间盘退变。结论与多节段固定融合术相比,椎弓根螺钉、椎板钩加峡部植骨术治疗腰椎峡部不连是对腰椎正常生理活动范围干扰小、临近节段退变率低的一种可靠、有效的单椎体动态固定术式。     

植骨加钉-钩固定治疗青年腰椎峡部裂

目的探讨应用植骨加椎弓根钉-椎板钩系统固定治疗青年腰椎峡部裂的临床疗效。方法 2005年12月～2011年9月,应用植骨加椎弓根钉-椎板钩系统固定治疗青年腰椎峡部裂患者82例,患者均主诉反复腰痛〉3个月,非手术治疗3～6个月无效,术前腰椎疼痛视觉模拟量表（visual analogue scale,VAS）评分为7.9分。结果术后腰部疼痛症状明显缓解,VAS评分1.5分,根据Nakai评分标准,优良率为95%,随访12～48个月,除1例峡部裂植骨未愈合外,均骨性融合,无内固定松动、断裂。结论腰椎峡部修复植骨、椎弓根钉-椎板钩系统单节段固定是治疗青年腰椎峡部裂的一种简单、安全、有效的方法,避免了脊柱融合,应用时注意适应证的选择。     

经肌间隙峡部"T"形植骨钉钩固定治疗腰椎峡部裂

目前腰椎峡部裂手术方式较多,包括钢丝捆绑技术、钉钩固定技术、椎板螺钉技术等,钉钩固定技术是较常用的术式,但传统术式椎旁肌剥离程度较高,处理峡部断端硬化骨咬除后进行植骨、钉钩加压后远期随访峡部可能短缩,且难以满足峡部断端的植骨量,接触面局限,影响植骨融合率[1].为进一步降低钉钩固定治疗腰椎峡部裂手术创伤,提高植骨融合率,本科室近年采用经肌间隙入路,采用"T"字形自体髂骨植骨块作为补丁进行椎弓峡部的植骨重建,获得了一定的临床疗效,现报道如下.     

Wiltse微创入路治疗青年军人腰椎峡部裂

[目的]探讨Wiltse微创入路治疗青年军人腰椎峡部裂的临床疗效及体会。[方法]回顾性分析2011～2016年30例腰椎双侧峡部不连的青年军人,均为男性,年龄19～32岁,平均(23.72±3.69)岁。所有患者均采用Wiltse入路椎弓根螺钉-椎板钩、峡部植骨内固定的手术方式治疗。[结果] 30例患者术后3、6、12、24个月均获得随访。峡部裂植骨均骨性愈合,未发现断钉、脱钩等现象。所有患者术后腰痛症状明显缓解,术前及末次(术后2年)随访VAS评分分别为(6.70±1.32)、(1.54±0.62),术后VAS评分较术前明显改善,差异有统计学意义(P0.05)。根据Henderson疗效评定标准:优24例,良6例,优良率100%。[结论] Wiltse入路椎弓根螺钉-椎板钩加峡部植骨术进行峡部固定既可恢复椎弓的骨性连接,又可以更少的干扰正常组织结构、减轻组织破坏。在保守治疗无效的情况下,Wiltse入路椎弓根螺钉-椎板钩、峡部植骨术是一种行之有效的方法     

椎弓根钉-椎板钩系统治疗青少年腰椎峡部裂的临床疗效

目的探讨椎弓根钉-椎板钩系统在治疗青少年腰椎峡部裂时的临床疗效。方法从1999-02-2011-02,应用椎弓根钉-椎板钩节段内固定及植骨修复重建青少年腰椎峡部裂22例。保守治疗至少6个月无效,术前腰痛VAS评分8.1分,术中彻底清除峡部裂之间的纤维组织、瘢痕及增生组织,切除裂部骨端的硬化骨,至断面出现渗血为止,取自体髂骨条植骨,安放椎弓根钉-椎板钩系统。结果所有患者术后随访9～48个月,平均24个月。术后恢复满意,无内固定断裂、神经损伤等并发症,术后腰痛VAS评分降到2.1分,所有病例均获得骨性愈合。结论椎弓根钉-椎板钩系统及植骨修复重建青少年腰椎峡部裂效果确实,值得推广应用。     

椎弓根钉-椎板钩系统固定治疗单纯腰椎峡部裂

目的：观察应用椎弓根钉-椎板钩系统固定治疗单纯腰椎峡部裂的临床疗效。方法：自2002年6月以来．使用椎弓根钉-椎板钩系统治疗单纯腰椎峡部裂15例，均为男性，年龄19～36岁，平均27岁。L46例，L59例，均为双侧病变。所有患者均主诉明确的腰痛，持续6个月以上。术前腰痛疼痛评分（VAS）7．8分，采用后正中入路，暴露烈侧病灶，将峡部裂中的纤维瘢痕组织彻底清除，咬除骨残端硬化部分至出血为止，髂后上棘取骨行峡部裂局部植骨。安放病椎竹弓根螺钉及椎板钩，放置连杆后将同定系统锁紧。结果：术后疼痛症状明显缓解，VAS评分2．4分。随访12～26个月，峡部裂植骨均骨性愈合，末见骨不连及内同定断裂。结论：对于年轻的、单纯峡部裂患者可以采用椎弓根钉-椎板钩系统进行峡部修复，避免脊柱融合术：椎弓根钉-椎板钩系统是一种安全、有效的内同定装置。     

峡部植骨固定术治疗腰椎峡部裂

目的探讨峡部植骨固定术治疗腰椎峡部裂的临床疗效。方法自1998年12月~2005年8月应用峡部植骨固定术治疗腰椎峡部裂患者26例,经椎板AO空心拉力螺钉固定峡部裂7例,椎弓根螺钉合并椎板钩固定19例,峡部裂处均取髂骨植骨。术后3~6个月复查。术前及复查时采用VAS评分进行临床功能评价,摄腰椎双斜位和动力位X线片观察峡部愈合情况和椎间活动度变化。结果术前和随访时VAS评分分别为6.25±1.24、2.14±1.13,差异有显著统计学意义(P<0.01);椎间活动度分别为8.3°±2.4°、8.1°±2.1°,差异无统计学意义(P>0.05)。所有患者斜位X线片示峡部已经无透亮线。结论峡部植骨固定术是治疗腰椎峡部裂所致腰痛的一种合理、简单、安全的术式。     

椎弓根钉-椎板钩系统结合植骨治疗青少年腰椎峡部裂

目的观察应用椎弓根钉-椎板钩系统结合植骨治疗青少年腰椎峡部裂的临床疗效。方法回顾自2010年6月至2015年3月,北京积水潭医院脊柱外科应用椎弓根钉-椎板钩系统节段内固定及植骨治疗青少年腰椎峡部裂16例,男性13例,女性3例;年龄14~32岁,平均19.5岁。L_46例,L_510例。所有患者均主诉有明确的持续6个月以上腰痛。采用后正中入路,暴露双侧椎板及两侧小关节外缘,将峡部裂病灶处的纤维瘢痕组织彻底清除,去除峡部裂骨面残端硬化部分至出血;髂后上脊取骨或病椎椎板取骨行峡部裂局部植骨。安放病椎椎弓根螺钉及椎板钩,放置连杆后将固定系统加压锁紧。分别对患者术前以及末次随访进行疼痛视觉模拟评分(visual analogue scale,VAS)。结果患者术后疼痛症状明显缓解,随访6~24个月,平均14个月。14例峡部裂处已达到骨性愈合,另外2例斜位片可见无透亮线通过。未见骨不连及内固定断裂。末次随访VAS评分(1.78±0.19)分,应用SPSS 13.0中配对t检验进行统计学分析,t=25.29,P=0.00,配对差值95%的可信区间为(6.26~7.41)。结论对于青少年腰椎峡部裂患者可以采用椎弓根钉-椎板钩系统结合植骨进行峡部固定并修复,避免脊柱融合术。椎弓根钉-椎板钩系统是一种安全、有效的内固定装置。     

Segmental wire fixation for lumbar spondylolysis associated with spina bifida occulta

Introduction  The effectiveness of segmental wire fixation technique in repairing lumbar spondylolysis has already been reported. However, whether the technique can be indicated for spondylolysis associated with spina bifida, which is occasionally found with spondylolysis, is not well known. In this study, the authors report the mid-term clinical outcome of the procedure performed in patients with symptomatic lumbar spondylolysis associated with spina bifida occulta. Materials and methods  Among 20 patients with symptomatic lumbar spondylolysis who underwent segmental wire fixation between 1996 and 2001, four patients associated with spina bifida occulta were evaluated with an average of 32 months follow-up. Bony union at spondylolysis sites and spina bifida was evaluated using plain X-rays and computed tomography (CT) scans. Clinical symptoms were assessed using Japanese Orthopedic Association scores for back pain (JOA scores) and Henderson’s evaluation of functional capacity. Results  The radiographic examinations of the latest follow-ups revealed the following results. Pars defect; in three cases with bilateral defect, one case healed bilaterally and two healed only unilaterally. One case with unilateral defect healed. Spina bifida; two cases showed bony union and two showed no union. Of the four patients operated, two were rated excellent with the remaining two good according to Henderson’s evaluation. The recovery rate of JOA score was averaged at 69.7 ± 23.5%. No serious complications were noted. Conclusions  In four cases associated with lumbar spondylolysis and spina bifida, segmental wire fixation provided satisfactory clinical outcomes.     

Direct repair of multiple levels lumbar spondylolysis by pedicle screw laminar hook and bone grafting: clinical, CT, and MRI-assessed study

INTRODUCTION: A prospective analysis of 6 cases with multiple-level spondylolysis treated by direct repair with pedicle screw laminar hook is presented. The objective of the study was to evaluate the clinical outcome, plain radiographs, computed tomography (CT) scan, and magnetic resonance imaging to demonstrate the result of direct repair in the treatment of multiple-level spondylolysis. MATERIALS AND METHODS: Ten patients with multiple-level spondylolysis of lumbar spine were treated with segmental pedicle screw hook fixation and autogenous bone graft. Four patients had lost follow-up. Six patients were followed up for a minimum of 2 years (mean 34.3 mo, range 24 to 55 mo). Patient's average age was 22 years old (range from 20 to 25 y old). All lytic defects were bilateral and located at 2 different lumbar vertebras (levels). CT scans and MR images were obtained at the latest follow-up postoperatively to assess the healing of the bony defects and the adjacent disc conditions. Fusion was considered to be presented when trabecula across the lytic defect was detected. RESULTS: The union rate was 87% (21 pars/24 pars) on plain radiographs and 75% (18 pars/24 pars) on CT scans. Follow-up magnetic resonance imaging of lumbar spine showed no disc degeneration. All patients were satisfied (either excellent or good) with the postoperative outcomes. CONCLUSIONS: Direct repair of multiple-level spondylolysis by pedicle screw laminar hook and autogenous bone graft would be the alternative of treating patients with persistent back pain after 6 months of conservative treatment The favorable clinical outcome was correlated with bony healing rate in this series.     

青年性腰椎弓根崩裂直接修复后TSRH钩钉系统固定12例初步报告

[目的]评价TSRH钩钉系统对青年患者腰椎弓崩裂直接修复后固定的临床疗效。[方法]自2001年7月~2003年10月,对12例男性单纯腰椎弓崩裂患者(16~31周岁)行腰椎弓崩裂自体骨直接修复峡部裂后TSRH椎板钩、椎弓根钉固定术。术后随访,根据术后X线、CT结果评价修复效果,并根据MacNab's标准进行临床评价。[结果]经过6~19个月随访,所有患者腰椎弓崩裂影像学全部融合;临床下腰痛显著缓解,按MacNab's标准,优8例,良3例,一般1例;无手术及内固定相关并发症发生。[结论]直接修复后TSRH钩钉系统固定治疗青年性腰椎弓崩裂能充分保留腰椎运动节段,在减少融合节段的同时能有效恢复腰椎稳定,操作简便、安全,固定可靠,是一种合乎逻辑的治疗青年性腰椎弓崩裂方法。     

Clinical and CT scan evaluation after direct defect repair in spondylolysis using segmental pedicular screw hook fixation.

Direct defect repair using segmental pedicular screw hook fixation was carried out in nine patients with spondylolysis and a mean age of 24.2 years. One patient was fused 3 years after isthmic reconstruction. In the remaining eight patients, after a mean follow-up of 41 months (range, 12-78), three self-evaluation scales revealed a significant (p < 0.05) improvement in clinical status. Computed tomography scans were carried out in seven patients. There was bilateral bony union in two cases, in three pars healing was unilateral, and in two the isthmic defect persisted bilaterally. No correlation was observed between the status of the pars and follow-up. We conclude that repair of defects in spondylolysis may result in a favorable clinical outcome even when anatomic reconstruction of pars interarticularis is not successful.     

Repair of spondylolysis using compression with a modular link and screws

We describe the results of a prospective case series of patients with spondylolysis, evaluating a technique of direct stabilisation of the pars interarticularis with a construct that consists of a pair of pedicle screws connected by a U-shaped modular link passing beneath the spinous process. Tightening the link to the screws compresses bone graft in the defect in the pars, providing rigid intrasegmental fixation. We have carried out this procedure on 20 patients aged between nine and 21 years with a defect of the pars at L5, confirmed on CT. The mean age of the patients was 13.9 years (9 to 21). They had a grade I or less spondylolisthesis and no evidence of intervertebral degeneration on MRI. The mean follow-up was four years (2.3 to 7.3). The patients were assessed by the Oswestry Disability Index (ODI) and a visual analogue scale (VAS). At the latest follow-up, 18 patients had an excellent clinical outcome, with a significant (p < 0.001) improvement in their ODI and VAS scores. The mean ODI score at final follow-up was 8%. Assessment of the defect by CT showed a rate of union of 80%. There were no complications involving the internal fixation. The strength of the construct removes the need for post-operative immobilisation.     

Biomechanical and clinical study on screw hook fixation after direct repair of lumbar spondylolysis

Objective : To evaluate the biomechanical effect and clinical results of hook screw fixation after direct repair of lumbar spondylous defects in the pars interarticularis. Methods: L2-L6 spines of 8 fresh-frozen and thawed calf cadavers were used for mechanical testing. Bilateral spondylous defects were created in the L4 vertebra. The intervertebral rotation ranges between L4 and L5 were scanned and computerized in various states of motion, such as flexion/extension, lateral bending and torsional loadings applied on the intact spine and the spondylous spine when the spondylous spine was fixed with modified Scott' s fixation, hook screw fixation and Buck ' s fixation sequentially and respectively. Between July 2002 and February 2004, 14 young male patients (aged 15-31 years) suffering from symptomatic lumbar spondylolysis were treated with TSRH hook screw fixation after direct repair of the defects. MacNab criteria were used to assess their pre-and post-operative status. Results: Each fixation technique could significantly increase the intervertebral rotational stiffness and made the stiffness return to nearly the intact level. Hook screw technique provided more rotational stability than the others. Hook screw and Buck' s techniques provided more flexion/extension stability than modified Scott' s technique. Neither complication nor instrumental failure was observed in this study. The mean follow-up period was 21 months. All the patients except one acquired union during the follow-up period. Thirteen patients had a“good”or“excellent”result according to MacNab criteria. Conclusions: Hook screw fixation shows biomechanical advantages and is safe and effective for young patients with lumbar spondylolysis.     

In situ fixation of pelvic nonunions following pathologic and insufficiency fractures

BACKGROUND: A nonunion of the pelvic ring after a pathologic or insufficiency fracture of osteopenic bone is rare. The purpose of the present study was to evaluate the radiographic and clinical results of in situ fixation of these nonunions. METHODS: The records of forty-four patients who had been managed with in situ fixation of pelvic fracture nonunions were reviewed retrospectively. Twenty-seven patients had sustained pathologic fractures after a simple fall, and seventeen had sustained insufficiency fractures. Forty-two of the forty-four nonunions were unstable and were located unilaterally or bilaterally in the posterior pelvic arch, and thirty-six involved the lateral aspect of the sacrum. Two of the forty-four non-unions involved only the pubic rami. The average age of the patients was sixty-six years (range, thirty-five to eighty-seven years), and the average duration of postoperative follow-up was four years (range, two to eleven years). All patients were assessed with regard to fracture union, residual pelvic pain, pelvic instability, and functional status. In addition, all patients were asked to rate the surgical result as highly satisfactory, satisfactory, or unsatisfactory. RESULTS: Thirty-six (82%) of the forty-four nonunions healed after in situ fixation, and seven of the eight persistent nonunions healed after additional surgery. Thirteen patients (30%), including five patients who had radiographic evidence of union, had persistent pain at the one-year follow-up assessment. None of the forty-three patients in whom the fractures eventually healed complained of persistent pelvic instability. At the time of the final follow-up examination, twenty-four patients (55%) were highly satisfied, twelve (27%) were satisfied, and eight (18%) were unsatisfied with the surgical result. CONCLUSIONS: In situ fixation of a nonunion of the pelvic ring following a pathologic or insufficiency fracture can result in a decrease in pelvic pain and instability along with an improvement in walking ability. A high percentage of patients complain of persistent pain, even if there is radiographic evidence of union of the pelvic ring.     

Defect in the articular process of the lumbar facet

Bone defect in the lumbar articular facet is rarely noted, and only a few reports on its clinical course have been presented. We report on seven cases with lumbar inferior facet defect whose symptoms were mimicking spondylolysis. We have found three types of the defect shape on radiographs: linear, blunt, and irregular. There were five cases with linear type, one with blunt, and one with irregular. All patients had persistent low back pain, especially when doing physical activity or sports, but no one had history of major trauma or accident. Injection of a small amount of anesthetic temporarily alleviated the low back pain. The low back pain in six patients was controlled with conservative treatments, such as bracing or medication; bone union was especially gained in one case. However, a volleyball player's pain could not be controlled conservatively, and removal of the bone fragment was performed. It is considered that facet defect is not as rare as presumed, and more attention should be paid to it as a source of low back pain.     

Clinical outcome after segmental wire fixation and bone grafting for repair of the defects in multiple level lumbar spondylolysis

The aim of this retrospective study was to assess clinical outcomes after segmental wire fixation and bone grafting for repair of pars defects in patients with multiple-level lumbar spondylolysis. Subjects were 7 patients (5 men and 2 women, mean age 26.7 y) with multiple-level lumbar spondylolysis treated by segmental wire fixation and bone grafting at one of our affiliated institutions between 1983 and 2004. Clinical outcomes were determined by comparing preoperative and postoperative Japanese Orthopaedic Association scores and Mancab criteria, and healing of pars defects was evaluated by radiographic and computed tomography study. The condition involved 2 levels in 5 cases and 3 levels in 2 cases. The mean postoperative follow-up period was 51.0 months. The mean Japanese Orthopaedic Association score improved significantly from 21.29 before surgery to 27.86 after surgery, and the recovery rate was 85.21%. An "excellent" result was achieved in 5 cases, a "good" result in 1 case and a "fair" result in 1 case according to the Macnab criteria. Postoperative radiographs revealed healing of all defects in 4 cases, healing of 3 out of 4 defects in 2 cases, and no healing of any defect in 1 case. Pseudoarthrosis was related to wire breakage, and patients who did not obtain complete healing were patients who did not fully comply with instructions to wear a lumbar corset or restrict activity postoperatively. Segmental wire fixation and bone grafting were shown to be effective for multiple-level lumbar spondylolysis.