人工颈椎间盘置换术在后纵韧带骨化症中的应用

[目的]观察应用Bryan颈椎间盘假体置换术治疗后纵韧带骨化症的近期效果。[方法]2005年10月～2007年6月应用Bryan人工颈椎间盘假体置换术治疗局限型后纵韧带骨化症患者15例,术前和术后6个月时进行JOA评分,并摄颈椎前屈后伸位X线片,观察假体稳定性及颈椎置换节段的活动度。[结果]患者术后症状均明显缓解,随访6～24个月,JOA评分由术前平均8.5分上升至术后平均15.8分。置换节段保留了运动功能,假体稳定无移位。[结论]人工颈椎间盘置换术近期可保持前路减压的良好效果,同时可获得术后即刻稳定性。维持颈椎近正常的活动度。人工颈椎间盘置换术是治疗局限型后纵韧带骨化症的一种有效方法。     

双节段BRYAN人工颈间盘置换的中期疗效分析

[目的]观察相邻双节段BRYAN人工颈椎间盘置换术治疗相邻节段颈椎病的临床疗效与影像学结果.[方法]回顾2006年1月～ 2009年2月在本院行相邻双节段BRYAN人工颈椎间盘置换术并获得随访的颈椎病患者19例.术前及术后1周,术后3、6、12、24、36个月进行JOA评分、NDI评分及颈痛VAS评分,评估手术临床疗效;术前及术后3、6、12、24、36个月通过颈椎动力位X线片评定置换节段、上下相邻节段和C2-7颈椎活动度;术后12、24、36个月,通过X线椎间盘退变评分系统评估手术相邻节段退变.[结果]所有患者术后神经症状均明显好转,各随访点JOA评分、NDI评分、颈痛VAS评分较术前显著改善,差异有统计学意义(P＜0.05),3个月后各随访时点两两比较差异无统计学意义(P＞0.05).两置换节段活动度术后各随访点与术前比较差异有统计学意义(P＜0.05);3个月后随访,上下相邻节段活动度与术前相比略减小,C2-7活动度较术前略增加,差异无统计学意义(P＞0.05).至末次随访时,手术未导致相邻节段椎间盘退变加剧,无严重并发症发生.[结论]BRYAN人工颈椎间盘置换治疗相邻双节段颈椎间盘退变性疾病临床疗效良好,不仅保留了颈椎的运动学特性,防止置换节段与相邻节段退变,而且术后近中期无严重并发症.     

人工髓核假体置换的临床疗效

[目的]探讨人工髓核假体置换治疗腰椎间盘突出症的临床效果。[方法]2002年4月至2004年5月，作者采用PDN人工髓核置换术治疗单节段椎间盘突出症25例，男性16例，女性9例；平均年龄28岁。突出节段分布为：L3、4 2例、L4、5 16例、L5S1 7例。所有病人均主诉典型的单侧坐骨神经痛，其中8例伴有腰痛。病人术前均经过3个月以上的保守治疗，且效果不满意。手术采用后正中入路标准髓核摘除术后，按假体植入要求准备椎间隙，植入适当型号的人工髓核假体。[结果]本组所有病例均经过1a以上的随访，平均随访17．7个月。按照MaeNab疗效标准评定，优16例，良7例，可1例，差1例，优良率为92％。[结论]临床随访结果显示了人工髓核假体置换术的短期临床疗效满意。应用时要注意适应证的把握、椎间隙的准备、假体型号的选择等关键问题。长期的临床效果还需进一步观察。     

人工腰椎间盘置换26例6年疗效分析

[目的]对人工腰椎间盘置换术的疗效进行临床和影像学评价。[方法]自1998年9月～2007年12月,应用SBCharit啨Ⅲ型假体对29例患者施行人工腰椎间盘置换术,对其中获得平均6.9年(3～9年)随访的26例30个节段假体进行疗效评价分析。26例患者中,男25例,女1例;平均年龄44.2岁(38～59岁);腰椎间盘退变性病变3例,腰椎间盘退变合并腰椎间盘突出症21例,腰椎间盘突出术后复发2例。VAS疼痛评分术前平均9.1分,Oswes-ty功能评分术前平均46.4分。所有患者均在全身麻醉下经腹壁前路行人工腰椎间盘置换术。22例行单节段置换,其中L4、58例、L4、5,L5S116例;二节段4例,均为L4、5和L5S1。本组分别在术前和术后1、3、6、12个月及末次随访时进行疗效分析。[结果]疼痛VAS评分:术后1、3、6和12个月分别为3.7、3.2、3.0和2.5分,2年时2.3分,末次随访时2.0分;Oswesty功能评分:术后1个月27.7分,术后3年9.7分,末次随访时7.4分,活动度:末次随访时1例活动度减小(4°),其余患者均有活动度,平均5.6°。所有患者术后无假体移位、松动和下沉;1例患者术后尚满意,总满意率96%。[结论]人工腰椎间盘置换术是治疗腰椎间盘退变的有效方法。     

人工椎间盘置换术治疗腰椎间盘突出症

目的 探讨人工腰椎间盘置换术治疗腰椎间盘突出症的临床效果。方法 自1999年12月～2001年12月对22例腰椎间盘突出症患者采用Link SB ChariteⅢ型人工椎间盘行椎间盘置换术,共置换假体30个,随访4～28个月（平均16个月）,分别于手术前后对患者的情况进行JOA评分。结果所有病例无术中并发症发生,术中出血100～800ml（平均320 ml）。术后第2d（早期病例为术后第7d）,患者可佩戴腰围下地,术后6周除去腰围恢复正常活动。术后X线片显示人工椎间盘位置正确,椎间隙高度恢复正常。患者腰腿痛症状消失,直腿抬高试验阴性。3例患者术后出现健侧肢体麻木。JOA评分较术前提高,差异有非常显著性意义（P<0.001）。无椎间盘假体脱落、失效,远期感染等术后并发症发生。结论 人工椎间盘置换术是治疗腰椎间盘突出症的有效方法,但应严格掌握手术适应证。     

人工腰椎间盘置换术中期疗效分析

目的 对人工腰椎间盘置换术的中期疗效进行评价分析.方法 1999年12月至2006年12月应用Charité SBⅢ假体对65例患者施行人工椎间盘置换术,对其中获得平均5.8年(2～7.5年)随访的48例52个假体进行疗效评价分析.48例患者中,男性22例,女性26例,平均年龄43岁(36～58岁);椎间盘退变9例,椎间盘退变合并椎间盘突出34例,椎间盘突出术后复发5例.VAS疼痛评分术前平均9.3分,Oswestry功能评分术前平均45.8分.所有患者均在全身麻醉下经前路行人工椎间盘置换术.44例患者行单间隙椎间盘置换,其中L3,43例,L4,523例,L5～S118例;双节段4例,其中L3,4和L4,51例,L4,5和L5～S13例.分别在术前和术后1、3、6、12、24个月和末次随访时进行疗效评定.结果 疼痛视觉模拟评分:术后1、3、6、12、24个月分别为4.3、4.3、3.8、3.1、2.6分,末次随访时1.8分;Oswestry功能评分:术后1个月28.6分,术后24个月12.5分,末次随访时8.2分;活动度:末次随访时仅1例患者丧失活动度,其余患者保留活动度,平均5.5°.所有患者术后无假体移位、松动及下沉;1例患者对手术不满意.总满意率为98%.结论 人工椎间盘置换术是治疗腰椎间盘退变的有效方法之一,其远期疗效有待进一步观察.     

人工颈椎间盘置换术后邻近节段退变情况的早中期随访

目的研究人工颈椎间盘置换术治疗颈椎病的临床疗效及邻近节段退变情况。方法 2008年1月-2010年10月,采用人工颈椎间盘置换术治疗颈椎病患者39例。其中男20例,女19例;年龄32～60岁,平均45.7岁。病程1个月～10年,平均30个月。其中脊髓型颈椎病26例,神经根型颈椎病11例,混合型颈椎病2例(神经根型加脊髓型)。单节段病变27例,双节段病变12例。使用Prestige假体9例、Prodisc-C假体4例、Discover假体26例。采用日本骨科协会(JOA)评分评价患者神经功能恢复情况,测量置换节段及邻近节段活动度(Cobb角变化),并采用Kellgren X线颈椎退变分级评估法对邻近节段颈椎间盘退变情况进行评价。结果所有患者均顺利完成手术,术后切口均Ⅰ期愈合。39例均获随访,随访时间12～36个月,平均23.1个月。末次随访时患者JOA评分较术前显著提高(P<0.05),置换节段及置换节段相邻上、下位节段活动度与术前比较差异均无统计学意义(P>0.05)。根据Kellgren X线椎间盘退变分级评价结果显示,末次随访时有5例患者出现退变情况改变,其中从无(0级)退变为轻度(1、2级)3例,由轻度1级退变到轻度2级1例,由轻度2级退变到中度(3级)1例,退变发生率为12.8%,但退变情况分级与术前比较差异无统计学意义(χ2=1.793,P=0.406)。术后15个月(32例患者)邻近椎间盘未发生退变情况。结论人工颈椎间盘置换术治疗颈椎病有良好疗效,可较好地保留置换节段及邻近节段活动度,并可能对邻近节段的椎间盘起保护作用。     

人工颈椎间盘置换与颈前路融合术治疗脊髓型颈椎病3年随访结果报道

[目的]比较人工颈椎间盘置换与颈前路减压植骨融合术治疗脊髓型颈椎病的3年随访结果。[方法]回顾性分析2004年11月²009年3月在本院接受手术治疗,并完成3年随访的65例脊髓型颈椎病患者。31例行人工颈椎间盘置换术,其中单节段置换26例,双节段置换5例,13例14个节段应用Bryan假体,18例22个节段应用Prestige LP假体,34例行颈前路减压植骨融合术,其中单节段融合28例,椎体次全切双节段融合6例。分别在术前,术后1周,术后12、24及36个月对患者进行SF-36生活质量量表、JOA评分、NDI评分、Nurick分级的评估,术后36个月采用Odom’s标准评价临床效果;在各随访时点采用颈椎正侧位X线片观察置入物的稳定性,并采用动力位X线片测量手术节段屈伸活动度;同时记录患者术中、术后并发症及二次手术的发生情况。[结果]两组患者的JOA评分、Nurick分级术后各随访时点较术前比较均有明显改善(P<0.05),两组之间差异无统计学意义(P>0.05),两组患者SF-36躯体评分及心理评分、NDI评分术后各随访时点较术前有明显改善(P<0.05),两组间比较,置换组优于融合组(P<0.05)。术后各随访时点置换组手术节段屈伸活动度维持在术前水平(P>0.05),而融合组手术节段屈伸活动度较术前明显下降(P<0.05)。置换组中2例患者发生假体前移,2例发生轻度异位骨化,1例因脑脊液漏接受二次手术。融合组中1例患者发生了假关节形成,6例存在供骨区的疼痛,3例因邻近节段退变接受二次手术。[结论]人工颈椎间盘置换术与颈前路减压植骨融合术治疗脊髓型颈椎病3年随访疗效均满意,且前者保留了手术节段运动功能,减少了融合导致的多种并发症。     

DISCOVER人工颈椎间盘假体置换术治疗颈椎病近期疗效分析

[目的]探讨应用DISCOVER人工颈椎间盘假体置换术治疗颈椎病的近期效果及并发症.并探讨DISCOV-ER人工颈椎间盘假体置换术的特点.[方法]2009年2月～2011年8月对14例颈椎病患者行DISCOVER人工颈椎间盘置换术.置换后1个月、末次随访时患者日本矫形外科协会评分(JOA)明显升高,随访时间为12 ～42个月,平均24.2个月,JOA评分由术前平均(10.8±1.2)分增至术后平均(14.2±1.5)分以及末次随访时的平均(15.6±0.6)分,颈项和上肢痛觉疼痛评分,术前与术后值统计有显著性差异,同时X线未发现假体松动、下沉或异位骨化等不良反应.[结论] DISCOVER人工颈椎间盘置换术治疗颈椎病近期疗效满意,但仍需长时间随访以评估其远期疗效.     

延长融合节段治疗腰椎滑脱合并相邻节段椎间盘退变的中期疗效

[目的]探讨延长融合节段治疗腰椎滑脱并相邻节段椎间盘退变患者的中期疗效.[方法]2002年9月～2007年9月本科对79例腰椎滑脱并相邻节段退变的患者实施后路延长融合节段植骨内固定术,通过对患者术前及术后不同时期JOA评分、VAS评分进行比较,调查术后患者满意率,复查X线片及CT观察植骨融合及脊柱稳定性.[结果]术后随访2～6.5年,平均4.6年.术后不同时期JOA评分明显高于术前(P<0.05),VAS评分明显低于术前(P<0.05).依据JOA评分及VAS评分标准评定疗效:优61例,良10例,可7例,差1例,优良率达89.87%,未出现滑脱畸形加重、内固定松动断裂、伤口感染及神经损伤加重、腰椎间盘突出复发及顽同性腰痛等.[结论]延长融合节段治疗腰椎滑脱并相邻节段椎间盘退变,术后中期疗效满意.     

脊柱前路手术的适应证

脊柱外科手术入路的选择常常取决于脊柱外科医师的手术技能。随着脊柱生物力学研究的深入、影像诊断技术的发展以及脊柱融合与内固定技术的进步 ,脊柱前路手术已作为许多脊柱疾患的常规治疗方法而逐渐普及。掌握适应证对于脊柱外科手术的成功至关重要 ,笔者就脊柱前路手术适应证的选择作一讨论。1　前方减压与稳定包括椎体和椎间盘在内的脊柱前部结构担负着脊柱的大部分生物力学功能 ,因而多数脊柱伤病系以累及脊柱前部结构为主。1.1　 感染与肿瘤　脊柱感染和肿瘤最容易累及的是椎体和椎间盘 ,经前路施行病灶清除及椎管减压手术常常为病情…     

侧方途径切除胸腰椎肿瘤和脊柱重建

目的探讨侧方入路手术途径切除胸腰椎肿瘤和重建脊柱稳定性的临床疗效和意义。方法29例T3～T4肿瘤患者，Frankel神经功能分级：A级3例，B级5例，C级7例，D级6例，E级8例。经侧方入路手术途径显露病椎前方、侧方和后方，切除肿瘤以及上下相邻椎间盘，然后根据肿瘤的具体情况进行不同肜式的脊柱稳定性的重建。结果围手术期无死亡病例，患者出院时Frankel神经功能分级，A级2例，B级3例．C级4例，D级4例，E级16例。术后获访23例，随访时间13～58个月，死亡4例；神经功能情况，13例较出院时有改善，加重1例。结论侧方入路手术途径无需经胸／腹膜腔，患者容易耐受手术，适合于某些胸腰椎肿瘤的切除和脊柱稳定性的重建。     

Atypical forms of spinal tuberculosis

Summary Twenty-three patients with atypical forms of spinal tuberculosis treated between 1975 and 1985, are described.All presented with signs and symptoms of compression of the spinal cord or cauda equina, ranging from paraesthesiae and increasing weakness of extremities to paraplegia and loss of sphincter control. None of them showed visible or palpable spinal deformity nor the typical radiographic appearance of destruction of the intervertebral disc and the two adjoining vertebral bodies. These atypical forms constituted about 12 percent of all the cases of spinal tuberculosis seen (a total of 190 cases); and fell into three well-defined groups: those with the involvement of neural arch only; those with the inolvement of a single vertebral body; and, those without bony involvement. The correct surgical approach in these groups was found to be different: spinal cord compression caused by the tuberculous disease of the neural arch was best treated by laminectomy; whereas single vertebral body disease required an anterior or anterolateral approach. Spinal computerized tomography was helpful in defining the extent of disease and planning the surgical approach. Histological confirmation of tuberculosis was obtained in all the cases and acid fast bacilli (A.F.B.) were found in, and cultured from, the biopsy specimens of 18 cases.     

Incidence and significance of findings on spinal MRIs in a paediatric population with spinal column complaints

PurposeWe sought to identify correlations between working diagnosis, surgeon indication for obtaining spinal MRI and positive MRI findings in paediatric patients presenting with spinal disorders or complaints.MethodsSurgeons recorded their primary indication for ordering a spinal MRI in 385 consecutive patients. We compared radiologist-reported positive MRI findings with surgeon response, indication, working diagnosis and patient demographics.ResultsThe most common surgeon-stated indications were pain (70) and coronal curve characteristics (63). Radiologists reported 137 (36%) normal and 248 (64%) abnormal MRIs. In total, 58% of abnormal reports (145) did not elicit a therapeutic or investigative response, which we characterized as ‘clinically inconsequential’. In all, 42 of 268 (16%) presumed idiopathic scoliosis patients had intradural pathology noted on MRI.Younger age (10.3 years versus 12.0 years) was the only significant demographic difference between patients with or without intradural pathology. Surgeon indication ‘curve magnitude at presentation’ was associated with intradural abnormality identification. However, average Cobb angles between patients with or without an intradural abnormality was not significantly different (39° versus 37°, respectively). Back pain without neurological signs or symptoms was a negative predictor of intradural pathology.ConclusionRadiologists reported a high frequency of abnormalities on MRI (64%), but 58% of those were deemed clinically inconsequential. Patients with MRI abnormalities were two years’ younger than those with a normal or inconsequential MRI. ‘Curve magnitude at presentation’ in presumed idiopathic scoliosis patients was the only predictor of intrathecal pathology. ‘Pain’ was the only indication significantly associated with clinically inconsequential findings on MRI.Level of evidence:III     

椎管内肿瘤的诊断及手术治疗

探讨椎管内肿瘤的临床特点及手方法。方法１０３例椎管内肿瘤患者均经手术治疗,颈椎行单开门术暴露椎管,胸椎行全椎板切除,腰椎椎则行次全椎板切队鹘椎椎管内外哑铃型肿瘤分别采用颈前路和肋骨横突切除术入路。结果随访８２例平均随访时间３．５年,优良率为８１．７％。     

MR-imaging of chronic spinal cord injury. Association with neurologic function

Twenty-two para- and tetraplegic patients with chronic spinal cord injuries were examined with magnetic resonance imaging (MRI). The clinical course in the entire rehabilitation period was recorded and an attempt was made to associate the functional status of the patients with the morphologic findings on MRI. Small and large spinal cord cysts and syringomyelia, cord atrophy, and spinal stenosis were found. Additionally, in a number of patients regions of increased signal intensity within the cord, interpreted as myelomalacia, and obliteration of the intradural extramedullary space, interpreted as arachnopathy, were noted. The large number (13/22) of cystic lesions in our patients was unexpected. It was in contrast to the rate reported in autopsy studies of paraplegics which note only few cysts. Whereas a direct association of morphologic findings with neurologic symptoms and the clinical course was difficult, it was found that patients with large cysts and spinal cord atrophy generally showed no tendency to improve in spite of the measures taken during the rehabilitation period. It is difficult to decide whether the initial trauma with cord hemorrhage is limiting the chance of neurological improvement or if a sequence of events leading from hemorrhage to gliosis and cystic necrosis is the determining factor.     

椎体成形术治疗老年骨质疏松脊柱压缩骨折

目的探讨椎体成形术治疗老年骨质疏松脊柱压缩骨折的疗效和安全性.方法在C臂X线机监测下对20例36个椎体行椎体成形术(均为后壁完整疼痛剧烈老年骨质疏松脊柱压缩骨折).观察术后症状改善情况,分析并发症.结果20例椎体成形术术后均未出现肺栓塞、神经损伤等并发症,CT检查无椎管内或椎间孔渗漏.术后随访5～18个月,17例疼痛消失,2例明显减轻,1例缓解.结论椎体成形术是治疗老年骨质疏松脊柱压缩骨折安全有效的方法.     

Somatosensory evoked potential

Summary Somatosensory evoked potentials (SSEPs) have been used to help minimize neurologic morbidity during spinal surgery. While this is a sensory test it has been used as an inference of motor function. The failure to always achieve the latter goal has resulted in some pessimism regarding the value of this test. In this series of 161 operations in 150 patients, it was demonstrated that SSEPs were recordable under anesthesia in 87% of patients. Of these patients, 12% had their spinal surgery interrupted due to significant neurophysiologic changes; of these patients, 18% had new neurologic deficits postoperatively. There were no cases with new neurologic deficits who had no changes in their SSEPs. It was concluded that SSEP monitoring may be helpful in identifying potentially neurologically threatening surgical maneuvers in a significant number of patients.     

胸腰椎爆裂骨折损伤部位和椎管内占位程度与神经损伤的关系

目的探讨胸腰椎爆裂骨折骨折部位及椎管内骨块占位程度与神经损伤的关系。方法对213例胸腰椎爆裂骨折根据骨折部位及CT测出的椎管内骨折骨块占位程度与神经损伤进行分析评定。结果神经损伤组椎管骨折骨块占位程度明显高于无神经损伤组;在有神经损伤情况下,骨折部位椎管内骨块占位程度腰段大于胸腰段;神经损伤程度与椎管内骨块占位程度无显著相关。结论胸腰椎爆裂骨折椎管内骨块占位压迫是神经损伤的重要因素;神经损伤与骨折部位和椎管内骨块占位程度联合相关。     

胸椎管狭窄症术后脊髓缺血再灌注损伤的临床分析

目的 探讨胸椎管狭窄症患者手术后出现脊髓功能受损的原因,总结脊髓手术后缺血再灌注损伤(spinal cord ischemic reperfusion injury,SCII)[1]的预处理和早期治疗方法.方法 回顾性分析我科2年内收治的32例胸椎管狭窄症患者术后脊髓恢复情况,出现脊髓损伤患者的临床资料及处理方法,并对其预后进行客观评估.结果 2年内在收治并手术的胸椎管狭窄症患者中,手术减压前给予1克甲基强的松龙预防.5例患者于手术后出现不同程度的脊髓功能受损,即刻给予大剂量甲基强的松龙冲击治疗、脱水药及神经营养药,1例患者症状改善不理想,2例患者症状部分改善,生活可自理,2例患者基本恢复正常.结论 胸椎管狭窄症患者手术后出现的脊髓功能受损可能是脊髓缺血再灌注损伤引起,再灌注损伤在胸椎管狭窄症患者中较多见,但出现严重监床症状的少见,诊断有一定的困难.妥善的处理可望改善患者的生存质量.