Titanium wire internal fixation for stabilization of injury of the cervical spine: clinical results and postoperative magnetic resonance imaging of the spinal cord

Nine patients with dislocation of the cervical spinal with posterior ligamentous damage were treated with posterior internal fixation using a twisted pair of 22-gauge titanium wires and iliac crest bone fusion. Fixation using the titanium wire was compared with fixation using stainless steel wire for differences in surgical insertion, long term stability of bony fusion, and postoperative magnetic resonance imaging (MRI) artifacts near the implanted wire. MRI of the cervical spine is valuable for diagnosing the acute and chronic consequences of traumatic cervical spinal injury by providing anatomic evaluation of both the spinal cord and the supporting bony/ligamentous structures in the neck. Because MRI is an accurate and sensitive noninvasive test, it is especially useful for the long-term serial assessment of the region near the cervical dislocation site to detect the sequelae of spinal cord injury, including syrinx, arachnoid cyst, cord tethering, and persistent mechanical impingement on the spinal cord or spinal roots. Previous attempts at our institution to obtain useful MRI scans of the cervical region adjacent to stainless steel wires after posterior wire fixation have failed due to marked imaging artifacts from the ferromagnetic properties of these wires. Our substitution of biocompatible titanium wire (Titanium 6 A1-4V ELI alloy, Specialty Steel and Forge, Leonia, New Jersey) for stainless steel wire produced identical immediate stabilization and ultimate bony fusion of the fracture and yielded minimal MRI artifacts overlying the immediately adjacent spinal cord and neural canal; however, the installation was technically more difficult, because of the titanium wire's greater stiffness.(ABSTRACT TRUNCATED AT 250 WORDS)     

Magnetic resonance imaging after pedicular screw fixation of the spine.

Magnetic resonance imaging (MRI) of the thoracolumbar spine is valuable in the diagnosis of acute and chronic spine injuries. It allows evaluation of the nerve roots, spinal cord, and the supporting bony and ligamentous structures. Magnetic resonance imaging can be used to detect sequelae of spinal cord injury and any mechanical impingement on the spinal cord or nerve roots. Pedicular screw fixation of the spine is becoming the procedure of choice for stabilization of the lumbar spine, yet it limits the postoperative use of MRI because of marked imaging artifacts arising from the ferromagnetic properties of the used stainless steel implants. The authors have compared extensive artifacts produced by the stainless steel implants with those produced by titanium implants. Titanium implants produced fewer artifacts in the spinal canal. The use of MRI compatible materials in thoracolumbar spine stabilization would permit detailed examinations by serial MR imaging.     

The Utility of 3D Ultramicroscopy for Evaluating Cellular Therapies After Spinal Cord Injury

Cell therapies have shown promise for repairing the injured spinal cord in experimental models and are now being evaluated in clinical trials for the treatment of human spinal cord injury (SCI). To date, experimental evaluation of implanted cell survival, migration, and integration within the injured central nervous system (CNS) of animals has been technically demanding, requiring tissue sectioning, staining, imaging, and manual reconstruction of 2-dimensional (2D) specimens in 3 dimensions (3D). Not only are these histological procedures laborious and fraught with processing artifacts during manual 3D reconstruction, but they are time-intensive. Herein we describe the utility of 3D ultramicroscopy for assessment of cell therapies after SCI, a new state-of-the-art imaging modality in which whole brain and spinal cord samples are optically sectioned to allow evaluation of intact, macroscopic specimens with microscopic resolution.     

高渗盐水治疗脊髓急性压迫损伤的实验研究

目的观察高渗盐水对脊髓损伤的治疗作用,并探讨其作用机制.方法 36只SD大鼠造成T10节段脊髓急性压迫损伤后,随机分为三组:高渗盐水治疗组、生理盐水治疗组及对照组,每组观察损伤后1、4周两时间段;评价动物神经功能,观察各时间段脊髓病理改变,计算脊髓残留组织保留率.结果①高渗盐水治疗组动物神经功能恢复更快、更完全,与生理盐水组及对照组相比差异有显著意义(P＜0.05);②损伤后1周,高渗盐水治疗组脊髓组织炎症反应、水肿明显减轻;③损伤后4周,高渗盐水治疗组脊髓残留组织保留率显著增加,与其它两组相比差异有显著性意义(P＜0.01).结论高渗盐水能减轻脊髓组织病理改变,促进神经功能恢复;减轻损伤后脊髓组织的炎症反应及水肿是其作用机制之一.     

Orthopedic management of the patient with a spinal injury

I have tried to make clear that there are no absolute principles in the orthopedic management of patients with a spinal cord injury. Although debate continues regarding the approach to the problem, the goals remain optimal patient care, free of complications, and preparation for a smooth transition of the patient into a new life with handicaps. Most strides in spinal cord injury care have been made in improvement of internal fixation and immobilization, advances in rehabilitation techniques and marked shortening of hospitalization. Active research continues to investigate the pathophysiology of the injury and a means of reversing or impeding the damage to neural tissue. Currently, certain spinal cord injuries are considered irreversible despite treatment with spinal cord hypothermia, reanastomosis of spinal cords or administration of enzyme injections. The person with a spinal cord injury and paralysis rarely loses the hope that a cure might be the next great discovery of medical science and active spinal cord injury research centers have the same goal.     

经后路一期全脊椎切除治疗胸椎肿瘤

目的 探讨后正中入路行上胸椎肿瘤全脊椎切除的可行性及疗效.方法 采用后正中入路行上胸椎肿瘤切除,环脊髓减压,植骨融合内固定重建脊柱稳定性.结果 无术中死亡及脊髓医源性损伤等并发症.随访8～18个月,1例转移肿瘤患者术后6个月颅内转移于10个月后死亡,余未见肿瘤复发.脊髓功能恢复情况:术后6个月,A级2例恢复至E级1例、D级1例;B级1例恢复至D级;C级2例均恢复至E级.所有患者术后局部疼痛症状均明显缓解.复查X 线片未发现脊柱失稳现象,内固定材料无断裂.结论 经上胸椎后正中入路切除上胸椎肿瘤,创伤相对较小,手术视野显露清楚,内固定容易操作,肿瘤切除彻底,并发症少,是一种切除上胸椎肿瘤理想的手术方法.     

Anterior and posterior cervical spine fixation using titanium implants to facilitate magnetic resonance imaging evaluation

Magnetic resonance (MR) imaging of the cervical spine is useful in the evaluation of both acute and chronic injuries to the spinal cord and meninges as well as in demonstration of mechanical impingement on the spinal canal and nerve roots. Anterior or posterior plate fixation of unstable cervical spine injuries has limited the postoperative use of MR imaging due to the extensive magnetic field distortion produced by the stainless steel implants commonly used in these procedures. We have compared titanium implants in a cadaver against stainless steel implants in two patients and show no significant MR artifacts produced in the spinal canal by titanium plates as opposed to extensive image distortion and obliteration by the steel plates. We recommend consideration of titanium (Ti6A14V) as a substitute for stainless steel in cervical spine fixation to preserve the option of subsequent examination by MR scanning.     

Delayed transplantation of foetal cerebral tissue into injured spinal cord of adult rats

Summary Delayed transplantation of foetal cerebral tissue into injured spinal cord of adult rats was performed for the purpose of evaluating the usefulness of the procedure for reconstructing the spinal cord and providing motor recovery. Transplanted tissue showed a survival rate greater than 80% and integration with the host tissue. Nerve fibers of the host surrounded the transplanted tissue, penetrating it. Foetal cerebral neurons matured into recipient spinal cord, but they were not organized in layers. The experience obtained suggests that delayed transplantation of foetal cerebral tissue into contused spinal cord is useful in morphological spinal cord reconstruction. Nevertheless, at least during the first two months after transplantation, clinical assessment of motor recovery showed no differences between transplanted and nontransplanted rats.     

颈椎椎弓根钉固定结合单开门椎管扩大成形治疗颈椎管狭窄伴无骨折脱位型颈脊髓损伤的临床研究

目的探讨颈椎椎弓根钉固定结合单开门椎管扩大成形治疗颈脊髓前方无局限性压迫、颈椎不稳定的颈椎管狭窄伴无骨折脱位型颈脊髓损伤的临床疗效。方法自2006-06--2011-03纳入颈椎管狭窄伴无骨折脱位型颈脊髓损伤44例。包括脊髓中央综合征26例,前脊髓损伤综合征12例,Brown-Sequard综合征4例,其他2例。结果所有患者均顺利完成手术。获12—60个月随访40例,平均（25．2±17．6）个月,末次随访时JOA脊髓功能评分改善率为68．5％;但双上肢功能恢复较差,出现双手不同程度肌肉萎缩5例;X线片检查显示颈椎生理曲度良好,无断钉、断棒及颈椎失稳;CT检查显示螺钉位置良好,椎管扩大成形满意,无门轴断裂及再关门。结论颈椎椎弓根钉固定结合单开门椎管扩大成形治疗颈脊髓前方无局限性压迫、颈椎不稳定的颈椎管狭窄伴无骨折脱位型颈脊髓损伤可取得较满意疗效。     

脊柱脊髓损伤的修复重建研究进展

目的阐述脊柱、脊髓损伤最新研究及治疗进展.方法广泛查阅文献,并结合研究及临床经验,总结近几年脊柱、脊髓损伤的研究动向及临床应用结果.结果后路寰枢椎固定技术由既往的侧块关节直接螺钉内固定术发展到今天较为常用的寰枢椎椎弓根或侧块螺钉相组合的钉板、钉棒内固定技术.经口咽入路寰枢椎复位钢板固定术能较好解决难复性环枢椎脱位的问题.胸腰椎骨折的手术入路、固定节段、融合方式等目前仍没有统一的标准,只要条件允许,前路和后路手术均能达到有效减压和稳定重建的目的.单节段骨折固定术较既往的跨节段固定术有一定优势.内窥镜辅助下或影像介导下的脊柱诊疗技术在我国逐渐开展.对治疗顽固疼痛性骨质疏松性压缩骨折患者,国内紧跟国外潮流及时开展经皮椎体成形术和后凸成形术,以重建椎体高度,修复椎体稳定性,改善症状,提高生活质量.相关的基础和临床研究使人们对急性脊髓损伤的药物治疗有了重新认识,而生物学治疗方法为神经的修复再生提供了新的思路,其中细胞移植和基因疗法是极有前景的治疗策略.结论随着脊柱外科的飞速发展,脊柱脊髓损伤的修复重建取得了长足的进步.     

以椎间盘坏死突出为主脊柱结核的手术治疗

目的探讨临床上以椎间盘坏死突出为主的胸腰椎脊柱结核的致病机制、临床特点及外科治疗方法。方法对22例结核病灶局限于椎间盘组织的胸腰椎脊柱结核患者,采用彻底病灶清除、椎管减压、植骨及选择性前路或后路器械内固定手术,并分析手术适应证、疗效及外科治疗特点。结果术后随访9个月～5年,平均3.8年。21例结核病灶清除彻底,结核治愈无复发。合并不全瘫6例中,术前Frankel分级C级1例恢复至E级,1例恢复至D级;D级4例中恢复至E级3例,1例无变化,2例大小便功能障碍者均恢复正常。结论结核性椎间盘坏死及突出时对脊髓造成压迫和损伤,来自结核病灶的机械性直接压迫和结核炎性刺激所致的脊髓硬膜组织变性两个方面,早期手术可有效减轻脊髓进行性损伤。     

复位内固定治疗脊柱骨折脱位合并脊髓损伤

本文报告1989年3月至1990年1月外院转入我院53例脊柱骨折脱位合并脊髓损伤患者,其中50例曾行手术治疗。结果,复位:向后成角平均20.5°,37例有成角,占70％;椎体移位平均0.5cm,47例有移位,移位率88％。固定:53例中仍存有内固定者18例,有11例内固定失败,占61％。减压:27例做核磁检查,有椎管狭窄脊髓受压者19例占70.4％。我院1981～1989年对32例新鲜脊柱骨折脱位进行复位内固定术。结果,复位:完全复位24例(75％),大部复位6例(19％),部分复位2例(6％)。内固定:无改变29例,3例失败,占9％。通过对比分析,提出充分复位、减压及有效内固定的重要性。     

Spinal cord distraction: an in vitro study of length, tension, and tissue pressure.

Since the Scoliosis Research Society released a report on cord injury related to Harrington rod instrumentation for scoliosis, little has been published on the pathophysiology of this disorder. Dolan et al. (4) described diminished cord blood flow associated with spinal distraction in a cat model, but failed to demonstrate its cause. In this article, we describe a series of in vitro experiments performed on dog and sheep cadaver spinal cords. Controlled distractive forces were applied to spinal cords while monitoring both cord interstitial pressure and cord elongation. A close (Ravg = 0.986) correlation was noted between applied tensile forces and cord interstitial pressure. At 1,000-g loads, the average tissue pressure obtained was 29.5 cm H2O, ranging from 17 to 47 cm H2O. However, it was noted that the cord demonstrated nonlinear tensile elastic properties that appeared exponential in the range examined. These properties are consistent with those described for collagen-containing compounds. We conclude that spinal cord distraction is capable of generating cord tissue pressures that could cause a spinal cord compartment syndrome and thereby seriously impair spinal cord blood flow causing spinal cord injury.     

脊柱夏科氏关节病的诊断与治疗

脊柱夏科氏关节病是一种罕见的具有进展性的严重的退行性脊柱疾病。其临床表现隐匿且不典型,容易导致漏诊、误诊,延误病情,影响预后。目前国内尚无系统性分析脊柱夏科氏关节病的文献。脊柱夏科氏关节病的病因主要分为脊髓损伤及非损伤性神经病变两类,其中脊髓损伤引发脊柱夏科氏关节病的危险因素包括长节段固定、脊柱侧凸、椎板切除、脊柱负荷过大的运动和肥胖。脊柱夏科氏关节病好发于下胸椎或腰椎,常见症状是脊柱畸形、坐姿不平衡和局部疼痛。根据潜在疾病引起本体感觉及痛温觉损害,影像学上大量的骨破坏和吸收以及大量新骨形成,组织学提示非特异性慢性炎症,并排除其他炎性和肿瘤性疾病,可以作出诊断。对稳定性好、未合并感染、神经功能平稳、未出现皮肤瘘口、坐姿不平衡或自主神经功能紊乱的脊柱夏科氏关节病患者,可以考虑保守治疗。对症状持续大于6个月、脊柱不稳定、皮肤出现瘘口或并发感染的患者建议优先选择手术。术前应评估髋关节的异位骨化或强直,术中重视病灶内坏死组织、炎症组织的充分清除以及足量的植骨,建议融合至骶骨或骨盆。术后并发症包括内固定失败、新的夏科氏关节形成、伤口愈合困难、感染等。对脊髓损伤合并截瘫的术后患者,建议定期、系统、长期随访,观察整体胸腰椎而非仅仅手术部位的影像。熟知脊柱夏科氏关节病的危险因素及典型症状,有助于早期发现和诊断,并选择适当的治疗方案。     

急性脊髓损伤MRI影像学评价

目的23例急性脊髓损伤病人在伤后一周内行MRI检查,表现为脊髓受损区T2加权高信号T1加权等或低信号.方法同时对不同损伤程度及不同预后的患者进行比较.脊髓损伤程度、水肿范围、脊髓受压、髓内出血与预后有关,认为MRI检查对判断脊髓损伤程度、指导治疗及判断预后有一定作用.结果认为在脊髓损伤中MRI是一种很有价值的检查手段.通过MRI检查可将脊髓损伤分为两类脊髓受压型和非受压型.T2加权高信号范围大小是估计预后的简便方法,治疗上以脊髓内外联合减压以及防止脊神经进一步损害.结论早期诊断、早期固定牵引及手术是重要的.     

保留后结构环状减压手术治疗急性胸腰段脊柱损伤

目的探讨保留脊柱后结构环状减压复位内固定的手术方法,治疗急性胸腰段脊柱脊髓损伤的临床效果.方法对38例急性脊柱脊髓损伤伴不全瘫痪的病例进行椎管内骨块复位,环状的脊髓及神经根减压,保留棘突、棘间韧带、小关节的手术方法治疗.结果随访31例,时间10～42个月,平均16个月,按Frankel分级,术后神经功能恢复3级者5例,2级者24例,1级者2例.结论对于急性脊柱脊髓务的病例,应用保留脊柱后结构环状减压内固定的方法,是兼顾脊髓减压的彻底性和保持脊柱稳定性较为合理、有效的手术方法.     

Hypothermia in spinal surgery

The authors present the clinical and experimental substantiation of the method of local cooling of the cerebrospinal formations and the evaluation of its efficiency in various surgical interventions on the spinal column and the spinal cord. The method of performing local hypothermia of the spinal cord in 64 patients is described. Having compared three versions of local cooling, the authors recognize that the optimum method was that with the cooling element placed directly on the dura mater and with compulsory neurovegetative protection during the performances. The high efficiency of local hypothermia of the spinal cord was confirmed by rapid stabilization during the postoperative period of the values of central hemodynamics and the oxygen budget of the patients' organisms, while there was regression of the neurologic deficiency, prevention and arresting of the brain tissue edema and analgesia.     

前路减压、钛网支撑植骨、Z-Plate钢板内固定治疗陈旧性胸腰段脊柱骨折

目的 探讨陈旧性胸腰段脊柱骨折伴脊髓损伤的前路减压和应用Z-Plate钢板内固定及钛网支撑植骨的优点。方法 对48例陈旧性胸腰段脊柱骨折伴脊髓损伤的病例进行回顾性分析。结果 48例均行前路椎管减压、钛网支撑植骨及Z-Plate钢板内固定。平均随访时间16．5个月,术后椎体间均获骨性融合,95．8％患者神经功能有不同程度恢复,平均改善1．1级,无并发症发生。结论 该方法可充分利用切除的肋骨和减压碎骨块进行植骨,避免取自体髂骨,纠正脊柱后凸,提高椎体问融合率,以重新获得脊柱的稳定性。     

Retro-odontoid soft tissue mass associated with atlantoaxial subluxation in an elderly patient: a case report

BACKGROUND: We present the case of an elderly patient with a retro-odontoid soft tissue mass associated with atlanto-axial subluxation. CASE DESCRIPTION: A 74-year-old man was admitted to our hospital with progressive motor weakness in his right arm and neck pain. Radiological examinations revealed atlantoaxial subluxation and diffuse degenerative changes. Cervical MRI revealed a syrinx at the C1 level and a retro-odontoid soft tissue mass that severely compressed the spinal cord. The mass was of low signal intensity on both T1- and T2-weighted images. Conservative therapy could not stop the progression of his symptoms, so posterior decompression via a laminectomy of C1 and occipitocervical fixation was performed. These procedures resulted in an improvement of his neurological condition and in reduction of the mass and the compression of the spinal cord. CONCLUSION: The patient lacked any specific conditions that might have caused chronic atlantoaxial subluxation. The degenerative changes alone might have provoked chronic atlantoaxial subluxation and a subsequent retro-odontoid soft tissue mass. In patients with this condition, posterior fixation without direct removal of the mass should be the first choice for surgical intervention.     

Heme oxygenase-1 expression after spinal cord injury: the induction in activated neutrophils

Tissue damage and neurological dysfunction after spinal cord injury may result, in part, from delayed or secondary mechanisms that appear to involve several endogenous factors. Among them, neutrophils are known to play important roles in the pathomechanisms of the secondary injury, that is, neutrophils are activated by an interaction with the endothelial cells, migrate into the damaged tissue and release several kinds of proteases or oxygen radicals. In the present study, we examined heme oxygenase-1 expression in the damaged spinal cord. The administration of an inhibitor of heme oxygenase-1 in vivo produced a delayed recovery of motor function after spinal cord injury, suggesting that heme oxygenase-1 may play roles as an endogenous anti-inflammatory enzyme and protective gene in the damaged and inflammatory tissue. We found that many neutrophils expressing heme oxygenase-1 mRNA and protein were recruited into the damaged spinal cord with extensive hemorrhages during early stage of spinal cord injury. In an in vitro study, neutrophils incubated with proinflammatory cytokines, such as interleukin-1, 6 or interferon-gamma, expressed heme oxygenase-1 mRNA and protein. Based on these findings we conclude that the activated neutrophils can express heme oxygenase-1 in the injured spinal cord tissue, perhaps expecting modulatory and neuroprotective actions in the inflammatory response to spinal cord injury.