腰椎后路手术对其稳定性的影响

目的 从生物力学角度探讨不同的腰椎后路手术对其稳定性的影响。方法 采用新鲜入体脊椎骨制作成双侧开窗、小关节内侧半切除、小关节全切、全椎板减压及全椎板减压合并小关节全切共5种手术模型，利用脊柱三维运动实验系统进行稳定性的测试和分析，并与正常组进行比较。结果 脊椎全椎板切除及双侧开窗对腰椎稳定性影响不显著，小关节部分或者全部切除则显著影响腰椎的侧弯、前屈和旋转活动度。结论 腰椎手术应尽量避免损伤小关节，以维护腰椎稳定性，减少术后并发症的发生。     

应用超声骨刀行腰椎后路椎板切除术与传统手术技术的对比研究

目的 :探讨应用超声骨刀行腰椎后路椎板切除术的效果及安全性。方法 :总结分析2015年2月~2016年11月由北京大学国际医院完成的腰椎手术病例共计85例,A组为采用超声骨刀行腰椎后路椎板切除的62例患者,其中28例由具备2年脊柱外科手术经验的医师c完成(Ac组),34例由具备25年脊柱外科手术经验的医师d完成(Ad组);B组为采用传统操作器械行腰椎后路椎板切除术的23例患者,其中10例由医师c完成(Bc组),13例由医师d完成(Bd组)。所有病例术前诊断均为腰椎管狭窄症,手术切除腰椎椎板共计119节段,手术方式均采用后路腰椎体间融合术(posterior lumbar interbody fusion,PLIF),实时记录术中椎板切除时间,手术出血量,统计术中硬膜损伤及神经根损伤等并发症发生情况,手术前1d及术后1周行ODI评分评估患者症状缓解情况。结果:A组椎板切除平均耗时分别为3.24±0.80min(Ac组)和3.48±0.82min(Ad组);B组椎板切除平均耗时分别为18.84±4.21min(Bc组)和3.72±1.03min(Bd组),Bc组手术耗时较其他组显著延长(P0.05)。术中出血量、各组手术前后ODI及VAS改善情况无显著统计学差异(P0.05)。A组硬膜损伤2例,B组1例,Ad组神经根损伤1例。结论:采用超声骨刀行腰椎后路椎板切除术具备可行性,应用超声骨刀并没有增加硬膜损伤及神经根损伤的发生率,相对于应用骨刀及椎板咬骨钳等普通器械切除腰椎椎板,超声骨刀技术更加容易掌握,学习曲线更短。     

改良腰椎单椎全椎板切除对脊柱稳定性的影响

目的探讨改良的腰椎单椎全椎板切除手术对脊柱的稳定性的影响。方法应用保留棘突和棘上、间韧带,单椎全椎板切除的方法,治疗中央型椎间盘突出32例,并对所有病例统一标准摄X线片,Posner标准判定脊椎稳定性。结果术后康复功能评价结果:优67.7%,良21.3%,差11.0%。Posner标准判定结果:无椎体失稳和滑脱发生。结论改良的腰椎单椎全椎板切除手术对脊柱的稳定性的影响小。     

腰椎板切开关闭术治疗椎管内肿瘤

目的　探讨椎管内肿瘤后路手术方法的改进和临床疗效。方法　对 2 1例患者采用腰椎板切开、肿瘤切除椎板关闭手术。结果　肿瘤全部切除 18例 ,部分切除 3例。随访半年以上者 ,17例患者腰痛消失 ,复查 X光线见脊柱稳定性好。结论　该术式对椎管内肿瘤的治疗彻底 ,能有效地防止全椎板切除术后脊柱稳定性差、纤维瘢痕粘连的并发症     

全脊柱植骨融合内固定治疗腰椎滑脱症

目的: 探讨腰椎滑脱症的手术治疗方法。方法: 1999年 4月~2003年 6月采用全脊柱植骨 (全椎板切除, 椎管减压, 后路“H”型植骨 椎间、横突间植骨融合 ) RF内固定治疗腰椎滑脱症 35例。结果: 随访 1~3年, 平均 30个月。根据日本骨科学会腰背痛手术评分标准评定, 优 24例, 良 9例, 可 2例。结论: 全脊柱植骨 (全椎板切除, 椎管减压, 后路“H”型植骨 椎间、横突间植骨融合) RF内固定治疗腰椎滑脱症, 既能彻底解除脊柱、神经根的压迫, 又能通过重建椎管维持脊柱的稳定性, 恢复椎间隙高度, 阻止术后椎板切除膜的形成, 达到治疗的目的。     

胸腰椎三柱同时损伤内固定方法的实验与临床初步观察

利用传感器及电测技术,采用新鲜人体胸腰段脊柱标本,评价后路短节段内固定器Steffee钢板、前路Kaneda器械、前路Kaneda与后路CD棒联合应用及后路节段性椎板下钢丝固定哈氏撑开棒四种手术在植骨状态下,治疗脊柱完全性三柱损伤提供的生物力学稳定能力。Steffee、Kaneda器械及节段性椎板下钢丝固定的哈氏撑开棒手术在这种严重损伤类型各有力学弱点,Steffee后伸、Kaneda前屈、节段性椎板下钢丝固定的哈氏撑开棒旋转明显失稳,前后路联合手术在轴压、前屈、后伸、侧弯、旋转五种运动方式皆能提供良好的稳定性。以此方法治疗1例腰椎半椎体切除与1例腰椎肿瘤全切除,随访1年,脊柱稳定,植骨融合满意。作者建议,在脊柱三柱损伤时宜采用前后路联合固定手术。     

Bioflex弹性椎弓根钉内固定系统对全椎板切除术与椎间植骨融合术后腰椎活动范围的影响

[目的]比较施行全椎板切除术后Bioflex弹性椎弓根钉内固定与传统刚性椎弓根钉内固定对腰椎活动范围的影响,为临床应用选择提供实验依据.[方法] 12具新鲜小牛脊柱标本,随机平均分为弹性内固定组和刚性内固定组,首先测试术前腰椎活动范围,再按照后路全椎板切除术式行硬膜囊和神经根减压手术,分别安装弹性椎弓根钉内固定与刚性椎弓根钉内固定,再比较同一标本减压术前术后活动范围差异.最后两组均进行PLIF手术,比较同一标本融合术前术后活动范围差异.[结果] Bioflex弹性椎弓根钉内固定系统与传统刚性椎弓根钉内固定系统相比,更能有效的保留全椎板切除术后的正常腰椎活动功能和提供足够的稳定性,有效减少椎间植骨融合区应力遮挡.[结论] Bioflex后路弹性内固定系统是一种后路椎节动态稳定装置,可充当椎体后方附件与韧带的功能;且比传统的刚性椎弓根内固定更有效的保留术后腰椎的活动范围和提供足够的稳定性,能有效的提高融合率.     

经后路用骨刀行脊髓前减压术治疗外伤性截瘫25例报告

[目的]介绍经后路用骨刀行脊髓前减压术的手术方法。[方法]经后路行单侧半椎板、椎弓根入路，保留脊神经根和硬膜管，切除椎体后缘压迫脊髓的骨块，同时行椎体间植骨内固定。[结果]对25例创伤性截瘫和不全截瘫病人行后路脊髓前减压术，疗效优良率达72％。[结论]采用田氏脊柱骨刀经后路行脊髓前减压治疗创伤性截瘫和不全截瘫的手术方法，要比单纯后路全椎板切除减压脊髓的手术方法，疗效明显提高，是值得推广应用的一种治疗手段。     

后路椎板切除入路手术治疗椎管内神经鞘瘤的疗效

目的:探讨后路椎板切除入路手术治疗椎管内神经鞘瘤的临床疗效。方法:我院2005年1月~2011年1月收治71例椎管内神经鞘瘤,男39例,女32例,年龄25~99岁,平均51.6岁;颈段22例,胸段24例,腰、骶段25例,3例肿瘤位于髓内,66例位于髓外硬膜下,2例位于硬膜外。均行后路椎板切除入路手术治疗,术中57例采用半椎板切除,6例行全椎板切除,2例行多节段半椎板切除,6例行半椎板联合患侧关节突关节切除以完全暴露肿瘤组织,切除肿瘤;其中载瘤神经根与肿瘤无法分离而一并切除者9例;14例行全椎板切除或多节段半椎板切除或半椎板联合患侧关节突切除者采用脊柱内固定及植骨融合术。术后随访8~70个月,观察临床疗效,复查X线片观察脊柱稳定性及植骨融合情况,复查MRI观察肿瘤有无复发。结果:手术时间2~6h,平均3.5h;术中出血量300~800ml,平均450ml。71例患者肿瘤均获完全切除,术后均经病理检查证实为神经鞘瘤。术中无脊髓神经损伤。术后12例患者出现不同程度脑脊液漏,4例患者出现脊髓缺血再灌注损伤,给予对症治疗后康复。随访期内(8~70个月)全部患者临床症状及神经功能均有明显改善,复查MRI未见肿瘤残留或复发。14例采用脊柱内固定及植骨融合术患者植骨融合,内固定稳定。随访期间所有患者未见椎体滑脱、失稳现象。结论:后路椎板切除入路能充分暴露肿瘤,有利于完全切除肿瘤,采用此入路手术治疗椎管内神经鞘瘤临床疗效满意。     

有限椎板切除减压与全椎板切除减压内固定术治疗腰椎管狭窄症的疗效对比(英文)

[目的]探讨采用有限椎板切除减压后路椎弓根螺钉内固定术与传统全椎板切除减压后路椎弓根螺钉内固定术治疗腰椎管狭窄症的疗效并进行对比研究。[方法]在63例腰椎管狭窄症患者中(年龄52⁶8岁,平均61.3岁),30例采用有限椎板切除减压后路椎弓根螺钉内固定术,33例采用传统全椎板切除减压后路椎弓根螺钉内固定术。观察两组手术时间、出血量及并发症的差异。术前、术后随访时分别采用ODI和VAS评分进行相关功能评价。随访时间最少为2年。[结果]两组患者术后下肢痛VAS、ODI评分较术前均明显下降,无明显差异。但有限椎板切除减压组患者的腰背痛VAS评分明显优于全椎板切除减压组(P<0.01),并且其手术时间和出血量明显少于后者。[结论]两种手术方法对腰椎管狭窄症患者均有较好的效果。但有限椎板切除减压术治疗下腰痛效果明显优于全椎板切除减压术,前者术中创伤较少,手术时间短,出血量少,且保留了竖脊肌、棘突、棘间和棘上韧带,并对这些脊柱后部结构元素进行解剖重建,起到了维持术后腰椎稳定的作用。     

腰椎管潜行扩大桥式椎管成形术

传统的全椎板切除减压术治疗腰椎管狭窄症，不仅影响脊柱的稳定性，还可能并发腰椎管继发狭窄．作者采用腰椎管潜行扩大桥式椎管成形术治疗１５例，优良率为９３．４％。本术式特点：１．充分扩大椎管，包括神经根管。２．不破坏脊柱稳定性。３．保持原腰椎活动范围、４．不再形成新的压迫．     

保留后韧带结构的椎管成形术治疗腰椎管狭窄症

目的；探讨使椎板开门椎管扩大成形术更完善的方法。方法：设计保留后韧带结构的椎板开门椎管扩大成形术治疗椎管狭窄症107例，结果：术后矢状径平均为1．7cm，平均扩大0．75cm，截面积平均1．86cm^2，平均增加0.91cm^2，随访87例，时间为术后5－8年，疗效评定：优64例，良23例。结论：后韧带结构为坚韧有弹性的骨－韧带条，在维护脊柱稳定的过程中，有无法替代的价值，术式既有后路手术直视减压的优点，又有效地扩大椎管撩状径，增加截面积，术后脊柱较稳定。     

不同开窗潜行减压术治疗腰椎管狭窄症

采用单纯开窗、间断开窗、连续开窗和交叉开窗潜行减压治疗腰椎管狭窄症173例,随访了168例,优良率达92.7％。不同开窗潜行减压具有手术创伤小,较好地保留了腰椎后部结构,既解除了对马尾和神经根的压迫因素,又维持了腰椎稳定性及其活动程度,减少了瘢痕粘连,达到了椎管减压的目的。临床随访表明不同开窗优于传统的椎板切除术。     

Spinaplasty following lumbar laminectomy for multilevel lumbar spinal stenosis to prevent iatrogenic instability

Background:

Iatrogenic instability following laminectomy occurs in patients with degenerative lumbar canal stenosis. Long segment fusions to obviate postoperative instability result in loss of motion of lumbar spine and predisposes to adjacent level degeneration. The best alternative would be an adequate decompressive laminectomy with a nonfusion technique of preserving the posterior ligament complex integrity. We report a retrospective analysis of multilevel lumbar canal stenosis that were operated for posterior decompression and underwent spinaplasty to preserve posterior ligament complex integrity for outcome of decompression and iatrogenic instability.

Materials and Methods:

610 patients of degenerative lumbar canal stenosis (n=520) and development spinal canal stenosis (n=90), with a mean age 58 years (33–85 years), underwent multilevel laminectomies and spinaplasty procedure. At followup, changes in the posture while walking, increase in the walking distance, improvement in the dysesthesia in lower limb, the motor power, capability to negotiate stairs and sphincter function were assessed. Forward excursion of vertebrae more than 4 mm in flexion–extension lateral X-ray of the spine as compared to the preoperative movements was considered as the iatrogenic instability. Clinical assessment was done in standing posture regarding active flexion–extension movement, lateral bending and rotations

Results:

All patients were followed up from 3 to 10 years. None of the patients had neurological deterioration or pain or catch while movement. Walking distance improved by 5–10 times, with marked relief (70–90%) in neurogenic claudication and preoperative stooping posture, with improvement in sensation and motor power. There was no significant difference in the sagittal alignment as well as anterior translation. Two patients with concomitant scoliosis and one with cauda equine syndrome had incomplete recovery. Two patients who developed disc protrusion, underwent a second operation for a symptomatic disc prolapse.

Conclusion:

Spinaplasty following posterior decompression for multilevel lumbar canal stenosis is a simple operation, without any serious complications, retaining median structures, maintaining the tension band and the strength with least disturbance of kinematics, mobility, stability and lordosis of the lumbar spine.     

保留脊柱后韧带复合结构多椎板切除的临床应用

本文报道196例腰椎管狭窄症患者采用保留脊柱后韧带复合结构多椎板切除减压术。男121例,女75例。并通过生物力学方法评价其对腰椎稳定性的影响。实验结果表明:(1)多椎板切除减压术明显破坏腰椎的稳定性(p<0.01)。(2)保留脊柱后韧带复合结构将明显提高腰椎的抗弯强度(p<0.01和降低腰椎术后屈伸活动度(p<0.01)。(3)脊柱后韧带复合结构对维持腰椎的稳定,减轻术后腰椎过度屈曲和后凸畸形具有重要作用。本文还简介了该手术基本方法和临床效果,认为手术简单易行,安全有效,符合尽量减少后柱破坏的手术原则。     

椎管重建内固定术有限元模型的构建及稳定性分析

目的:构建椎管重建内固定术的有限元模型,并分析椎管重建内固定术对脊柱稳定性的影响,验证椎管重建内固定术在椎管内手术中的有效性和可靠性。方法:筛选1名30岁男性,身高172 cm,体重75 kg的健康志愿者并采集其腰椎CT资料,建立正常腰椎L₃-L₅的有限元模型,并与体外实体结果和已发表的有限元分析结果进行比较,以验证该模型的有效性。根据处理方式不同分为正常组、椎板切除组和椎管重建组。在相同边界固定和生理载荷条件下,实施前屈、后伸、左弯、右弯、左旋和右旋6种工况活动,分析6种工况活动下L₃-L₄和L₄-L₅观察节段的活动度(range of motion,ROM)和L₃-L₅整体最大ROM的变化情况。结果:构建的L₃-L₅有限元模型各节段ROM位移与体外实体结果和既往文献数据结果吻合,确认了该模型的有效性。在L₃-L₄中,椎管重...     

Intradiscal pressure and kinematic behavior of lumbar spine after bilateral laminotomy and laminectomy.

BACKGROUND CONTEXT: Bilateral laminotomy has been proposed as an alternative to laminectomy for decompression of lumbar spinal stenosis. Preservation of the posterior midline ligaments with laminotomy is presumed to maintain spinal segment stability. There have been no previous studies that directly compare the amount of destabilization and increase in disc pressures between the two procedures. PURPOSE: To quantify spinal segmental instability caused by bilateral laminotomy and laminectomy, and to compare the central and peripheral intradiscal pressures after the two procedures. STUDY DESIGN/SETTING: Mechanical testing of the lumbar motion segments of calf spines. METHODS: Nine fresh calf spines were tested under flexion, extension, lateral bending and axial rotation, intact first, then after laminotomy and laminectomy at the level of L4-L5. Four miniature pressure transducers were implanted in the central and peripheral disc at L4-L5 to measure intradiscal pressures. Three-dimensional motion was measured with motion analysis system. RESULTS: Comparing with bilateral laminotomy, laminectomy showed significant increase in segmental motion at the surgical level in flexion (16%, p<.05), extension (14%, p<.04) and right axial rotation (23%, p<.03). In flexion, the stress at the anterior annulus increased a nonsignificant 20% after laminotomy, but significant 130% after laminectomy (p<.02). In the intact spine, the posterolateral annulus experienced the highest stress with lateral bending to the same side when compared with other loading directions. This stress remained unchanged after laminotomy but increased 9% after laminectomy (p<.06). In rotation, axial intradiscal stresses were evenly distributed and unchanged after each procedure. CONCLUSIONS: Laminectomy causes more destabilization of a spinal motion segment than laminotomy and significantly increases disc stress in the anterior annulus.     

开窗减压术治疗中央型腰椎管狭窄症

１９８６年以来，使用开窗减压术治疗中央型腰椎管狭窄症５３例，４９例（９２．５％）得到随访，优良率达９１．８％，仅有１例发生术后腰椎不稳。该手术损伤小，在较大程度上保留了腰椎后部结构均完整性，术后腰椎稳定性好，硬膜及神经根不易发生瘢痕粘连。虽然开窗减压范围小，但通过腰椎两侧对称性和多节段开窗，椎管可得到充分减压。临床应用表明该法较传统的椎板切除术疗效好。     

Experimental study of osteoplastic laminectomy in the lumbar spine of rabbits

Osteoplastic laminectomy has been used to treat lumbar canal stenosis and to prevent postoperative lumbar spinal instability by reconstructing the posterior element of the lumbar spine, which has been documented in many clinical studies. However, the biological sequence of repairing the posterior lumbar element, which is replaced at the time of surgery, has not yet been made clear. An in vivo rabbit study was designed to observe the biological sequence of repairing the replaced posterior element of the lumbar spine. Twenty-one adult rabbits underwent osteoplastic laminectomy at the L6. Animals were killed at 2, 4, 8, 12, 26, and 52 weeks after surgery. The samples of the L6 vertebra, which contained the replaced lamina and spinous process, were analyzed by radiography, computed tomography (CT), and a histological method. Overall, radiograms demonstrated clearly the union of interarticular osteotomized sites from 4 to 8 weeks. CT findings revealed that the union of interarticular osteotomized sites could be confirmed beginning at 12 weeks, and that postoperative narrowing of the lumbar spinal canal had not occurred in the rabbit model. The biological sequence of repairing the replaced lamina and spinous process was characterized by slowly progressive creeping substitution, with continuous remodeling.     

Biomechanical analysis of posterior instrumentation systems after decompressive laminectomy. An unstable calf-spine model

Mechanical non-destructive cyclical testing in rotation, axial compression, and flexion were performed on twelve fresh spinal segments from calves. Each segment contained five motion segments. Each spine was destabilized with bilateral laminectomy and facetectomy of the fourth and fifth lumbar vertebrae, resection of the pars interarticularis of the fourth lumbar vertebra, and resection of the disc between the fourth and fifth lumbar vertebrae. Sequential stabilization of each spine was used to compare the stiffness of: (1) Harrington distraction instrumentation of five levels, (2) Luque rectangular instrumentation of five levels, (3) modified Steffee transpedicular notched-rod instrumentation of three and five levels, and (4) Cotrel-Dubousset transpedicular instrumentation of three and five levels with and without transverse approximating rods. This in vitro study of a calf-spine model led to three reproducible conclusions: (1) after laminectomy and discectomy, the instrumented spine was more unstable in rotation and flexion than when it was subjected to axial compressive loads; (2) the most rigid implant was the Cotrel-Dubousset transpedicular instrumentation of five vertebral levels (p less than 0.05); and (3) with the Steffee or the Cotrel-Dubousset transpedicular instrumentation of three vertebral levels, it was possible to restore torsional, compressive, and flexural rigidity to the destabilized spine of the calf. Furthermore, transpedicular fixation of only three vertebral levels provided more in vitro stability than either traditional Harrington or Luque rectangular instrumentation, which require fixation of five vertebral levels to stabilize a spine after laminectomy.