扩大开窗神经根管减压术与全椎板切除减压内固定术治疗老年退行性腰椎管狭窄症疗效对比

[目的]比较扩大开窗神经根管减压术和全椎板切除减压内固定术两种术式在老年退行性腰椎管狭窄症治疗中的疗效。[方法]选取本科近两年收治的老年退行性腰椎管狭窄症患者,包括65例行全椎板切除减压内固定术的对照组,65例行扩大开窗神经根管减压术的观察组,统计两组患者手术综合情况、JOA评分及神经功能的恢复情况,并随访比较两组的并发症。[结果]观察组较对照组手术切口短、住院时间短、出血量少;观察组并发症发生率为10.77%,较对照组23.08%低;观察组JOA评分优良率为92.31%,对照组为53.85%;同时,术后神经功能的恢复情况观察组明显优于对照组。上述各项比较差异均具有统计学意义(P0.05)。[结论]对于老年退行性腰椎管狭窄症患者,采用扩大开窗神经根管减压术减压效果佳,能改善临床疗效,恢复神经系统功能,规避不良反应。     

椎间孔镜BEIS技术治疗老年腰椎管狭窄症的临床分析

目的:观察应用椎间孔镜BEIS技术治疗老年腰椎管狭窄症的临床疗效。方法:选取接受传统手术治疗的37例老年腰椎管狭窄症患者(对照组)和同期接受椎间孔镜BEIS技术治疗的41例老年腰椎管狭窄症患者(观察组)作为研究对象,对比和分析两组患者VAS评分、JOA评分等的差异。结果:术前两组患者的疼痛程度(VAS评分)无统计学差异(P0.05),术后3d、7d观察组患者的VAS评分均较对照组患者低(P0.05);观察组患者的术后并发症发生率为4.8%,较对照组患者(18.9%)降低(P0.05);术前两组患者的腰椎JOA评分差异无统计学意义(P0.05),术后3个月、6个月观察组患者的腰椎JOA评分(分别为24.2±2.5、26.4±1.8)均较对照组患者(分别为19.6±2.4、22.7±1.5)高(P0.05);术后随访6个月,观察组患者的手术治疗优良率为90.3%,较对照组患者的73.0%高(P0.05)。结论椎间孔镜BEIS技术治疗老年腰椎管狭窄症,创伤性小,安全性高,疗效确切。     

扩大开窗神经根管减压术治疗老年退行性腰椎管狭窄症的疗效及影响因素分析

目的分析扩大开窗神经根管减压术治疗老年退行性腰椎管狭窄症(DLSS)的疗效及其影响因素。方法 90例老年DLSS患者根据手术方法不同分为观察组60例、对照组30例,分别行扩大开窗神经根管减压术、常规全椎板切除减压内固定术治疗。比较两组手术情况、腰、腿痛改善程度及疗效,比较观察组痊愈与未痊愈患者临床相关资料差异,并进行Logistic多因素回归分析。结果与对照组相比,观察组手术时间、术后下床时间显著缩短,术中出血量明显减少,手术并发症发生率明显降低,差异有统计学意义(P0.05),两组术后3个月、2年腰痛、腿痛视觉模拟疼痛评分(VAS)评分均较术前明显降低,但观察组降低幅度明显大于对照组(P0.05)。观察组临床总有效率为88.33%,显著高于对照组的70.00%(P0.05),痊愈率为58.33%,略高于对照组的40.00%,但差异无统计学意义(P0.05)。观察组中,与未痊愈者相比,痊愈者中多节段腰椎管狭窄、合并腰椎滑脱、合并骨质疏松症、术前焦虑或抑郁占比显著增高(P0.05),上述因素为影响扩大开窗神经根管减压术治疗老年DLSS临床疗效的主要因素(P0.05)。结论扩大开窗神经根管减压术治疗老年DLSS临床疗效显著,可有效减少并发症,改善腰腿痛,但仍需根据患者是否合并腰椎滑脱、骨质疏松症、焦虑或抑郁等适当调整治疗或干预方案。     

单纯减压与减压融合术治疗老年退行性腰椎管狭窄症中远期疗效的Meta分析

目的通过Meta分析比较单纯减压术与减压融合术治疗老年退行性腰椎管狭窄症的中远期疗效。方法检索自1980-06—2019-01收录在PubMed、Embase、Cochrane、中国知网、万方等数据库关于比较单纯减压术与减压融合术治疗老年退行性腰椎管狭窄症的相关文献,采用Cochrane协作网提供的RevMan 5.3软件进行Meta分析。比较单纯减压组与减压融合组末次随访时腰痛VAS评分、腿痛VAS评分、ODI指数,以及疗效优良率、术后并发症发生率、再次手术率。结果纳入11篇文献,共21 303例,单纯减压组2 710例,减压融合组18 593例。Meta分析结果显示单纯减压组与减压融合组末次随访时腰痛VAS评分、腿痛VAS评分、疗效优良率、术后并发症发生率与再次手术率比较差异无统计学意义(P0.05);减压融合组末次随访时ODI指数较单纯减压组低,差异有统计学意义(P 0.05)。结论减压融合术治疗老年退行性腰椎管狭窄症的中远期疗效并不优于单纯减压术。     

导航电子显微镜下腰椎后路椎管减压植骨融合术治疗老年退行性椎管狭窄症疗效观察

目的比较导航电子显微镜下腰椎后路椎管减压植骨融合术与常规腰椎后路椎管减压植骨融合术治疗老年退行性椎管狭窄症的临床疗效。方法回顾性分析自2016-01—2017-02诊治的120例老年退行性腰椎管狭窄症,64例采用导航电子显微镜下腰椎后路椎管减压植骨融合术治疗(观察组),56例采用常规腰椎后路椎管减压植骨融合术治疗(对照组),比较2组手术时间、术中出血量、术后引流量、术后6个月ODI指数。结果观察组出现1例轻度硬脊膜撕裂伴脑脊液漏,1例伤口感染;对照组出现3例硬脊膜撕裂伴脑脊液漏,2例切口感染,行对症治疗均治愈,无神经根损伤、融合失败、内固定物断裂、截瘫等并发症。观察组手术时间较对照组短,术中出血量较对照组少,术后引流量较对照组少,术后6个月ODI指数较对照组低,差异有统计学意义(P <0.05)。结论导航电子显微镜下腰椎后路椎管减压植骨融合术治疗老年退行性腰椎管狭窄症在手术时间、术中出血量、术后引流量、术后功能恢复方面较常规腰椎后路椎管减压植骨融合术具有显著优势。     

减压融合手术治疗复杂型腰椎管狭窄症的疗效分析

目的分析减压融合手术与传统减压手术治疗复杂型腰椎管狭窄症的临床疗效。方法 127例复杂型腰椎管狭窄症患者,按手术方法不同分为2组,减压组60例采用单纯椎板间开窗减压术,减压融合组67例采用椎板切除减压及椎间植骨融合内固定手术。比较两组患者JOA评分和VAS评分情况。结果 127例均获得随访,时间2年。JOA评分:减压组术前为13.46分±1.85分,术后2年为23.86分±1.71分,差异有统计学意义(P0.05);减压融合组术前为13.72分±1.69分,术后2年为24.60分±1.55分,差异有统计学意义(P0.05)。术后JOA改善率减压组为66.92%±8.03%,减压融合组为71.20%±7.83%,差异无统计学意义(P0.05)。术后2年VAS评分:减压组为3.85分±1.05分,减压融合组为2.26分±1.54分,减压融合组低于减压组(P0.05)。椎间隙高度:减压组术前为6.4 mm±2.6 mm,术后2年为5.3 mm±1.8 mm,差异有统计学意义(P0.05);减压融合组术前为6.2 mm±2.9 mm,术后2年为7.1 mm±1.6 mm,差异有统计学意义(P0.05)。滑脱程度:减压组术前为16.3%±5.2%,术后2年为15.4%±3.0%,差异无统计学意义(P0.05);减压融合组术前为17.3%±4.9%,术后2年为12.6%±5.8%,差异有统计学意义(P0.05)。结论减压融合手术与单纯减压手术治疗腰椎管狭窄症早期疗效相当,但术后2年临床症状改善情况较单纯减压手术效果更好。     

不同椎板减压手术治疗腰椎管狭窄症效果观察

目的分析有限椎板减压与全椎板切除减压治疗腰椎管狭窄症的效果。方法将90例腰椎管狭窄症患者随机分为2组,每组45例。对照组行全椎板切除减压治疗,观察组行有限椎板减压治疗,比较2组术中出血量、住院时间、术后疼痛程度及功能障碍评分、多裂肌MRI信号强度分级、并发症发生率等指标。结果观察组术中出血量、引流量、术后住院时间优于对照组,差异具有统计学意义(P0.05);术后随访6~10个月,其间2组并发症发生率差异无统计学意义(P0.05)。6个月时2组患者的ODI、VAS腿痛、VAS腰痛评分均明显低于手术前,但观察组明显低于对照组,而且多裂肌MRI信号强度分级优于对照组,差异均有统计学意义(P0.05)。结论与全椎板切除减压比较,有限椎板减压治疗腰椎管狭窄症,患者疼痛轻,腰椎稳定性高,脊椎功能改善明显,且不增加术后并发症发生率,可促进患者早期康复。     

后路减压与后路减压内固定术治疗腰椎管狭窄效果比较

目的比较后路减压与后路减压内固定术治疗腰椎管狭窄的效果。方法随机将2016-08—2017-07间新野县中医院收治的98例腰椎管狭窄患者分为2组,各49例。对照组实施单纯后路减压术,观察组实施后路减压内固定术。比较2组的疗效。结果术前2组患者的JOA、VAS评分差异无统计学意义(P0.05)。术后观察组JOA评分高于对照组,VAS评分低于对照组,差异有统计学意义(P0.05)。2组并发症发生率差异无统计学意义(P0.05)。结论后路减压内固定术治疗腰椎管狭窄,可有效减轻患者疼痛程度和功能障碍,术后并发症少,效果确切。     

经椎间孔及经后路椎间融合术治疗退行性腰椎滑脱合并腰椎管狭窄的疗效对比

目的:对比两种手术方法治疗退行性腰椎滑脱合并腰椎管狭窄的疗效。方法:退行性腰椎滑脱合并腰椎管狭窄患者45例,根据手术方式分为经椎间孔椎间融合术(TLIF)组24例、经后路椎间融合术(PLIF)组21例,比较两组临床疗效、术前与术后半年ODI指数和腰腿痛VAS评分、植骨融合情况、术后并发症以及手术时间、术中出血量和术后引流量。结果:术后随访11~30个月,平均16个月,TLIF组临床优良率87.5%,PLIF组为85.70%,两组差异无统计学意义(P0.05)。术前TLIF组ODI指数为(18.7±4.5),PLIF组为(19.0±4.7);TLIF组与PLIF组VAS评分分别为(7.6±0.8)、(7.7±0.7),两组差异无统计学意义(P0.05)。术后半年ODI指数TLIF组(3.7±2.4)、PLIF组(3.9±3.1),VAS评分分别为(1.9±0.6)、(2.1±0.7),两组差异无统计学意义(P0.05)。术后半年植骨融合率TLIF组91.7%、PLIF组90.5%,两组差异无统计学意义(P0.05)。两组术后医源性神经损伤发生率分别为4.2%、28.6%,差异有统计学意义(P0.05)。与手术前相比,两组患者术后半年ODI指数、VAS评分均降低(P0.05)。与PLIF相比,TLIF手术失血量少、手术时间短、术后引流量少、手术并发症少(P0.05);结论:TLIF、PLIF治疗退行性腰椎滑脱合并腰椎管狭窄疗效相似,TLIF较PLIF具有术中创伤小、术后并发症少和降低医源性神经根损伤等优点。     

单纯减压与减压融合术治疗老年退行性腰椎管狭窄症的Meta分析

目的对单纯减压术与减压融合术治疗老年退行性腰椎管狭窄症进行Meta分析。方法计算机检索Pub Med、Embase、Cochrane图书馆、万方数据库和中国期刊全文数据库中2016年2月以前的相关文献。根据纳入与排除标准,由2名研究者分别独立筛选文献,按照Cochrane偏倚风险评估工具严格进行质量评估,并利用Rev Man 5.2软件对相关结局指标(总体疗效、手术时间、术中出血量、并发症发生率、二次手术率)进行Meta分析。结果纳入9篇符合纳入标准的随机对照试验,共964例,单纯减压组580例,减压融合组384例。Meta分析结果显示,与减压融合组比较,单纯减压组手术时间和术中出血量明显更少,差异有统计学意义(P0.05);而2组在术后总体疗效、并发症发生率和二次手术率方面差异无统计学意义(P0.05)。结论单纯减压和减压融合术治疗老年退行性腰椎管狭窄症的疗效相当,但单纯减压术具有手术创伤小、出血量少、手术时间短、术后康复快的优点。     

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.     

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％。     

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     

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.     

Monosegmental fixation for the treatment of fractures of the thoracolumbar spine

Background:

A short vertebral arthrodesis has been one of the objectives of the surgical treatment of fractures of the thoracolumbar spine. We present here clinical, functional and radiographic outcome obtained after monosegmental fixation (single posterior or combined anterior and posterior) of specific types of unstable thoracolumbar fractures.

Materials and Methods:

Twenty four patients with fractures of the thoracolumbar spine submitted to monosegmental surgical treatment (Group I - 18 single posterior monosegmental fixations and Group II - 6 combined anterior and posterior fixations) were retrospectively evaluated according to clinical, radiographic and functional parameters. The indication for surgery was instability or neurological deficit. All the procedures were indicated and performed by the senior surgeon (Helton LA Defino).

Results:

The patients from group I were followed-up from 2 to 12 years (mean: 6.65±2.96). The clinical, functional and radiographic results show that a single posterior monosegmental fixation is adequate and a satisfactory procedure to be used in specific types of thoracolumbar spine fractures, The patients from group II were followed-up from 9 to 15 years (mean: 13 ± 2,09 years). On group II the results of clinical evaluation showed moderate indices of residual pain and of satisfaction with the final result. The values obtained by functional evaluation showed that 66.6% of the patients were unable to return to their previous job and presented a moderate disability index (Oswestry = 16.6) and a significant reduction of quality of life based on the SF-36 questionnaire. Radiographic evaluation showed increased kyphosis of the fixed vertebral segment during the late postoperative period, accompanied by a reduction of the height of the intervertebral disk.

Conclusion:

It is possible to stabilize the fractures which have an anterior good load-bearing capacity by a standalone posterior monosegmental fixation. However this procedure, even with an anterior support is not suitable for fracture involving the vertebral body.     

Flow characteristics of Luer and non‐Luer spinal needles

We investigated the flow rates of 25‐G and 27‐G spinal needles, of 90‐mm and 120‐mm lengths, from Vygon, BD, B. Braun and Pajunk; the needles had either a Luer connector, or a Surety^® or UniVia^® non‐Luer connector. We used a bench‐top model of entering the spinal space, pressurised to 35 cmH₂O to simulate cerebrospinal fluid pressure in the sitting position. We examined the time to first appearance of simulated cerebrospinal fluid in the needle hub, as well as the amount of fluid collected over 120 s after the needle was introduced. The mean (SD) times to first appearance of fluid in the needle hub of Luer spinal needles varied from 0.36 (0.22) s for the 25‐G 90‐mm BD to 3.14 (0.72) s for the 27‐G 120‐mm B. Braun, and in the non‐Luer spinal needles from 0.22 (0.17) s for the 25‐G 90‐mm B. Braun to 2.99 (0.71) s for the 27‐G 120‐mm Pajunk. There was a significant difference in the time to first appearance of fluid in the needle hub between Luer and non‐Luer needles of the same type for seven of 14 comparisons made, of which four showed slower appearance of fluid in the non‐Luer version. In some of these cases, the time to appearance of fluid was nearly twice as long with the non‐Luer counterpart. The mean (SD) weight of fluid collected in 120 s using the Luer spinal needles varied from 0.21 (0.05) g for the 27‐G 120‐mm Pajunk to 1.21 (0.18) g for the 25‐G 90‐mm Vygon, and using the non‐Luer spinal needles from 0.25 (0.05) g for the 27‐G 120‐mm Pajunk to 1.55 (0.05) g for the 25‐G 90‐mm B. Braun. All of the needle types showed a greater weight of fluid collected using the non‐Luer compared with the Luer version, with six of the 14 needle types showing a significant difference. Significant variations in flow were also seen between the same needle type from different manufacturers. We conclude that changing from Luer to non‐Luer versions of spinal needles does not merely change the hub design and connection, but may introduce important differences in function.     

Efficacy of intrathecal neostigmine for the relief of postinguinal hemiorrhaphy pain

BACKGROUND: Intrathecal administration of various doses of neostigmine has been reported to produce analgesia without neurotoxicity in both animal and human studies. The present study was undertaken to evaluate the efficacy and safety of intrathecal neostigmine for the relief of pain for patients having undergone inguinal herniorrhaphy surgery. METHODS: Sixty men scheduled for elective inguinal herniorrhaphy with spinal anaesthesia were randomly allocated to three groups: group I (n=20) received intrathecal (IT) tetracaine 15 mg, group II (n=20) received IT tetracaine 15 mg+ neostigmine 50 microg, and group III (n=20) received IT tetracaine 15 mg+neostigmine 100 microg. The onset of anaesthesia, duration of analgesia, time to use of first rescue analgesics, the overall 24 h VAS pain scores and the incidence of adverse effects were recorded for 24 h postdrug administration. RESULTS: Onset of anaesthesia (time to T6 sensory block) was significantly faster for group II and III patients compared with group I patients. Motor block (time to lift leg) was greatly prolonged for group III patients, with an average of 6.4 h, compared with 4.1 h for group II patients. Group III patients also showed a later onset of postsurgical pain, lower overall 24-h VAS pain score and prolonged time to first rescue analgesics than did group II patients. There was a significantly greater incidence of adverse effects associated with IT neostigmine, especially nausea and vomiting. CONCLUSION: Our study showed that intrathecal neostigmine at 50 pg or 100 microg enhanced the onset of tetracaine anaesthesia and provided analgesia lasting for 6-9 h, although increased incidences of prolonged motor blockade and nausea or vomiting were noted.