Computer-assisted screw insertion for cervical disorders in rheumatoid arthritis

To reconstruct highly destructed unstable rheumatoid arthritis (RA) cervical lesions, the authors have been using C1/2 transarticular and cervical pedicle screw fixations. Pedicle screw fixation and C1/2 transarticular screw fixation are biomechanically superior to other fixation techniques for RA patients. However, due to severe spinal deformity and small anatomical size of the vertebra, including the lateral mass and pedicle, in the most RA cervical lesions, these screw fixation procedures are technically demanding and pose the potential risk of neurovascular injuries. The purpose of this study was to evaluate the accuracy and safety of cervical pedicle screw insertion to the deformed, fragile, and small RA spine lesions using computer-assisted image-guidance systems. A frameless, stereotactic image-guidance system that is CT-based, and optoelectronic was used for correct screw placement. A total of 21 patients (16 females, 5 males) with cervical disorders due to RA were surgically treated using the image-guidance system. Postoperative computerized tomography and plane X-ray was used to determine the accuracy of the screw placement. Neural and vascular complications associated with screw insertion and postoperative neural recovery were evaluated. Postoperative radiological evaluations revealed that only 1 (2.1%; C4) of 48 screws inserted into the cervical pedicle had perforated the vertebral artery canal more than 25% (critical breach). However, no neurovascular complications were observed. According to Ranawat's classification, 9 patients remained the same, and 12 patients showed improvement. Instrumentation failure, loss of reduction, or nonunion was not observed at the final follow-up (average 49.5 months; range 24-96 months). In this study, the authors demonstrated that image-guidance systems could be applied safely to the cervical lesions caused by RA. Image-guidance systems are useful tools in preoperative planning and in transarticular or transpedicular screw placement in the cervical spine of RA patients.     

陈旧性创伤性腰椎管狭窄症的后路手术治疗

[目的] 探讨采用椎板减压、髓核摘除、椎体间植骨融合并CAPSTONE融合器植入、椎弓根螺钉内固定的方法(TLIF)对陈旧性创伤性腰椎管狭窄、腰椎轻度后突、椎间隙狭窄的后路手术治疗.[方法] 因创伤造成下腰椎椎管、椎间隙狭窄,腰椎轻度后突畸形20例,男13例,女7例;年龄22～49岁,平均31.4岁.其中L3、44例,L4、5,10例,L5S16例.1例患者为伤后4年接受手术,3例患者为伤后9～15个月手术,6例患者为伤后3～6个月手术,10例患者为伤后1～3个月手术.所有病例均采用狭窄部位的椎板扩大减压,髓核摘除、椎体问植骨融合并CAP-STONE融合器植入、椎弓根螺钉内固定的方法(TLIF)进行手术治疗.术后1周,病人配带胸腰髂支具下床活动.[结果] 经上述手术方法处理的病例,术后1周内病人的腰痛、下肢疼痛、肌力及感觉的减退均有不同程度的恢复,术后x线片证实,狭窄的腰椎间隙恢复,同时恢复了腰椎的生理弯曲.经1～3年的临床随访,20例患者均有明显的神经功能恢复和改善,平均Frankel分级改善1.4级.复查X线片,20例患者植骨均愈合,椎间隙高度及生理弯曲角度没有丢失.[结论] 对陈旧性、创伤性腰椎管狭窄患者,恢复椎体原有的高度已不可能,在进行减压解除对神经压迫的同时,进行椎体间的植骨,同时植入椎问融合器,用椎弓根钉棒系统进行固定,既有利于植骨愈合,恢复椎间隙高度,恢复腰椎的生理弯曲,又有利于病人早期下床进行功能锻炼,防止卧床带来的并发症.此方法简单,操作便利,临床并发症少,值得临床推广.     

Short segment pedicle screw instrumentation and augmentation vertebroplasty in lumbar burst fractures: an experience

To assess the efficacy and feasibility of vertebroplasty and posterior short-segment pedicle screw fixation for the treatment of traumatic lumbar burst fractures. Short-segment pedicle screw instrumentation is a well described technique to reduce and stabilize thoracic and lumbar spine fractures. It is relatively a easy procedure but can only indirectly reduce a fractured vertebral body, and the means of augmenting the anterior column are limited. Hardware failure and a loss of reduction are recognized complications caused by insufficient anterior column support. Patients with traumatic lumbar burst fractures without neurologic deficits were included. After a short segment posterior reduction and fixation, bilateral transpedicular reduction of the endplate was performed using a balloon, and polymethyl methacrylate cement was injected. Pre-operative and post-operative central and anterior heights were assessed with radiographs and MRI. Sixteen patients underwent this procedure, and a substantial reduction of the endplates could be achieved with the technique. All patients recovered uneventfully, and the neurologic examination revealed no deficits. The post-operative radiographs and magnetic resonance images demonstrated a good fracture reduction and filling of the bone defect without unwarranted bone displacement. The central and anterior height of the vertebral body could be restored to 72 and 82% of the estimated intact height, respectively. Complications were cement leakage in three cases without clinical implications and one superficial wound infection. Posterior short-segment pedicle fixation in conjunction with balloon vertebroplasty seems to be a feasible option in the management of lumbar burst fractures, thereby addressing all the three columns through a single approach. Although cement leakage occurred but had no clinical consequences or neurological deficit.     

伤椎置钉治疗胸腰椎骨折

目的回顾性分析探讨后路伤椎置钉治疗胸腰椎骨折的疗效。方法回顾性分析我科2006-03-2010-03后路手术治疗的82例胸腰椎骨折临床资料,分为2组,其中A组(40例)伤椎置钉治疗胸腰椎骨折,B组(42例)跨伤椎用椎弓根螺钉内固定。比较A组和B组后凸Cobb角矫正率、术后椎管面积改善率、远期丢失率、内固定失效率。结果 A组在术后矫正率、术后椎管面积改善率、远期丢失率、内固定失效率方面优于B组(P<0.05),差异具有统计学意义。结论胸腰椎骨折应用伤椎置钉可以增加内固定系统的牢固性,并利于矫正后凸畸形和维持矫正效果。     

钉棒及钩棒系统治疗胸腰椎多节段脊柱骨折

目的评价钉棒及钩棒系统治疗胸腰椎多节段脊柱骨折的临床疗效。方法23例多节段胸腰椎骨折患者，后路切开复位，选择性椎管减压．钉棒或钩棒系统内固定及后外侧植骨融合进行手术治疗。其中相邻多节段型13例，非相邻多节段型8例，混合型2例。结果全组病例平均随访14个月，未发现内固定物松动、断离，无继发性脊柱后凸畸形加重。椎体高度由术前平均48．4％恢复至术后平均92．4%。2例完全性及11例不完全性脊髓损伤者．脊髓神经功能获改善。结论在椎管进行充分减压的基础上．钉棒及钩棒系统能有效复位椎体骨折，重建脊柱稳定性，是多节段胸腰椎不稳定性骨折合并脊髓神经损伤后路手术的理想选择。     

椎弓根钉固定及高压分步注射椎体成形术治疗老年胸腰椎爆裂骨折并神经损伤

目的探讨椎弓根螺钉内固定结合高压注射椎体成形术治疗老年胸腰椎爆裂性骨折并神经损伤的疗效。方法回顾分析椎弓根螺钉内固定结合经椎弓根高压分步注射骨水泥治疗老年胸腰椎爆裂性骨折并神经损伤患者22例,随访平均19月。术后观察骨折椎体前缘压缩率、椎管侵占率、Cobb角、神经功能改善情况及并发症。结果椎体前缘压缩率由术前的58.7%恢复为术后7.0%,后凸Cobb角由术前平均24.0°矫正至6.6°,椎管侵占率由术前52.6%恢复为术后11.8%,术后与术前比较差异均有统计学意义(P0.01)。VAS术前平均8.7分,术后2.2分。脊髓功能恢复按Frankel分级,除1例A级病例术后截瘫症状无明显恢复外,其他病例均达到1级或1级以上的恢复。有2椎体发生椎体外骨水泥渗漏,无肺栓塞、感染和神经损伤等并发症发生。未发现内固定松动、断裂现象。结论椎弓根螺钉内固定结合椎体成形术有利于同时解决胸腰椎骨折对神经的压迫、脊柱的不稳定及骨质疏松椎体压缩骨折造成的顽固性胸腰背疼痛等问题。高压分步注射可降低骨水泥渗漏的风险。     

胸腰椎骨折伤椎复位技术的改进及临床应用

背景：胸腰椎骨折伤椎复位效果经常不满意,手术方式仍有争议。 目的：探讨经伤椎椎弓根置钉撬拨复位联合短节段内固定治疗胸腰椎骨折的疗效。 方法：回顾性分析2010年8月至2012年10月40例行经伤椎椎弓根置钉撬拨复位短节段内固定的单节段胸腰椎骨折患者的临床资料。其中男32例,女8例,年龄23-63岁,平均45岁。比较患者手术前后伤椎前后缘高度比（伤椎前后缘高度与相邻上、下椎体前后缘高度平均值之比）、矢状面Cobb角、神经功能,进行疗效评价。 结果：患者随访6-18个月,平均12个月,无内固定失败发生。术前有神经功能不全损害的4例患者获得完全恢复。患者矢状面Cobb角由术前平均17.4°±8.0°恢复到术后2.1°±5.7°（P=0.000）;伤椎前缘平均高度比由术前52.7%±13.2%恢复到术后91.2%±9.4%（P=0.000）;伤椎后缘平均高度比由术前92.6%±8.3%恢复到术后98.5%±2.9%（P=0.005）。 结论：对于单节段胸腰椎骨折患者,伤椎椎弓根置钉撬拨复位联合短节段内固定的治疗方法是安全、有效的。     

一期经后路三柱重建技术治疗胸腰椎爆裂骨折

目的 探讨严重胸腰椎爆裂骨折应用经后路进行脊柱三柱重建技术的临床效果.方法 对24例胸腰椎爆裂骨折采用经后路椎体次全切除、钛网置入及椎弓根钉重建术治疗.采用Frankel评定标准评定术后神经功能恢复情况.通过影像学变化评价后凸畸形矫正情况和椎管减压程度.结果 本组获随访13～46个月,平均24个月.椎体高度术后恢复至正常高度的97.8％.椎体后凸畸形角度矫正至术后3.5°.椎管容积矫正至术后椎管压迫完全解除.所有患者神经症状均有不同程度恢复.结论 经后路进行脊柱三柱重建技术,能有效矫正胸腰椎爆裂骨折的后凸畸形、解除椎管内压迫,达到术后即刻稳定,具有骨折复位满意,手术创伤较小及并发症少等特点.     

Complications following Harrington instrumentation for fractures of the thoracolumbar spine

The purposes of using Harrington instrumentation for the treatment of thoracolumbar fractures are to reduce the fracture, decompress the spinal canal, create stability at the fracture site, and shorten the hospitalization period. However, technical problems or the injudicious use of Harrington-instrumentation systems can also complicate the management of these fractures. We have studied forty patients (forty-five Harrington-instrumentation stabilization procedures) who had significant complications. Twenty-six of the thirty patients who were followed for more than two years required additional spinal reconstructive surgical procedures. Five patients had neurological deterioration (one died), nine patients had an inadequate reduction of translational displacement of a vertebral fracture, sixteen patients had dislodgment or disengagement of the Harrington components with resultant loss of fixation, six patients had a deep wound infection, three patients had a complete wound dehiscence with exposure of metal, and sixteen patients had persistent unrecognized neural compression. Several factors were associated with these failures of Harrington instrumentation: translational (flexion-rotation) injuries of the osteoligamentous middle column; failure to obtain either myelographic or computed tomographic studies, or both, postoperatively; failure to identify persistent neural compression; wound dehiscence; the use of distraction rods for high thoracic kyphosis; and instrumentation across the lumbosacral joint.     

Computer-assisted Magerl's transarticular screw fixation for atlantoaxial subluxation

We report two patients with rheumatoid arthritis in whom posterior atlantoaxial fixation was carried out using transarticular screws with computer assistance. Two bilateral transarticular screws were inserted in one patient; however, in the other patient, only a unilateral screw was used, because computerized images showed that the vertebral artery at the other side was placed too medially to allow insertion of the screw. Neither of these patients had any neurovascular complications after surgery. Computer-assisted surgery is useful for avoiding neurovascular complications with transarticular screw fixation of C1-2. Received: January 26, 2001 / Accepted: August 13, 2001     

经椎弓根RF手术治疗胸腰椎骨折的临床报告

本文报告作者采用RF系统治疗36例胸腰椎骨折患者。其中男25例,女11例,年龄22～48岁,平均32岁。全部病例均在伤后7d内手术。术后22例压缩性骨折患者获得解剖复位,余病例X线片显示脊柱生理前凸及伤椎高度恢复满意。作者认为RF系统结构简单,操作方便,并发症少,疗效优于Harrington和其他脊柱固定器械。     

多节段胸腰椎脊柱骨折的手术治疗

目的探讨椎弓根钉棒系统治疗多节段胸腰椎脊柱骨折的手术方式与疗效。方法采用后路切开复位、椎弓根钉棒系统内固定、选择性椎管减压及后外侧植骨融合手术治疗44例多节段胸腰椎骨折患者,对患者术前与随访时的ASIA分级、伤椎椎体高度矫正率进行分析。结果全部患者平均随访12个月,未发现内固定物松动、断裂,椎体高度由术前平均49.3%恢复至术后平均92.5%。ASIA分级较术前平均提高1.2级。结论后路切开复位、椎弓根钉棒系统内固定基础上选择性椎管减压＋植骨融合是治疗多节段胸腰椎脊柱骨折的理想选择。     

椎板重建在腰椎滑脱症手术治疗中的应用

目的:探讨椎管减压椎弓根钉复位固定椎间植骨加椎板重建术治疗腰椎滑脱症的临床疗效。方法:自2007年8月至2008年8月,选择32例腰椎滑脱症患者行全椎板切除椎管减压椎弓根钉复位固定椎间植骨术,然后在椎板切除减压区硬膜外植微粒骨重建椎板,其中26例获得1年以上随访,男16例,女10例;年龄55～76岁,平均62.5岁;病程2～10年。所有病例术前有不同程度的腰痛,一侧或双下肢麻木、疼痛、间歇性跛行等。影像学检查为L3、L4或L5的Ⅰ-Ⅲ度前滑脱,其中退行性滑脱18例,峡部裂性滑脱8例。术后3个月及末次随访时从临床症状体征改善程度、滑脱椎体复位情况、植骨融合情况及椎管狭窄情况等方面对疗效进行评定。结果:26例患者平均随访时间为1年8个月(1～3年)。术后切口均愈合良好,无并发症发生。临床改善情况按JOA下腰痛评分标准,术前为(5.2±1.5)分,术后3个月为(23.1±1.9)分,优20例,良5例,可1例;末次随访评分(22.9±2.4)分,优19例,良5例,可2例。术后3个月和末次随访JOA评分较术前有明显改善(P=0.00),术后3个月和末次随访时疗效无明显差异(P>0.05)。滑脱椎体复位情况:Ⅰ度滑脱的17例完全复位;Ⅱ度滑脱的7例中5例完全复位,2例改善为Ⅰ度;Ⅲ度滑脱的2例改善为Ⅰ度。植骨融合情况:术后3个月20例融合,末次随访时全部融合,重建椎板骨质大片融合形成替代椎板。椎管狭窄情况:术后3个月及末次随访时CT检查示椎管无狭窄,神经根、硬膜囊无压迫。结论:椎管减压椎弓根钉复位固定椎间植骨加椎板重建术治疗腰椎滑脱症可以同时达到椎体复位、充分减压和脊柱生物力学稳定,能有效预防术后腰椎不稳以及瘢痕压迫、粘连等形成的医源性椎管狭窄,早期及中期疗效满意,为腰椎滑脱症的治疗提供了另外思路。     

Treatment of acute thoracolumbar burst fractures with kyphoplasty and short pedicle screw fixation: Transpedicular intracorporeal grafting with calcium phosphate: A prospective study

Background:

In the surgical treatment of thoracolumbar fractures, the major problem after posterior correction and transpedicular instrumentation is failure to support the anterior spinal column, leading to loss of correction and instrumentation failure with associated complaints. We conducted this prospective study to evaluate the outcome of the treatment of acute thoracolumbar burst fractures by transpedicular balloon kyphoplasty, grafting with calcium phosphate cement and short pedicle screw fixation plus fusion.

Materials and Methods:

Twenty-three consecutive patients of thoracolumbar (T₉ to L₄) burst fracture with or without neurologic deficit with an average age of 43 years, were included in this prospective study. Twenty-one from the 23 patients had single burst fracture while the remaining two patients had a burst fracture and additionally an adjacent A1-type fracture. On admission six (26%) out of 23 patients had neurological deficit (five incomplete, one complete). Bilateral transpedicular balloon kyphoplasty with liquid calcium phosphate to reduce segmental kyphosis and restore vertebral body height and short (three vertebrae) pedicle screw instrumentation with posterolateral fusion was performed. Gardner kyphosis angle, anterior and posterior vertebral body height ratio and spinal canal encroachment were calculated pre- to postoperatively.

Results:

All 23 patients were operated within two days after admission and were followed for at least 12 months after index surgery. Operating time and blood loss averaged 45 min and 60 cc respectively. The five patients with incomplete neurological lesions improved by at least one ASIA grade, while no neurological deterioration was observed in any case. The VAS and SF-36 (Role physical and Bodily pain domains) were significantly improved postoperatively. Overall sagittal alignment was improved from an average preoperative 16° to one degree kyphosis at final followup observation. The anterior vertebral body height ratio improved from 0.6 preoperatively to 0.9 (P<0.001) postoperatively, while posterior vertebral body height improved from 0.95 to 1 (P<0.01). Spinal canal encroachment was reduced from an average 32% preoperatively to 20% postoperatively. Cement leakage was observed in four cases (three anterior to vertebral body and one into the disc without sequalae). In the last CT evaluation, there was a continuity between calcium phosphate and cancellous vertebral body bone. Posterolateral radiological fusion was achieved within six months after index operation. There was no instrumentation failure or measurable loss of sagittal curve and vertebral height correction in any group of patients.

Conclusions:

Balloon kyphoplasty with calcium phosphate cement secured with posterior short fixation in the thoracolumbar spine provided excellent immediate reduction of posttraumatic segmental kyphosis and significant spinal canal clearance and restored vertebral body height in the fracture level.     

腰骶内固定的适应证与主要技术

腰骶融合手术为脊柱外科中常用术式,而腰骶内固定有助于腰骶融合。其手术适应证包括腰椎滑脱椎间盘突出与椎管狭窄、畸形以及其他原因缃起的腰骶不稳。腰骶内固定的主要技术有Ｇａｌｖｅｓｔｏｎ技术、髂骨螺钉、骶骨椎弓根螺钉、骶骨构、骶骨棒、骶骨杆、关节突螺钉、腰骶椎体间融合、人工椎间盘等。     

Complete rotational burst fracture of the third lumbar vertebra managed by posterior surgery. A case report

STUDY DESIGN: Case report of a young man with rotational burst fracture of the third lumbar vertebra, treated by posterior surgery. OBJECTIVES: To describe the management of a rotational burst fracture of the third lumbar vertebra by posterior surgery consisting of reduction, decompression, fusion, and transpedicular instrumentation. SUMMARY OF BACKGROUND DATA: Surgery is the generally recommended means of managing lumbar burst fractures with neurologic deficit. Some surgeons recommend anterior decompression, fusion, and instrumentation. Posterior surgery with decompression through laminectomy, spongioplasty of the vertebral body, interbody fusion of damaged discs, posterolateral fusion, and transpedicular fixation is also a safe and successful management technique. The combined approach consists of posterior decompression, fusion, transpedicular fixation, and anterior fusion using pelvic autografts. The optimum method of management remains in question. METHOD: An 18-year-old man with complete rotational burst fracture of the third lumbar vertebra was treated by posterior surgery. This surgery consisted of reduction, laminectomy, decompression, structure of dural sac tears, spongioplasty of the vertebral body, interbody fusion of both damaged discs, and the implantation of a transpedicular Socon fixator (Aesculap, Tuttlingen, Germany), including a transverse connector. The case was documented by radiographs and computed tomography scans before surgery and after fixator removal 19 months after surgery. RESULTS: The patient healed solidly with no instrumentation failure. The neurologic deficit Frankel Grade B improved to Frankel Grade D. CONCLUSION: Surgery to manage lumbar burst fracture must include reduction, decompression, restoration and fusion of anterior and posterior elements by using autologous pelvic spongious autografts, and anterior or posterior instrumentation. Posterior surgery including suturing of dural sac tears, fusion of damaged structures, and transpedicular fixation is successful in young patients and patients with good bone quality.     

通用型脊柱椎弓根内固定系统治疗腰椎滑脱的临床研究

目的 观察自行研制的通用型脊柱内固定系统用于退行性腰椎滑脱患者手术治疗的疗效。方法 16例退行性腰椎滑脱合并椎管狭窄的患者,均接受了通用型脊柱内固定系统手术治疗。其中男10例,女6例。平均年龄58．5岁(42～72岁)。术前Ⅰ度滑脱10例,Ⅱ度滑脱6例,术后定期随访记录患者的症状改善、滑脱复位程度及并发症等情况。结果 16例患者术后平均随访21．2个月(18～24个月),术后即刻及末次随访时X线摄片显示滑脱腰椎均完全复位,于末次随访时15例患者术前临床症状均消失,滑脱复位满意且无丢失,后外侧植骨融合术后及随访过程中未发现与植入物或手术相关的并发症。结论 初步结果显示,通用型脊柱内固定系统用于腰椎滑脱的手术治疗可获得满意的滑椎复位效果和良好临床疗效。     

可扩张微创通道管系统下单切口治疗退行性腰椎管狭窄症

目的探讨采用MAST—QUADRANT可扩张微创通道管系统下单切口治疗退行性腰椎管狭窄症的疗效。方法2009年6月～2011年6月对28例退行性腰椎管狭窄症在MASTQuADRANT通道下行单切口髓核切除＋神经根管扩大＋椎弓根螺钉固定＋椎间植骨融合术。结果手术时间（180±36）min,出血量（195±74）ml,所有患者均未输血。2例切口皮肤暗红;1例硬脊膜损伤。VAS评分由术前（6．8±1．7）分降至术后7d（1．3±0．5）分（P=0．00）。28例随访6～18个月,平均13．6月,末次随访时采用MacNab疗效评价标准评价手术效果,优17例,良9例,可2例,优良率92．8％（26／28）。结论在严格掌握手术适应证的情况下,MAST．QUADRANT可扩张微创通道管系统下单切口技术是治疗退行性腰椎管狭窄症安全有效的微创方法。     

腰椎狭窄软性椎管的应力改变分析

目的 探讨腰椎软性椎管改变与椎管狭窄的关系。方法 在本研究52例中分为椎管狭窄组和对照组，2003年1月至2007年12月，推管狭窄组从因腰椎管狭窄病行后路椎板减压术的患者中取黄韧带标本对照组黄韧带标本共为10例，取自青年腰椎骨折行后路椎板减压术患者，后纵韧带标本共4例取自腰椎爆裂骨折前路椎体减压术患者。分别观察两组标本切片镜下的表现并加以分析。结果 在腰椎管狭窄病组，黄韧带及后纵韧带镜下表现为纤维肥大，基质内可见脂肪及小囊肿；对照组则表现为纤维细胞排列规则、无纤维化表现。结论 腰椎管软性椎管的应力改变及退行性变，是导致腰椎管狭窄的一个因素。     

Complete burst fracture of the fifth lumbar vertebra treated by posterior surgery using expandable cage

Study design  This report characterises a 25 year old male patient with a complete burst fracture of the fifth lumbar vertebra with dislocation. He was treated by posterior surgery with transpedicular instrumentation and an expandable cage from the posterior approach. Objectives  Burst fractures of the fifth lumbar vertebra are extremely rare. Patients with positive neurological findings should be treated by the posterior approach. This surgery consists of reduction, decompression, transpedicular stabilisation and fusion. Materials and methods  The young man in our report was treated by posterior surgery only. It consisted of laminectomy, suture of the thecal sac tear, discectomies and subtotal removal of the fifth lumbar vertebra. Repositioning was carried out simultaneously with support using Synex TM Synthes USA telescopic cage and SOCON TM Aesculap Germany transpedicular fixator. Results  The patient suffered neither wound complications nor instrumentation failure. He is currently able to walk with the help of peroneal bands but without crutches. Conclusions  Treatment of fractures of the fifth lumbar vertebra depends on fracture type and neurological findings. Conservative management of this condition is appropriate provided there is no neurological damage and canal stenosis and deformity is minimal. Surgical treatment of burst lumbar fractures with neurological deficit is strongly recommended. The optimum treatment remains debatable