前路腰间盘摘除术远期疗效及再手术原因分析

目的：应用定量指标判定前路腰间盘摘除术远期疗效，分析再手术原因，为临床工作提供一定的理论根据。方法：应用Roland及Greenough定量评级标准，随访1987～2000年于本院行首次前路腰间盘摘除术的患者。结果：有效随访56例，随访时间3—6年。应用以上两标准，术后优良率分别为83．92％、89．42％，再手术5例(5．35％)。根据年龄及病程进行分层分析，各层间无显著差异。结论：前路手术可获得较高的手术成功率，提高手术技巧及指导病人康复可有效避免再手术。病程及年龄并不是判定是否应用前路手术的绝对指标。术前影像学诊断判定无椎管和神经根管狭窄及准确定位是手术成功的关键。     

侧后路椎间孔镜下髓核摘除术治疗腰椎间盘突出症

目的 探讨侧后路椎间孔镜下髓核摘除术治疗腰椎间盘突出症的临床疗效。方法 将80例腰椎间盘突出症患者根据手术方法不同分为孔镜组(采用侧后路椎间孔镜下髓核摘除术治疗，42例)和开窗组(采用后正中入路椎板间开窗髓核摘除术治疗，38例)。比较两组手术时间、切口长度、术中出血量及JOA评分。结果 患者均获得随访，时间3～14个月。两组手术时间比较差异无统计学意义(P>0.05)。切口长度、术中出血量孔镜组均短(少)于开窗组(P<0.001)。术后3个月JOA评分两组均较术前明显改善(P<0.05),两组间比较差异无统计学意义(P>0.05)。结论 侧后路椎间孔镜下髓核摘除术治疗腰椎间盘突出症具有切口小、出血少等优点，且能达到同开放手术相同的直接减压效果。     

腰椎间盘微创摘除手术的疗效评估

目的：分析与评估经小切口用内镜在荧屏监神下摘除腰椎间盘这一手术治疗方法的远期效果。方法：随访全部手术41例，用Nakano标准测定术后状况，优良率为92．7％；分析再次手术原因，并与其它方法进行的椎间盘摘除手术进行对比研究。结果：术后患者症状和功能障碍均消失，术后3个月均恢复原工作（41例），有3例分别于术后12、16和52个月复发，经常规开窗术治疗后，皆恢复正常。结论：微创荧屏镜下腰椎间盘摘除术创伤小，恢复快，成本低，不破坏脊柱的生物力学结构，近、远期疗效满意，是一种新型的手术选择方法。     

后路椎间盘镜治疗腰椎间盘突出症的远期疗效分析

目的 探讨在椎间盘镜下行腰椎间盘摘除术的远期疗效和技术要点.方法 对48例患者全部行后路椎间盘镜下腰椎间盘摘除术(NED).经术前影像学资料结合临床症状全部诊断为腰椎间盘突出或伴有短节段的椎管狭窄,经保守治疗无效后,均以小切口后正中入路,建立镜下工作通道,对椎管及神经根管充分减压,分别于术前、术后1周和术后2年后对患者的腰疼情况进行视觉痛觉自我评定尺(VAS)评分.结果 48例患者手术中,出血量为40～120 ml,平均为50ml,所有患者术前症状在1周后的测定中均消失,无一例神经损伤,但在2年后的随访评估时,有7例VAS评分值明显下降.本组患者随访时间最长40个月,最短24个月,平均31.3个月.48例患者,优19例,良25例,差4例,优良率91.6%.结论 后路椎间盘镜下对于单纯的腰椎间盘突出患者行腰椎间盘摘除术近期和远期疗效可靠.对伴有椎管狭窄的患者,实际应用中具有近期疗效可靠,远期疗效比期望值低.     

腰椎间盘镜单节段髓核摘除术远期疗效分析

[目的]评价腰椎间盘镜(microendoscopic discectomy,MED)单节段髓核摘除术的远期疗效.[方法]回顾性分析2004年1月～2005年1月在本院行MED单节段髓核摘除术的32例患者.术前和术后第1,2,3年行JOA评分、腰椎X线检查,在X线片上测量腰椎前凸角及手术节段椎间隙高度.[结果]术后平均随访36个月(24～46个月),术前与术后JOA评分、手术节段椎间隙高度差异具有统计学意义(P<0.05),腰椎前凸角的变化无统计学意义(P>0.05).[结论]腰椎间盘镜单节段髓核摘除术治疗腰椎间盘突出症的远期疗效肯定,对脊柱稳定性的影响小,且并发症少.     

腹腔镜下腰椎前路手术治疗腰椎间盘突出症

目的探讨腹腔镜下经腹前路腰椎间盘突出髓核摘除术的临床应用及疗效观察。方法对2003年3月至2005年3月采用腹腔镜经皮腹膜后入路监视、C型臂X光透视定位下手术,对行单纯性腰椎间盘突出前路髓核摘除术32例的患者进行回顾性分析。结果采用MacNab标准评定:本组32例随访3~16个月,显效26例,(81%),有效4例(13%),无效2例(6%),有效率为94%,并且均无严重并发症发生。结论腹腔镜下经腹膜后腰椎前路手术治疗单纯性腰椎间盘突出症具有创伤小、脊柱稳定性强、疗效好等优点。     

脊柱内窥镜下腰椎间盘摘除术(附80例初步报告)

目的：报告应用脊柱内窥镜行突出腰椎间盘摘除术的治疗体会，探讨此技术的基本概念、手术要点和临床早期效果。方法：对８０例单平面腰椎间盘突出症患者行脊柱内窥镜下间盘摘除术。所有病例均在局麻下于工作三角区内行脊柱内窥镜直视下工作通道内突出间盘摘除术，并对病人术后的疗效及手术前后病变节段的ＭＲＩ表现进行分析比较。结果：本组病人均在术后５ｄ内出院，无手术并发症。所有病人获得随访，平均随访４．５个月，临床疗效优良率为８６％。术后ＭＲＩ检查显示突出间盘得以摘除，脊髓及神经根已获得充分减压。结论：经脊柱内窥镜下的突出椎间盘摘除术手术创伤小，病人术后恢复快，疗效肯定，是治疗腰椎间盘突出症的有效方法之一     

影响老年人腰椎间盘突出症手术疗效的原因及对策

目的：总结分析自１９ ８９ 年～１９９ ６ 年本院手术治疗老年人腰椎间盘突出症的效果,探讨老年人腰椎间盘突出症的病理特点,并提出改进措施。方法：４９ 例老年人腰椎间盘突出症行小切口开窗髓核摘除术３６ 例,扩大开窗髓核摘除术１０ 例,半椎板切除髓核摘除术３ 例。结果：随访１ 年～８５ 年,平均４ 年,优良率仅４７２ ％ 。术后近期随访疗效尚好,随访时间越长疗效越差。结论： 应根据老年人腰椎间盘突出症的病理特点选择正确的术式,过分强调小切口开窗髓核摘除术是不正确的。     

脊柱内窥镜下腰椎间盘摘除术远期疗效评价

目的: 评价脊柱内窥镜下腰椎间盘摘除术后的远期疗效。方法: 对 1995 ~1999年间行脊柱内窥镜下腰椎间盘摘除术治疗的 156例腰椎间盘突出症患者进行信件问卷随访。分析患者的术后症状缓解、恢复工作情况。结果: 共收到有效回信 43封, 随访率 27. 6%。临床疗效优良率 81. 4%, 内窥镜组和开窗组疗效比较差异无显著性 (P>0. 05)。术后恢复工作时间平均为 1个月, 恢复原工种, 占 88. 49%。影像学结果表明手术节段椎间隙无明显的高度下降或间隙失稳表现。结论: 脊柱内窥镜下腰椎间盘摘除术是一种有效的治疗方法, 应严格掌握手术适应证。     

椎间盘镜治疗腰椎间盘突出症177例的临床疗效分析

目的总结椎间盘镜（MED）治疗腰椎间盘突出的临床效果，探讨其适应证、技术要点。方法对177例（213个间隙）腰椎间盘突出症患者施行后路显微内窥镜椎间盘摘除术，对其疗效进行回顾性分析。结果本组患者均在术后7d内出院；全组患者均获得随访，平均随访时间7．8个月，术后按Macnnab标准行功能评级：优141例，良27例，可9例，优良率94．9％。结论椎间盘镜摘除术具有手术创伤小、出血量少、脊柱稳定性影响小、住院时间短的特点，是脊柱微创外科的发展方向之一。     

Surgically treated cervical myelopathy: a functional outcome comparison study between multilevel anterior cervical decompression fusion with instrumentation and posterior laminoplasty

Background contextMultilevel cervical myelopathy can be treated with anterior cervical discectomy and fusion (ACDF) or corpectomy via the anterior approach and laminoplasty via the posterior approach. Till date, there is no proven superior approach.PurposeTo elucidate any potential advantage of one approach over the other with regard to clinical midterm outcomes in this study.Study designA prospective, 2-year follow-up of patients with cervical myelopathy treated with multilevel anterior cervical decompression fusion and plating and posterior laminoplasty.Patient sampleIn total, 116 patients were studied. Sixty-four patients underwent ACDF two levels and above or anterior cervical corpectomy and fusion one level and above. Fifty-two patients underwent posterior cervical surgery (laminoplasty C3–C6 and C3–C7).Outcome measuresSelf-report measures: Japan Orthopedic Association (JOA) score, JOA recovery rate, visual analog scale for neck pain (VASNP), neck disability index (NDI), and American Academy of Orthopaedic Surgeons (AAOS) neurogenic symptom score (AAOS-NSS). Physiologic measures: range of motion (ROM) flexion and extension of neck. Functional measures: short-form 36 (SF-36) score comprising physical functioning, physical role function, bodily pain, general health, vitality, social role function, emotional role function, and mental health scales.MethodsComparison of the JOA scores, JOA recovery rates, NDI scores, SF-36 scores, VASNP, and ROM preoperatively to 2 years. Chi-square and two-sided Student t tests were used to analyze the variables.ResultsPosterior surgery took an hour shorter (p<.05) and had better improvement in JOA scores at early follow-up of 6 months (p=.025). Anterior surgery group had better improvement of NDI scores at early follow-up of 6 months (p=.024) and was associated with less blood loss intraoperatively compared with posterior surgery. There was no statistical difference between the two groups for JOA scores, JOA recovery rates, SF-36 quality-of-life scores, NDI, AAOS-NSS, VAS neck pain, and ROM at 2 years. Complications were higher for anterior surgery group: two hematoma postoperation, one vocal cord paresis, and one new onset C6/C7 dermatome numbness versus one dura leak in posterior surgery group.ConclusionsOur study showed that patients with multilevel disease treated with laminoplasty do well and compare favorably with patients treated with an anterior approach. Notably, posterior surgery was associated with shorter operating time, better improvement in JOA scores at 6 months, and a tendency toward lesser complications. Posterior surgery was not associated with increased neck disability and neck pain at 2 years. Anterior surgery had better NDI improvement at early follow-up. There is a need for a larger study that is prospectively randomized with long-term follow-up before we can confidently advocate one approach over the other in the management of cervical myelopathy.     

Anterior cervical discectomy with or without bone graft placement in the treatment of cervical radiculopathy. Long-term results

BACKGROUND AND PURPOSE: Anterior approach for cervical radiculopathy is a frequently performed operation in neurosurgery. The goal of this study is to evaluate the short and long-term results of anterior cervical discectomy with and without fusion. METHODS: Between 1984 and 1999, we operated on 101 patients presenting with cervical radiculopathy by an anterior approach. The operation consisted of one-level discectomy in 74 cases, two-level discectomy in 25 cases and three-level discectomy in 2 cases. Eighty-four out of 130 levels operated on were fused. Evaluation was done following a consultation with dynamic cervical X-rays and by telephone using a detailed questionnaire. Follow-up was obtained in 91 cases with a mean of 54 months in fused patients, and a mean of 45 months in the non-fused patients. RESULTS: Post-operative results were good in 95% in the 2 groups of patients. We encountered 8 complications, all in patients operated with bone graft placement. Five patients were reoperated on at an adjacent level, 4 being fused previously. CONCLUSIONS: The 2 techniques are comparable in term of goods results at short and long-term follow-up. Anterior discectomy without fusion is associated with less complications, less post-operative pain, and less operative time cost.     

Minimally invasive anterior contralateral approach for the treatment of cervical disc herniation

BACKGROUND: During the practice of ipsilateral approach to the offending lesion in anterior simple discectomy, the authors realized that it achieves better surgical exposure of the opposite foraminal area. In addition, it was also realized that routine procedures for better visualization of the foraminal area, such as stripping longus colli muscles, further excising of the anterior longitudinal ligament, or using a spreader, which cause more invasive surgery during the standard anterior approach, are not necessary because the contralateral approach already achieves sufficient exposure of the target foraminal area. OBJECTIVE: Evaluation of the results and effectiveness of this minimal invasive technique in patients with either soft or hard disc herniations. METHODS: Between January 1994 and April 2002, 216 patients underwent anterior contralateral microdiscectomy without fusion for cervical disc herniation at 1 or 2 adjacent levels. Anterior contralateral microdiscectomy is a less invasive technique than standard anterior simple discectomy in which longus colli muscles are not stripped, and the lateral part of annulus fibrosis at the side of intervention and ventrolateral part of it at the opposite side are not removed. In addition, a mini Zenker handheld retractor is used for retraction of paravertebral soft tissues and a spreader is not used during the discectomy procedure. There were 182 patients diagnosed with radiculopathy and 34 patients with myelopathy. Assessments of the neurological status of patients with radiculopathy were done by physical examinations, and of those with myelopathy according to the modified Japanese Orthopaedic Association cervical spine functional assessment scale. These neurological assessments were repeated in the 18th month after surgery. In the follow-up period, the outcomes of surgery were also assessed for all patients in 4 categories, from failure to excellent. RESULTS: Surgery outcomes generally have been good to excellent and none of the patients were made worse by the procedure. The outcomes were significantly better in the radiculopathy and soft disc herniation groups. Other positive outcome factors were short duration and sudden onset of symptoms, normal cervical curvature, and single-level disease. Follow-up radiological studies revealed fibrous healing with normal or slight loss of disc height in 199 (92.1%) patients and total obliteration of the involved disc space representing radiological fusion signs in 13 (6%) patients. The overall complications observed in this study were 2 spontaneous and 2 postinfection collapses of disc level, 1 excessive fibrosis of disc level, and 2 adjacent-level diseases. CONCLUSION: Anterior contralateral microdiscectomy without fusion achieves better exposure for resection of the offending foraminal or far lateral lesions, ventral osteophytes, or a disc fragment under direct microscopic visualization. Collapse and instability of the involved disc level can also be avoided via this less invasive technique.     

Surgical management of cervical soft disc herniation. A comparison between the anterior and posterior approach

Anterior cervical fusion was initially described in the 1950s for cervical spondylotic radiculopathy. The indications for this procedure in the management of soft disc herniation have not been clearly defined. In addition, controversy exists as to whether a cervical soft herniation should be managed by an anterior approach or a posterior cervical laminotomy-foraminotomy. The authors report the results of a prospective study comparing anterior discectomy and fusion to posterior laminotomy-foraminotomy for the management of soft cervical disc herniation. Twenty-eight patients underwent anterior discectomy and fusion (Robinson horseshoe graft) while 16 patients underwent posterior laminotomy-foraminotomy. The disc herniations were classified into two types. Type I were single level anterolateral herniations (33 patients) while type II were central soft disc herniations (11 patients). Clinically, patients with type I herniations manifested signs and symptoms of radiculopathy while patients with type II herniations manifested signs of myelopathy or neck pain and bilateral upper extremity paresthesias in 4 patients. Confirmatory studies were myelography in 12 patients, myelography combined with computed tomography (CT) in 26 patients, and magnetic resonance imaging (MRI) in 6 patients. For type I herniations, 17 patients underwent anterior fusion while 16 patients had a posterior laminotomy-foraminotomy. The 11 patients classified as type II herniation all underwent anterior discectomy and fusion. There were 27 men and 17 women. The age range was 21 to 52 years (mean, 41 years). The follow-up was 1.6 to 8.2 years (mean, 4.2 years).(ABSTRACT TRUNCATED AT 250 WORDS)     

脊髓型颈椎病手术方式的选择

目的 :探讨对脊髓型颈椎病前、后路两种手术方式的选择标准。方法 :对 12 0例前路手术及 110例后路手术的术后日本骨科学会评分标准的改善率 (JOA改善率 )、颈椎管扩大率、颈椎生理前弯度、相邻椎间的稳定性及颈椎屈伸活动度等进行比较。结果 :(1)病变小于或等于两个间隙的病例 ,两种术式术后的JOA改善率无明显差异 ,对颈椎生理前弯度及屈伸活动度的影响前路手术优于后路手术。 (2 )病变等于或大于三个间隙的病例 ,JOA改善率后路手术大于前路手术 ,对颈椎生理前弯度的影响两者无明显差异 ,对屈伸活动度的影响后路手术优于前路手术。结论 :(1)病变小于或等于两个间隙时 ,应选择前路手术。 (2 )病变等于或大于三个间隙时应选择后路手术。 (3 )合并发育性颈椎管狭窄时选择后路手术为宜     

Surgical treatment of cervical spondylotic myelopathy with anterior compression: a review of 67 cases

OBJECT: In patients with cervical spondylotic myelopathy (CSM), ventral disease and loss of cervical lordosis are considered to be relative indications for anterior surgery. However, anterior decompression and fusion operations may be associated with an increased risk of swallowing difficulty and an increased risk of nonunion when extensive decompression is performed. The authors reviewed cases involving patients with CSM treated via an anterior approach, paying special attention to neurological outcome, fusion rates, and complications. METHODS: Retrospectively, 67 cases involving consecutive patients with CSM requiring an anterior decompression were reviewed: 46 patients underwent anterior surgery only (1-to3-level anterior cervical discectomy and fusion [ACDF] or 1-level corpectomy), and 21 patients who required > 3-level ACDF or > or = 2-level corpectomy underwent anterior surgery supplemented by a posterior instrumented fusion procedure. RESULTS: Postoperative improvement in Nurick grade was seen in 43 (93%) of 46 patients undergoing anterior decompression and fusion alone (p < 0.001) and in 17 (81%) of 21 patients undergoing anterior decompression and fusion with supplemental posterior fusion (p = 0.0015). The overall complication rate for this series was 25.4%. Interestingly, the overall complication rate was similar for both the lone anterior surgery and combined anterior-posterior groups, but the incidence of adjacent-segment disease was greater in the lone anterior surgery group. CONCLUSIONS: Significant improvement in Nurick grade can be achieved in patients who undergo anterior surgery for cervical myelopathy for primarily ventral disease or loss of cervical lordosis. In selected high-risk patients who undergo multilevel ventral decompression, supplemental posterior fixation and arthrodesis allows for low rates of construct failure with acceptable added morbidity.     

Irreducible dislocations of the cervical spine with a prolapsed disc: preliminary results from a treatment technique

STUDY DESIGN: The preliminary results from a treatment technique for irreducible dislocations of the cervical spine with prolapsed disk are reported. OBJECTIVE: To report the success of a technique for grafting and instrumentation of the anterior cervical spine before reduction. This technique is useful in cervical fracture-dislocations irreducible through the anterior approach that must be approached first from the front because of a prolapsed disc. SUMMARY OF BACKGROUND DATA: In the treatment of cervical facet dislocations, a third anterior procedure often is necessary to accomplish the anterior instrumentation and fusion. The reported technique describes a method that eliminates this third procedure by using a cervical buttress plate. METHODS: Between August of 1996 and October 1998, four patients had dislocation of the cervical spine with a prolapsed disc that could not be reduced using the anterior approach. After discectomy and endplate preparation, a tricortical bone graft was harvested from the iliac crest, placed in the interspace, and held with a buttress plate screwed in two places into the superior vertebral body. The anterior wound then was closed. The posterior elements were exposed and the facets reduced by flexing the neck and posteriorly translating the superior segment. Fluoroscopy was used during the reduction to ensure that the graft was pulled into the interspace, that the screws in the buttress plate did not pull out of the superior vertebral body, and that the reduced graft did not impinge on the spinal cord. A posterior fusion was performed and the posterior wound closed. RESULTS: All the patients had consolidation of both anterior and posterior fusions. No cases of instrument failure occurred, either anteriorly or posteriorly. No cases of neurologic deterioration occurred, and no complications were attributable to the use of this technique. CONCLUSION: The reported technique was used successfully in the treatment of four patients with irreducible dislocations of the cervical spine.     

胸椎管狭窄症的诊断和治疗

目的: 总结胸椎管狭窄症的临床特点, 加强对胸椎管狭窄症临床特点的认识。方法: 回顾总结获随访 120例经过手术治疗的胸椎管狭窄症患者的临床资料。98例行椎管后壁切除术, 侧前方入路行胸椎间盘或胸椎后纵韧带骨化病灶切除 17例 (其中经胸腔入路 7例, 经胸膜外或胸腹膜外 10例), 后路环椎管减压术 5例。随访时间最长 64个月, 最短 3个月, 平均 28个月。结果: 功能评定采用改良的Epstein评分标准, 优 51例, 良 42例, 改善 17例, 差 10例。优良率为 77. 5%。结论: 退变性胸椎管狭窄症症状复杂多样, 手术治疗是唯一选择。根据胸椎管狭窄症的不同病理改变选择手术方式, 可获得满意的效果。     

Comparison of anterior and posterior surgical approaches in the treatment of ventral spinal hemangioblastomas in patients with von Hippel-Lindau disease

OBJECT: Von Hippel-Lindau (VHL) disease is an autosomal-dominant neoplastic syndrome with manifestations in multiple organs, which is evoked by the deletion or mutation of a tumor suppressor gene on chromosome 3p25. Spinal hemangioblastomas (40% of VHL disease-associated lesions of the central nervous system) arise predominantly in the posterior aspect of the spinal cord and are often associated with an intraspinal cyst. Rarely, the tumor develops in the anterior aspect of the spinal cord. Ventral spinal hemangioblastomas are a surgical challenge because of difficult access and because vessels feeding the tumor originate from the anterior spinal artery. The goal of this study was to clarify whether an anterior or posterior surgical approach is better for management of hemangioblastomas of the ventral spinal cord. METHOD:. The authors performed a retrospective analysis of clinical outcomes and findings on magnetic resonance (MR) imaging studies in eight patients (two women and six men with a mean age of 34 +/- 15 years) who underwent resection of ventral spinal hemangioblastomas (nine tumors: five cervical and four thoracic). Two surgical approaches were used to resect these tumors. A posterior approach was selected to treat five patients (laminectomy and posterior myelotomy in four patients and the posterolateral approach in one patient); an anterior approach (corpectomy and arthrodesis) was selected to treat the remaining three patients. Immediately after surgery, the ability to ambulate remained unchanged in patients in whom an anterior approach had been performed, but deteriorated significantly in patients in whom a posterior approach had been used, because of motor weakness (four of five patients) and/or proprioceptive sensory loss (three of five patients). This difference in ambulation, despite significant improvements over time among patients in the posterior access group, remained significant 6 months after surgery. In all cases, MR images revealed complete resection of the tumor and in five patients significant or complete resolution of the intramedullary cyst was demonstrated (present in six of eight patients). CONCLUSIONS: The outcomes of these eight patients with hemangioblastomas of the ventral spinal cord indicate that both immediate and long-term results are better when an anterior approach is selected for resection.     

Anterior cervical discectomy with hydroxylapatite fusion

The outcome of microscopic anterior cervical discectomy with iliac crest interbody fusion in a group of 75 patients was compared with that of microscopic anterior cervical discectomy with synthetic hydroxylapatite fusion in a group of 84 patients. The rate of relief of myelopathy (70%) was similar in both groups, but those who underwent synthetic fusion had better long-term relief of radiculopathy, less need for a second operation at the same or an adjacent level, no resorption of the bone plug, comparable spinal alignment and stability, and the elimination of complications at the iliac crest donor site. The data suggest that hydroxylapatite fusion may be equal or superior to autologous iliac crest interbody fusion for anterior cervical disc surgery.