钛笼与髂骨块植骨修复椎骨缺损治疗胸腰椎结核的疗效比较

[目的]探讨后路病灶清除、植骨融合内固定术治疗胸腰椎结核的疗效,并比较钛笼与自体髂骨块植骨重建椎骨缺损的疗效差异。[方法]回顾性分析2011年1月~2013年12月行后路病灶清除、植骨融合内固定治疗的49例单节段胸腰椎结核患者的临床资料。其中钛笼组25例、髂骨块组24例。观察VAS评分、ODI评分、Cobb角和椎间高度的改善及丢失、神经功能恢复情况、植骨融合时间及术后并发症等。[结果]平均随访35.3(15~56)个月;术后植骨均融合。两组Cobb角和椎间高度的矫正较术前改善,组间差异无统计学意义(P>0.05)。钛笼组Cobb角和椎间高度丢失明显少于髂骨块组(P<0.05)。神经功能较术前明显改善。主要并发症有脑脊液漏(钛笼组1例)、窦道形成(钛笼组和髂骨块组各1例)、术区椎间隙感染(髂骨块组1例),无内置物及取髂骨区相关并发症。[结论]后路手术治疗胸腰椎结核可获得良好的临床疗效,结核病灶累及单节段时自体髂骨与钛笼植骨重建椎骨缺损均是较佳选择。     

In vivo evaluation of calcium sulfate as a bone graft substitute for lumbar spinal fusion

BACKGROUND CONTEXT: Posterolateral fusions of the lumbar spine have nonunion rates as high as 35%. The availability of autologous bone to promote fusion is limited, particularly for multilevel fusions. Bone substitutes have been proposed to augment or replace autologous bone for spinal surgery. Calcium sulfate offers high porosity, osteoconductivity, and high resorption rate. This material has been used successfully for treatment of long bone defects but has not been investigated as a bone graft substitute for spinal fusions. PURPOSE: To determine whether the use of calcium sulfate granules in conjunction with an implantable electrical stimulator is a safe and effective means of attaining spinal fusion. STUDY DESIGN/SETTING: A rabbit lumbar fusion model was used to assess a calcium sulfate bone graft substitute in combination with electrical stimulation for spinal fusion. METHODS: Thirty-six adult New Zealand White female rabbits were divided into three groups. Each group underwent a single-level (L5-L6) fusion, receiving 3.0 cc calcium sulfate granules with bone marrow aspirate from the iliac crest. Group 1 had no electrical stimulator applied. Groups 2 and 3 received a 40-microA (Group 2) or a 100-microA (Group 3) implantable electrical stimulator. The animals were sacrificed at 8 weeks, and the rabbit spines were subjected to radiographic assessment, manual palpation, and mechanical testing. RESULTS: Two rabbits died postoperatively. The radiographic assessment revealed no fusions occurred at the adjacent nonoperated control levels (L4-L5). There were no fusions observed within Group 1, containing the calcium sulfate and bone marrow aspirate alone. The sites with the implantable stimulators showed a dose-dependent increase in fusion stiffness. However, no fusion mass in Group 2 or 3 was graded as bilaterally complete. CONCLUSION: This study found that calcium sulfate as a bone graft substitute was unsuccessful in promoting spine fusion in a rabbit model. There was radiographic evidence of rapid resorption of the calcium sulfate within 4 weeks after surgery. The use of electrical stimulation created a dose-dependent increase in mechanical competence of the bony mass. However, the addition of direct current (DC) current did not significantly alter fusion rates with calcium sulfate used as the bone graft substitute in this model.     

Posterior-only approach with titanium mesh cages versus autogenous iliac bone graft for thoracic and lumbar spinal tuberculosis

Objective: This study aimed to compare the effectiveness of titanium mesh cages (TMCs) with autogenous iliac bone grafts (AIBG) in posterior-only surgery for thoracic and lumbar spinal tuberculosis.Design: Retrospective investigative design.Setting: The First Affiliated Hospital of Fujian Medical University, Fuzhou, China.Participants: A total of 146 patients with thoracic or lumbar tuberculosis.Interventions: All patients underwent a posterior-only approach with either a TMC (86 cases) or AIBG (60 cases).Outcomes measures: Operation duration, intraoperative blood loss, erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), visual analogue scale (VAS), and related complications were used to compare the effectiveness and feasibility of the two techniques. Frankel grading system, Cobb angle, and loss of angular correction were employed to assess neurological and kyphotic improvements.Results: There were significant improvements in ESR, CRP, VAS, Frankel grade, and Cobb angle at the last follow-up (P < 0.05) when compared with the preoperative state. The TMC group was superior in operation duration (P < 0.001), intraoperative blood loss (P = 0.007), VAS (P < 0.001), loss of angular correction (P < 0.001), and surgical complications as compared with the AIBG group. There were no significant differences in the improvement of the Frankel grade and Cobb angle between the TMC and AIBG groups (P > 0.05). A recurrence of tuberculosis was not found in either of the groups.Conclusion: Compared to autogenous iliac bone grafts, titanium mesh cages could serve as a superior material in posterior-only operative therapy for thoracic and lumbar spinal tuberculosis.     

Rib bone graft for posterior spinal fusion in children

Treatment of columnar instability in children with conventional fusion procedures may preclude normal growth and cause dysfunction and pain due to malalignment or reduced mobility. To achieve normal growth, we have treated spinal instability in 7 children with posterior fusion, using bilateral rib transplants secured by horizontal laminar cerclages. Solid fusion was obtained and no serious complications occurred.     

Rib bone graft for posterior spinal fusion in children

Treatment of columnar instability in children with conventional fusion procedures may preclude normal growth and cause dysfunction and pain due to malalignment or reduced mobility. To achieve normal growth, we have treated spinal instability in 7 children with posterior fusion, using bilateral rib transplants secured by horizontal laminar cerclages. Solid fusion was obtained and no serious complications occurred.     

椎间植骨融合加SRS 系统治疗腰椎滑脱症

目的 探讨运用Spondylolisthesis Reduction System(SRS)提拉复位系统加环锯取髂骨于椎体间行单侧或双侧植骨融合治疗峡部不连性腰椎滑脱症。方法 临床共治疗43例腰椎峡部不连性滑脱病人，按手术复位，症状改善，骨性融合，内固定材料牢固情况进行疗效评价。结果 43例患者获得1～5年(平均3年2个月)随访，按我们自拟疗效标准，优33例，良7例，可3例，无症状加重病例。完全复位38例。无内固定松动断裂发生。结论 环锯椎间植骨融合加SRS系统，能达到很好的复位及牢固的固定，从而达到椎间的骨性融合。手术操作简便，效果满意，如能采取双侧椎间同时植骨，增加融合面积，效果更佳。     

后路病灶清除仿生骨支撑植骨融合内固定术治疗胸腰椎结核的疗效分析

目的 :评估后路一期病灶清除辅以纳米仿生骨支撑植骨融合内固定术治疗胸腰椎结核的临床疗效。方法:回顾性分析2011年1月~2015年5月收治的17例胸腰椎结核患者,其中男性11例,女性6例,年龄25~71岁,平均41.2±5.6岁;胸椎(T4~T10)结核9例,胸腰段(T11~L2)结核7例,下腰椎(L3~L5)结核1例;单节段病变12例,两节段病变5例;脊髓神经损伤情况按照ASIA损伤分级:B级1例、C级4例、D级6例、E级6例。本组患者均行后路一期病灶清除纳米仿生骨笼支撑植骨融合内固定术治疗,从术前2周~术后18个月规范应用抗结核药物。术后1个月、3个月、6个月、12个月、24个月定时随访,观察植骨区融合情况并比较术前及术后患者疼痛视觉模拟评分(VAS)、脊柱后凸Cobb角、神经功能ASIA分级变化情况。结果:本组17例患者均成功完成手术,手术时间264~366min,平均294±88min;术中出血量457~1350ml,平均731±78ml。所有患者均获得随访,随访时间18~27个月,平均23±6个月,随访期间无结核症状加重及相关并发症,术后切口均Ⅰ期愈合,均未出现切口感染及内固定物松动。1例患者术中出现胸膜破裂,予以修补并采用胸腔闭式引流后正常出院。术后6个月植骨融合率为88.2%,术后12个月时植骨区均可见骨性融合,融合率为100%。术前VAS评分为8.1±0.6分,术后2周时为2.1±0.3分,末次随访时为1.1±0.2分;术前Cobb角为28.3°±9.8°,术后2周时为8.1°±1.5°,末次随访时为9.8°±2.1°,终末矫正率为65.3%。末次随访时ASIA分级D级4例,E级13例。手术前后VAS评分、Cobb角、ASIA分级差异比较均有统计学意义(P0.05)。结论:在抗结核药物治疗的基础上,一期后路病灶清除结合纳米仿生骨植骨融合内固定手术治疗较局限的胸腰椎结核可取得较为满意的效果。     

兔骨髓基质干细胞体外培养复合β-磷酸三钙进行胸椎后侧融合实验研究

[目的]评价β-磷酸三钙复合骨髓基质干细胞为骨移植替代物进行脊柱融合的效果。[方法]60只兔子分四组进行胸椎后路融合：Ⅰ组（组织工程化骨即β—TCP复合BMSCs），Ⅱ组（β—TCP＋自体红骨髓），Ⅲ组（单纯β—TCP），Ⅳ组（自体髂骨）。术后12周处死其余动物进行放射学、手工力学和组织学检查。[结果]从影像学和手工力学比较，Ⅰ组的融合率高于Ⅱ、Ⅲ、Ⅳ组且有统计学差异。组织学上，Ⅰ组新骨形成量较多，陶瓷微孔内部充满新生骨；Ⅱ组骨小梁形成量较Ⅰ组少，为新生骨与纤维组织混杂；Ⅲ组陶瓷骨颗粒微孔内多为结缔组织，新生骨的量少，只见少量新生骨贴附于陶瓷骨表面；Ⅳ组在椎板与移植骨的交界处有稀疏的新生骨小梁形成。[结论]β—TCP复合BMSCs是脊柱融合自体骨的良好替代物。     

Electrical bone graft stimulation for spinal fusion: a review

Although electrical stimulation to aid bone fusion is well established in the treatment of long-bone fractures, its use as an aid in spinal fusion is not as well documented. This article presents the history and scientific basis of electrical stimulation to aid bone fusion and extensively reviews the clinical literature. It is intended to provide an objective review of the indications and limitations of electrical stimulation to enhance spinal fusion and to serve as a reference source for further study.     

Posterolateral lumbar spine fusion with INFUSE bone graft.

BACKGROUND CONTEXT: INFUSE has been proven effective in conjunction with threaded cages and bone dowels for single-level anterior lumbar interbody fusion (ALIF). The published experience with posterolateral fusion, although encouraging, utilizes a significantly higher dose and concentration of recombinant human bone morphogenic protein-2 (rhBMP-2) and a different carrier than the commercially available INFUSE. PURPOSE: To present an assessment of fusion rate for posterolateral spine fusion with INFUSE Bone Graft. STUDY DESIGN/SETTING: Retrospective review of patients treated using INFUSE in posterolateral spine fusion in a single institution. PATIENT SAMPLE: 91 patients with minimum 2-year follow-up who underwent posterolateral spine fusion using INFUSE as an iliac crest bone graft (ICBG) substitute. OUTCOME MEASURES: Fusion rate based on fine-cut computed tomographic (CT) scans with sagittal and coronal reconstructions. METHODS: Fusion was performed using one large INFUSE kit (12 mg rhBMP-2, 1.5 mg/mL), which was prepared according to the manufacturer's instructions. The INFUSE sponge was wrapped around the local bone or graft extender and placed over the decorticated surfaces in the lateral gutters. Postoperative CT scans with reconstructions were reviewed by two independent orthopedic spine surgeons. CT scans of a comparison group of 35 patients who underwent primary single-level posterolateral fusion with ICBG were also reviewed. RESULTS: The overall group had a mean 4.38 CT fusion grade and a 6.6% nonunion rate. Primary one-level fusion cases (n=48) had a mean 4.42 fusion grade a 4.2% nonunion rate. Primary multilevel fusions (n=27) had a mean 4.65 CT grade and no nonunions detected. Assessment of the 35 primary one-level ICBG control cases demonstrated a mean CT grade of 4.35 and a nonunion rate of 11.4%. In the 16 cases of revision for prior nonunion, mean CT grade was 3.81 and 4 subjects had nonunions. Additional subgroup analysis showed that smokers (n=14) had a mean 4.32 CT grade with no nonunions. Men had a mean 4.04 CT grade and an 11.1% nonunion rate compared with a mean 4.61 CT grade and 3.6% nonunion rate in women. This difference was statistically significant (p=.036). No significant differences in fusion rate were observed based upon the specific graft extender used (p=.200). CONCLUSIONS: Posterolateral spine fusion involves a more difficult healing environment with a limited surface for healing, a gap between transverse processes and the milieu of distractive forces. Historically, only ICBG has been able to overcome these challenges and reliably generate a successful posterolateral lumbar spine fusion. In contrast to prior studies, clinically available INFUSE delivers only 12 mg rhBMP-2 at a concentration of 1.5 mg/mL. Despite the lower dose and concentration of rhBMP-2, this study suggests that fusion success with INFUSE is equivalent to ICBG for posterolateral spine fusion. As with ICBG, development of solid fusion or nonunion is a multifactorial process. The use of INFUSE is not a substitute for proper surgical technique or optimization of patient-related risk factors. Additional studies are needed to determine the incremental benefit of a greater rhBMP-2 dose or use of alternative carriers for posterolateral fusion. Finally, correlation between radiographic findings and clinical outcomes, and a cost-benefit analysis are needed. Despite these issues, this study presents compelling evidence that commercially available INFUSE is an effective ICBG substitute for one- and two-level posterolateral instrumented spine fusion.     

后路颗粒骨植骨融合内固定治疗退行性腰椎不稳

目的探讨颗粒骨后路植骨融合内固定治疗退行性腰椎不稳的效果。方法48例退行性腰椎不稳患者,行腰椎椎弓根钉棒内固定,全椎板或半椎板减压,颗粒状骨植骨治疗。结果全部获随访时间6个月～4年,4～6个月后可见植骨灶骨融合征象,无复位丢失和螺钉断裂。患者腰痛、下肢疼痛症状均明显缓解。疗效及功能评定结果：优22例,良24例,可2例,优良率96%。结论脊柱后路颗粒植骨结合椎弓根钉内固定是治疗退行性腰椎不稳一种有效的手术方法。     

不同植骨融合术治疗腰椎滑脱症的疗效比较分析

目的：比较3种不同植骨融合术治疗腰椎滑脱症的疗效。方法：自2006年1月至2008年12月共收治腰椎滑脱症患者85例,男36例,女49例;年龄38～65岁,平均51.8岁。采用3种手术方法：后外侧植骨融合术32例（A组）、后路椎体间植骨融合术28例（B组）、前路椎体间植骨融合术25例（C组）。疗效评定采用Nakai评分标准,骨性融合标准采用Suk标准判断。结果：所有患者均获得随访,随访时间均不少于2年。A组：优19例,良9例,中4例;B组：优16例,良9例,中3例;C组：优14例,良8例,中3例。A、B、C组的融合率分别为68.8%（22/32）、92.9%（26/28）、92.0%（23/25）。B、C组的椎间隙高度维持及融合率均优于A组（P〈0.05）。结论：对于治疗腰椎滑脱症,前路及后路椎体间植骨融合术在椎间隙高度维持及融合率优于后外侧植骨融合术,但腰椎滑脱症病情及伴随并发症多样化,应具体根据患者滑脱类型、程度、有无椎间盘突出及神经症状等做出相应的选择。     

三种不同植骨方式在胸、腰椎结核手术治疗中的观察

目的:对比观察块状植骨、颗粒植骨和钛网植骨三种不同植骨方式在后路胸腰椎结核手术中的临床应用效果.方法:选取我院93例胸、腰椎结核患者,分为三组,彻底结核病灶清除后,分别采用块状植骨(32例)、颗粒植骨(35例)、钛网植骨(26例)三种不同植骨方式,对三组术中植骨所需时间,术中出血量,术后后凸畸形角纠正状况,末次随访后凸畸形角丢失状况,植骨融合时间进行对比.结果:患者均得到12～36个月随访,植骨所需手术时间A组为23.4±4.3min,B组为5.2±2.4min,C组为25.6±3.6min,B组植骨所需时间明显短于A组、C组(P＜0.05),A组、C组比较差异无统计意义(P＞0.05);术中出血量A组为553±53ml,B组为352±48ml,C组为564±47ml,B组明显少于A组、C组(P＜0.05),A组、C组比较差异无统计意义(P＞0.05);术前Cobb角A组为36.5°±5.9°,B组为36.2°±4.7°,C组为36.8°±5.1°,三组差异无统计学意义(P＞0.05),术后Cobb角A、B、C三组分别为15.3°±3.6°、15.6°±3.1°及15.1°±2.9°,三组间差异无统计学意义(P＞0.05);末次随访时Cobb角A组为16.9°±3.6°,平均丢失1.6°,B组为17.5°±3.1°,平均丢失1.9°,C组为16.8°±2.9°,平均丢失1.7°,三组差异无统计学意义(P＞0.05);植骨融合时间A组为5.9±0.4个月,B组为4.1±0.3个月,C组为6.2±0.5个月,B组明显短于A组、C组(P＜0.05),A组、C组比较差异无统计意义(P＞0.05).结论:颗粒骨植骨较传统块状植骨和钛网植骨植入方便易行,植入时间短,出血量少,植骨融合时间短,是后路胸椎结核病灶清除术后理想的植骨方式.     

三种腰椎后路椎间融合植骨材料的临床对比研究

目的探讨3种不同植骨材料及骨质疏松因素对腰后路椎间植骨成功率的影响、、方法回顾分析使用自体髂骨块（A组）、同种异体骨（B组）、融合器＋自体松质骨（C组）3种不同植骨材料行腰椎后路椎M融合手术患者共1121例,其中骨质疏松者共180例,通过X线及CT检查,对植骨融合率、融合时间、椎间高度、内同定火败率进行随访并对数据进行统计学分析。结果B组6l例中,11例患者（18．5％）出现植骨不融合．其中断钉6例,断棒2例．该组l在植骨融合率、内固定失败率、椎间高度丢失、融合时间等方面比另2组差（P〈O．05）。A组和C组植骨融合率分别为97．6％、98．2％,2组比较在各方面差异无统计学意义（p〉0．05）。在180例骨质疏松患行中,A绀患者融合率（90．3％）高于C组（84．6％）,差异有统计学意义（P〈0．05）。结论后路腰椎椎间融合,使用同种异体骨融合率最低,内固定失败、惟间隙塌陷发生率较高;自体髂骨块与融合器＋自体骨植骨融合率高,内固定失败发生率小;埘于骨质疏松者,自体髂骨块融合情况更佳。     

Silicate-substituted calcium phosphate ceramic bone graft replacement for spinal fusion procedures

STUDY DESIGN.: Retrospective study. OBJECTIVE.: To assess the clinical and radiographical outcomes in spinal fusion procedures using silicate-substituted calcium phosphate (Si-CaP). SUMMARY OF BACKGROUND DATA.: Si-CaP is a newer-generation synthetic ceramic designed to maximize osteoinduction and osteoconduction. METHODS.: This is a retrospective analysis of a prospectively collected patient database including 108 patients (204 individual spinal levels). Different surgical procedures performed included 25 anterior cervical discectomy and fusions, 17 posterior cervical fusions, 7 combined anterior and posterior cervical fusions, 10 thoracic fusion surgeries, 18 transforaminal lumbar interbody fusions with 12 axial lumbar interbody fusions, 11 transpsoas discectomy and fusions, and 8 combined thoracolumbar fusion procedures. Si-CaP was used as bone extender without any additional graft material, bone marrow aspirate, or bone morphogenetic protein. Clinical outcomes were assessed using the visual analogue scale (VAS), Oswestry Disability Index, and Neck Disability Index. Fusion was determined by the presence of bony bridging on 2 consecutive sections in at least 2 planes on computed tomographic imaging. RESULTS.: At a follow-up of 12 (±4.7) months, 90% of all patients demonstrated radiographical fusion. Fusion rates were highest in the cervical spine (97%) followed by thoracic and lumbar spines (86% and 81%, respectively). There were significant improvements in all clinical outcome measures-Oswestry Disability Index, 11.1 (±10.2) and Neck Disability Index, 9.0 (±11.4); VAS-back, 3.1(±3.0); VAS-leg, 3.5 (±3.6); VAS-neck, 3.7 (±2.5); and VAS-arm 4.0 (±3.2). There was no radiographical loosening of instrumentation due to infection or nonunion in this series, and no subsequent revisions for nonunion were required. CONCLUSION.: Si-CaP is an alternative to autogenous bone graft in spinal arthrodesis procedures. At 12-month follow-up, we detected high levels of bony fusion using Si-CaP in combination with various surgical spinal techniques.     

后路钉棒系统复位内固定植骨融合治疗退行性腰椎滑脱

1997年3月-2005年6月,我院采用椎板开窗潜行减压,后路椎弓根钉短节段内固定植骨融合治疗退行性腰椎滑脱32例,获随访者27例,效果满意。