S2骶骨翼螺钉技术进展

很多脊柱疾病的手术治疗须将活动的腰椎部分固定融合至稳定的骶骨结构上,而腰骶区特殊的生理解剖结构决定了骶骨侧为内固定系统的应力集中区,因此,内固定松动、断裂常先出现于骶骨侧,最终导致融合失败,严重影响临床疗效。随着影像学技术的进展及骶骨生物力学研究的深入,S2骶骨翼螺钉技术因其是在不跨越骶髂关节的基础上增加骶骨侧固定点和固定强度,可避免固定骶髂关节带来的相关并发症,越来越受到脊柱外科医师的关注,本文就国内外近年来该技术的应用解剖学、生物力学、技术要点及临床应用的相关研究做一综述,以期为临床医师和研究者提供参考。     

五种骶骨螺钉内固定的应用解剖研究

目的　评价五种骶骨内固定的安全性。方法　解剖七具尸体 ,以克氏针穿透模拟五种骶骨螺钉法 ,克氏针穿透骶椎前缘。分析骶骨螺钉损伤骶前重要结构的可能性 ,测量骶前安全区范围和螺钉钉道长度。结果　PTSF法螺钉不应穿透L5椎体前缘皮质 ,前外骶翼方向和垂直骶翼方向S1螺钉易损伤髂内动、静脉和腰骶干 ,前内骶岬方向S1螺钉的主要危险是骶正中血管 ,S2 螺钉易损及S1神经前支和交感链。结论　五种骶骨固定法均可损伤骶前重要结构 ,手术时应谨慎操作     

五种骶骨螺钉内固定的应用解剖研究

目的 评价五种骶骨内固定的安全性。方法 解剖七具尸体,以克氏针穿透模拟五种骶骨螺钉法,克氏针穿透骶椎前缘。分析骶骨踝螺钉损伤骶前重要结构的可能性,测量骶前安全区范围和螺钉道长度。结果 PTSF法螺钉不应穿透L5椎体前缘皮质,前外骶翼方向和垂直骶翼方向S1螺钉易损伤髂内动、静脉和腰骶干,前内骶岬方向S1螺钉的主要危险是骶正中血管,S2螺钉易损及S1神经前支和交感链。结论 五种骶骨固定法均可损伤骶前重要结构,手术时应谨慎操作。     

骶骨螺钉固定方式的应用解剖学及生物力学研究进展

腰骶椎短器械内固定技术在治疗脊柱创伤、腰椎滑脱等退行性腰骶椎病变等疾病中,用于复位和重建脊柱稳定性方面已得到广泛应用,并取得了显著疗效.由于骶骨具有独特的三维解剖结构,腰骶部承受较大的载荷和腰骶角的存在引起局部剪切应力,故骶骨螺钉植入的牢固度相对较差,再加上腰、骶椎前面重要的血管、神经走行及变异.术后并发症发生率较高,致使骶骨螺钉的植入很难取得牢固有效的固定.因此,骶骨螺钉的固定方式成为国内外骨科医师研究的热点.该文就骶骨螺钉固定方式的应用解剖学和生物力学的最新研究进展作一综述.     

经皮骶前轴向腰骶椎间融合术(AxiaLIF)在成人脊柱侧凸长节段脊柱融合术中的应用研究进展

成人脊柱侧凸的长节段融合手术中,腰骶段融合失败率较高。为了提高融合率,既往采用Galveston技术,改良luque-Glaveston技术,四棒技术,髂骨螺钉,和经第2骶骨翼骶髂关节螺钉等来进行加固。最近经皮微创骶前轴向腰骶椎融合术(Axialif)的应用逐渐成为热门,现就Axialif在成人脊柱侧凸长节段脊柱融合术中的解剖学、生物力学特性,手术适应证及技术、临床疗效及并发症等方面进行综述。     

腰-骶-骨盆固定技术及研究进展

近年来脊柱外科内固定器械研发及手术技术取得了许多新的进展,但是腰骶关节固定失败、假关节形成等难题仍是脊柱外科医师面临的挑战之一.骶骨骨质薄弱、复杂的区域解剖结构、腰骶关节承载的巨大生物应力等均是导致局部容易发生固定融合失败的原因.     

经皮长骶髂螺钉内固定治疗TileC型骶骨骨折

目的探讨经皮长骶髂螺钉内固定治疗TileC型骶骨骨折的可行性、有效性以及技术要点。方法2例TileC型骨盆骨折骨牵引至骨折竖直方向复位满意后行骨折复位内固定术,自骶骨伤侧行经皮长骶髂螺钉固定骶骨骨折．以重建钢板固定耻骨上支骨折。结果术中无重大血管、神经损伤,术后无感染、严重双下肢静脉血栓形成、双下肢不等长及内固定失效,骨折均顺利愈合。Matta评分和Majeed功能评分结果均为优。结论经皮长骶髂螺钉内固定治疗TileC型骶骨骨折是一种有效且相对安全的骶髂螺钉固定方式。     

腰髂固定联合骶管减压治疗不稳定型骶骨U型骨折

目的探讨腰髂固定联合骶管减压治疗不稳定型骶骨U型骨折的临床疗效。方法采用腰椎椎弓根螺钉联合髂骨螺钉固定联合骶管神经孔减压治疗8例不稳定型骶骨U型骨折患者。结果 8例均获得随访,时间8~18个月,骨折均愈合。根据Gibbons评分标准评定神经功能改善情况,术前2.8~3.8分,术后1.3~2.47分。结论腰髂固定手术相对简单安全,同时可以减压骶管和骶前孔,重建骨盆稳定性,促进神经功能的恢复,是治疗不稳定骶骨骨折的有效方法。     

Abdu手术（经椎弓根椎体间内固定）治疗腰椎滑脱症

目的 应用Abdu手术（经椎弓根椎体间内固定）治疗腰椎滑脱症。方法 采用一种治疗腰椎滑脱症的新方法“经椎弓根椎体间内固定系统”（PTSF），其特点在于两枚骶骨螺钉从骶1椎弓根进入，向上、内、前方穿过骶岬、L5、S1椎间盘，进入L5椎体内，不穿透其前缘，结合两枚L4椎弓根螺钉，以具有防止螺钉轴向滑移功能的棘齿槽式钢板、垫片连接 ，构成PTSF内固定系统对腰骶椎的坚持固定。结果 临床应用6例，获随访5例，平均随访5－8月，按Henderson标准评价；优四例，良一例，无严重并发症。结论 经椎弓椎体间内固定系统（PTSF）具有内固定坚强、安全、有效的特点，近期随访临床疗效满意。     

三种骶骨螺钉的生物力学研究

目的 研究三种骶骨螺钉植入法的生物力学性能。方法 对经椎弓椎间体内固定（PTSF）法、前内骶岬法、前外骶翼法三种骶骨固定法进行二个方面的研究：①摆动试验②轴向拨出试验。以助于对上述三种骨螺钉植入法的力学行为有较深入的了解。结果 轴向拨出试验结果：PTSF法抗拔出力最大,平均最大抗拔出力可达930N,明显大于前内骶岬方向螺钉的586N和前外骶螺钉的414N。在相同摆角下,PTSF法较其余二种方法所需力矩大,也就是说若要螺钉松动所作的功也就越大,前内骶岬螺钉固定较前外骶翼螺钉固定坚强。结论 PTSF法骶骨螺钉的抗拨出力和摆动力矩最大,固定最坚强,前骨骶岬方向骶骨螺钉次之,前外骶翼方向骶骨螺钉固定最差。     

The role of transpedicular fixation systems for stabilization of the lumbar spine

Transpedicular fixation devices are extremely useful tools to achieve stabilization of the lumbosacral spine. The indications for the use of these systems are still evolving. These systems are able to obtain rigid fixation in vertebra lacking posterior elements, obtain solid sacral fixation, connect vertebra without distraction and maintain lordosis, fuse short spinal segments, and preserve motion segments. Stable, short segment constructs can be achieved even in the face of the most radical decompressions and vertebral resection. This technique is not, however, without risks. A thorough understanding of pedicle anatomy, pedicle screw insertion technique, fusion biology, and biomechanical considerations are paramount to achieve safe stabilization of the lumbosacral spine with this technique.     

Mini posterior lumbar interbody fusion with presacral screw stabilization in early lumbosacral instability

Background:Surgical options for the management of early lumbosacral spondylolisthesis and degenerative disc disease with instability vary from open lumbar interbody fusion with transpedicular fixation to a variety of minimal access fusion and fixation procedures. We have used a combination of micro discectomy and axial lumbosacral interbody fusion with presacral screw fixation to treat symptomatic patients with lumbosacral spondylolisthesis or lumbosacral degenerative disc disease, which needed surgical stabilization. This study describes the above technique along with analysis of results.Results:We had nine females and three males with a mean age of 47.33 years (range 26–68 years). Postoperative assessment revealed three patients to have screw placed in anterior 1/4^th of the 1^st sacral body, in rest nine the screws were placed in the posterior 3/4^th of sacral body. At 2 years followup, eight patients (67%) showed evidence of bridging trabeculae at bone graft site and none of the patients showed evidence of instability or implant failure.Conclusion:Presacral screw fixation along with micro discectomy is an effective procedure to manage early symptomatic lumbosacral spondylolisthesis and degenerative disc disease with instability.     

Translaminar screw fixation in the lumbar spine: technique, indications, results

Translaminar screw fixation of the lumbar spine represents a simple and effective technique for short segment fusion in the degenerative spine. Clinical experience with 173 patients who underwent translaminar screw fixation revealed a fusion rate of 94%. The indications for translaminar screw fixation as a primary fixation procedure are: segmental dysfunction, lumbar spinal stenosis with painful degenerative changes, segmental revision surgery after discectomies, and painful disc-related syndromes such as internal disc disruption and lumbar disc herniation with concomitant degenerative changes. As an additional stabilization procedure, translaminar screws can be used to augment anterior fusion or reinforce pedicle systems. Translaminar screw fixation achieves as high fusion rate provided the biomechanical principles of the lumbar spine with an intact anterior column are respected and a meticulous operative technique is employed to enhance bony ingrowth of the graft. Received: 12 January 1998 Revised: 18 March 1998 Accepted: 6 April 1998     

Comparison of perioperative morbidity in translaminar facet versus pedicle screw fixation

This retrospective study evaluated the perioperative morbidity of patients undergoing lumbar, sacral, or lumbosacral fusion using either pedicle or translaminar facet screw fixation following interbody fusion. Hospital charts of all patients who presented to a single tertiary care institution during a 4-year period were reviewed. Findings indicated translaminar facet screw fixation was a less invasive spinal fixation method with decreased perioperative morbidity compared to pedicle screw fixation.     

Transverse Fracture-Dislocation of the Sacrum: a Diagnostic Pitfall and a Surgical Challenge

Transverse fracture-dislocations of the sacrum are rare. Associated lesions of the lumbosacral spine as well as neurological injuries are common. Conventional radiographs of the pelvis often fail to clearly visualize the fracture. Delayed diagnosis increases the risk of progressive neurological disfunction. True lateral sacral views and CT-scans with 3-dimensional reconstructions are very helpful in establishing the full extent of the injury. These examinations should be considered in all patients with a history of high energy trauma and clinical signs indicating lumbosacral injury, such as severe low back pain and neurological disturbances of the lower extremities.

The management of transverse sacral fracture-dislocations with or without associated neurological damage is controversial. Conservative treatment is associated with a high rate of persistent deformity and residual neurological dysfunction. Surgical management allows for anatomical fracture reduction, stable fixation and revision of the spinal canal and lumbosacral nerve roots. The dorsal approach is preferred.

Two patients with transverse sacral fracture-dislocations and neurological disturbances are presented. One patient had an additional fracture-dislocation of the lumbar spine at the L4L5 level with intrusion of the lumbosacral spine into the pelvis. Both lesions in this patient were successfully stabilized using an internal fixator system. The other patient presented with a bilateral transforaminal sacral fracture. The transverse component was not recognized on the initial radiographs, which resulted in loss of reduction and progressive neurological disfunction after sacroiliac screw fixation.     

Transverse fracture-dislocation of the sacrum: a diagnostic pitfall and a surgical challenge

Transverse fracture-dislocations of the sacrum are rare. Associated lesions of the lumbosacral spine as well as neurological injuries are common. Conventional radiographs of the pelvis often fail to clearly visualize the fracture. Delayed diagnosis increases the risk of progressive neurological disfunction. True lateral sacral views and CT-scans with 3-dimensional reconstructions are very helpful in establishing the full extent of the injury. These examinations should be considered in all patients with a history of high energy trauma and clinical signs indicating lumbosacral injury, such as severe low back pain and neurological disturbances of the lower extremities. The management of transverse sacral fracture-dislocations with or without associated neurological damage is controversial. Conservative treatment is associated with a high rate of persistent deformity and residual neurological dysfunction. Surgical management allows for anatomical fracture reduction, stable fixation and revision of the spinal canal and lumbosacral nerve roots. The dorsal approach is preferred. Two patients with transverse sacral fracture-dislocations and neurological disturbances are presented. One patient had an additional fracture-dislocation of the lumbar spine at the L4L5 level with intrusion of the lumbosacral spine into the pelvis. Both lesions in this patient were successfully stabilized using an internal fixator system. The other patient presented with a bilateral transforaminal sacral fracture. The transverse component was not recognized on the initial radiographs, which resulted in loss of reduction and progressive neurological disfunction after sacroiliac screw fixation.     

棘突椎板作为骨源椎间植入在下腰椎椎间融合中的应用

目的探讨腰椎后路棘突椎板作为骨源椎间植入加椎弓根钉系统固定在下腰椎椎间融合中的可行性和临床效果。方法应用自体棘突椎板作为骨源椎间植入加椎弓根钉系统固定下腰椎98例，其中椎间盘脱出症30例，椎间盘突出症复发11例，腰椎不稳45例，椎管狭窄12例。结果10例失访，88例术后随访12—56个月，腰腿痛症状消失或明显减轻，腰椎间融合好，椎间隙高度无明显减少。结论棘突椎板作为骨源椎间植入加椎弓根钉系统固定在下腰椎的应用具有操作简单、安全、可靠及融合效果好的优点。     

椎间融合器联合椎弓根钉系统内固定治疗腰椎间盘突出伴椎管狭窄症

目的 探讨椎间融合器联合椎弓根钉系统内固定治疗腰椎间盘突出伴椎管狭窄症的疗效.方法 在2005-01-2009-02期间对18例腰椎间盘突出伴椎管狭窄症的患者采用了经椎弓根固定,全椎板切除椎管减压、单枚或双枚椎间融合器植入融合术(内固定组).并随机抽取18例同期单纯椎板切除椎管减压及髓核摘除的此类患者作为对照组(非内固...     

Complex multilevel lumbar spine fractures with transverse sacral fracture

We report an unusual and complex case of spinal trauma in a 17-year-old boy who presented with a transverse sacral fracture associated with multiple-level lumbar fractures, paraparesis, and bladder involvement. A two-stage surgery was performed. The lumbar spine fractures were treated with posterior instrumented correction of displacements, followed by anterior instrumentation and fusion. The sacral fracture was left untreated. At 5-year followup, the patient had complete neurological recovery except for the right L5 root function. The long-segment lumbar fusion and the untreated displaced sacral fracture contributed to spinal imbalance, due to which the patient is now able to stand only in a crouched posture. Determining the optimal treatment for the case is presented due to the relative rarity of transverse sacral fracture and paucity of evidence-based treatment approaches. In patients with associated lumbar spine fractures that require extension of instrumentation to the upper lumbar spine, it is critical to restore sacropelvic alignment to achieve spinal balance. Adequate reduction of sacropelvic anatomy can be achieved with iliac screw fixation.     

Lumbosacral fixation using expandable pedicle screws. an alternative in reoperation and osteoporosis.

BACKGROUND CONTEXT: Pedicle screw fixation in osteoporotic bone and in revision of previous pedicle screw fixation cases presents a significant challenge to spine surgeons. Biomechanical tests have shown that a pedicle screw that expands within the vertebrae body can substantially improve fixation in the presence of compromised bone. PURPOSE: To review the clinical and radiographic results with the use of expandable pedicle screws. STUDY DESIGN: One hundred forty-five patients received one or more expandable pedicle screws from the Omega21 spinal fixation system (EBI, L.P., Parsippany, NJ) to obtain thorocolumbar or lumbosacral stabilization. PATIENT SAMPLE: The indications for use of the expandable screws were osteoporosis (21 cases), reoperation of previous pedicle instrumentation (27 cases), intraoperative screw relocation (17 cases), construct reinforcement (23 cases), and sacral anchoring to avoid the necessity of anterior penetration of the sacral cortex (57 cases).OUTCOME MEASURES: The presence of radiographic fusion and complications arising from the instrumentation were reviewed at a mean follow-up period of 35 months (range, 24-72 months). METHODS: A retrospective clinical and radiographic review was performed. Fusion was evaluated based on anterior-posterior and lateral radiographs as well as dynamic radiographs in flexion and extension. RESULTS: Radiographic evidence of fusion was obtained in 125 of the 145 cases (86%). Eighty-six percent of patients with osteoporosis and 89% of reoperations fused. There were no instances of screw loosening or pullout of the expandable screws. Screw breakage occurred in four patients (2.8%), including three patients where fusion was not obtained. In six patients the expandable screws were removed without difficulty after fusion because of local discomfort. CONCLUSION: The results of this study have shown that expandable pedicle screws can be efficacious in cases in which pedicle screw fixation is difficult and adds a valuable tool to the growing armamentarium of spinal instrumentation.