一期前后联合手术固定治疗严重下颈椎骨折脱位

目的 探讨一期前后联合手术固定治疗严重下颈椎骨折脱位的效果。方法 12例严重下颈椎骨折脱位患者采用一期前后联合手术复位、减压和内固定。其中前路采用Orion带锁钢板5例，Zephir带锁钢板7例；前路减压后采用自体骨移植4例，采用钛网加自体骨移植8例；后路均采用Axis钛板螺钉，其中采用侧块螺钉4例，颈椎椎弓根螺钉8例。结果 术后随访4～18个月，神经功能均有一级以上改善，其中有3例Frankel C级患者术后接近E级。未见内植物松动、脱落及断裂者，植骨在3～4个月内融合，未出现与手术固定技术直接相关的并发症。有1例发现椎弓根螺钉紧靠椎间孔上缘进入椎体，但无神经损伤症状。结论 颈椎前后路一期联合手术固定严重下颈椎骨折脱位可使损伤节段获得早期稳定，方便术后护理和功能锻炼，有利于脊髓功能的恢复。     

一期前后联合手术减压固定治疗严重下颈椎疾病

目的:对严重下颈椎疾病,包括骨折脱位、脊髓型颈椎病及颈椎后纵韧带骨化症采取一期前后联合手术治疗,探讨该疗法的可行性和疗效。方法:本组48例中男35例,女13例;年龄21~75岁,平均48岁。严重下颈椎骨折脱位16例,伤后至手术时间5 d~3周;钳夹脊髓型颈椎病(脊髓夹持型颈椎病)19例;严重颈椎后纵韧带骨化症13例。本组均采用全麻下一期前后路联合减压,前路带锁钢板固定,自体植骨或钛网加自体骨移植。本组前路采用O rion带锁钢板17例,AO带锁钢板3例,Zephir带锁钢板28例;前路减压后采用自体骨移植9例,采用钛网加自体骨移植39例。后路采用Axis钛板螺钉固定45例,Vertex系统3例,其中采用侧块螺钉9例,颈椎椎弓根螺钉39例。结果:随访6~36个月,经椎弓根螺钉固定者术后经斜位及CT检查发现有7个椎弓根螺钉位置稍差,其中6枚穿破外侧皮质,1枚穿破内侧皮质,但无神经血管并发症。假关节形成1例,而且1枚螺钉断裂。钳夹型颈椎病19例和后纵韧带骨化症13例,术后疗效按JOA评分标准评定,术后1周及1、3、6个月评分均较术前增加(P<0.05)。结论:严重下颈椎疾病采用一期前后联合手术治疗是可行的,术后稳定性好,患者康复快。     

前后路联合手术治疗严重颈椎后柱骨折脱位并椎间盘突出

目的 讨论前后路联合手术治疗颈椎后柱骨折脱位并椎间盘突出的效果.方法 共收治颈椎后柱骨折脱位并颈椎间盘突出13例,均采用前后路联合手术治疗.前路采用带锁钢板结合钛网或骨块自体骨移植固定,后路采用侧块螺钉或椎弓根螺钉内固定.结果 术前、术后依据ASIA评分标准评估患者的神经功能,术前A级3例,B级10例,术后3～6个月随访达D级9例、C级3例、B级1例,术后6个月～3年平均改善率为81.6%.结论 应用前后路联合手术行脊髓减压内固定治疗严重颈椎后柱骨折脱位并颈椎间盘突出,可使脊髓功能早期恢复,早期获得颈椎节段稳定,有利于以后的康复和护理.     

一期前后联合手术减压固定治疗严重下颈椎骨折脱位

目的：探讨下颈椎骨折脱位的有效治疗。方法：一期前后联合手术复位、减压、内固定14例，其中前路Orion带锁钢板9例，Zephir带锁钢板固定5例，前路减压后采用自体髂骨植骨融合10例，钛网加自体骨4例，后路采用Axis侧块钢板固定。结果：术后随访6．18个月，神经功能均有一级以上的改善，其中3例Frankel C级患者接近E级。植骨在2～4个月融合。结论：颈椎前后路一期联合手术固定治疗严重下颈椎骨折脱位，可使损伤节段获得早期稳定，方促术后护理和功能锻炼，有利于脊髓功能恢复。     

一期前后联合手术减压内固定治疗严重下颈椎疾病

目的 探讨严重下颈椎疾患的一期前后联合手术的可行性和疗效。方法 全麻下一期前后路联合减压、前路带锁钢板固定及自体植骨或钛网加自体骨移植,后路侧块钢板固定9例和颈椎椎弓根固定8例。10例为严重的颈椎骨折脱位,7例为钳夹型颈椎病。结果 本组17例经3～36个月的随访,围手术期无明显并发症。脊髓功能都有不同程度改善。结论 严重下颈椎疾患的一期前后联合手术是可行的,具有稳定性好、病人康复快的优点。     

一期前后联合手术减压内固定治疗严重下颈椎疾病

目的 探讨严重下颈椎疾患的一期前后联合手术的可行性和疗效。方法 全麻下一期前后路联合减压、前路带锁钢板固定及自体植骨或钛网加自体骨移植，后路侧块钢板固定9例和颈椎椎弓根固定8例。10例为严重的颈椎骨折脱位，7例为钳夹型颈椎病。结果 本组17例经3～36个月的随访，围手术期无明显并发症。脊髓功能都有不同程度改善。结论 严重下颈椎疾患的一期前后联合手术是可行的，具有稳定性好、病人康复快的优点。     

上颈椎失稳并脊髓不全损伤的手术治疗

目的探讨和评价上颈椎失稳并脊髓不全损伤的手术治疗方法。方法对12例不同原因的上颈椎不稳并脊髓不全损伤行手术治疗,采用后路经寰枢椎椎弓根系统固定寰枢融合10例,枕颈融合2例,一期前路减压或病灶清除3例,后路减压或枕骨大孔扩大2例。结果置入寰椎椎弓根螺钉20枚,枢椎椎弓根螺钉24枚,枕骨上用椎弓根螺钉固定2枚,其他螺钉4枚,随访中均获骨性愈合,无螺钉松动、退钉、螺钉钢板断裂,神经症状改善率为82.8%。结论前柱结构基本完整者,后路手术能满足减压和稳定目的;对仅有寰枢椎不稳而C1、2结构完整者,应作寰枢融合;经寰枢椎椎弓根固定是首选的固定方法。     

同期前后路减压重建器械固定治疗钳夹脊髓型颈椎病

目的 :对钳夹脊髓型颈椎病患者应用颈椎螺旋融合器或颈椎带锁钢板进行同期前后路减压重建 ,一次性手术治疗 ,并进行分析。方法 :对 1 6例颈脊髓前后受钳夹的颈椎病患者 ,先后路颈椎扩大式半椎板切除减压术 ,后行前路减压 ,颈椎椎间螺旋融合器或带锁钢板内固定植骨术 ,术后采用JOA 1 7分法进行测评。结果 :平均随访 2 3个月 ,1 6例患者术后均有不同程度皮肤感觉改善和四肢肌力提高 ,其中 2例大小便障碍者括约肌功能恢复 ,脊髓功能改善率 75 .6 %。结论 :本手术方法减压彻底 ,安全有效 ,颈椎螺旋融合器和颈椎带锁钢板的应用解决了颈椎稳定性问题。     

一期前后联合手术内固定治疗严重下颈椎骨折脱位

目的探讨一期前后联合手术内固定治疗严重下颈椎骨折脱位的效果。方法对11例严重下颈椎骨折脱位采用一期前后联合手术内固定治疗。其中前路采用带锁钢板结合钛网自体骨移植固定;后路均采用侧块螺钉固定。结果术后随访4~18个月,不完全损伤患者神经功能均有1级以上改善。未见内植物松动、脱落及断裂者,植骨在3~4个月内融合,未出现与手术固定技术直接相关的并发症。结论颈椎前后路一期联合手术内固定治疗严重下颈椎骨折脱位可使损伤节段获得早期稳定,方便术后护理和功能锻炼,有利于脊髓功能的恢复。对于脊髓前方有致压物的不完全脊髓损伤颈椎骨折脱位患者,选择前后联合手术入路应严格遵循前路-后路-前路的顺序进行,以免进一步加重脊髓损伤。     

骨科——脊柱

经后路寰椎椎弓根螺钉系统内固定融合术治疗颈椎疾患；双侧寰椎椎板挂钩及寰枢椎关节间隙螺钉固定术治疗创伤性寰枢椎不稳；两种下颈椎经关节固定技术的静力学比较；前路单枚空心螺钉内固定术治疗齿状突骨折12例临床报道;椎动脉损伤后颈椎前路减压的疗效评价;前后路联合减压植骨带锁钢板内固定治疗复杂颈椎损伤的分析;[编者按]     

Spinal canal size in ossification of the posterior longitudinal ligament of the cervical spine

BACKGROUND: The size of the spinal canal is a factor that contributes to the neurologic deficits associated with cervical ossification of the posterior longitudinal ligament (OPLL). METHODS: Bone-window computed tomography (CT) examinations of the cervical spine in 64 patients with cervical OPLL were reviewed. Forty-two patients underwent surgical treatment (anterior decompression: 16 patients, posterior decompression: 26 patients). The remaining 22 patients were managed conservatively. Selection of the surgical approach, anterior or posterior, was based on the longitudinal extent of cord compression. RESULTS: The mean developmental size of the spinal canal in the posterior decompression group (10.7 mm at C4) was significantly smaller than the other 2 groups. The spinal canal was narrowed by OPLL to 2.9 to 10.0 mm. The proportion of the patients showing motor deficits of the lower extremities significantly increased when the sagittal canal diameter was narrowed to less than 8 mm. CONCLUSIONS: This study demonstrates critical values of CT-determined spinal canal stenosis. Developmental size of the spinal canal and the residual anterior-posterior canal diameters resulting from OPLL spinal cord compression are important factors influencing clinical management and the neurologic state.     

颈椎后纵韧带切除术的方法改进及其临床意义

目的 探讨颈前路经后纵韧带外缘与椎体后缘附着处(解剖切入点)进入椎管,再行后纵韧带切除新方法的可行性、安全性及治疗游离犁颈椎间盘脱出症、脊髓型颈椎病、后纵韧带骨化症的疗效.方法 自2003年11至2007年9月,采用改进的颈前路后纵韧带切除新方法36例,其中游离型颈椎间盘脱出症19例、脊髓型颈椎病12例、后纵韧带骨化症5例.对其术后疗效、X-线射片及MRI检查进行分析评定.结果 根据JOA评分:手术前平均10.7分,随访8月至52月,增加到16.2分.平均增加5.4分.结论 经颈前路后纵韧带切除、减压加融合固定治疗游离型颈椎间盘脱出症、后纵韧带肥厚型颈椎病及后纵韧带骨化症具有良好的手术疗效,而采用解剖切入点的后纵韧带切除方法,其操作较简单、安全.     

Cervical ossification of the posterior longitudinal ligament: factors affecting the effect of posterior decompression

Objective: Decompression procedures for cervical myelopathy of ossification of the posterior longitudinal ligament (OPLL) are anterior decompression with fusion, laminoplasty, and posterior decompression with fusion. Preoperative and postoperative stress analyses were performed for compression from hill-shaped cervical OPLL using 3-dimensional finite element method (FEM) spinal cord models.

Methods: Three FEM models of vertebral arch, OPLL, and spinal cord were used to develop preoperative compression models of the spinal cord to which 10%, 20%, and 30% compression was applied; a posterior compression with fusion model of the posteriorly shifted vertebral arch; an advanced kyphosis model following posterior decompression with the spinal cord stretched in the kyphotic direction; and a combined model of advanced kyphosis following posterior decompression and intervertebral mobility. The combined model had discontinuity in the middle of OPLL, assuming the presence of residual intervertebral mobility at the level of maximum cord compression, and the spinal cord was mobile according to flexion of vertebral bodies by 5°, 10°, and 15°.

Results: In the preoperative compression model, intraspinal stress increased as compression increased. In the posterior decompression with fusion model, intraspinal stress decreased, but partially persisted under 30% compression. In the advanced kyphosis model, intraspinal stress increased again. As anterior compression was higher, the stress increased more. In the advanced kyphosis +?intervertebral mobility model, intraspinal stress increased more than in the only advanced kyphosis model following decompression. Intraspinal stress increased more as intervertebral mobility increased.

Conclusion: In high residual compression or instability after posterior decompression, anterior decompression with fusion or posterior decompression with instrumented fusion should be considered.     

Long-term follow-up results of anterior interbody fusion applied for cervical myelopathy due to ossification of the posterior longitudinal ligament

STUDY DESIGN: A long-term follow-up study was carried out in 30 patients who underwent anterior interbody fusion for cervical myelopathy associated with ossification of the posterior longitudinal ligament (OPLL). OBJECTIVE: To investigate whether anterior interbody fusion without decompression is an appropriate surgical method for long-term relief of cervical OPLL myelopathy. SUMMARY OF BACKGROUND DATA: Several studies of operative results after posterior decompression for cervical myelopathy due to ossification of the posterior longitudinal ligament have been reported. There has been no report about anterior interbody fusion without decompression. The postoperative results of this treatment method applied in cervical OPLL myelopathy have been evaluated by the authors of the present study for more than 10 years. No reports on such a long-term follow-up study have been published in the literature. METHODS: Thirty patients who underwent anterior interbody fusion for cervical OPLL myelopathy were evaluated clinically and radiographically. The mean follow-up period was 14.7 years (range, 10-23 years). RESULTS: Clinical results were evaluated according to Okamoto's classification. At the time of the final follow-up evaluation, 16 patients had improved in functional score by two grades, and their surgical results were regarded as excellent; eight patients improved by one grade, and their clinical outcomes were regarded as good; five patients showed no change; and the condition of one patient deteriorated. As for radiographic analysis, the type of ossification had changed in four cases. Ossification width and thickness increased in 26 patients. Postoperative alignment of the cervical spine showed kyphosis in three patients, straight spine in 11 patients, and lordosis in 16 patients. CONCLUSION: Anterior interbody fusion without decompression is an effective treatment for cervical OPLL myelopathy that resulted in stable long-lasting conditions.     

一期后路经关节螺钉联合前路钢板固定治疗下颈椎骨折脱位

目的 探讨一期后路经关节螺钉联合前路钢板固定技术治疗下颈椎骨折脱位的效果. 方法 自2005年10月至2007年5月对12例下颈椎骨折脱位患者采用一期前后路联合手术.单纯脱位者,先行后路复位经关节突螺钉固定,再改行前路椎间隙减压,植骨融合,钢板内固定;椎体骨折伴脱位者,前路先行椎体次全切除,植骨融合,钢板内固定,然后行后路经关节螺钉固定脱位节段,小关节间行植骨融合.术前ASIA分级:A级21例,B级6例,C级3例,D级1例. 结果 12例患者获6～21个月(平均14.8个月)随访,椎间及小关节间植骨全部愈合.无螺钉松动及神经、血管并发症.术后除1例完全性瘫痪患者神经功能无恢复外,其余11例均有一级以上恢复.术后ASIA分级:A级1例,B级1例,C级4例,D级4例,E级2例. 结论 下颈椎经关节螺钉联合前路钢板固定融合术,具有操作简单安全、固定可靠、植骨融合率高等优点,是治疗下颈椎骨折脱位较为理想的术式.     

Posterior approaches in the management of cervical spondylosis and ossification of the posterior longitudinal ligament

BACKGROUND: If the cervical lordotic curvature has been well preserved, spondylostenosis or ossification of the posterior longitudinal ligament, with or without instability, may be approached posteriorly in selected older patients (over 65 years of age). Posterior surgical alternatives include the laminectomy with or without fusion, or laminoplasty. However, in younger patients or in geriatric patients with predominantly anterior disease with kyphosis, direct anterior surgical procedures yield better results. METHODS: Laminectomy with medial facetectomy and foraminotomy is classically performed in cases in which stability is preserved. However, posterior stabilization using either facet wiring or lateral mass fusion may be warranted. Although some consider the "open door" laminoplasty a reasonable alternative for dorsal decompression, limitations include restricted access to the hinged side, a potential for "closing of the door," and it does not offer a "real" fusion. RESULTS: Postoperative neurologic improvement may approximate an 85% incidence of good to excellent results. However, where a posterior decompression has been chosen, particularly in younger individuals with or without a lordotic curvature, or in older patients with kyphosis, they will fail to significantly improve, and will be susceptible to early neurologic deterioration. CONCLUSIONS: Posterior approaches to cervical disease may be successful in geriatric individuals in whom the cervical lordotic curvature has been well preserved. However, it is inappropriate for either older or younger patients with predominantly anterior disease, for whom direct anterior decompression with or without posterior stabilization is indicated. In those patients with significant ventral ossification of the posterior longitudinal ligament (OPLL), direct anterior resection will result in improved neurologic outcomes, whereas posterior decompression will fail to achieve a similar degree of neurologic recovery. Furthermore, dorsal decompression of OPLL may promote a more rapid progression of OPLL growth and concomitant neurologic deterioration.     

多节段脊髓型颈椎病合并后纵韧带骨化症患者的手术方式探讨

目的探讨多节段脊髓型颈椎病合并局灶型后纵韧带骨化症患者手术入路的选择、不同手术方式及结果。方法本组56例多节段脊髓型颈椎病合并局灶型后纵韧带骨化症患者,18例施行前路椎体及病灶切除减压 髂骨或钛网植骨钢板内固定术。30例行后路全椎板减压 Axis侧块钢板固定 关节突植骨。前后路联合手术8例．3例后路术后一期联合前路手术,5例为后路术后症状改善不明显或症状有加重,二期行前路手术。所有病例随访2年以上,采用JOA评分,观察前路、后路和前后路联合3种手术入路的减压效果。结果随访56例,颈前路患者的手术改善率69．69%;颈后路患者的手术改善率65．04%;前后路联合患者的手术改善率75．25%。3种术式存在显著差别。并发症发生率以颈后路手术者最低。结论多节段脊髓型颈椎病合并局灶型后纵韧带骨化症患者手术效果虽然以前后路联合手术为最好,但并发症发生率也最高,而颈后路手术并发症发生率最低。因此应根据患者体质、病情以及影像学表现仔细分析。选择相应的手术方式。     

后纵韧带钩辅助下颈椎后纵韧带骨化物切除减压术

目的探讨后纵韧带钩辅助下颈椎后纵韧带骨化物前路切除的适应证、方法及其临床效果。方法患者19例,男14例,女5例;年龄51-71岁,平均59岁。术前影像学检查结果示后纵韧带骨化物局限型6例,分节型13例;椎管狭窄率32％-75％,平均54％。术前神经功能JOA评分4-14分,平均9．6分。行颈前路常规手术入路,椎体开槽切骨达椎体后壁,范围超过后纵韧带骨化灶。利用后纵韧带钩插入后纵韧带下,钩起后纵韧带及骨化物,在后纵韧带与硬膜间形成一间隙,直视下用超薄型枪状咬骨钳切除后纵韧带及骨化物,而后植骨固定,恢复颈椎稳定性。结果随访6-36个月,平均16个月。术后JOA评分8～16分,平均12．8分,恢复率42％＇-92％,其中疗效优9例,良7例,可3例,优良率84．2％。4例患者术后并发脑脊液漏,保守治疗后均获得痊愈。术后CT和MR检查显示骨化后纵韧带切除完全,脊髓和硬膜囊形态恢复良好。结论后纵韧带钩可提高颈椎前路手术切除后纵韧带骨化物的安全性和有效性,适用于局限型和分节型、切除范围在两个椎节之间的颈椎后纵韧带骨化症患者。     

单节段颈椎后纵韧带骨化症前后路手术的疗效比较

目的比较前路与后路手术治疗颈椎后纵韧带骨化症(ossification of posterior longitudinal ligament,OPLL)的疗效。方法回顾2006年1月～2010年12月,收治的24例单节段颈椎OPLL患者,根据手术入路分为2组,前路手术(A组)10例,行前路骨化节段椎体次全切除、骨化的后纵韧带切除,前路植骨融合内固定;后路手术(B组)14例,行后路减压,以骨化节段椎板为中心,切除3节段全椎板,后路植骨融合,内固定。比较2组患者术前、术后1周、3个月、12个月和24个月的日本骨科学会(Japanese Orthopaedic Association,JOA)评分以及并发症情况。结果所有患者JOA评分均有不同程度的改善,较术前的差异有统计学意义(P<0.05)。但2组患者术后JOA评分差异无统计学意义(P<0.05)。A组术后并发脑脊液漏及脊髓功能下降各1例;B组术后并发C5神经综合征及切口脂肪液化各1例。结论单节段颈椎OPLL前路手术与后路手术的近中期疗效无明显差异。后路手术风险相对较小,前路手术难度较大,并发症较严重。     

节段型严重颈椎后纵韧带骨化症前路、后路手术的疗效比较与选择策略

 目的 探讨前路和后路手术治疗节段型严重颈椎后纵韧带骨化症的疗效与选择策略。方法 2007年1月至2011年5月,手术治疗59例节段型严重颈椎后纵韧带骨化症患者,男41例,女18例;年龄43～73岁,平均55.7岁。24例行前路椎体次全切减压植骨融合内固定术,35例行后路全椎板减压侧块螺钉内固定术。比较两组患者的手术时间、出血量、整体和节段曲度变化、并发症等情况;采用日本骨科协会评分(Japanese Orthopaedic Association Scores,JOA)评估手术前后的神经功能并计算改善率。结果 所有患者随访12～18个月,平均15.4个月。前路手术组患者JOA评分术前平均为(7.33±1.09)分,末次随访时平均为(13.63±0.82)分,改善率为65.16%±7.50%;后路手术组患者JOA评分术前平均为(7.20±1.05)分,末次随访时平均为(12.23±1.11)分,改善率为51.46%±9.64%,两组间差异有统计学意义。手术部位的节段曲度术后即刻均较术前明显增加,前路手术组为5.38°±1.14°,后路手术组为3.89°±1.65°,差异有统计学意义。末次随访时颈部轴性症状发生率前路手术组为20.83%,后路手术组为51.43%,差异有统计学意义。结论 对于骨化范围在3个节段以内的严重后纵韧带骨化症患者,前路手术能直接去除压迫,神经功能恢复良好,并有效地恢复颈椎曲度,术后轴性症状发生率低;后路手术在减压同时应用侧块螺钉内固定,能较好地维持减压节段的曲度。