脊柱-骨盆曲线和谐角在脊柱畸形矢状面评价中的应用

 目的 探讨脊柱-骨盆曲线和谐角（curve harmony angle, CHA）在量化矢状面相邻弯曲间相关性的作用,并评估其用于评价脊柱畸形矢状面平衡的可行性。方法 收集 93 名正常志愿者及 95 例脊柱畸形患者（包括退变性脊柱侧凸、特发性脊柱侧凸及强直性脊柱炎）的影像学资料,测量常见脊柱-骨盆矢状面局部参数和整体参数,并对其进行相关分析。测量脊柱-骨盆曲线和谐角,包括颈胸和谐角（cervical-thoracic angle,CTA）、胸腰和谐角（thoracic-lumbar angle,TLA）和腰骶和谐角（lumbar-sacral angle,LSA）,比较正常人及不同畸形患者间 CHA 的特征性改变。根据 Schwab-SRS 成人脊柱畸形分型矢状面参数进行分组,比较不同矢状面平衡状态下 CHA 的改变,以检验 CHA 评价脊柱畸形矢状面平衡的可行性。结果 正常志愿者与各类型脊柱畸形患者常用脊柱骨盆参数呈现典型改变。CHA 在不同类型的脊柱畸形中呈特征性改变。与正常组比较,退变性脊柱侧凸组与强直性脊柱炎组均表现 CTA 与 LSA 减小、TLA 增大,且强直性脊柱炎组变化程度更为显著;特发性侧凸组仅 TLA 减小,而 CTA 及 LSA 与正常组的差异无统计学意义。矢状面代偿平衡组较平衡组有较小的 LSA,失衡组较平衡组有较小的 CTA 与 LSA 和较大的 TLA,CHA 能反映各代偿阶段的特征性改变。结论 CHA 可用于量化描述矢状面相邻弯曲间的关系。正常人、各类型脊柱畸形、以及不同平衡状态下 CHA 表现出不同的特点,其用于临床矢状面平衡及畸形矫正效果的评估具有可行性。     

全脊柱拼接成像技术对中学生脊柱侧凸的应用及侧凸常见原因分析

目的:运用X线全脊柱拼接成像技术对脊柱侧凸图像进行分析,调查大庆市部分地区中学生脊柱侧凸的患病情况,确定脊柱侧凸的程度及分析中学生脊柱侧凸的常见原因.方法:利用全脊柱拼接功能的后处理工作站对192例中学生分次所摄的脊柱正位、侧位影像进行拼接处理后作测量并打印图像.结果:经拼接处理后的全脊柱正位、侧位均能将颈、胸、腰、骶椎完整拼接,显示在1张14×17的激光片上,.其中男生18例,女生174例.X线摄片Cobb 角〈10患病率为1.33%(3/192),X线摄片Cobb 角≥10患病率98.67%(189/192).对其中3 例Cobb 角>40°者进行了手术治疗.结论:全脊柱拼接成像技术克服了以往颈、胸、腰、骶椎单独成像后测量上的误差.通过全脊柱拼接成像技术,可以早发现、早诊断中学生脊柱侧凸的程度,对分析中学生脊柱侧凸的常见原因及为临床手术提供了更精确的数据.     

青少年特发性脊柱侧凸术前柔韧性评估方法概述

青少年特发性脊柱侧凸矫形手术的目的是：在融合较短脊柱节段的条件下矫正畸形,阻止畸形进展,得到一个在冠状面和矢状面平衡的躯干。术前柔韧性评估在确定脊柱侧凸的结构性特点、选择手术入路、确定融合节段、预测矫形效果等方面有重要意义。虽然柔韧性作为脊柱侧凸术前常规评估的指标已被广泛使用,但仍存在以下问题：柔韧性的定义模糊,导致很多学者对柔韧性一词的误解和误用;     

Fulcrum像评价青少年特发性脊柱侧凸柔韧性和预测矫形的意义

[目的]前瞻性研究术前支点弯曲(fulcrum)像评价青少年特发性脊柱侧凸(AIS)柔韧性和预测手术矫形效果的价值.[方法]根据入选和排除标准选择2003年10月～2006年8月的AIS患者64例,病例均为单弯(PUMC Ⅰa/Ⅰb/Ⅰc型),根据术前站立正位X像Cobb's角大小分为4组中度胸弯组(20例,40°＜Cobb's≤60°)、重度胸弯组(15例,Cobb's＞60°)、中度腰弯组(17例,35°＜Cobb's≤60°)和重度腰弯组(8例,Cobb's＞60°).各组按PUMC原则接受相同手术方法,均采用第3代节段性内固定系统.测量术前站立全脊柱正位像、fulcrum像及术后正位像的Cobb's角,分析fulcrum像和术后正位像Cobb's角的相关性并计算出fulcrum像侧凸柔韧性和术后侧凸矫正率,所得结果进行统计学分析.[结果]除中度胸弯组fulcrum像柔韧性和手术矫正率相比无显著差异(P=0.141)外,其余组均差异显著;中度胸弯组术后正位像和fulcrum像的Cobb's角相比无显著差异(P=0.094),其余组均差异显著;术后正位像和fulcrum像的Cobb's角呈正相关,但中度腰弯组相关性一般(r=0.525).[结论]Fulcrum只能评价和预测中度胸弯的柔韧性和术后矫正率,现代内固定器械发展尤其是全椎弓根螺钉的应用可获得更好的侧凸矫正率.     

支点弯曲位X线片在辅助青少年脊柱侧凸柔韧性评估中的作用

目的评估支点弯曲位X线片在特发性脊柱侧凸近端胸弯（proximal thoracic,PT）,主胸弯（main thoracic,MT）和胸腰弯/腰弯（thoracolumbar/lumbar,TL/L）冠状位矫形中的作用。方法本研究包括38例连续的行单纯后路椎弓根螺钉矫形固定融合术的青少年脊柱侧凸患者。影像学评估包括术前站立前后位X线片、支点弯曲位X线片,仰卧侧曲位X线片以及术后站立前后位及侧位X线片。测量患者的Cobb角并计算支点弯曲影像（fulcrum bendingradiograph,FBR）柔韧性及支点弯曲矫正指数（fulcrum bending correction index,FBCI）。术后影像学资料包括术后即刻（1周）、3个月、6个月、12个月以及2年随访时的X线片。结果本研究手术节段包括9例PT,37例MT,9例TL/L。平均手术年龄为15.1岁。术前PT组、MT组和TL/L组的FBR柔韧性分别为42.6%、61.1%和66.2%;而平均手术矫正率分别为43.4%、69.3%和73.9%;平均FBCI分别为103.8%、117.0%和114.8%。FBR柔韧性正相关于手术矫正率。尽管MT组和TL/L组的手术矫正率高于PT组,3组的FBCI差异无统计学意义（P〈0.05）。结论支点弯曲位X线片可以用来辅助青少年脊柱侧凸患者的柔韧性评估。采用支点弯曲位X线片对侧凸的柔韧性加以评估后发现,椎弓根螺钉对PT、MT和TL/L的矫形能力是相同的。     

全脊柱核磁共振成像法评估青少年特发性脊柱侧凸的可行性研究

目的 探讨全脊柱MRI检查法测量Cobb角的可行性.方法 2名研究者分别对60例青少年特发性脊柱侧凸(AIS)的后前位及侧位X线片和全脊柱MRI片测量主弯及次弯Cobb角、T5～T12后凸、顶椎旋转,记录测量时间和测量的上下端椎,2名研究者在1周后进行重复测量.对比X线片和MRI测量结果使用Pearson相关法,而研究者之间和研究者内部进行可靠性评估.结果 研究发现在所有X线片和MRI测量结果之间具有显著相关性(P=0.01);主弯Cobb角(R =0.912),代偿弯角度(R=0.826),后凸(R =0.939).X线片和MRI测量结果的研究者组间主弯Cobb角的可靠性分别是R=0.958,0.889;代偿弯Cobb角的可靠性分别是R=0.948,0.858;椎体旋转R=0.954是有显著性的.X线片和MRI测量结果的研究者组内主弯Cobb角的可靠性分别是R=0.965,0.966;代偿弯Cobb角R=0.949,0.944,均有显著性.结论 研究结果示MRI能够获得的冠状面和矢状面测量结果与传统X线片测量结果有高度相关性.另外,MRI除具有可靠的椎体旋转测量外,MRI最大优势就是无辐射,并可替代用于MS诊断性评估.     

仰卧支点加压位X线片预测青少年特发性脊柱侧凸患者矫形效果的价值

目的研究运用仰卧支点加压位X片评价青少年特发性脊柱侧凸（adolescent idiopathic scoliosis,AIS）脊柱柔韧性和预测矫形效果的价值。方法AIS患者65例,根据站立位X线片Cobb角角度分为中度侧凸组和重度侧凸组。术前均拍摄脊柱全长站立位正位X线片、仰卧位左右侧屈位X线片、悬吊正位X线片、支点弯曲位X线片、仰卧位支点加压位X线片及术后站立位正位X线片。所有病例均采用TSRH内固定系统。测量每位患者各种体位X线片Cobb角角度。结果在两组中支点加压位X线片Cobb角大小与术前其他体位X线片Cobb角大小差异均有统计学意义（P〈0．05）,在中度侧凸组中支点加压位X线片与术后站立位X线片Cobb角大小相比差异无统计学意义,（P〉0．05）,并呈正相关（r=0．799）,预测的矫正率与术后矫正率比较差异也无统计学意义,（P〉0．05）。柔软性侧凸组中支点加压位发X线片与术后站立位X线片Cobb角大小相比较差异无统计学意义,（P〉0．05）,并呈正相关（r=0．682）。结论仰卧位支点加压位X线片能较为准确的评价AIS患者脊柱的柔韧性,预测柔软性侧凸患者术后的矫正率,并为手术方案的选择提供重要的参考依据。     

正常脊柱-骨盆矢状位参数的影像学研究

目的 描述正常成人的骨盆矢状位形态,分析正常成人脊柱-骨盆矢状位序列类型.方法 采用前瞻性影像学分析对139名志愿者进行研究,男94名,女45名;年龄21～28岁,平均(23.5±1.5)岁.所有志愿者行全脊柱正、侧位X线检查,利用院内影像归档与通信系统(picture archiving and communication systems,PACS)测量骨盆入射角(pelvic incidence,PI)、骨盆倾斜角(pelvic tilt,PT)、骶骨倾斜角(sacral slope,SS).按照脊柱矢状面解剖定义和形态特点描述脊柱各矢状面形态参数,分析各参数间相关性,并根据腰椎前凸顶点位置不同分析国人腰椎-骨盆矢状位序列类型.结果 PI平均值为45.1°±9.6°,明显小于西方成人,并明显小于韩国成人;女性PI值明显高于男性.骨盆各参数间密切相关,脊柱相邻前凸节段、后凸节段间密切相关,腰弯前凸还与颈弯前凸、矢状位平衡(sagittal vertical axis,SVA)密切相关;依据腰弯前凸顶点位置,将腰椎-骨盆矢状位序列分为四型:Ⅰ型,顶点位于L5椎体或L4,5椎间隙,共11名(占7.8％);Ⅱ型,顶点位于L4底部或中部,共61名(占43.3％);Ⅲ型,顶点位于L4上部或L34椎间隙,共33名(占23.4％);Ⅳ型,顶点位于L3椎体及其以上,共34名(占24.5％).所有志愿者的胸弯后凸顶点为T6.7,颈弯胸弯拐点为C7.各类型间骨盆矢状位形态、腰弯倾斜程度存在明显差异.结论 中国正常成人骨盆矢状位形态与西方和韩国人群存在明显差异.腰椎通过骨盆的调节后,在维持脊柱整体矢状位平衡方面起到核心作用;随着腰弯前凸顶点提高,脊柱-骨盆序列将出现骶骨增加倾斜、下腰弯前凸角度增加、下腰弯组成椎体数量增加、腰弯倾斜减小等变化.     

数字影像拼接技术拼接脊柱全长片

目的 探索对分次曝光获得的胸腰椎数字影像进行拼接获得脊柱全长X片的方法.材料2007年7月-2008年7月在我院同时接受胸椎腰椎DR片检查的患者的数字影像.方法 在PACS系统的浏览终端通过ImageViewer界面将原始数字影像另存为.JPG格式,在AutoCAD软件中测出其参考标尺的差异,在Adobe Photoshop软件中通过图片尺寸的放大缩小功能使得拟拼接影像的参考标尺一致.将参与拼接的数字图片移动复制到同一图片文件上,通过移动,使得投照时重复的脊椎部分恰好吻合,从而形成拼接好的脊柱全长片.将脊柱全长片在AutoCAD中打开,可完成角度测量等操作.结论 通过数字影像拼接技术可获得满意的脊柱全长片,满足观察和测量要求.     

全脊柱整块切除技术在脊柱肿瘤中的应用

全脊柱整块切除技术是一种将脊柱肿瘤及其卫星病灶所在的间室整块切除的手术方式。既往研究表明,该术式能够降低脊柱肿瘤患者的术后复发率,但是手术适应证的选择尚不统一,而脊柱肿瘤外科分期与预期寿命评分系统的广泛应用,使其手术的适应证更加明确。但是,由于该手术具有出血多、难度大、风险高等特点,难以广泛的开展手术,而对TES技术的不断改良、内窥镜的应用以及3D打印人工椎体的出现,使得手术不断走向成熟。     

The Length and Proportions of the Thoracolumbar Spine in Children with Idiopathic Scoliosis

The length of the thoracolumbar spine was measured on standardized X-ray films from 274 children (61/2-181/2 years) with idiopathic scoliosis and 212 controls. Where possible, the height and width (transverse diameter) of two vertebral bodies (T-6 and L-4) were also measured.

Although a tendency towards longer spines in the scoliotics could be found, there was no significant difference between children with idiopathic scoliosis and controls in this respect. In girls the pubertal growth-spurt of the spine was found to start about 1 year earlier than in the controls and the growth of the spine seemed to cease later in the scoliotics.

The height and width of T-6 was significantly greater in the scoliotics than in the controls for girls under 13 years of age. In the older girls and in the boys no significant difference could be demonstrated. The height of L-4 tended to be greater in the scoliotic boys and younger girls, though the differences were not statistically significant. The index height/width was calculated for T-6 and L-4 in all groups of patients and higher values could be demonstrated in the scoliotics for all test groups.

The greater height of T-6 in scoliotics might indicate a longer thoracic spine in these children. The higher values of the height/width indices suggest that the thoracolumbar spine in children with idiopathic scoliosis has an increased slenderness compared with the spine in non-scoliotic children.     

Overview of Robotic Technology in Spine Surgery

As robotics in spine surgery has progressed over the past 2 decades, studies have shown mixed results on its clinical outcomes and economic impact. In this review, we highlight the evolution of robotic technology over the past 30 years, discussing early limitations and failures. We provide an overview of the history and evolution of currently available spinal robotic platforms and compare and contrast the available features of each. We conclude by summarizing the literature on robotic instrumentation accuracy in pedicle screw placement and clinical outcomes such as complication rates and briefly discuss the future of robotic spine surgery.     

Postural and Time-Dependent Effects on Body Height and Scoliosis Angle in Adolescent Idiopathic Scoliosis

Changes in body height and scoliosis angle under the influence of gravity were studied in 40 patients with adolescent scoliosis. The average decrease in body height was 1% during a day. There were no significant changes in the mean angles of the scoliosis curves during the day. The patients were grouped according to age, standing and sitting heights, weight and skeletal maturation. A decrease in the scoliosis angles occurred in younger, more skeletally immature and lighter individuals, while an increase occurred in older, more skeletally mature and heavier individuals.

The difference between the scoliosis angles measured from standing and supine views was also analyzed. The correction of the scoliosis angle in the supine position was on average 19%. No correlation was found between the change in angle and any of the growth factors studied. There was also no correlation between the change in angle and the degree of curvature.     

Idiopathic Scoliosis as a Rotatory Decompensation of the Spine

Many years of dedicated research into the etiology of idiopathic scoliosis have not led to one unified theory. We propose that scoliosis is a mechanical, rotatory decompensation of the human spine that starts in the transverse, or horizontal, plane. The human spine is prone to this type of decompensation because of its unique and individually different, fully upright sagittal shape with some preexistent transverse plane rotation. Spinal stability depends on the integrity of a delicate system of stabilizers, in which intervertebral disc stiffness is crucial. There are two phases in life when important changes occur in the precarious balance between spinal loading and the disc's stabilizing properties: (i) during puberty, when loads and moment arms increase rapidly, while the disc's “anchor,” the ring apophysis, matures from purely cartilaginous to mineralized to ultimately fused to the vertebral body, and (ii) in older age, when the torsional stiffness of the spinal segments decreases, due to disc degeneration and subsequent laxity of the fibers of the annulus fibrosus. During these crucial periods, transverse plane vertebral rotation can increase during a relatively brief window in time, either as adolescent idiopathic or degenerative de novo scoliosis. Much more is known of the biomechanical changes that occur during disc aging and degeneration than of the changing properties of the disc during maturation. © 2020 American Society for Bone and Mineral Research (ASBMR).     

Postoperative Respiratory Complications in Non-Idiopathic Scoliosis

The medical records of 303 patients undergoing fusions for scoliosis correction were retrospectively reviewed. The frequency and type of postoperative respiratory complications were compared in idiopathic versus non-idiopathic scoliosis patients in relation to age, type of spinal fusion procedure, pulmonary function test (PFT) results and preoperative diagnoses. The following factors were found to increase the incidence of problems in the postoperative period: a non-idiopathic type of scoliosis, mental retardation, anterior spinal fusion procedures, age of 20 or more years, a relative arterial hypoxemia and an obstructive component to the PFT's. Topics for further investigation are suggested.     

脊柱侵袭性纤维瘤的外科治疗

目的探讨临床上少见的脊柱侵袭性纤维瘤的特点和外科手术联合放射治疗的效果。方法总结1998年1月至2006年9月收治的7例脊柱侵袭性纤维瘤患者,其中颈椎3例、胸椎2例、腰椎2例。所有病例肿瘤均侵犯椎弓根和附件,2例胸椎肿瘤侵犯硬膜囊。7例患者均采用手术治疗,术后进行正规放疗。结果所有患者局部疼痛消失,除1例胸腔镜辅助手术患者拔管后出现包裹性胸腔积液外,其余病例均无围手术期并发症。3例术前神经系统功能障碍者术后神经症状均得到不同程度的改善。术后平均随访17.6（13～23）个月,未见内固定失败和肿瘤复发。结论脊柱侵袭性纤维瘤是一种极为少见的局部侵袭性软组织肿瘤,临床上有侵袭性生长的生物学行为。外科手术切除肿瘤是脊柱侵袭性纤维瘤的主要治疗方法,但因该肿瘤具有较高的复发率,故需联合术后正规化疗才能获得满意的临床治疗效果。     

Thoracoscopic Approaches to the Thoracic Spine

Summary  Microsurgical approaches for the treatment of pathology located in the ventral thoracic spine using video-assisted thoracic surgery (VATS) allow neurosurgeons to access the disc spaces, vertebral bodies, paravertebral soft tissues, spinal cord, spinal nerves, and sympathetic chain with minimally invasive surgery. This has been associated with substantial clinical benefits including reduced postoperative pain, lower complication rates and shorter recovery times when compared with standard thoracotomy techniques. This article describes the experience at our institution with VATS for discectomy (20 cases), corpectomy and spinal reconstruction (8 cases), thoracic sympathectomy (3 cases), and nerve sheath tumor removal (1 case). The technique can be mastered but requires surgeons to learn the new psychomotor skills needed to perform endoscopic spine surgery. The learning curve is steep. Special training in instructional seminars, surgical skill laboratories, and clinical preceptorships is needed before this surgical approach can be used clinically to treat spinal pathology. VATS has significant advantages compared to standard thoracotomy, including reduced incisional pain and avoidance of the postthoracotomy pain syndrome. If intercostal neuralgia develops postoperatively, it is milder and usually transient compared to the pain associated with standard thoracotomy. Better cosmetic outcomes, earlier mobilization, and faster recovery are added benefits. The surgical techniques are relatively new for neurosurgeons and require dedicated practice to master them. Once the surgical skills are perfected, VATS is feasible for spinal pathology and can be performed safely and effectively.