后路椎体间融合治疗腰椎滑脱症对腰椎生理前凸的影响

目的探讨后路椎弓根螺钉内固定加椎体间BAK融合手术治疗低度(Ⅰ～Ⅱ度)腰椎滑脱症的临床与放射学结果的变化。方法行椎弓根螺钉内固定加椎体间融合器BAK融合者共26例。峡部不连性18例,退变性8例。L4滑脱14例、L5滑脱12例。测量所有患者的术前、术后、最后一次随访的站立位侧位X线片,测量项目包括腰椎曲线指数(irldex of lumbar spinal curvaturc,LCI)、L4、5、L5S1节段前凸角、全腰椎前凸角。结果排除1例未融合数据,术后融合节段的节段前凸角明显改善,且经随访后无明显丢失。术前、术后、随访时全腰椎前凸角与LCI的差别无显著性意义。结论后路椎弓根螺钉内固定加椎体间BAK融合治疗腰椎滑脱症可以有效改善并维持腰椎的正常生理曲线。     

L5 incidence: an important parameter for spinopelvic balance evaluation in high-grade spondylolisthesis

Background

In high-grade spondylolisthesis (HGSPL), the pelvic incidence (PI) is not a reliable measurement because of doming of the sacrum. Measurement of L5 incidence (L5I) was described as a tool to measure pelvic morphology in HGSPL and for surgical follow-up.

骨盆入射角对成人腰骶部峡部裂滑脱程度和矢状面形态的影响

目的 :探讨成人腰骶部低度峡部裂性滑脱患者骨盆入射角(pelvic incidence,PI)分布情况及其对滑脱程度和脊柱骨盆矢状面形态的影响。方法:回顾性分析2012年1月～2017年8月在我院就诊的Meyerding分型Ⅰ～Ⅱ度腰骶部峡部裂性滑脱患者的临床资料。按照SDSG滑脱分型中PI分组标准分为低PI组(PI45°)、中PI组(45°～60°)和高PI组(PI60°)。测量的参数包括滑脱率、椎间隙高度、骨盆入射角、骨盆倾斜角(pelvic tilt,PT)、骶骨倾斜角(sacral slope,SS)、腰椎前凸角(lumbar lordosis,LL)、上腰椎前凸角、下腰椎前凸角、胸椎后凸角、矢状面垂直距离(sagittal vertical axis,SVA),同时计算腰椎前凸分布指数(lordosis distribution index,LDI=下腰椎前凸角/LL)、PT/PI。采用单样本K-S检验本组患者PI分布情况,采用单因素方差分析比较三组之间影像学参数的差异,采用Pearson相关性分析PI与其他参数的关系。结果:共153例患者纳入本研究,其中男50例、女103例,年龄51.7±10.4岁(31～71岁)。腰骶部峡部裂性滑脱患者PI呈正态分布(P=0.20),均值为59.9°±10.5°,低、中和高PI组分别有12(8%)、67(44%)和74(48%)例。低PI组滑脱率明显低于中PI组和高PI组(P0.001),而高PI组L5/S1椎间隙高度明显低于其余两组(P0.05)。低PI组PT、SS、PT/PI、LL、上腰椎前凸角、下腰椎前凸角均显著低于中PI组和高PI组(P0.01);而LDI明显高于中PI组和高PI组(P=0.001)。高PI组SVA明显高于低PI组和中PI组(P0.05)。Pearson相关性分析发现PI与滑脱率、PT、SS、PT/PI、LL、上腰椎前凸角、下腰椎前凸角、SVA成正相关,与LDI呈负相关(P0.05)。结论:成人腰骶部低度峡部裂性滑脱患者PI呈正态分布,低PI患者滑脱程度较轻,高PI患者腰骶部椎间隙塌陷、滑脱程度重,骨盆后旋导致下腰椎前凸丢失。     

髋关节发育不良晚期病变的联合手术治疗

目的　探讨治疗髋关节发育不良晚期病变的有效治疗方法。方法　采用髋臼成形、转子间截骨和带血管蒂骨瓣转移的联合手术方法治疗髋关节发育不良晚期病变 2 5例 ,35侧。结果　随访 1年 2个月～ 10年 ,平均随访 4 5年 ,所有病例均取得了满意的疗效。结论　针对髋关节发育不良晚期病例的病理改变 ,采用联合术式是治疗髋关节发育不良晚期病例的有效手段     

Single segment of posterior lumbar interbody fusion for adult isthmic spondylolisthesis: reduction or fusion in situ

Objective

We prospectively compared surgical reduction or fusion in situ with posterior lumbar interbody fusion (PLIF) for adult isthmic spondylolisthesis in terms of surgical invasiveness, clinical and radiographical outcomes, and complications.

Methods

From January 2006 to June 2008, 88 adult patients with isthmic spondylolisthesis who underwent surgical treatment in our unit were randomized to reduced group (group 1, n = 45) and in situ group (group 2, n = 43), and followed up for average 32.5 months (range 24–54 months). The clinical and radiographical outcomes were compared between the two groups.

Results

The average operative time and blood loss during surgery showed insignificant difference (p > 0.05) between two groups. The radiological outcomes were significantly better in group 1, but there was no significant difference between two groups of clinical outcomes, depicting as VAS, ODI, JOA and patients’ satisfaction surveys. Incident rate of surgical complications was similar in two groups, but in group 1 the complication seemed more severe because of two patients with neurological symptoms.

Conclusions

For the adult isthmic spondylolisthesis without degenerative disease in adjacent level, single segment of PLIF with pedicle screw fixation is an effective and safe surgical procedure regardless of whether additional reduction had been conducted or not. Better radiological outcome does not mean better clinical outcome.     

MRI对肝不典型增生结节癌变的诊断价值

目的:探寻肝不典型增生结节癌变的早期MRI表现,并评价其诊断价值。方法:对29例32个肝不典型增生结节癌变灶常规MRI及动态增强图像进行分析,并经手术及病理证实。结果:MRI检出32个癌变灶中的25个,检出率78%;25个病灶中,在T1WI上呈略高信号13个,等信号7个,略低信号5个;T2WI上呈略高信号的病灶6个,8个呈等信号,11个表现为"结节中结节";增强扫描动脉期21个病灶明显强化;7个病灶内可见脂肪变性。结论:肝不典型增生结节癌变的早期MRI表现具有典型特征,对帮助诊断具有一定价值。     

Sagittal spinopelvic alignment and body mass index in patients with degenerative spondylolisthesis

The sagittal orientation and osteoarthritis of facet joints, paravertebral muscular dystrophy and loss of ligament strength represent mechanical factors leading to degenerative spondylolisthesis. The importance of sagittal spinopelvic imbalance has been described for the developmental spondylolisthesis with isthmic lysis. However, it remains unclear if these mechanisms play a role in the pathogenesis of degenerative spondylolisthesis. The purpose of this study was to analyze the sagittal spinopelvic alignment, the body mass index (BMI) and facet joint degeneration in degenerative spondylolisthesis. A group of 49 patients with L4–L5 degenerative spondylolisthesis (12 males, 37 females, average age 65.9 years) was compared to a reference group of 77 patients with low back pain without spondylolisthesis (41 males, 36 females, average age 65.5 years). The patient’s height and weight were assessed to calculate the BMI. The following parameters were measured on lateral lumbar radiographs in standing position: L1–S1 lordosis, segmental lordosis from L1–L2 to L5–S1, pelvic tilt, pelvic incidence and sacral slope. The sagittal orientation and the presence of osteoarthritis of the facet joints were determined from transversal plane computed tomography (CT). The average BMI was significantly higher (P = 0.030) in the spondylolisthesis group compared to the reference group (28.2 vs. 24.8) and 71.4% of the spondylolisthesis patients had a BMI > 25. The radiographic analysis showed a significant increase of the following parameters in spondylolisthesis: pelvic tilt (25.6° vs. 21.0°; P = 0.046), sacral slope (42.3° vs. 33.4°; P = 0.002), pelvic incidence (66.2° vs. 54.2°; P = 0.001), L1–S1 lordosis (57.2° vs. 49.6°; P = 0.045). The segmental lumbar lordosis was significantly higher (P < 0.05) at L1–L2 and L2–L3 in spondylolisthesis. The CT analysis of L4–L5 facet joints showed a sagittal orientation in the spondylolisthesis group (36.5° vs. 44.4°; P = 0.001). The anatomic orientation of the pelvis with a high incidence and sacral slope seems to represent a predisposing factor for degenerative spondylolisthesis. Although the L1–S1 lordosis keeps comparable to the reference group, the increase of pelvic tilt suggests a posterior tilt of the pelvis as a compensation mechanism in patients with high pelvic incidence. The detailed analysis of segmental lordosis revealed that the lordosis increased at the levels above the spondylolisthesis, which might subsequently increase posterior stress on facet joints. The association of overweight and a relatively vertical inclination of the S1 endplate is predisposing for an anterior translation of L4 on L5. Furthermore, the sagittally oriented facet joints do not retain this anterior vertebral displacement.     

青少年L5滑脱患者脊柱-骨盆矢状面形态的特征及临床意义

目的:研究青少年L5滑脱患者的脊柱-骨盆矢状面形态,分析不同类型滑脱的矢状面参数特征及临床意义。方法:回顾性分析2010年1月～2019年12月在我院就诊的资料完整的青少年L5滑脱患者36例,男、女各18例,平均年龄14.1±2.5岁(10～18岁);按照Wiltse滑脱分型分为峡部裂组28例和发育不良组8例;按照Meyerding分度标准分为轻度滑脱组32例(Ⅰ度29例、Ⅱ度3例)和重度滑脱组4例(Ⅲ度2例、Ⅳ度2例)。在站立位全长脊柱侧位片上测量脊柱-骨盆矢状面参数。其中滑移参数包括:滑脱率(slip rate,SR)、滑脱角(slip angle,SA);骨盆矢状面参数包括:骨盆入射角(pelvic incidence,PI)、骨盆倾斜角(pelvic tilt,PT)、腰骶角(lumbosacral angle,LSA)、骶骨平台角(sacral table angle,STA);脊柱矢状面参数包括:胸椎后凸角(thoracic kyphosis,TK)、腰椎前凸角(lumbar lordosis,LL)和矢状垂直偏距(sagittal vertical axis,SVA)。对比研究峡部裂组和发育不良组以及轻度和重度滑脱患者的脊柱-骨盆矢状面参数特点和相关临床意义。结果:峡部裂组SR=(13.7±8.1)%,PT=15.7°±8.3°,LSA=105.9°±11.8°,STA=102.8°±6.5°;发育不良组SR=(42.4±27.8)%,PT=34.2°±9.6°,LSA=78.7°±11.2°,STA=76.4°±9.5°;两组相比具有显著的统计学差异(P0.05)。轻度滑脱组SR=(14.4±7.8)%,PT=18.1°±10.4°,LSA=102.1°±15.5°,STA=99.9°±10.8°;重度滑脱组SR=(65.0±19.6)%,PT=33.9°±11.1°,LSA=77.4°±6.7°,STA=77.7°±8.8°,两组相比具有显著的统计学差异(P0.05)。峡部裂组SA=2.6°±13.1°,PI=54.6°±9.0°,TK=23.5°±15.5°,LL=-53.0°±18.3°;发育不良组SA=11.2°±10.5°,PI=60.8°±14.5°,TK=21.5°±14.3°,LL=-45.3°±15.9°;两组相比无统计学差异(P0.05)。轻度滑脱组SA=3.3°±12.6°,PI=55.3°±10.4°,TK=24.0°±13.1°,LL=-52.7°±17.4°;重度滑脱组SA=14.5°±12.8°,PI=61.0°±12.2°,TK=14.8°±3.7°,LL=-40.0°±20.0°,两组相比无统计学差异(P0.05)。结论:青少年L5滑脱中,发育不良性多为重度滑脱,而峡部裂性多为轻度滑脱。发育不良性重度滑脱容易出现矢状面失衡和滑脱进展,其脊柱-骨盆矢状面呈现躯干前倾,骶骨垂直和骨盆后倾的形态。     

关节面方向和终板倾斜角度对退变性腰椎滑脱的影响

目的探讨退变性L4-5滑脱的生物力学机制.方法测量L4～5关节面与椎体冠状面角度和L5终板倾斜的角度,并与同年龄组没有退变性腰椎滑脱的腰痛患者作对照,对有退变性滑脱病人的L4～5关节面与椎体冠状面角度和L5终板倾斜的角度与椎间隙的高度,腰椎的生理曲度进行相关性分析.结果有L4～5退变性腰椎滑脱的患者L4关节面较对照组更偏向于矢状位,L5终板倾斜度的增大,L4～5关节面的角度变大与椎间盘高度的降低及L5终板倾斜角度增大与腰椎曲度的减小有相关.结论在有L4～5退变性滑脱的病人中,L4～5关节面的方向更接近矢状位,L5椎体终板的倾斜度更大.     

青少年发育不良性腰椎滑脱症合并脊柱侧凸的临床分析

目的:对青少年发育不良性腰椎滑脱症患者合并脊柱侧凸的情况进行调查并对侧凸情况做术后随访。方法:回顾性分析2007年3月~2017年10月于我院行滑脱复位固定融合手术治疗的28例青少年发育不良性腰椎滑脱症患者,滑脱节段均为L5,依据Meyerding滑脱分度将其分为重度滑脱(Ⅲ、Ⅳ、Ⅴ度)组与轻度滑脱(Ⅰ、Ⅱ度)组。以术前全脊柱正侧位X线片评估两组患者有无脊柱侧凸(Cobb角≥10°诊断为脊柱侧凸)、滑脱情况(滑脱程度、Dubousset腰骶角)以及脊柱-骨盆矢状位参数(骨盆入射角、骶骨倾斜角、骨盆倾斜角)。青少年腰椎滑脱合并的脊柱侧凸分为特发性侧凸和痉挛/疼痛性侧凸两大类,其中痉挛/疼痛性侧凸又分为单纯痉挛性侧凸和"滑脱性"侧凸两种,"滑脱性"侧凸主要由滑脱椎体的旋转造成。对有侧凸的患者测量其末次随访时的侧凸角度以了解侧凸改善情况。结果:发育不良性重度腰椎滑脱15例,年龄12.5±2.6岁,男2例,女13例;轻度滑脱者13例,年龄14.5±2.6岁,男6例,女7例,两组年龄、性别比例及各脊柱-骨盆矢状位参数均无统计学差异(P0.05)。重度滑脱组的Dubousset腰骶角明显小于轻度滑脱组(55.6°±17.0°vs.83.3°±18.4°,P0.05)。28例患者中合并脊柱侧凸者14例,其中重度滑脱组合并脊柱侧凸13例,轻度滑脱组中仅1例符合脊柱侧凸诊断,两组合并侧凸比例有统计学差异(86.7%vs.7.7%,P0.001)。重度滑脱患者术前冠状位平均Cobb角明显大于轻度滑脱患者(18.1°±13.0°vs.4.6°±3.7°,P=0.001)。重度滑脱组中脊柱侧凸的构成情况:特发性侧凸5例,Cobb角11.6°~52.6°,平均30.2°±17.0°;痉挛/疼痛性侧凸8例,其中单纯痉挛性侧凸4例(Cobb角12.5°~17.5°,平均14.8°±2.1°),"滑脱性"侧凸4例(Cobb角11.2°~12.6°,平均11.9°±0.6°)。对13例重度滑脱伴侧凸患者进行术后随访,其中12例获得随访,随访时间为1~100个月(23.8±28.7个月),末次随访时单纯痉挛性侧凸的平均矫正率为92%,特发性脊柱侧凸的平均矫正率为7.5%,"滑脱性"脊柱侧凸的平均矫正率为4%。结论:青少年发育不良性腰椎滑脱症患者中,重度滑脱患者合并脊柱侧凸的比例高于轻度滑脱者,发育不良性重度腰椎滑脱与脊柱侧凸可能具有相关性,其中单纯痉挛性侧凸在滑脱复位固定融合术后可大部分自发矫正。     

腰椎滑脱手术治疗的并发症分析

目的探讨手术治疗腰椎滑脱的并发症及其预防措施。方法通过对我院从1998年9月1日至2003年9月1日的5a时间内收治的行手术治疗的198例腰椎滑脱的患者进行了回顾性分析,198例患者中男74例,女124例,其中Ⅰ°滑脱97例,Ⅱ°滑脱86例,Ⅲ°滑脱12例,Ⅳ°滑脱3例。结果术后3个月获得随访174例,术后6个月获得随访136例,术后1a或者更长时间获得随访52例,平均随访1.9a(3个月~4年)。围手术期并发症:神经损伤3例,硬膜撕裂3例,取骨处疼痛3例。远期并发症:术后残留神经症状3例,复位丢失10例,内固定失败9例,假关节形成8例;邻近节段退变加速4例。结论术后复位丢失,假关节形成和邻近节段退变的加速是腰椎滑脱手术治疗的多发并发症,应该引起足够的重视。     

Moss Miami内固定系统治疗退变性腰椎滑脱症

目的探讨应用Moss Miami内固定系统手术治疗退变性腰椎滑脱症的疗效。方法应用Moss Miami系统手术治疗退变性腰椎滑脱32例，其中Ⅰ度滑脱12例，Ⅱ度13例，Ⅲ度7例；最短随访时间为1a。结果术后及随访时的X线显示平均复位率在82．5％，无明显复位丢失。临床疗效综合评价优良率达90％以上。结论在手术中进行阶段性彻底减压的条件下，应用Moss Miami内固定系统结合椎间支撑融合很好地恢复了腰椎正常的解剖关系，可以获得滑脱腰椎的基本复位，具有良好的临床效果。该系统是治疗退变性腰椎滑脱的最理想的内固定之一。     

青少年L5/S1发育不良性滑脱患者的骶骨矢状面形态

目的 :研究青少年L5/S1发育不良性滑脱患者的骶骨矢状面形态。方法 :回顾性分析2002年5月~2016年3月入院手术治疗的13例青少年L5/S1发育不良性滑脱患者,男2例,女11例,年龄12.2±3.1岁(9~18岁)。以年龄匹配的30例正常青少年为对照组。在站立位全脊柱侧位X线片上测量骶骨形态、姿势等参数。采用独立样本t检验对滑脱组和对照组以及滑脱组内低度发育不良亚组和高度发育不良亚组的各参数进行对比分析。结果:滑脱组患者中,10例存在S1上终板拱顶样改变,6例L5椎体楔形变,9例L5-S1后凸成角畸形。其腰骶角、骶骨平台角和S1指数均显著低于对照组;骶骨形态也异于对照组,骶骨角和S1上角显著小于对照组,骶骨头端(S1)曲度减小,然而骶骨的整体后凸角度显著大于对照组(Cobb法:50.1°±10.6°比18.1°±10.4°;Ferguson法:40.5°±9.9°比23.1°±11.5°)。滑脱组矢状面平衡显著大于对照组(46.5±42.3mm比-25.6±21.8mm),且其骨盆入射角、L5入射角、骨盆倾斜角、骨盆矢状面厚度均显著大于对照组(P0.01),而骶骨倾斜角却显著小于对照组(P0.05)。滑脱组呈现出躯干明显前倾、骨盆后旋、骶骨直立的姿态。滑脱组中高度发育不良8例,低度发育不良5例。高度发育不良组与低度发育不良组相比,其滑脱程度、骶骨后凸角及矢状面轴向垂直距离均显著增大[(67.3±18.6)%比(45.4±12.5)%;45.8°±8.4°比32.2°±5.1°;52.6±24.7mm比21.6±9.5mm(P0.05)。结论:青少年L5/S1发育不良性腰椎滑脱患者除腰骶局部发育不良外,骶骨呈明显后凸形态。因躯干前倾,骨盆后旋和骶骨垂直化以代偿矢状面失衡,而这些异常形态受发育不良程度影响。     

椎间植骨融合加椎弓根螺钉内固定治疗腰椎滑脱

目的探讨椎间植骨融合联合椎弓根螺钉内固定治疗腰椎滑脱症的效果。方法114例腰椎滑脱患者采用后路椎弓根螺钉复位固定加椎间植骨融合术。结果平均手术时间(267±23)min,出血量(915±175)ml,术中无神经、输尿管及大血管损伤等严重并发症。平均随访17.9(9~48)个月。椎间植骨融合率95.6%,融合时间平均9.3(3.5~6.5)个月,未融合5例。椎间隙高度维持良好,滑脱椎体复位无丢失。疗效评价:优73例,良29例,可9例,差3例,优良率为89.5%。结论椎间植骨融合加椎弓根螺钉内固定是治疗腰椎滑脱症的一种有效措施。     

腰椎退变性滑脱的病理变化及诊断与治疗

目的：探讨因退行性病变因素，造成相邻椎节相互位移并导致该节段椎管变形和狭窄，引起马尾神经或神经根压迫症。方法：报告９２例腰椎退变性滑脱伴有神经根压迫，均经手术治疗。根据临床表现及影像学特征分别采用了３种手术方法，其中４５例实施病变节段椎板部分切除减压及植骨融合术；单纯神经根减压２１例；前路植骨融合术２６例。结果：８４例获随访平均５年６个月，根据Ｍａｃｎａｂ评定法，优良者７３例（８６９％）。研究认为，退变性腰椎滑脱在病理和临床上与因峡部因素的滑脱有明显差别，因此，治疗方法的选择也不同     

Effect of PLIF and TLIF on sagittal spinopelvic balance of patients with degenerative spondylolisthesis

Objective

The aim of this study was to evaluate the effects of PLIF and TLIF on sagittal spinopelvic balance and to compare radiological results of two surgical procedures with regard to spinopelvic parameters.