经胸膜外和腹膜外间隙手术治疗胸腰段脊椎病变

目的　介绍一种改良的胸腹联合切口治疗胸腰段病变。方法　回顾性分析了 19例胸腰段病变的患者 ,采用不经胸腔的和不切开膈肌的改良胸腹联合切口 ,直接暴露胸腰段椎体 ,实行各类脊柱手术。结果　采用此手术切口治疗的 19例病人 ,手术暴露时间平均为 33min ,入路时的出血量约 5 0～ 80ml,术后无一例出现胸腔并发症。结论　该手术切口对组织损伤小 ,手术视野好 ,术后并发症少 ,适用于胸腰段脊椎病变的手术     

脊柱胸腰段疾病手术经膈肌胸膜外前入路的临床应用

目的探讨前路经膈肌胸膜外前入路在治疗胸腰段脊柱病变手术中的应用,研究手术入路技巧和相关并发症的防范。方法通过回顾性分析29例胸腰段病变的患者,采用前路切除第11肋的经膈肌胸膜外前切口,暴露胸腰段椎体,施行各类脊柱手术。结果本组平均手术时间为3小时20分钟,病灶清除彻底,螺钉位置理想。无术后伤口感染、气胸及乳糜胸发生。29例平均随访19个月,无钢板断裂、植骨不融合、脊柱后凸畸形等并发症发生。结论此手术切口比邻重要组织器官,手术风险较大,但只要医生熟悉局部解剖是安全的。此入路对组织损伤小,手术视野好,术后并发症少,适用于胸腰段脊椎病变的手术。     

有限切口腹膜外入路下胸段腰段脊柱前路手术

目的讨论有限切口腹膜外入路下胸段腰段脊柱前路手术的疗效。方法46例患者,年龄为17～70岁,平均41．5岁,行有限切口腹膜外入路下胸段腰段脊柱前路手术。其中爆裂性骨折．29例,结核10例,不稳定滑脱2例,坏死2例,肿瘤3例。结果有限切口腹膜外入路下胸段腰段脊柱前路手术具有良好的手术视野,组织损伤小,骨折骨碎片及病灶组织清除彻底,椎管减压充分,植骨愈合好,无血管损伤等并发症。结论有限切口腹膜外入路下胸段腰段脊柱前路手术具有损伤性小、安全性高、疗效好的优点。     

前后联合入路切除胸腰段椎管巨大哑铃形肿瘤的疗效观察

目的探讨前后联合入路切除胸腰段椎管巨大哑铃形肿瘤的临床疗效。方法 2009年1月-2015年3月,采用经后正中入路联合侧前方经膈肌脚、胸膜外腹膜后入路切除胸腰段椎管巨大哑铃形肿瘤12例。男9例,女3例;年龄30~65岁,平均45岁。病程8~64周,平均12.7周。椎管外肿瘤部分位于T12、L1 6例,L1、25例,L2、3 1例;肿瘤大小范围为4.3 cm×4.0 cm×3.5 cm~7.5 cm×6.3 cm×6.0 cm。根据椎管外肿瘤累及的范围与部位,在Eden分型基础上对胸腰段Ⅱ、Ⅲ、Ⅳ型肿瘤在纵向和横向的侵犯范围进行二次评估,横向为b型5例,d型2例,e型4例,f型1例;纵向累及2个节段椎体8例,2个以上节段椎体4例。术后定期随访观察肿瘤切除情况、是否复发及脊柱稳定性等;采用语言疼痛程度分级法(VRS)评价术后疼痛改善情况。结果手术时间150~230 min,平均170 min;术中失血量270~600 m L,平均350 m L。术后切口均Ⅰ期愈合,无切口及胸腔感染等并发症发生。术后组织病理学确诊为神经鞘瘤10例,神经纤维瘤2例。12例均获随访,随访时间6个月~6年,平均31个月。神经症状均明显改善,腰背部无异常酸痛感。复查胸腰段X线片、MRI未见肿瘤残留,随访期间无病变复发及内固定物松动、断裂,脊柱侧弯等并发症发生。患者术前VRS分级为Ⅰ级2例、Ⅱ级8例、Ⅲ级2例,末次随访时恢复至0级10例、Ⅰ级2例,与术前比较差异有统计学意义(Z=—3.217,P=0.001)。结论经后正中入路联合侧前方经膈肌脚、胸膜外腹膜后入路可安全、完整地切除胸腰段椎管巨大哑铃形肿瘤,并可较好地保护胸腰段脊柱稳定性及椎旁肌肉功能,对于复杂分型的胸腰段椎管哑铃形肿瘤可取得较好疗效。     

脊柱侧凸微创技术(完)

5小切口胸腰椎侧凸前路矫形手术 5．1胸腰椎脊柱侧凸前路手术的标准入路T10至腰段脊柱的暴露通常需要经过胸膜外腹膜后入路或经胸腹膜后入路。对于胸腰段脊柱如果没有特殊的禁忌证通常可以采用胸膜外腹膜后入路,因为这种入路创伤较小而且由于没有胸腔引流管术后恢复较快。采取胸膜外入路时,因为胸膜比较薄需要小心地将壁层胸膜从胸壁上分开,避免胸膜的破裂。因为儿童和青少年的胸膜通常较成年人厚,对于幼年患者通常更适于采用胸膜外入路。     

保护膈肌的小切口胸腰段脊柱侧凸前路矫形

目的:探讨用保护膈肌的小切口行胸腰段脊柱侧凸前路矫形技术的可能性及临床应用效果。方法:胸腰段特发性脊柱侧凸患者17例(男3例,女14例),年龄12～19(平均14.6)岁,术前Cobb角44°～76°(平均56°),其中4例伴有胸腰段后凸10°～18°,其余病例矢状面正常。内固定节段T11～L312例,T11～L43例,T11～L22例。手术时取凸侧在上的侧卧位,在保护膈肌的前提下在膈肌上下各作长约8cm的切口,暴露至脊柱。内固定器械采用CDH。切除椎间盘后在脊椎上置钉。将矫形棒从膈肌角处小洞中穿过,应用去旋转技术完成腰椎前凸化,同时采用凸侧加压技术进一步矫正侧凸畸形。结果:手术时间为210~270min,平均240min,术中出血310～520ml,平均400ml。术后Cobb角4°～16°(平均10°,纠正率为80%),4例胸腰段后凸畸形术后矢状面恢复形态良好。无术中术后并发症,2例出现手术侧下肢皮温升高。随访3～11个月,无内固定并发症,2例出现6°的额状面纠正度丢失。结论:保护膈肌的小切口胸腰段脊柱侧凸前路矫形是可行的,在减少手术创伤的同时能够达到与传统入路相似的临床疗效,没有明显的并发症增加,具有较大的临床实用价值。     

经骶棘肌腰方肌间隙行胸腰段脊柱脊髓损伤侧前方减压术

目的：寻求胸腰段脊柱脊髓损伤侧前方减压的新入路。方法：利用胸腰段的解剖关系设计经骶棘肌腰方肌间隙入路行胸腰段脊柱侧前方减压术。结果：临床应用１２例,手术时间１～１．５ｈ,从皮肤切口到完全显露椎体出血４０～６０ｍｌ。此入路不切断骶棘肌、腰方肌、腰大肌及膈肌,不会伤及胸膜等。随访３～６个月,基本痊愈４例,显著进步３例,进步５例。结论：经骶棘肌腰方肌间隙行胸腰段脊柱侧前前方减压入路简捷,损伤小,出血少。既能充分减压,又能最大限度保持脊柱的稳定性,还可避免加重脊髓损伤、胸膜损伤等并发症。     

胸腰段脊柱骨折,椎体结核前路手术治疗体会

目的:讨论胸腰段骨折,椎体结核的前路手术方法和临床疗效.方法:对55例严重胸腰段骨折的患者采用经胸膜后、腹膜后或胸腹联合切口和经胸入路椎管前方减压去除位于后纵韧带前方的致压物如骨折块及破裂后突的椎间盘组织.1 7例椎体结核病灶清除,结果:72例均无术中并发症.术后随访半年-六年,无脊髓再损伤病例,伤、病椎部位脊椎曲度恢复正常,无明显侧凸或后凸畸形发生;术后3个月复查植骨愈合良好,无植骨块塌陷及高度丢失现象,随访期内无植骨不愈合或钢板螺钉断裂现象.结论:胸腰段骨折,结核前路入路安全可靠,对脊髓减压彻底,有利于神经恢复,重建脊柱稳定性好,为患者顺利恢复创造条件.     

胸腔镜辅助下经膈肌手术治疗胸腰椎爆裂骨折

目的探讨胸腔镜辅助下经膈肌切开手术治疗胸腰椎爆裂骨折的可行性及临床应用效果。方法2002年9月至2004年9月应用胸腔镜辅助下经膈肌手术治疗胸腰椎爆裂骨折22例,男15例,女7例;年龄28～71岁,平均39岁。骨折节段位于T112例、T1210例、L110例。完全性截瘫7例,不完全性截瘫15例。所有病例均行前路减压、植骨及钢板内固定。结果手术时间180～320min,平均230min;出血量500～2000ml,平均900ml。全部病例随访9￣35个月,平均19.5个月。CT显示骨折碎块清除彻底,椎管减压充分。椎间植骨均融合,融合时间平均3.8个月。1例螺钉固定时穿入椎间隙,经术中透视后及时纠正;1例术后出现脑脊液漏,经改变体位1周后愈合。术后未出现胸腔积液、气胸、膈肌疝等并发症。4例全瘫未恢复,14例神经功能明显恢复。结论胸腔镜辅助下经膈肌手术治疗胸腰椎爆裂骨折可做到良好的椎管减压、植骨及内固定。胸腔镜下切开及修复膈肌无须特殊的内镜设备,能避免经胸腹膜后及胸腹联合切口的并发症。     

前路一期手术治疗胸椎及胸腰段脊柱结核

目的观察前路一期病灶清除联合植骨融合内固定治疗胸椎及胸腰段脊柱结核的外科治疗效果。方法 2004－2008年收治胸椎及胸腰段脊柱结核初治病例184例,经胸或胸腹前路行一期病灶清除、椎间肋骨（钛网）植骨、椎体棒板系统内固定术。术后根据药物敏感试验以个体化的化疗方案治疗1.0－1.5年。结果伤口均Ⅰ期愈合。并发症包括肋间神经痛、气胸/胸腔积液。随访1－4年,平均2.3年,随访期内结核无复发,神经损害改善或完全恢复,所有患者均显示骨性融合,后凸畸形平均矫正29.5°。结论经胸或胸腹前路一期病灶清除联合肋骨（钛网）植骨及钢板内固定术是治疗胸椎或胸腰段脊柱结核较好的手术方式之一。     

前路减压植骨内固定治疗胸腰椎爆裂性骨折

目的探讨前路减压植骨融合内固定手术在治疗胸腰椎爆裂性骨折的疗效。方法回顾性分析2000年5月～2005年3月前路减压植骨融合內固定治疗胸腰椎爆裂性骨折58例。骨折节段—单椎体骨折:T101例,T114例,T1213例,L118例,L211例,L32例;双椎体骨折:T12与L16例,L1与L23例。结果平均随访13.5个月,按Frankel分级评定神经功能恢复1级以上。影像学检查比较,未发现明显的矫正度丢失。植骨块位于中央、己融合,无假关节形成及內固定失败。结论前路减压植骨内固定治疗胸腰椎爆裂性骨折,减压更彻底、更安全,能较好地重建前中柱稳定性。     

改进的侧前方手术径路在胸腰椎爆裂性骨折中的应用

目的 探讨改进的侧前方手术径路减压内固定治疗胸腰椎爆裂性骨折的疗效. 方法 2003年4月至2006年9月利用胸腰段的解剖关系,改进成"L"形肌间隙经椎间孔入路行骨折减压内固定治疗胸腰椎爆裂性骨折,临床应用16例(改进径路组),并将11例经传统胸腹膜外入路(传统径路组)作为对照组,比较两组住皮肤切口到完全显露椎体出血量、手术时间及总出血量、疗效等方面的差异,并观察术中、术后并发症情况. 结果 27例患者于术均获成功.所有患者获得6～26个月(平均13个月)随访.改进径路组从皮肤切口到完全显露椎体的出血量平均为(80.0±56.5)mL,总出血量平均为(450.0±273.1)mL,手术时间平均为(119.0±35.5)min;传统径路组从皮肤切口到完全显露椎体的出血量平均为(350.0±145.5)mL,总出血量平均为(900.1±421.3)mL,手术时间平均为(193.2±48.3)min,两组上述指标比较差异均有统计学意义(P<0.05).两组在Cobb角改善、伤椎前缘高度比值及神经功能恢复差异均无统计学意义(P>0.05).两组术中均无严重并发症发生,无截瘫加重、植骨块塌陷及高度丢火现象,无假关节肜成和内固定失败. 结论改进的"L"形肌间隙经椎间孔径路行胸腰椎爆裂性骨折侧前方减压入路简捷,出血少.既能充分减压,又能最大限度保持脊柱的稳定性,还可避免加重脊髓损伤、胸腹膜损伤等并发症.     

带血管蒂肋骨瓣植骨融合治疗胸腰椎化脓性椎间隙感染

目的 观察带血管蒂肋骨瓣植骨融合治疗胸腰椎化脓性椎间隙感染的结果。方法 1993年11月以来,对7例胸腰椎化脓性椎间隙感染经骶棘肌、腰方肌间隙行彻底病灶清除,同一切口内切取带血管蒂肋骨瓣椎体间植骨融合。结果 术后7例获10个月－5年随访,平均随访2年4个月,椎体间骨愈合时间3个月5例,4个月2例,无一例病灶复发及脊柱后凸畸形。结论 经骶棘肌腰方肌间隙病灶清除彻底,采用带血管蒂肋骨瓣椎体间植骨手术操作简便,缩短骨愈合时间,重建了脊柱的稳定性。     

A modified retroperitoneal approach to the kidney in patients with a highly deformed thorax: obtaining a wide operative field through subperiosteal resection of the 10th, 11th and 12th ribs

We herein report a technique which facilitates a retroperitoneal approach to the kidney in cases of highly deformed thorax due to kyphoscoliosis. The operation consists of a lumbar oblique incision with removal of the 11th rib, combined with the additional removal of the 12th and 10th ribs. Resection of the upper two ribs was performed subperiosteally, leaving the periosteum of the deep side untouched. However, the deep side periosteum of the 12th rib was incised caudal from the pleural margin in order to facilitate exposure of the diaphragm. The retroperitoneal space was entered through the tip of the 11th rib bed. The diaphragm was incised dorso-medially at a level 1 cm caudal from the lower margin of the pleura, to an extent necessary to enable the pleura together with the cranial diaphragm to be manoeuvred in an upward direction. Two cases with renal tuberculosis associated with high-grade kyphosis and one case with staghorn calculi accompanied with lordosis were operated on utilizing this technique. In the former two cases, the thoracic cage was in direct contact with the iliac bone and there was practically no space between the rib border and the iliac crest. This was also true of the third case, but the grade of deformity was not as extensive as in the former two cases. Removal of the 10th, 11th and 12th ribs could be achieved without injuring the pleura and a satisfactorily large operating field could thus be developed which enabled a simple nephrectomy to be performed without difficulty. The characteristic feature of the described approach is that resection of the 10th and 11th ribs is simply to facilitate manoevrability of the wound margin, without going through the rib bed. The technique could be advantageous in selected cases where there is a highly deformed thorax.     

胸腰椎屈曲牵张型骨折的诊断与手术治疗策略

目的探讨胸腰椎屈曲牵张型骨折的诊断和手术治疗方法。方法22例胸腰椎屈曲牵张型骨折,均为男性,年龄为21~56岁,平均34.8岁。损伤节段:T128例,L18例,L25例,L31例。神经功能Frankel A级3例,B级1例,C级2例,D级6例,E级10例。骨折按Denis分型,A型9例,B型1例,C型11例,D型1例。行短节段椎弓根螺钉复位内固定治疗,术中根据骨折情况个体化运用撑开与压缩技术。随访时间为10~47个月,平均29个月。结果1例因操作方法不当而复位不良,其余21例术后畸形矫正满意,后凸畸形完全恢复。除Frankel A级3例神经功能无明显恢复外,其余神经损伤者均获得了不同程度神经功能的改善。结论个体化灵活运用椎弓根螺钉的撑开与压缩技术治疗胸腰椎屈曲牵张型骨折,效果满意。     

Clinical study of a new approach to thoracolumbar surgery

Objective： The conventional approaches for treatment of thoracolumbar diseases require extensive surgical exposure, often leading to postoperative pain and morbidity. Thoracoscopic-assisted surgery in these regions usually requires an extended recovery period due to the placement of drainage. We developed an innovative retroperitoneal-extrapleural approach to thoracolumbar involvement by an extra-diaphragmatic technique using dedicated instruments. Neither incision nor reconstruction of the diaphragm was necessary. Exposure to the lateral part of the thoracolumbar vertebrae could be achieved without crus resection. This study is aimed to evaluate the clinical outcomes of this new surgical procedure.
Methods： A total of 9 cases （5 cases of thoracolumbar fracture-dislocation, 1 each of spinal infection, tumor, thoracolumbar scoliosis and ossification of posterior longitudinal ligament） were subjected to the study. The average age of the patients was 52.3 years. The results were compared with the control group consisting of thoracoscopic surgery subgroup （5 patients, mean age 52.1 years） and conventional surgery subgroup （12 patients, mean age 61.3 years）.
Results： Compared with the control group, the average period of bed confinement and mean intra- and postoperative blood loss decreased significantly. Pulmonary complications were avoided in all cases. The surgical time was shortened, postoperative pain was reduced, and early postoperative ambulation became possible. Conclusion： The diaphragm-preserving retroperitoneal-extrapleural approach that we developed is a valid minimally invasive alternative for the treatment of thoracolumbar diseases.     

钉棒治疗胸腰椎爆裂型骨折

[目的]评价钉棒系统治疗胸腰椎多节段脊柱骨折的临床疗效。[方法]19例多节段胸腰椎骨折患者，其中男14例，女5例；骨折分类采用目前综合分类法，本组病例中Ba．ml T11 1例，Ba．m．p2T11 2例，Ba．ml T12 1例，Ba．m．p2T12 3例，Ba．m，p3T12 1例，Ba．ml L1 4例，Ba．m．p2 L1 3例，Fa．m．p3（T12，L1）2例，Sa．m．03 L2 1例，Ba．m．p1 L2 1例。均采用前路切开复位，选择性椎管减压，钉棒系统内固定及前外侧植骨融合进行手术治疗。[结果]全组病例随访6～15个月，平均10．5个月，未发现内固定物松动、离断，无继发性脊柱后凸畸形加重，椎体高度由术前平均48．14％恢复至术后平均92．14％，2例完全性及11例不完全性脊髓损伤者，术前术后采用JOA评分显示，脊髓神经功能获改善。术后随访X线片显示所有病例植骨块均已融合，无植骨块塌陷及高度丢失现象。[结论]前外侧入路椎管减压充分，钉棒系统能有效复位椎体骨折，重建脊柱稳定性，是胸腰椎不稳定性骨折合并脊髓神经损伤手术的理想选择。     

Simultaneously anterior decompression and posterior instrumentation by extrapleural retroperitoneal approach in thoracolumbar lesions

Background:

Anterior decompression with posterior instrumentation when indicated in thoracolumbar spinal lesions if performed simultaneously in single-stage expedites rehabilitation and recovery. Transthoracic, transdiaphragmatic approach to access the thoracolumbar junction is associated with significant morbidity, as it violates thoracic cavity; requires cutting of diaphragm and a separate approach, for posterior instrumentation. We evaluated the clinical outcome morbidity and feasibility of extrapleural retroperitoneal approach to perform anterior decompression and posterior instrumentation simultaneously by single “T” incision outcome in thoracolumbar spinal trauma and tuberculosis.

Patients and Methods:

Forty-eight cases of tubercular spine (n = 25) and fracture of the spine (n = 23) were included in the study of which 29 were male and 19 female. The mean age of patients was 29.1 years. All patients underwent single-stage anterior decompression, fusion, and posterior instrumentation (except two old traumatic cases) via extrapleural retroperitoneal approach by single “T” incision. Tuberculosis cases were operated in lateral position as they were stabilized with Hartshill instrumentation. For traumatic spine initially posterior pedicle screw fixation was performed in prone position and then turned to right lateral position for anterior decompression by same incision and approach. They were evaluated for blood loss, duration of surgery, superficial and deep infection of incision site, flap necrosis, correction of the kyphotic deformity, and restoration of anterior and posterior vertebral body height.

Results:

In traumatic spine group the mean duration of surgery was 269 minutes (range 215–315 minutes) including the change over time from prone to lateral position. The mean intraoperative blood loss was 918 ml (range 550–1100 ml). The preoperative mean ASIA motor, pin prick and light touch score improved from 63.3 to 74.4, 86 to 94.4 and 86 to 96 at 6 month of follow-up respectively. The mean preoperative loss of the anterior vertebral height improved from 44.7% to 18.4% immediate postoperatively and was 17.5% at final follow-up at 1 year. The means preoperative kyphus angle also improved from 23.3° to 9.3° immediately after surgery, which deteriorated to 11.5° at final follow-up. One patient developed deep wound infection at the operative site as well as flap necrosis, which needed debridement and removal of hardware. Five patients had bed sore in the sacral region, which healed uneventfully. In tubercular spine (n=25) group, mean operating time was approximately 45 minutes less than traumatic group. The mean intraoperative blood loss was 1100 ml (750–2200 ml). The mean preoperative kyphosis was corrected from 55° to 23°. Wound healing occurred uneventful in 23 cases and wound dehiscence occurred in only 2 cases. Nine out of 11 cases with paraplegia showed excellent neural recovery while 2 with panvertebral disease showed partial neural recovery. None of the patients in both groups required intensive unit care.

Conclusions:

Simultaneous exposure of both posterior and anterior column of the spine for posterior instrumentation and anterior decompression and fusion in single stage by extra pleural retroperitoneal approach by “T” incision in thoracolumbar spinal lesions is safe, an easy alternative with reduced morbidity as chest and abdominal cavities are not violated, ICU care is not required and diaphragm is not cut.     

Anterior approach to the thoracolumbar spine: technical considerations.

Forty-five patients, of whom most were children, underwent extensive exposure of the thoracolumbar spine to correct serious orthopedic abnormalities. The spine was exposed through a combined thoracotomy and retroperitoneal approach that gave excellent access with minimal morbidity. The diaphragm was opened circumferentially after the peritoneum had been dissected from its muscular portion. This permitted repair of the diaphragm with no detectable loss of function. Although this approach was developed for exposure of the spine, it can also be utilized to expose the entire aorta, both kidneys and their blood supply, and the retroperitoneal area for possible excision of large tumors.