Endoscopic thoracoplasty and anterior spinal release in scoliotic deformity

Severe rigid and complex deformities of the spine often require a first stage procedure to adequately mobilize the spine to provide adequate flexibility during the actual application of instrumentation for surgical correction. This first stage involves soft tissue releases and removal of intervertebral disks from the anterior spine. Exposure to the anterior spine has traditionally been accomplished through thoracotomy or a thoracolumbar incision. The open thoracotomy, however, has several disadvantages, such as post-thoracotomy pain, a large scar, and breathing difficulties. Since the first thoracoscopy at the beginning of this century, the procedure, at first limited by the available technology, has gradually gained more uses and favor among physicians. The last 10 years have seen significant improvement in optical technology and instrumentation. These advances have allowed the spine surgeon to begin performing anterior spinal releases using endoscopic techniques. These endoscopic techniques can carry the same efficacy as the open thoracotomy but less morbidity. Thoracoplasty, the resection of rib segments, is an excellent way to not only correct the convex rib deformities seen in scoliosis but it is also an excellent source of bone which can be used as a graft for fusion. Although traditionally, thoracoplasty has also been done through an open procedure, it can be performed endoscopically. This prospective study presents nine patients who underwent combined endoscopic anterior spinal release and thoracoplasty followed by same day posterior instrumentation and fusion for correction of their spinal deformities. All nine procedures were completed successfully endoscopically. It is our conclusion that in the hands of an experienced surgeon, the endoscopic technique is an excellent procedure providing the same efficacy as the open thoracotomy. There is however a learning curve associated with the procedure. In addition, a team approach in which the surgeon and an experienced anesthesiologist with experience with double lumen intubation and selective single lung ventilation and thoracoscopic surgery is crucial. Although there were no surgical complications related to the thoracoscopic technique one patient did require prolonged intubation postoperatively, which leads us to believe that single lung ventilation in and of itself is very demanding and each patient must be considered carefully prior to its undertaking.     

前后路联合手术治疗伴结构异常的颈脊髓损伤

目的 探讨伴结构异常的颈脊髓损伤患者的临床治疗效果。方法从2002年4月-2007年8月对伴结构异常的颈脊髓损伤患者进行一期或分期前后路联合减压固定手术。结果11例患者术后随访5～27个月，以Sunnybrook分级判定脊髓功能，平均提高3．7分。结论伴有结构异常的颈脊髓损伤患者，颈髓前后方同时有压迫和椎间不稳，需进行前后路联合减压和颈椎稳定性重建。     

胸腰椎前路K形钛钢板在爆裂性骨折中的应用

目的：评价胸腰椎前路K形钛钢板内固定系统在治疗胸腰段爆裂性骨折中的作用和价值。方法：16例胸腰椎爆裂性骨折伴脊髓损伤患者行前路减压、复位、髂骨块植骨、胸腰椎前路K形钛钢板内固定系统固定。结果：16例患者均获术后2－12月随访，无术中、要后并发症发生，无钢板断裂和松动现象，伤椎高度恢复80％－90％。术后3月植骨界面获骨性融合，脊髓神经功能恢复1－3级（除A级3例末恢复外）。结论：胸腰椎前路K形钢板内固定系统系统应用于胸腰椎爆裂性骨折前路减压，植骨后的固定具有恢复伤椎高度，增加节段固定及脊柱稳定性的作用，有利于脊髓神经功能的恢复和防止并发症的发生，并具有操作简单、安全、无磁性、生物相容性好等优点。     

脊柱手术中脊髓损伤的危险因素分析及其预防策略

目的探讨脊柱外科术中导致脊髓损伤的危险因素及其预防策略。方法报告2000年2月～2006年3月,作者共手术治疗脊柱患者1357例次。分组按照术前危险因素:临床因素、影像学因素、病理因素和手术因素4大部分。干预措施包括:出血倾向患者术前术中应用止血药物或成分输血,控制性降压,激素,高压氧等。结果在1357例中,根据界定标准,共有43例符合高危患者的标准,其中颈椎21例,胸椎19例,腰椎3例。结论胸椎的危险性及发生率明显高于颈椎,腰椎最少。年龄不是影响术中脊髓损伤的主要原因。多节段骨性狭窄的颈椎前路手术是脊髓损伤的危险因素。颈椎手术中高血压和糖尿病患者的出血控制相对困难。脊柱侧凸的术前牵引,解除前方压迫的经椎间孔途径减压,以及脊髓肿瘤术中应用"布袋"技术可以减少脊髓损伤。高速磨钻可以避免胸椎黄韧带骨化和颈椎OPLL患者的脊髓损伤。激素和高压氧可以促进脊髓损伤的恢复。     

Minimally invasive surgery in the treatment of empyema: intraoperative decision making

BACKGROUND: Pneumonia, parapneumonic effusions, and empyema continue to be significant health problems, especially in elderly individuals. Minimally invasive thoracic surgery in the treatment of empyema has been demonstrated but has not been well defined. Furthermore, it has not been determined how to choose patients who can be treated with thoracoscopy versus thoracotomy. We report the results of a strategy in which all patients were initially approached with thoracoscopy and converted to open decortication only if the lung could not be inflated to fill the chest. METHODS: A total of 172 patients underwent decortication for empyema over a 5-year period. Thoracoscopic decortication was attempted in all patients; patients were converted to open decortication if access to the pleural space was not possible, or if the lung could not be mobilized sufficiently to reach both the chest wall and the diaphragm. Proportions were compared using the chi(2) test. RESULTS: Of the 172 patients, 66 successfully underwent decortication with thoracoscopic techniques only. The remaining 106 patients required complete thoracotomy. No difference was found in the reoperation rate; 3 of 106 open thoracotomy patients underwent reexploration for recurrent empyema, whereas two of 66 thoracoscopy patients required reoperation for hemothorax (p = 0.347). There was a tendency for thoracoscopic patients to require reoperation for bleeding (p = 0.08); both patients taken back to the operation room for bleeding had undergone thoracoscopic pleurectomy. Eleven of 166 patients (all explored with open thoracotomy) died after decortication, for a mortality rate of 6.6%. All of these patients had gone to surgery from the intensive care unit. CONCLUSIONS: Using the criteria of complete expansion of the lung surface to the chest wall and diaphragm allowed accurate selection of patients who could undergo complete thoracoscopic decortication without risk of recurrent empyema. Computed tomographic scans did not help to predict which patients would require open procedures. Thoracoscopic patients were more likely to require reoperation for bleeding if thoracoscopic pleurectomy was performed.     

前路减压、钛网支撑植骨、Z-Plate钢板内固定治疗陈旧性胸腰段脊柱骨折

目的 探讨陈旧性胸腰段脊柱骨折伴脊髓损伤的前路减压和应用Z-Plate钢板内固定及钛网支撑植骨的优点。方法 对48例陈旧性胸腰段脊柱骨折伴脊髓损伤的病例进行回顾性分析。结果 48例均行前路椎管减压、钛网支撑植骨及Z-Plate钢板内固定。平均随访时间16．5个月,术后椎体间均获骨性融合,95．8％患者神经功能有不同程度恢复,平均改善1．1级,无并发症发生。结论 该方法可充分利用切除的肋骨和减压碎骨块进行植骨,避免取自体髂骨,纠正脊柱后凸,提高椎体问融合率,以重新获得脊柱的稳定性。     

枕颈部畸形伴脊髓损伤的外科治疗策略

目的探讨枕颈部畸形伴脊髓损伤患者的外科治疗。方法回顾性研究28例枕颈部畸形伴脊髓损伤患者的临床资料,仔细分析患者的影像学资料,明确枕颈部畸形的种类、颈脊髓受压方向,选择合适的手术入路。结果 28例均接受手术治疗,其中8例行经口咽入路减压加后路减压植骨枕颈融合内固定术,20例行后路减压植骨枕颈融合内固定术;术中未发生感染、脑脊液漏、椎动脉损伤等并发症;术后Frankel B级2例恢复至C级,C级6例恢复至D级,D级15例恢复至E级、另外3例无变化。结论枕颈部畸形伴脊髓损伤的患者,术前仔细分析影像学资料,合理选择手术入路,彻底解除压迫、重建枕颈部的稳定,可以取得良好的临床疗效。     

Thoracoscopic anterior spinal release and fusion: evolution of a faster,improved approach

Purpose: The aim of this study was to compare the perioperative parameters and outcomes of video-assisted thoracoscopic surgery (VATS) with open thoracotomy for anterior release and fusion in the treatment of pediatric spinal deformities. Methods: Twenty-six patients treated with VATS anterior spinal release and posterior spinal fusion by the authors were reviewed retrospectively. Fourteen age- and disease-matched patients who underwent open thoracotomy for anterior spinal release and posterior spinal fusion by the same group of surgeons during the same time period were evaluated for comparison. Patients whose anterior level of exposure extended below the diaphragm were excluded. Results: Blood loss, operative transfusion, and length of postoperative chest tube use all were decreased in the VATS patients compared with thoracotomy patients (P [le ] .05). The average operating time for VATS was less than that for thoracotomy but did not reach statistical significance. However, operating time was significantly shorter in the second 13 VATS patients compared with the first 13 patients. No complications specifically related to the VATS approach were identified. Conclusions: The VATS technique is a safe and comparable alternative to open thoracotomy. Although there is a learning curve for VATS, greater experience could show an advantage in this approach to the anterior spine for the treatment of pediatric spinal deformity.     

陈旧性下颈髓损伤的手术治疗

[目的]探讨陈旧性下颈髓损伤的手术方式和疗效.[方法]2005年1月～ 2009年12月,共收治陈旧性下颈椎损伤并引起颈脊髓或神经根损伤的患者39例,所有患者均为伤后1个月以上.手术方式包括前路减压复位、椎体间植骨融合钢板内固定术与前后路联合减压复位内固定术.通过术后颈椎的稳定性、植骨融合率及神经功能恢复情况进行评价.[结果]20例患者获得解剖复位,19例患者复位达到80％以上,术后平均随访32个月.植骨完全融合,无假关节、骨不连发生,颈椎椎间高度、生理曲度及颈椎稳定性维持良好.术后ASIA的感觉及运动评分较术前明显提高.所有患者术中无神经损害加重及血管损伤等并发症发生.[结论]陈旧性下颈椎骨折脱位引起的颈脊髓损伤的治疗应按照脱位程度及脊髓损伤程度选择不同手术方案,手术治疗能够恢复颈椎的序列和高度、解除脊髓压迫,改善神经功能.     

下颈椎骨折脱位伴急性脊髓损伤的手术疗效分析

[目的]分析颈椎前路钢板内固定治疗颈椎骨折脱位伴急性脊髓损伤的临床治疗效果.[方法]对63例颈椎骨折脱位伴急性脊髓损伤的患者进行颈椎前路减压、植骨及颈椎前路带锁钢板内固定术.术后定期X线片观察损伤节段的稳定性和融合率以及有无内置物并发症,以JOA评分判定脊髓功能恢复情况.[结果]62例获得随访,时间13～37个月,平均20.4个月.62例患者均损伤节段稳定,植骨愈合良好,无内置物并发症,脊髓功能JOA评分平均提高7.56分,取得满意疗效.[结论]颈椎前路钢板内固定治疗颈椎骨折脱位伴急性脊髓损伤,能使损伤节段获得即刻、坚强的稳定,方便护理和功能锻炼,有利于脊髓功能的恢复.     

氟骨症性椎管狭窄症的手术治疗

１９８７～１９９０年手术治疗氟骨症性椎管狭窄症１００例。包括颈椎９例，胸椎８例，腰、骶椎８３例。术后随访１～４年，复查结果：临床治愈９３例（９３％）：显效３例（３％）、有效３例（３％）、无效１例（１％）。手术原则是彻底减压，因氟骨症具有椎骨及其骨周组织严重退变、异化和骨化的临床病理特点，故在胸、腰椎减压术后，一般不影响其稳定性，在颈椎施行双开式或单开式椎管扩大加植骨融合术，则可收减压、稳定及防止或减少椎板间隙瘢痕狭窄的效果。     

钉棒及钩棒系统治疗胸腰椎多节段脊柱骨折

目的评价钉棒及钩棒系统治疗胸腰椎多节段脊柱骨折的临床疗效。方法23例多节段胸腰椎骨折患者，后路切开复位，选择性椎管减压．钉棒或钩棒系统内固定及后外侧植骨融合进行手术治疗。其中相邻多节段型13例，非相邻多节段型8例，混合型2例。结果全组病例平均随访14个月，未发现内固定物松动、断离，无继发性脊柱后凸畸形加重。椎体高度由术前平均48．4％恢复至术后平均92．4%。2例完全性及11例不完全性脊髓损伤者．脊髓神经功能获改善。结论在椎管进行充分减压的基础上．钉棒及钩棒系统能有效复位椎体骨折，重建脊柱稳定性，是多节段胸腰椎不稳定性骨折合并脊髓神经损伤后路手术的理想选择。     

Treatment of spinal cord compression caused by C2 osteochondroma with reconstruction and fusion after total resection: Case report and literature review

Context: Osteochondroma is the most common benign tumor of the bone, but spinal osteochondroma is rare. We report a case of cervical osteochondroma in multiple exostoses arising from the lamina of the C2 vertebra, presenting with features of compressive myelopathy in a 22-year-old male. Total resection of the tumor and atlantoaxial fixation and fusion after reconstruction of the C1 posterior arch were performed.Findings: The patient recovered significantly. He was asymptomatic and no sign of recurrence was observed after one-year follow-up.Conclusions: Osteochondroma should be considered as a rare cause of spinal cord compression. Entire removal of the tumor will result in complete decompression and can reduce the risk of recurrence. We provide a new approach to reconstruct after resection.     

前路减压植骨融合及钛板固定治疗胸腰椎骨折合并脊髓损伤

目的观察前路减压、植骨融合及钛板固定治疗胸腰椎骨折合并脊髓损伤的临床疗效。方法1999年3月～2004年5月有68例胸腰椎骨折合并脊髓损伤的患者接受前路减压、结构性植骨及钛板固定治疗。本组男45例，女23例，年龄14～61岁，平均36．7岁。骨折节段：T11 1例、T12 20例、L1 33例、L2 12例，为L1．2 1例和L2．3 1例。神经功能情况：完全性截瘫10例，不全性截瘫58例。固定器材：Z-PLATE钛板43例，PROFILE钛板19例，ALPS钛板6例。植骨材料：自体髂骨块45例和充填自体碎骨的钛网23例。采用Frankel分级和ASIA评分评估神经功能恢复情况，通过影像学检查脊柱畸形角(Cobb角)的纠正、减压范围、骨块或钛网的位置及骨愈合情况。结果65例随访8～48个月(3例失访)，平均15．6个月。61例术后神经功能均有不同程度的改善，平均提高了1．25级，ASIA评分明显提高。Cr及M砒检查示椎管减压彻底。髂骨块和钛网均无松动、移位等变化。三种钛板均无松动、移位及断裂。所有随访病例脊柱畸形均获得良好矫正和骨性融合，无畸形矫正的丢失。结论胸腰椎骨折合并脊髓损伤行前路减压安全彻底，有利于神经功能恢复。钛板内固定和结构性植骨稳定性好，骨性愈合率高。     

借助胸腔镜技术的胸段、上腰段脊柱前路手术

目的探讨胸腔镜辅助胸椎、上腰椎前路手术的适应证 ,单肺或双肺通气的选择以及术中注意事项。方法　应用胸腔镜、骨科常规手术器械或自制的骨科器械 ,在胸腔镜辅助下行病灶清除、脊髓减压、植骨、钢板螺丝钉内固定术。结果　全部病例手术都顺利完成 ,切口均一期愈合 ,随访 3～ 10个月 ,影像学检查显示病灶清除彻底 ,脊髓减压充分 ,除 1例骨折复位、固定后仍有轻度侧方成角畸形外 ,其他病例复位满意、内固定可靠 ,位置良好。结论胸椎、上腰椎疾患 ,不论是否并发脊髓、马尾神经压迫 ,都能在胸腔镜辅助下完成病灶清除术 ,必要时还可进行脊髓减压、脊柱前路植骨、内固定手术。原则上可选择常规气管插管、双肺通气下完成手术。     

早期后路椎管减压伤椎椎弓根螺钉内固定治疗中上胸椎骨折脱位

目的探讨早期后路椎管减压伤椎椎弓根螺钉内固定治疗中上胸椎骨折脱位伴脊髓损伤的临床效果。方法对41例中上胸椎骨折脱位患者49椎采用早期后路椎管减压伤椎椎弓根螺钉内固定植骨融合,固定节段4～6节。患者均在72 h内手术。结果 41例均获随访,时间12～46(28±2)个月。脊髓神经功能按ASIA分级:A级6例恢复至B级4例,2例无恢复;B级10例恢复至C级6例、D级3例、1例无恢复;C级15例恢复至D级9例、E级2例,4例无恢复;D级6例恢复至E级3例,3例无恢复;E级4例仍为E级。椎体前缘高度:术前为35.36%±7.48%,术后纠正到91.48%±2.15%,末次随访时为90.56%±1.63%;Cobb角:术前为37°±8°,术后及末次随访为-4°±2°。骨折脱位完全复位,无内固定松动及断裂,末次随访均达到骨性融合。结论早期后路椎管减压伤椎椎弓根螺钉内固定是治疗急性中上胸椎骨折脱位的有效方法,能达到椎体早期复位和脊髓减压目的 ,利于患者早期康复。     

Spinal cord compression caused by a brown tumor at the cervicothoracic junction

BACKGROUND CONTEXT: Brown tumors are classic benign skeletal manifestations of hyperparathyroidism, but the spine involvement is very rare. Spinal reconstruction in these patients is controversial because of the severe osteoporosis and impaired bone healing. Of the reported 12 cases of spinal brown tumors in the literature, only in 5 were reconstructions with bone graft used. PURPOSE: To describe our management in a patient with brown tumor and also to review the previous published cases. STUDY DESIGN: Case report. METHODS: A case of a brown tumor in the T1 vertebra of a 72-year-old male patient is described. He had a previous diagnosis of secondary hyperthyroidism caused by renal failure. First, posterior transpedicular open biopsy was performed for the diagnosis and also for the decompression of the root causing brachialgia. After the diagnosis of a brown tumor, the patient was reoperated through anterior approach for total tumor removal and reconstruction of the spine. An autolog 3-cortical iliac crest strut graft was used for fusion, and medical treatment of hyperparathyroidism was given immediately after the operation. Decompression of spinal canal and fusion of bone graft was shown by a computed tomography scan 1 year after the operation. RESULTS: Complete resolution of the complaints of the patient and fusion of the graft were achieved. CONCLUSION: The determination of a spinal tumor in a patient with renal failure and hyperparathyroidism should bring to mind the probability of a brown tumor. Although it is of a benign nature, it can cause severe neurologic deficit because of spinal compression. The recommended treatment modality is surgical resection of the tumor, spinal reconstruction, and aggressive treatment of hyperparathyroidism both with parathyroidectomy and medically.     

手术治疗急性无骨折脱位型颈髓损伤的回顾性分析

[目的]分析前路和后路内固定治疗急性无骨折脱位型颈髓损伤的临床治疗效果。[方法]对56例急性无骨折脱位型颈髓损伤的患者进行颈椎前路减压、植骨及颈椎前路带锁钢板内固定术或后路减压侧块钢板螺钉内固定术。术后定期X线片观察损伤节段的稳定性和融合情况以及有无内置物并发症,以JOA评分判定脊髓功能恢复情况。[结果]56例获得随访,时间13～48个月。平均26个月。56例患者均损伤节段稳定,植骨愈合良好,无内置物并发症,脊髓功能JOA评分平均提高5.78分,取得满意疗效;前路术式与后路术式在改善脊髓功能方面无明显差异(P>0.05)。[结论]颈椎前路和后路术式治疗无骨折脱位型颈髓损伤,能使损伤节段获得即刻、坚强的稳定,解除颈髓压迫,为颈髓功能的恢复提供了有利条件。     

Thoracoscopic placement of dual-rod instrumentation in thoracic spinal trauma

OBJECTIVE AND IMPORTANCE: Traditionally, thoracic fractures that require anterior stabilization are treated through an open thoracotomy approach. Thoracoscopic instrumentation avoids many of the complications associated with an open thoracotomy but is technically challenging. We report the first cases of dual-rod internal fixation systems placed thoracoscopically for thoracic spinal trauma. CLINICAL PRESENTATION: Two male patients sustained midthoracic spinal trauma falling from motorcycles in separate incidents. Both injuries led to unstable spinal columns, but the patients had no neurological deficits and had minimal spinal cord compression. One patient had a complex spiral fracture from T6 to T8; the other had T7 burst and T8 compression fractures. Based on the complex morphological features of the patients' fractures, anterior internal fixation was the treatment of choice for both. The two available options for an anterior stabilization were open thoracotomy and thoracoscopic instrumentation. Because extensive decompression was unnecessary, a thoracoscopic approach was used. INTERVENTION: A dual-rod internal fixation system (Medtronic Sofamor Danek, Inc., Memphis, TN) was placed with two screws each in the T6 and T9 vertebral bodies of each patient. Thoracoscopy was used for direct visualization of the operative site with fluoroscopic guidance for screw placement. Surgery was completed without complications, and both patients did well afterward. Upright and supine x-rays demonstrated that the constructs were stable at 10 weeks and 6 months, respectively. CONCLUSION: Thoracoscopic instrumentation offers the advantages of a minimally invasive approach but is technically challenging. The characteristics of dual-rod fixation systems (small-profile components and step-wise insertion) provide the best biomechanical profile and facilitate thoracoscopic instrumentation.     

Chronic compression of the cervical myelon as complication of anterior interbody fusion (AIF): neurological improvement after late anterior decompression. Case report

Severe neurological deficits directly related to intraoperative injury of the spinal cord and the nerve roots is rare complication of anterior interbody fusion (AIF) in cervical spondylosis. A case of radiculopathy and Brown-Séquard Syndrome caused by a bone fragment following AIF in which a late anterior decompression and fusion of the cervical spine was performed four years after the initial operation is presented. Immediate relief of the radicular pain, improvement of the spasticity, and better spincter control could be achieved. Therefore, patients with chronic anterior compression of an incomplete spinal cord injury after AIF may benefit from a late anterior decompression and fusion.