改良PVCR治疗胸腰段先天性楔形椎引起脊柱后凸畸形的疗效分析

目的：探讨后路单侧截骨部分椎体切除矫形术（ PUVCR）治疗胸腰段先天性楔形椎引起脊柱后凸畸形的临床疗效。方法采用前瞻性随机对照研究,选择河北医科大学第三医院脊柱外科2010年1月-2013年5月29例胸腰段先天性楔形椎引起脊柱后凸畸形患者纳入研究。随机分为两组：观察组14例,接受PUVCR;对照组15例,接受后路全椎体切除术（ PVCR）。观察组男6例,女8例,年龄（26.7±4.7）岁（17~33岁）,术前后凸Cobb角平均为62.3°±7.6°;对照组男7例,女8例,平均年龄为（24.3±3.8）岁（18~32岁）,术前后凸Cobb角平均为58.3°±8.7°。评估并比较两组患者手术时间、术中出血量及术后引流量、后凸矫正度（ Cobb角法）、神经功能改善情况（ Oswestry功能障碍指数）及疼痛缓解程度（视觉模拟评分）。结果两组患者的年龄、性别组成、术前后凸Cobb角比较差异无统计学意义（P值均〉0.05）。观察组的手术时间、术中出血量、术后引流量均少于对照组（P值均〈0.05）。两组间比较,术后2周后凸Cobb角的矫正度、术后1年矫形丢失程度、术后1年神经功能恢复指标Oswestrg功能障碍指数、疼痛视觉模拟评分的改善程度差异均无统计学意义（ P值均〉0.05）。对照组术中神经根损伤发生2例,观察组术中发生1例。两组病例术后1年椎间植骨均骨性融合。结论对于胸腰段先天性楔形椎引起的脊柱后凸畸形,改良PVCR可获得与PVCR同等的后凸矫正、神经功能恢复及疼痛改善,但手术时间更短、出血更少、神经根损伤发生率更低,疗效确切。     

The development of the avian vertebral column

Segmentation of the paraxial mesoderm leads to somite formation. The underlying molecular mechanisms involve the oscillation of ”clock-genes” like c-hairy-1 and lunatic fringe indicative of an implication of the Notch signaling pathway. The cranio-caudal polarity of each segment is already established in the cranial part of the segmental plate and accompanied by the expression of genes like Delta1, Mesp1, Mesp2, Uncx-1, and EphA4 which are restricted to one half of the prospective somite. Dorsoventral compartmentalization of somites leads to the development of the dermomyotome and the sclerotome, the latter forming as a consequence of an epithelio-to-mesenchymal transition of the ventral part of the somite. The sclerotome cells express Pax-1 and Pax-9, which are induced by notochordal signals mediated by sonic hedgehog (Shh) and noggin. The craniocaudal somite compartmentalization that becomes visible in the sclerotomes is the prerequisite for the segmental pattern of the peripheral nervous system and the formation of the vertebrae and ribs, whose boundaries are shifted half a segment compared to the sclerotome boundaries. Sclerotome development is characterized by the formation of three subcompartments giving rise to different parts of the axial skeleton and ribs. The lateral sclerotome gives rise to the laminae and pedicles of the neural arches and to the ribs. Its development depends on signals from the notochord and the myotome. The ventral sclerotome giving rise to the vertebral bodies and intervertebral discs is made up of Pax-1 expressing cells that have invaded the perinotochordal space. The dorsal sclerotome is formed by cells that migrate from the dorso-medial angle of the sclerotome into the space between the roof plate of the neural tube and the dermis. These cells express the genes Msx1 and Msx2, which are induced by BMP-4 secreted from the roof plate, and they later form the dorsal part of the neural arch and the spinous process. The formation of the ventral and dorsal sclerotome requires directed migration of sclerotome cells. The regionalization of the paraxial mesoderm occurs by a combination of functionally Hox genes, the Hox code, and determines the segment identity. The development of the vertebral column is a consequence of a segment-specific balance between proliferation, apoptosis and differentiation of cells. Accepted: 25 May 2000     

青壮年胸腰段椎体骨折术后"蛋壳样椎体"解剖结构的Mimics分析

目的 了解青壮年胸腰段椎体骨折术后"蛋壳样椎体"的解剖结构及解剖特征.方法 收集我科青壮年胸腰段椎体骨折术后形成"蛋壳样椎体"的病例18例,对其进行CT扫描;然后将DICOM图片导入Mimics 21中,进行新建蒙版、计算,得出3D模型,后行多平面划线切割、容积计算,观察分析"蛋壳样椎体"的上终板解剖变化及其他解剖特征.结果 "蛋壳样椎体"上终板的解剖变化:椎体上终板碎裂塌陷,上终板下方的松质骨骨缺损,椎体内形成空腔样结构.好发部位:位于椎体的上1/3～1/2;形状:形状不规则,为椭圆形、类圆形、倒圆锥型等;大小:容积为0.2～1.3 cm3.结论 明确"蛋壳样椎体"的解剖结构,从解剖结构上解释青壮年胸腰椎骨折术后并发症发生的原因,为其手术治疗提供了重要的解剖学基础与参考.     

From somites to vertebral column.

We report on the development and differentiation of the somites with respect to vertebral column formation in avian and human embryos. The somites, which are made up of different compartments, establish a segmental pattern which becomes transferred to adjacent structures such as the peripheral nervous system and the vascular system. Each vertebra arises from three sclerotomic areas. The paired lateral ones give rise to the neural arches, the ribs and the pedicles of vertebrae, whereas the vertebral body and the intervening disc develop from the axially-located mesenchyme. The neural arches originate from the caudal half of one somite, whereas the vertebral body is made up of the adjacent parts of two somites. Interactions between notochord and axial mesenchyme are a prerequisite for the normal development of vertebral bodies and intervening discs. The neural arches form a frame for the neural tube and spinal ganglia. The boundary between head and vertebral column is located between the 5th and 6th somites. In the human embryo, proatlas, body of the atlas segment, and body of the axis fuse to form the axis.     

The role of the notochord in vertebral column formation

The backbone or vertebral column is the defining feature of vertebrates and is clearly metameric. Given that vertebrae arise from segmented paraxial mesoderm in the embryo, this metamerism is not surprising. Fate mapping studies in a variety of species have shown that ventromedial sclerotome cells of the differentiated somite contribute to the developing vertebrae and ribs. Nevertheless, extensive studies in amniote embryos have produced conflicting data on exactly how embryonic segments relate to those of the adult. To date, much attention has focused on the derivatives of the somites, while relatively little is known about the contribution of other tissues to the formation of the vertebral column. In particular, while it is clear that signals from the notochord induce and maintain proliferation of the sclerotome, and later promote chondrogenesis, the role of the notochord in vertebral segmentation has been largely overlooked. Here, we review the established role of the notochord in vertebral development, and suggest an additional role for the notochord in the segmental patterning of the vertebral column.     

Polytopic anomalies with agenesis of the lower vertebral column

We describe clinical, pathological and radiological findings in 15 cases of sporadic and familial lower spine agenesis with additional anomalies of the axial skeleton and internal organs and speculate about the cause and pathogenesis of this malformation complex. We show that all of these findings are defects of blastogenesis, originate in the primary developmental field and/or the progenitor fields, thus representing polytopic field defects. This concept appears applicable in our cases and makes such terms such as “caudal regression syndrome” or “axial mesodermal dysplasia spectrum” redundant. Am. J. Med. Genet. 87:99–114, 1999. © 1999 Wiley-Liss, Inc.     

Nerves and nerve plexuses of the human vertebral column

The origin, distribution, and termination pattern of nerves supplying the vertebral column and its associated structures have been studied in the human fetus by means of an acetylcholinesterase whole-mount method. The vertebral column is surrounded by ventral and dorsal nerve plexuses which are interconnected. The ventral nerve plexus consists of the nerve plexus associated with the anterior longitudinal ligament. This longitudinally oriented nerve plexus has a bilateral supply from many small branches of the sympathetic trunk, rami communicantes, and perivascular nerve plexuses of segmental arteries. In the thoracic region, the ventral nerve plexus also is connected to the nerve plexuses of costovertebral joints. The dorsal nerve plexus is made up of the nerve plexus associated with the posterior longitudinal ligament. This nerve plexus is more irregular and receives contributions only from the sinu-vertebral nerves. The sinu-vertebral nerves originate from the rami communicantes and, in the cervical region, also from the nerve plexus of the vertebral artery. Thick and thin sinu-vertebral nerves are found. Most frequently three types of thick sinu-vertebral nerves are observed, i.e., ascending, descending, or dichotomizing ones. Finally, the distribution of the branches of the ventral and dorsal nerve plexuses and of the sinu-vertebral nerves is described.     

经皮椎体成形术治疗骨质疏松性胸腰椎压缩骨折

目的:观察经皮椎体成形术治疗骨质疏松性胸腰椎压缩骨折的临床疗效.方法:C臂X线透视监控下,以骨水泥为充填材料,经单侧或双侧椎弓根穿刺行经皮椎体成形术(PVP)10例12椎、经皮后凸成形术(PKP)5例8椎.结果:随访2～14个月,10例疼痛完全缓解,4例疼痛部分缓解,1例无效.有效率93.3%.术中穿刺针穿透椎体前壁1例,髓泥渗漏3例,均未产生严重后果.结论:PVP治疗骨质疏松性胸腰椎压缩骨折安全、有效,但要把握好确认"疼痛椎"、准确穿刺、注射骨水泥关键技术.     

The role of the notochord in vertebral column formation

The backbone or vertebral column is the defining feature of vertebrates and is clearly metameric. Given that vertebrae arise from segmented paraxial mesoderm in the embryo, this metamerism is not surprising. Fate mapping studies in a variety of species have shown that ventromedial sclerotome cells of the differentiated somite contribute to the developing vertebrae and ribs. Nevertheless, extensive studies in amniote embryos have produced conflicting data on exactly how embryonic segments relate to those of the adult. To date, much attention has focused on the derivatives of the somites, while relatively little is known about the contribution of other tissues to the formation of the vertebral column. In particular, while it is clear that signals from the notochord induce and maintain proliferation of the sclerotome, and later promote chondrogenesis, the role of the notochord in vertebral segmentation has been largely overlooked. Here, we review the established role of the notochord in vertebral development, and suggest an additional role for the notochord in the segmental patterning of the vertebral column.     

双节段、单节段去松质骨截骨与全脊柱截骨强直性脊柱后凸矫形策略的有限元分析

文题释义： 全脊椎截骨：即全椎体切除,是截骨矫形中的常用截骨矫形方式,切除截骨节段的整个椎体,相关数据显示该技术可以很好地纠正骨盆倾斜与脊柱冠状面及矢状面畸形,但是手术并发症较多,包括脊髓损伤、胸腔积液、肺部感染及伤口深部感染等严重并发症,同时出血量较大,与手术时间和患者体质量相关。 去松质骨截骨：由301医院的王岩首次提出,具体切除范围包括椎体后方椎板、上下关节突及棘突,对椎体行横Y形截骨,闭合椎体后方并张开前方截骨面。 背景：单节段与双节段的截骨手术常用于治疗强直性脊柱后凸畸形,但制定术前策略时对截骨节段、截骨方式的选择常依赖临床经验。目前国内外对双节段去松质骨截骨及全脊柱截骨的生物力学研究鲜有报道。 目的：建立强直性脊柱后凸的单节段、双节段截骨模型,针对全脊柱位移、内固定系统应力、截骨接触面等效应力强度等方面进行比较与探讨。 方法：通过MIMICS与Geomagic studio等医学软件建立强直性脊柱后凸畸形全脊柱截骨与去松质骨截骨两种模型,每种模型中再分为单节段截骨与双节段截骨,即L₁单节段全脊柱截骨模型、L₁单节段去松质骨截骨模型、L₂单节段全脊柱截骨模型、L₂单节段去松质骨截骨模型、T₁₂L₂双节段全脊柱截骨模型、T₁₂L₂双节段去松质骨截骨模型、T₁₂L₃双节段全脊柱截骨模型、T₁₂L₃双节段去松质骨截骨模型8组。导入ANASYS软件对模型进行加载,记录不同截骨工况下的全脊柱位移,以及椎弓根螺钉、连接棒、截骨接触面的等效应力云图。结果与结论：①无论是去松质骨截骨还是全脊柱截骨模型,单节段截骨的全脊柱位移小于双节段截骨;无论是单节段截骨还是双节段截骨模型,全脊柱截骨的全脊柱位移小于去松质骨截骨;L2单节段全脊柱截骨模型的位移最小;②无论是去松质骨截骨还是全脊柱截骨模型,单节段截骨的内固定装置等效应力均小于双节段截骨;无论是单节段截骨还是双节段截骨模型,全脊柱截骨的内固定装置等效应力均小于去松质骨截骨;其中L1单节段全脊柱截骨的内固定装置等效应力最小;③所有单节段截骨模型的截骨接触面等效应力值均较小,未超过28 MPa;在双节段截骨模型中,全脊柱截骨的截骨接触面等效应力值均小于去松质骨截骨;④结果表明,单节段截骨的生物力学稳定性优于双节段截骨,全脊柱截骨的稳定性优于去松质骨截骨。 ORCID: 0000-0002-7114-3696(段延辑) 中国组织工程研究杂志出版内容重点：人工关节;骨植入物;脊柱;骨折;内固定;数字化骨科;组织工程     

犬胸腰段脊髓节段性营养动脉的应用解剖与DSA对照研究

目的：研究犬胸腰段节段性营养动脉扔解剖形态学。方法：用乳胶混合剂经股动脉注入,在手术显微镜下解剖,并与血管造影进行对照,观察脊髓节段营养动脉的来源、分布和外径。结果：犬有13对肋间动脉起于胸主动脉或锁骨下、肋颈干;节段性营养动脉均营养神经节并形成丛;只有直径0.4mm左右的动脉才到达脊髓;根大动脉在T8、T9脊髓节段出现率较高,左侧多于右侧。结论：本文结果为实验形态学提供解剖学基础。     

应用弯角椎体成形装置修复胸腰段骨质疏松性椎体压缩骨折

BACKGROUND: Currently, the cement delivery device used in vertebral augmentation vertebral augmentation (vertebroplasty and kyphoplasty) has flat tips that cannot be bent. During surgery, we always choose injection cement by symmetric way to keep the balance of power on the biomechanics of the vertebral body, while the traditional cement delivery tube can only be used in ipsilateral vertebral body.     

Biomechanics of thoracolumbar junction vertebral fractures from various kinematic conditions

Thoracolumbar spine fracture classifications are mainly based on a post-traumatic observation of fracture patterns, which is not sufficient to provide a full understanding of spinal fracture mechanisms. This study aimed to biomechanically analyze known fracture patterns and to study how they relate to fracture mechanisms. The instigation of each fracture type was computationally simulated to assess the fracture process. A refined finite element model of three vertebrae and intervertebral connective tissues was subjected to 51 different dynamic loading conditions divided into four categories: compression, shear, distraction and torsion. Fracture initiation and propagation were analyzed, and time and energy at fracture initiation were computed. To each fracture pattern described in the clinical literature were associated one or several of the simulated fracture patterns and corresponding loading conditions. When compared to each other, torsion resulted in low-energy fractures, compression and shear resulted in medium energy fractures, and distraction resulted in high-energy fractures. Increased velocity resulted in higher-energy fracture for similar loadings. The use of a finite element model provided quantitative characterization of fracture patterns occurrence complementary to clinical and experimental studies, allowing to fully understand spinal fracture biomechanics.     

胸腰椎椎弓根的解剖学测量及其临床意义

目的　观测胸腰椎椎弓根形态结构特征 ,为临床提供解剖学参数。方法　测量 31例成年男性椎骨T1～L5的横径、矢径、椎弓根间距及椎弓根通道长度。结果　横径 :T1～T6逐渐变小 ,T6～T12 逐渐增大 ,L1和L2 小于T12 ,L2 ～L5逐渐增大 ;矢径 :T1～T3 逐渐增大 ,T4～T7均小于T3 和T8,T7～T12 又逐渐增大 ,L1～L3 逐渐变小 ,L3 ～L5又逐渐增大 ,T1～L5均明显大于其横径 (P <0 0 1) ;模仿弓根通道长 :T1～T10 逐渐增长 ,T11和T12 均较T10 和L1短 ,L1～L4逐渐增长 ,L5较L4短 ;椎弓根间距 :T1～T4逐渐变窄 ,T5～L5逐渐增宽 ;左右侧比较无显著性差异 (P >0 0 5 )。结论　进行椎弓根螺钉固定时应根据不同节段椎弓根形态特点 ,结合影像学资料 ,选择相应的螺钉直径、长度、进钉部位及方向。     

The orientation of the cervical vertebral column in unrestrained awake animals

Summary Quantitative techniques were used to demonstrate cortical layer differences in cutaneous receptive fields (RF's) in the rat SI cortex. Two- and three-dimensional (2-D and 3-D) RF maps were constructed showing the responsiveness of single neurons to standardized punctate stimulation of each of a matrix of points on the skin or the mystacial vibrissa pad. These allowed a visualization not only of the overall sizes of such RF's, but also their shape and response profile. Initial experiments showed that the sizes and response profiles of such RF's were similar whether they were mapped by sinusoidal mechanical vibration of skin, punctate touch, or direct intracutaneous electrical stimulation. This method was used to quantitatively determine distoproximal lengths of RF's of single units recorded at different depths in the forepaw area of the SI cortex. Plots of these RF lengths as a function of cortical depth showed that the smallest RF's were found in the granular layers (IV and deep III). RF's up to double that size were found in supragranular layers, and up to triple that size in infragranular layers. 3-D maps of RF's in the granular layers showed sharp central response peaks surrounded by very steep dropoffs to the RF boundaries. In the whisker areas, granular layer RF's were typically circular in shape and contained from 1–4 whiskers. By contrast, in supragranular layers they were often elongated in shape, and were oriented along rows or columns of whiskers. RF's in layer V resembled large, high plateaus, often supporting clearly separated peaks. RF's mapped in the fore- and hindpaw areas were similar, but, even in the granular layers, were often slightly elongated along the limb axis. In all regions of the SI, both the locations and shapes of the granular layer RF's appeared to be conserved as subsets of other more topographically heterogeneous RF's encountered elsewhere in the column. These findings may correlate with patterns of axonal connectivity in the rat SI.