新的脊柱-骨盆矢状面测量参数：骶骨骨盆角的提出及意义

【摘要】 目的：提出一个新的脊柱-骨盆矢状面测量参数：骶骨骨盆角（sacral pelvic angle,SPA）,探讨SPA与其他参数间的相关性,评估其可信度和可重复性。方法： 将脊柱侧位X线片上股骨头中点至骶骨后上角的连线（PR线）与骶骨终板垂线的夹角定义为SPA。从几何学上观测SPA与骨盆角（PA）、骶骨倾斜角（SS）之间的关系。在111例（女56例,男55例）成人志愿者的脊柱全长Ｘ线片上测量SPA及其他脊柱-骨盆矢状面相关参数,包括：SPA、胸椎后凸角（TK）、胸腰段后凸角（TLK）、腰椎前凸角（LL）、SS、骨盆倾斜角（PT）、骨盆指数（PI）、矢状面垂轴（SVA）、脊柱骶骨角（SSA）、PA、PR-S1（pelvic morphology）、总腰-骨盆前凸角（total lumbopelvic lordosis,PR-T12）。采用Pearson相关分析各参数间的相关性。从111例志愿者的脊柱全长Ｘ线片中随机抽取80例,由2位脊柱外科主治医师分别测量SPA 5次,间隔1个月后再次分别测量SPA 5次,取平均值,采用变异系数（CV）评价SPA指标稳定性,采用组内相关系数（introclass correlation coefficient,ICC）判定观测者间和两次测量间的一致性。结果：SPA=PA+SS=90°－ PR-S1。SPA与PI、PR-S1、PA、PT、SS、SSA呈显著性正相关（r=0.994,1.000,0.482,0.538,0.699,0.465,P均<0.05）,与LL呈显著性负相关（r=-0.532,P<0.05）。SPA前后两次测量的CV分别为0.0023±0.02及0.0085±0.053,观测者间ICC分别为0.99,P<0.01及0.97,P<0.01,两次测量间ICC为0.99,P<0.01。结论：SPA是一个解剖学常数,SPA=PA+SS;SPA具有良好的可信度和可重复性;SPA与其他参数的相关性同PI与其他参数的相关性接近,可作为评估脊柱-骨盆矢状面平衡的参数。     

Sacral magnetic stimulation in non-inflammatory chronic pelvic pain syndrome

OBJECTIVES: To prospectively evaluate sacral magnetic high-frequency stimulation as a treatment option for patients with non-inflammatory chronic pelvic pain syndrome (CPPS, category IIIB). PATIENTS AND METHODS: Fourteen men with CPPS IIIB were treated with high-frequency sacral magnetic stimulation, with 10 treatment sessions once a week for 30 min at a frequency of 50 Hz. The National Institutes of Health Chronic Prostatitis Symptom Index (NIH-CPSI) and quality-of-life index were determined before and after treatment. RESULTS: All patients tolerated the stimulation well and 12 of 14 reported agreeable sensations during stimulation. There were no complications; only one patient did not complete the treatment course. The mean (range) total NIH-CPSI score did not change with treatment, at 27 (18-38) before and 27 (4-40) after treatment. Moreover, there was no sustained effect on the mean scores for pain, micturition complaints or quality of life. CONCLUSIONS: High-frequency sacral magnetic stimulation in patients with CPPS IIIB only reduces pain during stimulation, with no sustained relief of symptoms. Therefore, intermittent sacral magnetic stimulation cannot be recommended as a treatment option for CPPS IIIB.     

Sacral resection for control of pelvic tumors.

A surgical approach for treating patients with resected, recurrent, posterior pelvic visceral tumors involving the sacrum is detailed. Of 11 patients, 9 had rectal cancers, 1 had chordoma, and 1 had cancer of the cervix. Five total pelvic exenterations and five posterior exenterations were performed en bloc with involved sacrum. One patient had a sacral resection only. Surgical mortality was 9%, and the average hospital stay was 1 month. Mean disease-free survival was 1 year, and mean survival was 3 years. Absolute cure rate was 18% with a complete 5-year follow-up. This experience confirms the value of this procedure in selected patients.     

Surgical treatment of pelvic sarcomas: oncologic and functional outcome

The experiences in treating 93 consecutive patients (56 males, 37 females; mean age, 38.5 years; range, 4-69 years), including 76 patients with primary malignant bone tumors and 17 patients with soft tissue sarcomas involving the innominate bone, are reported. Oncologic and functional results were investigated in relation to the tumor stage, to the achieved surgical margin, and to the surgical procedure (hemipelvectomy, internal hemipelvectomy and endoprosthetic replacement, and continuity resection). The mean followup was 48 months (range, 8-222 months). The 5-year survival was 86% in patients with low-grade malignant bone tumors, 42% in patients with high-grade malignant bone tumors, and 25% in patients with high-grade soft tissue sarcomas. Survival was influenced by the grade of malignancy, the tumor stage, and the achieved surgical margins. Forty-six patients who survived were examined an average of 36 months after primary surgery. Excellent and good functional results were seen in 82% of patients who underwent continuity resection and in 55.5% of patients who underwent partial or total internal hemipelvectomy. All patients who survived hemipelvectomy had poor functional results. Surgical treatment of pelvic sarcomas is an extensive procedure with a considerable incidence of complications. It requires the knowledge of different techniques of resection and reconstruction of bone, joints, soft tissue, and intrapelvic organs.     

Reconstruction after pelvic resectionfor sarcomas of bone

Reconstruction of the pelvis after tumor resection requires careful preoperative planning, meticulous surgicaltechnique, and soft tissue coverage. The method of reconstruction depends on the type of pelvic resection and may involve autologous tissue, allografts, and metal. Often, a combination of bone grafts and metal constructs are needed to provide continuity between the axial and appendicular skeleton and to maximize function. Complications are frequent and can result in diminished function and occasional loss of limb. The goal of independent function without assistive devices is achieved in only a small number of patients.     

Sacral nerve stimulation in patients with chronic intractable pelvic pain

PURPOSE: Transforamenal sacral nerve stimulation with an implantable neuroprosthetic device has been shown to benefit patients with chronic voiding dysfunction. In this study we measured the effectiveness of sacral nerve stimulation in 10 patients with chronic intractable pelvic pain. MATERIALS AND METHODS: After successful percutaneous trial stimulation, a neuroprosthetic sacral nerve stimulation device was surgically implanted in 10 patients with chronic intractable pelvic pain. Leads were placed in the S3 and S4 foramen in 8 and 2 cases, respectively. Patients were evaluated throughout the study using a patient pain assessment questionnaire on a scale of 0-absent to 5-excruciating pain. Pain was assessed at baseline, during test stimulation, and 1, 3 and 6 months after surgical lead implantation. An additional long-term assessment was done at a median followup of 19 months. RESULTS: Of the 10 patients with the implant 9 had a decrease in the severity of the worst pain compared to baseline at a median followup of 19 months. The number of hours of pain decreased from 13.1 to 6.9 at the same followup interval. There was also an average decrease in the rate of pain from 9.7 at baseline to 4.4 on a scale of 10-always to 0-never having pain. At a median of 19 months 6 of 10 patients reported significant improvement in pelvic pain symptomology. CONCLUSIONS: These data imply that transforamenal sacral nerve stimulation can have beneficial effects on the severity and frequency of chronic intractable pelvic pain. Future clinical studies are necessary to determine the long-term effectiveness of this therapy.     

Sacral neuromodulation for urinary retention after pelvic plexus injury

Injury to the pelvic plexus with resultant urinary retention is a known complication of colectomy. We describe a case of urinary retention after colectomy successfully treated with the insertion of a pelvic neuromodulator.     

Sacral and pelvic osteotomies for correction of spinal deformities

Aim

Rett syndrome is a progressive neurodevelopmental disorder that predominantly affects females and is associated with a high incidence of scoliosis and epilepsy. There is scant published work about intraoperative spinal cord monitoring in these patients and little more regarding the rate of perioperative complications. We investigated our institutions’ experience with both.

Methods

We retrospectively reviewed the records of 11 patients with Rett syndrome who underwent surgical correction of scoliosis at our institution between 2004 and 2010.

Results

Eleven patients underwent successful correction of their scoliosis at an average age of 12. Eight of the patients suffered one or more significant complications. The average curve was corrected from 71° to 27°. Successful spinal cord monitoring was achieved in eight of the nine patients where it was attempted. No patient suffered any neurological complications. Average inpatient stay was 18.2 days.

Conclusion

Scoliosis surgery in patients with Rett syndrome carries a very high rate of complications and an average hospital stay approaching 3 weeks. Both caregivers and surgeons should be aware of this when planning any intervention. These patients frequently have useful lower limb function and spinal cord monitoring is a valid tool to aid in its preservation. We would suggest aggressive optimisation of these patients prior to surgery, with an emphasis on nutrition.

     

Incidence and mechanisms of infiltration of sarcomas in the shoulder

The intraarticular infiltration of sarcomas around the shoulder was analyzed. Of 58 sarcomas located around the shoulder, which were treated between 1993 and 1998, 15 osteosarcomas, 12 chondrosarcomas, and one Ewing's sarcoma that abutted the shoulder were selected. Radiologic images of 28 tumors were analyzed and compared with pathologic examinations. In 17 of 28 sarcomas (15 in the proximal humerus and two in the scapula), joint infiltration was suspected radiologically because of the existence of a tumor mass probably inside the joint or disruption of the joint surface and protrusion of the tumor. Seven of 17 tumors with radiologically positive and zero of 11 tumors with radiologically negative findings showed histologically positive findings for tumor inside the joint. Four of 11 osteosarcomas and three of four chondrosarcomas of the proximal humerus showed histologic findings of joint infiltration. Pericapsular extension was seen in two patients, direct articular spread with a pathologic fracture was seen in two patients, direct articular spread was seen in one patient, direct articular spread with pericapsular extension was seen in one patient, and pericapsular extension with a pathologic fracture was seen in one patient. The current study showed that pericapsular or direct articular infiltration into the glenohumeral joint is a phenomenon in sarcoma around the shoulder. Exact assessment of tumor existence inside the joint can be difficult in osteosarcoma and chondrosarcoma, so abnormal radiologic findings should be regarded as proof of existence of tumor, and extraarticular wide resection should be planned.     

Sacral and pelvic osteotomies for correction of spinal deformities

Introduction

Restoring a physiological sagittal spine balance is one of the main goals in spine surgery. Several technics have been described previously, as pedicle subtraction osteotomy. In more complicated cases involving spino-pelvic disorders, three authors proposed sacral osteotomy to restore sagittal balance of the spine. The authors describe the use of pelvic osteotomies for the correction of lumbo-sacral kyphosis, for decreasing pelvic incidence and for achieving sagittal balance correction in cases of lumbo-sacral sagittal deformity as an alternative of pedicle subtraction osteotomies (PSO).

Materials and methods

We simulate four types of pelvic osteotomies previously described for hip pathology (Salter, modified Salter, Chiari and posterior sacral osteotomy) on drawing software, and calculate during these osteotomies the variation of pelvic incidence (PI). Then, we compare the behaviour in this simulation to a cadaveric model where we perform the same four pelvic osteotomies. Via X-rays made the study, we calculate also the PI. Then, we analyse 11 patients who underwent pelvic osteotomies for sagittal unbalance, analysing operative and clinical data.

Results

We find a mathematical law governing the PI during anterior opening and posterior closing osteotomies (respectively Salter and sacral osteotomy):

$$ {\text{PI end}} = {\text{PI initial}} {-} a \times {\text{osteotomy angle}}.$$

These laws are confirmed in the cadaveric model which retrieves the same behaviour. In the clinical series, Salter osteotomy is easy and efficient on sagittal rebalancing; sacral osteotomy is more powerful.

Discussion

The Salter osteotomy is efficient for restoring sagittal balance of the spine. The posterior sacral osteotomy is more powerful but technically demanding. The indications of such special osteotomies are fixed lumbo-sacral kyphosis, especially high-grade spondylolisthesis, previously operated or not.

Conclusion

A study of a more substantial series would be considered.

     

Reliability and reproducibility analysis of the AOSpine Sacral Fractures Classification System by spinal and pelvic surgeons

Study DesignRetrospective Cohort StudyObjectivesThe AOSpine Sacral Classification System was proposed as a comprehensive and universally accepted new classification for Sacral Fractures, and was recently internally validated. However, an external, independent and multidisciplinary reports on validation of this classification is lacking. Aim of the present study is to analyze the interobserver reliability and intraobserver reproducibility of the AOSpine Sacral Classification System for Sacral Fractures between orthopedic spinal and pelvic surgeons with different levels of experience.MethodsOur institutional database was searched to retrieve patients with acute, traumatic sacral injury admitted from June 2017 to June 2020. For each patients, X-Rays and CT scans were collected. Three Orthopedic Pelvic Surgeons (Group A) and three Spine Surgeons (Group B), with different level of experience (Junior, 〈 5 years; Middle, 5–10 years; Expert 〉 10 years) independently classified all the sacral fractures included in the dataset, with two separate evaluation three weeks apart. Both intra and interobserver reliability were calculated with k-coefficient.ResultsOverall, 150 patients were included in the final dataset, for a total of 1800 different assessments, with all the subtypes reported. The intraobserver reproducibility for the whole group was substantial (κ=0.72). Overall, the interobserver reliability was moderate, with a κ=0.57. When only fracture type was taken in account, the κ value became substantial (κ=0.62). No significant differences were found comparing group A and group B (0.55 vs κ 0.55, p>0.05). No significant differences according to surgeon's experience were found; however, the κ value was slightly lower among the junior surgeons.ConclusionsOur findings confirmed the reliability and reproducibility of this classification in clinical practice. In the current study the surgeon's expertise (pelvic and spinal trauma) and the level of experience does not influence the reliability of the classification system.     

Sacral anomaly and pelvic floor muscle in imperforate anus: a clinical and experimental study

Influences of sacral anomalies on the postoperative continence of imperforate anus were evaluated clinically and experimentally. Postoperative continence was clinically assessed by the quantitative scoring system for 77 patients (44 of high-type anomalies and 33 of low-type anomalies). Incidence of combined sacral anomalies was 28.6% (38.6% in high type anomalies and 15.2% in low type anomalies). Combined sacral anomalies had harmful effects on the postoperative defecational function, especially on the parameters of rectal sensation and soiling. Patients with more than four segments of sacral vertebrae had relatively satisfying results on the postoperative assessment. For a teratological study to obtain a model of sacral anomalies, Donryu rats were used. Trypan blue was injected as the teratogen intraperitoneally on the nineth day of gestation. Of the 198 live fetuses, 5 rats had tail defect and sacral anomalies. Two of the 5 anomalous rats also had imperforate anus. Four of 5 rats had vertebrae intact above the first sacral segment. In these 4 rats the pelvic floor muscles had developed to some degree. All the vertebrae were agenetic below the thoracic segments in the other rat fetus. This rat had no pelvic floor muscles. These studies showed that the severity of sacral anomalies had a relationship to postoperative continence. Intact sacral vertebrae above the 4th in humans and the 1st in rats correlated with fair development of pelvic floor muscles and satisfying postoperative continence.     

Sacral nerve modulation in the treatment of chronic pain after pelvic surgery

Aim The aim of the study was to evaluate the efficacy of sacral nerve modulation for chronic pelvic pain after pelvic or anal surgery for benign disease. Method From January 2004 to December 2009, 17 (14 female; age 56 years) consecutive patients suffering from chronic pelvic pain underwent evaluation for sacral nerve modulation in three pelvic floor units. Results The previous surgery included stapled transanal rectal resection (five), hysterectomy (four), haemorrhoidectomy (two), stapled haemorrhoidopexy (one), fistulectomy (one), urethral sphincterotomy (one), appendicectomy (one), discectomy (one) and laparoscopy for endometriosis (one). Eight (47%) patients fulfilled the criteria for definitive implantation and were followed for a mean of 39 months. Using a visual analog pain score, pain levels fell from 8.2 preoperatively to 1.9, 2.1, 2.0 and 1.8 at 6, 12, 24 and 36 months, respectively. Age < 60 years and duration of symptoms of < 24 months were good predictors and stapling was a poor predictor of success. Conclusion Sacral nerve modulation seems to be effective over time in some patients with chronic pain related to previous surgery.     

An experimental analysis of three-dimensional hip joint force after pelvic osteotomies

A three-dimensional analysis of the resultant forces on the hip was carried out using a fresh cadaver of a 40 year old male. A cross sectional area of each of twenty-four muscles around the hip was measured. Markers were fixed at the proximal and the distal insertions of the muscles and the direction of muscular forces was calculated. From these data, three-dimensional resultant forces on the hip and muscular forces around the hip were calculated through the computer in the normal and the postoperative states of Salter pelvic osteotomy, Chiari pelvic osteotomy and rotational acetabular osteotomy. The results showed the resultant forces to be 3.38 times the body weight in the normal specimen, and 3.79 times for the Salter pelvic osteotomy, 2.74 times for the Chiari pelvic osteotomy, and 4.07 times for the rotational acetabular osteotomy. However, as the loaded area on the femoral head also had increased to 1.12 times for the Salter pelvic osteotomy, and 1.20 times for the rotational acetabular osteotomy, the resultant force in each square centimeter was 0.94 times for the Salter pelvic osteotomy, and 0.71 times for the rotational acetabular osteotomy.     

The use of pelvic radiation in stage II rectal cancer: a population-based analysis

National Institutes of Health (NIH) guidelines recommend the use of pelvic radiation in T3N0 rectal cancer. We sought to determine the rate of compliance with NIH radiation guidelines for patients with T3N0 rectal cancer. We performed a retrospective cohort study of T3NO rectal cancer diagnosed between January 1, 1994, and December 31, 2003, in Region 5 of the California Cancer Registry (R5 CCR). Three hundred twenty-nine patients with T3N0 rectal cancer were identified. The mean age of the study population was 68 years (range, 28 to 93 years). Only 54.1 per cent of patients with T3N0 cancer received pelvic radiation. There was no difference in gender (P = 0.13) or the number of nodes examined (P = 0.19) between patients who had treatment with pelvic radiation and those who did not. However, patients receiving radiation were significantly younger (mean 64 years with radiation therapy [XRT] vs. 72 years without XRT, P < 0.001) and significantly more likely to be treated with systemic chemotherapy (75% with XRT vs. 8.6% without XRT, P < 0.001). Significant numbers of patients with T3N0 rectal cancer are not receiving pelvic radiation in R5 CRR. NIH guidelines are not being translated into clinical practice. The reasons for this warrant continued investigation.