颈胸段脊柱结核的手术治疗策略

目的:探讨颈胸段脊柱结核病灶部位与胸骨柄上缘切迹位置关系对手术治疗策略选择的影响及临床预后。方法:2003年1月~2013年1月45例颈胸段脊柱结核患者采用手术治疗,其中男29例,女16例;年龄17~62岁(35.4±16.7岁)。病变节段:C7~T1 8例,T1 11例,T1~T2 7例,T2 6例,T2~T3 8例,T3 5例。术前神经功能ASIA分级:A级2例,B级5例,C级9例,D级22例,E级7例。术前颈胸段后凸成角、颈椎残障功能量表(neck disability index,NDI)评分和JOA评分分别为34.7°±6.8°、39.6±4.6及10.7±2.8。根据患者颈胸段MRI矢状位上胸骨柄上缘切线与结核病灶的关系采取不同手术方案,19例椎体结核病灶位于胸骨柄上缘水平切迹线之上的患者采用一期前路病灶清除、植骨融合内固定术,26例病灶平齐于胸骨柄上缘水平切迹线或在之下的患者采用一期前路病灶清除、植骨融合及后路植骨融合内固定术。术前及术后均用四联敏感抗结核药物规律治疗。对患者后凸成角、NDI评分和JOA评分变化情况进行统计学分析来评价疗效。结果:手术时间为178.0±48.3min;术中出血量为590.0±76.4ml。随访6.6±3.2年(3~13年),在随访期内无内固定松动、断裂、失败等情况出现。末次随访时患者颈胸段后凸成角、NDI评分及JOA评分分别为10.2°±2.4°、11.4±3.6及17.6±2.4,与术前比较均有统计学差异(P0.05)。1例单纯行一期前路病灶清除、植骨融合内固定术治疗的患者在术后6个月时手术切口窦道形成,再次行一期前路内固定取出、病灶扩大清除植骨融合和二期后路植骨融合内固定治疗,随访5.5年结核治愈。其余44例患者在术后7.2±1.1个月获得融合。在伴有神经功能减退的38例患者中,29例(76%)末次随访时神经功能ASIA分级提高1~3级,9例分级无变化。结论:颈胸段脊柱结核患者在规律抗结核药物治疗的基础上,根据患者颈胸段MRI矢状位上胸骨柄上缘切线与结核病灶的关系,对不同类型患者采用不同手术方式可完成彻底的病灶清除、固定及融合,中长期随访效果较好。     

一期病灶清除并植骨内固定术治疗颈椎结核

目的探讨规范抗结核药物治疗基础上一期手术病灶清除术并植骨融合内固定治疗颈椎结核的临床疗效。方法回顾性分析2008年1月—2014年12月在本院接受规范抗结核治疗基础上一期手术行病灶清除并自体髂骨植骨融合内固定术治疗的26例颈椎结核患者资料,男17例,女9例;年龄26~75岁,平均45.4岁。其中累及颈椎单椎体7例、相邻双椎体12例、3椎体4例,合并脊柱其他部位结核病灶3例(包括T5 1例、T12 1例、L3 1例)。1例合并颈椎后纵韧带骨化症。术前颈部疼痛视觉模拟量表(VAS)评分4~9分,平均5.7分;日本骨科学会(JOA)评分7~12分,平均10.1分;术前病变节段Cobb角21.5°±6.1°;美国脊髓损伤协会(ASIA)分级C级2例,D级3例,E级21例。术前行规范的抗结核治疗,待红细胞沉降率(ESR)50 mm/h后行手术治疗。根据手术节段及病变情况选择颈椎前路、后路或联合入路进行手术。术后继续规范抗结核治疗12~18个月。结果术后随访13~49个月,平均25.3个月。术前症状均明显改善,骨性融合时间3~6个月,平均4.5个月。末次随访时,颈部VAS评分(1.1±2.7)分,JOA评分(15.1±3.9)分,病变节段Cobb角4.7°±6.1°。1例上颈椎结核患者术后出现取骨区皮下脂肪液化、切口不愈合,给予手术清创缝合后二期愈合。术后未发生颈椎结核复发。结论在术前规范抗结核治疗基础上,根据病变节段采用一期彻底病灶清除联合植骨融合内固定手术可有效治疗颈椎结核,术后规范的抗结核治疗是提高颈椎结核治愈率的关键。     

颈椎射频消融术后颈椎感染的翻修手术治疗

目的 :分析颈椎射频消融术后颈椎感染的翻修手术效果。方法 :回顾性分析2010年7月~2016年7月在我科接受翻修手术的9例颈椎射频消融术后颈椎感染患者资料。其中男5例,女4例,年龄51.8±4.3岁(34~61岁),均在接受颈椎射频消融术后1周内(3~7d)神经症状再次出现或加重,其中5例患者神经症状加重程度超过射频消融术前,影像学检查和实验室检查提示存在颈椎感染,9例均存在椎间隙感染,3例伴有硬膜外脓肿,1例伴有椎体感染。入院后行翻修手术治疗,均行颈椎前路病灶清除+植骨融合内固定术,其中3例行椎体次全切除植骨融合内固定术,6例行椎间盘切除植骨融合内固定术。测量评估射频消融术前患者手术节段椎间隙的高度和椎间盘退变情况,用VAS评分评估患者翻修手术前后的颈部及上肢疼痛情况,用JOA评分评估翻修手术前后的神经功能情况。结果:射频消融术前,接受射频消融的11个节段椎间隙相对高度为0.19±0.07(0.14~0.25),Pfirrmann椎间盘退变分级为Ⅲ级4个节段、Ⅳ级7个节段。翻修术后所有患者颈部及上肢疼痛VAS评分及神经功能JOA评分较翻修术前明显改善(P0.05)。平均随访2.8年(1~3.6年)。末次随访时,患者颈部及上肢VAS评分由翻修术前的6.3±1.2分和5.8±2.1分改善到1.6±1.0分和1.5±0.9分(P0.05);JOA评分从翻修术前的9.5±3.8分改善到13.5±3.6分(P0.05)。随访期间未出现植骨不融合等其他并发症。结论:颈椎翻修手术是处理颈椎射频消融术后严重颈椎感染的有效方法。严格控制颈椎射频消融术适应证可以有效减少并发症发生。     

一期前路病灶清除植骨内固定术治疗颈椎布鲁杆菌性脊柱炎

[目的]探讨颈椎布鲁杆菌性脊柱炎有效的外科治疗方法及临床效果。[方法]对2002年1月~2012年1月期间,经临床及实验室检查确诊且具有手术指征的颈椎布鲁杆菌性脊柱炎的患者32例采用一期前路病灶清除植骨内固定术治疗。男21例,女11例;年龄40~69岁,平均49.5岁。病程3~6个月,平均4.5个月。2个椎体受累24例,3个椎体受累8例。均合并不同程度神经功能损伤。术后末次随访行疼痛视觉模拟评分(VAS)、日本骨科协会评分(JOA)、临床疗效评价以及X线片、MRI影像学观察。[结果]术后32例均获随访,随访时间24~48个月,平均32个月。术后椎体间植骨融合,无断钉、断板、复发病例。术前及末次VAS评分为(9.0±0.6)、(1.0±0.7),JOA评分为(8.0±1.6)、(14.9±1.7),术后VAS评分和JOA评分均较术前显著改善,差异有统计学意义(P0.05)。临床疗效评价:术后均无加重患者,末次随访优良率为100%。末次随访复查X线片及MRI未发现复发。[结论]一期前路病灶清除植骨内固定术治疗颈椎布鲁杆菌性脊柱炎,可以控制病变部位发展,缓解疼痛,重建颈椎稳定性,恢复神经功能,临床效果满意。     

XLIF联合病灶清除内固定治疗单节段腰椎结核

目的探讨极外侧椎间融合(XLIF)联合病灶清除内固定治疗单节段腰椎结核的初步临床效果。方法回顾性分析2013年1月至2014年5月广西贵港市人民医院收治的9例单节段腰椎结核患者的临床资料,其中3例L1/2椎体结核、2例L2/3椎体结核、4例L3/4椎体结核,均在微创通道下行XLIF联合病灶清除内固定治疗。记录手术时间和术中出血量,评估患者手术前后视觉模拟量表(VAS)、日本骨科学会(JOA)评分,观察术后并发症及植骨融合情况。结果所有患者均手术顺利,手术时间(70±22)min,术中出血量(110±32)m L,植骨融合时间(7.0±1.3)个月。术后随访6~13个月(平均9.6个月)。末次随访VAS、JOA评分均较术前明显改善,差异有统计学意义(P0.05);末次随访JOA评分改善率为56%。2例患者术后出现左大腿前内侧皮肤感觉障碍及髂腰肌肌力下降,对症处理后3个月内恢复;随访期间影像学检查显示内固定位置良好,未出现植骨块吸收和骨不连,无结核复发病例。结论应用XLIF联合病灶清除内固定治疗单节段腰椎结核,具有手术创伤小、并发症少、术后恢复快、可早期下床活动、明显缓解疼痛症状和改善腰椎功能等优点。     

外伤性颈椎间盘突出型脊髓损伤的手术治疗

目的评价外伤性颈椎间盘突出型脊髓损伤手术治疗的效果.方法回顾分析48例外伤性颈椎间盘突出型脊髓损伤患者的临床资料,术前Frankel分级A级2例,B级16例,C级20例,D级10例;JOA评分平均5.5±3.5分.均采用颈椎前路椎间盘切除、椎体间植骨、钛板内固定术,依据术前、术后Frailkel分级情况及JOA评分改善率评价治疗效果.结果术后除1例Frankel分级B级患者无恢复外,其余患者恢复l一4个等级.随访4～36个月.平均18个月.术后2个月时JOA评分为12.2±3.2分,改善率为59.9%±17.8%;末次随访时JOA评分为14.4±3.6分.改善率为68.0%±17.0%.随访中未见内置物松动、脱落或断裂等并发症发生,固定节段均获得骨性融合.结论应用颈椎前路椎间盘切除、椎体间植骨、钛板内固定术治疗外伤性颈椎间盘突出型脊髓损伤可获得较理想的脊髓功能恢复效果.     

一期前后路手术治疗寰枢椎结核合并神经功能损害

[目的]分析评价一期前后路联合手术治疗寰枢椎结核合并神经功能损害的临床疗效。[方法]2005年1月~2015年1月,12例寰枢椎结核合并神经功能损害患者采用一期前后路手术治疗。所有患者术前颈椎CT及MRI检查提示寰椎单侧或双侧侧块骨质破坏及枢椎齿突不同程度骨质破坏,寰枢椎稳定性丢失,结核病灶突入椎管内,导致相应节段脊髓受压。术前神经功能评估ASIA分级为:C级4例,D级8例。所有患者术前及术后均使用四联敏感抗结核药物规律治疗。通过对患者NDI评分和JOA评分变化情况进行统计学分析来评价临床手术疗效。[结果]手术时间平均(228±65.32)min;出血量平均(460±116.38)ml。平均随访(5.77±3.62)(2~12)年,在随访期内未见内固定松动、断裂、失败等情况出现。患者NDI评分及JOA评分分别由术前(39.67±4.32)分和(7.63±2.38)分改善至末次随访时(10.82±4.63)分和(15.58±1.21)分,差异有统计学意义(P0.05)。末次随访时12例患者神经功能ASIA分级均恢复至E级。[结论]对于寰枢椎结核合并神经功能损害的治疗,采用一期前后路联合手术能够完成结核病灶的彻底清除、脊髓的彻底减压及上颈椎稳定性的重建,通过中长期随访观察能够取得良好的临床疗效。     

在退变性颈椎后凸畸形手术中应用纳米羟基磷灰石/聚酰胺66人工椎体的疗效观察

目的 探讨在退变性颈椎后凸畸形手术中应用纳米羟基磷灰/聚酰胺66人工椎体(n-HA/PA66 strut)的疗效。方法 2014年1月至2021年1月在重庆医科大学附属第一医院骨科行颈椎后凸畸形手术且具备完整随访资料的患者31例。记录性别、年龄、出血量、手术时间、并发症发生率等基本信息。影像学评价包括颈椎曲度、颈椎过伸过屈曲度、局部节段曲度、局部节段过伸过屈曲度,采用Brantigan评分判断植骨融合。临床疗效采用JOA评分、VAS评分和NDI评价。结果 随访(21.6±10.9)个月。患者年龄、病程、手术时间、术中失血量、住院费用、住院时间分别为(50.5±13.0)岁、(18.2±21.9)个月、(134.3±57.0)min、(110.3±128.1)ml、(54 406±17 703)元、(10.7±5.1)d。末次随访时VAS、NDI和JOA评分较术前明显改善(P<0.05)。末次随访颈椎曲度、颈椎过伸曲度、颈椎过屈节曲度、局部节段曲度、局部节段过伸曲度、局部节段过屈曲度较术前明显改善(P<0.05)。术后出现2例并发症,1例术后出现前路切口血肿,经急诊手术,术后...     

颈椎前路椎体次全切减压全接触钛网植骨融合治疗脊髓型颈椎病对患者NDI评分的影响观察

目的观察颈椎前路椎体次全切减压全接触钛网植骨融合治疗脊髓型颈椎病对患者颈椎功能障碍指数(NDI)评分的影响。方法选择我院2012年2月至2017年10月收治的脊髓型颈椎病患者56例,分对照组(28例)和观察组(28例),对照组进行颈椎前路髓核摘除加植骨内固定术,观察组进行颈椎前路椎体次全切减压全接触钛网植骨融合术。术后进行为期6个月的随访,比较两组患者手术时间、术中失血量、住院时间和椎间丢失高度,并统计患者术前和术后6个月NDI、日本骨科学会(JOA)评分,计算植骨融合率和术后改善率。结果观察组手术时间短于对照组(P0.05),术中失血量少于对照组(P0.05),住院时间与对照组无显著差异(P0.05);观察组椎间丢失高度与对照组无显著差异(P0.05);观察组术后JOA评分明显高于对照组(P0.05),NDI明显低于对照组(P0.05);观察组植骨融合率96.43%与对照组的82.14%无显著差异(P0.05),术后改善率86.94±3.52%高于对照组的83.77±4.16%(P0.05)。结论颈椎前路椎体次全切减压全接触钛网植骨融合治疗脊髓型颈椎病疗效较好,可明显降低患者NDI。     

不同开槽减压宽度在ACCF治疗脊髓型颈椎病的疗效对比

目的比较不同开槽减压宽度在椎体次全切除减压融合术(anterior cervical corpectomy and fusion,ACCF)治疗脊髓型颈椎病(cervical spondylotic myelopathy,CSM)的临床疗效。方法纳入2013年4月～2016年4月于本院行ACCF术治疗的67例CSM患者,进行病历资料回顾性分析。32例患者开槽减压宽度为1.0 cm,设为对照组,35例减压宽度为1.4 cm,设为观察组,两组术后均随访24个月以上。记录手术相关指标,术前、术后6月、末次随访时评价JOA评分以及NDI指数,记录植骨融合及并发症发生情况。结果观察组手术时间、引流量、出血量均显著高于对照组,差异有统计学意义(P0.05);两组术后6个月、末次随访时的JOA评分均显著高于术前,NDI指数显著低于术前,且术后6月、末次随访观察组JOA评分均显著高于对照组,NDI指数显著低于对照组,差异有统计学意义(P0.05);术后6个月、末次随访时两组融合率差异无统计学意义(P0.05);两组并发症发生率差异无统计学意义(P0.05)。结论 ACCF术1.4 cm的开槽减压宽度较1.0 cm能显著改善患者颈椎功能障碍,两组融合率相当,并发症无明显差异,但1.4 cm的开槽减压宽度手术耗时更长,出血更多,有待进一步手术改良。     

Hip resurfacing and anterior approach

Abstract: Conceptually, resurfacing arthroplasty is less invasive for the bones than classical prosthetic replacement surgery. Combination of such resurfacing surgery with a surgical approach, also non-invasive, is a logical option: the Hueter's anterior access that has been utilized in prosthetic surgery by Robert and Jean Judet for more than 50 years and developed as a mini-invasive procedure by Marc Siguier and other surgeons is suitable for resurfacing for the following reasons: – anatomical reasons: best exposure of the femoral head and neck, and of the acetabulum; – anterior approach and dislocation do not compromise posterior vascular contribution in the femoral head and neck. The technique of resurfacing prosthetic implantation by anterior access on an orthopaedic table is described, and important points are specified. The results of a preliminary series of 61 patients having undergone this surgery between 2002 and 2004 are prospectively analyzed. In all patients except two, outcomes were clinically and radiologically good or excellent, with all targeted implantation criteria adequately met. The authors are still using the technique of resurfacing prosthesis implantation; their excellent results make them recommend the mini invasive anterior access and the use of an orthopaedic operating table.     

经前侧入路达芬奇机器人辅助肺段切除术的临床分析

目的总结经前侧入路达芬奇机器人辅助肺段切除术治疗肺部结节的临床价值。方法回顾性分析2018年6月至2019年10月于我科行前侧入路达芬奇机器人辅助肺段切除术77例患者的临床资料,其中男22例、女55例,年龄53(30~71)岁。对患者症状、一般情况、术前影像学资料、切除肺段分布、手术时间、出血量、淋巴结清扫数、术后带管时间、引流量、术后住院时间、术后并发症以及围术期死亡等指标进行分析。结果所有患者均顺利完成手术,无中转开胸,无严重并发症,无围术期死亡。术后病理48例为早期肺癌,29例为良性肿瘤。机器人Docking时间4(1~30)min,机器人腔内操作时间76(30~170)min,出血量30(20~400)mL,术后胸腔闭式引流管引流时间4(2~15)d,术后总引流量780(200~3980)mL;术后住院时间7(3~19)d。结论经前侧入路机器人辅助肺段切除治疗肺部结节安全、便捷和有效,值得临床推广应用。     

前路手术治疗多节段脊髓型颈椎病的分析

目的评价颈前路手术治疗多节段脊髓型颈椎病的术后疗效及并发症。方法33例患者中,14例行多节段椎间盘摘除、植骨前路钢板固定;19例行椎体次全切除长条植骨前路钢板内固定。结果术后平均随访19个月。33例术前JOA评分2~14(8·88±0·64)分,术后最终随访时8~16(14·10±0·39)分,差异有显著性(P<0·01)。优良21例,好转11例,加重1例。术后改善率10%~93%,平均61%。结论对于多节段脊髓型颈椎病不伴有连续性后纵韧带骨化的患者,前路减压植骨融合内固定有显著疗效。     

The basal interhemispheric approach for acute anterior communicating aneurysms

Summary We reviewed the surgical outcome in 85 patients with ruptured anterior communicating artery (ACoA) aneurysms, who were operated on within 72 hours of onset via a basal interhemispheric (BIH) approach (Group 1, N=48), or an anterior interhemispheric (AIH) approach (Group 2, N=37). The age, sex ratio and pre-operative grade (Gr) were similar for both groups. The outcome at the time of discharge was as follows for group 1: excellent or good 88%; fair, 6%; vegetative state, 2% and death 4%. For group 2, it was: excellent or good 78%; fair, 16%; vegetative state, 3%; and death, 3%. A significant correlation between admission grade and outcome was found in both groups. The outcome in group 1 was better than in group 2 for patients with a Glasgow Outcome Scale (GOS) better than fair (p < 0.07). No patient in group 1 had postoperative anosmia, but nine patients in group 2 became anosmic. The total number of complications was also significantly less in group 1. Our overall mortality rate was 4%. In conclusion, the BIH approach was more beneficial for treating acute ACoA aneurysm.     

Perioperative results of 214 laparoscopic adrenalectomies by anterior transperitoneal approach

Background The present study attempts to evaluate the perioperative results of the anterior approached laparoscopic adrenalectomy (LA) in a large cohort of patients, and report the advantages and disadvantages of this route. Methods 204 patients, 125 female and 79 male with a mean age 52.8 years (range, 19–75 years), underwent LA by the anterior transperitoneal approach from 1994 to 2005 in our institution. There were 100 right and 114 left LAs. Ten patients underwent bilateral LA. Associated surgical procedures were performed in 17 cases. During the same period 47 LAs had been performed by different approaches (flank and submesocolic). Results Mean operative time was 80 minutes for right (40–150), 109 minutes for left (64–300) and 194 minutes for bilateral adrenalectomy. Intraoperative major complications were observed in six patients. Mortality occurred in one diabetic patient who was converted to open surgery because of a colonic perforation and subsequently developed a Candida sepsis in the postoperative course. The mean size of lesion removed was 6.2 cm (1.5–12 cm). Oral intake started within 24 hours and the mean hospital stay was 2.5 days (1–8 days). Histology results were as follows: nonsecreting adenoma 65, Cushing’s adenoma 58, Conn’s adenoma 53, pheochromocytoma 24, metastases 9, myelolipoma 3, adrenogenital syndrome 1, carcinoma 1. Conclusions LA by anterior transperitoneal approach is safe and effective in our experience, despite the inherent limitation that this was not a prospective randomized study. The main advantage of this route is early ligature of the adrenal vein on both sides, enabling the performance of associated surgical procedures and bilateral adrenalectomy.     

Minimally invasive total hip arthroplasty with the anterior approach

Background:

Total hip athroplasty with the anterior surgical approach is advised because the dissection is entirely within intermuscular planes. In this report we describe a minimally invasive technique of anterior total hip arthroplasty, with the early outcomes.

Materials and Methods:

The technique of minimally invasive total hip arthroplasty with anterior approach (Smith-Petersen) is described. We reviewed data on 100 consecutive patients who underwent anterior total hip arthroplasty with uncemented components. Mean patient age was 61 years (range 33-91). Mean patience BMI 29.8 (range 18.1-51.8).

Results:

Minumum follow up duration is 10 months. The mean duration of surgery was 53 min (range 34-87) with mean blood loss 185 cc (range 65-630), and the mean incision length was 10.4 cm. Clinical and radiographic outcomes were similar to historical outcomes of standard total hip arthroplasty.

Conclusions:

With proper surgeon training, minimally invasive total hip replacement with the anterior surgical interval is safe and efficacious.     

Is dysphonia permanent or temporary after anterior cervical approach?

The rate, causes and prognosis of dysphonia after anterior cervical approach (ACA) were investigated in our clinical series. During a 10-year interval, 235 consecutive patients with cervical disc disease underwent surgical treatment using anterior approach. Retrospective chart reviews showed recurrent laryngeal nerve (RLN) injury in 3 (1.27%) patients. All three patients were men and only one patient had multilevel surgery. These patients had RLN injury after virgin surgery. Laryngoscopic examination demonstrated unilateral vocal cord paralysis in all patients who had postoperative dysphonia. No permanent dysphonia was observed in our series and patients recovered after a mean of 2 months (range 1–3 months) duration. Dysphonia after ACA was a rare complication in our clinical series. Pressure on RLN or retraction may result in temporary dysphonia.     

微小乳头状甲状腺癌的内镜手术治疗

目的 探讨微小乳头状甲状腺癌(PTMC)内镜手术治疗的可行性、有效性及安全性.方法 收集2006年3月至2007年9月经胸乳人路内镜下甲状腺手术164例患者的临床资料,对其中经术中冰冻切片检查报告为PTMC的28例患者的临床资料进行回顾性分析.28例患者平均年龄35.2岁,女性27例,男性1例.术前诊断为甲状腺微小癌的12例,结节性甲状腺肿的16例.全部PIMC患者在内镜下行患侧甲状腺腺叶全切除+对侧腺叶次全切除+Ⅵ区淋巴结清扫术.结果 平均手术时间(115±43)min.肿瘤最大径0.2～1.0 cm,平均0.56 cm.5例(17.9%)术后出现一过性声音嘶哑.无术后出血、皮下气肿、饮水呛咳以及低血钙的表现.术后病理报告均为PTMC.Ⅵ区淋巴结清扫数目2～10个,平均4.6个,其中13例(46.4%)淋巴结有癌转移.随访时间1～17个月,B超和ECT提示患侧甲状腺无残留腺体,局部无复发.结论 内镜甲状腺手术治疗PTMC是安全可行的,可作为PTMC手术治疗的一种选择.