选择性椎弓根置钉矫形治疗青少年特发性脊柱侧凸

[目的]回顾性观察分析后路选择性椎弓根置钉矫形治疗青少年特发性脊柱侧凸(AIS)的临床疗效。[方法]2005年1月～2009年6月采用后路选择性椎弓根置钉矫形手术治疗AIS,测量术前和术后胸侧凸冠状面Cobb角、矢状面Cobb角,腰侧凸冠状面Cobb角,顶椎椎体旋转和身高变化。分析临床疗效。[结果]手术时间平均186min;术中失血量平均800 ml。术中无脊髓、神经及血管损伤,术后无胸腔积液及切口感染。随访2.1～6.4年,平均3.6年。胸侧凸冠状面Cobb角、胸侧凸矢状面Cobb角和冠状腰弯Cobb角分别由术前57.38°±10.93°、29.3°±7.8°、33.03°±7.75°矫正为12.88°±8.79°、17.9°±10.3°和8.85°±3.65°,手术前后有显著性差异(P<0.01),末次随访分别为:13.89°±9.36°、19.3°±5.4°和9.06°±3.78°,与术后比较无显著性差异(P>0.01)。顶椎椎体旋转由术前2.83°±1.25°矫正为1.37°±1.13°(P<0.01),末次随访(1.32°±1.04°)与术后比较无显著性差异(P>0.05);身高平均增长4.45 c...     

椎弓根钉置入自攻钻孔导向器的设计及临床试验

目的设计一种自攻钻孔导向式椎弓根钉置入钻孔器,以期达到准确置入椎弓根钉的目的。方法术前根据X线片及CT扫描,确定椎弓根钉进钉点及椎弓根轴线;术中一侧应用传统的三棱锥钻孔,另一侧应用自攻钻孔导向器钻孔,采用左右侧分别插入粗细不同的克氏针C型臂X线机透视等三种方法,确定进钉孔的恰当程度。结果自攻钻孔导向器组158个椎弓根有9个椎弓根（5．7％）破穿,传统三棱锥组158椎弓根有22个椎弓根（13．92％）破穿,统计学分析显示两者有显著性差异。结论应用自攻钻孔导向器钻孔引导置入椎弓根钉,能明显降低失败率。     

CT导航系统在重度僵硬性脊柱畸形矫形术中的置钉准确性及临床疗效评估

目的 评估CT导航系统在重度僵硬性脊柱畸形矫形术中的置钉准确性及临床疗效。方法 回顾性纳入2017年1月至2022年12月我院收治的43例重度僵硬性脊柱畸形病人,其中21例采用术中CT导航系统辅助置钉（421枚螺钉）的病人纳入导航组,22例采用传统徒手置钉（386枚螺钉）的病人纳入徒手组。收集两组病人的一般资料、手术前后主弯Cobb角、矫正率、置钉数量以及顶椎区域置钉数量。采用Gertzbein和Robbins分级分析两组病人术后CT图像,以评估置钉准确性。结果 两组病人手术前后主弯Cobb角及矫正率比较,差异无统计学意义（P＞0.05）。较之徒手组,导航组置入于顶椎区域的螺钉数量更多［（7.37±1.12）个 vs. （6.45±0.96）个］,手术时间更长［（376.19±56.26） min vs. （331.36±50.92） min］,差异均有统计学意义（P＜0.05）;但出血量无明显差异（P＞0.05）。两组病人总体置钉准确率比较,差异无统计学意义（P=0.586）;但在顶椎区域,导航组置钉准确率显著高于徒手组（96.1% vs. 89.4%,χ²=5.051,P=0.025）。此外,术中CT导航系统明显降低了椎弓根内侧穿孔率（χ²=5.122,P=0.024）。结论 CT导航系统可有效提高重度僵硬性脊柱畸形顶椎区域的置钉准确性。     

漏斗技术结合徒手椎弓根探针技术在椎弓根置钉术中的应用

目的探讨利用漏斗技术结合徒手椎弓根探针技术置入椎弓根钉的安全性及准确性。方法术前测量目标椎的e角、f角及椎弓根直径,选择准确的进针点:骶椎以下关节突左7点右5点为进针点,腰椎以人字嵴顶点作为进针点,胸椎按Kim推荐的入点进针。在椎弓根入口去皮质后据e、f角徒手推进椎弓根探针至椎体前缘,测量所需螺钉长度,再沿钉道扩孔、攻丝及置入相应直径与长度的螺钉;术后CT片按照椎弓根内侧壁穿透<2 mm,外侧壁穿透<4 mm作为安全评价标准。回顾性分析自2009年6月~2012年1月利用该技术在184例中置入736枚椎弓根钉的情况。结果所有螺钉椎弓根内侧壁穿透<2 mm,外侧壁穿透<4 mm,总合格率100%;无一例出现神经根或脊髓损伤加重的表现,无一例出现脑脊液漏。结论利用合理的进针点,在个体化置钉的基础上,利用漏斗技术结合徒手椎弓根探针技术能成功置入胸腰椎椎弓根钉。     

胸腰椎椎弓根钉置入导向器的设计及应用实验

目的：设计一种新型椎弓根钉置入导向装置，以期减少椎弓根钉置入的失败几率。方法：术前CT扫描拟置钉椎体，确定椎弓根轴线。右侧以导向器辅助钻孔，左侧徒手钻孔。钻孔后孔内置克氏针，椎弓根环绕钢丝，摄正侧位X线片，评价其准确程度。结果：导向器组36个椎弓根有2个椎弓根(5．6％)穿破，徒手组36个椎弓根有8个椎弓根(22％)失败。经统计学处理显示，两组结果有显著性差异。结论：应用新型导向器，能明显降低下胸椎及腰椎椎弓根钉置入中的失败率。     

侧卧位椎弓根钉植入技术在脊柱外科手术中的应用

[目的]建立并评价侧卧位椎弓根钉植入技术。[方法]对需采用前后联合入路固定手术患者进行侧卧位椎弓根钉植入，并与同期单纯俯卧位椎弓根钉植入患者进行对比，术后进行X线片和CT检查。[结果]两者的不良置钉率没有明显差别，神经根损伤率均为0％。[结论]侧位椎弓根钉植入技术固定确实可靠，在临床实践中具有很好的实用价值。     

双侧椎弓根交叉间隔置钉矫形治疗Lenke 1型青少年特发性脊柱侧凸

目的:观察双侧椎弓根交叉间隔置钉矫形治疗Lenke 1型青少年特发性脊柱侧凸(AIS)的临床疗效。方法:2007年1月～2008年12月采用后路双侧椎弓根交叉间隔置钉矫形手术治疗Lenke 1型AIS患者36例,其中男7例,女29例,年龄11～18岁,平均15.3岁,术前胸椎侧凸角度均<75°,且侧凸柔韧性均>50%。测量术前和术后冠状面主胸弯Cobb角、胸椎矢状面Cobb角、C7铅垂线与骶骨正中线(CSVL)的距离、C7铅垂线与S1椎体后上角的垂直距离、双侧肋骨后凸的高度差(RH)、顶椎上下横突侧方5个肋间距总和的左右侧差值(ARSD)、胸弯顶椎椎体外侧缘至两侧胸壁距离的比值(AVB-R),分析临床疗效。结果:手术时间150～240min,平均176min;术中失血量460～1100ml,平均840ml。术中无脊髓、重要神经及血管损伤,1例患者术后出现左侧胸腔积液,2例患者术后2周出现伤口浅表感染。随访1.6～3.2年,平均2.06年。主胸弯冠状面Cobb角由术前56.7°±8.0°矫正为14.1°±6.0°(P<0.05),末次随访(17.2°±3.2°)与术后比较无显著性差异(P>0.05)。胸椎矢状面Cobb角由术前的28.9°±7.9°减小为21.9°±10.6°(P<0.05),末次随访(24.3°±5.1°)与术后比较无显著性差异(P>0.05)。矢状面C7铅垂线与S1椎体后上角的垂直距离由术前-11.7±12.1mm变为术后-1.4±9.4mm(P<0.05),末次随访(-2.7±4.7mm)与术后比较无显著性差异(P>0.05)。RH、ARSD、AVB-R术前分别为37.7±5.8mm、20.1±6.6mm和1.56±0.16,术后分别为19.3±6.9mm、8.1±4.7mm和1.22±0.20,差异有显著性(P<0.05)。C7铅垂线与CSVL的距离术前、术后及末次随访无显著性差异(P>0.05)。随访期间未发现内固定失败征象。结论:双侧椎弓根交叉间隔置钉矫形治疗柔韧性好的轻中度Lenke 1型AIS可以获得良好的三维矫形效果。     

脊柱椎弓根钉角度定位器的研制及临床应用

在脊柱后路手术固定骨折、脱位和滑脱时,正确确定椎弓根的水平角和矢状角,准确置入合适椎弓根螺钉,顺利完成矫形、复位固定是手术成功的关键.1997年10月～2006年6月,笔者设计了一种简易的椎弓根角度定位器,用于198例脊柱外科手术时矢状角及水平角的确定,取得了较好的效果.报告如下.     

万向椎弓根螺钉在重度脊柱侧后凸中的应用

[目的]分析和总结万向椎弓根螺钉在治疗重度脊柱侧凸患者手术矫形中的疗效.[方法]回顾性分析了2008年3月～2009年4月期间本科使用万向椎弓根内手术矫形的66例重度脊柱侧凸病人的临床资料,其中男性25例,女性41例;平均18.2岁.侧凸主弯Cobb角平均113.4°(80°～165°),后凸角度平均90.5°(49°～165°),旋转Ⅱ-Ⅳ度.手术行后路矫形38例,截骨矫形28例,其中二期手术矫形13例.[结果]全部病例均安全完成矫形手术,手术时间3.5～6.5 h,平均5.6 h,出血450～3 300 ml,平均1 577 ml.术后出现一过性单侧下肢不全瘫1例,给予甲强龙冲击、神经营养治疗3个月后完全恢复.术后侧凸Cobb角平均42.9°,矫形率62.1%,后凸角度平均32.3°,矫形率64.3%,身高平均增长8.9 cm.[结论]万向椎弓根螺钉是治疗重度脊柱侧凸的安全有效的方法,具有良好的矫形率.     

Complications associated with thoracic pedicle screws in spinal deformity

Thoracic pedicle screws have superior anchoring strength compared with other available fixation techniques. However, these are not universally accepted in many developing countries because of the concerns regarding safety and complications. In addition, there is evidence that pedicle morphology is unique in Chinese patients. The goal of this study was to analyze the complications seen at our institution, while using thoracic pedicle screws for the treatment of thoracic deformity, and to determine the safety of our techniques for the treatment of thoracic deformity in a Chinese population. From 1998 to 2005, there were 208 thoracic deformity patients treated at our institution, 70 of whom were male and 138 were female. Their age ranged from 11 to 55 years (mean of 14.9 years). All of them underwent corrective deformity surgery using posterior pedicle screw systems and follow-up was available for at least 3 years. Etiologic diagnoses included adolescent idiopathic scoliosis in 119 patients, congenital kyphoscoliosis in 38, adult scoliosis in 37 and undetermined in 14. Screw positions were evaluated using intraoperative and postoperative radiographs and a CT scan was performed when a concern for screw malposition was present. All radiographic evaluations were carried out in a double-blinded fashion. A total of 1,123 thoracic pedicle screws were inserted (5.4 thoracic screws/patient). The deformity correction rate was 81, 65 and 62% for idiopathic, congenital and adult scoliosis patients, respectively. The overall complication rate was 16.5% at the final follow-up. Complication rates directly and indirectly related to pedicle screws were 7.2 and 9.3%, respectively. There were no significant screw-related neurologic or visceral complications that adversely affected long-term results. The complications seen with thoracic pedicle screws in a Chinese population were similar to other populations and could be utilized safely for the treatment of thoracic deformity in this population.     

低龄儿童脊柱侧凸矫正术中椎弓根螺钉置入的精确性和安全性评估

目的:评估10岁及以下脊柱侧凸患儿侧凸矫正术中椎弓根螺钉置入的精确性及安全性,并分析其相关影响因素。方法:回顾性分析2008年2月~2008年7月我院收治的行后路椎弓根螺钉固定的10岁及以下脊柱侧凸41例患儿的临床资料,所有患者术前、术后均行CT检查,男26例,女15例,年龄2~10岁,平均5.4岁。先天性脊柱侧凸36例,特发性脊柱侧凸2例,神经肌肉源性脊柱侧凸2例,先天性软骨发育不全伴脊柱侧凸1例。术中根据解剖标志徒手置入椎弓根螺钉。在PACS系统上通过Pacs Client软件测量螺钉尖距椎弓根内壁、外壁、上壁、下壁以及椎体前缘的距离。若左侧椎弓根螺钉穿破椎弓根外壁或椎体前缘,测量钉尖与主动脉的距离。根据椎弓根螺钉所在位置(节段、凹凸侧、脊椎发育是否异常)分析其破壁率差别。不良置钉定义为椎弓根螺钉穿破椎弓根内、外壁或椎体前缘的距离超过2mm,和椎弓根螺钉进入椎间孔或穿破终板进入椎间盘。结果:本组病例共置入242枚椎弓根螺钉,胸椎128枚,腰椎114枚,平均每例患者置入5.8枚螺钉。螺钉完全在椎弓根内208枚,占86.0%。破壁34枚(占14.0%),其中不良置钉18枚(占7.4%),18枚中有5枚穿破外壁,8枚穿破内壁,5枚穿破椎体前缘。形态异常椎和凹侧的椎弓根螺钉的破壁率较高(分别为24.1%和17.9%)。术中一枚螺钉拔出,未出现其他螺钉置入相关并发症。穿破椎体前缘螺钉距离主动脉距离平均2.3mm。结论:10岁及以下儿童椎弓根螺钉的徒手置入有较高的精确性和安全性,但在发育不良椎体及凹侧置钉时应谨慎。     

漏斗技术结合探针技术置入胸椎椎弓根螺钉在脊椎畸形矫形术中的应用

目的 探讨应用漏斗技术结合探针技术置入胸椎椎弓根螺钉在脊椎畸形矫形术中的实用性和安全性。方法 12例脊椎畸形患者接受了后路矫形固定术,在手术矫形过程中,胸椎椎弓根螺钉的置入均采用“漏斗技术结合探针技术”,记录术中和术后并发症;术后常规复查X线片和CT,记录穿出骨皮质螺钉数目及距离。结果 采用“漏斗技术结合探针技术”共置入胸椎椎弓根螺钉129枚,术后复查CT见129枚螺钉中2枚穿透椎弓根内侧壁,3枚螺钉穿破外侧壁;1枚螺钉穿透椎体前壁。Heary分级,其置钉准确性达96.12%。结论 在脊椎畸形矫形术中,应用“漏斗技术结合探针技术”置入胸椎椎弓根螺钉的方法是实用的、安全的。     

后路半椎体切除椎弓根螺钉内固定治疗小儿先天性脊柱畸形

目的评价后路半椎体切除、椎弓根螺钉内固定治疗小儿先天性脊柱畸形的临床疗效.方法2003年6月～2005年6月应用后路半椎体切除、椎弓根螺钉内固定和自体骨短节段植骨融合治疗28例小儿先天性脊柱侧凸畸形患者,男10例,女18例,年龄1.6～7岁,平均3.8岁.完全分节半椎体24例,半椎体伴对侧分节障碍4例.术后定期复查脊柱X线片,观察脊柱融合、畸形矫正率及内固定稳定情况.结果术中发生胸膜损伤和脑脊液漏各1例,分别经胸腔和伤口引流痊愈;术后切口浅表感染1例,经抗炎和换药处理治愈;无神经系统损伤.随访23～48个月,平均35个月,术前主弯冠状面Cobb角平均为35.2°±2.2°,术后为5.2°±1.2°,末次随访为7.4°±1.1°,丢失2.2°;后凸角平均为26.2°±3.1°,术后为4.2°±0.8°,末次随访为4.8°±1.0°,丢失0.6°;均获得良好骨融合,融合时间3～6个月,平均4.2个月;无内固定失败及假关节形成.结论后路半椎体切除、椎弓根螺钉内固定植骨融合能安全有效地矫正小儿先天性脊柱侧凸畸形,并能达到稳定的短节段内固定及优良的融合效果.     

胸椎椎弓根髓腔内径CT分型在严重僵硬性脊柱畸形矫形中的临床意义

目的探讨基于胸椎椎弓根髓腔内径CT分型在对严重僵硬性脊柱畸形行经后路全脊椎切除术(posterior vertebral column resection,PVCR)矫形徒手植钉中的临床意义。方法 2004年10月-2010年7月对56例严重僵硬性脊柱畸形患者一期行PVCR矫形,T2～12共植入1 098枚椎弓根螺钉。于CT片测量胸椎椎弓根髓腔内径,并划分为4个区间:区间1(0～1.0 mm),区间2(1.1～2.0 mm),区间3(2.1～3.0 mm),区间4(3.1 mm);对各区间椎弓根螺钉植钉成功率进行统计学分析。根据结果将无统计学意义的区间合并,再次行统计学分析。根据Lenke的椎弓根形态学分型,行各型植钉成功率统计学分析。结果 1 098枚胸椎椎弓根螺钉中,826枚(75.23%)植钉成功。根据髓腔内径分区,除区间3与区间4椎弓根植钉成功率比较差异无统计学意义(χ2=2.540,P=0.111)外,其余各组间比较差异均有统计学意义(P0.008)。区间3、4合并后,区间1、2、3植钉成功率分别为35.05%、65.34%、88.32%,两两比较差异均有统计学意义(P0.017)。根据Lenke的椎弓根形态学分型,A、B、C、D型植钉成功率分别为82.31%、83.40%、80.00%、30.28%,D型植钉成功率显著低于其余各型(P0.008),其余各型间差异均无统计学意义(P0.008)。基于胸椎椎弓根髓腔内径CT分型标准,Ⅰ型椎弓根占总数的17.67%,凹、凸侧椎弓根分别为24.59%、10.75%;Ⅱa型占总数的16.03%,凹、凸侧分别为21.13%、10.93%;Ⅱb型占总数的66.30%,凹、凸侧分别为54.28%、78.32%。各型凹、凸侧分布比较差异均有统计学意义(P0.001)。结论基于胸椎椎弓根髓腔内径提出了量化分型标准,Ⅰ型为无髓腔型,椎弓根内径0～1.0 mm;Ⅱ型为有髓腔型,其中Ⅱa型椎弓根内径为1.1～2.0 mm,Ⅱb型2.1 mm。该分型标准可在行PVCR时指导徒手植入胸椎椎弓根螺钉,但其有效性需进一步临床观察验证。     

O型臂联合CT三维导航系统辅助颈椎椎弓根螺钉置入的准确性研究

目的:探讨O型臂联合CT三维导航系统辅助颈椎椎弓根螺钉置钉的准确性,并与侧块螺钉置钉进行比较.方法:回顾性分析2017年3月～2021年2月在我院分别使用O型臂联合CT三维导航系统辅助置入椎弓根螺钉与徒手置入侧块螺钉行颈椎后路内固定术的54例患者,其中男44例,女10例,年龄42～79岁(58.3±9.3岁).根据置钉...     

多节段椎弓根螺钉内固定系统矫正胸椎侧凸畸形的有效性和安全性评价

目的:评价多节段椎弓根螺钉内固定系统矫正胸椎侧凸畸形的有效性和安全性。方法:回顾我院1994年3月～2002年3月应用椎弓根钉-棒系统矫治的118例胸椎侧凸畸形患者的临床资料,分析评价其手术并发症、侧凸矫正率及长期随访结果。结果:胸椎椎弓根总计置入螺钉916枚,术中及术后螺钉松动16枚;螺钉位置不良12枚;椎弓根骨折7例;脑脊液漏3例;1例术后螺钉松动压迫脊髓。术后平均随访5年,脊柱侧凸畸形平均矫正率为75%,平均矫正度丢失率1.2%,1例出现交界性后凸再次手术治疗。结论:多节段椎弓根螺钉内固定系统是矫正脊柱侧凸畸形一种较安全、有效的三维内固定方式。     

Iliac crest orientation and geometry in able-bodied and non-treated adolescent idiopathic scoliosis girls with moderate and severe spinal deformity

Purpose

To identify pelvic rotation and/or distortion in able-bodied and untreated AIS girls with moderate and severe scoliosis and verify association of pelvic morphological changes with Cobb angle increase.

Methods

The 3D coordinates of nine anatomic bony landmarks were identified to estimate pelvic orientation using a Flock of Birds system. The distances between the first sacral vertebral body (S1) and each of the eight iliac spine landmarks in all three planes were calculated to identify pelvic distortion. Analysis of variance was used to assess pelvic orientation and determine pelvic distortion. Pearson coefficients of correlation were used to identify any relationships between Cobb angle and pelvic morphological parameters.

Results

Pelvic orientation was similar in able-bodied and scoliotic girls regardless of the severity of the spinal deformity. Significant differences were observed in pelvic morphology between AIS with severe untreated scoliosis and those with a moderate scoliosis for the right anterosuperior iliac spines (ASIS), the tip of the superior iliac crest (TSIC) and the widest tip of the iliac crest (WTIC) widths from S1. Statistically significant correlations were observed between the Cobb angles and the iliac crest distances measured from S1.

Conclusions

Differences in iliac spine geometries occurred in the transverse plane correlating to Cobb angles which suggest altered bone growth in AIS girls. Such findings could indicate right thoracic spinal deformity as a result of pelvic torsion.

     

超声骨动力椎弓根寻路器的研制及其引导置钉的可行性研究

目的:探讨自行研制的超声骨动力椎弓根寻路器辅助椎弓根螺钉置入的准确度及安全性.方法:自行研制一种超声骨动力椎弓根寻路器,选择2具成年人脊柱标本(T1～L5节段),男性1具,年龄62岁,女性1具,年龄57岁,排除畸形、外伤及骨质疏松症等骨科疾病,将标本左侧椎弓根设置为实验组,通过超声骨动力椎弓根寻路器引导下置钉;右侧椎弓...     

Two-level pedicle subtraction osteotomy for severe thoracolumbar kyphotic deformity in ankylosing spondylitis

Study design

A retrospective clinical study.

Objective

To evaluate the outcomes of two-level (T12 and L3) pedicle subtraction osteotomy (PSO) for severe thoracolumbar kyphosis in ankylosing spondylitis (AS), and to discuss the surgical strategies of this surgery.

Background

Cases were limited on the results of two-level PSO for correction of severe kyphosis caused by AS, nor on surgical strategies of this type of surgery.

Methods

From March 2006 to December 2010, nine consecutive AS patients with severe kyphotic deformity, underwent T12 and L3 PSOs. Chin-brow vertical angle (CBVA) and radiographic assessments which contain thoracic kyphosis (TK), lumbar lordosis (LL), global kyphosis (GK), and sagittal vertical axis were carefully recorded pre and postoperatively to evaluate the sagittal balance. Intra and postoperative complications were also registered. All patients were asked to fill out Oswestry Disability Index before surgery and at the last follow-up visit.

Results

All nine patients (8M/1F), averaged 41.4 years old (range 35–51 years), were received two-level (T12 and L3) PSO, and were followed up after surgery for a mean of 39.9 months (range 24–68 months). Good cosmetic results were achieved in all patients. Mean correction at two-level PSO was 67.9 ± 5.5°. All CBVA, TK, LL, and GK were changed significantly after surgery (P < 0.05), the mean amount of correction of which were 59.5 ± 13.8, 34.7 ± 3.8, 33.2 ± 2.4, and 54.0 ± 14.8 degrees, respectively, and with a small loss of correction at the last follow-up visit. Sagittal imbalance was significantly improved from 27.3 ± 4.4 to 3.4 ± 0.7 cm postoperatively. Neither mortalities nor any major neurological complications were found. The mean ODI score was significantly improved from 53.4 ± 15.5 before surgery to 8.2 ± 4.7 at the last visit.

Conclusion

The outcomes of follow-up showed that two-level (T12 and L3) PSO can effectively and safely correct severe thoracolumbar kyphosis in AS.