颈椎曲率指数(Ishihara法)与颈椎(C2-7)夹角的关系

目的　探讨颈椎曲率指数 (Ishihara法 )与颈椎 (C2 - 7)夹角的关系。方法　随机选择 6 3例颈椎病患者的颈椎侧位 X线片 ,测量颈椎曲率指数和颈椎 (C2 - 7)夹角。结果　颈椎曲率指数 (Ishihara法 )平均为 10 .1(SD,11.6 ) ,颈椎(C2 - 7)夹角平均为 17.5 (SD,13.5 ) ,两种方法明显相关 (P<0 .0 1)。结论　颈椎曲率指数 (Ishihara法 )与颈椎 (C2 - 7)夹角呈显著相关。     

Single-stage Anterior and Posterior Fusion Surgery for Correction of Cervical Kyphotic Deformity Using Intervertebral Cages and Cervical Lateral Mass Screws: Postoperative Changes in Total Spine Sagittal Alignment in Three Cases with a Minimum Follow-up of Five Years

The surgical treatment of cervical kyphotic deformity remains challenging. As a surgical method that is safer and avoids major complications, the authors present a procedure of single-stage anterior and posterior fusion to correct cervical kyphosis using anterior interbody fusion cages without plating, as illustrated by three consecutive cases. Case 1 was a 78-year-old woman who presented with a dropped head caused by degeneration of her cervical spine. Case 2 was a 54-year-old woman with athetoid cerebral palsy. She presented with cervical myelopathy and cervical kyphosis. Case 3 was a 71-year-old woman with cervical kyphotic deformity following a laminectomy. All three patients underwent anterior release and interbody fusion with cages and posterior fusion with cervical lateral mass screw (LMS) fixation. Postoperative radiographs showed that correction of kyphosis was 39° in case 1, 43° in case 2, and 39° in case 3. In all three cases, improvement of symptoms was established without major perioperative complications, solid fusion was achieved, and no loss of correction was observed at a minimum follow-up of 61 months. We also report that preoperative total spine sagittal malalignment was improved after corrective surgery for cervical kyphosis and was maintained at the latest follow-up in all three cases. The combination of anterior fusion cages and LMS is considered a safe and effective procedure in cases of severe cervical kyphotic deformity. Preoperative total spine sagittal malalignment improved, accompanied by correction of cervical kyphosis, and was maintained at last follow-up in all three cases.     

青少年特发性脊柱侧凸患者上颈椎序列变化特点及各参数间的相关性

目的:测量青少年特发性脊柱侧凸(adolescent idiopathic scoliosis,AIS)患者上颈椎序列参数,探讨各参数间的相关关系及其在维持前视平衡中所起的作用。方法:回顾性分析2014年1月~2016年1月期间就诊的196例AIS患者,排除其中资料不全者、接受过治疗者、患有影响脊柱序列疾病者以及上胸段脊柱侧凸累及颈段者,共有103例患者纳入研究,其中男26例,女77例,年龄10~17岁(14.66±2.31岁)。在脊柱侧位X线片上测量颈椎Cobb角(cervical Cobb angle,CCA)、C0-C2角(occiput-C2 angle)、C1-C2角(C1-C2 angle)、硬腭-C2角(palatum-C2 angle)、C2椎体轮廓线(C2 vertebra contour angle)、C1-C7矢状面轴向距离(C1-C7 SVA)、T2倾斜角(T2 sagittal tilt)。根据Lenke胸椎修正分型(修正+、修正N、修正-)将患者分为(+)、N、(-)3组,比较各组间参数的差异性以及各参数间的相关性。结果:颈椎Cobb角10.29°±8.65°;C0-C2角13.86°±8.33°;C1-C2角25.61°±9.17°;硬腭-C2角12.06°±8.91°;C2椎体轮廓线98.43°±6.75°;C1-C7矢状面轴向距离28.41±10.69mm;T2倾斜角10.73°±8.11°。在Lenke胸椎修正分组中颈椎Cobb角及T2倾斜角在各组间有统计学差异(P0.05)。C0-C2角、C1-C2角、C1-C7矢状面轴向距离、硬腭-C2角相互之间有显著性正相关(P0.01)。结论:AIS患者的T2倾斜角很大程度上受到T5~T12后凸的影响。当AIS患者的颈椎在矢状位发生位移减少时,机体可通过减小C1-C2角来维持前视平衡。     

Endplate abnormalities,Modic changes and their relationship to alignment parameters and surgical outcomes in the cervical spine

Modic changes (MC) and endplate abnormalities (EA) have been shown to impact preoperative symptoms and outcomes following spinal surgery. However, little is known about how these phenotypes impact cervical alignment. This study aimed to evaluate the impact that these phenotypes have on preoperative, postoperative, and changes in cervical alignment in patients undergoing anterior cervical discectomy and fusion (ACDF). We performed a retrospective study of prospectively collected data of ACDF patients at a single institution. Preoperative magnetic resonance imagings (MRIs) were used to assess for the MC and EA. Patients were subdivided into four groups: MC-only, EA-only, the combined Modic-Endplate-Complex (MEC), and patients without either phenotype. Pre and postoperative MRIs were used to assess alignment parameters. Associations with imaging phenotypes and alignment parameters were assessed, and statistical significance was set at p < 0.5. A total of 512 patients were included, with 84 MC-only patients, 166 EA-only patients, and 71 patients with MEC. Preoperative MC (p = 0.031) and the MEC (p = 0.039) had significantly lower preoperative T1 slope compared to controls. Lower preoperative T1 slope was a risk factor for MC (p = 0.020) and MEC (p = 0.029) and presence of MC (Type II) and the MEC (Type III) was predictive of lower preoperative T1 slope. There were no differences in postoperative alignment measures or patient reported outcome measures. MC and endplate pathologies such as the MEC appear to be associated with worse cervical alignment at baseline relative to patients without these phenotypes. Poor alignment may be an adaptive response to these degenerative findings or may be a risk factor for their development.     

单节段颈前路椎间融合术后ROI-C融合器沉降的相关因素分析

目的 :分析采用ROI-C行颈前路单节段椎间盘切除减压融合(anterior cervical discectomy and fusion,ACDF)术后融合器沉降的相关因素。方法:回顾总结采用ROI-C行单节段ACDF治疗颈椎间盘退变性疾病的83例患者资料。记录患者年龄、性别、手术节段、吸烟史及骨密度检查结果。在术前颈椎侧位X线片上测量颈椎整体曲度(cervical alignment,CA)、融合节段角度(segmental angle,SA)、椎间隙前高度(anterior disc height,ADH)和椎间隙后高度(posterior disc height,PDH)。将随访的中立位颈椎侧位X线片与术后即刻比较,ADH或PDH丢失2mm判定为融合器沉降,分入沉降(subsidence)组(S组,22例),并记录沉降的部位;≤2mm分入未沉降(nonsubsidence)组(N组,61例)。应用独立样本t检验、χ~2检验对以上参数行组间比较,采用多变量Logistic回归分析单节段ACDF术后ROI-C沉降的危险因素。将危险因素进一步分组使用χ~2检验计算似然比(likelihood ratio,LR)进行评价。结果 :单节段ACDF术后ROI-C沉降发生率为26.5%(22/83),其中陷入椎体前方终板者占63.6%(14/22)。S组、N组年龄分别为59.86±12.11岁、52.77±10.34岁,差异有统计学意义(P=0.010);性别、吸烟史、手术节段和骨密度均无统计学差异(P0.05)。S组术前的CA、SA、ADH分别为-0.800°±5.637°、0.432°±2.162°和3.768±1.210mm,N组分别为4.893°±5.718°、1.198°±1.826°和5.066±1.257mm,两组比较差异有统计学意义(P0.001,P=0.031和P0.001),两组的PDH差异无统计学意义(P=0.092)。多变量Logistic回归分析显示术前CA和年龄是ROI-C沉降的危险因素(P=0.014和P=0.038)。根据术前CA情况将患者分为术前CA后凸(CA0°)和前凸(CA≥0°)组,根据术前年龄将患者分为60岁和≥60岁组,χ~2检验显示术前CA后凸和60岁以上病例ROI-C沉降概率分别比前凸和60岁以下病例高12.5倍和4.5倍(LR=12.529,P0.001;LR=4.454,P=0.030)。结论 :术前CA后凸和年龄60岁以上是单节段ACDF术后ROI-C沉降的危险因素。选择ROI-C行单节段ACDF治疗颈椎间盘退变性疾病时应考虑这两项因素的影响。     

C2–C3 vertebral disc angle: An analysis of patients with and without cervical spondylotic myelopathy

Study designRetrospective analysis.ObjectiveTo define C2–C3 vertebral disc angle (VDA) in patients with and without cervical spondylotic myelopathy.Summary of background dataC2–C3 VDA is a new radiological index of cervical spine alignment. Recent studies have suggested that high postoperative values are associated with greater mechanical complications in patients with cervical spondylotic myelopathy. However, normative values for patients without myelopathy has yet to be defined.MethodsPatients with and without cervical myelopathy between 2017 and 2019 were included. Inclusion criteria were patients above 18 years of age with antero-posterior (AP) and lateral (LAT) cervical X-rays. In the non-myelopathic group, patients were excluded if they had neurological symptoms or deficits, presence of cervical axial pain, previous spinal surgery, or diagnosis of either spondylolisthesis or scoliosis. In the myelopathic group, patients were excluded if they had previous spinal surgery. Radiological indices evaluated include: C2–C3 disc angle, C2–C7 Cobb angle, C7 sagittal vertical axis, T1 slope.ResultsIn total, 99 patients without myelopathy and 22 patients with myelopathy were identified and analyzed. In patients without myelopathy, the mean for C2–C3 VDA was 25.9 ± 7.9. For patients with myelopathy, preoperative values were 24.4 ± 10.0 and 27.1 ± 7.9 postoperatively. No statistically significant differences were found between patients with and without myelopathy. C2–C3 disc angle was not correlated with age (R = −0.173).ConclusionThis study did not find statistically significant differences in C2–C3 VDA values between patients with and without cervical myelopathy. This study provides normative data for C2–C3 vertebral disc angle in patients with and without cervical spondylotic myelopathy. Furthermore, C2–C3 vertebral disc angle may be independent from age.     

保留颈半棘肌肌止的椎板成形术的临床应用

[目的]研究确定行颈椎单开门椎板成形术时完整保留C2颈半棘肌肌止是否能有效维持颈椎术后矢状序列,降低术后颈椎轴性症状的发生。[方法]2002年3月～2003年12月,本院行保留颈半棘肌肌止的椎板成形术48例,其中32例获得至少2a的随访列为试验组,对患者术前、术后的JOA评分、颈椎轴性症状严重程度、颈椎曲度指数、颈椎活动度进行比较评估。[结果]本组患者术前、术后JOA评分分别为(9.0±2.9)和(12.5±3.1),恢复率(44.9±26.9)。手术前、后有明显症状颈椎轴性症状的患者比例分别为46.8%和18.7%,差别有统计学意义(P<0.05)。手术前后患者颈屈指数、颈椎活动范围等指标无统计学意义差别。[结论]保留颈半棘肌肌止的椎板成形术可以减少对颈椎后伸机理的破坏,有效维持术后颈椎矢状序列减少轴性症状的发生。     

单节段椎间盘切除联合ROI-C植入术后颈椎弧度改变对疗效的影响

目的 分析颈前路采用零切迹颈椎融合器（ROI-C）行单节段椎间盘切除减压融合术（anterior cervical discectomy and fusion, ACDF）术后颈椎整体弧度（global cervical alignment, GCA）改变对疗效的影响。方法 回顾性分析我院于2012年1月至2014年5月使用ROI-C行单节段ACDF治疗颈椎间盘退变性疾病病人82例,其中男48例,女34例,年龄为35~81岁,平均55.3岁。末次随访的颈椎侧位X线片与术前比较：①维持组,GCA手术前后均为前凸者;②矫正组,术前GCA后凸、术后矫正为前凸者;③后凸组,手术前后均后凸者。记录术前和末次随访的颈部、手臂疼痛视觉模拟量表（neck/arm pain visual anologue scales, NVAS/AVAS）评分和颈部功能障碍指数（neck disability index, NDI）。结果 2012年3月至2016年12月对病人进行术后随访,随访时间为21~39个月,平均25.6个月。维持组46例,矫正组17例,后凸组19例,三组病例年龄分布存在差异（F_组间=4.593,P=0.014）;三组病人性别和手术节段之间比较,差异均无统计学意义（均P＞0.05）。术后GCA后凸发生率为23.17%（19/82）。术前三组间NVAS、AVAS和NDI各指标单变量方差分析,差异均无统计学意义（均P＞0.05）。三组末次随访的NVAS、AVAS和NDI与各组术前比较,差异均具有统计学意义（均P＜0.05）。三组之间AVAS术后改善情况比较,差异没有统计学意义（F_组间=0.580,P=0.562）;而改善程度△NVAS和△NDI的比较,差异均有统计学意义（均P＜0.05）。使用Dunnett-t检验行两两比较显示,矫正组的改善程度△NVAS和△NDI优于维持组和后凸组,差异均有统计学意义（均P＜0.05）。结论 采用ROI-C行单节段ACDF治疗颈椎退变性疾病,颈椎弧度由术前后凸矫正为前凸可获更多的NVAS和NDI改善,说明恢复和维持生理性前凸的GCA是取得最优疗效的重要因素;但术前存在GCA后凸的部分病例术后仍有颈椎后凸的影像学表现,因此治疗伴有GCA后凸的病例时,术者应谨慎确定融合固定的方式。     

Cage subsidence does not, but cervical lordosis improvement does affect the long-term results of anterior cervical fusion with stand-alone cage for degenerative cervical disc disease: a retrospective study

Objective

Clinical outcomes of the stand-alone cage have been encouraging when used in anterior cervical discectomy and fusion (ACDF), but concerns remain regarding its complications, especially cage subsidence. This retrospective study was undertaken to investigate the long-term radiological and clinical outcomes of the stand-alone titanium cage and to evaluate the incidence of cage subsidence in relation to the clinical outcome in the surgical treatment of degenerative cervical disc disease.

Methods

A total of 57 consecutive patients (68 levels) who underwent ACDF using a titanium box cage for the treatment of cervical radiculopathy and/or myelopathy were reviewed for the radiological and clinical outcomes. They were followed for at least 5 years. Radiographs were obtained before and after surgery, 3 months postoperatively, and at the final follow-up to determine the presence of fusion and cage subsidence. The Cobb angle of C2–C7 and the vertebral bodies adjacent to the treated disc were measured to evaluate the cervical sagittal alignment and local lordosis. The disc height was measured as well. The clinical outcomes were evaluated using the Japanese Orthopaedic Association (JOA) score for cervical myelopathy, before and after surgery, and at the final follow-up. The recovery rate of JOA score was also calculated. The Visual Analogue Scale (VAS) score of neck and radicular pain were evaluated as well. The fusion rate was 95.6% (65/68) 3 months after surgery.

Results

Successful bone fusion was achieved in all patients at the final follow-up. Cage subsidence occurred in 13 cages (19.1%) at 3-month follow-up; however, there was no relation between fusion and cage subsidence. Cervical and local lordosis improved after surgery, with the improvement preserved at the final follow-up. The preoperative disc height of both subsidence and non-subsidence patients was similar; however, postoperative posterior disc height (PDH) of subsidence group was significantly greater than of non-subsidence group. Significant improvement of the JOA score was noted immediately after surgery and at the final follow-up. There was no significant difference of the recovery rate of JOA score between subsidence and non-subsidence groups. The recovery rate of JOA score was significantly related to the improvement of the C2–C7 Cobb angle. The VAS score regarding neck and radicular pain was significantly improved after surgery and at the final follow-up. There was no significant difference of the neck and radicular pain between both subsidence and non-subsidence groups.

Conclusions

The results suggest that the clinical and radiological outcomes of the stand-alone titanium box cage for the surgical treatment of one- or two-level degenerative cervical disc disease are satisfactory. Cage subsidence does not exert significant impact upon the long-term clinical outcome although it is common for the stand-alone cages. The cervical lordosis may be more important for the long-term clinical outcome than cage subsidence     

全膝关节置换术中下肢对线方式的研究进展

膝骨关节炎已成为当今老年人常见疾病之一,目前,对于终末期膝骨关节炎,行全膝关节置换术(total knee arthroplasty,TKA)是最为有效的治疗手段。在TKA中,下肢力线的有效恢复则是手术成功的关键因素之一,极大影响患者术后的临床效果及假体存活率。最早被提出、认可并被广泛应用于TKA的对线方式是机械对线。近年来,随着对下肢力线的深入研究及计算机技术的迅速发展,TKA对线技术实现了由“统一化”向“个性化”,二维向三维的转变,调整机械对线、解剖学对线、运动学对线、反向运动学对线、限制运动学对线及功能学对线等新的对线方式被相继提出,为外科医师提供了更多选择。但对于何种对线方式是最佳选择,目前尚未有定论。本文对目前TKA中各种对线方式的研究现状及优缺点进行总结阐述,旨在为临床上TKA中对线方式的选择提供一定参考。     

微创膝关节单髁置换术股骨髓内定位与髓外定位假体位置的影像学比较

[目的]通过对膝关节单髁置换术股骨假体的力线测量,评价股骨髓外定位法指导假体放置的有效性.[方法]回顾性分析2007年5月～2010年5月采用微创单髁置换术治疗膝关节内侧间室骨性关节炎的患者73例(80膝),其中股骨髓内定位组(intramedullary alignment guide,IM) 54例(56膝),男23例(23膝),女31例(33膝);股骨髓外定位组(extramedullary alignment guide,EM)19例(24膝),男9例(10膝),女10例(14膝).测量术后即刻股骨假体内翻/外翻和屈/伸力线.[结果]IM组股骨假体内翻/外翻力线为0.59°内翻±3.98°,EM组股骨假体力线平均为0.81°外翻±3.30°,P=0.235 2.IM组股骨假体屈/伸力线为0.70°伸直±3.89°,EM组股骨假体力线为1.12°伸直±3.43°,P=0.564 3.[结论]微创膝关节单髁置换术股骨髓内定位可取得与髓外定位法相同优良的股骨假体力线.     

A Comparison of Classical and Anatomical Total Knee Alignment Methods in Robotic Total Knee Arthroplasty : Classical and Anatomical Knee Alignment Methods in TKA

The purpose of this study was to compare the clinical and radiological outcomes achieved using classical and anatomical alignment methods in primary total knee arthroplasty (TKA). One hundred and seventeen patients were randomly assigned to undergo robotic-assisted TKA using either the classical (56 patients) or the anatomical alignment method (61 patients). Clinical outcomes including varus and valgus laxities, ROM, HSS and WOMAC scores and radiological outcomes were evaluated after a minimum follow-up of 2 years. Varus and valgus laxity assessments showed no significant inter-group differences (P > 0.05). Moreover, no significant differences were observed in ROM, HSS and WOMAC scores (P > 0.05). We could not find any significant difference in mechanical alignment of the lower limb. The results of this study show that two alignment methods provide comparable clinical and radiological outcomes after primary TKA.     

Radiographic measurements on hindfoot alignment view in 1128 asymptomatic subjects

BackgroundThe primary aim of this study was to determine the mean values for three of the most common parameters measured to assess hindfoot alignment in asymptomatic subjects: hindfoot alignment angle (HAA), hindfoot alignment ratio (HAR), and hindfoot moment arm (HMA). The secondary aim was to evaluate the mean value of each parameter according to age and sex.MethodsWe assessed 1128 asymptomatic subjects from January 2014 to June 2019. HAA, HAR and HMA were measured to evaluate the degree of hindfoot varus or valgus deviation on the hindfoot alignment view, described by Saltzman and el-Khoury. All subjects were divided into subgroups according to sex and age (<45 years versus ≥45 years).ResultsThe overall mean HAA, HAR, and HMA were –4.07 ± 3.48°, 0.21 ± 0.15, and –6.12 ± 5.22 mm, respectively. Female subjects ≥45 years old had the largest valgus deviation (HAA, –7.08 ± 6.34°; HAR 0.09 ± 0.25; HMA, –10.58 ± 11.46 mm).ConclusionsHAA, HAR, and HMA evaluation revealed that asymptomatic subjects had a hindfoot alignment with valgus deviation. Furthermore, the degree of valgus deviation was the largest in female subjects aged ≥45 years. We hope that the results of our study will be helpful to inform other researchers about the usefulness of these parameters as references.     

颈前路减压植骨融合内固定术在治疗颈性眩晕中的作用

目的 探讨分析颈前路减压植骨融合内固定术在治疗颈性眩晕中的作用及其作用机制.方法 回顾分析了1998～2005年本治疗组采用颈前路减压植骨融合内固定术所治疗的伴有颈性眩晕的颈椎病患者32例.观察比较术前、术后颈椎正侧位及动力位X片和症状改善情况,并进一步通过颈性眩晕症状和功能评分法对患者术前及术后进行评定.结果 所有患者术前X片上都有不同程度的颈椎不稳或椎间盘突出现象,单节段不稳者9例,两节段者13例,三节段者7例.单节段椎间盘突出者10例,两节段者15例,三节段者7例.所有患者行颈前路减压植骨融合内固定术后获10～48个月的随访,平均26个月,术后有效率为87.5%,症状和功能评分分值有明显提高(均数由术前13.89提升到术后23.98),具有统计学意义(＜0.05),结论 颈前路减压植骨内固定术在治疗伴有颈性眩晕颈椎病中对颈性眩晕症状具有良好改善作用.     

Posterior stabilization of the lower cervical spine with lateral mass plates and screws

Posterior cervical fixation using lateral mass plates and screws is becoming increasingly used and accepted.Advantages include increased rigidity, ability to be used in cases where the lamina or spinous processes are deficient or missing, use across the occipito-cervical or cervico-thoracic junction, and need for less postoperative bracing. Safe placement of lateral mass screws requires complete exposure and identification of the boundaries of the lateral masses. The starting point for screw placement is 1 to 2 mm medial to the center of lateral mass. The screws are angulated outward 10 to 20 degrees and cranially 20 to 30 degrees to be parallel to the facet joints. An adjustable drill guide facilitates safe drilling and tapping techniques. All 102 patients with unstable cervical spines treated with AO reconstruction plates and autogenous bone graft had healed fusions based on flexion-extension radiographs. The reductions achieved postoperatively were maintained at follow-up. Two patients had transient radiculopathies secondary to screw placement. The indications for lateral mass fixation include cases where the lamina or spinal processes are deficient or missing, multilevel or rotational instabilities, when extension to the thoracic spine or occiput is required or when decreased bracing is beneficial.     

Posterior cervical plate-screw fixation

Posterior cervical plate-screw fixation is a safe, effective, and versatile fixation technique. It offers clear advantagesover other posterior cervical fixation techniques in the treatment of traumatic, neoplastic, or degenerative disorders in which the spinous processes, laminae, or facets are fractured, deficient, or absent. Because the occiput, C2 pedicles, C3-C7 lateral masses, C6-T4 pedicles, and T1-T4 transverse processes represent potential sites for screw fixation, it is particularly useful when fixation across multiple levels or across the occipitocervical or cervicothoracic junction is required. Familiarity with the bony anatomy of the potential sites for screw fixation and the relationship of this anatomy to the anatomy of adjacent neural and vascular structures is essential for safe, biomechanically effective fixation. With careful preoperative planning and meticulous performance of the surgical procedure, arthrodesis rates of approximately 90% to 100% without substantial loss of alignment may be expected. The small but finite incidence of clinically significant screw malposition (approximately 0.8%/screw) even in the hands of surgeons familiar with the technique suggests that its use should not supplant the use of posterior cervical wire techniques unless a specific indication for its use exists.     

Neutral mechanical alignment: Stickin’ with the one that brung ya- Affirms

Restoring the overall mechanical alignment to neutral has been the gold standard in total knee arthroplasty since the 1970s. Recently, there has been renewed interest in alternative alignment goals that place implants in a more “physiologic” position with the hope of improving clinical outcomes. However, placing components outside of the classic “safe zone” of ± 3° is controversial, as studies have shown increased risk of mechanical failure, especially in obese patient populations. This paper will outline mechanical and kinematic alignment and present the evidence for why mechanical alignment is still the gold standard in total knee arthroplasty.     

Weightbearing CT in normal hindfoot alignment — Presence of a constitutional valgus?

Background

The normal hindfoot angle is estimated between 2° and 6° of valgus in the general population. These results are solely based on clinical findings and plain radiographs. The purpose of this study is to assess the hindfoot alignment using weightbear CT.