手术治疗胸腰段椎间盘突出症5例报告

胸腰段椎间盘突出症是临床较少见的一种病症,作者在多年的临床实践中确诊5例病人,均行侧前方入路椎间盘切除、肋骨植骨、V en trofix内固定,效果较好,汇报如下。1临床资料1.1一般资料我科自1997~2002年间手术治疗胸腰段椎间盘突出症5例,其中男4例,女1例;年龄在35~59岁,平均47岁     

胸腰段椎间盘突出症的手术治疗及入路选择

目的：探讨胸腰段椎间盘突出症手术治疗的入路选择.方法：对我院1992～2000年间接受手术治疗并获得随访的38例胸腰段椎间盘突出症患者的临床资料进行回顾性分析.男27例,女11例;年龄20～65岁,病程3个月～11年.侧前方入路行椎间盘切除术30例,15例同时行内固定;侧后方肋骨横突切除入路行椎间盘切除术5例;后方椎板切除入路行椎间盘切除术3例.结果：侧前方入路组术野直视、显露清晰、便于操作,无神经系统并发症发生,术中发生胸膜破裂2例,腹膜破裂1例,硬脊膜破裂2例;术后发生胸腔积液2例,气胸1例,肺炎1例,脑脊液漏1例.经相应处理后获得治愈.侧后方肋骨横突切除入路难以直视硬膜和脊髓的腹侧,显露欠佳,未发生神经系统并发症;术中发生胸膜破裂2例,经修补术后未出现肺部并发症.后方椎板切除入路组手术方法相对简单,但术中难以避免对脊髓造成的牵拉损伤,2例术后发生下肢神经症状加重,至术后2周出院时1例恢复至术前水平,另1例加重的症状无明显缓解.术后平均随访5.8年（4～12年）,疗效参照Macnab法和Otani法评定,优17例（44.7%）,良15例（39.5%）,可5例（13.1%）,差1例（2.7%）.结论：经侧前方入路行胸腰段椎间盘切除术术野直视、清晰,相对安全且有效,是胸腰段椎间盘突出症外科治疗的首选术式;经侧后方肋骨横突切除入路只适合于极外侧型或外侧型胸腰段椎间盘突出症;经后方椎板切除入路应视为胸腰段椎间盘突出症手术的禁忌.     

胸腰段椎间盘突出症

目的：探讨胸腰段椎间盘突出症的发病机制、临床特点及治疗方法。方法：报告35例胸腰段椎间盘突出症。T11～12 26例，T12～L1 12例，L1～2 17例。均行侧前方椎间盘切除、植骨及内固定术。结果：术后随访10～41个月，疗效优良19例，良8例，可5例，差3例。结论：胸腰段椎间盘突出症发病率低，症状不典型，临床表现复杂，容易漏诊、误诊。侧前方椎间盘切除、植骨及内固定术对脊柱的损伤及其稳定性的影响较小，操作安全，疗效可靠。     

胸腰段椎间盘突出症的诊断与治疗

目的探讨胸腰段椎间盘突出症的临床诊断和治疗方法。方法4例病人分别为T11-12、T12-L1、L1-2、L2-3椎间盘突出症,均行手术治疗,下胸段2例采用半椎板和部分肋骨头及椎弓根切除,行椎管减压及胸椎问盘切除,极高位腰椎间盘突出症患者采用椎板大部分切除,椎管减压髓核切除术。结果4例瘫痪症状明显好转,随访6月～9年,2例下胸段手术患者,恢复正常工作,但踝震挛仍轻度存在,上腰段2例患者,1例全部恢复,1例瘫痪症状在恢复中。结论瘫痪为胸腰段椎间盘突出症的首发临床症状,而腰痛及自下而上的进行性双下肢无力是其突出物渐进性压迫脊髓的表现,胸腰段MRI检查可以确诊,有症状者早期手术,可免于瘫痪。     

手术治疗胸腰段椎间盘突出症35例

胸腰段椎间盘突出症临床上较少见，临床症状及体征多变，缺乏特异性，易于造成漏诊或误诊。1998年3月至2002年6月我院共诊治此病35例，占同期椎间盘突出症的9‰，现报告如下。     

侧前方入路手术治疗胸椎间盘突出症

1992年2月～1996年4月开展经胸腔侧前方入路手术切除椎间盘治疗胸椎间盘突出症9例，经1～4年随访，效果良好。     

胸腰段椎间盘突出症（附6例临床报道）

目的：提出胸腰段椎间盘出突症概念,并探讨其诊治要点。方法：对近年来收治的6例胸腰段椎间盘突出症的临床资料进行分析。结果：6例中4例有外伤史,其临床表现多样,确诊靠MRI检查,侧后方或侧前方手术后效果良好。结论：早期诊断,及早手术是获得满意的手术效果的关键。     

Scheuermann病致胸腰段椎间盘突出症的手术治疗

目的 探讨 Scheuermann病引起胸腰段椎间盘突出症的临床特点及手术治疗.方法 手术治疗因Scheuermann病所致胸腰段椎间盘突出症共3例.均采用后路椎管减压椎间盘切除椎弓根钉内固定、椎间植骨融合术.结果 术后1例出现下肢神经症状加重,1例出现脑脊液漏,经相应处理后获得治愈.平均随访20个月,获得较好的植骨融...     

胸腰段椎间盘突出症诊断的临床研究

目的探讨胸腰段椎间盘突出症临床表现的特点与规律，提高胸腰段椎间盘突出症的诊断水平。方法回顾性分析1995年9月～2004年1月我院经X线、CT、MRI及手术证实的胸腰段椎间盘突出症65例的临床资料，并将其分为低位胸椎组（T10-T12L1）43例，高位腰椎组（L1-2-L2-3）16例，多节段突出组6例。结果躯体感觉障碍89．2％（58／65）和下肢无力83．1％（54／65）是最多见的症状。9．2％（6／65）表现为上运动神经元损害，47．7％（31／65）表现为下运动神经元损害，43．1％（28／65）表现为上、下运动神经元混合性损害。仅3例为单根神经根损害，其余表现为多根神经或马尾神经的损害。腰背痛44．6％（29／65）和下肢无力40．0％（26／65）是最常见的首发症状。低位胸椎间盘突出以混合性运动神经元损害为主，占58．1％（25／43），易导致行走障碍、足下垂、下肢肌张力升高和病理征阳性；而高位腰椎间盘突出则以下运动神经元损害为主，占93．8％（15／16），易造成腰背、下肢疼痛及马尾神经损害。结论胸腰段椎间盘突出症的症状广泛、体征多样，当临床上存在以下情况时应高度怀疑胸腰段椎间盘突出症：①大腿前方、外侧或腹股沟部位出现感觉障碍者；②下肢无力，股四头肌，胫前肌肌力减退者（如足下垂）；③下肢运动或感觉障碍范围广泛、不规则，缺乏根性分布特征者；④上、下运动神经元损害同时存在，或虽表现为下运动神经元损害，但难以用低位腰椎间盘突出症解释者。     

胸腰段椎间盘突出症的临床特点

目的：分析胸腰段椎间盘突出症不同节段病变的临床特点，为安性与定位诊断提供依据。方法：经手术证实胸腰段椎间盘突出症16例，其中T10／11 2例，T11／12 3例，T12／L1 3例，L1／2 4例，L2／3 4例。分别分析各节段病变的临床症状与体征。结果：中央或旁中央型胸腰段椎间盘突出主要引起背痛、下肢疼痛、行走功能障碍、括约肌功能障碍等症状；外侧型突出症状与体征主要表现为神经根病变。T10／11及T11／12间盘突出表现为上运动神经元受损症状；T12／L1间盘突出可表现为下运动神经元受损或上运动神经元受损症状及神经根病变；L1／2与L2／3间盘突出表现为神经根病变和（或）马尾神经受压症状。结论：各节段病变的临床表现有一定的规律，应注意非典型和特殊病例。     

经后外侧入路椎间盘摘除椎间融合术治疗胸椎间盘突出症

【摘要】 目的：评价经后外侧入路椎间盘摘除椎间融合术治疗胸椎间盘突出症的安全性和有效性。方法：2006年1月~2012年8月采用经后外侧入路椎间盘摘除椎间融合术治疗胸椎间盘突出症（TDH）患者24例,男15例,女9例,年龄37~64岁,平均45.3岁。病程4个月~2年,平均14个月。均为单节段椎间盘突出,中央型突出16例,旁中央型8例;突出为硬性18例,软性6例。突出部位：T7/8 2例,T8/9 4例,T9/10 4例,T10/11 5例,T11/12 9例。其中3例合并胸椎黄韧带骨化,4例合并胸椎后纵韧带骨化。手术前后进行JOA评分和Otani分级,并通过Bridwell标准评价骨融合情况。结果：患者均顺利完成手术,未出现神经损伤。1例切口脂肪液化延迟愈合,其余均Ⅰ期愈合。3例术中硬脊膜损伤,术中修补后2例术后未发生脑脊漏,1例发生脑脊液漏,经置管引流后治愈。24例均获随访,随访时间0.5~3.5年,平均2.1年。术后定期门诊复查。患者症状均得到不同程度改善,随访期间未见神经症状加重及脊柱不稳等情况。术前改良JOA评分为4.4±2.4分,术后3个月为8.7±2.3分,末次随访时为9.0±2.3分,术后3个月和末次随访时与术前比较差异均有统计学意义（P＜0.05）。末次随访时临床改善率为（74.6±16.6）%。根据Otani分级,优9例,良11例,可2例,差2例,优良率为83.3%。2例截瘫患者中,1例无明显恢复,1例术后半年由Frankel A级恢复至C级。术后3个月随访植骨块均达到Ⅱ级或Ⅲ级愈合,术后6个月时Ⅰ级愈合6例,其余均达Ⅱ级愈合,19例随访9个月以上的患者9个月时均达到Ⅰ级愈合。随访期内无内固定松动、断裂和节段间塌陷等。结论：采用经后外侧入路椎间盘摘除椎间融合术治疗胸椎间盘突出症可获得较好的临床效果。     

Results of hemivertebrectomy and fusion for symptomatic thoracic disc herniation

We retrospectively analysed ten consecutive patients (age range 32-77 years) treated surgically from 1994 to 1999 for symptomatic thoracic disc herniation between the 6th and 12th thoracic discs. Clinically, eight patients had varying grades of back pain and eight patients had paraparesis. Radiography showed calcification in 50% of the herniated discs. Two patients had two-level thoracic disc herniation. Hemivertebrectomy followed by discectomy and fusion was carried out in all patients. Instrumentation with cages was performed in eight patients and bone grafting alone in two patients. The average follow-up was 24 months (range 13-36 months). Six patients had an excellent or good outcome, three had a fair outcome and one had a poor outcome. One patient had atelectasis, which recovered within 2 days of surgery. Another patient had developed complete paraplegia, detected at surgery by SSEPs, and underwent resurgery following magnetic resonance (MR) scan with complete corpectomy and instrumented fusion. At 2 years, she had a functional recovery. The patient with poor outcome had undergone a previous discectomy at T9/10. He developed severe back pain and generalised hyper-reflexia following corpectomy and fusion for disc herniation at T10/11. We advocate anterior transthoracic discectomy following partial corpectomy for symptomatic thoracic disc herniation between the 6th and 12th thoracic discs. This procedure offers improved access to the thoracic disc for an instrumented fusion, which is likely to decrease the risk of iatrogenic injury to the spinal cord.     

胸椎间盘突出症的诊断和手术治疗

目的：回顾性研究３０例胸椎间盘突出症的临床表现、诊断及手术治疗效果。方法：分别对胸椎间盘突出症的临床表现、影像学特征和手术治疗方法进行描述。结果：后路全椎板切除减压５例,侧后方或侧前方入路摘除致压物１４例,后路全椎板切除侧后方入路摘除致压物１１例,术后随访１～８年,手术优良率达８３．４％,结论：胸椎侧后方或侧前方入路摘除椎间盘及后路全椎板切除侧后方入路摘除椎间盘是手术治疗胸椎间盘突出症的有效术式。     

Three-level thoracic disc herniation: Case report and review of the literature

A rare case of three-level thoracic disc herniation with associated neurological impairment, including motor, sensor and urinary disturbances, is reported. The diagnosis and localization of the level of cord compression were mainly based on the clinical examination supported by the findings of magnetic resonance imaging and somatosensory evoked potentials. An anterolateral transthoracic approach at the uppermost affected level was selected for removal of all herniated discs, with the use of a surgical microscope; the resected rib was used for intervertebral fusion. An improvement in the patient's subjective and neurological condition was already apparent a few months after the operation, and solid fusion was roentgenographically found at all operated levels. The use of a surgical microscope allows complete removal of the herniated disc while avoiding wide vertebrectomy and associated iatrogenic damage to the spinal cord.     

Surgical outcomes of posterior thoracic interbody fusion for thoracic disc herniations

Introduction

Surgical strategy for thoracic disc herniation (TDH) remains controversial. We have performed posterior thoracic interbody fusion (PTIF) by bilateral total facetectomies with pedicle screw fixation. The objectives of this retrospective study are to demonstrate the surgical outcomes of PTIF for TDH.

Materials and methods

We enrolled 11 patients who underwent PTIF for myelopathy due to TDH and were followed for at least 1 year. The mean age at surgery was 55.2 years and the average period of follow-up was 4.3 years. The levels of operation were T10–T11 in three cases, T12–L1 in three, and T2–T3, T3–T4, T9–T10, T11–T12, and T10–T12 in one case, respectively. The pre- and postoperative clinical status was evaluated according to the modified Frankel grade and the Japanese Orthopaedic Association (JOA) score modified for thoracic myelopathy. Additionally, postoperative complications were assessed. Local kyphosis at the operated segment and status of fusion were evaluated using plain radiographs and computed tomography.

Results

Improvement of at least one modified Frankel grade was observed in all but one patient. Average pre- and postoperative JOA scores were 4.9 and 8.8 points, respectively. The average recovery rate was 61 %. Bony union was observed in ten cases. One patient’s postsurgical outcome resulted in pseudoarthrosis, which required revision surgery due to kyphosis deterioration. Cerebrospinal fluid leakage was observed in one patient postoperatively with neither neurological deficit nor evidence of infection.

Conclusion

PTIF has produced satisfactory outcomes for myelopathy due to TDH. Therefore, PTIF is one of the surgical treatments of choice for patients with TDH causing myelopathy.     

经后外侧入路椎管减压椎间融合内固定术治疗胸椎间盘突出症

目的:观察经后外侧入路椎管减压椎间融合内固定术治疗胸椎间盘突出症的手术疗效。方法:选择2009年1月~2015年8月收治的47例单节段胸椎间盘突出症患者,采用椎管减压椎间融合内固定术治疗,其中经后外侧入路组26例,经侧前方入路组21例。术前两组患者的年龄、性别分布、病程、病变节段、突出类型、脊髓受压情况、临床表现、随访时间均无统计学差异(P0.05)。记录两种术式的手术时间、术中出血量和手术并发症;术前及术后3d、6个月采用疼痛视觉模拟评分(VAS)评估疼痛情况;术后6个月采用Otani分级评定其临床疗效,采用改良胸脊髓神经功能JOA评分及神经功能Frankel分级评估神经功能恢复情况,影像学测算椎管矢状径残余率评估椎管减压程度,CT薄层扫描重建评估椎间融合情况,动态X线片对固定情况进行评估。结果:经后外侧入路组的手术时间、术中出血量、切口长度和住院时间均优于经侧前方入路组,差异有统计学意义(P0.05)。经侧前方入路组术后发生胸腔积液4例、肺炎4例、脑脊液漏2例、肠麻痹5例,经后外侧入路组术后无上述并发症出现,两组并发症发生率的差异有统计学意义(P0.05)。术后6个月两组Otani分级优良率无统计学差异(P0.05)。术后3d经后外侧入路组VAS评分优于经侧前方入路组,差异有统计学意义(P0.05)。术后6个月两组患者的疼痛、神经功能及椎管有效容积均较术前明显改善,差异有统计学意义(P0.05)。术后6个月,两组间VAS评分、JOA评分、神经功能Frankel分级和椎管矢状径残余率比较均无统计学差异(P0.05),CT三维重建显示两组椎间融合率均为100%,差异无统计学意义(P0.05);动态X线片检查脊柱连续性及稳定性良好,无钉棒断裂和松动现象,椎间高度无明显丢失,椎体间cage无下陷及移位。结论:后外侧入路椎管减压椎间融合内固定术治疗胸椎间盘突出症的近期效果满意。     

复发性腰椎间盘突出症的手术治疗策略

[目的]探讨复发性腰椎间盘突出症患者的病因和手术治疗方法。[方法]回顾性分析1996年12月~2003年12月收治的获得1~5年随访的复发性腰椎间盘突出症患者74例。男41例,女33例;年龄21~53岁,平均37.2岁。初次手术术式:全椎板间盘切除术9例;半椎板间盘切除术23例;椎板间开窗间盘切除31例;间盘镜显微间盘切除术11例。初次手术至复发时为6~192个月,平均37个月。再次手术术式:5例再次行腰椎间盘切除术;69例采用椎体融合术,其中45例采用PLIF手术,23例采用TLIF手术。[结果]本组无围手术期死亡病例。出现并发症18例次,经对症处理后好转。行间盘切除术患者术后3周配戴腰围下床活动;行融合手术患者3~5d下床活动。平均随访18个月,Oswestry评分从术前(52.32±9.17)分改善至(20.33±5.72)分。73.5%的患者对手术疗效满意。[结论]复发性腰椎间盘突出症患者根据影像学和临床表现及手术史,采用相应的手术方法,充分减压,可获得较满意的临床疗效。     

扩大后外侧入路处理中央型胸腰段椎间盘突出症

目的胸腰段中央型椎间盘突出采取扩大后外侧入路去除突出及钙化的椎间盘。方法本组病例男16例,女5例,年龄21～65岁,平均43.9岁,L1-2突出为11例次,T11-12为8例次,T12-L1为5例次。均为中央型突出为主,均行扩大后外侧入路处理。结果所有病例均获得改善,随访1～3.5年,平均2年。结论扩大后外侧入路行胸腰段中央型椎间盘突出,出血少,创伤小,对脊髓影响小,能达到完全减压的目的。     

Abdominal wall pseudohernia - One secondary to a thoracic extraforaminal disc herniation and other due to thoracic paracentral disc protrusion

An abdominal wall pseudohernia is a rare clinical entity which consists of an abnormal bulging of the abdominal wall that can resemble a true hernia, but without an associated underlying fascial or muscle defect. It is caused by segmental neuropathy and subsequent denervation of abdominal wall musculature. We present two cases of an abdominal wall pseudohernia. One secondary to a thoracic extraforaminal disc herniation in a 57-year-old male, which, as far as the authors are aware, has not been described previously. The other in a 67 year old male due to right foraminal and paracentral disc protrusion at T9/10.