后侧半椎体切除治疗先天性角状脊柱后凸

[目的]介绍先天性后侧半椎体切除术的适应证和手术方法.[方法]经后路暴露双侧的椎板,自双侧分离暴露关节突外侧和横突,切除横突沿椎弓根自骨膜下向前分离,暴露多余的后侧半椎体,切除多余的一节椎弓和后侧半椎体,自后路行双侧椎弓根螺钉加压棒固定.[结果]手术治疗先天性后侧半椎体畸形35例,取得优异的治疗效果,但手术操作比较复杂,相当于全脊柱截骨术的难度.[结论]先天性后侧半椎体切除术的年龄范围:8～25岁,年龄越大越趋向于作全脊柱截骨术.     

一期后路经椎弓根半椎体切除节段固定治疗先天性胸腰椎侧后凸畸形

目的：评价一期后路经椎弓根半椎体切除节段固定术治疗完全分节的胸腰椎半椎体畸形所致的先天性脊柱侧后凸畸形的疗效。方法：采用一期后路经椎弓根半椎体切除内固定矫形术治疗了12例完全分节的胸腰椎半椎体畸形所致的脊柱侧后凸畸形，其中，男8例，女4例，年龄7～17岁，平均11．3岁。观察并测量术前术后及随访时站立位脊柱X线片冠状面和矢状面Cobb角、侧凸的顶椎偏移。结果：随访10-34个月，平均16个月。术后冠状面平均矫正64．1％，随访中无明显丢失。后凸由术前平均320矫正至190，随访中无明显丢失，顶椎偏移由术前4．5cm矫正至1．2cm。无脊髓损伤及切口感染等并发症。结论：一期后路经椎弓根半椎体切除内固定矫形术是治疗完全分节的胸腰椎半椎体畸形所致的脊柱侧后凸畸形的有效方法。     

一期后路经椎弓根半椎体切除节段固定治疗先天性胸腰椎侧后凸畸形

目的：评价一期后路经椎弓根半椎体切除节段固定术治疗完全分节的胸腰椎半椎体畸形所致的先天性脊柱侧后凸畸形的疗效。方法：采用一期后路经椎弓根半椎体切除内固定矫形术治疗了12例完全分节的胸腰椎半椎体畸形所致的脊柱侧后凸畸形,其中,男8例,女4例,年龄7～17岁,平均11．3岁。观察并测量术前术后及随访时站立位脊柱X线片冠状面和矢状面Cobb角、侧凸的顶椎偏移。结果：随访10～34个月,平均16个月。术后冠状面平均矫正64．1％,随访中无明显丢失。后凸由术前平均32。矫正至19。,随访中无明显丢失,顶椎偏移由术前4．5cm矫正至1．2cm。无脊髓损伤及切口感染等并发症。结论：一期后路经椎弓根半椎体切除内固定矫形术是治疗完全分节的胸腰椎半椎体畸形所致的脊柱侧后凸畸形的有效方法。     

一期后路经椎弓根半椎体切除节段固定治疗先天性胸腰椎侧后凸畸形

目的评价一期后路经椎弓根半椎体切除节段固定术治疗完全分节的胸腰椎半椎体畸形所致的先天性脊柱侧后凸畸形的疗效。方法采用一期后路经椎弓根半椎体切除内固定矫形术治疗了12例完全分节的胸腰椎半椎体畸形所致的脊柱侧后凸畸形。其中男8例，女4例，年龄为7～17岁，平均11．3岁。观察并测量术前术后及随访时站立位脊柱X线片冠状面和矢状面Cobb角、侧凸的顶椎偏移。结果随访10～34个月，平均16个月。术后冠状面平均矫正64．1％，随访中无明显丢失。后凸由术前平均32。矫正至平均19°，随访中无明显丢失，顶椎偏移由术前平均4．5cm矫正至平均1．2cm。无脊髓损伤及切口感染等并发症。结论一期后路经椎弓根半椎体切除内固定矫形术是治疗完全分节的胸腰椎半椎体畸形所致的脊柱侧后凸畸形的有效方法。     

先天性后侧半椎体切除术治疗角形脊柱后凸畸形

目的探讨先天性后侧半椎体切除术治疗角形脊柱后凸畸形的适应证、手术方法及临床效果. 方法采用该方法手术治疗角形脊柱后凸25例,经后路暴露双侧椎板,自双侧分离暴露关节突外侧和横突, 切除横突.沿椎弓根自骨膜下向前分离, 暴露多余的半椎体, 切除多余的一节椎弓和后侧半椎体,自后路行双侧弓根螺钉加压棍固定. 结果本组无脊髓损伤、感染等术后并发症发生.20例随访5～10年, 远期效果好; 3例随访1年以上, 矫正效果良好; 2例术后尚未及1年, 正在随访中.Cobb's角从术前平均68°降至术后平均11°. 结论先天性后侧半椎体切除术的年龄范围为8～22岁,年龄越大越趋向于作全脊柱截骨术.     

经椎弓根椎体截骨术治疗脊柱后凸畸形效果观察

目的探讨经椎弓根椎体截骨术治疗脊柱后凸畸形的效果。方法将88例脊柱后凸畸形并脊髓神经功能障碍患者,根据不同手术分为2组,各44例。对照组行经椎板小关节突截骨术,观察组行经椎弓根椎体截骨术。对比2组治疗效果。结果观察组术中及术后各指标、椎体愈合及神经功能恢复情况等均明显优于对照组,差异有统计学意义(P0.05)。结论经椎弓根椎体截骨术治疗脊柱后凸畸形创伤小,术后愈合佳,可有效纠正后凸畸形,提高神经功能。     

先天性脊柱侧弯的三维分析

[目的]运用三维CT重建技术对先天性脊柱侧弯进行脊椎的三维分析,得出畸变椎体和后方椎板结构的对应关系,从而指导先天性脊柱侧弯的进一步诊断及治疗方案的制定.[方法]对40例先天性脊柱侧弯患者进行脊柱三维CT重建检查,观察畸变脊椎的前后方结构.将前方结构畸形分为形成障碍(完全分节半椎体、半分节半椎体、楔形椎和蝴蝶椎)和分节障碍(融合椎和单侧不分节骨桥),将后方结构分为完全分节单侧半椎板、完全分节双侧半椎板、半分节半椎板、错位椎板、融合椎板、椎板裂及正常椎板.根据畸变椎体找到对应后方椎板,分析椎体畸形和椎板的对应关系.[结果]40例先天性脊柱侧弯患者共有105个畸变椎体,其中33个完全分节半椎体对应6种后方结构,14个半分节半椎体对应5种后方结构,8个楔形椎体对应3种后方结构,18个蝴蝶椎对应3种后方结构,5组融合椎体对应2种后方结构,7组单侧不分节骨桥对应1种后方结构.[结论]先天性脊柱侧弯患者不仅存在不同类型椎体的畸形,同时伴有不同类型的椎板结构,并且两者存在对应关系.     

胸椎椎弓根钉内固定治疗胸椎椎管内髓外肿瘤62例体会

既往胸椎椎管内肿瘤主要手术方式为椎板切除、肿瘤摘除术。然而脊柱为三关节复合体,全椎板切除术后远期易并发后凸畸形,一侧关节突关节切除术后易引发双侧关节活动不对称。2005年3月～2011年3月,本院采用椎板切除、椎弓根钉内固定治疗胸椎椎管内肿瘤取得了良好的手术效果,并保留了脊柱的长期稳定性,现报告如下。     

后路全脊椎截骨术的适应证及手术成功关键点

脊椎截骨术最早用于强直性脊柱炎的后路截骨矫形，其截骨方法包括经小关节椎板截骨术和经椎弓根椎体V型截骨术．临床上已经获得良好的效果。但是对于僵硬的重度脊柱侧后凸，由于截骨范围的限制．往往无法使畸形得到满意的矫正。对于严重的僵硬性脊柱侧后凸。文献报道有采用前后路联合截骨矫正的方法，但创伤较大，并发症较多。作者认为应用后路全脊椎截骨术治疗严重脊柱侧后凸畸形患者可取得优良的临床疗效．其适应证为：（1）重度先天性混合型侧后凸畸形的矫形及翻修术；（2）脊柱柔韧性低于25％的成人侧后凸或先天性侧后凸患者；（3）僵硬性或感染后导致的脊柱侧后凸畸形，     

半椎体后方结构的形态分析

[目的]研究半椎体后方结构的形态变异.[方法]运用Mimics软件观察2008年9月～2010年4月西京医院脊柱外科收治的34例含有半椎体的先天性脊柱畸形患者的脊柱三维CT图像.分析半椎体后方结构的形态及其与前方椎体和邻椎的空间关系.[结果]34例患者共有53个半椎体.其中颈段2个,胸段37个,腰段14个.半椎体后方结构的形态有以下几种类型:(1)单椎弓根半椎板型33个;(2)单椎弓根双椎板型5个;(3)双椎弓根双椎板型9个;(4)错配型5个;(5)无后方结构型1个.半椎体椎板与邻椎椎板全分节36个、部分分节14个、未分节2个.16个半椎体椎板的分节情况与前方椎体不一致.[结论]半椎体的后方结构形态存在变异,了解这些变异有助于判断其形成机制、预测其自然史、完善治疗方案并保证手术的顺利实施.     

青少年特发性胸椎侧凸患者胸椎椎弓根横径的分型及其临床意义

目的 探讨胸椎椎弓根横径的测量及分型在青少年特发性胸椎侧凸患者治疗中的临床意义.方法 对2008年10月至2009年7月收治的30例青少年特发性胸椎侧凸患者(侧凸组)和2008年8月至2009年7月于本院就诊的20例年龄匹配的非侧凸青少年患者(对照组)采用螺旋CT行胸椎连续扫描,在图像编档和通信系统(PACS)上逐层阅片,选择胸椎椎弓根显示最清楚的层面对椎弓根横径进行测量,并根据测量结果将其分为4型.分别对侧凸组凹凸侧和对照组左右侧椎弓根横径进行对比,并对侧凸组与对照组椎弓根分型的构成比进行分析.结果 两组患者胸椎椎弓根横径T1～4逐渐减少,T5～12逐渐增加.对照组同节段双侧胸椎椎弓根横径差异无统计学意义(P>0.05).侧凸组顶椎区凹侧的椎弓根横径明显小于凸侧,差异有统计学意义(P<0.05).侧凸组中4型椎弓根的比例明显高于对照组,1型椎弓根的比例低于对照组,差异均有统计学意义(P<0.05).结论 青少年特发性胸椎侧凸患者胸椎椎弓根横径常较小,术前应根据CT胸椎椎弓根形态制定置钉策略,以减少经胸椎椎弓根置入螺钉的并发症的发生.     

胸椎椎弓根形态测量研究

目的:观察不同节段胸椎椎弓根形态特征,探讨其临床意义。方法:测量40具国人胸椎标本的椎弓根横径、矢状径、矢状面夹角、椎弓根间距、椎弓根后缘皮质到椎体前缘皮质距离及椎弓根-椎板夹角,观察椎弓根后缘中点与相应横突根部的关系。结果:（1）除T1外,各节段椎弓根矢状径均明显大于横径（P<0.01）;（2）椎弓根矢状面夹角从T1到T9逐渐减小,T10以下为负角;（3）椎弓根后缘皮质沿其轴线到椎体前缘的长度从T1到T7逐渐增加,T7到T12基本相同;（4）T1与T12椎弓根螺钉拟进钉点位于横突根部中点,T2及T11位于横突根部中上1/3点,其余各节段均位于横突根部上缘。结论:进行胸椎椎弓根螺钉固定时,应根据不同节段椎弓根形态特点,结合X线片或CT片,选择相应的螺钉直径、长度、进钉部位及方向。     

中国青少年特发性脊柱侧凸患者胸椎椎弓根形态学三维CT分析

目的 总结中国青少年特发性脊柱侧凸患者胸椎椎弓根形态学特点,与其他人种特发性脊柱侧凸患者胸椎椎弓根形态比较,为手术中胸椎安全置钉提供参考.方法 回顾性分析2007年7月至2012年6月期间56例于我院行术前CT扫描三维重建的青少年特发性脊柱侧凸(右胸弯)患者的资料,男10例,女46例;年龄10～18岁,平均14.8岁.Lenke分型:Ⅰ型28例、Ⅱ型12例、Ⅲ型14例、Ⅳ型2例.术前主胸弯Cobb角平均为55°(36°～90°).测量其胸椎两侧椎弓根在矢状面、冠状面、轴面的置钉长度、椎弓根宽度及角度等形态学指标,总结其变化规律,并与文献报道的其他人种数据进行对比.结果 主胸弯顶椎区凹侧椎弓根宽度小于凸侧,椎弓根置钉长度大于凸侧,椎弓根尾倾角度小于凸侧.椎弓根矢状面宽度自头端向尾端逐渐增加,平均值范围为0.68～1.36 cm;轴面椎弓根宽度平均值范围为0.30～0.70 cm.冠状面椎弓根最小径略小于轴面椎弓根宽度,平均值范围为0.28～0.67 cm.结论 与欧美人种相比,中国特发性脊柱侧凸患者椎弓根宽度较小.顶椎区凹侧置钉难度大、风险高,建议使用直径3.5 mm椎弓根螺钉或采用极外侧置钉法.     

Structural vertebral changes in the horizontal plane in idiopathic scoliosis and the long-term corrective effect of spine instrumentation

Summary The rotation and structural changes of the apex vertebra in the horizontal plane as well as of the thoracic cage deformity were quantified by measurements on computed tomography (CT) scans from patients with right convex thoracic idiopathic scoliosis (IS). The CT scans were obtained from 12 patients with moderate scoliosis (mean Cobb angle 25.8°, r 13°–30°) and from 33 with severe scoliosis (mean Cobb angle 46.2°, r 35°–71°). In addition, CT scans of thoracic vertebrae from 15 patients without scoliosis were used as reference material. Ten of the scoliotic cases had had Cotrel-Dubousset instrumentation (CDI) and posterior fusion and had entered a longitudinal study on the effect of operative correction on the re-modelling of the apical vertebra. An increasingly asymmetrical vertebral body, transverse process angle, pedicle width and canal width were found in the groups with scoliosis as compared with the reference material. Vertebral rotation and rib hump index were significantly larger in patients with early and advanced scoliosis than in normal subjects. The modelling angle of the vertebral body, the transverse process angle index and the vertebral rotation in relation to the middle axis of the thoracic cage were significantly greater in patients with severe than with moderate scoliosis. The results of this longitudinal study suggest that the structural changes of the apical vertebra regress 2 years or more after CD instrumentation.     

Clinical anatomy of vertebrae in scoliosis: global analysis in four different diseases by multiplanar reconstructive computed tomography

Background contextFew accurate analyses of clinically useful vertebral anatomy have been conducted, and most have focused on thoracic idiopathic scoliosis.PurposeTo evaluate the different anatomic characteristics in scoliosis by disease type and level.Study designObservational cohort study.Patient sampleForty-eight patients with scoliosis were included in this study.Outcome measuresSubjects underwent computed tomography (CT) of the whole spine.MethodsForty-eight patients with scoliosis were included in this study: 15 adolescent idiopathic, 11 cerebral palsy (CP), 10 muscular dystrophy (MD), and 12 congenital (CG) scoliosis patients with similar demographics. Subjects underwent CT of the whole spine, preoperatively. Eight anatomic parameters were measured in multiplanar reconstructive CT images, and statistical analysis was performed to investigate differences.ResultsIn general, values in the anatomic parameters were similar for the four diseases. Each parameter showed the unique change pattern according to the spinal level regardless of curvature shape, direction, or magnitude. In particular, chord length (CL) in MD and CG scoliosis was lower than in adolescent idiopathic scoliosis (AIS) and CP, and pedicle rib unit length was lower in CG scoliosis than in the other diseases (p<.05). Comparisons of convex and concave anatomies in AIS showed that inner pedicle width (PWI) and outer pedicle width (PWO) were wider for convex side, CL, pedicle width, and transverse pedicle angle were greater for concave side (p<.05), and differences were more significant at apices. However, in CP, PWI and PWO were similar between convex and concaves sides (p>.05). Although PWI and PWO were wider for convex sides and CL and pedicle length were greater for concave sides in MD (p<.05), differences were less significant at apices. Particularly, CG scoliosis showed severely deformed anatomy, with differences of seven parameters at apical vertebrae (p<.05).ConclusionClinical anatomies of vertebrae in scoliosis were found to differ significantly at different levels and in terms of convexity and disease type.     

胸椎经关节突关节椎弓根螺钉固定的可行性研究

 目的明确胸椎后路经关节突关节椎弓根螺钉固定的解剖学可行性和技术参数.为临床应用提供参考。方法取 20具胸椎标本.仔细解剖胸椎的后侧和前侧方.以清楚地暴露胸椎椎板和椎弓根。以椎板下缘向上、外缘向内各 7 mm为进钉点.在 T_1.2、T_5.6、T_9.10直视下置入经关节突关节椎弓根螺钉.通过直接的置钉和 CT重建.观察胸椎后路经关节突关节椎弓根螺钉实际置钉的可行性.测量经关节突关节椎弓根螺钉内固定进钉角度和钉道长度。结果所有胸椎后路经关节突关节椎弓根螺钉均由上位胸椎下关节突经关节突关节.进入下位胸椎的椎弓根.成功置入下位胸椎的椎体内。重建 CT测量发现螺钉在横断面的外倾角度为 2.1°±0.7°.在矢状面的尾倾角度为 41.4°±3.2°.在各节段间略有不同.但差异无统计学意义。平均的螺钉钉道长度为(40.6±4.9) mm.钉道长度由上胸椎向中、下胸椎呈逐渐增加趋势.差异有统计学意义(F=74.09, P<0.01)。结论胸椎后路经关节突关节椎弓根螺钉具有解剖学可行性.可以作为胸椎椎弓根螺钉固定的一种补充内固定方法.但置钉时要求较高的准确性。     

寰椎椎弓根螺钉置钉的解剖与临床研究

目的：建立和验证寰椎后路椎弓根螺钉固定的进钉技术。方法：利用40套干燥配套寰枢椎标本测量进钉技术的相关参数，而后临床应用该技术方法置钉并行X线、CT复查其准确性。结果：寰椎椎弓根平均宽度为7．78mm，进钉点在寰椎椎弓根中线外侧2．2m，螺钉进钉点可由经枢椎下关节突中点的纵垂线来确定；手术中该方法不仅能简化操作过程，而且术后检查发现螺钉均准确置入。结论：用枢椎下关节突中点作为术中判定寰椎椎弓根螺钉进钉点的方法准确可靠。     

Applied anatomy of the lower cervical pedicle screw insertion

OBJECTIVE: To ascertain an accurate approach to inserting the pedicle screw into C3-C7 segments of the cervical vertebra. METHODS: Anatomic morphology of lateral mass and pedicle, and their anatomic relationship with the adjacent tissue were observed on C3-C7 segments of 25 adult embalmed cadavers (50 sides). RESULTS: 1) The inferior edge of the base of the posterior tubercle of the transverse process and the inferior edge of the pedicle were connected with each other on 25 adult embalmed cadavers (50 sides). The transverse section which passed through the median point between the superior edge and the inferior edge of the base of the posterior tubercle of the transverse process, and the transverse section which passed through the central axis between the superior edge and the inferior edge of the pedicle, were in the same horizontal plane. The superior and inferior position of placing the pedicle screw was determined by this transverse section, which passed through the median point between the superior and the inferior edge of the base of the posterior tubercle of the transverse process. 2) There was a directed internal-downwards "triangular sulcule" between the base of the posterior tubercle of the transverse process and the anterolateral edge of the inferior articular process. The anterior wall of the triangular sulcule was the base of the posterior tubercle of the transverse process, the posterior wall was the anterolateral edge of the inferior articular process, and the bottom of the sulcule was connected with the interior edge of the pedicle. The vertical length between the top of triangle and the planes of inferior edge of the pedicle was (2.78+/-1.71) mm. The inferior edge of the cervical pedicle could be detected using a blunt probe along the "triangular sulcule" between the base of the posterior tubercle of the transverse process and the anterolateral edge of the inferior articular process in surgical operation. 3) The lateral fovea of the articular process was observed on all lateral masses (50 sides). The internal and external position of the entrance point could depend on anatomic landmarks: the lateral edge of the lateral fovea of the articular process. The horizontal length between the lateral fovea of the articular process and the entrance point was (3.14+/-1.45) mm. 4) The diameter of pedicle screw, about (2.78+/-1.71) mm, was the transverse diameter of the cancellous bone of the greatest narrow part of the cervical pedicle. CONCLUSIONS: The median point between the superior edge and the inferior edge of the base of the posterior tubercle of the transverse process, the lateral fovea of the articular process, and the triangular sulcule between the base of the posterior tubercle of the transverse process and the anterolateral edge of inferior articular process, are easy to be exposed and identified in surgical operation. The pedicle screw can be precisely inserted through this method.