青少年特发性脊柱侧凸患者顶椎区脊髓位置变化及其临床意义

目的:分析青少年特发性脊柱侧凸(AIS)患者顶椎区脊髓偏移和旋转情况,并探讨其临床意义.方法:在28例AIS患者横断面MRI图像上测量顶椎区脊髓中心到椎管前、后内壁及凹、凸侧内壁的距离和脊髓、椎体的旋转角度,将脊髓旋转与椎体旋转的关系按Maruta分型分为O型、U型和R型,并分析脊髓在椎管内的位置及脊髓位置与Cobb角、脊髓旋转角度、椎体旋转角度之间的相关性.结果:顶椎区脊髓中心距脊柱凹侧、凸侧椎管内壁距离分别为7.13±1.89mm、13.68±2.93mm,距凹侧距离明显小于距凸侧距离(t=-9.56,P<0.01);距椎管内壁前、后缘距离分别为7.50±1.63mm、6.99±1.61mm,两者比较无显著性差异(t=1.22.p=0.23).椎体旋转角度为17,53°±6.70°,脊髓旋转角度为16.46°±9.16°,O型8例,U型13例,R型7例.脊髓旋转角度与椎体旋转角度、Cobb角及脊髓中心到凸凹侧椎管内壁的差值之间均呈正相关(分别为r=0.45,P=0.01;r=0.43,P=0.02;r:0.64,P<0.01),与脊髓中心列椎管内壁前后缘的差值之间无显著相关性(r=0.28,P=0.15).结论:AIS患者顶椎区脊髓向凹侧偏移,椎体与脊髓都存在旋转,脊髓的旋转方向因人而异.在行后路脊柱矫形椎弓根螺钉置入时,应特别注意凹侧脊髓及神经根,避免损伤.     

青少年特发性脊柱侧凸与神经源性脊柱侧凸患者椎体和椎间盘的楔形变及其临床意义

目的:观察青少年特发性脊柱侧凸(adolescent idiopathic scoliosis,AIS)与神经源性脊柱侧凸(neurological scoliosis,NS)患者的椎体和椎间盘的楔形变情况,探讨其临床意义。方法:对35例AIS患者和31例NS患者(继发于Chiari畸形)应用Cobb法测量胸椎和腰椎每个侧凸范围内顶椎及其上、下各两个椎体和相应椎间盘的楔变角,计算其占整个侧凸角度的百分比(楔变率),得出侧凸范围内5个椎体的平均楔变率和4个椎间盘的平均楔变率。应用SPSS10.0统计软件进行统计分析,组间比较采用单因素方差分析。结果:相同病因、相同侧凸部位、相同Cobb角分组情况下,椎体与椎间盘的楔变率存在显著性差异(P0.05)。相同病因、相同侧凸部位,Cobb角60°组的椎体楔变率和椎间盘楔变率与Cobb角≥60°组比较均无显著性差异(P0.05)。相同侧凸部位、相同Cobb角分组,AIS组椎体和椎间盘的楔变率分别与NS组比较均无显著性差异(P0.05)。结论:AIS与NS患者椎体与椎间盘的相对楔形变方式相同,AIS患者的椎体楔形变可能是继发的。在治疗脊柱侧凸时,即便是较小角度的脊柱侧凸,都应该考虑到其存在椎体和椎间盘的楔形变。     

应用脊髓造影计算机断层扫描技术评价青少年特发性脊柱侧凸患者顶椎区置钉的风险

[目的]分析青少年特发性脊柱侧凸患者(adolescent idiopathic scoliosis,AIS)顶椎区凸凹侧脊髓偏移空间及其规律,并探讨临床意义. [方法]回顾性分析本院29例AIS患者并在其横断面脊髓造影的计算机断层扫描(computed tomography myelograhy,CTM)图像上测量顶椎区脊髓中心到凸、凹侧硬膜囊及椎弓根内侧壁的距离,计算凸凹侧脊髓的偏移空间,和椎体、脊髓的旋转角度,并以Cobb角大小为依据,将其分为A组(40°～50°),B组(50°～70°),C组(＞70°)等三组,分别测量各组以上数据,分析脊髓偏移空间在不同的Cobb角度间的变化趋势以及凹侧脊髓偏移空间与Cobb角之间的相关性,借此定量分析顶椎区置钉的可能性.[结果]脊髓在顶椎区凸侧的偏移空间明显大于凹侧的偏移空间(P＜0.01).在凹侧,A组脊髓偏移空间与B组脊髓偏移空间、B组脊髓偏移空间与C组脊髓偏移空间、A组脊髓偏移空间与C组脊髓偏移空间,各组间比较有显著性差异(P＜0.01).凹侧脊髓偏移空间与Cobb角、椎体旋转角度、脊髓旋转角度之间均呈负相关(分别为r=-0.93,P＜0.01; r=-0.77,P＜0.01;r=-0.67,P＜0.01),也即侧弯角越大,凹侧脊髓偏移空间越小.而脊髓旋转角度与椎体旋转角度呈正相关(为r =0.95,P＜0.01).[结论]Cobb角＜70°时,凹侧脊髓偏移空间较大,可以安全置钉;但是在＞70°时,因为凹侧脊髓偏移空间较小甚至消失,不主张此类患者顶椎区置钉.而CTM检查的应用,对术前评估和降低术中风险有提示意义,必要时可以列为常规检查.     

脊柱侧凸椎旁肌肌纤维群化现象的研究

目的对椎旁肌肌纤维群化现象与青少年特发性脊柱侧凸(adolescent id iopath ic scoliosis,AIS)的发生、发展之间的关系进行研究。方法本实验分三组,AIS组:20例,平均年龄15.3岁,平均Cobb角56.8°。顶椎位于T7~12。其中Cobb角>50°11例,Cobb角≤50°9例。先天性脊柱侧凸(congen ital scoliosis,CS)组:11例,平均年龄13.9岁,平均Cobb角66.7,°顶椎位于T7~12。对照组:取10例非脊柱侧凸病例作为对照。AIS和CS组取顶椎区两侧椎旁肌,对照组取非病变区两侧椎旁肌行病理分析。结果AIS和CS组均存在凸侧椎旁肌Ⅰ型肌纤维群化现象,对照组未观察到肌纤维群化现象。CS组的肌纤维群化程度显著高于AIS组(P<0.05),AIS组中Cobb角>50°的患者肌纤维群化程度显著高于Cobb角≤50°的患者(P<0.05)。结论脊柱侧凸凸侧椎旁肌Ⅰ型肌纤维群化现象系继发性改变,且与侧凸的严重性呈正相关。     

青少年特发性脊柱侧凸不同弯型患者椎体和椎间盘楔形变的差异及临床意义

目的:比较不同弯型、不同Cobb角的青少年特发性脊柱侧凸(adolescent idiopathic scoliosis,AIS)患者椎体和椎间盘楔形变及其对整体Cobb角构成的差异,探讨其临床意义。方法:2007年1月~2009年6月对收治的110例单弯型AIS患者按弯型分组,其中主胸弯39例(A组),胸腰弯33例(B组),主腰弯38例(C组)。每组根据侧凸Cobb角大小再分为<40°和≥40°两个亚组。分别测量每个主弯范围内所有椎体和椎间盘的楔形变角(楔变角),并分别计算椎体与椎间盘楔变角之和分别占整个主弯Cobb角的百分比(楔变角所占Cobb角比率)。结果:全部患者平均年龄13.6±1.9岁;平均Cobb角34.4°±10.5°;平均Risser征2.4±1.7。三组间平均年龄、Cobb角、Risser征均无显著性差异(P>0.05)。A组椎体楔变角及所占比率明显大于椎间盘(21.9°±5.6°比13.7±5.9°,62.3%比37.7%,P<0.001),B组与C组椎间盘楔变角及所占比率明显大于椎体(24.1°±9.2°比10.4°±3.8°,69.0%比31.0%,P<0.001;25.1°±7.2°比7.7°±2.4°,76.6%比23.4%,P<0.001)。各组内Cobb角≥40°患者的椎体与椎间盘楔变角均显著大于Cobb角<40°患者的楔变角(P<0.001)。随Cobb角增加,A组患者椎体楔变角占整体Cobb角比率仍然大于椎间盘,而B组和C组患者椎间盘楔变角占整体Cobb角比率仍然大于椎体。三组顶椎楔变角均与相应Cobb角大小成显著线性正相关(P<0.001)。结论:AIS各种弯型侧凸均存在不同程度的椎体与椎间盘楔形变。主胸弯Cobb角构成以椎体楔形变为主,胸腰弯和主腰弯则以椎间盘楔形变为主,提示不同弯型间可能存在不同的生物力学发生机制。     

凹侧肋骨抬高胸廓成形对"剃刀背"畸形的矫正作用

目的:探讨凹侧肋骨抬高胸廓成形在脊柱侧凸后路手术中矫正“剃刀背”畸形的可行性。方法:自2000年10月～2005年10月,共有30例胸椎侧凸患者在我科施行后路三维矫形术,男13例,女17例;年龄10～31岁,平均17岁;先天性脊柱侧凸20例,特发性脊柱侧凸8例,马凡综合征2例。术前Cobb角60°～165°,平均118°;“剃刀背”畸形15°～60°,平均34.5°;双侧背部高度差为5～16cm,平均8.9cm。均同时在同一切口下行凹侧肋横突关节处截断并抬高肋骨胸廓成形,其中22例患者还同时行凸侧胸廓成形,凸侧肋骨切除的长度约为5～7cm。结果:每例患者肋骨抬高数为3～6根,平均4.5根。无手术死亡及严重并发症发生。术后Cobb角18°～85°,纠正率平均为58%;“剃刀背”畸形5°～18°,平均10.4°;双侧背部高度差1.5～5.2cm,平均3.4cm。随访12个月～5年,平均28个月,末次随访时Cobb角20°～90°,纠正率平均为56%;“剃刀背”畸形与术后无明显改变。结论:在严格掌握适应证的情况下仔细操作,凹侧肋骨抬高胸廓成形可使“剃刀背”畸形得到满意矫形效果。     

青少年特发性脊柱侧凸胸椎形态学的MRI测量及临床意义

目的 通过磁共振成像(MRI)观察青少年特发性脊柱侧凸(AIS)和正常同年龄组青少年胸椎的形态学差异,探讨其临床意义.方法 胸椎轻度侧凸(MS)组患者10例(Cobb角15°～39°),胸椎中度侧凸(SS)组患者10例(Cobb角40°～75°).另选健康青少年10名作为对照(非侧凸组).所有研究对象均为女性,年龄13～14岁.用1.5 T磁共振扫描仪(Sonata,Siemens,Erlanger,德国)对所有研究对象进行全脊柱矢状面扫描,在图像工作站(Easy Vision,Philips Medical Systems,Best,荷兰)上重建脊柱矢状面图像,测量每个胸椎椎体前壁高度,后壁高度,棘突间高度,在横截面测量椎体横径长度,并进行对比分析.结果 椎体前后高度、宽度从T1到T12逐渐增加,并呈线性分布,脊柱侧凸组椎体高度普遍>正常同年龄非侧凸组患者.脊柱侧凸组患者椎体高度横径比值以及脊椎前后高度比值均>无侧凸组.胸椎侧凸顶椎区T6～T9椎体前方高度、椎体高度横径比值以及脊椎前后高度比值,脊柱侧凸组明显>非侧凸组,差异均有统计学意义(P<0.05).结论 AIS胸椎侧凸女性患者胸椎顶椎区存在显著的脊柱生长模式异常,与正常胸椎相比AIS的胸椎更高、并显得更为瘦长.     

退行性脊柱侧凸患者冠状面和矢状面影像学参数分析

目的 :分析退行性脊柱侧凸(DS)患者的影像学特征,探讨与DS患者冠状面影像学参数与矢状面平衡之间的关系。方法:回顾性分析99例DS患者的人口统计学资料和影像学资料,包括年龄、性别、冠状位Cobb角、顶椎椎体/椎间盘的位置、侧凸的方向、顶椎旋转度、侧凸节段、胸椎后凸角(TK)、腰椎前凸角(LL)、胸腰椎后凸角(TL)、骶骨角(SS)、骨盆倾斜角(PT)、骨盆入射角(PI)、矢状位垂直轴(SVA)和PI-LL。根据矢状面平衡情况将患者分为两组:失平衡组(A组),SVA5cm;平衡组(B组),SVA≤5cm,比较两组患者的人口学和影像学参数。结果:99例患者中女83例,男16例;年龄41~92岁(中位数为67岁);冠状位Cobb角10°~75°(中位数为23°);侧凸长度3~7个椎体(中位数为5个椎体)。顶椎最常见的位置在L2/3(81%),顶椎椎体旋转程度的中位数为Ⅱ度(Ⅰ~Ⅲ度)。冠状位Cobb角和侧凸节段相关(r=0.23,P0.005),和顶椎旋转亦相关(r=0.53,P0.005)。A组33例,B组66例;两组间年龄、LL、PT、冠状位Cobb角、顶椎旋转度和PI-LL均有显著性差异(P0.05),两组间性别、TK、TL、SS和PI无显著性差异(P0.05)。结论:DS患者冠状位Cobb角与侧凸节段和顶椎旋转间有相关关系;矢状位平衡和失衡患者的年龄、冠状位Cobb角、LL、PT和PI-LL均不同。     

青少年特发性脊柱侧凸患者椎旁肌中钙调蛋白的表达及临床意义

目的:探讨青少年特发性脊柱侧凸(AIS)患者椎旁肌钙调蛋白的表达及其对肌浆网钙离子通道的影响。方法:AIS患者共30例,Cobb角40°～100°,其中Cobb角≥50°者15例(A组),Cobb角<50°者15例(B组);对照组(C组)5例患者均为非脊柱侧凸病例。于手术中取A、B组患者顶椎区两侧椎旁肌、取C组患者非病变部位两侧椎旁肌作为标本进行分子生物学分析,采用RT-PCR方法检测所有标本钙调蛋白和肌浆网钙离子通道的mRNA表达量。结果:A、B组患者椎旁肌钙调蛋白mRNA的表达比C组高(P<0.05),并且A组患者凸侧椎旁肌钙调蛋白mRNA显著高于凹侧(P<0.05),而B组患者其凹凸侧钙调蛋白mRNA没有显著性差异(P>0.05);C组椎旁肌肌浆网钙离子通道mRNA的表达比A组患者高(P<0.05),A组患者凸侧椎旁肌肌浆网钙离子通道mRNA显著低于凹侧(P<0.05),而B组患者其凹凸侧肌浆网钙离子通道mRNA没有显著性差异。结论:钙调蛋白mRNA在AIS患者椎旁肌中的表达较无脊柱侧凸者高,而且其表达随着侧凸程度的加重而增高;AIS患者椎旁肌肌浆网钙离子通道表达有异常,钙调蛋白的过度表达可能导致了钙离子通道的损伤。     

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...     

Comparison of ultrasonography and radiography in diagnosis of rib fractures

Purpose: Rib fractures are the most common skeletal thoracic injuries resulting from blunt chest trauma. Half of the rib fractures are not detected upon a precise physical evaluation and radiographs. Recently ultrasonography (USG) has been investigated to detect rib fractures. But based on literature the usefulness of USG varies widely. This study was conducted to investigate the role of USG in the detection of possible rib fractures in comparison with radiography. Methods: In this cross-sectional study, consecutive patients with minor blunt chest trauma and suspected rib fractures presenting in Imam Reza Hospital located in Mashhad-Iran, between April 2013 and October 2013 were assessed by USG and radiography. The radiography was performed in a posteroanterior (PA) chest projection and oblique rib view centered over the area of trauma. The time duration spent in taking USG and radiography were recorded. The prevalence and location of fractures revealed by USG and radiography were compared. Results: Sixty-one suspected patients were assessed. The male to female ratio was 2.4:1 (43 men and 18 women) with a mean ± SD age of (44.3 ± 19.7) years. There were totally 59 rib fractures in 38 (62.3%) patients based on radiography and USG, while 23 (37.7%) patients had no diagnostic evidence of rib lesions. USG revealed 58 rib fractures in 33 (54.1%) of 61 suspected patients and radiographs revealed 32 rib fractures in 20 (32.8%) of 61 patients. A total of 58 (98.3%) rib fractures were detected by USG, whereas oblique rib view and PA chest radiography showed 27 (45.8%) and 24 (40.7%) rib fractures, respectively. The average duration of USG was (12 ± 3) min (range 7e17 min), whereas the duration of radiography was (27 ± 6) min (range 15-37 min). The kappa coefficient showed a low level of agreement between both USG and PA chest radiography (kappa coefficient=0.28), and between USG and oblique rib view (kappa coefficient=0.32). Conclusion: USG discloses more fractures than radiography in most patients presenting with suspected rib fractures. Moreover USG requires significantly less time than radiography.     

Surgical treatment of rib fracture nonunion: A single center experience

IntroductionIn contrast to the emerging evidence on the operative treatment of flail chest, there is a paucity of literature on the surgical treatment of rib fracture nonunion. The purpose of this study was to describe our standardized approach and report the outcome (e.g. patient satisfaction, pain and complications) after surgical treatment of a rib fracture nonunion.MethodsA single centre retrospective cohort study was performed at a level 1 trauma centre. Symptomatic rib nonunion was defined as a severe persistent localized pain associated with the nonunion of one or more rib fractures on a chest CT scan at least 3 months after the initial trauma. Patients after initial operative treatment of rib fractures were excluded.ResultsNineteen patients (11 men, 8 women), with symptomatic nonunions were included. Fourteen patients were referred from other hospitals and 8 patients received treatment from a pain medicine specialist. The mean follow-up was 36 months. No in-hospital complications were observed. In 2 patients, new fractures adjacent to the implant, without new trauma were observed. Furthermore 3 patients requested implant removal with a persistent nonunion in one patient. There was a mean follow-up of 36 months, the majority of patients (n = 13) were satisfied with the results of their surgical treatment and all patients experienced a reduction in the number of complaints. Persisting pain was a common complaint. Three patients reporting severe pain used opioid analgesics on a daily or weekly basis. Only 1 patient needed ongoing treatment by a pain medicine specialist.ConclusionSurgical fixation of symptomatic rib nonunion is a safe and feasible procedure, with a low perioperative complication rate, and might be beneficial in selected symptomatic patients in the future. In our study, although the majority of patients were satisfied and the pain level subjectively decreases, complaints of persistent pain were common.     

Laminated multi-segment rib graft in anterior column reconstruction

Rib harvested during thoracotomy can be effectively used for anterior column reconstruction. An innovative technique is described to convert multiple individual rib segments into a robust single anterior column reconstruction graft using cortical screws.     

Evaluation of intramedullary rib splints for less-invasive stabilisation of rib fractures

Background

Intramedullary fixation of rib fractures with generic Kirschner wires has been practiced for over 50 years. However, this technique has not been advanced to address reported complications of wire migration and cut-out. This biomechanical study evaluated a novel rib splint designed to replicate the less-invasive fixation approach of Kirschner wires while mitigating their associated complications.

Methods

The durability, strength, and failure mode of rib fracture fixation with intramedullary rib splints were evaluated in 27 cadaveric ribs. First, intact ribs were loaded to failure to determine their strength and to induce realistic rib fractures. Subsequently, fractures were stabilised with a novel rib splint made of titanium alloy with a rectangular cross-section that was secured with a locking screw. All fixation constructs were dynamically loaded to 360,000 cycles at five times the respiratory load magnitude to determine their durability. Finally, constructs were loaded to failure to determine their residual strength and failure modes.

Results

Native ribs had a strength of 9.7 ± 5.0 N m, with a range of 3.5-19.6 N m. Fracture fixation with rib splints was uneventful. All 27 splint constructs sustained dynamic loading without fixation failure, implant migration or implant cut-out. Dynamic loading caused no significant decrease in construct stiffness (p = 0.85) and construct subsidence remained on average below 0.5 mm. The residual strength of splint constructs after dynamic loading was 1.1 ± 0.24 N m. Constructs failed by splint bending in 44% of specimens and by developing fracture lines along the superior and inferior cortices in 56% of specimens. Regardless of the failure mode, all rib splint constructs recoiled elastically after failure and retained functional reduction and fixation. No construct exhibited implant cut-out or migration through the lateral cortex.

Conclusions

Rib splints can provide sufficient stability to support respiratory loading throughout the healing phase, but they cannot restore the full strength of native ribs. Most importantly, rib splints mitigated the complications reported for rib fracture fixation with generic Kirschner wires, namely implant cut-out and migration through the lateral cortex. Therefore, rib splints may provide an advanced alternative to the original Kirschner wire technique for less-invasive fixation of rib fractures.     

带血管蒂肋骨移位治疗神经纤维瘤病性脊柱侧弯

目的：评价采用带血管蒂肋骨移位治疗神经纤维瘤病性柱侧弯的临床效果。方法：回顾性分析16例神经纤维瘤病性脊柱侧弯手术治疗的临床资料。结果：术后16例均获满意的治疗效果，全部6个月融合。结论：应用带血管蒂肋骨移位是治疗神经纤维瘤病性柱侧弯的一种可行的手术方法。     

Aneurysmal bone cyst originating from the first rib

Aneurysmal bone cyst is a benign tumor of the skeletal system and rare in the ribs. A 25-year-old woman was found to have an abnormal shadow in the left chest on the radiologic examinations. The first rib containing tumor was removed. Pathologic findings showed an aneurysmal bone cyst.     

The significance of first rib fractures in children

Purpose

The purpose of the study was to determine if first rib fractures are associated with an increased incidence of thoracic vascular injury in pediatric patients.

Methods

The medical records of all children diagnosed with a first rib fracture or a central vascular injury after blunt trauma treated at a state-designated level 1 pediatric trauma center from 2000 to 2009 were reviewed.

Results

Thirty-three children (0.27% of patients; mean age, 10.9 ± 0.9 years) were identified with either a first rib fracture or thoracic vascular injury owing to blunt trauma. Thirty-two children had a first rib fracture, and only 1 child (3%) had significant thoracic vascular injury. Mediastinal abnormalities (indistinct aortic knob) were identified in 3 children, 2 with first rib fracture on initial chest radiograph. Despite a normal cardiovascular examination result, 25 (74%) children with a normal mediastinum on screening chest radiograph underwent computed tomography. No child with a normal mediastinum on initial chest radiograph was found to have associated intrathoracic injuries requiring further intervention. In children with first rib fractures and a normal mediastinum by screening chest x-ray, the negative predictive value for thoracic vascular injury was 100%.

Conclusions

Children with first rib fractures without mediastinal abnormality on chest radiograph require no further workup for thoracic vascular injury.