The use of allograft (and avoidance of autograft) in anterior lumbar interbody fusion: a critical analysis

The aim of this report is to analyze the validity of allograft in anterior lumbar interbody fusion. Forty-three patients underwent anterior lumbar interbody fusion using allograft in the period between 1995 and 1998. All suffered from crippling chronic low back pain with or without sciatica. Discogenic disease was verified in 40 cases by discography. All patients were investigated preoperatively with magnetic resonance imaging (MRI). The surgical technique is described. Follow-up radiographs were performed postoperatively, then at 1.5, 3, 6 and 12 months, as required. Radiological fusion was confirmed in all single-level fusions (100%, n=24). In two-level fusions the rate was 93% (n=28/30). However, radiological union could only be confirmed in 11 of the 12 levels in the three-level fusions. Allograft offers a better alternative to autograft for anterior lumbar interbody fusion. Donor site morbidity is avoided, hospital stay is shorter and fusion rates are satisfactory.     

Bertolotti综合征1例报告并文献复习

腰骶部移行椎(LSTV)是腰骶椎最常见的先天性畸形之一,发生率为4.0％ ～ 35.0％,骶化的腰椎椎体形态表现多样,包括从横突肥大到横突与骶骨完全融合等多种类型[1-3].腰化的骶椎椎体倾向方形化,并且有完整的S1/S2椎间盘结构.LSTV易合并腰椎椎间盘突出症及腰椎滑脱,LSTV的上位节段更容易发生退行性疾病,当腰...     

Lumbosacral extradural arachnoid cysts: diagnostic and indication for surgery

No critical discussion of the indication for the surgical treatment of lumbosacral extradural arachnoid cysts is found in the literature. Therefore, we want to compare the results in patients with operative and conservative treatment to define standards for a good surgical result. Over a period of 9 years, we operated on eight patients with a lumbosacral extradural arachnoid cyst and treated eight others conservatively. Only three of the operated patients experienced a postoperative relief of pain, but none was symptom free. The only one with continuing success had a preoperative history of 1 year only. MRI scans without contrast agent were misinterpreted in one included and one excluded case. The results of conservative treatment were nearly the same as those of operative treatment. MRI is the best diagnostic tool, but a variety of sequences must be used. Patients with a short pain history and a clear neurological deficit profited most from surgery. Patients with slight and not clearly related uncharacteristic symptoms should be excluded from surgery. Received: 9 March 1998 Revised: 22 January 1999 Accepted: 28 January 1999     

Simultaneous combined anterior and posterior fusion

Summary This paper reviews the principles, developments and concepts embodied in the experience gained over 10 years with simultaneous combined anterior and posterior fusion (SCAPF) of the spine in over 750 patients. The procedure was initially designed for the surgical treatment of failed post-discectomy syndromes. Indications have expanded due to increasing experience and the rapid, predictable fusion which accompanies this technique. The current technique allows for a solid anterior fusion combined with extensive posterior decompression and removal of the primary anatomical pain sources involved with low back pain and disability.     

前/后路腰椎椎间融合术治疗椎间盘源性腰痛

目的　比较前路腰椎椎间融合术(ALIF)与后路腰椎椎间融合术(PLIF)治疗椎间盘源性腰痛的疗效。方法回顾性分析2010年1月—2015年12月分别接受ALIF(31例)和PLIF(34例)治疗的退行性椎间盘源性腰痛患者的临床资料,比较2组患者术中出血量、术后症状无缓解例数、恢复工作时间及并发症发生情况,术前和术后6周、3个月、1年疼痛视觉模拟量表(VSA)评分、Oswestry功能障碍指数(ODI)及融合率。结果所有手术顺利完成,所有患者随访≥1年。ALIF组术中出血量、术后症状无缓解例数低于PLIF组,恢复工作时间长于PLIF组,术后6周、3个月、1年腰痛VAS评分和ODI改善较PLIF组显著,术后6周、3个月下肢痛VAS评分改善较PLIF组显著,差异均有统计学意义(P 0.05);术后1年下肢痛VAS评分、术后融合率组间差异无统计学意义(P 0.05)。术后3例患者(ALIF组1例、PLIF组2例)出现切口愈合不佳,经换药后好转。PLIF组1例硬膜撕裂于术中修补,术后未出现脑脊液漏;1例持续存在神经根刺激症状,经复查可能为1枚椎弓根螺钉位置偏内所致,经非手术治疗3个月症状缓解。ALIF组1例发生难治性呃逆,术后15 d缓解。2组均无内固定松动、断裂等并发症发生。结论治疗椎间盘源性腰痛,ALIF在改善症状方面更具优势,术中出血量更小。     

椎间盘源性腰痛合并下位椎间隙塌陷2例报告

腰痛为骨科临床常见症状,其可能源于腰椎椎间盘,而椎间盘源性腰痛（DLBP）最常见节段为L₄/L₅和L₅/S₁^[1-3]。DLBP是椎间盘内各种病变（如退行性变等）刺激椎间盘内疼痛感受器引起的功能丧失的下腰痛,不伴根性症状,无神经受压或节段过度活动的影像学证据^[4]。目前DLBP的诊断、治疗仍存在诸多疑问,特别是椎间隙塌陷且MRI显示塌陷节段为“黑间盘”时容易将塌陷节段臆断为责任节段,造成误诊。海军军医大学附属长征医院收治DLBP合并下位椎间隙塌陷患者2例,联合应用椎间盘造影和椎间盘阻滞确诊后行椎间融合术,术后患者腰痛均缓解。现将诊疗过程报告如下,并对诊断存在的争议进行讨论。     

三种后路融合方式治疗腰椎滑脱的外科疗效评价

目的比较后外侧融合、后路椎间融合与后路环形融合治疗腰椎滑脱的手术疗效,探讨其适应证。方法分别应用3种术式治疗不同类型及合并症的腰椎滑脱患者58例,比较手术时间、并发症、椎体滑脱矫正与复位丢失率、椎间隙高度以及下腰痛症状改善情况。结果三者均可以明显改善下腰痛;后外侧融合减少了术后一过性下肢麻痛的发生率但易出现植骨不融合及内固定失败;后路椎间融合及后路环形融合明显提高了植骨融合率,降低了假关节发生率和滑脱矫正度的丢失。结论3种后路融合术都是治疗腰椎滑脱的有效术式,退变性腰椎滑脱宜选用后外侧融合;峡部裂性腰椎滑脱宜选用后路椎间融合技术;Ⅱ度以上严重峡部裂性腰椎滑脱症或合并腰椎管狭窄需行广泛减压者宜选用后路环形融合。     

去神经化治疗腰椎关节突关节源性腰痛的有效性与安全性研究

目的:探讨脊神经后内侧支阻滞模拟去神经化治疗腰椎关节突关节源性腰痛的有效性与安全性。方法:自2009年3月至2010年10月,采用脊神经后内侧支阻滞模拟去神经化治疗腰椎关节突关节源性腰痛患者10例,男6例,女4例;年龄41～68岁,平均56.4岁;病程0.5～3年,平均1.2年。每例患者分别进行脊神经后内侧支单支阻滞、双支阻滞、三支阻滞、四支阻滞(分别在C形臂X线透视引导下行病变腰椎关节突关节和(或)上下邻近几个关节行腰脊神经后内侧支阻滞),其中5例双支阻滞时行同位脊神经后内侧支及上位神经阻滞,5例行同位及下位神经阻滞。以相应上关节突与横突根部交界处为靶点。用药均为:0.5%盐酸利多卡因15ml加入确炎舒松-A1ml(10mg/ml)、甲钴铵注射液1ml(500μg)。评价患者阻滞前、阻滞腰脊神经后内侧支单支、双支、3支、4支后腰背部疼痛的VAS评分、致痛关节突关节水平多裂肌表面肌电信号及腰部背伸肌力。多裂肌表面肌电信号用表面肌电测定仪记录,背部肌力采用背力计测定。结果:所有患者脊神经阻滞后腰背疼痛VAS评分、多裂肌平均肌电(averageEMG,AEMG)均低于阻滞前(阻滞前VAS评分为6.85±1.55,肌电值为69.25±2.13)。腰脊神经后内侧支单支、双支、3支、4支阻滞后腰背部的VAS评分分别为5.80±1.05、3.65±1.20、2.80±1.10、2.75±1.15,肌电值分别为62.15±1.85、51.25±1.28、47.30±1.85、45.96±1.98。腰背伸肌力:腰脊神经后内侧支阻滞前和单支、双支、3支、4支阻滞后分别为60、55、48、44、43kg。VAS评分:3支阻滞后<双支阻滞后<单支阻滞后;腰背伸力:3支阻滞后<双支阻滞后<单支阻滞后。4支阻滞后的VAS评分、腰背伸力与3支阻滞后差异无统计学意义。同位脊神经后内侧支及上位双支阻滞VAS评分及背伸力下降幅度明显大于同位及下位双支阻滞。结论:脊神经后内侧支去神经化治疗腰椎关节突关节源性腰痛是有效的,单支、双支去神经化治疗是相对安全的;双支阻滞首选同位脊神经后内侧支及上位双支阻滞,其疗效明显。3支、4支去神经化治疗有一定风险,应谨慎使用。     

Lumbosacral fusion using the Boucher technique in combination with a posterolateral bone graft

This study evaluates the clinical and radiological results of using the facet screw fixation technique described by Boucher in combination with a posterolateral fusion rather than a posterior fusion for symptomatic degenerative disease of the lumbosacral junction. It is a retrospective review of 38 consecutive patients with an average follow-up of 28 months. Radiologically, all patients had a solid fusion. Clinically, 23 patients (60%) had excellent results, 11 patients (29%) good results, 3 patients (8%) fair results and 1 patient (3%) had a poor result. There were no neurological complications. The findings support the view that the Boucher technique of facet joint fixation in combination with a posterolateral fusion is a safe and effective method of dealing with chronic symptoms relating to degenerative changes at the lumbosacral junction. The authors stress the importance of patient selection and attention to operative technique if the clinical results are to correlate with the results of fusion.     

42例腰椎融合术后难治性下腰痛的治疗体会

目的探讨腰椎融合术后骶髂关节病变的特点及治疗方法与疗效。方法回顾性分析42例因腰椎退变性滑脱、腰椎椎间盘突出、腰椎椎管狭窄曾行后路减压、后外侧或椎体间植骨融合及椎弓根内固定术,术后随访12～72个月(平均42.6个月)出现新的难治性持续性下腰痛症状的病例。本研究运用骶髂关节内封闭进行诊断性治疗。阳性标准:疼痛缓解≥75%,采用疼痛视觉模拟量表(visual analogue scale,VAS)进行定量分析。结果阳性12例(28.57%),是否融合L5/S1、术后疼痛缓解期是否≥3个月与诊断阳性率相关,有统计学意义(P<0.05)。结论腰椎融合术后下腰痛部分可能是由骶髂关节病变引起的,L5/S1融合可能促进骶髂关节发生退变。症状以下腰痛症状为主者,手术应慎重。     

New possibilities in L2–L5 lumbar arthrodesis using a lateral retroperitoneal approach assisted by laparoscopy: preliminary results

Four patients underwent lumbar interbody fusion, performed via a video-assisted retroperitoneal laparoscopic approach, complementary to posterior osteosynthesis at the L2–L3, L3–L4 and/or L4–L5 level. In three cases the interventions were for lumbar fractures, and in one case for microcristalline arthritis. After surgical training on human cadavers and several porcine operative sessions, retroperitoneal lateral approaches on the left side were performed by the authors without CO₂ insufflation, assisted by videoscopy. The fusion process was monitored by fluoroscopy. It is possible to perform this technique cranially above L2 or caudally below L5. Minimal blood loss was observed. Average time for these interventions was 127 min. Interbody fusion was achieved in the first, second and fourth cases; the outcome in the third case at the final check-up, 6 months after operation, was uncertain. The first patients had a complication of ureteral wound, which was certainly caused by insufficient experience with the new technique. The authors hope to extend the application of this technique to other procedures as they become more experienced.No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article     

Quantitative assessment of the motion of the lumbar spine in the low back pain population and the effect of different spinal pathologies on this motion

There are few objective means by which disability caused by low back pain (LBP) can be quantified. The purpose of this study was to investigate the usefulness of motion measurements in the assessment of LBP. The motion characteristics of 138 LBP subjects were investigated, and the data compared with a previously published database of normal subjects. Values of range of motion and angular velocity were obtained for all subjects in each plane of motion. Analysis of these motion characteristics demonstrated significant differences (P < 0.0001) between the two populations; however both populations demonstrated considerable intersubject variation. Multiple regression analysis revealed that some of the variance in the LBP population was attributable to the underlying diagnosis. Patients with a spondylolisthesis tended to be hypermobile whilst those with spinal stenosis, disc prolapse or degenerative disc disease tended to be hypomobile. All diagnostic groups showed impairments in their velocity characteristics.     

腰骶内固定的适应证与主要技术

腰骶融合手术为脊柱外科中常用术式,而腰骶内固定有助于腰骶融合。其手术适应证包括腰椎滑脱椎间盘突出与椎管狭窄、畸形以及其他原因缃起的腰骶不稳。腰骶内固定的主要技术有Ｇａｌｖｅｓｔｏｎ技术、髂骨螺钉、骶骨椎弓根螺钉、骶骨构、骶骨棒、骶骨杆、关节突螺钉、腰骶椎体间融合、人工椎间盘等。     

Free gas in the spinal canal as cause of low back pain and sciatica

We describe two patients suffering from sciatica for the presence of epidural gas compressing the nerve root. Previously, only one patient had undergone spinal surgery. The aim of this report is to describe the origin and the treatment of radiculopathies caused by epidural gas. Received: 5 December 2000/Accepted in revised form: 2 June 2000     

Transforaminal lumbar interbody fusion: a safe technique with satisfactory three to five year results

The unilateral transforaminal approach for lumbar interbody fusion as an alternative to the anterior (ALIF) and traditional posterior lumbar interbody fusion (PLIF) combined with pedicle screw instrumentation is gaining in popularity. At present, a prospective study using a standardized tool for outcome measurement after the transforaminal lumber interbody fusion (TLIF) with a follow-up of at least 3 years is not available in the current literature, although there have been reports on specific complications and cost efficiency. Therefore, a study of TLIF was undertaken. Fifty-two consecutive patients with a minimum follow-up of 3 years were included, with the mean follow-up being 46 months (36–64). The indications were 22 isthmic spondylolistheses and 30 degenerative disorders of the lumbar spine. Thirty-nine cases were one-level, 11 cases were two-level, and two cases were three-level fusions. The pain and disability status was prospectively evaluated by the Oswestry disability index (ODI) and a visual analog scale (VAS). The status of bony fusion was evaluated by an independent radiologist using anterior–posterior and lateral radiographs. The operation time averaged 173 min for one-level and 238 min for multiple-level fusions. Average blood loss was 485 ml for one-level and 560 ml for multiple-level fusions. There were four serious complications registered: a deep infection, a persistent radiculopathy, a symptomatic contralateral disc herniation and a pseudarthrosis with loosening of the implants. Overall, the pain relief in the VAS and the reduction of the ODI was significant (P<0.05) at follow-up. The fusion rate was 89%. At the latest follow-up, significant differences of the ODI were neither found between isthmic spondylolistheses and degenerative diseases, nor between one- and multiple-level fusions. In conclusion, the TLIF technique has comparable results to other interbody fusions, such as the PLIF and ALIF techniques. The potential advantages of the TLIF technique include avoidance of the anterior approach and reduction of the approach related posterior trauma to the spinal canal.     

RF与圆柱状骨笼椎间融合治疗腰椎滑脱

腰椎滑脱临床并非罕见 ,对其治疗既往多应用游离椎弓切除减压 ,以椎弓根螺钉系统复位固定 ,同时用碎骨条植入横突间或椎体间融合 ,然临床并发症较多 ,少数病例术中复位良好 ,但术后却发生螺钉断裂、拔出及松动或滑脱的椎体复位后再滑脱 ,造成手术失败。基于上述问题 ,我们采用后方入路椎体圆柱状骨笼椎间植骨融合同时行ＲＦ系统复位固定 ,临床应用 6例 ,有效解决了上述并发症 ,现报告如下。1　临床资料　　本组患者共 6例 ,男 4例 ,女 2例 ;年龄 2 4～ 5 7岁 ,平均 33岁。病程最短 9个月 ,最长 2 2年 ,平均 4年 3个月。均有腰痛和神经痛 ,其…     

不同术式治疗伴终板Modic改变的腰椎椎间盘突出症的疗效分析

目的 评估采用后路椎间盘镜下髓核摘除术(microendoscopic discectomy,MED)或后路椎间融合术(posterior lumbar interbody fusion,PLIF)治疗伴有终板Modic改变的腰椎椎间盘突出症患者的手术疗效.方法 回顾性分析2005年5月～2009年12月收治的73例伴...     

腰骶椎前路融合笼的设计及临床应用

目的　研制出腰骶椎前路融合笼 (AnteriorFusingCage-AFC)并选定相应的放置方式用于下腰痛患者的治疗。 方法　1、通过在人尸椎骨及牛椎骨标本上的生物力学试验 ,人尸椎骨的解剖学测量 ,结合手术要求 ,设计了AFC及相应辅助器械 ,并筛选出相应的放置方式。 2、将该技术用于 14例下腰痛患者的治疗。结果　 1、AFC直径≈ 1/ 2 (a +p) +12～ 16 (mm) ,AFC长度≈S - 6 -S×滑脱百分比。 2、放置方式为在L5S1间隙取正中 1枚AFC放置法及L4.5间隙取左前外斜向 1枚AFC放置法。 3、随访 2 4～ 4 5个月 ,初步结果满意。结论　AFC有助于施术节段的融合与稳定 ,增加椎间隙高度 ,不需术后长时间石膏外固定 ,该技术较国外同类方法简便安全     

Computer analysis of the safety of using three different pedicular screw insertion points in the lumbar spine in the Chinese population

To help decide the best starting point for lumbar spine pedicle screw insertion in the Chinese population using three different techniques (Roy-Camille, Magerl, and Du). Three-dimensional CT reconstructions were created from 40 adult lumbar vertebral segments. Three different starting points for lumbar pedicle screw insertion were used. The direction of the pedicle screw through each hole was simulated on three-dimensional reconstructed images. Precise CT measurements were made to assess the distance from the simulated screw and the medial and lateral pedicle walls at the smallest transverse section of each pedicle. To measure a pedicle transverse section angle (TSA) lines were drawn on a CT scan in the direct axis of the pedicle, tangential to the medial, and separately lateral, walls of the pedicles at the isthmus. The angle these lines made with an anterior to posterior line, which directly bisected the mid-portion of the vertebral body was called the TSA. The greater the difference between the TSA between the medial and lateral walls provides the greatest flexibility for the insertion angle of the pedicle screw. Additionally, the distance from a line drawn in the direct central axis of the pedicle was measured from the point of exit from the pedicle to the entry point of each of three insertion techniques (Du, Mageral, and Roy-Camille), to help understand potential risk factors. There were statistically significant differences between the distances from the entrance point to the direct pedicle axis among the three methods (P < 0.001). Du’s insertion point was the shortest from L1 to L4. The distances measured following Magerl’s technique were shortest at L5 (P < 0.05). There was no significant difference of the safe range of the TSA between the three methods from L1 and L2 (P > 0.05), but significant differences at L3, L4, and L5 (P < 0.05). At L3 and L4 the safe ranges of TSA using Du and Magerl’s methods were significantly larger than those measured by Roy-Camille (P < 0.05). At L5 the safe ranges of TSA for the Magerl technique were the greatest among the three methods (P < 0.05). These results demonstrate that Du’s method provides the safest starting point to place pedicle screws from L1 to L4, as its distance from the entrance point to the pedicle axis is the shortest and the safe range of TSA the largest of the three techniques. Magerl’s technique can be safely used in the pedicles from L3 to L5, and is the safest choice at L5. Roy-Camille’s technique is most applicable at L1 and L2, but has the highest risk when applied from L3 to L5.     

Anterior lumbar interbody fusion with threaded fusion cages and autologous bone grafts

The goal of this study was to evaluate the ability of Ray threaded fusion cages, when used in an anterior approach, to restore intervertebral height and to improve the functional and occupational performance of the patients. The present study was initiated because insertion of fusion cages through a posterior approach causes destruction of facet joints and violation of the spinal canal. The anterior approach for insertion of threaded fusion cages to accomplish lumbar interbody fusion was evaluated in a series of 13 patients suffering monosegmental disc disease. The patients’ functional and occupational performance was evaluated using the Prolo score. Radiological measurements were used to evaluate disc height and degree of penetration into the endplates, and to confirm fusion. Seven of the 13 patients were short-term failures and had to be revised within 2 years. The study found that revised patients had poorer Prolo scores than non-revised patients. Although for the non-revised patients, the mean Prolo scores remained relatively stable during the 1st year, they dropped after 3 years. We were not able to identify any further clinical or radiological differences between the groups. These results indicate that although the anterior approach seems technically suitable for insertion of threaded fusion cages, destruction of the anterior longitudinal ligament and the anterior part of the annulus fibrosis appears to result in destabilisation of the motion segment. Received: 9 August 1999 Accepted: 17 November 1999