胸腰椎骨折椎管狭窄与神经功能的关系

对１０６例连续性胸腰椎爆裂肌折进行回顾性研究,探讨椎管狭窄与神经功能的关系。按自行设计的改良Ｆｒａｎｋｅｌ法将神经功能分六级,将椎管分脊髓圆锥段和马尾神经段,用直线回归相关法分析椎管狭窄与神经损伤程度之间的关系,用等级相关法分析椎管狭窄与发生神经损伤可能性之间的关系。     

胸腰椎爆裂型骨折椎管狭窄与脊髓损伤的关系

胸腰椎爆裂型骨折的主要特征为椎体前高的减低和后壁骨皮质的连续性中断,骨折常常发生向后移位突入椎管导致神经损伤。据统计,胸腰椎爆裂型骨折后有３０％～９０％的患者发生包括脊髓、圆锥或马尾在内的神经损伤〔１〕。但迄今有关创伤后椎管狭窄与神经损伤的关系尚不明...     

72例胸腰段爆裂性骨折患者神经功能缺失与伤后椎管狭窄相关性的研究

目的：研究胸腰段爆裂性骨折患者脊髓损伤程度与相应椎管狭窄两者间的相关性。方法：对1998年6月～2004年3月间收治的72例胸腰段爆裂骨折患者进行回顾性分析,脊髓功能按照Frankel分级进行评定,使用透明毫米尺对患者CT片椎管正中矢状径进行测量以此代表椎管面积,分别计算T11、T12、L1、L2四个节段两者的相关系数并进行直线相关分析。结果：T1、T12、L1、L2节段两者问相关系数分别为：O．3348、0．8457、0．6691、0．3336。提示T12水平两者具有较高的相关性,而在L1、L2节段两者的相关性较低。对相关系数进行显著性检验,结果显示在T12、L1椎管狭窄和脊髓功能损伤之间具有直线相关关系（P〈O．001）,而在T11、L2两个节段不能认为椎管狭窄和脊髓功能损伤间具有直线相关关系（P〉0．5,0．10〈P〈0．20）。结论：脊髓的损伤程度与椎管狭窄程度具有相关性。测量患者胸腰段爆裂骨折CT扫描图像中椎管占位面积的大小可以作为神经损伤程度的一个预测因素。     

胸腰段骨折椎管内骨折块与脊髓损伤的关系

目的：探索胸腰段椎管内骨折块对脊髓损伤的影响程度,确定脊髓受压的临界椎管狭窄率,为临床治疗的选择提供参考标准。方法：对121例不稳定性胸腰骨折进行改良Frankel分级法脊髓功能评估和CT椎管面积测量,作统计学分析。结果：56例有不同程度的脊髓功能损伤,其截瘫程度与椎管内骨块占位显著相关,相关程度以T12最高,L2最低。脊髓受压的椎管占位临界值为T1230％,T1135％,L140％,L255％。结论：胸腰段椎管内骨块占位程度与脊髓损伤有显著相关性。     

脊髓,圆锥与马尾损伤分类：附106例胸腰段脊柱与脊髓损伤分析

本文将１０６例胸１０到腰４的脊柱脊髓损伤的病例进行神经损伤的分类：Ｉ型：完全性脊髓损伤；Ⅱ型：完全性脊髓－圆锥损伤；Ⅲ型：不完全性圆锥马尾损伤；Ⅳ型：完全性圆锥损伤，合并部分马尾损伤：Ⅴ型：完全性圆锥马尾损伤；Ⅵ型：单纯圆锥损伤；Ⅶ型：部分马尾损伤．文章论述了每一型损伤的诊断标准，讨论了分类的意义，神经损伤与膀眈功能分级的关系；提出了以感觉、运动及膀胱功能为指标的截瘫量化功能评价的格式．     

脊柱后结构在胸腰段脊髓神经损伤及爆裂骨折分类中的作用

目的观察脊柱后结构在脊髓神经组织损伤中的作用,为脊髓神经损伤程度评估和预测脊髓神经功能恢复的可能性及进一步完善分类提供依据。方法实验采用高速准静态轴向加载法复制脊椎爆裂型骨折模型,检测椎管内压力变化及脊柱后结构损伤程度。对127例胸腰椎爆裂骨折合并截瘫患者的脊髓神经损伤程度及脊髓神经功能恢复情况与后结构损伤的相关性进行回顾性研究。结果实验证实后柱有损伤者椎管内压力变化峰值较小,无损伤者峰值较大。55例后结构损伤患者中伴脊髓神经损伤38例(69.09%),其中24例(63.16%)神经功能得到恢复,而72例无后结构损伤者有52例(72.22%)合并脊髓神经损伤,其中20例(38.46%)有神经功能改善。两组之间差异有显著性,提示无后结构损伤患者脊髓神经损伤和功能缺失的程度更重。结论无后结构损伤时脊髓神经损伤和功能缺失的程度明显高于有后结构损伤者,脊柱后结构的完整与否对脊髓神经损伤程度起着重要作用,可作为伤情评估、功能恢复预测和完善Denis分类的有效尺度。     

胸腰段脊柱前路手术并发症及防治

胸腰段椎体骨折、结核、肿瘤或椎间盘突出常伴有脊髓圆锥或马尾神经损害,从而导致其致残率较高。近年来,随着高处坠落及交通事故的不断增加,胸腰段脊柱骨折有逐渐上升的趋势。临床研究发现,胸腰段脊柱损伤后,常伴有脊     

马尾神经吻合治疗截瘫的应用解剖学研究

目的：观察马尾神经的形态特征，为胸腰椎骨折脱位所致截瘫患者的神经根吻合术提供解剖学依据。方法：取24具成人脊柱标本，暴露T11节段以下脊髓神经根，观察马尾神经的形态特征：测量T11～S3各神经根穿出相应脊髓节的中点与不同损伤平面（T11、T12椎体下缘平面）之间的距离；观察脊髓圆锥下极位置变异情况。结果：马尾神经根的排列位置很有规律，各神经根可以辨别。T11、T12椎体下缘平面以上可利用的神经根分别主要为T11～L1、T11～L4神经根，损伤平面以上可利用的神经根数目与损伤平面高低呈负相关．与脊髓圆锥位置高低呈正相关。结论：损伤平面以上有一些残存的神经根可供利用，椎管内神经根吻合需考虑损伤平面高低与脊髓圆锥下极位置的关系。     

腰椎爆裂性骨折腹腔镜辅助下前路小切口内固定技术11例疗效分析

目的探讨腹腔镜辅助下前路小切口对腰椎爆裂性骨折椎压、植骨、内固定手术的可行性及手术特点及临床疗效。方法 2009年12月至2012年1月,11例腰椎爆裂性骨折在腹腔镜辅助下经腹膜后腰肌间隙入路,行腰椎爆裂骨折并脊髓圆锥、马尾神经压迫症椎管减压、植骨、内固定手术。其中男性8例,女性3例;平均年龄39岁（20-57岁）。所有病例均为车祸伤或高处跌落伤,骨折后3-7天手术。11例均为腰椎爆裂骨折,椎管狭窄程度达25%-100%。L1骨折3例,L2骨折5例,L3骨折3例,以上11例中并发脊髓圆锥、马尾神经损伤4例。11例中5例分别伴发骨盆骨折、肋骨骨折、肱骨骨折、小腿骨折、胸部损伤、脾破裂、休克等。结果随访6个月以上,效果满意。全部病例切口甲级愈合,椎管内骨块清除彻底,椎管减压充分,植骨块融合良好,内固定器无松动;4例圆锥、马尾神经受压,术后功能基本恢复。结论腹腔镜辅助下经腹膜后腰肌间隙前路小切口入路的腰椎手术,可以完成椎体爆裂性骨折并脊髓圆锥、马尾神经压迫症的椎管减压、植骨、内固定术。     

胸腰椎爆裂骨折椎管内骨块占位与神经损伤

目的　观察胸腰椎爆裂骨折部位及椎管内骨块占位与神经损伤的关系。方法　对 14 1例包括胸椎 (T1 - T1 0 )、胸腰段 (T1 1 - L2 )及腰椎 (L3- L5)三个水平爆裂骨折 CT显示的椎管内骨块占位与神经功能关系进行了分析。结果　神经损伤组椎管内骨块占位程度明显高于无神经损伤组 (P <0 .0 5 ) ;在有神经损伤情况下椎管骨块占位严重程度依次为 :胸椎 <胸腰段 <腰椎 (P <0 .0 5 ) ;在 Frankel分类有功能障碍的四个神经功能级之间其椎管骨块占位程度无显著差异 (P>0 .0 5 )。结论　椎体爆裂骨折椎管内骨块占位压迫是神经损伤的重要危险因素 ;神经损伤的出现与骨折椎体节段和椎管内骨块占位程度联合相关 ;但神经损伤的严重程度与就诊时 CT表现的椎管内骨块占位程度具有不一致性     

Anterior decompression of traumatic thoracolumbar fractures with incomplete neurological deficit using a retroperitoneal approach

Between 1973 and 1981, seventy patients with a spinal cord injury secondary to a thoracolumbar fracture were treated by anterior spinal-canal decompression through a retroperitoneal approach. All of these patients had an incomplete neurological deficit caused by retropulsed vertebral-body fragments and intervertebral disc material in the spinal canal. Forty-eight patients have been followed for an average of 3.4 years (range, two to 8.6 years). Either computed tomography or lateral tomography, or both, was performed after surgery on these forty-eight patients, and confirmed the successful removal of the cause of compression in all of them. No patient lost further cord or cauda equina function after the anterior decompression. Thirty-seven of the forty-two patients who had a motor deficit improved by at least one class in motor strength. Fourteen of the thirty patients whose quadriceps and hamstrings were too weak to permit walking regained full independent walking ability. Twelve of the thirty-two patients who had a conus medullaris injury demonstrated neurogenic bowel and bladder recovery. The degree of neurological recovery of spinal cord injury after anterior spinal decompression of thoracolumbar fractures appears more favorable than after other, previously reported techniques that do not decompress the spinal canal.     

前路手术治疗胸腰段爆裂型骨折伴不全性神经损伤——附19例报告

目的探讨对胸、腰椎爆裂型骨折伴不全性神经损伤患者行前路手术治疗的疗效。方法对19例不稳定性胸、腰椎爆裂型骨折伴不全性神经损伤患者行侧前方椎管减压、自体骨植骨融合、Kaneda器械内固定治疗。结果全部患者经1~6年随访,脊椎后凸畸形由术前平均25.1°提高到术后平均13°,平均椎管占位率由术前45%提高到最终随访的10%。神经功能按ASIA分级示,提高1级者有12例,2级者有4例;14例膀胱/直肠障碍者有5例完全恢复,8例有不同程度的改善,1例无变化。结论胸、腰椎爆裂型骨折伴不全性神经损伤患者经侧前路减压融合、Kane-da内固定器可较好地提供脊柱的即刻稳定性、矫正后凸畸形、有利于早期下床行走和防止继发性脊髓或马尾神经损伤。大多数不全性神经损伤的患者,其神经功能至少可提高1级,而脊髓圆锥创伤的患者可表现为部分直肠和膀胱功能的恢复。     

A case of traumatic spinal subarachnoid hematoma causing compression of the cauda equina]

A case of traumatic spinal subarachnoid hematoma causing compression of the cauda equina is reported here. The patient, a 76 year-old woman, who had fallen down by accident 1 month before, was admitted to our hospital presenting lumbar pain radiating into her right thigh, monoplegia of the right leg and urinary incontinence. Myelography and metrizamide CT demonstrated a filling defect mimicking intradural extramedullary tumor at the level of L1 and L2. Magnetic resonance imagings (MRI) revealed a subacute or chronic hematoma compressing the conus medullaris and the cauda equina. Operation was performed and an old hematoma, which occupied most of the spinal subarachnoid space and compressed the conus and cauda equina from right to left, was removed. No definite bleeding point was detected and no traumatic change was seen on the cord. Neither tumor nor abnormal vessel was detected. After surgery, the symptoms improved partially. On a review of the literature, we found only 4 cases of traumatic spinal subarachnoid hematoma, all of which occupied the cervical or thoracic portion of the spine. Our case is the first report, except for the cases following lumbar spinal tap, of traumatic spinal subarachnoid hematoma causing compression of the cauda equina. Though usually blood in CSF diffuses immediately, a clot may be formed when a large amount of bleeding obstructs the spinal canal. In our case, furthermore, deformity and narrowing of the spinal canal had preceded for many years, following lumbar vertebral compressed fracture related with osteoporosis. This might have promoted the process of canal obstruction and clot formation.(ABSTRACT TRUNCATED AT 250 WORDS)     

Die Bedeutung des Wirbelkanaldurchmessers im thorakolumbalen und lumbalen Bereich nach Trauma

A relationship between traumatic spinal canal stenosis and the degree of neurological deficit is known for the cervical spine. However, this has not been proven for the thoracolumbar and lumbar spine. During a period of 4 years, from 1996 to 1999, 1168 patients with a spinal injury were treated at our department, 473 of these by operation. Thirty-five were examined in a separate group.They showed a single fracture of the thoracolumbar and lumbar spine with stenosis of the spinal canal. All fractures were single burst fractures after blunt trauma. All patients were conscious and fully oriented at the time of admission and a thorough neurological examination could be performed. The fractures were diagnosed by conventional X-ray in two views and computed tomography (CT). Using the transverse CT scans in horizontal view, the sagittal diameter was measured and the degree of stenosis calculated in percent at the level of the fracture and one below and above. The group included 25 male and 10 female patients, with a mean age of 38 years (range: 17-61 years). Of the 35 patients, 19 (54.3%) showed neurological deficits after spinal cord injury,and 16 (45.7%) were without any neurological complications at the time of first admission to the hospital. There was no correlation between the extent of spinal canal stenosis and the degree of the neurological deficit. One patient with stenosis of 20% suffered from neurological dysfunction, others with stenosis up to 80% were without spinal cord injury. The average stenosis of the spinal canal was 49.6% in cases with cord injury and 46.3% in patients without neurological dysfunction. No correlation and no predisposing anatomical structures could be found between stenosis and neurological deficit.     

Conus perimedullary arteriovenous fistula with multiple shunt points including the cauda equina: a case report

Perimedullary arteriovenous fistula (AVF) is usually located on the surface of the spinal cord and is fed by the anterior spinal artery and/or the posterior spinal artery. We report a rare case of Conus perimedullary AVF with multiple shunt points including the cauda equina. A 68-year-old man presented with leg pain when walking long distances. Magnetic resonance imaging at the thoracic and lumbar level revealed multiple signal voids with marked cord signal change. Angiography showed the perimedullary AVF fed by the anterior spinal artery from the right T9 intercostal artery at the level of the conus medullaris and the fistula fed by the left lateral sacral artery from the left internal iliac artery at the level of the cauda equina. In the first surgery, we performed surgical interruption of feeding arteries from the filum terminale and coagulated AV shunt of the conus medullaris. However residual perimedullary AVF was found at the conus medullaris in the postoperative angiography. Secondary surgery was carried out to treat residual AVF. Follow-up angiography showed complete disappearance of all AVFs. Postoperatively, the patient`s symptoms were improved. Because the Conus perimedullary AVF has the characteristics of multiple feeding arteies, multiple shunt points, and complex venous drainage, it must be kept in mind that other fistula could exist in the cauda equina or filum terminale.     

CT scan prediction of neurological deficit in thoracolumbar burst fractures.

In 139 patients with burst fractures of the thoracic, thoracolumbar or lumbar spine, the least sagittal diameter of the spinal canal at the level of injury was measured by computerised tomography. By multiple logistic regression we investigated the joint correlation of the level of the burst fracture and the percentage of spinal canal stenosis with the probability of an associated neurological deficit. There was a very significant correlation between neurological deficit and the percentage of spinal canal stenosis; the higher the level of injury the greater was the probability. The severity of neurological deficit could not be predicted.     

Multimodal intraoperative monitoring (MIOM) during 409 lumbosacral surgical procedures in 409 patients

A prospective study on 409 patients who received multimodel intraoperative monitoring (MIOM) during lumbosacral surgical procedures between March 2000 and December 2005 was carried out. The objective of this study was to determine the sensitivity and specificity of MIOM techniques used to monitor conus medullaris, cauda equina and nerve root function during lumbosacral decompression surgery. MIOM has increasingly become important to monitor ascending and descending pathways, giving immediate feedback information regarding any neurological deficit during the decompression and stabilisation procedure in the lumbosacral region. Intraoperative spinal- and cortical-evoked potentials, combined with continuous EMG- and motor-evoked potentials of the muscles, were evaluated and compared with postoperative clinical neurological changes. A total of 409 consecutive patients with lumbosacral spinal stenosis with or without instability were monitored by MIOM during the entire surgical procedure. A total of 388 patients presented true-negative findings while two patients presented false negative and 1 patient false-positive findings. Eighteen patients presented true-positive findings where neurological deficit after the operation was intraoperatively predicted. Of the 18 true-positive findings, 12 patients recovered completely; however, 6 patients recovered only partially. The sensitivity of MIOM applied during decompression and fusion surgery of the lumbosacral region was calculated as 90%, and the specificity was calculated as 99.7%. On the basis of the results of this study, MIOM is an effective method of monitoring the conus medullaris, cauda equina and nerve root function during surgery at the lumbosacral junctions and might reduce postoperative surgical-related complications and therefore improve the long-term results.

     

Detrusor function with lesions of the conus medullaris.

Conventional urodynamic evaluation is unable to distinguish between a pure conus lesion and one with concomitant cauda equina involvement. Lumbosacral evoked potentials to tibial nerve stimulation assesses the sensory root and dorsal horn interneurons of the L5 to S2 spinal cord segments. This allows for the diagnosis of a pure lesion of the conus medullaris with preservation of the sensory root response (R wave) with absence of the dorsal horn gray matter response (S wave). Urodynamic evaluation in 5 patients with a conus lesion showed a variety of detrusor responses ranging from hyperreflexia through areflexia with decreased compliance to areflexia with normal compliance. The ability to diagnose a pure conus lesion may have prognostic significance as newer modalities of treatment emerge, all of which require intact gray matter of the spinal cord.     

Lower urinary tract dysfunctions in patients with spinal cord tumors

AIMS: The objective of this study was to elucidate the incidence and pathophysiology of lower urinary tract dysfunctions (LUTS) in patients with spinal cord tumors. METHODS: Urinary questionnaire and urodynamic studies were done in 76 patients with spinal cord tumors. RESULTS: The patients included 56 with cervical-thoracic (C1 to T11) and 20 with lumbosacral tumors. The lumbosacral tumors consisted of 12 epiconus/conus medullaris (below T11) and 8 cauda equina tumors. These tumors were further subdivided into intramedullary, intradural extramedullary, and dumbbell-type. More than 83% of the patients had urinary symptoms. Patients with cervical-thoracic tumors commonly had voiding symptoms (75%). Detrusor hyperreflexia (39%), and detrusor areflexia on voiding (21%) were the main urodynamic features. Patients with epiconus/conus medullaris tumors commonly had voiding symptoms as well (58%), but decreased urge to void (50%), detrusor-sphincter dyssynergia (42%), and detrusor areflexia on voiding (32%) were the main features. Patients with cauda equina tumors commonly had storage symptoms (88%), of which sensory urgency was most common (63%). Severe LUTS occurred in the epiconus/conus medullaris tumors and in the intramedullary tumors. These dysfunctions tended to appear late and rarely appeared as the initial symptom in the course of the disease. There was no significant relationship between neurologic abnormalities and LUTS. Urodynamics showed that spinal cord tumors cause a variety of LUTS, depending on the location and the type of the tumor. CONCLUSION: Spinal cord tumors are commonly accompanied by LUTS. Clinical and urodynamic evaluation is crucial to diagnosis and management since there is little relationship between symptoms and findings.