用带血管蒂肋骨行脊柱前方植骨固定术

随着脊椎结核的减少,需要脊柱前路植骨的病例也逐渐减少,但由于近年来脊柱外科长足进展,前路植骨的适应证正在扩大,包括对骨愈合能力较低的高龄者亦积极地采用骨移植术。带血管蒂的肋骨移植术,能促进骨愈合,是一极好的方法。该法自Bradford(1980年)首次报告后,相继有许多作者的报导,我们自1982年起采用此法,现介绍如下。1与带血管蒂肋骨移植术有关的局部解剖 在12对肋骨中,近端7对在前方与胸骨侧缘相接,第8、9、10肋骨的末端,依靠肋软骨汇合在一起形成肋弓。第11、12肋骨前端游离为浮肋。第3～10肋骨是与本术式有关的主要解剖结构。每一肋…     

胸腔镜在脊柱外科中的应用进展

内镜微创脊柱外科新技术是目前脊柱外科领域中一项新型实用技术，由于该技术(尤其是胸腔镜在脊柱前路手术中的应用)具有前路脊柱开放手术无法比拟的微小创伤优势，因而在国外已得到广泛开展，国内也正逐渐开展此方面的研究和临床应用。本文就胸腔镜在脊柱前路手术中应用的有关历史、优缺点、适应证和禁忌证、手术技术、初步的临床应用结果和前景做一综述。     

肋骨结构性支撑植骨在脊柱侧凸前路矫形手术中应用的长期随访

[目的]评价肋骨结构性支撑植骨在青少年特发性脊柱侧凸前路矫形融合手术中应用的长期随访结果.[方法]回顾性分析术后随访时间超过4年的青少年特发性脊柱侧凸前路矫形手术病例30例,男3例,女27例;年龄12～ 17.5岁,平均14.3岁.侧凸类型包括PUMC Ⅰ b型5例、Ⅰc型5例、Ⅱd1型20例.全部病例均行前路矫形融合手术,植骨方式采用自体肋骨结构性支撑植骨.术前、术后及随访时摄脊柱站立位X线片,测量冠状面及矢状面Cobb角,并观察植骨融合情况,有无假关节形成及内置物并发症.[结果]随访4～10.2年,平均6.3年.融合弯冠状面矫形率术后平均为75.1％,末次随访时矫形丢失平均4.6°;固定融合节段冠状面矫形率术后平均为93.2％,末次随访时丢失平均2.1°;固定融合节段矢状面Cobb角术前与术后比较无显著性差异,末次随访时矫形丢失平均3.1°.13例胸腰段后凸患者术前后凸平均8.3°,术后矫正为前凸平均5.6°,末次随访时保持前凸平均3.7°.全部病例末次随访时均未见假关节形成或内置物并发症.[结论]肋骨结构性支撑植骨在青少年特发性脊柱侧凸前路矫形融合手术中能获得并维持良好的冠状面及矢状面矫形,且融合率高、远期矫形丢失少,是一种可靠、有效的植骨方法.     

双枚经第2骶椎骶髂螺钉固定技术在严重脊柱侧后凸畸形中的应用

目的探讨在严重脊柱侧后凸畸形患者后路矫形术中,采取单侧或双侧双枚经第2骶椎骶髂螺钉(second sacral alar-iliac,S2AI)固定技术的适应证,并且探究此技术的可行性并评估其临床疗效及并发症情况。方法收集2014年1月至2019年12月共11例应用双S2AI固定技术进行后路脊柱矫形融合术的患者的病例资料,男5例,女6例;年龄(28.8±16.8)岁(范围12～60岁)。所有患者术前、术后均拍摄全脊柱正位、侧位X线片以及全脊柱CT,根据Gertzbein & Robbins评分法评价螺钉置入的精确性,测量术前、术后以及末次随访时的侧凸Cobb角,冠状面平衡(coronal balance,CB),脊柱骨盆倾斜角(spinal pelvic obliquity,SPO),局部后凸角(regional kyphosis,RK),探究描述患者采取双S2AI固定技术的原因,并且比较患者术前、术后及末次随访时的影像学差异及疗效评价差异。结果 11例中9例患严重脊柱侧后凸畸形伴骨盆倾斜,另外2例为既往脊柱术后医源性后凸畸形患者。11例患者术后随访(11.6±8.5)个月(范...     

SSEP、MEP和DNEP在重度脊柱畸形截骨矫形术中同时联合监测的意义

目的探讨在重度脊柱畸形截骨矫形术中,体感诱发电位（somatosensory evoked potential,SSEP）、运动诱发电位（motor evoked potential,MEP）和下传神经源性诱发电位（descending neurogenic evoked potential,DNEP）同时联合监测的安全性和准确性。方法回顾性分析2010年8月～2011年7月采用3种诱发电位同时联合监测的重度脊柱畸形截骨矫形患者16例,所有患者均在全静脉麻醉并小剂量肌松剂泵注维持下行脊柱畸形截骨矫形术,术中均行SSEP、MEP和DNEP同时联合监测。结果 16例患者术中出现3种诱发电位皆阳性5例,唤醒试验也为阳性,术后均出现不同程度的神经并发症。单纯MEP阳性,而SSEP、DNEP正常者4例,术中唤醒试验均为阴性,术后无异常神经体征。单纯SSEP阳性,而MEP、DNEP正常者1例,术中唤醒阴性,术后查体正常。另外6例术中SSEP、MEP和DNEP皆正常,但其中1例考虑因神经根牵拉出现术后一过性股四头肌肌力下降,余5例术后查体均正常。结论术中DNEP与SSEP、MEP同时联合监测可减少传统SSEP和MEP监测产生假阳性对手术的干扰,对重度脊柱畸形截骨矫形术中脊髓损伤监测具有较好的敏感性和准确性,术中如有2种及以上诱发电位异常则出现脊髓损伤的可能性增大。     

非融合技术治疗脊柱侧凸的应用进展

非融合技术治疗脊柱侧凸，其特点是无需进行植骨融合，在保留脊柱正常活动性的前提下，通过特殊的装置延缓或阻止脊柱畸形的进展。集中支具及融合手术优势的同时，避免两者的弊端。目前非融合技术主要包括：内镜下椎体钉置入技术、前路胸椎钉技术、畸形凸侧栓系技术、机械性脊柱生长调节技术、脊柱生长导向治疗等。本文针对最主要的三种方法进行综述如下。     

微创技术在脊柱外科中的应用进展

传统手术在治疗脊柱疾患时，为了充分显露，会给患者带来新的创伤，影响患者的康复。如何在解决患者疾患的同时又尽可能少的破坏邻近组织、减少创伤、缩短恢复期，这就是现代微创技术的根本目标。近几年来，微创技术在外科领域逐步为广大医生和患者所接受。     

3D打印技术辅助成人脊柱侧后凸畸形的术前规划及应用价值

目的:探讨3D打印技术在成人脊柱侧后凸畸形的术前规划及术中辅助操作的应用价值。方法 :回顾性分析2017年9月至2019年1月收治的12例成人脊柱侧后凸畸形患者,其中男3例,女9例;年龄21⁶3(47.67±13.32)岁;先天性脊柱侧后凸畸形4例,脊柱陈旧性结核伴后凸畸形2例,特发性脊柱侧后凸畸形2例,退变性脊柱侧后凸畸形4例。将患者脊柱CT断层扫描数据导入Mimics17.0软件中,建立脊柱三维模型,通过3D打印机制作脊柱模型,然后进行术前规划及模拟手术操作,分析其术后影像学参数的改善情况。所有患者随访时间1年以上,于手术前后及末次随访时测量侧凸Cobb角,最大后凸Cobb角,冠状面平衡(distance between C7plumbline and center sacral vertical line,C7PL-CSVL)和矢状面平衡(sagittal vertical axis,SVA),骨盆参数等相关影像学参数,进一步评估其矫形效果。结果:12例脊柱侧后凸畸形患者的脊柱矫形术在1∶1脊柱模型的指导下,采用不同的截骨矫形内固定融合方式(其中4例畸形较重...     

生物植骨材料在脊柱融合术中的应用

自1911年Albee与Hibbs报道第1例脊柱融合术至今近100年，各种脊柱内固定器械日新月异，大大提高了脊柱疾病的治疗成功率。然而，即使如此，融合失败及假关节的发生率仍然较高（5％～35％），现有的手术方法完全可以达到对脊柱坚强的内固定，但始终不能完全避免融合失败的发生。影响脊柱融合成功的因素有：（1）患者自身条件：如年龄、全身状况、营养、骨质疏松等；（2）植骨方式的选择：后外侧植骨、横突间植骨、去皮质、前路椎间植骨融合等；（3）植骨床的制备；（4）植骨材料的选择。国内外学者一直寻求通过提高骨移植材料性能以提高脊柱的融合率。据统计在北美每年大约有5000，000例手术涉及骨移植，已经成为仅次于输血的第二大移植手术。理想的骨移植材料应具备：无毒、无副作用、取材方便，价格低廉，同时具有骨形成、骨传导、骨诱导等生物活性。     

Vascularized Nerve Grafts and Vascularized Fascia for Upper Extremity Nerve Reconstruction

Since 1976, experimental and clinical studies have suggested the superiority of vascularized nerve grafts. In this study, a 27-year experience of the senior author is presented regarding vascularized nerve grafts and fascia for complex upper extremity nerve reconstruction. The factors influencing outcomes as well as a comparison with conventional nerve grafts is presented. Since 1981, 21 vascularized nerve grafts, other than vascularized ulnar nerve, were used for reconstruction of nerve injuries in the upper extremity. Indications were prolonged denervation time, failure of the previously used conventional nerve grafts, and excessive scar in the recipient site. Injury was in the hand/wrist area (n = 5), in the forearm (n = 4), in the elbow (n = 2), in the arm (n = 4), or in the plexus (n = 6). Vascularized sural (n = 9), saphenous (n = 8), superficial radial (n = 3), and peroneal (superficial and deep) nerves were used. The mean follow-up was 31.4 months. Vascularized nerve grafts for upper extremity injuries provided good to excellent sensory return in severely scarred upper extremities in patients in whom conventional nerve grafts had failed. They have also provided relief of causalgia after painful neuroma resection and motor function recovery in selective cases even for above the elbow injuries. Small diameter vascularized nerve grafts should be considered for bridging long nerve gaps in regions of excessive scar or for reconstructions where conventional nerve grafts have failed.     

Surgical Results for Spinal Metastases

Summary  Among a series of 740 spinal tumours treated in the Department of Neurosurgery at the Nordstadt Hospital in Hannover, Germany, between September 1977 and December 1996, 106 spinal metastases in 101 patients were operated on. After an average period of 4.0±6 months (2 days to 5 years) patients presented at an average age of 62±12 years. 79% of the tumours were operated on by a posterolateral approach, 12% by an anterior and the remaining 9% by an anterior and posterior approach. A complete resection was achieved for 43.4% of the metastases while 48.1% were removed partially, 7.5% were biopsied and one patient received an opiate pump. Operations were followed by radiotherapy, chemotherapy or hormone treatment.  The overall local recurrence rates as determined by the Kaplan Meier method were 57.9% after 6 months, 69.3% after 1 year and 96% after 4 years. Multiple regression analyses revealed that an independent preoperative status of ambulation, favourable tumour histology, cervical level, complete resection, low number of affected vertebral bodies, and elective surgery were significant, independent predictors of a low rate of local metastatic recurrence.  Postoperative neurological outcome was related to preoperative neurological deficits. 96% of patients walking preoperatively kept this ability for at least 3 months postoperatively. However, only 22% of patients unable to walk regained walking capacity for 3 months. Correspondingly, 89% of patients remained continent of urine postoperatively for 3 months while only 31% regained sphincter control for this amount of time postoperatively.  In terms of postoperative survival, multiple regression anlyses showed longer survival times for patients with a favourable tumour histology, independent ambulation, long history, male sex, cervical level, complete resection, posterior approach, no additional metastases in other organs, and no instability. The overall survival rates were 58.8% after 6 months, 48% after 1 year and 19.5% after 5 years postoperatively.  In conclusion, surgery has a place in the treatment of patients with metastatic disease of the spine and neurological symptoms and/or spinal instability. The surgical strategy should be tailored according to the general health of the patient and expected time of survival. Primary radiotherapy should be administered to patients without neurological deficits or instability and to patients who cannot undergo or do not accept surgery.     

胆道重建术式的手术技巧和疗效评估

随着现代普通外科理论与技术的快速发展,肝胆外科手术变得日趋复杂、精细。胆道损伤或病变致狭窄后,外科治疗需要重建肠道与胆管之间的连续性。胆管引流重建的方式很多,主要有四种方式,即胆管对端吻合术、胆管十二指肠吻合术、胆管空肠吻合术和间置空肠胆管十二指肠吻合术,现加以讨论以供商榷。1胆管对端吻合术1.1适应证胆管对端吻合术的适应证包括:①术中或术后24h内发现的胆总管及肝总管横断,胆管缺损<5mm,且胆管直径在6～10mm,两端距离不大,吻合后无张力者;②胆囊或胆管良性病变(如肝外胆管环形狭窄)切除术后,两端口径大小一致,张力不大…     

脊柱肿瘤切除术后稳定性重建

目的：探索脊柱肿瘤切除术后稳定性重建的方法与效果。方法：本组对28例脊柱肿瘤实施了椎体切除。扇形半脊椎切除，附件切除和全脊椎发除四种术式，同时采用了椎体间植骨，人工椎体及前，后路内固定重建技术。结果：全组病人局部疼痛及放射痛缓解。13例截瘫患者中11例肌力均有不同程度改善。11例原发良性肿瘤中2例术后4和10年复发，1例伴恶变，均再次治疗，11例原发恶性肿瘤中2例术后9和12个月死亡，1例植骨块脱出，再次手术。另1例局部肿瘤复发截瘫加重，再次手术但神经功能无恢复。内固定并发症有；钉尾螺母松动脱落1例，椎弓根螺钉位置不良4例计9枚。结论：应用椎体间植骨，人工椎体并辅以前。后路内固定可有效重建脊柱稳定性，促进患者术后早期康复。