脊柱内固定翻修的原因和对策

目的：回顾性分析脊柱内固定翻修手术的原因，寻求避免内固定失败或失效的对策。方法：本组3l例患者，男20例，女11例，年龄22—58岁，颈椎病前路带锁钢板内固定术后钢板螺钉位置不佳、松动脱出4例，颈椎前路Cage松动或脱出l例，胸腰骶椎骨折内固定椎弓根螺钉位置不佳9例，松动或脱出3例，螺钉断裂3例，胸腰椎前路钢板松动2例，术后矫形丧失出现后凸畸形5例，腰椎BAK脱出2例。内植物选择不当2例。临床症状有畸形、局部疼痛、肢体疼痛麻木等。结果：内固定选择不当或螺钉位置不佳等引起内固定失败和/和失效的为22例，占70．9％；内植物断裂4例，占12．9％，患者过早负重或外伤引起的5例，占16．1％。共18例更换内植物，其它13例调整内植物位置。术后随访6个月-3年8个月，平均2年3个月。翻修术后19例患者局部症状及肢体疼痛麻木等症状消失，X线片上显示内植物位置良好，原有畸形消失；2例吞咽困难获得改善，其它患者无不适主诉。结论：技术性原因是造成翻修手术的首要原因，其次是应力遮挡。应加强脊柱外科领域的专业培训。     

脊柱内固定翻修的原因和对策

目的回顾性分析脊柱内固定翻修手术的原因,寻求避免内固定失败或失效的对策.方法本组31例患者,男20例,女11例,年龄22～58岁,颈椎病前路带锁钢板内固定术后钢板螺钉位置不佳、松动脱出4例,颈椎前路Cage松动或脱出1例,胸腰骶椎骨折内固定椎弓根螺钉位置不佳9例,松动或脱出3例,螺钉断裂3例,胸腰椎前路钢板松动2例,术后矫形丧失出现后凸畸形5例,腰椎BAK脱出2例.内植物选择不当2例.临床症状有畸形、局部疼痛、肢体疼痛麻木等.结果内固定选择不当或螺钉位置不佳等引起内固定失败和/或失效的为22例,占70.9%;内植物断裂4例,占12.9%,患者过早负重或外伤引起的5例,占16.1%.共18例更换内植物,其它13例调整内植物位置.术后随访6个月～3年8个月,平均2年3个月.翻修术后19例患者局部症状及肢体疼痛麻木等症状消失,X线片上显示内植物位置良好,原有畸形消失;2例吞咽困难获得改善,其它患者无不适主诉.结论技术性原因是造成翻修手术的首要原因,其次是应力遮挡.应加强脊柱外科领域的专业培训.     

胸腰椎骨折内固定术后翻修原因分析

目的分析胸腰椎骨折术后翻修手术的原因,寻找对策。方法本组病人21例,男17例,女4例。年龄18～56岁。仍有神经压迫者9例,椎弓根钉位置不佳9例,椎弓根钉松动、脱出3例,包括椎弓根钉断裂1例。行彻底减压、调整椎弓根钉位置或重新行椎弓根钉固定。自体髂骨重新植骨。结果术后随访6～18个月,平均9个月。腰背部或下肢疼痛消失者3例,明显改善者8例,好转者5例,无疼痛加重者。神经损害有轻度改善。所有病人均显示植骨部位融合。结论椎弓根钉内固定器械是目前比较理想的脊柱内固定系统,但需彻底减压、保证椎弓根钉的正确位置及确实的植骨融合。     

胸腰椎后路内固定翻修术的原因及对策

目的:分析胸腰椎骨折后路内固定术后翻修术的常见原因,寻求减少内固定失败和内固定翻修的有效措施。方法:对因胸腰椎骨折后路内固定术后需要进行翻修术的35例患者的内固定材料、翻修原因等进行回顾性分析。结果:本组病例随访3~46个月,平均18.5个月。按照VAS、ODI评分对患者主观感觉进行疗效判定,优10例,良17例,可8例。结论:严格掌握内固定的适应证、术中操作规范,是减少翻修的有效途径,翻修手术只要处理得当,仍可获得较好的疗效。     

严格脊柱内固定适应证,提高翻修手术效果

脊柱外科的核心理论是清除病变、矫正畸形、解除神经压迫并恢复和重建脊柱生理功能，脊柱生物力学和生理解剖功能的重建或(和)恢复是各种技术要达到的目标。20世纪90年代后期，我国脊柱外科各种器材和技术经历了高速引进、高速发展的时期。尤其是AO新理念、新技术的广泛普及，为我国骨科尤其脊柱外科的发展提供了良好的契机。在我国各大城市的相关医院逐步开始采用现代先进的内固定技术，取得了卓有成效的结果，并产生相     

颈椎翻修手术的原因及对策

目的 探讨颈椎翻修术的适应证、手术方式及其临床疗效.方法 自1998年4月～2007年12月,对21例颈椎手术后患者进行了翻修手术.翻修手术距离首次手术的时间2～42个月,平均15.3个月.所有病例均出现临床症状,其中表现为放射性颈肩痛16例、颈部活动受限5例,原有的脊髓受压表现加重8例,再次出现新的脊髓压迫症状7例.首次手术的术前诊断包括:下颈椎骨折脱位6例,神经根型颈椎病2例,脊髓型颈椎病9例,颈椎不稳4例.手术方式包括:单纯前路减压加自体髂骨植骨4例,前路减压加颈椎前路钢板固定8例,前路减压加Cage融合2例,前路椎体次全或全切除加内固定3例,后路CerviFix单纯内固定3例,后路双开门减压1例.结果 本组术后疗效优良13例(61.9%),好转6例(28.6%),无效及加重各1例(9.5%).21例术前评分2～14(8.65±0.37)分,术后8～16(14.27±0.69)分,差异有显著性(P<0.01).植骨于术后3～6个月融合.未出现喉上、喉返神经损伤、气管食管漏、脑脊液漏以及呼吸系统并发症.结论 颈椎翻修术式视具体情况而定,术前宜详细制定手术方案,彻底减压与正确的固定是手术成败的关键.     

脊柱后路减压融合内固定术失败原因分析

目的探讨脊柱后路减压融合内固定术的失败原因及防治措施。方法统计265例采用脊柱后路减压融合内固定术中和术后失败的病例,分析发生原因并探讨预防措施。结果265例患者中,术中失败9例,占3．4％,其中椎弓根爆裂3例,硬脊膜撕裂6例;术后失败28例,占10．6％,其中脑脊液漏5例,切口血肿2例,深部感染2例,椎间隙感染1例,神经根刺激症6例,内固定失败5例,植骨不融合4例,术前诊断失误4例。结论脊柱后路减压融合内固定术并发症较多,应严格掌握手术适应症,术中仔细操作,术后密切观察,积极预防和及时处理并发症。     

病变椎体部分切除、髂骨植骨及内固定术治疗脊柱结核

目的:探讨病变椎体部分切除、植骨、内固定手术治疗脊柱结核的临床效果。方法:对55例脊柱结核患者,术前抗痨治疗9~38d后采用前路病变椎体部分切除、大块髂骨支撑植骨、前路或后路器械内固定手术。融合2个椎间隙以下者行前路固定24例;融合3个椎间隙以上者行后路固定31例,其中前后路同期手术者14例,分两期手术者17例。术后负压引流3~5d。结果:随访24~70个月,平均38个月。24例伴脊柱畸形者后凸Cobb角由术前平均22°矫正至术后平均9°,随访时平均11°。19例伴神经功能障碍者均有不同程度恢复。术后半年87%的患者血沉达到正常,CRP93%达到正常;1例出现并发症,经再次手术治愈。X线片复查见全部患者于术后3~6个月(平均5.5个月)植骨愈合,均恢复了正常生活与工作。结论:病变椎体部分切除、植骨、内固定术病灶清除彻底,病椎骨融合快,复发率低,患者卧床时间短,缩短了脊柱结核的疗程,是治疗脊柱结核的有效术式。     

胫骨平台骨折术后行内固定翻修的治疗策略

[目的]探讨胫骨平台骨折术后行内固定翻修的指征、策略和临床效果.[方法]回顾2006年10月～2009年9月收治的胫骨平台骨折术后患者23例,均为首次术后4～12周症状改善不佳或出现内固定失败后来本院就诊.术前Schatzker分型Ⅳ型6例,V型7例,Ⅵ型10例.入院后评估首次手术的不足并制定个体化的翻修手术方案.术中对骨折行重新复位,调整关节面和膝关节力线,并选择恰当的锁定或非锁定接骨板对内侧、外侧及后侧骨块进行充分固定.术后视膝关节稳定程度尽早开始功能锻炼.[结果]术后未发生感染、深静脉血栓等早期并发症.随访骨折均愈合良好,平均愈合时间为12.7周,未发现复位丢失和内固定失败.术后12个月膝关节功能评分(HSS)达77.9,较术前明显改善(P=0.000).[结论]笔者认为胫骨平台骨折术后翻修的指征包括严重的关节面塌陷(>5mm)、膝关节力线不良(胫骨平台内翻角≧95°或≦80°)以及固定不充分.针对性的翻修手术辅以术后早期功能锻炼可获得良好的治疗效果.     

脊柱后路去松质骨截骨术用于脊柱畸形翻修手术的安全性和有效性

目的 :探讨脊柱后路去松质骨截骨术(vertebral column decancellation,VCD)应用于脊柱畸形翻修手术中的安全性和有效性。方法:回顾性分析2010年1月~2012年1月在我院接受脊柱畸形翻修手术的20例患者的临床资料,年龄17~58岁(34.5±11.6岁),男12例,女8例。强直性脊柱炎后凸畸形6例,先天性半椎体后凸畸形4例,结核性脊柱侧后凸畸形4例,先天性侧后凸畸形3例,青少年特发性脊柱侧凸3例。翻修手术距初次手术时间为5.6±3.3年(1~16年)。翻修术前10例冠状面失衡患者冠状面Cobb角45°~85°(64.2°±15.6°),17例矢状面失衡患者矢状面畸形后凸Cobb角75°~110°(92.7°±9.7°)。均在插管全麻下行VCD进行畸形矫正。记录患者翻修手术时间、术中出血量及围手术期并发症等一般情况。所有患者翻修术前、术后1周及末次随访均拍摄包括骨盆的站立位脊柱全长正侧位X线片,测量脊柱矢状面、冠状面Cobb角,冠状位顶椎偏移距离、双肩相对高度差,矢状面偏移距离、矢状位腰前凸角、胸腰段后凸角、骨盆倾斜角、骨盆入射角及骶骨倾斜角。采用SRS-22调查表评估患者术前及术后6个月生存质量。结果 :均顺利完成手术,平均截骨椎体数量1.5±0.6个(1~2个)。手术时间为4~6.5h(5.3±0.7h),术中出血量为600~1300ml(830.0±150.5ml)。所有患者术中脊髓监测未发现在复位过程中有体感诱发电位(SEP)及运动诱发电位(MEP)异常变化,术中唤醒试验患者下肢运动感觉功能正常。术后切口均Ⅰ期愈合。3例发生脑脊液漏,2例后凸畸形患者术后并发肠系膜上动脉综合征,围手术期未发生感染、呼吸衰竭、下肢深静脉血栓等其他并发症。住院时间13.9±2.4d。随访时间18~40个月(27.6±2.8个月),随访期间未出现内固定棒断裂、螺钉松动及深部感染等并发症。冠状面和矢状面畸形获得良好矫正,术后1周冠状面和矢状面Cobb角分别矫正至15.7°±4.9°、28.7°±8.7°。术后1周脊柱冠状面和矢状面Cobb角、顶椎偏移距离及双肩相对高度差、矢状面偏移距离与翻修术前比较均明显变小(P0.05),末次随访时与术后1周比较无统计学差异(P0.05);脊柱-骨盆矢状面参数除骨盆入射角与术前比较无统计学差异(P0.05)外,腰前凸角、胸腰段后凸角、骨盆倾斜角及骶骨倾斜角与术前比较均有明显改善(P0.05)。术后1周冠状面Cobb角矫正率为(75.5±4.5)%,矢状面Cobb角矫正率为(63.5±5.7)%;末次随访时与术后1周比较,冠状面矫形丢失率为26.5%,矢状面矫形丢失率为34.1%。翻修术后6个月SRS-22量表功能、疼痛、外观、精神健康、满意度评分与翻修术前比较均明显增加(P0.05)。结论:VCD在脊柱畸形翻修手术中可重新恢复脊柱矢状面、冠状面的平衡和稳定,尤其在脊柱矢状面平衡的恢复中有良好的效果,同时可避免脊髓过度短缩、神经卡压等并发症,是一种较安全有效的补救措施。     

腰椎内固定多次翻修原因初步探讨(附9例报告)

目的: 初步分析腰椎内固定多次翻修的原因, 并提出预防措施。方法: 自 1994年4月~2004年 2月, 共收治腰椎内固定多次翻修病例 9例 (31次), 患者均接受 2~4次腰椎内固定翻修术。翻修原因累计有: 3例内固定指征扩大 (3次), 2例内固定选用不当 (2次); 6例椎弓根螺钉位置错误(9次、21枚), 2例松动或脱出 (4次、7次), 2例螺钉断裂 (3次、3枚), 2例腰椎BAK脱出 (2次、3枚 ), 2例腰椎肿瘤复发 (6次)。结果: 扩大内固定指征或技术不当引起内固定失败 5例, 占 55. 6%; 未能综合考虑腰椎应力分布致内植物失败 4例, 占 33. 3%。腰椎骨巨细胞瘤行囊内切除后复发, 进行多次翻修, 占 16. 6%。结论: 初次不恰当的内固定及内固定指征的扩大是多次翻修的主要原因。掌握内固定指征、综合考虑下腰椎的生物力学是避免多次内固定的主要方法。     

A further development in spinal instrumentation

Summary The purpose of this paper is to describe the concepts and use of a new, versatile instrumentation system, the universal spine system (USS), that has been designed to have wide application for pathology of the thoracolumbar spine. Many instrumentation systems for thoracolumbar spinal surgery now exist that were each originally designed to address specific areas of spinal pathology. For example, the recent systems designed to treat scoliosis deformities do not provide the instrumentation and implant support to adequately address other spinal disorders, such as fractures. In addition, most posterior implant systems were not designed for use anteriorly, and vice versa. As a result, surgeons have been required to become familiar with several different instrumentation systems in order to meet the varied needs of a spinal surgery practice. The objective of designing a new system was to simplify the surgical treatment of the commonly encountered spinal disorders by providing the surgeon with a single set of instruments and implants that could be used to treat tumors, trauma, deformities, and degnerative conditions affecting the thoracolumbar spine, via either an anterior or a posterior approach. This paper describes the development of the concepts, instruments, and implants of the USS and provides examples of its application in several case illustrations.     

Neuropathology with spinal instrumentation

Neurohistologic examination of the spinal cord and cauda equina were compared for 28 beagles undergoing anterior and posterior spinal destabilization procedures--Group I (n = 7), destabilized operative controls; Group II (n = 7), posterolateral bone grafting; Group III (n = 7), Harrington distraction instrumentation and posterolateral fusion; and Group IV (n = 7), Luque rectangular instrumentation and posterolateral fusion. All dogs had appeared neurologically intact upon repeated examinations prior to death. Neurohistological abnormalities (Wallerian degeneration of the dorsal columns, corticospinal tracts, and nerve roots, focal cystic degeneration, and intraspinal central cavitation) occurred in only 1 of the 14 animals (7%) in Groups I and II (noninstrumented) and in 9 of the 14 animals (64%) in Groups III and IV (instrumented). This result is statistically significant (p less than 0.001). Transient sensory disturbances and radicular paresthesias have been described in clinical reports of spinal instrumentation. It is probable that subclinical neurologic injuries, such as intraspinal and nerve root infarction in posterior neural tissue, can occur with the use of sublaminar hooks or wires. The chondrodystrophic beagle spinal model in this study should be considered a "worst case situation," and the clinical incidence of neurohistologic changes is expected to be lower.     

Predisposing factors for surgical site infection of spinal instrumentation surgery for diabetes patients

Purpose

Diabetes mellitus (DM) is known as an important risk factor for surgical site infection (SSI) in spine surgery. It is still unclear however which DM-related parameters have stronger influence on SSI. The purpose of this study is to determine predisposing factors for SSI following spinal instrumentation surgery for patients with DM.

Methods

110 DM patients (66 males and 44 females) who underwent spinal instrumentation surgery in one institute were enrolled in this study. For each patient, various preoperative or intraoperative parameters were reviewed from medical records. Patients were divided into two groups (SSI or non-SSI) based on the postoperative course. Each parameter between these two groups was compared. Univariate and multivariate analyses were performed to determine predisposing factor for SSI.

Results

The SSI group consisted of 11 patients (10 %), and the non-SSI group of 99 patients (90 %). Univariate analysis revealed that preoperative proteinuria (p = 0.01), operation time (p = 0.04) and estimated blood loss (p = 0.02) were significantly higher in the SSI group compared to the non-SSI group. Multivariate logistic regression identified preoperative proteinuria as a statistically significant predictor of SSI (OR 6.28, 95 % CI 1.58–25.0, p = 0.009).

Conclusions

Proteinuria is a significant predisposing factor for SSI in spinal instrumentation surgery for DM patients. DM patients with proteinuria who are likely to suffer latent nephropathy have a potential risk for SSI. For them less invasive surgery is recommended for spinal instrumentation. In this retrospective study, there was no significant difference of preoperative condition in glycemic control between the two groups.     

寰枢椎脱位手术后翻修的原因及策略

目的 :分析寰枢椎脱位手术后翻修的原因,探讨其策略。方法 :回顾性分析15例寰枢椎脱位手术后翻修患者,男11例,女4例,翻修时年龄15~68岁(46.60±14.95岁);两次手术相隔2~120个月(28.73±38.59个月)。根据影像资料及手术探查情况分析翻修原因。翻修手术中均行8~10kg颅骨牵引及后方松解;后方结构完整患者行后路固定,根据松解后复位情况决定是否选择前路松解术;1例后路减压患者行前路松解复位固定术。导航模板辅助置入寰枢椎螺钉;自体髂骨松质骨颗粒植骨。随访观察寰枢椎复位、螺钉位置、植骨融合及手术疗效。结果:翻修原因,减压或复位不足10例,内固定失败3例,植骨未融合3例(含植骨未融合致内固定失败1例)。15例翻修手术中,14例为后路固定手术,1例为前路固定手术。通过术中颅骨牵引及充分松解,13例获得解剖复位;2例因广泛骨性融合,无法牵引复位,切除齿状突后彻底减压。导航模板辅助下共置入寰枢椎螺钉42枚,均一次性置入;置钉准确率97.6%。随访3~36个月(16.0±4.2个月),所有病例骨性融合,融合时间为3~6个月(3.7±0.5个月);末次随访JOA评分为13.8±3.1分(11~16分),较术前评分8.1±2.3分(6~11分)明显提高,改善率为(64.0±21.2)%(45.4%~88.8%)。结论:寰枢椎脱位手术后翻修的原因为减压或复位不足、内固定失败以及植骨未融合。充分的术中松解、8~10kg的颅骨牵引、恰当的骨质切除减压有利于翻修术中寰枢椎的复位,导航模板辅助有利于提高置钉准确性。     

三椎体复位固定行腰椎滑脱翻修手术探讨

目的：分析腰椎滑脱症手术失败原因,探讨三椎体复位固定翻修腰椎滑脱症手术失败病例的疗效。方法：回顾性分析2009年1月至2012年12月收治的19例腰椎滑脱症翻修手术病例的临床资料,男12例,女7例;年龄36-68岁,平均51.5岁。其中滑脱节段复位丢失6例,内固定物松动或断裂5例,滑脱加重8例。临床症状有下腰部疼痛、单侧或双侧下肢疼痛麻木等。翻修手术采用后路三椎体椎弓根钉内固定,后路减压、复位,椎体间加后外侧植骨,对初次手术后发生椎弓根钉松动或断裂的椎体采用取出松动或断裂的螺钉,换用加粗或加长椎弓根螺钉进行再次置入,或者采用骨水泥灌注,置入椎弓根螺钉。应用X线正侧位片和伸屈动力位片评价椎间融合的效果,并采用JOA评分对疗效进行评定。结果：翻修手术后均获随访,时间为10-30个月,平均18个月。X线显示所有翻修手术病例植骨融合良好,植骨融合时间5.5-7个月,滑脱椎体再次复位后矫正度无丢失,椎弓根螺钉无松动及断裂。JOA评分改善率为（78.06±3.90）%,以患者手术前及术后6个月随访时的JOA评分进行统计学分析,Ⅰ度滑脱3例,术前评分13.33±1.53,术后26.33±0.58;Ⅱ度滑脱7例,术前评分12.85±2.19,术后26.29±2.21;Ⅲ度滑脱9例,术前评分12.21±2.73,术后26.44±1.81。手术前后比较差异有统计学意义（P〈0.01）。结论：腰椎滑脱症初次手术失败原因主要与内固定物松动断裂和植骨不融合有关。翻修手术采用三椎体椎弓根钉内固定,可获得坚强内固定、充分减压、植骨融合,结合术后对患者功能锻炼的指导,可以取得满意的治疗效果。     

Anterior thoracoscopic surgery followed by posterior instrumentation and fusion in spinal deformity

Many authors believe thoracoscopic surgery is associated with a lower level of morbidity compared to thoracotomy, for anterior release or growth arrest in spinal deformity. Others believe that anterior release achieved thoracoscopically is not as effective as that achieved with the open procedure. We evaluated the clinical results, radiological correction and morbidity following anterior thoracoscopic surgery followed by posterior instrumentation and fusion, to see whether there is any evidence for either of these beliefs. Twenty-nine patients undergoing thoracoscopic anterior release or growth arrest followed by posterior fusion and instrumentation were evaluated from a clinical and radiological viewpoint. The mean follow-up was 2 years (range 1–4 years). The average age was 16 years (range 5–26 years). The following diagnoses were present: idiopathic scoliosis (n = 17), neuromuscular scoliosis (n = 2), congenital scoliosis (n = 1), thoracic hyperkyphosis (n = 9). All patients were satisfied with cosmesis following surgery. Twenty scoliosis patients had a mean preoperative Cobb angle of 65.1° (range 42°–94°) for the major curve, with an average flexibility of 34.5% (42.7°). Post operative correction to 31.5° (50.9%) and 34.4° (47.1%) at maximal follow-up was noted. For nine patients with thoracic hyperkyphosis, the Cobb angle averaged 81° (range 65°–96°), with hyperextension films showing an average correction to 65°. Postoperative correction to an average of 58.6° was maintained at 59.5° at maximal follow-up. The average number of released levels was 5.1 (range 3–7) and the average duration of the thoracoscopic procedure was 188 min (range 120–280 min). There was a decrease in this length of time as the series progressed. No neurologic or vascular complications occurred. Postoperative complications included four recurrent pneumothoraces, one surgical emphysema, and one respiratory infection. Thoracoscopic anterior surgery appears a safe and effective technique for the treatment of paediatric and adolescent spinal deformity. A randomised controlled trial, comparing open with thoracoscopic methods, is required. Received: 11 October 1999 Revised: 20 April 2000 Accepted: 16 May 2000     

Isolated posterior instrumentation for selected cases of thoraco-lumbar spinal tuberculosis without anterior instrumentation and without anterior or posterior bone grafting

Purpose

The aim of this prospective study is the analysis of the clinical and radiological outcomes of active thoraco-lumbar spinal tuberculosis treated with isolated posterior instrumentation without any posterior bone grafting or anterior inter-body bone grafting or anterior instrumentation.

Methods

The study was a prospective follow-up of 25 patients with active thoraco-lumbar spinal tuberculosis who underwent posterior spinal instrumentation with pedicle screws and rods. These patients had posterior stabilization of the involved segment of the spine without anterior or posterior bone grafting. The mean duration of follow-up was 3.3 years and the minimum duration of follow-up was 2 years.

Results

The mean kyphotic angle improved from 32.4° pre-operatively to 7.2° in the early follow-up period. Following a minor loss of correction during follow-up, the mean kyphotic angle settled at 11.5° at the time of final follow-up. Inter-body bony fusion was noticed at the final follow-up in all patients despite the absence of anterior bone grafting or cages.

Conclusion

Posterior instrumented stabilization followed by chemotherapy seems to be adequate for obtaining satisfactory healing of the lesions. Anterior inter-body bony arthrodesis occurs despite the absence of anterior bone grafts or cages. Careful patient selection is critical for successful outcome with this technique.