Chronic compression of the cervical myelon as complication of anterior interbody fusion (AIF): neurological improvement after late anterior decompression. Case report

Severe neurological deficits directly related to intraoperative injury of the spinal cord and the nerve roots is rare complication of anterior interbody fusion (AIF) in cervical spondylosis. A case of radiculopathy and Brown-Séquard Syndrome caused by a bone fragment following AIF in which a late anterior decompression and fusion of the cervical spine was performed four years after the initial operation is presented. Immediate relief of the radicular pain, improvement of the spasticity, and better spincter control could be achieved. Therefore, patients with chronic anterior compression of an incomplete spinal cord injury after AIF may benefit from a late anterior decompression and fusion.     

Single level arthrodesis as treatment for midcervical fracture subluxation: a cohort study

Although many different techniques exist for fusion of midcervical facet fracture dislocations, limiting arthrodesis to a single level could have a theoretical advantage: fewer fused segments could lessen long-term negative effects of fusion on adjacent segments. Therefore, we prospectively treated 22 consecutive patients with midcervical fracture dislocation without vertebral body fracture with single level arthrodesis even if anterior/posterior surgery were required. Twelve patients with unilateral facet subluxation underwent anterior cervical discectomy, distraction reduction with Caspar posts (AESCULAP, Tuttlingen, Germany) with allograft fusion and anterior cervical plating. Ten patients with any component of bilateral facet subluxation underwent anterior cervical discectomy, distraction reduction with Caspar posts, allograft fusion and plating followed by posterior lateral mass plating. No patients demonstrated worsening of nerve root or spinal cord function postoperatively. Interbody stability occurred in all cases. Only complications were 4 cases of pneumonia, 1 case of wound leakage, and 1 case of superficial wound infection. Good reduction was achieved for both unilateral and bilateral facet fractures. Single level interbody arthrodesis is safe and effective strategy with both unilateral and bilateral facet fractures. Single level arthrodesis may also offer long-term benefit compared with multilevel fusions.     

Recovery of nerve root function after complete quadriplegia from cervical spine fractures

Thirty-five patients with complete myelopathies secondary to cervical spine fractures from C-4 to C-7 underwent spinal decompressions and fusions between 1975 and 1981. Twenty-five of these patients underwent simultaneous nerve root decompressions, 23 with an accompanying anterior decompression and fusion and 2 with an accompanying posterior fusion. Substantial recovery of nerve root function occurred in 15 of these patients. A posterior reduction and fusion without nerve root decompression was performed in each of the remaining 10 patients. None of these patients demonstrated a significant improvement neurologically. Operation for nerve root decompression is indicated in selected victims of spinal cord injury.     

Circumspinal decompression for thoracic myelopathy due to combined ossification of the posterior longitudinal ligament and ligamentum flavum

Ossification of the posterior longitudinal ligament (OPLL) combined with ossification of the ligamentum flavum (OLF) in the thoracic spine can result in serious myelopathy, leading to circumferential compression of the spinal cord in advanced stages of the disease. The authors performed circumspinal decompression (circumferential decompression of the spinal cord) on these patients. This operation consists of two steps: posterior and lateral decompression of the spinal cord by removal of the OLF (first step) and anterior removal of the OPLL for anterior decompression (second step), followed by interbody fusion. In the first step, two deep parallel gutters, covering the extent of the OPLL to be removed anteriorly, are drilled down from the rear into the vertebral body along both sides of the dura to easily and safely remove the OPLL anteriorly at the second step. In the second step, the surgical approach varies according to the affected level; costotransversectomy in the upper thoracic spine and standard thoracotomy in the middle or lower thoracic spine. According to the authors, circumspinal decompression is not an easy procedure, but from their results in 10 patients, they identify it as a radical and promising surgical procedure.     

Radiculopathy caused by osteoporotic vertebral fractures in the lumbar spine

The clinical features of radiculopathy caused by osteoporotic vertebral fractures (OVFs) in the lumbar spine were investigated in 66 patients treated for pain caused by OVFs from January 2006 to December 2009. Ten of the patients complained of persistent radiculopathy. The cause of radiculopathy was initially diagnosed as lumbar canal stenosis (LCS) in seven patients, lumbar foraminal stenosis (LFS) in two, and both in one. One patient with LFS had reduced pain with conservative treatment, and the other nine needed surgical treatments. LCS was treated with posterior decompression, and LFS complicated with LCS at the same spinal level was treated with posterior lumbar interbody fusion (PLIF). Vertebroplasty was performed for one patient with LFS to attain indirect nerve root decompression achieved as a result of vertebral reconstruction and stabilization. Four of the patients treated with posterior decompression for LCS suffered from residual radiculopathy postoperatively, which was caused by LFS at the same level or the level below the treated level. Two patients underwent second operative procedure (PLIF) for recurrent radiculopathy. The Japanese Orthopedic Association and Visual Analogue Scale scores of the pain improved after operations, but the scores of the patients treated without spinal fusion gradually worsened during the follow-up period, whereas the scores of the patients treated with PLIF remained stable at various levels. Seven of the ten patients developed LFS following OVF, suggesting that radiculopathy following OVF involves LFS with high frequency.     

Anterior decompression via a wide transvertebral approach and a ceramic insert in a patient with cervical degenerative disease

BACKGROUND: The transvertebral approach is useful for decompression in patients with cervical radiculopathy; because the intervertebral disk is preserved, moveability is retained. We performed wide deletion of the vertebral body to increase the patient population eligible for treatment with this approach and include patients with compression of the cervical spinal cord. METHODS: In patients undergoing anterior decompression, we performed vertebrotomy (13 x 8 mm) at the midline of the cervical vertebral body at the upper level using a surgical saw. The resulting hole facilitates decompression of the cervical cord and nerve root; a ceramic insert is introduced in the area of deletion. To prevent graft extrusion, the bilateral wings of the bone graft are fastened with bioabsorbable screws. RESULTS: We used this approach in 163 patients with several cervical diseases. Collapse of the vertebral body and fusion of the operated intervertebral disk were encountered in only 1 patient (0.61%). There was no significant difference between pre- and postoperative alignment. Reoperation was required in 7 patients whose symptoms did not improve, in 1 with disk hernia, in 5 with severe spondylosis, and in 1 with combined-type OPLL. CONCLUSIONS: Although this approach is appropriate in patients undergoing cervical anterior decompression, the narrowness of the visual field may result in insufficient decompression, and its indication is restricted to patients with cervical disk hernia, mild cervical spondylosis, and segmental OPLL. In patients with segmental instability, continuous or combined OPLL, severe cervical spondylosis, and kyphosis, this approach should not be used.     

胸腰椎爆裂骨折前路减压手术疗效分析

目的评价脊柱前路减压、植骨内固定手术治疗胸、腰椎爆裂骨折伴脊髓损伤的疗效。方法23例胸腰椎爆裂骨折伴脊髓损伤病例采用前路脊髓减压、植骨、前路钢板内同定术，通过术前、术后影像学对比，了解椎间隙高度、植骨融合等情况，以Frankel评定法来评价病人神经功能恢复情况。结果23例患者术后随访4～16个月，平均9．5个月，全部病例椎间植骨均牢固融合，椎间高度和生理曲度保持满意．钢板螺钉未松动．神经功能恢复良好．有效恢复率为94％。结论胸腰椎爆裂骨折伴脊髓损伤采用脊髓前路减压、植骨固定方法可使骨折减压彻底．植骨融合率高，能有效维持椎间高度和生理曲度，有利于神经功能恢复．是治疗严重胸腰椎爆裂骨折的理想方法之一。     

Cervical ossification of the posterior longitudinal ligament: factors affecting the effect of posterior decompression

Objective: Decompression procedures for cervical myelopathy of ossification of the posterior longitudinal ligament (OPLL) are anterior decompression with fusion, laminoplasty, and posterior decompression with fusion. Preoperative and postoperative stress analyses were performed for compression from hill-shaped cervical OPLL using 3-dimensional finite element method (FEM) spinal cord models.

Methods: Three FEM models of vertebral arch, OPLL, and spinal cord were used to develop preoperative compression models of the spinal cord to which 10%, 20%, and 30% compression was applied; a posterior compression with fusion model of the posteriorly shifted vertebral arch; an advanced kyphosis model following posterior decompression with the spinal cord stretched in the kyphotic direction; and a combined model of advanced kyphosis following posterior decompression and intervertebral mobility. The combined model had discontinuity in the middle of OPLL, assuming the presence of residual intervertebral mobility at the level of maximum cord compression, and the spinal cord was mobile according to flexion of vertebral bodies by 5°, 10°, and 15°.

Results: In the preoperative compression model, intraspinal stress increased as compression increased. In the posterior decompression with fusion model, intraspinal stress decreased, but partially persisted under 30% compression. In the advanced kyphosis model, intraspinal stress increased again. As anterior compression was higher, the stress increased more. In the advanced kyphosis +?intervertebral mobility model, intraspinal stress increased more than in the only advanced kyphosis model following decompression. Intraspinal stress increased more as intervertebral mobility increased.

Conclusion: In high residual compression or instability after posterior decompression, anterior decompression with fusion or posterior decompression with instrumented fusion should be considered.     

腰5椎体Ⅱ度以上峡部裂性滑脱的手术策略

目的探讨腰5椎体Ⅱ度以上峡部裂性滑脱的手术治疗策略。方法 2003年8月～2008年10月,应用经椎间孔腰椎间融合（transforaminal lumbar interbody fusion,TLIF）技术,以小关节突为中心椎管减压、椎间隙松解撑开复位、椎弓根钉棒系统补充复位固定、椎间隙打压植骨联合椎间融合器技术治疗腰5椎体Ⅱ度以上峡部裂性滑脱26例。结果经18～36个月（平均30个月）随访,滑脱椎体复位无丢失,椎间隙高度维持良好,下腰椎生理弧度恢复正常,椎弓根螺钉无断裂、松动,融合器无移位、沉降。25例获骨性融合。根据NaKai评分标准,优良率为84.6%。结论采用TLIF技术治疗腰5椎体Ⅱ度以上滑脱,神经根管减压是影响疗效的关键因素,滑脱椎体复位有利于神经根减压以及椎间融合率的提高,椎体间融合是维持长期疗效的基础。     

Anterior decompression and stabilization of the spine as a treatment for vertebral collapse and spinal cord compression from metastatic malignancy

During a ten-year period, 77 patients with spinal instability caused by metastatic pathologic fractures of one or more vertebrae were treated with anterior decompression and stabilization by replacement of the affected vertebral bodies with methylmethacrylate, polymerizing in situ, augmented by Knodt distraction rods positioned anteriorly. No postoperative external support was required, and the fixation achieved by this method was not affected adversely by subsequent irradiation at a mean of 4020 rads. Sixty-two patients had major neurologic impairments preoperatively and required spinal cord and/or nerve root decompression anteriorly prior to fixation. Of these, 26 had complete neurologic recovery postoperatively, 16 others improved significantly, 20 remained unchanged, and one patient deteriorated neurologically. Five patients suffered failures of fixation, although two were successfully restabilized after a second operation. The remaining 72 patients enjoyed good or excellent resolution of spine pain postoperatively, and, in patients surviving their underlying malignancies, stability did not deteriorate during the follow-up period ranging from 42 to 146 months. Six patients developed spinal instability from tumor lysis at a different level between five and 95 months postoperatively. All were treated with successful decompression and stabilization. There was one wound infection among the 83 anterior stabilization procedures. However, three of the six patients requiring secondary posterior stabilization suffered wound dehiscences, and three of these became infected.     

TLIF术式治疗双节段腰椎滑脱症的临床研究

【摘要】 目的 探讨经椎间孔椎间融合术(TLIF术)式治疗双节段腰椎滑脱症的手术疗效。方法 采用TLIF后路减压、复位、椎弓根螺钉内固定、椎间植骨融合术治疗双节段腰椎滑脱11例,按Lenke标准评价脊柱融合情况,按Henderson标准评价临床疗效。结果 所有病例均获得较大程度的复位,术后随访1~2年,根据Lenke标准评价脊柱植骨融合:A级10例,B级1例;根据Henderson标准评价临床疗效:优9例,良1例,可1例。结论〓TLIF术式治疗双节段腰椎滑脱症,其脊柱融合满意,疗效显著可靠。     

Cervical spine lateral approach for myeloradiculopathy: technique and pitfalls

BackgroundThe authors describe the rationale of cervical spine lateral approach technique to manage spondylotic myeloradiculopathy with its advantages, disadvantages, complications, and pitfalls.MethodsThe cervical lateral approach could be indicated to treat spondylotic myeloradiculopathy where anterior compression is predominant and the spine is straight or kyphotic without instability.ResultsUsing the present approach the lateral aspect of the cervical spine is easily reached and the vertebral artery is well controlled. The lateral part of the pathological intervertebral discs, uncovertebral joints, vertebral bodies and posterior longitudinal ligament are removed as necessary and decompression tailored to each patient to completely free the nerve roots and/or spinal cord.ConclusionThe cervical lateral multilevel corpectomy/foraminotomy technique allows wide anterior decompression of the spinal cord and complete unilateral nerve root decompression preserving spinal stability and physiological spinal motion.     

扩张式椎间融合器在腰椎融合术中的应用

目的探讨扩张式椎间融合器（expanding cage,EC）在腰椎融合术中应用的适应性、技术要点和疗效。方法本组47例患者,均行后路扩张式椎间融合术（PELIC）。术前分别诊断为腰椎管狭窄、腰椎间盘突出、腰椎滑脱和退变性腰椎不稳,经非手术治疗无效后,以手术对椎管及神经根管减压,用EC融合固定并植骨。术前、术后对患者的腰疼情况进行视觉痛觉自我评定尺（VAS）评分。结果所有患者术前症状消失,术中未发生神经损伤,随访最长时间为61个月,最短53个月,平均57．3个月,无假关节形成,无明显椎体塌陷。结论EC在腰椎融合术应用中具有融合可靠、症状改善明显等优点。     

颈椎前路手术早期并发症原因分析及对策

目的总结颈椎前路手术的术中、术后早期并发症,分析原因并提出对策。方法回顾1992年1月至2003年12月颈椎前路手术412例,男308例,女104例;年龄18～76岁,平均45.6±12.9岁。颈椎病258例,颈椎外伤138例,颈椎肿瘤8例,颈椎结核8例。412例患者,病史最短4小时,最长达20年,平均548d。全瘫58例(14.1%),不全瘫192例(46.6%),无瘫痪症状162例(39.3%)。麻醉包括三大类(5种)局麻(局部浸润35例、颈丛阻滞52例、局部浸润 颈丛阻滞6例、全麻318例、全麻 颈丛1例。前路减压、自体髂骨植骨融合33例,前路减压、椎间融合器椎间融合术32例,前路减压、自体髂骨植骨融合、前路钢板内固定术347例。结果共42例51例次出现早期并发症,并发症的例次发生率为12.37%。28例次(6.80%)同手术直接相关,喉上神经损伤5例次,喉返神经损伤4例次,颈部切口感染及血肿4例次,脊髓损害症状加重5例次,神经根损伤2例次,植骨块移位2例次,取骨区感染及血肿各1例次,钢板、螺钉松动2例次,螺钉位置不当1例次,食管瘘1例次;23例次(5.08%)同手术间接相关。结论降低颈椎前路手术并发症的发生率,不仅要熟悉颈椎前路临床解剖,提高手术技巧,还要做好颈椎前路手术围手术期的处理。     

经后路椎间植骨融合椎弓根钉内固定治疗腰椎失稳

[目的]探讨经后路椎体间植骨融合椎弓根钉内固定治疗腰椎失稳的临床疗效。[方法]对37例腰椎失稳的患者采用后路椎管、神经根管减压,椎弓根钉内固定,自体骨植骨治疗,并对术后植骨融合和手术效果进行评价。[结果]所有患者均获得随访,随访时间12～32个月(平均25个月)。术后融合情况:优29例,良8例;优良率100%。根据JOA标准疗效评定结果:术后JOA评分较术前明显增高(P0.05),术后优良率为92.9%,所有病例无螺钉折断、松动,无植骨块脱出、塌陷、移位,无马尾神经损伤等并发症。[结论]经后路椎间植骨结合椎弓根钉内固定治疗腰椎不稳提高了融合成功率,降低了手术花费,达到稳定脊柱解除症状的目的,治疗效果满意。     

胸、腰椎脊柱结核一期病灶清除前方钛网支撑矫形内固定

目的探讨胸、腰椎结核一期病灶清除、脊髓减压、前方畸形矫正、植骨融合内固定的疗效。方法本组19例,男11例,女8例;平均年龄43.3岁(15～66岁)。病变部位:胸椎8例,胸、腰椎7例,腰椎4例。2个椎体13例,3个椎体5例,4个椎体1例,无跳跃型。椎旁脓肿15例,髂窝流注性脓肿4例。本组患者皆伴有后凸畸形,平均Cobb角44.7°。术前血沉正常5例,其余为22～127mm/h。本组患者术前应用三联(异烟肼、利福平、链霉素)化疗2周,手术采用一期病灶清除、脊髓减压、前方钛网支撑畸形矫正、植骨融合内固定术。术后化疗持续10个月,定期进行脊柱影像学检查和血沉、肝功能检查。结果刀口皆为Ⅰ期愈合,无窦道。最先解除的症状是疼痛,随访8～29个月(平均17个月),畸形矫正、植骨融合满意,未见内固定失败;后凸角度平均矫正21.3°,脊髓功能皆有不同程度地恢复。3例胸、腰段结核术中出现胸膜破裂,1例术后气胸;4例出现神经根刺激症状,1例钛网位置欠佳。无脓胸发生和迟发性脊髓功能丧失。术后血沉恢复正常时间为2～8个月。结论胸、腰椎脊柱结核一期病灶清除、脊髓减压、植骨融合,同时前方钛网支撑畸形矫正和脊柱稳定性重建,在临床上取得了满意的疗效。未见使用在脊柱结核治疗过程中的支撑物和内固定物产生的不良反应。     

Treatment of Spinal Tuberculosis by Debridement,Interbody Fusion and Internal Fixation via Posterior Approach Only

Surgical treatment for spinal tuberculosis includes focal tuberculosis debridement, segmental stability reconstruction, neural decompression and kyphotic deformity correction. For the lesions mainly involved anterior and middle column of the spine, anterior operation of debridement and fusion with internal fixation has been becoming the most frequently used surgical technique for the spinal tuberculosis. However, high risk of structural damage might relate with anterior surgery, such as damage in lungs, heart, kidney, ureter and bowel, and the deformity correction is also limited. Due to the organs are in the front of spine, there are less complications in posterior approach. Spinal pedicle screw passes through the spinal three‐column structure, which provides more powerful orthopedic forces compared with the vertebral body screw, and the kyphotic deformity correction effect is better in posterior approach. In this paper, we report a 68‐year‐old male patient with thoracic tuberculosis who underwent surgical treatment by debridement, interbody fusion and internal fixation via posterior approach only. The patient was placed in prone position under general anesthesia. Posterior midline incision was performed, and the posterior spinal construction was exposed. Then place pedicle screw, and fix one side rod temporarily. Make the side of more bone destruction and larger abscess as lesion debridement side. Resect the unilateral facet joint, and retain contralateral structure integrity. Protect the spinal cord, nerve root. Clear sequestrum, necrotic tissue, abscess of paravertebral and intervertebral space. Specially designed titanium mesh cages or bone blocks were implanted into interbody. Fix both side rods and compress both sides to make the mesh cages and bone blocks tight. Reconstruct posterior column structure with allogeneic bone and autologous bone. Using this technique, the procedures of debridement, spinal cord decompression, deformity correction, bone grafting, and internal fixation can be completed with only one incision and surgical position, and the deformity correction efficiency is higher than anterior surgery.     

Anterior decompression and plate fixation in fracture dislocations of the lower cervical spine

Summary Surgical treatment of unstable traumatic injuries of the cervical spine can be carried out by a posterior or anterior approach, with different advantages and disadvantages. Twenty patients were treated with anterior decompression, interbody fusion with autogenous iliac bone graft, and osteosynthesis with a Louis anterior plate. The screws were inserted in the vertebral body without reaching the posterior vertebral wall. There were 18 male and 2 female patients, aged between 18 and 66 years (average 36 years). The osteoarticular lesion was in 8 cases a tear-drop fracture and in 12 a fracture-dislocation. The mechanisms of injury were flexion-compression, flexion-rotation, hyperflexion, and hyperextension. A complete spinal cord lesion was present in 10 cases, central cord syndrome in 5, isolated radiculopathy in 3, and anterior cord syndrome in 1; one patient had normal neurological function. At long-term follow-up fusion of the graft was observed in all cases without evidence of spinal malalignment, breakage of the implant, or aseptic hardware loosening. Neurological deterioration was not observed in any case. In one case, complicated by late infection, healing was uneventful after plate removal, surgical debridement, and antibiotic therapy. A fistula of the hypopharynx due to perforation of the piriform recess appeared following repeated bronchoscopy 12 months after surgery. There were no signs of implant loosening and the lesion was surgically repaired. From a neurological point of view the 10 patients with complete cord lesion remained unchanged; those with incomplete cord lesions improved by 1 or 2 degrees on the Frankel scale; those with isolated radiculopathies recovered fully; and the neurologically intact patient remained unchanged. The present study and the data reported in the literature prove that anterior surgery with plate fixation in cervical spine injuries allows the achievement of complete neural decompression by direct visual examination. On the other hand, posterior surgery can result in incomplete decompression and associated neurological deterioration. Anterior plate instrumentation has proved itself mechanically adequate, even if it is less stable than posterior constructs. The advantages of anterior surgery compared to those of posterior surgery are such that several specific risks are acceptable. Posterior surgery is nevertheless indicated if the lesion cannot be reduced preoperatively under closed conditions.Read at the International Meeting of the Cervical Spine Research Society, Athens, 25th–28th June, 1992     

胸腰段椎体骨折的手术治疗

目的探讨胸腰段椎体骨折的手术治疗方法及其临床疗效。方法回顾性分析2003年1月至2010年12月我院76例新鲜胸腰段椎体骨折手术治疗病例。其中T113例,T1219例,L;40例,L214例。根据AO胸腰椎骨折分类,A型骨折34例,B型骨折7例,c型骨折35例。术前脊髓损伤（americanspinalinjuryassociation,ASIA）分级,A级14例,B级14例,C级38例,D级5例,E级5例。胸腰椎损伤分类及损伤程度评分系统（thoracolumbarinjuryclassificationandseverityscore,TLICS）评分均大于4分。采用后路减压固定后外侧植骨融合术66例,前路减压固定椎体间植骨融合10例,其中多节段固定31例,单节段固定45例。根据Oswestry功能障碍指数（oswestrydisabilityindex,ODD评分标准和脊髓损伤ASIA分级结合椎体压缩率、Cobb角和椎管狭窄率变化进行术前和术后的疗效评价,并对术前和术后椎体压缩率、Cobb角和椎管狭窄率进行统计学分析。结果76例患者获得12～48个月随访,平均32个月。ODI术后平均手术改善率为62．5％,优良率为69．8％;术后脊髓损伤ASIA分级均有不同程度的改善;术后所有患者的椎体压缩率、Cobb角和椎管狭窄率均有明显改善,与术前相比差异均有统计学意义（P〈0．05）。结论根据胸腰段椎体骨折患者病情和影像学检查结果,确定椎体骨折节段、损伤程度、AO分类及脊髓损伤严重程度等,选择适合的手术方法：术中椎管彻底减压,恢复和重建椎体高度,坚强稳定的内固定和植骨融合,可避免术后椎体高度丢失、内固定松动及断裂等并发症,获得较好的手术疗效。     

退变性腰椎管狭窄症的手术治疗

目的探讨退变性腰椎管狭窄症（degenerative lumbar spinal stenosis,DLSS）手术治疗方法。方法回顾性分析2003年1月至2011年1月我院185例退变性腰椎管狭窄症手术治疗病例。其中神经根管狭窄6例,中央管狭窄179例。单节段狭窄者96例,双节段狭窄者55例,3个节段狭窄者34例。采用单纯开窗减压者6例,后路全椎板切除减压、后外侧植骨融合、内固定70例,后路全椎板切除减压、椎体间植骨融合、内固定109例。根据日本矫形外科学会腰腿痛评分系统（15分）进行术前和术后的疗效评价。结果 185例患者获得8～72个月随访,平均随访时间19.5个月。三种手术方法术后平均改善率分别为77.9%、78.8%和79.5%,优45例,良120例,可20例,优良率为89.2%。术后并发脑脊液漏6例。结论根据DLSS患者病情和影像学检查结果,确定狭窄的部位和节段,对神经根管狭窄者,采用单纯开窗减压;对中央管狭窄者,采用全椎板切除减压、椎体间植骨融合和/或后外侧植骨融合、椎弓根系统内固定,尤其是对于合并腰椎节段性不稳定、退变性滑脱、侧弯和后凸者,可获得满意的疗效。