术中椎管造影对胸腰椎骨折复位减压的意义

目的：应用术中椎管造影检测胸腰椎骨折伴不全瘫手术减压的程度。方法：应用ＡＦ系统椎弓根螺钉复位内固定的３３例胸要椎骨折伴不完全瘫患者,在Ｃ臂Ｘ线下行椎管造影,检测骨折复位及椎管的减压情况。结果：２８例（８４．８０％）造影显示椎管通畅,脊髓神经根无受压,未行椎板切开减压;２例硬膜囊破裂,２例椎间盘破裂突入椎管内,２例椎体激离骨折块突入椎管内,此５例给予有限的椎板减压,修补破裂的硬膜囊,取出破裂的椎间盘     

有限化手术治疗复发性腰椎间盘突出症

目的　评价有限化手术治疗复发性腰椎间盘突出症的疗效。方法　采用CT、MRI、CTM、脊髓造影定位 ,了解硬膜囊、神经根受压的程度和范围。手术有限切除病变节段椎板及关节突 ,摘除髓核 ,潜行扩大椎管、神经根管。结果　经 2～ 18年随访 ,优良 2 0例 ,可 2例 ,差 1例。结论　有限化手术能摘除髓核 ,也能行根管减压 ,脊柱损伤小 ,远期疗效好     

OLIF手术间接减压失败的风险因素分析

目的 探讨融合器高度和融合器位置等因素对OLIF手术间接减压效果的影响,同时分析OLIF术后间接减压失败的影响因素。方法 回顾性分析该科2019年3月～2022年3月开展OLIF手术的103例LSS患者资料,手术节段为L_2-3节段～L_4-5节段;其中单节段手术63例,两节段手术26例,三节段手术14例。测量以下影像学指标：硬膜囊直径,椎管直径,硬膜囊横截面积(cross sectional area, CSA),椎管CSA,左右侧关节下直径,左右侧黄韧带厚度和黄韧带面积,椎间盘突出物的直径,椎间盘高度,节段性前凸角,椎间孔高度和椎间孔面积等。所有患者均随访6个月以上,观察间接减压失败的发生率,并分析其影响因素。结果 103例患者均成功完成OLIF手术,与术前相比,患者术后6个月时的疼痛VAS评分均获得显著改善(P<0.001)。高度为14 mm的融合器(n=18)置入后,其硬膜囊直径、右侧黄韧带厚度和椎间盘突出物直径的收缩值等指标的改善程度,均显著大于高度为10 mm(n=9)和12 mm(n=76)的融合器(P<0.05)。融合...     

三维可视化技术在腰骶神经根成像中应用的进展

<正>正常成人的腰神经根从硬膜囊穿出后在神经通道里向外下斜向走行一段距离,最后紧贴上半椎间孔出孔,神经根与硬膜囊之间的夹角(根囊角)逐渐减小,从L1～L5的腰神经根在其通道中的行程从上至下逐渐变长,且直径逐渐增粗,下腰神经根更靠近其上位椎弓根的下缘,因此L4～S1神经根容易在脊神经通道内受到卡压,脊神经通道     

神经电生理监测在椎管内肿瘤患者术中应用的价值

目的:探讨神经电生理监测在椎管内肿瘤患者术中应用的价值。方法:2000年10月~2010年10月手术治疗椎管内肿瘤患者358例,均为硬膜内肿瘤,其中髓外硬膜下肿瘤234例,髓内肿瘤124例。术前均行肿瘤累及相应节段的肌电图(EMG)及体感诱发电位(SEP)检测。术中监测神经电生理变化,用SEP监测脊髓功能,EMG确定肿瘤切除范围。均在术中神经电生理监测下显微镜下操作完成手术。结果:358例患者术中自发性EMG监测无异常;124例髓内肿瘤患者术中应用激发性EMG确立"安全地带",判定病变切除范围,避免了"危险操作"。术中监测SEP异常36例,其中29例SEP波幅降低20%～30%时,监测人员提醒术者寻找原因,减少刺激、牵拉及压迫后10~20min,SEP波形逐渐恢复至术前水平;7例髓内病变患者SEP波幅降低超过50%,暂停手术操作后30min左右,SEP有所恢复,继续完成手术。358例患者均在神经电生理监测下显微镜下操作切除病变,肿瘤全切292例,其中硬膜内髓外肿瘤234例(100%)显微镜下全切,术中无SEP异常。髓内肿瘤124例,显微镜下全切58例(46.8%),次全或大部分切除66例(53.2%);7例术中SEP波幅降低超过50%的患者术后神经症状加重,其中6例用甲基强的松龙及神经营养药等治疗7~10d神经症状恢复至术前水平,1例改善不明显。结论:术中应用神经电生理监测指导椎管内肿瘤的切除,可提高肿瘤切除率,避免副损伤,提高肿瘤切除的安全性。     

脊柱胸腰段骨折截瘫合并胸外伤的治疗体会

目的总结胸腰段骨折截瘫合并严重胸外伤治疗经验。方法回顾自1989年7月-2002年7月,共收治22例胸腰段骨折伴截瘫并发严重胸外伤患者。胸外科处理情况包括胸腔闭式引流21例,气管切开7例,呼吸机辅助呼吸6例,开胸探查止血肺、膈肌修补6例,不稳定型骨折椎管狭窄硬膜囊受压并行后路椎管减压加经椎弓根系统复位内固定手术治疗12例,保守治疗10例。结果胸外伤治愈21例,死亡1例;截瘫治疗情况为痊愈4例,好转4例,无变化13例。结论正确处理胸腰段骨折和严重胸外伤两者的关系,及时后路手术解决截瘫和脊柱骨折,增加脊柱的稳定性,提高患者的生活质量。     

马尾神经根松弛症1例

患者男性，60岁。因腰及双下肢疼痛10年，加重伴间歇性跛行1年，于1995年5月28日入院。曾诊断为“坐骨神经痛”，治疗无效。查体见平腰状，下腰段压痛、放射痛、传导叩击痛（＋），双下肢肌肉萎缩，双足底、小腿外侧感觉减退，长伸肌Ⅲ-，双下肢直腿抬高试验30°。CT示L4-5、L5-S1间盘向后突入椎管内，压迫硬膜囊及神经根。以“腰椎间盘突出症”手术治疗。切除L5椎板，见椎管内脂肪消失，局部硬膜囊膨隆，张力大，无搏动，且硬膜囊壁菲薄、透明，可见其囊内的神经根。常规摘除突出的L4-5、L5-S1髓核。切开硬膜囊，无脑脊液流出，局部神…     

老年腰椎椎管狭窄症患者术中硬膜囊撕裂位置及术中术后处理对策

目的探讨老年腰椎椎管狭窄症患者手术发生硬膜囊撕裂的解剖学机制,比较撕裂位置及术中、术后处理对策。方法回顾性分析2012年01月~2014年01月本院行腰椎后路手术的216例〉70岁老年患者,记录患者一般资料、病程时间、术前诊断、手术方式和节段、术中硬膜囊撕裂的位置、术后脑脊液漏情况和处理方法以及并发症等。结果共计151例患者入选,其中男89例,女62例,年龄70~93岁,平均78.12岁。术中发生硬膜囊撕裂共计34例,术后出现脑脊液漏23例,硬膜囊撕裂位置发生率硬膜囊后外侧〉根袖〉硬膜囊外侧〉硬膜囊腹侧。术中采取硬膜囊缝合修补、明胶海绵压迫、生物蛋白胶粘合等处理,术后常规给予预防感染、神经根脱水、补液等治疗,均于术后3~10 d拔管,3~4周切口愈合,全部患者未出现严重并发症。结论 〉70岁老年腰椎椎管狭窄症患者术中硬膜囊撕裂及术后脑脊液漏的发生率高于整体人群,且多位于硬膜囊后外侧及根袖,术中及时发现并仔细缝合或修补破损的硬膜、术后间断夹闭引流管、延长拔管时间能获得良好的效果。     

下腰部神经根管的解剖学观察及临床意义

目的 探讨腰骶神经根管的形态、结构、走行及比邻组织病理改变的特点,提高对病因的认识和临床诊疗水平.方法 选择5具无脊柱疾患的成人腰骶椎段标本,依照后路椎管及神经根管手术探查的习惯入路,分别对下腰部椎管和神经根管后方冠状面、神经根管后壁、前壁及椎间盘横断面进行解剖及观察.结合临床78例腰骶椎手术患者的椎管和神经根管探查所见,相互印证.结果 下腰部神经根自硬膜囊穿出后,随着序列的下降,与硬膜囊的夹角也随之减小,而出发点则随之升高;在途径椎管内及椎间管内两个阶层中,前段一般不受退变及异常应力作用产生形变,增厚的黄韧带多为致病因,后段为纤维管道,不越过间盘组织,可能与骨退变及增生有更大的相关性.结论 神经根自硬膜囊发出后,因序列不同,出发点及角度均不同,与椎间盘关系亦不同,在作髓核摘除时应避免损伤;在整个神经根行走径路中,均可由自身的增生退变或以合并存在的形式导致途径的神经根发生嵌压引发临床症状和体症,由于病变部位和病变组织性质不同,手术方法也不同.     

后路椎间盘镜显微治疗腰椎椎管狭窄症

目的 报道显微后路椎间盘镜治疗退行性腰椎椎管狭窄症的临床效果。方法 选取退行性腰椎管狭窄症病例，椎板间隙入路椎间盘镜下行椎管减压，单侧单节段开窗减压23例，双侧单节段开窗减压12例，单侧双节段开窗减压9例，单侧双节段半椎板切除减压4例。结果 除1例术中硬膜破裂改常规手术外，其余病例均在手术显微镜下完成腰椎管减压术。所有病例获得5～18个月随访，平均8．3个月，优良率92％。结论 显微后路椎间盘镜治疗退行性腰椎管狭窄症具有手术创伤小、神经根减压彻底、术后恢复快的特点；单纯腰椎间盘膨出或突出、黄韧带肥厚和小关节增生引起的退行性腰椎管狭窄症是其适应证。     

Posture-dependent bilateral compression of L4 or L5 nerve roots in facet hypertrophy. A dynamic CT-myelographic study

In 12 patients with myelographic evidence of bilateral root involvement at the L3-L4 or L4-L5 levels postmyelographic computerized tomography (CT) studies were performed in flexion and extension. They showed concentric narrowing of the spinal canal in extension and widening with relief of nerve root involvement in flexion. This could be attributed to the presence of marked degenerative hypertrophy of the facet joints, narrowing the available space for dural sac and emerging root sleeves. In extension of the lumbar spine, bulging of the disc toward the hypertrophic facets causes a pincers mechanism at the anterolateral angles of the spinal canal with the risk of bilateral root compression. This mechanism is enhanced in these cases by marked dorsal indentation of the dural sac because of anterior movement of the dorsal fat pad in extension. The authors believe that the radiologically described mechanism forms the anatomic basis of neurogenic claudication and posture-dependent sciatica.     

Eccentric compression of the spinal canal causing dominantly contralateral-side symptoms

In this retrospective study, five patients are described in whom the dural sac at the thoracic and lumbar spine was compressed by a herniated disk or stenosis, located eccentrically in the spinal canal. In all of them, the symptoms or neurologic findings were dominantly in the limb contralateral to the side of compression. All five patients were operated on and the compressing disk or lamina was removed, resulting in immediate improvement of symptoms. In only one of the patients was the compression at the common level of L4-L5. In the remaining four patients, compression was at the low thoracic or upper lumbar spine. With the exception of one patient, the area of canal compression was greater than 50%.     

Axially loaded magnetic resonance image of the lumbar spine in asymptomatic individuals.

STUDY DESIGN: For this study, 43 asymptomatic individuals underwent magnetic resonance imaging of the lumbar spine in both supine psoas-relaxed position and supine axial compression in extension. The change in dural cross-sectional area between positions at each disc level was calculated. OBJECTIVES: To evaluate the effect of axial loading on asymptomatic individuals, as compared with the effect on patients who have clinical signs of lumbar spinal canal stenosis, and to assess the effect that different magnitude and duration of the applied load have on the dural cross-sectional area. SUMMARY OF BACKGROUND DATA: Degenerative changes in the spine are found in both symptomatic and asymptomatic individuals. A study of patients with suspected clinical lumbar spine encroachment examined in both psoas-relaxed position and axial compression in extension with computed tomographic myelography or magnetic resonance imaging of the lumbar spine is reported. A significant decrease in dural cross-sectional area was found, respectively, in 80% and 76% of the patients. METHODS: The study subjects underwent magnetic resonance imaging examinations in both psoas-relaxed position and axial compression in extension. The examination of the subject under axial compression in extension was performed with the lumbar spine in a supine position using a compression device. Degenerative changes in and adjacent to the spinal canal were registered. The dural cross-sectional areas were determined for psoas-relaxed position and axial compression in extension, then compared. In seven reexamined individuals, the dural cross-sectional area was calculated after an axial load corresponding to 25% and 50% of their body weight and a loading time of 5 to 60 minutes. RESULTS: A significant decrease in dural cross-sectional area from psoas-relaxed position to axial compression in extension was found in 24 individuals (56%), most frequently at L4-L5, and increasingly with age. In four individuals (5 disc levels), a decrease in dural cross-sectional area to less than 100 mm2 from psoas-relaxed position to axial compression in extension was found. In seven reexamined individuals, a significant decrease in dural cross-sectional area was found: in five after 5 minutes load of 25% of their body weight, and in two with 50% of their body weight. CONCLUSIONS: Using magnetic resonance imaging, a significant decrease in dural cross-sectional area after axial loading was found less frequently in asymptomatic than in symptomatic subjects. The decrease was more frequent at L4-L5, and increasingly with age. The load should be 50% of the subject's body weight applied for at least 5 minutes.     

马尾冗余症在腰椎管狭窄症患者中的临床意义及相关危险因素分析

目的:探究马尾冗余症(redundant nerve roots,RNRs)在腰椎管狭窄患者中的诊疗意义,并筛选与RNRs相关的危险因素。方法:回顾性分析2015年4月1日至2020年11月30日196例于皖南医学院弋矶山医院脊柱外科就诊的腰椎管狭窄症患者临床资料。根据是否出现RNRs将所有患者分为RNRs阳性组和RNRs阴性组。比较两组患者一般临床资料、影像学参数、视觉模拟评分(visual analogue scale,VAS)、Oswestry功能障碍指数(Oswestry disability index,ODI)等指标差异性,利用二元Logistic回归分析筛选与RNRs高度相关的危险因素。结果:RNRs阳性组59例,RNRs阴性组137例。196例腰椎管狭窄症患者RNRs发生率为30.10%(59/196)。两组患者VAS、ODI组间差异有统计学意义(P<0.05),RNRs阳性组患者临床症状较RNRs阴性组重。年龄、狭窄节段数、腰椎硬膜囊面积平均值、最狭窄节段及最狭窄节段硬膜囊面积差异有统计学意义(P<0.05)。二元Logistic回归分析显示狭窄节段数、椎...     

The effect of flexion-extension motion of the lumbar spine on the capacity of the spinal canal. An experimental study

The symptoms of lumbar spinal stenosis are often posture-dependent, and it is generally accepted that the capacity of the spinal canal is affected by flexion-extension motions of the lumbar spine. A study of spinal capacity in flexion-extension of ten cadaver specimens on the lumbar spine was done and measurements were obtained from the flexion-extension lateral myelograms. There proved to be a larger capacity of dural sac of 3.5 to 6.0 ml (4.85 +/- 0.75 ml) in flexion than in extension, and the differences were highly significant (P less than 0.001). In addition, the sagittal diameter of the dural sac and the length of the spinal canal increased from extension to flexion. Because of the effect of flexion-extension motion of the lumbar spine on the spinal capacity, we suggest that maintaining the lumbar spine in flexion is more suitable since spinal canal capacity is enlarged and symptoms may be mitigated.     

自控腰椎纵轴加压器诊断隐匿性腰椎退行性变

目的探讨自控腰椎纵轴加压器对隐匿性腰椎退行性变的诊断价值。方法采用自制"自控腰椎纵轴加压器"对120例腰腿痛(98例坐骨神经痛、22例腰痛)患者行腰椎纵轴加压CT/MR检查,所加压力不超过患者体质量的50%,并与常规腰椎CT/MR检查进行比较,硬膜囊面积减小(>15mm2)并降至75mm2以下、侧隐窝狭窄、椎间盘突出或程度增加等异常征像为腰椎纵轴加压检查的附加有效信息(AVI)。结果 120例中43例存在AVI,包括硬膜囊面积减小33例,椎间盘突出11例和突出程度增加15例,侧隐窝或椎间孔狭窄12例。98例坐骨神经痛患者中40例(40/98,40.82%)出现AVI,22例腰痛患者中仅3例(3/22,13.64%)出现AVI(P<0.05)。结论腰椎纵轴加压CT/MR检查对显示腰椎及椎管的隐匿性退行性变具有重要临床价值。     

Cerebrospinal fluid volume and nerve root vulnerability during lumbar puncture or spinal anaesthesia at different vertebral levels

Cerebrospinal fluid (CSF) and nerve root volumes within the lumbosacral dural sac were estimated at various vertebral levels, in an attempt to determine any possible relevance to the incidence of nerve root trauma during lumbar puncture or spinal anaesthesia. Magnetic resonance images from seven patients were studied. Volumes were calculated by semi-automatic threshold segmentation combined with manual editing of each slice. The mean dural sac volume from S1 to T12 was 42.8±5.8 ml and the mean CSF volume 34.3±5.1 ml with the mean root volume being 10.4±2.2 cm(3). The mean CSF volume per vertebral segment ranged from 4.3±0.7 ml at L5, to 5.8±2.5 ml at L1, with high inter-individual variability. The mean root volume ranged from 0.6±0.1 cm(3) at L5 to 2.4±0.5 cm(3) at T12. The conus medullaris was located at L1 in four of the five patients scanned at upper lumbar levels, and at the lower border of L2 in the other. Vulnerability to nerve root damage was expressed as the Vulnerability Index (%), being defined as the ratio of root volume to dural sac volume (CSF volume + root volume). The value ranged between 7 and 14% at L5, increasing rostrally to 30 to 43% at T12. Caution is obviously required in high punctures to avoid contact with the conus medullaris, but the cauda equina is also vulnerable to contact with more caudal punctures and had a Vulnerability Index of about 25% at L4, that increased rostrally.     

体感诱发电位在腰椎间盘突出症患者功能评定中的应用简

目的探讨体感诱发电位技术在腰椎间盘突出症患者下肢感觉功能评定中的临床应用。方法腰椎间盘突出症患者64例,按照下肢感觉神经功能是否合并下肢麻木,分为疼痛组（A组）和麻木组（B组）。分别采集两组患者的体感诱发电位,分析P40峰潜伏期变化。结果主要表现为P40峰值潜伏期延长,两组患者体感诱发电位检测阳性率分别达91．7％、92．8％,A、B两组患者患侧P40峰潜伏期较健侧均降低（P〈0．05）,组间比较：两组患者健侧P40峰潜伏期比较差异无统计学意义（P〉0．05）,B组较A组患者患侧P40峰潜伏期及两侧间差异值均降低（P〈0．05）。结论体感诱发电位检测可以作为一种无创检测腰椎间盘突出症及评定下肢感觉神经功能状态的工具。     

腰神经根管减压术

本文报告了１９８５年～１９９４年的１７８例腰神经根管减压术．该组病例腰神经根的致压因素中，腰椎间盘突出５３例，腰椎间盘膨出合并黄韧带肥厚４８例，关节突增生２８例，椎体后缘 增生１９例，纤维粘连带压迫１１例．椎体假性滑脱１５例，神经根袖囊肿４例．其中１５８例术后经平 均４．８年的随访，疗效优良率９５．０％。该手术的要点是针对致压因素，彻底解除神经根压迫．优点 为神经根减压充分，并保护了脊柱的稳定性。