A single-stage combined surgical approach for vertebral resections.

Five patients with a destructive vertebral lesion (infectious or tumorous) in the thoracolumbar or lumbar spine were treated with single-stage resection, anterior spine fusion, and posterior Harrington distraction instrumentation. Twelve patients with a fracture-dislocation were also so treated. Correction of vertebral instability and deformity and early mobilization of the patient were the advantages realized. Of the seventeen patients, ten with an incomplete neural deficit improved, three of them to complete recovery. The conditions of five patients with traumatic, complete paraplegia remained unchanged postoperatively. All patients began walking or sitting within fourteen days of the operative procedure. The reported complications were one failure of Harrington instrumentation eight months after the operation and one wound infection one month postoperatively.     

脊柱截骨术治疗创伤僵硬性胸腰段后凸畸形的解剖与临床研究

目的探讨经椎弓根椎体楔形截骨术治疗创伤僵硬性胸腰段后凸畸形的安全性和有效性。方法解剖研究中将16具新鲜胸腰段脊柱标本按不同脊柱截骨术分为3组,A组：脊柱开放-闭合截骨术,B组：经椎弓根椎体楔形截骨术,C组：改良经椎弓根椎体楔形截骨术（截骨包括上位椎间盘后半部分）。测量截骨前后Cobb角的变化、椎体高度和椎体前缘高度的变化。临床研究中共26例患者,其中男性18例,女性8例,平均36岁。受伤至本次手术时间3个月～11年,平均25个月。入院前治疗包括非手术治疗9例,手术治疗17例。神经损伤程度按照Frankel分级：A级10例,B级2例,C级10例,D级2例,E级2例。本组病例均有不同程度的腰背部疼痛,VAS评分平均4．5分（2．5～6．0分）。后凸角20°～75°,平均35°。根据后凸角大小选择行后路经椎弓根椎体楔形截骨术或改良椎体楔形截骨术。结果解剖研究胸腰段标本中A组平均纠正（38．0±2．5）°,B组（36．0±3．6）°,C组（49．0±2．0）°。A组椎体高度平均增加（13．8±1．4）mm,椎体前缘增加（30．2±2．5）mm,而B、C组椎体高度平均短缩（2．8±0．8）mm和（3．8±0．7）mm,前缘增加（25．0±1．2）mm和（2．2±0．9）mm。临床研究患者均获随访,随访时间10个月～6年,平均12．5个月,患者获得满意减压和后凸畸形矫正,术后后凸角度平均为10．8°（0°～40°）,脊柱后凸畸形平均矫正24°。50％患者的神经功能得到了不同程度恢复,全瘫患者恢复率为30％,主要是感觉功能恢复,而不全瘫患者的恢复率为64．3％,感觉和运动功能均有恢复。腰背部疼痛有不同程度好转,VAS评分平均2．3分（1．0～3．5分）。结论创伤僵硬性胸腰段后凸畸形患者可以选择经椎弓根椎体楔形截骨术或改良经椎弓根椎体楔形截骨术。术后可获得满意的减压效果和后凸畸形纠正,神经功能有不同程度恢复,腰背部疼痛有不同程度好转。     

脊椎肿瘤的外科治疗

目的：探讨采用不同经路切除脊椎肿瘤与改进的人工椎体和自体植骨术治疗脊椎不同节段肿瘤的疗效。方法：对13例脊椎肿瘤采取切除瘤椎、人工椎体置换和自体植骨术;肿瘤包括颈椎4例,胸椎3例,腰椎6例。术前颈脊髓瘫痪1例,不完全瘫痪4例,肿瘤的术后病理学诊断有骨巨细胞瘤3例,骨囊肿、Ewing瘤、骨神经鞘瘤、软骨瘤、骨成纤维细胞瘤、骨纤维细胞瘤、骨嗜酸性肉芽肿、骨转移瘤、骨肉瘤和骨血管瘤各1例。结果：13例安全度过围手术期,无脊髓神经症状加重。除1例3个月恢复良好后失访外,余12例获平均4．3年随访,瘫痪5例完全恢复,12例均恢复家务和工作,X线片显示假体无松动、移位,植骨融合。结论：应根据肿瘤的脊柱节段和类型,选择手术治疗方式,采用人工椎体置换和自体植骨术,对完全切除脊椎肿瘤和重建脊椎稳定性是十分有益的。     

Treatment of symptomatic flatback after spinal fusion

Fifty-five patients who had loss of lumbar lordosis after spinal fusion and subsequently had corrective osteotomies were studied. When they were first seen, fifty-two patients (95 per cent) were unable to stand erect and forty-nine (89 per cent) had back pain. The previous use of distraction instrumentation with a hook placed at the level of the lower lumbar spine or the sacrum was the factor that was most frequently identified as leading to the development of the flatback syndrome. Sixty-six extension osteotomies were performed in these fifty-five patients. Nineteen patients (35 per cent) had an associated anterior spinal fusion. Thirty-three patients (60 per cent) had one or more complications, including pseudarthrosis, a dural tear, failure of hardware, neurapraxia, and urinary tract infection. The results of the operation were evaluated at follow-up by review of clinical records, radiographs, and questionnaires. At an average follow-up of six years (range, two to fourteen years), most patients felt that they had benefited from the corrective osteotomies. However, twenty-six patients (47 per cent) continued to lean forward and twenty patients (36 per cent) continued to have moderate or severe back pain. The failure to restore sagittal plane balance led to a higher rate of pseudarthrosis, which was associated with recurrent deformity. Anterior spinal fusion combined with posterior osteotomy resulted in greater maintenance of correction. The prevention of flatback syndrome is important, since its treatment is difficult. When a spinal fusion must be extended to the level of the lower lumbar spine or the sacrum, the use of distraction instrumentation should be avoided in order to prevent this deformity.     

Benign osteoblastoma of the spine in childhood

Osteoblastoma of the spine is a rare but important cause of back pain in children. Ten children with this tumor were treated at the Alberta Children's or Foothills Hospital in Calgary, Alberta, between 1974 and 1986. There were seven boys and three girls; the age at diagnosis ranged from 2 to 16 years (average 11 years). In nine patients the tumor involved the posterior vertebral elements. One of the cervical lesions was in the vertebral body. Three patients had tumor in the extradural space. The commonest symptom was pain in the back and neck. Bone scans were positive in all patients, and computerized tomography scans were abnormal in the eight patients who had this imaging performed. Nine children were treated with laminectomy and removal of the abnormal pedicle and facet. Two patients required two operations each because of incomplete tumor excision at the first operation; in these, subsequent surgery gave complete relief of symptoms and radiographic studies showed no further tumor. In three other patients, tumor removal was incomplete, and one patient received postoperative radiation therapy. Bone grafts were placed in four patients. The diagnosis of benign osteoblastoma was confirmed histologically in nine patients. The outcome was good in all cases, with excellent pain relief. The follow-up period has varied from 8 to 153 months (average 66 months) and there have been no recurrences. Based on this experience, complete excision of spinal osteoblastomas is recommended whenever possible. However, a satisfactory outcome may be achieved following incomplete excision and bone grafting.     

Posterior decompression and in situ fusion for the treatment of degenerative scoliosis

Surgical Principles Asymmetric disc degeneration in the lumbar spine often creates a segmental instability that will result in progressive arthrosis of the facet joints and development of a lumbar scoliosis. Although the progression of the curve is slow, it may cause in the adult and elderly significant back pain and radicular pain [2, 3]. If conservative management fails, then surgical treatment should consist of a thorough decompression of the involved nerve roots and fusion of the involved vertebral segments. The technique described advocates an in situ fusion with no attempt at correction of the deformity and no use of instrumentation. This procedure is often required in elderly, osteopenic patients with systemic illnesses and therefore is designed to minimize intra- and postoperative morbidity.     

Hemangioendothelioma of the spine

A review of the patient files from our institution's oncology department showed that between 1950 and 2000, 11 patients were diagnosed with hemangioendothelioma of the spine, a rare, low-grade malignant vascular tumor. After reevaluation of the diagnoses by orthopaedic oncologists and pathologists, three patients were excluded; therefore eight patients formed the study group. The eight lesions were located in the thoracic (three) or lumbar spine (five, one in each vertebral level). Computed tomography scans revealed expansile lytic process. All lesions involved the vertebral body, but only one was diffuse with spinous process involvement. Treatment included: external beam irradiation alone (one patient), curettage and external beam irradiation (one patient), laminectomy and external beam irradiation (two patients), anterior resection only (two patients), and anterior resection with postoperative external beam irradiation (two patients). Patients without spinal stabilization had chronic low back pain; no patient with spinal stabilization had such pain. One patient who had surgical resection and radiation therapy had a radiation-induced sarcoma develop after 4 years. One patient who was treated with radiation therapy alone had a metastatic lung lesion develop. No other patient had tumor recurrence or progression. Therefore, patients with hemangioendothelioma of the spine may be treated with radiation therapy alone, surgery alone, or a combination thereof. However, because the number of patients in the current series was small, no definitive recommendations regarding treatment may be made. Resection of large lesions and stabilization of vertebral collapse may decrease back pain.     

Double-segment total vertebrectomy for the surgical treatment of congenital kyphoscoliosis: a case report

BACKGROUND CONTEXT: Congenital kyphosis or kyphoscoliosis is an uncommon deformity that usually is progressive without surgical intervention. In the lately diagnosed or neglected cases of congenital kyphoscoliosis, the patients may come with shoulder-trunk imbalance anomalies, severe deformity in coronal and sagittal plane, rib cage deformities, pelvic tilt, presence of intramedullary anomalies, neurological deficit, and difficulty in walking and cardiopulmonary problems. PURPOSE: To present a technical note related with double-segment total vertebrectomy for the surgical treatment of a patient who had neglected congenital kyphoscoliosis in lumbar spine. STUDY DESIGN: Case report. METHODS: A 19-year-old girl had submitted to our center with complaints of deformity and pain in her back. Her physical examination revealed scoliosis and gibbosity in lumbar region. Her neurological examination was normal. In the radiological examination, X-ray films showed 42 degrees lumbar scoliosis in frontal plane and 35 degrees kyphotic curvature in the sagittal plane. RESULTS: Three-staged (posterior-anterior-posterior) surgery in the same session (same anesthesia) was performed. CONCLUSION: Total or partial vertebrectomy on the apex of the deformity and the adjacent vertebral bodies along with anterior stabilization by means of a cylindrical cage combined in one operative procedure preceded by temporary posterior instrumentation and followed by posterior instrumentation and fusion may be preferred for the treatment of congenital kyphoscoliosis in neglected cases to provide spinal cord decompression.     

Partially Overlapping Limited Anterior and Posterior Instrumentation for Adult Thoracolumbar and Lumbar Scoliosis: A Description of Novel Spinal Instrumentation, “The Hybrid Technique”

Progressive and/or painful adult spinal deformity in the thoracolumbar and lumbar spine is sometimes treated surgically by long posterior fusions from the thoracic spine down to the pelvis, especially where there is a major thoracic curve component. Recent advances in anterior spinal instrumentation and spinal surgery technique have demonstrated the improved corrective ability offered by anterior stabilization systems, and the added benefit of limiting the number of vertebral fusion levels required for control of the deformity. The "hybrid technique" is a novel use of anterior instrumentation that applies limited anterior instrumentation down to the low lumbar spine (rods and screws), and partially overlapping short-segment posterior instrumentation to the sacrum (pedicle screws and rods). These constructs avoid posterior thoracic instrumentation and fusions, and avoid extension of posterior instrumentation to the pelvis. In the first 10 patients treated using this technique, thoracolumbar and lumbar major curve correction has averaged 71 and 82% in the immediate postoperative period (n = 7), respectively, and 59 and 68% at 2-year follow-up, respectively. The technique is an appealing and attractive alternative for treatment of thoracolumbar and lumbar scoliosis in the adult population, and avoids the requirement for applying spinal fixation to the thoracic spine and the pelvis.     

Osteoporotic vertebral fracture adjacent to a nonsegmented hemivertebra

A combination of osteoporotic vertebral fractures and congenital spinal deformity is theoretically possible, but there have been no reports on this combination in the literature. We describe a rare case of an osteoporotic vertebral fracture adjacent to the nonsegmented hemivertebra. A 60-year-old postmenopausal woman who did not recall any specific trauma presented with severe back pain. She had markedly decreased bone mineral density and significant lumbar kyphoscoliosis with a nonsegmented hemivertebra between L1 and L2 on radiographs of the lumbar spine. Magnetic resonance imaging (MRI) revealed a vertebral fracture adjacent to the nonsegmented hemivertebra. Laboratory studies showed increased serum bone-specific alkaline phosphatase (BAP) and urinary type I collagen crosslinked N-telopeptide (NTx). A thoracolumbar brace was applied for 3 months. Daily administration of alendronate normalized her serum BAP and urinary NTx levels. MRI scans of the lumbar spine after 6 months also confirmed normalized signal intensities of the fractured vertebra adjacent to the nonsegmented hemivertebra. The vertebral fracture seemed to be induced by spinal malalignment, increased stress on the adjacent level of the fused segment, and its fragility due to osteoporosis.     

钉棒及钩棒系统治疗胸腰椎多节段脊柱骨折

目的评价钉棒及钩棒系统治疗胸腰椎多节段脊柱骨折的临床疗效。方法23例多节段胸腰椎骨折患者，后路切开复位，选择性椎管减压．钉棒或钩棒系统内固定及后外侧植骨融合进行手术治疗。其中相邻多节段型13例，非相邻多节段型8例，混合型2例。结果全组病例平均随访14个月，未发现内固定物松动、断离，无继发性脊柱后凸畸形加重。椎体高度由术前平均48．4％恢复至术后平均92．4%。2例完全性及11例不完全性脊髓损伤者．脊髓神经功能获改善。结论在椎管进行充分减压的基础上．钉棒及钩棒系统能有效复位椎体骨折，重建脊柱稳定性，是多节段胸腰椎不稳定性骨折合并脊髓神经损伤后路手术的理想选择。     

Sekundäre Deformitäten nach Resektion primärer Knochentumoren der Wirbelsäule bei Kindern und Jugendlichen

Primary bone tumors and tumor-like lesions of the vertebral column are rare in children. After operative tumor resection, 25 children under the age of 17 could be reviewed in a retrospective analysis. Malignant bone tumors occurred only twice in the region of the vertebral body. No deformity was registered in 9 of 16 cases after local tumor resection with and without laminectomy on one level. In contrast, after resection of one or both facets in combination with laminectomy cranial to L4 or thoracal, progressive kyphosis was found within 6-22 months postoperatively in four cases. This required a secondary fusion. After primary fusion and instrumentation, no deformity was registered. In nine cases with a location of the tumor in the vertebral body, only two patients developed a secondary instability of the spine. Both cases had no primary fusion. The other seven patients with initial fusion and instrumentation showed no deformity within 24 up to 127 months postoperatively. These results are compared with data from the current literature.     

胸腰段陈旧骨折继发后凸畸形的外科治疗

目的总结分析胸腰段陈旧骨折继发后凸畸形的手术治疗效果。方法回顾研究胸腰段陈旧骨折继发后凸畸形33例,平均年龄40 3岁。病史平均36 0个月。后凸Cobb角平均40 8°(20°~82°)。全部患者均有脊髓损伤,括约肌功能障碍26例。12例有显著腰背部疼痛。23例既往曾有手术史。手术方式包括前路椎体间隙松解植骨+后路截骨矫形固定15例,后路截骨减压矫形12例,前路松解、椎体间撑开植骨固定6例。结果全部患者后凸畸形矫正率平均为86 0%。无严重手术并发症。随访时间平均24 6个月(6个月~84个月), 32例骨性融合, 1例植骨未融合,行二次手术后骨性融合。10例术后神经功能有改善, 10例术后括约肌功能部分恢复。有显著腰背部疼痛者术后症状均明显减轻。结论单纯后路截骨矫形适用于角度较小( <45°)的后凸畸形。前路松解、后方经关节突截骨矫形适用于不同程度的后凸畸形,尤其对后凸严重或二次手术的病例更显优势。对于合并脊髓不全损伤的病例即使病史较长,手术仍然可能获得一定疗效,特别是对于腰部疼痛的缓解效果显著。     

前后路联合手术治疗胸腰椎骨折伴不全瘫(附32例报告)

目的 探讨应用后路椎弓根内固定系统复位固定联合前路减压植骨术治疗胸腰椎骨折伴不全瘫的临床疗效。方法 应用后路RF或AF复位固定骨折推体，结合前路经胸腹膜外途径椎体减压植骨术治疗胸腰椎爆裂型骨折伴不全瘫32例。结果 32例均能耐受手术，并获6～24个月的随访，X线片复查椎体前缘高度恢复，后突角消失，RF或AF螺钉无松动断裂，CT复查椎管减压彻底。32例均在术后2～4周内恢复排尿功能，6个月内两下肢均有Frankle 2～3级以上的神经功能恢复。结论 ①后路RF或AF复位、固定满意，前路手术减压彻底；②后路RF或AF复位内固定联合前路减压植骨术是治疗胸腰椎骨折伴不全瘫的安全有效价廉的手术方式。     

Vertebral column resection and arthrodesis for complex spinal deformities.

Sixteen patients aged 13 to 55 with severe rigid spine deformities were treated by two-stage anterior and posterior vertebral column resection, fusion, and segmental spinal instrumentation. The purpose of the vertebral column resection was to eliminate pain, prevent progressive deformity, and obtain the maximum correction necessary to achieve spinal balance in the coronal and sagittal plane. The final scoliosis correction averaged 43%. Physiologic sagittal alignment was achieved in all patients. Complications occurred in seven patients (43%). It is our conclusion, based on this series, that the concept of decancellation, radical vertebral column resection, spinal shortening, and segmental instrumentation posteriorly can achieve a balanced correction and significant pain relief for the select patient who presents with severe rigid spine deformity not adequately treatable by more established techniques.     

Spinal cord compression caused by vertebral hemangioma being symptomatic during pregnancy

BACKGROUND: Hemangioma is one of the most common benign tumors of the spine, and it remains silent in the vast majority of subjects afflicted. Pregnancy is a known risk factor for symptomatic conversion of the previously silent vertebral hemangiomas. However, the occurrence is rare with only 26 cases reported in the English medical literature. CASE DESCRIPTION: A 22-year-old woman in her 36th week of gestation presented with acute onset of upper back pain and progressive paraplegia. Imaging studies revealed a T4 vertebral hemangioma, which involved the vertebral body, pedincules, transverse, and spinous process with a focal extradural extension of soft tissue component. She underwent emergent cesarean delivery and endovascular embolization, respectively. Her symptoms and neurologic deficits improved quickly. Her complaints restarted 2 years after embolization. Surgical treatment which consists of intraoperative vertebraplasty and segmental fixation was performed. The patient's postoperative recovery was excellent. CONCLUSION: According to literature review and our patient's outcome, pregnancy may induce neurologic symptoms and signs in silent spinal hemangiomas. The way of management is decided by whether the neurologic deficits depend on the deformity caused by hemangioma or some other factors including vascular insufficiency.     

Spinal intradural capillary hemangioma

BACKGROUND: Capillary hemangiomas are typically superficial lesions found in the skin or mucosa of the head and neck, but intradural locations are rare. We report a case of the spinal intradural capillary hemangioma of the lumbar spine with a review of the pertinent literature. CASE DESCRIPTION: A 59-year-old man presented with a 3-month history of low back pain and left leg pain. On examinations, the patient was shown to have paresthesia in the left L4, L5, and S1 dermatome and a diminution of the left knee jerk. Magnetic resonance imaging revealed an approximately 2-cm intradural enhancing lesion at the level of the L1-2 disk space. Laminectomy of L1-2 was performed for tumor removal. A reddish mass was covered by matted adherent nerve roots and derived its blood supply from radicular vessels. Complete excision was accomplished. Histologic diagnosis was capillary hemangioma. After operation, the patient's symptoms were improved. CONCLUSION: We experienced a rare spinal intradural vascular tumor of the lumbar spine. Histologic diagnosis was capillary hemangioma. We report a rare case of spinal intradural capillary hemangioma of the lumbar spine.     

Anterior instrumentation for the treatment of pyogenic vertebral osteomyelitis of thoracic and lumbar spine

Anterior radical debridement and bone grafting is popular in the treatment of pyogenic infection of the spine, but there remains great concern of placing instrumentation in the presence of infection because of the potentiality of infection recurrence after surgery. The objective of this study was to prospectively evaluate the efficacy and safety of anterior instrumentation in patients who underwent simultaneous anterior debridement and autogenous bone grafting for the treatment of pyogenic vertebral osteomyelitis. The series consisted of 22 consecutive patients who were treated with anterior debridement, interbody fusion with autogenous bone grafting and anterior instrumentation for pyogenic vertebral osteomyelitis of thoracic and lumbar spine. The patients were prospectively followed up for a minimum of 3 years (average 46.1 months; range 36–74 months). Data were obtained for assessing clinically the neurological function and pain and radiologically the spinal alignment and fusion progress as well as recurrence of the infection. All the patients experienced complete or significant relief of back pain with rapid improvement of neurological function. Kyphosis was improved with an average correction rate of 93.1% (range 84–100%). Solid fusion and healing of the infection was achieved in all the patients without any evidence of recurrent or residual infection. The study shows that combined with perioperative antibiotic regimen, anterior instrumentation is effective and safe in the treatment of pyogenic vertebral osteomyelitis of thoracic and lumbar spine directly following radical debridement and autogenous bone grafting.     

Shear fracture-dislocations of the thoracic and lumbar spine associated with forceful hyperextension (lumberjack paraplegia).

Twelve patients sustained a shear fracture-dislocation of their thoracic or lumbar spines by a hyperextension mechanism of injury. Ten male and two female patients were injured; their average age was 29 years (range, 22 months to 56 years). Ten fracture-dislocations occurred in the thoracic spine, one at the thoracolumbar junction, and one in the lumbar spine. Eleven patients had complete paraplegia, and one had incomplete paraplegia at the time of injury. Dural tears were found in six of the patients. Eleven patients were treated by posterior spinal fusion with instrumentation, and one was treated with a brace. Three patients were treated with Harrington distraction rods alone, six had Harrington distraction rods supplemented with a midline Harrington compression rod or interspinous wiring, and two were treated with Cotrel-Dubousset instrumentation. No patient was lost to follow-up. The average length of follow-up was 3.5 years (range, 1-9 years). Six of the patients treated with Cotrel-Dubousset instrumentation or Harrington distraction rods supplemented with either a midline compression rod or interspinous wiring healed anatomically; two patients developed pseudarthroses. None of the patients treated with Harrington distraction rods alone healed in an anatomic position. The use of Harrington distraction rods alone was associated with overdistraction and nonanatomic alignment of the spine. The disruption of the anterior stabilizing structures of the spine associated with hyperextension injuries necessitates the use of instrumentation that can stabilize the spine and prevent overdistraction. This injury can be successfully treated with Cotrel-Dubousset or Harrington distraction rods supplemented with either a midline compression rod or interspinous wiring.     

Giant cauda equina schwannoma. A case report

STUDY DESIGN: Case report. OBJECTIVES: To present a rare case of a giant schwannoma of the cauda equina. SUMMARY OF BACKGROUND DATA: Giant spinal schwannoma of the cauda equina, which involves many nerve roots, is rare and there is usually no ossification in the schwannoma. It is unknown whether or not complete excision is preferable if the tumor is located in the lumbar lesion. METHODS: A 57-year-old woman had a 10-year history of low back pain. Scalloping of the posterior surface of the vertebral bodies from L3 to the sacrum was found. Magnetic resonance imaging disclosed a giant cauda equina tumor with multiple cysts. Central ossification revealed by computed tomography and an unusual myelogram made the preoperative diagnosis difficult. RESULTS: The patient underwent incomplete removal of the tumor, decompression of cysts, and spinal reconstruction. The tumor was proved to be a schwannoma. The postoperative course was uneventful and she has been almost free from low back pain for 3 years and 4 months. CONCLUSIONS: Giant schwannoma in the lumbar spine region is usually excised incompletely, because complete removal had the risk of sacrificing many nerve roots. In spite of the incomplete removal of the tumor, the risk of recurrence is low.