单纯颈椎屈曲骨折手术治疗与非手术治疗疗效比较

目的比较采用头颈胸石膏外固定和颈椎前路手术内固定治疗下颈椎不稳屈曲骨折病人的治疗结果。方法对45例下颈椎不稳屈曲骨折患者随访2～3年,其中24例用头颈胸石膏外固定,21例行颈椎前路手术内固定;通过调查表格对患者的治疗结果进行分析;拍片检查患者骨折愈合及颈椎后突畸形程度。结果两组患者治疗后的症状和体征以及患者对治疗结果的满意程度没有明显的差异;骨折处均完全愈合,愈合时间平均12.5周;外固定组患者住院时间平均20d,而手术组为14d;外固定组颈椎平均后突畸形的角度是12.6°,而前路手术组为4.2°,两组之间有显著差异(P<0.001)。结论治疗下颈椎不稳屈曲骨折患者,颈椎前路手术能更好的恢复脊柱的矢状位对线,缩短住院时间。     

颈椎病与急性颈脊髓损伤

从１９８０年１０月至１９９４年１月我们收治４１例无颈椎骨折脱位的急性颈脊髓损伤，同时在Ｘ线、ＣＴ及ＭＲＩ皆有颈椎病的改变。分两组治疗方法比较，手术组皆在颅骨牵引下进行颈椎前路减压、钩椎关节增生部刮除、取自体髂骨或异体骨作椎间植骨融合术，非手术组行颅骨牵引、脱水、皮质激素、神经营养药物、中药及激光血疗，以及早期康复脊髓功能。随访１－９年４个月，平均５年１个月。手术组优１４例、显效４例、差３例。非手术     

退行性下颈椎不稳症的临床特征与放射学测量：（附197例临床 …

目的：研究退行性下颈椎不稳的临床特征与放射学特征之关系及二者对诊断和治疗的意义，方法：回顾性总结１９７退行性颈椎不稳症的临床资料，并以１００例正常无颈部症状的老年人作为对照，比较手术组、非手术组及正常人之间的差异。结果：下颈椎不稳者多有颈部症状，合并椎管狭窄者还易出现颈脊髓压迫症状。手术组椎管矢状径和Ｐａｖｌｏｖ率与正常人相比有明显差异（Ｐ〈０．０１）。结论：临床症状与放射学改变有密切关系。退行性     

颈椎病与急性颈脊髓损伤

从1980年10月到1994年1月我们收治41例无颈椎骨折脱位的急性颈脊髓损伤,同时在X线、CT及MRI皆有颈椎病的改变.分两组治疗方法比较,手术组皆在颅骨牵引下进行颈椎前路减压、钩椎关节增生部刮除、取自体髂骨或异体骨作椎间植骨融合术.非手术组行颅骨牵引、脱水、皮质激素、神经营养药物、中药及激光血疗,以及早期康复脊髓功能.随访1～9年4个月,平均5年1个月.手术组优14例、显效4例、差3例.非手术组优5例、显效7例、差8例.治愈显效率:前者为85.5%,后者为60%.手术组优于非手术组,P<0.05,有显著意义.治愈显效者皆在不同时间内恢复原来工作,无任何并发症.治疗的关键是选择适当的病例及严格的手术指征,熟练手术方法的技巧及术前术后的精心护理.本文对发病机理、诊治及命名亦进行了初步探讨.     

桡骨远端骨折伴腕关节不稳的临床分析

目的分析合并腕关节不稳的桡骨远端骨折不同治疗的功能影响。方法临床随访72例合并腕关节不稳的桡骨远端骨折,通过传统的手法复位石膏固定及手术治疗,根据X线片测量判断治疗前后腕关节的变化,按Frykman分型、汤锦波提出的腕关节不稳定的分型标准及Gartland和Werley评分评定腕关节功能恢复情况作分析。结果随访中发现有背侧偏移、掌侧偏移、背屈不稳(DISI)、掌屈不稳(VISI)和舟月分离5种腕关节不稳;腕关节不稳纠正率为75%;手术组为90.9%;非手术组为46.7%;手术组功能优良率为85.2%,非手术组为72.2%。结论桡骨远端骨折后常可合并不同类型的腕关节不稳定,手术治疗能提高腕关节不稳的纠正率,提高临床疗效。     

退行性下颈椎不稳症的临床特征与放射学测量(附197例临床报告)

目的：研究退行性下颈椎不稳的临床特征与放射学特征之间的关系及二者对诊断和治疗的意义。方法：回顾性总结１９７例退行性颈椎不稳症的临床资料，并以１００例正常无颈部症状的老年人作为对照，比较手术组、非手术组及正常人之间的差异。结果：下颈椎不稳者多有颈部症状，合并椎管狭窄者还易出现颈脊髓压迫症状。手术组椎管矢状径和Ｐａｖｌｏｖ率与正常人相比有明显差异（Ｐ＜００１）。结论：临床症状与放射学改变有密切关系。退行性下颈椎不稳的Ｘ线诊断标准以角位移＞１０°或水平位移＞３０ｍｍ的标准较适合国人。     

颈椎管扩大成形术在治疗无骨折脱位型颈脊髓损伤中的作用

目的:探讨颈椎管扩大成形术治疗无骨折脱位型颈脊髓损伤的临床疗效。方法:对24例无骨折脱位型颈脊髓损伤患者行颈椎管扩大成形术,早期进行康复训练,比较患者在治疗前后ASIA评分及改善率,并与10例保守治疗者进行对比。结果:两组在治疗后感觉及运动功能较治疗前有明显提高(P<0.05)。但手术组疗效明显优于保守治疗组(P<0.01)。结:论对无骨折脱位型颈脊髓损伤患者早期施行减压及稳定手术可取得比保守治疗更好的效果。线锯法颈椎管扩大成形术结合早期康复训练为无骨折脱位型颈脊髓损伤的治疗与功能恢复提供了新的思路。     

伴关节突交锁的下颈椎骨折脱位的手术策略

目的 探讨前路和一期后前路联合手术治疗下颈椎骨折脱位伴关节突交锁的手术策略。方法 手术治疗68例下颈椎骨折脱位伴关节突交锁患者,其中单侧关节突交锁23例,双侧关节突交锁45例。所有患者先行持续闭合颅骨牵引复位,分为复位成功前路手术组(A组,40例)和复位失败后前后路联合手术组(B组,28例)。结果 68例复位成功率58.8%,双侧交锁较单侧交锁复位成功率高。术后患者无脊髓损伤,12例完全性脊髓损伤者无恢复。ASIA评分平均提高1~2级,牵引后感觉评分增加,末次随访感觉、运动评分均显著增加,与术前比较差异有统计学意义(P<0.05)。两组间评分比较差异无统计学意义(P>0.05),所有患者术后3 d及术后3、6、12个月定期行X线检查显示椎体序列及椎间高度良好,植骨正常融合,无内置物松动、断裂等并发症。结论 前路手术可以直接处理椎间盘损伤并即刻消除颈椎不稳;前后联合入路可以同时处理颈椎骨折脱位和椎间盘损伤,需根据患者损伤类型,制定个体化的手术方案。     

创伤性上颈椎不稳的修复重建

目的：总结和分析19例创伤性上颈椎不稳的治疗效果,并对治疗方式以及疗效分析进行研究。方法：外伤患者19例,男16例,女3例;年龄21～56岁;包括寰椎骨折3例,齿突骨折10例,枢椎椎弓根骨折3例,寰枢椎半脱位3例,其中6例（单纯齿突骨折1例,寰椎骨折合并齿突骨折1例,枢椎椎弓根骨折1例,寰枢椎半脱位3例）选择非手术治疗,其余13例均采用手术治疗。结果：19例经随访6个月～6年,平均随访1.8年,根据JOA评分标准,非手术和手术患者术后改善率分别为42.5%和87.0%。结论：创伤性上颈椎不稳应早期诊断早期治疗,在选择术式时应保证上颈椎充分固定的同时尽量保留颈椎的功能,而且上颈椎的确切融合对远期疗效起决定性作用。     

下颈椎骨折脱位的手术入路选择与疗效分析

目的 探讨下颈椎骨折脱位伤合并脊髓损伤的外科手术人路选择及疗效分析. 方法回顾性分析2002年6月～2006年12月手术治疗的56例下颈椎骨折脱位合并脊髓损伤患者的临床资料.按照手术入路不同分为三组:前路手术组35例,后路手术组18例,前后路联合手术组3例.对手术时间、术中出血量、术中术后并发症和术后神经功能恢复情况等进行分析. 结果术中均无大血管、气管、食道、脊髓损伤.术中出血量前路少于后路,手术时间前路短于后路,三组患者神经功能均有明显恢复.55例患者术后获6～49个月(平均38个月)随访,95.4%的患者于植骨术后12周获骨性融合,全部患者植骨均于术后半年获骨性融合.术后颈椎椎间高度、生理曲度无丢失.前路手术组3例发生螺钉松动.结论 采用前路、后路或前后路联合手术治疗下颈椎骨折脱位均能达到良好的解剖复位,保持椎体稳定,促进神经功能恢复,术后疗效跟手术人路无必然联系,手术入路取决于损伤机制及分型.     

Management of post-traumatic cervical spine instability: operative fusion versus halo vest immobilization. Analysis of 49 cases

A 5-year retrospective analysis was conducted for all cervical spine fractures associated with neurologic deficit initially treated at the University of Michigan Hospitals. Forty-nine cases of lower cervical spine fracture (C3-C7) were reviewed. Twenty-eight patients underwent early operative fusion followed by immobilization with either halo vests, or hard cervical collars, and 20 patients were initially immobilized in halo vests only. One patient refused treatment and was kept in a hard cervical collar. The average period of immobilization was 3 months. Eight patients in the halo vest group demonstrated radiographic evidence of spinal instability following immobilization (40%). Five of these eight patients subsequently required operative stabilization. Two of these five suffered progression of neurologic deficit secondary to loss of reduction while immobilized. Spinal instability occurred in two of the 28 patients initially fused (7%) (p less than 0.01), and in the patient treated in a collar. The findings indicate: 1) the halo vest does not protect patients with cervical instability from neurological injury, nor does it absolutely immobilize the cervical spine; 2) surgery may be required to provide spinal stability, even after a 3-month orthotic treatment period; and 3) there appears to be an increased rate of spinal stability with fusion and immobilization versus immobilization alone.     

老年颈椎损伤的特点及治疗

目的：评价老年人颈椎损伤的特点与治疗方法。方法：对31例老年颈椎损伤进行回顾性分析。结果：本组老年颈椎损伤发生率5．47％,其原因多为跌落伤,损伤类型以颈椎过伸性损伤和中央脊髓损伤综合征为常见。77．42％的患者伴有脊髓损伤,病死率为9．67％,保守治疗的骨折不愈合率为18．57％,21．43％的患者神经功能无改善,手术治疗后仍有14．28％患者神经功能无明显改善。结论：老年颈椎损伤死亡率及骨折不愈合率较高,手术治疗应在伤后早期进行。     

脊髓腹背受压合并颈椎不稳定脊髓型颈椎病的手术选择

目的 探讨由多因素(腹背侧受压和不稳定)所引起的脊髓型颈椎病的治疗方法。方法 对32例脊髓型颈椎病施行了颈后路单开门加铰链侧植骨,并对其随访,平均随访时间为3年4个月。结果 JOA评分平均改善率为68.1％,按Hirabayshi恢复率评定标准,优良率为81.2％。结论 颈椎单开门结合铰链侧植骨为治疗脊髓腹背侧受压合并颈椎不稳定脊髓型颈椎病的有效方法。     

颈椎后路单开门手术对颈椎三维运动及刚性的影响

目的研究颈椎后路单开门椎管扩大成形术对颈椎三维运动及刚性的影响。方法脊髓型颈椎病单开门手术后病例 55例,平均随访 35.9个月,对手术前后的颈部轴性症状、神经功能变化 (JOA评分 )和颈椎动态侧位片进行比较。运用 ZMS－ 1型人体颈椎三维运动及刚度测试仪对颈椎单开门术后组 (12例 )和术前对照组 (10例 )进行活体力学测试。测试内容包括 :(1)颈椎主动及被动运动范围; (2)载荷－位移关系和颈椎刚度; (3)颈椎伸、屈肌群主动等长收缩力矩。结果术后 JOA评分平均改善率 66.2％,优良率 78.2％。术后出现明显或严重颈部轴性症状的病例较术前增加 (P< 0.01);术后颈部轴性症状明显者颈椎弧度较小 (P< 0.01);颈部轴性症状分级与 JOA评分改善率两者差异无显著性意义 (P >0.05)。手术后颈椎区域主动及被动伸屈、旋转和侧屈运动范围减小 (P< 0.05),主要影响中下颈椎。颈椎载荷－位移关系可拟合为指数方程 T=b0e。在颈椎各向运动中侧屈刚度最大,其次为后伸与前屈,旋转刚度最小。术后组颈椎刚度大于术前组。结论单开门手术损害颈椎矢状面的静态力学平衡,并使颈椎运动范围减小、柔韧性下降。颈椎弧度改变同颈部轴性症状轻重相关,而与 JOA评分改善率无关。     

Acute mortality and complications of cervical spine injuries in the elderly at a single tertiary care center

STUDY DESIGN: Retrospective database review of all traumatic cervical spine injuries at a single tertiary care center. OBJECTIVE: To determine the acute survival of patients aged 65 and over with a variety of cervical spine injuries, regardless of operative or conservative treatment. SUMMARY OF BACKGROUND DATA: Elderly patients with cervical spine injuries have historically suffered from high mortality rates. More recent literature has demonstrated improved outcomes among operatively treated elderly, but has suggested that the nonoperative treatment of cervical injuries in this population may itself contribute to increased mortality rates. METHODS: One thousand seventy-three consecutive patients were identified and initial hospitalization records reviewed. Ninety-four patients were excluded for incomplete data. The remaining 979 patients were divided by age into young and elderly groups. Sex distribution, mechanism, injury type, comorbidities, and mortality and complication rates were compared. Elderly patients were further divided into operative and nonoperative groups and acute outcomes were compared. RESULTS: The overall acute mortality rate for all patients with cervical spine injuries was 5.92%. Eighty-six percent of all patients 65 and over survived, as did 96.1% of younger patients. Seventy-three percent of elderly patients with complete injuries survived, as did 80% of those with incomplete injuries, and 95.6% of intact elderly. Acute mortality rates were statistically comparable in both the operatively and nonoperatively treated groups of elderly. CONCLUSIONS: In this large comprehensive series of elderly patients with cervical spine injuries, statistically comparable survival rates were achieved in both operatively treated and nonoperatively treated patient populations. This finding challenges the conclusion that the nonoperative treatment of the elderly necessarily results in increased acute mortality.     

颈椎前路融合术后颈部运动功能的评价

目的观察颈椎前路融合术后相邻节段的退变情况和颈部症状的关系,以及颈椎各节段和整体活动度在手术前后的变化。方法对66例颈椎前路融合术后的患者随访1-16年,平均10.5年,观察融合相邻节段在过伸、过屈侧位X线片上的活动度和成角、滑移程度,及其和颈部症状之间的关系。将其中59例患者的手术前后整体颈椎和未融合节段的活动度进行对比,寻找其变化规律。结果在随访期内观察到的相邻节段不稳定发生率为72.7％,有明显颈部症状者占40.9％。融合相邻节段不稳定的患者中有明显颈部症状者占48.0％,相邻节段稳定者中出现明显颈部症状者占18.8％,其差异有显著性意义(P<0.05),轻度不稳定和显著不稳定者发生明显颈部症状的差异无显著性意义(P>0.1)。患者手术后整体颈椎的活动度明显变小(P<0.001),相邻节段活动度显著增大(P<0.01),非相邻节段活动度无明显变化(P>0.05)。结论颈椎前路融合术后多数患者将出现相邻节段不稳定,但是多数患者颈部无明显症状,相邻节段不稳定是颈部症状发生的原因之一。     

Increased risk of death with cervical spine immobilisation in penetrating cervical trauma

The purpose of this study was to determine if cervical spine immobilisation was related to patient mortality in penetrating cervical trauma. One hundred and ninety-nine patient charts from the Louisiana State University Health Sciences Center New Orleans (Charity Hospital, New Orleans) were examined. Charts were identified by searching the Charity Hospital Trauma Registry from 01/01/1994 to 04/17/2003 for all cases of penetrating cervical trauma. Thirty-five patient deaths were identified. Cervical spine immobilisation was associated with an increased risk of death (p < 0.02, odds ratio 2.77, 95% CI 1.18-6.49).     

One stage anterior-posterior approach for traumatic atlantoaxial instability combined with subaxial cervical spinal cord injury

Objectives

To explore the clinical features of traumatic atlantoaxial instability combined with subaxial cervical spinal cord injury (CSCI), and to analyze the feasibility, indication and therapeutic effects of anterior-posterior approach in such cases.

Methods

From March 2004 to September 2009, 16 cases with this trauma were admitted and surgically treated in our department. Before surgery, skull traction was performed. Posterior atlantoaxial pedicle screw internal fixation and bone graft fusion were conducted to manage traumatic atlantoaxial instability. As for subaxial CSCI, anterior cervical corpectomy or discectomy decompression, bone grafting and internal fixation with steel plates were applied.

Results

All operations were successful. The average operation time was 3 hours and operative blood loss 400 ml. Satisfactory reduction of both the upper and lower cervical spine and complete decompression were achieved. All patients were followed up for 12 to 36 months. Their clinical symptoms were improved by various levels. The Japanese Orthopaedic Association (JOA) scores ranged from 10 to 16 one year postoperatively, 13.95±2.06 on average (improvement rate=70.10%). X-rays, spiral CT and MRI confirmed normal cervical alignments, complete decompression and fine implants' position. There was no breakage or loosening of screws, nor exodus of titanium mesh or implanted bone blocks. The grafted bone achieved fusion 3-6 months postoperatively and no atlantoaxial instability was observed.

Conclusions

Traumatic atlantoaxial instability may combine with subaxial CSCI, misdiagnosis of which should be especially alerted and avoided. For severe cases, one stage anterior-posterior approach to decompress the upper and lower cervical spine, together with reposition, bone grafting and fusion, as well as internal fixation can immediately restore the normal alignments and stability of the cervical spine and effectively improve the spinal nervous function, thus being an ideal approach.     

Unilateral facet dislocations and fracture-dislocations of the cervical spine: a review.

Unilateral facet dislocations or fracture-dislocations of the cervical spine constitute an important subgroup of cervical spine injuries. According to the literature, the diagnosis of this entity is often missed and the treatment is controversial. On the basis of our patient review, we conclude that operative intervention appears superior to nonoperative treatment of these injuries. Nonoperative management is often fraught with inability to obtain and maintain anatomic reduction and, in addition, late pain and instability frequently ensue. Alternatively, operative intervention provides the greatest probability for achieving and maintaining anatomic reduction and appears to eliminate chances of late symptoms.     

上颈椎损伤合并不连续下颈椎损伤的一期手术治疗

目的 探讨上颈椎损伤合并不连续的下颈椎损伤的临床特点及手术治疗策略.方法 2004年5月至2007年8月,对上颈椎损伤合并不连续的下颈椎损伤9例患者进行一期手术治疗.术前神经功能按Frankel评级:A级2例,C级3例,E级4例.其中上颈椎损伤均采用后路手术,经椎弓根寰枢固定融合8例,枕颈固定1例;下颈椎损伤采用后路手术6例,其中以不连续经椎弓根短节段钉棒固定融合4例,2例采用联合上颈椎经椎弓根连续固定;余3例同期行前路减压钛板固定.结果 所有患者获得6～48个月(平均13.7个月)随访.术中无一例椎动脉损伤.术后无气管切开或拔管延迟情况,无严重肺部感染、呼吸衰竭、应激性溃疡等并发症发生.患者复位及融合满意,1例2枚下颈椎椎弓根断钉.神经功能:除2例Frankel A级的患并无恢复外,余均为E级.结论 上颈椎损伤合并不连续下颈椎损伤导致颈椎极度不稳定,伴有的神经损伤常源于下颈段.一期手术治疗,包括上颈椎后路经椎弓根固定及下颈椎后路经椎弓根或前路减压固定,相对安全且可获得满意疗效.