胸腔镜辅助下胸椎、上腰椎前路手术的体会

目的 探讨胸腔镜技术在胸、腰椎前路手术的适应证、操作要点以及单肺或双肺通气麻醉的选择。方法 对5例结核病人行胸腔镜下结核病灶清除术，其中2例同时行自体髂骨植骨术，1例以自固化磷酸钙人工骨(CPC)植入；对3例爆裂性骨折截瘫及1例L1陈旧性爆裂骨折并马尾综合征病人进行脊髓减压、自体髂骨植骨、钢板螺丝钉内固定术。结果 全部病例都得到随访，术后切口一期愈合，X光、CT检查也都显示病灶清除彻底，脊髓减压充分，复位满意，内固定可靠，位置良好。结论 胸椎、上腰椎结核或骨折，不论是否并发脊髓、马尾神经压迫的病例，均适宜在胸腔镜辅助下进行病灶清除、脊髓减压、脊柱前路内固定术。     

借助胸腔镜技术的胸段、上腰段脊柱前路手术

目的探讨胸腔镜辅助胸椎、上腰椎前路手术的适应证 ,单肺或双肺通气的选择以及术中注意事项。方法　应用胸腔镜、骨科常规手术器械或自制的骨科器械 ,在胸腔镜辅助下行病灶清除、脊髓减压、植骨、钢板螺丝钉内固定术。结果　全部病例手术都顺利完成 ,切口均一期愈合 ,随访 3～ 10个月 ,影像学检查显示病灶清除彻底 ,脊髓减压充分 ,除 1例骨折复位、固定后仍有轻度侧方成角畸形外 ,其他病例复位满意、内固定可靠 ,位置良好。结论胸椎、上腰椎疾患 ,不论是否并发脊髓、马尾神经压迫 ,都能在胸腔镜辅助下完成病灶清除术 ,必要时还可进行脊髓减压、脊柱前路植骨、内固定手术。原则上可选择常规气管插管、双肺通气下完成手术。     

胸腔镜辅助下小切口在胸椎前路手术的临床应用

目的探讨胸腔镜辅助下小切口行胸椎前路手术的可行性. 方法 2001年10月～2002年10月,我院在胸腔镜辅助下小切口行胸椎前路手术14例.其中6例胸椎转移瘤行病变椎体切除、钢板骨水泥椎体重建及前路针棒内固定;4例胸椎结核行病灶清除、植骨及前路钉棒内固定;2例胸椎间盘突出症行髓核摘除、椎间植骨融合;2例胸椎椎体骨折合并脱位行脱位椎体复位、椎管减压、椎体间植骨及前路钉棒内固定. 结果术后影像学显示病灶清除彻底,内固定效果确切.14例术后随访 4～12个月,14例胸背痛完全消失,13例脊髓压迫症中除1例转移瘤无改善外,其余12例肌力术前A～D级,术后恢复至C～E级. 结论胸腔镜辅助下小切口行胸椎前路手术方法可行,近期疗效满意.     

腰椎爆裂性骨折腹腔镜辅助下前路小切口内固定技术11例疗效分析

目的 探讨腹腔镜辅助下前路小切口对腰椎爆裂性骨折减压、植骨、内固定手术的可行性及手术特点与临床疗效.方法 2009年12月至2012年1月,11例腰椎爆裂性骨折在腹腔镜辅助下经腹膜后腰肌间隙入路行骨折并脊髓圆锥、马尾神经压迫症椎管减压、植骨、内固定手术,随诊至6个月以上观察其疗效.结果随访6个月以上,效果满意.全部病例切口甲级愈合,椎管内骨块清除彻底,减压充分,植骨块融合良好,内固定器无松动;4例圆锥、马尾神经受压,术后功能基本恢复.结论腹腔镜辅助下经腹膜后腰肌间隙前路小切口入路的腰椎手术,可以完成椎体爆裂性骨折并脊髓圆锥、马尾神经压迫症的椎管减压、植骨、内固定术.     

胸椎多椎体结核的手术治疗

目的探讨评价胸椎多椎体结核经胸腔前路病灶清除、椎管减压,一期植骨单钉棒内固定术的治疗效果。方法自2002年6月至2010年3月收治多椎体胸椎结核14例,男8例,女6例;年龄23～59岁,平均45岁。病变范围T4～10椎体,病变累及3个椎体5例,4个椎体6例,5个及以上椎体3例。术前Frankel评分2例B级,4例C级,8例D级。MRI均显示椎体破坏、椎旁脓肿,其中椎管内脓肿或致压物导致脊髓明显受压7例,压迫均来自脊髓前方,X线片测量后凸Cobb角为40°～22°,平均25°。均采用经胸腔前路病灶清除、椎管减压、一期椎体间植骨单钉棒内固定术。结果随访1～9年,平均5年6个月。脊髓功能恢复按Frankel分级,D级2例,E级12例。植骨全部骨性愈合,后突畸形矫正率为84%,后凸角平均矫正21°,无结核复发及继发脊柱后凸畸形。结论经胸腔前路病灶清除、椎管减压、一期椎体间植骨、单钉棒内固定是治疗胸椎多椎体结核的有效方法之一。     

腰椎爆裂性骨折腹腔镜辅助下前路小切口内固定技术11例疗效分析

目的探讨腹腔镜辅助下前路小切口对腰椎爆裂性骨折椎压、植骨、内固定手术的可行性及手术特点及临床疗效。方法 2009年12月至2012年1月,11例腰椎爆裂性骨折在腹腔镜辅助下经腹膜后腰肌间隙入路,行腰椎爆裂骨折并脊髓圆锥、马尾神经压迫症椎管减压、植骨、内固定手术。其中男性8例,女性3例;平均年龄39岁（20-57岁）。所有病例均为车祸伤或高处跌落伤,骨折后3-7天手术。11例均为腰椎爆裂骨折,椎管狭窄程度达25%-100%。L1骨折3例,L2骨折5例,L3骨折3例,以上11例中并发脊髓圆锥、马尾神经损伤4例。11例中5例分别伴发骨盆骨折、肋骨骨折、肱骨骨折、小腿骨折、胸部损伤、脾破裂、休克等。结果随访6个月以上,效果满意。全部病例切口甲级愈合,椎管内骨块清除彻底,椎管减压充分,植骨块融合良好,内固定器无松动;4例圆锥、马尾神经受压,术后功能基本恢复。结论腹腔镜辅助下经腹膜后腰肌间隙前路小切口入路的腰椎手术,可以完成椎体爆裂性骨折并脊髓圆锥、马尾神经压迫症的椎管减压、植骨、内固定术。     

一期前后联合入路治疗胸腰段脊柱结核

目的回顾性分析一期后路椎弓根螺钉内固定和前路病灶清除植骨融合术治疗胸腰椎脊柱结核的临床疗效。方法 2004年12月～2010年8月,采用一期后路椎弓根螺钉系统内固定和前路病灶清除、神经减压、自体骨椎间植骨治疗胸腰段脊柱结核患者27例,2个椎体16例,3个椎体8例,4个椎体2例,5个椎体1例。分析术前与术后脊髓神经功能Frankel分级情况以及脊柱融合情况。结果所有患者术后随访9个月～3年,平均16.5个月。脊柱后凸畸形由术前平均46.3°改善到术后平均14.3°(P<0.05)。术后所有病例神经功能均获得改善。结论经后路椎弓根螺钉内固定和前路病灶清除植骨融合术治疗脊柱结核能彻底清除结核病灶,矫正脊柱后凸畸形,促进脊髓及神经功能恢复。     

胸腰椎严重爆裂骨折前路内固定治疗

脊柱胸腰椎严重爆裂性骨折是临床上常见的脊柱损伤,常因伤椎后缘骨块后移压迫脊髓或马尾而致神经功能障碍。随着各种优良内固定器的研制和应用,前路减压,植骨加内固定术治疗的腰椎严重爆裂性骨折在临床上应用越来越广泛。笔者就2000～2005年32例应用前路Z—plate内固定系统治疗腰椎严重爆裂性骨折疗效情况进行分析评价。     

胸腰椎前路内固定技术临床应用及技术要点

目的 探讨胸腰椎前路内固定技术在胸腰椎病变的临床应用及其技术要点.方法 分析从2000年5月-2005年7月采用胸腰椎前路内固定技术治疗胸腰椎病变41例(21例采用Z-PLATE-Ⅱ钢板、17例采用TSRH单棒、3例采用施泰保前路K钢板)其中胸腰椎骨折29例,结核6例,脊柱原发肿瘤及转移癌各2例,椎间盘损伤椎体脱位2例.其适应证包括:椎体肿瘤、椎体爆裂骨折骨块突入椎管超过1/2者、高位椎间盘病变、后纵韧带骨化、椎体其它病变如结核、炎症病灶清除需植骨内固定者.技术要点:缩短手术时间,采用有效椎管减压,应用合适引流,可减少出血,解除脊髓压迫,防止脊髓损伤,减少感染及窦道形成.结果 41例植骨均融合、内固定牢固,脊椎后凸畸形大部份得到矫正.32例有不全性脊髓损伤,神经功能均得到改善.结论 胸腰椎前路内固定手术暴露清楚,病灶清除彻底,有效解除脊髓前方压迫,内固定节段短,植骨成活率高,采用钛质内固定物,不影响术后MRI检查,采用合适技术可减少出血,防止脊髓损伤,降低感染率,大部分病例免第二次手术取内固定物.     

胸腔镜下胸腰段疾病的前路手术及内固定

目的回顾胸腔镜下前路减压、植骨内固定治疗胸腰椎骨折、结核和椎间盘突出症的经验,评价胸腔镜技术在脊柱前路手术中的应用价值。方法收集12例接受胸腔镜下前路手术患者的临床资料,分析操作技术、手术时间、出血量以及功能恢复情况。结果胸腰椎骨折8例;结核3例;椎间盘突出症l例。平均手术时间210min,平均出血量600ml,平均住院时间12d。1例结核患者因严重骨质疏松而放弃内固定,仅作病灶清除植骨术。所有患者随访3—10个月,神经功能恢复与普通开胸前路手术近似,骨折复位良好,植骨块和内固定未发现移位,活动基本恢复正常。结论胸腔镜下脊柱前路手术创伤小,并发症及出血量少,术后恢复快,为胸腰椎前路手术提供了一种安全、有效的操作技术。     

多椎体结核内固定与非内固定疗效的比较

目的　探讨多椎体结核内固定与非内固定疗效的差异 ,比较二者的优缺点。方法　总结 1990年～ 2 0 0 1年采用脊柱前路病灶清除植骨术与同时用饶氏椎体钉、Ventrofix、Z -Plate钢板、USS等器械内固定治疗胸腰椎结核病人共 12 4例。其中非内固定 6 8例 ,内固定 5 6例。观察术后植骨融合、神经恢复、畸形纠正情况及治愈率。结果　经平均 2 5年的随访证实 ,内固定植骨融合速度快于非内固定组 ,有显著性差异 ;神经功能Frankel分级二组全部得到改善 ;畸形纠正内固定组后弓角较术前平均改进 2 9°、非内固定组平均改进 5°,有显著性差异。内固定组治愈率为 10 0 % ,非内固定组治愈率为 87% ,有显著性差异。结论　脊柱结核内固定可早期重建脊柱稳定性并加速植骨融合 ;有明显改善畸形的作用 ;减少结核复发 ,在治疗多椎体结核中有重要意义     

Roentgenographic and biomechanical analysis of lumbar fusions: a canine model

An animal model of anterior and posterior column instability was developed to allow in vivo observation of bone remodeling and arthrodesis after spinal instrumentation. Various combinations of spinal fusions and instrumentation procedures were performed after an initial anterior and posterior destabilizing lesion was created at the L5-L6 vertebral levels in 35 adult beagles. After 6 months of postoperative observation, there was improved probability of achieving a spinal fusion if spinal instrumentation had been used. All biomechanical testing was performed after removal of instrumentation to test the inherent stiffnesses and quality of the spinal fusions. The fusions performed in conjunction with instrumentation (group V = Harrington instrumentation and posterolateral fusion; group VI = Luque instrumentation and posterolateral fusion) demonstrated the greatest axial rotation stiffnesses (group V, p less than .05); axial compressive stiffness (group V, p less than .05); and flexural stiffness (group VI, p less than .05). The results show that a spinal fusion can be more reliably achieved and will be more rigid if it is accompanied by spinal instrumentation.     

Comparison of sprotte and Quincke needles with respect to spinal fluid leakage using artificial spinal cord

Purpose This research investigated whether the Sprotte needle causes less leakage of CSF than the Quincke needle in the artificial spinal cord. Methods The changes in intradural pressure, extradural pressure, and leaked volume of CSF were evaluated following puncture with Sprotte and Quincke needles in the artificial spinal cord. Results The decrease in intradural pressure was 9.7±1.8 mm H₂O with the Sprotte needle and 20.5±2.7 mm H₂O with the Quincke needle (P<0.05). The volume of leakage of artificial CSF was 2.0±0.3 ml with the Sprotte needle and 3.3 ±0.3 ml with the Quincke needle (P<0.01). The extradural pressure increase was 166.1±8.2 mm H₂O with the Sprotte needle and 186.8±13.2 mm H₂O with the Quincke needle (P<0.05). Conclusion The Sprotte needle produces less CSF leakage than the Quincke needle.     

A thoracic and lumbar spine injury severity classification based on neurologic function grade, spinal canal deformity, and spinal biomechanical stability

BACKGROUND CONTEXT: Current well regarded thoracic and lumbar spine injury classifications use mechanistic and anatomical categories, which do not directly rely on quantifiable management parameters. Their clinical usefulness is not optimal. PURPOSE: Formulate an injury severity based classification. STUDY DESIGN/SETTING: This retrospective investigation studied patients who suffered thoracic and lumbar spine injuries, and examined the following three quantifiable parameters: 1) neurologic function grade; 2) spinal canal deformity; 3) biomechanical stability. These parameters are the primary clinical indications for management decisions. PATIENT SAMPLE: One hundred twenty-six consecutive patients with spinal trauma admitted to a level 1 tertiary trauma center from January 1997 to November 2005 were enrolled in this study. OUTCOME MEASURES: Spine injury severity was independently scored on three parameters: 1) neurologic function impairment grade according to the modified Frankel grading method and the American Spinal Injury Association (ASIA) function scale; 2) spinal canal deformity from translation and intrusion, measured as percent canal cross-sectional area compromise; 3) failure of five possible biomechanical functions in Denis's three anatomic columns, and a sixth group of unstable deformities. All three columns contribute to tensile function. Only the anterior and middle columns provide compression load-bearing function. A combination of three or more column biomechanical function failure or an unstable deformity renders the injury unstable. METHODS: Five fellowship-trained spine surgeons from one institution took part in the study. Hospital medical records, including admission history and physical examination, discharge summary, and operative report (if surgery was performed), were examined for neurologic deficit. Plain radiographs, computed tomographic scans and magnetic resonance imaging were assessed for canal compromise and biomechanical function status. RESULTS: Injuries were located from T3 to L5, 58% of which were at the thoracolumbar junction (T11-L2). Neurologic impairment occurred in 45% (57/126) of patients, with 19 complete paraplegias (Frankel grade A). The average spinal canal cross-sectional area compromise was 56.1% in neurologically impaired and 14.2% for patients who where neurologically intact. The number of tensile element failure patients in neurologically impaired versus intact are as follow: tri-columns 22/4; two columns 16/8; one column 11/17; all columns intact 8/40. Load-bearing element failed in 55/57 neurologically impaired and 63/69 intact patients. Sixty-seven patients had spinal reconstructive surgery. Their average instability profile score was 4.4 out of 6, and canal compromise score was 3.3 out of 5. CONCLUSIONS: A clinically useful thoracic and lumbar spine injury classification should be based on parameters that are the primary indications for management decisions. The same parameters should be injury severity quantifiable as to guide treatment. In this study we introduced spinal canal deformity and column biomechanical functions as quantifiable parameters in thoracic and lumbar injury severity classification. Validation of this method is beyond the scope of this preliminary study.     

Extradural spinal meningioma: case report

Objectives

We report a case of purely extradural spinal meningioma and discuss the potential pitfalls in differential diagnosis.

Background

Spinal meningiomas account for 20–30% of all spinal neoplasms. Epidural meningiomas are infrequent intraspinal tumors that can be easily confused with malignant neoplasms or spinal schwannomas.

Case

A 62-year-old man with a previous history of malignant disease presented with back pain and weakness of the lower limbs. Magnetic resonance imaging revealed a well-enhanced T4 intraspinal lesion. The intraoperative histological examination showed a meningioma (confirmed by postoperative examination). Opening the dura mater confirmed the purely epidural location of the lesion. The postoperative course was uneventful with no recurrence 12 months after surgery.

Conclusion

Purely extradural spinal meningiomas can mimic metastatic tumors or schwannomas. Intraoperative histology is mandatory for optimal surgical decision making.     

Surgical decompression: a life-saving procedure for an extensive spinal epidural abscess

Extensive spinal epidural abscesses (SEAs) carry a high mortality rate. Traditionally they are treated non-operatively with longterm antibiotics and/or surgical decompression, but there is a continuing debate as to whether they should be managed by emergency surgical decompression. However, such decisions are made in the light of the clinical setting. We report the successful management of a female patient who presented with features of upper cervical cord compression and later developed septic shock and multisystem failure. Surgical decompression of the cervical spine and irrigation of the epidural space with a paediatric catheter was performed followed by tricortical strut grafting and plating. At review, 36 weeks after surgery, the patient remained asymptomatic, having made full neurological recovery. The purpose of this report is to highlight the importance of emergency surgical intervention for extensive SEA in the presence of progressive neurological loss associated with multisystem failure.     

扩大半椎板切除术治疗颈脊髓损伤

OBJECTIVE: To treat cervical spinal cord injury (SCI) accompanied with narrowing spinal canal by expanded hemilaminectomy. METHODS: From 1995 January to 1998 April 51 patients of cervical SCI were treated by expanded hemilaminectomy. Spinal injury classified in to 3 types: no fracture-dislocation (39 patients) fracture dislocation at the lower cervical spine (11), and burst fracture (1). The types of SCI included central cord injury (18 patients) incomplete cord injury (19), and complete cord injury (14). MR imaging in 23 patients showed degenerative changes with normal intensity of the cord in 14 patients, multiple level hyperintensity in 3, cystic changes in 3, myelomalasia in 3, and cord brocken in 1. Expanded hemilaminectomy was performed in 24 hours in 3 patients, in 48 hours in 9, in one week in 2, after one week in 35, and after one year in 2. The left or right laminae were removed from C(7) to C(3) in 42 patients, C(3) - T(1) in 3, C(2) - C(7) in 2, C(3) - C(6) in 3 and C(4) - C(7) in 3. Hemilaminectomy was expanded lateral to the inner of apophyseal joint and medial to the inner lamina beneath the spinal process. RESULTS: Follow-up lasted for 1 year and 7 months. Six patients with complete cord injury had of the no recovery lower extremity but recovery of the brachialis and extensor radial longus. 12 patients of central cord injury had full recovery except intrinsic muscles of the hand (5). They operated were on 2 weeks after injury. 17 patients of incomplete cord injury recovered to Frankel IV. CONCLUSIONS: Expanded hemilaminectomy is indicated for patients of cervical SCI with narrowing spinal canal or without fracture dislocation. Best results can be obtained in patients of central cord injury, and incomplete cord injury. Even in complete cord injury, 1 - 2 forearm muscle may recover (24.8%), securing a pinch grip reconstruction.     

胸腰椎骨折伴脊髓损伤治疗进展

脊柱骨折伴脊髓损伤的治疗，一直是脊柱外科关注的课题，随着对神经损伤的病理生理研究深入和手术方法的改进，对其治疗方法和观点也有了进一步的发展。本文就胸腰椎骨折伴脊髓损伤治疗方面的进展进行综述。     

胸腰椎肿瘤全脊椎切除术后的重建方式

目的:探讨胸腰椎肿瘤全脊椎切除术后脊柱稳定性的重建方式。方法:1993￣2003年我院治疗各类胸腰椎(T5￣L5)肿瘤患者72例,其中全脊椎切除、随访2年以上、没有肿瘤复发和转移且有完整影像学资料者12例,骨巨细胞瘤9例,单发浆细胞性骨髓瘤2例,非何杰金氏淋巴瘤1例。一期前后路联合全脊椎切除11例,次全脊椎切除1例,以5种不同方式重建,分别为前路内固定加后路短节段经椎弓根内固定(ASP)5例、前路内固定加后路多节段Luque环内固定(AMP)4例、单纯后路短节段经椎弓根内固定(SP)1例、单纯后路多节段经椎弓根内固定(MP)1例、单纯前路内固定(A)1例。观察术前、术后即刻及末次随访时矢状面Cobb角度变化、植骨融合情况、有无植骨骨折及下沉等并发症。结果:随访2.5￣13年,平均6.6年。ASP方式重建的5例患者矢状面Cobb角丢失0°～7°,平均2.4°,植骨全部融合,无植骨骨折,1例因术中损伤终板而出现人工椎体轻度下沉。AMP方式重建的4例患者矢状面Cobb角丢失0°～9°,平均5°,植骨全部融合,无植骨骨折或下沉;其中1例术后1.5年植骨融合后取出后方固定,仅保留前方固定,出现植骨骨折及后凸畸形。SP或MP方式重建的2例患者矢状面Cobb角分别丢失12°和13°,植骨块均骨折。次全脊椎切除A方式重建的1例患者矢状面Cobb角无丢失,植骨融合且无植骨骨折及下沉。结论:本组病例较少,但初步可以看出ASP和AMP是全脊椎切除后坚强的重建方式,能够使植骨顺利融合,防止Cobb角度丢失。但ASP能够减少固定节段、保留运动单元,是更好的固定方式。SP和A不宜单独应用于全脊椎切除后稳定性重建。     

Spontaneous spinal epidural hematomas: is the role of dural arteriovenous malformations underestimated?

Two recent observations of spinal epidural hematomas (SEH) are presented: one of them was associated with iatrogenic coagulopathy, the other, apparently spontaneous, required reoperation for early recurrence and was finally attributed to ruptured epidural arteriovenous malformation missed during the first procedure. Both patients underwent complete recovery. Although modern neuroimaging provides quick, noninvasive, and sensitive assessment of spinal epidural bleeding, we believe that preoperative spinal angiography is indicated in spontaneous SEH with subacute clinical course. Demonstration of underlying vascular anomaly would allow better surgical planning, complete obliteration of abnormal vessels, and prevention of recurrences. Essential epidemiological, pathogenetical, and clinical aspects of SEH are reviewed.