TSRH内固定系统临床应用初步报告

目的：通过使用新的通用脊柱内固定器脊柱疾病,获得更好的疗效。方法：１９９７年８月－１９９９年３月共用ＴＳＲＨ系统手术治疗脊柱疾病１８例,平均年龄１７．２岁,术后随访２￣２１个月。结果：;特性脊柱侧凸１５例,矫正率在ＫｉｎｇⅡ型为６５．５％,ＫｉｎｇⅢ／Ⅳ为５７．３％;马凡氏综合征脊柱侧凸１例,矫正率６０％;强直性脊椎为驼背１例,矫正率８６．５％,所有病例植骨融合良好无假关节形成,无脊髓神经损伤,植     

成人脊柱畸形多节段融合内固定术后假关节形成

背景：自从现代脊柱内固定技术应用于临床以来，鲜有详细的关于成人脊柱畸形采用脊柱融合内固定术后假关节形成的报道。本研究的目的是分析成人脊柱融合内固定术后假关节形成的趋势、危险因素，并应用脊柱侧凸研究学会-24评价表对结果进行评分。 方法：对同一机构的232例手术治疗成人脊柱畸形的病例进行临床和影像学评估。患者平均年龄40．8岁，初次手术150例，翻修术82例。所有患者均接受了长节段（4个或4个以上椎体）的固定融合，至少有2年以上的随访。临床结果的评估采用脊柱侧凸协会的问卷调查表。 结果：40例患者有假关节形成。与假关节形成有关的因素包括术前患者胸腰椎后凸大于20。（p〈0．0001）、年龄超过55岁（p〈0．001）、融合S，节段（相比融合L5或更近端的节段，p=0．002）、融合多于12个节段（p=0．037）。问卷调查得出的有假关节形成患者的评分平均低于无假关节形成患者的评分（p=0．001）。 结论：用长节段的现代脊柱融合内固定治疗成人脊柱畸形后，假关节发生率为17％，且临床随访效果不满意。 可信水平：预后性研究，Ⅱ级。详细的可信水平描述参见作者须知。     

成人脊柱畸形行多节段椎体内固定和关节固定术后假关节形成

自从现代椎体节段性内固定技术引进以来就很少有人详细报道过成人脊柱畸形行脊柱内固定和关节固定术后有关假关节形成的问题，Kim YJ等从临床和影像学方面评估了232例脊柱畸形成人患者，均在同一机构行外科手术治疗。患者的平均年龄是40．8岁，其中150例患者是首次手术，82例患者是行二次翻修术。所有患者都行长节段内固定和关节固定（至少4个椎体），随访时间2年以上。临床效果通过脊柱侧凸研究会的调查表来评估。结果：40例患者出现假关节。发现的与假关节并发症明显相关的危险因素包括胸腰段后凸大于20。（P〈0．0001）、年龄〉55岁（P=0．001）、关节固定至S．相对与固定至L或者头侧水平（P=0．002）以及关节固定超过12个椎体（P=0．037）。一般来说，出现假关节的患者比那些没有出现假关节患者的（关于脊柱侧凸研究会的调查表）临床效果总评分要低（P=0．001）。结论：脊柱畸形成人患者在行现代脊柱节段器械内固定术伴长节段关节固定术后假关节发生率是17％，这些患者也会因为假关节的发生临床效果下降。     

脊柱侧凸手术后的失败因素分析

断棒、脱钩、假关节形成可导致脊柱侧凸手术后矫形失败，对脊柱侧凸畸形的矫正及防止脊柱畸形的发展是明显不利的，对其原因的分析及提出预防措施是非常重要的。我们对25例脊柱侧凸中断棒、脱钩及假关节患者进行全面检查后再手术，现报告如下。     

脊柱侧凸后路术后矫正度丢失的原因

分析经长期随诊脊柱侧凸术后矫正度丢失的程度及原因。１４２例脊柱侧凸采用后路器械矫正固定，８６例随诊６个月～８年６个月（平均３年４个月），术前、术后及随诊的Ｘ线片对比，分析丢失度与侧凸类型、年龄、内固定种类等之间的关系。２８例（３２．５％）丢失度大于１５°，丢失度与年龄、侧凸类型无明显关系，而与内固定节段的选择、内固定种类及融合技术明显相关。正确选择内固定种类及融合节段，提高融合技术，减少假关节及脱钩的发生率，是长期维持脊柱侧凸术后矫正度的关键。     

骨外固定技术治疗先天性胫骨假关节

先天性胫骨假关节（ＣＰＴ）仍是一个了解最少与治疗最困难的问题。传统方法治疗的成功率仅约５０％。作者报告用半环槽式外固定器治疗１１例ＣＰＴ。病人年龄２～１７岁，平均９岁。下肢短缩４～９ｃｍ。９例接受过１７次手术，包括３次带血管腓骨移植。手术治疗包括切除假关节端加压外固定同时行近干骺端截骨延长。结果９例假关节５～８个月愈合，１例２次手术１４个月愈合，１例未愈合。１１例骨延长５～９．５ｃｍ，平均７ｃｍ，愈合指数３３ｄ／ｃｍ。１０例随诊１～９年，平均３年１０个月。９例骨愈合与肢体功能良好，１例术后３年１１个月因明显外伤再骨折。作者认为骨外固定治疗ＣＰＴ创伤小，方法简便，同时可充分矫正患肢短缩畸形。半环槽式外固定器用克氏针做三维式外固定，固定稳固与负重活动产生的动力性轴向应力刺激是促进ＣＰＴ愈合的关键因素。     

双极股骨头转换术及其关节活动的观察

１９８５年１月－１９８９年５月施地双极人工股骨头转换术３８例，２９例随诊１－５年（平均３６．３月）。依疼痛、关节功能及关节活动度逐项评定，优良率为８０．８％，３例失败（１１．５％（，原因系假体构型不良，假体安放位置不佳及骨水泥技术的缺陷。     

双极股骨头置换术及其关节活动的观察

１９８５年１月～１９８９年５月施行双极人工股骨头置换术３８例，２９例随诊１～５年（平均３６．３月）。依疼痛、关节功能及关节活动度逐项评定，优良率为８０．８％，３例失败（１１．５％），原因系假体构型不良，假体安放位置不佳及骨水泥技术的缺陷。对１０例不同病因及术后时间不等的置换关节在透视下动态观察内外关节活动方式，发现小范围活动时，以内关节活动为主，而大范围活动时，以外关节为主。提出提高疗效的措施，即改进假体设计，假体安放在中立位及改进骨水泥技术。     

脊柱旋转手法治疗腰椎间盘突出症的实验研究

采用模拟手法对３具新鲜尸体的脊柱标本，进行了Ｌ４．５、Ｌ５Ｓ１椎间盘后外缘应力变化的测定，和脊柱不同位置变化下腰椎小关节突相互关系改变的观察。结果发现前屈侧弯旋转法对腰椎小关节突的活动幅度最大，直立旋转法次之，向左侧旋转时小关节突作切面的旋转滑动，右侧小关节间隙增大；向右侧旋转时反之。做前屈侧弯旋转法时，当脊柱向左侧旋转时，椎间盘左后外侧压力增高，同时右后外侧压力减低；向右旋时则反之。而当旋转动作结束复原时，出现负压的一侧均出现一个微小的正压，这种正负压力多次反复的变化，可以使突出的髓核变位或变形，从而使受压的神经根减张。     

脊柱间隔性骨折受伤机理和漏诊原因分析

１４年间收治５３７例脊柱骨折患者中２４例为间隔性骨折，占４．４６％。其中颈－胸组合骨折５例，占２０．８％；颈－腰者４例，占１６．７％；胸－腰者６例，占２５％；颈－颈者２例，占８．３％；胸－胸者３例，占１２．５％；腰－腰者４例，占１６．７％。未表现出神经症状的骨折段易漏诊。本组漏诊共９例，占３７．５％。对受伤机理和漏诊原因做了分析。     

Closed loop instrumentation of the lumbar spine

A review of 40 consecutive nonreported multilevel lumbar fusions revealed an unacceptable pseudarthrosis rate of 32.5%. In an attempt to reduce this complication, a modification of segmental spinal instrumentation with use of a closed loop was performed on 50 consecutive patients treated by multilevel lumbar stabilizations. The primary diagnoses were degenerative disc and/or facet disease in 32, spondylolisthesis in 14, and pseudarthrosis in four. Thirty-eight percent had three or more levels to be fused. Thirty-two percent had had previous spinal surgery. Follow-up study was a minimum of one year. Seventy-three percent had posterior facet fusions. Twenty-seven percent had bilateral transverse process fusions. A pseudarthrosis occurred early in six patients, an incidence of 12%; three of the six occurred in patients with spondylolisthesis. Four of the six pseudarthroses occurred following posterior fusions. Subjective symptoms were improved in 80%. Working capacity was the same or better in 56%. Closed loop instrumentation (CLI) decreased the overall incidence of pseudarthrosis. When combined with transverse process fusion, CLI produced a slightly higher rate of success (90%) than did posterior fusion alone (87%) but did not reduce the incidence of pseudarthrosis in patients with spondylolisthesis.     

The safety and efficacy of Isola-Galveston instrumentation and arthrodesis in the treatment of neuromuscular spinal deformities

BACKGROUND: Implant systems that realign and stabilize a deformed spine continue to evolve. The purpose of the study of this case series was to determine the safety and effectiveness of a system designed to integrate hook, wire, screw, and post anchors for the treatment of a wide spectrum of neuromuscular disorders associated with pelvic deformity or the potential for deformity. METHODS: Forty-seven consecutive patients who had a spinal deformity that was due to cerebral palsy or an upper motor-neuron cerebral palsy-like disease (thirty-one patients), myelomeningocele (nine), Duchenne muscular dystrophy (four), or other disorders (three) were managed with Isola-Galveston instrumentation and arthrodesis. The average age at the time of the operation was fourteen years and three months (range, five years and four months to twenty-three years and nine months). Eight patients (17 percent) had an additional anterior discectomy and arthrodesis without instrumentation, and three (6 percent) had an additional decancellation egg-shell osteotomy. The forty-seven patients were followed for an average of forty-seven months (range, twenty-four to 100 months). The complications were tabulated to assess the safety of the procedure, and the correction of each deformity was calculated to determine the efficacy. RESULTS: There were no deaths, acute wound infections, or serious neurological problems. Reoperation was necessary in five patients (11 percent). One reoperation was performed because of a delayed deep wound infection; one, because of delayed sterile drainage; and one, for a pseudarthrosis repair. The remaining two reoperations were done for removal of an implant because the cephalad portion had become prominent. In addition to the pseudarthrosis that required a reoperation, there were three possible pseudarthroses that did not require a reoperation (overall prevalence of pseudarthrosis, 9 percent). Postoperative bracing was used for eleven patients (23 percent); it did not influence the rate of pseudarthrosis or possible pseudarthrosis. The average preoperative scoliosis of 70 degrees was corrected to 24 degrees (a 66 percent correction) at the time of the latest follow-up, and the average preoperative pelvic obliquity of 27 degrees was corrected to 5 degrees (an 81 percent correction). A survey of the patients, parents, and caregivers indicated that 96 percent of them were satisfied or very satisfied with the result of the operation. CONCLUSIONS: Isola-Galveston instrumentation seems as safe and effective as other types of instrumentation that have been studied in comparable series in the literature. Isola-Galveston instrumentation is probably more effective for the correction of pelvic obliquity and the maintenance of correction. Only a posterior procedure is used, and the instrumentation appears to decrease the need for an additional anterior approach. Spinal hook, wire, screw, and post anchors have been successfully integrated into one posterior spinal implant system.     

The Cotrel-Dubousset system--results in spinal reconstruction. Early experience in 47 patients.

Forty-seven patients were treated with spinal fusion and Cotrel-Dubousset instrumentation and were followed for an average of 28 months. Spinal procedures included: 1) posterior spinal fusion for idiopathic scoliosis (26 patients); 2) posterior pseudarthrosis repair (5 patients); 3) combined anterior/posterior fusion to the sacrum (6 patients); and 4) combined anterior/posterior osteotomies (10 patients). Group 1: Partial derotational correction was achieved for adolescent idiopathic scoliosis. Group 2: Successful pseudarthrosis repair was achieved in four patients. Group 3: A solid arthrodesis was obtained in two patients, whereas the other three patients underwent revision of sacral screw fixation for pseudarthrosis. One patient died postoperatively. Group 4: Pain relief and a balanced correction was achieved in all patients. The Cotrel-Dubousset system appears to be a versatile system and provides a wide range of possibilities for a variety of spinal problems.     

Pseudarthrosis in adult spinal deformity following multisegmental instrumentation and arthrodesis

BACKGROUND: There have been few detailed reports concerning pseudarthrosis following spinal instrumentation and arthrodesis in adults with spinal deformity since the introduction of modern segmental fixation techniques. The purposes of this study were to analyze the prevalence, risk factors, and outcome scores on the Scoliosis Research Society Instrument-24 associated with pseudarthrosis following instrumentation and arthrodesis for the treatment of spinal deformity in adults. METHODS: A clinical and radiographic assessment of 232 adults with spinal deformity who were treated surgically at a single institution was conducted. The average age of the patients was 40.8 years, and the operation was a primary procedure in 150 patients and a revision procedure in eighty-two patients. All patients who underwent a long (four vertebrae or more) spinal instrumentation and arthrodesis with a minimum follow-up of two years were included in the analysis. Clinical outcomes were assessed with the Scoliosis Research Society questionnaire. RESULTS: Forty patients had a pseudarthrosis. Factors that were found to be significantly associated with pseudarthrosis were preoperative thoracolumbar kyphosis of >20 degrees (p < 0.0001), an age of more than fifty-five years (p = 0.001), arthrodesis to S1 compared with arthrodesis to L5 or a cephalad level (p = 0.002), and arthrodesis of more than twelve vertebrae (p = 0.037). Patients with a pseudarthrosis had lower total outcome scores on the Scoliosis Research Society questionnaire, on the average, than those without a pseudarthrosis (p = 0.001). CONCLUSIONS: The prevalence of pseudarthrosis following long arthrodesis with use of modern segmental spinal instrumentation for the treatment of spinal deformity in adults was 17%, and the clinical outcome in these patients can be negatively affected by the pseudarthrosis.     

Combined anterior and posterior fusion for spinal deformity in myelomeningocele

Since 1973, 50 of 54 children have been treated by the author with a combined anterior and posterior fusion. Twenty males and 34 females, ranging in age from 1 to 16 years, have been followed for a mean period of 5.5 years. Sixteen patients with a kyphosis averaging 113 degrees (range, 77 to 170 degrees) had correction of deformity to a mean of 35 degrees. Thirty-seven patients with a scoliosis averaging 73 degrees (range, 20 to 135 degrees) had correction to an average of 34 degrees (range, 0 to 75 degrees). There were 4 cases of deep wound infection successfully treated with drainage and antibiotics and only one case required implant removal after fusion/maturation. A pseudarthrosis was noted by radiograph in 6 patients, 3 of whom had isolated asymptomatic lumbosacral pseudarthroses. Three patients had pseudarthrosis at the thoracolumbar junction. These required repair and were successfully treated by supplemental posterior fusion resulting in an overall pseudarthrosis rate of 5.7%. Anterior fusion of the dysraphic spine allows greater correction of both spinal deformity and pelvic obliquity in addition to contributing significant strength to the fusion mass. Segmental spinal instrumentation with sublaminar and pedicular wiring to custom-contoured Luque rods provides excellent correction and immediate postoperative stability.     

Hardware failure in an unconstrained lumbar pedicle screw system. A 2-year follow-up study.

STUDY DESIGN: A consecutive study of patients who underwent lumbar spinal arthrodesis with an unconstrained pedicle screw system. OBJECTIVES: To determine the rate of arthrodesis and of clinical success and to examine and characterize the cases of hardware failure with the AO/Dynamic Compression Plate system (Synthes, Paoli, PA). SUMMARY OF BACKGROUND DATA: Although the advantages and disadvantages of nonconstrained versus constrained systems have been studied extensively, instrumentation failure has not. Additionally, the association between pseudarthrosis and hardware failure per se is unclear. METHODS: Seventy-four consecutive cases of lumbar spinal fusion are reviewed. Standard outcome scores based on pain relief and medication usage were tabulated, along with pertinent demographic data. The patients were observed at five intervals after surgery for at least 2 years (range, 24 to 35 months; mean, 27 months). Standard statistical analyses were used to analyze data. Status of the arthrodesis was determined by standard radiographic criteria. RESULTS: The overall fusion rate was 61%. At final follow-up, 60% of patients believed that their back pain had improved, whereas 70% believed that their limb pain had improved. The presence of a solid fusion (r = 3.3, P = 0.010) was correlated positively with a successful clinical outcome; the presence of pseudarthrosis and preoperative narcotic use were negatively correlated with a successful clinical outcome. Twenty-two percent of patients (16) experienced hardware failure. Twelve of the 16 had pseudarthrosis; in the majority of these patients, hardware failure occurred at the level of the pseudarthrosis. CONCLUSIONS: The results of this study demonstrate an extremely high rate of hardware failure and pseudarthrosis using an unconstrained pedicle screw system. Interestingly, the initial rate of pain relief was higher and declined over time and was quite possibly associated with loosening of the hardware. Based on these data, it is difficult to recommend the use of an unconstrained fixation system in the lumbar spine.     

Scoliosis surgery in neurofibromatosis

Twenty-three patients who were treated by posterior spinal fusion with neurofibromatous scoliosis were reviewed to study the adequacy of spinal fusion, rate of pseudarthrosis, and incidence of complications. Twenty patients achieved a solid fusion with posterior surgery alone. Thirteen patients required one or more posterior augmentation procedures because of progressive deformity. Three patients with dystrophic kyphoscoliosis required an anterior spinal fusion in addition to the posterior fusion to achieve a solid fusion mass. The type of graft material, Harrington instrumentation, and degree of kyphosis or scoliosis had no effect on the rate of pseudarthrosis. Preoperative neuroradiographic evaluation was found to be warranted for all patients with neurofibromatous scoliosis.     

Surgical correction of spinal deformities following spinal cord injury occurring in childhood

This article reports on the surgical treatment of 14 consecutive patients with paralytic spinal deformities secondary to spinal cord injury occurring in childhood. Eleven patients underwent a posterior spinal fusion and three patients underwent a combined anterior and posterior spinal arthrodesis. Luque rods were used in all but one patient. The spinal fusion extended to the sacrum in 10 patients. No patient developed postoperative wound infections or medical complications. Four patients (28.6%) who underwent initially a posterior spinal arthrodesis developed pseudarthrosis. This was treated successfully by a combined anterior and posterior spinal fusion in two patients. The remaining patients underwent a revision posterior spinal fusion with recurrence of the nonunion in one patient. A combined anterior and posterior spinal arthrodesis could be considered the treatment of choice for patients with severe deformities who can tolerate anterior surgery. If pseudarthrosis develops following posterior spinal fusion, this can be best treated by a combined anterior and posterior revision procedure with instrumentation.     

The orthopedic manifestation of neurofibromatosis. A clinical experience and review of the literature

A retrospective review of 47 patients with neurofibromatosis was performed to evaluate the effects of that disease on patient function and disability. Clinical manifestations were distributed as follows: cafe-au-lait markings were the most prevalent manifestation (87%), followed by a positive family history (49%), scoliosis (53%), neurofibromata (19%), and pseudarthrosis of the tibia (19%). The classic scoliosis was resistant to brace treatment; bracing failed in 70% of patients, necessitating spinal fusion. Pseudarthrosis of the tibia can be subdivided into normal, narrow sclerotic, and cystic medullary canal groups. This study supported the theory that tibias with narrow sclerotic medullary canals should be prophylactically braced until skeletal maturity to prevent fracture. Once fractured, the incidence of non-union is high regardless of treatment mode. Eighty percent of patients with pseudarthrosis of the tibia did not heal with multiple bone grafts and were amputated below the knee. Many patients in this study were educable or only mildly mentally retarded, and performed quite well in activities of daily living.     

Anterior lumbar interbody fusion

This is a report of 85 patients who underwent anterior lumbar interbody fusion (ALIF) for treatment of painful disc disruption (PDD) or symptomatic pseudarthrosis. The fusion rate was 80% by disc. The pseudarthrosis rate increased from 16% at L5-S1 to 21% and 31% at L4-5 and L3-4, respectively. There was a significant increase in pseudarthrosis rate in patients who smoked more than one pack per day. There was no difference in the fusion rate whether autogenous or cadaveric iliac crest graft or dowel versus tricortical block graft was used. Sixty-eight percent of patients were "able to work" after ALIF. The complication rate was low and retrograde ejaculation occurred in only one patient.