Percutaneous pedicle screw fixation through the pedicle of fractured vertebra in the treatment of type A thoracolumbar fractures using Sextant system: an analysis of 38 cases

Objective： To prospectively evaluate the feasibility, safety and efficacy of the percutaneous pedicle screw fixation through the pedicle of fractured vertebra in the treatment of type A thoracolumbar fractures using Sextant system in the retrospective non-randomized case-control study. Methods： Atotal of 38 consecutive non-randomized patients with type A thoracolumbar fractures, which had been stabilized posteriorly from December 2006 to March 2009, were examined retrospectively more than 9 months after surgery. Twenty-one patients had been treated conventionally with open pedicle screw fixation （OPSF） and 17 patients received minimally invasive treatment with Sextant percutaneous pedicle screw fixation （SPPSF）. As a method of evaluation, the incision size, the intraoperation and post- operative volume of blood loss, operation time, postoperative hospital stay, blood transfusion, the radiological assessment of the sagittal Cobb＇s angle, vertebral body angle and vertebral body height were recorded and compared. Results： All patients were followed up for 8-24 months （average 11.6 months）. There were significant differences in the incision size, surgical blood loss, surgical draining Joss, operation time, hospital stay after operation, blood transfusion, the proportion of antalgic supplement and postoperative incisional VAS between the two groups （P〈0.05）. Mean preoperative kyphotic deformity was 16.0° and improved by 9.3° after surgery in OPSF group, but 15.2° and 10.3° respectively in SPPSF group. Mean preoperative angle of the fractured vertebral body was 15.9°and improved by 7.9° after surgery in OPSF group, but 14.9° and 6.6° respectively in SPPSF group. Mean anterior vertebral body height （% of normal） was 67.3% before surgery and 95.8% after surgery, but 69.1% and 90.1% respectively in SPPSF group. Mean posterior vertebral body height （% of normal） was 93.3% before surgery and 99.5% after surgery, but 88.9% and 93.3% respectively in SPPSF group. Among the patients whose 9-month follow-up films were available, 3.0° ofkyphosis correction was lost in OPSF group, but 3.2° in SPPSF group. And 1.0°of the angle of the fractured vertebral body correction was lost in OPSF group, but 1.5°in SPPSF group. Then 3.0% of the anterior vertebral body height correction was lost in OPSF group, but 2.2% in SPPSF group. And 3.0% of the posterior vertebral body height correction was lost in OPSF group, but 2.5% in SPPSF group. The sagittal Cobb＇s angle, vertebral body angle and anterior height of the fractured vertebra were all significantly different in each group before and after operation （P〈0.05）. There were no significant differences in the postoperative sagittal Cobb＇s angle, vertebral body angle and the improvement of the vertebral body height and the kyphotic deformity correction between OPSF and SPPSF groups （P〉0.05）, but there was significant difference in the postoperative anterior height of the fractured vertebra between the two groups （P〈0.05）. Conclusion： The percutaneous pedicle screw fixation through the pedicle of fractured vertebra using Sextant system is a good minimally-invasive surgical therapeutic choice for patients with type A thoracolumbar fracture except for that the SPPSF has a little insufficiency in resuming the anterior height of the fractured vertebra compared with OPSF.     

改良肩后入路手术治疗肩胛骨骨折

目的　介绍肩胛骨骨折手术的改良后入路,分析手术治疗肩胛骨骨折的临床发现和结果。方法　11例肩胛骨骨折接受改良后入路切开复位内固定手术,其中5例肩胛盂骨折,3例肩胛颈骨折,2例肩胛体骨折,1例肩胛颈、盂和体部复杂型骨折。术后随访5～6 8个月,平均2 3.9个月。按Constant和Murley提出的评分方法评价患肩功能。结果　7例优,2例良,2例可。7例无肩部疼痛,7例肩部外展和屈曲>130°,外展肌力4 ～5级;6例恢复伤前工作,2例主妇能够完成家务。本组病例无术后并发症。结论　改良肩后入路是一种治疗肩胛骨骨折的有效手术入路,切开复位内固定及其术后早期康复锻炼,能够成功防止肩胛骨骨折并发肩部疼痛、僵硬和功能障碍。     

下颈椎小关节突脱位前路稳定手术疗效分析

目的探讨下颈椎小关节脱位前路融合内固定的临床效果。方法39例新鲜下颈椎小关节脱位患者,首先在透视下行颅骨牵引复位,34例复位成功(87％)。其中32例完成了颈前路减压、植骨内固定,5例未成功者和3例陈旧性脱位,先行后路切开复位,再一期行前路减压、植骨内固定。结果全部患者均获骨性融合,无迟发性不稳和后凸畸形,术前神经功能正常者术后无一例出现神经损害症状,不全瘫患者术后均有不同程度恢复。结论前路减压融合是治疗下颈椎小关节脱位安全、有效的方法,可获良好的生物学稳定。     

前路后凸偏心撑开复位技术治疗下颈椎小关节脱位

目的:探讨前路后凸偏心撑开复位技术治疗下颈椎小关节脱位的临床疗效与安全性。方法 :收集2014年1月～2017年12月陆军军医大学第二附属医院骨科采用前路后凸偏心撑开复位技术治疗的下颈椎小关节脱位患者63例,其中男55例,女8例,年龄21～73岁(48.8±12.2岁)。脱位节段:C3/4 4例,C4/5 9例,C5/6 26例,C6/7 22例,C7/T1 2例;单侧脱位22例,双侧脱位41例。合并创伤性椎间盘突出18例,椎体骨折20例,关节突骨折14例。伤后ASIA分级:A级17例,B级3例,C级3例,D级23例,E级17例。从受伤至手术的间隔时间为3～64d(9.5±8.5d)。复位成功后,椎间置入装满自体骨的cage并用前路钢板椎体钉固定。术后随访9～24个月(15.7±5.1个月)。分析其复位成功率、手术时间、术中出血量及出院后随访神经功能恢复情况(ASIA分级)、融合率等指标。结果:63例患者均顺利完成手术。经后凸偏心撑开复位技术直接复位成功52例(82.5%),其中包括单侧小关节脱位22例,双侧脱位30例;合并椎体骨折15例,关节突骨折7例;受伤至手术的间隔时间在2周以内46例、2～4周6例;手术时间为76.2±21.9min,术中出血量为66.3±37.0ml。复位失败的11例患者辅以前路小关节突切除术,最终均成功复位。末次随访时,经后凸偏心撑开复位技术复位成功的52例患者中,20例(38.5%)的ASIA分级至少升高1级(3例术前A级患者末次随访时升至B级2例、C级1例,3例由术前C级升至D级,14例由术前D级升至E级),其余32例的ASIA分级保持不变(包括9例A级,2例B级,7例D级及14例E级);融合率为100%,无内固定松动、断裂。结论 :前路后凸偏心撑开复位技术复位下颈椎小关节脱位成功率高、手术操作简单、创伤小、安全有效。     

心肌营养素-1基因转移对大鼠脊髓损伤后红核神经元的保护作用

目的：观察腺病毒介导心肌营养素-1基因转移对大鼠脊髓损伤(spinal cord injury，SCI)后红核神经元的保护作用。方法：制备大鼠颈3脊髓外侧索横切(C3Hx)模型，损伤区植入明胶海绵饱和的不同成分治疗及对照溶液。分为AdCMV-CT1组、空白对照组、AdCMV-eGFP对照组及正常对照组。荧光金(FG)于C2注射，1，4，8周脑切片，荧光显微镜下红核神经元记数观察红核神经元的存活。结果：在损伤后1～4周，标记红核神经元数几乎无变化。损伤后8周，损伤组、Adv-eGFP组、Adv-CT1组标记神经元分别减少31％，32％，19％。Adv-CT1组与损伤组相比，差异有显著性意义(P&;lt;0．05)。表明脊髓损伤后，红核神经元存在迟发性损伤。Adv-CT1在脊髓中长期表达，明显支持红核神经元的存活。结论：腺病毒介导心肌营养素-1基因转移长时间支持红核神经元的存活。     

颈椎前路减压植骨界面间螺钉固定的实验研究和临床应用

目的 比较单纯植骨,皮质骨螺钉与松质骨螺钉界面间固定的稳定性,并报告临床应用结果。方法 自行设计物制作松质骨螺钉在新鲜颈椎标本间盘切除及椎体部分切除的Ｓｍｉｔｈ－Ｒｏｂｉｎｓｏｎ法和Ｂａｉｌｅｙ法植骨模型中,应用ＷＤ－１０Ｅ万能电子试验机测试有无界面钉固定的拔出载荷。临床应用２０例中男１６例,女４例;平均４３．４岁。颈椎骨折脱位１３例均为不稳定型。     

显微内窥镜下椎间盘切除术治疗复发性腰椎间盘突出症

目的:探讨显微内窥镜下椎间盘切除术(MED)治疗MED术后复发性腰椎间盘突出症的可行性和有效性。方法:2000年10月～2006年5月1572例腰椎间盘突出症患者进行MED治疗,术后9～61个月8例患者出现同节段典型的神经根损害症状和体征,MRI和CT证实为腰椎间盘突出。男5例,女3例,年龄25～47岁,平均35.6岁。均再次行单侧MED手术,其入路和经过与常规MED相似。结果:8例患者的神经根显露和减压良好,无转为开放手术病例。平均手术时间68min,平均失血量45ml,平均住院12.7d。1例术中发生脑脊液漏,无其它并发症。随访5～46个月,平均20.8个月,采用改良Macnab标准评价临床效果,优5例,良3例。结论:对于首次MED术后复发性腰椎间盘突出症患者,再次行MED仍是安全有效的治疗方法。     

颈椎椎间融合术后邻近节段椎间盘退变的临床观察

目的：观察颈椎椎间融合术后邻近节段椎间盘退变的程度。方法：随访40例颈体融合术后患者,颈部和神经系统体检,行X线及MRI检查,观察椎体融合术后邻近节段退变的发生时间和程度。结果：颈椎体融合术邻近节段退变发生率为86％,约1－11年发生退变,平均9年,严重者发生椎间盘突出不全瘫。结论：颈椎体融合术后邻近节段退变容易发生,故对术后患者的指导和处理非常重要。     

椎间孔镜YESS与TESSYS技术治疗腰椎间盘突出症

目的 探讨椎间孔镜YESS(Yeung endoscopic spine system)和TESSYS(transforaminal en-doscopic spine system)技术治疗腰椎间盘突出症的适应证、手术技巧及临床效果.方法 2005年9月至2008年5月,201例腰椎间盘突出症患者分别采用YESS(150例)和TESSYS(51例)椎间孔镜手术治疗.男122例,女79例;年龄17～79岁,平均33.5岁.疗效评定依据疼痛视觉模拟评分(visual analogue score,VAS)和Nakai分级法.结果 162例(80.6%)获得随访,YESS手术组119例(79.3%)、TESSYS手术组43例(84.3%).随访3～36个月,平均12.5个月.YESS手术组术前腿痛VAS评分(8.4±2.1)分,术后1年(2.4±0.8)分,差异有统计学意义;TESSYS手术组术前腿痛VAS评分(8.6±2.3)分,术后1年(2.6±1.3)分,差异有统计学意义.YESS手术组优良率87.5%,TESSYS手术组88.4%.两组均无永久性神经根损伤、大血管损伤和硬脊膜囊撕裂等并发症.YESS手术组6例术后无效,4例术后复发者行翻修术;TESSYS手术组1例术后无效,2例术后复发者行翻修术.结论 椎间孔镜手术治疗腰椎间盘突出症安全、有效.根据不同类型和不同部佗,正确选择YESS技术或TESSYS技术是手术成功的关键.     

经后路椎间盘椎弓根间截骨矫正胸腰段脊柱后凸畸形

目的 探讨经后路途径矫正胸腰段脊柱后凸畸形安全有效的手术方式.方法 利用改良的经后路椎间盘椎弓根截骨椎弓根钉棒系统固定技术矫正胸腰段脊柱后凸畸形16例,男11例,女5例;年龄13岁～53岁,平均26.5岁.其中陈旧性胸腰椎骨折9例,强直性脊柱炎4例,先天性发育不良2例,椎体结核l例,X线术前Cobb角45°～85.,平均58.1°.后凸畸形部位:T10 2例,T11 2例,T12 6例,L1 3例,L2 3例.主要临床表现为腰背部不同程度疼痛,畸形进行性加重,影响工作和生活.病程4～17年,平均8.5年,所有患者均行I期截骨、植骨融合、椎弓根钉内固定术,术后卧床休息4周,外支具制动3个月.结果 经后路椎间盘椎弓根截骨手术时间平均190min(125～240 min),失血量平均750 ml(450～1 900 ml),48 h引流量平均170 ml(100～280 ml).所有病例均为单节段截骨,截骨过程未发生椎体移位,无脊髓损伤并发症.术后矢状面畸形得到矫正,矫正度数平均55°(44°～76.),矫正率平均83%.随访10～24个月,X线片示内固定牢固,脊柱融合好,无假关节形成,无内固定松动,矫正度未见明显丢失.全部患者外观畸形明显改善,腰背部疼痛消失,生活质量大大提高.结论 Ⅱ期后路经椎间盘椎弓根截骨椎弓根钉棒系统内固定技术可使脊柱后凸畸形得到一次性矫正,降低了神经、血管损伤的发生率,是一种治疗胸腰段脊柱后凸畸形安全有效的外科手术方法.

Abstract：

Objective To explore a safe and effective posterior surgical operation for correction of the horacolumbar kyphotic deformity. Methods The study involved 16 patients with thoracolumbar kyphotic deformity treated with the modified posterior transpedicular-intervertebral disc wedge resection osteotomy and screws-rods internal fixation apparatus.There were 11 males and 5 females at an average age of 26.5 years(13-53 years).The kyphosis deformity was caused by ankylosing spondylit in four patients,old lumbothoracic fracture in nine,vertebral dysplasia in two and vertebral body in one.The preoperative kyphosis Cobb angle was 58.1(45°-85°),with the kyphosis deformity at T10 in two patients,at Thin two,at T12in six,at L1 in three and at L2 in three.The main clinical manifestations were different degrees of lower back pain and progressive aggravation of the deformity,influencing the work and living.The course of disease was 8.5 years(4-17 years).All patients underwent pesteriortotal vertebral osteotomy on the apex vertebra,trails-pedicular fixation combined with correction and fusion,after which the patients stayed in bed for four weeks and received orthosis fixation for three months after operation. Resuits The operation lasted for average 190 minutes(125-240 minutes),with average blood loss of 750 ml(450-1 900 m1).All patients were with single segment cut bone,with no spinal cord injury,neurological injury or hardware failure.The post-operative vertical plane facial deformity was corrected for average 55(44°-76°),wit average correction rate of 83%.The follow-up for 10-24 months showed firm internal fixation on the X-ray film and good fusion ofthe vertebral column,with no pseudoarticulation formation,loosening internal fixation or loss of correction.All the patients obtained obvious improvement in appearance of the deformity,with disappearance of the lower back pain and improvement of the quality of life. Conclusion One stage posterior transpedicular-interverte-bral disc wedge resection osteotomy is all effect and safe surgical technique for correction of horacolumbar kyphotic deformity.