后路椎间融合术治疗成人腰椎滑脱的前瞻性研究

目的前瞻性比较采用自体髂骨块和椎间融合器治疗成人腰椎滑脱的效果。方法自1998年2月～2002年2月治疗78例腰椎滑脱患者,所有患者均行椎弓根螺钉固定、后路椎间融合术,根据椎间融合材料的不同,前瞻性将患者随机分为融合器组36例(采用后方斜向单枚椎间融合器)和自体骨组42例(采用自体髂骨块)。男33例,女45例;年龄35～59岁,平均43岁。其中Ⅰ度滑脱29例,Ⅱ度滑脱39例,Ⅲ度滑脱10例。比较两组患者的基本情况、临床效果和影像学结果(融合率和手术节段椎间隙高度的变化)。结果术后随访2年～3年7个月,平均35个月。两组在性别、年龄、滑脱程度、手术时间、失血量以及住院时间上差异无显著性,两组患者均无严重并发症。融合器组优良率为88.8%,自体骨组为83.2%(P=0.99)。术后1年融合器组的融合率为86.1%,自体骨组为83.3%,两组间差异无显著性意义(P=0.87);最终随访时椎间隙高度融合器组平均减少1.7 mm,自体骨组平均减少2.6 mm,两组间差异有非常显著性意义(t=1.38,P< 0.005)。结论采用自体骨为植骨材料者术后椎间隙高度丢失明显增加,但两组之间融合率和临床优良率差异无显著性。椎间融合器和自体髂骨块均可以作为腰椎滑脱后路椎间融合的植骨材料,临床疗效好。     

Cervifix在陈旧性寰枢椎脱位并高位颈髓压迫症中的应用

目的:探讨Cervifix内固定系统治疗陈旧性寰枢椎脱位并脊髓不全损伤的价值。方法:36例陈旧性寰枢椎脱位并脊髓不全损伤行后路融合、Cervifix内固定。男23例、女13例,年龄15～62岁,平均38.3岁。陈旧性外伤21例,先天性畸形9例,类风湿性关节炎伴寰椎前脱位6例。结果:随访8～42个月,平均19个月。术后脊髓功能按JOA17分法评定,改善率为71.4％。全部患者均获骨性融合,内置物无松动、断裂及脊髓损伤加重等并发症。结论:Cervifix内固定可提供坚强有效的节段性固定,提高融合率。同时,可预防单纯减压融合术后早期失稳导致的高位脊髓损伤加重。     

PLF与PLIF手术治疗腰椎滑脱症的疗效比较

目的:对比研究后外侧融合(PLF)与经后路椎体间融合(PLIF)治疗Ⅰ度和Ⅱ度腰椎滑脱症的疗效。方法:67例腰椎滑脱症患者分为PLF组32例,PLIF组35例。两组年龄、病程、术前临床表现及影像学资料相近似。PLF组JOA评分16.3±7.8分,PLIF组14.5±6.5分。两组均进行了后路椎板减压,短节段经椎弓根钉系统复位与固定。结果:PLF组手术时间平均187min,出血量平均680ml;PLIF组手术时间248min,出血量平均945ml。PLIF组慢性下腰痛改善明显高于PLF组(P=0.042),而临床疗效JOA评分两组间无显著性差异。骨融合率PLF组74.8%,PLIF组94.3%(P=0.011),经随访PLF组矫正率丢失30.9%,而PLIF组为9.8%(P<0.05)。PLF组各种并发症19例,PLIF组11例。结论:PLF与PLIF手术均是治疗腰椎滑脱症的有效术式,PLIF手术时间较长,创伤大,但骨融合率高,内固定失败率低,滑脱矫正率丢失少,晚期慢性下腰痛发生率低。     

Computed axial tomography-MIBI image fusion for preoperative localization in primary hyperparathyroidism

BACKGROUND: An imaging-guided unilateral surgical approach in patients with primary hyperparathyroidism (HPTH) requires reliable preoperative localization procedures. Using present imaging techniques, 60% to 80% of patients with primary HPTH can be treated successfully with limited surgery. Thus, further improvement of diagnostic accuracy is required. Computed axial tomography (CAT)-MIBI image fusion was introduced as a new technique for localizing enlarged parathyroid glands. We describe the new method and present its first results. METHODS: Six consecutive patients with primary HPTH underwent CAT-MIBI image fusion for preoperative parathyroid localization. CAT and technetium-99m-sestamibi scan were performed separately. The patient's head and neck were fixed with the noninvasive Vogele-Bale-Hohner Head Holder (VBH HeadFIX; Medical Intelligence, Schwabmünchen, Germany) and the BodyFIX (Medical Intelligence) vacuum cushion. Radiographic and scintigraphic markers were mounted at the head holder and the patient. CAT and MIBI images were fused by overlaying radiographic markers using a commercial software and workstation. RESULTS: In 5 patients, localization and dimension of the solitary adenomas were exactly predicted. In 1 patient with multiglandular disease (3 enlarged glands), CAT-MIBI image fusion was not able to predict multiple gland involvement. However, in a retrospective analysis of the localization study, the other two enlarged parathyroid glands could be correctly identified regarding their site and size. CONCLUSIONS: First results of CAT-MIBI image fusion are promising. The new technique provides a higher image resolution and better delimitation of enlarged parathyroid glands and adjacent anatomic structures than conventional scintigraphic methods.     

Adjacent segment disease after anterior cervical interbody fusion

BACKGROUND CONTEXT: There have been many follow-up studies on anterior interbody fusion for cervical nerve root and spinal cord compression, and excellent neurological outcomes have been reported. However, postoperative degenerative changes at adjacent discs may lead to the development of new radiculopathy or myelopathy. In the previous reports, the incidence of symptomatic adjacent segment disease has ranged from 7% to 15%. PURPOSE: The present study was undertaken to investigate the incidence of symptomatic adjacent segment disease after anterior cervical interbody fusion (ACIF) and to identify the factors that are related to the development of this disease. STUDY DESIGN/SETTING: This is a retrospective cohort study. PATIENT SAMPLE: A total of 112 patients were followed up clinically and radiologically for more than 2 years. OUTCOME MEASURES: Follow-up evaluation was primarily by means of clinical visits. The postoperative course of any symptoms, the findings of neurological examination and serial follow-up radiographs were performed in all patients. METHODS: The diagnosis of symptomatic adjacent segment disease was based on the presence of new radiculopathy or myelopathy symptoms referable to an adjacent level, and the presence of a compressive lesion at an adjacent level by magnetic resonance imaging or myelography. We evaluated the correlation between the incidence of symptomatic adjacent segment disease and the following clinical parameters (age at operation, sex, number of the levels fused) and radiological parameters (preoperative cervical spine alignment, preoperative range of motion of C2-C7 cervical spine, anteroposterior spinal canal diameter, preoperative existence of an adjacent segment degeneration on plain radiograph, myelography and magnetic resonance imaging [MRI]). RESULTS: Symptomatic adjacent segment disease developed in 19 of 112 patients (19%) followed. A Kaplan-Meier survival analysis was performed in order to follow the disease-free survival of the entire series of patients. The disease-free survival rates were 89% at 5 years, 84% at 10 years and 67% at 17 years. The incidences of indentation of dura matter on preoperative myelography or disc protrusion on MRI at the adjacent level were significantly higher in disease cases (p=.0087, .0299, respectively; chi-squared test). However, the other parameters did not show a statistically significant difference. There were seven cases (37%) who had failure of nonoperative treatment and additional operations were performed. CONCLUSIONS: The incidence of symptomatic adjacent segment disease after ACIF was higher when preoperative myelography or MRI revealed asymptomatic disc degeneration at that level regardless of the number of the levels fused, preoperative alignment, spinal canal diameter or fusion alignment.     

Does rigid instrumentation increase the fusion rate in one-level anterior cervical discectomy and fusion?

BACKGROUND CONTEXT: Although plate fixation enhances the fusion rate in multilevel anterior cervical discectomy and fusion (ACDF), debate exists regarding the efficacy of nonplating to rigid plate fixation in one-level ACDF. PURPOSE: To determine the efficacy of nonplating to rigid plate fixation in regards to fusion rate and clinical outcome in patients undergoing one-level ACDF with autograft. STUDY DESIGN: A review of 69 consecutive patients who underwent one-level ACDF with autograft and with or without rigid anterior cervical plate fixation. PATIENT SAMPLE: Sixty-nine patients who underwent one-level ACDF (mean age, 45 years) were evaluated for radiographic evidence of fusion (mean, 14 months) and for clinical outcome. All patients received tricortical iliac crest autografts. Disc space distraction was 2 mm, the grafts were inserted with the cortical surface positioned anteriorly, and each graft was countersunk 2 mm from the anterior vertebral border. Thirty-eight patients underwent nonplated ACDF and 31 patients underwent plated ACDF. Eighteen Orion (Sofamor-Danek, Memphis, TN), eight Atlantis (Sofamor-Danek) and five PEAK polyaxial (Depuy-Acromed, Rayham, MA) anterior cervical plating systems were used. Rigid plate fixation was used in all patients with instrumentation. Postoperatively, hard collars were worn 6 to 8 weeks in nonplated patients and soft collars were worn for 3 to 4 weeks in plated patients. Twenty-four patients were smokers (54.2% nonplating; 45.8% plating) and work-related injuries entailed 23 patients (47.8% nonplating; 52.2% plating). OUTCOME MEASURES: Fusion was assessed based on last follow-up of lateral neutral, flexion and extension radiographs. Radiographs were evaluated blindly to assess fusion and instrumentation integrity between nonplated and plated patients. Clinical outcomes were assessed with the Cervical Spine Outcomes Questionnaire and also assessed on last follow-up as excellent, good, fair or poor based on Odom's criteria. METHODS: Fusion rate and postoperative clinical outcome were assessed in 69 patients who underwent one-level ACDF with autograft and with or without rigid anterior plate fixation. Additional risk factors were also analyzed. Statistical significance was established at p<.05. RESULTS: Sixty-six patients (95.7%) achieved a solid fusion (100% nonplated; 90.3% plated). Nonunions occurred in three patients (1 smoker; 2 nonsmokers) with Orion instrumentation. Slight screw penetration into the involved and uninvolved interbody spaces occurred in one patient who was a nonsmoker and did not achieve fusion. One superficial cervical wound infection was noted in a nonplated patient. No other intraoperative or postoperative complications were noted. No statistically significant difference was noted between nonplating to rigid plating upon fusion rate (p>.05). All nonunions occurred at the C5-C6 level. Mean estimated intraoperative blood loss was significantly greater in plated patients (p=.043). Revision surgery involved 9.7% of the plated patients, whereas none of the nonplated patients required reoperation. Postoperative clinical outcome was assessed in all patients (mean, 21 months). Excellent results were noted in 18.8%, good results in 72.5% and fair results in 8.7% of the patients. Nonunion patients reported satisfactory clinical outcome. No statistical significance was noted between clinical outcome of fused and nonfused patients, the presence of a work-related injury and the use of plating (p>.05). Demographics and history of smoking were not factors influencing fusion or clinical outcome in this series (p>.05). The effect on fusion by various plate types could not be discerned from this study. CONCLUSION: A 100% and 90.3% fusion rate was obtained for one-level nonplated and plated ACDF procedures with autograft, respectively. The effects of smoking or level of fusion could not be discerned from these one-level cases. Excellent and good clinical outcome results were obtained for 91.3%. Nonplating or rigid plate fixation for ACDF in properly selected patients to treat radiculopathy with or without myelopathy has a high fusion rate and yields a satisfactory clinical outcome. Although controversy exists as to the efficacy of rigid plate fixation in one-level ACDF, solid bone fusion can be adequately obtained without plate fixation and instrumentation-related complications can be avoided. In line with the literature, plate fixation should be reserved for patients unwilling or unable to wear a hard orthosis postoperatively for an extended period of time or for those patients who seek a quicker return to normal activities. Proper patient selection, meticulous operative technique and postoperative care is essential to promote optimal graft-host incorporation.     

胸椎结核椎管内外病灶清除同期后路内固定矫形

目的:探讨胸椎结核Ⅰ期病灶清除及后路短节段椎弓根螺钉系统重建脊柱稳定性的外科治疗方法。方法:对1999年2月以来收治的15例合并椎管内外脓肿的胸椎结核患者,采用后路Ⅰ期双侧肋骨横突切除病灶清除、短节段椎弓根螺钉矫正脊柱后凸畸形、取髂骨植骨的综合性手术方法进行治疗,并对其疗效进行分析。结果:术后随访6个月-2年5个月,平均1年8个月,本组15例术后胸部症状均完全消失,术后脊柱后凸角度为6°-15°,平均矫正度数为17°。术后脊髓神经功能均有不同程度的改善,植骨全部骨性融合,植骨融合时间平均3.2个月。结论:经后路可Ⅰ期有效地进行胸椎结核的彻底病灶清除及脊柱稳定性的重建。     

腰椎滑脱后路矫形固定的疗效评定

目的通过对腰椎滑脱症手术治疗的长期随访分析,比较不同术式治疗效果。方法通过对1986年-2000年收治的腰椎滑脱患者临床资料及功能进行分析。结果60例患者分别采用Luque术式、Steffee术式、RF-Ⅱ、RF-Ⅱ加BAK术式,随访3～8年,其矫正率分别为42%、67%、95%、97%。结论手术器械矫正加融合对腰椎滑脱的疗效是肯定的,尤以BAK的应用可进一步维持滑脱的矫正,减少远期并发症。     

Rectal perforation after AxiaLIF instrumentation: case report and review of the literature

Background contextBowel perforation is an uncommon complication of posterior spinal surgery. The AxiaLIF transsacral instrumentation system has been used for the treatment of L5–S1 spondylolisthesis and degenerative disc disease since its introduction in 2005 as a potentially less invasive alternative to traditional anterior or posterior interbody fusion.PurposeIn this article, we report a case of a rectal perforation as a complication of placement of the AxiaLIF instrumentation system that was successfully treated without the removal of the device.Study designCase report.MethodsThe patient presented with progressive back pain and sepsis 3 weeks after an L5–S1 fusion done with the AxiaLIF technique at an outside facility. The patient was managed with antibiotic therapy and a diverting ileostomy, without the removal of the AxiaLIF device.ResultsOver the next year, she had symptoms indicative of nonunion of the operated level and breakdown at the adjacent level, which were confirmed with imaging. She underwent revision posterior spinal fusion without the removal of the AxiaLIF device. Eighteen months after the AxiaLIF device was placed, the patient continued to demonstrate no signs of infection recurrence.ConclusionsDelayed presentation of rectal perforation with a subsequent anaerobic sepsis is a potential complication of the presacral approach to the L5–S1 disc space. Recognition and treatment with fecal diversion and long-term intravenous antibiotics is an alternative to device removal and sacral reconstruction.