极外侧椎问融合术微创治疗退变性脊柱侧凸

目的 介绍侧方人路极外侧椎间融合术微创治疗退变性脊柱侧凸的方法、技术要点,评估其临床价值.方法 采用极外侧椎间融合术微创治疗退变性脊柱侧凸8例,3例椎间融合器矫形加椎体螺钉内固定,5例单纯椎间融合器矫形.分析其临床效果、侧弯矫正率和并发症.结果 手术顺利,术中出血每例平均50 ml,术后腰腿痛明显减轻,下肢神经源性间歇性跛行缓解,侧弯矫正率为64%.随访6～30个月椎间隙高度无丢失,融合器无移位,2例有矫形角度的轻度丢失.无术中和术后并发症.结论 侧方入路的前面无注释微创治疗退变性脊柱侧凸是一种创伤小、出血少、恢复快和安全有效的方法.     

10 November 2009: In-Depth Oral Presentations and Oral Communications

Background  To date, there have been no published studies of the degenerative changes in the cervical spine in adult idiopathic scoliosis patients with thoracic and lumbar curves severe enough to require major reconstructive surgery. Materials and methods  The primary study group was 48 adult patients who had previously undergone a fusion from T10 or higher to the sacrum as an adult for idiopathic scoliosis. These were compared to 38 adults with unfused idiopathic scoliosis of 30°–50° and to 42 symptomatic adults presenting with cervical pain. Cervical degeneration was assessed using a new cervical degenerative index (CDI). Results  The amount of degenerative change seen in the cervical spine in the long-fusion group was significantly higher at baseline (just prior to the fusion) than the two control populations and became much higher at a mean follow-up of 8.5 years. Conclusions  This unique subgroup of patients, those having fusion from the thoracic spine to the sacrum as adults for adolescent idiopathic scoliosis, had a high incidence and severity of degenerative changes in their cervical spine. Due to the presence of advanced cervical degenerative changes prior to the fusion, it is not possible to blame the fusion as the main cause for these findings. These changes are either related to the thoracic and lumbar deformities or are more likely due to this subgroup having a higher natural propensity for degenerative changes.     

Arthrodesis to L5 versus S1 in long instrumentation and fusion for degenerative lumbar scoliosis

There is a debate regarding the distal fusion level for degenerative lumbar scoliosis. Whether a healthy L5-S1 motion segment should be included or not in the fusion remains controversial. The purpose of this study was to determine the optimal indication for the fusion to the sacrum, and to compare the results of distal fusion to L5 versus the sacrum in the long instrumented fusion for degenerative lumbar scoliosis. A total of 45 patients who had undergone long instrumentation and fusion for degenerative lumbar scoliosis were evaluated with a minimum 2 year follow-up. Twenty-four patients (mean age 63.6) underwent fusion to L5 and 21 patients (mean age 65.6) underwent fusion to the sacrum. Supplemental interbody fusion was performed in 12 patients in the L5 group and eleven patients in the sacrum group. The number of levels fused was 6.08 segments (range 4–8) in the L5 group and 6.09 (range 4–9) in the sacrum group. Intraoperative blood loss (2,754 ml versus 2,938 ml) and operative time (220 min versus 229 min) were similar in both groups. The Cobb angle changed from 24.7° before surgery to 6.8° after surgery in the L5 group, and from 22.8° to 7.7° in the sacrum group without statistical difference. Correction of lumbar lordosis was statistically better in the sacrum group (P = 0.03). Less correction of lumbar lordosis in the L5 group seemed to be associated with subsequent advanced L5-S1 disc degeneration. The change of coronal and sagittal imbalance was not different in both groups. Subsequent advanced L5-S1 disc degeneration occurred in 58% of the patients in the L5 group. Symptomatic adjacent segment disease at L5-S1 developed in five patients. Interestingly, the development of adjacent segment disease was not related to the preoperative grade of disc degeneration, which proved minimal degeneration in the five patients. In the L5 group, there were nine patients of complications at L5-S1 segment, including adjacent segment disease at L5-S1 and loosening of L5 screws. Seven of the nine patients showed preoperative sagittal imbalance and/or lumbar hypolordosis, which might be risk factors of complications at L5-S1. For the patients with sagittal imbalance and lumbar hypolordosis, L5-S1 should be included in the fusion even if L5-S1 disc was minimal degeneration.     

Oxygen dynamics at paraspinal muscles during exertion using near-infrared spectroscopy in patients with degenerative lumbar scoliosis

 Oxygen dynamics were measured in both sides of the paraspinal muscles of patients with degenerative lumbar scoliosis. The objective was to investigate the extent of stress by measuring the changes in oxygenation and blood flow volume using near-infrared spectroscopy. There were 44 patients with degenerative lumbar scoliosis (7 men, 37 women) and 11 controls with no scoliosis (2 men, 9 women). The measured recovery time for deoxyhemoglobin indicated the recovery from energy deficit after exercise. The average recovery time of the 11 control subjects was 2.4 ± 0.7 s on the right and 2.4 ± 0.8 s on the left. Among the 44 patients the average recovery time was 3.8 ± 1.8 s on the convex side and 2.1 ± 1.1 s on the concave side. There was a significant difference between the two groups. The recovery time on the concave side in patients was faster than that on the convex side. The results of the current study support the theory that stretching the muscles at the convex side results in chronic increases in the intramuscular compartment and reduced muscular blood flow. Received: May 23, 2002 / Accepted: October 29, 2002 Offprint requests to: M. Miyake, Department of Orthopaedic Surgery, Eiko Hospital, 1381 Takuma, Takuma-cho, Mitoyo-gun, Kagawa 769-1101, Japan     

Grading of degenerative disk disease and functional impairment: imaging versus patho-anatomical findings

Degenerative instability affecting the functional spinal unit is discussed as a cause of symptoms. The value of imaging signs for assessing the resulting functional impairment is still unclear. To determine the relationship between slight degrees of degeneration and function, we performed a biomechanical study with 18 multisegmental (L2-S2) human lumbar cadaveric specimens. The multidirectional spinal deformation was measured during the continuous application of pure moments of flexion/extension, bilateral bending and rotation in a spine tester. The three flexibility parameters neutral zone, range of motion and neutral zone ratio were evaluated. Different grading systems were used: (1) antero-posterior and lateral radiographs (degenerative disk disease) (2) oblique radiographs (facet joint degeneration) (3) macroscopic and (4) microscopic evaluation. The most reliable correlation was between the grading of microscopic findings and the flexibility parameters; the imaging evaluation was not as informative.     

Union versus nonunion after posterolateral lumbar fusion: a comparison of long-term surgical outcomes in patients with degenerative lumbar spondylolisthesis

It has been reported that in patients undergoing posterolateral lumbar fusion (PLF), the fusion status is not related to the short-term operative results. To determine whether the fusion status influences the long-term operative results of PLF, we retrospectively examined the surgical outcomes of uninstrumented PLF for a minimum of 8 years (average, 9.5 years), by comparing cases exhibiting union with those exhibiting nonunion. Uninstrumented PLF was performed for the treatment of lumbar canal stenosis (LCS) with degenerative spondylolisthesis. Since nine patients were lost to final follow-up, the study included 42 patients, and the follow-up rate was 82.4%. The mean age of the patients was 64.1 years (range 46–77 years). Eight patients exhibited fusion at the L3–4 level and 34 patients, at the L4–5 level. The fusion status was assessed using plain radiographs. The clinical outcomes were evaluated using the Japanese Orthopaedic Association (JOA) scores. Nonunion was noted in 26% (11/42) of the patients. There were no statistically significant differences between the groups exhibiting union and nonunion with respect to age, sex, preoperative JOA score, or preoperative lumbar instability. The union group achieved better operative results than the nonunion group at the 5-year and final follow-up (P = 0.006 and 0.008, respectively) although there was no significant difference in the percent recovery at 1 and 3-year follow-up (P = 0.515 and 0.506, respectively). A stepwise regression analysis revealed that the best combination of predictors for percent recovery at the time of final follow-up included the fusion status and the presence of comorbid disease. The results indicate that the fusion status following PLF is a critical factor influencing the long-term but not short-term operative results in the treatment of LCS with degenerative spondylolisthesis.     

Surgical treatment of symptomatic degenerative lumbar spondylolisthesis by decompression and instrumented fusion

Degenerative spondylolisthesis is characterized by the slippage of one vertebral body over the one below, with association of intervertebral disc degeneration and degenerative arthritis of the facet joints, which cause spinal stenosis. The aim of this study was to evaluate the clinical and radiographic results of 22 patients with symptomatic degenerative spondylolisthesis, operated on by decompressive laminectomy and instrumented posterolateral fusion associated with interbody fusion (PLIF). Mean age at surgery was 64 years (range, 57–72). Clinical results were evaluated on a questionnaire at the last follow-up visit concerning postoperative low back and leg pain, restriction of daily life activities, and resumption of sports activity. Lumbar spine radiographs were used to evaluate the status of fixation devices, the reduction of the spondylolisthesis, the lumbar sagittal balance and the presence of spinal fusion. No intraoperative or postoperative complications were encountered. There were no superficial or deep infections, fixation device loosening, or hardware removal. Mean follow-up time was 4 years (range, 3–6 years). Clinical outcome was excellent or good in 19 patients and fair in 3 patients. Preoperatively, mean forward vertebral slipping on neutral lateral radiographs was 5 mm, while postoperatively it decreased to 3 mm. Preoperatively, mean sagittal motion was 3 mm and angular motion was 8°, while postoperatively these values decreased to 1 mm and 1°, respectively. This study demonstrated that spinal decompression followed by transpedicular instrumentation associated with PLIF technique is a valid surgical option for the treatment of degenerative spondylolisthesis with symptomatic spinal stenosis. Clinical outcome, intended as relief of pain and resumption of activity, was improved significantly and fusion rate was high.     

No difference in clinical outcome after posterolateral lumbar fusion between patients with isthmic spondylolisthesis and those with degenerative disc disease using pedicle screw instrumentation: a comparative study of 112 patients with 4 years of follow-up

We compared the clinical outcome after spinal fusion between patients with isthmic spondylolisthesis and those with degenerative disc disease of the lumbar spine, using multiple logistic regression analysis. A questionnaire describing medication, pain, vocational status and patient satisfaction was mailed to all the patients at a median interval of 4 years after their operation. Fusion was evaluated on plain radiographs at a minimum of 12 months after surgery, and patients were classified as fused or not fused. The overall satisfaction rate was 70%. The results of the present study showed no difference in the outcome after spinal fusion between the two groups of patients. The factors that significantly increased the likelihood of an optimal result - defined as patient satisfaction, return to work, and reduced medication - were male gender, being in work prior to surgery, and being a non-smoker. Since spinal fusion is an expensive treatment with potentially serious risks, and leaves one-third of the patients with an unsatisfactory result, we believe that more studies focusing on the indications for surgery should be performed.     

高龄腰椎管狭窄症患者的手术方式选择及疗效

目的 :探讨高龄腰椎管狭窄症患者的手术方式选择及其疗效。方法 :回顾分析2012年3月~2015年3月在我院行手术治疗并获得至少1年随访的39例80岁以上腰椎管狭窄症患者的临床资料,男21例,女18例;年龄80~90岁(82.4±3.1岁)。术前13例伴有一种合并症,12例伴有两种或两种以上合并症。按相关科室会诊意见处理合并疾病,应用美国麻醉医师协会(ASA)体格状态分级评估患者可耐受全麻下手术。12例根性疼痛和间歇性跛行症状为主、无明显腰椎不稳者,采用椎板开窗减压术(单纯减压组);27例明确存在腰椎不稳/腰椎滑脱或术中需要手术切除小关节突、椎板范围较大发生继发性不稳者采用经椎间孔入路椎间融合内固定术(TLIF)(融合内固定组)。采用日本骨科协会(JOA)评分和疼痛视觉模拟评分法(VAS评分)评估手术的临床疗效。结果:39例患者均完成手术。12例患者发生围手术期并发症,单纯减压组3例(肺炎1例,尿路感染1例,肺炎合并术后贫血1例),融合内固定组9例(肺炎3例,硬膜撕裂、尿潴留、心律失常、术后贫血、术后认知功能障碍各1例,尿路感染合并认知功能障碍1例),均经保守治疗后好转;无围手术期死亡病例。单纯减压组JOA评分由术前的10.8±2.3分改善至末次随访时的19.0±4.8分,融合内固定组JOA评分由术前的11.8±2.2分改善至末次随访时的21.8±3.4分,两组患者末次随访时与术前比较均有统计学差异(P0.05)。两组患者末次随访时的腰痛和腿痛VAS评分(单纯减压组3.2±1.7分和3.5±2.1分,融合内固定组3.0±1.2分和2.9±1.2分)与术前(单纯减压组7.4±0.9分和7.8±1.0分,融合内固定组7.4±1.7分和7.7±1.1分)比较均有统计学差异(P0.05)。结论 :对于高龄退行性腰椎管狭窄症患者,术前充分评估患者全身状况,积极处理合并疾病后,根据临床症状、体征及影像学资料,确定责任节段及致病因素,合理选择手术方式,可获得满意的疗效。     

长节段固定治疗成人退变性腰椎侧凸不同近端固定椎患者手术并发症和翻修情况的Meta分析

目的 :分析长节段固定治疗成人退变性腰椎侧凸不同近端固定椎患者的手术并发症和翻修情况。方法:于2018年3月15日通过计算机系统检索Pubmed、Embase、Cochrane、维普、万方数据库、中国知网数据库,截止时间为2018年3月15日。根据上端内固定椎的不同分为两组:近端固定到T10及以上节段为高位椎(upper vertebra,UV)组,近端固定到T10以下节段为低位椎(lower vertebra,LV)组。纳入标准:(1)国内外公开发表比较后路长节段不同上端内固定椎治疗成人退变性腰椎侧凸文献;(2)随机或者非随机对照研究;(3)患者年龄≥18岁;(4)随访时间≥1年。提取文献基本信息,并发症[围手术期及非围手术期术后并发症:硬脊膜破裂,深静脉血栓形成,创口深部感染,创口浅表感染,神经系统并发症,近端邻近节段退变性疾病,近端交界处后凸畸形(proximal junctional kyphosis,PJK),内固定失败,假关节形成,总并发症等],术中出血量和翻修情况(如PJK、假关节形成、内固定失败、感染等不同原因导致的翻修情况)。并通过非随机实验方法学指数法(methodological index for non-randomised studies,MINORS)评价方法对最终纳入文献进行质量评分,Begg法评估发表偏倚。通过STATA 12.0软件进行Meta分析。结果:最终纳入10篇文献,中文2篇,英文8篇,共883例患者,其中UV组353例,LV组530例。所有文献MINORS评分为16~20分,Begg法分析无明显发表偏倚。并发症包括围手术期并发症和非围手术期并发症两大类。其中围手术期并发症中,UV组患者术中出血量显著多于LV组,权重均数差(weight mean difference,WMD)(95%CI)为409.33ml(288.74,529.92),而硬脊膜破裂、深静脉血栓形成、创口深部感染、创口浅表感染、神经系统并发症和围手术期总并发症对比无显著性差异(P0.05)。非围手术期术后并发症中,UV组近端邻近节段退变性疾病发生率低于LV组,风险比(relative risk,RR)(95%CI)为0.26(0.11,0.63),P0.05;PJK、内固定失败、假关节形成和非围手术期术后总并发症对比无显著性差异(P0.05);PJK、假关节形成、内固定失败、感染等原因引起翻修及总翻修率均无统计学差异(P0.05)。结论:长节段固定治疗成人退变性腰椎侧凸近端固定椎向中上胸椎延长可能有利于降低近端邻近节段退变性疾病的发生,但患者术中出血量更多,在其他并发症和翻修率方面尚未发现优势。