退行性腰椎管狭窄症手术方式及选择探讨

目的研究退行性腰椎管狭窄症患者不同手术方式的疗效,并且对其选择进行探讨。方法将本院2009年10月～2011年10月43例退行性腰椎管狭窄症患者根据其病情和手术方式分为两组,其中A组20例,主要采用椎板间隙开窗、椎管潜行扩大术;B组23例,主要采用全推板或半推板切除减压、髓核摘除加植骨融合钉棒系统内固定术,比较两组术中的并发症率和术后的优良率。结果 B组的优良率为78.26%略高于A组的75.00%,但通过χ2检验后,P〉0.05,差异无统计学意义;B组的并发症发生率为21.7%,显著高于A组并发症发生率的11.5%,且P〈0.05,差异具有统计学意义。结论椎板间隙开窗、椎管潜行扩大术创伤小、花费少、术后效果优良,且能不破坏脊柱稳定性,但是不适合多阶段狭窄及腰椎存在不稳者;而全推板或半推板切除减压、髓核摘除加植骨融合钉棒系统内固定术虽然有较高的并发症率,但是能够治疗多阶段狭窄及腰椎存在不稳者。因此,在选择术式时,应该坚持在术前进行仔细的临床症状和影像学资料的评估,确定狭窄的程度,以提高疗效,减少并发症发生率。     

Intermediate clinical and radiological results of cervical TDR (Mobi-C®) with up to 2 years of follow-up

The interest in cervical total disc replacement (TDR) as an alternative to the so-far gold standard in the surgical treatment of degenerative disc disease (DDD), e.g anterior cervical discectomy and fusion (ACDF), is growing very rapidly. Many authors have established the fact that ACDF may result in progressive degeneration in adjacent segments. On the contrary, but still theoretically, preservation of motion with TDR at the surgically treated level may potentially reduce the occurrence of adjacent-level degeneration (ALD). The authors report the intermediate results of an undergoing multicentre prospective study of TDR with Mobi-C^® prosthesis. The aim of the study was to assess the safety and efficacy of the device in the treatment of DDD and secondary to evaluate the radiological status of adjacent levels and the occurrence of ossifications, at 2-year follow-up (FU). 76 patients have performed their 2-year FU visit and have been analyzed clinically and radiologically. Clinical outcomes (NDI, VAS, SF-36) and ROM measurements were analyzed pre-operatively and at the different post-operative time-points. Complications and re-operations were also assessed. Occurrences of heterotopic ossifications (HOs) and of adjacent disc degeneration radiographic changes have been analyzed from 2-year FU X-rays. The mean NDI and VAS scores for arm and neck are reduced significantly at each post-operative time-point compared to pre-operative condition. Motion is preserved over the time at index levels (mean ROM = 9° at 2 years) and 85.5% of the segments are mobile at 2 years. HOs are responsible for the fusion of 6/76 levels at 2 years. However, presence of HO does not alter the clinical outcomes. The occurrence rate of radiological signs of ALD is very low at 2 years (9.1%). There has been no subsidence, no expulsion and no sub-luxation of the implant. Finally, after 2 years, 91% of the patients assume that they would undergo the procedure again. These intermediate results of TDR with Mobi-C^® are very encouraging and seem to confirm the efficacy and the safety of the device. Regarding the preservation of the status of the adjacent levels, the results of this unconstrained device are encouraging, but longer FU studies are needed to prove it.     

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.     

不同程度椎间盘退变相应椎间孔的影像学变化及其临床意义

目的：从影像学角度研究腰椎间盘不同退变程度时相应椎间孔形态改变的规律,探讨其临床意义。方法：自2006年12月至2008年2月选取37例L4,5椎间盘呈退行性变化的影像学资料（MRI、CT）进行研究,男23例,女14例,年龄28～62岁,平均41.6岁;分别将其矢状位MRIT2WI成像,采用MRI机内Mean/Curve测量软件测量计算L4,5节段退变椎间盘信号强度与相应节段脑脊液平均信号强度比值（RSI）,判断椎间盘退变程度并进行分组。分为3组：轻度退变组11例（A组）,中度退变组13例（B组）,重度退变组13例（C组）。根据CT1.25mm薄层二维旁矢状位重建测量L4,5节段椎间孔的最大高度、最大宽度与面积。分析椎间盘在不同退变程度下相应椎间孔变化规律及可能对神经根状态的影响。结果：①中、轻度退变组椎间孔的最大高度及面积差异均无统计学意义（P〉0.05）,重、中度退变组椎间孔最大高度及面积均有统计学意义（P〈0.05）,重、轻度退变组椎间孔最大高度差异有统计学意义（P〈0.01）;②重、中、轻度退变组椎间孔最大宽度差异均无统计学意义（P〉0.05）。结论：随着腰椎间盘退变程度加重相应椎间孔的高度及面积也逐渐减小,而其对椎间孔宽度影响不大;椎间孔高度及面积变小有可能导致神经根受压。     

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.     

老年退行性腰椎管狭窄症不同手术方式的疗效分析

目的 探讨老年退行性腰椎管狭窄症患者手术方式和疗效.方法 回顾分析1999年1月～2004年12月收治的65岁以上且获得2～6年随访的退行性腰椎管狭窄症116例的临床资料.其中男54例,女62例;年龄65～82岁,平均74.3岁.保留椎板上1/3或全椎板切除减压术共58例;多节段全椎板切除减压术45例;采用椎板减压、椎弓根固定、椎间植骨融合术13例.结果 随访2～6年,平均3年11个月.JOA评分从术前(7.5±1.8)分改善至(14.0±1.3)分.94.2%的患者自诉生活质量明显提高,腰腿痛明显缓解,行走距离明显增加.结论 老年退行性腰椎管狭窄症患者在积极控制并存内科疾病的基础上,依据个体情况采取有限化减压手术可获得较满意的临床疗效.     

The value of fat saturation sequences and contrast medium administration in MRI of degenerative disease of the posterior/perispinal elements of the lumbosacral spine

Degenerative-inflammatory lumbar spinal pathology is one of the most common reasons why individuals seek medical care, and low back pain is the main symptom among those most commonly associated with this pathologic condition. Pain is commonly attributed to degenerative disc disease, particularly herniated discs, but many different spinal and perispinal structures may undergo degenerative-inflammatory phenomena and produce pain: discs, bone, facet joints, ligaments and muscles. In particular, in patients with non-radicular low back pain, this syndrome may arise from changes of the posterior elements/perispinal tissues of the lumbar spine (i.e., the “posterior vertebral compartment”). They include: facet joint pathology (e.g., osteoarthritis, joint effusion, synovitis and synovial cysts), spondylolysis, spinal/perispinal ligamentous degenerative-inflammatory changes and perispinal muscular changes. It is well known that magnetic resonance is the most sensitive imaging method for the evaluation of spinal degenerative pathology, even in the initial stages of the disease. T2-weighted sequences with fat saturation, and when indicated the use of contrast-enhanced T1-weighted images with fat saturation, permit the visualization of degenerative-inflammatory changes of the posterior elements of the lumbar spine that in most cases would have been overlooked with conventional non-fat suppressed imaging.     

Trauma to the ankylotic spine: imaging spectrum of vertebral and soft tissue injuries

The objectives of the study were to review the clinical entities that can cause ankylosis of the spine and to illustrate the spectrum of traumatic injury patterns. Ankylosing spondylitis, diffuse idiopathic systemic hyperostosis, degenerative spondyloarthropathy, and spinal canal stenosis can render the spine susceptible to trivial trauma. Multidetector computed tomography and magnetic resonance imaging can accurately diagnose vertebral and soft tissue traumatic injury patterns in this patient population.     

老年性腰椎退行性病变X线、CT影像学表现与临床分析

目的①总结老年性腰椎退行性病变的X线与CT影像学表现;②探讨老年性腰椎退行性改变导致临床症状的原因。方法随机抽取我院2003年1月~2009年1月共检查、治疗老年性腰椎退行性病变60例,就其腰椎X线平片与CT影像学表现分析。结果60例老年性腰椎骨质疏松有35例(53.33%),60例90节椎间盘中检出退变83节(92.22%),各椎小关节均有不同程度的退行性改变(100%)。结论需重视影像学与临床方面对老年性腰椎退行性的改变表现,尤其是对于椎间盘变性、椎小关节病变、继发性椎管狭窄导致老年性腰腿症状因素的再认识。     

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.