经伤椎椎弓根植骨结合椎弓根螺钉治疗胸腰椎骨折远期疗效

目的 探讨经伤椎椎弓根植骨结合椎弓根螺钉治疗胸腰椎爆裂性骨折的远期疗效.方法 采用经伤椎椎弓根椎体内植骨结合后路短节段椎弓根螺钉内固定、椎管减压治疗胸腰椎爆裂性骨折62例.测量伤椎椎体前缘、中央及后缘高度压缩率变化,Cobb角改善情况;经伤椎椎弓根平面CT扫描,观察椎管减压及椎体内植骨融合情况.结果 术后全部患者经随访...     

后路椎弓根器械治疗胸腰椎骨折脱位

目的研究短节段椎弓根器械复位固定治疗胸腰椎骨折脱位的方法和疗效。方法应用短节段椎弓根器械复位固定治疗胸腰椎骨折脱位66例,41例行横突间或椎板间植骨融合,9例经伤椎椎弓根行可吸收球囊椎体成形术,平均随访14个月。结果短节段椎弓根器械(Dick除外)复位固定治疗胸腰椎骨折脱位,伤椎术后椎体高度比和Cobbs角有显著改善,41例后路植骨融合和9例椎体成形术患者无断钉、钉松动或矫正度丢失现象。结论短节段椎弓根器械复位固定,结合后路植骨融合或椎体成形术是治疗胸腰椎骨折脱位的良好方法。     

后路短节段椎弓根螺钉内固定椎体间植骨融合治疗胸腰椎单椎体爆裂性骨折

目的 探讨后路短节段椎弓根螺钉内固定结合经椎间孔椎体间植骨融合治疗胸腰椎单椎体爆裂骨折的疗效.方法 对2004年1月至2007年12月采用后路短节段椎弓根钉内固定结合经椎间孔椎体间植骨融合治疗且获得随访的31例胸腰椎单椎体爆裂骨折患者的临床资料进行回顾性分析.其中T11 2例,T12 9例,L1 11例,L2 6例,L3 3例;骨折按AO分型:A2型17例,A3型14例.术前脊髓神经功能按Frankel分级标准评定:A级3例,B级7例,C级12例,D级7例,E级2例.结果 所有患者随访12～41个月,平均17.5个月.术后1周及1年矢状面后凸Cobb角、伤椎前缘高度比值及椎骨横截面侵占率较术前均明显改善,差异有统计学意义(P＜0.05);术后1年与术后1周比较差异无统计学意义(P＞0.05).脊髓神经功能除A级3例无恢复外,其他患者均有不同程度恢复.结论 后路短节段椎弓根螺钉内固定经椎间孔椎体间植骨融合术可以通过一个切口完成三柱重建,创伤较小、减压充分彻底、复位固定可靠、融合节段少,是治疗胸腰椎单椎体爆裂骨折的有效方法之一.     

腰椎斜外侧椎间融合术后融合器沉降的原因分析

目的:观察斜外侧椎间融合(oblique lateral interbody fusion,OLIF)治疗腰椎病变术后融合器沉降现象,总结融合器沉降特点,并分析其原因,提出预防性措施。方法:回顾性分析2015年10月至2018年12月收治的144例腰椎病变资料,其中男43例,女101例;年龄20~81(60.90±10.06)岁;腰椎间盘退行性病变17例,巨大型腰椎间盘突出12例,椎间盘源性腰痛5例,腰椎管狭窄症33例,腰椎退行性滑脱26例,腰椎椎弓峡部裂伴椎体滑脱28例,腰椎内固定术后邻椎病11例,炎症转归期原发性椎间隙炎7例,腰椎退行性侧后凸5例。术前双能X线骨密度检查提示存在骨量减少或骨质疏松57例,骨密度正常87例。融合节段数:单节段124例,2节段11例,3节段8例,4节段1例。采用Stand-alone OLIF 40例,OLIF联合后路椎弓根螺钉固定104例。记录术后融合器沉降的发生情况,对可能风险因素进行单因素分析,观察融合器沉降对于临床结果的影响。结果:所有手术顺利完成,手术时间中位数99 min,术中出血量中位数106 ml;术中发生终板损伤30例,合并椎体骨折5例。所有患者获得随访,时间6~30(14.57±7.14)个月。随访过程中除原发性腰椎间隙炎病例、部分腰椎椎弓峡部裂伴椎体滑脱病例,其余出现不同程度的融合器沉降现象,其中正常沉降119例,异常沉降25例(Ⅰ级23例,Ⅱ级2例)。未出现椎弓根螺钉系统松动或断裂现象,椎间隙高度由术前的(9.48±1.84) mm恢复至术后3~5 d的(12.65±2.03) mm及末次随访时的 (10.51±1.81) mm,术后3~5 d与术前比较、末次随访与术后3~5 d比较差异均有统计学意义(P<0.05)。椎间融合率为94.4%(136/144)。腰痛和腿痛视觉模拟评分(visual analogue scale,VAS)分别由术前的(6.55±2.29)、(4.72±1.49)分降低至末次随访时的(1.40±0.82)、(0.60±0.03)分(P<0.000 1);ODI由术前的(38.50±6.98)%恢复至末次随访时的(11.30±3.27)%(P<0.05)。并发症发生率为31.3%(45/144),再手术率9.72%(14/144),其中因融合器沉降或移位而再次手术8例,占再手术的57.14%(8/14)。单因素分析结果显示:在骨量减少或骨质疏松组、Stand-alone OLIF组、2节段或以上融合组、终板损伤组中其异常沉降例数分别高于骨量正常组、OLIF联合椎弓根螺钉固定组、单节段融合组、终板无损伤组。结论:融合器沉降是OLIF术后较为常见的现象,术前骨量减少或骨质疏松、Stand-alone OLIF应用、2节段或以上融合和术中终板损伤可能是术后融合器沉降的重要因素。虽然融合器沉降程度与临床症状无明显相关,但存在融合器移位的风险,需要加强预防,以降低因融合器沉降而带来的严重并发症,包括再手术。     

经椎间孔椎体间融合单节段椎弓根螺钉内固定治疗胸腰椎A3型爆裂骨折

目的:探讨后路单节段椎弓根螺钉内固定结合经椎间孔椎体间融合治疗胸腰椎单椎体A3型爆裂骨折的临床疗效及其安全性。方法:2005年3月～2007年10月收治并获得随访的胸腰椎单椎体A3型(AO分型)爆裂骨折患者16例,其中T112例,T122例,L15例,L25例,L31例,L41例。术前脊髓神经功能按Frankel分级标准评定,C级1例,D级4例,E级11例。均行后路单节段椎弓根螺钉内固定结合经椎间孔椎体间植骨融合治疗,随访观察治疗效果。结果:所有手术均顺利完成,无椎弓根螺钉置入位置错误及神经血管损伤等并发症发生。手术时间90～180min,平均125min;出血量200～600ml;平均330ml。随访10～38个月,平均14.6个月,无内固定松动、断裂,椎间植骨均获得骨性融合。术后1周及末次随访时骨折节段矢状面后凸角、伤椎椎体前缘高度与预计正常高度的比值较术前均明显改善(P0.01);末次随访时与术后1周时比较无显著性差异(P0.05)。术前脊髓神经功能受损的5例患者术后均恢复到E级。结论:采用后路切开复位减压单节段椎弓根螺钉内固定结合经椎间孔椎体间植骨融合治疗胸腰椎单椎体A3型爆裂骨折手术时间短、出血少,复位固定可靠,融合节段少,是治疗胸腰椎单椎体A3型爆裂骨折的有效方法之一。     

后路短节段结合骨折椎椎弓根螺钉复位内固定治疗胸腰椎骨折

目的:探讨后路短节段结合骨折椎椎弓根螺钉复位内固定治疗胸腰椎骨折的可行性及临床疗效。方法:自2005年9月至2007年9月,行后路短节段结合骨折椎椎弓根螺钉复位内固定治疗胸腰椎骨折82例,其中男50例,女32例;年龄18～63岁,平均36岁;病程2h～7d,平均2d。骨折根据AO分型:A1型25例,A2型48例,B2型9例。根据ASIA脊髓神经功能损伤分级:C级9例,D级17例,E级56例。术中将椎弓根螺钉置入骨折椎与相邻的上下椎体中,复位固定,后外侧植骨融合。结果:82例患者均获得随访,时间12～24个月,平均18.3个月,无一例内固定断裂或松动,全部获得骨性融合。术后骨折椎的椎体前缘压缩率及Cobb角均明显小于术前(P0.05),而术后随访骨折椎的椎体前缘压缩率及Cobb角与术后相比无明显变化(P0.05);术后骨折椎的尾侧椎间盘高度(h/H)与术前相比无明显变化(P0.05)。不完全性神经损伤术后脊髓神经功能有1～2级的恢复。结论:后路短节段结合骨折椎椎弓根螺钉复位内固定治疗胸腰椎骨折是安全可靠的方法,在骨折椎前柱撑开的同时可有效控制正常椎间盘高度的撑开,并有利于矫正后凸畸形和维持矫正效果。     

后路多节段固定结合经椎弓根椎间融合治疗胸腰椎爆裂性骨折

[目的]用多节段椎弓根螺钉或椎弓根螺钉加钩棒系统后路固定,结合经椎弓根椎间融合治疗胸腰椎爆裂性骨折的临床疗效.[方法]对25例Denis分类Type B型胸腰椎爆裂性骨折实施了后路椎弓根钉系统固定术.受伤至手术间隔时间平均7 d,平均年龄38.6岁.平均随访时间28个月.采用多节段椎弓根螺钉或椎弓根螺钉加钩棒系统的后路固定法.植骨采用经椎弓根切除椎间盘椎体间植骨的方法.[结果]局部后弯从术前的Cobb角平均15.5°改善到4.7°.术后平均28个月随访时为9.4°,平均损失4.7°.[结论]多节段椎弓根螺钉或椎弓根螺钉加钩棒系统,经椎弓根椎体间植骨,加强前柱的支持性是治疗胸腰椎爆裂性骨折的有效方法.     

单侧椎弓根螺钉内固定联合椎体间融合治疗腰椎退行性疾病的临床研究

目的探讨腰椎后路单侧椎弓根螺钉内固定联合经椎间孔椎体间融合术(transforaminallumbar interbody fusion,TLIF)治疗腰椎退行性疾病的临床疗效。方法回顾性分析35例腰椎退行性疾病患者,采用经后路单侧椎弓根螺钉内固定联合TLIF并单枚Cage手术进行治疗,其中男性20例,女性15例,年龄29～68岁(平均53.3岁),病程0.5～5年。使用使用Oswestry(ODI)功能障碍指数和日本JOA评分法评估术后疗效,依据SUK法对术后脊柱融合情况进行评估。结果所有患者手术前后Oswestry功能障碍指数之间比较差异有统计学意义,根据日本JOA评分法评估优25例(71.4%)、良8例(22.8%)、可1例(2.9%)、差1例(2.9%),依据SUK标准证实本组病例椎体间植骨融合率为97.1%。有1例患者节段间有明显间隙,椎间植骨有不同程度的吸收,但动态片上节段间相对活动<4 mm。内固定未见松动、拔出、断钉。结论单侧椎弓根螺钉内固定联合椎间植骨并Cage支撑治疗腰椎退行性疾病融合率高,临床疗效良好。     

多节段腰椎峡部裂的手术治疗

目的探讨多节段腰椎峡部裂伴腰椎滑脱的临床特点及手术治疗方式。方法回顾自1999年3月~2004年12月收治的多节段腰椎峡部裂10例。全部为L4、L5双节段峡部裂,4例伴L5椎体滑脱,6例伴L4椎体滑脱。3例术前没有发现滑脱邻近节段峡部裂。6例行双节段椎弓根螺钉固定和双椎间融合手术,另4例行双节段椎弓根螺钉固定结合滑脱节段椎间融合及邻近节段峡部与后外侧植骨手术。结果随访10~52个月。按Macnab评分标准,优2例,良6例,可2例。放射学检查显示10例腰椎滑脱复位良好,平均椎间高度由术前8.10mm恢复至术后13.11mm。本组未见内固定松动、断裂,无融合器塌陷,无滑脱复发现象。结论多节段腰椎峡部裂临床少见,术前漏诊率较高。对于手术方式的选择要综合考虑脊柱节段稳定性、椎间盘退变程度或突出情况等,结合椎弓根螺钉内固定的后路椎间融合或后外侧融合手术有较好的治疗效果。     

后路短节段固定结合椎弓根植骨治疗胸腰段骨折

目的 探讨经椎弓根后路短节段复位内固定椎体、后外侧植骨联合、经椎弓根向伤椎椎体内植骨治疗胸腰椎段骨折的手术方法和临床疗效.方法 回顾性分析2007年6月至2011年4月收治的39例胸腰椎骨折患者资料,男21例,女18例;年龄18 ～48岁,平均31.5岁.按照治疗方法的不同分为观察组(经椎弓根后路短节段复位内固定、椎体后外侧植骨联合经椎弓根向伤椎椎体内植骨)和对照组(经椎弓根后路短节段复位内固定椎体、后外侧植骨),通过回顾病历资料及随访资料,对其影像学进行评价.结果 39例患者获12 ～ 36个月(平均20.1个月)随访,观察组与对照组术后即刻伤椎前缘高度恢复程度及成角的矫正程度比较差异无统计学意义(P＞0.05),术后12个月,对照组伤椎前缘高度变化及成角的矫正程度丢失不明显;而未经椎弓根植骨组变化明显,二组比较差异有统计学意义(P＜0.05). 结论 经椎弓根后路短节段复位内固定椎体、后外侧植骨联合经椎弓根向伤椎椎体内植骨治疗胸腰段脊柱骨折有良好的临床疗效,可有效地维持伤椎前缘高度,减少内固定失败率.     

斜外侧椎间融合在Modic改变伴终板硬化腰椎间盘退变治疗中的应用CSCD

目的:探讨Stand-alone斜外侧椎间融合(oblique lateral interbody fusion,OLIF)应用于Modic改变伴终板硬化的腰椎间盘退变治疗的可行性和临床效果。方法:回顾性分析2015年1月至2018年12月3家医疗中心收治的16例Modic改变伴终板硬化的腰椎间盘退变患者。其中男6例,女10例;年龄45~67(55.48±8.07)岁;病史36~240(82.40±47.68)个月。病变部位:L2,32例,L3,45例,L4,59例;均表现为慢性腰痛,伴下肢神经症状3例。采用单纯斜外侧腰椎椎间融合术治疗,术后对临床和影像学结果,以及并发症情况进行观察。结果:术中无血管、终板损伤和椎体骨折。切口长度(4.06±0.42)cm,手术时间(45.12±5.43)min,术中出血量(33.40±7.29)ml;术后72 h切口疼痛视觉模拟评分(visual analogue scale,VAS)为1.14±0.47。所有患者无切口皮肤坏死、愈合不良或感染;出现交感链损伤1例、左大腿前外侧疼痛并麻木2例、左侧髂腰肌无力1例,均为一过性损伤,并发症发生率为25%(4/16)。16例患者均获得随访,时间12~36(20.80±5.46)个月。术后椎间隙高度获得明显的恢复,随访过程中有轻度丢失。末次随访时腰椎冠状面和矢状面平衡均获得良好的改善。融合器无明显沉降或移位,均获得椎间融合。末次随访时日本骨科协会(Japanese Orthop-aedic Association,JOA)评分和Oswestry功能障碍指数(Oswestry disability index,ODI)明显改善。结论:只要严格病例选择,充分的术前检查,采用Stand-alone OLIF治疗Modic改变伴终板硬化的腰椎间盘退变效果良好,临床优势明显,是较好的手术选择。     

斜外侧腰椎椎体间融合治疗腰椎退行性疾病的疗效及术后融合器沉降情况

目的探讨斜外侧腰椎椎体间融合(OLIF)治疗腰椎退行性疾病的疗效,观察术后融合器沉降发生情况。方法采用OLIF治疗109例腰椎退行性疾病患者。手术前后采用疼痛VAS评分、Oswestry功能障碍指数(ODI)评分评估疗效,根据术后影像学资料判定是否有融合器沉降情况。结果患者均获得随访,时间13~39个月。术后患者腰腿痛症状明显缓解,VAS评分及ODI评分均较术前下降(P<0.05)。末次随访时植骨融合103例(94.49%),未出现假关节形成及螺钉松动、断裂等并发症,腰椎生理曲度维持良好。80例行OLIF联合后路椎弓根螺钉内固定治疗的患者中4例(5.0%)发生融合器沉降,均为无症状性0度沉降;29例行单纯OLIF治疗的患者中10例(34.5%)发生融合器沉降,其中6例为无症状性0度沉降,4例为Ⅰ度沉降(1例伴侧方移位)。融合器沉降发生率单纯OLIF治疗方式高于OLIF联合后路椎弓根螺钉内固定方式(P<0.05)。结论OLIF治疗腰椎退行性疾病具有手术创伤小、效果确切、恢复快的优点,术后融合器沉降与适应证的选择、术者的手术技巧密切相关,联合后路椎弓根螺钉治疗可减少术后融合器沉降的发生。     

Complications and Prevention Strategies of Oblique Lateral Interbody Fusion Technique

Objective

To analyze the early complications and causes of oblique lateral interbody fusion, and put forward preventive measures.

Methods

There were 235 patients (79 males and 156 females) analyzed in our study from October 2014 to May 2017. The average age was 61.9 ± 0.21 years (from 32 to 83 years). Ninety‐one cases were treated with oblique lateral interbody fusion (OLIF) alone (OLIF alone group) and 144 with OLIF combined with posterior pedicle screw fixation through the intermuscular space approach (OLIF combined group). In addition, 137/144 cases in the combined group were primarily treated by posterior pedicle screw fixation, while the treatments were postponed in 7 cases. There were 190 cases of single fusion segments, 11 of 2 segments, 21 of 3 segments, and 13 of 4 segments. Intraoperative and postoperative complications were observed.

Results

Average follow‐up time was 15.6 ± 7.5 months (ranged from 6 to 36 months). Five cases were lost to follow‐up (2 cases from the OLIF alone group and 3 cases from the OLIF combined group). There were 7 cases of vascular injury, 22 cases of endplate damage, 2 cases of vertebral body fracture, 11 cases of nerve injury, 18 cases of cage sedimentation or cage transverse shifting, 3 cases of iliac crest pain, 1 case of right psoas major hematoma, 2 cases of incomplete ileus, 1 case of acute heart failure, 1 case of cerebral infarction, 3 case of left lower abdominal pain, 9 cases of transient psoas weakness, 3 cases of transient quadriceps weakness, and 8 cases of reoperation. The complication incidence was 32.34%. Thirty‐three cases occurred in the OLIF alone group, with a rate of 36.26%, and 43 cases in the group of OLIF combined posterior pedicle screw fixation, with a rate of 29.86%. Fifty‐seven cases occurred in single‐segment fusion, with a rate of 30.0% (57/190), 4 cases occurred in two‐segment fusion, with a rate of 36.36% (4/11), 9 cases occurred in three‐segment fusion, with a rate of 42.86% (9/21), and 6 cases occurred in four‐segment fusion, with a rate of 46.15% (6/13).

Conclusion

In summary, OLIF is a relatively safe and very effective technique for minimally invasive lumbar fusion. Nonetheless, it should be noted that OLIF carries the risk of complications, especially in the early stage of development.

     

斜外侧椎间融合术联合小切口Wiltse入路椎弓根螺钉固定治疗腰椎滑脱症早期疗效

目的探讨斜外侧椎间融合术(oblique lateral interbody fusion,OLIF)联合小切口Wiltse入路椎弓根螺钉固定治疗腰椎滑脱症的早期疗效。方法2016年1月-12月,采用OLIF联合小切口Wiltse入路椎弓根螺钉固定治疗21例腰椎滑脱症患者。男9例,女12例;年龄57~73岁,平均64.5岁。病程24~60个月,平均34.6个月。患者均为L4椎体滑脱(Ⅰ度15例、Ⅱ度6例);合并椎弓峡部裂1例、椎管狭窄20例。术前及末次随访时采用日本骨科协会(JOA)评分评价临床疗效;术前及术后2 d摄腰椎正侧位X线片及CT,测量椎管矢状径和椎管横截面积,并计算椎间高度和椎体滑脱程度;术后6个月根据CT评价椎间融合情况。结果手术时间120~180 min,平均155 min;术中出血量100~340 mL,平均225.5 mL。1例患者术中下终板轻度损伤,1例术后出现大腿麻木、屈髋无力症状,l例出现腰交感神经干损伤症状。21例均获随访,随访时间12~18个月,平均14.3个月。术后患者下腰痛、腿痛、下肢麻木症状较术前明显改善,无椎间融合器脱出、螺钉断裂、终板塌陷等并发症发生。术后2 d测量椎间高度、椎体滑脱程度、椎管矢状径和椎管横截面积均较术前显著改善(P<0.05)。术后6个月CT检查示1例患者椎间融合欠佳(Ⅲ级),余20例椎间融合良好(Ⅰ、Ⅱ级),椎间融合率为95.2%。末次随访时腰椎JOA评分较术前显著增加,差异有统计学意义(t=24.980,P=0.000)。结论OLIF联合小切口Wiltse入路椎弓根螺钉固定治疗腰椎滑脱症,具有创伤小、并发症少等微创特点以及较高的椎间融合率,是一种安全、有效的治疗术式。     

Low Hounsfield units on computed tomography are associated with cage subsidence following oblique lumbar interbody fusion (OLIF)

BACKGROUND CONTEXTCage subsidence is one of the most common complications following lumbar interbody fusion surgery. Low bone mineral density (BMD) is an important risk factor that contributes to cage subsidence. Hounsfield units (HU) obtained from clinical computed tomography (CT) scans provided a reliable method for determining regional BMD. The association between HU and cage subsidence following oblique lumbar interbody fusion (OLIF) remains unclear.PURPOSEThe objective of this study is to evaluate the association between vertebral HU value and cage subsidence following OLIF.STUDY DESIGN/SETTINGA retrospective study.PATIENT SAMPLEAdults with degenerative spinal conditions underwent single-level OLIF at our institution from October 2017 and August 2020OUTCOME MEASURESCage subsidence, disc height, vertebral body global HU value, upper and lower instrumented vertebrae HU value, endplate HU value, fusion rate.METHODSThis retrospective study was conducted on patients who underwent single-level OLIF at one institution between October 2017 and August 2020. Cage subsidence was measured using the CT scan postoperatively based on the cage protrusion through the vertebral endplates. The HU values were measured from preoperative CT according to previously reported methods.RESULTSA total of 70 patients with a mean follow-up of 15.4 months were included in the analysis. The subsidence rate was 25.7% (n=18/70). The average cage subsidence was 2.2 mm, with a range of 0–7.7 mm. No significant difference was found in age, sex, or body mass index (BMI) between the two groups. The mean global HU value of the lumbar vertebral body (L1–5) was 142.7±30.1 in nonsubsidence and 103.7±11.5 in subsidence (p=.004). The upper instrumented vertebrae (UIV) HU value was 141.4±29.7 in the nonsubsidence and 101.1±10.2 in subsidence, (p=.005). The lower instrumented vertebrae (LIV) HU value was 147.4±34.9 in nonsubsidence and 108.1±13.7 in subsidence, (p<.001). The AUC of the UIV HU value was 0.917 (95% CI: 0.853–0.981), and the most appropriate threshold of the HU value was 115 (sensitivity: 84.6%, specificity: 100%). The AUC of the LIV HU value was 0.893 (95%CI: 0.819–0.966), and the most appropriate threshold of the HU value was 125 (sensitivity: 76.9%, specificity: 100%). The mean upper endplate HU value was 235.4±50.9, and the mean lower endplate HU value was 193.4±40.3. No significant difference (upper endplate p=.314, lower endplate p=.189) was observed between the two groups.CONSLUSIONSLower preoperative vertebral body HU values were associated with cage subsidence after single-level OLIF. However, the endplate HU values were not associated with cage subsidence. Preoperative HU measurement is useful in the prediction of the cage subsidence.     

腰椎两种不同椎间融合方式终板损伤的病例对照研究

目的:总结并比较肌间隙入路通道下经椎间孔椎间融合联合椎弓根螺钉固定方式与斜外侧椎间融合联合椎弓根螺钉固定方式治疗腰椎病变终板损伤的特点与临床结果。方法:回顾性分析2016年1月至2019年6月收治的213例腰椎病变患者,男73例,女140例;年龄24~81(54.9±10.5)岁;病程6~180(40.30±28.71)个月;腰椎间盘退行性病变35例,巨大型腰椎间盘突出症22例,椎间盘源性腰痛15例,炎症转归期原发性腰椎间隙炎9例,腰椎管狭窄症52例,腰椎退行性滑脱47例,腰椎椎弓峡部裂伴或不伴椎体滑脱33例;单节段191例(L_2,3 5例、L_3,4 24例、L_4,5 162例),双节段22例(L_2,3和L_3,4 3例、L_3,4和L_4,5 19例)。采用后方肌间隙入路通道下双侧椎弓根螺钉固定并椎间融合术110例(后路融合组),斜外侧椎间融合联合后方肌间隙入路通道下双侧椎弓根螺钉固定术103例(斜外侧融合组)。观察两组患者终板损伤的发生特点,并比较两组患者的临床和影像结果及并发症情况。结果:后路融合组发生终板损伤8例9个节段,发生率7.27%(8/110),男1例,女7例,年龄(63.22±3.51)岁;8例中术前存在骨量减少或骨质疏松7例;使用香蕉型融合器5例,解剖型融合器3例;发生于椎体上终板3个节段,椎体下终板6个节段。斜外侧融合组发生终板损伤21例24个节段,发生率20.39%(21/103),男4例,女17例,年龄(62.50±5.02)岁;21例中术前存在骨量减少或骨质疏松16例;使用融合器偏大(指融合器高度)5例,终板解剖形态异常4例,髂嵴过高3例;发生于椎体上终板20个节段,椎体下终板4个节段;21例终板损伤中合并椎体骨折2例。后路融合组终板损伤发生率低于斜外侧融合组。两组患者均未发生切口感染,随访时间12~48个月,中位数12个月。随访中后路融合组出现融合器沉降22例,斜外侧融合组43例,两组各发生1例融合器移位,均无内固定松动、移位或断裂。斜外侧融合组并发症发生率33.98%(35/103),高于后路融合组23.64%(26/110),两组比较差异有统计学意义(P=0.039)。两组患者术后椎间隙高度均获得良好的恢复,但在随访时出现不同程度的丢失。融合率后路融合组为94.5%(104/110),斜外侧融合组为96.1%(99/103),两组差异无统计学意义(P=0.083)。末次随访时两组患者临床症状均得到明显改善。结论:两种方法治疗单或双节段腰椎病变均能获得良好的临床效果。两种融合方式终板损伤的特点不完全相同。虽然两种固定融合方式的终板损伤没有影响最终的临床结果,但仍需要加以重视,做好终板损伤的预防和有效处理,尤其是对于斜外侧椎间融合方式。     

微创腰椎斜前方椎间融合术治疗退变性腰椎疾病的中早期疗效和并发症分析

目的:探讨微创经腹膜外斜前方入路椎体间融合术(oblique lumbar interbody fusion,OLIF)治疗退变性腰椎疾病的中早期疗效并分析其并发症.方法:回顾性分析2017年10月至2019年3月以OLIF术式治疗的退变性腰椎疾病患者22例,男14例,女8例,年龄51～72(63.15±7.22)岁,...     

Risk factors for postoperative ileus after oblique lateral interbody fusion: a multivariate analysis

Background ContextOblique lateral interbody fusion (OLIF)–has become a widely used, efficient surgical tool for various degenerative lumbar conditions. Postoperative ileus (POI) is a relatively common complication after anterior lumbar interbody fusion due to the manipulation of the intestine during the surgical approach. However, to our knowledge, little is known about POI following OLIF even though it also involves bowel manipulation during a surgical procedure.PurposeTo assess the incidence of POI and identify independent risk factors for POI development after OLIF.Study Design/SettingRetrospective cohort study.Patient SampleAll consecutive patients who underwent OLIF and percutaneous pedicle screw instrumentation from August 2012 until October 2019 at a single institutionOutcome MeasuresPatient demographics (sex, age, body weight, height, and body mass index), comorbidities (diabetes mellitus, gastroesophageal reflux disease, antithrombotic medication, previous abdominal surgery, and previous lumbar surgery), and perioperative details (preoperative diagnosis, number of levels fused, inadvertent endplate fracture during cage insertion, type of interbody graft, intraoperative estimated blood loss, duration of surgery and anesthesia, the amount of intraoperative remifentanil and propofol used as anesthetic agents, the total postoperative retroperitoneal closed-suction drainage output, and the cumulative opioid dosage administered in the first 72 hours postoperatively).MethodsPOI was defined as 2 or more of the following at 72 hours postoperatively: (1) ongoing nausea or vomiting postoperatively, (2) the absence of flatus over last 24-hour period, (3) inability to tolerate an oral diet over last 24-hour period, (4) ongoing abdominal distention postoperatively, and (5) radiological confirmation. The subjects were divided into 2 groups: patients with POI and those without POI. Binary logistic regression analyses were performed on demographics, comorbidities, and perioperative factors to identify independent risk factors for POI.ResultsEighteen (3.9%) of 460 patients experienced POI after OLIF and percutaneous pedicle screw instrumentation. Patients with POI had a significantly longer postoperative length of hospital stay than those without POI (8.61 ± 2.66 vs 6.48 ± 2.64, p = .001). Multivariate logistic regression analysis identified inadvertent endplate fracture (adjusted odds ratio = 6.017, p = .001) and the amount of intraoperative remifentanil (adjusted odds ratio = 1.057, p = .024) as independent risk factors for the occurrence of POI following OLIF.ConclusionThis study identified inadvertent endplate fracture and the amount of intraoperative remifentanil as independent risk factors for the development of POI after OLIF.     

斜外侧椎间融合术联合Wiltse入路单侧椎弓根钉棒固定治疗腰椎管狭窄症

目的:探讨斜外侧椎间融合术(oblique lumbar interbody fusion,OLIF)联合Wiltse入路单侧椎弓根钉棒固定治疗腰椎管狭窄症的疗效。方法:对2017年7月至2019年1月采用OLIF联合Wiltse入路单侧椎弓根钉棒固定治疗腰椎管狭窄症90例进行回顾性分析,男38例,女52例,年龄43~75(59.9±8.8)岁。责任节段分布:单节段L₂-L₃ 8例,L₃-L₄ 12例,L₄-L₅ 30例;双节段中L₂-L₄ 10例,L₃-L₅ 22例;3节段L₂-L₅ 8例,共138个手术节段。记录患者的手术时间、术中出血量以及并发症发生情况,采用腰痛和腿痛视觉模拟评分(visual analogue scale,VAS)和Oswestry功能障碍指数(Oswestry Disability Index,ODI)以及SF-36评分量表评估临床疗效;术后3 d拍摄腰椎X线片和腰椎MRI,测量椎间隙高度、椎间孔高度、椎间孔面积和椎管面积变化;术后半年根据CT评价椎间融合情况,定期随访拍摄腰椎X线片及MRI检查相邻节段退变的情况。结果:所有病例获得随访,时间12~33(20.2±6.6)个月。手术时间(103.3±35.9) min,术中出血量(70.4±17.8) ml;腰痛和腿痛VAS和ODI分别由术前的(6.2±1.1)分、(6.1±0.9)分和(59.9±4.2)%下降至术后半年时的(2.7±0.5)分、(2.5±0.5)分和(31.3±8.8)%,SF-36量表由术前的(37.2±3.1)分增加到术后半年时的(54.9±6.1)分(P<0.05);术后3 d测量椎间隙高度、椎间孔高度、椎间孔面积、椎管面积均较术前明显改善(P<0.05);术后6个月CT检查3例融合欠佳,发生在单节段1例,多节段2例,余87例融合良好。总融合率96.7%(87/90),单节段融合率为98.0%(49/50),多节段融合率为95.0%(38/40)。总体并发症发生率为17.8%(16/90),其中一过性髂腰肌无力5例(5.6%),终板骨折2例(2.2%),腹膜损伤1例(1.1%),术后血肿1例(1.1%),邻椎病1例(1.1%),融合器沉降6例(6.7%)。3例患者术后随访复发神经根性疼痛,行翻修手术后症状缓解。所有并发症在随访期间得到不同程度地缓解或消失,无融合器移位、螺钉断裂等并发症发生。结论:OLIF联合Wiltse入路单侧椎弓根钉棒固定治疗腰椎管狭窄症疗效满意,具有创伤小、并发症少等微创优势,在严格掌握适应证的前提下,该术式应用于多节段时同样能取得满意的临床疗效。     

单侧椎弓根螺钉固定在腰椎退行性疾病的研究进展

〓【摘要】〓保守失败的腰椎退行性疾病常需要手术治疗,传统的双侧椎弓根螺钉腰椎融合术可能增加邻近节段退变的发生率。近年研究表明,单侧椎弓根螺钉结合椎体间融合术治疗腰椎退行性疾病可获得与传统双侧椎弓根螺钉固定相似的稳定性与融合率,并可预防固定融合节段的邻近节段退变,但应用单侧椎弓根螺钉固定需要严格掌握手术适应证。