后路经椎弓根椎体楔形截骨治疗胸腰段创伤性后凸畸形

目的探讨后入路经椎弓根椎体楔形截骨治疗胸腰段创伤性后凸畸形的临床疗效。方法对我院脊柱外科2011-03-2015-05收治的26例脊柱胸腰段创伤性后凸畸形患者,全部采用后路经椎弓根椎体截骨矫形、神经减压,结合椎弓根螺钉系统固定和植骨融合手术治疗,并进行回顾性分析,观测术前、术后初期(3天内)、末次随访(术后1年左右)时胸腰段Cobb角、腰背痛VAS评分、下腰痛JOA评分以及脊髓神经损伤ASIA分级情况。结果 26例患者均获得随访,随访时间10~24个月,平均13.8个月,术后下腰痛JOA评分、腰背痛VAS评分及后凸畸形均有明显改善。术前胸腰段后凸畸形Cobb角为28~58°、平均(40.28±5.66)°,术后2~10°、平均(6.12±3.76)°,平均畸形矫正率86.2%,下腰痛JOA评分标准术前评定为(10.38±1.56)分,术后评定为(22.76±2.23)分,腰背痛VAS评分术前5~8分,平均(6.72±0.33)分,术后2~4分,平均(2.93±0.64)分,以上指标与术前相比较差异均有显著性意义(P0.05);术后神经功能ASIA分级:6例C级5例改善至E级,1例为D级,16例D级15例改善至E级,1例仍为D级;至末次随访,Cobb角矫正丢失角度不明显(1~3°),平均(1.85±0.68)°,平均矫正丢失率3.8%,与术后初期检查比较,差异无统计学意义(P0.05);截骨面均于术后6个月左右骨性愈合,无内固定松动、断裂、假关节形成、感染等并发症。结论后路经椎弓根椎体楔形截骨治疗脊柱胸腰段创伤性后凸畸形,可重建胸腰段矢状面生理曲度,获得满意的后凸畸形矫正和神经减压,改善临床症状。     

保留椎弓根下壁的椎体截骨术治疗陈旧性胸腰椎骨折后凸畸形

目的 评估经后路保留椎弓根下壁椎体截骨术治疗陈旧性胸腰椎骨折后凸畸形的手术方式及其临床疗效.方法 37例陈旧性胸腰椎骨折后凸畸形患者经后路行保留椎弓根下壁椎体截骨术,平均随访38.6个月.术前、术后3个月分别测量胸腰椎后凸Cobb角、截骨区前缘和后缘的高度以及填写视觉模拟疼痛量表（visual analog scale,VAS）.末次随访时测量胸腰椎后凸Cobb角.结果 术前Cobb角为41.6°±7.8°,术后3个月Cobb角为7.8°±4.3°,与术前相比差异有显著统计学意义（P＜0.05）;末次随访时Cobb角为8.6°±4.1°,较术后3个月无明显丢失（P＞0.05）.截骨区前缘高度增加（2.7±0.8）mm.截骨区后缘高度压缩（7.2±3.1）mm.术前、术后3月VAS评分分别为（7.1±2.9）分和（2.5±1.3）分,较术前明显改善（P＜0.05）.结论 保留椎弓根下壁椎体截骨术能够安全有效地矫正胸腰椎后凸畸形,完整地保留了伤椎峡部及下关节突,保持了伤椎与下位脊椎的连续性,减少了截骨区脊椎矢状面的移位,同时也保留了神经根通道的上壁,从而减少了神经根的损伤.     

经椎弓根椎体椎间隙截骨脊柱短缩术治疗脊柱后凸畸形

目的 评价经椎弓根椎体椎间隙截骨脊柱短缩术治疗脊柱后凸畸形的效果,并探讨其适应证.方法 对17例脊柱后凸畸形行经椎弓根椎体椎间隙截骨脊柱短缩术治疗.后凸畸形Cobb角平均42.4˙.脊髓损伤按Frankel分型:C级1例,D级2例.E级14例.17例均有腰背部疼痛不适,1例伴有膀胱括约肌功能障碍.2例先天性后凸还表现为后凸进行性加重.结果 术后脊柱后凸Cobb角平均7.2˙.术后腰痛均消失,神经功能Frankel C级1例恢复到D级,1例膀胱括约肌功能障碍者术后症状有改善.结论 经椎弓根椎体椎间隙截骨脊柱短缩术治疗脊柱后凸畸形可安全实施,矫正效果良好.     

后路楔形截骨治疗胸腰椎陈旧性骨折伴后凸畸形

目的探讨后路楔形截骨椎弓根钉内固定术治疗胸腰椎陈旧性压缩性骨折伴后凸畸形的临床疗效。方法回顾性分析2007年9月至2011年12月采用后路楔形截骨椎弓根钉内固定术治疗胸腰椎陈旧性压缩性骨折伴后凸畸形患者27例。术前、术后3个月、术后12个月分别采用日本骨科协会(Japanese orthopaedics association,JOA)评分、视觉模拟评分法(visual analogue scale,VAS)评分及测量后凸Cobb角,评价临床症状的改善及后凸畸形的纠正情况。结果 25例获得随访,余2例失访,25例患者临床症状均缓解,后凸畸形得到明显矫正。术后3个月后凸Cobb角(5.1±1.7)°,JOA评分(19.2±2.3)分,VAS评分为(3.5±1.3)分,术前与术后3个月比较差异有统计学意义(P0.05);术后12个月后凸Cobb角(6.4±2.1)°,JOA评分(24.5±3.2)分,VAS评分为(1.7±0.7)分,术后3个月与12个月比较差异无统计学意义(P0.05)。结论采用后路楔形截骨椎弓根钉内固定术能够充分减压、矫正后凸畸形,并具有创伤小、短期内纠正角度无明显丢失等优点,是治疗胸腰椎陈旧性压缩性骨折后凸畸形的理想方法。     

改良经椎弓根截骨治疗陈旧性胸腰段脊柱骨折后凸畸形

目的 对改良经椎弓根截骨治疗陈旧性胸腰段脊柱骨折后凸畸形的临床治疗效果进行评价.方法 2000年6月至2003年6月共收治26例胸腰段陈旧性骨折后凸局部畸形患者,其中男性16例,女性10例;年龄21～42岁,平均30.6岁.均采用单纯后路经椎弓根+椎间盘截骨路径,切除后凸顶点(包括伤椎后上角和伤椎上方椎间盘),截骨矫正手术前、后进行系统影像学检查,测量胸腰段Cobb角的变化;手术中记录手术时间,出血量等指标;全部患者术前及手术后3年进行神经功能Frankel评分、腰痛VAS评分和Oswestry腰背、下肢功能评分,并进行对比分析.结果 所有患者均获随访,随访时间3～5年,平均4.1年.手术固定范围包括伤椎上、下方各2个节段,平均手术时间(186.0±22.8)min,平均出血量(680.0±31.5)ml.术后胸腰段后凸畸形均明显改善,T_(10)～L_2 Cobb角由手术前22.3°±3.5°矫正为2.2°±2.1°,矫正率90.1%±4.5%;没有明显神经损害和其他严重并发症;没有发现椎弓根钉松动、断裂.术前存在神经功能损害的20例患者(Frankel评分D级12例、C级6例、B级2例),术后3年Frankel评分得到改善(E级14例、D级4例、C级1例、B级1例),腰背疼痛VAS评分由术前8.6±1.3改善至2.2±0.5,Oswestry评分由术前(62.5±8.6)%改善至(16.2±4.3)%.结论 经椎弓根+椎间盘截骨治疗陈旧性胸腰段脊柱骨折后凸畸形安全、可靠,具有良好的治疗效果.     

经椎弓根V型截骨治疗陈旧性胸腰椎骨折后凸畸形

目的 探讨经椎弓根V型截骨结合内固定在陈旧性胸腰椎骨折后凸畸形的矫正中的疗效和并发症.方法 自2005年7月至2011年3月,我院采取经椎弓根V型截骨结合内固定治疗不同原因所致陈旧性胸腰段脊柱骨折后凸畸形患者共10例,其中强直性脊柱炎伴骨折所致后凸2例,均经椎弓根V型截骨结合内固定治疗.结果 术后获得随访8例,随访时间1个月～3年,平均6个月,矫正角30°～42°,平均35°.所有患者腰背疼痛症状明显缓解或消失.随访病例截骨融合率100％,1例术后神经症状加重在2年后不全恢复.结论 经椎弓根V型截骨结合内固定是陈旧性胸腰椎骨折后凸畸形矫正安全有效的治疗手段,具有效果确切可靠、操作相对简单、并发症较少等优点.     

骨水泥强化椎弓根钉内固定治疗陈旧性骨质疏松性胸腰椎压缩骨折并后凸畸形

目的探讨骨水泥强化椎弓根钉内固定治疗陈旧性骨质疏松性胸腰椎压缩骨折并后凸畸形的疗效。方法自2006-06—2013-08采用骨水泥强化椎弓根钉内固定治疗陈旧性胸腰椎骨质疏松性椎体压缩骨折并后凸畸形30例。观察术后后凸Cobb角、疼痛视觉模拟评分(VAS)的改善程度。结果本组手术时间115~178 min,平均145 min;术中出血量660~1 240 ml,平均810 ml。30例均获得随访7~48个月,平均21.5个月。植骨骨性愈合,后凸矫正角度无明显丢失,固定相邻节段无明显椎间不稳征象。末次随访胸腰段后凸Cobb角、VAS评分较术前明显改善。结论骨水泥强化椎弓根钉内固定治疗陈旧性骨质疏松性胸腰椎压缩骨折并后凸畸形既增强了椎弓根钉的固定强度,又矫正了脊柱后凸畸形。     

脊柱去松质骨化截骨术治疗中老年陈旧性胸腰椎骨折后凸畸形

目的探讨脊柱去松质骨化截骨术治疗中老年陈旧性胸腰椎骨折并发后凸畸形的疗效。方法选取2016-04-2017-01收治的中老年陈旧性胸腰椎骨折并发后凸畸形患者5例,均采用脊柱去松质骨化截骨术联合椎弓根内固定治疗,观察其手术疗效。结果与术前相比,5例患者术后及末次随访的后凸Cobb角、VAS评分、ODI指数均显著改善,差异有统计学意义(P0.01);5例患者椎体间植骨均获得骨性融合,随访期间未见内固定物断裂、松动、脱落,术后神经根损害刺激症状均消失,未见脊髓损害表现。结论脊柱去松质骨化截骨术应用于中老年陈旧性胸腰椎骨折并发后凸畸形患者,可有效恢复脊柱高度,防止矫形过度或丢失,提高植骨融合率。     

有限截骨联合椎间盘切除治疗陈旧性胸腰椎骨折后凸畸形

目的研究有限脊柱截骨、切除损伤椎间盘、椎弓根螺钉内固定治疗陈旧性胸腰椎骨折后凸畸形的临床疗效。方法本研究纳入2014年1月至2017年1月于我院脊柱外科治疗的陈旧性胸腰椎骨折后凸畸形患者28例,男18例,女10例;平均年龄(43.23±4.11)岁。所有患者均接受有限脊柱截骨、切除损伤椎间盘、椎弓根螺钉内固定治疗,随访25个月以上,记录手术及住院相关指标以及术前、术后14 d、术后1个月、末次随访疼痛视觉模拟评分(visual analogue scale,VAS)、Cobb角以及Oswestry功能障碍指数(oswestry disability index,ODI),记录神经功能恢复及并发症发生情况。结果 28例患者手术均顺利完成,获得完整随访,随访时间平均为(30.65±4.01)个月。手术耗时(145.21±23.87)min,出血量(681.32±87.32)mL,引流量(843.11±121.30)mL,住院时间(16.01±1.87)d。术后14 d、术后1个月、末次随访疼痛VAS评分、Cobb角以及ODI均较术前显著降低(P0.05),末次随访VAS评分、ODI显著低于术后14 d、术后1个月的数据(P0.05),后凸Cobb角显著高于术后14 d、术后1个月的数据,差异具有统计学意义(P0.05)。末次随访美国脊髓损伤协会(Amenican spinal injury association,ASIA)分级较术前显著改善,差异具有统计学意义(P0.05)。术后截骨面均获得骨性融合,1例切口感染,无螺钉松动、神经损伤等严重并发症出现。结论有限脊柱截骨、切除损伤椎间盘、椎弓根螺钉内固定治疗陈旧性胸腰椎骨折后凸畸形能获得满意的畸形矫正效果,改善疼痛症状及腰椎功能障碍,手术安全有效。     

经椎弓根椎体去松质骨切除治疗儿童胸腰段半椎体并侧后凸畸形

目的 观察经椎弓根椎体去松质骨切除治疗儿童胸腰段半椎体并侧后凸畸形的临床效果.方法 对自2006年12月～2011年6月收治的儿童胸腰段半椎体并侧后凸畸形7例均行经椎弓根椎体去松质骨切除内固定植骨融合治疗.结果 随访6～48个月,平均(24.8±3.5)个月.手术时间160～200 min,平均(182±25) min.术中出血量1200～2000 ml,平均(1520±200)ml.固定融合节段4～10节.脊柱侧凸Cobb角由术前平均(50.5±16.3)°矫正到术后1个月(16.7±5.4)°,后凸Cobb角由术前平均(48.9±21.5)°矫正到术后1个月(19.8±10.7)°,3例有神经系统损伤者平均JOA评分由术前(8.0±1.6)分提高到末次随访时(24.0±1.5)分.结论 儿童胸腰段半椎体并侧后凸畸形应尽早手术干预,经椎弓根椎体去松质骨切除技术能达到满意矫正效果,同时减少并发症的发生.     

Vertebral hemangioma presenting with intermittent claudication

Summary The case of a patient with vertebral hemangioma and unusual clinical presentation is reported, with an attempt to explain these unusual clinical complaints. Vertebral hemangioma is a common and often asymptomatic tumor. Neurologic symptoms may appear due to pressure on the neural tissue caused by extraosseous extension. The patient reported here presented with intermittent claudication. Conventional radiography CT, and MRI revealed vertebral hemangioma at T5 and extraosseous extension compressing the spinal cord. Gravity-related vascular dilatation may induce further compression of the spinal cord and, thus, is thought to be the underlying event in the induction of the intermittent clinical symptoms. The lesion was treated with subtotal corpectomy after embolization and fusion with a strut iliac crest graft. At the 9-month follow-up, the patient was without complaints. We conclude that a diagnosis of vertebral hemangioma should be considered in cases of intermittent neurologic symptoms of the lower extremities.     

Vertebral lesions associated with palmoplantar pustulosis

Summary. Spinal lesions were reviewed in 9 patients (3 men and 6 women) who presented with palmoplantar pustulosis. Cervical lesions were found in 3 patients and lumbosacral involvement in 7. The duration of disease averaged 4.8 years. Seven patients had associated sterno-costo-clavicular hyperostotic lesions, and all showed abnormalities in blood tests which suggested chronic inflammation. Vertebral lesions were assessed as a spondylodiscitis type in 4, single level syndesmophyte-forming type in 1, multiple hyperostosis type in 4, and an ivory vertebra type in 1. Five patients were treated conservatively, and 4 with progressive spondylodiscitis type lesions underwent curettage and anterior interbody fusions. At follow-up, all patients improved in both spinal and cutaneous presentations, and 4 who underwent surgery and 1 with tonsillectomy attained complete cure. The vertebral manifestations of palmoplantar pustulosis may vary, but rapidly progressive lesions need surgery for favourable early improvement from the vertebro-cutaneous symptom complex.

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Résumé. Revue de 9 patients présentant des lésions vertébrales associées à une pustolose palmo-plantaire. Il s’agissait de 3 hommes et 6 femmes avec une maladie évoluant en moyenne depuis 4,8 ans. Des lésions cervicales ont été trouvées 3 fois, et des lésions lombo-sacrées 7 fois. 7 patients avaient des lésions hyperostosiques de la ceinture scapulaire, ce qui est classique, et tous présentaient un syndrome biologique inflammatoire. Les lésions vertébrales étaient une spondylodiscite 4 fois, une syndesmophytose d’un niveau, 1 fois, une hyperostose étendue 4 fois et une vertèbre ivoire 1 fois. 5 patients ont eu un traitement conservateur et 4 qui présentaient une spondylodiscite ont été opérés par curetage et arthrodèse vertébrale antérieure. Au dernier recul, tous les patients ont eu une amélioration tant de la symptomatologie vertébrale que des lésions cutanées et 5 peuvent être considérés comme guéris: les 4 opérés pour spondylodiscite et 1 opéré par amygdalectomie. Les lésions vertébrales associées à la pustulose palmo-plantaire sont variables mais si elles sont d’évolution rapide, le traitement chirurgical est utile pour l’amélioration du syndrome cutanéo-vertébral.

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Accepted: 9 May 1996     

Vertebral hemangiomas presenting with neurologic symptoms

Six cases of spinal hemangiomas with neurologic symptoms are reported. In three of them the diagnosis was obtained before surgery using plain x-rays and spinal computed tomography scan or biopsy. In the other cases the diagnosis was not done before surgery. In two cases preoperative embolization had minimized blood loss during surgery. Laminectomy was performed in three cases. Large removal and/or vertebrectomy was carried out in the other cases. Our results and a review of the literature about the investigations and treatment of vertebral hemangiomas led us to propose a stereotypical management of spinal hemangiomas with neurologic symptoms.     

Vertebral arterio-venous fistula presenting with intracranial hemorrhage

Vertebral arteriovenous fistulas are rare lesions consisting of an abnormal shunt between the extracranial vertebral artery and the neighboring veins. The authors present a case of post-surgical high-flow left vertebral arteriovenous fistula presenting with intracranial hemorrhage. The patient underwent endovascular balloon occlusion of the fistula: after endovascular treatment a reduction of the flow was evident but the patient presented neurological deterioration related the occurrence of intraventricular-subarachnoid hemorrhage. Intracranial hemorrhage is a potential manifestation of high-flow vertebral AVF and a possible complication of endovascular fistula balloon occlusion. Direct endovascular occlusion of the vertebral artery may be primarily considered in selected cases.     

Vertebral body replacement with expandable titanium cages

OBJECTIVES: The aim of vertebral body replacement is the stabilisation and restoration of the anterior column of the spine with removal of the diseased region. We present our results of stabilisation, pain reduction and neurological improvement using vertebral-body replacement systems METHODS: Between April 1997 and December 2002, 53 patients with malignant vertebral destruction or instability due to traumatic and osteoporotic fracture were treated. We evaluated the results after vertebrectomy and vertebral body replacement by using expandable titanium cages in a retrospective study. RESULTS: The average follow-up time was 18.9 +/- 19.9 months. The mean operation time was 173.2 +/- 77.4 minutes. Intraoperatively, we saw no implant-related complications. Perioperatively, complications appeared in 18 patients (34.0 %). 4 of them were severe, with 2 patients dying. In the total follow-up, 16 patients died, 10 of them (62.5 %) due to tumour progression. Pain reduction was reported in 52.7 %, neurological improvement in 48.0 %. One patient had a loosening of his posterior instrumentation in the further follow-up due to tumour growth with dislocation of the cage and a deterioration of his neurological deficit. CONCLUSION: By using vertebral body replacement systems, sufficient stabilisation of the vertebral column, pain reduction and neurological improvement can be achieved with an acceptable perioperative risk.