微创经椎间孔腰椎间融合术联合经皮螺钉内固定融合术治疗退行性腰椎滑脱

目的探讨微创经椎间孔腰椎间融合术(MIS-TLIF)联合经皮螺钉内固定融合术治疗退行性腰椎滑脱的临床疗效。方法采用MIS-TLIF联合经皮螺钉内固定融合术共治疗32例退行性腰椎滑脱患者,比较术前和术后1周、3个月、末次随访时视觉模拟评分(VAS)、Oswestry功能障碍指数(ODI)和36条简明健康状况调查表(SF-36)评分,以及X线测量腰椎前凸角、冠状位Cobb角、冠状位和矢状位躯干偏移、腰椎滑脱程度(Meyerding分度)并计算滑脱率,X线或CT判断椎体融合率,MRI评价减压程度。结果 32例患者平均手术时间160 min,术中出血量120 ml,住院时间7.22 d,术后随访10.83个月。手术融合41个椎体节段,范围覆盖L2~S1节段。与术前相比,术后1周、3个月和末次随访时VAS(均P=0.000)和ODI(均P=0.000)评分增加,SF-36评分减少(P=0.002,0.000,0.000),腰椎前凸角(均P=0.000)、冠状位Cobb角(均P=0.000)和滑脱率(均P=0.000)均减小。至末次随访时,ODI改善率为(80.51±6.02)%,椎体融合率达92.22%且螺钉位置均良好。32例患者中1例术后感染、2例脑脊液漏,经对症治疗均痊愈;无一例发生神经功能缺损等严重并发症、内固定失败、椎弓根螺钉和钛棒断裂或Cage移位,无一例死亡。结论 MIS-TLIF联合经皮螺钉内固定融合术创伤小、术中出血量少、并发症轻微、复位效果好、疗效确切,尽管存在手术时间较长、学习曲线较长、术中X线照射量较大等缺点,但仍是治疗退行性腰椎滑脱的有效方法。     

微创经皮椎弓根螺钉内固定术治疗无神经症状的单节段胸腰椎骨折

目的探讨微创经皮椎弓根螺钉内固定术治疗无神经症状的单节段胸腰椎骨折的临床效果。方法分别采用开放式椎弓根螺钉内固定术(16例)和微创经皮椎弓根螺钉内固定术(22例)治疗38例无神经症状的单节段胸腰椎骨折患者,记录手术切口长度、手术时间、术中出血量、术后引流量和术后并发症,胸腰椎正侧位和过伸过屈位X线测量手术前后矢状位Cobb角和伤椎前缘高度,改良Macnab标准评价手术疗效。结果 38例患者手术成功率达100%,手术融合114个椎体节段,共植入228枚椎弓根螺钉。与开放式手术组相比,微创经皮手术组患者手术切口长度缩短[(10.55±1.23)cm对(18.50±2.50)cm,P=0.000]、术中出血量减少[(32.55±7.22)ml对(320.50±15.48)ml,P=0.000]、住院时间缩短[(6.55±1.50)d对(13.50±2.52)d,P=0.000],且无需引流。术后平均随访(4.65±1.24)个月,术后3个月时两组患者矢状位Cobb角较术前减小(P=0.000)、伤椎前缘高度较术前增加(P=0.000);开放式手术组总显效率为14/16,微创经皮手术组为86.36%(19/22),组间差异无统计学意义(P=1.000)。结论微创经皮椎弓根螺钉内固定术治疗胸腰椎骨折具有手术创伤小、术中出血量少、恢复迅速等优点,近期疗效与开放式手术相似,但远期疗效尚待进一步研究。     

解剖型融合器置入治疗腰椎不稳症：46例腰椎矢状面形态2年随访☆

2003-01/2004-06南京中医药大学附属无锡医院骨科采用解剖型融合器治疗下腰椎不稳症46例，男19例，女27例；年龄53~71岁，平均62岁。融合节段：L3/45例，L4/529例，L5/S110例，L3/4＋L4/51例，L4/5＋L5/S1 1例。行后路椎体间融合术，均植入2枚解剖型钛制实心融合器，全部加用椎弓根螺钉内固定并辅以后外侧植骨，椎间隙不予植骨。全部病例均得到随访，平均随访27个月。术后腰椎矢状面形态恢复满意，融合节段稳定性良好。Oswestry功能障碍指数均显示神经功能得到满意的恢复。     

两种不同材料椎间融合器治疗腰椎不稳症的应用比较*

背景：碳纤维箱型和钛合金螺纹状椎间融合器是两种材料及形状均不同的椎间融合器,均取得了良好的临床效果。 目的： 应用碳纤维箱型及钛合金螺纹状Cage联合椎弓根内固定系统治疗腰椎不稳症,比较影像学变化及临床症状改善情况。 方法：对59例行后路短节段椎弓根钉系统复位与内固定单节段腰椎不稳症患者进行随访,其中实施碳纤维楔型椎间融合器37例,钛合金螺纹状椎间融合器22例。用M-JOA评分的症状改善率评价患者治疗效果;术前、术后1周及1年摄X射线片及CT,观察椎体间高度、融合节段前凸弧度及植骨融合情况。 结果与结论：术后1周,碳纤维箱型Cage组术后的椎体间高度及腰椎前凸弧度的恢复值与钛合金螺纹状Cage组差异无显著性意义(P > 0.05);术后1年,碳纤维箱型Cage组椎体间高度及腰椎前凸弧度的恢复值高于钛合金螺纹状Cage组(P < 0.01)。两组患者术后1年均获得骨性融合,临床症状缓解良好,下腰痛症状改善率差异无显著性意义(P > 0.05)。结果表明,应用碳纤维箱型Cage与钛合金螺纹状Cage行椎间融合联合椎弓根内固定系统治疗腰椎不稳症,二者在缓解下腰部疼痛及植骨融合方面效果显著,但碳纤维箱型Cage行椎间融合联合椎弓根内固定系统行后路腰椎融合术可以维持较好的椎体间高度及腰椎前凸弧度。 关键词：椎间融合术;椎间融合器;腰椎不稳症;内固定系统;碳纤维箱型Cage;钛合金螺纹状Cage     

椎弓根螺钉置入内固定与单纯椎管减压治疗退行性腰椎滑脱的比较

背景：随着脊柱内固定和脊柱融合技术的发展,脊柱融合已成为腰椎退行性滑脱症毫无争议的“金标准”。同时,邻近节段退行性变的问题引起人们越来越多的关注。 目的：观察椎弓根螺钉内固定置入植骨融合治疗退行性腰椎滑脱的临床疗效、手术节段稳定性及其对相邻节段的影响,并与单纯椎管加压进行对比。 方法：选择天津医科大学总医院骨科收治的退行性腰椎滑脱患者38例,排除失访3例,余35例中采用椎弓根固定后外侧融合21例,单纯椎管减压14例。单纯椎管加压组用咬骨钳咬除黄韧带和椎板解除神经根后方的压迫,用骨凿凿除向前滑脱的椎体后缘与下位相邻椎体后缘形成的相对性突起;椎弓根螺钉固定植骨融合组按Wein-stein 法定位椎弓根钉进针,拧入椎弓根螺钉,根据受压情况进行椎板减压。按Oswestry功能障碍指数综合评价临床疗效,观察过伸、过屈位时的水平位移及角移位,采用UCLA系统来评价邻近节段退变情况。 结果与结论：35例患者随访时间1年。椎弓根螺钉固定植骨融合组优良率显著高于单纯椎管加压组(P < 0.05)。椎弓根螺钉固定植骨融合对腰椎稳定性影响不大,邻近节段退变置入前和置入后1年无明显变化。单纯椎管加压对腰椎稳定性影响显著,同时治疗前和治疗后1年邻近节段退变无明显变化。提示椎弓根螺钉内固定置入植骨融合治疗退行性腰椎滑脱疗效满意,对腰椎稳定性影响小,并且置入后早期对椎间盘的邻近节段影响不大。     

椎弓根螺钉置入内固定联合自体颗粒骨移植治疗退行性腰椎病变

背景：植骨材料来源、形态及植骨方式对腰椎融合的影响目前仍有争议。自体颗粒骨打压植骨作为一种新的植骨方式,具一定的优点,但目前在腰椎融合的临床应用报道不多。 目的：探讨后路椎弓根螺钉置入内固定联合自体颗粒骨打压移植治疗退行性腰椎疾患的临床可行性。 方法：纳入接受后路腰椎融合治疗的退行性腰椎疾病患者21例(28个节段),其中腰椎间盘突出合并节段性不稳定7例,腰椎间盘突出合并椎管狭窄6例,退变性腰椎不稳8例。对21例(28个节段)退行性腰椎疾病患者行后路自体颗粒骨打压植骨联合椎弓根螺钉置入内固定治疗。根据植骨前后X射线片评价植骨融合率,采用腰腿痛VAS目测评分法、ODI评分法及标准Macnab疗效评价临床症状改善情况。 结果与结论: 全部患者随访12个月以上,3~5个月后可见骨融合征象,无高度及复位丢失、螺钉断裂等现象,患者腰腿痛等症状均有不同程度缓解。末次随访VAS目测类比评分、ODI评分均较术前明显改善(P < 0.01),脊柱融合率为95%。1例患者术后6 d CT检查示椎管内小骨粒压迫神经;1例术后第5天出院后伤口浅表软组织感染。采用Macnab标准评价临床结果：优10例,良9例,差2例,优良率91%。说明后路自体颗粒骨打压移植联合椎弓根螺钉置入内固定治疗退行性腰椎疾患短期临床效果良好,植骨融合率高,手术并发症少。 关键词: 自体颗粒骨; 打压植骨; 椎体间融合;椎弓根螺钉;内固定;硬组织植入物     

成人颈椎椎弓根螺钉在儿童腰椎应用的可行性*

背景：由于1~3岁幼年儿童椎体发育未完全成熟,各种解剖径线相对较成人小得多,尚无幼儿专用的椎弓根螺钉固定器械,现有能够利用的直径最小的椎弓根螺钉是用于成人颈椎侧块或椎弓根固定的钉棒系统。 目的：观察将成人颈椎椎弓根螺钉应用到成年猪颈椎与幼猪腰椎固定后的生物力学对比。 方法：将6具完整新鲜成年猪颈段C3~C6脊椎标本和6具完整8周龄新鲜幼猪腰段脊柱标本自椎间盘及关节处离断,游离成单个椎体,共54个椎体108侧椎弓根。按照标准操作将成人颈椎椎弓根螺钉分别安置在成年猪颈椎标本和幼猪腰椎标本的椎弓根上,应用生物力学方法测试螺钉的最大轴向拔出力。 结果与结论：颈椎标本最大轴向拔出力高于腰椎标本,但差异无显著性意义(P > 0.05);L1椎弓根螺钉的拔出力均值明显小于L3椎弓根螺钉的拔出力均值(P < 0.05);C5椎弓根螺钉的拔出力均值明显大于C3椎弓根螺钉的拔出力均值(P < 0.05);颈椎和腰椎标的骨密度差异有显著性意义(P < 0.01),椎体椎弓根力学数值与椎体骨密度之间存在线性正相关。说明取得了成人颈椎椎弓根螺钉在轴向拉力方面适应于幼儿腰椎的初步实验依据。     

腰椎间孔入路腰椎体间植骨融合结合椎弓根螺钉置入内固定：能提高退行性病变腰椎的稳定性与植骨融合率吗？

背景：腰椎融合已广泛应用于治疗各种腰椎退行性疾病,然而传统的经后方或后外侧入路融合率较低,并发症较多,影响相邻脊柱节段的稳定性,破坏了脊柱的机械载荷分布。 目的：探讨经腰椎间孔入路行腰椎体间植骨融合结合椎弓根螺钉置入内固定治疗腰椎退行性疾病的临床效果。 方法：68例腰椎退行性疾病患者行腰椎间孔入路腰椎体间植骨融合结合短节段椎弓根螺钉置入内固定,其中峡部裂型腰椎滑脱24例、退变性腰椎滑脱16例、退变性腰椎管狭窄18例和退变性腰椎间盘疾病10例。 结果与结论：所有患者无神经损伤、椎间隙感染和脑脊液漏等并发症,一期愈合。均获得随访,平均随访29个月(10~60个月)。所有病例未发生内置物断裂、松动移位和椎间隙高度丧失等并发症,骨融合率为91%。依据日本JOA疗效评定标准,优35例,良26例,可5例,差2例,总优良率为90%。结果说明基于椎弓根置入内固定的椎间孔入路腰椎体间植骨融合可有效治疗腰椎退行性疾病,近期随访结果满意。 关键词：经腰椎间孔入路;椎间融合;椎弓根固定;腰椎退行性疾病;硬组织植入物     

斜外侧腰椎间融合术(OLIF)并发症的临床分析

目的探讨斜外侧腰椎间融合术(oblique lateral interbody fusion,OLIF)并发症的发生原因及防治策略。方法回顾性分析四川省人民医院神经外科2014年12月到2016年12月间收治的67例采用OLIF治疗的各类腰椎疾病患者的病历资料,其中联合后路经皮椎弓根螺钉固定术18例,联合前路单侧椎体螺钉内固定术26例,未行钉棒系统固定者23例。统计各类手术术中及术后并发症,探讨并发症发生的相关因素。结果 67例接受OLIF手术的患者共发生各类并发症15例,发生率22.4%。术中并发症5例,包括Cage位置不良2例;手术侧大腿短暂麻木无力2例、交感神经丛损伤1例。术中无腹腔大血管损伤、输尿管损伤等严重并发症发生。术后并发症10例,包括Cage沉降7例;手术切口脂肪液化2例,切口疝1例。术后无椎间隙及腹膜后感染等并发症发生。结论 OLIF是治疗腰椎退行性病变等疾患的一种安全有效的微创术式,并发症的发生率与适应症的选择、术者的手术技巧密切相关。     

骨水泥固定融合治疗腰椎退行性疾病合并骨质疏松效果研究

目的探讨分析骨水泥强化固定融合治疗骨质疏松性腰椎退行性疾病的效果。方法选取64例骨质疏松性腰椎退行性疾病患者随机分为实验组和对照组,实验组采用骨水泥强化椎弓根钉内固定+椎间融合术治疗,对照组采用传统双侧椎弓根钉内固定+椎间融合术,比较两组患者,术前、术后VAS疼痛评分、JOA功能评分、术后融合情况及术后并发症情况。结果治疗后1月、6个月、2年VAS评分均高于单纯固定融合治疗的患者,JOA评分亦是如此,差异均具有统计学意义。实验组与对照组术后患者并发症差异无统计学意义。结论骨水泥强化椎弓根钉内固定融合较单纯双侧椎弓根钉内固定+椎间融合术治疗骨质疏松性腰椎退行性疾病能够提高患者术后功能,降低疼痛感,有减少术后并发症发生的趋势,值得临床推广。     

Percutaneous endoscopic lumbar discectomy for lumbar disc herniation

This study aims to compare the advantages and disadvantage of percutaneous endoscopic lumbar discectomy (PELD) and standard discectomy (SD) for the treatment of lumbar intervertebral disc herniation (LDH). We searched in MEDLINE, EMBASE, PubMed, Web of Science and Cochrane databases for relevant trials that compare PELD and SD for the treatment of LDH. The Cochrane Collaboration’s Revman 5.3 software was used for data analyses. This meta-analysis compiled 1301 cases from four random controlled trials and three retrospective studies. Compared with SD, PELD showed a shorter operative time (mean difference (MD) = −18.68, 95% confidence interval (CI): −24.92 to −12.43; p < 0.00001), less blood loss (MD = −64.88, 95% CI: −114.51 to −15.25, p < 0.0001), shorter hospital stay (MD = −3.51, 95% CI: −4.93 to −2.08, p < 0.00001), and shorter mean disability period (MD = −34.34, 95% CI: −53.90 to −14.77, p < 0.006). However, there were no significant differences in the visual analogue scale (VAS) scores at the final follow up (MD = −0.23, 95% CI: −0.53 to 0.07, p = 0.14), Macnab criteria at the final follow up (MD = 1.04, 95% CI: 0.72 to 1.50, p = 0.82), complications (RR = 0.76, 95% CI: 0.40 to 1.43, p = 0.39), recurrence rate (risk ratio (RR) = 1.00, 95% CI: 0.61 to 1.64, p = 1) and reoperation rate (RR = 1.40, 95% CI: 0.90 to 2.16, p = 0.13). In conclusion, despite PELD showing significant benefit in short term outcomes such as hospital course and mean disability period, similar clinical efficacy and long term outcomes were observed when compared to SD. Therefore, we suggest that PELD can be a feasible alternative to the conventional posterior approach for the LDH depending on surgeon preference and indication. High-quality randomized controlled trials with sufficient large sample sizes necessary further confirm these results.     

经皮腰椎间盘摘除术治疗腰椎间盘突出症62例探讨

目的探讨经皮腰椎间盘摘除术(PLD)在腰椎间盘突出症治疗中的临床应用。方法采用PLD技术在DSA监控下行经皮腰椎间盘摘除术。结果62例患者均达到了治疗效果,其中60例全愈,22例术后短期内出现症状“反跳”,经治疗后症状消失;结论PLD手术的有效率达90%以上,并发症发生率几乎为零,为一安全、有效的治疗手段。     

Posterolateral lumbar fusion versus transforaminal lumbar interbody fusion for the treatment of degenerative lumbar scoliosis

This study compares the safety and efficacy of posterolateral lumbar fusion (PLF) and transforaminal lumbar interbody fusion (TLIF) in the treatment of degenerative lumbar scoliosis (DLS). Forty DLS patients with Cobb angles of 20–60 degrees were randomized into either the PLF or TLIF treatment group, and were followed up for 2–5 years. Operating time, intraoperative blood loss, clinical outcomes, complications and imaging were compared between the two groups. There were significant differences between the PLF and TLIF treatment groups in operative time (187.8 ± 63.5 minutes and 253.2 ± 57.6 minutes, respectively; p = 0.002) and intraoperative blood loss (1166.7 ± 554.1 mL and 1673.7 ± 922.4 mL, respectively; p = 0.048). The occurrence rates of early complications in the two groups were 11.1% and 26.3%. The recovery rates of the lumbar lordotic angle and spinal sagittal balance were significantly different (36.7% versus 62.5% and 44.8% versus 64.1%, respectively). In various domains of the Scoliosis Research Society-22 (SRS-22) questionnaire, the scores for pain and satisfaction with the treatment showed significant differences between PLF and TLIF group (p = 0.033 and p = 0.006, for pain and satisfaction respectively), and the TLIF group showed better outcomes than the PLF group. There were no significant differences in the recovery rates in the Cobb angle and the spinal coronal balance, function, self-image, or mental health scores. Although TLIF increases the surgical trauma and occurrence of complications, it helps to improve lumbar lordosis and sagittal balance and shows better clinical outcomes. For patients without significant loss of lumbar lordosis and with good spinal sagittal balance preoperatively, PLF is still an option.     

Juvenile lumbar discs

One hundred and two patients, ages 10–18 years, were operated upon for herniated lumbar discs. Until age 17, the male-to-female ratio was even. A significant relationship was found between traumatic etiology and the occurrence of free disc rupture. Disc material was found outside the annular ligament in more than half of the patients. Results of surgical excision have been excellent in 95% of cases. Same level recurrence remains below 3%.     

不同融合方式对腰椎生物力学的影响

背景：腰椎融合已广泛应用于腰椎疾患,但腰椎融合后对邻近节段的影响尚存争议,不同融合方式的节段稳定性及对邻近节段的影响尚不清楚。 目的：利用动物模型研究腰椎融合节段生物力学稳定性及相邻上节段的生物力学特点。 方法：将新西兰大白兔随机分为前路椎体间融合组(切除L5~6椎间盘,终板去皮质化,自体髂骨移植)、后外侧融合组(L5~6双侧横突去皮质化后自体髂骨移植)、环状融合组(先行前路椎体间融合,1周后作后外侧融合)、对照组(不作手术)。术后12周处取标本作影像学检查、手触测试、生物力学测试。对融合标本分别施加屈伸,左右侧弯,左右旋转6个方向的纯力矩,比较不同融合方式融合节段的稳定性及邻近节段运动范围。 结果与结论：与对照组比较,前路椎体间融合组、环状融合组、后外侧融合组L5~6节段屈曲活动度分别下降86.24%(P < 0.05),88.74%(P < 0.05),73.10%(P < 0.05),融合节段近上节段L4~5屈曲运动范围分别增加52.22%(P < 0.05),55.89%(P < 0.05),27.11%(P < 0.05)。说明3种融合方式均显著提高融合节段稳定性,环状融合提供的节段稳定性最高,后外侧融合提供的节段稳定性最低。3种融合方式均使融合节段邻近上节段运动范围显著增加。前路椎体间融合,360°融合使邻近上节段屈曲运动范围增加无统计学差异。后外侧融合使邻近上节段屈曲运动范围增加最少。     

Sex differences in lumbar spinal cord gene expression following experimental lumbar radiculopathy

Considerable evidence indicates that there are sex-related differences in clinical and experimental pain sensitivity. In the present study, we sought to determine what genes were expressed in the spinal cord in a sexually dimorphic manner. We first analyzed global gene expression in the lumbar spinal cord of uninjured male and female rats using the Affymetrix RAE230A GeneChip platform in order to identify genes that are selectively expressed in male and female rats at a basal level. We subsequently analyzed global gene expression in the lumbar spinal cord of male and female rats at two time points (7 days and 14 d) following a rodent model of lumbar radiculopathy (L5 nerve root ligation) in order to determine what genes were regulated in a sexually dimorphic manner following nerve root injury. We utilized a linear regression analysis method to identify genes that were significantly different from the corresponding sham surgical controls. The expression patterns of several genes of interest were subsequently confirmed using RT-PCR. Our findings demonstrate significant differences in lumbar spinal cord gene expression in both uninjured and injured (L5 nerve root ligation) male and female rats. Further confirmation of a subset of the genes identified Neuregulin 1 and its high affinity receptor, ErbB4, Tachykinin 1, and Metabotropic glutamate receptor 6 as female specific genes upregulated following L5 nerve root injury. These findings provide several target genes for further study that may elucidate the neurochemical mechanisms underlying sex differences in pain sensitivity and lead to improved treatments for chronic pain syndromes.     

显微镜下经管道与开放式腰椎间盘摘除术综合疗效对比分析

目的 探讨显微镜下经管道与开放式腰椎间盘摘除术的综合疗效。方法 回顾性分析2014年6月至2016年6月手术治疗的165例腰椎间盘突出症的临床资料，其中96例行显微镜下经管道腰椎间盘摘除术（观察组），60例行开放式腰椎间盘切除术（对照组）。所有病人术后平均随访（12.7±1.1）个月。采用视觉模拟量表（VAS）评分、Oswestry功能障碍指数（ODI）评估疗效。末次随访采用Macnab标准评定术后功能。结果 与对照组相比，观察组手术时间明显延长，住院时间明显缩短（P<0.05），术中出血量明显减少（P<0.05）。观察组术后并发症发生率（4.1%）与对照组（3.0%）无统计学差异（P>0.05）。两组术前VAS评分、ODI均无统计学差异（P>0.05）；两组术后1周、3个月、12个月VAS评分、ODI均较术前均明显降低（P<0.05）；而且，术后1周、3个月，观察组VAS评分均显著低于对照组（P<0.05）。末次随访两组Macnab功能无统计学差异（P>0.05）。结论 与开放式腰椎间盘切除术比，显微镜下经管道腰椎间盘摘除术治疗腰椎间盘突出症康复快、住院时间短。     

Intradural lumbar cystic schwannoma

Intradural lumbar cystic schwannomas are a very rare entity and only 10 case reports have been reported in the literature. The diagnosis and management remains a challenge for clinical physicians. Herein, we report a 51-year-old female presenting with lower back pain and radiating pain at the left upper thigh. Magnetic resonance images of lumbar spine demonstrated an intradural cystic mass approximately 18 x 17 x 35 mm in size occupying L4 to L5, which appeared as the same signal intensity as CSF. At operation, a well encapsulated cystic mass was found. The pathological examination confirmed a diagnosis of schwannoma. The relevant literature was also reviewed.