后路全脊椎截骨术治疗合并脊髓空洞重度僵硬性脊柱侧后凸畸形的安全性及疗效分析

目的探讨后路全脊椎截骨术(Posterior Vertebral Column Resection,PVCR)治疗合并脊髓空洞的重度僵硬性脊柱侧后凸的安全性及临床疗效。方法回顾分析2009-10-2013-03在我院接受PVCR手术治疗的合并脊髓空洞的重度僵硬性脊柱侧后凸畸形患者16例;其中同时伴发Chiari畸形I型患者在脊柱畸形截骨矫行前均先于神经外科进行后颅凹减压术;对于单纯合并脊髓空洞患者,直接进行脊柱截骨畸形矫治;记录手术时间、出血量及围手术期并发症情况。结果手术前、后冠状面及矢状面主弯Cobb角比较,差异具有统计学意义(P0.05);手术后与末次随访时冠状面及矢状面主弯Cobb角比较,差异无统计学意义(P0.05)。结论对于合并脊髓空洞的重度僵硬性脊柱侧后凸畸形,采用PVCR进行治疗,可获得安全、有效的临床结果。     

后路半椎体切除矫治半椎体所致脊柱侧后凸畸形

[目的]评价后路半椎体切除术治疗半椎体所致脊柱侧后凸畸形的临床效果。[方法]2000年5月~2005年11月,采用后路半椎体切除及矫形固定融合术治疗14例完全分节半椎体所致脊柱侧后凸畸形患者。年龄2.5~14.4岁,平均7.4岁,半椎体均为侧后方半椎体,其中胸椎7例,腰椎7例。[结果]手术时间2~7 h,平均4.7h,术中出血量150~2 500 m l,平均560 m。l固定节段2~8个椎体,平均3.5。术后随访6~36个月。平均15.6个月。术后站立位脊柱正侧位X线片示冠状面Cobb's角由术前46.2°矫正到17.3°,平均矫正率62.6%,矢状面Cobb's角由术前48.3°矫正至术后16.2°,平均矫正率68.7%。终末随访时冠状面Cobb's角平均21.7°,丢失4.4°,矢状面Cobb's角平均18.7°,丢失2.5°。围手术期并发症包括:伤口愈合不良2例,术中术后椎弓根螺钉切割椎体2例。[结论]后路半椎体切除可直接去除致畸因素,在冠状面及矢状面均获得良好的矫形效果,与前后路手术相比可缩短手术时间,减少创伤,适用于从胸段到腰段的半椎体畸形。     

先天性脊柱侧后凸畸形的治疗现状

先天性脊柱侧后凸是由脊柱的结构发育异常所导致的一种常见的脊柱畸形。该类型发现早,畸形重,对心肺的发育及功能影响大,矫形困难,并发症多,近十年来其治疗有较大进展。本文将就其治疗现状进行综述。     

无前柱支撑PVCR治疗脊髓功能Ⅰ型重度僵硬性脊柱侧后凸的神经并发症分析

背景:无前柱支撑后路全椎体切除术(posterior vertebral column resection,PVCR)治疗脊髓功能Ⅰ型重度僵硬性脊柱侧后凸畸形的神经并发症发生原因尚未明确,对神经并发症的充分认识有助于对该手术方式的深入理解。目的:分析无前柱支撑PVCR治疗脊髓功能I型重度僵硬性脊柱侧后凸畸形的神经并发症发生原因。方法:回顾性收集2013年3月至2019年2月无前柱支撑PVCR治疗的36例脊髓功能Ⅰ型重度僵硬性脊柱侧后凸患者的术中电生理监测资料。男15例,女21例;年龄12~51岁,平均(17.6±6.1)岁。手术前,所有患者均无脊髓神经功能障碍,MRI均未显示脊髓发育异常。术中采用体感诱发电位、运动诱发电位、下行神经源性诱发电位的联合监测模式。评估术中诱发电位变化数据资料,分析神经并发症发生的原因。结果:所有36例患者均成功接受无前柱支撑PVCR手术并获得满意的手术矫形效果,术后随访3~60个月,平均(32.5±8.2)个月。术中电生理监测无假阴性发生,共出现电生理阳性事件10例(27.8%,10/36):7例发生于截骨阶段,置钉、矫形、矫形后各出现1例。通过系统排查并采取相关处理措施后按照评价标准确定真阳性6例(60%,6/10)、假阳性4例(40%,4/10)。2例(5.6%,2/36)患者表现为术后神经功能障碍,均发生于截骨阶段。1例在随访期间表现为持久性神经功能障碍;1例出现术后短暂性神经功能障碍,在术后9个月随访期间内神经功能障碍完全恢复(ASIA E级)。结论:无前柱支撑PVCR是治疗脊髓功能Ⅰ型重度僵硬性脊柱侧后凸畸形的有效方式。本组患者神经并发症发生率为5.6%。70%神经电生理阳性事件发生于截骨阶段,主要为截骨阶段的平均动脉压过低、血红蛋白过低及机械性刺激所致。多模式诱发电位监测在无前柱支撑PVCR矫形手术中可有效地发现并辅助降低术后神经系统并发症的发生。     

对后路全脊椎切除术治疗严重脊柱侧后凸畸形的体会

重度僵硬性脊柱侧后凸是严重的脊柱三维畸形。广泛前后柱结构的僵硬，以及脊柱冠状面和矢状面的严重失衡。使得单纯传统后路内固定矫形或前路松解联合后路矫形技术不能获得满意矫正效果，并具有较高的脊髓神经损伤风险。虽然常用于强直性脊柱炎胸腰椎后凸畸形治疗的后路脊椎截骨术（spinal osteotomy）（经关节突“V”型截骨或经椎弓根椎体截骨）在轻、中度成人僵硬侧凸或脊柱侧凸翻修手术中取得成功，但对于重度、僵硬的脊柱侧后凸畸形，由于截骨范围有限，该两种方法均不能取得畸形的满意矫正和躯干平衡恢复。基于先天性脊柱侧凸半椎体切除和脊柱恶性肿瘤后路全脊椎切除的经验，全脊椎切除术（vertebral column resection，VCR）主要适应证为：     

重度脊柱侧后凸畸形的后路分期手术治疗

目的:探讨严重脊柱侧后凸重度畸形的后路分期手术治疗方法及疗效.方法:2005年2月～2008年2月共收治19例侧凸或后凸Cobb角大于100°的重度脊柱侧后凸畸形患者,男5例,女14例,年龄10～18岁,平均13.7±2.5岁.术前侧凸主弯冠状面Cobb角平均为123.6°±26.3°(100°～169°),胸腰段矢状位后凸角平均为96.1°±30.0°(58°～145°).均采用后路分期两次手术进行矫形.第一次手术采用小切口微创手术、内撑开技术,使侧凸得到约50%的矫正,3～12个月后再进行后路的松解、截骨和第二次矫形,并行剃刀背切除和植骨融合.随访观察治疗效果.结果:所有病例均顺利完成两次手术,第一次手术后无并发症,第二次手术后出现肺部感染、切口感染、气胸、应激性溃疡、肠系膜E动脉综合征各1例,无严重并发症如脊髓损伤、呼吸衰竭等出现.第二次术后冠状面主弯Cobb角为45.6°±6.1°(35°～55°),胸腰段后凸为38.2°±10.0°(25°～56°).患者躯干和双肩的失平衡均得到显著改善.随访1年,2例出现椎弓根螺钉松动,侧弯矫正无明显丢失,无脱钩、断棒.结论:对于严重的脊柱侧后凸畸形患者采用后路矫形分2期手术治疗,能够获得良好的矫形效果.     

重度僵硬型脊柱侧后凸畸形术前及术后护理

目的总结重度僵硬型脊柱侧后凸畸形矫形术的护理经验。方法对14例重度僵硬型脊柱侧后凸畸形进行手术治疗的患者实施相应护理,制定系统全面的护理计划,术前心理护理,呼吸功能训练,唤醒试验,完善各种术前准备。术后严密监测生命体征及病情变化,脊髓神经功能观察,胃肠道反应,做好引流管及翻身的护理,重视功能锻炼及出院指导,这些都是手术成功的重要组成部分。结果 14例术后患者侧凸Cobb′s角15°-71°,平均31.3°,纠正率71.9%;后凸22°-48°,平均34.9°,纠正率59.3%。患者均获得术后随访7-31个月,平均12.7个月。     

脊柱后路截骨及PRSS内固定系统矫正脊柱后凸畸形

目的介绍矫治强直性脊柱新型装置PRSS的优点及临床应用效果。方法强直性脊柱炎患者13例,平均年龄31岁,术前平均后凸畸形74°,行1～2个阶段Ⅴ形截骨后用PRSS矫正后凸畸形,利用X线检查测量比较术前术后随诊时畸形度进行分析。结果后凸畸形由平均后凸74°矫正至平均29°,矫正率61％,无并发症。结论脊柱后路截骨及PRSS内固定系统矫正脊柱后凸畸形效果安全可靠。     

先天性脊柱侧凸患者中的脊髓畸形和脊椎畸形

目的:探讨先天性脊柱侧凸患者的各类脊髓畸形与脊椎畸形之间的关系。方法:对我院2003年～2005年收治的211例已确诊的先天性脊柱侧凸患者的临床资料进行回顾性分析,统计先天性脊柱侧凸患者脊髓畸形、脊椎畸形的发生率及其好发部位,观察两者间的关系。结果:211例先天性脊柱侧凸患者中脊髓畸形44例(20.85%),其中脊髓空洞症25例次(11.85%),脊髓纵裂30例次(14.22%),马尾终丝栓系28例次(13.27%),低位圆锥12例次(5.69%),其他类型少见,多种畸形常并发存在;脊髓畸形好发于脊柱胸段、胸腰段、腰段、腰骶段。44例伴有脊髓畸形的先天性脊柱侧凸病例中不良分节34例(77.27%),孤立性半椎体1例(2.27%),非孤立性半椎体21例(47.73%),脊柱裂30例(68.18%),混合型41例(93.18%);脊椎畸形好发于脊柱胸段、腰段、腰骶段。结论:先天性脊椎畸形常合并脊髓畸形,总体上脊髓畸形与脊椎畸形的好发部位相似,但各种脊髓畸形、脊椎畸形间缺少显著的、特定的对应关系。     

后路一期全脊椎截骨术治疗重度脊柱侧后凸畸形

目的 探讨后路一期全脊椎截骨术治疗重度脊柱侧后凸畸形的临床效果.方法 回顾性分析解放军联勤保障部队第九九○医院脊柱外科2016-04—2019-04间采用后路一期全脊椎截骨术治疗的26例重度脊柱侧后凸畸形患者的临床资料.男15例,女11例;年龄12～60岁,平均30.8岁.胸段13例,腰段8例,胸腰段5例.观察术中情况...     

Surgical management of neurologically complicated kyphoscoliosis using transposition of the spinal cord: Case report

BackgroundTransposition of the spinal cord made it possible to achieve mobilization of the fixed kyphoscoliosis, significantly increase spinal canal volume and improve spinal canal shape. This helped to eliminate spinal cord compression and achieve complete regression of the existing neurological symptoms.Methods and resultsWe report the clinical case of surgical management of neurologically complicated kyphoscoliotic deformity of the thoracic spine by transposition of the spinal cord and correction using posterior segmental spinal instrumentation.ConclusionsThe required correction of severe kyphoscoliosis was performed; the risks of trunk imbalance, deformity progression, and instrumentation failure in the long-term postoperative period were reduced.Level of evidenceLevel IV – 1 case.     

体感诱发电位联合运动诱发电位在严重脊柱侧后凸畸形患者矫形手术中的应用价值

目的 :评估体感诱发电位(somatosensory evoked potentials,SSEPs)联合经颅电刺激运动诱发电位(transcranial electric motor evoked potentials,TCeMEPs)在严重脊柱侧后凸畸形患者矫形内固定术中的应用价值。方法:2015年8月～2017年10月在我院行脊柱后路矫形手术的69例严重僵硬性脊柱侧后凸畸形患者(侧凸或后凸Cobb角90°)术中应用SSEPs和TCeMEPs监测,回顾性分析患者术中SSEPs和TCeMEPs的监测结果,分别计算单模式SSEPs、单模式TCe MEPs和联合应用SSEPs与TCeMEPs的成功率、报警率、真假阳性率、真假阴性率、阳性预测值、阴性预测值、监测的敏感性和特异性等。比较分析采用卡方检验。结果:58例患者SSEPs得到稳定的监测基线,其中5例监测改变达到报警标准,术后2例患者出现了神经损害,3例患者术中监测逐渐恢复,术后无明显神经损害。67例患者TCeMEPs得到稳定基线,术中预警3例,术后2例为真阳性,1例术后无神经损害。单模式SSEPs监测的成功率为84.1%(58/69),预警率为8.6%(5/58),真阳性率为3.4%(2/58),误检率为5.2%(3/58),真阴性率为91.4%(53/58),漏检率为0(0/58),阳性预测值为40%(2/5),阴性预测值为100%(53/53),敏感性为100%(53/53),特异性为94.6%(53/56)。TCeMEPs监测的成功率为97.1%(67/69),预警率为4.4%(3/67),真阳性率为3.0%(2/67),误检率为1.5%(1/67),真阴性率为95.5%(64/67),漏检率为0(0/67)、阳性预测值为66%(2/3),阴性预测值为100%(64/64),敏感性为100%(64/64),特异性为98.5%(64/65)。联合应用SSEPs和TCe MEPs监测的预警率为3.4%(2/58),真阳性率为3.4%(2/58),误检率为0(0/58),真阴性率为96.6%(56/58),漏检率为0(0/58),阳性预测值、阴性预测值、敏感性与特异性均为100%。三种模式的成功率、预警率、真阳性率、真阴性率、漏检率、阴性预测值、敏感性及特异性无统计学差异(P0.05),误检率及阳性预测值有统计学差异(P0.05)。结论 :联合应用SSEPs和TCeMEPs两种监测方法可提高严重脊柱侧后凸畸形患者矫形手术中神经监测的预警价值,降低术中不可逆神经损伤风险。     

脊髓诱发电位的实验研究

为探索脊髓诱发电位（Spinalcordevokednotentials，SCEP）在术中监测的安全范围，将刺激和记录线电极分别置于24只大耳白兔T7～T8、L4～L5间隙硬障外，记录正常电位后对脊髓施加纵向牵张力，至实验要求的波幅。波幅下降至正常的80％组脊髓组织结构轻微改变，脊髓功能正常；下降至50％组及＜50％组则出现不可逆损害。结果表明，SCEP波形稳定，其波幅下降至80％是脊髓损伤的危险信号，下降至50％或50％以下将产生不可逆的脊髓损伤。     

The prevention of iatrogenic spinal cord injury utilizing the evoked spinal cord potential

Summary The evoked spinal cord potential elicited by direct stimulation of the cord has been used clinically to monitor cord function in the course of operations on the spine. The technique used allows measurement of a relatively large amplitude of potential, which is fairly stable against anaesthetics and related drugs, by means of a simple recording system and is sensitive enough to indicate cord damage. Continuous monitoring can easily be carried out. We have encountered no complications when using this method on 99 patients.

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Résumé Le potentiel évoqué provoqué par la stimulation directe de la moelle épinière a été utilisé en clinique pour contrôler la fonction de la moelle lors des interventions sur le rachis. Cette technique permet de mesurer une assez grande amplitude de potentiel, qui est relativement stable à l'égard des anesthésiques et d'autres drogues de même type, grâce à un système simple d'enregistrement; il est suffisamment sensible pour détecter des altérations de la moelle. Une surveillance continue peut aisément être effectuée. Aucun incident n'a été rencontré chez 99 malades lors de l'utilisation de cette méthode.

     

Inpatient rehabilitation outcomes in patients with malignant spinal cord compression compared to other non-traumatic spinal cord injury: A population based study

Abstract

Objective

To compare and describe demographic characteristics, clinical, and survival outcomes in patients admitted for inpatient rehabilitation following malignant spinal cord compression (MSCC) or other causes of non-traumatic spinal cord injury (NT-SCI).

Design

A retrospective cohort design was employed, using data retrieved from administrative databases.

Setting

Rehabilitation facilities or designated rehabilitation beds in Ontario, Canada, from April 2007 to March 2011.

Participants

Patients with incident diagnoses of MSCC (N = 143) or NT-SCI (N = 1,274) admitted for inpatient rehabilitation.

Outcome measures

Demographic, impairment, functional outcome (as defined by the Functional Independence Measure (FIM)), discharge, healthcare utilization, survival, and tumor characteristics.

Results

There was a significant improvement in the FIM from admission to discharge (mean change 20.1 ± 14.3, <0.001) in the MSCC cohort. NT-SCI patients demonstrated a higher FIM efficiency (1.2 ± 1.7 vs. 0.8 ± 0.8, <0.001) and higher total (24.0 ± 14.4 vs. 20.1 ± 14.3, <0.001) FIM gains relative to MSCC cases. However, there were no differences between the MSCC and NT-SCI cohorts in length of stay (34.6 ± 30.3 vs. 37.5 ± 35.2, P = 0.8) or discharge FIM (100.7 ± 19.6 vs. 103.3 ± 18.1, P = 0.1). Three-month, 1-year, and 3-year survival rates in the MSCC and NT-SCI cohorts were 76.2% vs. 97.6%, 46.2% vs. 93.7%, and 27.3% vs. 86.7%, respectively. The majority (65.0%) of patients with MSCC was discharged home and met their rehabilitation goals (75.5%) at comparable rates to patients with NT-SCI (69.7 and 81.3%).

Conclusion

Despite compromised survival, patients with MSCC make clinically significant functional gains and exhibit favorable discharge outcomes following inpatient rehabilitation. Current administrative data suggests the design and scope of inpatient rehabilitation services should reflect the unique survival-related prognostic factors in patients with MSCC.     

Inpatient rehabilitation outcomes in patients with malignant spinal cord compression compared to other non-traumatic spinal cord injury: A population based study

ObjectiveTo compare and describe demographic characteristics, clinical, and survival outcomes in patients admitted for inpatient rehabilitation following malignant spinal cord compression (MSCC) or other causes of non-traumatic spinal cord injury (NT-SCI).DesignA retrospective cohort design was employed, using data retrieved from administrative databases.SettingRehabilitation facilities or designated rehabilitation beds in Ontario, Canada, from April 2007 to March 2011.ParticipantsPatients with incident diagnoses of MSCC (N = 143) or NT-SCI (N = 1,274) admitted for inpatient rehabilitation.ResultsThere was a significant improvement in the FIM from admission to discharge (mean change 20.1 ± 14.3, <0.001) in the MSCC cohort. NT-SCI patients demonstrated a higher FIM efficiency (1.2 ± 1.7 vs. 0.8 ± 0.8, <0.001) and higher total (24.0 ± 14.4 vs. 20.1 ± 14.3, <0.001) FIM gains relative to MSCC cases. However, there were no differences between the MSCC and NT-SCI cohorts in length of stay (34.6 ± 30.3 vs. 37.5 ± 35.2, P = 0.8) or discharge FIM (100.7 ± 19.6 vs. 103.3 ± 18.1, P = 0.1). Three-month, 1-year, and 3-year survival rates in the MSCC and NT-SCI cohorts were 76.2% vs. 97.6%, 46.2% vs. 93.7%, and 27.3% vs. 86.7%, respectively. The majority (65.0%) of patients with MSCC was discharged home and met their rehabilitation goals (75.5%) at comparable rates to patients with NT-SCI (69.7 and 81.3%).ConclusionDespite compromised survival, patients with MSCC make clinically significant functional gains and exhibit favorable discharge outcomes following inpatient rehabilitation. Current administrative data suggests the design and scope of inpatient rehabilitation services should reflect the unique survival-related prognostic factors in patients with MSCC.     

大网膜移植对治疗脊髓缺血性损害的实验研究──应用磁性刺激MEP监测

应用预先作了大网膜脊髓移植的实验组狗和未作大网膜移植的对照组狗各７只，分别阻断其脊髓局部血供，观察两组的运动功能改变、组织学改变及磁性刺激运动诱发电位（ＭＥＰ）的变化。结果两组具有显著性差异，显示预先作大网膜移植对脊髓的急性缺血性损害有保护作用。作者认为：用磁性刺激技术获取ＭＥＰ作神经生理学检查，能准确客观地反映运动神经传导系统的功能状况，亦不会对神经组织产生损害。     

Intraoperative urodynamics in spinal cord surgery: a study of feasibility

Intraoperative monitoring (IOM) of bladder function in spinal cord surgery is a challenging task due to vegetative influences, multilevel innervation and numerous supraspinal modulating factors. Despite routine use of urodynamics in neurosurgery for implantation of bladder stimulators or denervation of nerve fibres in spastic reflex bladders, application of IOM in patients with spinal cord tumours or tethered-cord syndrome is not widespread. Combining urodynamics with sphincter electromyography (EMG) in IOM enables identification of bladder efferents responsible for contraction and continence. We monitored four patients with ependymoma of the Cauda equina, one patient with tethered-cord syndrome and two patients with cervical intramedullary tumours. In all patients undergoing operations of the Cauda equina, identification of bladder efferents responsible for detrusor contraction was possible. There was good correlation between preoperative bladder dysfunction, preoperative urodynamics and intraoperative pressure increase by bladder contraction or latency between stimulation and contraction. This method proved unsuitable for intramedullary tumours where no contraction of the bladder could be observed while stimulating the spinal cord. Intraoperative monitoring of urodynamics is an effective tool for identifying bladder efferents in the Cauda equina. Intraoperative conclusions on bladder dysfunction through registration of pressure increase and latency are possible.     

胸、腰段脊柱脊髓损伤外科治疗失误的处理

目的:分析急性胸、腰段脊柱脊髓损伤外科治疗失误的主要原因,探讨处理原则。方法:对104例首次外科治疗失误的急性胸、腰段脊柱脊髓损伤患者的临床资料和影像学资料进行分析,并根据临床具体情况进行外科处理。结果:104例患者中,残存腰痛45例次,脊柱畸形30例次,脊柱不稳35例次,脊髓神经受压8例次,坐位失平衡8例次。经再次手术治疗后脊柱畸形患者明显改善;椎管残存压迫的不完全性脊髓损伤患者椎管减压术后运动指数和感觉指数均增加;30例脊柱不稳定患者重建了脊柱稳定性;45例腰痛患者中40例腰痛消失或基本消失,5例仍有轻度腰痛需应用止痛药物,但不影响轮椅活动。结论:胸、腰段脊柱脊髓损伤手术治疗失误的主要因素包括手术适应证选择不当、手术技术失误和保守治疗不当。再处理方案主要参考首次治疗主要失误因素来确定。     

Intraoperative assessment of human spinal cord perfusion using near infrared spectroscopy with indocyanine green tracer technique

Background contextDespite the significant interest in the assessment of human cerebral perfusion, investigations into human spinal cord perfusion (SCP) are scarce. Current intraoperative monitoring of spinal cord relies on the assessment of neural conduction as a surrogate for SCP. However, there are various inherent limitations associated with the use of these techniques. Near infrared spectroscopy (NIRS) has been successfully used for monitoring and assessment of human cerebral perfusion and has shown promising results in intraoperative assessment of SCP in animal models.PurposeThe aim of this study was to investigate whether it is possible to monitor physiological changes in human SCP intraoperatively using NIRS with indocyanine green (ICG) tracer technique. We used this technique to calculate the human spinal cord carbon dioxide (CO₂) reactivity index. In addition, we investigated whether the lamina causes significant attenuation of NIRS signals.Study design/settingIntraoperative human experimental study.Patient sampleEighteen patients undergoing elective posterior cervical spine surgery.Outcome measuresCarbon dioxide reactivity of human SCP.MethodsNine patients underwent transdural assessment of SCP, with an additional nine patients undergoing translaminar measurements. Patients' SCP was continuously monitored using an NIRO-500 NIRS monitor via a set of purpose built optodes. Their arterial ICG concentration was simultaneously assessed using a pulse dye densitometer. Patients' end-tidal CO₂ was gradually increased by 7.5 mm Hg and then returned back to baseline. Three sets of measurements were taken: baseline, hypercapnic, and return to baseline.ResultsAfter hypercapnia, SCP increased by a mean of 57.2±23.3% in the transdural group and 46.6±36.3% in the translaminar group. Carbon dioxide reactivity index was 7.6±3.2%ΔSCP/mm Hg in the transdural group and 6.4±5.3 %ΔSCP/mm Hg in the translaminar group. There was no significant difference in the increase in SCP (p=.475) or the CO₂ reactivity index (p=.581) observed between the transdural and the translaminar groups.ConclusionsIntraoperative NIRS with ICG tracer technique can identify an increase in the SCP in response to hypercapnia. It is possible to use this technique for monitoring SCP over the dura and the lamina. This technique could potentially be used to provide insight in to the pathophysiology and autoregulation of commonly acquired spinal cord conditions. Further research assessing the use of NIRS for monitoring of SCP is required.