目的 探討前路小切口頂椎切除聯合后路矯形手術治療重度僵硬性脊柱側凸的可行性及療效。 方法 2009 年7月－2010年9月，采用前路小切口頂椎切除聯合后路矯形手術治療重度僵硬性脊柱側凸18例。其中男9例，女9例，年齡10～24歲，平均14.5歲。其中15 例特發性脊柱側凸（Lenke 2型6例，Lenke 3型1例，Lenke 4型8例），2 例脊髓空洞合并脊柱側凸，1 例Chiari畸形合并脊柱側凸。術前剃刀背高度（6.8 ± 2.3）cm，主胸彎Cobb角（99.6 ±10.0）°，主胸彎頂椎偏距（7.3 ± 1.3）cm。 結果 前路手術切口10～13 cm，平均（11.4 ± 1.0）cm；前路手術時間170～300 min，平均（215.3 ± 36.8）min；失血量300～1 300 mL，平均（662.5 ± 274.8） mL。所有患者隨訪25～39個月，平均30.7個月。末次隨訪時，剃刀背高度（1.0 ± 0.6）cm，矯正率86.7%；主胸彎Cobb角（31.4 ± 11.4）°，矯正率68.7%；主胸彎頂椎偏距（2.2 ± 0.9） cm，矯正率69.6%。上胸彎、胸腰彎/腰彎的Cobb 角及頂椎偏距亦明顯矯正，冠狀面及矢狀面平衡與術前相比，差異無統計學意義（P＞0.05）。未發生神經系統并發癥，1例患者在前路手術后入ICU行呼吸支持治療12 h，1例患者出現椎弓根螺釘穿透椎弓根上壁，2例患者出現鈦網位置不佳，隨訪未見鈦網位置改變。 結論 采用前路小切口頂椎切除聯合后路矯形治療重度僵硬性脊柱側凸安全可行，矯形效果滿意。
Objective To investigate correlation between preoperative C2 slope (C2S) and effectiveness at 2 years after short-segment anterior cervical discectomy and fusion (ACDF), with the aim of providing reliable indicators for predicting effectiveness. Methods One hundred and eighteen patients with cervical spondylotic myelopathy, who received short-segment ACDF between January 2018 and December 2022 and met the selection criteria, were enrolled in the study. There were 46 males and 72 females, aged from 26 to 80 years, with a mean age of 53.6 years. The operative duration was (127.6±33.46) minutes and the intraoperative blood loss was (34.75±30.40) mL. All patients were followed up 2 years. The pre- and post-operative Neck Disability Index (NDI), Japanese Orthopaedic Association (JOA) score, and visual analogue scale (VAS) score for pain were recorded. Based on the anteroposterior and lateral cervical X-ray films, the sagittal parameters of the cervical spine were measured [C2-C7 Cobb angle, C0-C2 Cobb angle, T1 slope, C2S, sagittal segmental angle (SSA) of the surgical segment, and average surgical disc height (ASDH) of the surgical segment]. Statistical analyses were performed to assess the differences in these indicators between pre- and post-operation, as well as the correlations between the preoperative C2S and the JOA score, NDI, and VAS score at 2 years after operation. The patients were allocated into group A (C2S >11.73°) and group B (C2S≤ 11.73°) according to the median value of the preoperative C2S (11.73°). The JOA score, NDI, and VAS score before operation and at 2 years after operation, as well as the differences between pre- and post-operative values (change values), were compared between the two groups. ResultsThe T1 slope, C2-C7 Cobb angle, C0-C2 Cobb angle, SSA, and ASDH at immediate after operation and JOA score, NDI, and VAS score at 2 years after operation significantly improved in 118 patients when compared with preoperative ones (P<0.05). Pearson correlation analysis showed that preoperative C2S was not correlated with JOA score and NDI at 2 years after operation (P>0.05), but negatively correlated with VAS score (P<0.05). There were 59 patients with preoperative C2S>11.73° (group A) and 59 with C2S≤11.73° (group B). There was no significant difference in preoperative JOA score, NDI, and VAS score between the two groups (P>0.05). There were significant differences in VAS score at 2 year after operation and the change value between the two groups (P<0.05); there was no significant difference in the JOA score and NDI (P>0.05). Conclusion Patients with cervical spondylotic myelopathy and a higher preoperative C2S exhibited superior long-term pain relief and effectiveness following short-segment ACDF.
To probe the etiopathogenisis of adjacent-segment disease by analyzing the imageology data and cl inical neurological function in patients with anterior cervical discectomy and fusion (ACDF) harvested by long-term follow-up. Methods A retrospective study was performed on 52 patients who had undergone ACDF with perfect documents from January 1990 to April 2003. Of the patients, 45 were males and 7 were females with a mean age of 48.5 years (range from 25 to 72 years). There was the fusion of 10 one-levels, 38 two-levels and 4 three-levels. The cervical anterior-posterior and lateral X-ray, CT and MRI examination were performed before the operation. Cl inical neurological function was recorded by the Nurick score, and this score at 6 weeks after the operation was compared with the later follow-up. In the radiological examination, the motion of adjacent vertebrae and osteophyte formation were reviewed on X-ray and CT, and were converted to the semi-quantitative degeneration score according to the Goffin method. The correlation between Nurick score or degeneration score and the age at operation or fusion levels was compared by Spearman correlation coefficients. The cervical canal sizes of adjacent level and remote level on MRI were reviewed and compared with each other by t test. Results The follow-up period was 3 to 10 years, 6.9 years on average. There was difference in the Nurick score between the 6th week after operation (1.07 ± 0.84) and the later follow up (1.92 ± 1.28) by rank test (P lt; 0.05). There was no correlation between the Nurick score change and the age at operation (r = 0.21, P gt; 0.05) or fused levels(r = 0.30, P gt; 0.05) by Spearman correlation coefficients. There was obvious difference in degeneration score between the 6th week after operation (0.73 ± 0.67) and the later follow up (1.58 ± 1.06), (P lt; 0.01). There was no correlation between the degeneration score change and the age at operation (r = 0.35, P gt; 0.05) or fusion levels (r = 0.38, P gt; 0.05) by Spearman correlation coefficients. The cervical canal size reductions were (1.7 ± 1.1) mm at superioradjacent level, (1.2 ± 0.6) mm at inferior adjacent level and (0.30 ± 0.68) mm at remote level. There was obvious difference between superior or inferior and remote level by t test (P lt; 0.01). The adjacent level developed prominent degeneration together with nerve function change after the fusion operation and displayed correlation between degeneration and nerve function change(r = 0.41, P lt; 0.05). Conclusion The adjacent-segment disease after interbody fusion is produced by multiple factors. The natural progression in adjacent disc, biomechanical natural change resulting from interbody fusion, destruction to l igament structure in front of cervical vertebrae by operation, and bone graft model are important factors not to be ignored.
Objective To evaluate the long-term effect of excessive length of bone graft via anterior cervical approach and over distraction of intervertebral space on cervical curvature and postoperative neck axial symptom (AS). Methods FromJune 2001 to June 2004, 30 patients with nerve root cervical spondylosis at the C5,6 level underwent anterior cervicaldecompression, autogenous il iac bone graft and internal fixation with titanium plate. There were 14 males and 16 females aged 32-73 years old (average 54.7 years old), and the course of disease was 1-31 months (average 7 months). No instabil ity of cervical vertebrae was noted on the cervical dynamic position x-ray films. Intervertebral height was measured immediately after operation, and accordingly the patients were divided into two groups: the over distraction group (n=11), in which the length of bone graft was excessive, the intervertebral space was over distracted, and the intervertebral height was increased by more than 3 mm compared with the preoperative value; the proper distraction group (n=19), in which the length of bone graft was proper, no over distraction of the intervertebral space occured, and the intervertebral height was increased by less than 3 mm compared with the preoperative value. Regular X-ray exams were performed 1 week and 3, 24, and 48 months after operation to analyze bone fusion condition of the grafted bone, changes of the intervertebral height of the fused segments, and variation of physiological curvature of the cervical vertebra. The postoperative neck AS was evaluated according to the the neck AS evaluation criteria set by ZENG Yan and co-workers. Results All patients were followed up for 48-66 months (average 54.5 months). Cl inical symptoms were el iminated in all cases. No compl ications occurred in the proper distraction group; 1 patient of the over distraction group had ostoperative nerve root paralysis at C5 level, and recovered 3 months after proactive treatment. Bone fusion was achieved in all patients 3-6 months after operation, except for 1 case in the proper distraction group suffering from non-fusion 12 months after operation. There was no occurrence of loosening or breakage of steel plate and screw, and no displacement of the grafted bone. At 48 months after operation, the intervertebral height of the proper distraction group and the over distraction group was increased by (1.9 ± 1.8) mm and (3.5 ± 2.7) mm, respectively, when compared with the preoperativevalue (P gt; 0.05). The physiological curvature of the operated cervical segment was well maintained. The curvature of the proper distraction group and the over distraction group at the final follow-up visit was increased by (2.17 ± 1.83)° and (3.32 ± 2.71)°, respectively, when compared with the preoperative value (P gt; 0.05). The physiological curvature of the whole cervical vertebra at the final follow-up visit was increased by (4.57 ± 3.71)° in the proper distraction group and decreased by (2.43 ± 2.13)° in the over distraction group, when compared with the preoperative value (P lt; 0.05). The incidence rate of postoperative neck S at 48 months after operation was 15.79% in the proper distraction group (11 cases excellent, 5 cases good, 3 cases fair) and 54.55% in the over distraction group (3 cases excellent, 2 cases good, 5 cases fair, 1 case poor), showing a significant difference between two groups (P lt; 0.05). Conclusion Excessive length of bone graft via anterior cervical approach and over distraction of intervertebral space are bad for maintaining the physiological curvature of the whole cervical vertebra, and increase the incidence of postoperative neck AS. Selection of bone graft at the proper height is essential in anterior cervical operation.
Objective To evaluate the cl inical outcomes of anterior decompression, bone graft and internal fixation in treating fourth lumbar burst fractures with il iac fenestration. Methods From February 2001 to May 2006, 8 cases of fourth lumbar burst fractures were treated by anterior decompression, correction, reduction, il iac autograft, Z-plate internal fixation with il iac fenestration. Of them, there were 7 males and 1 female, aging 24-46 years with an average of 29.3 years, including 3 cases of Denis type A and 5 cases of Denis type B. The decompression, intervertebral height were compared betweenpreoperation and postoperation by CT scanning. According to Frankel assessment for neurological status, 2 cases were at grade C, 5 at grade D and 1 at grade E before operation. Four cases had different degrees of disturbance of sphincter. Time from injury to operation was 8 hours to 11 days. The preoperative height of the anterior border of the L4 vertebral body was (13.8 ± 2.3) mm, the Cobb angel of fractured vertebral body was (13.2 ± 2.5)°, the vertebral canal sagittal diameter of L4 was (10.6 ± 3.5) mm. The bone graft volume was (7.5 ± 1.3) cm3 during operation. Results Operations were performed successfully. The mean operative time was (142 ± 25) minutes and the mean amount of blood loss was (436 ± 39) mL. The incisions obtained heal ing by first intention after operation. Two cases suffered donor site pain and recevied no treatment. The follow-up time of 8 cases was from 21 months to 52 months (mean 24.5 months). At one week after operation, the height of the anterior border of the L4 vertebral body was (32.5 ± 2.6) mm, the Cobb angel of fractured vertebral body was (6.8 ± 3.7)°, and the vertebral canal sagittal diameter of L4 was (19.8 ± 5.1) mm, showing significant difference when compared with those of preoperation (P lt; 0.01). At the final follow-up, the results showed that the pressure was reduced sufficiently, all autograft fused well, the neurological status improved at Frankel grade from C to D in 1 patient, from D to E in 3 patients, but the others had no improvement. In 4 patients who had disturbance of sphincter, 3 restored to normal and 1 was better off. Conclusion Cl inical outcomes of anterior surgery for fourth lumbar burst fractures with il iac fenestration are satisfactory. It can facil icate operation, reduce the pressure sufficiently, maintenance intervertebral height and recover the neurological function.
OBJECTIVE: To discuss the value of anterior operation in fracture-dislocation of connect of cervical vertebrae and thoracic vertebrae. METHODS: From 1997, 21 patients with fracture-dislocation of connect of cervical vertebra and thoracic vertebrae were operated on. The interval between injury and operation was within 24 hours in 4 cases, 2-7 days in 9 cases, 8-14 days in 3 cases and within 4 weeks in 5 cases. The locations were C6,7 in 7 cases, C7 in 9 cases and T1 in 5 cases. The nerves function of spinal of all the cases have different degrees of injury. Classification of Frankel were the following: 3 cases of grade A, 6 cases of grade B, 9 cases of grade C, and 3 cases of grade D. The operative procedure included the following: anterior operation of cervical vertebrae; incision of most fracture vertebral body to decompress; transplantation of ilium bone grafting fusion; and internal fixation of anterior cervical vertebrae with locking-steel. RESULTS: In 21 patients, 1 died of accompanying by pulmonary infection; 20 were followed up 8 months to 3 years with an average of 21 months. All transplanted ilium had fused. The nerve function of spinal cord had recovered in different degrees(2 cases of grade A, 1 case of grade C, 9 cases of grade D and 8 cases of grade E); the turn of vertebral column was normal. No internal fixation failed. CONCLUSION: Anterior operation is a better way to treat fracture-dislocation of connect of cervical vertebrae and thoracic vertebrae with easy operation, less complications, satisfactory reduction of fracture and good stability.
Objective To evaluate the effect of polymethylmethacrylate (PMMA) augmentation on cervical stabil ity after anterior cervical interbody fusion (ACIF) before and after fatigue. Methods Twelve porcine cervical spines (C3-7) were subjected to testing angular displacement parameters, including the range of motion (ROM), neutral zone (NZ), and elastic zone (EZ), in nondestructive flexion and extension, right/left lateral bending, and left/right rotation on Motion Analysis motion capture system and MTS-858 servo-hydraul ic testing machine. Intact cervical spines served as control group (group A); oneleveldiscectomy and fusion was performed with anterior plate fixation based on group A as group B; flexion and extension,left/right lateral bending (5 000 cycles) fatigue testing based on group B as group C; the augmentation screw channel was used based on group C as group D; and flexion and extension, left/right lateral bending fatigue testing were performed based on group D as group E. Results The ROM, NZ, and EZ in group A were significantly different from those in other groups (P lt; 0.05) at flexion/extension, left/right bending, and left/right rotation. The ROM, NZ, and EZ in group B were significantly smaller than those in group C (P lt; 0.05) in flexion/extension, left/right bending, and left/right rotation, but there was no significant difference when compared with group D (P gt; 0.05). The ROM and NZ in flexion/extension and the EZ in flexion in group B were significant smaller than those in group E (P lt; 0.05), but there was no significant difference in the other indexes (P gt; 0.05). The ROM, NZ, and EZ in group C in flexion and extension, left/right lateral bending, and left/right rotation were significantly higher than those in groups D and E (P lt; 0.05). The ROM and NZ in flexion and extension and left/right lateral bending, and the ROM in left/right rotation, and the EZ in flexion and extension, right bending, and left/right rotation in group D were significantly smaller than those in group E (P lt; 0.05), but there was no significant difference in the other indexes (P gt; 0.05). Conclusion PMMA augmentation can significantly increase the instant cervical stabil ity and provide a biomechanics basis in cervical anterior plate fixation.
Anterior cervical decompression and fusion (ACDF) treatment for cervical spondylosis has been more than half a century, and achieved good clinical results. However, with the continuous extension of follow-up time, the fusion segment-associated postoperative complications emerged gradually. Reserved cervical stability and activity, the concept of non-fusion was born. As a non-fusion technique, cervical artificial disc replacement (CADR) developed rapidly. With the continuous development of artificial prosthesis materials and design concepts, and specification and proficiency of surgical procedures, CADR has achieved better short- and mid-term clinical efficacy than ACDF. Compared with ACDF, the main advantages of CADR are that the postoperative recovery is quick, the activity and stability of cervical vertebra are maintained, the height of cervical intervertebral space is restored, and the stress of adjacent segments and the rate of surgical renovation are reduced. In clinical work, as an emerging technology, CADR requires spine surgeons to control the surgical indications, contraindications, and patients’ conditions strictly. This article reviews the research progress of CADR in order to provide new ideas for clinical treatment of cervical spondylosis.