脊柱畸形翻修术

脊柱畸形翻修术 侯树勋 解放军总医院 304 临床部（原 304 医院）骨科 100037   （一）脊柱畸形翻修术所面临床的困难 1 、解剖标志不清，内固定难度增大，易损伤神经、血管。 2 、脊柱畸形僵硬，部分已融合导致矫正困难。 3 、受内固定和植骨融合影响使畸形复杂化。 Linville 比较了初次手术（ N=18 ）与翻修手术（ N=26 ）后的早期并发症，结果显示：二 者的并发症发生率无显著差异 ( 分别为 22  2% 和 19  3%) 。 (Spine  1999;24(4):355 ～ 63) Voos 采用椎体截骨 方法 快递客服问题件处理详细方法山木方法pdf计算方法pdf华与华方法下载八字理论方法下载 对 27 例成人僵硬性脊柱畸形进行了翻修手术 , 术后矫正率为 40%, 手术并发症 29  6%( 脊柱假关节、内固定失败和一过性神经功能障碍 ) 。（ Spine  2001;26(5 ):526 ～ 33 ） （二）临床资料 1 、一般情况 :31 例患者 , 男 19 例 , 女 12 例 , 翻修手术，平均年龄 14  7 岁（ 4 ～ 35 岁）。原 发病诊断：先天性 17 例（ 54  8% ） , 特发性 7 例 (22  6%), 神经纤维瘤病 4 例 , 结核后凸 2 例，外 伤后凸 1 例。手术史 :1 次 -23 例 ,2 次 -6 例 ,3 次 -1 例 ,5 次 -1 例 2 、就诊原因 腰背部酸痛 20 例 (65  2%)(3 例需配带支具 ) ，内植物断裂、松脱或外露 4 例，畸形加重 17 例 （三）手术方法： 椎体截骨，节段椎弓根螺钉固定 18 例；分期手术 9 例，即采用前路松解 , 颅盆环固定；后 路节段椎弓根螺钉固定，在原有内固定基础上扩大固定范围 4 例。 （四）效果及手术并发症 表 关于同志近三年现实表现材料材料类招标技术评分表图表与交易pdf视力表打印pdf用图表说话 pdf 1 脊柱侧凸矫正情况 表 2 脊柱后凸矫正情况 22 例患者，术后平均随访 19  5 个月 (9 个月～ 46 个月 ) ，其主要并发症为暂时性神经功能 障碍 4 例，术后 1 ～ 3 周恢复切口皮缘部分坏死 1 例，术后 3 周内愈合；内植物断裂 1 例。 X 线片 ： 21 例脊柱植骨融合良好，矫正率，无丢失，无腰背部疼痛等不适症状。 （五）以往手术失败原因 1 、内植物失败：脱钩，断棒。 2 、植骨融合不良：假关节形成。 3 、单纯后路植骨或单纯半椎体切除治疗先天性半椎体畸开支导致畸形加重。 （六）手术方法选择 1 、椎体截骨：畸形矫正，初次手术导致脊柱结构广泛僵硬或骨性融合，单纯器械矫正 很难象初次手术那样将矫正度均匀分散在各脊柱节段 , 只能采用截骨矫正畸形加重多局限于 弧顶或假关节形成部位 , 造成角状畸形，截骨可直接矫正畸形截骨同时切除假关节，使脊柱 获得良好融合。 2 、内固定方式：椎弓根结构正常者——节段椎弓根螺钉固定。椎弓根发育差或因植骨 融合使其显示不清者—— Luque 系统 + 椎弓根螺钉固定。 3 、如何避免再手术 严格遵循脊柱畸形的矫正原则 ; 节段椎弓根螺钉固定 , 分散矫正应力 , 提高固定强度；椎 体截骨矫正，可最大限度改善脊柱的力学结构，降低内植物的应力负荷，减少内植物失败的 发生率。充分植骨融合，确保脊柱稳定。     One Stage Surgery (anterior and posterior) for Craniovertebral Junction Anomalies. Lessons learnt from 632 cases   Shashank Sharad kale Associate Professor Neurosurgery All India Institute of Medical Sciences New Delhi 110029 India Craniovertebral junction anomalies are a major part of the referred complex spin e cases at AIIMS - a leading tertiary referral center in South Asia . Their manag ement in a developing country is discussed with special reference to single sitt ing surgery. The data of 632 patients of CV Junction anomalies managed between 1992 and 2003 was reviewed and analyzed statistically. Males were 504/632. Developmental anoma lies were commonest 472/632, followed by traumatic, inflammatory and neoplastic. Patients with only syringomyelia &/or Chiari malformation, without bony anomali es were excluded from this study. Pyramidal tract signs and symptoms were the co mmonest. Irreducible AAD with/without basilar invagination was the most frequent ly occurring bony anomaly - 540/632. 499 patients underwent transoral odontoid e xcision, 489 underwent posterior fixations O-C 2 C 3 contoured loop fixations (con toured loop made from a Steinmann pin at surgery), titanium plate and screw or c able fixation. Other operations included Magerl's, Brooks', Gallie's and anterio r plating of C 2 C 3. 220 patients underwent both procedures in a single sitting. Results: Post-operatively 416 patients improved, 136 were unchanged and 51 worsened. 35 p atients had wound infections and 15- CSF leaks. Only three patients had failure of construct (2 Gallie's wire breakage and 1 loop failure). 29 patients died - 8 cardiac causes, 8 chest infections, 2 meningitis, 6 septicemias, 1 secondary he morrhage from the oral wound and 2 posterior circulation infarcts following fixa tion. 2 year follow-up data is available for 252 patients. Patients operated in single stage (vs. 2 stage) had a shorter stay, lower infection rate and lower mo rtality. Conclusions: Developmental CV Junction anomalies are the commonest. Single stage surgery mean s shorter stay, lower infection and lesser mortality. Contoured loop fixation us ing Steinmann pin and Stainless Steel wire gives a stable and economical posteri or fixation.