目的 调查分析训练伤导致的腰椎峡部裂的发生原因,为降低腰椎峡部裂发生率提供理论依据.方法 对2016年1月—2021年3月解放军总医院第七医学中心收治的因训练导致腰椎峡部裂的234例患者进行问卷调查,记录患者身高、体质量、日常训练项目、训练强度、受伤时姿势、受伤时从事的训练项目、骨折部位等资料,并进行统计学分析,总结腰椎峡部裂的好发部位、危险因素等.结果 训练导致的腰椎峡部裂好发于L5(发生率为85.0％),发生率显著高于L3、L4,差异均有统计学意义(P<0.05).负重行进和负重蹲起造成腰椎峡部裂的发生率显著升高.受伤瞬间腰部姿势:后伸102例(43.6％),前屈49例(20.9％),旋转39例(16.7％),侧曲12例(5.1％),不确定32例(13.7％),训练中腰椎在后伸状态下更容易发生峡部裂.结论 腰椎在后伸状态下峡部剪切力增大,负重会造成峡部剪切力进一步增大而导致骨折,负重行进及负重蹲起是最易造成腰椎峡部裂的训练项目.

回顾脊柱外科过去数十年的发展及技术进步,脊柱创伤、退变及畸形矫正等手术越来越趋向于在重建脊柱稳定的基础上保留或重建运动功能.自1911年Hibbs和Albee首次提出脊柱融合术以来,采用神经减压联合脊柱融合固定手术已成为脊柱外科医师治疗脊柱疾患不可或缺的标准方法.随着对脊柱生理功能研究的不断深入和大量脊柱融合病例的长期随访,人们逐渐认识到脊柱融合手术牺牲脊柱运动功能也会有一些不利影响.保留或重建脊柱运动功能-非融合的手术治疗理念因此被提出,其理论和技术的发展正逐渐得到一些学者的关注认可和重视.对于颈椎、腰椎而言,已有人工椎间盘、人工髓核等多个非融合技术应用于临床,虽然还存在运动丧失、椎间隙骨化、移位松动等问题,但有些病例也取得了一定的效果.然而,目前切除颈椎椎体骨质后,还没有相应的保留椎间生理运动功能的临床方法.

目的:评估后路减压Dynesys动态内固定治疗腰椎退变性疾病的长期临床疗效.方法:收集2008年7月～2013年12月在我院采用后路减压Dynesys动态内固定治疗的腰椎退变性疾病患者的临床资料,其中163例患者获得78～144个月(95.4±15.6个月)随访,男97例,女66例;年龄31～60岁(43.5±11.7岁).单节段固定117例,双节段固定42例,三节段固定4例.比较患者术前、术后3个月和末次随访时的Oswestry功能障碍指数(Oswestry disability index,ODI)和腰腿痛视觉模拟量表(visual analogue scale,VAS)评分;在术前、术后3个月和末次随访时的腰椎正侧位和前屈后伸位X线片上测量手术节段和上位邻近节段活动度(range of motion,ROM)及椎间高度,评估影像学和症状学邻近节段退变(adjacent segment degeneration,ASD)发生情况以及内固定相关并发症.结果:术后3个月及末次随访时的ODI和VAS评分均较术前显著性改善(P＜0.05),末次随访时与术后3个月时比较差异亦有统计学意义(P＜0.05).术前、术后3个月和末次随访时手术节段的ROM分别为7.8°±2.1°、4.6°±1.4°和3.9°±1.5°,手术节段椎间高度分别为12.1±2.9mm、12.8±3.5mm和10.9±2.8mm,上位邻近节段ROM分别为8.3°±1.9°、9.2°±2.7°和10.2°±2.8°,术后3个月及末次随访时与术前比较、末次随访时和术后3个月比较均有统计学差异(P＜0.05);上位邻近节段椎间高度分别为12.7±3.1 mm、12.6±3.2mm和12.1±2.8mm,差异均无统计学意义(P＞0.05).末次随访时32例(19.6％)患者手术节段ROM小于4°(临床融合组),131例(80.4％)大于4°(非融合组),两组患者术前、术后3个月和末次随访时的VAS评分和ODI均无统计学意义(P＞0.05).末次随访时30例(18.4％)患者出现影像学ASD;2例(1.2％)患者出现症状学ASD,其中1例行翻修手术,另1例行保守治疗.1例患者术后2个月出现术区深部感染,抗感染治疗后痊愈;6例患者在术后5年随访时出现单侧螺钉松动,均未行手术治疗.2例患者出现椎弓根螺钉断裂,无不适症状未给予翻修手术.所有患者均无手术节段症状复发.结论:后路减压Dynesys动态内固定治疗腰椎退变性疾病可获得良好的长期临床疗效,并能保留手术节段部分活动度.

[目的]比较单开门椎板成形术中采用与不采用椎间孔切开的临床结果.[方法] 2015年1月～2019年6月,对68例混合型颈椎病患者行后路单开门椎板成形术,其中,早期的38例行单纯单开门成形术(非切开组),后期的30例行单开门成形联合椎间孔切开术(切开组).比较两组患者围手术期、随访与影像资料.[结果]两组患者均顺利手术,术中无血管、神经损伤.早期并发症方面,切开组30例中,仅1例(3.33％)出现术后脑脊液漏;非切开组38例中,7例(18.42％)出现肩背轴性疼痛症状,6例出现(15.79％)C5神经根病,两组间差异有统计学意义(P＜0.05).随时间推移,两组患者的颈痛和上肢痛VAS评分均显著下降(P＜0.05),而JOA评分均显著增加(P＜0.05).术后各时间点切开组的上肢痛VAS评分均显著优于非切开组(P＜0.05).影像方面,末次随访时两组患者椎管矢状径均较术前显著增加(P＜0.05);未次随访时切开组神经根管直径较术前显著增加(P＜0.05).[结论]椎间孔切开可有效减少单开门椎板成形术后C5神经根麻痹,改善根性症状.

Objective:To investigate the complications and prevention strategies of Dynesys stabilization in the treatment of lumbar degenerative disease.Methods:Two hundred and forty-three patients underwent lumbar spine stabilization with Dynesys owing to lumbar degenerative disease were retrospectively analyzed from July 2008 to December 2016. The mean follow-up time was 5.6 years (48-148 months). There were 152 patients with lumbar disc herniation and 91 patients with lumbar spinal stenosis. 167 cases underwent single-level operation, 71 cases underwent two-level operation, and 5 cases underwent three-level operation. All patients had low back pain, radiating pain in the lower extremities, and/or intermittent claudication. Clinical outcomes were evaluated using Oswestry disability index (ODI) and visual analogue scale (VAS). The occurrence of perioperative complications (with in 3 months) and postoperative complications (after 3 months) after the operation were recorded and analyzed. Radiographic adjacent segment degeneration (ASD) was evaluate dusing University of California at Los Angeles Grading Scale (UCLA).Results:All patients underwent surgery successfully. ODI score of patients improved from 55.1%±16.8% preoperatively to 15.6%±5.8% at the final follow-up, the difference was statistically significant ( t=34.6, P<0.01). VAS score decreased from 6.4±2.3 preoperatively to 1.1±0.4 at the final follow-up, the difference was also statistically significant ( t=35.4, P<0.01). There were 25 cases (10.29%) with complications, and 3 cases (1.23%) underwent secondary operation. Perioperative complications occurred in 13 patients (5.35%), including 5 cases of cerebros pinal fluid leakage, 5 cases of poor wound healing (2.06%), and 3 cases of deep wound infection (1.23%). Twelve patients (4.94%) had long-term postoperative complications, including 6 patients (2.47%) of unilateral screw loosening at the 5-year follow-up, 3 patients (1.23%) of screw fracture, and 3 patients (1.23%) of symptomatic ASD, among whom 2 patients underwent secondary operation, and 1 patient underwent conservative treatment. There was no recurrence at the operated segments in all patients. At the final follow-up, 41 patients (16.87%) had radiographic ASD. The UCLA score atthe final follow-up was significantly different from that preoperatively ( Z=2.60, P=0.01). Conclusion:Dynesys dynamic system combined with decompression in the treatment of degenerative lumbar spine diseases can achieve good long-term clinical outcome, with low incidence of complications and ASD.

目的 评估短节段减压固定术治疗老年退行性脊柱侧凸合并腰椎管狭窄的临床疗效.方法 回顾性分析2014年1月至2017年12月,我院采用后路短节段(<3节段)固定融合手术治疗的59例老年(>65岁)退行性脊柱侧凸合并腰椎管狭窄患者,根据Berjano分型分为Ⅰ型组(40例)和Ⅱ型组(19例).患者年龄65～88岁,平均75.4岁,随访时间18～36个月,平均25.1个月.记录患者手术时间、术中失血量、术后并发症的发生情况,评估两组患者术前、术后随访时腰部和下肢的疼痛视觉模拟评分(visual analogue scale,VAS)和Oswestry功能障碍指数(oswestry disability index,ODI),比较术前和术后随访时患者侧凸Cobb's角、脊柱矢状位平衡(sagittal vertical axis,SVA)和腰椎前凸角(lumbar lordosis,LL)的变化情况.结果 两组患者年龄、性别、随访时间、术前神经根阻滞患者数、手术时间、术中失血量差异均无统计学意义(P>0.05),组间手术节段差异有统计学意义(χ2=5.09,P=0.02).末次随访时两组患者腰部和下肢VAS以及ODI均较术前明显改善,差异有统计学意义(P<0.05),组间差异无统计学意义(P>0.05).BerjanoⅠ型和Ⅱ型患者侧凸Cobb's角分别由术前的(17.2±3.5)° 和(19.1±4.2)° 降至术后3个月时的(10.3±2.7)° 和(10.5±3.1)°,而末次随访时分别增加至(14.3±2.9)° 和(15.2±3.9)°,与术前相比差异均有统计学意义(FⅠ=51.5,P<0.01;FⅡ=25.5,P<0.01),而SVA和LL术前、术后无显著变化(P>0.05).两组共有20例(33.9％)出现并发症,其中围术期并发症15例,远期并发症5例,两组间差异无统计学意义(P>0.05).结论 短节段减压固定手术治疗BerjanoⅠ型和Ⅱ型老年退行性脊柱侧凸合并腰椎管狭窄,具有满意的短期临床疗效,能够改善侧凸畸形.

[目的]比较单纯自体与自体骨混合骨形态蛋白(BMP)原位植入修复青年腰椎峡部裂的临床效果.[方法]回顾分析2015年1月～2019年6月,本科手术治疗的80例腰椎峡部裂患者.原位清创后,40例于峡部单纯植入自体骨,40例植入自体骨混合BMP,均给予节段间椎弓根钉固定.比较两组患者围手术期、随访和影像资料.[结果]两组患者均顺利完成手术,均无严重并发症.随访18个月以上,随时间推移,两组患者VAS和ODI评分均显著减少(P＜0.05);相应时间点,两组间VAS和ODI评分的差异均无统计学意义(P＞0.05).影像方面,随时间推移,两组患者峡部愈合率均显著增加(P＜0.05).术后3、6和12个月时,BMP组的峡部骨性愈合率显著高于自体骨组(P＜0.05);术后18个月,BMP组的峡部骨性愈合率仍高于自体骨组,但差异已无统计学意义(P＞0.05).[结论]青少年腰椎峡部裂采用峡部原位自体髂骨植骨合并BMP可以有效促进峡部骨愈合.

背景:全身麻醉下单节段腰椎间盘切除术中需留置导尿管.导尿管置入可能给患者带来局部甚至全身的不良反应或并发症.目的:探讨加速康复外科(ERAS)模式下单节段腰椎间盘切除术患者围手术期不置导尿管的安全性和可行性.方法:前瞻性选择2018年11月至2019年6月采用椎间盘切除术治疗的单节段腰椎间盘突出症患者110例,随机均分为研究组(不置导尿管)和对照组(置入导尿管)两组,每组各55例.记录并比较两组患者麻醉时间、术中出血量、术中输液量、麻醉苏醒期躁动程度,术后镜下血尿、膀胱刺激征、尿路感染、尿潴留发生率等.记录并比较两组患者术后下地时间、术后住院时间,术后3d及末次随访时对治疗的满意度.结果:两组患者麻醉时间、术中出血量、术中输液量差异均无统计学意义.与对照组患者比较,研究组患者术后下地早,住院时间短,且差异均有统计学意义(P均<0.05).研究组患者术后镜下血尿、膀胱刺激征发生率均低于对照组患者,且差异均有统计学意义(P均<0.001);而两组患者术后尿路感染、尿潴留发生率差异均无统计学意义.所有患者随访5～12个月,平均随访(6.1±2.4)个月.研究组患者术后3 d对治疗的满意度高于对照组患者,且差异有统计学意义(P<0.05);而末次随访时两组患者对治疗的满意度差异无统计学意义.结论:ERAS模式下行单节段腰椎间盘切除术患者围手术期不置导尿管能够降低术后尿路感染发生率,避免尿道损伤;促进早期下地活动,缩短住院时间,提高患者术后满意度;是腰椎间盘突出症患者手术加速康复的一个安全可行的措施.

腰椎后路短节段手术是脊柱外科最常见,同时也是最基本的手术方式之一.通过引入加速康复外科(ERAS)理念,优化围手术期处理措施,可进一步提高脊柱外科患者的诊疗效果.为了规范ERAS临床路径在脊柱外科不同术式中的应用,在《脊柱外科加速康复——围术期管理策略专家共识》基础上,结合腰椎后路短节段手术的自身特点,经过全国专家组反复讨论,达成腰椎后路短节段手术ERAS实施流程专家共识,供脊柱外科医师在临床工作中参考.

急性成人胸腰段脊柱脊髓损伤后路手术是脊柱损伤常见的手术之一.将加速康复外科(ERAS)理念应用于胸腰段脊柱脊髓损伤后路手术能优化围手术期的临床疗效,减少不良反应和手术并发症.为了规范ERAS临床路径在急性成人胸腰段脊柱脊髓损伤后路手术中的应用,在《成人急性胸腰段脊柱脊髓损伤循证临床诊疗指南》的基础上,结合胸腰段脊柱脊髓损伤后路手术的特点,经过全国专家组反复讨论,达成了相关实施流程的专家共识,供脊柱外科医师在临床工作中参考.

后路矫形手术是治疗青少年特发性脊柱侧凸最常用的手术方式之一.如何促进患者加速康复,一直是脊柱外科医师追求的目标.加速康复外科(ERAS)理念下的系列围手术期优化措施有助于提高脊柱外科患者的诊疗效果.为规范ERAS临床路径在脊柱外科不同术式中的应用,在《脊柱外科加速康复——围术期管理策略专家共识》的基础上,结合青少年特发性脊柱侧凸后路矫形手术的特点,经过全国专家组反复讨论,达成其ERAS实施流程专家共识,供脊柱外科医师在临床工作中参考.

随着微创技术的发展,脊柱内镜手术逐步成为治疗腰椎间盘突出症和腰椎管狭窄症的常用微创术式.加速康复外科(ERAS)通过优化围手术期处理措施,减少患者术中和术后的应激反应,促进患者功能恢复.为了规范ERAS实施流程在腰椎内镜手术中的应用,我们在前期编制的《脊柱外科加速康复——围术期管理策略专家共识》的基础上,结合内镜手术的特点,经过全国专家组反复讨论,达成腰椎内镜手术ERAS实施流程专家共识,供脊柱外科医师在临床工作中参考应用.

目的 探讨个性化手术对多节段脊髓型颈椎病(CSM)的治疗效果.方法 对122例CSM患者依据压迫部位、退变范围、颈椎矢状位序列、手术史及合并症等综合因素制订个性化手术:颈前路椎间盘切除椎间植骨融合内固定术(ACDF)组32例,ACDF联合颈前路椎体次全切除减压融合术(ACCF)组48例,后路单开门椎管成形微型钛板内固定术(ODLF)组42例.通过疼痛VAS评分、JOA评分及颈椎曲度指数(CCI)进行疗效分析.结果 患者均获得随访,时间10～19个月.ODLF组手术时间较短,失血量较多,与ACDF组和ACDF+ACCF组比较差异有统计学意义(P<0.05);ACDF组和ACDF+ACCF组的手术时间和失血量比较差异无统计学意义(P>0.05).术后VAS、JOA评分:3组均较术前有明显改善(P<0.05),3组间比较差异无统计学意义(P>0.05).术后CCI:ACDF组、ACDF+ACCF组与术前比较差异均有统计学意义(P<0.05),ODLF组与术前比较差异无统计学意义(P>0.05),3组间比较差异无统计学意义(P>0.05).ODLF组并发症发生率高于ACDF组和ACDF+ACCF组,差异有统计学意义(P<0.05).结论 个性化手术治疗多节段CSM能取得较好疗效,手术方式对CSM疗效无影响.前路手术时间略长,失血量少,ODLF并发症发生率较高.

Aim: To explore whether transplantation of bone marrow mesenchymal stem cells (BMSCs) would reduce the immune response and protect vital organs in a rat model of femur shaft fracture combined with craniocerebral injury. Methods: The rats were divided into an experimental group (multiple traumas and receiving BMSCs injection, n = 25), a positive control group (only received the combination injuries, n = 25) and a negative group (n = 5). Results: Compared with the positive control group, plasma IL-6 and IL-8 were significantly lower at the early stage, and IL-10 was higher at the late period in the experimental group (p < 0.05). TNF-alpha ex-vivo synthesis descended quickly after trauma. Conclusion: BMSCs reduced the inflammatory response and were effective in immunomodulations during severe trauma.

Enhanced recovery after surgery (ERAS) is a series of evidence-based multimodal approaches during all stages (preoperative,intraoperative,and postoperative) of care.It has been developed to reduce the stress response and complications,and accelerate recovery after surgery.However,spine surgeons are now paying more attention to surgical procedures rather than perioperative management.There are two reasons for the problem.First,there is insufficient knowledge on the effect of surgical stress on normal physiological status.Second,surgeons are not very clear with the comprehensive measures to dispose of the stress responses.So,this article mainly describes the core components of spinal ERAS,involving fluid management,pain management and bleeding control.

Enhanced recovery after surgery (ERAS) is a series of perioperative optimization measures based on evidencebased medicine,in order to reduce perioperative physiological and psychological trauma stress and complications,and achieve accelerated rehabilitation.However,there is not a complete set of ERAS system for spinal surgery in China,which can help patients recover quickly.A thorough literature search was undertaken to examine the use of ERAS pathways in spinal surgery,and the results presented in this paper.This expert consensus mainly contains patients' education,pre-operative evaluation and management,antibiotics usage and skin preparation,analgesia,surgical techniques,steroids,perioperative blood and infusion management,venous thromboembolism (VTE) prophylaxis,pain management,post-operative management of the digestive system,drainage tube and ureter management,functional exercise and postoperative follow-up management.