胸腰椎爆裂性骨折的治疗新进展

胸腰椎爆裂骨折是常见的脊柱损伤性疾病之一,其发病率、致残率较高是由胸腰段脊柱的解剖学特点所决定。国内外有多种脊柱骨折的分类,临床中使用较多的有AO分类及Denis分类,脊柱载荷分享分类现多用于评价患者是否适合于后路手术,而不能应用于评估手术指征。目前国内外胸腰椎爆裂性骨折的治疗尚无统一定式,大多数学者倾向于积极的手术治疗,其中尤以后路手术治疗为主,后路手术多采取短节段椎弓根定内固定加植骨治疗。近些年又出现了经后路270°或360°椎管减压,重建脊柱的三柱稳定性。前路及前后路联合手术都有其各自的适应症。保守治疗多采取卧床休息、体位复位、外固定支具法及功能康复等。本文总结了近年来关于胸腰椎爆裂骨折的最新治疗进展。     

综合疗法治疗胸腰椎骨折脱位205例

脊柱损伤中,以胸腰椎压缩性骨折脱位最为常见,是临床常见的一种较严重的损伤,如治疗不当,容易遗留或（和）并发多种后遗症。我们１９８８～１９９７年采用垫枕练功、中药内服、外敷等手法,药物局部熨烫以及手术治疗等中西医结合综合疗法治疗胸腰椎骨折、脱位２０５例...     

胸腰椎结核患者手术前后的护理

脊柱结核占全身关节结核的首位,而腰椎结核最常见,其次为胸椎、颈椎.我科2004年5月至2007年8月对36例胸腰椎结核患者进行了病灶清除、椎体减压及植骨融合内固定术.经给予精心护理,疗效满意.现总结如下.     

AF手术治疗胸腰椎骨折56例观察及护理

AF脊柱椎弓根固定器治疗胸腰椎骨折,是近年来骨科开展的一项新技术。其优点为治疗胸腰椎骨折具有短节段三维固定,固定强度可独立完成。固定既精确又稳定,可提高复位效果,重建生理弯曲,防止脊柱慢性失稳导致的脊髓受压,利于神经功能的恢复,减少长期卧床所致的各种并发     

脊柱三扳法联合塞来昔布对强直性脊柱炎患者胸腰椎活动和BMP/Smad信号通路的影响

摘要 目的：探讨脊柱三扳法联合塞来昔布对强直性脊柱炎（AS）患者胸腰椎活动和骨形态发生蛋白（BMP）/细胞信号转导分子(Smad)信号通路的影响。方法：选取2016年7月~2018年12月期间我院收治的AS患者150例,根据随机数字表法分为A组（n=50,给予脊柱三扳法治疗）、B组（n=50,给予塞来昔布治疗）和C组（n=50,给予脊柱三扳法联合塞来昔布治疗）,比较三组患者疗效、胸腰椎活动指标、BMP/Smad信号通路相关指标及不良反应发生率。结果：C组治疗6个月后的临床总有效率为94.00%（47/50）高于A组的66.00%（33/50）、B组的72.00%（36/50）（P<0.05）;C组治疗6个月后胸廓活动度、腰椎活动度均高于A组、B组（P<0.05）,指-地距离短于A组、B组（P<0.05）。C组治疗6个月后BMP-Ⅰ受体、BMP-Ⅱ受体、Smad1、Smad4表达水平均低于A组、B组（P<0.05）。三组不良反应发生率比较差异均无统计学意义（P>0.05）。结论：脊柱三扳法联合塞来昔布治疗AS患者,疗效显著,可有效改善胸腰椎活动,且不增加不良反应发生率,其具体作用机制可能是通过调节BMP/Smad信号通路实现。     

椎弓根螺钉用于植骨融合术治疗胸腰椎结核的临床研究

目的:探讨椎弓根内固定联合植骨融合术治疗胸腰椎结核的临床效果。方法:回顾性分析2013年5月至2014年5月在我院接受治疗的50例胸腰椎结核患者的临床资料,结合影像资料评价患者手术前后的红细胞沉降率、后凸畸形矫正情况、Frankel分级及术后并发症的发生情况等。结果:所有患者术后病理均证实为脊柱结核,术中27例植入大块自体髂骨,23例植入自体肋骨捆绑植骨。24例采用椎体侧前方钉棒内固定,26例采用后路椎弓根螺钉系统内固定。术中未出现脊髓、神经、血管损伤及血气胸等并发症。患者术后红细胞沉降率获得改善,差异具有统计学意义(P0.05)。术后Cobb角明显获得矫正,差异具有统计学意义(P0.05)。患者术后脊柱损伤程度明显改善,差异具有统计学意义(P0.05)。结论:椎弓根内固定联合椎体间植骨融合术治疗胸腰椎结核具有良好的临床效果,不仅可以改善红细胞沉降率,而且可以矫正患者脊柱后凸畸形,值得临床推广应用。     

鲑鱼降钙素对胸腰椎脊柱骨折术后I型胶原氨基端延长肽、I型胶原C端肽β降解产物的作用

目的:探讨鲑鱼降钙素对胸腰椎脊柱骨折术后Ⅰ型胶原氨基端延长肽、Ⅰ型胶原C端肽β降解产物的作用。方法:选择2014年3月至2016年5月我院收治的胸腰椎脊柱骨折患者80例,将其随机分为观察组和对照组,每组40例。两组均采用微创经皮椎弓根螺钉内固定术,对照组术后给予常规治疗,观察组术后给予鲑鱼降钙素治疗。比较两组患者治疗前后的骨密度、Ⅰ型胶原氨基端延长肽、Ⅰ型胶原C端肽β降解产物、视觉模拟疼痛评分(VAS)评分、Oswestry功能障碍指数评分(ODI)评分、Harris评分的变化、骨折愈合时间及不良反应的发生情况。结果:治疗后,观察组患者骨密度及Harris评分明显高于对照组(P0.05),Ⅰ型胶原氨基端延长肽、Ⅰ型胶原C端肽β降解产物、VAS评分和ODI评分均低于对照组(P0.05);观察组患者骨折愈合时间明显短于对照组(P0.05),不良反应发生率(7.50%)较对照组(10.00%)比较无显著性差异(P0.05)。结论:鲑鱼降钙素用于胸腰椎脊柱骨折术后可有效改善患者骨密度,促进骨折愈合且不会增加不良反应。     

椎弓根钉置入内固定治疗胸腰椎骨折的应用进展

目的:分析椎弓根钉置入内固定治疗胸腰椎骨折的应用。方法:采用计算机检索CNKI数据库,在检索词处输入椎弓根钉、内固定、胸腰椎骨折、进展等检索词。选择与椎弓根钉置入生物力学分析、解剖学基础以及临床应用相关的文献。共选入文献5篇。结果:椎弓根钉置入内固定可以帮助患者神经管得到全面有效的改善,其作用机理是能够有效恢复生理弧度以及椎体高度,恢复移位骨块结构同时进行有效固定,从而提供更好的生物力学稳定性。随着医学技术的不断发展,胸腰椎骨折的治疗方式越来越多,但椎弓根钉置入内固定依然是治疗的基础。结论:在对胸腰椎骨折患者进行治疗的过程中,选择采用椎弓根钉置入内固定治疗,能够起到良好的治疗效果,矫正畸形同时维持脊柱三维位置,临床中值得推广使用。     

“S”型生理弯曲的形成及作用

人的脊柱从背面看是一条直线,而从侧面看则有四道弯曲,即呈“S”型。这四道弯曲分别叫做颈前曲、胸后曲、腰前曲和骶后曲。脊柱的这种“S”形是正常的生理弯曲,对维持人的正常生理功能和运动均有重要意义。那么脊柱的这种“S”形生理弯曲是怎样形成的?有什么作用? 人的脊柱是由24块椎骨、1块骶骨和1块尾骨组成的。椎骨又分为7块颈椎、12块胸椎和5块腰椎。在椎骨与椎骨之间均有椎间盘。在脊柱的四周又有很多韧带和肌肉将其紧     

脊柱后路减压R—F器内固定术治疗胸腰椎新鲜骨折并截瘫

我院对１２例胸腰椎新鲜骨折并截瘫采用后路减压,Ｒ－Ｆ器复位内固定治疗经过１年至１年半随访,骨折复位满意,脊柱稳定,除完全截瘫外,神经功能按Ｆｒａｎｋｅｌ分类法评定,均较术前进步１～２级,无１例症状加重。现报道如下。１临床资料１．１一般资料本组１２例,...     

Prediction of biomechanical parameters in the lumbar spine during static sagittal plane lifting.

A combined approach involving optimization and the finite element technique was used to predict biomechanical parameters in the lumbar spine during static lifting in the sagittal plane. Forces in muscle fascicles of the lumbar region were first predicted using an optimization-based force model including the entire lumbar spine. These muscle forces as well as the distributed upper body weight and the lifted load were then applied to a three-dimensional finite element model of the thoracolumbar spine and rib cage to predict deformation, the intradiskal pressure, strains, stresses, and load transfer paths in the spine. The predicted intradiskal pressures in the L3-4 disk at the most deviated from the in vivo measurements by 8.2 percent for the four lifting cases analyzed. The lumbosacral joint flexed, while the other lumbar joints extended for all of the four lifting cases studied (rotation of a joint is the relative rotation between its two vertebral bodies). High stresses were predicted in the posterolateral regions of the endplates and at the junctions of the pedicles and vertebral bodies. High interlaminar shear stresses were found in the posterolateral regions of the lumbar disks. While the facet joints of the upper two lumbar segments did not transmit any load, the facet joints of the lower two lumbar segments experienced significant loads. The ligaments of all lumbar motion segments except the lumbosacral junction provided only marginal moments. The limitations of the current model and possible improvements are discussed.     

Validation of single-segment and three-segment spinal models used to represent lumbar flexion

Changes in spinal posture between the erect and flexed positions were calculated using angular measurements from lateral photographs and radiographs of ten adult male subjects. For photographic measurements, the thoracolumbar vertebral column was modelled as either a single segment or as three segments. In the three-segment model, there was a non-significant correlation between the decrease in lumbar concavity and intervertebral motion. In addition, there was a non-significant negative correlation between the increase in thoracic convexity and lumbar motion determined radiographically. In the single-segment model, the decrease in angulation between the thoracolumbar spine and pelvis was a good representation of lumbar spine flexion as determined by the mean lumbar intervertebral angular change. Therefore, modelling the thoracolumbar vertebral column as a single segment allowed better estimation of lumbar intervertebral angular change during flexion than a three-segment model. The results indicate that large range dynamic motion of the lumbar vertebral column can be represented using photographic analysis of the positions of three easily identified anatomical landmarks: the anterior superior iliac spine, posterior superior iliac spine and the spinous process of the first thoracic vertebra.     

Mechanical response of a simple finite element model of the intervertebral disc under complex loading

A simple axisymmetric finite element model of a human spine segment containing two adjacent vertebrae and the intervening intervertebral disc was constructed. The bodies and disc were modeled by three substructures; one to represent each of the vertebral bodies, the annulus fibrosus, and the nucleus pulposus. A semi-analytic technique was used to maintain the computational economies of a two-dimensional analysis when non- axisymmetric loads were imposed on the model. The response of the model to compression, shear, torsion and bending loads applied to the superior vertebral body was examined to determine the effects of disc geometry and material properties on response. Comparisons of model responses with experimentally measured responses were made to estimate material property values for which model behaviors are in agreement with measured behaviors.     

Biomechanical analysis of the anterior cervical fusion

This paper presents a biomechanical analysis of the cervical C5–C6 functional spine unit before and after the anterior cervical discectomy and fusion. The aim of this work is to study the influence of the medical procedure and its instrumentation on range of motion and stress distribution. First, a three-dimensional finite element model of the lower cervical spine is obtained from computed tomography images using a pipeline of image processing, geometric modelling and mesh generation software. Then, a finite element study of parameters' influence on motion and a stress analysis at physiological and different post-operative scenarios were made for the basic movements of the cervical spine. It was confirmed that the results were very sensitive to intervertebral disc properties. The insertion of an anterior cervical plate influenced the stress distribution at the vertebral level as well as in the bone graft. Additionally, stress values in the graft decreased when it is used together with a cage.     

Biomechanical analysis of the anterior cervical fusion

This paper presents a biomechanical analysis of the cervical C5-C6 functional spine unit before and after the anterior cervical discectomy and fusion. The aim of this work is to study the influence of the medical procedure and its instrumentation on range of motion and stress distribution. First, a three-dimensional finite element model of the lower cervical spine is obtained from computed tomography images using a pipeline of image processing, geometric modelling and mesh generation software. Then, a finite element study of parameters' influence on motion and a stress analysis at physiological and different post-operative scenarios were made for the basic movements of the cervical spine. It was confirmed that the results were very sensitive to intervertebral disc properties. The insertion of an anterior cervical plate influenced the stress distribution at the vertebral level as well as in the bone graft. Additionally, stress values in the graft decreased when it is used together with a cage.     

Novel model to analyze the effect of a large compressive follower pre-load on range of motions in a lumbar spine

A 3-D finite element model (FEM) of the lumbar spine (L1-S1) was used to determine the effect of a large compressive follower pre-load on range of motions (ROM) in all three planes. The follower load modeled in the FEM produced minimal vertebral rotations in all the three planes. The model was validated by comparing the disc compression at all levels in the lumbar spine with the corresponding results obtained by compressing 10 cadevaric lumbar spines (L1-S1) using the follower load technique described by Patwardhan et al. [1999. A follower load increases the load-carrying capacity of the lumbar spine in compression. Spine 24(10), 1003-1009]. Further validation of the model was performed by comparing the lateral bending and torsion response without pre-load and the flexion-extension response without pre-load and with an 800 N follower pre-load with those obtained using cadaver lumbar spines. Following validation, the FEM was subjected to bending moments in all three planes with and without compressive follower pre-loads of up to 1200 N. Disc compression values and the flexion-extension range of motion under 800 N follower pre-load predicted by the FEM compared well with in vitro results. The current model showed that compressive follower pre-load decreased total as well as segmental ROM in flexion-extension by up to 18%, lateral bending by up to 42%, and torsion by up to 26%.     

A patient-specific computer tomography-based finite element methodology to calculate the six dimensional stiffness matrix of human vertebral bodies

In most finite element (FE) studies of vertebral bodies, axial compression is the loading mode of choice to investigate structural properties, but this might not adequately reflect the various loads to which the spine is subjected during daily activities or the increased fracture risk associated with shearing or bending loads. This work aims at proposing a patient-specific computer tomography (CT)-based methodology, using the currently most advanced, clinically applicable finite element approach to perform a structural investigation of the vertebral body by calculation of its full six dimensional (6D) stiffness matrix. FE models were created from voxel images after smoothing of the peripheral voxels and extrusion of a cortical shell, with material laws describing heterogeneous, anisotropic elasticity for trabecular bone, isotropic elasticity for the cortex based on experimental data. Validated against experimental axial stiffness, these models were loaded in the six canonical modes and their 6D stiffness matrix calculated. Results show that, on average, the major vertebral rigidities correlated well or excellently with the axial rigidity but that weaker correlations were observed for the minor coupling rigidities and for the image-based density measurements. This suggests that axial rigidity is representative of the overall stiffness of the vertebral body and that finite element analysis brings more insight in vertebral fragility than densitometric approaches. Finally, this extended patient-specific FE methodology provides a more complete quantification of structural properties for clinical studies at the spine.     

A new material mapping procedure for quantitative computed tomography-based, continuum finite element analyses of the vertebra

Inaccuracies in the estimation of material properties and errors in the assignment of these properties into finite element models limit the reliability, accuracy, and precision of quantitative computed tomography (QCT)-based finite element analyses of the vertebra. In this work, a new mesh-independent, material mapping procedure was developed to improve the quality of predictions of vertebral mechanical behavior from QCT-based finite element models. In this procedure, an intermediate step, called the material block model, was introduced to determine the distribution of material properties based on bone mineral density, and these properties were then mapped onto the finite element mesh. A sensitivity study was first conducted on a calibration phantom to understand the influence of the size of the material blocks on the computed bone mineral density. It was observed that varying the material block size produced only marginal changes in the predictions of mineral density. Finite element (FE) analyses were then conducted on a square column-shaped region of the vertebra and also on the entire vertebra in order to study the effect of material block size on the FE-derived outcomes. The predicted values of stiffness for the column and the vertebra decreased with decreasing block size. When these results were compared to those of a mesh convergence analysis, it was found that the influence of element size on vertebral stiffness was less than that of the material block size. This mapping procedure allows the material properties in a finite element study to be determined based on the block size required for an accurate representation of the material field, while the size of the finite elements can be selected independently and based on the required numerical accuracy of the finite element solution. The mesh-independent, material mapping procedure developed in this study could be particularly helpful in improving the accuracy of finite element analyses of vertebroplasty and spine metastases, as these analyses typically require mesh refinement at the interfaces between distinct materials. Moreover, the mapping procedure is not specific to the vertebra and could thus be applied to many other anatomic sites.     

A finite element model technique to determine the mechanical response of a lumbar spine segment under complex loads

This study presents a CT-based finite element model of the lumbar spine taking into account all function-related boundary conditions, such as anisotropy of mechanical properties, ligaments, contact elements, mesh size, etc. Through advanced mesh generation and employment of compound elements, the developed model is capable of assessing the mechanical response of the examined spine segment for complex loading conditions, thus providing valuable insight on stress development within the model and allowing the prediction of critical loading scenarios. The model was validated through a comparison of the calculated force-induced inclination/deformation and a correlation of these data to experimental values. The mechanical response of the examined functional spine segment was evaluated, and the effect of the loading scenario determined for both vertebral bodies as well as the connecting intervertebral disc.     

Effects of the rib cage on thoracic spine flexibility.

Besides protecting the internal organs of the thorax, the rib cage is the site of numerous muscle attachments. It also decreases the overall flexibility of the thoracic spine. This study developed finite element (FE) models of the thoracic spine with and without the rib cage, and the effects of the rib cage on thoracic spine flexibility were determined. The numerical models were validated by comparing the maximum rotation of the models for several loading cases with experimental data in the literature. After adapting the material properties for the discs and ligaments, the calculated maximum rotations differed from the measured median values by less than 1 degrees without the rib cage and by less than 2.5 degrees with it. The rib cage decreased the mean flexibility of the thoracic spine by 23% to 47%, depending on the loading plane. Assuming the ribs to be rigid beams required a corresponding reduction of ligament stiffnesses in order to achieve the same agreement of the maximum rotations with the measured median values. Interconnecting the FE thoracic spine model plus rib cage with the existing detailed FE lumbar spine model improves the simulation of force directions of muscles attached to the rib cage or thoracolumbar spine. In addition, such a model is suitable for determining the effects of lumbar spine implants on spinal balance.