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腰椎间盘突出症护理查房
潜山县中医院骨伤一科 椎间盘的生理作用
对脊柱具有连接、稳定、增加活
动及缓冲震荡的弹性垫作用。
病因 1、椎间盘退变； 2、损伤； 3、遗传因素； 4、妊娠。
诱因 ①、腹压增高：剧烈咳嗽、便秘时用力排便等。 ②、腰姿不当：当腰部处于屈曲位时，如突然 旋转则易诱发髓核突出。 ③、突然负重：在未有充分准备时，突然使腰 部负荷增加，易引起髓核突出。 ④、腰部外伤：急性外伤时可波及纤维环、 软骨板等结构，而促使已退变的髓核突出。 ⑤、职业因素：如汽车驾驶员长期处于坐位 和颠簸状态，易诱发椎间盘突出。
椎间盘正常:椎间盘无退变组织均在椎间盘内
椎间盘膨出:纤维环环状均匀性超出椎间隙范围，椎间盘组织没有呈局限性突出。
椎间盘脱出 :移位椎间盘组织的直径大于基底连续部，并移向于椎间隙之外 ，并通过此裂隙位于椎管内
椎间盘突出:移位椎间盘组织尚与原椎间盘组织相连，其基底连续部直径大于超出椎间隙的移位椎间盘部分。 临床表现 腰痛 下肢放射痛 肢体冷感 间歇性跛行 肌肉麻痹 马尾神经症状 辅助检查 X线检查：不能作为确诊腰椎间盘突出症的依据，但可借此排除如腰椎结核、骨性关节炎、骨折、肿瘤和脊椎滑脱等。 脊髓碘油造影、CT扫描和磁共振等特殊检查，以明确诊断及突出部位。 直腿抬高试验阳性：患侧抬腿受限并感到向小腿或足的放射痛即为阳性。此点对诊断有较大价值。
（二）检查方法 直腿抬高试验（Lasegue征） 患者取仰卧位，检查者站于患者右侧，一手握患者踝关节上方，一手置于 　　　患者大腿前方保持膝关节伸直，然后将下肢徐徐 　　　抬高。一般直腿抬高４５度受限并出现下肢放射 　　　痛
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: &&&&DOI: 10.3969/j.issn.14.40.014
脊柱植入物 spinal implant
腰椎动态植入物内固定系统治疗腰椎间盘突出症的早期疗效
明江华1，赵&奇1，杨&斌2，郑慧锋1
1武汉大学人民医院骨科，湖北省武汉市 &430060，2阳新县人民医院，湖北省阳新县&435200
Early effect of lumbar dynamic fixation for treatment of lumbar disc herniation
Ming Jiang-hua1, Zhao Qi1, Yang Bin2, Zheng Hui-feng1
1 Department of Orthopedics, Renmin Hospital of Wuhan University, Wuhan 430060, Hubei Province, C2 Yangxin County People&s Hospital, Yangxin 435200, Hubei Province, China
参考文献(0)
Currently, the rear decompression and fusion are still the conventional methods for treatment of lumbar disc herniation[1-2]. However, it can cause the rear lower back pain after surgery for soft tissue injuries of the spine, and increasing adjacent segments compensatory activities due to the fixed segment after fixation and fusion[3-4], which can lead to the long-term degeneration of adjacent segments[5-6]. To solve this problem, lumbar dynamic stabilization systems are designed and used in clinic[7-8], it can not only keep the normal physiological activity of the fixed lumbar spine, so as to achieve both fixation without causing adjacent segment degeneration in theory[9-10]. However, it can cause extensive soft tissue damage via the traditional approach behind the lumbar part[11-12], while the implanted screw-rod close to the facet joints, to a certain extent, limits the activities of the facet joints, affecting the outcome. In order to reduce damage to the soft tissue, we tried lumbar dynamic fixation through Wiltse approach (between multifidus and longissimus muscle gap).
杂志出版内容重点：；骨植入物；；；内固定；数字化骨科；
全文链接：
A retrospective study.
Time and setting
This study was performed in Renmin Hospital of Wuhan University between January 2011 and January 2013.
The patients were due to lumbar disc herniation from January 2011 to January 2013 in our hospital.
Inclusion criteria: eligible patients had single segment disc, and showed low back pain and pain associated with unilateral lower limb reflex leg and dorsum of the foot feeling loss, straight leg raising and strengthening the tests were positive. Preoperative MRI,
symptoms, signs were consistent with the imaging findings. All of them are ineffective after six weeks of conservative treatments.
Exclusion criteria: disc multi- non-lumbar
merger spondylol non-dynamic non- non Wiltse approach.
Of 46 patients, the traditional behind approach was used in 25 cases, and Wiltse approach in 21 26 males, 20 females, aged 24 to 60 years, averagely 45.5 years. Eligible patients were single segment disc, L4-5 in
26 cases, L5-S1 in 20 cases, 28 cases of cent 18 cases showed low back pain and pain associated with unilateral lower limb reflex leg and dorsum of the foot feeling loss, straight leg raising and strengthening the tests were positive. Preoperative MRI, symptoms, and signs were consistent with the imaging findings. All patients underwent dynamic
the choice of screw-rod system includes Cosmic System (Ulrich Medical, Germany) 10 cases, Dynesys system (Zimmer, Inc., USA) 10 cases, and Devine-Elrod Systems (Orthmed company, China) 26 cases.
Operation method
After the success of anesthesia, the patient was prone on the operating table. C-arm X-ray positioned surgical segment. All of the incision was after founder of spine, the traditional approach was 7-8 cm, and Wiltse approach was 4-5 cm. Founder of the traditional approach was used to peel Erector bilateral facet, not repeat them here. Wiltse approach after the incision, the skin after skin incision, to the separation between the subcutaneous muscle membranes between two layers may be needed for further free. Spinous process to open a cross refers to about 1.5-2.0 cm at the incision fascia, blunt dissection and multifidus dorsi muscle gap to the target facet, facet coagulation exposed outer edge of the root and vice sudden. We selected the external facet the lower edge of the root or roots and vice facet junction point as pedicle screws protruding needle point, protecting the the needle direction was parallel to the sagittal plane and the end plate, the coronal plane with the longitudinal axis of the spinous process 30&-45& angle pedicle screws, C-arm fluoroscopy set nail correct, according to the patient&s condition needs to be inside the multifidus muscle stripping, exposing the lamina and facet, the &unilateral fenestration or fenestration less pressure and then with discectomy& if necessary, &the nerve root canal augmentation& mounting pole, complete hemostasis, the drainage tube placed layered suture the wound (Figure 1).
Postoperative management
Using of a dehydrating agent, dexamethasone (5 mg, ivgtt, bid) and antibiotics within 3 days postoperatively. The drainage tube was pulled out after 48 hours. Start straight leg raising training and back muscle function during exercise in patients with no significant back pain after postoperative 2 days. They got out of bed with the aid of a walker 1-2 weeks later.
Observational index
We compared the two approaches surgical incision length, operative time, blood loss, postoperative drainage and complications. Pain visual analog scale was assessed before and after evaluation of surgical patients with low back pain. Periodic review of postoperative X-ray evaluation of the situation of internal fixation was conducted.
Main outcome measures
There were incision length (cm), operation time (minute), intraoperative blood loss (mL), postoperative drainage (mL), visual analog scale score of low back pain at different time points, such as preoperative, after 1 week, and six months.
Statistical analysis
All data were analyzed with SPSS 19.0 (SPSS Inc., USA) statistical software, and were expressed as mean & standard deviation, using the t test to compare indicators. A value of P & 0.05 was considered statistically significant.
杂志出版内容重点：；骨植入物；；；内固定；数字化骨科；
全文链接：
Lumbar disc herniation is a common clinical disease, and it often needs surgery failed conservative treatment[13-18]. The goal of surgery included disc removal, reconstruction of spinal or nerve root canal decompression and lumbar stability[19-24]. Lumbar fusion surgery is the gold standard since Hibbs and Albee against degeneration caused by lower back pain and spine instability in 1911. After the posterior discectomy and fusion plus also become a routine method for lumbar disc herniation[25-28]. However, due to the fixed segment fusion lesions cause the disappearance of the activities of the segment, and adjacent segments will appear compensatory increase in activity and intradiscal pressure, it will occur degeneration and corresponding symptoms with the elapsing of time, and to patients with new pain[29]. If not fixed after discectomy fusion, it will cause instable and degenerative lumbar acceleration[30-32]. Thus, how can we maximize the retention of physical activity segmental lesions become the direction of research.
Fixed non-fusion, also known as fixed or dynamic fixation of soft, rigidly fixed to the fixed mode differs, which allows the fixed segment in the normal range of motion[33-37]. At present, the fixed devices for dynamic system had multiple types, such as Graf ligament system[38], Dynesys system[39-41], Cosmic system[42-44], and Devine-Elrod system. Schmoelz&s[45] study showed that the human spine specimens with Dynesys system while maintaining the stability of the spine can retain its normal range of motion, and exhibit good dynamic fixation. Stoll et al[46] conducted a multicenter prospective clinical study and showed that the use of the treatment of lumbar disease Dynesys system was safe and satisfactory. Erbulut et al[47] showed that the use of an interim efficacy Dynesys system for the treatment of lumbar disc herniation satisfaction from the rear into the road. In this study, two groups of patients before surgery compared with preoperative symptoms and signs of significant improvement in the last follow-up position when the fixture was good, no loose and broken, this was consistent with the results of the research scholars to prove that the use of dynamic stabilization system fixed lesions again lumbar effectiveness and practicality.
Founder of the approach is the classical type of posterior decompression and fixation approach, with a clear anatomical structure and a short learning curve[48]. However, the following disadvantages present: (1) posterior lumbar is mainly composed by paraspinal muscles and multifidus dorsi muscle, and supported by the spinal s it has an important role in maintaining the stability of the spine. The traditional Founder approach requires extensive dissection of paraspinal muscles, which can cause iatrogenic postoperative adhesions and scar back pain[49-50]; (2) Erector after peeling strength required to achieve joint distraction on both sides of the conflict, long powerful distraction can cause partial muscle ischemia, necrosis and denervation[51], is not conducive to the recovery of postoperative back muscle and can lead to increased postoperative drainage
(3) dynamic fixed goal is to retain as much as possible facet of physical activity, and extensive soft tissue stripping and integration will result i (4) dynamic fixed screw-rod system should not interfere with normal activities facet, therefore, need to be placed in the lateral facet nail, and through this approach it is more difficult to complete the operation.
Wiltse et al[52] proposed the multifidus dorsi muscle and into the road in 1968, this road through the muscle into the gap operation is relatively simple, without stripping the muscles, and the muscle is not formed between postoperative scar tissue, and can also direct articular surface and transverse processes. In 2013, Buttermann et al[53] reported the paraspinal muscles approach for lumbar spondylolisthesis, lumbar disc herniation and lumbar spinal stenosis. Given the approach of the above characteristics, we try to approach the dynamic lumbar fixed, in order to overcome the lack of road into the Founder. The results of this study show that the approach of the surgical incision in intraoperative blood loss, and postoperative drainage volume is better than the Founder of the approach. Without approach-related complications except that two patients had partial necrosis of the skin incision edges. In addition, the incision also has the following advantages: (1) small incision, single-segment fixation may be about 4 cm incision after subcutaneous free in the incision, the incision can be made according to operational needs, down, left, right movement, the group showed that the average length of 4.5 (2) After blunt dissection of muscle gap can be directly oriented lateral facet, reduce blood loss, can be directly exposed set screws, without a strong distraction, to protect the integrity of muscle and blood supply, there conducive to early rehabilitation of low back muscles, this group of postoperative bleeding less th (3) clearance from pedicle screws can be increased according to the requirements set nail abduction angle (45& left and right), both to avoid stick on nail facet of oppression, but also to choose longer nails, screws holding force increases, more in line with the dynamic characteristics of th (4) this approach can be done through unilateral or bilateral spinal windows, fenestration, discectomy, nerve root decompression operation, with good usability.
In conclusion, Wilste approach has some advantages such as minimal invasion, simple and practical method, and quick recovery. However, the limitations of this study include small sample size, and short following-up, but long-term efficacy remains to be seen.
杂志出版内容重点：；骨植入物；；；内固定；数字化骨科；
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文章概要：尝试Wiltse入路行腰椎动态固定，旨在探讨能否达到微创减压、操作简便、实用性强、术后康复快等目的。与传统后方入路相比，Wiltse入路具有手术切口小，术中失血量少和术后引流少等优点。
杂志出版内容重点：；骨植入物；；；内固定；数字化骨科；
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研究亮点: 1 实验特点在于通过对比Wiltse入路和传统后方入路行腰椎间盘摘除+腰椎动态稳定植入物系统固定治疗腰椎间盘突出，证实Wiltse入路腰椎动态内固定植入物系统治疗腰椎间盘突出的早期疗效与传统后方入路接近，但术后功能恢复效果更好。
2 文章创新之处在于将Wiltse入路结合动态非融合联合应用治疗腰椎间突出症。不足之处在于尽管选取病例尽量为单节段腰椎间盘突出症的患者，但因存在着个体化的差异，无法达到基线水平完全一致。因此，证实文中的观点需要大样本、多中心、设计更合理的方案。
杂志出版内容重点：；骨植入物；；；内固定；数字化骨科；
全文链接：
方法：纳入因腰椎间盘突出症于2011年1 月到2013年1月分别在武汉大学人民医院行腰椎间盘摘除+腰椎动态稳定系统固定的患者46例，其中经传统后方入路25例，Wiltse入路21例。
结果与结论：46例患者均获得随访，随访时间7-31个月，平均(13.8&2.4)个月。Wilste入路组患者切口长度、内固定中失血和内固定后引流均低于传统后方入路组(P & 0.05)；但2组患者内固定后1周和6个月目测类比评分与手术时间比较差异无显著性意义(P & 0.05)。X射线显示所有患者内固定物位置良好，无松动或断裂。提示Wiltse入路腰椎动态植入物内固定系统治疗腰椎间盘突出的早期疗效与传统后方入路接近。
杂志出版内容重点：；骨植入物；；；内固定；数字化骨科；
全文链接：
Abstract：BACKGROUND: Currently, one of common methods is discectomy, nerve root decompression and fusion rigid fixation from the midline approach for disc herniation which is inefficient by conservative treatments. Thus, it is causing degeneration and limiting lumbar physiological activity of adjacent segments. The treatment of non-fusion lumbar disc herniation with the traditional posterior midline incision approach has some disadvantages such as big incision, wide peeling, and back muscle denervation.
OBJECTIVE: To observe therapeutic effects of dynamic stabilization system through Wiltse approach on lumbar disc herniation, and to compare the outcomes with traditional posterior approach.
METHODS: A total of 46 patients, who had undergone discectomy and internal fixation using dynamic stabilization systems for lumbar disc herniation at the Renmin Hospital of Wuhan University from January 2011 to January 2013, were enrolled in this study. The operation was performed through the traditional posterior approach in 25 patients and Wiltse approach in 21 patients.
RESULTS AND CONCLUSION: All 46 patients were followed up for 7 to 31 months (averagely, 13.8&2.4 months). The length of incision, intraoperative blood loss, and postoperative drainage amount were less in the Wiltse approach group than in the traditional posterior approach group (P & 0.05). No significant difference in visual analog scale scores and operative time was detected between the two groups at 1 week and 6 months after fixation (P & 0.05). Radiographs revealed that the position of implants was good in all patients, no loosing or breakage. These data verified that the early effect of dynamic stabilization system through Wiltse approach for lumbar disc herniation is similar to that of traditional posterior approach.
杂志出版内容重点：；骨植入物；；；内固定；数字化骨科；
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Key words：
中图分类号:&
作者简介: 明江华，男，1966年生，主任医师，硕士生导师，主要从事脊柱外科方面的研究。
并列第一作者：赵奇，主要从事脊柱外科方面的研究。
引用本文: &&
斌等. 腰椎动态植入物内固定系统治疗腰椎间盘突出症的早期疗效[J]. 中国组织工程研究, ): .
Ming Jiang-hua,Zhao Qi,Yang Bin et al. Early effect of lumbar dynamic fixation for treatment of lumbar disc herniation[J]. Chinese Journal of Tissue Engineering Research, ): .
Quantitative analysis of subjects
All participants were included in the final analysis. The groups of 46 patients were followed up for 7 to 31 months, mean 13.8 & 2.4 months.
Effects of lumbar dynamic fixation through Wiltse approach
Two groups of patients at 1 week after low back pain were significantly reduced, and the difference between the visual analog scale score before surgery was statistically significant (P=0.000 0). Compared to the length of the incision, the differences in intraoperative blood loss and postoperative drainage were statistically significant between two groups of patients, while no significant difference in the operation of low back pain visual analog scale score and time after 1 week and after 6 months was found (P & 0.05; Table 1).
Adverse reactions of lumbar dynamic fixation through Wiltse approach
Four patients wound suffer from effusion postoperative and delayed healing after puncture with bandaged in traditional approach group, and the remaining wounds healed. In Wilste approach group, two patients had partial necrosis of the skin incision edge, after dressing healed. At the final follow-up, X-ray showed a good fixation position and no loose or broken in all patients.
Typical case of lumbar dynamic fixation through Wiltse approach
There was a typical case, female, aged 52, L4/5 disc herniation with right lower extremity pain and numbness for three months (Figure 2).
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没有本文参考文献
艾克热木江o木合热木，孙宇庆，武忠炎，田
伟. [J]. 中国组织工程研究, ): 634-641.
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椎弓根钉棒系统内固定椎间CAGE植入融合治疗腰椎间盘突出症围手术期护理体会
优质期刊推荐颈前路髓核摘除人工椎间盘植入术围手术期护理体会--《2014年河南省骨伤护理学术交流会论文集》2014年
颈前路髓核摘除人工椎间盘植入术围手术期护理体会
【摘要】：目的探讨适合颈前路髓核摘除人工椎间盘植入术的最佳围手术期护理方案。方法观察我科50例行颈前路髓核摘除人工椎间盘植入术患者围手术期的护理方法,回顾性分析了所选患者护理方案的优劣并进行了术后随访。所选取50例患者其中男性32例,女性18例,平均年龄48岁,平均病程25个月。其中高血压病患者5例,余患者均未合并其他疾病。所有颈椎病的患者均符合颈前路手术指证。对50例患者术前及术后JOA评分进行统计学分析,从而总结出了适宜该手术方式的合理护理措施。结果 50例颈椎病术后患者均取得满意手术效果,症状较术前有明显缓解,术后JOA评分较术前明显改善,术后JOA评分改善有统计学意义。结论合适的护理措施配合临床手术,对于颈椎病患者可取的满意的疗效。
【作者单位】：
【关键词】：
【分类号】：R473.6【正文快照】：
颈椎病是现代人的多发病,也是骨科最常见的疾病之一。颈椎病常常引起颈部疼痛、上肢麻木、四肢无力等症状,还会引起因交感神经兴奋而导致的颈性眩晕[1],其发病率逐年增加并存在年轻化的趋势。目前,颈椎间盘突出症外科治疗均以减压解除神经压迫、刺激来达到缓解、消除临床症状
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