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10、Natural History of Progressive Adult Scoliosis
进行性成人脊柱侧弯的自然发展史
Study Design. A retrospective analysis of the progression of adult scoliosis.
研究设计：对成人脊柱侧弯进展的回顾性分析
Objective. To establish an individual prognosis.
目的：确定个人预后
Summary of Background Data. Most studies have investigated the adolescent scoliosis after skeletal maturity, but the results are discordant.
背景摘要：许多课题对骨骼成熟后的青少年脊柱侧弯进行研究，所得结果各异。
Methods. Two senior physicians measured all the radiographs of 51 adults who had a progressive scoliosis. The mean delay between the first and last radiograph was 27 years. For each patient, a diagram was established with the Cobb angle on the y-axis and the corresponding age on the x-axis. We noted the age and Cobb angle of the first radiograph showing a rotatory subluxation and the age of menopause. We used linear regression and the analysis of variance test.
方法：两名资深医生对51例患有进行性脊柱侧弯的成年患者X线进行测量，其初次及末次摄片间隔平均为27年。每个患者的测量结果用座标表示，y轴为Cobb角值，x轴为相应年龄。记录出现旋转性半脱位的年龄和其初次摄片的Cobb角，以及记录绝经的年龄，所得数据采用直线回归及变量分析统计。
Results. The mean number of radiographs per patient was 6. The linear test was significant in 46 patients. Two main types exist. Type A is an adolescent scoliosis that continues to progress after skeletal maturity, whereas type B appears or progresses late. There were 13 type A and 20 type B of which 11 progressed around menopause. Significant differences were noted between groups A and B regarding loss of body height (group A, 5 cm and group B, 9.5 cm; P _ 0.001), rate of progression in lumbar single and thoracolumbar single curves (group A, 0.82°/y and group B, 1.64°/y; P _ 0.004), Cobb first radiograph (group A, 37° and group B, 20°; P _ 0.0001), age rotatory subluxation (group A, 42 years and group B, 56 years; P _ 0.0001), and Cobb rotatory subluxation (group A, 52° and group B, 29°; P _ 0.0001).
结果：每例患者平均摄片6次，46例患者回归结果呈直线，共呈现两种类型。A型脊柱侧弯持续进展出现在青少年骨骼成熟后，B型则出现较晚。13例患者呈A型表现；20例呈B型，其中11例在围绝经期出现症状。A型和B型间在下列几方面存在显著差异：身体高度的丢失（A型5cm，B型9.5cm，P<0.001）、腰椎及胸椎进展曲率（A型0.82°/y，B型1.64°/y，P<0.004）、初次摄片Cobb角（A型37°，B型20°，P<0.001）、出现旋转性半脱位的年龄（A型为42岁，B型为56岁，P<0.001）、旋转性半脱位的Cobb角（A型52°，B型29°，P<0.001）。
Conclusions. The originality of our study is the diagram. We demonstrated that the rate of progression was linear, and it can be used to establish an individual prognosis. The diagrams visualized 2 main distinct types. There was a significantly faster rate of progression in type B. In type A, rotary subluxation occurs during progression of the curvature. In type B, it seems to be the initial event. Menopause is a period of deterioration in type B.
结论：研究的初期结果形成图表，我们发现进展率呈线性，故其可以用来确定个人预后。图表呈现两种直线形式，B型进展率明显快于A型。A型患者旋转性半脱位出现在曲率增加过程中，而B型似乎初期即发生旋转性半脱位。绝经期是B型患者病情加重的时期。
Key words: adult scoliosis, natural history, prognosis, rotatory subluxation.
关键词：成人脊柱侧弯，自然发展，预后，旋转性半脱位
12、Three-Dimensional Lumbar Spine Postures Measured by Magnetic Resonance Imaging Reconstruction
采用MRI重建术测量腰椎三维姿势
Study Design. Investigation of method.
研究设计：调查研究
Objective. This study presents a novel method of accurately determining relative bone position in vivo using magnetic resonance imaging (MRI).
目的：本研究目的在于展现一种全新的方法，该法采用MRI精确测定了体内骨骼相对位置。
Summary of Background Data. Biomechanical modeling of the human body requires measurement of the relative positions of skeletal elements. Spinal orientation is particularly difficult to measure due to small joint movements, relative inaccessibility of the bones to direct measurement, and joint complexity.
背景摘要：人体生物模型的建立需要对骨骼间相对位置进行测定，而脊柱定位特别困难，原因在于小关节间的运动、骨骼直接测量的相对困难性以及关节复杂性。
Methods. A process incorporating both positional and conventional MRI was used to measure the skeletal positions of the lumbar spine and pelvis. The method uses higher quality conventional MRI to determine bone geometries and then registers these with lower resolution, positional MRI images of various postures to determine the relative locations of the bones. Flexion/extension, lateral bend, and axial twist rotations were measured for each joint.
方法：常规MRI及定位MRI相结合，用于测定腰椎及骨盆骨骼位置。该法利用高质量的常规MRI测定骨骼的几何形状，然后记录不同位置的低分辨力定位MRI图像，以确定骨骼的相对位置。每个关节的屈、伸、侧弯、 轴向旋转一并测量。
Results. The results indicate good intrameasurer reliability, with a maximum rotational difference for all vertebral registrations of less than 1° and a maximum translational difference of less than 3 mm. While there did not appear to be significant patterns between the 2 Subjects, there were trends within each Subject as well as identifiable postural characteristics.
结果：结果显示了良好的测量可靠性，所有椎体记录的误差旋转小于1°，移位少于3mm。两位受试者之间没有表现出显著的模式，但和位置的可辨认性一样，显现了形成模式的趋势。
Conclusions. Although processing times are currently lengthy, the data collected are 3-dimensional, and represent the anatomy and movement of a specific individual.
结论：尽管测量过程费时，所得数据呈现三维形式，可以用以表现特定个体的解剖及运动。
Key words: positional, magnetic resonance imaging, lumbar, pelvis, spinal kinematics, registration.
关键词：位置，核磁共振，腰椎，骨盆，脊柱运动学，记录
Brain-Derived Neurotrophic Factor Gene Transfer With Adeno-Associated Viral and Lentiviral Vectors Prevents Rubrospinal Neuronal Atrophy and Stimulates Regeneration-Associated Gene Expression After Acute Cervical Spinal Cord Injury.
转化自腺病毒和慢病毒载体的大脑源性神经营养性因子能阻止急性脊索损伤后红核脊髓神经性萎缩并激发再生基因的表达
Abstract:
摘要：
Study Design. Experimental animal study.
研究设计：动物试验研究
Objective. To determine if viral vectors carrying the gene for brain-derived neurotrophic factor (BDNF) could be used to promote an axonal regenerative response in rubrospinal neurons after an acute cervical spinal cord injury.
目标：本研究在于确定病毒带菌体存在着一种大脑源性神经营养因子(BDNF)的基因，这种基因可以在急性颈髓脊索损伤所致病例中引发红核脊索神经元的轴性再生反应。
Summary of Background Data. Following axotomy in the cervical spinal cord, rubrospinal neurons undergo severe atrophy and fail to up-regulate important genes for regeneration. This can be attenuated or reversed with the infusion of BDNF to the injured cell bodies. This infusion technique, however, causes substantial parenchymal damage around the red nucleus and is limited by occlusion of the infusion pumps. This study examined whether viral vectors could be used to deliver the BDNF gene in a less damaging fashion and whether this could promote a regenerative response in injured rubrospinal neurons.
背景概述：在颈椎脊索轴性切开后，往往会出现红核脊髓神经元的严重萎缩，合并决定再生的重要基因上调不能。这种现象可以通过对所损细胞注入BDNF来减弱甚至逆转。但是，这种注入技术却会引起红核周围的红核脊髓实质性损伤，并且还会收到注入阻塞的限制。本研究检测了病毒载体是否可以用来在比较小的损伤模型上促进BDNF基因的释放，以及它是否可以激发受损红核脊髓神经元的再生反应。
Methods. Following a cervical spinal cord injury, the viral vectors were injected into the vicinity of the injured red nucleus. The extent of parenchymal damage around the red nucleus was assessed, as was the immunoreactivity to BDNF and cellular transfection patterns. Rubrospinal neuronal cross-ectional area was measured to determine if atrophy had been reversed, and in situ hybridization for GAP-43 and T[alpha]1 tubulin was performed to determine if there genes, which are important for axonal regeneration, were up-egulated.
方法：在颈椎脊索损伤后，我们在损伤的红核神经元附近注入了病毒载体。对于红核附近实质性损伤的程度，我们通过对BDNF的免疫反应程度以及细胞转染方式两方面进行了测量。同时，我们还测量了红核脊髓神经元的交叉外膜的面积，以此来确定萎缩是否发生了逆转。另外，还测定了GAP-43 和T[alpha]1微管蛋白的原位杂交是否上调。它们对于轴性再生是非常重要的。
Results. Parenchymal damage associated with viral injection was significantly less than with previous infusion techniques. BDNF immunoreactivity around the red nucleus indicated that the BDNF transgene was expressed. Both viral vectors reversed rubrospinal neuronal atrophy and promoted the expression of GAP-43 and T[alpha]1 tubulin.
结果：与原先的注射技术相比，注射病毒的实质性损伤要明显少得多。在红核周围的BDNF免疫反应提示BDNF的转化基因得到了表达。两种病毒载体都逆转了红核脊髓神经元的萎缩并且促进了GAP-43和T[alpha]1微管蛋白的表达。
Conclusions. Viral-ediated transfer of the BDNF gene was successful at promoting a regenerative response in rubrospinal neurons following acute cervical spinal cord injury, with significantly less parenchymal damage than previously observed when infusing the BDNF protein.
结论：病毒编码的BDNF转化基因对于促进急性颈椎脊索损伤后红核脊髓神经元的再生反应非常有效。与以往的技术相比，注入BDNF蛋白可以显著减少实质损伤。
(C) 2007 Lippincott Williams & Wilkins, Inc.
The In Vivo Biological Effects of Intradiscal Recombinant Human Bone Morphogenetic Protein-2 on the Injured Intervertebral Disc: An Animal Experiment.
受损椎间盘的椎间盘内重组体人类骨形态基因蛋白2的体内生物学效应：一个动物试验研究
Abstract:
摘要：
Study Design. Prospective analysis.
研究设计：前瞻性分析研究。
Objective. To investigate biologic influences of recombinant human bone morphogenetic protein (rhBMP)-2 on intervertebral discs after anular tears.
目的：调查椎间盘环撕裂后重组体人类骨形态基因蛋白(rhBMP)2的生物学效应。
Summary of Background Data. Treatments for intervertebral disc injury or degeneration are unsatisfactory. rhBMP-2, a high-potency osteoinductive and chondroinductive substance, is approved for use in anterior lumbar interbody fusions. rhBMP-2 stimulates the proliferation of rat disc cells and the secretion of extracellular matrix in vitro. In vivo responses in the intervertebral disc after anular tears are rarely studied.
背景概述：对于椎间盘损伤或退化的处理，一直以来就不令人满意。rhBMP-2作为一种高效骨和软骨诱导性的物质，已经被允许在前腰椎介体融合中使用。rhBMP-2可以在大鼠体内激发椎间盘细胞的增殖，并且可以促进细胞外介质的释放。对于椎间盘环撕裂后的体内反应，目前研究还很少。
Methods. Twenty New Zealand white rabbits received full-thickness anular tears and intradiscal injections of saline (control) and rhBMP-2 0.1 mg with and without coral grafts at L2-L3, L3-L4, and L4-L5, respectively. Three died or had infection. Therefore, 17 underwent radiography and sacrifice at 12 weeks. Spinal sections were stained with hematoxylin and eosin to examine responses to rhBMP-2.
方法：20只新英格兰兔子接受了穿透性的环撕裂处理，并且还在椎间盘内注入了生理盐水（对照）和rhBMP-2 0.1 mg。它们有的在L2-L3, L3-L4, 或L4-L5接受了珊瑚移植物，有的则没有。相对地，3只兔子死了或发生了感染。因此，总共17只兔子在第12周接受了影像学检查并处死。脊髓切片用苏木精和伊红染色，从而检测其对rhBMP-2的反应情况。
Results. Radiographs revealed degenerative changes, such as disc space narrowing and irregularity, subchondral sclerosis, osteophyte formation, and hypertrophy of vertebral endplates in all groups. Degeneration was more frequent and severe with rhBMP-2 with (P < 0.01) and without (P < 0.05) coral than with saline. Two rabbits receiving rhBMP-2 and coral achieved solid interbody bony fusion. New bone formation was noted in 2 controls, in 3 animals treated with rhBMP-2, and in 4 treated with rhBMP-2 and coral. Vascularity and fibroblast proliferation increased with rhBMP-2 (n = 14) and rhBMP-2 with coral (n = 9) compared with control (n = 3; P < 0.01 and P = 0.03, respectively). Inflammatory infiltrates increased with rhBMP-2 (n = 8) compared with control (n = 2; P = 0.03).
结果：影像学检查在所有组中都显示了退化性改变，如椎间盘空间变窄以及排列无序、软骨下硬化、骨赘形成以及锥体终板的萎缩。接受rhBMP-2试验组比生理盐水组的退化情况要严重的多，其中珊瑚移植为P < 0.01而不接受珊瑚移植为P < 0.05。两只接受rhBMP-2和珊瑚移植的兔子出现了坚固的介体骨性融合。在2只对照兔子、3只接受rhBMP-2的兔子和4只接受rhBMP-2和珊瑚移植的兔子出现了新骨形成。与对照组（n＝3）相比接受rhBMP-2的兔子(n = 14)和接受rhBMP-2合并珊瑚移植的兔子(n = 9)出现了血管和纤维增生（P < 0.01 and P = 0.03）。并且与对照组(n = 2)相比，接受rhBMP-2 (n = 8)的兔子出现炎性浸润的情况增加了（P = 0.03)）。
Conclusions. Degenerative changes were more frequent and severe in the groups treated with rhBMP-2 with or without coral in radiographic findings. In histopathologic findings, rhBMP-2 promoted hypervascularity and fibroblast proliferation of the intervertebral disc after an anular tear.
结论：在影像学检查中，接受rhBMP-2伴或不伴珊瑚移植的兔子出现退化改变的情况要更加频繁而且严重。在组织病理学检查中，rhBMP-2可以激发环撕裂后的椎间盘血管过度形成以及纤维增殖。
The Load-Sharing Classification of Thoracolumbar Fractures: An In Vitro Biomechanical Validation.
Biomechanics
胸腰椎骨折载荷分担分类:一种体外生物力学验证
生物力学
Abstract:
摘要:
Study Design. An in vitro biomechanical investigation
研究设计：一种体外生物力学的研究
Objectives. The purpose of this study was to investigate the association between various load-sharing score and the acute flexibility of thoracolumbar fractures by measuring the 3-dimensional flexibility data.
目的：此次研究的目的是通过三维弹性材料的测量，研究各种载荷分担评分与胸腰椎骨折急性弹性量之间的相关性。
Summary of Background Data. The load-sharing classification is a way to describe the injury severity of a spinal fracture and can be very useful in determining successful candidates for the choice of operative approaches. However, this classification needs to be validated by biomechanical and more clinical studies before its widespread use. To date, no biomechanical study was available
背景资料概要：载荷分担分类是一种描述脊柱骨折损伤严重程度的方法，在手术入路选择的决定因素中是非常有用的。然而这种分类法在广泛应用之前需要通过生物力学和更多的临床研究来验证。迄今为至,生物力学研究仍是一片空白。
Methods. Eighteen fresh bovine T12-L3 specimens were harvested and divided into 3 groups, and subjected to axial compressive impact with 63.8, 107.8, and 137.2 J energy, respectively. Radiograph films and computed tomography scans of the experimental spine were taken in neutral posture after trauma. Multidirectional flexibility of each specimen was measured under flexion-extension, right/left lateral bending, and right/left axial rotation before and after trauma. The association between the multidirectional instabilities and the vertebral injuries to each of load-sharing point score was analyzed.
方法：18具牛的胸12-腰3椎的新鲜样本被收集并分成3组，分别以63.8，107.8，137.2 J的能量对标本进行轴向压缩撞击。于创伤后采取中立位对实验的脊柱样本行X光片拍摄和CT平扫。每个样本多向的弹性量在创伤前后于屈-伸，右/左侧弯，右/左轴向旋转方向上进行测量。针对每个载荷分担点评分的椎骨损伤与多向不稳定性之间的相关性被予以分析.
Results. The load-sharing score of a fracture increased with the level of impact energy. Significant positive correlations were found between the load-sharing score and the motion parameters (average R2 = 0.434, average P = 0.004). Fractures with mild comminution (<=6 points) showed more stability as compared to those with more comminution (>=7 points) (P <= 0.016).
结果：骨折载荷分担评分随着撞击能量水平的加强而提高。载荷分担评分和动态参数之间发现有明显的相关性(回归方程R2=0.434,平均P值=0.004)。轻度粉碎的骨折(评分<=6分)与粉碎程度更严重的骨折(>=7分)相比显示出了更好的稳定性.(P<=0.016)。
Conclusion. This study confirms that assessing the load-sharing score should be helpful in evaluating the acute instability of thoracolumbar fractures, and justifies the use of load-sharing classification in the thoracolumbar fractures.
结论：此研究表明：估计载荷分担评分对于预测胸腰椎骨折急性不稳定性是有益的，证实了载荷分担分类法在胸腰椎骨折上应用的合理性。
Biomechanical Comparison of Instrumented and Uninstrumented Multilevel Cervical Discectomy Versus Corpectomy
多节段颈椎间盘切除固定和不固定与椎体切除的生物力学比较
[Biomechanics]
Abstract
Study Design. In vitro flexibility test comparing biomechanics of cervical corpectomy versus discectomy with and without instrumentation.
研究设计：通过体外扰度试验，对颈椎椎体切除与椎间盘切除内固定或非内固定进行生物力学比较。
Objectives. To evaluate whether the additional effort required to perform multilevel discectomies instead of corpectomies is worthwhile biomechanically.
目的：从生物力学上评价，是否值得对多节段椎间盘切除术而不是椎体切除术进行额外的处理。
Summary of Background Data. Both cervical corpectomy and discectomy have been shown to be effective clinically. No previous biomechanical comparison exists.
背景资料概述：颈椎间盘切除术和椎体切除术都显示出了临床有效性，并不存在以前所说的生物力学对比（差异）。
Methods. Fourteen human cadaveric cervical spines were studied: 1) intact, 2) after discectomy and wedge grafting at C4–C5, C5–C6, and C6–C7 (Group 1) or corpectomy and strut grafting of C5 and C6 (Group 2), 3) after attaching a locking metal plate from C4–C7, and 4) after adding posterior locking lateral mass screw/rod instrumentation across C4–C7. Nonconstraining, nondestructive torques induced flexion, extension, lateral bending, and axial rotation (maximum, 1.5 Nm) while angular motion was measured stereophotogrammetrically.
方法：对14例人类尸体颈椎进行了研究：1），保持完整，不做处理；2）经C4–C5、C5–C6和 C6–C7椎间盘切除楔状植骨（第1组）或C5和C6椎体切除支撑性植骨（第2组）；3） 经C4–C7放置锁定金属板；4）经C4–C7放置后路锁定侧块钉-棒内固定系统。应用立体摄影测量技术，对非限制性非破坏性扭矩导致的屈、伸、侧弯和轴向旋转（最大为1.5 Nm）的活动角度进行测量。
Results. Discectomy and grafting did not alter the range of motion (ROM) significantly from normal during any loading mode (P > 0.11). Corpectomy and grafting allowed a significantly greater range of motion than normal during flexion, lateral bending, and axial rotation (P < 0.05). Addition of an anterior plate reduced ROM to significantly less than normal during all loading modes in both groups (P < 0.005). Addition of posterior instrumentation further reduced ROM significantly in both groups (P < 0.01). There was no significant difference in ROM between corpectomy and discectomy groups in any loading mode whether uninstrumented (P > 0.18), anteriorly plated (P > 0.33), or anteriorly and posteriorly instrumented (P > 0.30).
结果：与正常者相比，在任何一种负荷模型下，椎间盘切除植骨都没有明显改变活动范围（ROM）(P > 0.11)。而椎体切除植骨再屈曲、侧弯和轴向旋转的时候，则提供了一个明显较大的活动范围(P < 0.05)。加用前路钢板者与正常者相比，两组在所有负荷方式下活动度都明显减少(P < 0.005)。加用后路内固定后，两组ROM则进一步明显地减少(P < 0.01)。椎体切除组和椎间盘切除组之间，在任何一种负荷方式下，无论是非内固定(P > 0.18)、前路钢板(P > 0.33)、或后路和前路内固定(P > 0.30)，其ROM都差异都没有统计学意义。
Conclusions. Less difference in stability was observed than was predicted between specimens receiving multilevel discectomy versus multilevel corpectomy, regardless of whether specimens were left unplated, plated anteriorly, or fixated with combined anterior/posterior instrumentation.
结论：标本接受多节段椎间盘切除与多节段椎体切除之间观察到的稳定性上的差异，比预想的要小，无论是没有进行钢板固定的标本，还是前路钢板或联合前后路内固定者都是如此。
Key words: biomechanics; cervical spondylosis; corpectomy; discectomy
关键词：生物力学；颈椎病；椎体切除术；椎间盘切除术
Evidence-Based Spine Surgery
循证脊柱外科学
[Health Services Research]
Resnick, Daniel K. MD
Abstract
Study Design. Literature review.
研究设计：文献综述。
Objective. To describe the state of the literature regarding the performance of lumbar fusion for low back pain due to degenerative disease of the spine.
目的：对脊柱退变引起的下腰痛进行腰椎融合的相关文献，就其现状作一描述。
Summary of Background Data. The effectiveness and costs associated with spinal surgery have been a topic of significant debate in both the popular press and professional literature.
背景资料概述：与脊柱手术相关的有效性和经济费用，无论在通俗读物还是在专业书籍中都已经成为一个很有争议的话题。
Methods. Evidence-based medicine techniques have been applied to many areas of spinal surgery. The results of these analyses are being used by practicing physicians, payors, and others to determine what procedures are appropriate for certain patient populations.
方法：循证医学的方法已经被应用到脊柱外科的很多领域。通过这一分析得出的结果，可使临床医生、付款人以及其他人决定什么手术适合那些病人。
Results. This manuscript describes the methodology, strengths, and weaknesses of evidence-based medicine approaches to spinal surgery. The case for lumbar fusion as a treatment for chronic low back pain due to degenerative disc disease is described as an example.
结果：这篇文章描述了脊椎外科中循证医学的方法、力度以及不足。这里所描述的将腰椎融合作为治疗由于椎间盘退变引起的慢性下腰痛的病例就是一个例子。
Conclusion. Evidence-based medicine is a useful tool for summarizing and grading the evidence available in the literature for or against a particular treatment strategy. Its utility is limited by the quality of the primary literature, and the absence of proof cannot be equated with the proof of absence.
结论：通过对文献中可用到的证据进行概述和分类，以支持或反对应用某一特定的治疗方案，对此，循证医学是一个有用的工具。其效用受原始文献质量的限制，且没有证据并不等于证据不存在。
Key words: spine surgery; evidence-based medicine; lumbar fusion; outcomes
关键词：脊椎外科；循证医学；腰椎融合；结果