一個50年腰痛病史的故事

  一位苗條，受過良好教育的77歲女士，身著典雅的洋服和淡妝，優雅地走進了診室。她說她有慢性腰痛，自從她25歲在懷孕第一個孩子到現在 (77-25= 52年)。

（疼痛指數視覺擬量表“ VAS”：0至10分; 0 =無痛，10 =極度痛）

 在她三十幾歲（約 1960年代），（疼痛指數：8至10分），她曾一度因持續折騰的背痛臥床不起四年，無法做任何事，除了躺在床上。這一事件過後，背痛下降到一個可容忍的程度（疼痛指數：4至6分），她可以恢復正常的日常活動，甚至找到工作，直到她六十幾歲退休。當然，她偶爾會因背痛請病假。
52年 腰痛的盤旋，直到今天，她生活如常（疼痛指數：2至5分）：購物，旅遊，家務事，照顧孫兒，等等。 。

問：“在先前那些痛苦的年間，你有沒有考慮過手術，以減輕背痛？

答：“從來沒有。”

問：“為什麼？”

答：“我不敢接受手術。”

問：“你現在感覺如何？”

答：“我很好。背痛已經是我的一部分；它困擾，但我可以應付。”

       她的腰椎正位X光顯示退行性脊柱側彎 15度左右。

腰椎磁共振矢狀 T2的影像顯示 : 顯著的椎間盤退變，從腰1 - 2至腰5 -骶1的椎節，與Modic變化。

此案例顯示，遇到一個慢性腰痛病史50年的病人，這是對任何醫生都是一個非常難得的機會與體驗。

 雖然她的病史，有點是逸事性的，但是從影像來看，它確定是一個椎間盤源性下背痛 （discogenic low back pain）的病例。 椎間盤源性腰痛，此醫學術語: 椎間盤源性腰痛（discogenic low back pain），可能是衍生於僅不過25年前從亨利克羅克醫師( HV Crock) 的假設 : 間盤內部破裂（1986年）。在這 25年間，手術治療椎間盤源性下腰痛的蓬勃發展：如椎間盤內電熱療法（IDET），Neulecoplasty（髓核成形術 : 射頻），人工椎間盤置換術（ADR, artificial disc replacement)，髓核置換術，經皮激光(雷射) 椎間盤切除，椎體間融合，小關節置換，等等。

 此網頁有非常平衡的關點，值得一看(抱歉，是英文)，是關於上述各種侵入性治療下背痛的療效。

我們從這位女士學到了什麼？

1。至目前還沒有針對於椎間盤源性下背痛長期的縱向研究（超過 10年）。一個對疾病自然病史的必要研究;

2。長期使用保守的治療，似乎結果樂觀，至少在一定比例的患者（即：時間可以愈合）;

3。我們對椎間盤源性腰痛的本質與病理機轉知道得太少，但手術治療方式卻太多;

4。因此，椎間盤源性腰痛的各種手術治療方式，包括已經淘汰的，目前流行的，還是新發展的，它們都存有許多可以討論空間;

5。這位女士是明智的。

 目前一項動物試驗：以注射方式達成脊柱融合術，這是否是對椎間盤源性腰痛的未來治療方式的選擇之一？我們且拭目以待。

Mozart The Magic Flute Queen of the Night Aria (莫札特 魔笛 夜之后 詠嘆曲, Lucia Popp)

 

A Tale of 50 years' Low Back Pain

A slender, well-educated 77 years old lady, in elegant dress and light make-up, walked gracefully into the clinic room. She said she already had chronic low back pain since 25 years old during pregnancy of her first baby until now. 

(Visual Analog Scale "VAS": 0 to10 points; 0= no pain, 10= extremely painful) 

  At her 30's (around 1960s), due to agonizing persistent backache (VAS: 8 to 10), that she had been bedridden for 4 years and was unable to do anything except lying in bed. After that episode, backache decreased to an extent of tolerable (VAS: 4 to 6) and she could resume normal daily activities, even found a job until retirement at her 60's; of course, she had sick leave once in a while due to backache.  
  Low back pain lingers for 52 years until today, and she is doing well (VAS: 2 to 5): shopping, touring, housekeeping, taking care grand children, and so on. . 

Q: "Did you ever consider surgery to alleviate backache at one time in all those painful years? 
A: "Never."  
Q: " Why?"
A: " I was afraid of surgery."
Q: "How do you feel now?" 
A: " I am doing well. Backache is already part of me, it bothers but I can cope." 

 Her lumbar anteroposterior radiography show degenerative scoliosis about 15 degrees.

Lumbar MRI sagittal T2 image shows significant disc degeneration from L1-2 to L5-S1 levels, and Modic changes.

 
 This case demonstrates that it is a very rare chance for any physician who may encounter a case of chronic low back pain for 50 years. 
  Although her clinical history may be anecdotal, but from the image findings, it suggests that it is definitely a case of discogenic low back pain.  Amazingly, the terminology of discogenic low back pain (LBP) is possibly derived only 25 years ago from the Henry Crock's hypothesis of Internal disc disruption (1986). In these 25 years, the surgical treatments for discogenic LBP are flourishing: intradiscal electrothermal therapy (IDET), Neulecoplasty (Bipolar RF/”Coblation”), artificial disc replacement (ADR), nucleus replacement, percutaneous laser discectomy, interbody fusion, facet replacement, and so on.    
  
   This web page is very well-balanced and must see, regarding the efficacy of above mentioned interventional treatments for LBP.


 What did we learn from this lady?
1. There is no long-term longitudinal study (more than 10 years) for discogenic LBP. A real regret;

2.  Long-term outcomes using conservative measures seem optimistic, at least for a certain portion of patients (read: time heals);

3. We knew too little about the nature of discogenic LBP but do too much;
4. therefore, various surgical modalities for discogenic LBP, whether the already phased-out ones, currently popular, or the new-comers, they all leave something to be desired;
5. The lady is wise.

  Is this: Injectable spinal fusion, one of the future options? We shall see.

    

母親節

 每個人都在慶祝母親節。它仍然是我的工作日子。偶爾片刻的回憶母親的臉，是我的慶祝方式。

 想想在加護病房的病人：她50歲出頭'，單身，沒有母親可慶祝連她自己也不是，她唯一的兄弟也無視於她（在施行心肺復甦術時，她的哥哥 在電話中回答說：“我兩個晚上沒有睡，我要去洗澡。“）。她幾乎不屬於這個世界：沒有人要她，除了少數的不那麼親密的朋友（或說同情者比較恰當）和兩位醫生。令人驚訝的是，她曾被五個醫生拒絕，他們不想處理這個麻煩的病案：胸椎9- 10節化膿性脊椎炎:

 胸十椎體已被破壞，僅剩三分之一 (箭頭)；脊髓神經被感染組織壓迫，兩下肢麻木無力。

  錐心背痛持續3個月，幾近癱瘓，腎衰竭接受血液透析洗腎，糖尿病，四根腳趾頭已截肢，高血壓，名下沒有一分錢，不理她的手足，只剩一個苦痛腐爛的軀殼，和一個哭泣的靈魂。她曾經孤獨的被留置在急診室一個星期。

心痛。

 術後，昏迷前，至少，她曾有30小時的希望和喜悅，她高興著抬起恢復力量的雙腳，寄望不久後能走路，並成為一名導遊。但美夢很快變成了無盡的噩夢。 

  不，也許她寧可留住在她甜美的夢裡，不想醒來面對這個殘酷的，不確定的世界。


母親節快樂。

Mother's Day

  Everybody's celebrating Mother's day. It is still a working day to me. A short moment of recalling mother's face once in a while is my way of celebration. 

 Think about the patient in ICU: at her early 50s', single, no mother to celebrate not even herself, disregarded by her only sibling (at the moment of CPR, her brother replied "I didn't sleep for two nights and I am going to take a shower."). She was almost not belong to this world: nobody cares about her except a handful of not-so-close friends (sympathizers at best) and two doctors. Amazingly, she had been denied by five surgeons that they didn't want to take care of this troublesome case: T9-10 pyogenic spondylodiscitis, 

T10 vertebral body was destructed and only 1/3 left (arrow); spinal cord was compressed by infected tissues.

near paralyzed, persistent backache for 3 months, renal failure underwent hemodialysis, diabetes, 4 toes had been amputed, hypertension, not a penny to her name but a rotten body with agonizing pain and a weeping soul).  She once had been left alone in ER for one week.

A Heartache. 

 Postoperatively and before comatose, at least, she had 30 hours of hope and joy that she raised her once paralyzed legs, and talked happily about she could walk again and wanted to be a tour guide; but the sweet dream shortly turned into an endless nightmare. 
  No, perhaps she is rather staying in her sweet dream and does not want to wake up to face this cruel and uncertain world.

Happy Mother's Day.

How Many Surgical Options for Degenerative Spondylolisthesis?

1. Decompression: laminectomy, laminotomy (bilateral, or uni-lateral with bilateral decompression), laminoplasty, indirect decompression.
2. Fusion with or w/o instrumentation: posterolateral, PLIF, ALIF, Lateral fusion, TLIF.
3. Non-fusion: dynamic stabilization, inter-spinous process device (IPD).
4. Cage: cylindrical, rectangular (single or pleural); Materials: titanium, PEEK, carbon-fiber, tantalum, ceramic,
5. Graft materials: autograft, allograft, DBM, BMP, 
6. Did I miss anything..

The menu list goes on.

Cage Migration of Lumbar Interbody Fusion Cage

  Just heard a buzz from a representative of German Spine company that titanium lumbar cage is revived in Europe instead of PEEK cage. That, titanium cage has less incidence of migration than PEEK cage.

Cage protruded posteriorly. L5-S1 PLIF Ti Cage + pedicle screw,

  Talking about pull out force of both materials , it is understandable from this paper: "The titanium cage pull out force was significantly (P=0.0002) higher compared to both radiolucent cage constructs."
 No wonder, the hearsay may be true of higher incidence of PEEK cage migration.
  Even you make a bigger footprint of PEEK cage, migration is still likely :"The larger footprint radiolucent cage did not increase stability as compared to the standard footprint."

PEEK stand-alone cage at L3-4 level; the cage migrated persistently inside the space  eroding the vertebrae and resulted in a big defect (red arrow). The 58 y/o male was disabled then cured by other method.

  Supplemental posterior instrumentation is not even a safeguard to prevent migration of PEEK cage.
  Fortunately, this case report used lateral access, and the cage migrated to lateral side, no sequel occurred. The authors are thinking about solution of putting a lateral plate with screws to prevent the cage slip away.

  Posterior migration may result in disaster, either titanium or PEEK are alike.

Functional Analgesic Discography (FAD), what happened?

 Functional Analgesic Discography (FAD), a once promising successor of provocative discography (PD) in diagnosing discogenic low back pain. PD, the already bruised gold standard, has been beaten by Dr. Carragee to half dead and stays at the intensive care unit at this moment. For surgeons and radiologists alike, we almost lost a strong persuader to lure the patients into the operating or radiology rooms.

 FAD is a simpler test than PD that you inject anesthetic agent into the suspected disc, then ask the patients whether their chronic, daily agonizing low back pain has been decreased or gone. If so, lumbar interbody fusion surgery then may be indicated.
 Curiously, the FAD  clinical trial had been withdrawn prior to enrollment, dated Sept. 15, 2010.
 What happened?
 Here, if the news of withdrawn was true, I would like to do a mini-autopsy of this still-born yet important functional test, based on my personal experience of FAD in last 6 years:
 1. in relatively hydrated discs (young patients), the anesthetic agent may be contained inside the nucleus and cannot reach the annulus or bony endplates which have rich yet abnormal innervation (presumed to be the pain sources), hence no analgesic effect occurs;
 2. the amount of anesthetic agent injected may be another one of the important factors;
 3. leakage of the anesthetic agent into the spinal canal may result in false-positive outcomes;
 4. pain provocation does not occur in advanced dessicated discs, as opposed to their findings;
5.  a certain percentage of false-negative FAD proved otherwise by the later successful interbody fusions.

Anesthetic Discography in an 81 years old gentleman. Contrast inside the disc (red arrow).

FAD, like PD has certain limitations. It is a regret that they withdrew the clinical trial. There would have been an interesting and useful (with reservation) report.

P.S. the abbreviation: FAD is an unlucky one, according to urban dictionary: a thing that becomes very popular in a short amount of time, and then is forgotten at about the same speed.

DYNAMIC STABILIZATION?

 DYNAMIC STABILIZATION? 

Dynamic stabilization: A flexible rod in place of a solid metal rod.

 It means: you want to stabilize the lumbar spine (the segment which would have been fused), at the same time, you want to maintain mobilization (of the adjacent normal segment).
 Paradoxical, isn't it? No wonder the US FDA banned this fantastic, heavenly idea: thou shalt not have the best of both worlds.

Dynamic Stabilization:" I am screw, but I have a beautiful, wavy, flexible waist and can do mambo that no other screws can."

FDA: "You look like a screw, taste like a screw, smell like a screw, feel like a screw, so you must be a screw, you have to act like a screw. No mambo here, sorry."  

dynamic stabilization system implanted.

Europeans are more open-minded and optimistic than the die-hard American who can't enjoy the good things in life, as I see it.
 On the other hand, dynamic stabilization of nowadays seems to be a revived zombie (Graf system), or face changing .  

Semi-rigid device. Wider screw holes at each end of the plate which allow motions for upper and lower vertebrae.

The Mother of all Dynamic Stabilization. Graf Device: An elastic band looping around the screws.

  
The basic issue is still there: the pedicle screw. A screw is a screw is a screw. Period.
  Dynamic stabilization is intended to decrease the incidence of adjacent segment disease in which rigid pedicle screw instrumentation is the main culprit. If rigid is bad, then soft must be good, as long as the logic is as such simple. History showed that semi-rigid device failed, Graf system was long gone; are we expecting an almost-doomed-to-fail newly bottled good-old idea to do magic-- surgeons and patients both live happily thereafter forever?
  Screw caused problem cannot be solved by a new screw. In the end, history always repeats itself until we wake up.

脊椎骨釘 (椎弓根螺釘) 疾病 Pedicle Screw Disease

脊椎骨釘 (椎弓根螺釘) 疾病
  脊椎骨釘，是一個繼哈靈頓棒(Harrington rod) 用來矯正脊柱側彎後的偉大創新，它是強有力的脊柱固定物。由於其提供足夠的剛性，脊椎骨釘已成功用於治療脊柱骨折，畸形，脊柱轉移瘤等。脊椎骨釘是治療許多從頸到腰椎的脊椎疾病中不可或缺的武器。

  但不幸的是，脊椎骨釘使用在腰椎退行性疾病卻又是另一回事。此外，在脊椎上安置脊椎骨釘是一個技術熟練上要求度很高的手術，並存有高發生率的併發症(54%)。
讓我們來看看美國FDA(食品藥物管理局) 在1998年對椎弓根螺釘的裁決： ``警告：脊椎骨釘其 安全性和有效性僅適用於 .. ..顯著不穩定的退行性滑脫合併神經損傷，脊椎骨折，脫位，脊柱側彎，脊柱後凸，脊椎腫瘤，和以前的融合術失敗（造成假關節)。其安全性和有效性..使用在其他脊椎疾病時不明。'' ``注意事項：脊椎骨釘 .. ..只能由經專門培訓，有經驗的外科醫生使用.. ..這是一個技術上要求度很高的手術，亦對病人有造成嚴重傷害的風險。''

 今天全球的外科醫生廣泛使用脊椎骨釘，幾乎到一個輕率的程度，特別是在退行性腰椎疾病。 12年後，我們有足夠的研究文獻，來瞭解脊椎骨釘使用於病患，會有發生率高達54％，嚴重程度不一的併發症：
1。深部感染：超過 4％。據一位同仁，他曾在一個大醫院的脊椎部門待過，他說，深部感染發生率約6％，超過文獻的統計報告，有些是災難性的，導致四肢癱瘓或下半身癱瘓，甚至死亡。
2。永久性神經根損傷：2.3％
3。錯位的骨釘：11-20％

4。背部肌肉損傷

5。後期背痛，需要取出骨釘：23％
6。鄰近節段病變，需要再次腰椎手術。 （骨釘上一節之原本正常節段發生病變）：手術五年後發生率為16.5％，十年後發生率升到36.1％，即十年後有三分之一的病人需要再次腰椎手術。
  
另一篇研究發現，使用脊椎骨釘發生有症狀的鄰近節段病變比率較高（12.2-18.5％）；相比較，不使用脊椎骨釘或使用其他類固定物，此群患者，鄰近節段病變的發生率較低（5.2-5.6％）。

左: 經腰椎骨釘固定後深部感染，傷口分離。右: 大量膿液流蓋住神經管。(慈濟陳世豪醫師提供)

62歲女士，經脊椎骨釘固定術後五年，腰 1-2節 發生鄰近節段病變。箭頭顯示不穩定。

70歲男士，因下背痛兩年經脊椎反覆手術四次，包括一次深部感染(腰 2-3節) ，胸12-腰1節發生鄰近節段病變，骨釘全部鬆脫。。

 上面顯示的可怕且嚴峻的科學數據，是否說明我們需要重新考慮審慎使用脊椎骨釘，尤其是用在腰椎退化疾患。

 

Pedicle Screw Disease

  Pedicle screw, one of the great innovations in spinal implants since Harrington rod  for correction of scoliosis. It has been used successfully in treating spinal fracture, deformities, and spinal metastasis, thanks to its provided rigidity.  Pedicle screw is indispensable in some spinal disorders from top to bottom of the spine.

  But unfortunately, its use in lumbar degenerative disorders is anther story. Also, pedicle screw placement is a technically demanding procedure with a high complication rate. Let's take a look at U.S. FDA's ruling of pedicle screw in 1998:

``Warning: The safety and effectiveness of pedicle screw ..only for.. significant mechanical instability...degenerative spondylolisthesis with..neurologic impairment, fracture, dislocation, scoliosis, kyphosis, spinal tumor, and failed previous fusion (pseudarthrosis). The safety and effectiveness..for any other conditions are unknown.'' ``Precaution:..pedicle screw..performed only by experienced..surgeons with specific training..this is a technically demanding procedure presenting a risk of serious injury to the patient.'' 

 Globally, surgeons have used pedicle screw to an extent of indiscretion (excuse me, folks, I am not pointing the finger at you.)  especially at the degenerative lumbar spines.

12 years later, we have enough literature regarding complications of pedicle screw,  of varying severity in 54% of the patients:

1. deep infection: more than 4%. According to my associate, Dr. SH Chen, who once worked at a gigantic spine unit, he said the actual infection rate was around 6%, higher than the reported statistics; some were devastating, resulting in quadriparesis or paraplegia, even death.

2. permanent nerve root Injury: 2.3% . crippled.

3. Misplacement of screw: 11-20% , some were inside the spinal canal.

4. Back muscle injury: weakness of the back.

5. Late backache requiring screw removal: 23%

6. Adjacent segment disease (ASD):  16.5% at five years and 36.1% at ten years, requiring additional surgery.

The rate of symptomatic ASD is higher in patients with transpedicular instrumentation (12.2–18.5%) compared with patients fused with other forms of instrumentation or with no instrumentation (5.2–5.6%)

(Left) Deep infection after pedicle screw fixation, Wound Dehiscence .  Right: Pus flew out flooding all over the dura sac. (Courtesy of Dr. SH Chen)

Angulation of L1-2 level (ASD), fortunately no nerve injury. 62 years lady.

T12-L1 ASD, 70 years old male, crippled, underwent 4 spine surgeries in 2 years, including once for deep infection. T12-L1 ASD, screw penetrating the disc and all screws were loosened.

 

The sad and grim scientific evidences shown above indicate that we need to rethink the use of pedicle screw, particularly in degenerative lumbar vertebrae.

Note: I invented the term: Pedicle Screw Disease, all rights reserved (joke). 

國際脊柱視訊會議，羅馬和台北。後感

台灣一向幾乎是醫療科技產業與技術的淨輸入國，輸出的多是量多價低的醫藥器材的產品，如病床，外國已失專利時效的藥品等。這次國際脊柱視訊會議向歐洲醫生展示的全是台灣本身研發並握有世界專利的脊椎產品與手術概念，其中第一位德國講者是在講她使用台灣出口的脊椎注射器，另兩位國外講者(印尼與香港)亦同，我則是介紹我個人設計的經腰側路腰椎間融合椎籠 。
  林智一先生曾提到要取得台灣衛生署證照的困難與辛酸。幾年的向衛生署的反覆申請與答辯完全沒下文。最後得到衛生署證照是一夕之間，在一經濟部舉辦的發展台灣生物科技研討會上，林智一先生特別向經濟部高級官員抱怨取得台灣衛生署證照的困難。此官員立即找來衛生署商榷，後不旋踵即發放許可證照。
 這讓我想到在台灣申請專利案時我本身的事例 。台灣專利局拿出兩項台灣專利說我的申請案與前二者相似而不欲與給專利。我看過它們提出的兩項台灣專利後發現，怎麼會拿皮球與橘子來比擬? 顯然台灣專利局審查人似未詳查兩者的差異，只注意到都是圓的。再看同一案在歐盟專利局它們的提出疑問就相當切題，並同時幫申請人寫出一兩項專利申請案內未書及，而對申請人有利的專利範圍。日本專利局則是對本國人寬鬆，對外國人極度嚴謹，在在是及時保障其本國人，以取得經濟優勢。
   取得專利與商品化完全是兩回事，再好的專利概念若不能商品化，提升生活上的便利，那不過是一張讓自己高興的證書而已。歐盟專利局亦對專利申請。。。再補上，做工去。。。

Live Lateral fusion Surgery for Malaysian Doctors & XLIF

  The Malaysian doctors encountered some trouble when performing XLIF (NuVasive).  They flied to Taipei and wanted to know what was the difference between XLIF and my designed cage using lateral access.
  They were told by XLIF Co. that stand-alone XLIF cage was effective. Also, by elevating the disc height, posterior spinal stenosis might  be relieved (so called indirect decompression) and no need to do decompression.
 My replies were: 
1. stand-alone cage has been shown that it cannot control extension and rotation. This biomechanical fact has been repeated in several papers, unless XLIF rectangular cage has some secret stabilizing mechanism built-in (a case report of XLIF cage migration).  I am wondering whether NuVasive says the same to all western surgeons including Asian ones.
2. Indirect decompression by using cage to elevate disc height is a wishful thinking. I would like to say that decompression procedure is such a simple job. Why not spend a little time to do it and go home sleep tight? Instead of leaving the decompression to the cage, and worrying about the actual outcome?
  They said it took about an hour to setup the whole operating set including probing the nerves inside the psoas muscle before starting lateral fusion procedure. I was joking that when you finish the setup, I had already left the operating table and sipping a cup of espresso. 
  Even they used neuromonitoring, patients still had paresthesia of the thigh.  Some most recent papers show that there was no safe zone or narrow margin of safety for the nerves when performing trans-psoas approach. The most secure way is to retract the psoas muscle and use the muscle to protect the nerves. 
  I told them my principle: respect the anatomy, don't burn the bridge, you or others may have to go back again.

Implanting Fusion Cages in Pig's Vertebrae.

Meet Henry (if presumed male) or Mary, the lab guys did not know the sex, or they kept it as confidential to protect him/her.

Pig has 5 to 7 lumbar vertebrae.  Interestingly, implanting lumbar fusion cage (much smaller ones than in human lumbar interspace, the size is similar to cervical cage for human) is not as difficult as I once thought.  The approach is my preferred one: lateral access. Using this approach, there was not much bleeding, but the psoas muscle had to be transected in order to expose 3 to 4 levels of lumbar discs. The caudal disc (above sacrum) could not be accessed due to obstruction by the pelvis.  But in human, the last lumbar disc can be accessed laterally after mobilizing the great veins, plus other tricks.
  To my surprise, those pigs who had the psoas muscle transected did not have lumbar nerve injury occurred. Unlike human, the opposite is true. All those pigs survived well after cage implantation, without limp, life was as usual: eat, hanging around, and sleep, but no sex, all were castrated. But they seemed to have a short period time of melancholy, possibly due to surgical pain.
  Pig's lumbar disc heights are pretty narrow, may be less than 5 mm. Also the axial surface is more elongated, unlike the oval shape of human disc. The AP diameter may be only 1/2 of transverse diameter.

Axial view of pig's lumbar disc

Implanting the cage in is a difficult task, because of the narrow disc height. Wedge osteotomy has to be done in order to get the curet inside the disc space and clean out disc material. Complete discectomy is difficult not to mention decortication. It seems that only lateral 1/2 or 1/3 of discectomy can be done. Cage insertion is another challenge that you have to use force to punch the cage in. Metal cage is fine but PEEK cage has to be careful not to break it during hammering.

3 months follow-up X-ray. No idea if fused or not.

    Sacrificing the pig and take the lumbar column out is a new experience.  This only happens in autopsy which surgeons rarely do. Fortunately, it is not my routine work. The lab did not provide the necessary tools (chisel, osteotome), the column had to be transected using hand saw.

國際脊柱視訊會議，羅馬和台北，2011年4月16日

2011年4月16日
國際脊柱視訊會議，羅馬和台北， 

 4月16日下午2時至7時（台北時間) (羅馬時間:上午9時至下午2點），我們舉辦了羅馬和台北之間的國際脊柱視訊會議。主辦機構為 MOVINGTECH，這是一個新興的歐洲脊柱產品公司，位於羅馬，意大利。 CEO Diego先生（Diego Pizzicaroli）是一個聰明，幽默，富有雄心，誠實的紳士，連同他的勤奮工作人員: Giuseppe Tricarico 先生，秘書小姐Daniela Pellegrino 等; Sabatino Vittorio 先生因工作疲勞未能參加，很遺憾，祝他早日康復。
  此次五小時的學術脊柱視訊會議圓滿完成。國際與會者來自德國，意大利，印尼，香港和台灣。總共有18個專業醫生; 在歐洲方面（意大利，羅馬)，有15個著名的德國和意大利的教授和脊椎外科醫生參加了會議（他們從德國和意大利不同城市到羅馬）;  在亞洲這一面（台北，台灣），有三個演講者：印尼Bambang Darwano 醫生，香港（William Lu教授，香港大學）和我（瀚群骨科醫療中心）。

印尼醫生Bambang （左)，香港大學盧教授（中），我（右），

，林先生（站立）和他的秘書辛迪。

  本次會議的主題是向歐洲醫生介紹和展示台灣的脊柱新產品：Vessel-X，Vessel-lock，活性骨水泥（以鍶元素為基礎）由台灣林智一先生發展，和我自己設計的腰椎椎間融合器 Latero。 
  第一位發言者是博士Jaqeline Repman（Diego先生的配偶，一個經驗豐富的德國骨科醫生），她敘述使用Vessel-X在治療骨質疏鬆性椎體骨折經驗，Vessel-X有一多孔囊袋以避免骨水泥滲漏造成的神經損傷。我是第二個發言者，介紹Latero的設計概念基於簡單物理學，並與類似產品SynFix（Synthes公司，瑞士）在生物力學測試(由慈濟陳世豪醫師施行) 結果上相比較，與Latero其臨床上用於腰椎融合的表現。印尼Bambang Darwano 醫生談到有關Vessel-lock在穩定和治療因多節骨質疏鬆椎體壓迫性骨折造成脊柱後凸畸形，臨床的滿意結果。盧教授介紹以鍶元素（Sr，與鈣元素幾乎相同）的生物活性水泥，他豐富的動物實驗的研究資料，令人印象深刻 ; 此活性骨泥可以跟人骨相生長，以減少傳統骨水泥（PMMA ，聚甲基丙烯酸甲酯）的缺點與併發症。  
  所有議程都準時開始與結束，就如同在一個正式的國際會議。在問答部分很熱絡，一位德國籍翻譯女士從旁協助。雙方的聲音都能清楚地聽到並回答，無異於我們都坐在同一個房間使用麥克風。 

視頻會議現場一景。該助理：德籍翻譯（中間女士）， MediaPlus兩位女士（左，右）。

  當我們看幾個最常見的脊椎手術種類，椎體成形術 vertebroplasty（或後凸成形術 kyphoplasty)，與腰椎椎間融合術 lumbar interbody fusion，兩者是經常使用的，由於全球老齡化社會。這兩種手術有很多來自不同公司的醫療產品，欲達到同樣的目標: 緩解疼痛，改善生活品質。然而，此兩種手術的併發症並不少見，且可能導致災難性的後果。為了盡量減少併發症和保護病人，新的，安全的，並經證明的醫療產品是醫病兩者的急需。
 本次國際視訊會議展示了新的方法來治療: 骨質疏鬆性的腰椎壓縮性骨折，和腰椎退化疾病需要椎間融合的兩方面新產品。我們都希望將來有更多的視訊會議，在未來繼續作學術溝通和意見交流，在不同的國家同步討論，以節省越洋飛行的費用和時間。 

   最後，我要感謝 Diego 先生與同仁的策劃與辛勞，印尼Bambang Darwano 醫生和香港大學 William Lu教授飛到台北參加此次國際視訊會議會議，與台中慈濟骨科主任陳世豪醫師的加入。