先天性脊柱侧凸合并脊髓纵裂的临床特点及手术疗效

目的 :研究手术治疗先天性脊柱侧凸合并脊髓纵裂的患者的临床特点,评估其手术疗效及并发症发生情况。方法:回顾性分析2005年3月～2017年3月间我院收治并行手术治疗的先天性脊柱侧凸合并脊髓纵裂患者69例,其中女性41例,男性28例,平均年龄13.9±4.5岁(7～34岁)。所有患者术前均行全脊柱正侧位X线、CT及MRI检查,术后即刻及末次随访行全脊柱正侧位X线检查,测量影像学参数(主弯Cobb角、次弯Cobb角、主弯顶椎偏距、躯干偏移、胸椎后凸角及腰椎前凸角),分析先天性脊柱侧凸合并脊髓纵裂的影像学特点及临床表现,并评估脊柱侧凸矫形率及相关并发症[矫形率=(术前Cobb角-术后即刻Cobb角)/术前Cobb角]。结果:在69例脊髓纵裂患者中,单纯膜性纵裂50例,骨性纵裂4例,膜性合并骨性纵裂15例。合并椎板畸形38例,半椎体24例,肋骨畸形25例,37例同时存在其他椎管内畸形,椎管外畸形8例。临床表现主要有:背部毛发10例,跛行6例,腰背痛4例,截瘫2例。双下肢/双足异常8例,神经系统阳性体征20例。脊髓纵裂好发于下胸段及腰段,占72.4%(50/69),纵裂累及椎体节段平均为4.2±2.7个。所有患者中,1例在矫形前行骨嵴切除,余均未对纵裂做预防性切除,仅单纯行侧凸矫形内固定术。60例得到随访,随访率为86.9%。平均随访时间32.4±22.7个月(13～115个月)。术前主弯Cobb角平均为71.8°±29.4°,次弯Cobb角为46.4°±17.3°,胸椎后凸角为39.5°±36.1°,腰椎前凸角为50.4°±17.3°;主弯顶椎偏距为6.2±3.6cm,躯干偏移平均为2.8±3.0cm。术后即刻主弯Cobb角28.8°±21.6°,次弯Cobb角25.6°±14.5°,胸椎后凸角25.5°±19.1°,腰椎前凸角42.3°±15.4°;主弯顶椎偏距4.2±3.3cm,躯干偏移2.4±2.8cm,主弯顶椎旋转度所有患者术后即刻冠状位主弯矫形率为(59.9±22.0)%,末次随访时矫形率为(53.6±25.7)%。术后即刻与术前相比,主弯Cobb角、次弯Cobb角、胸椎后凸角、腰椎前凸角及主弯顶椎偏距均有明显统计学差异(P0.01),主弯顶椎旋转度及躯干偏移无明显统计学差异。末次随访时主弯Cobb角平均为33.3°±25.9°,次弯Cobb角为27.1°±16.9°,胸椎后凸角为25.1°±16.1°,腰椎前凸角为45.6°±17.6°;主弯顶椎偏距为4.9±6.0cm,躯干偏移平均为2.1±2.0cm,末次随访与术后相比,均无明显统计学差异(P0.05)。术后共6例出现神经系统并发症,发生率为8.7%,均为不完全神经损伤,无截瘫发生。内固定相关并发症3例,包括螺钉松动2例,内固定棒断裂1例。2例螺钉松动患者无任何临床症状,予以随访观察;1例内固定棒断裂患者手术翻修,未再次出现并发症。结论:先天性脊柱侧凸合并SCM手术治疗患者纵裂好发于下胸段及腰段,椎体畸形以混合型最多见;中下胸段肋骨畸形的伴发率最高。     

一期后路楔形截骨治疗青春期后严重先天性脊柱侧弯

[目的]介绍一期后路楔形截骨治疗青春期后严重的先天性脊柱畸形的安全操作及探讨其融合固定范围的选择.[方法]自2000年2月～2006年7月对16例青春期后严重的先天性脊柱侧弯采用一期后路楔形截骨内固定矫形.男10例,女6例;年龄16～29岁,平均21.4岁.其中单纯半椎体11例,半椎体合并对侧骨桥或肋骨融合5例,既往有脊柱矫正手术史者2例.术前脊柱侧凸Cobb' s角64°～108°,平均84.7°;脊柱后凸角28°～91°,平均52.6°;躯干偏移3～23.6 mm,平均15.4 mm.CT或MRI显示椎管内骨性分隔2例.[结果]手术时间平均231 min,术中出血平均1 400 ml.术后平均随访2年6个月.固定融合节段8～14个椎体,平均10.6个.侧凸Cobb' s角18°～47°,平均38.5°,平均矫正率54.5%;后凸Cobb' s角15°～40°,平均27.7°,平均矫正率47.4%;术后躯干偏移0～11.4 mm,平均为4.6 mm.侧、后凸和躯干偏移无明显矫正丢失.手术并发症包括术中椎弓根骨折2例;L1神经根损伤1例;肠系膜上动脉综合征1例;术后切口渗液1例.[结论]采用一期后路楔形截骨内固定治疗青春期后严重的先天性脊柱侧弯是一个安全、可靠的方法,矫形效果满意,远期疗效可靠.     

一期后路病灶清除植骨融合内固定矫形治疗伴后凸畸形的儿童胸腰段脊柱结核的临床初步报告

[目的]探讨经后路一期病灶清除、植骨融合内固定矫形治疗伴后凸畸形的儿童胸腰段脊柱结核的可行性及疗效.[方法]7例胸腰段脊柱结核患儿,均伴有后凸畸形.其中男5例,女2例;年龄9～12岁.术前脊柱后凸角为35°～45°,平均37.9°.Frankel分级:B级2例,C级3例,D级2例.采用经后路一期病灶清除、植骨融合加钉棒系统矫形固定治疗.[结果]术后随访27～42个月,平均34个月.切口均一期愈合,无1例结核复发.Frankel分级:4例恢复2级,3例恢复1级.术后后凸角为2°～9°,较术前明显改善,最后随访时后凸角为2°～12°,较术后无明显丢失.术后3个月血沉均恢复正常;所有患儿均获得满意的植骨融合.[结论]一期后路病灶清除、后方植骨内固定矫形手术治疗伴后凸畸形的儿童胸腰段脊柱结核是矫正后凸畸形和预防晚期后凸畸形发生的有效方法.     

后路单侧经椎弓根半椎体截骨治疗青少年先天性脊柱侧凸

目的评估后路经椎弓根截骨矫形部分半椎体保留治疗先天性半椎体所致脊柱侧凸畸形的临床疗效。方法共18例先天性半椎体合并脊柱侧凸患者纳入随访研究,平均年龄16.17岁（14～21岁）,术前测量半椎体所致脊柱畸形的节段性主弯Cobb角45.39°±6.81°,头侧代偿弯Cobb角27.5°±2.71°,尾侧代偿弯Cobb角为26.44°±6.85°,顶椎偏距为4.28±0.58cm,节段性后/前凸角度为14.11°±18.07°。所有病例均采用后路一期经半椎体椎弓根截骨,双侧固定矫正侧凸畸形。随访时间为14.17±6.56个月。综合评估影像学、临床疗效以及并发症的情况。结果手术时间为2.82±0.74h,术中失血量317.22±65.15ml。术后节段性主弯Cobb角为11.33°±4.68°,矫正34.06°±7.88°,末次随访14.61°±4.96°;头侧代偿弯Cobb角为8.72°±1.44°,矫正18.78°±3.17°,末次随访18.78°±3.17°;尾侧代偿弯Cobb角为7.98°±1.82°,矫正18.47°±5.83°,末次随访18.47°±5.83°;节段性后/前凸角为-1.94°±12.35°,矫正14.94°±10.18°,末次随访-1.5°±12.67°。顶椎偏距的矫正为2.31±0.52cm,末次随访2.1±0.24cm。术中没有血管、神经损伤、骨折等重大并发症发生,术后没有发生冠状面和矢状面的失代偿。结论后路半椎体经椎弓根截骨矫形能有效矫正轻、中度先天性半椎体所致脊柱侧凸畸形,缩短手术时间,创伤小,减少术中失血量,矫形效果满意,所选病例骨骼发育相对成熟者,避免矫形丢失。     

脊柱侧凸伴发Chiari畸形和(或)脊髓空洞的手术治疗

目的探讨伴发Chiari畸形和(或)脊髓空洞的脊柱侧凸的临床特征和治疗策略,并分析手术疗效。方法52例伴发Chiari畸形和(或)脊髓空洞的脊柱侧凸患者的治疗方案分三类:(1)单纯脊柱侧凸矫形手术(18例):对脊柱侧凸有手术矫形指征、伴发无明显神经损害的ChiariⅠ型畸形和(或)脊髓空洞者,行脊柱侧凸矫形手术;(2)单纯颈枕部手术(12例):对脊柱侧凸尚无手术矫形指征者,无论Chiari畸形和脊髓空洞是否存在神经损害,均行后路枕大孔扩大、C1后弓切除、硬脊膜成形术和脊髓空洞分流术;(3)颈枕部手术加脊柱侧凸矫形手术(22例):对脊柱侧凸有矫形手术指征、伴发的Chiari畸形和脊髓空洞有神经损害者,先行枕大孔扩大、C1后弓切除、硬脊膜成形术和脊髓空洞分流术,术后6个月再行脊柱侧凸矫形术。结果34例颈枕部手术患者中24例术前存在明显的神经损害,术后6个月内仅6例有轻度的神经功能改善。40例脊柱侧凸矫形手术患者中,Cobb角<90°者额状面平均矫正率为63%、矢状面后凸平均矫正率为80%;Cobb角>90°者额状面平均矫正率为49%、矢状面后凸平均矫正率为74%。随访6个月～5年,平均19个月,矫正率平均丢失6%。结论脊柱侧凸在伴发Chiari畸形和(或)脊髓空洞时不仅具有外科矫治性,而且可以获得与特发性脊柱侧凸类似的矫形效果。     

Fulcrum-bending像与伴发脊髓空洞或(和)Chiari畸形脊柱侧凸的手术治疗

[目的]探讨Fulcrum-bending(支点弯曲位)像对伴发Chiari畸形和(或)脊髓空洞的脊柱侧凸手术治疗的帮助及新思路,并分析手术疗效。[方法]18例伴发脊髓空洞和(或)Chiari畸形的脊柱侧凸患者的治疗方案分两组:(1)牵引后前后路联合脊柱侧凸矫形手术(6例):对脊柱侧凸有手术矫形指征、伴发无明显神经损害的Chiari畸形和(或)脊髓空洞者,先行Halo颅骨牵引,1周后行脊柱侧凸矫形手术;(2)直接行后路脊柱侧凸矫形手术(12例):术前拍Fulcrum-bending像,并根据其结果对脊柱侧凸进行矫形。[结果]6例牵引后手术患者Cobb’s角平均矫正率为61%;6例柔软型侧凸患者直接后路手术患者均未出现神经并发症,Cobb’s角平均矫正率为60%,且术前Fulcrum-bending像与术后Cobb’s角相接近;6例僵硬型侧凸患者中1例出现轻微神经损害情况,后逐渐恢复,Cobb’s角平均矫正率为52%,手术存在过度矫正。[结论]对无明显神经损害的伴发脊髓空洞或ChiariI型畸形的脊柱侧凸柔软患者,不必行术前牵引而直接行后路手术,且可以获得与牵引后前后路联合手术类似的矫形效果。     

合并Chiari畸形Ⅰ型和脊髓空洞症的脊柱侧凸与特发性脊柱侧凸影像学特征和矫形效果比较

目的 比较合并Chiari畸形Ⅰ型和脊髓空洞症的脊柱侧凸与特发性脊柱侧凸（IS）患者的影像学特征和矫形效果。 方法 回顾性分析2007年1月—2015年6月在昆明医科大学第二附属医院接受一期后路脊柱融合术治疗的合并Chiari畸形Ⅰ型和脊髓空洞症的22例脊柱侧凸患者资料（研究组）,并与年龄、性别、主弯位置、侧凸数量、冠状面影像学参数1∶1配对的22例IS患者（IS组）进行比较。记录所有患者手术时间、预估出血量、融合节段数、螺钉密度等。在手术前后站立位脊柱全长正侧位X线片上测量并计算冠状面影像学参数（主弯Cobb角、侧曲角、柔韧性、顶椎位置、冠状面平衡）、矢状面后凸角、胸椎后凸角（TK）、腰椎前凸角（LL）、矢状位垂直轴（SVA）、畸形角度比（DAR）、矫形率及矫形丢失率。 结果 所有手术顺利完成,研究组随访（6.2±1.2）年,IS组随访（6.2±1.1）年。2组患者手术时间、预估出血量、融合节段数、螺钉密度差异均无统计学意义（P ＞ 0.05）。2组患者手术前后影像学参数差异均无统计学意义（P ＞ 0.05）。所有患者均未发生螺钉松动、断裂、术后神经功能损伤等并发症。 结论 术前年龄、性别、主弯位置、侧凸数量、冠状面影像学参数相匹配的情况下,伴发Chiari畸形Ⅰ型和脊髓空洞症的脊柱侧凸患者与IS患者具有相似的矢状面影像学参数和主弯柔韧性,且在一期后路脊柱融合术治疗后可获得相似的矫形效果。     

前路Moss Miami器械矫形治疗特发性胸腰段或腰段脊柱侧凸

目的:评价MossMiami前路矫形系统对特发性胸腰段或腰段脊柱侧凸的手术效果。方法:对21例胸腰段或腰段特发性脊柱侧凸患者经前路胸腹联合入路行MossMiami矫形内固定,自体肋骨椎间植骨融合术。测量手术前后Cobb角以及躯干侧方位移。结果:Cobb角术前平均53°,术后平均5°,矫正率为90%。上方代偿性胸椎侧凸术前平均17°,术后矫正至平均5°。下方代偿性腰骶椎侧凸术前平均43°,术后自发矫正至19°。随访12~24个月,Cobb角平均丢失19.7°,胸腰段(T11~L1)术前平均前凸0.3°(0~4°),术后平均后凸3°(0~5°)。躯干侧方位移从术前平均26mm矫正至术后5mm。1例术后出现一侧下肢交感神经切断症状,2例术后并发气胸。无感染、截瘫及内固定失败等并发症发生。结论:MossMiami前路器械具有操作简单和低切迹的优点。棒的预弯、去旋转矫形、正确选择螺钉置入部位和椎间植骨可防止固定节段后凸畸形的形成。对Risser征小于4度的患者应密切观察上方代偿性胸椎侧凸进展情况。     

脊柱侧凸前路矫形固定术后椎间角的变化及下融合椎后滑移

目的探讨特发性脊柱侧凸前路矫形内固定术后椎间角的变化及下融合椎后滑移的发生情况。方法回顾性分析近4年来我院青少年特发性脊柱侧凸患者接受前路矫形内固定手术前后及随访时的X线片,对侧凸Cobb角、侧凸矫形率、躯干偏移、下融合椎旋转度、下融合椎相对于骨盆的倾斜度、椎间角及下融合椎后滑移等参数进行测量分析。结果50例患者符合入选标准,主侧凸位于胸腰段或腰段。手术前后主弯冠状面Cobb角分别为47.78°±9.39°和10.32°±8.50°,侧凸矫形率平均79.05%。手术前后下融合椎旋转度分别为1.54°±0.58°及1.06°±0.47°。手术前后下融合椎相对于骨盆的倾斜度分别为23.80°±7.91°和9.16°±9.46°。椎间角术前平均为3.72°±3.05°,Bending相上为-2.22°±5.85°,术后即刻为1.56°±5.97°,较术前明显改善(P=0.029);末次随访时为4.87°±7.95°,与术后即刻相比差异有统计学意义(P=0.038)。术后19例(38%)患者发生下融合椎后滑移,平均滑移距离(4.79±1.75)mm。发生与未发生后滑移的患者在术前顶椎旋转度及Bending相椎间角的差异均有统计学意义(P=0.047,0.033)。结论特发性脊柱侧凸前路矫形内固定术后椎间角较术前明显改善,但在随访时椎间角又逐渐增大。下融合椎后滑移的发生可能与术前顶椎旋转度及B     

Lenke1BN型青少年特发性脊柱侧凸后路三维矫形有限元模拟研究

[目的]利用建立的Lenke1BN型青少年特发性脊柱侧凸(adolescent idiopathic scoliosis,AIS)三维有限元模型,模拟后路三维矫形手术,并探讨选择不同下固定椎对矫形效果的影响.[方法]应用建立的Lenke1BN型AIS有限元模型,模拟后路全椎弓根螺钉固定三维矫形手术.具体约束加载如下:约束骶骨整体水平固定,参照文献在T1～L5各椎节分别施加模拟自身重力和肌肉因素的向下载荷,在固定节段凹侧模拟植入"椎弓根螺钉",并放入"预弯"矫形钛棒,在棒末端施加向凹侧的旋转力矩,使棒向凹侧旋转90°,模拟旋棒矫形;旋棒同时在顶椎区(T7～10)固定螺钉施加10 Nm的扭矩,模拟椎体直接去旋转矫形.上固定椎选择T4(上端椎+2),下固定椎分别选择T12(中立椎)、L1(稳定椎)和L2(稳定椎+1),比较三种固定方案的矫形效果.[结果]顺利完成加载模拟矫形,选择T12(中立椎)、L1(稳定椎)和L2(稳定椎+1)作为下固定椎模拟矫形后,上胸弯、主胸弯和腰分别矫正为:7.1°、7.4°、9.2°,6.4°、6.8°、8.3°和6.5°、7.2°、8.6°;矢状面胸椎后凸(T5～12)分别为21.3°、20.7°和20.5°;三种矫形方案,矫形效果无显著差异.[结论]首次通过有限元模拟研究表明:对于中度Lenke1BN型AIS,选择性融合主胸弯可获得满意的腰弯自发矫正;应用全椎弓根螺钉固定结合顶椎区椎体去旋转技术,可将下固定椎从稳定椎上移至中立椎,减少远端融合节段.     

Perioperative and long-term morbidity and mortality after above-knee and below-knee amputations in diabetics and nondiabetics

We performed a retrospective review of a vascular surgery quality assurance database to evaluate the perioperative and long-term morbidity and mortality of above-knee amputations (AKA, n = 234) and below-knee amputations (BKA, n = 720) and to examine the effect of diabetes mellitus (DM) (181 of AKA and 606 of BKA patients). All patients in the database who had AKA or BKA from 1990 to May 2001 were included in the study. Perioperative 30-day cardiac morbidity and mortality and 3-yr and 10-yr mortality after AKA or BKA were assessed. The effect of DM on 30-day cardiac outcome was assessed by multivariate logistic regression and the effect on long-term survival was assessed by Cox regression analysis. The perioperative cardiac event rate (cardiac death or nonfatal myocardial infarction) was at least 6.8% after AKA and at most 3.6% after BKA. Median survival was significantly less after AKA (20 mo) than BKA (52 mo) (P < 0.001). DM was not a significant predictor of perioperative 30-day mortality (odds ratio, 0.76 [0.39-1.49]; P = 0.43) or 3-yr survival (Hazard ratio, 1.03 [0.86-1.24]; P = 0.72) but predicted 10-yr mortality (Hazard ratio, 1.34 [1.04-1.73]; P = 0.026). Significant predictors of the 30-day perioperative mortality were the site of amputation (odds ratio, 4.35 [2.56-7.14]; P < 0.001) and history of renal insufficiency (odds ratio, 2.15 [1.13-4.08]; P = 0.019). AKA should be triaged as a high-risk surgery while BKA is an intermediate-risk surgery. Long-term survival after AKA or BKA is poor, regardless of the presence of DM.     

Postoperative nausea and vomiting and opioid-induced nausea and vomiting: guidelines for prevention and treatment

Postoperative nausea and vomiting (PONV) causes patient discomfort, lowers patient satisfaction, and increases care requirements. Opioid-induced nausea and vomiting (OINV) may also occur if opioids are used to treat postoperative pain. These guidelines aim to provide recommendations for the prevention and treatment of both problems. A working group was established in accordance with the charter of the Sociedad Espa?ola de Anestesiología y Reanimación. The group undertook the critical appraisal of articles relevant to the management of PONV and OINV in adults and children early and late in the perioperative period. Discussions led to recommendations, summarized as follows: 1) Risk for PONV should be assessed in all patients undergoing surgery; 2 easy-to-use scales are useful for risk assessment: the Apfel scale for adults and the Eberhart scale for children. 2) Measures to reduce baseline risk should be used for adults at moderate or high risk and all children. 3) Pharmacologic prophylaxis with 1 drug is useful for patients at low risk (Apfel or Eberhart 1) who are to receive general anesthesia; patients with higher levels of risk should receive prophylaxis with 2 or more drugs and baseline risk should be reduced (multimodal approach). 4) Dexamethasone, droperidol, and ondansetron (or other setrons) have similar levels of efficacy; drug choice should be made based on individual patient factors. 5) The drug prescribed for treating PONV should preferably be different from the one used for prophylaxis; ondansetron is the most effective drug for treating PONV. 6) Risk for PONV should be assessed before discharge after outpatient surgery or on the ward for hospitalized patients; there is no evidence that late preventive strategies are effective. 7) The drug of choice for preventing OINV is droperidol.     

Body composition assessment and methodology in nonathletic and athletic adolescent and adult males and females

The purpose of this review is to outline methodology for assessing body composition utilizing anthropometric and densitometric techniques. The objective of body composition assessment is to measure body fat and lean body mass. The quantity of these components varies due to growth, physical activity, dietary regimens, and aging. Anthropometric techniques incorporate selected skinfolds, circumferences, skeletal widths, or other variables to estimate body composition within k2.0-4.0%. These techniques are adequate for field testing of groups or individuals, but are population specific. Densitometry measures body volume irrespective of physique, sex, or age. This laboratory technique estimates body composition within 1.0-2.0%, is more difficult to administer, but is not population specific. Some limitation exists with any present technique due to biological variability and incomplete research of reference body composition in children, females, and the aged. J Orthop Sports Phys Ther 1984;5(6):336-347.