经椎旁肌间隙入路椎弓根钉棒系统置入内固定治疗胸腰椎爆裂骨折:与传统方法比较

背景:采用经椎旁肌间隙入路应用于胸腰椎爆裂骨折的手术治疗实现了经椎旁肌间隙入路行椎弓根钉棒植入及整复固定。目的:比较经椎旁肌间隙入路与传统后正中入路手术治疗胸腰椎爆裂骨折的临床疗效。方法:纳入53例无明显神经损伤且后凸大于20°和/或椎体前缘高度塌陷大于50%的胸腰椎爆裂骨折患者。分别采用经椎旁肌间隙入路(n=28)及传统后正中入路(n=25)进行治疗。结果与结论:与传统后正中入路比较,经椎旁肌间隙入路治疗的患者疼痛目测类比评分明显降低(P<0.05),而在伤椎Cobb角改善、椎体前缘高度恢复和椎管正中矢径变化方面两组差异无显著性意义(P>0.05)。说明经椎旁肌间隙入路内固定治疗胸腰椎爆裂骨折可以达到与传统后正中入路治疗相同的效果,且可促进患者功能恢复。     

椎弓根螺钉椎旁肌间隙与后正中入路内固定修复胸腰椎骨折：稳定性比较

背景：脊柱后路手术是胸腰段椎体骨折最常用的治疗方法,传统后路手术显露过程中,大范围椎旁肌的剥离和牵拉,容易发生腰椎手术失败综合征。 目的：比较椎弓根螺钉椎旁肌间隙入路与传统后正中入路内固定修复胸腰椎骨折的复位情况及稳定性。 方法：对62例无神经损伤胸腰椎骨折的患者进行回顾性分析,采用椎旁肌间隙入路并GSS内固定系统治疗22例,传统正中入路并GSS内固定系统治疗21例,传统正中入路并AF内固定系统治疗19例。通过比较3组患者的手术时间、术中出血量、术后引流量、术毕切口内残腔体积、腰背痛目测类比评分、切口并发症、伤椎高度、Cobb角等各项临床指标,对比3种内固定方案的治疗效果。 结果与结论：3组患者手术时间、术中出血量、术毕切口内残腔体积、内固定后引流量比较,椎旁肌间隙入路并GSS内固定组优于传统正中入路并GSS内固定组及传统正中入路并AF内固定组（P〈0.05）。3组内固定后3 d椎体高度、Cobb角比较,差异无显著性意义（P〉0.05）。腰痛目测类比评分内固定后1周3组差异无显著性意义（P〉0.05）,内固定后3,6个月椎旁肌间隙入路并GSS内固定组明显低于传统正中入路并GSS内固定组及传统正中入路并AF内固定组。3组患者均未见切口感染。提示椎旁肌间隙入路显露方式与传统后入路显露方式比较,具有创伤小,出血少,术后恢复快、患者满意度高等优势,GSS内固定系统与AF内固定系统修复胸腰椎骨折内固定效果相近,但GSS内固定系统操作简单,具有省时、出血量少、固定牢靠和复位良好的优点,结合椎旁肌入路,是目前修复胸腰段脊柱骨折较好的方法之一。     

经肌间隙入路病椎置钉联合中药内服治疗胸腰段椎体骨折临床观察

目的:观察经肌间隙入路病椎置钉联合中药内服治疗胸腰段椎体骨折的临床效应。方法:将41例胸腰段骨折患者随机分为对照组(19例)和治疗组(22例),2组均采用经肌间隙入路病椎置钉技术,治疗组配合身痛逐瘀汤内服治疗。比较2组术前、术后及末次随访时伤椎矢状面Cobb角、椎前缘相对高度、疼痛视觉模拟评分(visual anaglogue scale,VAS),评估阳性体征、腰背痛、活动障碍等恢复总体疗效。结果:术后与术前比较,2组患者伤椎前缘相对高度、椎体局部Cobb角、VAS比较,差异均有统计学意义(P0.01);治疗组与对照组比较,VAS降低明显,差异有统计学意义(P0.05);末次随访与术后比较,两组差异均无统计学意义(P0.05);2组患者阳性体征、腰背痛、活动障碍等症状,恢复明显,治疗组总体疗效达100%,效应显著。结论:经肌间隙入路病椎置钉术治疗胸腰段骨折临床疗效确切,且联合中药改善术后疼痛及促进功能恢复更为显著,值得发展、应用。     

Wiltse入路与传统后正中入路手术治疗胸腰段椎体骨折的临床比较研究

目的探讨胸腰段椎体骨折经Wiltse入路与传统后正中手术入路置入椎弓根螺钉棒系统的临床治疗效果,并进行比较。方法选骨外科收治并实施手术的单节段胸腰椎骨折患者47例,入院后随机分为两组进行手术治疗。Wiltse入路组25例,传统后正中入路组22例,均在入院1周内应用椎弓根钉棒系统行椎体骨折复位内固定手术。记录并分析、比较两组不同入路的手术效果、伤椎Cobb角纠正率、VAS评分法评估切口区域腰背痛的疼痛程度、血清中骨骼肌损伤的标志物肌酸激酶(CK)含量、术后复查MRI显示的多裂肌副损伤程度的情况指标。结果两组在伤椎Cobb角纠正率比较中无显著差异(P0.05);Wiltse入路组手术时间、术中患者创面渗血量、术后引流管引流计量、腰背痛VAS评分均低于传统后正中入路组,差异有统计学意义(P0.05);Wiltse入路组CK值及术后1年MRI评分亦明显低于传统后正中入路组,差异有临床统计学意义(P0.05)。结论胸腰段椎体骨折经Wiltse入路置入椎弓根螺钉棒系统可减少椎旁肌的副损伤,有效避免多裂肌的瘢痕变性,缩短手术时间,减少手术出血量,明显减轻术后慢性腰背痛,且操作简单,值得在临床上推广应用。     

经皮入路与经肌间隙入路行胸腰椎骨折手术的疗效对比

目的:对比胸腰椎骨折经皮入路与经肌间隙入路行椎弓根螺钉内固定治疗的疗效。方法:选取2017年2月～2018年2月收治的需行椎弓根螺钉内固定治疗的70例胸腰椎骨折患者,按照手术入路不同分为经皮组和经肌间隙组,各35例。经皮组采用微创经皮入路椎弓根螺钉内固定治疗,经肌间隙组采用经肌间隙入路椎弓根螺钉内固定治疗。对比两组手术及术后情况,手术前后腰背部疼痛评分、伤椎椎体前缘高度及后凸Cobb's角。结果:经肌间隙组手术时间短于经皮组,术中透视次数少于经皮组(P<0.05);经皮组切口长度短于经肌间隙组,术中失血量少于经肌间隙组(P<0.05);两组住院时间比较无显著性差异(P>0.05);两组术后2周及术后1年伤椎椎体前缘高度较术前显著升高,后凸Cobb's角较术前减小,腰背部疼痛评分较术前显著降低(P<0.05),但两组术后伤椎椎体前缘高度、后凸Cobb's角及腰背部疼痛评分比较无显著性差异(P>0.05)。结论:微创经皮入路及经肌间隙入路椎弓根螺钉内固定术治疗胸腰椎骨折各有优势,在具体临床实践中应综合考虑术者习惯与经验以及患者意愿,选择合理的手术入路。     

跨伤椎固定与经伤椎固定治疗胸腰段脊柱骨折的对比研究

目的比较跨伤椎固定与经伤椎固定治疗胸腰段脊柱骨折的疗效。方法根据随机数字表方法将2016年1月~2017年6月收取的68例胸腰段脊柱骨折患者分为观察组和对照组各34例。对照组采用跨伤椎固定,观察组采用经伤椎固定。比较两组患者手术平均操作时间、手术中平均出血水平、术后平均留院时间、胸腰段脊柱骨折恢复优良率和术后并发症发生率,并对比两组患者术前和术后半年Cobb角、椎体前缘高度、椎体后缘高度、JOA评分。结果观察组胸腰段脊柱骨折恢复优良率明显高于对照组(P0.05);观察组术后并发症率明显低于对照组(P0.05);观察组患者手术平均操作时间、手术中平均出血水平、术后平均留院时间均明显低于对照组(P0.05)。术前两组患者的Cobb角、椎体前缘高度、椎体后缘高度、JOA评分比较无显著性差异(P0.05),手术后半年两组患者Cobb角、椎体前缘高度、椎体后缘高度、JOA评分均显著改善(P0.05),但其中观察组改善幅度更大(P0.05)。结论胸腰段脊柱骨折采用经伤椎固定效果优于跨伤椎固定,可更好恢复椎体高度和Cobb角,改善腰椎功能,减少并发症,减轻手术创伤,加速术后康复进程。     

椎旁肌入路复位治疗胸腰椎骨折临床疗效观察

对22例无须椎管减压的胸腰椎骨折患者行内固定治疗,其中经椎旁肌入路12例(经椎旁肌入路组),传统正中后入路10例(传统后正中入路组),比较2组手术相关指标(手术时间、术中出血量、术后引流量)、手术前后相关影像指标(Cobb角改变、椎体前缘高度恢复情况)及患者疼痛程度。结果手术均顺利,所有患者均随访12~18个月,X线片显示骨折复位及内固定良好,无内固定松动、断裂,植骨融合。椎旁肌入路组手术时间、术中出血量及术后引流量明显低于传统后正中入路组(均P﹤0.05);2组患者术前、术后及术后1年椎体前缘高度、Cobb角变化比较差异无统计学意义(均P0.05);术后1、2、3d椎旁肌入路组疼痛程度低于传统后正中入路组(均P﹤0.05),术后1w2组疼痛程度差异无统计学意义(均P0.05)。经椎旁肌入路具有入路简单、术中创伤小、出血少、术后恢复快等优点。     

短节段椎旁入路经伤椎椎弓根钉治疗胸腰段骨折疗效分析

目的探讨短节段椎旁入路经伤椎椎弓根钉治疗胸腰段骨折的适应证、手术方法及固定效果。方法对30例胸腰段压缩性骨折和轻中度爆裂性骨折患者行短节段椎旁入路经伤椎椎弓根钉固定,统计手术时间、术中出血量及随访情况。结果所有患者手术均顺利完成,手术时间（75．3±12．5）min,术中出血量（168．1±25．6）mL。术后后突畸形得以矫正,椎体高度接近正常。所有患者随访9-32个月,均取得良好的复位效果。术后6个月以上复查X线片均证实骨折愈合,内固定无失效。结论短节段椎旁入路经伤椎椎弓根钉治疗胸腰段压缩性骨折和轻中度爆裂性骨折创伤小、复位固定效果满意。     

伤椎单侧与双侧置钉治疗胸腰段椎体骨折的比较研究

目的对比研究胸腰段椎体骨折伤椎单侧与双侧置钉的临床疗效。方法回顾分析2012年6月至2015年5月对胸腰椎骨折患者采用伤椎单侧(5钉组)和双侧置钉(6钉组)技术治疗86例(5钉组45例,6钉组41例)。分析对比组内及组间术前、术后、末次随访时的矢状位Cobb角、伤椎前缘高度和椎管内骨折复位情况;评估术前和术后VAS评分和ODI指数。结果两组患者性别、年龄、损伤节段和损伤类型、TLICS评分、椎体前缘高度和矢状位Cobb角差异无统计学意义。两组患者手术时间和出血量差异无统计学意义。末次随访时5钉组椎体前缘高度(23.1±4.3)mm、Cobb角11.7°±5.4°、VAS(1.4±0.9)、平均ODI(16.5%);6钉组椎体前缘高度(23.0±4.0)mm、Cobb角11.4°±3.4°、VAS(1.5±0.7)、平均ODI(17.2%);两组间差异无统计学意义(P>0.05)。6钉组出现2例骨折块复位不全,但两组差异无统计学意义(P>0.05)。结论对A型和部分B型胸腰段椎体骨折而言,伤椎单侧置钉技术同双侧置钉技术一样,可以有效地维持复位后伤椎的高度,维持胸腰段脊柱序列。     

椎旁肌间隙入路固定联合椎体内植骨治疗胸腰椎骨折疗效

目的:探讨椎旁肌间隙入路椎弓根钉固定联合椎体内植骨治疗胸腰椎骨折患者的疗效。方法:选取2016年12月～2018年2月收治的胸腰椎骨折患者106例,根据手术入路不同分为研究组与参照组,各53例。研究组行椎旁肌间隙入路椎弓根钉固定联合椎体内植骨治疗,参照组采用传统入路椎弓根钉固定联合椎体内植骨治疗,比较两组手术相关指标(手术时间、术中出血量),手术前后伤椎前缘高度比、疼痛程度及Cobb's角。结果:研究组手术时间短于参照组,术中出血量低于参照组(P<0.05);术后12个月两组患者伤椎前缘高度比大于术前,疼痛评分低于术前,Cobb's角小于术前,且研究组术后伤椎前缘高度比大于参照组,疼痛评分低于参照组,Cobb's角小于参照组(P<0.05)。结论:椎旁肌间隙入路椎弓根钉固定联合椎体内植骨治疗胸腰椎骨折患者可缩短手术时间,减少术中出血量,有效修复伤椎,降低患者疼痛程度。     

Guns and Knives in New Mexico: Patterns of Penetrating Trauma, 1978–1993

Objective: To identify patterns of nonfatal and fatal penetrating trauma among children and adults in New Mexico using ED and medical examiner data.
Methods: The authors retrospectively sampled in 5-year intervals all victims of penetrating trauma who presented to either the state Level-1 trauma center or the state medical examiner from a 16-year period (1978–1993). Rates of nonfatal and fatal firearm and stabbing injury were compared for children and adults.
Results: Rates of nonfatal injury were similar (firearm, 34.3 per 100,000 person-years; stabbing, 35.1). However, rates of fatal injury were significantly different (firearm, 21.9; stabbing, 2.7; relative risk: 8.2; 95% confidence interval: 5.4, 12.5). From 1978 to 1993, nonfatal injury rates increased for children (p = 0.0043) and adults (p < 0.0001), while fatal penetrating injury remained constant. The increase in nonfatal injury in children resulted from increased firearm injury rates. In adults, both stabbing and firearm nonfatal injury rates increased.
Conclusions: Nonfatal injury data suggest that nonfatal violence has increased; fatal injury data suggest that violent death rates have remained constant. Injury patterns vary by age, mechanism of trauma, and data source. These results suggest that ED and medical examiner data differ and that both are needed to guide injury prevention programs.     

Systematic Reviews Published in the January 2011 Issue of The Cochrane Library

ABSTRACT

The Cochrane Library of Systematic Reviews is published quarterly as a DVD and monthly online. The January 2011 issue (first quarterly DVD for 2011) contains 4515 complete reviews, 1985 protocols for reviews in production, and 13,521 one-page summaries of systematic reviews published in the general medical literature. In addition, there are citations of 641,000 randomized controlled trials, and 14,018 cited papers in the Cochrane methodology register. The health technology assessment database contains over 9300 citations. One hundred and seven new reviews have been published in the last 3 months, of which five have potential relevance for practitioners in pain and palliative medicine.     

Interprofessional approaches to creating safe,high quality health care

Three supplementary perspectives are presented arguing that interprofessional collaboration is both necessary and desirable. Nonetheless, there are often too many serious intra-professional barriers and obstacles to interprofessional collaboration to make it successful. Some of these barriers, it is argued and illustrated, are found in the multiple ways in which professional identity is tacitly acquired and embodied in the practitioners' habitual, everyday practice. The paper then explores ways in which reflection, especially Second order reflection, can help to elucidate and overcome these obstacles, as well as increasing professional adaptability and competence.     

Prise en charge des entorses externes de cheville : étude clinique préliminaire sur l’efficacité du dispositif Myolux™

Ankle sprains are the most common injury of the musculoskeletal system and are associated with significant societal and economic impacts. It has been proven that classical therapeutic strategies may not be effective in preventing recurrent injuries: the recurrence rates reported in the literature can reach 73%. In order to provide an effective rehabilitation solution, a destabilizing orthosis was developed. This device is equipped with a mechanical articulator reproducing the subtalar mechanics and placed under the heel. In this paper, we present the main results of a preliminary clinical study conducted between 2004 and 2007. All subjects included in this study were treated with the abovementioned orthosis during 10 rehabilitation sessions of 30 minutes each. Data show a relatively low recurrence rate of 12% for the overall population. Moreover, it's of primary importance to note that this satisfactory ratio is largely reduced (3% of recurrence rate) for the 29 patients who performed one training session per month after the 10th initial rehabilitation sessions. Hence, the destabilizing orthosis appears to be an effective solution to prevent recurrent ankle sprains. However, joint protection requires long-term and regular training sessions. This result has motivated the development of a similar device allowing patients to perform training sessions at home. Finally, data obtained in this study are promising awaiting the final results of the comparative, multicentric and independent clinical trials currently managed by the Hospices Civils de Lyon.     

Determination of creatine kinase isoenzyme MB activity in serum using immunological inhibition of creatine kinase M subunit activity. Activity kinetics and diagnostic significance in myocardial infarction.

This is a new method for the determination of creatine kinase isoenzyme MB activity in serum. The method uses direct activity measurement of creatine kinase B subunit activity after blocking of CK-M subunit activity by inhibiting antibodies. The test takes no longer than 15 min. The method yields an intra-serial C.V. of 2.0-12.9%, and a C.V. from day to day of 5.5%. The detection limit is 3.4 U/l creatine kinase MB. In the 95 cases with proven myocardial infarction several types of creatine kinase MB activity kinetics could be determined. The percentage of creatine kinase MB of peak CK-total is 6-25%, with a mean of 11.1%. The amount of creatine kinase MB with respect to total CK activity after reinfarction is higher than the amount after initial infarction.     

俯卧位通气对高海拔地区肺复张治疗无效急性呼吸窘迫综合征患者氧合的影响

目的 探讨俯卧位通气对高海拔地区肺复张术(RM)治疗无效急性呼吸窘迫综合征(ARDS)患者的治疗作用.方法 从海拔2260m的地区医院筛选RM治疗无效的41例ARDS患者[平均氧合指数( PaO2/FiO2)较RM前升高＜20％视为RM无效],依不同病因分为肺内源性ARDS组(ARDSp组)和肺外源性ARDS组(ARDSexp组),每组再按信封法随机分为俯卧位组和仰卧位组,即ARDSp俯卧位组(11例)、ARDSp仰卧位组(9例)、ARDSexp俯卧位组(10例)、ARDSexp仰卧位组(11例).在通气前及通气1、2、3、4h监测动脉血氧分压( PaO2)、PaO2/FiO2、静态顺应性(Cst)、气道阻力(Raw)的变化.结果 通气lh时,ARDSexp俯卧位组PaO2/FiO2( mm Hg,l mm Hg=0.133 kPa)即较通气前显著升高(157.4±40.6比129.3±48.7,P＜0.05),并随通气时间延长呈持续增高趋势,4h达峰值(219.1 ±41.1);且ARDSexp俯卧位组通气3h内PaO2/FiO2较其他3组显著增高,另3组间则差异无统计学意义.ARDSp俯卧位组、ARDSexp俯卧位组通气4h时PaO2/FiO2均较相应仰卧位组显著增高(208.8±39.7比127.4±47.1,219.1±41.1比124.9±50.8,均P＜0.05).4组通气前后Cst无显著改变,各组间差异也无统计学意义.ARDSp俯卧位组通气4h时Raw(cmH2O·L-1·s-1)较通气前显著降低(6.8±1.7比10.7±1.8,P＜0.05),且明显低于其他3组;其他3组各时间点Raw组内及组间比较差异均无统计学意义.结论 俯卧位通气作为ARDS机械通气重要策略之一,可以改善RM无效高原ARDS患者的氧合,为抢救患者赢得宝贵的时间.     

Digital imaging among medical facilities

The Department of Veterans Affairs (VA) in the USA operates a network of 172 medical centres which all utilize a hospital information system (HIS) which has been developed and is currently maintained by the VA. During the past several years, an image management and communication module has been developed, installed and clinically utilized at the Washington DC and Maryland VA Medical Centres. This image management and communication system, referred to as the decentralized hospital computer program (DHCP) imaging system, is fully integrated with a commercial picture archiving and communication system (PACS). The system is utilized to capture, archive, and display all images generated within the hospital including radiology, nuclear medicine, pathology, endoscopy, bronchoscopy, and dermatology, intraoperative photographs, ECG data, and a limited number of paper documents. The ultimate goal of the project is to have all patient text and image data available at any clinical workstation to any authorized user anywhere within the network of medical centres. Clinical requirements for an imaging workstation include ease of use, rapid and reliable access to the complete set of patient information, and images which are of acceptable quality to meet the requirements of the user and the subspecialty. Patient confidentiality and data security must be safeguarded at all times. Integration of the images with the remainder of the patient's database was found to be critical to the success of the project. The experience at the Washington and Maryland facilities suggests that an imaging system that is successfully integrated with a hospital information system can provide substantial clinical and economic benefits both within and among medical centres. Clinical acceptance and utilization of the system has been excellent, particularly in diagnostic radiology where DHCP Imaging has been interfaced to a commercial PAC system. Based upon this initial experience, the VA has begun to deploy the system throughout its large network of medical centres.     

Myocardial elastography at both high temporal and spatial resolution for the detection of infarcts

Myocardial elastography is a novel method for noninvasively assessing regional myocardial function, with the advantages of high spatial and temporal resolution and high signal-to-noise ratio (SNR). In this paper, in-vivo experiments were performed in anesthetized normal and infarcted mice (one day after left anterior descending coronary artery [LAD] ligation) using a high-resolution (30 MHz) ultrasound system (Vevo 770, VisualSonics Inc., Toronto, ON, Canada). Radiofrequency (RF) signals of the left ventricle (LV) in longitudinal (long-axis) view and the associated electrocardiogram (ECG) were simultaneously acquired. Using a retrospective ECG gating technique, 2-D full field-of-view RF frames were acquired at an extremely high frame rate (8 kHz) that resulted in high-quality incremental displacement and strain estimation of the myocardium. The incremental results were further accumulated to obtain the cumulative displacements and strains. Two-dimensional and M-mode displacement images and strain images (elastograms), as well as displacement and strain profiles as a function of time, were compared between normal and infarcted mice. Incremental results clearly depicted cardiac events including LV contraction, LV relaxation and isovolumetric phases in both normal and infarcted mice, and also evidently indicated reduced motion and deformation in the infarcted myocardium. The elastograms indicated that the infarcted regions underwent thinning during systole rather than thickening, as in the normal case. The cumulative elastograms were found to have higher elastographic SNR (SNR(e)) than the incremental elastograms (e.g., 10.6 vs. 4.7 in a normal myocardium, and 6.0 vs. 2.4 in an infarcted myocardium). Finally, preliminary statistical results from nine normal (m = 9) and seven infarcted (n = 7) mice indicated the capability of the cumulative strain in differentiating infracted from normal myocardia. In conclusion, myocardial elastography could provide regional strain information at simultaneously high temporal (>/=0.125 ms) and spatial ( approximately 55 microm) resolution as well as high precision ( approximately 0.05 microm displacement). This technique was thus capable of accurately characterizing normal myocardial function throughout an entire cardiac cycle, at the same high resolution, and detecting and localizing myocardial infarction in vivo.