单纯性腰椎管狭窄症手术方法比较

目的 比较单纯性腰椎管狭窄症的手术方法，并介绍棘突截骨椎管成形术的临床应用。方法 对48例单纯性腰椎管狭窄症患者分组进行椎板切除术，椎板开窗术和棘突截骨椎管成形术，术后进行Oswestry疗效评分和影像学观察。结果 术后1年疗效优良率椎板切除组为81.9%，椎板开窗组为79.7%，椎管成形组为82.1%，疗效优良率各组无显著差别，术后4年疗效优良率椎板切除组为74.3%，椎板开窗组为78.2%。椎管成形组为80.4%。术后4年椎板切除组疗效下降显著，椎板开窗组和椎管成形组疗效下降不显著，术后1年所有患者X线检查未显示腰椎不稳定，术后4年X线显示有5名患者腰椎不稳定或退行性滑脱，其中椎板切除组3例，椎板开窗组和椎管成形组各1例。结论 椎板切除术，椎板开窗术，椎管成形术治疗单纯性腰椎管狭窄，3组术后近期疗效均满意，术后中期评估表明椎管成形术和椎板开窗术优于椎板切除术，后者腰椎不稳定和交界处再狭窄发生率较高。     

全椎板切除椎管扩大成形术治疗腰椎管狭窄症

目的　设计并临床应用全椎板切除减压椎管扩大成形术治疗腰椎管狭窄 ,观察其疗效。方法　全椎板切除去除狭窄因素 ,彻底减压 ,棘突椎板复合体旋转 90°横架于减压处 ,重塑椎管 ,术后随访 ,复查腰椎 CT。结果　随访 32例患者中 ,优良率 96 .9% ,未发生术后腰椎不稳及医源性椎管狭窄 ,取得较满意效果。结论　该术式弥补了椎板切除术的不足 ,操作简便易行     

改良椎管成形术在腰椎管狭窄症的疗效观察

目的探讨改良椎管成形术治疗腰椎管狭窄症的临床疗效,及其对术后腰椎稳定性的影响。方法自2013-05-2015-02手术治疗74例腰椎管狭窄症患者:对照组38例采用传统的全椎板切除减压术;观察组36例采用改良椎管成形术治疗,术中以薄骨刀进行椎板截骨,待减压操作完成后,将截除的椎板及韧带予以回植,从而尽量保留了脊柱后柱结构的完整性。结果两组患者术后随访24-35个月,观察组回植的棘突椎板连接处均顺利愈合,愈合时间为6-12个月,平均8.7个月;其椎管矢状径、横径与术前相比,有明显增加(P0.05)。末次随访时,两组患者腰痛、下肢痛的VAS评分以及JOA评分均较术前有显著改善(P0.05)观察组末次随访时的腰痛VAS评分显著优于对照组(P0.05)。对照组有3例发生腰椎滑脱、2例发生腰椎不稳,总发生率为13.2%;观察组无一例腰椎不稳或滑脱现象。结论与传统全椎板切除减压术相比,采用改良的椎板棘突复合体截骨、原位回植椎管成形术式治疗腰椎管狭窄症,其疗效可靠,有利于进一步缓解腰部疼痛、维持腰椎术后的稳定性。     

自体椎板-棘突复合体回植腰椎管扩大成形术在基层医院的应用

目的观察自体椎板-棘突复合体(即患者病变节段椎板、棘突及其间韧带作为自体椎板-棘突复合体,以下简称复合体)回植腰椎管扩大成形术的疗效及实用性。方法采用后正中切口,切取复合体,去除狭窄因素,彻底减压,再将复合体侧向旋转90°回植减压处,重塑椎管后壁,使腰椎管扩大成形。术后随访,复查CT。结果随访28例,优良率96.43%,未发生术后椎管狭窄及腰椎不稳,临床效果满意。结论本术式显露好、减压充分、回植的复合体固定方便牢固、愈合快,弥补了全椎板切除的不足,重塑并扩大了椎管,符合生物力学原理,减少了瘢痕粘连,无异物反应,未增加患者副损伤和经济负担,值得基层医院临床推广。     

椎管扩大成形治疗腰椎管狭窄症长期疗效观察

目的 :介绍一种椎板减压后椎板棘突复合体翻转 90°回植椎管成形术治疗腰椎管狭窄症的方法 ,评价其在治疗腰椎管狭窄症中的应用效果。方法 :对 33例腰椎管狭窄症患者采用全椎板复合体切取后 ,翻转 90°回植重建椎管后壁的方法进行治疗 ,分别于术前、术后 1年及术后 5年进行下腰痛JOA评分及影像学检查。结果 :33例患者均获得随访 ,术后 3个月复查CT示 :椎管成形术后 ,椎管扩大显著 ,大部分椎板棘突复合体已与周围骨质完全融合固定 (88% )。术后 1年时下腰痛评分较术前有显著性差异 ,术后 5年评分与术后 1年无显著性差异。结论 :椎板棘突复合体回植椎管成形术有利于脊柱稳定性的重建 ,减少硬脊膜疤痕粘连的机会 ,椎管扩大明显 ,长期疗效肯定 ,值得临床推广使用。     

退行性腰椎滑脱合并腰椎管狭窄症的手术策略和方法

目的 :评估椎管成形术、椎板减压融合术、减压融合固定术治疗退行性腰椎滑脱合并腰椎管狭窄症。方法 :16例稳定性腰椎滑脱患者接受棘突截骨椎管成形术 ,15例不稳定性腰椎滑脱患者接受椎板减压加后外侧融合术 ,14例不稳定性腰椎滑脱患者接受椎板减压椎间融合经椎弓根内固定术。术后进行疗效评分和影像学观察。结果 :术后 1年功能改善率 :椎管成形术为 85 .7% ,减压融合术为 84.8% ,固定融合术为 86.2 % ,各组疗效无显著差别 (P >0 .0 5 )。术后 4年功能改善率 :椎管成形术为 84.9% ,减压融合术为 75 .6% ,固定融合术为 84.6% ,减压融合术疗效下降显著 (P <0 .0 5 )。结论 :椎管成形术治疗稳定性腰椎滑脱 ,术后近中期疗效与影像学评估满意。椎板减压后外侧融合术治疗不稳定性腰椎滑脱 ,腰椎假关节发生率较高和术后中期疗效明显下降。椎板减压椎间融合内固定治疗不稳定性腰椎滑脱 ,术后中期疗效无明显改变     

椎板复合体后移椎管扩大成形术治疗腰椎管狭窄症

目的了解椎管扩大成形术治疗腰椎管狭窄症的效果,探讨腰椎管狭窄症的治疗方法。方法分别对15例不同类型的腰椎管狭窄症患者进行棘突、椎板及韧带复合体切除并后移固定,使椎管容积扩大,从而使神经组织充分松解,根据神经受压范围决定椎板后移个数,腰椎后部结构基本保留原有状态。结果术后随访6个月～5年,平均30个月,按日本骨科协会下腰痛JOA评分标准,术后及末次随访治疗改善率分别为84.6%及78.3%,未发现症状明显复发及椎体滑脱病例。结论椎管扩大成形术是目前治疗腰椎管狭窄症比较有效的方法,尤其在减少术后瘢痕粘连、症状复发、维持脊柱稳定性及防止脊柱退变方面优势明显。     

带蒂复合体回植成形术治疗腰椎管狭窄症

带蒂复合体回植成形术治疗腰椎管狭窄症张丙磊，戚大春，朱晓东治疗腰椎管狭窄症多采用椎板切除减压术。近年来，许多学者注意到椎板切除是导致术后腰椎不稳的重要原因之一，另外椎板切除造成的椎管后壁缺损处疤痕组织增生粘连，可导致医源性椎管狭窄。我们自１９９２年开...     

改良骨刀截骨椎板棘突复合体回植治疗腰椎管狭窄症

目的分析改良骨刀截骨椎板棘突复合体回植治疗腰椎管狭窄症的疗效。方法腰椎管狭窄症患者56例,所有患者均采取改良骨刀截骨椎板棘突复合体回植治疗,复查CT,测量术前及末次随访的椎管矢状径、椎管横径,观察预后及并发症,并按照日本骨科学会下腰痛评分标准(Japanese orthopaedics asso ciation,JOA)评价临床疗效。结果 56例患者末次随访时椎管矢状径、椎管横径均较术前明显扩大;JOA评分较术前明显提高,差异有统计学意义(P0.05);临床疗效优良率为96.43%;所有患者CT复查显示,椎板原位融和率为100%,无腰椎不稳、继发性腰椎管狭窄症、椎板棘突复合体移位、下陷、脱落等并发症;6个月基本达到骨性愈合。结论改良骨刀截骨椎板棘突复合体回植治疗腰椎管狭窄症疗效确切,可有效重建腰椎后部结构的稳定性、完整性,减少并发症发生。     

棘突截骨椎管成形术治疗退行性腰椎疾病

目的采用棘突截骨椎管成形术治疗退行性腰椎疾病,术后进行临床与影像学评估。方法术式为后正中切口,显露一侧椎板后在棘突基底部截骨,并将棘突-韧带-骶棘肌推离对侧椎板,完成全椎板显露。切除椎板上、下缘和黄韧带,并潜式扩大中央椎管和神经根管或摘除椎间盘。应用此术式治疗退行性腰椎管狭窄症、腰椎间盘突出合并发育性腰椎管狭窄症、腰椎间盘中央型突出钙化、腰椎黄韧带骨化患者共37例。其中单节段减压24例,两节段减压13例。术后进行Oswestry疗效评分与影像学观察。结果术后1年随访34例,疗效优良率为82.4%;术后3年随访27例,疗效优良率为81.5%。术后CT显示椎管直径明显增加,棘突截骨愈合率为87%。结论棘突截骨椎管成形术操作简单,手术并发症少,对腰椎后柱张力带结构破坏小,主椎管和侧椎管减压充分,是治疗退行性腰椎疾病疗效较为满意的一种术式。     

Vasopressor hormone response following mesenteric traction during major abdominal surgery

Background : We investigated the vasopressor hormone response following mesenteric traction (MT) with hypotension due to prostacyclin (PGI₂) release in patients undergoing abdominal surgery with a combined general and epidural anesthesia. Methods : In a prospective, randomized, placebo-controlled study we administered 400 mg ibuprofen (i.v.) in 42 patients scheduled for abdominal surgery. General anesthesia was combined with epidural anesthesia (T4-L1). Before as well as 5, 15, 30, 45, and 90 min after MT we recorded plasma osmolality, hemodynamics and measured 6-keto-PGFlα (stabile metabolite of PGI₂), TXB₂ (stabile metabolite of thromboxane A₂) active renin, and arginine vasopressin (AVP) plasma concentrations by radioimmunoassay. Catecholamine levels were assessed by high-pressure liquid chromatography (HPLC) with electrochemical detection. Results : Following MT, arterial hypotension occurred along with a substantial PGI₂ release. This was completely abolished by ibuprofen administration. Although plasma levels of 6-keto-PGF_1α (1133 (708) vs. 60 (3) ng/L, median (median absolute deviation), P=0.0001, placebo vs. ibuprofen) remained significantly elevated, blood pressure was restored within 30 min after MT in the placebo group. At the same point in time plasma concentrations of TXB² (164 (87) vs. 58 (1) ng/L, P=0.0001), epinephrine (46 (33) vs. 14 (6) ng/L, P=0.001), AVP (41 ± (18) vs. 12 (7) ng/L, P=0.0004), and active renin (27 (12) vs. 12 (4) ng/L, P = 0.001) were significantly higher in placebo-treated patients. Conclusion : Under combined general and epidural anesthesia arterial hypotension following MT due to endogenous PGI₂ release is associated with enhanced release of AVP, active renin, epinephrine and thromboxane A₂, presumably contributing to hemodynamic stability within 30 min after MT.     

A comparison of the inhibitory effects of four volatile anaesthetics on the metabolism of chlorzoxazone, a substrate for CYP2E1, in rabbits

Background: Halothane inhibits in vitro and in vivo activity of cytochrome P-450 (CYP) 2E1. There are several fluorinated volatile anaesthetics besides halothane, and most of them are defluorinated by CYP2E1. It is unclear whether other fluorinated anaesthetics inhibit the in vivo activity of CYP2E1.
Methods: We compared the inhibitory effects of therapeutic concentrations of four inhalational anaesthetics, halothane, enflurane, isoflurane, and sevoflurane, on chlorzoxazone metabolism in rabbits receiving artificial ventilation.
Results: All four inhalational anaesthetics decreased arterial blood pressure and increased plasma chlorzoxazone concentration. However, no significant differences in the plasma chlorzoxazone concentration were found between the four anaesthetics. The estimated chlorzoxazone clearance increased after beginning inhalation with all four agents, but no significant difference in clearance was noted between agents.
Conclusions: At therapeutic concentrations, the in vivo inhibitory effect on chlorzoxazone metabolism was similar for all four inhalational anaesthetics examined, even though their chemical characteristics and extent of hepatic metabolism differ considerably.     

A Teaspoon Pump for Pumping Blood with High Hydraulic Efficiency and Low Hemolysis Potential

Abstract: Virtually all blood pumps contain some kind of rubbing, sliding, closely moving machinery surfaces that are exposed to the blood being pumped. These valves, internal bearings, magnetic bearing position sensors, and shaft seals cause most of the problems with blood pumps. The original teaspoon pump design prevented the rubbing, sliding machinery surfaces from contacting the blood. However, the hydraulic efficiency was low because the blood was able to "slip around" the rotating impeller so that the blood itself never rotated fast enough to develop adequate pressure. An improved teaspoon blood pump has been designed and tested and has shown acceptable hydraulic performance and low hemolysis potential. The new pump uses a nonrotating "swinging" hose as the pump impeller. The fluid enters the pump through the center of the swinging hose; therefore, there can be no fluid slip between the revolving blood and the revolving impeller. The new pump uses an impeller that is comparable to a flexible garden hose. If the free end of the hose were swung around in a circle like half of a jump rope, the fluid inside the hose would rotate and develop pressure even though the hose impeller itself did not "rotate"; therefore, no rotating shaft seal or internal bearings are required.     

Microspheres Based Detoxification System: A New Method in Convective Blood Purification

Abstract: A variety of protein-bound or hydrophobic substances, accumulating as a result of pathologic conditions such as exogenous or endogenous intoxications, are removed poorly by conventional detoxification methods because of low accessibility (hemodialysis), insufficient adsorption capabilities (hemosorption), low efficiency (peritoneal dialysis), or economic limitations (high-volume plasmapheresis). Combining advantages of existing methods with microspheric technology, a module-based system was designed. Major operating parameters of the latter can be modified to allow for adjustment to individual clinical situations. An extracorporeal blood circuit including a plasmafilter is combined with a secondary high-velocity plasma circuit driven by a centrifugal pump. Different microspheric adsorbers can be combined in one circuit or applied in sequence. Thus, a prolonged treatment can be tailored using specially designed selective adsorber materials. Comparing this system with existing methods (high-flux hemodialysis, molecular adsorbent recycling system), results from our in vitro studies and animal experiments demonstrate the superior efficiency of substance removal.     

Is the recovery profile of mivacurium independent of the rate of decay of its plasma concentration in patients with normal plasma cholinesterase activity?

Background: The duration of action of muscle relaxants is poorly correlated to the rate of decay of their plasma concentration. The plasma concentration of mivacurium may rapidly decrease below its active concentration because of the extensive hydrolysis of mivacurium. By inflating a tourniquet on one upper limb for 3 min after the administration of atracurium, mivacurium or vecuronium, we studied the influence of the initial decline of their plasma concentration on their effect. Methods: In 50 patients anaesthetised with thiopental, isoflurane and fentanyl, the effect of bolus doses of 0.15 or 0.25 mg . kg^?1 mivacurium (MIV 15, MIV 25), 0.3 or 0.5 mg . kg^?1 atracurium (ATR 30, ATR 50) and 0.06 or 0.1 mg . kg^?1 vecuronium (VEC 06, VEC 10) were measured on both arms (evoked response of the adductor pollicis to train-of-four stimulation every 12 s), a tourniquet being applied on one arm just before and during 3 min after the muscle relaxant bolus. Results: Tourniquet inflation of 3 min almost abolished the neuromuscular effect of mivacurium. In the vecuronium groups and in the ATR 50 group, tourniquet inflation did not modify the maximum degree of depression of the twitch response. Also, the duration of action of vecuronium was unaffected by the tourniquet. In the ATR 30 group, times to return of the twitch response to 25% (duration 25%) and 75% (duration 75%) of control response were significantly shorter in the cuffed arm, 23 min vs 27 min, and 41 min vs 45 min, respectively. In the ATR 50 group, only duration 25% was significantly shorter in the cuffed arm (41 min vs 45 min). Conclusion: The results suggest that the rate of decline of the plasma concentration of mivacurium is so rapid, that a very low and almost clinically ineffective concentration is present as soon as 3 min after its administration. The results also indicate that the recovery from a mivacurium-induced neuromuscular blockade is not influenced by the rate of decay of its plasma concentration in patients with genotypically normal plasma cholinesterase.     

Membranes in Artificial Organs

Abstract: Membrane processes play a pivotal and enabling role in modern replacement therapy for acute and chronic organ failure and in the management of immunologic diseases. In fact, virtually all contemporary extracorporeal blood purification methods employ membrane devices, and the next generation of artificial organs and tissue engineering therapies are almost certain to be similarly grounded in membrane technology. In this short essay, we comment on the similarities and differences among synthetic membranes and their natural counterparts and also provide a critical overview of the demographics and technology of hemodialysis, hemofiltration, apheresis, oxygenation, and emerging membrane technologies and applications.     

Tissue perfusion in relation to cardiac output during continuous positive-pressure ventilation and administration of propranolol or verapamil

Background : Our objective was to determine whether administration of propranolol or verapamil modifies the hemodynamic adaptation to continuous positive-pressure ventilation (CPPV), in particular the regional distribution of cardiac output (CO).
Methods : General hemodynamics and regional blood flows assessed by microsphere technique (15 (μm) were recorded in 16 anesthetized pigs during spontaneous breathing (SB) and CPPV with 8 cm H₂O end-expiratory pressure (CPPV8) before and after intravenous administration of propranolol (0.3 mg · kg⁻¹ followed by 0.15 mg · kg⁻¹ · h⁻¹, n=8) or verapamil (0.1 mg · kg⁻¹ followed by 0.3 mg · kg⁻¹ · h⁻¹, n=8).
Results : CPPV8 depressed CO by 25% without shifts in its relative distribution with the exception of a noteworthy increase in adrenal perfusion. Propranolol increased arterial blood pressure, and due to a fall in heart rate, CO dropped by 25%. The kidneys and, to a lesser extent, the splanchic region and central nervous system received increased fractions of the remaining CO at the expense of skeletal muscle flow. Similar patterns were seen during SB and CPPV8 such that the combination of propranolol and CPPV8 depressed CO by 50%. The circulatory effects of verapamil were less evident but myocardial perfusion tended to increase.
Conclusions : The combination of propranolol or verapamil with CPPV does not result in any specific hemodynamic interaction in anesthetized pigs, except that the combined effect of propranolol and CPPV may severely reduce CO.     

Volatile anaesthetics reduce adhesion of blood platelets under low-flow conditions in the coronary system of isolated guinea pig hearts

Background : Inhibitory effects of volatile anaesthetics on platelet aggregation have been demonstrated in several studies. However, the influence of volatile anaesthetics on intracoronary platelet adhesion has not been elucidated so far.
Methods : Isolated hearts of guinea pigs were perfused with buffer in the absence or presence of volatile anaesthetics (0.5 and 1 MAC) at constant coronary flow rates of 5 ml/min for 25 min, then 1 ml/min for 30 min and again 5 ml/min for 10 min. Before, during and after low-flow perfusion, a bolus of human platelets was applied into the coronary system. To simulate thrombogenic conditions, 0.3 U/ml human thrombin was infused during low-flow perfusion and reperfusion. The number of platelets sequestered to the endothelium was calculated from the difference between coronary in- and output of platelets. The myocardial production of lactate and consumption of pyruvate and coronary perfusion pressure were also determined.
Results : At a flow rate of 5 ml/min only about 3% of the applied platelets did not emerge from the coronary system, in any group. In contrast, 13.1±1.2% (mean±SEM) of infused platelets became adherent in low-flow perfusion in the control group without anaesthetic. The adherence was reduced with each 1 MAC isoflurane (to 6.2±1.2%), sevoflurane (to 4.4±0.9%) or halothane (to 3.2±1.5%) (each P <0.05 vs. control). Volatile anaesthetic, 0.5 MAC, did not inhibit platelet adhesion to a statistically significant extent in any case. Perfusion pressure and metabolic parameters were not statistically different between the control and the hearts exposed to anaesthetics.
Conclusion : Volatile anaesthetics in a concentration of 1 MAC can reduce the adhesion of platelets in the coronary system under reduced flow conditions. This action does not arise from vasodilation or inhibition of ischaemic stress.     

Bariatric Surgery in Some "Central and East-European (former Eastern bloc)"Countries - Current Status and Prediction for the Next Millennium

Background: Obesity is increasing globallly, including in the formerly "Eastern Bloc" countries. Methods: A survey was made of obesity and bariatric surgery. Results: In the 8 East and Central European countries studied, with total population 300 million, roughly 43% of the population was overweight (BMI 25-30), 23% obese (BMI > 30), with about 15 million people morbidly obese (BMI > 40). From 0-10 morbidly obese individuals/100,000/year undergo bariatric surgery. Conclusion: Most countries were found to provide inadequate treatment for obesity.The majority of the morbidly obese are not treated effectively. However, health-care awareness of obesity and bariatric surgeons are slowly increasing.     

Dilemma of Membrane Biocompatibility and Reuse

Abstract: Numerous articles have been published on the multiple use of dialyzers and on the effect of different reprocessing chemicals and techniques on the dialyzer biocompatibility and performance. The results often appear contradictory, especially those comparing standard biocompatibility parameters. Despite this confusion, a discerning review of the published works allows certain limited conclusions to be drawn. Reprocessing of used hemodialyzers changes the biocompatibility profile of a dialyzer as defined by the parameters complement activation. leukopenia, and cytokine release. The effect of reprocessing depends on the chemicals and reprocessing technique applied and also on the type of membrane polymer being subjected to the reprocessing procedure. Reports of pyrogenic reactions indicate that the flux of the membrane also influences how suitable it is for safe reuse. An increased risk of allergic and pyrogenic reactions appears to be associated with dialyzer reuse. Furthermore, there has been a lack of investigations into the immunologic effect of the layer of adsorbed and chemically altered proteins that remains on the inner surface of reprocessed dialyzers. We conclude that the clinical benefit of dialyzer reuse cannot be generally accepted from a biocompatibility point of view.