椎间盘退变过程中碱性成纤维细胞生长因子和转移生长因子-β1的表达及其意义

目的：研究椎间盘退变过程中碱性成纤维细胞生长因子(bFGF)和转移生长因子-β1(TGF-β1)的表达及其意义。方法：收集腰椎后路手术切除的15例椎间盘源性下腰痛患者的21个通过腰椎间盘造影术证实的疼痛椎间盘，同时收集16个在MRIT2加权像上信号强度明显减弱的无腰痛症状的生理老化椎间盘和10个正常对照椎间盘，行组织学检查并用免疫组化方法检测bFGF、TGF-β1及其受体在不同椎间盘组织中的表达，观察增殖细胞核抗原在不同椎间盘的表达。结果：免疫组化染色显示bFGF、TGF-β1及其受体在疼痛椎间盘大量表达，生理老化椎间盘有少量表达，正常对照椎间盘没有表达。增殖细胞核抗原在疼痛椎间盘的肉芽组织区大量表达，在非肉芽组织区有少量表达；生理老化椎间盘有少量表达，正常对照椎间盘组织没有表达。结论：椎间盘退变和椎间盘源性下腰痛起源于椎间盘纤维环的损伤修复过程，bFGF、TGF-β1在纤维环外层的损伤修复和随之的椎间盘退变过程中可能起关键作用。     

肥大细胞和巨噬细胞在疼痛椎间盘的分布和意义

目的研究肥大细胞和巨噬细胞在疼痛椎间盘的分布并探讨其与椎间盘退变的关系。方法收集腰椎后路切除的15个椎间盘源性下腰痛病人的21个通过腰椎间盘造影术证实的疼痛椎间盘,同时收集16个在M RIT2加权上信号强度明显减弱的无腰痛症状的生理老化椎间盘和10个正常对照椎间盘,行组织学检查并用免疫组化方法观察肥大细胞和巨噬细胞在不同椎间盘的分布。结果免疫组织化学结果显示在疼痛椎间盘的肉芽组织区有大量的肥大细胞和巨噬细胞分布,在肉芽组织邻近区有少量分布,在非肉芽组织区、生理老化椎间盘和正常对照椎间盘没有分布。结论研究结果提示肥大细胞和巨噬细胞在纤维环外层损伤后激发的炎症反应和随之的椎间盘退变过程中起关键作用。     

退变腰椎间盘组织中碱性成纤维细胞生长因子的表达研究

目的 探讨碱性成纤维细胞生长因子（basic fibroblast growth factor,bFGF)在正常和退变椎间盘组织中的表达情况。方法 交30例来源于腰椎间盘突出症患者手术中所取得的椎间盘组织（观察组，男11例，女19例；年龄25－78岁，平均48岁；病程3个月－30年，平均9年11个月）与6例来源于脊柱侧凸患者前路松解术所取得的椎间盘组织（对照组，男女各3例，年龄10－17岁，平均14.2岁）进行对比，首先经病理组织学检查证实为退变椎间盘组织和政党椎间盘组织，然后将两组椎间盘组织分别通过免疫组织化学方法和原位杂交方法，检测各自椎间盘组织中的bFGF及其mRNA的表达。观察组30例均为退变椎间盘组织，免疫组化阳性率为90％（27／30），原位杂交阳性率为20％（6／30）；对照组6例均为正常椎间盘组织，其免疫组及原位杂交均为阴性，两组间免疫组化方法检测阳性率在统计学上差异有非常显著性意义。结论 bFGF在正常和退变椎间盘组织中表达的差异有显著性意义。提示 bFGF可能作为增生刺激因子促进椎间盘组织中的软骨细胞增生和细胞外基质合成，进而加速椎间盘退变。     

椎间盘源性下腰痛的发病机制

目的探讨椎间盘源性下腰痛的发病机制。方法收集腰椎后路切除的17例椎间盘源性下腰痛患者的19个经腰椎间盘造影术证实的疼痛腰椎间盘;同时收集12个在MRI T2加权像上信号强度明显减弱、无腰痛症状的生理老化椎间盘和10个正常对照椎间盘,行组织学检查和P物质、神经丝蛋白和血管活性肠肽的免疫组织化学染色检查。结果椎间盘源性下腰痛患者的疼痛椎间盘在组织学上的显著特征表现为,一条从髓核至纤维环外层的血管化肉芽组织条带区,其间伴有1个或多个裂隙;肉芽组织条带区与椎间盘造影术后CT上显示的纤维环裂隙一致,肉芽组织之外的纤维环结构基本正常。生理老化椎间盘和正常对照椎间盘表现为与年龄相关的改变。免疫组织化学染色显示,疼痛椎间盘中P物质、神经丝蛋白和血管活性肠肽3种神经肽阳性神经纤维分布数量和比例,较正常对照椎间盘和生理老化椎间盘明显增多;神经纤维主要沿伴有裂隙的肉芽组织条带区分布;疼痛椎间盘髓核中可见P物质和神经丝蛋白的阳性神经纤维分布。结论椎间盘后方神经分布广泛的肉芽组织条带区是椎间盘造影术疼痛和椎间盘源性下腰痛的起源部位。肉芽组织条带可能起源于椎间盘的创伤修复过程。生理老化椎间盘和疼痛椎间盘的差异是后者形成组织学上的肉芽组织条带区。     

间盘造影在近融合椎正常间盘的诊断价值

目的 采取回顾分析的研究方法，探讨椎间盘造影术在腰椎融合邻近正常椎间盘的诊断应用价值。方法 57例因椎间盘源性下腰痛行椎间盘切除和后路椎间融合术的患者。手术前行椎间盘造影时，不包括邻近融合节段的正常椎间盘。所有患者随访35．6个月（24-80个月）。对所有患者的临床疗效和影像学结果进行评价分析。结果 53例患者中49例临床效果优良，随访2年以上，38例患者无任何症状。15例患者在度过21个月的无症状期后出现疼痛复发，采用腰椎MRI和椎间盘造影复查。结果 MRI发现15例患者中的8例出现了邻近节段椎间盘的退变，而此8例中仅有1例（2％）经过MRI和椎间盘造影同时证实该节段为疼痛的原因，从而再次进行融合手术。结论 术前MRI上专现为正常的相邻椎间盘在椎间融合术后不容易变成病变节段，因此没有必要常规在术前为了排除病变节段，而行相邻于拟融合节段的正常椎间盘的造影检查。     

腰椎间盘造影在腰椎间盘源性腰痛诊治中的应用

目的：探讨椎间盘造影对腰椎间盘源性腰痛的诊断价值及椎间融合手术的疗效，研究椎间盘造影对椎间融合节段范围选择的意义。方法：2004年1月至2006年2月对35例具有腰椎间盘源性腰痛症状的患者进行了椎间盘造影，共74个椎间盘。所有病例均行MR和CT检查，观察造影图像和MRI表现，记录诱发痛。35例患者中根据椎间盘造影的结果，行腰椎间融合术20例，并随访手术患者的疗效。结果：35例中20例患者22个椎间盘出现了诱发痛（57．1％），20例诱发痛阳性患者的22个节段均行腰椎间盘融合术，并全部随访，随访时间10个月-2年，平均15个月，按改良MacNab评定标准判断：优13例，良4例，可2例，差1例。15例诱发痛阴性的患者予保守治疗，在同期随访中，5例腰痛完全消失，7例疼痛基本消失，3例疼痛没有变化，甚至加重。6例患者腰椎融合节段相邻的9个椎间盘有MRI异常改变，但造影无诱发痛，即无症状椎间盘，未包括在融合范围之内，在同期的随访中，1例因相邻无症状退变间盘退变加重并产生严重症状而接受融合手术。结论：腰椎间盘造影对椎间盘源性腰痛的诊断和选择治疗方法等方面具有独特的价值，对确定为疼痛原因的椎间隙实施腰椎间融合术可以消除患者的疼痛。在选择融合节段时，仅融合有症状的退变椎间盘即可。     

腰椎融合区相邻节段无症状退变椎间盘的转归

目的：观察腰椎融合区相邻节段无症状性退变间盘的转归，探讨腰椎融合节段的选择。方法：71例因椎间盘源性腰痛而接受椎阃盘切除、椎间植骨融合术患者，术前均进行仔细的体格检查、MRI和椎间盘造影，对MRI表现和柞间盘造影阳性的节段进行融合，其中53例相邻椎间盘MRI表现正常（A组），18例相邻20个节段为无症状性退变间盘（B组）比较两组术后的临床疗效、疼痛复发以及二次手术率。结果：所有患者均随访2年以上（平均35个月），临床疗效优良率A组为92.4％，B组为77．8％，无统计学差异（P=0.189）。A组中1例因相邻节段间盘发生退变并产生严重症状而进行了二次融合手术：B组叶14例因相邻的无症状性退变间盘退变加重并产生严重症状而接受一次融合手术。结论：柑邻于融合节段的无症状性退变间盘大多数（77.8％）不产生后期的疼痛症状，临床疗效满息、存初次进行融合时，仅融合有症状的退变间盘即可。     

腰椎间盘MRI高信号区的组织病理学特点和临床意义

目的研究椎间盘源性下腰痛患者腰椎间盘纤维环后方MRI高信号区的组织病理学特征及其临床意义。方法对52例经保守治疗无效、CT片显示无腰椎间盘突出的下腰痛患者行腰椎MR检查及腰椎间盘造影术。男39例,女13例;平均年龄38.8岁。选择纤维环后方出现高信号区的部分病例行腰椎后路椎间盘切除、椎体间融合、椎弓根螺钉内固定术,术中收集包括高信号区部位的椎间盘。对标本行矢状面连续组织学切片,光镜下观察高信号区椎间盘组织的组织病理学结构,并分析其临床意义。结果在行腰椎间盘造影的52例142个椎间盘中,17例17个椎间盘显示高信号区,且在椎间盘造影过程中全部呈现2或3级的纤维环破裂和疼痛复制反应。敏感性和特异性均为100%。高信号区与纤维环破裂程度分级呈正相关,说明纤维环破裂程度分级越高,越易出现高信号区(R=0.462,P<0.01)。共收集11例患者11个椎间盘,组织学研究发现对应高信号区的椎间盘组织表现为沿纤维环裂隙形成的不同程度的血管化肉芽组织,有成熟的瘢痕化胶原组织。结论症状性下腰痛患者的腰椎MRI上有椎间盘高信号区,可以作为椎间盘源性下腰痛诊断的重要征象。     

腰椎终板、椎间盘退变及椎间盘造影疼痛激发试验的相关性研究

目的探讨下腰痛患者腰椎终板Modic退变、椎间盘退变及CT引导下腰椎间盘造影疼痛激发试验的相关性.方法对45例下腰痛患者常规行腰椎X线和MR检查,分别按Modic终板退变标准（0～3级）与Pearce椎间盘退变标准（Ⅰ～Ⅴ级）对终板和椎间盘进行评估.在CT引导下对45例患者中的40例（120个椎间盘）进行造影和疼痛激发试验,并按Dallas椎间盘造影分级系统（DDD）测评椎间盘退变程度.采用SPSS 11.5统计学软件分析腰椎终板Modic退变、椎间盘退变与腰椎间盘造影疼痛激发试验之间的相关性.结果40例下腰痛患者的腰椎终板Modic分级与椎间盘退变Pearce分级存在较强的相关性（Pearson x^2=43.326,P=0.000）,与椎间盘造影疼痛激发试验有显著相关性（Pearson x^2=27.858,P=0.000）;椎间盘退变Pearce分级与CT椎间盘造影椎间盘退变Dallas分级也呈较强的相关性.结论腰椎终板Modic退变分级与椎间盘退变Pearce分级密切相关,而与椎间盘疼痛激发试验有显著相关性,提示终板Modic退变可能是下腰痛的原因之一.     

42例腰椎融合术后难治性下腰痛的治疗体会

目的探讨腰椎融合术后骶髂关节病变的特点及治疗方法与疗效。方法回顾性分析42例因腰椎退变性滑脱、腰椎椎间盘突出、腰椎椎管狭窄曾行后路减压、后外侧或椎体间植骨融合及椎弓根内固定术,术后随访12～72个月(平均42.6个月)出现新的难治性持续性下腰痛症状的病例。本研究运用骶髂关节内封闭进行诊断性治疗。阳性标准:疼痛缓解≥75%,采用疼痛视觉模拟量表(visual analogue scale,VAS)进行定量分析。结果阳性12例(28.57%),是否融合L5/S1、术后疼痛缓解期是否≥3个月与诊断阳性率相关,有统计学意义(P<0.05)。结论腰椎融合术后下腰痛部分可能是由骶髂关节病变引起的,L5/S1融合可能促进骶髂关节发生退变。症状以下腰痛症状为主者,手术应慎重。     

Presenteeism and Absenteeism Before and After Total Hip and Knee Arthroplasty

BackgroundAbsenteeism is costly, yet evidence suggests that presenteeism—illness-related reduced productivity at work—is costlier. We quantified employed patients’ presenteeism and absenteeism before and after total joint arthroplasty (TJA).MethodsWe measured presenteeism (0-100 scale, 100 full performance) and absenteeism using the World Health Organization’s Health and Work Performance Questionnaire before and after TJA among a convenience sample of employed patients. We captured detailed information about employment and job characteristics and evaluated how and among whom presenteeism and absenteeism improved.ResultsIn total, 636 primary, unilateral TJA patients responded to an enrollment email, confirmed employment, and completed a preoperative survey (mean age: 62.1 years, 55.3% women). Full at-work performance was reported by 19.7%. Among 520 (81.8%) who responded to a 1-year follow-up, 473 (91.0%) were still employed, and 461 (88.7%) had resumed working. Among patients reporting at baseline and 1 year, average at-work performance improved from 80.7 to 89.4. A Wilcoxon signed-rank test indicated that postoperative performance was significantly higher than preoperative performance (P < .0001). The percentage of patients who reported full at-work performance increased from 20.9% to 36.8% (delta = 15.9%, 95% confidence interval = [10.0%, 21.9%], P < .0001). Presenteeism gains were concentrated among patients who reported declining work performance leading up to surgery. Average changes in absences were relatively small. Combined, the average monthly value lost by employers to presenteeism declined from 15.3% to 8.3% and to absenteeism from 16.9% to 15.5% (ie, mitigated loss of 8.4% of monthly value).ConclusionAmong employed patients before TJA, presenteeism and absenteeism were similarly costly. After, employed patients reported increased performance, concentrated among those with declining performance leading up to surgery.     

The German emergency and disaster medicine and management systemdhistory and present

As well for optimized emergency management in individual cases as for optimized mass medicine in disaster management, the principle of the medical doctors approaching the patient directly and timely, even close to the site of the incident, is a long-standing marker for quality of care and patient survival in Germany. Professional rescue and emergency forces, including medical services, are the “Golden Standard” of emergency management systems. Regulative laws, proper organization of resources, equipment, training and adequate delivery of medical measures are key factors in systematic approaches to manage emergencies and disasters alike and thus save lives. During disasters command, communication, coordination and cooperation are essential to cope with extreme situations, even more so in a globalized world. In this article, we describe the major historical milestones, the current state of the German system in emergency and disaster management and its integration into the broader European approach.     

Tendon and Ligament Healing and Current Approaches to Tendon and Ligament Regeneration

Ligament and tendon injuries are common problems in orthopedics. There is a need for treatments that can expedite nonoperative healing or improve the efficacy of surgical repair or reconstruction of ligaments and tendons. Successful biologically-based attempts at repair and reconstruction would require a thorough understanding of normal tendon and ligament healing. The inflammatory, proliferative, and remodeling phases, and the cells involved in tendon and ligament healing will be reviewed. Then, current research efforts focusing on biologically-based treatments of ligament and tendon injuries will be summarized, with a focus on stem cells endogenous to tendons and ligaments. Statement of clinical significance: This paper details mechanisms of ligament and tendon healing, as well as attempts to apply stem cells to ligament and tendon healing. Understanding of these topics could lead to more efficacious therapies to treat ligament and tendon injuries. © 2019 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 38:7–12, 2020     

肝内胆管囊腺瘤和囊腺癌的CT、MRI及病理表现

目的探讨肝内胆管囊腺瘤和囊腺癌的CT、MRI和病理特点。方法回顾性分析经手术病理证实的6例肝内胆管囊腺瘤和2例肝内胆管囊腺癌的影像及临床病理资料，将病变的影像表现与其病理大体形态及组织学表现作对照分析。结果6例肝内胆管囊腺瘤，女4例、男2例；2例肝内胆管囊腺癌均为女性病人；8例病人平均年龄55岁。所有病灶均表现为多房囊性肿块，肿瘤囊腔各分房内常为多种液体成分，在CT上可表现为不同密度、在MRI上可表现为不同信号强度。囊内出现多发大小不等的壁结节在胆管囊腺癌内更常见，囊内有分隔但无壁结节只见于胆管囊腺瘤。在7例CT扫描中，4例胆管囊腺瘤和1例胆管囊腺癌可见囊壁或分隔上钙化，囊壁、囊内分隔及囊内结节均为轻、中度延迟增强。肿瘤中出现卵巢样间质见于3例胆管囊腺瘤和1例胆管囊腺癌，且均为女性病人。结论肝内胆管囊腺瘤和囊腺癌是肝脏不常见的囊性肿瘤，影像上多房、囊内有分隔且各分房囊内密度或信号不一致，高度提示肝内胆管囊腺瘤或囊腺癌的诊断，如囊内伴有多发大小不等的结节，则进一步提示囊腺癌的可能。但影像学表现不能区分肿瘤中有无卵巢样间质。