骶骨骨折的外科治疗

目的:探讨骶骨骨折的外科治疗方法和疗效。方法:对36例骶骨骨折病例作回顾分析,根据Denis骶骨骨折分类法,Ⅰ型15例,Ⅱ型16例,Ⅲ型5例。Ⅰ型骨折中2例伴有L4或L5神经根损伤,1例L4、L5神经根损伤。Ⅱ型12例伴有S1、S2神经根损伤。Ⅲ型3例单侧S1、S2神经根损伤,2例双侧S1、S2神经根及马尾神经损伤。Ⅰ型骨折15例予保守治疗,Ⅱ、Ⅲ型骨折21例均予手术治疗,其中8例无神经损伤或损伤轻微者单纯行骶骨骨折切开复位内固定术,13例伴有严重神经损伤者,予骨折切开复位内固定加神经探查松解术。结果:随访6~36个月,36例骶骨骨折均愈合,神经损伤均有不同程度恢复。3例Ⅰ型,10例Ⅱ型,3例Ⅲ型神经症状完全恢复,2例Ⅱ型残留骶神经损伤症状,2例Ⅲ型残留鞍区感觉减退、排尿乏力及性功能减退等症状。结论:骶骨骨折的治疗方案应取决于骨折类型及骶神经损伤程度。Ⅰ型骶骨骨折保守治疗效果满意,Ⅱ、Ⅲ型骶骨骨折需切复内固定手术,有严重骶神经损伤者需神经探查松解术。     

骨盆骨折合并骶丛神经损伤的手术治疗

目的探讨骨盆骨折合并腰骶丛神经损伤治疗的方法.方法回顾本组病例按Denis分类将骨盆骨折中骶骨骨折分为Ⅰ、Ⅱ、Ⅲ区,分析骨盆骨折合并腰骶丛神经损伤的临床特点及治疗效果.结果22例骨盆骨折合并腰骶丛神经损伤,随访6个月～5年.7例Ⅰ型骶骨骨折合并腰骶丛神经损伤,6例完全恢复正常,1例部分恢复;10例Ⅱ型骶骨骨折合并腰骶丛神经损伤,6例恢复正常,3例部分恢复,1例未恢复;5例Ⅲ型骶骨骨折合并腰骶丛神经损伤,2例恢复正常,2例部分恢复,1例未恢复.结论对于骨盆骨折并腰骶丛神经损伤的患者实施积极复位及内固定治疗,是非常重要的一环.有明显骨块压迫者,宜行神经探查松解术.     

Denis Ⅱ型骶骨骨折的外科治疗

骶骨骨折占脊柱骨折的1%,但25%～50%的患者合并神经损伤[1]。Denis Ⅱ型骶骨骨折常累及神经孔区[2],易导致腰骶丛神经损伤,是远期病残的重要原因[3]。既往针对骶骨骨折的治疗一般采取卧床保守或单纯骶孔减压治疗;现在随着内固定器械不断更新,治疗方法越来越多。我院自1998～2011年收治的22例Denis Ⅱ型骶骨骨折患者,分别行骶髂椎弓根固定、骶髂螺钉固定、髂后钉板固定及单纯骶孔减压,总结报道如下。     

骶骨骨折合并骶神经损伤的手术治疗

目的：探讨手术治疗骶骨骨折合并骶神经损伤的临床疗效。方法：2002年3月至2009年2月,对21例骶骨骨折合并骶神经损伤患者进行回顾性分析,男15例,女6例;年龄16～60岁,平均36.3岁。致伤原因：车祸伤13例,高处坠落伤5例,挤压伤3例。按Denis分型标准：Ⅰ型5例,Ⅱ型14例,Ⅲ型2例。12例单纯行骶骨骨折经皮重建钢板内固定,9例在内固定后同时行后路骶神经减压术。结果：21例全部获得随访,时间12～48个月,平均19个月。无切口感染、内固定松动及断裂、骨不愈合、明显双下肢不等长发生。9例行骶神经探查减压患者,神经损伤完全恢复4例,部分恢复3例,未恢复2例。12例单纯行骶骨骨折经皮重建钢板内固定患者,神经损伤完全恢复9例,部分恢复2例,未恢复1例。根据Majeed功能评价：优7例,良9例,可4例,差1例。结论：骶骨骨折切开复位内固定可以恢复骶骨的解剖关系,有利于神经损伤的恢复。对伴有明显骨块压迫者适宜行神经探查松解术。     

骶骨骨折合并神经损伤的治疗

目的探讨骶骨骨折合并神经损伤的手术治疗效果。方法1996～2003年收治9例骶骨骨折合并神经损伤患者,按Denis分型:3例Ⅱ区骨折,6例Ⅲ区骨折。回顾其临床表现,对治疗结果进行分析。结果随访6个月～3年,Ⅱ区骨折3例,骶神经损伤恢复良好;Ⅲ区6例,其中1例功能未恢复,2例肌力、感觉略下降,余3例感觉、运动功能恢复良好。结论骶骨骨折合并神经损伤,合理的神经减压有助于神经功能恢复。     

骶前减压骶孔成形术治疗陈旧性骶骨骨折合并骶丛神经损伤的疗效分析

目的探讨经腹直肌外侧入路骶前骶孔扩大成形、骶丛神经减压治疗陈旧性骶骨骨折合并骶丛神经损伤的方法及疗效。方法回顾性分析2013年1月至2018年6月南方医科大学第三附属医院骨科收治的11例陈旧性骶骨骨折合并骶丛神经损伤患者资料。男8例,女3例;年龄17~54岁,平均38岁;骶骨骨折按Denis分型均为Ⅱ区;神经损伤按英国医学研究会(BMRC)标准分级:完全损伤2例,部分损伤9例;受伤至手术时间0.7~12.0个月,平均6个月。经腹直肌外侧入路显露腰骶干及S1神经孔周围结构,直视下行骶孔扩大成形、松解骨折块及骨痂压迫的S1神经根及腰骶干,不稳定骶骨骨折者同时行复位内固定治疗。通过评价骨折愈合、神经功能恢复(BMRC标准)等观察疗效。结果本组11例患者中有10例顺利完成手术,1例因术中探查发现骶骨骨折完全愈合且S1神经孔完全闭塞,无法完成骶孔成形术而终止手术。手术时间70~220 min,平均110 min;术中出血量450~2800 mL,平均1100 mL。术后复查X线片、CT示骶孔扩大成形明显,无手术并发症发生。所有患者术后随访12个月至4年,平均18个月。所有患者末次随访时根据BMRC标准评价神经功能恢复情况:完全恢复5例,部分恢复4例,未恢复1例。结论经腹直肌外侧入路能较好地显露腰骶干及S1神经孔周围结构,直视下骶孔扩大成形、松解骨折块及骨痂压迫的S1神经根及腰骶干,是治疗陈旧性骶骨骨折合并骶丛神经损伤的一种可行的方法。     

骨盆损伤中移位骶骨骨折的手术治疗

目的 探讨不稳定型骨盆损伤中移位骶骨骨折的手术方法及治疗效果.方法 对2000年9月至2007年9月收治的33例伴有骶骨骨折的骨盆损伤患者行手术治疗.根据AO/OTA的分型方法,骨盆B型损伤5例,C型28例.根据Denis的分型方法,骶骨I型骨折13例、Ⅱ型11例、Ⅲ型9例.其中早期合并原发性神经损伤23例.骶骨骨折应用张力带钢板固定1例;脊柱椎弓根钉棒系统经骨盆后方沿双侧髂嵴横向固定10例,经L_(4,5)或L_5S_1及双侧髂嵴后方纵向固定16例;骶髂螺钉固定3例;骶骨棒固定2例;骶髂螺钉联合骶骨棒固定1例.术中间期行椎板切除、马尾神经减压11例,二期行神经松解、骶前孔扩大术2例.结果 术后随访12～82个月,平均27.3个月.根据Majeed疗效标准,优17例、良7例、可2例、差7例.骶骨I型骨折疗效优良率为92.3%、Ⅱ型为72.7%、Ⅲ型为44.4%.神经损伤恢复情况在手术治疗组中优6例、良4例、无变化3例;在非手术治疗组中优6例、良1例、无变化3例.术后并发症包括腰骶部切口深部感染2例,腰骶僵硬不适2例.神经损伤一过性加重4例,迟发性骶神经损伤3例.结论 手术治疗是改善骶骨骨折复位质量的重要途径,骨盆前、后环损伤的联合制动是提高骨折内同定强度的有效方法.对手术指征明确的骶神经损伤,早期定位减压有助于其功能恢复.     

骶骨骨折合并神经根损伤的手术治疗

目的　报道骶骨骨折合并神经损伤的手术治疗。方法　骶骨骨折合并神经损伤 7例 ,Ⅲ区骨折 5例 ,有明显的骶神经症状 ,其中 4例合并有植物神经功能损伤 ,采用后路椎板切除减压 ;Ⅱ区骨折 2例 ,表现为单侧的坐骨神经损伤症状 ,经前方腹膜外进路解除对骶神经根的压迫 ,无严重的术中和术后并发症。结果　 7例随访 6个月～ 4年 ,Ⅱ区骨折 2例神经功能完全恢复正常 ,Ⅲ区骨折 5例中 ,3例的感觉运动功能恢复满意 ,1例残留腓肠肌肌力下降 (Ⅳ级 )和足跟部感觉减退 ,另外 1例遗留植物神经功能下降。结论　在确诊骶骨骨折合并的神经损伤前提下 ,进行合理的神经减压有利于神经功能的恢复。     

DenisⅡ型骶骨骨折伴神经损伤早期手术疗效分析

目的：探讨DenisⅡ型骶骨骨折合并神经损伤的早期手术治疗的疗效。方法：2008年3月至2010年3月收治12例DenisⅡ型骶骨骨折伴神经损伤,男8例,女4例;年龄28～54岁,平均40岁。所有患者经详细体格检查及X线片、CT、MRI扫描等确诊,依据影像学资料进行Denis分型均为Ⅱ型。伤后6～14d手术,平均9d。8例骶前孔明显变形,责任骨块侵入骶孔压迫神经根,行后路骶神经减压内固定术;4例骶前孔轻度变形,无明显责任骨块侵入骶孔,行单纯切开复位内固定术。结果：12例均获随访,时间6个月～2年,骨折均Ⅰ期愈合,其中11例神经损伤患者均有不同程度恢复,Gibbons骶神经损害评分术前平均（2.67±0.49）分,术后平均（1.50±0.67）分,术后评分低于术前。结论：DenisⅡ型骶骨骨折伴神经损伤,全身情况许可应尽早手术治疗,可取得满意疗效。     

骶骨骨折合并神经根损伤的手术治疗

目的 报道骶骨骨折合并神经损伤的手术治疗。方法 骶骨骨折合并神经损伤7例，Ⅲ区骨折5例，有明显的骶神经症状，其中4例合并有植物神经功能损伤，采用后路椎板切除减压；Ⅱ区骨折2例，表现为单侧的坐骨神经损伤症状，经前方腹膜外进路解除对骶神经根的压迫，无严重的榱和术后并发症。结果 7例随访6个月－4年，Ⅱ区骨折2例神经功能完全恢复正常，Ⅲ区骨折5例中，3例的感觉运动功能恢复满意，1例残留腓肠肌肌力下降（Ⅳ级）和足跟部感觉减退，另外1例遗留植物神经功能下降。结论 在确诊骶骨骨折合并的神经损伤前提下，进行合理的神经减压有利于神经功能的恢复。     

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.