单开门颈椎管扩大椎板成形术治疗颈椎后纵韧带骨化症的中远期疗效观察

目的 :评估单开门颈椎管扩大椎板成形术治疗颈椎后纵韧带骨化症(OPLL)的中远期临床疗效。方法 :回顾性分析2005年3月~2012年4月在北京大学第三医院接受单开门颈椎管扩大椎板成形术的44例颈椎OPLL患者。其中,男26例,女18例;年龄57.1±8.5岁(28~72岁);术前改良JOA 17分法评分为11.39±3.27分(1.5~16分),颈痛VAS评分为2.32±2.59分(0~10分)。OPLL骨块累及3.20±1.64个(1~6个)椎体节段,骨块的椎管侵占率为(46.05±13.67)%(22%~72%)。手术范围:C3~C7 34例,C2~C7 7例,C2~C6 3例。术前及末次随访时分别测量颈椎侧位X线片上颈椎整体曲度及曲度指数、颈椎MRI中矢状位T2加权像C2/3~C6/7各节段脊髓整体后移距离(PCS)、脊髓前缘后移距离(PAS)、脊髓膨胀度(ESC)。结果:所有患者均获得随访,随访36.8±16.8个月(24~96个月)。末次随访时,JOA评分为14.70±1.96分(9.5~17分),颈痛VAS评分为3.59±2.97分(0~10分),与术前比较均有统计学差异(P0.05)。末次随访时JOA评分改善率为(57.59±30.88)%,其中神经功能恢复为优者12例,良19例,不理想13例,优良率为70.45%。末次随访时的颈椎曲度指数、颈椎整体曲度与术前比较无统计学差异(P0.05)。末次随访时,C2/3~C6/7各节段脊髓均有明显后移、脊髓前后径增加,PCS及PAS在C3/4~C6/7节段均明显高于C2/3节段(P0.05);而ESC在C3/4~C5/6节段明显高于C2/3及C6/7节段(P0.05)。10例患者末次随访时(术后2~8年)观察到OPLL骨块继续生长。结论:单开门颈椎管扩大椎板成形术治疗颈椎OPLL可获得脊髓症状的中长期缓解,但轴性症状较术前加重。减压节段的头端脊髓后移及膨胀程度幅度较小,应注意保证该节段的充分减压。     

影响颈椎后路减压内固定术治疗脊髓型颈椎病预后的影像学因素分析

目的:分析影响颈椎后路减压内固定术治疗脊髓型颈椎病的预后影像学因素。方法 :回顾性分析2014年5月～2018年5月北部战区总医院神经外科接受颈椎后路减压内固定手术治疗脊髓型颈椎病患者的临床及影像学资料(72例),其中男55例,女17例,年龄21～80岁,平均56.9±12.0岁,收集病程、压迫节段、术前/术后1周日本骨科协会(Japanese Orthopaedic Association,JOA)评分、术前Cobb角、压迫节段内致压物最大径、有效颈椎管率、平均压迫率、脊髓横切面积、脊髓椎管占有率以及术后脊髓漂移距离、JOA改善率等相关资料。根据JOA改善率将患者分为:预后优良组(改善率≥50%)58例和预后非优良组(改善率50%)14例。运用单因素、多因素二元Logistic回归分析患者临床资料与影像学参数等预后相关因素,进一步绘制受试者工作特征曲线(receiver operating curve,ROC),选取尤登指数最大的数值作为划界值,明确预后相关因素临界值。结果 :单因素分析显示,预后优良组术前Cobb角12.81°±4.27°,有效颈椎管率(33.71±9.87)%,脊髓漂移距离3.38±0.62mm,致压物最大径3.83±0.83mm,脊髓椎管占有率(64.02±7.74)%,与预后非优良组术前Cobb角9.68°±4.00°,有效颈椎管率(22.86±8.78)%,脊髓漂移距离2.13±0.75mm,致压物最大径5.38±1.01mm,脊髓椎管占有率(69.21±9.28)%相比,差异有统计学意义(P0.05);对上述相关因素进一步多因素分析显示,致压物最大径与脊髓漂移距离是脊髓型颈椎病预后主要影响因素(P0.05);ROC曲线显示,致压物最大径诊断临界值为4.950mm(曲线下面积为0.875);脊髓漂移距离诊断临界值为2.625mm(曲线下面积为0.897)。结论:致压物最大径与脊髓漂移距离是颈椎后路减压内固定治疗脊髓型颈椎病预后的主要影响因素,且当致压物最大径超过4.950mm时,提示颈椎后路减压预后较差,术后脊髓漂移距离低于2.625mm时,提示颈椎后路减压预后不佳。     

术前颈椎曲度与椎管扩大成形术后脊髓后移程度及疗效的相关性

目的:观察术前不同颈椎曲度的慢性压迫性颈脊髓病患者行单开门椎管扩大成形术后脊髓后移的距离及临床疗效,探讨颈椎曲度与椎管扩大成形术后脊髓后移程度及临床疗效的相关性.方法:选取我院2005年1月～2011年12月采用传统棘突、小关节囊悬吊法单开门椎管扩大成形术治疗并获得完整随访资料的慢性压迫性颈脊髓病患者共63例,包括脊髓型颈椎病26例,颈椎后纵韧带骨化症(OPLL)20例,发育性颈椎管狭窄合并颈脊髓病17例,均因多节段颈椎间盘退变突出、后纵韧带骨化导致多节段颈脊髓受压或合并发育性颈椎管狭窄而采用单开门椎管扩大成形术治疗.根据术前X线片上颈椎曲度将患者分为后凸畸形组(n=16)、曲度变直组(n=18)和曲度正常组(n=29),在术前、术后颈椎MRI T2加权像中心矢状位片上测量并计算C3～C7各节段脊髓后移距离(posterior shift of center of spinal cord,PCS),比较三组患者C3～C7各节段PCS的差异;评价术前和末次随访时神经功能(JOA评分),计算并比较三组患者末次随访时JOA评分改善率及差异.结果:三组患者的年龄、性别比、病程、随访时间、病种构成和术前JOA评分等无统计学差异(P＞0.05).术后各节段脊髓均有明显后移,三组患者C3～C7五个节段的PCS均无统计学差异(P＞0.05).随访时间15～90个月,平均47±24个月,三组患者末次随访时平均JOA改善率分别为59.81％、69.25％、54.44％,差异无统计学意义(P＞0.05).C5水平脊髓后移距离与末次随访时JOA改善率无线性相关关系(r=0.110,P=0.390).结论:术前不同颈椎曲度的慢性压迫性颈脊髓病患者椎管扩大成形术后脊髓均能后移,并可取得较好的临床疗效;椎管扩大成形术后脊髓后移程度、神经功能改善率与术前颈椎曲度无明显相关性.     

前后路手术治疗矢状序列异常的脊髓型颈椎病疗效比较和预后评估

[目的]对比前后路两种手术方式治疗矢状序列异常的脊髓型颈椎病的疗效,探讨影响脊髓型颈椎病预后的相关因素。[方法]对2009~2012年收治的脊髓型颈椎病患者89例进行回顾性研究。53例患者纳入本次研究。其中前路手术31例,后路手术22例,采用改良的日本骨科协会(m JOA)评分法评估脊髓型颈椎病手术疗效,颈椎功能障碍指数(NDI)进行颈椎功能的评价。随访时间12~35个月,平均16.5个月。影像学评估指标包括颈椎(C_(2~7))Cobb角,脊髓横截面积。[结果]前路手术组术后JOA评分较后路手术组高,差异有统计学意义(P=0.048),末次随访差异消除(P=0.31),前路手术组与后路手术组术后NDI评分差异无统计学意义(P=0.32),随访中也是如此(P=0.21)。前路手术组中立位术后Cobb角较后路手术组大,差异有统计学意义(P0.001),在随访中结果也是如此(P=0.021)。前路手术组得分较后路手术组脊髓横截面积更大(P=0.039)。术前Cobb角与术前JOA评分没有相关性(P=0.32),术前Cobb角与术前椎管横截面积没有相关性(P=0.20)。[结论]前路减压植骨融合内固定术、后路单开门椎管成形术治疗矢状面序列异常的脊髓型颈椎病患者疗效满意,随访疗效没有差异,尚没有有效方法能评估脊髓型颈椎病患者预后。     

颈前路椎体次全切除联合椎间隙减压融合治疗多节段脊髓型颈椎病

目的:探讨多节段颈椎病颈前路椎体次全切除联合椎间隙减压融合内固定术的疗效。方法 :对2012年10月至2014年6月行颈椎前路治疗的28例脊髓型颈椎病的临床资料进行回顾性分析,其中男18例,女10例;年龄45~77(60.11±9.37)岁;27例患者病变累及3个节段,1例累及4个节段;术前JOA评分为8.89±1.87,拟融合节段Cobb角为(4.87±4.56)°,颈椎曲度为(11.68±1.25)°,均行颈椎前路椎体次全切除联合椎间隙减压融合内固定术。通过影像学资料测量术后1、12个月时的融合节段Cobb角、颈椎曲度,并采用JOA评分评价疗效。结果:手术时间120~205 min,平均163 min;术中出血量100~300 ml,平均198 ml;术后1例患者出现声音嘶哑,术后3周恢复正常;1例出现饮水呛咳,术后1周恢复正常。28例患者均获得随访,时间12~24(18.46±3.20)个月。术后12个月植骨椎间隙均获骨性愈合,内固定物位置良好。术后1、12个月时融合节段Cobb角与颈椎曲度及JOA评分均较术前明显改善(P0.05)。术后12个月JOA评分改善率为(46.46±20.26)%,手术疗效根据改善率评定:优12例,良14例,好转2例。结论:颈椎前路椎体次全切除联合椎间隙减压融合内固定术治疗多节段颈椎病效果满意。     

颈椎后路椎管扩大成形加短节段固定手术疗效及影响因素分析

目的探讨颈椎后路椎管扩大成形加短节段固定手术治疗脊髓型颈椎病的疗效及影响因素。方法 2006-08-2008-06因脊髓型颈椎病行颈椎后路单开门椎管扩大成形加颈椎侧块钉棒系统固定融合术的患者21例,将患者的年龄、病程、术前椎管矢状径值、骨性椎管扩大率、脊髓后移距离、术前JOA评分诸影响因素与JOA改善率进行多元逐步回归分析,分析JOA改善率与上述诸因素的相关性。结果术前JOA评分、病程与JOA改善率明确相关,有显著性统计学意义。病程与JOA改善率呈明显负相关,术前JOA评分与JOA改善率呈明显正相关。结论颈椎后路单开门椎管扩大成形加颈椎侧块钉棒系统固定融合术是治疗脊髓型颈椎病的有效方法;术前JOA评分和病程是决定脊髓型颈椎病预后的重要因素,是判断预后的重要指标,两者相比,术前JOA评分更重要。     

T1倾斜角对颈椎后纵韧带骨化患者后路单开门椎板成形术后颈椎曲度的影响

目的评价T_1倾斜角对颈椎后纵韧带骨化(ossification of posterior longitudinal ligament,OPLL)患者颈椎后路单开门椎板成形术后颈椎曲度的影响。方法选取2014年1月—10月,因颈椎OPLL接受颈椎后路单开门椎板成形术病例38例,男20例,女18例;年龄44~75岁,平均53.3岁,随访5.1~6.6个月,平均6.0个月;手术节段C3~6 18例,C3~7 12例,C4~7 8例。记录术前和随访时疼痛视觉模拟量表(visual analogue scale,VAS)评分、日本骨科学会(Japanese Orthopaedic Association,JOA)评分,计算VAS、JOA评分改善率。通过X线片测量术前T_1倾斜角、术前和随访时C2~7 Cobb角及颈椎活动度(range of motion,ROM),计算C2~7 Cobb角改变值,即颈椎曲度改变值。运用SPSS 18.0软件分析数据,以明确T_1倾斜角与颈椎曲度改变之间的相关性。结果根据T_1倾斜角中位数将病例分为2组,2组病例之间性别、年龄、手术节段、随访时间、术前和随访时颈椎ROM、随访时Cobb角、VAS评分改善率及JOA评分改善率差异均无统计学意义(P0.05)。T_1倾斜角与随访时颈椎曲度改变明显相关,较大T_1倾斜角组(T_1倾斜角≥26.9°,n=19)病例在随访时的颈椎曲度改变明显高于较小T_1倾斜角组(T_1倾斜角26.9°,n=19),差异具有统计学意义(P0.05)。结论对于具有较大T_1倾斜角的OPLL病例,颈椎后路单开门椎板成形术后颈椎曲度丢失的风险有可能增加,提示在拟行颈椎后路单开门手术或其他颈椎后路术式之前,在考虑患者颈椎Cobb角等评估因素的同时,也应将T_1倾斜角作为一项重要考虑因素。     

棘突悬吊式椎管扩大椎板成形术治疗后纵韧带骨化症患者K线后移程度与临床疗效的相关性

目的探讨颈椎后路棘突悬吊式椎管扩大椎板成形术治疗K线阳性后纵韧带骨化症(OPLL)患者K线后移程度与手术疗效之间的相关性。方法回顾性分析2014年1月—2015年12月本院骨科收治的62例K线(+)OPLL患者的临床资料,所有患者均行颈椎后路棘突悬吊式椎管扩大椎板成形术。将椎管最狭窄处骨化块与K线之间的垂直距离定义为KM值,用以量化K线的位置,并用手术前后KM的差值(ΔKM)表示K线的移动程度。比较患者ΔKM值、手术前后C_(2~7) Cobb角的差异。根据患者ΔKM平均值将患者分为A组(ΔKM高于平均值)和B组(ΔKM低于平均值),比较2组患者年龄、手术时间、随访时间、手术前后C_(2~7) Cobb角、日本骨科学会(JOA)评分及JOA改善率。应用Pearson相关性分析探讨所有患者ΔKM值与JOA评分改善率之间的相关性。结果所有患者术后KM值均较术前增加,即K线后移;手术前后C_(2~7) Cobb角无明显变化。2组手术前后C_(2~7) Cobb角、手术时间及随访时间差异无统计学意义(P0.05);A组患者年龄明显低于B组,差异有统计学意义(P0.05);排除年龄影响后,A组患者术后JOA评分、JOA评分改善率高于B组,差异有统计学意义(P0.05);且ΔKM值与JOA评分改善率之间呈正相关。结论颈椎后路棘突悬吊式椎管扩大椎板成形术可有效改善OPLL患者临床症状,其机制可能是C_2、T_1处潜行减压后K线后移。     

治疗下颈椎骨折脱位伴脊髓损伤的三种手术方式

[目的]探讨三种手术方式治疗下颈椎骨折脱位伴脊髓损伤的临床效果。[方法]2009年6月~2012年6月根据损伤情况分别对116例下颈椎骨折脱位伴脊髓损伤患者采用不同手术方式,行脊髓减压,恢复颈椎序列、生理曲度并植骨融合内固定,其中36例前路手术,28例后路手术,52例前后路联合手术。术前美国脊髓损伤学会(ASIA)评分:A级18例,B级23例,C级34例,D级41例。对平均Cobb角、椎体间滑移距离及术后神经功能恢复情况进行分析。[结果]三种手术各组内术前、术后Cobbe角,椎体间滑移距离及JOA评分差异均有统计学意义,三组间术前Cobbe角,椎体间滑移距离及JOA评分比较差异均无统计学意义,但末次Cobb角、椎体间滑移距离及JOA评分,联合组分别与前路组或后路组比较差异有统计学意义,前路组与后路组比较差异无统计学意义。[结论]三种手术方式均有效果,应根据具体伤情选择,前后路联合手术能最大限度恢复颈椎序列,解除脊髓前后方压迫并使损伤节段牢靠固定,为脊髓恢复创造条件。     

经椎间隙减压融合治疗双节段脊髓型颈椎病

目的观察连续型双节段脊髓型颈椎病行前路经椎间隙减压植骨融合术的临床疗效。方法回顾性分析2011年12月至2013年6月手术治疗并获得随访的连续型双节段脊髓型颈椎病31例,其中男20例,女11例;年龄45~70岁,平均为(60.7±10.8)岁。典型的脊髓型颈椎病症状的病程为1~6个月;病变累及椎间隙为C3/4~C6/7,其中C3~5节段为15例,C4~6节段为11例,C5~7节段为5例。在术前、术后及末次随访时通过颈椎X线片对融合节段Cobb角及C2~C7Cobb角进行测量分析,观察颈椎曲度的改变和植骨融合情况;通过日本骨科协会(Japanese orthopaedic association,JOA)评分系统对术前、术后及末次随访的临床症状进行分析。结果随访时间为6~24个月,平均(12.4±8.2)个月。颈椎曲度有明显改善。JOA评分由术前的(9.6±3.2)分增加至末次随访时的(14.4±2.2)分,优良率为83.9%。31例患者随访结束时骨性融合率为96.8%。结论经椎间隙减压植骨融合术治疗连续型双节段脊髓型颈椎病具有能良好改善颈椎曲度、满意的临床治疗效果和较高的植骨融合率。     

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。