两种术式治疗中央型腰椎管狭窄症中远期疗效分析

目的 比较经椎板间隙潜行减压椎管成形术与腰椎全椎板减压后外侧融合术治疗腰椎管狭窄症术后中远期临床疗效.方法 2007年4月～2009年2月,收治腰椎管狭窄症患者98例,所有患者术前均有不同程度的间歇性跛行和下肢放射性疼痛.手术前均行腰椎过度屈伸位X线片和MRI检查,均无腰椎不稳和滑脱,结合临床症状明确诊断并确定减压范围...     

椎板间隙入路椎间盘镜治疗腰椎管狭窄症

目的：探讨在椎板间隙入路椎间盘镜下有限化手术治疗退行性腰椎管狭窄症。方法：选取退行性腰椎管狭窄症病例，在椎板间隙入路椎间盘镜下行椎管有限减压。咬除病变间隙上位椎板下缘、肥厚的黄韧带和下位椎板上缘，摘除突出椎间盘髓核，松解神经根粘连，侧隐窝减压，必要时切除部分关节突。结果：应用椎板间隙入路椎间盘镜治疗迟行性腰椎管狭窄症，行椎管有限减压87例，减压彻底。82例得到随访，优良串92．7％，手术效果满意。结论：单纯腰椎间盘膨出或突出、黄韧带肥厚和小关节增生引起的退行性腰椎管狭窄症是椎板间隙入路椎间盘镜下椎管有限减压的适应证。满意的手术效果取决于：病人选择适当，术中操作精细，减压彻底。     

卷帘式腰椎管成形术治疗老年退变性腰椎管狭窄症

目的探讨与总结采用卷帘式椎管成形术治疗老年退变性腰椎管狭窄症的疗效及优越性。方法自2004年5月至2009年12月,对22例老年退变性腰椎管狭窄症患者采用保留椎板棘突韧带复合结构椎管减压的卷帘式腰椎管成形术治疗。结果本组病人均获随访,时间3个月～5年,无症状复发,无腰椎不稳,取得良好的临床疗效。14例患者在术后2～3个月CT扫描可看到满意的骨痂生长,未见回植椎板移入椎管或有移入倾向,未见截骨前缘过度增生对硬膜产生新的压迫等。结论卷帘式腰椎管成形术安全、可靠、疗效好,具有避免椎管内黏连与瘢痕压迫,恢复局部解剖和维持脊柱稳定的特点。既可对腰椎管狭窄进行减压,又可减少对腰椎稳定性的损害。     

联合椎板间入路与后外侧入路内镜下减压治疗退变性腰椎管狭窄症的临床研究

目的分析联合椎板间与后外侧入路内窥镜下减压治疗退变性腰椎管狭窄症的临床疗效。方法退变性腰椎管狭窄症病人41例,行联合椎板间与后外侧入路内窥镜下减压治疗,通过手术前后椎管矢状径、盘黄间隙、椎管面积、椎间孔前后径,手术前后NRS评分、ODI指数及JOA评分评价疗效。结果手术时间82～114分钟,平均(91. 31±10. 64)分钟。术中出血130～210 ml,平均(174. 38±31. 18) ml。1例病人出现下肢放射性麻木,2例病人出现脑脊液漏。随访时间12～15周,平均随访(13. 37±2. 38)周。手术前后NRS评分、ODI指数、JOA评分比较差异有统计学意义(P 0. 05)。术后椎管矢状径、盘黄间隙、椎管面积、椎间孔前后径术后分别扩大24. 05%、53. 99%、45. 35%和21. 34%,与术前比较差异有统计学意义(P 0. 05)。结论联合椎板间及后外侧入路对退变性腰椎管狭窄症病人可在不影响腰椎稳定性的情况下,扩大腰椎管的有效空间,改善临床症状。     

骨科

数学化人体脊柱的初步临床应用；经口咽前路寰枢椎复位钢板系统治疗陈旧性齿状突骨折；Hangman骨折的前路手术治疗；EH复合型颈椎螺纹融合器的研制和临床应用；Ⅰ期前后联合入路脊髓减压病灶切除内固定治疗颈椎后纵韧带骨化症；多节段前路减压植骨融合并钢板内固定术治疗脊髓型颈椎病；Atlas钛缆内固定系统在寰枢椎脱位中的应用；前路植骨融合带锁钢板内固定治疗颈椎外伤性滑脱；用颈长肌重建预防颈前路植骨块滑脱的临床应用；青年非创伤性颈椎生理弧度异常的病因及机理探讨；CT三维重建椎弓根钉导航系统在胸椎手术中的应用；结束支具治疗后青少年特发性脊柱侧凸的进展及影响因素分析；CT三维重建在先天性脊柱侧凸诊疗中的价值；椎体后凸成形术棘突定位穿刺点与穿刺轨道的研究；椎体软骨终板在脊柱退行性疾病及脊柱侧凸发病中的作用（综述）；经椎间孔腰椎椎体问融合术的应用进展（综述）；老年骨质疏松椎体压缩骨折的经皮椎体后凸成形术；老年骨质疏松性胸腰椎爆裂骨折的前路减压内固定治疗；球囊扩张椎体后凸成形术治疗骨质疏松性脊柱压缩性骨折；异体骨管在胸腰椎爆裂骨折前路手术中的应用；钉棒及钩棒系统治疗胸腰椎多节段脊柱骨折；单节段腰椎后部结构逐级切除对脊柱三维运动稳定性的影响；腰椎滑脱症24例手术治疗体会；椎间盘镜治疗腰椎间盘突出伴椎管狭窄症；腰椎旁或骶管注射结合整脊推拿治疗腰椎闻盘突出症；腰椎管狭窄症的手术方式探讨；脊柱显微内镜在治疗腰椎管狭窄症的临床应用（附129例报告）；椎间盘源性腰痛动态摄片及其临床意义；椎体气囊扩张成形术治疗老年椎体压缩骨折；椎弓根螺钉断裂25例原因分析；仿生活性人工骨诱导兔椎板问多节段脊柱融合的研究；椎弓根螺钉对腰椎关节突关节破坏率的研究。[编者按]     

Quadrant辅助下TLIF治疗腰椎退变性疾病

[目的]探讨采用常规腰椎固定系统经椎旁肌间隙入路Quadrant辅助下经椎间孔椎体间融合(TLIF)治疗腰椎退变性疾病临床疗效。[方法]回顾性分析37例采用本手术方式治疗的腰椎退变性疾病患者,椎旁小切口Quadrant辅助下肌间隙入路,行患侧关节突切除,减压后椎体间融合,常规固定系统固定。术前、术后3个月及末次随访时采用疼痛视觉模拟评分(VAS)和Oswestry功能障碍指数(ODI)分别评估患者疼痛、神经功能情况,影像学检查评估椎体间融合情况。[结果]所有患者均完成1年以上随访时间,患者VAS、ODI和术前相比获得较好的改善(P0.05),影像学数据显示骨性融合率为84.4%。[结论]采用常规腰椎固定系统经椎旁肌间隙入路Quadrant辅助下TLIF治疗腰椎退变性疾病,手术损伤小、手术费用低,并有良好的临床疗效。     

退变性腰椎管狭窄症的诊断与手术治疗

目的　探讨退变性腰椎管狭窄症的诊断与手术治疗方式。方法　 1995～ 2 0 0 2年对 6 2例诊断为退变性腰椎管狭窄症的患者 ,仔细分型 ,采用 3种方法 ,a)开窗潜行扩大椎板减压术 ;b)扩大的半椎板切除减压术 ;c)全椎板切除加椎间融合术。结果　随访 1～ 6a ,按Nakal分级评定优 4 3例 ,良 16例 ,可 3例 ,优良率 96 .5 %。结论　退变性腰椎管狭窄症的手术治疗主要以充分彻底的减压、解除神经根的致压因素为主 ,但要兼顾减压的彻底性与腰椎的稳定性。单节段病变选择开窗潜行减压术或扩大半椎板切除减压术 ,多节段病变选择全椎板减压术同时行椎间融合术以保证腰椎稳定。     

经皮椎板间隙入路270°椎管减压治疗腰椎管狭窄症

[目的]探讨经皮椎板间隙入路的椎管减压技术治疗伴有双侧侧隐窝狭窄的腰椎管狭窄症临床疗效。[方法]本组单节段双侧侧隐窝腰椎管狭窄症患者20例,采取单侧经皮椎板间隙入路,通过改变内镜的倾斜角度并利用角度椎板钳和镜下磨钻行双侧侧隐窝和中央椎管270°减压,随访时间超过24个月,分析术后疗效参数如VAS评分、ODI评分、Macnab分级评分、单次连续行走距离和手术并发症。[结果]术后影像学证实所有患者进行了有效的中央椎管和双侧侧隐窝的减压。术后ODI评分和VAS评分较术前显著降低,差异有统计学意义;Macnab评分,80%的患者取得了满意或良好的疗效;单次连续行走距离较术前明显增加。[结论]单侧经皮椎板间隙入路双侧侧隐窝和中央椎管270°减压术,具有良好的中央椎管和双侧侧隐窝手术视野显示,可有效减压,是微创治疗退变性椎管狭窄症特别是合并双侧侧隐窝狭窄的有效安全的手术方式。     

单双入路后凸成形术治疗胸腰椎压缩骨折比较

目的：探讨单入路与双入路球囊扩张椎体后凸成形术治疗老年骨质疏松性胸腰椎压缩性骨折在疗效和安全性上的差异。方法：52例患者随机分为单入路组和双入路组。单入路组16例,经皮伤椎单侧入路穿刺建立工作通道,放置单枚球囊于伤椎内,行球囊扩张椎体后凸成形术 双入路组36例,经皮伤椎双侧入路穿刺建立工作通道,在双侧分别放置球囊于伤椎内,行球囊扩张椎体后凸成形术。结果：52例患者均未发现神经损伤等并发症,两组背痛缓解程度、脊柱后凸畸形矫正度、伤椎前缘高度恢复比较,差异无显著性（P〉0.05） 两组手术时间和透视次数比较,差异有显著性（P〈0.05）。结论：单入路与双入路椎体后凸成形术治疗老年骨质疏松性胸腰椎压缩性骨折疗效相似,单入路较双入路能明显减少手术时间和放射暴露。     

椎间植骨内固定在下腰退变性椎管狭窄症中的应用

目的探讨椎间植骨内固定术在治疗下腰退变性椎管狭窄症中的疗效。方法43例下腰椎退变性椎管狭窄症患者均采用椎板切除、椎间植骨融合术、椎弓根钉短节段内固定术。术后观察效果。结果患者均获随访,时间14～26个月。根据JOA评分标准：优32例,良9例,可2例,优良率为95.3%。结论椎弓根钉固定技术加椎间植骨确保维持腰椎稳定性,符合腰椎生物力学要求,在椎管充分减压的基础上,治疗下腰退变性椎管狭窄症是一种安全有效和经济的方法。     

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.     

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.     

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.     

Influence of dopexamine hydrochloride on haemodynamics and regulators of circulation in patients undergoing major abdominal surgery

Background: Catecholaminergic support is often used to improve haemodynamics in patients undergoing major abdominal surgery. Dopexamine is a synthetic vasoactive catecholamine with beneficial microcirculatory properties. Methods: The influence of perioperative administration of dopexamine on cardiorespiratory data and important regulators of macro- and microcirculation were studied in 30 patients undergoing Whipple pancreaticduodenectomy. The patients received randomized and blinded either 2 μg · kg^?1 · min^?1 of dopexamine (n=15) or placebo (n=15, control group). The infusion was started after induction of anaesthesia and continued until the morning of the first postoperative day. Endothelin-1 (ET-1), vasopressin, atrial natriuretic peptide (ANP), and catecholamine plasma levels were measured from arterial blood samples. Measurements were carried out after induction of anaesthesia, 2 h after onset of surgery, at the end of surgery, 2 h after surgery, and on the morning of the first postoperative day. Results: Cardiac index (CI) increased significantly in the dopexamine group (from 2.61±0.41 to 4.57±0.78 1 · min^?1 · m^?2) and remained elevated until the morning of the first postoperative day. Oxygen delivery index (DO₂I) and oxygen consumption index (VO₂I) were also significantly increased in the dopexamine group (DO₂I: from 416±91 to 717±110 ml/m² · m²; VO₂I: from 98±25 to 157±22 ml/m² · m²), being significantly higher than in the control group. pHi remained stable only in the dopexamine patients, indicating adequate splanchnic perfusion. Vasopressive regulators of circulation increased significantly only in the untreated control patients (vasopressin: from 4.37±1.1 to 35.9±12.1 pg/ml; ET-1: from 2.88±0.91 to 6.91±1.20 pg/ml). Conclusion: Patients undergoing major abdominal surgery may profit from prophylactic perioperative administration of dopexamine hydrochloride in the form of improved haemodynamics and oxygenation as well as beneficial influence on important regulators of organ blood flow.