注射型硫酸钙椎体成形结合椎弓根内固定治疗胸腰椎骨折

[目的]探讨经椎弓根注射硫酸钙椎体成形结合椎弓根内固定治疗胸腰椎骨折的疗效.[方法]自2005年4月～2007年6月,采用经椎弓根注射硫酸钙椎体成形结合椎弓根内固定治疗胸腰椎骨折43例.观察术后症状改善情况,并且在术前、术后和末次随访时拍摄胸腰椎正侧位X线片观察骨折复位和稳定情况.[结果]所有病例均顺利完成手术,术后Frankel分级神经功能均恢复至E级.其中38例获得完整随访.随访时间8～30个月,平均22个月.术前椎体前缘、中央和后缘高度丢失率分别为51.4%、41.5%和3.5%,Cobb's角为16.3°;术后分别为11.7%、14.3%和1.7%,cobb's角为0.8°,两者相比存在显著差异(P＜0.05).末次随访椎体前缘、中央和后缘高度丢失率分别为13.6%、15.0%和2.0%,cobb's角为1.2°,与术后相比无显著性筹异(P＞0.05),无断钉、内固定松动,VAs评分由术前8.5分降至1分.[结论]经椎弓根注射硫酸钙椎体成形结合椎弓根内固定治疗胸腰椎骨折,是一种微创、安全、有效的方法.它可重建稳定,减少并发症,提高疗效.     

经椎弓根固定结合硫酸钙椎体成形术治疗胸腰椎骨折

目的探讨经椎弓根注射硫酸钙椎体成形结合椎弓根内固定治疗胸腰椎骨折的疗效。方法采用经椎弓根注射硫酸钙椎体成形结合椎弓根内固定治疗胸腰椎骨折58例,术后观察骨折椎体前后缘及椎体中央高度压缩率变化,Cobb角改善情况及并发症。结果术中无脊髓、神经损伤等并发症,出血量100～300(200±50)ml,手术时间45～80(60±10)min。58例均获随访,时间12～24个月。患者椎体高度和生理弧度恢复满意,1例发生内固定松动、断裂。结论经椎弓根注射硫酸钙椎体成形结合椎弓根内固定治疗胸腰椎骨折,是一种安全、有效的方法,但需注意手术适应证。     

硫酸钙椎体成形结合短节段椎弓根钉固定治疗胸腰椎骨折

目的探讨硫酸钙椎体成形结合短节段椎弓根钉固定治疗胸腰椎骨折的临床疗效。方法采用硫酸钙椎体成形结合短节段椎弓根钉固定治疗胸腰椎骨折23例。结果本组获随访12～36个月,VAS评分由术前8.0分降至末次随访时的1.0分。术后3 d椎体前缘、中央、后缘高度丢失率以及后凸Cobb角与术前相比较,差异有统计学意义(P<0.05);而末次随访时与术后3 d相比较,差异无统计学意义(P>0.05)。结论硫酸钙椎体成形结合短节段椎弓根钉固定治疗胸腰椎骨折,可重建脊柱的稳定,减少并发症,是一种可靠、安全、有效的手术方法。     

实用骨科杂志微创内固定并注射硫酸钙治疗胸腰椎骨折

目的：探讨微创短节段经皮椎弓根螺钉结合伤椎内经椎弓根植入可注射硫酸钙手术治疗胸腰椎骨折的疗效。方法回顾性分析2008年11月至2012年10月收治的37例胸腰椎骨折患者的临床资料,其中男31例,女6例;年龄19～62岁,平均41.2岁。均采用手法结合体位复位、经皮椎弓根钉固定及经伤椎椎弓根椎体内植入硫酸钙人工骨,观察手术时间、术中出血量等围手术期指标及影像学指标。结果平均手术时间85 min,平均术中出血量80 mL,平均住院时间11.5 d,平均随访时间18个月。无脊髓、神经损伤及伤口感染,无内固定断裂、松动。术后即刻和终末随访时,患者伤椎前、后缘高度与正常椎体前、后缘高度的比值和Cobb角度均较术前改善。结论微创经皮椎弓根内固定结合硫酸钙人工骨强化椎体治疗胸腰椎骨折损伤小、出血少,椎体高度及脊柱序列恢复良好。     

微创内固定并注射硫酸钙治疗胸腰椎骨折

目的探讨微创短节段经皮椎弓根螺钉结合伤椎内经椎弓根植入可注射硫酸钙手术治疗胸腰椎骨折的疗效。方法回顾性分析2008年11月至2012年10月收治的37例胸腰椎骨折患者的临床资料,其中男31例,女6例;年龄19~62岁,平均41.2岁。均采用手法结合体位复位、经皮椎弓根钉固定及经伤椎椎弓根椎体内植入硫酸钙人工骨,观察手术时间、术中出血量等围手术期指标及影像学指标。结果平均手术时间85 min,平均术中出血量80 mL,平均住院时间11.5 d,平均随访时间18个月。无脊髓、神经损伤及伤口感染,无内固定断裂、松动。术后即刻和终末随访时,患者伤椎前、后缘高度与正常椎体前、后缘高度的比值和Cobb角度均较术前改善。结论微创经皮椎弓根内固定结合硫酸钙人工骨强化椎体治疗胸腰椎骨折损伤小、出血少,椎体高度及脊柱序列恢复良好。     

经皮椎弓根钉内固定联合球囊辅助复位椎体内植骨治疗胸腰椎骨折

目的探讨经皮椎弓根钉内固定联合球囊辅助复位椎体内植骨治疗胸腰椎骨折的疗效。方法采用经皮椎弓根钉内固定联合球囊辅助复位椎体内植骨治疗19例胸腰椎骨折患者。观察患者手术前后椎体前缘、中部、后缘高度的变化以及后凸Cobb角的矫正程度。结果 19例均获得获随访,时间12～24个月。后凸Cobb角以及椎体前缘、中部、后缘高度:术后1周、3个月、12个月与术前比较差异均有统计学意义(P 0.05),术后各时间段比较差异无统计学意义(P 0.05)。术后无内固定物松动及断裂发生。Frankel神经功能分级:3例术前D级者末次随访均改善至E级。结论采用经皮椎弓根钉内固定联合球囊辅助复位椎体内植骨治疗胸腰椎骨折,能够有效恢复和重建伤椎高度,矫正后凸畸形,恢复椎体的生物力学性能。     

硫酸钙椎体成形术联合椎弓根钉内固定治疗创伤性胸腰椎骨折的前瞻性研究

目的探讨注射型硫酸钙椎体成形术联合椎弓根钉内固定治疗创伤性胸腰椎骨折的初步临床疗效。方法自2008年3月~2010年5月,采用注射型硫酸钙椎体成形术联合后路短节段椎弓根钉内固定治疗25例无神经障碍的创伤性胸腰椎骨折,术后随访观察椎体前、中部的相对高度、Cobb角、伤椎角,并对疼痛和功能指标分别用视觉模拟评分(VAS)和Oswestry功能障碍指数(ODI)进行量化比较。结果 23例得到随访13~35个月,平均23.8个月。术后1周时椎体前、中部的相对高度、Cobb角,伤椎角分别与术前值比较,差异有统计学意义(P<0.05),而与末次随访时比较,差异无统计学意义(P>0.05)。结论硫酸钙椎体成形术联合椎弓根钉内固定治疗创伤性胸腰椎骨折可以有效防止内固定失败和矫正度丢失,临床效果满意。     

后路椎弓根钉固定结合硫酸钙骨水泥椎体成形术治疗新鲜胸腰椎压缩性骨折

目的探讨后路椎弓根钉固定结合硫酸钙骨水泥椎体成形术治疗新鲜胸腰椎压缩性骨折的临床疗效。方法选择性对70例新鲜胸腰椎压缩性骨折患者采用后路复位椎弓根钉内固定结合硫酸钙骨水泥椎体成形术治疗。分别于术前、术后1周及随访终末观测脊柱后突角、椎体前后缘高度压缩率变化;观察内固定稳定状况及神经损伤的恢复情况。结果 8例发生骨水泥渗漏。57例获得平均17个月随访,1例发生内固定断裂。脊柱后凸角、椎体前后缘高度压缩率:末次随访与术前比较,差异有统计学意义(P0.05);与术后1周比较,差异无统计学意义(P0.05)。术后神经功能按Frankel分级评定:E级54例,D级3例。结论后路椎弓根钉固定结合硫酸钙骨水泥椎体成形术治疗新鲜胸腰椎压缩性骨折,可有效恢复脊柱单元的生物力学稳定性,进而避免后突矫正度丢失、内固定松动断裂等并发症的发生及促进神经功能的恢复。     

伤椎椎弓根固定治疗胸腰椎骨折52例分析

目的 探讨胸腰椎骨折经伤椎椎弓根直接复位内固定的可行性和疗效.方法 采用经伤椎椎弓根固定胸腰椎骨折52例,术前、术后随访摄片观察椎体高度有无丢失,内固定物有无松动.结果 随访13～17个月,平均(14.97±1.12)个月.术前、术后伤椎椎体前缘高度比和Cobb氏角恢复良好,差异有统计学意义(P＜0.05),未出现内固定物松动和断裂.结论 胸腰椎骨折经伤椎椎弓根固定有利于恢复椎体高度,维持矫正效果,内固定系统固定牢固,显著增强了脊柱的强度和稳定性.     

经皮椎弓根钉体外撑开结合伤椎骨水泥注入治疗中老年胸腰椎骨折的临床研究

目的探讨经皮椎弓根钉体外撑开结合伤椎骨水泥注入治疗中老年胸腰椎骨折的可行性、安全性及有效性。方法回顾性分析20例经皮椎弓根钉体外撑开结合伤椎骨水泥注入治疗中老年胸腰椎骨折。测量手术前后伤椎Cobb角、椎体前缘的高度丢失率。结果术前平均腰背痛VAS评分(7.2±1.6)分,ODI(52.6±16)。术后平均腰背痛VAS评分(2.4±1.6)分,ODI(21.6±9),平均腰背痛VAS和ODI均明显低于术前(P<0.01)。术前椎体前缘的丢失率(49.4±12.5)%,术后(8.2±4.9)%,末次随访时(9.2±5.1)%;术前后凸角度(18.1±4.3)°,术后后凸角度(3.5±1.9)°,末次随访时(4.2±1.8)°。椎体高度丢失率、后凸角度术后、末次随访较术前差异有统计学意义(P<0.05);末次随访与术后比较差异无统计学意义(P>0.05)。结论经皮伤椎成形术结合体外椎弓根钉撑开系统一期矫正伤椎的压缩高度及恢复正常的脊柱生理曲度,创伤小,是中老年胸腰椎骨折安全有效的治疗方法。     

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.     

Reduction of Plasma Fibrinogen, Immunoglobulin G, and Immunoglobulin M Concentrations by Immunoadsorption Therapy with Tryptophan and Phenylalanine Adsorbents

Abstract Immunoadsorption (1A) therapy with tryptophan (TR-350) or phenylalanine (PH-350) adsorbents has been used to reduce the concentration of serum antibodies in human lymphocyte antigen (HLA)-immunized patients. Other forms of plasma purification have been reported to reduce the level of fibrinogen, which affects the blood properties. In this study we investigated the effects of IA therapy using both adsorbents on plasma fibrinogen and immunoglobulins G and M in 13 patients (8 patients were treated with TR-350, and 5 patients were treated with PH-350). During each session 1 plasma volume (2.8 ± 0.4 L of plasma) was processed through the immunocolumn and then returned to the patient together with the blood cells. Compared with the pretreatment values, the plasma fibrinogen, IgG, and IgM concentrations were significantly reduced after IA therapy (p < 0.01 for TR-350; p < 0.04 for PH-350). There was a positive correlation between the degree of reduction of plasma proteins and the number of IA treatments given. A nonpara-metric test (Wilcoxon's signed-rank test or the Mann-Whitney test) was used for statistical analysis. We conclude from our study that IA therapy effectively lowers the plasma levels of fibrinogen, IgG, and IgM and thus can be considered a valuable alternative to other blood purification methods.     

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.     

The analgesic effect of racemic ketamine in patients with chronic ischemic pain due to lower extremity arteriosclerosis obliterans

Background : Ketamine in sub-dissociative doses has been shown to have analgesic and phantom-Limb pain, where conventional treatment has often failed. Chronic ischemic pain due to lower extremity arteriosclerosis obliterans often responds poorly to analgesics, and the pain-generating mechanisms are not well understood.
Methods : Eight patients with rest pain in the lower extremity due to arteriosclerosis obliterans were given sub-dissociative doses of 0.15, 0.30, or 0.45 mg/kg racemic ketamine and morphine 10 mg as a 5-min infusion on four separate days in a cross-over, double-blind, randomised protocol. Plasma levels of (S)- and (R)-ketamine and their nor-metabolites were analysed with an enantioselective high-performance liquid chromatography (HPLC) method. Pain levels were evaluated with a visual analogue scale (VAS).
Results : Individual pain levels were highly variable during and after all the infusions but the pooled pain levels showed a dose-dependent analgesic effect of ketamine with a transient but complete pain relief in all patients at the highest dose (0.45 mg/ kg). Side-effects, mainly disturbed cognition and perception, were pronounced and dose-dependent. Morphine 10 mg had an analgesic peak at 20 min and 5/8 patients had complete pain relief. The remaining 3 patients also had high baseline pain scores, indicating a higher analgesic potency for the 0.30 and 0.45 mg/ kg ketamine doses than for morphine 10 mg.
Conclusion : We have demonstrated a potent dose-dependent analgesic effect of racemic ketamine in clinical ischemic pain. Due to a narrow therapeutic window, this analgesic effect is probably best utilised in combination with other analgesics.     

Intravenous endotoxin does not increase tissue extravasation of albumin in rats

Background : It is unclear whether activation of the inducible nitric oxide synthase (iNOS) increases or decreases the extravasation of plasma.
Methods : Chloralose anaesthetised male Wistar rats received E. coli lipopolysacharide (LPS), 3 mg kg^-1 i.v., or the corresponding volume of saline, 3 or 5 h before the end of the experiment. Mean arterial pressure (MAP) and heart rate (HR) were recorded. Tissue clearance of radio-labelled albumin, during the last 2 h of each experiment, was determined by a double-isotope method. In separate animals, the serum concentration of nitrite and nitrate was determined, 5 h after LPS or the solvent.
Main Results : LPS initially decreased MAP and lastingly increased HR. In the 3-h LPS animals (n=8), tissue plasma clearance was lower in the heart and calf muscle and increased only in diaphragm, compared to corresponding control animals (n=8). In the 5-h LPS rats, clearance was lowered (n=8) in the entire gastrointestinal tract and in testes, compared to controls (n=8). The serum nitrite/nitrate concentration was higher in animals given LPS (n=6) than in controls (n=6).
Conclusion : After LPS, tissue clearance of albumin was not increased in any major tissue, in spite of increased serum levels of NO end products. Apparently, after activation of iNOS, the augmented release of NO is not necessarily associated with increased albumin extravasation.     

Adrenaline markedly improves thoracic epidural analgesia produced by a low-dose infusion of bupivacaine, fentanyl and adrenaline after major surgery: A randomised, double-blind, cross-over study with and without adrenaline

Background: Basic pharmacological research indicates that there are synergistic antinociceptive effects at the spinal cord level between adrenaline, fentanyl and bupivacaine. Our clinical experience with such a mixture in a thoracic epidural infusion after major surgery confirms this. The objectives of the present study were to evaluate the effects on postoperative pain intensity, pain relief and side effects when removing adrenaline from this triple epidural mixture. Methods: A prospective, randomised, double-blind, cross-over study was carried out in 24 patients after major thoracic or abdominal surgery. Patients with only mild pain when coughing during a titrated thoracic epidural infusion of about 10 ml · h^?1 of bupivacaine 1 mg · ml^?1, fentanyl 2 μg · ml^?1, and adrenaline 2 μg · ml^?1 were included. On the 1^st and 2^nd postoperative days each patient was given a double-blind epidural infusion, at the same rate, with or without adrenaline. The effect was observed for 4 h or until pain when coughing became unacceptable in spite of a rescue analgesic procedure. Rescue analgesia consisted of up to two epidural bolus injections per hour and i.v. morphine if necessary. All patients received rectal paracetamol 1 g, every 8 h. Fentanyl serum concentrations were measured with a radioimmunoassay technique at the start and end of each study period. Main outcome measures were extent of sensory blockade and pain intensity at rest and when coughing, evaluated by a visual analogue scale, a verbal categorical rating scale, the Prince Henry Hospital pain score, and an overall quality of pain relief score. Results: The number of hypaesthetic dermatomal segments decreased (P <0.001) and pain intensity at rest and when coughing increased (P <0.001) when adrenaline was omitted from the triple epidural mixture. This change started within the first hour after removing adrenaline. After 3 h pain intensity when coughing had increased to unacceptable levels in spite of rescue analgesia (epidural bolus injections and i.v. morphine). Within 15–20 min after restarting the triple epidural mixture with adrenaline, pain intensity was again reduced to mild pain when coughing. Serum concentration of fentanyl doubled from 0.22 to 0.45 ng · ml^?1 (P <0.01), and there was more sedation during the period without adrenaline. Conclusions: Adrenaline increases sensory block and improves the pain-relieving effect of a mixture of bupivacaine and fentanyl infused epidurally at a thoracic level after major thoracic or abdominal surgery. Serum fentanyl concentrations doubled and sedation increased when adrenaline was removed from the epidural infusion, indicating more rapid vascular absorption and systemic effects of fentanyl.     

The multiply injured child

Blunt trauma is the principal cause of childhood death in many developed countries. This review outlines the differences between adults and children with respect to resuscitation and treatment of orthopaedic injuries in a child with polytrauma. Recent advances in techniques of fracture stabilization are reported.     

Utilisation des médicaments prokinétiques en réanimation : indications et limites ?

Enteral feeding is often limited by gastric and intestinal motility disturbances in critically ill patients, particularly in patients with shock. So, promotility agents are frequently used to improve tolerance to enteral nutrition. This review summaries the pathophysiology, presents the available pharmacological strategies, the clinical data, the counter-indications and the principal limits. The clinical data are poor. No study demonstrates a positive effect on clinical outcomes. Metoclopramide and erythromycin seems to be the more effective. Considering the risk of antibiotic resistance, the first line use of erythromycin should be avoided in favor of metoclopramide.