经胸前路病灶清除减压治疗胸椎结核并后凸畸形

目的:总结经胸前路病灶清除减压植骨内固定治疗胸椎结核截瘫并后凸畸形的临床疗效。方法:22例胸椎结核截瘫并后凸畸形患者,男12例,女10例,临床表现均有胸背痛、截瘫及脊柱后凸畸形,脊柱后凸角Cobb角为20～40°,平均25°。结核病损部位:T3～51例,T3～43例,T4～54例,T4～61例,T6～72例,T7～83例,T8～93例,T9～102例,T10～113例。ASIA分级:B级3例,C级11例,D级8例。MRI示椎管内均有压迫。9例行肩胛下经胸前路病灶清除矫形植骨内固定术,13例常规经胸病灶清除矫形植骨内固定术。术后继续抗痨治疗9～12个月。结果:22例患者切口均一期愈合,无肺部感染、呼吸衰竭等并发症。术后随访2～4年,14例在术后4周内瘫痪完全恢复,8例3个月内完全恢复。所有患者胸背痛消失,植骨融合,平均融合时间4个月,无1例结核复发,术后脊柱后凸Cobb角平均矫正18°,随访期间畸形矫正无丢失。结论:经胸前路病灶清除植骨内固定治疗胸椎结核截瘫并后凸畸形,能够一期完成病灶清除、脊髓减压、后凸畸形矫正和脊柱稳定性重建,是一种安全有效的治疗方法。     

前路病灶清除钛网植骨内固定治疗胸椎结核伴瘫痪

目的探讨上下段胸椎结核的手术入路和内固定方式,以及一期钛网植骨的早期临床疗效。方法2005年8月至2008年11月对16例胸椎结核伴瘫痪病例采用病灶清除,一期钛网植骨内固定治疗。其中上胸椎结核4例采用经肩胛下胸腔入路单钉棒内固定,下胸椎结核12例经常规胸前入路钉板系统内固定,术前术后正规抗痨治疗,术后带支具早期下床活动。结果16例病人术后随访时间2～24个月,平均8个月。所有病人伤口均一期愈合,无一例结核扩散,后凸角平均纠正20°。所有病例钛网植骨稳定,无明显移位和塌陷,内固定无松动和断裂。术前瘫痪症状基本消失,全部患者恢复正常生活和一般工作。结论经胸前路病灶清除一期钛网植骨内固定,不仅能彻底清除病灶,充分减压脊髓,还能纠正后凸畸形,早期完全重建脊柱稳定性,如配合术前后正规抗痨治疗,能获得满意的治疗效果。     

侧前方病灶清除椎弓根内固定治疗胸椎结核后凸畸形

目的观察侧前方病灶清除椎间植骨经椎弓根内固定术治疗脊柱结核并后凸畸形的疗效。方法胸椎结核并后凸畸形患者17例,男11例,女6例;年龄23～56岁,平均36.4岁。结核病损位于下胸椎,累及两或三个椎体。后凸成角15°～34°,平均25°。5例患者合并脊髓损伤,Frankel分级为C级2例、D级3例。手术方法为一期侧前方病灶清除椎间植骨经椎弓根内固定,抗结核药物治疗9个月。结果术后随访2~4年,切口一期愈合,椎间植骨全部融合,脊柱结核全部治愈,脊髓功能损害患者术后1年内完全恢复。术后后凸成角平均为7°,平均矫正18°,随访期间畸形矫正无明显丢失。结论侧前方病灶清除椎弓根内固定术治疗脊柱结核并后凸畸形,能够一期完成病灶清除、脊髓减压、脊柱稳定性重建和后凸畸形矫正。坚强的内固定可促进病椎植骨融合,有助于缩短术后药物治疗时间和提高脊柱结核治愈率。     

跳跃型脊柱结核的外科治疗

目的 探讨跳跃型脊柱结核的治疗方法 及临床效果.方法 回顾性分析2000年1月至2007年3月收治的资料完整的23例跳跃型脊柱结核患者的临床特点、治疗方法 及结果.患者年龄21～65岁,平均41.5岁.病灶位于颈椎+胸椎3例,胸椎+胸椎3例,胸椎+胸腰段6例,胸椎+腰椎4例,胸腰段+腰椎5例,颈椎+胸椎+胸腰段1例,颈椎+胸腰段+腰椎1例.术前后凸角度-5.0°～65.0°,平均30.6°.各处病灶根据病变特点、部位及椎体破坏程度选择行前路一期病灶清除、植骨内固定术,经肋横突入路病灶清除术、椎间植骨后路椎弓根系统内固定术,前路病灶清除植骨、后路椎弓根固定术,一期后路病灶清除、植骨内固定术,单纯病灶清除术或保守治疗.结果术后随访1.5～6.0年,平均3.2年.所有病灶均治愈,未再复发.术后6～12个月,行植骨者病灶X线片均显示植骨融合.术前11例合并截瘫者,7例完全恢复,4例部分恢复.末次随访时后凸角度改善至平均14.2°.术后9例次发生并发症,未造成机体残余损害.结论 跳跃型脊柱结核应根据各处病灶的部位、稳定性、畸形状况及神经损伤情况采取相应的治疗方法 .在有效的抗结核治疗和营养支持治疗前提下积极术前准备,对绝大多数跳跃型脊柱结核患者可一期行手术治疗.     

前路病椎切除一期植骨内固定治疗脊柱结核

目的:总结前路病椎切除同期植骨内固定治疗脊柱结核的临床效果。方法:自2002年1月至2003年1月对57例脊柱结核患者行前路病椎切除同期植骨内固定治疗,所有患者术前均有不同程度的结核中毒症状并局部疼痛,胸椎后凸Cobb角30°~60°,平均45°;腰椎后凸Cobb角15°~35°,平均25°。截瘫13例,窦道形成6例,ESR30~140mm/h,术前强化抗痨2~4周。术中彻底清除病灶,单纯自体骨移植48例,钛网 自体骨重建9例。术后规则应用抗结核药治疗1年。结果:无术中、术后并发症,切口均一期愈合。随访1.5~2.5年,平均2年,植骨块、钛网植骨术后6个月完全融合,13例截瘫患者术后6个月完全恢复,后凸畸形矫正,矫正角度丢失不明显。ESR于术后1个月逐渐下降,3个月后达到正常范围。随访期内病灶未见复发。结论:前路病椎切除同期植骨内固定治疗脊柱结核既可彻底清除病灶防止复发,又可矫正畸形、重建脊柱稳定性,早期恢复脊柱支撑功能,防止晚发截瘫。     

前路内固定治疗胸腰椎结核伴后凸畸形与截瘫

目的：探讨前路植骨内固定治疗胸腰段脊柱结核伴后凸畸形与截瘫的疗效。方法：1996年～2002年4月采用前路病灶清除，植骨内固定治疗胸腰椎结核伴后凸畸形与截瘫62例，观察术后植骨融合、畸形矫正、截瘫恢复及结核病灶愈合情况。结果：平均随访2年2个月，56例患者获访，平均融合时间为3．6个月。骨性融合率100％。在胸段、胸腰段及腰段后凸畸形分别平均纠正29°、15°及9°，随访时无矫正度丢失；伴截瘫者11例，Frankel神经功能平均恢复2级；本组脊柱结核均治愈。结论：一期前路病灶清除植骨内固定，融合时间短，畸形矫正效果好，减压彻底，有利于截瘫恢复。     

经胸入路一期病灶清除植骨内固定治疗胸椎结核

目的:评价经胸入路一期病灶清除自体骨植骨融合内固定治疗胸椎结核的疗效。方法:2000年3月至2005年7月共收治胸椎结核患者21例,均伴有胸背疼痛、乏力、低热、盗汗等结核中毒症状,其中11例有后凸畸形,平均Cobb角27°;20例伴神经功能障碍,Frankel分级B级1例,C级9例,D级10例。全部采用经胸入路一期病灶清除自体骨植骨融合前路内固定术治疗,随访观察治疗效果。结果:未发生肺部感染及呼吸衰竭等并发症。平均随访16个月,所有患者内固定位置良好,无松动、断裂等并发症。胸背疼痛及结核中毒症状消失;结核均治愈,无局部结核复发,植骨均获得骨性融合,融合时间平均为4.8个月。术后平均Cobb角15°,平均矫正12°。20例术前有神经功能障碍者术后有17例获得1级以上的恢复。结论:经胸入路一期病灶清除植骨融合内固定治疗胸椎结核暴露充分,有利于病灶清除、前方脊髓减压、重建脊柱稳定性,骨融合率高。     

一期前路病灶清除植骨内固定治疗胸腰椎结核临床观察

[目的] 探讨经前路病灶清除植骨一期前路/后路内固定术治疗胸腰椎结核的临床疗效.[方法] 对24例胸腰椎结核患者,经3～4周正规抗结核治疗,行前路病灶清除、椎间大块自体髂骨/肋骨植骨、一期前路/后路内固定术,术后继续抗结核治疗18～24个月.[结果] 1例脊柱结核复发(3%).23例植骨融合,植骨融合率为96.9%,植骨愈合时间 4～8个月(平均6个月).无窦道形成.脊柱后凸畸形平均矫正80%.[结论] 经前路病灶清除植骨一期前路/后路内固定术治疗胸腰椎结核能彻底清除结核病灶,对脊髓及神经根进行彻底减压,促进脊髓及神经功能恢复,矫正脊柱后凸畸形,同时一期建立和恢复脊柱的连续性和稳定性,促进脊柱植骨融合,提高脊柱结核的治愈率.     

同一切口椎弓根内固定侧前方病灶清除术治疗胸椎结核

目的探讨胸椎结核的手术方法和治疗效果。方法采用一期同一切口椎弓根内固定、后凸畸形矫形、病灶清除、椎体间自体骨植骨术21例。结果随访9个月~6年,患者切口愈合植骨全部融合,结核治愈无复发。后凸矫正16°。结论一期同一切口椎弓根固定、侧前方病灶清除、自体骨植骨手术治疗胸椎结核是可行的治疗方法。     

胸椎结核外科治疗不同术式选择探讨

目的探讨不同解剖节段胸椎结核外科治疗术式的选择策略及疗效。方法回顾分析2005年5月至2009年5月手术治疗36例成人胸椎结核的临床资料,其中男19例,女17例;年龄17~60岁,平均32.2岁;病变破坏2个椎体23例,3个椎体7例,4个椎体6例。术前所有患者均有不同程度的后凸畸形,后凸角10°~110°,平均21°。22例伴有神经功能障碍。将胸椎按照解剖特点分为颈胸结合部(C7~T2)、中部(T3~5)、下胸椎(T6~12)。依据解剖特点不同采用5种不同的手术入路(颈胸结合部前入路、经胸腔胸膜外入路、开胸、肋横突旁入路、后正中入路)对36例胸椎结核患者行一期病灶清除、植骨融合内固定术。结果所有患者随访18~48个月,平均26个月,术后胸背部疼痛减轻,切口一期愈合,术后1~3个月血沉逐渐恢复正常,术后后凸角度矫正至0°~60°,平均14°,自体骨植骨于术后3个月开始融合,22例伴有神经功能障碍者,术后Frankel分级提高1~2级,大部分完全恢复。结论根据胸椎结核病灶部位的解剖特点、累及的范围选择恰当的术式可有效清除结核病灶,矫正后凸畸形,重建脊柱的稳定性,改善神经功能,临床效果良好。     

Postoperative nausea and vomiting and opioid-induced nausea and vomiting: guidelines for prevention and treatment

Postoperative nausea and vomiting (PONV) causes patient discomfort, lowers patient satisfaction, and increases care requirements. Opioid-induced nausea and vomiting (OINV) may also occur if opioids are used to treat postoperative pain. These guidelines aim to provide recommendations for the prevention and treatment of both problems. A working group was established in accordance with the charter of the Sociedad Espa?ola de Anestesiología y Reanimación. The group undertook the critical appraisal of articles relevant to the management of PONV and OINV in adults and children early and late in the perioperative period. Discussions led to recommendations, summarized as follows: 1) Risk for PONV should be assessed in all patients undergoing surgery; 2 easy-to-use scales are useful for risk assessment: the Apfel scale for adults and the Eberhart scale for children. 2) Measures to reduce baseline risk should be used for adults at moderate or high risk and all children. 3) Pharmacologic prophylaxis with 1 drug is useful for patients at low risk (Apfel or Eberhart 1) who are to receive general anesthesia; patients with higher levels of risk should receive prophylaxis with 2 or more drugs and baseline risk should be reduced (multimodal approach). 4) Dexamethasone, droperidol, and ondansetron (or other setrons) have similar levels of efficacy; drug choice should be made based on individual patient factors. 5) The drug prescribed for treating PONV should preferably be different from the one used for prophylaxis; ondansetron is the most effective drug for treating PONV. 6) Risk for PONV should be assessed before discharge after outpatient surgery or on the ward for hospitalized patients; there is no evidence that late preventive strategies are effective. 7) The drug of choice for preventing OINV is droperidol.     

Perioperative and long-term morbidity and mortality after above-knee and below-knee amputations in diabetics and nondiabetics

We performed a retrospective review of a vascular surgery quality assurance database to evaluate the perioperative and long-term morbidity and mortality of above-knee amputations (AKA, n = 234) and below-knee amputations (BKA, n = 720) and to examine the effect of diabetes mellitus (DM) (181 of AKA and 606 of BKA patients). All patients in the database who had AKA or BKA from 1990 to May 2001 were included in the study. Perioperative 30-day cardiac morbidity and mortality and 3-yr and 10-yr mortality after AKA or BKA were assessed. The effect of DM on 30-day cardiac outcome was assessed by multivariate logistic regression and the effect on long-term survival was assessed by Cox regression analysis. The perioperative cardiac event rate (cardiac death or nonfatal myocardial infarction) was at least 6.8% after AKA and at most 3.6% after BKA. Median survival was significantly less after AKA (20 mo) than BKA (52 mo) (P < 0.001). DM was not a significant predictor of perioperative 30-day mortality (odds ratio, 0.76 [0.39-1.49]; P = 0.43) or 3-yr survival (Hazard ratio, 1.03 [0.86-1.24]; P = 0.72) but predicted 10-yr mortality (Hazard ratio, 1.34 [1.04-1.73]; P = 0.026). Significant predictors of the 30-day perioperative mortality were the site of amputation (odds ratio, 4.35 [2.56-7.14]; P < 0.001) and history of renal insufficiency (odds ratio, 2.15 [1.13-4.08]; P = 0.019). AKA should be triaged as a high-risk surgery while BKA is an intermediate-risk surgery. Long-term survival after AKA or BKA is poor, regardless of the presence of DM.     

Body composition assessment and methodology in nonathletic and athletic adolescent and adult males and females

The purpose of this review is to outline methodology for assessing body composition utilizing anthropometric and densitometric techniques. The objective of body composition assessment is to measure body fat and lean body mass. The quantity of these components varies due to growth, physical activity, dietary regimens, and aging. Anthropometric techniques incorporate selected skinfolds, circumferences, skeletal widths, or other variables to estimate body composition within k2.0-4.0%. These techniques are adequate for field testing of groups or individuals, but are population specific. Densitometry measures body volume irrespective of physique, sex, or age. This laboratory technique estimates body composition within 1.0-2.0%, is more difficult to administer, but is not population specific. Some limitation exists with any present technique due to biological variability and incomplete research of reference body composition in children, females, and the aged. J Orthop Sports Phys Ther 1984;5(6):336-347.