后路椎弓根螺钉系统内固定治疗齿状突骨折

目的评价后路椎弓根螺钉内固定治疗齿状突骨折疗效。方法对9例Anderson分类为Ⅱ型齿状突骨折患者行后路C1-2椎弓根螺钉固定。结果患者均获得随访,时间12-60（34.5±1.5）个月。术后3个月骨折线模糊,6个月全部骨性愈合。未见内固定物松动、脱出及断裂。4例有神经损伤患者中,1例B级恢复至C级,1例C级、2例D级均恢复至E级。结论后路C1-2椎弓根螺钉系统治疗齿状突骨折是安全有效的。     

寰枢椎椎弓根螺钉内固定术治疗儿童寰枢椎脱位的初步报告

目的:探讨寰枢椎椎弓根螺钉内固定手术治疗儿童寰枢椎脱位的可操作性和近期疗效。方法:2005年9月~2011年3月对16例儿童寰枢椎脱位患者采用寰枢椎椎弓根螺钉内固定术治疗,男9例,女7例;年龄5～13岁,平均9.1岁。均有枕颈部疼痛、颈部僵硬;3例有高位颈脊髓病表现,ASIA分级:D级2例,C级1例。术前均行颈椎正侧位及过伸过屈位X线片、CT和MRI检查,均诊断为寰枢椎脱位,其中寰椎横韧带断裂1例,寰枢椎骨折脱位1例,先天性齿状突畸形12例,寰枢椎固定旋转半脱位2例;颈脊髓受压5例。寰椎后弓(椎弓根)高度2.5~3.8mm,平均3.0mm;寰齿前间隙6~14mm,平均9mm。术前常规行牵引1~2周复位,完全复位7例,部分复位5例,不能复位4例。术中采用"寰椎椎弓根显露置钉法",在直视下行C1、C2置钉,复位固定,植骨融合。随访患者症状和神经功能改善情况,定期行颈椎X线片及CT复查,了解内固定及植骨融合情况。结果:16例均行双侧寰枢椎椎弓根螺钉内固定,手术过程顺利,64枚螺钉均成功置入,复位固定满意,无术中、术后神经和血管并发症。术中出血150~650ml,平均300ml;手术时间100~190min,平均130min。12例随访12~72个月,平均28.5个月,术后3~6个月寰枢椎均骨性融合;末次随访时,颈枕症状明显改善,3例术前有脊髓功能损害者均好转,2例术前ASIA分级D级者恢复到E级,1例术前ASIA分级C级者恢复到D级;未发现螺钉松动、断钉和寰枢椎再移位现象,未发现曲轴现象。结论:采用"寰椎椎弓根显露置钉法"行寰椎椎弓根螺钉内固定可操作性强,置钉安全性高;寰枢椎椎弓根螺钉内固定治疗儿童寰枢椎脱位的近期疗效满意。     

多节段椎弓根螺钉固定治疗中上胸椎骨折脱位

目的探讨多节段椎弓根螺钉内固定治疗中上胸椎骨折脱位伴脊髓损伤的临床效果。方法采用经多节段椎弓根螺钉内固定治疗中上胸椎骨折脱位15例。按受累椎体统计,15例共20椎:T43椎,T65椎,T710椎,T82椎。按Hanley-Eskay分类:爆裂骨折6例,骨折脱位7例,爆裂脱位2例。术前脊髓神经功能按美国脊柱脊髓损伤协会(ASIA)标准分级:A级6例,B级4例,C级4例,D级1例。均行胸后路复位、椎管减压、多节段椎弓根螺钉内固定、后外侧植骨融合术。结果 15例均获随访,平均20.3个月,术后伤椎前缘高度由术前平均40%恢复至术后90.3%,术后脊髓神经功能恢复按ASIA标准,除A级及1例B级无恢复外,余8例均有不同程度改善。无内固定松动及断裂,无伤椎高度及脊柱生理弧度再丢失。结论多节段椎弓根螺钉固定可靠,能达到良好的复位和减压目的,有利于患者的早期康复。     

椎弓根拉力螺钉内固定治疗Hangman骨折

探讨应用椎弓根拉力螺钉技术治疗Hangman骨折的临床疗效.方法 对12例Hangman骨折患者经颅骨牵引获得复位后,行C2椎弓根拉力螺钉内固定术治疗.术后行X线片检查观察骨折复位及愈合情况.结果 手术时间50～90min,失血量100～300ml.术中无脊髓神经损伤,骨折复位满意.12例均获随访,时间3~36个月.骨折完全愈合,无迟发畸形.2例脊髓神经损伤者术前Franke1分级为D级,术后3~6个月均恢复至E级.结论 C2椎弓根拉力螺钉技术治疗Hangman骨折,复位满意,固定可靠,疗效满意.     

椎弓根螺钉固定或联合侧块螺钉固定治疗Hangman骨折

目的：探讨C2椎弓根拉力螺钉或C2椎弓根螺钉联合C3侧块螺钉固定治疗Hangman骨折的适应证,并评价其临床应用价值。方法：2001年3月至2005年8月共收治Hangman骨折患者44例,Levine-EdwardsⅠ型12例,Ⅱ型15例,Ⅱa型11例,Ⅲ型6例。脊髓功能Frankel分级：C级4例,D级16例,E级24例。Ⅰ型Hangman骨折采用C2椎弓根拉力螺钉固定;Ⅱ型、Ⅱa型、Ⅲ型采用C2椎弓根螺钉联合C3侧块螺钉固定。结果：术中未发生椎动脉损伤及其他并发症。术后4例Frankel C级患者2例恢复至E级,2例恢复至D级;16例D级患者14例恢复至E级,2例神经症状无变化。3～6个月时复查X线片示骨折均愈合。结论：C2椎弓根拉力螺钉或C2椎弓根螺钉联合C3侧块螺钉治疗Hangman骨折可以取得良好疗效。     

寰枢椎椎弓根螺钉固定治疗上颈椎损伤

目的总结枕骨、枢椎椎弓根钉棒系统或寰枢椎椎弓根钉棒系统固定用于治疗上颈椎损伤的效果。方法对16例上颈椎损伤患者术前常规行颅骨牵引复位。术中寰枢椎椎弓根的进钉点选择在寰椎后结节中点旁开18~20 mm、后弓上缘下4 mm交点处。矢状面上螺钉向头侧倾斜约5°。冠状面垂直。枢椎进钉点为枢椎关节突根部中点,钉道与矢状面夹角为20°~25°,与横断面夹角30°~35°。椎弓根螺钉φ3.5 mm,寰椎、枢椎椎弓根螺钉长24~28 mm,术中遇阻力大时随时调整方向。结果平均手术时间110 min。术前Frankel分级C级1例,D级4例,术后均恢复至E级。随访6~38个月,16例全部植骨融合,内固定无松动。结论枕骨、寰枢椎椎弓根螺钉固定融合治疗上颈椎损伤是一种新技术,具有固定牢固、固定节段短和三维固定的优点。     

椎弓根钉棒治疗颈椎骨折脱位疗效分析

目的探讨椎弓根钉棒系统经椎弓根内固定治疗颈椎骨折脱位的疗效。方法 38例颈椎损伤患者术前复位牵引,采用颈椎前后路及后路切开复位、自体髂骨植骨及椎弓根钉棒带锁钢板内固定术。结合术前和术后1年Frankel神经功能评估方法评价手术疗效。结果 38例均获得随访,时间12~34个月。无手术相关并发症,无神经损伤加重现象。Frankel分级：B级11例恢复至C级9例、D级1例,1例无恢复;C级18例恢复至D级15例、E级3例;D级9例均恢复至E级。结论椎弓根钉棒系统治疗颈椎骨折脱位疗效满意。     

伤椎椎弓根钉固定加植骨治疗胸腰椎爆裂骨折

目的 评价经伤椎椎弓根钉固定结合经椎弓根植骨治疗胸腰椎爆裂骨折的临床疗效.方法 对30例胸腰椎爆裂骨折患者实施经伤椎椎弓根钉固定结合经椎弓根植骨术治疗,其中男性22例,女性8例,年龄18～62岁.30例均为单一椎体损伤.术前伤椎前缘高度平均40%,脊柱后凸角(Cobb角)25°,椎管正中矢状径55%,神经功能按ASIA评定标准:A级3例,B级6例,C级8例,D级7例,E级6例.结果 术后随访6～30个月,术后伤椎前缘平均高度恢复到95%,脊柱后凸角(Cobb角)为50°椎管正中矢状径恢复到90%,手术前后差异显著(P＜0.05).术后神经功能恢复情况:A级2例,B级1例,C级2例,D级7例,E级18例.术后骨折均获得复位,无一例发生内固定断裂、松动,矫正丢失等并发症.结论 伤椎椎弓根钉固定加经椎弓根植骨术能让骨折获得满意复位,重建椎体高度,增强脊柱的抗压稳定性,提供脊柱的长期稳定,减少内固定并发症,是一种治疗胸腰椎爆裂骨折的有效方法 .     

椎弓根螺钉内固定间接减压治疗胸腰椎骨折疗效观察

目的探讨经椎弓根螺钉内固定间接减压治疗胸腰椎骨折的疗效。方法32例胸腰椎骨折患者中，17例以4枚椎弓根螺钉固定伤椎上下相邻椎体，15例以6枚椎弓根螺钉固定含伤椎及相邻上下椎体，对患者术前术后的椎体高度、矢状径Cobb角、椎管矢状径占有率、神经功能Frankel分级变化等指标进行测量并随访。结果所有患者获4～42个月随访，伤椎平均高度由术前（43．2±1．8）％恢复至（91±2．0）％，矢状面Cobb角由术前（24．2±3．0）°恢复至（5±1．0）°，椎管内矢状径占有率由（60．2±8．7）％增到（85．5±12．8）％。神经损伤术后Frankel分级：A级2例无恢复；B级2例恢复至E级1例，1例无恢复；C级5例恢复至D级1例，E级4例；D级10例恢复至E级9例，1例无恢复。无死亡或神经损伤加重病例。1例螺钉松动，1例螺钉断裂。结论用椎弓根钉复位、内固定、间接减压治疗胸腰椎骨折具有创伤小、出血少、手术时间短、脊柱稳定性好、有效矫正及预防脊柱后凸畸形、手术并发症低等优点。     

寰枢椎椎弓根钉系统内固定治疗Ⅱ_C型齿状突骨折

目的探讨寰枢椎椎弓根钉系统内固定治疗ⅡC型齿状突骨折的临床疗效。方法对10例ⅡC型齿状突骨折行寰枢椎椎弓根钉系统内固定治疗。结果 10例均获随访,时间6~12个月,骨折均骨性愈合,内植物取出术后,颈椎活动均恢复正常。结论寰枢椎椎弓根钉系统内固定是治疗ⅡC型齿状突骨折的有效方法,可保留寰枢关节的旋转功能。     

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.     

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.     

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.     

Synergistic interaction between the effects of propofol and midazolam with fentanyl on phrenic nerve activity in rabbits

Background: It has been shown that the depressive effects of both propofol and midazolam on consciousness are synergistic with opioids, but the nature of their interactions on other physiological systems, e. g. respiration, has not been fully investigated. The present study examined the effect of propofol and midazolam alone and in combination with fentanyl on phrenic nerve activity (PNA) and whether such interactions are additive or synergistic. Methods: PNA was recorded in 27 anaesthetised and artificially ventilated rabbits. In three groups, propofol, fentanyl and midazolam were administered intravenously in incremental doses to construct dose-response curves for the depressant effects of each one on PNA. In another two groups, the effect of pretreatment with either fentanyl 1 μg · kg^?1 i. v. or midazolam 0.05 mg · kg^?1 i. v. on the effects of propofol and fentanyl respectively on PNA were studied. Results: Propofol and fentanyl caused a dose-dependent depression of PNA with complete abolition at the highest total doses of 16 mg · kg^?1 i. v. and 32 μg · kg^?1 i. v., respectively. In contrast, midazolam in incremental doses to a total of 0.8 mg · kg^?1 reduced mean PNA by 63%, but approximately 12% of PNA remained at a total dose as high as 6.4 mg · kg^?1. The mean ED₅₀s, calculated from dose-response curves, were 5.4 mg · kg^?1, 3.9 μg · kg^?1 and 0.4 mg · kg^?1 for propofol, fentanyl and midazolam, respectively. Initial doses of either fentanyl 1 μg · kg^?1 i. v. or midazolam 0.05 mg · kg^?1 i. v. acted synergistically with subsequent doses of either propofol or fentanyl to abolish PNA at total doses of 8 mg · kg^?1 and 8 μg · kg^?1, respectively. Conclusion: Fentanyl has a synergistic interaction with both propofol and midazolam on PNA and hence potentially on respiration.     

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.     

Systemic analgesia adapted to the children's condition

A concept of balanced analgesia using nonsteroidal anti-inflammatory drugs (NSAIDs), paracetamol (acetaminophen), opioids, and corticosteroids can also be used in patients with pre-existing illnesses. NSAIDs are the most effective treatment for acute pain of moderate intensity in children; however, these drugs should be avoided in patients at increased risk for serious side effects, e.g. patients with renal impairment, bleeding tendency, or extreme prematurity. NSAIDs can be given with minimal risks to the younger child with mild to moderate asthma, and, in these patients, the use of steroids can be encouraged; in addition to their antiemetic and analgesic action, a beneficial effect on asthma symptoms can be expected. In the non-intubated child with cerebral trauma, exaggerated sedation caused by opioids and increased bleeding tendency caused by NSAIDs must be avoided. In neonates and small infants, the oral administration of sucrose or glucose is helpful to minimize pain reaction during short uncomfortable interventions.     

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.