L5/S1椎间盘突出症的微创治疗策略

腰椎椎间盘突出症是脊柱微创技术应用最为活跃的疾病之一。近年来,各种新的脊柱微创技术,如椎间孔镜技术、椎间盘镜技术、微创小切口技术、微创经皮椎弓根螺钉技术等,纷纷运用于腰椎椎间盘突出症的治疗,并且取得了良好的效果。     

微创技术治疗胸腰椎间盘疾患的新动态

近期国外有较多采用微创技术治疗胸腰椎间盘疾患的研究论文发表。 Barrels等回顾比较了使用微创前路开胸胸椎间盘摘除术和胸腔镜技术治疗胸椎间盘突出症的结果[Spine，2007，32（20）：E581-584]。该研究中有7例胸椎间盘突出症患者使用胸腔镜手术治疗，21例使用微创开胸技术治疗。结果显示所有病例均完全切除了突出钙化的椎间盘组织，胸腔镜组2例患者出现胸廓处肋间神经的放射痛。     

脊柱外科动态与信息

1　脊柱外科动态1 1　胸椎间盘突出症的治疗胸椎间盘突出症是比较少见但是较难治疗的疾患 ,随着影像学诊断技术的进步和其诊断率逐渐提高 ,寻找微创且切实有效的手术治疗方法目前备受关注。最近Ｍｅｄｓｃａｐｅ网站(ｗｗｗ .ｍｅｄｓｃａｐｅ .ｃｏｍ)发表了一个专辑 ,详细讨论了胸椎间盘突出症的发病原因、流行病学、诊断、手术治疗、疗效和并发症预防等 ,其中介绍了椎板切除胸椎间盘摘除术、经椎弓根胸椎间盘摘除术、胸腔镜下胸椎间盘摘除术和内窥镜下胸椎间盘摘除术的手术技术、临床结果和并发症预防 ,认为利用微创技术治疗胸椎间盘突出…     

经皮激光椎间盘汽化减压术治疗颈椎间盘突出症

目的:探讨经皮半导体激光在颈椎间盘突出症的应用价值。方法:采用以色列Sharplan6020型半导体激光治疗仪对46例颈椎间盘突出症患者的81个椎间盘行经皮激光椎间盘汽化减压术(PLDD)。结果:46例患者获得3~18个月随访,按照肢体疼痛、麻木及活动情况评价,优良率93.1%。结论:PLDD治疗颈椎间盘突出症具有安全、微创、操作简便、痛苦少等优点,是治疗颈椎间盘突出症可供选择的微创技术之一。     

经椎板间入路完全内窥镜下椎间盘摘除术与显微内窥镜下椎间盘摘除术治疗L5/S1椎间盘突出症的比较

对保守治疗无效的腰椎间盘突出症患者,传统开放手术有确切疗效[1]。经椎板间入路完全内窥镜（full-endoscopic,FE）下椎间盘摘除术与显微内窥镜下椎间盘摘除术（microendoscopic discectomy,MED）是临床上用于治疗L5/S1椎间盘突出症较常用的微创手术方法,并获得了满意疗效[2-5]。此两种方法与传统开放手术比较均具有创伤小、术后恢复快等优点[2~5]。但这两种微创手术治疗L5/S1椎间盘突出症有何异同,目前报道较少。本研究对2010年12月~2012年5月我院采用上述两种微创手术治疗的L5/S1椎间盘突出症患者102例进行回顾性分析,比较这两种微创手术治疗L5/S1椎间盘突出症的手术创伤与临床疗效,为临床提供参考。     

CT引导经皮穿刺激光减压治疗胸椎间盘突出症

经皮穿刺椎间盘激光减压术（PLDD）是近年来发展起来的一种新的椎间盘微创治疗方法，主要应用于颈、腰椎椎间盘突出症的治疗，应用于胸椎间盘突出治疗的报道较少，现将2004年8月-2005年11月在CT引导下经皮穿刺激光减压治疗的6例胸椎间盘突出症，报告如下。     

巨大型腰椎椎间盘突出症的微创外科治疗

目的探讨巨大型腰椎椎间盘突出症微创手术策略。方法 2007年1月～2010年10月,对86例巨大型腰椎椎间盘突出症患者采用微创外科手术治疗。其中,椎间孔内镜椎间盘切除术(percutaneous endoscopic lumbar discectomy,PELD)28例,显微内镜椎间盘切除术(microendoscopic discectomy,MED)35例,微创经椎间孔腰椎椎间融合术(minimally invasive transforaminal lumbar interbody fusion,miTLIF)23例。术前与术后疼痛视觉模拟量表(visual analog scale,VAS)评分和改良Macnab标准评价临床疗效。结果 3种微创术式均能显著改善患肢放射性疼痛VAS评分。术后优良率都在85%以上。PELD术适于年轻人巨大型腰椎椎间盘突出症;MED术适于巨大型腰椎椎间盘突出症伴椎管狭窄;miTLIF术适于伴有腰椎退行性失稳或伴有马尾综合征或术后复发的巨大型腰椎椎间盘突出症。结论临床上应依据巨大型腰椎椎间盘突出症的不同类型,选择不同微创外科术式。     

青壮年腰椎间盘突出症椎间盘镜微创术疗效分析

目的探讨采用椎间盘镜治疗青壮年腰椎间盘突出症临床疗效与椎间盘突出类型和突出节段的相关性。方法对青壮年腰椎间盘突出症46例采用椎间盘镜微创术治疗。结果末次随访时85.4%(35/41)重新返回工作岗位,14.6%(6/41)带药出院。VAS评分平均减少4.7分。结论采用椎间盘镜治疗青壮年症状性椎间盘突出,具有创伤小、恢复快的特点,应用于L5S1间盘突出时疗效更好。     

射频消融髓核成形术治疗颈椎间盘突出症的研究进展

随着微创外科的发展,应用介入微创技术治疗颈椎间盘突出症已被广泛接受。20世纪90年代以来,随着高能射频技术和激光技术的发展,国外一些学者将其引入脊柱疾病治疗领域,经皮低温等离子射频消融髓核成形术（percutaneous cervical disc nucleoplasty,PCDN）被用于治疗颈椎间盘突出症。     

微创治疗颈椎间盘突出症的初步临床体会

目的 探讨治疗颈椎间盘突出症理想的微创手术方法,PLDD 医用臭氧椎间盘注射术用于治疗该病的可行性.方法 本组颈椎间盘突出症36例.在C型臂X光机监控下,将激光光导纤维经穿刺针腔置入到病变椎间盘的预定部位,按照预定激光量行椎间盘减压术,然后注入医用臭氧6-10ml.结果 术后1-6个月定期随访患者,结果是治愈21例(59.3%);显效11例(30.5%);有效4例(11.1%);无效1例(2.6%).优良率为89.1%.无一例严重并发症出现.结论 PLDD 医用臭氧椎间盘注射术具有痛苦小,安全性高,疗效肯定等突出优点,是治疗椎间盘突出症的理想的微创手术疗法.     

In situ forces of the anterior and posterior cruciate ligaments in high knee flexion: an in vitro investigation.

The function of the anterior and posterior cruciate ligaments (ACL and PCL) in the first 120 degrees of flexion has been reported extensively, but little is known of their behavior at higher flexion angles. The aim of this investigation was to study the effects of muscle loads on the in situ forces in both ligaments at high knee flexion (>120 degrees). Eighteen fresh-frozen human knee specimens were tested on a robotic testing system from full extension to 150 degrees of flexion in response to quadriceps (400 N), hamstrings (200 N), and combined quadriceps and hamstrings (400 N/200 N) loads. The in situ forces in the ACL and PCL were measured using the principle of superposition. The force in the ACL peaked at 30 degrees of flexion (71.7 +/- 27.9 N in response to the quadriceps load, 52.3 +/- 24.4 N in response to the combined muscle load, 32.3 +/- 20.9 N in response to the hamstrings load). At 150 degrees, the ACL force was approximately 30 N in response to the quadriceps load and 20 N in response to the combined muscle load and isolated hamstring load. The PCL force peaked at 90 degrees (34.0 +/- 15.3 N in response to the quadriceps load, 88.6 +/- 23.7 N in response to the combined muscle load, 99.8 +/- 24.0 N in response to the hamstrings load) and decreased to around 35 N at 150 degrees in response to each of the loads. These results demonstrate that the ACL and PCL carried significantly less load at high flexion in response to the simulated muscle loads compared to the peak loads they carried in response to the same muscle loads at other flexion angles. The data could provide a reference point for the investigation of non-weight bearing flexion and extension knee exercises in high flexion. Furthermore, these data could be useful in designing total knee implants to achieve high flexion.     

Genetic and environmental influences on bone mineral density in pre- and post-menopausal women

Genetic factors influencing acquisition of peak bone mass account for a substantial proportion of the variation in bone mineral density (BMD), although the extent to which genes also contribute to variation in bone loss is debatable. Few prospective studies of related individuals have been carried out to address this issue. To gain insights into the nature of the genetic factors contributing to variation in BMD, we studied 570 women from large Amish families. We evaluated and compared the genetic contributions to BMD in pre- and post-menopausal women, with the rationale that genetic variation in pre-menopausal women is due primarily to genetic determinants of peak bone mass, while genetic variation in post-menopausal women is due to the combined genetic effects of peak bone mass and bone loss. Bone mineral density was measured at one point in time at the hip and spine by dual energy X-ray absorptiometry (DXA). We used variance decomposition procedures to partition variation in BMD into genetic and environmental effects common to both groups and to pre- and post-menopausal women separately. Total variation in BMD was higher in post- compared to pre-menopausal women. Genes accounted for 58–88% of the total variation in BMD in pre-menopausal women compared to 37–54% of the total variation in post-menopausal women. In absolute terms, however, the genetic variance was approximately similar between the two groups because the environmental variance was 3 1/2- to 4-fold larger in the post-menopausal group. The genetic correlation in total hip BMD was 0.81 between pre- and post-menopausal women and differed significantly from one, consistent with the presence of at least some non-overlapping genetic effects in the two groups for BMD at this site. Overall, these analyses suggest that many, but not all, of the genetic factors influencing variation in BMD are common to both pre- and post-menopausal women.     

In silico modelling of physiologic systems

In silico modelling, in which computer models are developed to model a pharmacologic or physiologic process, is a logical extension of controlled in vitro experimentation. It is the natural result of the explosive increase in computing power available to the research scientist at continually decreasing cost. In silico modelling combines the advantages of both in vivo and in vitro experimentation, without subjecting itself to the ethical considerations and lack of control associated with in vivo experiments. Unlike in vitro experiments, which exist in isolation, in silico models allow the researcher to include a virtually unlimited array of parameters, which render the results more applicable to the organism as a whole. In silico modelling is best known for its extensive use in pharmacokinetic experimentation, the best-known example of which is the development of the three-compartment model. In addition, complex in silico models have been applied to pathophysiological problems to provide information which cannot be obtained practically or ethically by traditional clinical research methods. These experiments have led to the development of significant insights in subject matters ranging from pure physiology to congenital heart surgery, obstetric anaesthesia airway management, mechanical ventilation and cardiopulmonary bypass/ventricular support devices. The utility of these models is based on both the validity of the model framework as well as the corresponding assumptions. In vivo experimentation has validated some, but not all of the in silico strategies employed. We present a review illustrating by example how in silico modelling has been applied to a number of cardio-respiratory problems in states of health and disease, the purpose of which is to give the reader a sense of the complexity and assumptions which underlie this diverse and underappreciated research strategy, as well as an introduction to a research strategy that will likely continue to grow in importance.     

Topological Shifts of Sudanophilic Bodies in Ageing Male Gonad

The topological index of sudanophilic bodies was determined in 69 testicles of men aged from 16 to 87 years (mean age 53.5 years) divided into 3 age groups, from 16 to 40 years, from 41 to 60 years, and from 61 to 87 years. A significant fall of sudanophilia was demonstrated in Leydig cells from 17.6% in young men to 11.15% in middle-aged men, and with a further non-significant fall to 8.2% in old men. Since this index demonstrates relative changes of sudanophilia, a significant increase was found in the content of lipoid bodies in the tubular epithelium in middle-aged men in relation to those dying at younger age (from 82.4% to 88.85%), and with a non-significant increase in the group of old men as compared to middle-aged men (from 88.85% to 91.8%). The relevant data from the literature are discussed and the necessity is suggested of further studies on changes of the topological index of testicular sudanophilia in relation to changes in the number of Leydig's cells and other typical features of ageing testicles.     

Inestabilidad cervical: punto de vista del anestesiólogo

The experience in airway management permits the anesthesiologist to participate in cases of cervical spine instability in the operating room when the patient is subjected to surgical procedures, or in cases of difficulty to access or keep the airway open in emergencies. This article reviews the epidemiology, definition, etiology, diagnostic criteria, methods of approach to airway management, and current recommendations on handling cervical instability in different scenarios. There is no approach to the airway that ensures complete immobility of the cervical spine, but there are methods that are better adapted to specific contexts; at the end, the reader will be able to identify the virtues and defects of the various options that the anesthesiologists have to address the airway in cases of cervical instability.     

Toxicity of antiestrogens

The object of this article is to review briefly the preclinical and clinical safety of some antiestrogens. Tamoxifen, toremifene, droloxifene, and idoxifene are polyphenylethylene antiestrogens, whereas the pure antiestrogen, ICI 182,780 or faslodex, as well as raloxifene, is of a different structure. Tamoxifen has been shown to be genotoxic in several studies. It induces unscheduled DNA synthesis in rat hepatocytes and micronuclei in MCL-5 a cells in vitro. Tamoxifen also induces aneuploidy in rat liver in vivo and chromosome aberrations and micronuclei in mouse bone marrow. Toremifene has also shown to be genotoxic, but to a far lower extent, by inducing micronuclei in MCL-5 a cells in vitro and by inducing aneuploidy in rat liver in vivo. Tamoxifen has been shown to be hepatocarcinogenic in the rat in at least four independent long-term studies. The initiation of tumors in the rat is the result of metabolic activation by cytochrome P450 isoenzymes to an electrophile(s) that binds irreversibly to DNA. The other antiestrogens have not been shown to be carcinogenic in rodents. In several independent clinical studies, the risk of endometrial cancer has increased among tamoxifen-treated women. After reviewing the available data, the International Agency for Research on Cancer concluded that there was sufficient evidence to show that tamoxifen is a class I human carcinogen. The increased risk for endometrial cancer occurs predominantly among women who are 50 years old or older and who have been treated with tamoxifen. It is not yet clear whether the uterine tumor formation is a result of genetic mechanisms, analogous to those seen in the rat liver or due to the estrogen agonist action of tamoxifen. However, the other antiestrogens with a more or less similar intrinsic estrogenic potential have not been shown to be carcinogenic in humans.     

Telemedicine and neurosciences in developing countries

It is a universally accepted fact that the number of neurosurgeons in developing countries is woefully inadequate. It is also unrealistic to expect this limited number to work in professional isolation, in suburban and rural areas, without adequate infrastructure. Therefore, this has resulted in concentration of neurosurgeons in developing countries, in metropolitan areas, even at the risk of being underemployed. The phenomenal advances in communications and information technology in India are resulting in a new look at how secondary and tertiary health care can be provided to the underprivileged masses. Following a proof of concept validation ISRO (Indian Space Research Organization) in conjunction with the Apollo Hospitals, is ready to use satellite technology to provide specialist care not only to suburban and rural India but to other countries as well, by using the large number of highly qualified and trained specialists in urban India. The implications of these developments for the delivery of neurosurgical care to suburban and rural India is briefly reviewed.     

青年女性脑外伤合并四肢长管状骨骨折患者血清雌二醇和泌乳素水平的观察

目的 观察青年女性脑外伤合并四肢长管状骨骨折患者伤后不同时间段血清雌二醇(E2)及泌乳素(PRL)水平的变化.方法 2007年1月至2008年12月,对39例青年女性脑外伤合并四肢长管状骨骨折患者(观察组)和42例青年女性单纯四肢长管状骨骨折患者(对照组)均于伤后1～3 d、5～7 d、10～14 d、28～30 d和56～60 d时间段进行血清中E2和PRL浓度测定和比较. 结果 血清E2浓度比较中,观察组1～3 d、5～7d、10～14 d和28～30 d均明显高于对照组同期检测 结果 ,差异均有统计学意义(P<0.05);而56～60 d时间段两组差异无统计学意义(P>0.05);观察组其他时间段均明显低于1～3 d检测 结果 ,差异均有统计学意义(P<0.05),对照组各时间段间比较差异均无统计学意义(P>0.05).血清PRL浓度比较中,观察组全部时间段均明显高于对照组同期检测 结果 ,差异有统计学意义(P<0.05);观察组5～7 d、10～14 d和28～30 d时间段均明显高于1～3 d检测 结果 ,差异均有统计学意义(P<0.05);而56～60 d与1～3 d时间段比较差异无统计学意义(P>0.05);对照组各时间段间比较差异均无统计学意义(P>0.05).观察组的骨折愈合时间明显短于对照组,而前者住院总时间明显长于后者,差异均有统计学意义(P<0.05). 结论 青年女性脑外伤合并四肢长管状骨骨折的患者伤后早期E2和PRL水平明显升高.     

Matrix replenishment by intervertebral disc cells after chemonucleolysis in vitro with chondroitinase ABC and chymopapain

BACKGROUND CONTEXT: One of the advantages of chemonucleolysis for the treatment of a herniated intervertebral disc is the potential for the disc to self-repair. It has been suggested that the enzymes used for chemonucleolysis differentially affect the potential of the disc cells to promote repair. PURPOSE: To test the ability of nucleus pulposus and anulus fibrosus cells to repair the extracellular matrix degraded in vitro by either chondroitinase ABC or chymopapain. STUDY DESIGN: An alginate cell culture system was used to monitor the progress of matrix repair after chemonucleolysis in vitro. METHODS: Rabbit nucleus pulposus or anulus fibrosus cells precultured for 10 days in alginate gel were briefly exposed to low concentrations of chondroitinase ABC or chymopapain and then returned to normal culture conditions for up to 4 weeks. At each time point, the contents of DNA and matrix macromolecules and proteoglycan synthesis were measured. RESULTS: The DNA content of enzyme-treated alginate beads during the following 4 weeks of culture was higher in the chondroitinase ABC group than in the chymopapain group (NP, p<.01, and AF, p<.05). The content of proteoglycan in beads containing nucleus pulposus and anulus fibrosus cells in the chondroitinase ABC group was higher than that in the chymopapain group (NP and AF, p<.001). The rate of proteoglycan synthesis and the content of collagen did not, however, differ between those two groups. CONCLUSIONS: Intervertebral disc cells exposed to chondroitinase ABC reestablish a matrix richer in proteoglycan than cells exposed to chymopapain. This may be because of differences in the substrate spectrum of each enzyme. Although these results cannot be translated directly to the in vivo situation, they suggest the possibility that cells in discs subjected to chondroitinase ABC-induced chemonucleolysis retain a greater ability to replenish their extracellular matrix with proteoglycans than cells in discs exposed to chymopapain.     

In vitro and in vivo effects of diethylstilbestrol and estramustine phosphate (estracyt®) on the mitogen responsiveness of human peripheral blood lymphocytes

The responsiveness to diethylstilbestrol (DES) and estramustinephosphate (EMP) of human peripheral blood lymphocytes to T-cell mitogens has been investigated in vitro and in vivo. EMP demonstrated potent inhibiton of both Con A-and PHA-induced lymphocyte proliferation in vitro, while it had no detectable effects when given to patients with cancer of the prostate. DES reduced the response to Con A in vitro, but had only marginal effects on PHA-induced mitogen response. In contrast, the response to Con A was unaltered, while the response to PHA was significantly diminished after DES therapy in patients with prostatic cancer. This effect, however, was only seen when high doses of DES not included in conventional regimen were given. The proliferative response to T-cell mitogens in patients with prostatic cancer was not affected by serum source in the assay, indicating the absence of humoral factors able to inhibit mitogen response in these patients.