Zero-P系统治疗神经根型颈椎病致霍纳综合征

<正>神经根型颈椎病属于颈椎病的常见类型,约占颈椎病的60%～70%,是指颈椎间盘退行性改变及其继发病理改变累及神经根,并出现相应节段的上肢放射性疼痛、麻木等临床表现的一类疾病。对于症状持续存在、进行性加重或保守治疗无效者,颈前路减压植骨融合内固定术(ACDF)被视为治疗颈椎病的常见手术方式~([1])。近20年来,多种颈椎内固定装置应用于     

推拿联合下颈段阻抗运动治疗颈型颈椎病的疗效对比分析

正颈型颈椎病临床上又称局部型颈椎病,临床表现为头、颈、肩、臂疼痛,相应部位表现为压痛,X线检查无明显的退行性改变以及椎间隙狭窄,但可表现为颈椎生理曲线变化,较严重者还可出现轻度骨质增生以及椎体间不稳定等~([1])。本文探讨推拿联合下颈段抗阻运动治疗颈型颈椎病的临床疗效,为颈型颈椎病的物理治疗提供理论依据,报道如下。1资料与方法1.1一般资料随机选择2015年1月~2017年3     

颈型颈椎病诊断与发生机制的研究进展

随着生活方式和工作方式的改变,颈椎病患者数量快速增长且呈现年轻化的趋势[1]。其中颈型颈椎病被国内学术界广泛认为是早期颈椎病的代表,且有进展为其他各型颈椎病的可能。颈型颈椎病主要表现为缺乏影像学特异性的肩颈部不适,病情极容易反复,极大降低了患者生活质量,也给患者带来巨大的精神压力和经济负担,因此,如何对颈型颈椎病做出诊断并进行有效的早期干预成为重要课题。     

射频联合小针刀微创治疗颈椎病临床应用

近年来由于电脑的普及,人们伏案工作机会的增加,颈椎病发病有年轻化趋势,且发病率逐渐增加[1]。在各型颈椎病中,以神经根型颈椎病最多见,约占60%以上。其主要表现为颈肩臂疼痛、麻木、颈部功能障碍,经临床药物、针灸、手法按摩及牵引理疗等方法,症状改善多缓慢。笔者自2010-12—2012-12采用小针刀联合颈椎间盘射频消融治疗64例颈椎病,现报告如下。1资料与方法1.1一般资料选取64例颈椎病,均不同程度的使用药物作     

肌肉能量技术配合物理疗法治疗颈型颈椎病的疗效观察

正颈型颈椎病又称软组织型颈椎病,为颈椎病早期型~([1]),它是在颈部肌肉、韧带、椎体不稳、关节突关节错位等系列组织病理基础上所产生的系列临床症状,尤其是颈周围肌肉组织所产生的症状较为明显,其中颈痛和颈项僵硬是颈型颈椎病的临床特征之一~([2])。本研究自2014年以来,对收治的75例此类患者,分别采用观察肌肉能量技术(MET)+牵引+电脑中频与牵引+推拿+电脑中频这2种方式进行治疗,现进行     

加味蠲痹散药枕治疗颈型颈椎病的临床疗效分析

目的探讨加味蠲痹散药枕治疗颈型颈椎病的临床疗效。方法将137例颈型颈椎病患者随机分为治疗组65例,给予加味蠲痹散研粉后均匀装入薄布袋,布袋裹在约直径60cm的圆形竹筒外面成药枕,每天睡前及起床前枕在颈部,每次5min,连用3个月。对照组72例,采用自我双手按揉颈部肌肉及抗阻力后伸颈部,每次5min,2次/d,连用3个月。结果治疗3个月后治疗组总有效率为100.00%,对照组总有效率为83.33%,治疗组疗效明显优于对照组（P〈0.01）。结论加味蠲痹汤治疗颈型颈椎病安全、简便、有效。     

肌萎缩型颈椎病的诊治及预后

目的 探讨肌萎缩型颈椎病的发病机制、诊断、治疗及预后。方法 回顾性分析6例患者的起病、症状、体征、影像学资料、诊疗及预后。结果 患者均行颈前路椎体次全切除手术，术后均有不同程度恢复。结论 肌萎缩型颈椎病的发病与颈脊髓前角和颈脊神经前根受损有关；其临床表现、体征与一般的根型或髓型颈椎病有明显不同，易与部分神经内科疾患相混淆；提高对其发病饥制的认识，熟识其临床特点，有助于尽早明确诊断；前路手术应是主要手术方式，及早手术治疗对于该病的预后有重要意义。     

常规取穴与“颈腰同治”取穴行温针灸治疗颈型颈椎病的疗效对比

<正>颈型颈椎病(cervical spondylosis,CS)在颈椎病的各分型中较为常见,患者以颈部的疼痛、酸胀和沉重等不适为典型的临床表现。目前,多予以非手术治疗为首选方案,包括非甾体类药物、牵引、物理治疗和针灸疗法等。其中,针灸疗法可较好地放松颈部肌群,改善局部的血液循环,达到较好的镇痛效果,在CS治疗中应用较广。但传统的针灸治疗,一般以颈部取穴为主,患者虽可短时间内达到明显的缓解效果,治疗后随着时间的推移,上述症状易反复发     

内窥镜下颈椎间盘切除及椎体间植骨融合术

目的:探讨内窥镜下颈椎间盘切除及椎体间植骨融合术治疗颈椎疾患的疗效。方法:经内窥镜颈椎间盘切除及植骨术治疗颈椎疾病25例,包括脊髓型颈椎病17例,神经根型颈椎病3例,交感型颈椎病2例及外伤性颈椎间盘突出症3例。结果:本组患者颈部手术出血平均80ml,18例获10~46个月(平均27个月)随访,植骨全部融合,脊髓和神经根压迫症状改善满意,除1例出现术后植骨块移位外,未见其它合并症。结论:经内窥镜下颈椎间盘切除及植骨融合术是一种创伤小、安全、可靠的手术技术,适合于颈椎间盘突出症及部分颈椎病的治疗。     

一期前后路颈椎减压治疗钳夹型脊髓型颈椎病

目的观察一期前后路颈椎减压治疗钳夹型脊髓型颈椎病的临床效果。方法采用一期前后路颈椎减压手术方式治疗16例钳夹型脊髓型颈椎病,其中发育性颈椎管狭窄合并颈椎间盘突出11例,退变性颈椎管狭窄合并颈椎间盘突出5例。术前和术后通过神经功能JOA评分、颈椎动态侧位X线片、颈椎MRI评估临床疗效。结果患者术后3、6、24个月,JOA评分平均改善率分别为62.2%,69.4%,78%,MRI示颈髓压迫解除。结论一期前后路颈椎减压治疗钳夹型脊髓型颈椎病是一种有效可行的手术方法。     

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.     

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.     

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.     

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.     

Anesthésie générale chez l’enfant : quid des pratiques en 2010 ?

Introduction

The practice of pediatric anesthesia requires a regular update of scientific knowledge and technical skills. To provide the most adequate Continuing Medical Education programs, it is necessary to assess the practices of pediatric anesthesiologists. Thus, the objective of this survey was to draw a picture of the current clinical practices of general anesthesia in children, in France.

Material and methods

One thousand one hundred and fifty questionnaires were given to anesthesiologists involved in pediatric cases. These questionnaires collected information on various aspects of clinical practice relative to induction, maintenance, recovery from general anaesthesia and also classical debated points such as children with Upper Respiratory Infection (URI), emergence agitation, epileptoid signs or anaesthetic management of adenoidectomy. Differences in practices between CHG (general hospital), CHU (teaching hospital), LIBERAL (private) and PSPH (semi-private) hospitals were investigated.

Results

There were 1025 questionnaires completed. Fifty-five percent of responders worked in public hospitals (CHG and CHU); 77% had a practice that was 25% or less of pediatric cases. In children from 3 to 10 years: 72% of respondents used always premedication and two thirds performed inhalation induction in more than 50% of cases. For induction, 53% used sevoflurane (SEVO) at 7 or 8%. Respondents from LIBERAL used higher SEVO concentrations. Tracheal intubation was performed with SEVO alone (37%), SEVO and propofol (55%) and SEVO with myorelaxant (8%), 93% of respondents used a bolus of opioid. For maintenance, the majority of respondents used SEVO associated with sufentanil; desflurane and remifentanil were more frequently used in CHU. Two thirds of respondents used N₂O. Depth of anesthesia was commonly assessed by hemodynamic changes (52%), end tidal concentration of halogenated (38%) or automated devices based on EEG (7%). In children with URI, 98% of respondents used SEVO for anesthesia. To control the airway 42% used a tracheal tube, 30% a laryngeal mask and 20% a facial mask. Emergence agitation was an important concern for two thirds of respondents, while epileptoid signs were considered as important by only 20%. Eighty-nine percent of respondents practiced anesthesia for adenoidectomy. Anesthesia was induced by inhalation of SEVO 7–8% (41%), 6% (39%) or 4% (12%), 66% put an intravenous line (less frequently in LIBERAL). 67% of the responders managed adenoidectomy without any device to control the airway (more frequently in LIBERAL), 32% administrated a bolus of opioid (less frequently in LIBERAL).

Discussion

This survey demonstrated that the practices regarding general anesthesia in children are relatively homogenous. Most of the differences appeared between LIBERAL and the others structures; the anaesthetic management for adenoidectomy illustrates these findings.     

Intérêt d’une rééducation précoce pour les patients neurologiques

Rehabilitation improves the functional prognosis of patients after a neurologic lesion, and tendency is to begin rehabilitation as soon as possible. This review focuses on the interest and the feasibility of very early rehabilitation, initiated from critical care units. It is necessary to precisely assess patients’ impairments and disabilities in order to define rehabilitation objectives. Valid and simple tools must support this evaluation. Rehabilitation will be directed to preventing decubitus complications and active rehabilitation. The sooner rehabilitation is started; the better functional prognosis seems to be.