颈前路椎间盘切除椎间融合器融合术加颈后路单开门术治疗脊髓型颈椎病

[目的]探讨颈椎前路椎间盘切除椎间融合器融合术加颈椎后路单开门椎管扩大成形术治疗脊髓型颈椎病在临床上的应用价值。[方法]应用Cervical Cage行颈椎前路椎间盘切除椎间融合术，同时，颈椎后路行单开门椎管扩大成形术11例，平均随访6个月。按40分法和JOA评分对手术前后脊髓功能进行评分，并测量颈椎术前术后前柱高度及椎管宽度和进行相关性分析．[结果]颈椎前路椎间盘切除椎间融合器融合术加颈椎后路单开门椎管扩大成形术，明显改善脊髓型颈椎病的脊髓功能。40分法平均37分，改善率83％；JOA评分16．5分，改善率91％；前柱高度平均增加1．28mm；椎管宽度平均增加2．22mm。[结论]颈椎前路椎间盘切除椎间融合器融合术加颈椎后路单开门椎管扩大成形术，有效恢复了颈椎前柱高度、增加椎管宽度，明显改善了脊髓型颈椎病的脊髓功能。     

单开门与一期前后路手术减压治疗前后受压脊髓型颈椎病的疗效比较

目的:总结后路单开门与一期前后路联合手术减压治疗前后受压脊髓型颈椎病的疗效,探讨一期前后路联合减压的手术适应证.方法:1996年2月至2007年12月,对67例前后方均受压的脊髓型颈椎病患者分别采用后路单开门神经根管扩大减压术(A组,36例)或一期前后路联合减压术(B组,31例)治疗.随访患者临床和影像学情况,手术前后按日本矫形外科学会(JOA)评分标准评定神经功能,计算改善率,比较两组l临床疗效.结果:A组手术时间1～1.5h,平均72min;术中出血量110～500ml,平均370ml;无明显术中并发症发生,术后1例出现肩部放射痛.B组手术时间3～5h,平均3.6h;术中出血量400～1300ml,平均710ml;术中出现脑脊液漏4例.随访6个月～8年,平均28个月,前路植骨及后路门轴全部骨性愈合.A组神经功能改善率为72.4%.优良率为80.1%;MRI检查显示34例脊髓明显后移、前后方软性压迫解除、脑脊液通畅,2例显示脊髓明显后移、前方仍存在骨化块轻度压迫、予以二期前路骨化块切除减压、内固定术,随访时21例显示前方椎间盘突出明显消失或缩小;CT显示椎管扩大充分,开门度数平均为63.2°.B组神经功能改善率为74.1%,优良率为80.6%;MRI显示31例脊髓前后方压迫均解除、脑脊液通畅;CT显示椎管扩大充分.开门度数平均为53.3°.两组神经功能改善率和优良率均无统计学差异.结论:后路单开门减压治疗前方软性压迫的前后受压脊髓型颈椎病可使脊髓充分后移躲避前方的压迫,术后脊髓前方的软性压迫缩小或消失,疗效肯定;但对椎管狭窄合并脊髓前方超过椎管50%的骨性压迫者疗效欠佳,应采用一期或二期前后路联合减压治疗.     

后路单开门与一期前后路手术减压治疗前后受压脊髓型颈椎病的疗效比较

目的:总结后路单开门与一期前后路联合手术减压治疗前后受压脊髓型颈椎病的疗效,探讨一期前后路联合减压的手术适应证。方法:1996年2月至2007年12月,对67例前后方均受压的脊髓型颈椎病患者分别采用后路单开门神经根管扩大减压术(A组,36例)或一期前后路联合减压术(B组,31例)治疗。随访患者临床和影像学情况,手术前后按日本矫形外科学会(JOA)评分标准评定神经功能,计算改善率,比较两组临床疗效。结果:A组手术时间1～1.5h,平均72min;术中出血量110～500ml,平均370ml;无明显术中并发症发生,术后1例出现肩部放射痛。B组手术时间3～5h,平均3.6h;术中出血量400～1300ml,平均710ml;术中出现脑脊液漏4例。随访6个月～8年,平均28个月,前路植骨及后路门轴全部骨性愈合。A组神经功能改善率为72.4%,优良率为80.1%;MRI检查显示34例脊髓明显后移、前后方软性压迫解除、脑脊液通畅,2例显示脊髓明显后移、前方仍存在骨化块轻度压迫,予以二期前路骨化块切除减压、内固定术,随访时21例显示前方椎间盘突出明显消失或缩小;CT显示椎管扩大充分,开门度数平均为63.2°。B组神经功能改善率为74.1%,优良率为80.6%;MRI显示31例脊髓前后方压迫均解除、脑脊液通畅;CT显示椎管扩大充分,开门度数平均为53.3°。两组神经功能改善率和优良率均无统计学差异。结论:后路单开门减压治疗前方软性压迫的前后受压脊髓型颈椎病可使脊髓充分后移躲避前方的压迫,术后脊髓前方的软性压迫缩小或消失,疗效肯定;但对椎管狭窄合并脊髓前方超过椎管50%的骨性压迫者疗效欠佳,应采用一期或二期前后路联合减压治疗。     

重症脊髓型颈椎病前、后路联合手术治疗次序的选择

目的：探讨前、后路联合手术治疗重症脊髓型颈椎病手术次序选择的原则.方法：回顾性分析45例重症脊髓型颈椎病患者,男27例,女18例,先行颈椎前路减压再行后路椎管扩大成形手术19例（A组）,先行颈椎后路椎管扩大成形再行前路减压融合手术26例（B组）.术前、术后均采用JOA评分法进行评分,根据JOA评分改善率评价两组治疗效果的优良率.结果：术中A组1例因前路手术使椎管前方骨化组织进一步挤压脊髓组织致患者截瘫;2例因前路手术致压物切除不彻底,术后患者症状无明显改善.B组1例术后出现C5脊神经根麻痹,颈椎前路减压后逐渐恢复.术后随访9～38个月,平均20.4个月.两组优良率分别为69.23%（B组）、42.10%（A组）,B组患者手术治疗效果明显优于A组.结论：前后路联合手术治疗重症脊髓型颈椎病应先行后路椎管扩大成形再行前路减压融合,手术效果较好,并发症少,安全性高.     

多节段脊髓型颈椎病前后路手术疗效的临床观察

目的评估前路减压植骨内固定和后路椎管扩大成形术对多节段脊髓型颈椎病(CSM)的治疗效果。方法对67例多节段CSM分别采用前路手术(前路组)和后路手术(后路组)治疗。结果本组获随访12～24个月。前、后路组神经功能改善优良率分别为85.7%和84.4%,差异无统计学意义(P>0.05);两组间术后疗效(JOA评分、前凸Cobb角)差异无统计学意义(P>0.05),但同一入路术后较术前明显改善(P<0.05)。结论 CSM采用前路手术的疗效优于后路,可更大程度的恢复脊髓的受压,而对于来自脊髓后方的压迫,后纵韧带钙化、伴有颈椎椎管狭窄者,则以颈后路手术为主。     

脊柱结核前后路不同术式的选择及疗效分析

目的分析脊柱结核前后路不同术式的选择及疗效。方法选取2010年4月～2013年4月我院收治的成人腰骶段和胸腰椎结合患者188例,随机分成四组,每组47例。A组实施病灶前路清除手术、植骨融合术及前路内固定手术;B组实施椎弓根后路内固定手术、植骨融合术及病灶前路清除手术;C组实施病灶侧前方清除手术、植骨融合术及椎弓根后路内固定手术;D组实施病灶后路清除手术、椎弓根后路内固定手术及植骨融合术。对各组治疗效果进行观察。结果A组脊柱后凸畸形矫正率（47．5±11．8）%明显低于B、C、D组的（61．5±18．6）%、（58．7±15．9）%和（59．9±17．4）%（P〈0．05）;A组矫正角度丢失率（64．8±19．3）%明显高于B、C、D组的（53．6±15．6）％、（56．9±11．8）％和（54．9±5．4）％（P〈0．05）。结论治疗脊柱结核要依据正确的手术适应证选择不同的术式,从而将病灶清除、矫正脊柱后凸畸形;临床证明同前路固定手术方式相比,采用后路固定矫正脊柱后凸畸形能够取得更好的效果。     

单开门术后前方残留压迫阻碍神经功能恢复的研究

[目的]研究后路单开门成形术后脊髓前方残留压迫对神经功能恢复的影响,并探讨残留压迫与术前椎管侵占率以及致压物最大径之间的关系.[方法] 2008年1月～2010年12月在本院行单开门手术的脊髓型颈椎病患者60例,所有患者均获得随访.平均随访时间34个月(12 ～52个月).将患者分为两组,A组:22例术后存在前方残留压迫;B组:38例术后不存在前方残留压迫.比较和分析两组术后疗效及影像学资料,如JOA总体评分及改善率,JOA各项评分及改善率,术前及术后颈椎曲度,前方压迫物最大径以及椎管侵占率.[结果]两组平均年龄、病程、随访时间、术前JOA评分以及术前术后的颈椎曲度比较均无统计学差异(P＞0.05).A组JOA改善率(52.7±19.2)％,B组改善率(69.8±9.8)％,两组间改善率比较有统计学差异(P＜0.05),A组vs B组上肢运动功能改善率(44.6％ vs76.3％),下肢运动功能改善率(43.2％ vs57.2％),两组间比较有统计学差异(P＜0.05).A组压迫物最大径及椎管侵占率分别为(7.2±1.4) mm和(58.2±10.7)％,B组分别为(5.9±1.3)mm和(49.5±10.6)％,两组间比较有统计学差异(P＜0.05).[结论]单开门术后脊髓受到前方残留压迫时会阻碍神经功能的恢复,特别是在四肢运动功能方面.单开门手术对伴有前方巨大占位的脊髓型颈椎病的治疗具有局限性.     

3种手术方式治疗脊髓型颈椎病的疗效分析

目的 分析脊髓型颈椎病（CSM）前路3种手术方式的疗效。方法150例脊髓型颈椎病患者采用前路减压＋植骨融合术45例（A组）、前路减压＋cage融合术30例（B组）、前路减压＋钛网内植骨＋钢板内固定术75例（C组）。术后3d及6、12、24周摄颈椎正、侧位X线片。JOA评分系统评定不同手术方法的疗效。结果150例均获随访,时间6～60个月。除1例未融合外,余植骨均融合,时间为2—4个月。JOA评分均有改善,A组改善率为72．8％,B组为85．6％,C组为80．6％,B组与C组比较差异无显著性（P〉0．05）,B组和C组与A组比较差异有显著性（P〈0．05）。结论CSM的治疗关键在于充分减压及有效植骨融合,减压加椎间融合器植入术具有操作简单、出血少、减压充分、术后恢复好等优点,是治疗脊髓型颈椎病的较好方法。     

后前路联合手术治疗严重颈椎退行性疾病

目的探讨后前路联合手术治疗严重颈椎退行性疾病的疗效和手术适应证。方法施行后前路联合手术治疗严重颈椎退行性疾病17例,其中男11例,女6例;年龄46-72岁,平均56.3岁。3例分期后前路手术,14例一期后前路手术。手术步骤为先行后路单开门椎管扩大成形术,然后一期或分期（6个月后）行前路椎管前方减压、植骨融合内固定术。结果无围手术期死亡及神经功能加重病例,术后发生脑脊液漏2例,轴性疼痛2例。术后随访13例,JOA评分由术前平均（8.3±2.28）分增至术后平均（13.1±1.27）分,手术前后评分差异显著（t=11.5,P〈0.01）,脊髓功能改善率为66.5%。结论一期后前路联合手术疗效满意。该手术方式减压充分,可降低单纯前路手术脊髓损伤的风险和减少单纯后路手术后C5神经根麻痹的发生率,适用于全身情况较好、多节段颈椎病变伴脊髓前方局部受压严重的患者。     

一期前后路联合手术治疗脊髓型颈椎病的临床研究

目的 探讨前后方均有压迫的脊髓型颈椎病应用一期后路单开门及前路减压、Cage植人手术的治疗效果。方法对45例前后方均有压迫的脊髓型颈椎病患者行一期后路单开门椎板成形术和前路椎间盘切除减压、Cage植入术。结果术后随访6～29个月,平均18．7个月．显示椎间隙高度与颈椎生理曲度恢复,骨性融合率100％,融合时间平均4．5个月。JOA评分平均改善率83．5％,优良率82．2％。随访中未发现有Cage移位、下沉、假关节形成、椎间隙高度丢失、椎管再狭窄等问题。结论采用一期前后路手术治疗脊髓前后同时受压的脊髓型颈椎病减压彻底、神经功能恢复满意．前路减压后以Cage植入椎间隙可获得良好的术后即刻稳定性、提高了植骨融合率并可长期保持椎间隙的高度和颈椎的生理曲度。     

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.     

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.     

Development of Selective Low-Density Lipoprotein (LDL) Apheresis System: Immobilized Polyanion as LDL-Specific Adsorption for LDL Apheresis System

Abstract: Low-density lipoprotein (LDL) is widely recognized as one of the major risk factors for developing coronary heart diseases. Despite intensive development of LDL-lowering drugs, there still exist those patients with refractory hyperlipidemia whose plasma LDL levels are not sufficiently lowered by drugs. LDL apheresis, direct removal of plasma LDL from circulating blood, is thought to be the most promising treatment for such refractory patients. Various techniques, such as the use of an im-munoadsorbent utilizing an anti-LDL antibody, have been used in an attempt to achieve the selective removal of LDL. However, none were widely used because of complications, poor selectivity, and so forth. To establish a safe and effective LDL apheresis system, we chose a synthetic affinity adsorbent as the LDL-removing device. Synthetic polyanion compounds were used as the affinity ligands for LDL adsorbent to simulate the anion-rich sequence of LDL binding sites in the human LDL receptor. Among various polyanion compounds, those polyanions with sulfate or sulfonate groups and hydrophilic backbone were found to have strong affinity for LDL. In contrast, polyanions with carboxyl groups showed poor affinity. Dextran sulfate (DS) was selected as the affinity ligand of LDL adsorbent for its high affinity and low toxicity. The influence of its charge density and molecular weight on its affinity for LDL was suitable. The affinity rapidly increased as the charge density increased, then, reached a constant value. Little affinity was found for either the DS monomer (glucose sulfate) or DS with a molecular weight higher than 10⁴ daltons whereas DS with molecular weights in the midrange showed strong affinity. DS with a midrange molecular weight was immobilized on cellulose hard gel to give LDL adsorbent clinical application. The adsorbent demonstrated an excellent selectivity for LDL and very low density lipoprotein (VLDL) in vitro. Adsorption of high-density lipoprotein and major plasma proteins was almost negligible. Additional study of the LDL-binding mechanism revealed that DS directly interacts with positively charged sites on LDL, which demonstrates that the nature of the interaction is the same as that of LDL receptor. An LDL adsorption column (Liposorber) packed with an LDL adsorbent and polysulfone hollow-fiber plasma separator (Sulflux) was developed as an efficient LDL apheresis system. Clinical investigation proved that this system is capable of intensively lowering the plasma LDL level without affecting major plasma components.     

Artificial organs 2010: a year in review

In this Editor's Review, articles published in 2010 are organized by category and briefly summarized. As the official journal of The International Federation for Artificial Organs, The International Faculty for Artificial Organs, and the International Society for Rotary Blood Pumps, Artificial Organs continues in the original mission of its founders "to foster communications in the field of artificial organs on an international level."Artificial Organs continues to publish developments and clinical applications of artificial organ technologies in this broad and expanding field of organ Replacement, Recovery, and Regeneration from all over the world. We take this time also to express our gratitude to our authors for offering their work to this journal. We offer our very special thanks to our reviewers who give so generously of time and expertise to review, critique, and especially provide such meaningful suggestions to the author's work whether eventually accepted or rejected and especially to those whose native tongue is not English. Without these excellent and dedicated reviewers the quality expected from such a journal could not be possible. We also express our special thanks to our Publisher, Wiley-Blackwell, for their expert attention and support in the production and marketing of Artificial Organs. In this Editor's Review, that historically has been widely received by our readership, we aim to provide a brief reflection of the currently available worldwide knowledge that is intended to advance and better human life while providing insight for continued application of technologies and methods of organ Replacement, Recovery, and Regeneration. We look forward to recording further advances in the coming years.     

Avaliação do clube de revista de anestesiologia por meio de mudanças semânticas

Background and objectives

The interactive approach of a journal club has been described in the medical education literature. The aim of this investigation is to present an assessment of journal club as a tool to address the question whether residents read more and critically.

Methods

This study reports the performance of medical residents in anesthesiology from the Clinics Hospital – University of São Paulo Medical School. All medical residents were invited to answer five questions derived from discussed papers. The answer sheet consisted of an affirmative statement with a Likert type scale (totally disagree–disagree–not sure–agree–totally agree), each related to one of the chosen articles. The results were evaluated by means of item analysis – difficulty index and discrimination power.

Results

Residents filled one hundred and seventy three evaluations in the months of December 2011 (n = 51), July 2012 (n = 66) and December 2012 (n = 56). The first exam presented all items with straight statement, second and third exams presented mixed items. Separating “totally agree” from “agree” increased the difficulty indices, but did not improve the discrimination power.

Conclusions

The use of a journal club assessment with straight and inverted statements and by means of five points scale for agreement has been shown to increase its item difficulty and discrimination power. This may reflect involvement either with the reading or the discussion during the journal meeting.     

Lymphocytapheresis

Abstract: Leukocytapheresis has long been performed with the centrifugal method. But in 1989 in Japan, the Asahi Medical Co. developed the extracorporeal leukocyte-removal filter, Cellsorba. This filter consists of non-woven fabric, which can remove leukocytes from whole blood during extracorporeal circulation. In the incipient stage, this filter was applied to collagen diseases, rheumatoid arthritis, and systemic lupus erythematosus. During the following studies, this filter has been found to have an immunosuppressive effect. Now, it is beginning to be applied to various kinds of autoimmune diseases. Moreover, this filter has recently been recognized to be effective in inflammatory bowel diseases, ulcerative colitis, and Crohn's disease. The outline of Cellsorba and the application of this filter is described here.     

Soluble TNFα Receptors Are Increased in Chronic Renal Insufficiency and Hemodialysis and Inhibit Neutrophil Priming by TNFα

Abstract: The oxidative burst of neutrophils from azotemic patients is refractory to priming by tumor necrosis factor-α (TNFα). Soluble TNFα binding proteins (TNFR) accumulate in the plasma of azotemic patients. To test the hypothesis that these increased sTNFR concentrations inhibit TNFa priming of oxidative burst activity, we measured plasma sTNFR concentrations in nondialyzed azotemic patients, hemodialysis patients, and normal subjects, and determined TNFa priming of fMet-Leu-Phe-stimulated superoxide production in neutrophils incubated in plasma with differing levels of sTNFR. These sTNFR concentrations increased significantly as creatinine clearance decreased and were significantly greater in hemodialysis patients than could be accounted for by loss of renal function alone. TNFα primed superoxide production by normal neutrophils in normal plasma, but this effect was significantly reduced in plasma with increased concentrations of sTNFR. Neutrophils from azotemic and hemodialysis patients were refractory to priming by TNFα in autologous plasma, and incubation in normal plasma only partially corrected this defect. We conclude that sTNFR accumulate as a result of the loss of renal function and hemodialysis and inhibit TNFα priming of neutrophils in azotemic and hemodialysis patients, but that these cells also have an intrinsic functional defect.