胸腰椎爆裂骨折的外科治疗分析

目的探讨胸腰椎爆裂骨折的最佳治疗方法。方法根据骨折类型不同,采用不同方法治疗胸腰椎爆裂性骨折89例,其中AF系统椎弓根钉内固定68例,Dick固定6例,ALPS固定8例,Luque棒固定2例,中华长城5例,并行植骨49例。结果随访9个月～3年6个月,平均2年。术后内固定稳固,骨折复位佳,椎管有效径恢复,术后神经功能较术前均有恢复。结论胸腰椎爆裂骨折,如骨折块占椎管容积>30%以上,椎管矢径小于10mm及伴有脊髓损伤者应积极进行手术椎管减压复位固定,矫正后倾角,同时术中脊髓造影、C臂机监视复位应达到以下标准:压缩椎体扩张80%以上;后弓角<10°,恢复椎管容积及脊髓减压,椎体间脱位完全复位。     

脊髓损伤显微镜下清创修复之评价

自 1998年以来 ,对脊柱胸腰段骨折或脱位后行手术复位、弓根钉固定、椎体植骨完成后 ,损伤区域在手术显微镜下施以坏死碎片、凝血块的清除 ,探察、修复损伤的微小神经血管 ,早期恢复血运。 92例患者获得随访 ,按Ｆｒａｎｋｅｌ分级标准行术前、后评价 ,该法明显提高了损伤恢复的有效率。强调手术复位、减压及植骨、固定是重要的 ,同时脊髓损伤早期在显微镜下得以清创与修复有利于减少原发性、继发性创伤反应 ,降低神经组织水肿 ,缩短神经功能恢复时间。值得研究探讨脊髓损伤显微镜下清创修复之评价$浙江中医学院附属医院骨科@于建农 $浙…     

Schwann cell apoptosis in Wallerian-degenerated sciatic nerve of the rat

Objective: To investigate systematically Schwann cell apoptosis in Wallerian-degenerated sciatic nerve of the rat, and evaluate its time-related feature. Methods: Ninety-five SD rats were divided randomly into one normal group (8 rats) and 11 experimental groups (66 rats, 6 in each). Both hind legs of each rat in experimental groups were randomly divided into test leg (sciatic nerve transected ) and control one (nerve uninjured). All test legs constituted a test group and all control legs constituted a control one. After operation, all rats were respectivdy sacrificed at 1 h, 6 h, 12 h, 24 h, 2 d, 3 d, 4 d, 8 d, 14 d, 21 d, and 30 d. We analyzed the specimens of mid-distal sciatic nerve, especially the morphological changes of the nerve, the different expression levels of S-100 protein and apoptosis-related proteins such as Bel-2, Bax, and Fas in Schwann cells. The TUNEL method was used to detect the apoptotic rate of Schwann cells. Results： (1) The test group showed Wallerian degeneration. The number of Schwann cells began to decrease at 24 h, obviously decreased on day 3 and 4, then began to increase from day 8 and formed Bungner belt after 14 days. (2) Schwann cells generally expressed S-100 at a low level in all groups. The control group was not significantly different from the normal group. The test group had statistical significance at 1 h and day 21. (3) As an inhibitory gene protein of Schwann cell apoptosis, Bcl-2 positive rates in the control and test groups apparently elevated and were statistically different from the normal group. (4) As a promotive gene protein of Schwann cell apoptosis, the control and test groups expressed Bax at a high level and were statistically different from the normal group. (5) As a promotive gene protein of Schwann cell apoptosis, Fas positive rate in control group was slightly elevated, but had no statistical significance compared with the normal group. Fas positive rate in test group continuously elevated in a fluctuant way, with highly statistical significance compared with the normal group. (6) TUNEL detection further proved that Schwann cell apoptosis rarely existed in the normal group, and the left sciatic nerve had no statistical significance compared with the right sciatic nerve. While the test group showed lots of apoptotic nuclei at 6 h, 2 d, 4 d, and 21 d. It had highly statistical significance compared with the normal group. Conclusions: Schwann cell apoptosis does exist in Wallerian-degenerated sciatic nerve of the rat after transection. Schwann cell apoptosis and its apoptotic genes expression have a time-related feature.     

坐骨神经创伤性华勒氏变性中雪旺细胞凋亡初步研究

目的探讨成年大鼠坐骨神经创伤性华勒氏变性中雪旺细胞凋亡的存在及其时相性变化规律.方法利用成年雌性SD大鼠坐骨神经横断复制华勒氏变性模型.将74只SD大鼠随机分为12组.1个正常组(8只)、11个实验组(66只).每只实验组大鼠双后肢再随机分为试验肢(构成试验组)和对照肢(构成对照组).分别于术后1 h,6 h,12 h,24 h,2 d,3 d,4 d,8 d,14 d,21 d,30 d共11个时相点,切取坐骨神经中下段标本.检测各组神经纤维形态学改变,雪旺细胞S-100蛋白和凋亡基因相关产物Bcl-2、Fas、Bax表达水平变化,并用TUNEL法检测雪旺细胞凋亡指数.结果①试验组雪旺细胞数量术后24 h开始明显减少,术后8 d才开始重新增多.②S-100蛋白表达对照组变化无统计意义(P＞0.05),试验组则在术后1 h,21 d两个时间点变化有统计意义(P＜0.05).③雪旺细胞凋亡抑制基因产物Bcl-2表达,正常组双侧肢变化无差异(P＞0.05),而对照组术后6 h明显升高,术后24 h、4 d、21 d轻度增高(P＜0.01),试验组术后6 h,24 h,8 d,14 d,30 d进行性升高(P＜0.01).④雪旺细胞凋亡促进基因产物Bax表达,正常组双侧肢比较无差异(P＞0.05),而对照组术后6 h,3～21 d持续高表达(P＜0.01),试验组14 d开始进行性上升(P＜0.01).⑤雪旺细胞凋亡促进基因产物Fas表达,正常组双侧肢比较无差异(P＞0.05),对照组仅轻度增高(P＞0.05),而试验组术后12 h开始进行性升高(P＜0.01).⑥TUNEL法凋亡试剂盒原位检测显示正常组雪旺细胞凋亡发生率极低,双侧肢比较无差异(P＞0.05);试验组分别在术后6 h,24 h,2 d,21 d出现大量雪旺细胞凋亡阳性核(P＜0.01),高峰出现在华勒氏变性早期.结论成年大鼠坐骨神经横断后,远侧段创伤性华勒氏变性早期存在雪旺细胞凋亡高峰.并且雪旺细胞凋亡的发生,及凋亡相关促进基因Bax、Fas和抑制基因Bcl-2的表达均具有特定的时相性变化特点.     

椎弓根螺钉内固定加椎体间融合器治疗腰椎滑脱症

目的：探讨后路椎弓根螺钉内固定加椎体间Cage融合术治疗腰椎滑脱症的疗效。方法：手术治疗62例腰椎滑脱患者，其中行椎弓根螺钉内固定加Cage(21例)或植骨(3例)椎体间融合共24例：峡部裂型16例，退变性8例；腰4椎体滑脱13例，腰5椎体滑脱11例。按Meyerding分度：I度滑脱18例，Ⅱ度滑脱6例。2例先作后路椎弓切除减压椎弓根螺钉复位内固定，再作前路Cage植入，一期完成手术；其余22例均作后路切口行椎弓切除或椎板切除神经减压，椎弓根螺钉复位内固定，后路椎体间融合，其中19例加用单枚Cage后外侧斜向植入行椎体间融合，另3例行椎体问植骨融合，而使用Cage病例中有6例在其前方加用骨碎块植骨。结果：24例均获得3～48个月的随访，平均随访时间为18个月。根据Asher的疗效观察项目：优12例、良10例、可1例、差1例，优良率达91．7％。结论：腰椎滑脱的治疗减压后的融合是关键；为了达到融合的目的，复位内固定是必要的；减压后椎弓根螺钉内固定加后路腰椎椎体间融合是一个值得推荐的治疗腰椎滑脱的手术方法；而后外侧斜向放置单个Cage是一种安全有效的后路椎体间融合的方法。     

328例颈椎前路手术并发症的分析

目的　总结颈椎前路手术的并发症 ,分析原因并提出预防措施。方法　 1 989年 5月～2 0 0 0年 3月颈椎前路手术 (减压 椎间融合术 ) 32 8例 ,其中颈椎病 1 75例 ,颈椎间盘突出症 97例 ,颈椎骨折、脱位 56例。结果　随访 6个月～ 1 1年 (平均 32个月 ) ,发生并发症 38例 ,其中喉上神经损伤 5例 ,喉返神经损伤 4例 ,植骨块部分滑出 5例 ,植骨不融合 1 9例 ,BAK沉降 3例 ,颈动脉窦综合征 1例 ,睡眠性窒息 1例。结论　熟悉颈椎前路手术解剖 ,操作轻柔 ,植骨、内固定合理 ,可以减少或避免并发症的发生     

个体化颈椎弓根螺钉置钉技术的实验研究

目的探索一种较为安全、实用的颈椎弓根螺钉置钉方法.方法随机取7具福尔马林浸泡的成人颈椎标本(C1～T2),保留完整的脊柱三柱结构及相关的韧带和椎旁肌,根据影像学测量的进钉点和进钉方向,模拟颈椎后路手术过程,进行实际的个体化置钉,摄正位、侧位、45°斜位X线片、CT扫描,进行解剖学观察,评价置钉的成败.结果置钉84枚,失败7枚,失败率为8.3%.结论个体化经颈椎弓根螺钉置钉技术比较安全和可靠,可以在临床上应用推广.     

改良Bosworth法手术治疗肩锁关节脱位

本文介绍一种治疗肩锁关节脱位新的手术方法——军刀状切口,用松质骨螺丝钉将锁骨固定在喙突上,并修补喙锁和肩锁韧带.要求做到:①必须显露肩锁关节并作清创处理;②应修补喙锁和肩锁韧带;③必须获得稳定的肩锁关节复位.按此法治疗16例,13例治疗效果满意.作者认为军刀状切口对本症来说是一良好的手术途径,本手术适用于喜欢活动的年青患者.