上颈椎前侧手术入路和内固定技术研究进展

上颈椎由枕骨髁(C0)、寰椎(C1)、枢椎(C2)及其相互连接的关节、关节囊和韧带结构组成.该部位解剖结构重要且复杂,若发生畸形、肿瘤、外伤、结核或风湿等病变,会导致上颈椎失稳,压迫脊髓、椎动脉和神经.上颈椎疾病通常症状较重且致残、致死率较高,大部分患者需要手术治疗.由于C0～2周围解剖结构复杂,手术暴露和置钉都较为困难,所以熟练掌握其解剖结构并选择合适的手术入路和内固定技术就显得尤为重要.目前,上颈椎手术入路和内固定技术的选择在国内外尚未达成一致,如何选择合适的手术入路,采用何种内固定方式,是否需要前后路联合治疗等问题仍存在争议.本文通过查阅分析国内外相关文献,对上颈椎前侧手术入路和内固定技术作如下综述,旨在为临床对上颈椎疾病手术方式的选择提供参考.     

腋后路内固定治疗IdebergⅠa及Ⅱ型肩胛盂骨折的疗效分析

目的:探讨腋后路治疗IdebergⅠa及Ⅱ型肩胛盂骨折的疗效。方法:回顾性分析2018年12月至2021年9月采用腋后路治疗的9例肩胛盂下部分骨折患者的资料,男3例,女6例;年龄50～78岁。所有患者骨折为闭合性骨折,依据肩胛盂骨折Ideberg分型:Ⅰa型6例,Ⅱ型3例。分别于术后第6、12周及6、12个月摄肩关节正、侧位X线片,记录所有患者末次随访时的Constant-Murley肩关节评分,上肢功能障碍(disability of the arm,shoulder and hand,DASH)评分,骨折愈合情况以及其他并发症情况。结果:术后9例患者获得随访,时间6～15个月。末次随访时9例均获得骨性愈合,愈合时间3～6个月,末次随访时患者的Constant-Murley评分为55～96分;DASH评分为3.33～33.33分。结论:腋后路内固定治疗IdebergⅠa、Ⅱ型肩胛盂骨折有效解决了前方入路显露肩胛盂下部分骨折困难的问题,可避免肩胛下肌以及关节囊医源性损伤,临床效果满意,值得临床推广使用。     

Elevated monocyte distribution width in trauma: An early cellular biomarker of organ dysfunction

IntroductionTraumatic injury elicits an inflammatory response such as the one occurring during systemic infection. Monocyte distribution width (MDW) has been found to distinguish sepsis in a pool of patients with suspected infection. We hypothesized that an elevated MDW in trauma patients would be associated with the development of multiple organ dysfunction syndrome (MODS) and an increased mortality.Materials and MethodsObservational study in a dedicated trauma Intensive Care Unit (ICU) in Madrid during 2019–2020. Patients were classified according to their first MDW value on admission, as greater or lesser than 21 U. Clinical data was obtained and univariate and multivariate analysis were realized, as well as a test performance analysis.Results354 patients were studied, with a median age of 46 years, 78% male. Half presented with severe trauma ISS > 15, mostly with a blunt mechanism of injury. A MDW ≥ 21 U on admission was found in 17% of cases. These patients were more likely to present with hemodynamic instability and MODS. They had a higher length of stay (3.8 vs 2 days) and higher mortality (21 vs 5%) compared to the low MDW group. These findings remained statistically significant in the multivariate analysis, with an OR 4.6 (IC 95% 1.7–12) for MODS and 3.1 (IC 95% 1.2–8.3) for mortality.ConclusionsIn trauma patients, a MDW ≥ 21 U on admission was independently associated with a greater risk of MODS, a higher mortality and a higher length of stay. This biomarker could be useful in predicting severity in the initial evaluation of trauma patients.     

腰椎椎间融合术后置入物后移的危险因素

目的探讨腰椎椎间融合术后置入物后移的危险因素。方法回顾性分析2011年10月—2016年12月接受后路腰椎椎间融合术(PLIF)或经椎间孔腰椎椎间融合术(TLIF)治疗的628例患者临床资料,以术后是否发生置入物后移将患者分为后移组(22例)和非后移组(606例)。记录所有患者术后发生置入物后移的潜在影响因素,包括性别、年龄、骨密度、手术时间、术中出血量、手术方式、融合节段、置入物类型、螺钉类型、术中是否加压、终板是否刮除、置入是否充分等,分析以上因素组间差异是否具有统计学意义,并对差异有统计学意义的因素采用logistic回归分析评价其与术后置入物后移的相关性。结果 628例患者中22例发生置入物后移,其中轻度后移12例、重度后移10例,后移发生率为3.5%。组间比较显示,螺钉类型、术中是否加压、终板是否完全刮除、置入是否充分4个方面差异有统计学意义(P 0.05)。Logistic回归分析显示上述4个指标与术后置入物后移具有相关性。结论万向螺钉的应用、术中未加压、终板完全刮除及置入不充分是腰椎椎间融合术后出现置入物后移的危险因素,术中融合器的放置应尽量靠近椎体中央,对置入物后移合并神经功能受损者应尽早行翻修手术。     

A retrospective study of spine injuries in electric bicycles related collisions

BackgroundElectric bicycles related collisions could lead to severe consequences in spine injuries, while no study had comprehensively investigated the epidemiology and demography of spine injuries in electric bicycles related collisions.Questions/purposesThe aim of this study is to (1) describe the epidemiological characteristics of spine injuries in electric bicycles related collisions, (2) develop clinical guideline of spine injuries in electric bicycles related collisions and (3) support the new road safety policy for electric bicycle riders.MethodsA retrospective review of spine injuries in electric bicycle related collisions was performed from 86 patients in an urban trauma center between 2018 and 2020. The variables including gender, age, radiographic findings, associated injuries, neurologic injuries, treatment, average length of stay were fully collected. Chi-square test and paired sample mean t-test were used to test for statistically significant differences. All statistical analyses were performed using Statistical Product and Service Solutions 20.0.0 software. A P<0.001 was considered as significant.ResultsA total of 86 cases were involved in electric bicycles related collisions lead to spine injuries. The spine injuries victims were predominantly male (79.07%) and middle-aged (41-60years, 44.19%). The most common spine injuries were L1 fractures (10.48%). The most common fracture type was AO Fracture Classification type A (71.40%). Age and multivertebral fractures had significant difference between patients who suffered from an ASOI and from those who did not (P-value: 0.005, 0.005). There was significant difference between patients who suffered from neurologic injuries and from those who did not in AO Classification, multivertebral fractures and ASOI (P-value: 0.0001, 0.001, 0.032). Age, AO Classification, multivertebral fractures, ASOI and neurologic injuries had significant difference to influence patients’ ISS and ALOS.ConclusionsSpine injuries in electric bicycles related collisions may make patients suffer from severe consequences including their potential permanent disability, economic cost, or even life safety. Patients with spine injuries in electric bicycles related collisions should be paid close attention to avoid missed diagnosis and misdiagnosis. Helmet, protective clothing or other safety gear should be required to use to provide greater protection for electric bicycle riders.     

Gluteal compartment syndrome: A systematic review and meta-analysis

IntroductionGluteal compartment syndrome is a rare but devastating condition with limited characterization in the literature. The purpose of our systematic review, case series, and meta-analysis is to synthesize the current literature and provide recommendations on how to prevent gluteal compartment syndrome, identify at-risk patients, and avoid delays in diagnosis and treatment.MethodsInternational Classification of Disease codes were used to identify patients at our institution. PubMed, MEDLINE, and the Cochrane Library were searched to identify case reports between 1972 and March 1st, 2018. Cases were analyzed based on demographics, etiology, presentation, symptoms, diagnosis, treatment, and outcomes.Results139 cases – 13 from our institution and 126 previously published – were included. The most common etiologies were postoperative (41%), prolonged immobilization secondary to substance abuse or loss of consciousness (35%) and trauma (19%). 89% were male, mean age was 45 years (range, 16-74), and mean body mass index was 41 kg/m². Rhabdomyolysis and sciatic neuropathy were identified in 94% and 74% of patients, respectively. Fasciotomy was performed in 80% of patients. Overall, 93% of patients survived. However, 41% of patients suffered prolonged neurologic dysfunction. In patients with an initial neurologic deficit, there was a higher rate of permanent neurological deficit in patients treated medically than those treated surgically (12/14 vs 29/61, p=0.0153), but no statistical difference in mortality (0/14 vs 4/61, p=1). In patients without initial neurologic deficit, there were no statistical differences in rates of permanent neurological deficit (0/7 vs 2/20, p=1) or mortality (0/7 vs 3/20, p=0.545) between those receiving medical or surgical treatment.DiscussionGluteal compartment syndrome is an orthopaedic emergency that may be more prevalent and associated with higher morbidity and mortality than previously recognized. Risk factors may include prolonged surgical duration, immobilization secondary to substance abuse, and pelvic trauma. Intraoperative precautions and postoperative surveillance are recommended in obese patients undergoing prolonged procedures. Fasciotomies improve neurologic outcomes in patients presenting with an initial neurologic deficit. In patients who are neurologically intact on presentation, medical management with neurologic function surveillance may be the optimal initial treatment. Fasciotomies do not impact mortality. Additionally, a treatment algorithm is provided.     

术中微泵静脉注射右美托咪定对七氟烷全身麻醉小儿苏醒期躁动的影响

目的评价微泵静脉注射Dex 0.2μg/(kg·h)对七氟烷吸入全身麻醉下腹腔镜腹股沟斜疝手术小儿苏醒期躁动(EA)的影响。方法研究采用双盲、随机、对照方法。美国麻醉医师学会(ASA)Ⅰ级、择期全身麻醉下行腹腔镜腹股沟斜疝手术小儿60名,采用数字表法随机分为Dex组(D组)及生理盐水对照组(C组),每组30例。D组患儿气管插管后微泵静脉注射浓度为2μg/ml Dex 0.2μg/(kg·h),C组患儿微泵静脉注射生理盐水0.1ml/(kg·h)。术中吸入1%~2%七氟烷维持麻醉,保持BIS评分在40~60之间。缝合皮肤时,停用七氟烷及Dex,送至麻醉苏醒室(PACU)。以Wong-Baker疼痛脸谱评估患儿疼痛程度,以小儿苏醒期躁动量表(PAED)评估患儿EA程度,PAED≥10分表示EA。记录、比较两组患儿入室时(T0)、麻醉诱导完成后(T1)、手术开始5min(T2)、10min(T3)、术毕(T4)的平均动脉压(MAP)、心率(HR);患儿苏醒时间,拔管时间、PACU留置时间;苏醒期明显疼痛(Wong-Baker疼痛评分≥6)患儿人数、比例及曲马多用量;EA发生人(次)数、比例及丙泊酚用量;PACU期间患儿呼吸抑制、恶心、呕吐等不良反应发生情况。结果 T2、T3、T4时间点D组患儿HR明显慢于T0(P<0.05),也明显慢于C组患儿(P<0.05);C组、D组患儿T1时间点MAP均明显低于T0(P<0.05);D组患儿苏醒时间、拔管时间分别为8.9±2.1min、10.5±2.1min,明显长于C组(P<0.05),但PACU留置时间与C组相似(P>0.05);D组、C组患儿EA发生率分别为10%(3例)、53.3%(16例),C组EA发生率明显高于D组(P<0.05);明显疼痛人数两组发生率相似(P>0.05),两组各有1例(3.3%)患儿发生呼吸抑制不良反应,但均为一过性,通过吸氧、托下颌等措施及时纠正。两组患儿PACU期间未发生恶心呕吐。结论气管插管后以0.2μg/(kg·h)静脉注射Dex能有效降低七氟烷吸入全身麻醉腹腔镜下腹股沟斜疝手术小儿EA的发生率。     

Centerpiece钛板内固定在单开门颈椎管扩大成形术中的应用

目的:探讨Centerpiece钛板内固定在单开门颈椎管扩大成形术的临床应用。方法:自2009年1月至2010年12月采用单开门颈椎管扩大成形Centerpiece内固定术治疗颈椎管狭窄症患者25例,男16例,女9例;年龄44～75岁,平均(57.2±6.7)岁。其中多节段脊髓型颈椎病8例,颈椎后纵韧带骨化症12例,发育性颈椎管狭窄症5例。以JOA评分(17分法)及其改善率评价术后神经功能改善情况;术后复查颈椎X线、CT,在术前及术后6个月的颈椎侧位X线片上测量C5节段椎管矢状径,计算椎管扩大率,评价椎管扩大和维持情况及门轴侧骨融合情况。结果:手术时间为(165.5±35.6)min;术中出血量为(325.0±75.1)ml。随访时间6～18个月,平均(7.3±3.8)个月。术前JOA评分为9.3±1.1;术后6个月为14.7±2.1(t=4.12,P<0.05),JOA改善率为(64.5±10.2)%。术后随访X线片及CT示椎管扩大满意,门轴侧均骨性愈合,均未见椎板塌陷和再关门现象,术前C5节段椎管矢状径为(9.0±1.5)mm,术后6个月为(14.3±2.0)mm(t=7.61,P<0.05),椎管扩大率为(67.6±11.8)%。结论:Centerpiece钛板内固定应用在单开门颈椎管扩大成形术中是安全有效的,在抬起椎板获得即刻稳定的同时,可以恢复椎管的完整性。     

足跗外侧皮瓣移植修复虎口瘢痕挛缩

目的 探讨应用足跗外侧皮瓣移植修复虎口瘢痕挛缩的手术疗效.方法 采用游离足跗外侧皮瓣移植修复创伤术后虎口瘢痕挛缩12例.结果 12例均获随访,时间3~8(5.5±0.8)个月.术后虎口饱满,外形满意,皮色正常,无继发挛缩.术后虎口角由术前平均25°±5°提高到平均65°±6°,宽度术前平均15 mm±3.5 mm,术后平均50 mm±6.6 mm.术后3个月开始恢复感觉功能;拇指对掌、内收、外展功能明显改善,可完成日常生活及部分工作.结论 足跗外侧皮瓣移植治疗创伤性虎口瘢痕挛缩临床疗效满意.     

一种新型寰枢椎后路动态固定系统的稳定性研究

目的 　评价新型寰枢椎后路动态固定系统的稳定性。 方法　8具较新鲜的成人枕颈标本（C0~4）,随机分成4组：①完整状态组（A组）、②寰枢椎不稳状态组（B组）、③寰枢椎后路动态固定状态组（C组）和④寰枢椎后路椎弓根螺钉固定状态组（D组）。测量在1.50 Nm的力矩下,寰枢关节前屈/后伸,左/右侧弯和左/右旋转等6种运动方式下的运动范围（ROM）及稳定性指数（Sf值）,进行统计学分析。 结果　C组与A组的各方向ROM比较,差异无统计学意义（P>0.05）;而C组与D组的各方向ROM比较,差异有统计学意义（P<0.001）。C组与B组和D组的屈伸、侧屈和旋转的稳定性指数（Sf值）比较,差异有统计学意义（P<0.05）;C组的屈伸、侧屈和旋转的Sf值最接近完整状态组（A组）,差异无统计学意义（P>0.05）。 结论　寰枢椎后路动态固定在重建寰枢关节稳定性上有独特优势,既可维持寰枢椎的活动性,又可达到坚强固定的稳定性,为寰枢椎后路固定提供一种新的选择。