祛瘀接骨饮联合长骨接骨散治疗肱骨骨折的疗效观察

目的:探讨自拟中药方剂内服祛瘀接骨饮联合外敷长骨接骨散在骨折治疗中的疗效观察。方法:肱骨干闭合性骨折病例272例,随机分为2组,对照组136例,采用传统西医治疗方法复位后,夹板固定或肩肱石膏固定;治疗组136例,在上述方法治疗的基础上加服祛瘀接骨饮,并局部外敷长骨接骨散,对2组患者在止痛,消肿,骨痂形成的情况进行比较。结果:治疗组内服祛瘀接骨饮,联合外敷长骨接骨散的患者,全部在6周内愈合,较单纯采用西医治疗的对照组患者,缩短了骨折愈合时间,大大提高治愈率。治疗组总有效率明显优于对照组,治疗组骨痂形成,X线评分明显优于对照组,且差异具有统计学意义(P0.05)。结论:加服祛瘀接骨饮联合局部外敷长骨接骨散的患者,较单一西医方法复位后外固定,无药物干预的治疗方法,治疗肱骨干闭合性骨折,在止痛、消肿、骨痂形成及减少并发症等方面,具有确切疗效。     

Subsidence after single-level anterior cervical fusion with a stand-alone cage

To investigate the risk factors for subsidence in patients treated with stand-alone anterior cervical discectomy and fusion (ACDF) using polyetheretherketone (PEEK) cages for single-level degenerative cervical disease. Seventy-seven consecutive patients who underwent single-level stand-alone ACDF with a PEEK cage between 2005 and 2012 were included. Subsidence was defined as a decrease in the interbody height of more than 3 mm on radiographs at the 1-year follow-up compared with that in the immediate post-operative image. Patients were divided into the subsidence and non-subsidence groups. The following factors were investigated in relation to the occurrence of subsidence: age, pre-operative overall cervical sagittal angle, segmental angle of the operated level, interbody height, cage height, cage devices and cage location (distance between anterior margin of the body endplate and that of the cage). The clinical outcomes were assessed with visual analog scale, modified Japanese Orthopedic Association score and neck disability index. Twenty-six out of the 77 (33.8%) patients had radiological signs of cage subsidence. Solid fusion was achieved in 25 out of the 26 patients (96.2%) in the subsidence group and in 47 out of the 51 patients (92.2%) in the non-subsidence group. More than 3 mm distance between anterior margin of the vertebral body and that of the cage was significantly associated with subsidence (p < 0.05). However, subsidence did not correlate with fusion rate or clinical outcomes. Cage location was the only significant risk factor. Therefore, cage location should be taken into consideration during stand-alone ACDF using PEEK cages.     

Comparison of allograft and polyetheretherketone (PEEK) cage subsidence rates in anterior cervical discectomy and fusion (ACDF)

Structural allografts and PEEK cages are commonly used interbody fusion devices in ACDF. The subsidence rates of these two spacers have not yet been directly compared. The primary aim of this study was to compare the subsidence rate of allograft and PEEK cage in ACDF. The secondary aim was to determine if the presence of subsidence affects the clinical outcome. We reviewed 67 cases (117 levels) of ACDF with either structural allograft or PEEK cages. There were 85 levels (48 cases) with PEEK and 32 levels (19 cases) with allograft spacers. Anterior and posterior disc heights at each operative level were measured at immediate and 6 months post-op. Subsidence was defined as a decrease in anterior or posterior disc heights >2 mm. NDI of the subsidence (SG) and non-subsidence group (NSG) were recorded. Chi-square test was used to analyze subsidence rates. T-test was used to analyze clinical outcomes (α = 0.05). There was no statistically significant difference between subsidence rates of the PEEK (29%; 25/85) and allograft group (28%; 9/32) (p = 0.69). Overall mean subsidence was 2.3 ± 1.7 mm anteriorly and 2.6 ± 1.2 mm posteriorly. Mean NDI improvement was 11.7 (from 47.1 to 35.4; average follow-up: 12 mos) for the SG and 14.0 (from 45.8 to 31.8; average follow-up: 13 mos) for the NSG (p = 0.74). Subsidence rate does not seem to be affected by the use of either PEEK or allograft as spacers in ACDF. Furthermore, subsidence alone does not seem to be predictive of clinical outcomes of ACDF.     

Stand-alone interbody cage versus anterior cervical plate for treatment of cervical disc herniation: Sequential changes in cage subsidence

Anterior cervical discectomy and fusion with an autogenous iliac bone graft is the gold standard treatment for cervical disc herniation. However, autologous bone grafts obtained from the anterior iliac crest are associated with significant donor-site morbidity and complications. To decrease bone graft-related problems, several types of interbody fusion cage have been developed and are used widely in clinical practice. We compared the clinical and radiological outcomes for two surgical procedures used to treat cervical disc herniation: the stand-alone interbody cage and autologous iliac bone grafting with an anterior plate. The clinical results did not differ between patients treated with the two procedures. The stand-alone cage was less invasive and had less donor-site morbidity. In patients treated with the bone graft and plate, the alignment of the fused segment was maintained in all but one patient, who exhibited nonunion. In contrast, in the cage-treated group, 44% of patients exhibited loss of lordotic alignment of more than 5 degrees and cage subsidence of 3 mm or more. All cage subsidence occurred within 3 months of surgery. Although the stand-alone cage was a less invasive and more effective procedure to treat cervical disc herniation, surgeons should consider the possible drawbacks of the associated subsidence.     

Factors affecting sagittal malalignment due to cage subsidence in standalone cage assisted anterior cervical fusion

Fusion of cervical spine in kyphotic alignment has been proven to produce an acceleration of degenerative changes at adjacent levels. Stand-alone cages are reported to have a relatively high incidence of implant subsidence with secondary kyphotic deformity. This malalignment may theoretically lead to adjacent segment disease in the long term. The prospective study analysed possible risk factors leading to cage subsidence with resulting sagittal malalignment of cervical spine. Radiographic data of 100 consecutive patients with compressive radiculo-/myelopathy due to degenerative disc prolapse or osteophyte formation were prospectively collected in those who were treated by anterior cervical discectomy and implantation of single type interbody fusion cage. One hundred and forty four implants were inserted altogether at one or two levels as stand-alone cervical spacers without any bone graft or graft substitute. All patients underwent standard anterior cervical discectomy and the interbody implants were placed under fluoroscopy guidance. Plain radiographs were obtained on postoperative days one and three to verify position of the implant. Clinical and radiographic follow-up data were obtained at 6 weeks, 3 and 6 months and than annually in outpatient clinic. Radiographs were evaluated with respect to existing subsidence of implants. Subsidence was defined as more than 2 mm reduction in segmental height due to implant migration into the adjacent end-plates. Groups of subsided and non-subsided implants were statistically compared with respect to spacer distance to the anterior rim of vertebral body, spacer versus end-plate surface ratio, amount of bone removed from adjacent vertebral bodies during decompression and pre- versus immediate postoperative intervertebral space height ratio. There were 18 (18%) patients with 19 (13.2%) subsided cages in total. No patients experienced any symptoms. At 2 years, there was no radiographic evidence of accelerated adjacent segment degeneration. All cases of subsidence occurred at the anterior portion of the implant: 17 cases into the inferior vertebra, 1 into the superior and 1 into both vertebral bodies. In most cases, the process of implant settling started during the perioperative period and its progression did not exceed three postoperative months. There was an 8.7° average loss of segmental lordosis (measured by Cobb angle). Average distance of subsided intervertebral implants from anterior vertebral rim was found to be 2.59 mm, while that of non-subsided was only 0.82 mm (P < 0.001). Spacer versus end-plate surface ratio was significantly smaller in subsided implants (P < 0.001). Ratio of pre- and immediate postoperative height of the intervertebral space did not show significant difference between the two groups (i.e. subsided cages were not in overdistracted segments). Similarly, comparison of pre- and postoperative amount of bone mass in both adjacent vertebral bodies did not show a significant difference. Appropriate implant selection and placement appear to be the key factors influencing cage subsidence and secondary kyphotisation of box-shaped, stand-alone cages in anterior cervical discectomy and fusion. Mechanical support of the implant by cortical bone of the anterior osteophyte and maximal cage to end-plate surface ratio seem to be crucial in the prevention of postoperative loss of lordosis. Our results were not able to reflect the importance of end-plate integrity maintenance; the authors would, however, caution against mechanical end-plate damage. Intraoperative overdistraction was not shown to be a significant risk factor in this study. The significance of implant subsidence in acceleration of degenerative changes in adjacent segments remains to be evaluated during a longer follow-up.     

广州粮食仓库空气中螨的沉降量与螨种调查

选择有肺部螨感染人群的粮食仓库为试点，采用平皿沉降法逐月观察工作场所空气中螨的数量及其季节消长．结果表明，该观察点空气中螨的年平均沉降量为12．2个／皿／h；在当年4－6月和10－12月为密度高峰期，1－3月和7－9月为低密度时间．已鉴定出螨类12种，其中9种与从人体痰液中检获到的螨种相同．调查结果为防治提供了实验依据．     

Anterior placement of the talar component in total ankle arthroplasty: A risk factor for talar component subsidence

BackgroundComponent subsidence is considered as a cause of revision surgery. The talar component subsidence may be a risk factor for revision surgery; however, there are no reports regarding talar component placement and subsidence amount following total ankle arthroplasty (TAA). We therefore investigated the relationship between talar component placement and subsidence amount.MethodsFifty-two ankles from 49 patients (age: 71 years [range 62–83], 13 male/ 36 female), who underwent TAA with mean follow-up of 36 months (range 12–83), were included. The subjects were divided into two groups based on talar component placement: anterior placement (n = 20, group A) and posterior placement (n = 32, group P) using weight-bearing lateral plain radiographs. The amount of the talar component subsidence and clinical outcomes, which included the Japanese Society for Surgery of the Foot (JSSF) scale, range of the motion (ROM) and the revision rate, were compared between the groups.ResultsTalar component subsidence was significantly higher in group A (2.1 ± 2.0 mm) than in group P (0.6 ± 1.4 mm, P = .017). There was no significant difference in the JSSF scale and ROM between group A and group P. The revision rate was 10.0% in group A and 6.3% in group P, albeit not statistically significant.ConclusionGreater talar component subsidence was observed when the talar component was placed more anteriorly, suggesting that anterior placement of the talar component may need to be avoided during the surgery in order to minimize the postoperative talar component subsidence.     

两种手术方法在两节段颈椎退行性疾病的疗效比较

目的对比研究颈椎前路椎间盘切除植骨（ACDF）单纯cage内固定术与ACDF锁定钢板内固定术对两节段颈椎退行性疾病的疗效。方法回顾性研究42例采用了ACDF的两节段颈椎退变患者,其中22例采用了单纯cage内固定,20例采用锁定钢板内固定术,比较两组的影像及临床结果。随访时间为2年。结果大部分患者的颈后疼痛以及前臂疼痛症状均较术前有所改善。两组的融合率、沉降率、后凸成角、邻近节段退变方面无明显统计学差异。ACDF锁定钢板内固定组出现1例钢板松动,在ACDF锁定钢板内固定组出现2例吞咽困难。两组均未见cage的前移、脱位以及假关节的形成。结论在两节段的ACDF时,单纯cage内固定与锁定钢板内固定在影像与临床结果方面无明显统计学差异。我们认为在两节段的ACDF时常规采用锁定钢板螺钉是不可取的。     

Anatomy-related risk factors in Harm's mesh subsidence in cervical reconstruction after one-level corpectomy

Objective： To clarify anatomy-related factors in the cervical spine with subsidence of titanium mesh cage （TMC） after one-level cervical corpectomy and fusion. The effect of the cervical posture, segmental curvature and endplate gradient on this postoperative phenomenon was evaluated. Methods： Between August 2003 and March 2006, a total of the 236 patients underwent one-level corpectomy and TMC fusion. Their radiological examinations were reviewed and clinical outcomes evaluated. Results： In the patients who were followed up for 12 months, TMC subsidence occurred in 54 （28.6%） cases. C6 corpectomy had a significant higher risk （26/60, 43.3%） for TMC subsidence, which was correlated with the variation of the gradient of the vertebral endplates against cervical levels. Although the clinical outcome was comparable with those in the literature, the patients may have subsidence-related problems such as neck-shoulder pain, neurological deterioration and instrumental failure. Conclusion： To decrease the incidence of subsidence, TMC design should be optimized to be in line with anatomic characteristics of the cervical spine.     

椎体CT值在预测颈椎前路融合术后早期内置物沉降中的应用价值

【摘要】 目的：研究颈椎椎体CT值在预测颈椎前路融合术后早期内置物沉降中的应用价值。方法：回顾性分析2017年1月~2018年6月北京大学第三医院颈椎专业组收治的306例行颈椎前路融合手术的颈椎退行性疾病患者的临床资料。在影像归档和通信系统（picture archiving and communication system,PACS）上测量C2~C7椎体中横断面的CT值,通过双能X线吸收法（dual-energy X-ray absorptiometry,DXA）获得L1~L4总的骨密度T值。在术后第2天、术后3个月颈椎中立侧位X线片上分别测量颈椎前路融合节段前、后缘高度和融合节段Cobb角。定义术后3个月较术后2d融合节段前、后缘高度丢失的平均值≥2mm为内置物发生沉降。采用Spearman秩相关检验腰椎骨密度T值与C2~C7椎体CT均值的相关性,采用Spearman秩相关检验C2~C7椎体CT均值、腰椎骨密度T值分别与融合节段高度丢失数值、融合节段Cobb角改变的相关性。采用Logistic回归模型,分别检验C2~C7椎体CT均值、腰椎骨密度T值与沉降的关联。以沉降为标准,采用受试者工作特征（ROC）曲线确定C2~C7椎体CT均值的临界值。结果：术后3个月明确发生沉降122例,未发生沉降184例,沉降发生率为39.9%。C2~C7椎体CT均值与腰椎骨密度T值呈显著正相关（r=0.518,P＜0.001）,与融合节段Cobb角改变有显著相关性（r=-0.170,P=0.003）,呈负相关。但腰椎骨密度T值与融合节段Cobb角改变无显著相关性（P=0.605）。融合节段高度丢失值与C2~C7椎体CT均值无显著相关性（P=0.056）,与腰椎骨密度T值无显著相关性（P=0.274）。采用Logistic回归模型,控制性别、术式和节段的影响后,内置物沉降与C2~C7椎体CT均值有显著相关性（P=0.035）, CT值每升高1HU,沉降风险降低0.4%（OR=0.996,95%CI：0.992~1.000）;控制性别、术式和节段的影响后,内置物沉降与腰椎骨密度T值的无显著相关性（P=0.098）。以沉降为标准,采用ROC曲线分析,曲线下面积为0.562,ROC曲线上最佳C2~C7椎体CT均值为273HU。结论：预测颈椎前路融合术后早期内置物沉降时颈椎椎体CT值要优于腰椎骨密度T值,术前较高的颈椎椎体CT值患者术后发生内置物沉降的风险较低。