血糖控制情况对糖尿病周围神经病变(DPN)患者下肢神经减压术疗效的影响

目的 探讨糖尿病周围神经病变(diabetic peripheral neuropathy,DPN)患者的血糖控制情况对周围神经减压手术疗效的影响。方法 2014年12月至2016年6月在复旦大学附属中山医院接受单侧下肢神经减压术的DPN患者共计40例,以HbA1c=8%为标准分为血糖控制尚可组和血糖控制不佳组。在术前1天和术后6个月,测量视觉模拟评分(visual analogue scale,VAS)、两点辨别觉(two point discrimination,TPD)和10 g单丝测验,比较两组患者的手术疗效。结果 所有患者术后VAS、TPD和10 g单丝测验结果均较术前均明显改善。血糖控制尚可的患者术后VAS、TPD和10 g单丝测验结果均优于血糖控制不佳的患者。结论 良好的血糖控制对DPN患者下肢神经减压术后疼痛的缓解和肢体感觉的恢复具有积极作用,血糖控制尚可的患者手术疗效明显优于血糖控制不佳的患者。     

眼减压性视网膜病变研究进展

眼减压性视网膜病变(ocular decompression retinopathy,ODR)是一种由眼压降低引起的眼底多灶性出血性视网膜病变,且无法用其他机制解释。临床上多见于青光眼术后,也可发生在造成眼压下降的其他眼科手术。多数患者无明显症状,容易漏诊。本文综述了国内外ODR的研究进展,从危险因素、发病机制、临床表现、影像表现、鉴别诊断以及治疗与预防来论述。     

改良外伤骨瓣开颅减压术在高血压脑出血术后二次开颅中的应用

目的探讨改良的骨瓣开颅减压手术在高血压脑出血后二次开颅的应用效果。方法回顾性分析2007年2月至2010年10月36例将改良外伤骨瓣开颅减压术用于高血压脑出血后二次开颅手术的患者的临床资料,总结患者手术的原因,临床手术方法,并分析手术的有效性。结果 36例患者采用此手术方法,有6例患者术后恢复良好,12例患者术后为中度残疾,9例患者严重残疾,5例患者呈植物状态,4例患者死亡。患者主要的手术原因为术后再出血。结论改良外伤骨瓣开颅减压术在高血压脑出血术后二次开颅中的临床价值较高,能够有效提高患者的抢救成功率,值得在临床推广使用。     

半球骨瓣减压结合控制性减压治疗特重型颅脑损伤

目的：探讨半球骨瓣减压结合控制性减压治疗特重型颅脑损伤的临床疗效。方法采用去半球大骨瓣彻底减压技术，结合硬脑膜网状切开和有限渐次减压法等控制性减压，对60例特重型颅脑损伤患者进行手术治疗，术后6个月进行GOS评分评价，3～4分为良好，2分为中度残废，1分为重度残废。结果死亡25例（病死率为41．7％），存活35例，其中恢复良好10例，中度残废1例，重度残废14例。结论去半球骨瓣伴控制性减压技术具有显露好、减压充分等优点，可有效降低手术病死率。     

Acute Neurologic Changes in an Otherwise Healthy Young Adult

A healthy young man presents to a community clinic after returning home from spending 4 days at a beach resort. He reports symptoms of a headache, dizziness, fatigue, mild nausea and a hard time not falling when walking. Oddly he also has a vague dull ache in his right knee with intermittent spikes of shooting pain in both legs. Rapid onset of neurological symptoms in an otherwise healthy young man requires a thorough history and prompt intervention.     

主动脉瓣置换术后患者腹胀原因分析及不同减压方法的疗效比较

目的：分析主动脉瓣置换术后患者出现腹胀的原因，比较不同减压方法在主动脉瓣置换术后中重度腹胀患者中的疗效。方法：①选取2015年01月至2017年01月期间在我科行主动脉瓣置换术的患者，多因素Logistic regression分析腹胀的危险因素。②上述研究对象中术后出现中重度腹胀并需要胃肠减压的患者，随机分为2组，分别选用不同的减压方法：A组经鼻置入小肠减压管，B组经鼻置入普通胃管。比较2组患者腹胀缓解有效率以及缓解时间。结果：①498例主动脉瓣置换术后患者出现腹胀132例，发生率为26.5%。多因素Logistic regression分析显示术后持续镇静/肌松时间≥72h是腹胀的独立危险因素。② A组52例患者腹胀缓解41例，缓解有效率为78.8%，缓解时间为46.9±18.6h；B组51例患者腹胀缓解30例，缓解有效率为58.8%，缓解时间为55.2±21.4h。A组腹胀缓解有效率明显高于B组，且缓解时间明显短于B组，差异有统计学意义。结论：主动脉瓣置换术后患者持续镇静/肌松时间≥72h是腹胀的独立危险因素。小肠减压管在胃肠减压方面较普通胃管疗效更为显著，心脏术后患者出现腹胀需要胃肠减压时，可优先考虑使用。     

Indirect decompression in spinal surgery

Indirect decompression in spinal surgery means decompression of spinal nerve tissues, such as spinal cord and nerve, without resecting the compressing tissue. Indirect spinal decompression procedures largely can be divided into segmental procedures and global spinal alignment procedures. Segmental procedures are mainly performed by the distraction between two vertebrae, which lead to the opening of the neural foramen and increases the epidural space. Such distraction can be performed through the disc space or using posterior instrumentation. Global spinal alignment procedures allow the spinal cord to migrate dorsally away from areas of anterior compression. Understanding the indirect spinal decompression procedures may broaden the options for surgical treatment and decrease the risk of spinal nerve tissue injury.     

A Double‐blind,Randomized, Prospective Study of Epidural Steroid Injection vs. The mild® Procedure in Patients with Symptomatic Lumbar Spinal Stenosis

Background: Epidural steroid injections (ESIs) are commonly used to treat low back pain, including symptomatic lumbar spinal stenosis (LSS). Reports on LSS treatment with ESIs have not differentiated between neurogenic claudication, which is believed to result from nerve root compression, and lumbar radicular pain, thought to be caused by inflammation. While there is overlap between these groups, the clinical relevance of ESI treatment cannot be generalized between these 2 distinct diseases with completely different pathophysiological causes. Methods: This was a double‐blind, randomized, prospective study of ESI vs. the mild procedure in patients with symptomatic LSS, conducted at a single pain management center. Patient reported outcome measures included Visual Analog Scale, Oswestry Disability Index, and Zurich Claudication Questionnaire (ZCQ) patient satisfaction. Results: Thirty‐eight patients were randomized into 2 treatment groups, 21 in mild and 17 in ESI. At 6‐ and 12‐week follow‐up, patients treated with mild reported significantly greater pain decrease over time (P < 0.0001), and significantly greater functional mobility improvement over time (P < 0.0018) than ESI patients. At week 6, mild ZCQ patient satisfaction score of 2.2 indicated a higher level of satisfaction than for ESI with a score of 2.8. In addition, 12‐week ZCQ satisfaction score was 1.8, demonstrating sustained near‐term satisfaction in the mild group. No major mild or ESI device or procedure‐related complications were reported. Conclusions: This study demonstrated that in LSS patients suffering with neurogenic claudication, mild provides statistically significantly better pain reduction and improved functional mobility vs. treatment with ESI.     

Decompression of the anterior thoracic spinal canal using a novel full‐endoscopic uniportal transthoracic retropleural technique—an anatomical feasibility study in human cadavers

Surgery for thoracic disc herniation and spinal stenosis is comparatively rare and often demanding. The goal is to achieve sufficient decompression without manipulating the spinal cord. Individual planning and various surgical techniques and approaches are required. This anatomical study examines the feasibility of a novel full‐endoscopic uniportal technique with a transthoracic retropleural approach for decompression of the anterior thoracic spinal canal. Operations were performed on three fresh adult cadavers. The endoscope used, from RIWOspine, Germany, has a shaft cross‐section of 6.9 × 5.9 mm and a 25° view angle. It contains an eccentric intraendoscopic working channel with a diameter of 4.1 mm. A transthoracic retropleural approach was used. The anatomical structures were dissected and the anterior thoracic epidural space was decompressed. The planned steps of the operation were performed on all cadavers. The transthoracic retropleural approach allowed the target region to be accessed easily. The anatomical structures could be identified and dissected. The anterior thoracic epidural space could be decompressed sufficiently. Using the uniportal full‐endoscopic operation technique with a transthoracic retropleural approach, the anterior thoracic epidural space can be adequately reached. This is a minimally invasive method with the known advantages of an endoscopic technique under continuous irrigation. The retropleural approach allows direct access. The instruments are available for clinical use and have been established for years in other operations on the entire spine. Clin. Anat. 31:716–723, 2018. © 2018 Wiley Periodicals, Inc.     

小脑扁桃体下疝合并脊髓空洞症治疗分析

目的 探讨小脑扁桃体下疝合并脊髓空洞症的治疗.方法 回顾性分析1995年8月至2010年8月经治的29例小脑扁桃体下疝合并脊髓空洞症患者,均采用手术干预治疗,单纯行枕大孔减压术16例,行枕大孔减压加空洞-蛛网膜下腔分流术13例.术后随访6个月～3年观察治疗效果.结果 随访6个月～3年,单纯行后颅窝减压组中显效8例,有效6例,无效2例,恶化0例,总有效率为87.5％;后颅窝减压空洞-蛛网膜下腔分流组中显效6例,有效4例,无效2例,恶化1例,总有效率为76.9％,2组总有效率比较差异无统计学意义（P＞0.05）.结论 手术是小脑扁桃体下疝合并脊髓空洞症的首选治疗,因下疝和空洞致脊髓受损轻者减压术后恢复较好,而脊髓受损明显者则手术效果差.