殆垫及关节灌洗术治疗颞下颌关节盘不可复性前移位的临床分析

目的：对不可复性关节盘前移位的不同治疗方法进行临床分析和总结,进一步探索合理的治疗不可复性关节盘前移位的方法。方法：将48例不可复性关节盘前移位的关节病患者分成3组,即[牙合]垫治疗组、关节灌洗组、关节灌洗术联合[牙合]垫治疗组。将3种治疗方法对不可复性关节盘前移位治疗前后的疼痛指数、最大开口度进行统计分析,比较3种治疗方法的临床疗效。结果：疼痛指数：3组患者治疗前后疼痛指数的改变值,[牙合]垫治疗组〈关节灌洗组〈关节灌洗术联合[牙合]垫治疗组（P〈0.05）,关节灌洗组与关节灌洗术联合[牙合]垫治疗组治疗前后开口度的改善度,差异无显著性,但均优于[牙合]垫治疗组（P〈0.05）。结论：对不可复性关节盘前移位的治疗,关节灌洗术联合[牙合]垫治疗的临床疗效优于[牙合]垫治疗或关节灌洗术,同时,关节灌洗术的临床疗效显效方面优于[牙合]垫。     

可复性关节盘前移位患者的关节音特征

目的 比较青年人可复性关节盘前移位者和无颞下颌关节症状者的颞下颌关节音,探讨其关节音频谱图的特征和临床诊断价值.方法 运用BioJVA颞下颌关节振动分析仪记录21例可复性关节盘前移位患者与26例正常青年人节律性大开闭口运动中双侧颞下颌关节音;以临床诊断为标准,计算关节振动总能量,诊断可复性关节盘移位的灵敏度和特异性....     

Soluble tumour necrosis factor receptors in synovial fluids from temporomandibular joints with painful anterior disc displacement without reduction and osteoarthritis

The objective of this study was to detect soluble-form tumour necrosis factor receptors (sTNFRs) in temporomandibular joint (TMJ) synovial fluid aspirates, and to compare the sTNFR concentrations between painful anterior disc displacement without reduction and osteoarthritis (ADDwoR/OA) and asymptomatic TMJs.Synovial fluid was sampled from the superior TMJ cavity of 11 painful ADDwoR/OA cases (mean age: 36.9 years) and 10 asymptomatic females (mean age: 24.7 years) by diluted aspiration. The concentrations of sTNFR-I and -II in the synovial fluid were measured using human sTNFR-I and -II enzyme-linked immunosorbent assays. The total protein concentrations in synovial fluids were measured using a bicinchoninic acid protein assay kit. All data were normalised to the total protein concentration of each sample.Two-way factorial analysis of variance and post hoc multiple comparison revealed that: (1). mean normalised sTNFR-I and -II concentrations were higher in TMJ synovial aspirates from ADDwoR/OA patients than from healthy controls; (2). in the ADDwoR/OA patients and the healthy controls, the sTNFR-I concentration in TMJ synovial aspirates was higher than the sTNFR-II concentration; and (3). high TMJ synovial aspirate sTNFR-II seemed to be associated with less TMJ pain and a less restricted range of mouth opening in the ADDwoR/OA patients.The concentrations of sTNFRs in TMJ synovial fluid are higher in the presence of painful ADDwoR/OA, which could modulate intracapsular inflammation.     

混合现实技术引导的经皮内窥镜下腰椎椎间盘切除术的初步探索与应用

经皮内窥镜下腰椎椎间盘切除术（PELD）已经成为治疗腰椎椎间盘突出症（LDH）的首选方法^［1-3］。腰椎椎间盘突出类型多样化,术前须精确定位突出椎间盘的“靶点”位置,确定进针点、深度和角度等相关参数,以便术中可按照术前设计快速准确地穿刺和置入工作通道,这是靶向穿刺技术的核心,也是尽可能减少不必要创伤并发症的基础^［4］。常规手术通道的建立,需要根据椎间盘突出的不同病理类型并结合临床实践确定,且术中需要C形臂X线机透视辅助,存在学习曲线陡峭、辐射量大、手术风险高等问题^［5-6］。混合现实（MR）技术是近年发展起来的一门新兴技术,其将虚拟现实（VR）技术与增强现实（AR）技术相结合,操作者可从MR技术呈现的全息影像中获取相关信息,从而实现虚拟和真实的交互^［7-8］。目前,MR技术在复杂的脑外科手术、髋关节手术中已有应用,并获得良好的临床疗效^［9-11］,但尚无其应用于PELD的报道。本研究组在MR技术引导下,对1例LDH患者行PELD,取得了良好的临床疗效,现报告如下。     

经椎间孔入路经皮内窥镜下椎间盘切除术中应用可视化骨凿切除部分椎弓根上缘治疗极高度游离型腰椎椎间盘突出症

目的 评估经椎间孔入路经皮内窥镜下椎间盘切除术（PETD）中应用可视化骨凿切除部分椎弓根上缘治疗极高度游离型腰椎椎间盘突出症（LDH）的疗效。方法 2017年1月—2018年6月,采用PETD治疗极高度游离型LDH患者16例,术中应用可视化骨凿直视下切除部分椎弓根上缘以增加套管工作距离。采用疼痛视觉模拟量表（VAS）评分、Oswestry功能障碍指数（ODI）及改良MacNab标准评估手术疗效。术后复查MRI,以明确是否存在髓核残留,通过动力位X线片观察是否发生节段性不稳。结果 所有手术顺利完成,手术时间（54.2±10.7）min,术后所有患者随访（13.5±4.6）个月。术后1 d腰痛VAS评分、下肢痛VAS评分及ODI均较术前明显改善,且术后3个月较术后1 d改善更为明显,差异均有统计学意义（P < 0.05）。改良MacNab标准评定的术后1年疗效：优9例,良5例,可2例。所有患者术后无髓核残留、节段性不稳发生。结论 PETD术中应用可视化骨凿切除部分椎弓根上缘治疗极高度游离型LDH安全、有效,且髓核摘除彻底,功能恢复满意。     

对Garden指数作为股骨颈骨折复位质量评价标准的再认识

目的探讨Garden指数能否判断股骨颈骨折的旋转移位。方法取5具10侧健康股骨近端尸体标本,男3具,女2具;死亡年龄为45~70岁。于股骨头中心置入1枚直径为2.0 mm的克氏针,垂直于股骨颈中部截骨,在截骨处远端骨面标明旋转角度。在每侧标本上依次进行旋前及旋后0°、10°、20°、30°、40°、50°、70°、90°操作,并摄标本正、侧位X线片,利用影像归档和通信系统测量Garden指数,比较不同旋转角度下的正位、侧位Garden指数。同时观察在不同旋转角度下股骨头小凹面积的变化规律。结果从0°至旋前30°或旋后30°的过程中,正位、侧位Garden指数无明显变化,差异均无统计学意义(P>0.05),且数值均>155°。从旋前40°至旋前90°的过程中,正位Garden指数分别为152.36°±1.41°、146.04°±1.64°、143.95°±0.60°、141.73°±0.60°,侧位Garden指数分别为172.54°±0.86°、168.57°±0.98°、157.18°±1.17°、156.47°±1.63°,不同旋转角度之间比较差异均有统计学意义(P<0.05)。从旋后40°至旋后90°的过程中,正位Garden指数分别为151.67°±1.06°、147.32°±1.82°、142.77°±0.75°、139.88°±1.48°,侧位Garden指数分别为172.28°±0.79°、166.76°±1.02°、155.67°±1.74°、154.16°±1.27°,不同旋转角度之间比较差异均有统计学意义(P<0.05)。随着旋前角度的增大,股骨头小凹面积逐渐减少;随着旋后角度的增大,股骨头小凹面积逐渐增大。结论在0°~30°的旋前或旋后范围内,Garden指数无法准确判断股骨颈骨折复位时的旋转移位。股骨头小凹面积的变化可以辅助判断股骨颈骨折的旋转移位。     

Ruptured disc after arthroscopic repositioning in the temporomandibular joint: a retrospective magnetic resonance imaging study

Our aim was to explore the incidence of rupture after arthroscopic repositioning of the disc of the temporomandibular joint (TMJ) by reviewing magnetic resonance images (MRI) of the TMJ taken before and after operation, and to investigate correlations retrospectively. We studied 247 patients with anterior disc displacement of the TMJ, and categorised them into 3 groups based on the postoperative MRI. The first group comprised those whose disc ruptured after repositioning, the second those who had a possible rupture of the disc after repositioning, and the third had no rupture of the disc after repositioning. Age, sex, duration of symptoms, maximum incisal mouth opening, whether the anterior disc displacement was unilateral or bilateral, and the Wilkes stage, were included in the analysis. The incidence of rupture (5/247) was 2%. Weak points at the intermediate zone of the disc were found in 4 of the 5 joints. The patients whose discs ruptured were significantly younger than the other 2 groups (p = 0.001). There was no statistically significant difference in preoperative duration of symptoms and mouth opening among the groups. The proportions of unilateral and bilateral disc displacement (p = 0.047) and Wilkes stage (p = 0.027) differed among the 3 groups. The Wilkes stages was significantly more advanced in the ruptured group than in the other 2 groups (p = 0.027) with 4/5 being bilateral. The weak point in the intermediate zone of the disc on MRI could be a sign of rupture. Teenagers and young adults with anterior disc displacement without reduction, particularly those in whom it is bilateral, are at a higher risk of a rupture after repositioning of the disc by arthroscopy.     

Could different TMJ disc positions observed in MRI cause different sounds? Analysis on a group of subjects with ADD with reduction: a pilot study

Aims:

Magnetic resonance imaging (MRI) is the method of choice for examining soft-tissue pathology of the temporomandibular joint (TMJ). MRI shows a high spatial resolution with accuracy for the identification of internal derangement. Tasaki developed a classification system for disc displacement in the TMJ, identifying eight different types of disc displacements in addition to the superior disc position. This study aims to test the ability of electrosonography (ESG) in discriminating different kinds of disc displacement according to the disc position criteria proposed, comparing the ESG results with those obtained by MRI.

Methodology:

Twenty-seven patients were selected from an initial group of 50 patients with articular disc displacement, selected by means of clinical examinations, according to the Research Diagnostic Criteria for Temporomandibular Disorders (RDC/TMD) and who had both MRI and ESG studies performed. For each patient and for each peak in ESG, both in the opening and closing movements, three different parts of the sound were analyzed. The frequency (Hz) and the mean amplitude (μV) of the sounds were calculated in the three analyzed windows. Afterwards, gathering the data for the Tasaki’s classes and dividing opening and closing sounds, the number of peaks was calculated, as well as average and standard deviations for both the Hz and µV.

Results:

The peak frequency shows significant differences between different disc positions during the first and second third of the opening phase and during the first third of the closing phase. The peak amplitude shows significant differences between different disc positions during all of the opening and closing phases.

Conclusions:

Although limited by sample size, the present study shows the presence of different sounds with different Hzs and μVs associated with different disc positions that were recorded with ESG.     

改良腰椎板截骨回植治疗失稳性腰椎间盘突出症

目的：评价改良腰椎板截骨回植在失稳性腰椎间盘突出症中的疗效。方法：2009年3月至2011年8月对63例失稳性腰椎间盘突出症的患者行髓核摘除＋椎间融合＋椎弓根螺钉内固定＋改良腰椎板截骨回植手术,男33例,女30例;年龄22～68岁,平均48．4岁;病程3个月～13年,平均38．8个月。患者均有不同程度的腰腿疼痛,x线片、CT及MR检查诊断为失稳性腰椎间盘突出症。观测手术前后ODI和JOA评分、并发症发生率、影像学回植椎板愈合率及腰腿痛复发率。结果：62例患者切口I期愈合,1例11期愈合,无下肢深静脉血栓及椎间隙感染等并发症出现。61倒获1年或以上随访,平均随访时间33个月。术中神经损伤发生2例,硬膜囊损伤发生1例;术后1年回植椎板愈合58例：腰痛复发4例,腿痛复发1例。术后2周、6、12个月的ODI及JOA评分显著优于术前（P〈0．05）。结论：改良椎板截骨回植术治疗失稳性腰椎间盘突出症具有较低的术中神经硬膜囊损伤率和腰腿痛复发率、较高的椎板愈合率和较好的临床评分,是一种安全、有效的新方法,为临床失稳性腰椎间盘突出症手术开辟了一种新的术式。