Minimally invasive transmuscular approach for the treatment of lumbar far lateral disc herniation

Background

The purpose of this study was to evaluate a minimally invasive surgical technique for the treatment of lumbar far lateral disc herniation. This technique combines the tubular retractor with the operative microscope.

Objective and methods

This retrospective study analyzed the files of 26 patients: 15 men and 11 women. The average age was 56 years (range, 19-83 years). The most commonly operated level was L3-L4 (46%), then L4-L5 (30.5%) and finally L2-L3 (15.5%). All patients were operated under general anesthesia. The intraoperative radioscopic location was absolutely necessary. A 12-15 mm paramedian incision was made on the side of the herniation (30 mm from the medial line). We then inserted the tubular muscular retraction system followed by the 14 mm diameter working channel. Guided by operating microscope, the articular isthmus was reamed to expose the root and the disc. The disc herniation was then removed after opening and removing the inter-transverse ligament.

Results

The average duration of the surgery was 55 min. This operating time decreased as the surgeons gained experience. The radicular pain, estimated using the analogical visual scale, varied from seven before surgery to two during the postoperative period. All the patients were standing up the day after surgery. The average duration of the postoperative stay in the hospital was three days (range, 1-5 days). We noted no complications from the surgical procedure.The average duration of the follow-up was two years (range, 6-36 months).

Conclusion

This technique combines the advantages of endoscopic surgery (less muscular and osseous damage) and microscope-guided surgery (three-dimensional vision) and provided good functional results in this series.     

经腓骨入路显露后踝治疗三踝骨折

自2003年9月至2006年9月共治三踝骨折53例,均采用手术治疗,取得了满意疗效,现总结报告如下。     

经皮椎体后凸成形术中单双侧经椎弓根穿刺路径的选择

[目的]探讨骨质疏松性椎体骨折经皮后凸成形术中单双侧经椎弓根入路的选择.[方法]36例骨质疏松性椎体压缩性骨折患者,术前根据伤椎椎弓根CT层面经椎弓根进针线确定单、双侧入路,采用球囊或Sky扩张器行椎体后凸成形术.术前、术后1周及1年时摄x线片测量椎体高度恢复率、后凸Cobb's角及疼痛视觉类比评分(VAS).[结果]36例50节骨质疏松性椎体压缩性骨折中,44节椎体行经皮椎体后凸成形术.术前计划单侧经椎弓根入路32节椎体,双侧经椎弓根入路12节椎体;术中单侧入路22节椎体,双侧入路22节椎体,其中10节椎体由单侧入路改为双侧入路.术后1周及1年时VAS评分、椎体后凸Cobb's角及椎体高度恢复率较术前均改善(P<0.05).但单侧组与双侧组比较,上述参数无显著性差异(P>0.05).[结论]根据术前伤椎CT椎弓根进针线可以初步确定单、双侧椎弓根穿刺路径.腰椎及大部分胸椎可以采用单侧经椎弓根入路行经皮椎体后凸成形术,部分下胸椎骨质疏松性骨折患者需行双侧经椎弓根入路.     

骨质疏松性椎体骨折经皮后凸成形术中伤椎和手术入路的选择

目的 探讨骨质疏松性椎体骨折经皮后凸成形术中伤椎定位和手术入路选择.方法 36例骨质疏松性椎体压缩性骨折患者,术前根据CT及MRI确定伤椎,根据伤椎椎弓根CT层面经椎弓根进针线确定单、双侧入路,采用球囊或Sky扩张器行椎体后凸成形术.术前、术后1周及随访时摄X线片测量椎体高度恢复率、后凸Cobb角及疼痛视觉类比评分(VAS).结果 36例50节骨质疏松性椎体压缩性骨折中,44节椎体行经皮椎体后凸成形术.术前计划单侧经椎弓根入路32节椎体,双侧经椎弓根入路12节椎体;术中单侧入路22节椎体,双侧入路22节椎体,其中10节椎体由单侧入路改为双侧入路.术后1周及最末随访时椎体高度恢复率分别为66.3%、65.2%;术前后凸Cobb角为23.4°,术后1周及最末随访时分别为9.2°、10.2°,较术前显著改善(P<0.01);术前VAS评分为8.9分,术后1周及最末随访时分别为1.9分、2.3分,较术前均改善(P<0.01).结论 术前CT伤椎体清晰的骨折线是椎体新鲜骨折的依据,陈旧性骨折需进一步检查MRI确定责任椎.大部分中胸椎及腰椎可以采用单侧经椎弓根入路行经皮椎体后凸成形术,部分下胸椎骨质疏松性骨折患者需行双侧经椎弓根入路.     

不同手术径路纠治法洛四联症的围术期结果比较

目的比较经右心室（RV）和经右心房-右心室（RA—RV）小切口径路纠治法洛四联症（TOF）的围术期结果,以提高TOF根治术的疗效。方法回顾性分析1998年1月～2007年12月收治的1423例TOF行一期根治手术患者的临床资料,其中经RV径路手术736例,经RA—RV小切口径路手术687例。结果经RV径路手术从1998年的100％下降至2002年的65％,经RARV径路手术从2002年的35％增加至2007年的79％;经RA—RV径路手术患者主动脉阻断时间、体外循环时间、平均呼吸机辅助时间和平均住ICU时间均短于经RV径路手术患者（P〈0．05）;跨瓣环补片比率差异无统计学意义。经RA—RV径路手术患者发生1个和2个器官功能不全少于经RV径路手术患者,大于3个脏器功能不全发生率差异无统计学意义。残余室间隔缺损、残余梗阻、三尖瓣反流、肺动脉反流、心律失常、再手术率和死亡率均低于经RV径路手术患者（P〈0．05）。结论经RA—RV径路手术是一种较好的、适合我国TOF患者实际情况的手术方式。     

后路小切口全髋关节置换术疗效分析

目的介绍一种小切口全髋置换术,即后侧经股骨颈入路全髋置换术,并对这种小切口与传统切口全髋置换术的短期疗效进行对比研究。方法选择连续60例需要行全髋人工关节置换术的病人为研究对象,随机分为两组,A组30例为后侧经股骨颈入路小切口全髋置换手术组,B组30例为传统后侧切口手术组。采集并对比的数据有：年龄、性别、手术髋（左/右）、体重、身高、体重指数、失血量、输血量、手术时间、切口长度、并发症、假体位置、使用助步器的时间、术前和术后的Harris髋评分结果。所有病人均采用全麻。术后对所有病人进行同样的抗凝治疗,鼓励病人积极主动地进行康复训练。随访时间6～24个月,平均13个月。计数资料采用χ2检验,计量资料采用t检验,P〈0.05为差异具有显著性。结果两组病例的体重指数、Harris髋分值、并发症发生率没有差异（P〉0.05）。A组病例较B组病例在切口长度、手术时间、失血量、住院时间、助步器使用时间方面有优势且差异显著（P〈0.05）。小切口手术组术后早期X线片显示假体匹配良好,位置佳,无脱位,无髋内外翻。髋臼假体外展角为43°～48°,平均45.5°;前倾角为16°～22°,平均17.7°。结论本研究的近期随访结果证实,与传统切口术式相比,后侧经股骨颈入路小切口全髋置换术具有以下优势：不增加术后并发症和假体位置不良的风险（P〉0.05）,降低失血量,缩短住院时间,快速恢复功能,但是小切口全髋置换术对术者的技术知识水平要求较高。     

腮腺良性肿瘤的美容功能性术式临床应用

目的：探讨通过改良术式提高腮腺良性肿瘤手术的美容效果和功能的恢复。方法：手术治疗腮腺良性肿瘤47例,术式中对切口位置、SMAS腮腺筋膜瓣和胸锁乳突肌瓣的应用、保留导管的腮腺区域性切除、面神经及耳大神经的保护、腮腺残端及创区的处理等方面作了相应改良。并对术后美容效果和功能的恢复进行3～18个月的随访检查。结果：术后颌面部切口隐蔽瘢痕不明显,腮腺区外形良好,无凹陷畸形,无涎瘘和Frey氏综合征,耳垂和耳廓背部皮肤感觉功能及腮腺分泌功能基本正常。患者对面容和功能的恢复均较满意,未见肿瘤复发。结论：改良的腮腺肿瘤术式提高了手术的整体质量,取得了较好的美学和功能效果。     

经单鼻孔蝶窦入路显微手术切除垂体腺瘤

目的探讨经单鼻孔蝶窦入路显微手术切除垂体腺瘤的手术方法。方法回顾性分析46例垂体腺瘤患者的临床资料,均采用经单鼻孔蝶窦入路显微手术切除肿瘤。术前行高分辨率CT鞍区薄层扫描及MRI检查,充分了解蝶窦的气化程度、蝶窦分隔和鞍底隆突的解剖学特点。结果44例术中依靠蝶窦相关解剖标志,准确定位蝶窦及鞍底,2例出现偏差。肿瘤全切33例,大部分切除9例,部分切除3例,1例因海绵间窦出血终止手术,无手术死亡。术后一过性尿崩症12例,予药物治疗3～7d后好转 脑脊液漏4例,2例保守治疗治愈,1例予腰大池置管引流后治愈,1例再次经蝶入路修补鞍底后治愈。46例平均随访8个月（3个月～2年）,3例复发。结论单鼻孔蝶窦入路显微手术切除垂体腺瘤是一种安全有效的微侵袭手术方法 熟悉相关解剖标志,准确定位是手术成功的关键。     

经膀胱途径精囊肿块切除术(附5例报告)

目的:探讨经膀胱途径在精囊疾病外科治疗中的应用。方法:本组5例男性患者,年龄45～69岁,平均51岁。临床症状:3例主要表现为尿频、尿急、排尿不畅等下尿路症状,其中1例同时伴有排便不畅,大便变细。1例因血精就诊,1例因下腹部及会阴部隐痛不适,B超检查发现右侧精囊肿块入院。病程2～18个月,平均9个月。经直肠指检、直肠B超、盆腔CT及MRI等检查诊断为左侧精囊肿块2例,右侧3例,肿块长径3～10cm,平均5cm。5例均行经膀胱途径精囊肿块切除术。结果:5例手术均获得成功,平均手术时间75min,平均出血量140ml,术后平均住院时间10d。病理报告:精囊囊肿伴感染2例,精囊囊腺瘤1例,精囊低度恶性分叶状肿瘤1例,前列腺组织1例。随访时间3～72个月,术后症状消失或明显改善。复查B超及CT未见复发。结论:经膀胱途径精囊肿块切除术,手术切口小,视野清晰,操作简便,易于开展,是精囊疾病外科治疗的有效方法。     

Genetic variations as cancer prognostic markers: review and update

Cancer molecular epidemiology traditionally studies the relationship between genetic variations and cancer risk. However, recent studies have also focused on disease outcomes. The application and design of disease outcome studies have been an extension of disease risk assessment. Yet there are a number of unique considerations important in outcome assessments. We review how genetic approaches used for disease susceptibility, such as candidate gene and genome‐wide association study (GWAS) approaches, can be adapted carefully to systematically identify cancer prognostic and predictive alleles. We discuss the interrelatedness among the disease susceptibility, treatment response, and prognosis at the genetic level and focus on how the emerging technologies and approaches can uniquely benefit the genetic prognosis studies. Hum Mutat 30:1–9, 2009. © 2009 Wiley‐Liss, Inc.