胸腰段脊柱侧前方改良入路的临床应用

目的:探索胸腰段脊柱侧前方新型入路。方法:研究胸、腰段层次解剖的差别及复杂肌肉走行、毗邻和神经支配关系,汲取既往入路的各自优点,设计了独特的“┓”形切口、改良的“胸膜外 腹膜后”入路。新型入路由同一手术组医生操作,临床应用2 6例胸腰段疾患,均行减压、植骨及Z形钛钢板内固定。结果:手术时间75～180min ,平均135min ,输血量2 0 0～80 0ml,平均4 2 3ml。术中无一例胸膜破裂,术后摄片示矫形优良,矢状位指数(sagittalindex ,SI)术后平均矫正10 3°,内固定物植入无一错误,无胸腔积液、深部感染,无脊髓损伤加重,术后恢复快。2 6例患者中13例获随访8～34个月,未见腰背肌肉失神经表现,内植物无失败,脊髓损伤Frankel分级提高至少1级占83. 2 % (10 / 12 )。摄片或CT扫描示融合成功,无假关节形成。随访期间SI轻度丢失1°～5°,平均2 5°。结论:新型“┓”形切口改良入路适应证广(T11- L2 ) ,技术难度低,损伤小,出血少,暴露充分,利于操作,手术时间缩短,还能避免加重脊髓、神经根及胸膜损伤,值得推广。     

Open reduction and internal fixation of ankle fracture using wide-awake local anaesthesia no tourniquet technique

IntroductionAnkle fractures frequently occur and must be treated with open reduction for long-term stability. The existing anaesthesia methods include general anaesthesia, spinal and epidural anaesthesia, peripheral nerve block and local anaesthesia with IV sedation. However, each method has its inherent risks and potential costs, and the use of a tourniquet is inevitable. Therefore, the wide-awake local anaesthesia no tourniquet (WALANT) technique provides an alternative method for equivalent haemostasis and pain control without the use of a tourniquet.Patients and methodsWe prospectively enrolled 13 consecutive patients (9 males and 4 females) who presented ankle fractures and required ORIF from January 2017 to December 2017. The fracture types of the 13 patients included lateral malleolar fracture (three patients), bimalleolar fracture (two patients), bimalleolar equivalent fracture (three patients), medial malleolar fracture (two patients) and trimalleolar fracture (three patients; articular surface involvement <25%). We used a solution of 1% lidocaine mixed with 1:40,000 epinephrine for WALANT.ResultsAll patients underwent surgery if they exhibited an initial numerical pain rating scale (NPRS) score of 0 without using a tourniquet. Only two patients required an additional 5 ml of local anaesthesia due to NPRS score elevation during the surgery; no dose exceeded the safe limit of 7 mg/kg. No local complications occurred, and no shifts to other anaesthesia methods were required due to the failure of WALANT.ConclusionsWALANT simplified surgical preparations and provided a safe and reliable method for ankle fracture management. Because the use of a tourniquet was not required, reduced postsurgical pain was observed. Moreover, the use of local anaesthesia resulted in more satisfied patients and facilitated easier recovery.