高龄腰椎管狭窄症患者的手术方式选择及疗效

目的 :探讨高龄腰椎管狭窄症患者的手术方式选择及其疗效。方法 :回顾分析2012年3月~2015年3月在我院行手术治疗并获得至少1年随访的39例80岁以上腰椎管狭窄症患者的临床资料,男21例,女18例;年龄80~90岁(82.4±3.1岁)。术前13例伴有一种合并症,12例伴有两种或两种以上合并症。按相关科室会诊意见处理合并疾病,应用美国麻醉医师协会(ASA)体格状态分级评估患者可耐受全麻下手术。12例根性疼痛和间歇性跛行症状为主、无明显腰椎不稳者,采用椎板开窗减压术(单纯减压组);27例明确存在腰椎不稳/腰椎滑脱或术中需要手术切除小关节突、椎板范围较大发生继发性不稳者采用经椎间孔入路椎间融合内固定术(TLIF)(融合内固定组)。采用日本骨科协会(JOA)评分和疼痛视觉模拟评分法(VAS评分)评估手术的临床疗效。结果:39例患者均完成手术。12例患者发生围手术期并发症,单纯减压组3例(肺炎1例,尿路感染1例,肺炎合并术后贫血1例),融合内固定组9例(肺炎3例,硬膜撕裂、尿潴留、心律失常、术后贫血、术后认知功能障碍各1例,尿路感染合并认知功能障碍1例),均经保守治疗后好转;无围手术期死亡病例。单纯减压组JOA评分由术前的10.8±2.3分改善至末次随访时的19.0±4.8分,融合内固定组JOA评分由术前的11.8±2.2分改善至末次随访时的21.8±3.4分,两组患者末次随访时与术前比较均有统计学差异(P0.05)。两组患者末次随访时的腰痛和腿痛VAS评分(单纯减压组3.2±1.7分和3.5±2.1分,融合内固定组3.0±1.2分和2.9±1.2分)与术前(单纯减压组7.4±0.9分和7.8±1.0分,融合内固定组7.4±1.7分和7.7±1.1分)比较均有统计学差异(P0.05)。结论 :对于高龄退行性腰椎管狭窄症患者,术前充分评估患者全身状况,积极处理合并疾病后,根据临床症状、体征及影像学资料,确定责任节段及致病因素,合理选择手术方式,可获得满意的疗效。     

Gender-related outcomes in trauma

BACKGROUND: Recent data suggest that sex hormones may play a role in regulating posttraumatic immunosuppression, leading to gender-based differences in outcome after injuries. This study examined gender-related outcomes in trauma patients. METHODS: We conducted a retrospective review of trauma registry data from our Level I trauma center over a 4-year period. Patients > 15 years of age, with Injury Severity Scores > 15, who survived and received mechanical ventilation for > 48 hours were included. Patients were divided into two groups on the basis of age (15-45 years and > 45 years) and the groups were further stratified by gender. Groups were matched by Injury Severity Scores, Glasgow Coma Scale score, Abbreviated Injury Score for the head, and transfusion requirement. Gender-based outcomes consisted of ventilator days, intensive care unit length of stay (LOS), hospital LOS, pneumonia, and death. RESULTS: Data were reported as mean +/- SD. There were 612 patients. In the younger age group, male patients had a higher incidence of multiple organ failure (10.5% vs. 1.5%), longer intensive care unit (13.5 +/- 9.2 days vs. 9.2 +/- 7.2 days) and hospital LOS (30.2 +/- 37.7 days vs. 18.9 +/- 13.0 days), and higher mortality (13.4% vs. 6.8%) compared with female patients (p < 0.05 for all). These differences did not exist in the older age group. The incidence of pneumonia did not differ by gender. Age > 45 years was associated with higher mortality (odds ratio, 2.0; 95% confidence interval, 1.1-3.5). CONCLUSION: Although the incidence of pneumonia was not influenced by gender, female trauma patients had better outcomes than male patients in the younger age group. Outcome in the older age group was not gender-related. Our data support a gender-based difference in outcome after traumatic injuries in younger patients.     

Functional outcome in pediatric trauma

Two hundred fifty consecutive children hospitalized with severe injuries (at least one injury with an Abbreviated Injury Score [AIS] greater than or equal to 4 or two or more injuries with AIS scores greater than or equal to 2) were studied to determine their functional status at discharge and 6 months later using questions from the RAND Health Insurance Study (HIS) and the Glasgow Outcome Scale (GOS). Of the 217 surviving patients, 190 (88%) had one or more functional limitations by the HIS scale at discharge. Ten (5%) were in a vegetative state, 40 (18%) severely disabled, 97 (45%) moderately disabled, and 70 (32%) healthy by the GOS. Six-month followup was complete for 156 patients. Of these, 84 (54%) had one or more functional limitations by the HIS scale. Seven (4%) were in a vegetative state, 17 (11%) severely disabled, 50 (32%) moderately disabled, and 82 (53%) healthy by the GOS. A substantial proportion of the whole group of children hospitalized for the treatment of severe injuries had ongoing physical disabilities that limited their participation in normal activities 6 months after they were discharged. This suggests a need for greater emphasis on the rehabilitation of pediatric trauma patients.     

Assessing outcomes in paediatric trauma populations

INTRODUCTION: Assessing outcomes in the paediatric trauma population is important. Identifying suitable instruments can be problematic. This article highlights the commonly used outcome measures for assessing functional status and health related quality of life in paediatric trauma patients. Child specific characteristics which impact upon instrument development and selection are reviewed. METHODS: An electronic database search was conducted to identify suitable English language measures used for outcome assessment in paediatric trauma patients from 1966 to present. RESULTS: Nine suitable instruments were identified, the child health questionnaire (CHQ), Glasgow outcome scale (GOS), paediatric overall performance category (POPC), PedsQL 4.0 generic core scales, paediatric evaluation of disability inventory (PEDI), functional independence measure (FIM), WeeFIM and an unnamed paediatric trauma specific measure [Gofin R, Hass T, Adler B, The development of disability scales for childhood and adolescent injuries. J Clin Epidemiol 1995;48:977-84]. Each instrument was found to have advantages and disadvantages for assessing outcomes in a paediatric trauma population. CONCLUSION: The PedsQL 4.0 generic core scale could be feasible for administration as a routine outcome measure for paediatric trauma groups. For very young children an additional measure such as that proposed by Gofin et al. [Gofin R, Hass T, Adler B, The development of disability scales for childhood and adolescent injuries. J Clin Epidemiol 1995;48:977-84] may be indicated. Future use of these instruments in the paediatric population would benefit from further psychometric evaluation.     

Carotid endarterectomy in the octogenarian: outcomes of 345 procedures performed from 1995-2000

The purpose of this study is to evaluate the efficacy and the safety of carotid endarterectomy (CEA) in the octogenarian patient. From January 1995 to December 2000, we have performed 3430 CEAs in 2743 patients: 345 CEAs in 269 octogenarian patients (Group 1) and 3085 CEAs in 2474 younger patients (Group 2). Age was the only selection criteria for including patients in Group 1. Octogenarians' perioperative mortality (1.4%) was greater than that in Group 2 (0.3%) (p<0.05). No differences can be found between the groups' perioperative ipsilateral stroke rates (1.7% in Group 1 vs 1.2% in Group 2) and combined ipsilateral stroke and death rates (2.3% in Group 1 vs 1.3% in Group 2) (p>0.05). The octogenarians' Kaplan-Meier 6-year overall and free-stroke survival rates were 86 and 76% respectively. CEA can be performed in selected octogenarian patients with low early and late mortality and neurologic morbidity rates.     

Thoracotomy in the octogenarian

Octogenarians are rarely referred for thoracic operations, presumably owing to the perceived morbidity of thoracotomy and the presumed frailty and limited life span of the 80-year-old patient. To determine if these concerns are valid, we reviewed our operative experience in 50 patients 80 years of age or older (mean age, 82.7 years; range, 80 to 91 years; 29 men, 21 women) undergoing thoracotomy between Nov 1, 1980, and May 1, 1990, for cancer (39 patients) and benign disease (11 patients). Procedures included 25 lobectomies (24 cancer, 1 abscess), 4 pneumonectomies (all cancer), 3 esophagectomies (1 perforation, 2 cancer), 3 explorations for cancer, 2 bullectomies, 12 wedge or segmental resections (5 open lung biopsies, 5 cancer, and 1 each for benign nodule and hemoptysis), and 1 thymectomy. Five patients (10%) were operated on emergently for massive hemoptysis (1), Boerhaave's syndrome (1), or rapidly progressive respiratory insufficiency (3) with an operative mortality of 80%. Mortality for elective cases was significantly lower (13%, p less than 0.01). Major complications occurred in 19 patients (38%). Univariate analysis performed to identify predictors of operative mortality demonstrated no significant relationship between operative death and patient age, sex, type of operation, diagnosis of malignancy, or the presence of either cardiac disease or chronic obstructive lung disease. Twenty-three patients are alive 2 months to 5 years after thoracotomy. Actuarial survival for the 45 elective patients was 56% and 44% at 1 and 2 years, respectively.(ABSTRACT TRUNCATED AT 250 WORDS)     

Impact of cirrhosis on outcomes in trauma

BACKGROUND: Cirrhosis as an independent predictor of poor outcomes in trauma patients was identified in 1990. We hypothesized that the degree of preinjury hepatic dysfunction is, by itself, an independent predictor of mortality. STUDY DESIGN: The trauma registry at our Level I trauma center was queried for all ICD-9 codes for liver disease from 1999 to 2003, and patients were categorized as having Child-Turcotte-Pugh (CTP) class A, B, or C cirrhosis. Data analyzed included age, mechanism of injury, Abbreviated Injury Score (AIS), Injury Severity Score (ISS), Glasgow Coma Score (GCS), hospital length of stay, ventilator days, procedures performed, transfusion of blood products, admission lactate, base deficit, and mortality. Trauma Related Injury Severity Score (TRISS) methodology was used to calculate the probability of survival. Outcomes data were analyzed, and statistical comparison was performed using group t-test. RESULTS: Of the 50 patients meeting study criteria, 31 had alcohol-related cirrhosis, 18 had a history of hepatitis C, and 1 had cryptogenic cirrhosis. Twenty (40%) met CTP A classification, 16 (32%) met CTP B criteria, and 14 (28%) had CTP class C cirrhosis. One death occurred in the CTP A and B groups. Comparison between the five survivors and nine nonsurvivors from CTP class C showed no statistical significance in terms of age, ISS, TRISS, or GCS. CONCLUSIONS: The mortality rate for class C cirrhotic patients posttrauma continues to be higher than that predicted by TRISS, although patients with less severe hepatic dysfunction do not appear to have significantly lower than predicted survival. The degree of hepatic dysfunction remains an independent predictor of mortality and CTP C criteria must be considered when determining outcomes for patients posttrauma.     

Long-term fetal outcomes in pregnant trauma patients

BACKGROUND: Trauma during pregnancy is associated with significant maternal and fetal morbidity and mortality, typically occurring during the hospital admission. Less is known about the delayed effects of trauma on pregnancy outcome once the patient has been discharged from the hospital with a viable fetus. METHODS: A retrospective cohort study was conducted of pregnant trauma patients who were discharged from the trauma center with a viable fetus. Risk of preterm delivery (PTD) and low birth weight (LBW) were compared between injured patients (Injury Severity Score > 0) and those without identified injury (Injury Severity Score = 0), for the remainder of pregnancy. RESULTS: Even after trauma center discharge, injured patients had a nearly 2-fold higher risk of PTD (relative risk, 1.9; 95% confidence interval, 1.1-3.3) and LBW (relative risk, 1.8; 95% confidence interval, 1.04-3.2) for the remainder of the pregnancy. The risk was higher with increasing injury severity and among those injured early in gestation. CONCLUSION: The risk of PTD and LBW in pregnant trauma patients who were discharged from trauma centers with a viable fetus remains increased throughout the remainder of the pregnancy. A history of trauma during gestation is a risk factor for poor pregnancy outcome.     

Alcohol exposure and outcomes in trauma patients

Objective  

To determine the injury patterns, complications, and mortality after alcohol consumption in trauma patients.     

Cardiac surgery in the octogenarian

The increasing safety of cardiac surgery has led to the frequent referral of octogenarians for operation. Between 1980 and 1989, we reviewed our experience with 103 octogenarians (59 male, 44 female; mean age 82 years) to determine the surgical risk factors and outcome in the elderly population. There were 71 coronary bypasses (CABG), 11 aortic valve replacements (AVR), 11 AVR-CABG, 4 mitral valve replacements (MVR), 3 MVR-CABG and 3 AVR-MVR-CABG. Seventeen patients died during hospitalization (16.5%) including 9 CABG (13%); 1 AVR (9%), 2 AVR-CABG (18%), 2 MVR (50%), 1 MVR-CABG (33%) and 2 AVR-MVR-CABG (67%). Statistical analysis of 22 perioperative variables suggested that a preoperative intraaortic balloon, a history of congestive heart failure, mitral valve replacement, urgent operation, need for preoperative inotropic support and the number of anastomoses performed were significant or marginally significant (P less than 0.15) univariate predictors of operative mortality. Multivariate analysis revealed that the need for a preoperative intraaortic balloon (F = 13.1), history of congestive heart failure (F = 6.8), and MVR (F = 6.7) were significant (P less than 0.001) independent predictors of mortality. Postoperative complications included arrhythmias in 36 patients (35%), respiratory insufficiency in 11 (11%), reversible neurological deficit in 15 (14%), and a permanent neurological deficit in 6 patients (6%). Actuarial survival was 90% and 82% at 1 and 2 years, respectively. Seven of 86 (8%) long term survivors sustained a stroke in the follow-up interval. The mean follow-up of survivors was 23 +/- 19 months with a mean improvement in NYHA class of 1.4 (P less than 0.001).(ABSTRACT TRUNCATED AT 250 WORDS)     

Cardiac surgery in the octogenarian

Seventy-six consecutive patients, aged 80 to 89 (mean 82), underwent cardiac operations with cardiopulmonary bypass. Hypothermia (22 degrees C) and hyperkalemic cardioplegia were used in each. There were 35 men and 41 women. Thirteen patients (17%) were in New York Heart Association Functional Class III and 62 patients (81%) were in Class IV preoperatively. Coronary bypass procedures (Group I) were performed in 38 patients, of whom five had combined carotid endarterectomy. The average number of grafts was 3.7 per patient. There were two early deaths (5.2%). Single or double valve replacement, without coronary bypass (Group II), was done in 15 patients, with one early death (6.6%). Coronary bypass and valve procedures (Group III) were performed in 23 patients with seven early deaths (30%). Total early mortality was 10 deaths in 76 patients (13%). Of the 66 (87%) 30 day survivors, 19 (29.1%) had major postoperative complications, including bleeding, pericardial tamponade, sternal dehiscence, myocardial infarction, arrhythmia, and pump failure. Mean hospital stay was 23 days (9 to 117 days). Late cardiac-related deaths occurred in eight patients (9%) during the 58 (mean 28) months of follow-up. Thus combined early and late mortality was 18 deaths (24%). Mortality at any time was related to Functional Class IV status (17/18 deaths, 94% in Class IV); combined procedures (12/28 patients died, 43%); use of intra-aortic balloon pumping (8/13 patients died, 62%); and postoperative bleeding necessitating reoperation (4/6 patients died, 67%). At follow-up 84% of survivors had improved by one or more functional classes, and there was a low incidence of cardiac-related late deaths. This experience supports the concept that in octogenarians the indications for operation should be as for other patients of less advanced age, especially in those with isolated coronary artery disease and pure valve disease. Operation should not be delayed, so that these patients will not advance to higher-risk Class IV status preoperatively.     

Functional outcomes assessment in shoulder surgery

The effective evaluation and management of orthopaedic conditions including shoulder disorders relies upon understanding the level of disability created by the disease process. Validated outcome measures are critical to the evaluation process. Traditionally, outcome measures have been physician derived objective evaluations including range of motion and radiologic evaluations. However, these measures can marginalize a patient’s perception of their disability or outcome. As a result of these limitations, patient self-reported outcomes measures have become popular over the last quarter century and are currently primary tools to evaluate outcomes of treatment. Patient reported outcomes measures can be general health related quality of life measures, health utility measures, region specific health related quality of life measures or condition specific measures. Several patients self-reported outcomes measures have been developed and validated for evaluating patients with shoulder disorders. Computer adaptive testing will likely play an important role in the arsenal of measures used to evaluate shoulder patients in the future. The purpose of this article is to review the general health related quality-of-life measures as well as the joint-specific and condition specific measures utilized in evaluating patients with shoulder conditions. Advances in computer adaptive testing as it relates to assessing dysfunction in shoulder conditions will also be reviewed.     

Valve replacement in the octogenarian

Twenty-five patients (11 men and 14 women) aged 80 to 88 years (mean age, 82 years) underwent valve replacement at St. Louis University from August 1980 to June 1988. Isolated valve replacement was performed in 11 patients. Combined procedures included valve replacement with myocardial revascularization (7 patients), multiple valve procedures (5 patients), and ascending aortic plication (2 patients). Fifteen patients (60%) were in New York Heart Association functional class III and 10 (40%) were in class IV preoperatively. The operative mortality was 20% and late mortality was 20% (mean follow-up, 36 months). Isolated valve replacement carried a 9% early and 0% late mortality, whereas combined procedures of any type had a 16% early and 20% late mortality. Only 7 patients (28%) had a completely uncomplicated postoperative hospitalization. Twenty patients were discharged after a mean hospital stay of 18 +/- 16 days. Their mean New York Heart Association functional class was 1.6 +/- 0.66. The 1-year and 2-year actuarial survival rate is 79% and 69%, respectively. A significant increase in operative mortality is seen when valve replacement is combined with myocardial revascularization or an additional valve procedure. Late clinical improvement, as judged by return to an independent life-style, justifies this approach for select patients.     

Carotid endarterectomy in the octogenarian

During a 10-year period from January 1983 to December 1992, 79 carotid endarterectomies were performed in patients aged 80 years or older. This represented 7.4% of the total patient population undergoing carotid endarterectomy at Emory University Hospital. The indications for surgery in this elderly population were transient ischemic attacks in 24 (30.3%), cerebrovascular accident in 12 (15.2%), amaurosis fugax in seven (8.9%), vascular tinnitus in one (1.3%), and asymptomatic stenosis in 35 (44.3%). The average degree of ipsilateral stenosis was 76.8%. Concomitant risk factors included coronary artery disease in 43%, systemic arterial hypertension in 51.9%, diabetes mellitus in 10.1%, and significant smoking history in 53.2%. Seventy-six percent of the procedures were performed under local anesthesia, and in all but two intraluminal shunts were used. Combined 30-day mortality and postoperative stroke morbidity in this population was 1.3% (one patient). Long-term follow-up ranging from 1 to 10 years (average 35 months) revealed no ipsilateral strokes. This experience suggests that carotid endarterectomy can be performed in an elderly population with morbidity and mortality rates similar to those in a younger cohort.Presented at the Fourth Annual Winter Meeting of the Peripheral Vascular Surgical Society, Breckenridge, Colo., January 21– 24, 1994.     

Carotid surgery in the octogenarian

The records of 52 patients aged 80 years or older who underwent 56 carotid artery reconstructions were analyzed retrospectively. Four patients had amaurosis fugax, 27 patients had experienced one or more transient ischemic attacks, eight had a completely or partially reversible stroke, and 10 had vertebrobasilar insufficiency. Three patients were asymptomatic. Arteriograms documented stenosis >80% on the operated side in 48 cases, whereas the contralateral carotid artery was occluded or had >80% stenosis in 10 cases each. Two or more cerebral arteries were involved in 37 patients. CT scans were normal in only 21 (40%) patients. General anesthesia was used in 54 of 56 operations. Thirty-six endarterectomies, 18 bypasses, and two resection-anastomoses (for tortuosity) were performed. A shunt was employed in eight (14.3%) cases. One lethal stroke (1.9%) occurred during the first postoperative month. Three patients experienced nonfatal strokes, two of which gave rise to residual deficits. Two patients were lost to follow-up. For the remaining 49 patients the mean follow-up was 24 months. Two-year actuarial survival was 76.3% for the entire series and 67% for those surviving without neurologic events. This study shows that when properly selected the elderly population can safely undergo carotid surgery.Presented at the Annual Meeting of the Société de Chirurgie Vasculaire de Langue Française, Marseille, France, June 21–22, 1991.     

Obesity and outcomes after blunt trauma

BACKGROUND: Obesity has proven to be an independent risk factor of mortality in the intensive care unit (ICU) in both nontrauma and trauma patients. The purpose of this study was to determine whether the detrimental effect of obesity extend to morbidity as well as mortality in the intensive and nonintensive care blunt trauma patients. METHODS: A retrospective comparison of obese (body mass index [BMI] > 30 kg/m2) to nonobese (BMI < 30 kg/m2) blunt trauma patients was performed between January 2004 and December 2005. Patient demographics, morbidity, mortality and ventilator, ICU, and hospital length of stays were analyzed. Continuous variables were evaluated using the Wilcoxon Rank test and the nominal variables were evaluated using the Fisher's exact test. RESULTS: A cohort of 338 nonobese patients was compared with 115 obese patients during the study. These groups were similar in age (p = 0.19), gender (p = 0.37), and mechanism (p = 0.13). Their severity of injury were similar, demonstrated by nonsignificant differences in Injury Severity Score (p = 0.45), New Injury Severity Score (p = 0.51), Abdomen Abbreviated Injury Score (AIS; p = 0.49), and head AIS (p = 0.64). The subset of obese patients who never went to the ICU had a slightly longer hospital stay with a p value of 0.055. Overall the mortality rates were not different between the groups (3.5% obese versus 7.1% nonobese, p = 0.26). CONCLUSIONS: This group of obese blunt trauma patients had similar mortality rates to their leaner counterparts possibly because their complications were minimized. Despite this finding, a subset of obese patients had longer hospital stays which increases the financial burden to the patient and hospital. Effort should be made to facilitate their discharge to avoid complications and minimize cost.     

Reasons for lethal outcomes in severe multiple trauma

The article is based on an analysis of causes and terms of lethal outcomes of 490 patients after a severe combined trauma. Lethal outcome in 16.9% of the patients took place within an hour after admission to clinic. Within the first 24 hours died 50.2% of the patients, during the second day--8%, on the third day--8.4%. At the period from 3 to 7 days 14.3% of the patients died, during the second week--11.8% of the patients, 7.3% survived for more than 14 days. One direct cause of death was shown in 73.5% of cases, in 21.6%--there were two and in 4.9%--three causes. Acute massive blood loss was the direct cause of death of 43.9% of the patients, critical injury of the brain--in 25.1%, pneumonia--in 27.6%, sepsis--in 6.9%. Altogether 26 causes of lethal outcomes were formulated.