颈髓损伤合并低钠血症39例临床分析

目的总结急性颈髓损伤合并低钠血症的变化规律并探讨其发生机制。方法回顾性分析2000～2004年收治的39例急性颈髓损伤患者(排除肾病、糖尿病)的临床资料，分析发病时间、发生率、年龄、性别、损伤节段、损伤程度与低钠血症的相互关系及其可行的治疗方案。结果本组合并低钠血症23例，发生率为58．97％，低钠血症于伤后3d～2周出现，7～17d到高峰，持续时间与脊髓休克期基本吻合，发生率与脊髓损伤程度呈正相关。结论低钠血症是颈髓损伤的常见并发症，其发生机制可能与交感神经的功能完全抑制有关，对症治疗可防止脑水肿、脑细胞脱水，效果理想。     

脊髓

Chiari-I畸形并脊髓空洞症247例外科治疗；急性颈髓损伤后的低渗血症与内分泌改变的关系；缺血预处理对犬脊髓损伤及热休克蛋白70表达影响的研究；脊髓损伤自身免疫的研究进展(综述)；Chiari I畸形伴脊髓空洞的分型和手术方式的选择；166例脊髓髓内肿瘤的临床资料分析；大鼠牵张性脊髓损伤后细胞凋亡及相关基因表达的实验研究；颈髓室管膜瘤的外科治疗。     

颈脊髓损伤早期死亡临床研究

目的分析研究颈脊髓损伤(CSCI)早期死亡情况,探讨颈脊髓损伤早期死亡的主要影响因素及发生机理。方法收集整理2004-02-2012-02入院的131例CSCI患者的临床资料(早期死亡15例),分析CSCI早期死亡者的年龄、性别、受伤原因、脊柱损伤节段、脊髓损伤严重程度、是否手术及气管切开、是否存在低钠血症、是否存在低蛋白血症与CSCI早期死亡的关系,总结CSCI早期死亡的原因。结果 CSCI早期死亡率为8.40%(11/131),多死于呼吸功能衰竭。性别、受伤原因及是否手术统计分析,差异无统计学意义(P>0.05);颈髓不同损伤程度、颈髓不同损伤节段、不同年龄段、气管是否切开、是否存在低钠血症及是否存在低蛋白血症统计分析,差异有统计学意义(P<0.05或P<0.001)。结论呼吸衰竭是CSCI早期死亡的首要原因;颈髓不同损伤程度、颈髓不同损伤节段、不同年龄段、气管是否切开、是否存在低钠血症、是否存在低蛋白血症是CSCI早期死亡的主要影响因素。     

无骨折脱位型颈髓损伤的临床研究

目的：探讨颈椎在无骨折脱位情况下出现颈髓损伤的临床机制。方法：观察２４例无骨折脱位型颈髓损伤，重点分析其影像学检查特点。结果：２７％病例合并椎管狭窄，８３％的病例存在椎间盘突出，不同程度压迫脊髓。结论：无骨折脱位型颈脊髓损伤机制中，存在外伤致颈椎间盘损伤，突出的间盘向后压迫损伤颈髓。颈椎间盘损伤受力机制为屈曲→压缩→过伸。颈椎管狭窄、椎间盘退变等是此类脊髓损伤的病理解剖基础     

颈脊髓损伤后低钠血症与早期死亡的临床分析

目的 分析研究颈脊髓损伤(CSCI)低钠血症的相关因冈素、发病机制及对早期死亡的影响.方法 收集整理2005～2010年入院的131例CSCI患者的临床资料(早期死亡11例),分析CSCI后低钠血症与CSCI节段、损伤程度的关系及对早期死亡的影响.结果 颈脊髓不同损伤程度、不同损伤节段低钠血症发病率的统计分析,相互之间...     

急性颈髓损伤继发低钠血症的相关因素分析

急性颈髓损伤导致低钠血症发生率为45％-77％，其发病机制尚不完全清楚。因低钠血症可导致细胞水肿、内环境紊乱，加重神经损伤，延误手术时机，所以临床医师在治疗急性颈髓损伤时应高度重视低钠血症，并及时予以纠正。本文对我院2002-2005年收治的45例急性颈髓损伤患者的资料进行回顾性分析，对2006年1月-2007年6月收治的急性颈髓损伤患者59例进行前瞻分析，探讨机型颈髓损伤后低钠血症的相关因素，现报告如下。     

颈髓损伤患者并发症分析

目的探讨颈椎脊髓损伤患者易伴发的各种并发症,以及其预防及治疗。方法对2002～2006年我院收治的118例颈髓损伤患者并发症进行回顾性分析。结果颈髓损伤患者中最常见的并发症为呼吸系统并发症,在本组发生率为61.02%,其次发生率较高的还有低钠血症,占20.34%,并发褥疮、尿路感染、应激性溃疡的发生率分别为6.78%、5.93%、5.08%;C3-4颈髓损伤患者呼吸系统并发症及低钠血症发生率均明显高于其它节段;结论颈髓损伤后的并发症治疗及预防的关键就在于早期诊断,早期治疗,特别是对于呼吸系统并发症的预防和处理,在某种程度上要比处理脊髓损伤更为重要。     

急性颈髓损伤并发低钠血症的治疗

目的探讨急性颈髓损伤并发低钠血症的发病机制和治疗方法。方法回顾性分析本院2002年1月至2008年5月收治的187例颈髓损伤病人的临床资料,其中112例并发低血钠症。结果本组低钠血症发生率为59.89%（112/187）。颈髓损伤到出现低钠血症的时间平均为5.9±3.6天。血钠降至最低到血钠开始回升的时间为20.9天±11.6天。经补液、补钠等治疗。死亡2例,愈110例。结论低钠血症是急性颈髓损伤的常见并发症,其发病机制可能与抗利尿激素分泌异常综合征（SIADH）及脑耗盐综合征（CSWS）有关。低钠血症的严重程度和颈髓损伤平面及颈髓损伤程度相关,低钠血症的发生率与感染相关。     

脊髓

HIV-1来源的慢病毒载体转染大鼠脊髓神经干细胞,“特发性”胸椎左侧凸患者并发脊髓病变及其临床意义,急性颈髓损伤后的低钠血症,高压氧联合颈前路减压治疗早期外伤性颈髓损伤,NGF、BDNF基因修饰的BMSCs静脉注射治疗脊髓损伤,中央型颈脊髓损伤保守与手术治疗的对比研究[编者按]     

脊髓

骨髓间充质干细胞移植治疗大鼠脊髓损伤的抗凋亡机制；颈髓损伤早期死亡影响因素与时间分布；外伤性颈髓中央综合征的手术治疗；脊髓损伤后骨代谢形态改变的髂骨形态计量学研究；翼点小骨窗入路显微手术治疗前循环动脉瘤（附20例分析）；     

不同程度颈脊髓损伤后低钠血症的临床分析

 目的回顾性总结急性颈脊髓损伤后低钠血症的发生特点,并分析其可能的发生原因,以及脊髓损伤严重程度、性别、年龄等因素对血钠变化的影响。方法研究对象为2005年6月至2011年3月急诊收治的一组颈椎外伤患者,排除合并颅脑外伤及慢性疾病的患者,入选病例分为完全性脊髓损伤组、不完全性脊髓损伤组及无神经功能障碍组,回顾性分析各组病例的血钠变化情况。结果入选病例共102例,男83例,女19例;年龄17~68岁,平均45.6岁。完全性脊髓损伤组23例,不完全性脊髓损伤组60例,无神经功能障碍组19例。共发生低钠血症共39例,完全性脊髓损伤组15例(65%),不完全性脊髓损伤组23例(38%),无神经功能障碍组1例(5%)。低钠血症发生率在三组间两两比较,差异有统计学意义,完全性脊髓损伤组低钠血症的发生率明显高于不完全性脊髓损伤组和无神经功能障碍组。Logistic逐步回归分析结果显示低钠血症与患者脊髓损伤程度有明确相关关系,而与患者的年龄、性别、脊髓损伤节段无相关关系。结论急性颈脊髓损伤后具有较高的低钠血症发生率,虽然影响钠盐平衡的因素及相互作用非常复杂,但颈脊髓损伤致自主神经功能障碍、神经内分泌功能异常以及血液动力学改变可能是导致颈脊髓损伤后电解质系统异常的重要原因。     

心房肽分泌异常与颈髓损伤后低钠血症

目的 :探讨心房肽 (AtrialNatriureticPeptide ,ANP)分泌异常与颈髓损伤 (CervicalSpinalCordInjury ,CSCI)后低钠血症的关系。方法 :用放免法研究了 15例CSCI并低钠血症患者血浆ANP ,与 2 3例CSCI不伴低钠血症患者及12例正常同龄组的ANP进行比较。并检测血钠和部分患者的尿钠及尿量。结果 :( 1)CSCI伴低钠血症者 ,其血浆ANP水平较不伴低钠血症者及正常对照组显著升高 (P <0 .0 1)。 ( 2 )CSCI急性期血浆ANP水平与CSCI程度密切相关 ,CSCI越重 ,ANP水平越高 ;ANP水平越高 ,血钠越低 ,二者呈负相关 (r =-0 .85 ,P <0 .0 1)。结论 :CSCI后低钠血症患者ANP分泌明显异常 ,ANP分泌增加可能是导致CSCI后低钠血症的一个重要因素。纠正缺氧可能降低ANP水平 ,从而纠正CSCI后顽固性低钠血症。     

颈椎脊髓损伤早期死亡原因分析

目的探讨颈椎脊髓损伤早期死亡原因。方法回顾性分析1993年1月～2005年12月63例颈椎脊髓损伤早期死亡病例的一般状况、受伤原因、受伤至入院时间、脊柱损伤节段、脊髓损伤严重程度、合并伤、颈椎脊髓损伤影像学表现、治疗方法、过程及结果,总结其早期死亡的原因。结果本组49例因呼吸衰竭死亡,8例因多脏器功能衰竭死亡,2例因癫痫发作导致急性呼吸、循环衰竭死亡,2例因多发伤导致肺部感染及感染性休克死亡,2例因上消化道大出血导致出血性休克死亡。结论呼吸衰竭为颈椎脊髓损伤早期死亡的首要原因,其与脊髓损伤节段及损伤程度密切相关。     

Cervical spinal cord injury and the need for cardiovascular intervention

HYPOTHESIS: The level of cervical spinal cord injury (CSCI) can be used to predict the need for a cardiovascular intervention. DESIGN: Retrospective review. Data included level of spinal cord injury, Injury Severity Score, lowest heart rate, and systolic blood pressure in the first 24 hours and intensive care unit course. The level of CSCI was divided into high (cord level C1-C5) or low (cord level C6-C7). Neurogenic shock was defined as bradycardia with hypotension. Statistical analysis was performed with the t test and the chi2 test. SETTING: Level I trauma center. PATIENTS: The patients studied were those with quadriplegia who experienced a CSCI and were admitted to the hospital between December 1, 1993, and October 31, 2001. INTERVENTIONS: Pressors, chronotropic agents, and pacemakers.Main Outcome Measure Use of a cardiovascular intervention in the presence of neurogenic shock. RESULTS: Eighty-three patients met the criteria for CSCI and quadriplegia, 62 in the high (C1-C5) and 21 in the low (C6-C7) level. There was no significant difference between the 2 groups in mean +/- SD age (38.2+/-17.8 vs 34.7+/-15.6 years; P=.43), mean +/- SD Injury Severity Score (35.7+/-17.5 vs 32.5+/-11.2; P=.44), mean +/- SD admission base deficit (-0.7+/-3.6 vs 0.7+/-2.7; P=.06), or mortality (12 [19%] of 62 patients vs 2 [10%] of 21 patients; P=.29). Neurogenic shock was present in 19 (31%) of the 62 patients with high CSCI and in 5 (24%) of the 21 patients with low CSCI (P=.56). There was a marked difference in the use of a cardiovascular intervention between those with a high and those with a low CSCI: 15 (24%) of 62 patients vs 1 (5%) of 21 patients (P=.02). Two patients with C1 through C5 spinal cord injuries required cardiac pacemakers. CONCLUSIONS: There was no significant difference in the frequency of neurogenic shock by injury level. Patients with a high CSCI (C1-C5) had a significantly greater requirement for a cardiovascular intervention compared with patients with lower injuries (C6-C7).     

Pelvic fracture in multiple trauma: classification by mechanism is key to pattern of organ injury, resuscitative requirements, and outcome

Three hundred forty-three multiple trauma patients with major pelvic ring disruption were studied and subdivided into four major groups by mechanism of injury: antero-posterior compression (APC), lateral compression (LC), vertical shear (VS), and combined mechanical injury (CMI). Acetabular fractures which did not disrupt the pelvic ring were excluded. The mode of injury was: MVA, 57.4%; motorcycle, 9.3%; fall, 9.3%; pedestrian, 17.8%; crush, 3.8%. The LC and APC groups were divided into Grades 1-3 of increasing severity. The pattern of organ injury: including brain, lung, liver, spleen, bowel, bladder, pelvic vascular injury (PVASI), retroperitoneal hematoma (RPH) and complications: circulatory shock, sepsis, ARDS, abnormal physiology, and 24-hr total fluid volume administration were all evaluated as a function of mortality (M). As LC grade increased from 1 to 3 there was increased % incidence of PVASI, RPH, shock, and 24-hr volume needs. However, the large incidence of brain, lung, and upper abdominal visceral injuries as causes of death in Grade 1 and 2 fell in LC3, with limitation of the LC3 injury pattern to the pelvis. As APC grade increased from 1 to 3 there was increased % injury to spleen, liver, bowel, PVASI with RPH, shock, sepsis, and ARDS, and large increases in volume needs, with important incidence of brain and lung injuries in all grades. Organ injury patterns and % M associated with vertical shear were similar to those with severe grades of APC, but CMI had an associated organ injury pattern similar to lower grades of APC and LC fractures. The pattern of injury in APC3 was correlated with the greatest 24-hour fluid requirements and with a rise in mortality as the APC grade rose. However, there were major differences in the causes of death in LC vs. APC injuries, with brain injury compounded by shock being significant contributors in LC. In contrast, in APC there were significant influences of shock, sepsis, and ARDS related to the massive torso forces delivered in APC, with large volume losses from visceral organs and pelvis of greater influence in APC, but brain injury was not a significant cause of death. These data indicate that the mechanical force type and severity of the pelvic fracture are the keys to the expected organ injury pattern, resuscitation needs, and mortality.     

Prevalence of pre-existing factors causing spinal cord compression: Is there a difference between patients suffering from cervical spinal cord injury with and without bone injury?

BackgroundRecently, the prevalence of elderly patients suffering from cervical spinal cord injury (CSCI) without bone injury has been increasing in various countries. Pre-existing factors causing spinal cord compression, such as ossification of the posterior longitudinal ligament (OPLL), can increase the risk of CSCI without bone injury. However, no study has compared the prevalence of pre-existing factors between CSCI with and without bone injury. This study aimed to compare the prevalence of pre-existing factors between CSCI with and without bone injury.MethodsIn 168 consecutive patients with CSCI, pre-existing factors including OPLL, posterior spur of the vertebral body, developmental stenosis, disc bulge and calcification of yellow ligament (CYL) were evaluated on imaging studies. The prevalence of each type of pre-existing factors was compared between patients with and without bone injury.ResultsThe prevalence of pre-existing factors in patients without bone injury (86%) was significantly higher than in those with bone injury (20%) (P < 0.001; odds ratio, 23.9). The most common pre-existing factor was OPLL followed by developmental stenosis, posterior spur, disc bulge and CYL in both groups. OPLL, development stenosis and posterior spur were significantly more common in patients without bone injury compared to those with bone injury (P < 0.01).ConclusionsPrevalence of pre-existing factors, such as OPLL, development stenosis and posterior spur was significantly higher in patients without bone injury than in those with bone injury. Thus, these pre-existing factors might be a potential risk of CSCI without bone injury.     

Esophageal dysfunction in cervical spinal cord injury: a potentially important mechanism of aspiration

BACKGROUND: Respiratory complications are a major cause of morbidity and mortality in patients with cervical spinal cord injury (CSCI). We hypothesized that patients with CSCI had esophageal dysfunction, predisposing them to aspiration. The purpose of this study was to characterize esophageal function in these patients. METHODS: CSCI and similarly injured control (spinal cord injury below T1) subjects were prospectively enrolled from two trauma centers. All underwent esophageal manometry to measure lower (LES) and upper esophageal sphincter (UES) pressures. A subset of patients had detailed manometry and 24-hour pH studies performed to evaluate dynamic esophageal function. RESULTS: Eighteen CSCI and five control subjects were enrolled. The groups were similar with regards to age, sex, injury mechanism, Injury Severity Score, and hospital stay. Resting LES and UES pressures were similar in CSCI and control patients and did not differ from established norms. Five CSCI and two control patients underwent detailed manometric assessment. Defective UES relaxation was observed in all CSCI patients but not controls. CSCI patients had increased UES relaxation pressures (18.4 +/- 5.3 versus 3.9 +/- 0.7 mm Hg; p = 0.01) and UES bolus pressures (23.8 +/- 2.2 versus 10.2 +/- 6.9 mm Hg; p = 0.006) compared with controls. Esophageal body and LES function were normal. Two of five CSCI patients had abnormal 24-hour pH studies. CONCLUSION: Patients with CSCI demonstrate significantly disturbed dynamic function of the pharynx and UES while resting parameters remain normal. Because adequate UES relaxation is critical to the clearance of secretions and coordination of swallowing, this is an important potential mechanism of aspiration in patients with CSCI.     

Cervical spine injury is highly dependent on the mechanism of injury following blunt and penetrating assault

BACKGROUND: The mechanism of injury has not been highly regarded as an important variable when evaluating cervical spine injuries. The aim of this study was to determine the incidence of cervical spine fracture (CSF) and cervical spinal cord injury (CSCI) based on mechanism following blunt and penetrating assault to better aid prioritization of management. METHODS: Retrospective analysis from two large urban Level I trauma centers over 87 and 144 months caused by gunshot wounds (GSW), stab wounds (SW) or blunt assault (BA). RESULTS: During the study period, there were 57,532 trauma patients evaluated at the two trauma centers, of which 42.3% were following blunt or penetrating assault. The rates of CSF and CSCI for the various mechanisms were similar between the two centers. The rates for having CSF were significantly different (p < 0.05) for the various mechanisms. GSW (1.35%) was the highest followed by BA (0.41%) and then SW (0.12%). The rates of CSCI for GSW (0.94%) were significantly (p < 0.05) higher than BA (0.14%) and SW (0.11%). For GSW patients, all patients with CSF or CSCI had a point of entry between the ears and the nipple. For SW patients, the wound was directly in the neck below the mandible and above the trapezius muscle. Although many of the SW patients also suffered blunt assault, none of the CSF or CSCI injuries were from blunt forces. In addition, all patients, both blunt and penetrating who had CSCI had neurologic deficit at the time of presentation. Surgical stabilization or tongs were applied in 15.5% (26 of 168) of the GSWs, 27.8% (3 of 11) of the SWs and 31.6% (6 of 19) of the BA patients. There was a BA patient (1 of 4,390) patient with CSF that was neurologically intact that required surgical stabilization and this patient had neck pain on admission. No penetrating injury patients with CSCI regained significant neurologic recovery during the hospitalization. SUMMARY: The rate of CSF or CSCI is low following assault and dependent on mechanism of injury. Thus the concern and extent of evaluation should also be dependent on the mechanism of injury. Neurologic deficits from penetrating assault were established and final at the time of presentation. Concern for protecting the neck should not hinder the evaluation process or life saving procedures.     

颈脊髓损伤患者医院获得性肺炎及其病原菌分析

目的:了解颈脊髓损伤(CSCI)患者医院获得性肺炎(HAP)的发生情况及病原菌的分布特点和耐药情况。方法:2008年10月～2010年8月我院骨科监护病区(OICU)共收治CSCI患者123例,其中完全性损伤32例,不完全性损伤91例,C1～C4损伤51例,C5～C7损伤72例。回顾性分析本组患者HAP发生情况及其病原菌分布特点与耐药情况,并采用χ2检验比较CSCI平面、程度与HAP发生、再次感染及耐药菌感染的关系。结果:共33例(26.8%)患者出现51例次HAP,其中C1～C4 CSCI者的HAP发生率、再次感染率及多重耐药菌感染率分别为39.2%(20/51)、13.7%(7/51)、58.8%(30/51,按例次计算),C5～C7损伤患者分别为18.1%(13/72)、6.9%(5/72)、20.8%(15/72),C1～C4损伤者与C5～C7损伤者比较差异有统计学意义(P<0.05);完全性CSCI患者的HAP发生率、再次感染率及多重耐药菌感染率分别为56.3%(18/32)、28.1%(9/32)、68.8%(22/32,按例次计算),不完全性CSCI者分别为16.5%(15/91)、3.3%(3/91)、20.9%(19/91),两者比较差异有统计学意义(P<0.05)。33例(51例次)HAP患者痰标本中共分离出93株病原菌,其中革兰氏阴性(G-)杆菌占63.4%,主要为肺炎克雷伯菌(17.20%)、铜绿假单胞菌(15.05%)、大肠埃希菌(13.98%)、鲍曼不动杆菌(10.75%);革兰氏阳性(G+)球菌主要为金黄色葡萄球菌(8.60%);真菌主要为热带假丝酵母菌(8.60%)。G-杆菌和G+球菌普遍呈现多药耐药性,G-杆菌以碳青霉烯类敏感率最高,G+球菌对万古霉素均敏感。结论:CSCI患者HAP发生率较高,其发生率与CSCI平面及程度明显相关;病原菌以G-杆菌为主,常呈多药耐药。