Residual complaints following lumbar disc surgery: prognostic indicators of outcome

Physical as well as psychological features might be important prognostic factors for residual complaints following lumbar disc surgery in primary care. No studies have yet investigated both factors simultaneously. The aim of this prospective cohort study was to identify indicators of the short and long-term outcome of residual complaints following lumbar disc surgery. Patients (n=105), aged between 18 and 65 years, were included if they still suffered residual complaints 6 weeks after first-time lumbar disc surgery and had therefore been referred to physiotherapy. All potential indicators were measured at baseline except treatment expectancy, which was measured after two treatment sessions enabling patients to rate treatment expectancy based on their actual perception of the treatment. Dimensions of recovery included perceived recovery, functional status, and pain intensity (back and leg) at the 3-month and 12-month follow-up. It was found that high treatment expectancy was associated with a favorable outcome on perceived recovery and functional status, both at the 3 and the 12-month follow-up. Taking pain medication and a poor functional status at baseline were associated with poor perceived recovery and functional status at both follow-up measurements. Leg pain and back pain at baseline were associated with residual leg and back pain at the 3 and the 12-month follow-up, respectively. The results for perceived recovery and functional status were rather robust. However, for leg pain and back pain, the results were less stable. Apparently, the clinical course to recovery of residual leg pain and residual back pain is not strongly influenced by these indicators.     

Microendoscopic discectomy for recurrent lumbar disc herniation*

Introduction: The purpose of this study is to elucidate the feasibility of microendoscopic discectomy (MED) for the treatment of recurrent lumbar disc herniation. Methods: Thirty‐six patients with recurrent lumbar disc herniation were treated using MED (30 men and six women; mean age: 45.7 years, range: 26–80 years; mean follow‐up: 24.4 months, range: 12–52 months; mean duration between the primary and revision surgery: 65.9 months, range: 1–320 months) (recurrent group). Sex‐ and age‐matched patients with primary lumbar disc herniation treated by MED served as the control group (primary group). The clinical outcomes were evaluated using the Japanese Orthopaedic Association score for low back pain and questionnaires regarding MED. Results: The average Japanese Orthopaedic Association scores before surgery and at the final follow‐up were significantly lower in the recurrent group than in the primary group (10.8 ± 3.4 versus 15.0 ± 4.0 before surgery, P=0.001 and 25.4 ± 2.6 versus 26.8 ± 1.9 at follow‐up, P=0.013), while the average recovery rates were not significantly different between the two groups (80.3 ± 14.1% versus 84.5 ± 14.6, P=0.22). The surgical time was significantly longer for the recurrent group than for the primary group (83.0 ± 41.8 min versus 67.1 ± 18.1 min,P=0.042). Of the 18 questionnaire respondents, 17 answered that postoperative pain was milder after MED than after a standard discectomy. Conclusion: MED is a feasible surgical option for recurrent lumbar disc herniation, yielding surgical outcomes comparable to those obtained in primary lumbar disc herniation.     

老年腰椎间盘突出症的手术治疗策略

目的：探讨老年腰椎间盘突出症的手术治疗策略。方法：综述相关文献,对老年腰椎间盘突出症的手术治疗方案进行系统总结。结果：老年腰椎间盘突出症手术术式包括传统经典减压术、脊柱内窥镜技术、脊柱融合术,并配合基于快速康复理念的围手术期治疗。结论：老年腰椎间盘突出症患者常合并多种并发症,选择合理的手术治疗方案,积极预防并发症,术后均可取得满意疗效。     

Late renal transplant failure: an adverse prognostic factor at initiation of peritoneal dialysis.

BACKGROUND: Early renal transplant failure necessitating a return to dialysis has been shown to be a poor prognostic factor for survival. Little is known about the outcome of patients with late transplant failure returning to dialysis. It was our clinical impression that late transplant failure (>2 months) carries an increased morbidity and mortality risk in patients returning to dialysis. OBJECTIVE: To determine whether patients with a failed renal transplant have an outcome different to those on dialysis who have never received a kidney transplant. SETTING: Peritoneal dialysis (PD) unit in a teaching hospital. PATIENTS AND DESIGN: All failed renal transplant patients (fTx) in the Toronto Hospital Peritoneal Dialysis program between 1989 and 1996 were identified. This cohort of 42 fTx patients was compared with a cohort of randomly selected never-transplanted PD patients (non-Tx).The PD program was selected because of the availability of well-documented patient archival material. The non-Tx group was matched for age and presence of diabetes. Data were collected until retransplantation, change of dialysis modality or center, death, or until June 1998. RESULTS: There was no difference at initiation of PD between groups in serum albumin, residual renal function, or mean serum parathyroid hormone level. The mean low-density lipoprotein level was significantly higher in the fTx cohort. The duration of dialysis before Tx in fTx patients accounted for the increased total length of dialysis in fTx (mean 15 months). However, post-Tx the duration of PD was similar for both groups (30.7 months for fTx vs 31.6 months for non-Tx). The fTx group had a considerably worse outcome than the non-Tx group. The time to first peritonitis, subsequent episodes of peritonitis, catheter change, or transfer to hemodialysis occurred at a much faster rate in fTx patients.The most dramatic difference was in survival. There were 3 deaths in the non-Tx group and 12 in the fTx group (p < 0.01). The mean age at time of death in the fTx group was 47.5 years. Deaths were due mainly to gram-negative peritonitis and cardiovascular disease. CONCLUSIONS: We conclude that late failed renal transplant patients starting dialysis are at increased risk of complications and have strikingly higher mortality rates than non-Tx patients. A previously failed kidney transplant can be considered an adverse prognostic factor for patients commencing PD; these patients need to be closely monitored. Although this study was limited to PD patients, the same principles likely apply to fTx patients returning to any form of renal replacement therapy.     

腰椎间盘突出症康复治疗效果与腰椎CT影像结果的关系

目的：探讨腰椎间盘突出症患者康复治疗后腰椎功能恢复与腰椎CT影像的关系。方法：对134例腰椎间盘突出症患者治疗前后进行观察,根据突出物的不同水平层面分为单节段与多节段突出,根据突出物不同突,出程度分为膨出型,突出型和膨出加突出型。结果：治疗后单节段突出患者比多节段突出患者腰椎功能改善明显,膨出型患者比突出型和膨出加突出型患者腰椎功能改善明显,结论：腰椎间盘突出症患者康复治疗后功能恢复与椎间盘突出的程度和节段密切相关。     

Heterogeneity of Patients With Latent Autoimmune Diabetes in Adults: Linkage to Autoimmunity Is Apparent Only in Those With Perceived Need for Insulin Treatment: Results from the Nord-Tr?ndelag Health (HUNT) study

OBJECTIVE—Subjects with the diagnosis of latent autoimmune diabetes in adults (LADA) are more prone to need insulin treatment than those with type 2 diabetes. However, not all patients with LADA develop the need for insulin treatment, indicating the heterogeneity of LADA. We investigated this heterogeneity by comparing phenotypes of LADA with and without perceived need for insulin treatment (data obtained at times when diagnosis of LADA was not investigated) and also compared LADA and type 2 diabetes phenotypes.RESEARCH DESIGN AND METHODS—We used data from the all population–based Nord-Trøndelag Health study (n = 64,931), performed in 1995–1997. Data were assembled for individuals with LADA (n = 106) and type 2 diabetes (n = 943).RESULTS—In the comparison of individuals with LADA both with and without the need for insulin, insulin-treated subjects had higher titers of GAD antibodies (P < 0.001) and lower fasting C-peptide levels (P < 0.001). GAD antibodies and C-peptide correlated negatively (r = −0.40; P = 0.009). In the comparison of individuals with LADA and type 2 diabetes, all without the need for insulin, markers of metabolic syndrome were equally prevalent and pronounced. Age, C-peptide, and glucose levels were also similar. In the comparison of insulin-treated individuals with LADA and type 2 diabetes, more patients with LADA received insulin (40 vs. 22%, P < 0.001) and C-peptide levels were lower (P < 0.001). Patients with LADA were leaner but were still overweight (mean BMI 28.7 vs. 30.9 kg/m² in type 2 diabetes, P < 0.001). In the comparison of type 2 diabetic patients with and without insulin, insulin-treated subjects were more obese and had higher A1C and lower C-peptide levels (P < 0.001).CONCLUSIONS—Our conclusions are that 1) the need for insulin treatment in LADA is linked to the degree of autoimmunity and β-cell failure, 2) subjects with LADA and type 2 diabetes without the need for insulin treatment are phenotypically similar, and 3) insulin treatment in type 2 diabetic patients is associated with both insulin resistance and β-cell insufficiency.Autoimmunity is the major cause of type 1 diabetes. Autoimmunity is also assumed to be the major cause of latent autoimmune diabetes in adults (LADA) because this category of diabetes shares biochemical markers of β-cell–directed autoimmunity with “classic” type 1 diabetes. In clinical practice, autoimmunity in classic type 1 diabetes as well as in LADA is usually documented by antibodies against GAD.LADA is considered a “mild” form of type 1 diabetes. Mild indicates the fact that patients with LADA do not by clinical judgment need insulin from the time of diagnosis. However, within the first few years after the diagnosis of diabetes a need for insulin treatment develops in many patients with LADA. This distinguishes patients with LADA from those with nonautoimmune type 2 diabetes in whom a need for insulin treatment develops later than in those with LADA (1). An early need for insulin treatment in patients with LADA points to ongoing autoimmune-mediated destruction of β-cells in these patients.Risk factors for type 2 diabetes, such as age, obesity, and lack of physical activity, are associated with the development of LADA (2). In fact, odds ratios in terms of risk for diabetes for these factors of insulin resistance were the same for LADA and type 2 diabetes. This raises the question of the relative importance of autoimmunity vis-à-vis insulin resistance for the etiology of LADA and whether etiology differs among patients with LADA. Support for etiological heterogeneity comes from the large UK Prospective Diabetes Study (UKPDS), in which only a minority of patients with the diagnosis of LADA, when defined solely as GAD antibody positivity, developed the need for insulin treatment during 6 years of follow-up (1). The heterogeneity of LADA is also evident when one compares phenotypes of patients with LADA in different studies (3–6).Heterogeneity of patients with LADA could be further elucidated by comparing phenotypes of insulin-treated patients with LADA with those not treated with insulin. However, several conditions have to be met for such comparisons to be valid. First, groups of diabetic subjects to be compared must be drawn from the same geographically defined population. A population-based study is necessary to avoid the possible biases incurred by studying referral patients or patients selected for inclusion in clinical intervention studies. Second, the perceived need for insulin treatment has to be unbiased by LADA classification, because it has been shown that insulin treatment is initiated earlier when prior knowledge of autoimmunity, measured as GAD antibodies, is available (7). Third, valid comparison groups of insulin-treated and non–insulin-treated type 2 diabetic patients from the same population must be at hand.We had the opportunity to study patients with LADA and type 2 diabetes fulfilling the above-mentioned conditions, who were identified and characterized in the Nord-Trøndelag (HUNT) study. The HUNT study was performed between 1995 and 1997. The study was open to all adult subjects (∼90,000) living in a geographically defined area and had a high attendance rate (70%). To our knowledge, the patients with LADA and type 2 diabetes defined in the HUNT study did not participate in any study at the time of diagnosis and initiation of treatment, thereby minimizing any deviation from standard clinical practice and obviating increased attentiveness for signs of insufficient metabolic control and insulin requirement. Further, autoantibodies, such as GAD antibodies, were not measured by doctors (general practitioners) responsible for treatment in the region as part of the diabetes workup before and at the time of assembling data in 1995–1997. Thus, patients with autoimmune diabetes not requiring insulin at time of diagnosis were regarded and treated as type 2 diabetic patients. This assumption provided a unique opportunity to use the need for insulin as clinically perceived as a parameter for subclassifying patients with LADA and to compare phenotypes of insulin-treated and non–insulin-treated patients with LADA with respective groups of type 2 diabetic patients. Specifically, we wished to assess the influence of autoimmunity and β-cell insufficiency vis-à-vis insulin resistance factors for the perceived need for insulin treatment in patients with LADA.     

Effects of lumbar disc surgery on bone mineral density in women with lumbar disc disease

This prospective study evaluated 60 reproductive-age and postmenopausal women with lumbar disc disease to demonstrate the short-term effects of lumbar disc surgery on bone mineral density (BMD). Lumbar BMD was measured preoperatively and 3 months postoperatively by dual-energy X-ray absorptiometry (DEXA). Surgery was performed at only one level (L3-L4) and consisted of partial hemilaminectomy, discectomy, and, if necessary, partial facetectomy. Before surgery, 50% of the patients had osteopenia, and 31.7% had osteoporosis. After surgery, BMD decreased 5.5% in L3 vertebrae (P=.07), 14% in L4 vertebrae (P=.003), and 4.6% in L1-L4 (P=.039). Six of 11 patients with normal BMD before surgery became osteopenic postoperatively; 9 of 30 women with osteopenia fulfilled criteria for osteoporosis after surgery. Reproductive-age and postmenopausal women undergoing surgery for lumbar disc disease are at risk of bone loss and should be spared an extensive procedure, which can further increase the amount of bone lost. All women for whom a surgical intervention is planned should be evaluated by DEXA preoperatively and postoperatively.     

Re-operation after lumbar disc surgery: results in 85 cases

In this retrospective study, 85 patients previously operated on for lumbar disc herniation who had undergone re-operation due to persistent pain or recurrence of the symptoms were investigated. The surgical findings were: recurrent herniation (20%), epidural fibrosis alone (36.4%), small recurrent herniation with epidural fibrosis (28.2%), herniation at another level (10.6%), spinal stenosis (2.4%), lumbar pseudomeningocele (1.2%) and adhesive arachnoiditis (1.2%). The overall success rate of re-operation was 60%. The best results were obtained in recurrent disc herniation (47.1%) excellent and 35.3% good results) and in herniation at another level (77.8% excellent and 22.2% good). Re-operation in epidural fibrosis had less-satisfactory results (29.1% excellent and 12.9% good).     

Similar genetic features and different islet cell autoantibody pattern of latent autoimmune diabetes in adults (LADA) compared with adult-onset type 1 diabetes with rapid progression

OBJECTIVE: To compare the clinical parameters, C-peptide levels, pattern of islet cell-specific autoantibodies, and prevalence of predisposing genotypes in subjects with latent autoimmune diabetes in adults (LADA) and those with adult-onset type 1 diabetes with rapid progression. RESEARCH DESIGN AND METHODS: We evaluated the clinical parameters, C-peptide levels, and islet cell-specific autoantibodies in 54 LADA, 57 adult-onset type 1 diabetic, and 190 type 2 diabetic patients. Islet cell autoantibodies were also compared between subgroups of newly diagnosed patients with LADA and those with newly diagnosed adult-onset and childhood-onset type 1 diabetes. The genetic study was performed in subjects with LADA and those with adult-onset type 1 diabetes in comparison with a control population. RESULTS: There were no differences in the clinical parameters between LADA and adult-onset type 1 diabetes. Patients with LADA had lower BMI (P < 0.0001), waist-to-hip ratio (0.0029), total cholesterol (P = 0.001), and triglycerides (P = 0.001); higher HDL cholesterol levels (P < 0.0001); and lower prevalence of hypertension (P = 0.0028) compared with patients with type 2 diabetes. C-peptide levels were similar at onset (P = 0.403) but decreased less rapidly in LADA than in adult-onset type 1 diabetes (P = 0.0253). Single-autoantibody positivity was more often seen in LADA than in type 1 diabetes (P = 0.0001). The prevalence of predisposing HLA-DQB1*0302, -DR4, -DR3, and -DR3/DR4 genotypes and the DR4-DQB1*0302 haplotype were increased in both LADA and adult-onset type 1 diabetic subjects compared with the control population. There were no differences in the frequencies of these risk alleles and haplotypes between the two patient groups. CONCLUSIONS: Subjects with LADA had clinical characteristics similar to those with adult-onset type 1 diabetes with rapid progression. C-peptide levels did not differ at onset but decreased less rapidly in LADA. Patients with LADA rather had single islet cell-specific autoantibody positivity. The prevalence of HLA-DQB1*0302, -DR4, -DR3, and -DR3/DR4 risk alleles and the DR4-DQB1*0302 high-risk haplotype did not differ in the two forms of autoimmune diabetes.     

腰椎间盘镜治疗腰椎间盘突出症初步报告

目的 探讨显微内窥镜椎间盘切除术(MED)治疗腰椎间盘突出症的特点、适应症及并发症。方法 通道经腰棘突旁切口进入，在显微内窥镜下切除腰椎板下缘、黄韧带、关节突内侧。60例腰椎间盘突出症患者采用MED手术治疗，常规手术开窗法80例作对照，并比较两组出血量、手术时间、住院时间及恢复正常生活／工作时间。结果 所有病例均获得2—20个月随访，平均6．5个月按照Nakal分级，MED组优40例、良15例、可2例，优良率91．67％。结论 MED手术具有创伤小、疗效好、恢复快等特点。MED主要适用于单阶段外侧型腰椎间盘突出症，也适用于部分钙化或侧隐窝狭窄的腰椎间盘突出症，不适用于伴腰椎不稳或中央型腰椎管狭窄的腰椎间盘突出症患者。     

Artificial disc replacement--evolutionary treatment for degenerative disc disease

Back pain is a common problem that affects the majority of people at some point in their lives. Most back pain is not serious, but back pain caused by injury and aging can result in chronic pain that can last months, years, or indefinitely. Arthrodesis (ie, spinal, fusion) has been the treatment of choice for symptomatic degenerative disc disease that has not responded to conservative treatment modalities. Artificial disc replacement is a more recent option that preserves spinal motion but also recreates the natural function of the disc. The history of artificial disc replacement surgery, preoperative preparation, the surgical procedure, and postoperative recovery are discussed.     

The role of C-peptide levels in screening for latent autoimmune diabetes in adults

Early detection of latent autoimmune diabetes in adults (LADA) is important in that the earlier insulin therapy is initiated, the greater the preservation of pancreatic beta cells. This study assessed whether a random C-peptide level is an effective screening test for LADA. Random C-peptide levels were measured in 39 subjects with LADA and 39 subjects with type 2 diabetes who were matched for age, race, gender, and duration of diabetes. LADA was definitively diagnosed by the presence of antiglutamic acid decarboxylase antibodies. The mean C-peptide level in the LADA group was 1.0 +/- 0.2 ng/mL and 5.1 +/- 0.4 ng/mL in the group with type 2 diabetes. Only 1 LADA subject had a C-peptide level above the normal range, and all subjects with type 2 diabetes had a C-peptide level within or above the normal range. LADA can be ruled out in adult-onset diabetes by the presence of elevated C-peptide. The more expensive testing for anti-GAD antibodies to definitively diagnose LADA should be reserved for patients who on screening have a low or normal random C-peptide level.     

Microendoscopic discectomy for lumbar disc herniation in the elderly

Introduction: The purpose of this study was to elucidate the feasibility of microendoscopic discectomy (MED) for the treatment of lumbar disc herniation in elderly patients over the age of 65. Methods: The elderly group consisted of 44 patients (27 men and 17 women; mean age, 69.6 years; mean follow‐up, 27.7 months) with sciatic pain caused by lumbar disc herniation who were treated using MED. The younger group was comprised of 44 sex‐matched patients younger than 65 years. The younger group also had lumbar disc herniation treated with MED and served as the control group. The clinical outcomes were evaluated using the Japanese Orthopaedic Association score for low back pain (JOA score). Results: The results revealed that the good surgical outcomes achieved in the younger group were also achieved in the elderly group (JOA scores: 14.8 ± 4.1 in the younger group before surgery versus 13.0 ± 3.2 in the elderly group; 26.0 ± 2.4 at follow‐up versus 25.5 ± 2.7; recovery rates of JOA scores: 78.3 ± 17.8% versus 77.9 ± 16.6%, respectively). The mean surgical time was 78.3 ± 31.0 min in the elderly group and 69.2 ± 22.9 min (P=0.12) in the younger group; the blood loss was 33.9 ± 71.9 cc and 28.0 ± 37.8 cc (P=0.63), respectively. Complications included a dural tear in two elderly patients, and postoperative discitis and hematoma in one elderly patient each: all of these complications were managed successfully. Conclusion: The results of this study demonstrated that MED is a feasible minimally invasive surgical option for elderly patients with lumbar disc herniation.     

腰椎间盘突出症患者的腰背等速肌力评定

背景躯干生物力学的变化可能是腰椎间盘突出症发病和病后不愈的重要因素.目的通过对腰椎间盘突出症患者进行腰背肌力测试,以了解其躯干生物力学变化.设计以患者为研究对象,非随机化同期对照的回顾性研究.单位解放军第二军医大学长海医院康复医学科.对象2001-02/2002-01在第二军医大学长海医院康复医学科门诊治疗的腰椎间盘突出症患者30例为测试组,同期治疗非腰椎间盘突出症患者30例做对照组,均知情同意.方法利用多关节等速测试系统对受试者躯干的等速力矩进行测试.观察记录指标为腰背屈伸肌群的峰力矩(PT)、相对峰力矩(PT/BW)、到达峰力矩的时间(TPT)、0.2 s的力矩(T@0.2)、总功(TW)和平均功率(AP).同时测试了腰背屈/伸比值(F/E).结果利用SPSS 9.0软件包分析,采用t检验进行统计学处理.主要观察指标主要结局腰背部屈肌、伸肌等速肌力评定结果.次要结局腰背部屈伸比值评定结果.结果各种收缩速度时测试组患者的屈、伸肌力量均显著下降,肌肉的爆发力和做功的效率指标也变化明显,屈肌力量的下降比伸肌力量的下降更严重.F/E评定测试组等速向心收缩60°/s,180°/s分别为57.99±5.68,65.74±8.12;对照组分别为95.25±5.18,83.03±7.61,两组比较差异有显著性意义(P＜0.01).结论腰椎间盘突出症患者其力学改变是明确的,康复治疗应在准确评定这种改变的基础上,制订合适的、有针对性的训练方案,彻底纠正这种力学平衡,打断恶性循环.     

腰椎间盘突出症患者出院准备度与疼痛程度的相关性分析

目的探讨腰椎间盘突出症患者出院准备度现状、疼痛程度及其相关性。方法对2019年3月—9月河南省某三甲医院收治的196例腰椎间盘突出症患者采用出院准备度量表(RHDS)和疼痛数字分级法(NRS)进行问卷调查,并用Pearson相关分析法进行分析。结果腰椎间盘突出症患者RHDS总分为(94.17±8.56)分,处于偏高水平,3个维度中得分最高的是个人状态,其次是预期性支持,最后是适应能力。腰椎间盘突出症患者入院时NRS评分为(6.10±0.30)分,为中度疼痛;出院前4 h NRS评分为(1.70±0.50)分,为轻度疼痛;出院前4 h患者疼痛评分明显降低,差异有统计学意义(t=1.892,P<0.05)。腰椎间盘突出症患者的RHDS总分及3个维度得分均与患者出院前4 h的NRS评分呈负相关(P<0.05)。结论腰椎间盘突出症患者出院准备度处于较高水平,出院前疼痛程度明显减轻处于较低水平,两者呈负相关。医护人员应积极关注腰椎间盘突出症患者的出院准备度,帮助其减轻疼痛,促进患者康复。     

A clinical screening tool identifies autoimmune diabetes in adults

OBJECTIVE: Latent autoimmune diabetes in adults (LADA) is defined as adult-onset diabetes with circulating islet antibodies but not requiring insulin therapy initially. Diagnosing LADA has treatment implications because of the high risk of progression to insulin dependency. Currently, there are no recommendations for islet antibody testing in adult-onset diabetes. In this study, we aimed to develop a clinical screening tool to identify adults at high risk of LADA who require islet antibody testing. RESEARCH DESIGN AND METHODS: Subjects with LADA (n = 102, GAD antibody [GADA]+) and type 2 diabetes (n = 111, GADA-) (aged 30-75 years) were interviewed retrospectively. The clinical features documented were age of onset, acute symptoms of hyperglycemia, BMI, and personal and family history of autoimmune disease. Any clinical feature that was significantly more frequent in LADA was designated as a distinguishing clinical feature. In each subject, a "LADA clinical risk score," based on the total number of distinguishing features, was calculated. A prospective study of adults with newly diagnosed diabetes (n = 130) was used to determine whether the LADA clinical risk score could identify LADA. RESULTS: In the retrospective study, five clinical features were more frequent in LADA compared with type 2 diabetes at diagnosis: 1) age of onset <50 years (P < 0.0001), 2) acute symptoms (P < 0.0001), 3) BMI <25 kg/m2 (P = 0.0004), 4) personal history of autoimmune disease (P = 0.011), and 5) family history of autoimmune disease (P = 0.024). In the prospective study, the presence of at least two of these distinguishing clinical features (LADA clinical risk score > or =2) had a 90% sensitivity and 71% specificity for identifying LADA and a negative predictive value for a LADA clinical risk score < or =1 of 99%. CONCLUSIONS: At least two distinguishing clinical features are found in a majority of patients with LADA at diagnosis and can be used to identify adults with diabetes at higher risk for LADA.     

McKenzie疗法治疗腰椎间盘突出症的近期和远期疗效观察

目的:探讨McKenzie疗法对腰椎间盘突出症患者的近期和远期治疗效果。方法:将76例病人随机分为观察组和对照组,观察组采用牵引、推拿和McKenzie疗法治疗,对照组采用牵引和推拿治疗。观察两组患者治疗前、治疗后即时和治疗后10个月的腰椎功能评分及治疗后10个月的复发率。结果:两组间近期疗效差异不明显(P>0.05),但观察组治疗时间缩短(P<0.05);治疗后10个月观察组复发率明显低于对照组(P<0.01),腰椎功能评分则明显高于对照组(P<0.01)。结论:McKenzie疗法在缩短腰椎间盘突出症患者的治疗时间,提高远期疗效上有明显作用。     

经皮激光椎间盘减压术适应证的病例配对分析

背景:近年来经皮激光椎间盘减压术在国内逐步开展。但缺乏经皮激光椎间盘减压术适应证,禁忌证的细致研究。目的:分析经皮激光椎间盘减压术适应证的选择对疗效的影响。设计:以患者为观察对象的病例配对观察分析。单位:解放军第四七四医院放射科。对象:于1998-08/2004-12选取解放军第四七四医院经皮激光椎间盘减压术治疗的住院患者为观察对象。纳入病例对照68例。按照性别相同、年龄最接近(如同年龄的病例在2个或2个以上时,选择病程最接近的1个)的原则选择配对病例分两组,适应证不良组和适应证良好组,每组34例。方法:患者俯卧于血管造影床上,透视下在体表标记症状较重侧。局部麻醉。根据患者胖瘦不同,于患侧后正中线旁8～12cm进针,调整角度在神经根下方“安全三角”进入椎间盘,使其前端5mm裸露段,正好完全超出针尖。用15W激光烧灼,每持续1s,间隔4s,根据椎间盘面积调整激光总输出功率,一般1200-1700J。烧灼过程中将产生的气体抽出,至少抽3次,如患者出现胀痛的感觉要随时抽吸。术毕拔出穿刺针和光导纤维。局部贴创可贴。患者仰卧,检查疼痛缓解情况和功能恢复情况。出院时按照改良Macnab标准进行疗效评定。评估标准:优:疼痛消失,无运动功能受限,恢复正常工作和活动;良:偶有疼痛,能做轻工作;可:有些改善,仍有疼痛,不能工作;差:有神经受压表现,须进一步手术。将疗效优和良合并,作为疗效良好;可和差合并,作为疗效不佳。采用配对计数资料的χ2检验。主要观察指标:①所有病例出院时根据改良Macnab标准进行的适应证不良组和适应证良好组总体疗效评价;②椎间盘突出≥0.6cm组与椎间盘突出<0.6cm组疗效比较;③合并椎管狭窄组与椎管正常组疗效比较;④其他适应证不良组与适应证良好组疗效比较。结果:68例患者全部进入结果分析。①适应证良好组疗效良好明显高于适应证不良组,差异有显著性意义[85%(29/34),56%(19/34),χ2=5.06,P<0.05]。②椎间盘突出<0.6cm组疗效良好明显高于椎间盘突出≥0.6cm组,但差异无显著性意义[75%(6/8),50%(4/8),χ2=0.25,P>0.05]。③椎管正常组疗效良好与合并椎管狭窄组接近,差异无显著性意义[80%(12/15),73(11/15),χ2=0,P>0.05]。④适应证良好组疗效良好明显高于无其他适应证不良组,差异有显著性意义[100%(11/11),36%(4/11),χ2=5.14,P<0.05]。结论:适当地选择适应证能够有效地提高激光椎间盘减压术的治疗效果。     

Lower cervical disc prolapse may cause cervicogenic headache: prospective study in patients undergoing surgery

In 1983 Sjaastad published for the first time diagnostic criteria for cervicogenic headache. Until now there have been no prospective studies investigating whether cervical disc prolapse can cause cervicogenic headache. Between July 2002 and July 2003 50 patients with cervical disc prolapse proven by computed tomography, myelography or magnetic resonance imaging were recruited and prospectively followed for 3 months. Patients were asked at different time points about headache and neck pain by questionnaires and structured interviews. These data were collected prior to and 7 and 90 days after surgery for the disc prolapse. Fifty patients with lumbar disc prolapse, matched for age and sex, undergoing surgery were recruited as controls. Headache and neck pain was diagnosed according to International Headache Society (IHS) criteria. Twelve of 50 patients with cervical disc prolapse reported new headache and neck pain. Seven patients (58%) fulfilled the 2004 IHS criteria for cervicogenic headache. Two of 50 patients with lumbar disc prolapse had new headaches. Their headaches did not fulfil the criteria for cervicogenic headache. One week after surgery, 8/12 patients with cervical disc prolapse and headache reported to be pain free. One patient was improved and three were unchanged. Three months after cervical prolapse surgery, seven patients were pain free, three improved and two unchanged. This prospective study shows an association of low cervical prolapse with cervicogenic headache: headache and neck pain improves or disappears in 80% of patients after surgery for the cervical disc prolapse. These results indicate that pain afferents from the lower cervical roots can converge on the cervical trigeminal nucleus and the nucleus caudalis.     

Chronic complications in patients with slowly progressing autoimmune type 1 diabetes (LADA).

OBJECTIVE: To study the prevalence of chronic diabetic complications in patients with the slowly progressing autoimmune form of type 1 diabetes, also referred to as latent autoimmune diabetes in adults (LADA). RESEARCH DESIGN AND METHODS: We evaluated factors associated with chronic diabetic complications in 59 patients with GAD antibodies (GADAs) and age at onset of diabetes >35 years and in 59 GADA-negative type 2 diabetic patients. The prevalence of chronic complications was further compared with the prevalence in 111 type 1 diabetic patients. RESULTS: The LADA patients had lower BMI (P = 0.04), waist-to-hip ratio (P = 0.02 for men and P = 0.03 for women), and fasting C-peptide concentrations (P<0.001) higher HDL2 concentrations (P = 0.04), and less hypertension (58 vs. 75%, P = 0.05) than the type 2 diabetic patients. These differences were even more marked in patients with short disease duration. The prevalence of retinopathy (51 vs. 56%), neuropathy (29 vs. 27%), and microalbuminuria (27 vs. 29%) did not differ between the groups. The type 1 diabetic patients had lower prevalence of neuropathy (13%, P = 0.02) and higher prevalence of retinopathy (76%, P = 0.002) compared with the other groups. Neither the prevalence of coronary heart disease (CHD) (56 vs. 58%) nor cardiovascular mortality (7.4 vs. 12.4%, P = 0.2) significantly differed between the LADA and type 2 diabetic patients. In a multiple logistic regression analysis, glycemic control was associated with CHD (P = 0.02) in the LADA group but not in the type 2 diabetic group. CONCLUSIONS: Glycemic control is a stronger risk factor for cardiovascular disease in LADA patients than in patients with type 2 diabetes. This could be related to the lower prevalence of the metabolic syndrome seen in the former.