脊髓损伤早期手术及康复训练的疗效分析

目的介绍脊髓损伤早期脊髓探查和脊髓软化切开手术的术式和术后步行训练方法并分析其疗效。方法对40例完全性脊髓损伤30 d内的患者行脊柱脊髓损伤早期联合手术方式:一次性完成椎体内固定、松解硬脊膜下粘连、脊髓内外彻底清创减压,从而减轻脊髓二次损伤,保护神经细胞和残存神经纤维;术后辅以个体化脊柱固定减负背心,开展伤后早期康复训练;术后进行6个月的定期脊髓功能评价。结果术中术后未发生手术部位大出血、感染、残损加重等并发症。术后6个月,美国脊柱损伤协会(ASIA)残损分级A级17例、B级5例、C级11例、D级7例。ASIA评分:平均运动提高16.7分、针刺觉提高10.32分、轻触觉提高11.52分。结论在脊髓损伤早期行脊髓探查和脊髓软化切开手术是安全有效的,可恢复部分患者的部分脊髓功能。     

Electroconvulsive therapy is associated with lower readmission rates in patients with schizophrenia

BackgroundElectroconvulsive therapy is an important somatic treatment for severe mental disorders with established efficacy and safety. However, data on the relationship between ECT and the readmission rate of patients with schizophrenia are scarce. This study will explore the association between the administration of ECT and readmission rates using a machine learning method.MethodsInpatient medical records from the year of 2016 in one large psychiatric hospital in Beijing, China, were analyzed using a machine learning algorithm to determine the most important variables affecting readmission of patients with schizophrenia.ResultsThe medical records of 2131 inpatients with schizophrenia were reviewed. 1099 patients were followed up within 3 months of their index admission (642 ECT cases and 457 non-ECT cases) and 1032 patients were followed up within 6 months (596 ECT cases and 436 non-ECT cases) after discharge. The 3- and 6-month readmission rates in the ECT group (11.37% and 17.94%, respectively) were significantly lower than that of the patients who did not receive ECT (18.79% and 29.36%, respectively, both p < 0.001). The risk of readmission was significantly associated with male sex, older age, being married, having a lower income, a shorter inpatient length of stay, and receiving specific antipsychotic medications including olanzapine, paliperidone, clozapine, and haloperidol during the index admission. In the ECT group, patients who received 9 or more treatments were significantly less likely to be readmitted.ConclusionReceiving ECT may be associated with a lower risk of readmission in patients with schizophrenia.     

Factors associated with readmission to a psychiatric facility

This study examined patient-related factors that were associated with readmission to a tertiary care psychiatric hospital in Canada. The charts of a random sample of 200 patients were reviewed from an index discharge date in 1991 through subsequent rehospitalizations over the next three years. Eighty-eight patients (44 percent) were readmitted at least once. The only variable that significantly differentiated patients who were readmitted from those who were not was a history of admission. System variables or factors that are not patient related, such as staff attitudes and perceptions, may contribute to readmission and thus may warrant further exploration.     

The Seattle spine score: Predicting 30-day complication risk in adult spinal deformity surgery

BackgroundComplication rates in complex spine surgery range from 25% to 80% in published studies. Numerous studies have shown that surgeons are not able to accurately predict whether patients are likely to face post-operative complications, in part due to biases based on individual experience. The purpose of this study was to develop and evaluate a predictive risk model and decision support system that could accurately predict the likelihood of 30-day postoperative complications in complex spine surgery based on routinely measured preoperative variables.MethodsPreoperative and postoperative data were collected for 136 patients by reviewing medical records. Logistic regression analysis (LRA) was applied to develop the predictive algorithm based on patient demographic parameters, including age, gender, and co-morbidities, including obesity, diabetes, hypertension and anemia. We additionally compared the performance of the predictive model to a spine surgeon’s ability to predict patient complications using signal detection theory statistics representing sensitivity and response bias (A′ and B″ respectively). We developed a decision support system tool, based on the LRA predictive algorithm, that was able to provide a numeric probabilistic likelihood statistic representing an individual patient’s risk of developing a complication within the first 30 days after surgery.ResultsThe predictive model was significant (χ² = 16.242, p < 0.05), showed good fit, and was calibrated by using area under the receiver operating characteristics curve analysis (AUROC = 0.712, p < 0.01). The model yielded a predictive accuracy of 75.0%. It was validated by splitting the data set, comparing subset models, and testing them with unknown data. Validation also involved comparing the classification of cases by experts with the classification of cases by the model. The model significantly improved the classification accuracy of physicians involved in the delivery of complex spine surgical care.ConclusionsThe application of technology and data-driven tools to advanced surgical practice has the potential to improve decision making quality, service quality and patient safety.     

神经义肢技术在脊髓损伤患者康复中的应用进展

神经义肢技术基于脑机接口,通过分析脑电信号获得控制命令直接作用于肌肉系统或外部设备,从而代偿脑-脊髓-肌肉传出通路,恢复脊髓损伤患者运动功能。该项技术涉及脑科学、认知科学、生物医学工程、信息与通信工程、控制科学与工程等多学科。本文拟对近年来神经义肢技术在脊髓损伤患者康复中的应用进展进行概述。     

Indirect decompression in spinal surgery

Indirect decompression in spinal surgery means decompression of spinal nerve tissues, such as spinal cord and nerve, without resecting the compressing tissue. Indirect spinal decompression procedures largely can be divided into segmental procedures and global spinal alignment procedures. Segmental procedures are mainly performed by the distraction between two vertebrae, which lead to the opening of the neural foramen and increases the epidural space. Such distraction can be performed through the disc space or using posterior instrumentation. Global spinal alignment procedures allow the spinal cord to migrate dorsally away from areas of anterior compression. Understanding the indirect spinal decompression procedures may broaden the options for surgical treatment and decrease the risk of spinal nerve tissue injury.     

Predictors of 30-day postoperative systemic complications in geriatric patients undergoing elective brain tumor surgery

Little evidence exists to guide the preoperative selection of elderly brain tumor patients who are fit for surgery. We aimed to evaluate the safety of brain tumor resection in geriatric patients and identify predictors of postoperative 30-day systemic complications. We conducted a retrospective cohort study of 212 consecutive patients at or above the age of 60 years who underwent elective brain tumor resection between 2007 and 2017. The primary outcome measures analyzed were perioperative systemic complications within 30 days after the operation. A total of 212 geriatric brain tumor patients were included. Fifty-two (24.5%) had a 30-day systemic complication. Among them, 29 (13.7%) had systemic infections, 13 (6.1%) had perioperative seizures, 10 (4.7%) had syndrome of inappropriate antidiuretic hormone secretion (SIADH), five (2.4%) had deep venous thrombosis (DVT), four (1.9%) had perioperative stroke, three (1.4%) had acute myocardial infarction (AMI) and three (1.4%) had central nervous system (CNS) infections. One patient (0.5%) died. Perioperative stroke was predicted by previous stroke (p = 0.040), chronic liver disease (p < 0.001) and vestibular schwannoma (p = 0.002 with reference to meningiomas). Perioperative AMI was predicted by co-existing ischemic heart disease (p = 0.031). Systemic infection was predicted by female gender (p = 0.007) and preoperative Karnofsky Performance Scale (KPS) score < 70 (p = 0.019). DVT was predicted by GBM (p = 0.014). In conclusion, brain tumor surgery can be safe in carefully-selected geriatric patients. The risk factors identified in this study would be helpful to select suitable candidates for surgery.     

Development and validation of a prediction model for home discharge in patients with moderate stroke: The Korean stroke cohort for functioning and rehabilitation study

ABSTRACT

Background

Previous studies have investigated the predictors for home discharge without considering stroke severity.     

Preoperative embolization in spinal tumour surgery: Enhancing its effectiveness

We conducted a retrospective review of 221 patients, who underwent spinal oncologic surgery at a tertiary university hospital between 2005 and 2014; in order to identify and validate factors that influence the impact of preoperative embolization of spinal tumours on outcome measures of blood loss and transfusion requirements in spinal oncologic surgery. We also focused on primary tumour type and type of spinal surgery performed. Patients’ electronic and physical records were reviewed to provide demographic data, tumour characteristics, embolization techniques and surgical procedure details. These data were analysed against recorded outcome measures of blood loss (absolute volume and haemoglobin reduction) and transfusion requirements. Forty eight patients who received preoperative embolization were compared against 173 patients who did not. There was a tendency towards reduced blood loss and transfusion requirements in embolized spinal metastases from HCC and thyroid; as well as primary spine tumours, though the differences were not significant. Total embolization of arterial supply to spinal tumours resulted in significantly less blood loss as compared to partial or subtotal embolization. In addition, median blood loss was lower in patients receiving a more proximal embolization and in patients who underwent surgery between 13 and 24 h post-embolization despite the insignificant difference. To conclude, preoperative spinal tumour embolization is likely to be effective in reducing blood loss if a total embolization is performed 13–24 h prior to the surgery. Similarly, the impact of embolization is likely to be more profound in metastases from HCC, thyroid and primary spine tumours.     

功能锻炼在胸腰椎骨折合并脊髓损伤患者护理工作中的应用

目的探讨功能锻炼在胸腰椎骨折合并脊髓损伤患者护理工作中的应用。方法回顾性分析我院2014-05—2015-05收治的90例胸腰椎骨折合并脊髓损伤患者的临床资料,按照就诊时间顺序分为常规护理组与功能锻炼组,每组45例,对比2组康复情况、并发症发生率、焦虑抑郁评分。结果常规护理的康复恢复率为62.22%,功能锻炼组为82.22%,功能锻炼组的康复恢复率明显高于常规护理组,差异具有统计学意义(χ2=4.79,P0.05)。常规护理组并发症发生率为22.22%,功能锻炼组为8.89%,功能锻炼组的并发症发生率明显低于常规护理组,差异具有统计学意义(χ2=4.62,P0.05)。锻炼组焦虑评分与抑郁评分相比均明显低于常规护理组,差异具有统计学意义(t=4.32,P0.05;t=4.52,P0.05)。结论于常规护理基础上加用功能锻炼护理可提高胸腰椎骨折合并脊髓损伤患者的康复效果,降低并发症发生率,降低焦虑抑郁评分,值得推广与应用。     

Genomic microdeletions associated with epilepsy: not a contraindication to resective surgery

Purpose: Several recent reports of genomic microdeletions in epilepsy will generate further research; discovery of more microdeletions and other important classes of variants may follow. Detection of such genetic abnormalities in patients being evaluated for surgical treatment might raise concern that a genetic defect, possibly widely expressed in the brain, will affect surgical outcome. Methods: A reevaluation was undertaken of clinical presurgical data, histopathology of surgical specimen, and postsurgical outcome in patients with mesial temporal lobe epilepsy (MTLE) who have had surgical treatment for their drug‐resistant seizures, and who have been found to have particular genomic microdeletions. Key Findings: Three thousand eight hundred twelve patients with epilepsy were genotyped and had a genome‐wide screen to identify copy number variation. Ten patients with MTLE, who had resective epilepsy surgery, were found to have 16p13.11 microdeletions or other microdeletions >1 Mb. On histopathology, eight had classical hippocampal sclerosis (HS), one had nonspecific findings, and one had a hamartoma. Median postsurgical follow‐up time was 48 months (range 10–156 months). All patients with HS were seizure‐free after surgery, International League Against Epilepsy (ILAE) outcome class 1, at last follow‐up; the patient with nonspecific pathology had recurrence of infrequent seizures after 7 years of seizure freedom. The patient with a hamartoma never became seizure‐free. Significance: Large microdeletions can be found in patients with “typical” MTLE. In this small series, patients with MTLE who meet criteria for resective surgery and harbor large microdeletions, at least those we have detected, can have a good postsurgical outcome. Our findings add to the spectrum of causal heterogeneity of MTLE + HS.     

脊柱外科术后脑脊液漏并颅内感染的诊治分析

目的 探讨脊柱外科术后脑脊液漏并颅内感染的治疗方案及临床疗效.方法 回顾性分析2014年1月至2020年1月收治的11例脊柱外科手术后发生脑脊液漏并颅内感染的临床资料.5例单纯抗感染治疗,1例保持引流并抗感染治疗,5例抗感染联合腰大池引流治疗.结果 11例感染均有效控制;术后至出现发热时间5～11 d,平均(7.46±...     

Sleep-disordered breathing is associated with disturbed cardiac repolarization in patients with a coronary artery bypass graft surgery

BackgroundThe development of malignant ventricular arrhythmias due to abnormal cardiac repolarization is a major complication after coronary artery bypass graft surgery (CABG). Sleep-disordered breathing (SDB) is linked to prolonged cardiac repolarization in non-surgical patients. This study evaluates cardiac repolarization in patients with and without SDB who underwent CABG.Methods100 patients who had received CABG (84% men, age 68 ± 10 years, body-mass-index [BMI] 28.7 ± 4.2 kg/m²) were retrospectively evaluated. Polygraphy was recorded the night before CABG. SDB was defined as an apnea-hypopnea index (AHI) of ≥15/h and differentiated into central (CSA) and obstructive (OSA) sleep apnea. Cardiac repolarization was assessed by means of T-peak-to-end (TpTe) and QTc-intervals and TpTe/QT-ratios derived from 12-lead electrocardiography (ECG).Results37% of patients had SDB, 14% CSA and 23% OSA. Before CABG, patients with CSA and OSA had longer TpTe intervals than those without SDB (TpTe: CSA 100 ± 26 vs. OSA 97 ± 19 vs. no SDB 85 ± 14 ms, p = 0.013). QTc intervals and TpTe/QT ratios differed between the two groups (QTc: 444 ± 54 vs. 462 ± 36 vs. 421 ± 32 ms, p < 0.001; TpTe/QT ratio: 0.24 ± 0.04 vs. 0.23 ± 0.05 vs. 0.21 ± 0.03, p = 0.045). SDB was associated with abnormal cardiac repolarization independent of known risk factors for cardiac arrhythmias, such as age, sex, BMI, N-terminal-pro-brain-natriuretic-peptide (NT-proBNP), and heart failure (TpTe: B-coefficient [95%CI]: 16.0, [7.6–24.3], p < 0.001; QTc: 27.2 [9.3–45.1], p = 0.003; TpTe/QT ratio: 2.9 [1.2–4.6], p < 0.001).ConclusionIndependent of known risk factors for cardiac arrhythmias, SDB was significantly associated with abnormal cardiac repolarization before CABG. Data suggest that SDB may contribute to an increased risk of ventricular arrhythmias after CABG.     

Heat production associated with synaptic transmission in the bullfrog spinal cord

By using heat detectors made with pyroelectric film, rapid heat production by the bullfrog spinal cord in response to dorsal root stimulation has been demonstrated. The heat production rises to its peak in about 100 ms after the arrival of afferent impulses and falls slowly with a time course comparable to that of the dorsal root potential. Stimulation of the ventral roots produces no detectable heat. The heat production was reversibly suppressed by immersion of the cord in a low Ca2+, high Mg2+ salt solution, indicating that the underlying exothermic process is associated with intraspinal synaptic transmission. The source of this 'synaptic heat' is located near the boundary between the dorsal column and the substantia gelatinosa in the vicinity of the stimulated dorsal roots.     

Major histocompatibility complex class II expression by activated microglia caudal to lesions of descending tracts in the human spinal cord is not associated with a T cell response

Lesion-induced microglial/macrophage responses were investigated in post-mortem human spinal cord tissue of 20 patients who had died at a range of survival times after spinal trauma or brain infarction. Caudal to the spinal cord injury or brain infarction, a strong increase in the number of activated microglial cells was observed within the denervated intermediate grey matter and ventral horn of patients who died shortly after the insult (4–14 days). These cells were positive for the leucocyte common antigen (LCA) and for the major histocompatibility complex class II antigen (MHC II), with only a small proportion staining for the CD68 antigen. After longer survival times (1–4 months), MHC II-immunoreactivity (MHC II-IR) was clearly reduced in the grey matter but abundant in the white matter, specifically within the degenerating corticospinal tract, co-localising with CD68. In this fibre tract, elevated MHC II-IR and CD68-IR were still detectable 1 year after trauma or stroke. It is likely that the subsequent expression of CD68 on MHC II-positive microglia reflects the conversion to a macrophage phenotype, when cells are phagocytosing degenerating presynaptic terminals in grey matter target regions at early survival times and removing axonal and myelin debris in descending tracts at later survival times. No T or B cell invasion or involvement of co-stimulatory B7 molecules (CD80 and CD86) was observed. It is possible that the up-regulation of MHC II on microglia that lack the expression of B7 molecules may be responsible for the prevention of a T cell response, thus protecting the spinal cord from secondary tissue damage. Received: 12 October 1999 / Revised: 31 January 2000 / Accepted: 8 February 2000     

Inducing inflammation following subacute spinal cord injury in female rats: A double-edged sword to promote motor recovery

The inflammatory response following spinal cord injury is associated with increased tissue damage and impaired functional recovery. However, inflammation can also promote plasticity and the secretion of growth-promoting substances. Previously we have shown that inducing inflammation with a systemic injection of lipopolysaccharide in the chronic (8 weeks) stage of spinal cord injury enhances neuronal sprouting and the efficacy of rehabilitative training in rats. Here, we tested whether administration of lipopolysaccharide in female rats in the subacute (10 days) stage of spinal cord injury would have a similar effect. Since the lesioned environment is already in a pro-inflammatory state at this earlier time after injury, we hypothesized that triggering a second immune response may not be beneficial for recovery. Contrary to our hypothesis, we found that eliciting an inflammatory response 10 days after spinal cord injury enhanced the recovery of the ipsilesional forelimb in rehabilitative training. Compared to rats that received rehabilitative training without treatment, rats that received systemic lipopolysaccharide showed restored motor function without the use of compensatory strategies that translated beyond the trained task. Furthermore, lipopolysaccharide treatment paradoxically promoted the resolution of chronic neuroinflammation around the lesion site. Unfortunately, re-triggering a systemic immune response after spinal cord injury also resulted in a long-term increase in anxiety-like behaviour.     

Conservative treatment of spontaneous spinal epidural hematoma associated with oral anticoagulant therapy in a child

Objective Spontaneous spinal epidural hematoma (SSEH) is rare in the pediatric population. This case report reviews the indications and strategies for nonoperative management in selected patients. Methods An eight-year-old boy presented with back pain. There was no antecedent trauma, but the patient was anticoagulated for a mechanical heart valve. MRI revealed an epidural mass from T12 to L2 consistent with SSEH. The absence of focal neurologic deficits, combined with the high stroke risk with anticoagulation reversal, prompted a nonoperative approach. Clinical symptoms resolved over several weeks while maintaining therapeutic anticoagulation. Follow-up MRI demonstrated resolution of the hematoma. Conclusion SSEH can present in the setting of poorly controlled therapeutic anticoagulation in the pediatric population. This case supports the premise that patients who present with SSEH without focal neurologic deficit can be successfully managed while maintaining therapeutic levels of anticoagulation. Close follow-up with frequent neurologic examinations, imaging and monitoring of the prothrombin time is mandatory.     

Increased S-nitrosothiols are associated with spinal cord injury in multiple sclerosis

Multiple sclerosis (MS) is an immune-mediated disorder associated with inflammation, demyelination and axonal damage. In search of potential biomarkers of spinal cord lesions in MS related to nitric oxide metabolites, we measured total nitrite and nitrate levels, and protein-bound nitrotyrosine and S-nitrosothiol concentrations in the serum of MS patients at different stages of the disease. Sixty-eight patients and 36 healthy volunteers were included in the study. Total nitrite and nitrate levels were augmented in relapsing-remitting MS, while increased S-nitrosothiol concentrations were found both in relapsing-remitting and secondary-progressive MS. Further analysis demonstrated that S-nitrosothiol levels were selectively increased in patients with spinal cord injury. The data suggest that high S-nitrosothiol concentration may be a potential serum biomarker for spinal cord injury in MS.