合并椎管内骨块的胸腰椎爆裂性骨折的后路手术治疗

[目的] 探讨合并椎管内骨块的胸腰椎爆裂性骨折的后路手术治疗.[方法] 根据病人术前X线片,CT扫描,MRI检查结果,结合临床表现,采取体位复位和/或一侧半椎板切除处理椎管内骨块,包括突入椎管内的小关节突骨块、椎板下陷骨块及突入椎管内的椎体后缘骨块等,对于前二类骨块予清理,而对后者骨块采用体位复位及椎体推挤、顶压、撑开上下椎弓根钉等综合方式复位,然后行椎弓根内固定系统进行固定.对于椎管内占位＜33%(1/3),无神经症状者,则行单纯内固定;对椎管占位＞50%(1/2)或椎管占位＜50%(1/2)但合并神经症状者,则在内固定同时予以植骨.[结果] 本组56例患者通过6～63个月随访,椎体后缘骨块致椎管占位由术前平均42%恢复到术后平均6.1%.椎体前缘高度丢失:术前(33%～75%)平均58%,术后(5%～25%)平均18%.来于椎管后方的附件突入骨块全部得到清理;术前Cobb's角(18°～40°)平均28°,术后恢复到(0°～16°)平均8°.神经功能恢复:术后神经功能均无加重,Frankel分级A级5例中,1例恢复至B级,其余B级以下病人均获得1～3级改善.[结论] 合并椎管内骨块的胸腰椎爆裂性骨折,其骨块来源有小关节突、椎板及椎体后缘,通过体位复位和/或后路半椎板切除能获得有效的清除或良好的减压及复位,同时获得较好的畸形矫正及椎管容积的恢复,促进神经功能恢复.     

L形骨块复位器辅助减压结合内固定治疗胸腰椎爆裂性骨折

目的探讨L形骨块复位器辅助减压结合内固定治疗胸腰椎爆裂性骨折的疗效。方法采取后路切开L形骨块复位器辅助椎管减压结合椎弓根钉棒系统内固定及植骨治疗30例胸腰椎爆裂性骨折患者。观察术后腰痛VAS评分、椎管中心矢状径占位率、矢状面Cobb角、伤椎前缘相对高度、Frankel神经功能分级等指标。结果患者均获得随访,时间12～24个月。术后1年,VAS评分由术前6.86分±0.30分降低到1.08分±0.24分,椎管占位率由术前53%±16%降低到9%±5%,矢状面Cobb角由术前16.27°±9.66°降低到2.62°±7.57°,伤椎前缘相对高度由术前59%±13%增加到91%±6%,各项指标手术前后比较差异均有统计学意义(P0.001)。术后1年神经功能Frankel分级除A级中1例未恢复,20例A～D级患者获得了≥1级的神经功能恢复。结论 L形骨块复位器辅助减压结合内固定治疗胸腰椎爆裂性骨折操作简单、椎体高度及椎管重建良好,疗效满意。     

椎管占位无神经损伤胸腰椎爆裂性骨折的手术治疗

目的 研究不减压后路AF内固定在椎管占位无神经损伤胸腰椎爆裂性骨折患者的临床疗效.方法 采用切开不减压后路AF内固定治疗37例椎管占位无神经损伤胸腰椎爆裂性骨折,术前CT检查显示椎管占位率平均20%,后凸畸形平均30,椎体高度平均压缩50%.结果 术后椎管占位率平均15%,后凸畸形平均10,椎体高度恢复平均90%.随访6～48个月,骨折在5个月左右愈合,遗留术后腰部不适2例.结论 对于这类患者行单纯后路切开复位,接减压,临床效果明显.     

AF系统复位内固定治疗胸腰椎单节段爆裂性骨折

目的探讨AF系统复位固定治疗胸腰椎爆裂性骨折的疗效。方法 AF系统经后路复位内固定、选择性椎管减压治疗胸腰椎单节段爆裂性骨折53例,对临床资料进行回顾性分析。结果经6～24个月随访,X线片测定椎体前后缘高度,前缘术前平均高度42.3%,术后95.4%;后缘术前平均高度82.4%,术后98.8%。Cobb角术前23.5°,术后3.2°,除脊髓神经完全损伤有1例无恢复,其余皆有完全、部分不同程度的恢复。结论 AF系统经后路复位内固定治疗胸腰椎爆裂性骨折具有操作简单、手术创伤小、复位固定牢靠高效、可以早期下地活动,是治疗胸腰椎单节段爆裂性骨折的良好内固定器械。     

非椎板减压经椎弓内固定治疗胸腰段爆裂性骨折的体会

目的 分析评价非椎板减压经椎弓根内固定治疗胸腰段爆裂性骨折的临床疗效.方法 16例胸腰椎爆裂性骨折采用非椎板减压经椎弓根内固定治疗,全部病例病椎均存在后凸畸形,角度15～45度,椎管内骨块突入,椎管容积减少程度20%～65%.术前神经功能评价按Frank分级：C级5例,D级8例,E级3例.结果 随访时间6～36个月,平均2年.全部病例恢复满意,植骨达到骨性融合.结论 非椎板减压经椎弓根内固定治疗胸腰段爆裂性骨折,损伤小,操作简便,维持了原椎体稳定结构,避免了直接椎板减压引起的继发的医源性椎管狭窄所致的并发症,术后恢复快的优点.     

经椎弓根植骨内固定治疗胸腰椎爆裂性骨折体会

目的总结应用经伤椎椎弓根置钉内固定结合椎体内植骨治疗胸腰椎爆裂性骨折的临床体会。方法对32例胸腰椎爆裂性骨折患者采用经椎弓根植骨内固定治疗,回顾性分析患者的临床资料。结果术后随访12~24个月,术后1个月及12个月患者椎体前缘较术前明显增加、Cobb角较术前明显改善,差异均有统计学意义(P0.05)。复查CT显示伤椎椎管减压充分,椎体内植骨块融合良好。未出现内固定松脱断裂、椎体前缘高度及Cobb角矫正丢失等病例。根据Frankel神经功能恢复评定标准,术前有神经功能损伤患者末次随访时均有1~2级的恢复。结论经伤椎椎弓根置钉内固定结合椎体内植骨治疗胸腰椎爆裂性骨折,植骨融合良好,并发症少,伤椎高度和脊柱生理曲度恢复满意。     

经椎板开窗减压复位加经椎弓根植骨和内固定术治疗胸腰椎爆裂性骨折

目的分析经后路椎弓根内固定加经椎板开窗椎管减压和经椎弓根椎体植骨治疗胸腰椎爆裂性骨折的疗效。方法对28例胸腰椎新鲜爆裂性骨折,患者应用后路椎弓根内固定复位,椎板开窗减压+经伤椎椎弓根向椎体前缘植入自体骨及同种异体骨或人工骨。结果术后椎体高度及生理弧度恢复满意,经随访18个月,椎体高度无明显丢失,椎体无塌陷变形,无内固定松动、断裂。结论经后路椎弓根内固定+经椎板开窗减压复位+经椎弓根椎体植骨治疗胸腰椎新鲜爆裂性骨折,手术安全,效果满意,术后并发症低,远期脊柱稳定性好。     

胸腰椎爆裂骨折的外科治疗分析

目的探讨胸腰椎爆裂骨折的最佳治疗方法。方法根据骨折类型不同,采用不同方法治疗胸腰椎爆裂性骨折89例,其中AF系统椎弓根钉内固定68例,Dick固定6例,ALPS固定8例,Luque棒固定2例,中华长城5例,并行植骨49例。结果随访9个月～3年6个月,平均2年。术后内固定稳固,骨折复位佳,椎管有效径恢复,术后神经功能较术前均有恢复。结论胸腰椎爆裂骨折,如骨折块占椎管容积>30%以上,椎管矢径小于10mm及伴有脊髓损伤者应积极进行手术椎管减压复位固定,矫正后倾角,同时术中脊髓造影、C臂机监视复位应达到以下标准:压缩椎体扩张80%以上;后弓角<10°,恢复椎管容积及脊髓减压,椎体间脱位完全复位。     

椎弓根螺钉治疗胸腰椎爆裂性骨折

目的探讨椎弓根螺钉在胸腰椎爆裂性骨折治疗中的疗效。方法回顾性分析2002年以来应用椎弓根螺钉的治疗45例胸腰椎骨折患者资料。全部患者采用后路椎管减压,椎体植骨加椎弓根螺钉内固定治疗。结果全部病例得到随访,平均20个月(6～60个月),其中18例脊髓不全损伤患者Frankel分级提高l～3级(平均2级)。A级10例有2例恢复到B级,1例恢复到C级,其余患者部分术后感觉平面下降或下肢感觉部分恢复,运动功能无明显改善。术后遗留轻度腰背痛3例,1例螺钉松动,无一例发生感染。随访病例均行X线片检查,后凸角由术前平均25°(11°～35°)矫正到术后10°(0°～15°),椎体前缘高度矢状径指数术前30°(15°～55°),恢复到术后85°(72°～100°)。结论后路椎管减压,椎体植骨加椎弓根螺钉内固定治疗胸腰椎爆裂性骨折是一种较理想的手术方法。此方法操作简单、安全,在解除神经及硬膜囊压迫的同时扩大了椎管,杜绝了继发性椎管狭窄,增加了脊柱稳定性,值得推广。     

后路短节段椎弓根钉结合经椎弓根植骨治疗胸腰椎爆裂性骨折

目的:分析后路短节段椎弓根钉结合经椎弓根植骨治疗胸腰椎爆裂性骨折的临床疗效。方法:自2008年3月至2013年3月,采用后路短节段椎弓根钉结合经椎弓根植骨内固定治疗胸腰椎爆裂性骨折62例,其中男40例,女22例;年龄17~65岁,平均38岁。按AO分型:A3.1型34例,A3.2型7例,A3.3型21例。载荷评分4~6分,平均5.4分。根据ASIA脊髓神经功能损伤分级:C级2例,D级5例,E级55例。术前、术后3 d及末次随访行X线及CT检查,测量并比较Cobb角、椎体前缘相对高度及椎管占位程度,同时观察椎体骨愈合情况及神经功能恢复情况。结果:62例均获随访,时间11~14个月,平均12.2个月。内固定拆除时间9~13个月,平均11.5个月。术后1例切口出现感染,经清创引流后愈合,2例术后出现轻度腰背部疼痛。术后半年ASIA脊髓神经功能损伤分级:C级1例,D级3例,E级58例。末次随访X线及CT显示所有骨折及植骨愈合良好。术后3 d,Cobb角、椎体前缘相对高度、椎管占位程度均较术前有明显改善(P<0.05),末次随访与术后3 d比较Cobb角、椎体前缘相对高度、椎管占位程度无明显变化(P>0.05)。结论:后路短节段椎弓根钉结合经椎弓根植骨是治疗胸腰椎爆裂性骨折较理想的方法,能够减少术后复位的丢失和防止内固定失败的发生。     

Vasopressor hormone response following mesenteric traction during major abdominal surgery

Background : We investigated the vasopressor hormone response following mesenteric traction (MT) with hypotension due to prostacyclin (PGI₂) release in patients undergoing abdominal surgery with a combined general and epidural anesthesia. Methods : In a prospective, randomized, placebo-controlled study we administered 400 mg ibuprofen (i.v.) in 42 patients scheduled for abdominal surgery. General anesthesia was combined with epidural anesthesia (T4-L1). Before as well as 5, 15, 30, 45, and 90 min after MT we recorded plasma osmolality, hemodynamics and measured 6-keto-PGFlα (stabile metabolite of PGI₂), TXB₂ (stabile metabolite of thromboxane A₂) active renin, and arginine vasopressin (AVP) plasma concentrations by radioimmunoassay. Catecholamine levels were assessed by high-pressure liquid chromatography (HPLC) with electrochemical detection. Results : Following MT, arterial hypotension occurred along with a substantial PGI₂ release. This was completely abolished by ibuprofen administration. Although plasma levels of 6-keto-PGF_1α (1133 (708) vs. 60 (3) ng/L, median (median absolute deviation), P=0.0001, placebo vs. ibuprofen) remained significantly elevated, blood pressure was restored within 30 min after MT in the placebo group. At the same point in time plasma concentrations of TXB² (164 (87) vs. 58 (1) ng/L, P=0.0001), epinephrine (46 (33) vs. 14 (6) ng/L, P=0.001), AVP (41 ± (18) vs. 12 (7) ng/L, P=0.0004), and active renin (27 (12) vs. 12 (4) ng/L, P = 0.001) were significantly higher in placebo-treated patients. Conclusion : Under combined general and epidural anesthesia arterial hypotension following MT due to endogenous PGI₂ release is associated with enhanced release of AVP, active renin, epinephrine and thromboxane A₂, presumably contributing to hemodynamic stability within 30 min after MT.     

A Teaspoon Pump for Pumping Blood with High Hydraulic Efficiency and Low Hemolysis Potential

Abstract: Virtually all blood pumps contain some kind of rubbing, sliding, closely moving machinery surfaces that are exposed to the blood being pumped. These valves, internal bearings, magnetic bearing position sensors, and shaft seals cause most of the problems with blood pumps. The original teaspoon pump design prevented the rubbing, sliding machinery surfaces from contacting the blood. However, the hydraulic efficiency was low because the blood was able to "slip around" the rotating impeller so that the blood itself never rotated fast enough to develop adequate pressure. An improved teaspoon blood pump has been designed and tested and has shown acceptable hydraulic performance and low hemolysis potential. The new pump uses a nonrotating "swinging" hose as the pump impeller. The fluid enters the pump through the center of the swinging hose; therefore, there can be no fluid slip between the revolving blood and the revolving impeller. The new pump uses an impeller that is comparable to a flexible garden hose. If the free end of the hose were swung around in a circle like half of a jump rope, the fluid inside the hose would rotate and develop pressure even though the hose impeller itself did not "rotate"; therefore, no rotating shaft seal or internal bearings are required.     

Microspheres Based Detoxification System: A New Method in Convective Blood Purification

Abstract: A variety of protein-bound or hydrophobic substances, accumulating as a result of pathologic conditions such as exogenous or endogenous intoxications, are removed poorly by conventional detoxification methods because of low accessibility (hemodialysis), insufficient adsorption capabilities (hemosorption), low efficiency (peritoneal dialysis), or economic limitations (high-volume plasmapheresis). Combining advantages of existing methods with microspheric technology, a module-based system was designed. Major operating parameters of the latter can be modified to allow for adjustment to individual clinical situations. An extracorporeal blood circuit including a plasmafilter is combined with a secondary high-velocity plasma circuit driven by a centrifugal pump. Different microspheric adsorbers can be combined in one circuit or applied in sequence. Thus, a prolonged treatment can be tailored using specially designed selective adsorber materials. Comparing this system with existing methods (high-flux hemodialysis, molecular adsorbent recycling system), results from our in vitro studies and animal experiments demonstrate the superior efficiency of substance removal.     

Tissue perfusion in relation to cardiac output during continuous positive-pressure ventilation and administration of propranolol or verapamil

Background : Our objective was to determine whether administration of propranolol or verapamil modifies the hemodynamic adaptation to continuous positive-pressure ventilation (CPPV), in particular the regional distribution of cardiac output (CO).
Methods : General hemodynamics and regional blood flows assessed by microsphere technique (15 (μm) were recorded in 16 anesthetized pigs during spontaneous breathing (SB) and CPPV with 8 cm H₂O end-expiratory pressure (CPPV8) before and after intravenous administration of propranolol (0.3 mg · kg⁻¹ followed by 0.15 mg · kg⁻¹ · h⁻¹, n=8) or verapamil (0.1 mg · kg⁻¹ followed by 0.3 mg · kg⁻¹ · h⁻¹, n=8).
Results : CPPV8 depressed CO by 25% without shifts in its relative distribution with the exception of a noteworthy increase in adrenal perfusion. Propranolol increased arterial blood pressure, and due to a fall in heart rate, CO dropped by 25%. The kidneys and, to a lesser extent, the splanchic region and central nervous system received increased fractions of the remaining CO at the expense of skeletal muscle flow. Similar patterns were seen during SB and CPPV8 such that the combination of propranolol and CPPV8 depressed CO by 50%. The circulatory effects of verapamil were less evident but myocardial perfusion tended to increase.
Conclusions : The combination of propranolol or verapamil with CPPV does not result in any specific hemodynamic interaction in anesthetized pigs, except that the combined effect of propranolol and CPPV may severely reduce CO.     

Bariatric Surgery in Some "Central and East-European (former Eastern bloc)"Countries - Current Status and Prediction for the Next Millennium

Background: Obesity is increasing globallly, including in the formerly "Eastern Bloc" countries. Methods: A survey was made of obesity and bariatric surgery. Results: In the 8 East and Central European countries studied, with total population 300 million, roughly 43% of the population was overweight (BMI 25-30), 23% obese (BMI > 30), with about 15 million people morbidly obese (BMI > 40). From 0-10 morbidly obese individuals/100,000/year undergo bariatric surgery. Conclusion: Most countries were found to provide inadequate treatment for obesity.The majority of the morbidly obese are not treated effectively. However, health-care awareness of obesity and bariatric surgeons are slowly increasing.     

Volatile anaesthetics reduce adhesion of blood platelets under low-flow conditions in the coronary system of isolated guinea pig hearts

Background : Inhibitory effects of volatile anaesthetics on platelet aggregation have been demonstrated in several studies. However, the influence of volatile anaesthetics on intracoronary platelet adhesion has not been elucidated so far.
Methods : Isolated hearts of guinea pigs were perfused with buffer in the absence or presence of volatile anaesthetics (0.5 and 1 MAC) at constant coronary flow rates of 5 ml/min for 25 min, then 1 ml/min for 30 min and again 5 ml/min for 10 min. Before, during and after low-flow perfusion, a bolus of human platelets was applied into the coronary system. To simulate thrombogenic conditions, 0.3 U/ml human thrombin was infused during low-flow perfusion and reperfusion. The number of platelets sequestered to the endothelium was calculated from the difference between coronary in- and output of platelets. The myocardial production of lactate and consumption of pyruvate and coronary perfusion pressure were also determined.
Results : At a flow rate of 5 ml/min only about 3% of the applied platelets did not emerge from the coronary system, in any group. In contrast, 13.1±1.2% (mean±SEM) of infused platelets became adherent in low-flow perfusion in the control group without anaesthetic. The adherence was reduced with each 1 MAC isoflurane (to 6.2±1.2%), sevoflurane (to 4.4±0.9%) or halothane (to 3.2±1.5%) (each P <0.05 vs. control). Volatile anaesthetic, 0.5 MAC, did not inhibit platelet adhesion to a statistically significant extent in any case. Perfusion pressure and metabolic parameters were not statistically different between the control and the hearts exposed to anaesthetics.
Conclusion : Volatile anaesthetics in a concentration of 1 MAC can reduce the adhesion of platelets in the coronary system under reduced flow conditions. This action does not arise from vasodilation or inhibition of ischaemic stress.     

Synergistic interaction between the effects of propofol and midazolam with fentanyl on phrenic nerve activity in rabbits

Background: It has been shown that the depressive effects of both propofol and midazolam on consciousness are synergistic with opioids, but the nature of their interactions on other physiological systems, e. g. respiration, has not been fully investigated. The present study examined the effect of propofol and midazolam alone and in combination with fentanyl on phrenic nerve activity (PNA) and whether such interactions are additive or synergistic. Methods: PNA was recorded in 27 anaesthetised and artificially ventilated rabbits. In three groups, propofol, fentanyl and midazolam were administered intravenously in incremental doses to construct dose-response curves for the depressant effects of each one on PNA. In another two groups, the effect of pretreatment with either fentanyl 1 μg · kg^?1 i. v. or midazolam 0.05 mg · kg^?1 i. v. on the effects of propofol and fentanyl respectively on PNA were studied. Results: Propofol and fentanyl caused a dose-dependent depression of PNA with complete abolition at the highest total doses of 16 mg · kg^?1 i. v. and 32 μg · kg^?1 i. v., respectively. In contrast, midazolam in incremental doses to a total of 0.8 mg · kg^?1 reduced mean PNA by 63%, but approximately 12% of PNA remained at a total dose as high as 6.4 mg · kg^?1. The mean ED₅₀s, calculated from dose-response curves, were 5.4 mg · kg^?1, 3.9 μg · kg^?1 and 0.4 mg · kg^?1 for propofol, fentanyl and midazolam, respectively. Initial doses of either fentanyl 1 μg · kg^?1 i. v. or midazolam 0.05 mg · kg^?1 i. v. acted synergistically with subsequent doses of either propofol or fentanyl to abolish PNA at total doses of 8 mg · kg^?1 and 8 μg · kg^?1, respectively. Conclusion: Fentanyl has a synergistic interaction with both propofol and midazolam on PNA and hence potentially on respiration.     

Influence of dopexamine hydrochloride on haemodynamics and regulators of circulation in patients undergoing major abdominal surgery

Background: Catecholaminergic support is often used to improve haemodynamics in patients undergoing major abdominal surgery. Dopexamine is a synthetic vasoactive catecholamine with beneficial microcirculatory properties. Methods: The influence of perioperative administration of dopexamine on cardiorespiratory data and important regulators of macro- and microcirculation were studied in 30 patients undergoing Whipple pancreaticduodenectomy. The patients received randomized and blinded either 2 μg · kg^?1 · min^?1 of dopexamine (n=15) or placebo (n=15, control group). The infusion was started after induction of anaesthesia and continued until the morning of the first postoperative day. Endothelin-1 (ET-1), vasopressin, atrial natriuretic peptide (ANP), and catecholamine plasma levels were measured from arterial blood samples. Measurements were carried out after induction of anaesthesia, 2 h after onset of surgery, at the end of surgery, 2 h after surgery, and on the morning of the first postoperative day. Results: Cardiac index (CI) increased significantly in the dopexamine group (from 2.61±0.41 to 4.57±0.78 1 · min^?1 · m^?2) and remained elevated until the morning of the first postoperative day. Oxygen delivery index (DO₂I) and oxygen consumption index (VO₂I) were also significantly increased in the dopexamine group (DO₂I: from 416±91 to 717±110 ml/m² · m²; VO₂I: from 98±25 to 157±22 ml/m² · m²), being significantly higher than in the control group. pHi remained stable only in the dopexamine patients, indicating adequate splanchnic perfusion. Vasopressive regulators of circulation increased significantly only in the untreated control patients (vasopressin: from 4.37±1.1 to 35.9±12.1 pg/ml; ET-1: from 2.88±0.91 to 6.91±1.20 pg/ml). Conclusion: Patients undergoing major abdominal surgery may profit from prophylactic perioperative administration of dopexamine hydrochloride in the form of improved haemodynamics and oxygenation as well as beneficial influence on important regulators of organ blood flow.     

A comparison of the inhibitory effects of four volatile anaesthetics on the metabolism of chlorzoxazone, a substrate for CYP2E1, in rabbits

Background: Halothane inhibits in vitro and in vivo activity of cytochrome P-450 (CYP) 2E1. There are several fluorinated volatile anaesthetics besides halothane, and most of them are defluorinated by CYP2E1. It is unclear whether other fluorinated anaesthetics inhibit the in vivo activity of CYP2E1.
Methods: We compared the inhibitory effects of therapeutic concentrations of four inhalational anaesthetics, halothane, enflurane, isoflurane, and sevoflurane, on chlorzoxazone metabolism in rabbits receiving artificial ventilation.
Results: All four inhalational anaesthetics decreased arterial blood pressure and increased plasma chlorzoxazone concentration. However, no significant differences in the plasma chlorzoxazone concentration were found between the four anaesthetics. The estimated chlorzoxazone clearance increased after beginning inhalation with all four agents, but no significant difference in clearance was noted between agents.
Conclusions: At therapeutic concentrations, the in vivo inhibitory effect on chlorzoxazone metabolism was similar for all four inhalational anaesthetics examined, even though their chemical characteristics and extent of hepatic metabolism differ considerably.     

Systemic analgesia adapted to the children's condition

A concept of balanced analgesia using nonsteroidal anti-inflammatory drugs (NSAIDs), paracetamol (acetaminophen), opioids, and corticosteroids can also be used in patients with pre-existing illnesses. NSAIDs are the most effective treatment for acute pain of moderate intensity in children; however, these drugs should be avoided in patients at increased risk for serious side effects, e.g. patients with renal impairment, bleeding tendency, or extreme prematurity. NSAIDs can be given with minimal risks to the younger child with mild to moderate asthma, and, in these patients, the use of steroids can be encouraged; in addition to their antiemetic and analgesic action, a beneficial effect on asthma symptoms can be expected. In the non-intubated child with cerebral trauma, exaggerated sedation caused by opioids and increased bleeding tendency caused by NSAIDs must be avoided. In neonates and small infants, the oral administration of sucrose or glucose is helpful to minimize pain reaction during short uncomfortable interventions.