选择性脊神经后根切断术患儿的护理

20 0 0年 1月至 2 0 0 2年 1月 ,我院采用选择性脊神经后根切断术 (ＳＰＲ)解除 11例脑瘫患儿的肢体痉挛 ,效果较好 ,护理报告如下。1　临床资料一般资料 :11例中 ,男 8例、女 3例 ,年龄 6～ 14岁。致病原因为早产 6例 ,出生时窒息 3例 ,新生儿黄疸 1例 ,病因不明 1例。全瘫 3例 ,双下肢瘫 8例 ;单手扶物行走剪刀步态 5例 ,双手扶物站立 3例 ,能坐不能立 2例 ,生活完全不能自理 1例。肌张力按Ａｓｈｗｏｒｔｈ标准评定 ,Ⅲ级 8例 ,Ⅳ级 3例 ,智力均正常或接近正常。手术方法 :行气管内插管麻醉 ,取头低俯卧位。手术全程不用中、长效肌松剂 ,…     

选择性脊神经后根切断术治疗顽固性疼痛的临床分析

目的 探讨选择性脊神经后根切断术治疗顽固性疼痛的临床效果及应用价值. 方法 应用选择性脊神经后根切断术治疗顽固性疼痛,通过将手术前后患者的疼痛表现、止痛药物应用数量、睡眠时间、疼痛视觉模拟评分(VAS)进行比较,从而分析该术式的临床效果. 结果 临床应用3例患者,其中1例随访11个月,顽固性疼痛消失,触压痛消失,止痛药物应用减少,睡眠时间及质量明显改善,VAS评分明显下降,临床止痛效果确切. 结论 对患有四肢或躯体顽固性神经性疼痛的患者,选择性脊神经后根切断术对缓解疼痛是有效的,具有一定的临床应用价值.     

选择性腰骶脊神经后根+前根切断术治疗混合型脑瘫

目的:探讨选择性腰骶脊神经后根切断术(selective posterior rhizotomy,SPR)联合选择性脊神经前根切断术(selective anterior rhizotomy,SAR)治疗混合型脑瘫的疗效。方法:2004年1月~2010年1月,选择48例混合型脑瘫患者,其中男36例,女12例,年龄3～22岁,平均8.8岁,均以痉挛型为主,伴有下肢徐动,术前下肢肌张力均为3级(根据Ashworth 5级法),术前下肢功能情况:独立行走36例,简单介助行走8例,介助站立并有行走动作4例。采用SPR+SAR联合治疗,术中根据肢体痉挛程度切断部分脊神经后根,其中L5、S1后根38例,L4、L5、S1后根10例,后根切断比例为30%~50%;按徐动程度切断部分脊神经前根,其中L5前根28例,S1前根20例,切断比例为30%;术中尽可能保留椎板,以维持脊柱稳定性。结果:术后出现小腿或足底麻木感2例,下肢肌力下降3例,腰痛2例,腰部无力5例,小便控制差1例,经营养神经、康复锻炼、神经肌肉兴奋仪刺激等处理,6个月内症状基本消失。随访18个月。48例患者肌张力术后1周、6个月、18个月均较术前明显改善,痉挛缓解率100%。下肢徐动症状:术后1周时,1例症状加重,经联合应用镇静药物及巴氯芬3个月后恢复至术前,4例无变化,43例改善;术后6个月时,5例较术前无变化,43例改善,无加重病例;术后18个月时,44例明显改善,4例无明显变化,无加重病例。术后18个月随访时,术前介助行走的8例患者中,5例可独立行走,3例无变化;术前介助站立的4例患者中,1例可独立行走,2例可独自站立,1例无变化。结论:腰骶SPR+SAR治疗以痉挛型为主伴有下肢徐动的混合型脑瘫,能有效解除肢体痉挛,降低肌张力,而且能在一定程度上控制下肢徐动症状,是治疗此种混合型脑瘫比较合理的手术方法。     

选择性脊神经后根切断术临床应用及随访分析

选择性脊神经后根切断术临床应用及随访分析洪曼杰，杨力军，关权生，冯振华，郭洲，巫培康在参与肌体痉挛的神经环路中，脊神经后根起主导作用的Ｉａ纤维是导致痉挛的祸根。选择性脊神经后根切断术（ＳＰＲ）其目的就是部分切断来自肌梭的Ｉａ纤维，有效地阻断脊髓反射中...     

选择性脊神经后根切断术治疗痉挛性脑瘫

选择性脊神经后根切断术是治疗痉挛性脑瘫的较好方法，对近期解除痉挛和改善步态效果满意。远期疗效有待进一步随访，某些方面尚存争议，本文就选择性脊神经后根切断术的发展历史、长期疗效、并发症、特殊治疗效果及其与矫形手术的关系等方面进行回顾和讨论。     

脑瘫患者选择性脊神经后根切断术后康复训练效果观察

目的总结脑瘫患者选择性脊神经后根切断术(SPR)术后康复训练的效果。方法对随机选择的20例实施SPR手术的痉挛性脑性瘫痪患者执行预先拟订的康复训练方法并分别在术前、术后及康复后进行肌力、肌张力和关节活动度的测定,观察坐、立、跪、走的姿势。结果手术后康复训练与否肌力改变差异显著(P<0.05)。手术前、手术后与康复治疗后三者之间关节活动度改变在统计学上均有显著差异(P<0.05)。随访资料完整的18例显示坐位、直跪、站立及行走姿势均有明显改善。结论SPR可解除痉挛、降低部分肌张力,改善运动功能,而术后正确的康复训练是改善运动功能不可缺少的重要环节。     

双侧连续开窗式选择性脊神经后根切断术

目的：探寻一种对脊柱稳定性影响较小的选择性脊神经后根切断术治疗脑瘫肢体痉挛。方法：采用双侧连续开窗式行双侧Ｌ１～Ｓ１５个节段的椎板间开窗,将Ｌ２～Ｓ１神经根后根分开、分束,将阈值较低神经束切断。结果：痉挛解除率为９０％,功能改善率为７５％。结论：双侧连续开窗式ＳＰＲ可保留椎板、棘突及韧带,保持脊柱稳定,解除痉挛效果满意。     

选择性脊神经后根切断术治疗痉挛性脑瘫的综述

目的探讨选择性脊神经后根切断术（ＳＰＲ）治疗痉挛性脑瘫的适应证、禁忌证及手术方法,提高治疗效果,降低其并发症发生率。方法广泛查阅近期有关ＳＰＲ治疗痉挛性脑瘫的文献,综述其解除痉挛的机理,手术适应证、禁忌证,手术方法,术后肌张力的变化及并发症。结果ＳＰＲ选择性地切断肌梭传入神经的Ⅰα纤维,阻断骨髓γ反射环路,降低肌张力,解除肌痉挛。手术效果及并发症的发生率与适应证的选择有密切关系。脊神经切除比例小于５０％者效果良好。结论ＳＰＲ是解除痉挛性脑瘫患儿肢体痉挛的较好方法。     

选择性脊神经后根切断术的护理配合

痉挛性脑瘫占脑瘫总数的三分之二,其功能改善必须经康复训练才能达到,但是痉挛的持续存在使康复训练疗效很局限。解除痉挛、为康复训练创造条件是治疗痉挛性脑瘫的第一步。我院1998～2001年对11例患儿采用选择性脊神经后根切断术(SPR)为其解除痉挛,取得良好的效果。现将手术配合报告如下。     

对选择性脊神经根切断术的疗效评价

１９９３～１９９６年我们采用选择性脊神经后根切断术（ＳＰＲ）治疗脑瘫５７例,疗效满意,对术后病人肢体肌张力、肌力、反射、躯干和肢体自控能力进行了综合评价。１临床资料本组５７例,男３９例,女１８例;年龄３～３８岁,平均１０８岁;痉挛性脑瘫５１例（６例...     

Perioperative complications in children undergoing selective posterior rhizotomy: a review of 105 cases

Medical histories for 105 consecutive children who underwent selective posterior rhizotomy (SPR) were reviewed to determine the incidence and clinical significance of adverse events related to anaesthesia and surgery. No intraoperative or postoperative events with potential for lasting morbidity, nor life threatening events, were identified. Intraoperatively, the most common adverse events were moderate elevation of body temperature (13/105) and transient dysrhythmias (8/105). The most frequent postoperative complications were fever, marginal oxygen saturation in the absence of supplemental oxygen, and postcatheterization cystitis. Early surgical complications, such as wound infection, cerebrospinal fluid leak, haemorrhage, and bowel or bladder disturbance were absent in this series. Surgical technique and anaesthetic management are described.     

An acute pain service improves postoperative pain management for children undergoing selective dorsal rhizotomy

Background: A continuous epidural infusion of morphine is the pain treatment modality for children undergoing selective dorsal rhizotomy (SDR) in our institution. The aim of the study was to evaluate the impact of having an organized acute pain service (APS) on postoperative pain management of these children. Methods: We conducted a retrospective cohort study using anesthetic records and the APS database to compare the postoperative pain management of children undergoing SDR before and after the introduction of the APS at the Montreal Children’s Hospital in April 2001. Ninety‐two consecutive children who had their surgery between January 1997 and July 2006 were included. We collected data regarding postoperative pain, opioid‐induced side effects, complications (sedation, desaturations < 92%), and hospital length of stay. Results: Pain scores were documented more frequently after the implementation of the APS (61% vs 48.5%). Sedation scores were documented only after the implementation of the APS. Postoperative desaturation was significantly more frequent in the pre‐APS group compared to the APS group (45.5% vs 6.8%, P < 0.001). Despite the fact that the epidural catheter was in place for the same duration for both groups [median of 3 days (3–3 25–75%ile)], the duration of hospitalization was 1 day shorter in the APS group compared to the pre‐APS group [median of 5 (5–5 25–75%ile) vs 6 (5–6 25–75%ile) days, P < 0.001]. Conclusions: Although we recognize that it is possible that there were changes in care not related specifically to the introduction of a dedicated APS that occurred in our institution that resulted in improvements in general postoperative care and in length of stay, our study did show that having an organized APS allowed to significantly decrease the incidence of postoperative oxygen desaturation and to decrease the hospital length of stay by 1 day.     

选择性脊神经后根切断术中电生理监测的研究

[目的]分析选择性脊神经后根切断术中应用电生理监测得到的数据与术后解痉情况的相关性。[方法]选择2014年3月~2015年9月在本院行选择性脊神经后根切断术的患者52例,术中测定切除神经分束的阈值、保留神经分束的阈值,并记录切除比例,随访6个月分别统计内收肌群和小腿三头肌肌张力降低情况,术后6个月肌张力0级者为观察组,肌张力未降低至0级者为对照组,分析其术中监测数据与手术效果的相关性。记录术中肛门括约肌肌电出现动作电位的频率,并随访术后有无出现相应并发症。[结果]通过秩和检验分析除L2切除神经分束阈值和剩余神经分束阈值两组间比较有差异外(P<0.05),其余节段的切除比例、切除神经分束阈值和剩余神经分束阈值在两组间比较差异均无统计学意义(P>0.05)。术中监测发现7束神经分束出现肛门括约肌肌电波形,术后无相应并发症发生。[结论]脊神经后根切除比例、术中监测切除神经分束和保留神经分束的阈值与解痉程度无相关性,但术中应避免切除支配肛门括约肌的分束而避免相应并发症的发生。     

腰椎管成形在儿童选择性脊神经后根切断术中的应用及临床转归

[目的]探讨棘突椎板韧带复合体回植腰椎管成形在儿童选择性脊神经后根切断(SPR)术中的应用价值及术后转归。[方法]回顾性分析2007年7月～2009年12月本院腰椎SPR手术的脑瘫患儿36例68椎。手术时平均年龄6.5岁。椎管成形方法为棘突椎板棘上韧带复合体整块取出后纵劈开大,原位覆盖回植,丝线固定并重建棘上韧带连续性。术后随访患者症状和影像学评估腰椎稳定性、回植椎板骨融合及转归。[结果]随访平均32个月。术后患者均无腰痛。双下肢肌张力级别由术前平均2.2±0.6降至术后平均0.5±0.2,差异有统计学意义(P<0.05)。腰椎X线片19例未见明显异常;16例可见腰椎术后改变;12例腰椎屈伸位相术前和随访时比较未见明显变化。腰椎CT,椎管形态均基本完整,回植椎板融合率(85.3%),吸收率(61.8%)二者之间呈统计学负相关关系。2例腰椎MRI可见回植椎板部分缺失,硬膜囊无受压,棘上韧带连续。[结论]棘突椎板韧带复合体回植腰椎管成形应用于儿童SPR术可较好重建腰椎稳定性,随访2年以上有回植椎板吸收现象,但对腰椎发育无明显影响,残存椎板与周围软组织共同对椎管内神经起保护作用。     

选择性脊神经后根切断术改善脑瘫患者下肢功能的研究进展

脑性瘫痪是一种常见的儿童时期神经系统伤残的临床综合征,其严重影响患儿及家属的生活质量,同时给社会带来沉重的经济负担。国内外学者将选择性脊神经后根切断术应用于痉挛型脑瘫或伴有肢体痉挛的混合型脑瘫的治疗中已有很长的历史。其改善脑瘫患者下肢痉挛疗效确切,且极少出现复发现象。术后脑瘫患者结合康复治疗后,其肌力较前明显提高,关节活动度在术后即可出现明显改善,且中长期随访未见反弹,患者整体步态得到长期明显改善。笔者认为选择性脊神经后根切断术在改善脑瘫患者下肢运动功能方面疗效显著,值得推广,但必须遵循术前选择合适的病例,术中精细操作,术后及时有效康复治疗的原则,才能使其疗效更佳。     

超声引导下胸腰筋膜平面阻滞在脑瘫患儿选择性脊神经后根切断术中的应用

目的 探讨超声引导下胸腰筋膜平面（TLIP）阻滞在脑瘫患儿选择性脊神经后根切断术（SPR）中的应用效果。

方法 选择行SPR的脑瘫患儿56例,男31例,女25例,年龄6～12岁,体重18～47 kg,ASA Ⅰ或Ⅱ级。采用随机数字表法将患儿分为两组：超声引导下TLIP阻滞联合全麻组（T组）和单纯全麻组（C组）,每组28例。所有患儿静脉全麻用药方案一致。T组插管翻身后行超声引导下双侧TLIP阻滞,0.2%罗哌卡因 0.5 ml/kg,最大用量小于20 ml,30 min后开始手术。C组不行阻滞。记录术中丙泊酚和瑞芬太尼用量,镇痛泵首次按压时间、术后24 h内镇痛泵总按压次数和有效按压次数,术后2、6、12、24 h静息和活动时VAS疼痛评分,术后住院时间、补救镇痛情况、患儿家属满意情况,皮肤瘙痒、低氧血症、恶心呕吐等不良反应发生情况。

结果 与C组比较,T组术中丙泊酚和瑞芬太尼用量均明显减少（P＜0.05）,镇痛泵首次按压时间明显延长（P＜0.05）,术后24 h内镇痛泵按压的总次数和有效按压次数明显减少（P＜0.05）,术后2、6、12 h静息和活动时VAS疼痛评分明显降低（P＜0.05）,术后住院时间明显缩短（P＜0.05）,补救镇痛率明显降低（P＜0.05）,患儿家属满意率明显升高（P＜0.05）。两组皮肤瘙痒、呼吸抑制、恶心呕吐等不良反应的发生率差异无统计学意义。

结论 超声引导下TLIP阻滞可为行SPR的脑瘫患儿提供较为完善的镇痛,减少全麻药用量,加速术后康复。     

Long-term functional outcome after selective posterior rhizotomy

OBJECT: Selective posterior rhizotomy (SPR) is a well-recognized treatment for children with spastic cerebral palsy (CP). Few investigators have used quantitative outcome measures to assess the surgical results beyond 3 years. The authors analyzed data obtained from the McGill Rhizotomy Database to determine the long-term functional outcome of children who had undergone selective dorsal rhizotomy accompanied by intraoperative electrophysiological monitoring. METHODS: The study population was composed of children with spastic CP who underwent SPR and were evaluated by a multidisciplinary team preoperatively, and at 6 months and 1 year postoperatively. Quantitative standardized assessments of lower-limb spasticity, passive range of motion, muscle strength, and ambulatory function were obtained. Of the 93 patients who met the entry criteria for the study, 71 completed the 3-year and 50 completed the 5-year assessments, respectively. Statistical analysis demonstrated significant improvements in spasticity, range of motion, and functional muscle strength at 1 year after SPR. The preoperative, 1-, 3-, and 5-year values for the global score of the Gross Motor Function Measure were 64.6, 70.8, 80, and 85.6, respectively. The greatest improvement occurred in the dimensions reflecting lower-extremity motor function, where the mean change was 10.1% at 1 year, 19.9% at 3 years, and 34.4% at the 5-year follow-up review in comparison with the baseline value. This was associated with a lasting improvement in alignment and postural stability during developmental positions, as well as increased ability to perform difficult transitional movements. CONCLUSIONS: The results of this study support the presence of significant improvements in lower-limb functional motor outcome 1 year after SPR, and the improvements persist at 3 and 5 years. The authors conclude that SPR in conjunction with intraoperative stimulation is valuable for permanently alleviating lower-limb spasticity while augmenting motor function.     

改良式柱状APR术患者的围术期护理

对27例低位直肠癌患者行改良式柱状腹会阴联合直肠癌根治术(APR),其中切口感染合并裂开2例,切口延迟愈合6例,盆底小肠疝1例,输尿管梗阻1例,引流管拔除时间平均(13.9±4.6)d,平均住院18.0d出院.提出术前配合医生完善术前检查;术后注重骶尾部切口护理,引流管护理,造口护理及并发症的观察是其护理重点.