从脊柱拟手术前发生肺栓塞1例的启示

肺栓塞（pulmonary embolism,PE）是外科手术最严重的并发症之一,尤其以骨科手术常见,轻者影响患者的康复,重者危及生命。脊柱疾病患者以中、老年居多,大多合并有基础疾病（如：高血压、糖尿病、脑梗塞等）,往往接受较长时间的保守治疗,在保守治疗的同时,下肢深静脉血栓（deep vein thrombosis,DVT）乃至PE的风险大大增加。对于此类患者术前完善的栓塞风险筛查能够发现栓塞高危患者,预防性采用有效处理措施能够大大减少术中、术后PE的发生。我科遇到1例腰椎疾病拟手术前即发生PE的患者,报告如下。     

Cerebellar hemorrhage after spinal surgery: report of two cases and literature review

OBJECTIVE AND IMPORTANCE: Cerebellar hemorrhage remote from the site of surgery may complicate neurosurgical procedures. We describe our experience with two cases of cerebellar hemorrhage after spinal surgery and review the three cases previously reported in the literature to determine whether these cases provide insight regarding the pathogenesis of remote cerebellar hemorrhage. CLINICAL PRESENTATION: One of our patients developed cerebellar hemorrhage in the vermis and right hemisphere after transpedicular removal of a partially intradural T9-T10 herniated disc with the patient in the prone position. The other patient developed cerebellar hemorrhage in the vermis and bilateral hemispheres after L3-S1 decompression and instrumentation with the patient in the prone position, during which the dura was inadvertently opened. INTERVENTION: The first patient was treated conservatively and had mild residual dysarthria and gait ataxia 2 months after surgery. The second patient underwent exploration and revision of the lumbar wound with primary dural repair. The cerebellar hemorrhage was treated conservatively, and the patient had mild dysarthria and ataxia 1 month after surgery. CONCLUSION: Cerebellar hemorrhage must be considered in patients with unexplained neurological deterioration after spinal surgery. Dural opening with loss of cerebrospinal fluid has occurred in every reported case of cerebellar hemorrhage complicating a spinal procedure, supporting the hypothesis that loss of cerebrospinal fluid is central to the pathogenesis of this condition. Because remote cerebellar hemorrhage can occur after procedures with the patient in the supine, sitting, and prone positions, patient positioning seems unlikely to play a causative role in its occurrence.     

Pulmonary embolism was suspected during hip surgery under spinal anesthesia: a case report]

Most of the lower leg surgeries are done under spinal anesthesia. This 53 year old male had undergone a surgery for his left hip fracture previously and was scheduled for the removal of the screw. Spinal anesthesia was administered and sensory block was obtained up to T8. After the removal of the screw, he coughed weakly for several times. Suddenly ECG monitor showed severe bradycardia and hypotension was observed. He complained of chest pain, dyspnoea and went into shock. Immediately after giving atropine 0.5 mg iv, ephedrine 8 mg x 2 was necessary to raise his heart rate. About 3 minutes later he recovered from his shock state. ECG changes were transient and the bradyarrhythmia during his shock turned out to be AV dissociation. Arterial blood gas analysis showed decreased PaO2 and increased PaCo2. We suspected lung embolism. However, postoperative chest X-ray and pulmonary perfusion scans were within normal limits.     

Delayed epidural hematoma after spinal surgery: a report of 4 cases

Symptomatic postoperative epidural hematoma is a rare and potentially devastating complication of spinal surgery. The overwhelming majority of reported cases have occurred in the immediate postoperative period. A recent publication defined the clinical entity of delayed postoperative epidural spinal hematoma as neurologic deterioration due to an epidural hematoma occurring at least 3 days after the index procedure. Only 2 such cases have been reported in the lumbar spine to date. Four cases of delayed postoperative spinal epidural hematoma were identified over a 6-year period among the spine surgeons at a single large academic institution. Each case involved the lumbar spine. The details of each patient's initial surgery, presentation, and hospital course were then gathered from a retrospective chart review. The 4 patients presented are unusual in their delayed symptomatic presentations of postoperative spinal epidural hematoma. Despite the longer time to onset, however, our patients exhibited many of the characteristics common to cases that presented in the acute postoperative period. The spine surgeon must remain vigilant for the possibility of postoperative spinal epidural hematoma in at-risk patients, even weeks after the original surgical procedure.     

Pulmonary thromboembolism after spinal instrumentation surgery

A 57-year-old woman was hospitalized because of gait disturbance and dysuria. Close examination revealed a cauda equina tumor at the level of L2 and L3. Tumor resection was performed, with posterolateral fusion and spinal instrumentation. On the eleventh day after the surgery, she experienced dyspnea and chest pain during standing and walking exercise. Pulmonary thromboembolism was diagnosed, based on: (1) blood gas analysis findings of hypoxemia and (2) defective images in both of the upper lobes on urgent pulmonary blood flow scintigram. Her clinical status improved with urgent thrombolytic therapy (with tisokinase and urokinase) and anticoagulation therapy (with heparin and warfarin), and her life was saved. When pulmonary thromboembolism occurs, early diagnosis by pulmonary blood flow scintigram and early thrombolytic and anticoagulative therapies are necessary. Special attention should be paid to symptoms of pulmonary thromboembolism in patients after spinal surgery. Received for publication on Sept. 30, 1998; accepted on March 5, 1999     

Resolution of spontaneous spinal epidural hematoma without surgery: report of two cases.

STUDY DESIGN: Case report. OBJECTIVE: To report two cases of spontaneous spinal epidural hematoma that completely resolved, clinically and radiographically, without surgical treatment. SUMMARY OF BACKGROUND DATA: The treatment of spinal epidural hematoma is usually surgical. Spontaneous spinal epidural hematoma is an uncommon phenomenon and may be of uncertain cause. METHODS: One patient with acute onset of complete quadriplegia and another with complete paraplegia caused by spontaneous spinal epidural hematoma were treated without surgery. RESULTS: Both patients recovered nearly completely with respect to their neurologic function at 3-month follow-up. No source of hematoma was ever identified. CONCLUSIONS: Spontaneous spinal epidural hematoma should be considered in the differential diagnosis of sudden onset of spinal cord compression in association with back pain. Patients initially presenting with severe neurologic dysfunction are potential candidates for conservative management if they demonstrate rapid and progressive improvement in neurologic function. Patients treated in this manner can have nearly complete restoration of function.     

Rotationplasty after failed limb-sparing tumor surgery: a report of two cases

Rotationplasty was used in two cases of failed limb salvage in adults after tumor resection and reconstruction. Each patient had distal femoral osteosarcoma, one treated with osteoarticular allograft reconstruction, the other with a custom endoprosthetic reconstruction. Both patients had failure attributable to infection, and after multiple surgeries, elected to have rotationplasty. Both had complications associated with the rotationplasty but went on to have functional limbs with Musculoskeletal Tumor Society functional scores of 67% and 87%. One patient died of metastatic disease 29 months after rotationplasty, the other had no problems 50 months after rotationplasty. Although rotationplasty offers a functional improvement over transfemoral amputation in the salvage of failed tumor reconstructions, only 10 such cases have been reported in adults. Rotationplasty should be considered in selected patients for whom an amputation is being considered after failed limb salvage surgery.     

自发性椎管内硬膜外血肿2例报告

<正>自发性椎管内硬膜外血肿(spontaneous spinal epidural hematoma,SSEH)在临床较为少见,原因不明,临床易漏诊误诊,并可能导致永久性神经功能损害。2014年9月~2015年9月,我院脊柱骨科收治了2例SSEH患者,报道如下。病例1,女,76岁,因"突发双下肢瘫痪5d"于2014年9月9日入院。患者于5d前无明显诱因突发胸背部疼痛,后出现双下肢感觉及运动消失,伴大小便失禁。遂至当地医院住院治疗,MRI检查提示T7~L1椎管后部硬膜外长梭形病变,考虑血管畸形或血管瘤破裂出血伴血肿形成可能     

Acute pulmonary embolism following lung resection: report of two cases

We reported 2 cases of acute pulmonary embolism after resection for lung cancer. A 47-year-old male was admitted to our hospital with ground-glass opacity (GGO) on a chest computed tomography (CT). We performed a right upper lobectomy and node dissection (ND) 2a dissection. Two days after the operation, he developed hypotension and hypoxemia. He was diagnosed as acute pulmonary embolism by chest CT and lung scintigram. A 68-year-old women was performed right S6 segmentectomy for lung cancer. The next day, she complained of sudden chest discomfort and dyspnea. She was diagnosed as acute pulmonary embolism by chest CT. Immediately, we started anticoagration therapy with heparin and their condition were improved. It was very important to early diagnose and start anticoagration therapy immediately for acute pulumonary embolism.     

Diphenylhydantoin-induced pure red cell aplasia after neurological surgery: report of two cases

Pure red cell aplasia (PRCA) is characterized by severe anemia, reticulocytopenia, marked selective hypoplasia of the erythroid precursor cells in the bone marrow and normal peripheral leukocyte and platelet counts. We reported two cases of diphenylhydantoin (DPH)-induced PRCA after neurological surgery. They recovered completely with discontinuance of DPH therapy. Neurosurgeons should be aware of this side effect because most reported cases of PRCA have occurred about a few months after neurological surgery under general anaesthesia and DPH therapy.