腰椎超声横切扫描可为产科硬膜外穿刺提供可靠定位标志

背景近年来脊柱超声成像逐步显示出其具有辅助硬膜外间隙定位的能力。在本研究中，我们评估了“单屏”超声横切扫描辅助产科硬膜外穿刺的准确性和精密度。方法选择61例拟行硬膜外穿刺的产妇。采用超声成像（横切扫描，2～5MHz凸阵探头）定位脊柱正中线、椎间隙以及皮肤至硬膜外间隙的距离（超声深度，UD）。行硬膜外穿刺时，记录成功的穿刺点，利用标记有刻度的Tuohy穿刺针测量经皮肤到达硬膜外间隙的深度（进针深度，ND）（精确至0．5cm）。通过一致性相关系数分析和95％一致性限Bland-Altman分析来计算UD及ND间的一致性。结果产妇平均年龄33±4．6岁，体重指数29．7±4．8，UD为4．66±0．68cm，ND为4．65±0．72cm。超声辅助定位穿刺点成功率为91．8％，73．8％的患者无需重新调整穿刺方向。UD与ND之间的一致性相关系数为0．881（95％可信区间0．820～0．942）。95％一致性限为-0．666至0．687cm。结论超声定位硬膜外穿刺点成功率较高，UD与ND的一致性非常好。这提示单屏超声横切扫描法可以为产科硬膜外穿刺提供可靠的引导。     

胸段硬膜外麻醉对全麻下患者肝脏血流的影响

背景肝脏低灌注被认为是围手术期肝脏损害的一个重要病理生理因素。尽管硬膜外麻醉（EDA）应用广泛,但目前还没有关于阻滞平面仅局限在胸段的EDA对肝脏血流影响的相关数据。方法选择20例行全身麻醉的患者,通过经食道超声心动图（TEE）评估EDA前后肝右静脉和肝中静脉的肝血流指数。在T7～9间行硬膜外穿刺置管,推注１％的甲哌卡因,剂量中位数10ml（变化范围为8—16ml）。若EDA后,患者平均动脉压下降低于60mmHg,则持续输注去甲肾上腺素（NE）（EDA．NE组）。在研究过程中,其他患者不用任何儿茶酚胺类药物（EDA组）。另外将10例未接受EDA的患者作为对照组。结果本研究中,有5例患者必须连续输注NE以避免平均动脉压降至60intoHg以下。因此,EDA．NE组有5例患者,而EDA组有15例患者。在EDA组,肝脏两条静脉的血流指数下降中位数是24％（P〈0．01）。在EDA—NE组,所有5例患者的肝血流指数均下降,其中,肝右静脉下降的中位数为39（１１～45）％,而肝中静脉下降的中位数为32（7—49）％。对照纽患者肝血流指数保持恒定。与对照组相比,EDA组和EDA-NE组肝血流指数的减少差异具有显著性（Ｐ〈0．05）。相较于肝血流,心输出量不受EDA的影响。结论我们得出结论,胸段硬膜外阻滞与肝血流下降相关。胸段EDA复合连续静脉输注NE可能会导致肝血流进一步降低。     

高胸段硬膜外阻滞和冠状动脉疾病

高胸段硬膜外阻滞（T1～5）可缓解心绞痛,改善顿抑心肌的功能,减少心肌梗死的面积,抑制机体的应激反应,促进冠状动脉架桥术（CABG）病人的术的后恢复,因此越来越多地应用于冠状动脉疾病的治疗。本文综述了高胸段硬膜外阻滞对冠心病病人生理功能的影响及其临床应用情况。     

胸段硬膜外麻醉的非镇痛作用

胸段硬膜外麻醉(thoracic epidural anesthesia,TEA)被广泛用于心脏、胸部和腹部的手术及术后镇痛.然而,许多基础及临床研究都证实TEA除了减轻疼痛,还有更广泛的其他作用.TEA可以降低神经内分泌应激反应,对免疫和凝血系统也有积极的作用,减少围手术期并发症.此外,TEA导致的胸交感神经阻滞被建议用于围术期心、肺、胃肠道的保护.因此这项技术对于很多外科手术的预后有着重要的影响.此文针对TEA非镇痛方面的作用及新近关于TEA应用于重大手术的研究作一综述.     

胸段硬膜外麻醉对神经肽Y的影响

探讨胸段硬膜外麻醉对病人血浆神经肽的影响。方法：采用放射免疫分析法测定了３１例择期上腹部手术病人胸段硬膜外麻醉前后血浆ＮＰＹ的含量。结果麻醉后平均动脉压较麻醉前显著下降,血浆ＮＰＹ则无显著变化。结论：病人处于硬膜外麻醉状态下体内ＮＰＹ含量的变化与交感神经系统调节具有一定的关系。     

胸段硬膜外阻滞对冠心病病人治疗效果的观察

动物实验表明胸段硬膜外阻滞(TEA)可缓解心肌缺血,TEA有助于体外循环术后病人呼吸、循环功能的稳定。但TEA治疗冠心病的效果如何尚未定论。本研究拟观察冠心病病人TEA前后心肌灌注显像及左室射血分数(LVEF)的变化,探讨其对冠心病病人的疗效。     

罗比卡因行胸段硬膜外阻滞对浮腺手术病人动脉血气的影响

乳腺手术选择胸段硬膜外麻醉 (ｔｈｏｒａｃｉｃｅｐｉｄｕｒａｌａｎｅｓ ｔｈｅｓｉａ ,ＴＥＡ)仍是我国常用的麻醉方法之一。本文前瞻性观察乳腺手术患者应用 0 375 %罗比卡因行ＴＥＡ的效果以及对动脉血气的影响 ,探讨其临床应用的安全性和可行性。资料与方法一般资料　选择ＡＳＡⅠ～Ⅱ级择期行乳腺肿块切除术的女性患者 4 0例行ＴＥＡ。术前检查心血管系统和呼吸系统功能均无异常 ;体重超标准者不列入本观察范围。依硬膜外腔注射的局麻药不同随机分为两组 :Ｂ组 ,应用 0 2 5 %布比卡因 ;Ｒ组 ,应用 0 375 %罗比卡因。麻醉方法　麻…     

胸腰段巨大硬膜外囊肿1例报告

讨论椎管硬膜外囊肿在MRI广于硬膜外囊肿容易复发，对于骶管内访1个月，患者双下肢感觉、麻木症状 患者男，34岁，农民。无明显原因出现双下肢无力13年，逐渐出现双下肢麻木，感觉减退，未经诊疗。后双下肢无力及感觉障碍逐渐加重，并出现下肢肌肉萎缩，以右侧明显，小便无力，性功能障碍。查体：双下肢肌肉萎缩，股四头肌肌力4 级，小腿肌力4－级；会阴区皮肤感觉减退，双下肢自腹股沟以下触觉、痛觉减退，以右下肢及右胫骨外侧明显；右侧腹壁及提睾反射减弱，左膝腱反射消失，双跟腱反射消失，病理反射阴性。腰椎CT检查示椎管扩大，…     

胸段硬膜外阻滞转复慢性房颤1例

患者,男,70岁,体重70 kg。因间断无痛性全程血尿1个月以“左肾占位性病变”收入院,拟行左肾肿瘤切除术。既往有高血压病史10余年、心房纤颤10年,虽经药物治疗仍未得到有效控制,一直为房颤心律,且近期未服用任何针对性治疗用药。术前ECG诊断为:“心房纤颤,左室肥厚劳损,ST-T异     

Anterior approach to the thoracic spine

An anterior approach affords the spine surgeon excellent visualization and access to the anterior thoracic spine, the vertebral bodies, intervertebral disks, spinal canal, and nerve roots. This approach is currently used in the surgical treatment of thoracic disk disease, vertebral osteomyelitis or discitis, fractures and tumors of the vertebral bodies, allowing for proper decompression of neural elements and spine stabilization. Over a 10-year period in a single institution, a total of 142 patients with a mean age of 49.6 years underwent anterior thoracic exposure of the spine. The indication for surgery was trauma fracture in 20 patients, malignancy in 35, degenerative disease in 29 and correction of scoliosis in 58. Surgical approaches were determined based on the location and length of spinal involvement, including cervico-thoracic approach (15) thoracotomic approach (85) video-assisted thoracoscopy (10) and thoracolumbar exposure (32). Mean operative time was 334 min (range from 256 to 410 min). There was no perioperative mortality. Thirty-one patients (21.8%) developed postoperative complications. The anterior approach to the thoracic spine is safe and effective and even the presence of complications can be appropriately managed. An adequate preoperative evaluation stratifying the risk and instituting measures to reduce it, accurate surgical planning and careful surgical technique are key to yielding a good outcome and to reduce the risk of complications.     

Endoscopic medial parascapular approach to the thoracic spine

Background The traditional endoscopic-assisted approaches to the thoracic spine between the 4^th and 8^th thoracic vertebrae, whether in lateral or prone positions, are done ventrolateral to the scapula. Accordingly, the distance between the working portal and the spinal target is relatively long, and this increases the difficulty of the endoscopic surgery. Exposure of the spinal target necessitates excessive retraction and/or deflation of the corresponding lung. Both maneuvers are undesirable, particularly in old people with chronic obstructive lung disease.Methods This paper describes an endoscopic-assisted medial parascapular approach in the prone position that offers the surgeon a relatively short access to the upper-mid-thoracic spine. Fifteen patients (10 men and five women), mean age 68 years, with anterior lesions located between the 4^th and 8^th thoracic vertebrae, constituted this prospective study. The type of the anterior endoscopic procedure varied according to the surgical indication and was as follows; biopsy from a paravertebral swelling in two patients, debridement and fusion in four patients with spondylodiscitis, corpectomy and replacement with telescope cage (X-Tenz) in five patients with spinal tumors, corpectomy and replacement with X-Tenz in two patients with vertebral osteonecrosis, and intersomatic fusion in two patients with fractures. Posterior transpedicular fixation was done in 13 patients in the same sitting.Results Conversion to open thoracotomy was not needed. There were no instances of spinal wound infections, neurological deficits, dural tears or vascular injuries. Subcutaneous emphysema developed in one patient and resolved spontaneously. The mean blood loss was 1006.7 ml. Neither pseudarthrosis nor metal failure was encountered. The segmental kyphotic angle decreased from 13.6° at the preoperative period to 9.6° at the immediate postoperative period and reached 11.7° at the end of the follow-up.Conclusions The endoscopic medial parascapular approach, done in the prone position, provides the shortest access to anterior spinal lesions between the 4^th and 8^th thoracic vertebrae. This approach is associated with minimal manipulation and retraction of the lung so that a double-lumen tube is not needed.     

A surgical approach to the upper thoracic spine

We describe a surgical approach to the upper thoracic spine which allows an adequate exposure of the vertebral bodies from T1 to T3. The approach causes little functional disturbance and is especially useful in older patients with spinal tumours causing spinal cord compression.     

Limited approach to a thoracic spine osteoblastoma

Osteoblastoma (OB) is a rare primary benign bone tumor. It generally occurs in the axial skeleton, where it preferentially involves the neural arch. The peak incidence of this neoplasm is in the first two decades of life. Female/male ratio is 2:1. It is important to differentiate OB from osteoid osteoma, a very similar bone tumor. Neuroradiological imaging are diagnostics in most of the cases. This article describes a 18-year-old female affected from a thoracic osteoblastoma stemming from T9 lamina and extending to T11, with a diameter of about 2.5 cm. The patient complained of dorsal pain with progressive weakness to lower limbs. A dorsal approach was performed with a right partial T9 and T11 right laminectomy with total T10 right laminectomy. The mass was totally removed by a limited approach, with no consequent instability and no reason for any stabilization. OB is rare benign bone neoplasm that generally affect the posterior elements of the spine. Surgery is the treatment of choice in this kind of lesions: total removal is effective with no recurrence. When the lesion is placed in the cervical and thoracic spine the goal is to decompress spinal cord and reach the stability of the spine.     

借助胸腔镜技术的胸段、上腰段脊柱前路手术

目的探讨胸腔镜辅助胸椎、上腰椎前路手术的适应证 ,单肺或双肺通气的选择以及术中注意事项。方法　应用胸腔镜、骨科常规手术器械或自制的骨科器械 ,在胸腔镜辅助下行病灶清除、脊髓减压、植骨、钢板螺丝钉内固定术。结果　全部病例手术都顺利完成 ,切口均一期愈合 ,随访 3～ 10个月 ,影像学检查显示病灶清除彻底 ,脊髓减压充分 ,除 1例骨折复位、固定后仍有轻度侧方成角畸形外 ,其他病例复位满意、内固定可靠 ,位置良好。结论胸椎、上腰椎疾患 ,不论是否并发脊髓、马尾神经压迫 ,都能在胸腔镜辅助下完成病灶清除术 ,必要时还可进行脊髓减压、脊柱前路植骨、内固定手术。原则上可选择常规气管插管、双肺通气下完成手术。     

Anterior transsternal approach to the upper thoracic spine.

Cervicothoracic junction and upper thoracic spine down to T4 can be reached through anterior approach via sternotomy. Transsternal approach is the best route to gain access to lesions localized within vertebral bodies of the upper thoracic spine allowing for their resection, interbody fusion and replacement with bone cement. Consecutive modifications of transsternal approach evolved towards less extensive osteotomy from full median sternotomy, through manubriotomy with clavicle resection to partial lateral manubriotomy. Less extensive modifications provide limited lateral exposure of the spine and are more demanding technically. We present two cases of the upper thoracic spine tumours operated on through full medial sternotomy. We believe that median sternotomy has several advantages over less extensive modifications: it is technically simple to perform approach for trained thoracic surgeon, safer as it provides better exposure of the mediastinum and thus sufficient control of great vessels including subclavian ones, gives better exposure of T3, T4 and even T5 vertebral bodies, allows perpendicular sight and attack to anterior surface of the upper thoracic spine and therefore good visualizing of the posterior longitudinal ligament and dura, do not destabilize shoulder girdle nor affect function of the upper limb. Additional caudal exposure of the thoracic spine as down as T5 can be obtained by dissecting a plane between the brachiocephalic vein, vena cava superior and ascending aorta.     

Lateral parascapular extrapleural approach to the upper thoracic spine

The upper thoracic vertebrae are difficult to approach surgically because of the narrowing of the thoracic inlet, the proximity of the brachial plexus, and the parascapular shoulder musculature. A novel lateral parascapular extrapleural approach to the upper thoracic vertebrae is described. The parascapular shoulder musculature (trapezius, levator scapulae, and rhomboid muscles) is reflected off the spinous processes to the scapula as a musculocutaneous flap, preserving the neurovascular supply. The paraspinal musculature is mobilized and retracted, and the upper dorsal ribs are removed with caution to avoid injury to the C-8 and T-1 nerve roots. The rami communicantes are transected, and the sympathetic chain is displaced anterolaterally. The T2-4 vertebrae can be approached unobstructed. The T-1 nerve root obstructs posterolateral access to the T-1 vertebra, necessitating an inferolateral approach underneath the T-1 nerve root axilla. Four patients with compressive myelopathy from upper thoracic vertebral metastases underwent neural decompression, vertebral reconstruction, and posterior spinal fixation with this approach. Their postoperative neurological status was either unchanged or improved. Complications included radiographic pleural effusion and superficial wound dehiscence; one patient required posterior spinal reinstrumentation for progressive kyphosis. One patient developed pneumonia 7 days postoperatively which was unresponsive to appropriate treatment. It is believed that the anatomical limitations to this region have been overcome, and that excellent exposure of the T1-4 vertebrae for neural decompression and vertebral reconstruction can be performed safely. A major advantage is that posterior spinal fixation can be carried out simultaneously.