脊髓纵裂患者脊髓栓系综合征的手术疗效分析

目的分忻双管型脊髓纵裂患者脊髓栓系综合征的手术疗效。方法对34例行手术治疗的双管型脊髓纵裂TCS患者进行回顾性分析。结果通过手术后观察和3个月～5年的随访发现．手术的总有率可达91％，尤其是疼痛为主诉的患者恢复最为明显，术后恢复似乎与术前病程无关。结论双管型脊髓纵裂合并TCS的患者一旦确诊．无手术禁忌证就应尽早手术。只要手术操作细致，大多患者症状可缓解．不会出现明显的神经并发症。     

Direct spinal versus peripheral nerve stimulation as monitoring techniques in epidurally recorded spinal cord potentials

Summary We recorded spinal cord evoked potentials (SCEPs) and spinal somatosensory evoked potentials (spinal SEPs) in 30 operations following stimulation of the epidural spinal cord and the peripheral nerve, respectively, to compare their feasibility as an intraoperative technique for spinal cord monitoring. SCEPs produced quicker responses and had larger amplitudes with simpler waveforms. SCEPs could reflect residual function of the pathological spinal cord and predict the postoperative clinical outcome, findings which are not observed with spinal SEPs. Moreover, SCEPs had a much higher sensitivity to spinal cord insult. Therefore, we conclude that the SCEPs were more appropriate indicator than the spinal SEPs as an intra-operative monitoring method for spinal cord function.     

Intraspinal lipomas in infancy and childhood causing a tethered cord syndrome

The authors report on a series of 26 children with spina bifida occulta in combination with intraspinal lipoma and clinical signs of tethered cord syndrome. The age of the children at presentation ranged from 1 month to 12 years. The typical signs and symptoms consisted of skin lesions in the lumbar-sacral region, neurogenic foot deformities, and bladder and bowel disturbances.The diagnosis was confirmed by neuroradiological investigations including lumbar myelography, computerized tomography, and only recently magnetic resonance imaging. Indications for surgery were based on the radiological evidence of intraspinal lipoma and tethered cord and especially on the clinical signs of neurological deterioration.The results of the operative treatment are presented and the role of surgery before onset of symptoms as well as during the symptom-free interval is discussed.     

分期手术治疗先天性脊柱侧凸合并脊髓纵裂和脊髓拴系的安全性与近期疗效

目的:评估分期手术治疗先天性脊柱侧凸合并脊髓纵裂和脊髓拴系患者的安全性与近期疗效。方法 :回顾性分析我院2009年1月~2014年1月收治的66例先天性脊柱侧凸合并脊髓纵裂和脊髓拴系患者的临床资料。其中男20例,女46例,年龄17.2±4.5岁(7~26岁)。5例患者术前存在下肢神经功能障碍。脊柱侧凸冠状位主弯Cobb角97.6°±23.5°(50°~165°),主弯位于颈胸段1例,胸段58例,胸腰段7例。23例同时存在矢状位后凸畸形,Cobb角89.5°±13.9°(47°~165°)。伴有Ⅰ型脊髓纵裂45例,Ⅱ型脊髓纵裂21例,均合并脊髓拴系。所有患者均行分期手术治疗:Ⅰ型脊髓纵裂组患者一期切除骨性分隔、松解脊髓拴系,Ⅱ型脊髓纵裂组患者一期松解脊髓拴系;一期术后3~4周,二期行侧凸矫形手术。结果:一期手术时间208.7±107.2min(60~505min),术中出血量297.1±192.6ml(20~2000ml);二期手术时间392.6±150.7min(196~600min),术中出血量2158.8±1158.4ml(450~6000ml)。术前存在下肢神经功能障碍的5例患者中,1例术后下肢肌力提高2级,感觉功能有所恢复;其余4例术后神经功能无明显变化。2例术前神经功能正常患者二期术中出现脊髓损伤(3.0%,2/66),其中1例术后双下肢肌力降为4级,感觉稍减退,术后1周感觉、运动功能完全恢复正常;另1例术后双下肢肌力降低至2级,双下肢及会阴部感觉减退,经脱水、激素冲击治疗及高压氧治疗,术后1个月双下肢肌力恢复至3级,术后2年随访时双下肢肌力恢复至4级,双下肢残留轻度麻木感,大小便功能正常。4例(6.1%,4/66)患者二期术后并发胸腔积液。均获得随访,随访时间12.4±3.5个月(6~24个月)。随访期间未发现椎弓根螺钉松动及断裂现象。脊柱侧凸矫形术后冠状位Cobb角为41.6°±17.8°(12°~107°),矫正率为(61.3±14.3)%;末次随访时冠状位Cobb角为43.7°±16.6°(15°~108°),丢失率为(1.9±1.1)%。术后矢状位后凸Cobb角为38.4°±11.0°(2°~78°),矫正率为(67.6±23.4)%,末次随访时矢状位Cobb角为39.7±11.2°(3°~87°),丢失率为(2.3±1.3)%。结论:分期手术治疗合并脊髓纵裂和脊髓拴系的先天性脊柱侧凸具有较高的手术安全性,并可获得较满意的矫形效果。     

外固定器治疗脊髓栓系综合征僵硬性足部畸形

[目的]观察外固定器治疗脊髓栓系综合征僵硬性足部畸形的临床效果,探讨脊髓神经源性足部畸形外科矫正和功能重建的新技术.[方法] 1988年10月～2006年6月,回顾性分析脊髓栓系综合征僵硬性足部畸形61例97足;年龄6～42岁,根据足部畸形的特征,设计不同构型的外固定器.上运动神经元损伤型足部畸形主要实施选择性胫神经缩窄手术和距下关节外融合手术或距下关节融合术,同时安装外固定器.下运动神经元损伤型足部畸形主要实施软组织松解、肌腱转位术或截骨手术,同时安装外固定器.[结果]得到至少3年随访的54例、86足进行分析,马蹄内翻足39足,马蹄足21足,马蹄外翻足16足,跟行足6足,高弓足4足.其中上运动神经元损伤型足部畸形19足,下运动神经元损伤型67足.佩戴外固定器时间8～12周,平均11周.采用Laaveg - Ponseti足功能评分系统:优38足,良29足,可13足,差6足.优良率77.9％.第1次术后复发3足,复发率3.5％.钉道感染18足,清理炎性分泌物或更换钉道位置后治愈.足底溃疡3足,清创和短期避免负重后治愈.[结论]外固定器治疗脊髓栓系综合征僵硬性足部畸形符合生物学重建理论,可提高疗效,减少复发.     

TMS—MEP与CSEP诊断脊髓损伤的作用比较

目的比较脊髓损伤后经颅磁刺激运动诱发电位和皮层体感诱发电位检测的诊断价值。方法 １５只家猫脊髓部分切断和６９例ＳＣＩ的ＭＥＰ和ＣＳＥＰ检测。结果 ＭＥＰ对脊髓前柱损伤，前后柱混合损伤和肌力异常极敏感，对后柱损伤不敏感；而ＣＳＥＰ对脊髓后柱损伤，前后柱混合损伤和关节位置觉异常十分敏感，对前柱伤却相反。     

Aprotinin reduces injury of the spinal cord in transient ischemia

Objective: The protective effect of aprotinin, which is a protease inhibitor, was assessed in a rabbit spinal cord ischemia model. Design: Randomized, controlled, prospective study. Setting: University research laboratory. Subjects: New Zealand white rabbits (36) of both sexes. Methods: In 24 animals, ischemia was induced with midline laparotomy and clamping the aorta just distal to left renal artery and proximal to aortic bifurcation for 20 min. Aprotinin was given 30 000 KIU as a short intravenous injection after anesthesia, and was followed by 10 000 KIU/h by continuous infusion in group 1 (n=12). Similar volume of saline solution was used in control group of animals (group 2, n=12). Group 3 of animals (sham group, n=12) were anesthetized and subjected to laparotomy without aortic occlusion. Physiological parameters and somatosensory evoked-potentials (SEP) were monitored in animals before ischemia, during ischemia and in the first 60 min of reperfusion. Their neurological outcome was clinically evaluated up to 48 h postischemia. Their motor function was scored, and the intergroup differences were compared. The animals were sacrificed after two days of postischemia. Their spinal cord, abdominal aorta, and its branches were processed for histopathological examination. Results: In group 3, SEP amplitudes did not change during the procedures, and all animals recovered without neurologic deficits. At the end of ischemic period, the average amplitude was reduced to 53±7% of the baseline in all ischemic animals. This was followed by a gradual return to 89±8 and 81±13% of the initial amplitude after 60 min of reperfusion in group 1 and group 2 correspondingly (P>0.05). The average motor function score was significantly higher in group 1 than group 2 at 24 and 48 h after the ischemic insult (P<0.05). Histological observations were clearly correlated with the neurological findings. Conclusion: The results suggest that aprotinin reduces spinal cord injury and preserves neurologic function in transient spinal cord ischemia in rabbits.     

口腔错[牙合]畸形与青少年特发性脊柱侧弯相互关系的临床研究

目的:旨在研究错[牙合]畸形与青少年特发性脊柱侧弯的相关性,为临床早发现、早治疗青少年特发性脊柱侧弯提供依据。方法:选择南京邦德骨科医院门诊收治的100例青少年特发性脊柱侧弯患者为研究对象。随机按比例抽取100名在校大、中、小学生作为对照组,检查口腔咬合状况。观察两组人群中错[牙合]畸形发生率及类型,并进行统计学分析。结果:脊柱侧弯人群错[牙合]畸形的发生率略高于普通人群(P=0.04),安氏Ⅱ类2分类错[牙合]畸形的发生率略高于对照组(P<0.05)。脊柱侧弯不同部位发生错[牙合]畸形的类型略有不同,颈胸段侧弯患者偏[牙合]畸形的发生率明显高于对照组(P<0.05)。结论:安氏Ⅱ类2分类错[牙合]畸形与青少年特发性脊柱侧弯有一定的相关性,具体情况还有待进一步研究。     

慢性脊髓压迫及减压后运动诱发电位及病理学改变

目的探讨脊髓慢性压迫及减压后神经病理学及运动诱发电位(MEP)的变化.方法选用 54只SD大鼠,随机分为对照组,轻、中、重压迫组和减压组.应用磁刺激MEP各组行30 min、6 h和1、2、4周动态观察.用HE染色观察脊髓的组织学变化.结果轻度压迫组MEP潜伏期在损伤后30 min及6 h比术前分别延长0.29倍和0.32倍,至4周恢复,与术前相比,伤后30 min和6 h中度压迫组MEP潜伏期延长0.83倍和0.88倍,重度组延长1.14倍和1.22倍,减压后MEP潜伏期分别缩短了0.21倍和0.23倍.结论轻和中度压迫组的病变是可逆的,而重度压迫导致神经细胞和运动功能的不可逆改变.MEP能反映脊髓受损程度,可作为评价减压效果的客观指标.     

Ⅰ期三柱截骨矫形术治疗脊柱侧凸伴脊髓纵裂

目的 :分析Ⅰ期三柱截骨矫形术用于脊柱侧凸伴脊髓纵裂的有效性及安全性。方法 :对2015年1月至2017年12月接受Ⅰ期三柱截骨矫形术治疗的41例脊柱侧凸伴脊髓纵裂患者进行回顾性分析,其中男17例,女24例;年龄(25.14±4.51)岁;体重(65.14±9.11) kg。根据脊髓纵裂的分型进行分组,15例PangⅠ型纵裂为A组,26例PangⅡ型纵裂为B组。记录两组患者的一般情况;观察两组患者手术前后的Cobb角并计算冠状面Cobb角矫正率;术后对两组患者冠状位与矢状位躯干偏移距离进行比较,评价其躯干平衡性;记录两组患者并发症发生情况。结果:术后41例患者均获得12个月以上的随访。A组手术时间、术中失血量、围手术期输血量分别(610.14±115.02) min、(4 001.12±1 014.33) ml、(3 951.14±1 021.55) ml,B组分别为(520.12±101.14)min、(2 701.57±1 021.45) ml、(2 565.77±880.47) ml,两组差异有统计学意义(P<0.05);A、B两组术后住院时间分别为(9.45±4.21) ...     

Effects of dexmedetomidine on intraoperative motor and somatosensory evoked potential monitoring during spinal surgery in adolescents

Background: Dexmedetomidine may be a useful agent as an adjunct to an opioid–propofol total intravenous anesthesia (TIVA) technique during posterior spinal fusion (PSF) surgery. There are limited data regarding its effects on somatosensory (SSEPs) and motor evoked potentials (MEPs). Methods: The data presented represent a retrospective review of prospectively collected quality assurance data. When the decision was made to incorporate dexmedetomidine into the anesthetic regimen for intraoperative care of patients undergoing PSF, a prospective evaluation of its effects on SSEPs and MEPs was undertaken. SSEPs and MEPs were measured before and after the administration of dexmedetomidine in a cohort of pediatric patients undergoing PSF. Dexmedetomidine (1 μg·kg^?1 over 20 min followed by an infusion of 0.5 μg·kg^?1·h^?1) was administered at the completion of the surgical procedure, but prior to wound closure as an adjunct to TIVA which included propofol and remifentanil, adjusted to maintain a constant depth of anesthesia as measured by a BIS of 45–60. Results: The cohort for the study included nine patients, ranging in age from 12 to 17 years, anesthetized with remifentanil and propofol. In the first patient, dexmedetomidine was administered in conjunction with propofol at 110 μg·kg^?1·min^?1 which resulted in a decrease in the bispectral index from 58 to 31. Although no significant effect was noted on the SSEPs (amplitude or latency) or the MEP duration, there was a decrease in the MEP amplitude. The protocol was modified so that the propofol infusion was incrementally decreased during the dexmedetomidine infusion to achieve the same depth of anesthesia. In the remaining eight patients, the bispectral index was 52 ± 6 at the start of the dexmedetomidine loading dose and 49 ± 4 at its completion (P = NS). There was no statistically significant difference in the MEPs and SSEPs obtained before and at completion of the dexmedetomidine loading dose. Conclusion: Using the above‐mentioned protocol, dexmedetomidine can be used as a component of TIVA during PSF without affecting neurophysiological monitoring.     

脊柱截骨术治疗合并脊髓纵裂伴脊髓拴系综合征的先天性脊柱侧凸

目的:探讨脊柱截骨术治疗合并脊髓纵裂伴脊髓拴系综合征的先天性脊柱侧凸的安全性和有效性。方法:回顾性分析2007年6月~2013年6月在我院采用脊柱截骨手术治疗的23例合并脊髓纵裂伴脊髓拴系综合征的先天性脊柱侧凸患者。其中男6例,女17例;手术时年龄16.9±3.4岁(10~23岁)。腰骶部疼痛8例,其中5例仅表现为腰骶部疼痛,神经功能损害18例。术前冠状位Cobb角95.4°±25.2°(65°~156°)。Ⅰ型脊髓纵裂9例,Ⅱ型脊髓纵裂14例。脊髓圆锥位置均在L3水平以下。对合并Ⅰ型脊髓纵裂伴脊髓拴系的患者,采用骨性纵隔切除、一期脊柱截骨矫形;合并Ⅱ型脊髓纵裂伴脊髓拴系的患者单纯行一期脊柱截骨矫形(未处理纤维纵隔)。其中行全脊椎截骨13例,经椎弓根截骨10例。术前、术后3个月和末次随访时分别测量患者侧凸Cobb角,并按脊柱裂神经功能评分(SBNS)分级评估神经功能恢复情况。结果:手术时间571.1±136.5min(310~835min);术中失血量4888.3±2482.3ml(500~9600ml)。随访38.9±18.3个月(24~79个月)。术后冠状面Cobb角33.7°±15.9°(3°~73°),较术前明显改善(P0.05),矫正率平均为(62.3±14.1)%;末次随访时冠状面Cobb角37.4°±17.2°(5°~82°),矫正率平均为(58.1±14.7)%,较术后平均丢失4.2°±2.3°,与术后比较无明显矫形丢失(P0.05),但与术前相比有明显改善(P0.05)。末次随访时,18例患者神经损害症状获得不同程度改善,其中13例术前SBNS神经功能分级为Ⅱ级者术后恢复至Ⅰ级;2例Ⅲ级恢复至Ⅱ级;另外3例神经损害评分提高,SBNS分级维持不变,脊柱侧凸畸形及局部疼痛明显好转。围手术期出现并发症5例,其中2例术后出现单侧下肢肌力下降,1例术后2周下肢肌力恢复至4级,另1例于术后3个月恢复至术前水平,术后2年随访肌力基本恢复正常;术中发现胸膜破裂1例,术后脑脊液漏1例、泌尿系感染1例。所有病例术后无伤口感染、假关节形成、内固定松动/断裂及永久性神经损害并发症。结论:脊柱截骨术治疗合并脊髓纵裂伴脊髓拴系综合征的先天性脊柱侧凸患者安全有效,且对神经功能恢复有促进作用。     

脊髓急性牵拉损伤动物模型机理研究

目的对犬脊髓(神经根)急性牵拉损伤的病理机制进行初步探讨。方法12只健康成年杂种犬，随机分为对照组和不同程度牵拉损伤组。前后路联合手术离断脊柱后施加纵向牵拉损伤，对牵拉应变率、体感诱发电位(SEP)、神经源性脊髓运动诱发电位(NMEP)、硬膜下压力(SP)、硬膜血流量(EBF)等进行持续观察。伤后取脊髓及神经根标本进行HE、髓鞘神经中丝(NF)及胶原纤维酸性蛋白(GFAP)抗体免疫组织化学染色及电镜超微结构观察。结果牵拉损伤涉及牵拉节段和其上下脊髓及神经根的损伤。牵拉后出现硬膜下压力的显著增高和硬膜血流的显著降低。SEP异常的出现较NMEP更早。结论牵拉后脊髓内压力的增加导致脊髓血流减少。以及直接的机械性牵拉损伤可能是脊髓牵拉损伤的重要机制。     

体感诱发电位在椎体后凸成形术中的脊髓监测

目的探讨体感诱发电位（SEP）在椎体后凸成形术（PKP）中的脊髓监测作用。方法33例46个椎体行PKP,术中均予SEP监护。结果46个椎体疼痛均好转,椎体复位良好,2例出现波幅降低,1例出现潜伏期延长,无重大并发症。结论SEP在PKP中对脊髓有良好的监测作用。     

先天性脊柱侧凸与青少年特发性脊柱侧凸矫形术中神经电生理监测对比分析

目的:对比分析先天性脊柱侧凸(congenital scoliosis,CS)和青少年特发性脊柱侧凸(adolescence idio-pathic scoliosis,AIS)患者脊柱后路矫形术中神经电生理监测(intraoperative neurophysiological monitoring,IONM)的结果...     

兔颈髓牵张性损伤早期脊髓血流变化及其对运动诱发电位的影响

目的 :观察颈髓牵张性损伤早期脊髓血流的变化 ,并探讨其对运动诱发电位 (motorevokedpotentials ,MEP)的影响。方法 :构建兔颈髓牵张性损伤模型 ,应用激光多普勒血流仪监测C5～ 6段脊髓血流 (spinecordbloodflow ,SCBF) ,并同时观察运动诱发电位的变化。结果 :随着颈髓牵张程度的不断加重 ,血流呈进行性下降 ,而当脊髓微血管自我调节能力丧失时则SCBF不能恢复。颈髓牵张性损伤后MEP波幅及潜伏时均有明显的变化。结论 :颈髓血流量的下降与牵张程度呈正相关 ,是继发性脊髓神经功能障碍的基础 ,是脊髓牵张性损伤的早期指标。MEP能反映脊髓运动神经功能的改变 ,与SCBF的下降和脊髓病理学改变呈一致性     

Early Protective Effects of Iloprost after Experimental Spinal Cord Ischemia in Rabbits

The potential role of Iloprost, a stable analogue of prostocyclin, in treating spinal cord ischemia was investigated in rabbits subjected to aortic occlusion for 15 minutes. Ten adult rabbits weighing 2-2.5 kg received an intravenous infusion of saline (SF) as a control group and 14 rabbits received an intravenous infusion of Iloprost, 25 microg/kg/h. Iloprost infusion was started immediately after clamping of the aorta and continued 60 minutes thereafter. Cortical somatosensorial evoked potentials (CSEP) were recorded during the pre-ischemic period as a baseline and post-ischemic readings were taken at 15, 30 and 60 minutes. There was no statistically significant difference between CSEP of the saline and Iloprost treated groups (p < 0.05). All animals were examined neurologically by using a modification of Tarlov scale and all subjects were then deeply anesthetized and their spinal cords were removed for light and electron microscopic examinations at 24 h after spinal cord ischemia. In order to obtain an accurate comparison of ultrastructural changes between saline treated and Iloprost treated groups, a grading scale was performed. The light microscopic and ultrastructural analysis of the Iloprost treated group revealed that there was moderate protection of the myelin and axons and edema was attenuated. Findings of this study suggest that Iloprost exerts a protective effect on spinal cord ischemia. However, further studies are needed to reveal possible mechanisms of protection provided by Iloprost.