颈椎前路手术治疗食管型颈椎病伴后纵韧带骨化症1例报告

食管型颈椎病（ECS）是一种以进行性吞咽困难为主要症状,易误诊、漏诊的罕见疾病。多见于弥漫性特发性骨肥厚症（DISH）、强直性脊柱炎（AS）患者。60岁以上中老年人群中20% ~ 30%可出现椎前骨赘的影像学表现,但仅有1% ~ 2%可能出现颈痛、吞咽困难、呼吸困难等症状^[1]。后纵韧带骨化症（OPLL）是一种板层骨沉积的病理过程,由于后纵韧带骨化物压迫脊髓和神经根产生神经功能损伤症候群。CT检查中OPLL的发生率为18.22%;在东亚地区OPLL发生率为0.4% ~ 3.0%^[2-3]。目前,国内外对ECS合并OPLL的报道甚少,本研究对海军军医大学长征医院收治的1例采用颈椎前路手术治疗的ECS伴OPLL病例的诊治过程进行总结,报告如下。     

弥漫性特发性骨质增生症（DISH）

弥漫性特发性骨质增生症（diffuse idiopathic skeletal hyperostosis,DISH）,60余年前由Forestier和Rotes—Querol首次详细报告,又称Forestier病[1]。DISH在临床上并不少见,好发于中老年人,以软组织（主要为韧带、肌腱附着点）部位的钙化和骨化为特征,最常累及脊柱。病因不明,     

弥漫性特发性骨肥厚症诊断及合并脊柱骨折的临床特征和治疗进展

<正>弥漫性特发性骨肥厚症(diffuse idiopathic skeletal hyperostosis,DISH),又称为Forestier病,是一种好发于中老年却易被忽略的全身性骨骼疾病,表现为脊柱和关节的韧带及肌腱附着点的钙化和骨化~([1~3])。DISH累及脊柱时表现为多个椎体前外侧流注性骨赘和钙化等特征性改变,可导致脊柱强直,从而使脊柱易在创伤下甚至微小外力下出     

经皮内窥镜技术治疗老年单节段退行性腰椎椎管狭窄症

腰椎椎管狭窄症（LSS）是骨科常见病之一。随着我国老龄化的加速,老年退行性腰椎椎管狭窄症（DLSS）的发生率逐年增加,腰腿痛和间歇性跛行严重影响患者的生活质量^[1]。DLSS往往由椎间盘突出或合并钙化、小关节骨赘增生及黄韧带肥厚等原因引起,部分患者合并发育性椎管狭窄^[2-3]。临床上根据解剖部位将LSS分为中央管狭窄（椎管中央型狭窄）、关节下管狭窄（神经根管的关节下段,包括侧隐窝）和椎间管狭窄（椎弓根及椎间孔段）^[4-5]。老年DLSS患者一般病史较长,影像学资料提示多节段的椎间盘膨出或突出、黄韧带肥厚、小关节增生、侧隐窝狭窄,有时神经根病变的定位诊断也不明确,是否需要将所有狭窄的间隙部位减压,是否需要广泛的融合固定一直是临床争论的问题^[6]。传统腰椎减压融合术治疗DLSS效果明显,但手术创伤较大,术后感染、切口愈合不良、植骨区不融合、内固定松动断裂、邻椎病等手术并发症使得此类技术的应用受到限制^[7]。近年来,经皮内窥镜技术在治疗DLSS方面优势明显,通过术前病史询问、体格检查及相关影像学资料的反复研究,并根据病情需要可结合椎间盘造影,最终精准定位责任椎间隙及椎管狭窄部位行靶向穿刺,达到定点精准减压。2014年5月-2017年8月,本院采用经皮内窥镜下减压术并射频消融术治疗老年单节段DLSS患者40例,现将诊疗过程报告如下。     

放射影像学检查无异常的颈椎脊髓损伤的临床研究进展

放射影像学检查无异常的颈椎脊髓损伤（SCI）是指X线片或CT未见骨折、脱位,但合并颈椎SCI症状的一种特殊类型的SCI^[1],国外最早报道见于儿童,占儿童SCI的3%~66%^[1-3] ;国内主要见于成人,并命名为无骨折脱位型颈椎SCI,占颈椎SCI的20%^[4]。放射影像学检查无异常的颈椎SCI均可导致不同程度瘫痪等严重后果,主要有完全横断性损伤、中央管综合征、脊髓半切综合征、不完全性SCI 4种类型^[1,3-6],临床症状为损伤平面以下感觉减退或异常、肌力下降以及膀胱功能障碍,部分可合并颈神经根损伤;成人以中央管损伤综合征最为常见^[4,7],损伤可表现为非连续性、延迟性,在3~7 d达到高峰,此时的MRI表现较入院时与最终愈后具有明显相关性^[8-9]。儿童和成人放射影像学检查无异常的颈椎SCI各具特点,两者在临床发病、MRI表现及治疗上存在明显差异,本文查阅国内外文献,就当前的临床研究进展作如下综述。     

脊柱韧带骨化相关的易感基因研究进展

弥散性特发骨肥大症（diffuse idiopathic skeletal hyperostosis，DISH），也称Forestier病，是一种常见的老年型疾病，表现为脊柱前纵韧带骨化和各种脊柱外韧带骨化。DISH病与后纵韧带骨化（ossification of posterior longitudinal ligamentum，OPLL）和黄韧带骨化（ossification of the ligamentum flavum，OLF）的病理病变过程均为软骨内骨化；它们均是临床常见的多因素迟发疾病，起病隐匿，男性多见，男女比率为3—1：1。[第一段]     

单侧椎弓根螺钉联合对侧椎板关节突螺钉内固定椎间融合术的研究进展

椎弓根螺钉(PS)内固定技术由Roy-Camille等^[1]于1970年首次报道,特别是其联合椎间融合器植骨的应用,具有固定节段短、稳定性好、融合率高、疗效确切等优点,成为腰椎固定融合的标准术式^[2-3]。但双侧PS内固定增加了邻近节段的应力^[4],特别是采用正中切口显露的操作,存在切口大、软组织剥离范围广、出血量大等缺点^[5-6]。虽然经皮和经肌间隙入路明显减小了手术切口、减少了创伤和出血量,但固定方式和力学特性并没有改变^[7-9]。椎板关节突螺钉(TLFS)内固定技术由Magerl^[10]于1984年首次完整地描述,并报道了与PS联合应用的初步实践。TLFS可较好地控制腰椎三维6个方向的运动^[11-12],具有切口小、创伤小、操作简单等优点^[13-14]。单侧PS联合对侧TLFS内固定(联合固定)于2005年由Jang等^[15]首次报道,在临床上获得快速推广应用,成为一种独立、有效的腰椎固定融合方法^[6,16-17]。本文从生物力学、临床应用及适应证等方面对联合固定椎间融合术的进展作如下综述。     

寰枢椎脱位伴齿突后假瘤诊疗的研究进展

齿突后假瘤是由寰枢椎脱位或其他病因引起的炎性肉芽肿或反应性肥大导致齿突后软组织增生病变^[1]。其可压迫脊髓，导致疼痛、感觉异常，甚至瘫痪。引起齿突后假瘤较常见的病因有类风湿关节炎（RA）^[2-3]、寰枢椎脱位^[4]、颈椎退行性疾病^[5]，少见的病因有长期透析^[6]、晶体沉积^[7]、滑膜囊肿^[8]等。     

骨形态发生蛋白受体-ⅠA的单核苷酸多态性对后纵韧带骨化的影响

后纵韧带骨化症(OPLL)的特征是异位骨形成替代韧带组织^[1-2]。OPLL在亚洲人中的发生率高于欧洲人和美国人,有报道^[3]显示,OPLL在日本的发生率为1.9%~4.3%,在中国为0.44%~8.92%。目前OPLL的发生机制仍未完全阐明,遗传因素和环境因素在其发生过程中均起作用。既往研究[4-9]表明,遗传因素是OPLL的主要因素,并且和环境因素相互作用。骨形态发生蛋白(BMP)是转化生长因子-β(TGF-β)超家族的成员,BMP结合骨形态发生蛋白受体-ⅠA(BMPR-ⅠA)、BMPR-ⅠB和BMPR-Ⅱ,通过Smad信号转导通路刺激成骨细胞分化^[10-11]。BMPR-ⅠA是BMPR家族的一种亚型,在BMP信号转导通路中起着重要调节作用^[12-14]。既往研究^[10]表明,BMPR-ⅠA在异位骨化的发生、发展中起着重要作用。本研究旨在探讨BMPR-ⅠA在OPLL发展中的作用,评估其是否为OPLL的易感基因,现报告如下。     

平山病的诊疗进展

平山病于1959年由日本学者Hirayama等^[1]首次报道，以不对称的上肢远端肌力减弱和肌肉萎缩为首发症状，常累及手腕和手指并以骨间肌、小鱼际肌及前臂尺侧肌肉萎缩为著，主要见于亚裔青年男性^[2]。Singh等^[3]的研究发现，平山病患者以第一骨间背侧肌和小指展肌受累最为常见。发病年龄一般为20~30岁，男性多于女性，但也有儿童及中年发病的报道^[4]。平山病症状常为单侧，约10%的患者出现双侧对称受累，且临床症状较重^[5]。超过95%的患者可自觉寒冷环境中力弱加重^[6]。临床体征为C₇~T₁脊髓节段支配的前臂、手部肌肉进行性萎缩，手、前臂肌力减弱，但肱桡肌不受累，可勾勒出典型的掌侧及背侧前臂肌肉萎缩的斜行边界，较少伴有感觉异常或锥体束征^[2，7]，受累肌肉收缩时可出现收缩震颤。患者肌肉牵张反射正常，锥体束征阴性，不伴有排尿异常及颅神经麻痹。Holla等^[8]报道了1例罕见的肩胛带肌受累病例，患者肌无力从双上肢远端逐渐发展至近端，出现无法穿衣、梳头等症状，查体可见翼状肩胛和菱形肌、冈上肌、冈下肌、胸大肌及前锯肌肌肉萎缩。平山病起病隐匿，与运动神经元病相似，但预后不同，提高对此病的诊断和治疗水平尤为重要。MRI检查及神经电生理检测技术有助于平山病的诊断和评估。目前平山病的治疗根据病情决定：病程短、症状轻的一般选择非手术治疗（颈托）；反之，则选择手术治疗。本文通过查阅近年平山病相关文献，分析其诊断及治疗方法，以期为平山病的诊治提供参考，现综述如下。     

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.     

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.     

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.     

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.