预存自体输血在脊柱侧凸矫形术中的应用

目的：探讨预存自体输血在脊柱侧凸矫形术中应用的可行性。方法：选择９６例行后路器械矫形融合术的脊柱侧凸患者,５０例患者接受了预存自体输血。作为研究员,另４６例患者除术前未行预存自体输血外,其它条件如年龄、手术方式、手术时间等与研究组相似,作为对照组。所有患者术中均常规使用自体血回输。结果：预存自体输血组平均预存血量为６５０ｍｌ,围手术期异体血输入量平均为３５０ｍｌ。对照组围手术期异体血平均输入量为８     

控制性降压联合自体血回输在脊柱手术中的应用

目的 探讨控制性降压联合自体血回输技术应用于复杂脊柱外科大手术的临床效果及安全性. 方法 将40例脊柱外科大手术的患者用抽签法随机分为两组(每组20例):控制性降压联合自体血回输组(A组)和非自体血回输组(B组).A组全麻诱导后,术中用硝酸甘油行控制性降压,维持平均动脉压(mean arterial pressure,MAP)(65±5) mmHg(1mmHg=0.133 kPa),并用血液回输仪回收术野出血;B组未行自体血回输;两组术中血细胞比容(hematocrit,Hct)低于25％即输库血.两组术中连续监测心率(heart rate,HR)、MAP、心电图(electrocardiogram,ECG)和中心静脉压(central venous pressure,CVP).记录两组患者术中出血量、异体输血量及输血相关并发症,术前和术后24 h红细胞(red blood cell,RBC)、血红蛋白(hemoglobin,Hb)、Hct、血小板(platelet,PLT)及凝血酶原时间(prothrombintime,PT)、活化部分凝血酶原时间(activeated partial thromboplasting time,APTT)和纤维蛋白原(fibrinogen,FG). 结果 A组出血量(1 120±510) ml与B组(1 524±457) ml比较,差异有统计学意义(P＜0.05);A组输异体血发生率(10％)显著少于B组(100％)(P＜0.01);术后24 h两组患者RBC、Hb、Hct、PLT、PT、APTT和FG与术前比较差异有统计学意义(P＜0.05),但都在正常范围内,两组间比较差异无统计学意义(P＞0.05);两组均无肺水肿、心力衰竭及创面异常出血并发症. 结论 控制性降压复合术中自体血回输在复杂脊柱手术中的应用是安全可靠的,能明显减少出血量,减少甚至避免异体血输入.     

血液稀释法自体输血在脊柱侧凸后路手术中的应用

目的：探讨在脊柱侧凸矫形术中应用血液稀释法自体输血的可行性。方法：３６例脊柱侧凸患者在行后路器械矫形融合术中采用了血液稀释法自体输血。２０例患者术接受了预存自体输血,其中４例患者又应用了术中自体血回输。结果：平均轴血量为６２７ｍｌ（４２５～８３４ｍｌ）,血液稀释后红细胞压积达２９．８％。２０例平均预存血量为６５０ｍｌ。术中术后平均总失血量１８５０ｍｌ,平均异体血输入量７５０ｍｌ。４例应用术中自体血回输患者均未输异体血而安全度过手术期。所有患者在血液稀释采血后血红蛋白、红细胞压积均明显下降,术后１周基本恢复正常,未发现应用血液稀释法采血的相关并发症。结论：血液稀释法自体输血能有效减少异体血的输入量,且安全有效、节约区费;联合应用多种自体输血方法可大大减少甚至无需异体血输入。     

自体血回输对青少年特发性脊柱侧凸患者围手术期细胞免疫功能的影响

目的：探讨自体血回输对青少年特发性脊柱侧凸患者围手术期细胞免疫功能的影响。方法：2002年2月～2005年2月，根据术中输血的方式将特发性脊柱侧凸患者148例分为2组，异体输血组(Ⅰ组)42例：术中全部输异体成分血；自体血回输组(Ⅱ组)106例：术中采用血液回收机将自体血回输给患者，使患者红细胞比容(HCT)≥30％，Hb≥10g／L，如果达不到低限，适量补充异体血。观察两组异体血输入量、过敏反应发生率；并分别于入手术室、术后第1天及第5天抽取静脉血，测定T细胞亚群和NK细胞的数量。结果：Ⅰ组平均异体血输入量850±170ml，Ⅱ组中有58例除了自体血回输外补充了异体血，平均410±150ml。输血反应发生率Ⅰ组为26．2％(11／42)，Ⅱ组为4．7％(5／106)，两组间存在显著性差异(P＜0．01)。两组术后第1天CD3~+、CD4~+、CD4~+／CD8~+、NK细胞较术前显著减少(P＜0．05或P＜0．01)，异体输血组较自体输血组减少更明显(P＜0．05)。术后第5天异体输血组CD3~+、CD4~+、CD4~+／CD8~+、NK细胞仍较术前显著减少，自体输血组基本恢复正常，两组间存在显著差异(P＜0．05)。结论：自体血回输可明显减少脊柱侧凸矫形患者异体血输入量，术后自体输血患者细胞免疫功能的抑制较异体血输入者轻，术后细胞免疫功能恢复快。     

脊柱侧凸矫形术后的护理

脊柱侧凸是儿童及青少年的常见病 ,如不及时发现和治疗 ,可导致严重畸形和压迫相应周围脏器 ,并影响心肺功能和人体正常发育 ,出现一系列相应症状 ,增加病人的心理创伤 ,并对其工作、学习和生活造成极大的不便 ,增加了社会和家庭的负担。我科自 1997年至今 ,共开展了 6例脊柱侧凸的矫形手术 ,均取得了满意的疗效。现将术后的护理体会报告如下。临床资料一、一般资料　本组病人共 6例 ,其中男性 2例 ,女性 4例 ,年龄 12～ 2 4岁。术后脊柱侧凸明显改善 ,身高平均增长 4～ 5 cm。出院后石膏背心外固定。随访半年至一年 ,疗效满意。二、手术方…     

特发性脊柱侧凸三维矫形术后失代偿原因及防治的研究进展

特发性脊柱侧凸(idiopathicscoliosis)的手术矫治已有40多年的历史。近20年来,通过对这种疾病三维畸形病理改变的认识,其手术治疗的目的转变为纠正脊柱三维畸形,即达到冠状面矫形、矢状面恢复生理曲度和轴位消除旋转这三个目标[1]。随着以CD为代表的三维矫形器械的广泛应用,特发性脊柱侧凸手术矫治已取得较好的临床效果。同时,术后脊柱冠状面及矢状面平衡失代偿的现象也逐渐被人们所认识[1~5]。这一现象引起了许多医师的关注,并对失代偿的原因进行了探讨。1脊柱正常的生理曲线和平衡在站立正侧位X线片上,自C7椎体中心引一铅垂线,在脊柱冠…     

脊柱侧凸矫形术后的曲轴现象

曲轴现象是指骨骼未发育成熟的病人仅作脊柱后路矫形融合后 ,畸形再加重的一种现象。其表现为矫正度丢失、椎体旋转加重、肋骨隆起增加[1,2 ] 。 195 0年Ｐｏｎｓｅｔｉ首先报道了脊柱后路融合后畸形加剧的现象。 1973年Ｄｕｂｏｕｓｓｅｔ等认为脊柱前方的椎体环绕着后方融合的拴系发生扭曲 ,类似于曲轴的变化 ,故称之为曲轴现象。曲轴现象是脊柱侧凸术后严重影响手术效果的常见并发症之一 ,畸形严重者导致矫形失败 ,甚至需要再手术。本文就曲轴现象的危险因素、诊断标准和防治作一综述。1　发病机制脊柱生长来自三个区域 :关节突、椎体上…     

骨移植在青少年特发性脊柱侧凸后路矫形术的应用研究

[目的]通过不同植骨在青少年特发性脊柱侧凸后路矫形植骨融合术中的应用比较,探讨其临床应用效果.[方法]回顾性分析2000年～2005年行后路钉-棒系统矫形手术的71例青少年特发性脊柱侧凸患者,其中自体骨移植21例(A组),同种异体骨移植23例(B组),自体骨混合同种异体骨移植27例(C组),比较随访第3、9、15、36个月的融合率、Cobb's角丢失率及假关节发生率.[结果]A组平均融合节段7个,B组平均融合节段7.6个,C组平均融合节段8个.随访的第3个月,融合率、Cobb's角丢失率及假关节发牛率A组、B组、C组无显著性差异(P＞0.05).第9个月,A组融合率高于B、C两组,A组与B、C组有显著性差异(P＜0.05),B、C组间无显著性差异(P＞0.05),Cobb's角丢失率及假关节发生率A、B、C组无显著性差异(P＞0.05).第15、36个月,融合率、Cobb's角丢失率及假关节发牛率A、B、C组无显著性差异(P＞0.05).[结论]同种异体骨移植、自体骨混合同种异体骨移植与自体骨移植在青少年特发性脊柱侧凸后路矫形手术中对维持矫形效果可取得相近的近远期临床效果.     

全程健康教育在三维矫形术治疗脊柱侧凸患者中的应用

对78例三维矫形术治疗脊柱侧凸患者制订标准健康教育计划并分阶段实施全程健康教育。结果患者对自身疾病厦其治疗过程能全面系统地了解，能积极有效地配合治疗和护理，提高了对该病的治疗效果。提示加强疾病知识教育、心理疏导、护理指导等可增强患者治疗信心，提高其配合能力，促进疾病早日康复，提高患者生活质量。     

褪黑素在特发性脊柱侧凸中的作用

特发性脊柱侧凸（ｉｄｉｏｐａｔｈｉｃｓｃｏｌｉｏｓｉｓＩＳ）是青少年和儿童脊柱畸形最常见的类型。它以脊柱在冠状面上的向侧方弯曲为主要特征,同时伴有矢状面上的轻度后凸和椎体在脊柱纵轴上的旋转。由于一般是在青春期发病,所以青少年型特发性脊柱侧凸（ａｄｏｌｅｓｃｅｎｔｉｄｉｏｐａｔｈｉｃｓｃｏｌｉｏｓｉｓ,ＡＩＳ）在临床上最常见。如果将诊断标准定为Ｃｏｂｂ角＞１０°,ＡＩＳ的发病率是３％左右。如果诊断标准为Ｃｏｂｂ角＞２０°,发病率降为０．３％１。大多数患者侧凸相对较轻且稳定,少数患者侧凸会不断加重并…     

Gait analysis in patients with idiopathic scoliosis

Introduction The goal of this study was to observe scoliotic subjects during level walking to identify asymmetries—which may be related to a neurological dysfunction or the spinal deformity itself—and to correlate these to the severity of the scoliotic curve.Methods We assessed the gait pattern of ten females (median age 14.4) with idiopathic scoliosis characterised by a left-lumbar and a right-thoracic curve component. Gait analysis consisted of 3D kinematic (VICON) and kinetic (Kistler force plates) measurements. The 3D-segment positions of the head, trunk and pelvis, as well as the individual joint angles of the upper and lower extremities, were computed during walking and static standing. Calculation of pertinent kinetic and kinematic parameters allowed statistical comparison.Results All subjects walked at a normal velocity (median: 1.22 m/s; range:1.08–1.30 m/s; height-adjusted velocity: 0.75 m/s; range: 0.62–0.88 m/s). The timing of the individual gait phases was normal and symmetrical for the whole group. Sagittal plane hip, knee and ankle motion followed a physiological pattern. Significant asymmetry was observed in the trunks rotational behaviour in the transverse plane. During gait, the pelvis and the head rotated symmetrically to the line of progression, whereas trunk rotation was asymmetric, with increased relative forward rotation of the right upper body in relation to the pelvis. This produced a torsional offset to the line of progression. Minimal torsion (at right heel strike) measured: median 1.0° (range: 5.1°–8.3°), and maximal torsion (at left heel strike) measured 11.4° (range 6.9°–17.9°). The magnitude of the torsional offset during gait correlated to the severity of the thoracic deformity and to the standing posture, whereas the range of the rotational movement was not affected by the severity of the deformity. The ground reaction forces revealed a significant asymmetry of [Msz], the free rotational moment around the vertical axis going through the point of equivalent force application. On the right side, the initial endo-rotational moment was lower, followed by a higher exo-rotational moment than on the left. All the other force parameters (vertical, medio–lateral, anterior–posterior), did not show a significant side difference for the whole group. The use of a brace stiffened torsional motion. However the torsional offset and the asymmetry of the free rotational moment remained unchanged.Conclusion The most significant and marked asymmetry was seen in the transverse plane, denoted as a torsional offset of the upper trunk in relation to the symmetrically rotating pelvis. This motion pattern was reflected by a ground-reaction-force asymmetry of the free rotational moment. Further studies are needed to investigate whether this behaviour is solely an expression of the structural deformity or whether it could enhance the progression of the torsional deformity.No financial assistance was provided for this work     

前路胸腔镜下松解联合后路矫形对特发性脊柱侧凸患者肺功能早期影响的研究

目的研究前路胸腔镜下脊柱松解联合后路矫形术对特发性脊柱侧凸(idiopathic scoliosis,IS)患者肺功能早期影响。方法对2004年4月-2008年6月行前路胸腔镜下松解联合后路矫形手术治疗的21例IS患者肺功能进行评估。男9例,女12例;年龄12～24岁,平均15.6岁。左侧凸2例,右侧凸19例。Lenke分型:Ⅰ型12例,Ⅱ型9例。发现脊柱侧凸1年6个月～9年,平均2.5年。胸椎冠状面Cobb角为65～125°,平均为79.6°。于术前及术后6个月行肺功能检测,包括肺容量、通气功能、胸廓顺应性三部分。结果前路胸腔镜下松解术中胸腔开放时间为90～150 min,平均127 min。术后切口均Ⅰ期愈合,无胸腔内感染发生。后路矫形术完成后1周患者冠状面Cobb角为36～75°,平均43.7°。术后患者均获随访,随访时间6～36个月,平均13.5个月。术后6个月时,患者肺活量及最大通气量均较术前显著提高(P<0.05),但实测值占预计值的百分比较术前无明显变化(P>0.05);功能残气量较术前下降(P<0.05);残气量实测值及与预计值的百分比均较术前下降(P<0.05)。第1秒用力呼气肺活量及其与用力呼气肺活量比值与术前比较无明显改善(P>0.05),最大自主通气量较术前显著上升(P<0.05)。患者总气道阻力、吸入气道阻力及呼出气道阻力均较术前显著下降(P<0.05)。结论前路胸腔镜下脊柱松解联合后路矫形术对IS患者胸腔有一定干扰,但矫形后随着胸腔形态变化和软组织松解,术后早期患者肺容量、通气功能、胸廓顺应性均得到不同程度改善,肺储备能力提高,但远期肺功能情况仍需进一步观察。     

Intraoperative autotransfusion with a new disposable system

In the past 2 years we have used a simple, disposable set for Intraoperative autotransfusion. The system consists of a rigid plastic case with a flexible bag inside constituting a 600 ml reservoir which can be connected to any suitable vacuum source. We used it so far in 56 patients undergoing various vascular operations who were autotransfused a total of about 160 units of blood without any complications with regard to blood coagulation or hemolysis.     

复合用药控制性降压在颅脑手术的应用

目的比较单独用硝酸甘油与硝酸甘油加艾司洛尔,在颅脑手术时行控制性降压的效果。方法34例在异氟烷全麻下行颅脑手术病人,随机分为硝酸甘油组(Ⅰ组,16例)和硝酸甘油复合艾司洛尔组(Ⅱ组,18例),术中MAP降至并维持在60～65mmHg,观察此降压期间血流动力学的变化。结果1.两组各行控制性降压时间无显著差异。2.Ⅱ组硝酸甘油平均用量和总用量比Ⅰ组分别减少42%和39%(P<0.05)。3.Ⅰ组降压后心率明显增快(P<0.05)。Ⅱ组合并使用艾司洛尔50μg·kg-1·min-1后,心率变化不大,各时段心率均慢于Ⅰ组(P<0.01)。4.两组降压所需时间和停降压药后血压回升时间无显著差异(P>0.05)。结论异氟烷全麻下的颅脑手术患者,术中行控制性降压至MAP60～65mmHg,如联合应用硝酸甘油和艾司洛尔,可显著减少硝酸甘油的用药量,并可避免降压过程中的心率增快,使降压过程确切、满意。     

Intraoperative hypotension during surgical treatment for Marfan syndrome scoliosis in children

Purpose:To explore the occurrence and risk factors of intraoperative hypotension during children’s Marfan syndrome scoliosis surgery and summarize the associated hemodynamic features and handle measures.Methods:Twenty-two Marfan syndrome scoliosis patients who underwent spinal surgery at Beijing Children’s Hospital were retrospectively reviewed between January 2001 and January 2020. Intraoperative hypotension is defined as the minimum mean arterial pressure ≤ 60 mm Hg. The patients were divided into the hypotension group and the control group. Clinical, radiographic, and operative data were compared between the two groups. The risk factors, hemodynamic features, and handle measures for intraoperative hypotension in Marfan syndrome scoliosis surgery were analyzed and summarized.Results:Twenty-two patients were included in the study, with a mean age of 11.4 years at initial surgery. The follow-up period ranged from 24 to 152 months. Intraoperative hypotension occurred in 14 cases, with an incidence of 63.6%. The proportion of pulmonary dysfunction in the hypotension group was higher than in the control group (100.0% vs 50.0%, p < 0.05). The spinal flexibility was significantly lower in the hypotension group (28.3% ± 14.2% vs 46.5% ± 11.5%, p < 0.05). Fourteen patients with intraoperative hypotension had decreased intraoperative systolic blood pressure 21.0%–50.0% compared with baseline. One patient had a transient decrease in the muscle strength of the lower limbs. No complications were observed during the follow-up.Conclusion:The incidence of intraoperative hypotension in Marfan syndrome scoliosis children who underwent surgery was 63.6%. The risk factors included preoperative pulmonary dysfunction and poor spinal flexibility. Comprehensive preoperative evaluation and effective hemodynamic handling measures should be undertaken to prevent further complications in children with Marfan syndrome scoliosis.     

青少年特发性脊柱侧凸患者的中枢神经异常

目的 :检查青少年特发性脊柱侧凸 (AIS)患者的后脑及脊髓的结构和功能异常 ,探讨两者间的相关性及与Cobb角的关系。方法 :用MRI探查AIS患者的后脑及脊髓的解剖结构 ,用体感诱发电位 (SEP)检查体感传导通路功能 ,并对两者结果作相关性检验。结果 :MRI见小脑扁桃体脱垂或脊髓空洞和SEP显示体感传导通路功能异常病例在Cobb角 >45°患者中依次占 31%和 2 7 6 % ,而 <45°患者中分别只占 3 7%和 11 9% ,结构异常和功能异常有显著相关性。结论 :对严重脊柱侧凸或合并SEP异常患者应常规行全脊髓MRI检查 ,以便及早发现后脑及脊髓病变     

急性高容量血液稀释联合控制性降压对脊柱手术患者全身炎性反应的影响

目的研究急性高容量血液稀释(AHH)联合控制性降压(CH)对脊柱手术患者全身炎症反应的影响。方法择期脊柱手术患者60例,随机分为三组,每组20例。AHH组在麻醉诱导平稳后以30ml/min的速率输入6%羟乙基淀粉(130/0.4)15ml/kg,AHH+CH组在行AHH的同时采用硝酸甘油进行CH,MAP控制在60~70mm Hg。对照组常规输入复方乳酸钠15ml/kg补充禁食禁饮、生理需要量及第三间隙损失量。分别在AHH前(T1)、AHH后(T2)、手术开始后2h(T3)、术毕(T4)、术毕24h(T5)采集外周静脉血测定血清降钙素原(PCT)、C-反应蛋白(CRP)、白细胞介素-6(IL-6)浓度。记录手术时间、术中失血量和输血量。结果与T1时比较,三组T3~T5时CRP、IL-6浓度明显升高(P<0.05)。与对照组比较,AHH组和AHH+CH组在T2~T5时CRP、IL-6浓度明显降低(P<0.05);T4、T5时,AHH组和AHH+CH组PCT浓度均明显降低(P<0.05),AHH组和AHH+CH组术中失血量、输血量明显减少(P<0.05)。结论AHH或AHH联合CH不仅可减少脊柱手术患者术中失血量及输血量,而且可有效抑制围术期PCT、CRP、IL-6的表达,降低全身炎症反应。     

The development of adolescent idiopathic scoliosis

There are many conflicting actiological theories for adolescent idiopathic scoliosis. We present a simple new model of scoliosis and a mechanism by which it is initiated and progresses. This mechanism provides a final common pathway for the multiple aetiological factors. A simple model of the spine, incorporating its fundamental mechanical features, was constructed. The model consisted of interconnected anterior compression and posterior tension columns. It allowed normal spinal movements, with flexion limited by the posterior column and rotation centred around the anterior column. It also allowed deformities to develop. The ends of the model were fixed in the position of the vertebrae they represented. Overgrowth of the anterior column relative to the posterior column caused the model to take up the shape of an idiopathic scoliosis. The greater the overgrowth, the more marked the deformity. Normally anterior and posterior column growth are coupled. During the growth spurt the thoracic kyphosis flattens indicating that anterior growth temporarily exceeds posterior growth. If this overgrowth is marked a scoliosis will develop, as demonstrated by the model. Once this occurs the coupling is lost, anterior growth further outstrips posterior growth and the deformity progresses. Not all scolioses worsen, as the tendency to progress is balanced by neuromuscular factors and remodelling. Factors that increase the growth rate, induce asymmetry or decrease the inherent stability of the spine all encourage the development and progression of a scoliosis. This explains the complex biomechanics of scoliosis and provides a final common pathway by which the multiple aetiological factors can induce idiopathic scoliosis. It has important implications for the understanding and treatment of this condition.     

成人特发性脊柱侧凸患者脊柱-骨盆矢状位平衡分析

目的:分析不同类型成人特发性脊柱侧凸(IS)患者的脊柱-骨盆矢状位平衡情况。方法:回顾分析2002年4月~2009年4月收治的83例成人IS患者,男16例,女67例,年龄20~84岁,平均43岁。在全脊柱站立位X线正侧位片(包括双侧髋关节)上测量侧凸Cobb角、胸椎后凸角(TK)、胸腰段后凸角(TLJ)、腰椎前凸角(LL)、骨盆入射角(PI)、骶骨倾斜角(SS)、骨盆倾斜角(PT)以及C7铅垂线与S1后上缘的水平距离(SVA)。将患者分为胸弯组和腰弯组,比较两组患者的脊柱-骨盆矢状位参数,分析各参数间的相关性及各参数与年龄的相关性。结果:胸弯组共39例,平均年龄40.9岁,主弯角度平均45.8°;腰弯组共44例,平均年龄44.8岁,主弯角度平均39.5°。两组患者的年龄无统计学差异(P>0.05)。两组的TK、TLJ、LL、PI、SS、PT均无统计学差异(P>0.05),但腰弯组的SVA明显大于胸弯组(P<0.05)。在≤40岁患者中,胸弯组和腰弯组患者的脊柱-骨盆矢状位序列无统计学差异(P>0.05);在>40岁患者中,腰弯组患者SVA和PT大于胸弯组(P<0.05),余参数两组间无统计学差异(P>0.05)。胸弯组9例(23.1%)出现脊柱失平衡,其中7例为负向失平衡;腰弯组12例(27.3%)出现脊柱失平衡,其中8例为正向失平衡。两组的LL与TK、SS有相关性,PI与PT、SS有相关性,SVA与LL、SS、PT有相关性,年龄与SVA、PT有相关性。与胸弯组不同,腰弯组患者的PI与LL无相关性,而年龄与LL、SS有相关性,PT与LL、SS有相关性。结论:成人IS中,胸弯和腰弯患者的骨盆形态无差别,骨盆与脊柱的矢状位序列密切相关,年龄与躯干平衡相关。胸弯患者易出现脊柱负向失平衡,而腰弯患者更易出现脊柱正向失平衡。