前路一期手术治疗胸椎及胸腰段脊柱结核

目的观察前路一期病灶清除联合植骨融合内固定治疗胸椎及胸腰段脊柱结核的外科治疗效果。方法 2004－2008年收治胸椎及胸腰段脊柱结核初治病例184例,经胸或胸腹前路行一期病灶清除、椎间肋骨（钛网）植骨、椎体棒板系统内固定术。术后根据药物敏感试验以个体化的化疗方案治疗1.0－1.5年。结果伤口均Ⅰ期愈合。并发症包括肋间神经痛、气胸/胸腔积液。随访1－4年,平均2.3年,随访期内结核无复发,神经损害改善或完全恢复,所有患者均显示骨性融合,后凸畸形平均矫正29.5°。结论经胸或胸腹前路一期病灶清除联合肋骨（钛网）植骨及钢板内固定术是治疗胸椎或胸腰段脊柱结核较好的手术方式之一。     

一期后路固定前路病灶清除植骨治疗胸腰段椎体结核

目的探讨一期后路内固定联合前路病灶清除植骨融合治疗胸腰段椎体结核。方法2003年2月至2011年2月手术治疗胸腰段椎体结核23例,应用一期后路内固定联合经前路结核病灶清除植骨融合治疗胸腰椎体结核,根据术前、术后X线片分析植骨融合及术后畸形矫正效果。结果经14～54个月随访,脊髓功能得到不同程度的恢复,植骨融合满意,无内固定失败和脊柱结核病灶复发。结论一期后路内固定联合经前路结核病灶清除植骨融合治疗胸腰段椎体结核具有脊柱后凸侧弯畸形易于矫正、前路结核病灶减压彻底、内固定远离病灶等优点,是治疗脊柱胸腰段结核的一种有效手术方法。其缺点是手术创伤较大、时间较长、操作相对繁杂。     

前路病灶清除植骨Z-plate固定治疗胸腰段结核

目的探讨胸腰段脊柱结核外科治疗中一期前路病灶清除、椎间植骨、Z-plate钢板内固定治疗的效果。方法对91例胸腰段脊柱结核患者行一期前路病灶清除、椎体间自体骨移植并前路内固定治疗。结果91例脊柱结核患者平均随访13个月均治愈,无局部复发,植骨全部骨性融合,融合时间平均3.7个月,平均后突矫正角度20°,治疗优良率达95.5%。结论在治疗胸腰段脊柱结核中一期前路病灶清除椎体间自体骨移植并前路内固定是安全和有效的,在重建脊柱稳定性中具有重要的意义。     

胸椎或胸腰段脊柱结核后路手术后复治患者的外科治疗

目的：探讨胸椎或胸腰段脊柱结核后路内固定术后复治患者的外科治疗方法及疗效。方法：2004年6月～2007年12月共收治胸椎或胸腰段脊柱结核后路手术后复治患者15例，其中神经症状未缓解或加重、结核中毒症状持续6例，Frankel分级B级3例，C级1例，D级2例；切口窦道形成9例。经调整抗结核用药2-8周后．5例一期取出椎弓根内固定，同时行标准前路手术（经胸或经胸腹入路病灶清除、肋骨或钛网植骨、钢板内固定）：1例患者未取出椎弓根内固定，直接行前路病灶清除、钛笼植骨术；9例先行窦道切除、病灶清除、椎弓根内固定取出术，伤口愈合2周后再行标准前路手术。术后根据药敏结果进行个体化的化疗1-1．5年。随访观察患者病灶有无复发、植骨融合及神经功能恢复情况。结果：15例患者均顺利康复，切口均一期愈合。7例术后出现肋间神经疼痛或麻木。术中清除病灶组织送病理检测均确诊脊柱结核。8例培养出结核杆菌（57．1％），4株耐药．其中1株耐多药。随访3～32个月，平均18个月。末次随访时6例有神经损害的患者中2例由术前Frankel B级恢复到D级．其余神经症状均完全恢复，随访期内结核未见复发，8例随访1年以上者X线片显示植骨融合．结论：对后路手术后复治的胸椎或胸腰段脊柱结核患者，在有针对性的化疗基础上行前路彻底地病灶清除可取得较好效果。     

两种术式治疗胸腰椎结核的疗效观察

目的　比较病灶清除术与前路病灶清除椎间植骨内固定术治疗胸腰椎结核的临床疗效。方法　全组 6 8例 ,平均年龄 37岁。病灶清除术组 33例 ,病灶清除植骨内固定术组 35例 ;其中胸椎结核 2 1例 ,胸腰段结核 18例 ,腰椎结核 2 9例。病灶清除术采用经胸、胸膜外或腹膜外入路 ,清除病灶后 ,骨缺损大于 5 mm者取髂骨植骨 ;小于 5 mm者不植骨。病灶清除植骨内固定术采用经胸或腹膜外入路 ,彻底清除病灶 ,髂骨或填塞自体肋骨粒的钛网椎间植骨融合 ,一期前路内固定。术后抗结核治疗 12～ 18个月。结果　平均随访 2 7个月。病灶清除术组中 5例术后结核局部复发 ,再次手术治疗。病灶清除植骨内固定术组无结核局部复发 ,脊柱后凸畸形改善 ,矫正角度 15°;无内固定器械断裂。结论　前路病灶清除植骨内固定术 ,可重建脊柱的稳定性 ,利于结核病灶的稳定与修复 ,减少结核复发 ,矫正后凸畸形 ,较病灶清除术能取得更好的临床疗效。     

一期前路病灶清除植骨融合内固定治疗多椎体脊柱结核

目的:总结一期前路病灶清除、自体骨植骨融合及前路内固定治疗多椎体脊柱结核的临床效果。方法:1998年5月～2008年5月收治多椎体脊柱结核(≥3个椎体,包括跳跃性病灶)患者41例,病灶分布为C4～S1,颈椎2例,胸椎14例,胸腰段19例,腰椎4例,腰骶椎2例。伴截瘫者7例,Frankel分级C级4例,B级2例,A级1例。伴后凸成角21例。均采用一期前路病灶清除、自体骨植骨融合及内固定术治疗,随访观察治疗效果。结果:随访12个月～10年,平均67个月。7例截瘫患者术后1年神经功能较术前均有恢复。后凸畸形术前平均Cobb角23.5°,术后平均11.5°,末次随访时平均丢失3.8°。内固定松动1例,伤口及植骨延迟愈合2例。所有患者均骨性融合,结核无复发。结论:多椎体脊柱结核患者采用一期前路病灶清除、自体骨植骨融合、前路内固定治疗可取得良好效果。     

一期病灶清除、植骨及前路短节段固定治疗胸腰椎结核

目的探讨一期病灶清除、植骨及前路短节段固定治疗胸腰椎结核的疗效。方法本组33例采用前路病灶清除、植骨短节段固定治疗脊柱结核,手术前正规化疗2~4周,调整内科疾病,行病灶刮除,清除病变椎间盘,自体大块骼骨块或肋骨条植骨,侧前方安装内固定系统,尽可能安装在病椎上,术后正规抗痨治疗1~2年。结果全部病例伤口均一期愈合,术后随访1～4年,全部病例植骨均获完全骨性愈合,术后平均随访32个月未见脊柱结核复发。结论一期病灶清除、植骨及前路短节段固定治疗胸腰椎结核具有一次性完成手术,清除病灶彻底,手术时间短、出血少、内固定器械操作相对简单,创伤小,融合率高,复发率低等优点。     

一期后路内固定前路病灶清除植骨融合术治疗胸腰段脊柱结核

目的探讨一期后路内固定前路病灶清除植骨融合术治疗胸腰段脊柱结核的手术效果。方法对75例胸腰段脊柱结核患者均采用一期后路内固定前路病灶清除植骨融合术。其中后路采用AF内固定、前路采用自体肋骨支撑植骨8例,后路采用钉棒系统内固定、前路采用自体肋骨支撑植骨40例,后路用钉棒系统固定、前路采用钛网植骨27例。结果手术时间150～270 min;术中失血量750～2 100 ml。术中无大血管、硬脊膜损伤。术后并发症:前路切口感染1例,脊神经根激惹1例,交感神经激惹1例,均在3个月内恢复。75例均获随访,时间20～60个月。植骨融合率:术后6个月为91.5%,术后1年为100%。末次随访时Frankel分级:B级6例均恢复至D级,C、D级37例均恢复至E级。两下肢感觉运动功能、括约肌功能均得到一定程度恢复。无内固定松动断裂,结核病灶无复发。结论术前经过充分准备,以规范的全身抗结核治疗(化疗)为基础,加强营养支持治疗,采用后路固定前路病灶清除植骨融合术可以获得满意疗效。     

前路内固定治疗胸腰椎结核伴后凸畸形与截瘫

目的：探讨前路植骨内固定治疗胸腰段脊柱结核伴后凸畸形与截瘫的疗效。方法：1996年～2002年4月采用前路病灶清除，植骨内固定治疗胸腰椎结核伴后凸畸形与截瘫62例，观察术后植骨融合、畸形矫正、截瘫恢复及结核病灶愈合情况。结果：平均随访2年2个月，56例患者获访，平均融合时间为3．6个月。骨性融合率100％。在胸段、胸腰段及腰段后凸畸形分别平均纠正29°、15°及9°，随访时无矫正度丢失；伴截瘫者11例，Frankel神经功能平均恢复2级；本组脊柱结核均治愈。结论：一期前路病灶清除植骨内固定，融合时间短，畸形矫正效果好，减压彻底，有利于截瘫恢复。     

脊柱结核合并脊髓损伤的外科治疗

目的：探讨合并脊髓损伤的脊柱结核外科手术的方法及应用效果。方法：对1997年4月～2006年4月我科手术治疗的112例合并脊髓损伤的脊柱结核患者进行回顾性分析。颈椎结核11例，颈胸段结核11例，胸椎结核83例，腰椎结核21例，腰骶段结核11例，采用前路病灶清除植骨融合内固定87例，前后路病灶清除植骨融合内固定17例，结果：平均手术时间180min（90～240min），平均出血量650ml（300～1700ml）。术后胸腔积液1例，短暂性瘫痪加重2例。随访3～22个月，除一例外脊髓受累患者神经压迫症状和体征消失，神经功能明显恢复，无内固定松动、断裂。未见结核病灶复发。结论：根据合并脊髓损伤的脊柱结核部位病理破坏程度，一期病灶清除、植骨融合内固定手术是一种安全、有效的外科治疗方式。     

Perioperative and long-term morbidity and mortality after above-knee and below-knee amputations in diabetics and nondiabetics

We performed a retrospective review of a vascular surgery quality assurance database to evaluate the perioperative and long-term morbidity and mortality of above-knee amputations (AKA, n = 234) and below-knee amputations (BKA, n = 720) and to examine the effect of diabetes mellitus (DM) (181 of AKA and 606 of BKA patients). All patients in the database who had AKA or BKA from 1990 to May 2001 were included in the study. Perioperative 30-day cardiac morbidity and mortality and 3-yr and 10-yr mortality after AKA or BKA were assessed. The effect of DM on 30-day cardiac outcome was assessed by multivariate logistic regression and the effect on long-term survival was assessed by Cox regression analysis. The perioperative cardiac event rate (cardiac death or nonfatal myocardial infarction) was at least 6.8% after AKA and at most 3.6% after BKA. Median survival was significantly less after AKA (20 mo) than BKA (52 mo) (P < 0.001). DM was not a significant predictor of perioperative 30-day mortality (odds ratio, 0.76 [0.39-1.49]; P = 0.43) or 3-yr survival (Hazard ratio, 1.03 [0.86-1.24]; P = 0.72) but predicted 10-yr mortality (Hazard ratio, 1.34 [1.04-1.73]; P = 0.026). Significant predictors of the 30-day perioperative mortality were the site of amputation (odds ratio, 4.35 [2.56-7.14]; P < 0.001) and history of renal insufficiency (odds ratio, 2.15 [1.13-4.08]; P = 0.019). AKA should be triaged as a high-risk surgery while BKA is an intermediate-risk surgery. Long-term survival after AKA or BKA is poor, regardless of the presence of DM.     

Postoperative nausea and vomiting and opioid-induced nausea and vomiting: guidelines for prevention and treatment

Postoperative nausea and vomiting (PONV) causes patient discomfort, lowers patient satisfaction, and increases care requirements. Opioid-induced nausea and vomiting (OINV) may also occur if opioids are used to treat postoperative pain. These guidelines aim to provide recommendations for the prevention and treatment of both problems. A working group was established in accordance with the charter of the Sociedad Espa?ola de Anestesiología y Reanimación. The group undertook the critical appraisal of articles relevant to the management of PONV and OINV in adults and children early and late in the perioperative period. Discussions led to recommendations, summarized as follows: 1) Risk for PONV should be assessed in all patients undergoing surgery; 2 easy-to-use scales are useful for risk assessment: the Apfel scale for adults and the Eberhart scale for children. 2) Measures to reduce baseline risk should be used for adults at moderate or high risk and all children. 3) Pharmacologic prophylaxis with 1 drug is useful for patients at low risk (Apfel or Eberhart 1) who are to receive general anesthesia; patients with higher levels of risk should receive prophylaxis with 2 or more drugs and baseline risk should be reduced (multimodal approach). 4) Dexamethasone, droperidol, and ondansetron (or other setrons) have similar levels of efficacy; drug choice should be made based on individual patient factors. 5) The drug prescribed for treating PONV should preferably be different from the one used for prophylaxis; ondansetron is the most effective drug for treating PONV. 6) Risk for PONV should be assessed before discharge after outpatient surgery or on the ward for hospitalized patients; there is no evidence that late preventive strategies are effective. 7) The drug of choice for preventing OINV is droperidol.     

Body composition assessment and methodology in nonathletic and athletic adolescent and adult males and females

The purpose of this review is to outline methodology for assessing body composition utilizing anthropometric and densitometric techniques. The objective of body composition assessment is to measure body fat and lean body mass. The quantity of these components varies due to growth, physical activity, dietary regimens, and aging. Anthropometric techniques incorporate selected skinfolds, circumferences, skeletal widths, or other variables to estimate body composition within k2.0-4.0%. These techniques are adequate for field testing of groups or individuals, but are population specific. Densitometry measures body volume irrespective of physique, sex, or age. This laboratory technique estimates body composition within 1.0-2.0%, is more difficult to administer, but is not population specific. Some limitation exists with any present technique due to biological variability and incomplete research of reference body composition in children, females, and the aged. J Orthop Sports Phys Ther 1984;5(6):336-347.