脊柱结核的外科治疗进展

脊柱结核作为骨关节结核的最常见形式,近年来也随结核病的增加呈上升趋势。由于脊柱结核可引起骨质破坏、脊柱畸形,甚至截瘫,文献统计截瘫发生率10 %左右,若未及时治疗,将严重危害人民健康。目前国内外专家公认的脊柱结核的外科治疗应达到病灶清除彻底、有效减压和维持脊柱稳定     

微创技术在脊柱外科中的应用

随着临床医学水平的提高和工业技术的进步,越来越多的微创外科技术应用于脊柱外科领域,如关节镜技术、胸腔镜技术和腹腔镜技术等,取得了良好的效果,逐步形成了微创脊柱外科(Minimally Invasive Spinal Surgery).它代表了脊柱外科发展的趋势.目前在该领域所应用的微创技术主要有两类:经皮穿刺技术和内窥镜辅助下的手术技术.     

脊柱结核外科治疗临床疗效分析

目的:探讨脊柱结核外科治疗临床疗效.方法:回顾分析120例胸腰椎结核分别采用单纯病灶清除33例;一期经前路病灶切除椎体间植骨并内固定49例;经后路病灶清除、植骨融合并内固定17例;前路病灶切除、椎体间植骨并后路内固定41例,术后随访对植骨融合、截瘫恢复和后凸畸形矫正情况分别评估.结果:随防2～3.5年(平均2.4年),所有病例术后症状消失,未植骨病例骨性愈合时间平均3个月,植骨病例骨性愈合时间平均4.5个月.术后后凸畸形平均矫正18.8°,末次随访矫正角度丢失平均3.1°,瘫痪患者术后一年Frankel分级明显提高;108例患者完全恢复正常工作和生活.结论:脊柱结核治疗必须遵循局部与系统兼顾的原则,针对不同个体采用与之相应的治疗方式,疗效满意.     

前路Ⅰ期病灶清除、植骨、内固定治疗脊柱结核(附37例报告)

观察前路Ⅰ期病灶清除、植骨、内固定治疗脊柱结核的疗效。方法 :1996年 1月～ 2 0 0 2年 12月间采用该手术方法共治疗脊柱结核 37例。其中 :颈椎 3例 ,胸椎 5例 ,胸腰椎 17例 ,腰椎 12例 ;3例伴窦道形成 ;9例伴不同程度的脊髓和 (或 )神经根受压的症状 ;术前后凸成角 10°～ 72° ,平均 31°。结果 :平均随访 1.7年 ,优良率为 90 %,植骨融合率可达 95 %,后凸矫正角度 13°,术后无一例复发。结论 :前路彻底病灶清除、植骨、内固定治疗脊柱结核病灶清除彻底 ,有利于恢复脊柱的稳定性 ,提高骨融合率 ,可纠正及预防脊柱后凸畸形。     

病灶清除术治疗手指慢性感染

目的 介绍一种治疗手指慢性感染伤口经久不愈的手术方式。方法 27例化脓性指头炎切开引流术后及手指外伤感染经久不愈患者，采用彻底病灶清除术后一期缝合伤口。结果 27例伤口一期愈合。结论 彻底病灶清除，一期闭合伤口，是治疗手指急性感染切开引流术后伤口长期不愈和手指外伤感染所致慢性感染的一种有效方法。     

再谈脊柱结核的外科治疗

近年来脊柱结核的外科治疗发展迅速,一期病灶清除、植骨融合、内固定巳成为代表性术式,并得到多数学者的认可。但国内学者在脊柱结核手术的治疗理念、方法等方面仍存在某些不同的观点和争议。现就有关问题谈谈个人的认识,与同道商榷。[第一段]     

乳腺良性病灶的微创手术

目的：探讨B超引导下Mammotome微创旋切系统对乳腺良性病灶的应用价值，及其与常规手术对比的优点。方法：将行B超引导下Mammotome微创旋切65例84处乳腺良性病灶与同期行常规门诊手术的482例535处乳腺良性病灶作对比，评价它们的诊治效果。结果：65例84处乳腺病灶均被Mammotome微创旋切术切除．平均旋切15次，用时26min；操作无一例失败。与常规门诊手术比较，这种方法皮肤伤口小，除6例有轻度皮下淤血外无其他并发症。结论：用B超引导下的Mammotome微创旋切术行乳腺纤维腺瘤微创切除，与常规门诊手术相比，其近、远期效果相同，但手术疤痕较小，减轻了病人的痛苦。     

小切口开胸病灶清除术治疗空洞型肺结核和肺结核球(附18例报告)

目的 探讨病灶清除术治疗空洞型肺结核和肺结核球的效果和可行性。方法 胸部小切口入路治疗长期抗痨后或复治的空洞型肺结核和肺结核球。慢性纤维空洞型肺结核行空洞病灶清除术8例，肺结核球单纯病灶清除术10例，病灶清除后对遗留残腔进行冲洗和折叠缝合。结果 18例全部临床治愈，痰菌转阴，肺部阴影消失，无手术并发症。全组随访1年-4年，未见复发。结论 病灶清除术是一种有效的外科治疗肺结核的方法，这种方法减少对机体的创伤，最大限度地保留病人的肺功能，但应选择合适病人。     

脊柱结核外科治疗方式的选择

近年来脊柱结核发病率的增长及治疗手段的多样化为国内外同道所关注。手术对早期清除病灶、改善神经功能、防止和矫正后凸畸形以及缩短化疗疗程等方面的临床疗效已经得到充分肯定。但随着手术数量的增多及外科过度干预，手术并发症增加，因而不少学者对非手术治疗或非内固定的有限手术治疗重新重视，包括介入科医生在内的不少专家在微创手术治疗方面所做的不懈努力取得了成功，丰富了脊柱结核的治疗手段；而内科治疗对脊柱结核的治疗始终是重要一环，特别是围手术期化疗方案的新理念也在不断深化。因而如何正确选择和客观评价脊柱结核手术治疗方式，即脊枉结核外科治疗的策略亟待获得共识和规范化。     

重复肾的诊断和外科处理(附53例报告)

目的：探讨重复肾输尿管畸形的诊断与处理，方法：回顾性分析53例重复肾患者的临床资料，B超检查51例，41例确诊，7例误诊为肾上极囊肿，5例漏诊，45例行手术治疗，结果：45例重复肾患者经手术治疗，临床症状消失，尿常规无异常，病理检查均报告为重复肾，结论：B超诊断价值大，手术方式的选择取决于患侧肾功能，尿路感染情况以及是否并发其他畸形。     

Negative pressure wound therapy reduces incidence of postoperative wound infection and dehiscence after long-segment thoracolumbar spinal fusion: a single institutional experience

Background contextWound dehiscence and surgical site infections (SSIs) can have a profound impact on patients as they often require hospital readmission, additional surgical interventions, lengthy intravenous antibiotic administration, and delayed rehabilitation. Negative pressure wound therapy (NPWT) exposes the wound site to negative pressure, resulting in the improvement of blood supply, removal of excess fluid, and stimulation of cellular proliferation of granulation tissue.PurposeTo assess the incidence of wound infection and dehiscence in patients undergoing long-segment thoracolumbar fusion before and after the routine use of NPWT.Study designRetrospective study.Patient sampleOne hundred sixty patients undergoing long-segment thoracolumbar spine fusions were included in this study.Outcome measuresPostoperative incidence of wound infection and dehiscence.MethodsAll adult patients undergoing thoracolumbar fusion for spinal deformity over a 6-year period at Duke University Medical Center by the senior author (CB) were included in this study. In 2012, a categorical change was made by the senior author (CB) that included the postoperative routine use of incisional NPWT devices after primary wound closure in all long-segment spine fusions. Before 2012, NPWT was not used. After primary wound closure, a negative pressure device is contoured to the size of the incision and placed over the incision site for 3 postoperative days. We retrospectively review the first 46 cases in which NPWT was used and compared them with the immediately preceding 114 cases to assess the incidence of wound infection and dehiscence.ResultsOne hundred sixty (NPWT: 46 cases, non-NPWT: 114 cases) long-segment thoracolumbar spine fusions were performed for deformity correction. Baseline characteristics were similar between both cohorts. Compared with the non-NPWT cohort, a 50% decrease in the incidence of wound dehiscence was observed in the NPWT patient cohort (6.38% vs. 12.28%, p=.02). Similarly, compared with the non-NPWT cohort, the incidence of postoperative SSIs was significantly decreased in the NPWT cohort (10.63% vs. 14.91%, p=.04).ConclusionsRoutine use of incisional NPWT was associated with a significant reduction in the incidence of postoperative wound infection and dehiscence.     

Experience with wound complications after surgery for sacral tumors

Purpose

The aim of this article is to summarize our experience in treating sacral wound complications after sacrectomy. We focus, in particular, on factors associated with wound complications, including surgical site infection (SSI) and wound dehiscence.

Methods

The definition of SSI devised by Horgan et al. was applied. Wound dehiscence was defined as a wound showing breakdown in the absence of clinical signs meeting the diagnostic standard for SSI. Between September 1997 and August 2009, 387 patients with a sacral tumor underwent sacrectomy performed by the same team of surgeons and were followed up for ≥12 months. Potential risk factors were evaluated for univariate associations with SSI and wound complications. Multivariable conditional logistic regression was used to identify the combined effects of several risk factors.

Results

Of the 387 wounds studied, 274 healed uneventfully, and 113 (29.2 %) broke down because of infection or dehiscence. Fifty-one (13.2 %) patients developed a postoperative SSI, and 62 (16.0 %) patients developed wound dehiscence. Gram-negative bacteria grew in 45 cultures (91.8 %) and included 38 cases of Escherichia coli. Previous radiation, rectum rupture, longer duration of surgery, and cerebrospinal fluid leakage were significantly associated with increased likelihood of developing an SSI. Previous radiation, rectum rupture, age <40 years, history of diabetes mellitus, maximum tumor diameter ≥10 cm, and instrumentation used were risk factors for wound complications.

Conclusions

The incidence of wound complications is not so high at a musculoskeletal tumor center with surgeons experienced in treating sacral tumors. Controlling for these risk factors when possible may improve clinical outcomes.     

Improvement of surgical wound classification following a targeted training program at a children's hospital

Background

Inaccurate assignment of surgical wound class (SWC) remains a challenge in perioperative documentation. The purpose of our intervention was to increase the accuracy of SWC through a targeted training program directed toward pediatric surgeons and nurses.

Surgical site infection in spinal surgery: a comparative study between 2-octyl-cyanoacrylate and staples for wound closure

Background

Surgical site infection (SSI) after spinal surgery is a devastating complication. Various methods of skin closure are used in spinal surgery, but the optimal skin-closure method remains unclear. A recent report recommended against the use of metal staples for skin closure in orthopedic surgery. 2-Octyl-cyanoacrylate (Dermabond; Ethicon, NJ, USA) has been widely applied for wound closure in various surgeries. In this cohort study, we assessed the rate of SSI in spinal surgery using metal staples and 2-octyl-cyanoacrylate for wound closure.

Methods

This study enrolled 609 consecutive patients undergoing spinal surgery in our hospital. From April 2007 to March 2010 surgical wounds were closed with metal staples (group 1, n = 294). From April 2010 to February 2012 skin closure was performed using 2-octyl-cyanoacrylate (group 2, n = 315). We assessed the rate of SSI using these two different methods of wound closure. Prospective study of the time and cost evaluation of wound closure was performed between two groups.

Results

Patients in the 2-octyl-cyanoacrylate group had more risk factors for SSI than those in the metal-staple group. Nonetheless, eight patients in the metal-staple group compared with none in the 2-octyl-cyanoacrylate group acquired SSIs (p < 0.01). The closure of the wound in length of 10 cm with 2-octyl-cyanoacrylate could save 28 s and $13.5.

Conclusions

This study reveals that in spinal surgery, wound closure using 2-octyl-cyanoacrylate was associated with a lower rate of SSI than wound closure with staples. Moreover, the use of 2-octyl-cyanoacrylate has a more time saving effect and cost-effectiveness than the use of staples in wound closure of 10 cm in length.     

腰椎后路椎间融合(PLIF)术后深部感染手术治疗

目的 探讨腰椎后路椎间融合（PLIF）术后深部感染的诊断、治疗特点。方法通过对8例PLIF术后深部感染的检查及手术治疗,总结诊断PLIF术后深部感染的敏感指标、有效的治疗方法。结果血沉、CRP是诊断及监测PLIF术后深部感染的敏感化验指标;MRI对诊断急性感染有确诊意义,对诊断慢性感染早期意义不大;内固定牢固者可以保留内固定,不影响对感染的治疗;神经根刺激症状恢复不如腰痛症状恢复明显;所有病人经过规范治疗均在3个月内治愈。结论PLIF术后深部感染通过规范治疗,完全可以治愈,预后良好。     

Potential of Oncostatin M to accelerate diabetic wound healing

Oncostatin M (OSM) is a multifunctional cytokine found in a variety of pathologic conditions, which leads to excessive collagen deposition. Current studies demonstrate that OSM is also a mitogen for fibroblasts and has an anti‐inflammatory action. It was therefore hypothesised that OSM may play an important role in healing of chronic wounds that usually involve decreased fibroblast function and persist in the inflammatory stage for a long time. In a previous in vitro study, the authors showed that OSM increased wound healing activities of diabetic dermal fibroblasts. However, wound healing in vivo is a complex process involving multiple factors. Thus, the purpose of this study was to evaluate the effect of OSM on diabetic wound healing in vivo. Five diabetic mice were used in this study. Four full‐thickness round wounds were created on the back of each mouse (total 20 wounds). OSM was applied on the two left‐side wounds (n = 10) and phosphate‐buffered saline was applied on the two right‐side wounds (n = 10). After 10 days, unhealed wound areas of the OSM and control groups were compared using the stereoimage optical topometer system. Also, epithelialisation, wound contraction and reduction in wound volume in each group were compared. The OSM‐treated group showed superior results in all of the tested parameters. In particular, the unhealed wound area and the reduction in wound volume demonstrated statistically significant differences (P < 0·05). The results of this study indicate that topical application of OSM may have the potential to accelerate healing of diabetic wounds.     

Suction/irrigation for deep wound infection after spinal instrumentation: a case study

Deep wound infection after spinal instrumentation is a serious complication that is difficult to treat without removing the instruments and bone graft. Debridement and suction/irrigation is an effective method of treatment in these cases. It was performed on six patients in our department who developed this complication between 1985 and 1994. Four patients with early post-operative infection were cured by this method without removing the instruments and bone graft, and two patients with delayed post-operative infection were cured by this method with instrument removal. Debridement and suction/irrigation is a useful method of treatment for both groups of deep wound infection and gives good results when performed soon after infection onset together with additional antibiotic therapy.     

Improving wound healing and preventing surgical site complications of closed surgical incisions: a possible role of Incisional Negative Pressure Wound Therapy. A systematic review of the literature

Advances in preoperative care, surgical techniques and technologies have enabled surgeons to achieve primary closure in a high percentage of surgical procedures. However, often, underlying patient comorbidities in addition to surgical‐related factors make the management of surgical wounds primary closure challenging because of the higher risk of developing complications. To date, extensive evidence exists, which demonstrate the benefits of negative pressure dressing in the treatment of open wounds; recently, Incisional Negative Pressure Wound Therapy (INPWT) technology as delivered by Prevena? (KCI USA, Inc., San Antonio, TX) and Pico (Smith & Nephew Inc, Andover, MA) systems has been the focus of a new investigation on possible prophylactic measures to prevent complications via application immediately after surgery in high‐risk, clean, closed surgical incisions. A systematic review was performed to evaluate INPWT's effect on surgical sites healing by primary intention. The primary outcomes of interest are an understanding of INPWT functioning and mechanisms of action, extrapolated from animal and biomedical engineering studies and incidence of complications (infection, dehiscence, seroma, hematoma, skin and fat necrosis, skin and fascial dehiscence or blistering) and other variables influenced by applying INPWT (re‐operation and re‐hospitalization rates, time to dry wound, cost saving) extrapolated from human studies. A search was conducted for published articles in various databases including PubMed, Google Scholar and Scopus Database from 2006 to March 2014. Supplemental searches were performed using reference lists and conference proceedings. Studies selection was based on predetermined inclusion and exclusion criteria and data extraction regarding study quality, model investigated, epidemiological and clinical characteristics and type of surgery, and the outcomes were applied to all the articles included. 1 biomedical engineering study, 2 animal studies, 15 human studies for a total of 6 randomized controlled trials, 5 prospective cohort studies, 7 retrospective analyses, were included. Human studies investigated the outcomes of 1042 incisions on 1003 patients. The literature shows a decrease in the incidence of infection, sero‐haematoma formation and on the re‐operation rates when using INPWT. Lower level of evidence was found on dehiscence, decreased in some studies, and was inconsistent to make a conclusion. Because of limited studies, it is difficult to make any assertions on the other variables, suggesting a requirement for further studies for proper recommendations on INPWT.