L4、5神经前支和腰骶干与骶髂关节毗邻关系及其临床意义

目的 :为单纯或合并临近神经损伤的骨盆后环骨折手术提供解剖学基础。方法 :对 2 0具防腐成年尸体标本依次选取不同平面用分规和克氏针测量L4、5神经前支、腰骶干与骶髂关节间的水平距离。结果 :L5神经前支在其出椎间孔处、L4神经前支在L5椎间孔处、腰骶干在其汇合点处、腰骶干在平骶岬处、腰骶干在骨盆环处与骶髂关节间的距离分别为 :(2 3 .4± 4.0 )mm、(17.8± 4.8)mm、(13 .3± 2 .8)mm、(11.8± 3 .2 )mm、(9.6± 3 .6)mm ,其中在骨盆环处腰骶干与骶髂关节间距离最短 ;在分离神经时可见L4、5前支和腰骶干与骶骨之间有结缔组织相连 ;有 3具标本L4、5神经前支在进入小骨盆前未汇合成腰骶干。结论 :在单纯或者合并L4、5前支和腰骶干损伤的骨盆后环骨折手术中 ,由于骨盆环处腰骶干外缘与骶髂关节间距离最近 ,因此一定要小心辨认 ,勿损伤该神经。     

骶1螺钉固定毗邻结构的应用解剖

目的 :探讨骶骨毗邻结构与骶骨螺钉并发症的关系。方法 :在 5 8具骨盆标本上 ,对第 1骶前孔及骶管结构进行了观测。在 10具标本上 ,模拟骶骨进钉方法的手术过程 ,观察钉道位置与骶骨周围结构的关系。结果 :骶交感干、第 1骶神经与腰骶干围成一个三角形区域 ,在其内侧部无重要结构紧贴骨面走行 ,外侧区有臀上血管走行。此三角前方有髂动、静脉相邻。第 1骶神经粗 (11.0± 2 .8)mm (6.0～ 17.0mm) ,腰骶干粗 (7.6± 2 .2 )mm (3 .0～ 12 .0mm)。当螺钉与矢状面呈向内 0°～ 10°进钉时较为安全。第 1骶后孔可见小血管 ,骶骨外侧沟内有第 5腰椎血管后内侧支走行 ,是术中出血的原因。结论 :骶骨螺钉有损伤骶神经、髂血管的可能 ,5点 7点进钉方法较为安全。     

经第1～3骶后孔上下缘水平切除骶骨对骶髂关节面面积的影响

目的 研究经第1-3骶后孔上、下缘水平切除骶骨对骶髂关节面面积的影响。方法 观测50例成人干燥骶骨标本（男28例，女22例）及其骶髂关节面，并测量关节面面积以及经第1～3骶后孔上、下缘水平切除骶骨时所切除的骶髂关节面的面积，并计算出该切除面积占骶髂关节面面积的百分比。结果 男性经第1骶后孔上、下缘，第2骶后孔上、下缘切除的骶髂关节面所占的平均面积百分比为：72．6％、47．5％、22．4％、12．3％。1例（3．57％）经第3骶后孔上缘可切除约5．0％的关节面。女性各百分比为：76．1％、53．8％、26．4％、17．0％。2例（9．09％）经第3骶后孔上缘可切除约9％的关节面。结论 经第3骶后孔上缘水平切除骶骨对骶髂关节的稳定性影响不大。     

骶部下位脊神经节的观察

在130例尸体中发现一些下位骶、尾脊神经节向上移位,其中尾脊神经节移至蛛网膜下腔内有27例,占20.77±3.6％,第5骶脊神经节上移至蛛网膜下腔内有23例,占17.69±3.3％。又在43例尸体上继续观察硬脊膜囊内、外的骶、尾脊神经节,发现尾脊神经节缺如者有30例,占69.77±7.0％,第5骶脊神经节向上移至硬脊占膜下端附近有21例,占48.85±7.6％,     

骶中动脉变异与Rehbein改良根治术中异常出血的关系

目的 探讨骶中动脉的解剖变异与先天性巨结肠。Rehbein改良根治术中直肠分离异常出血的关系。方法对我院收治的49例先天性巨结肠Rehbein改良根治术中观察的骶中动脉解剖资料及异常出血的情况进行回顾性分析。结果49例病例中骶中动脉解剖变异10例，其中血管外径达到1．8mm．19例，占18．37％；缺如1例，占2．04％。异常出血5例，占8．16%，，其中2例伴骶中动脉解剖变异，需作骶中动静脉结扎方可止血；骶中动脉无解剖变异的3例中，2例作间接电凝止血，1例作纱布压迫即可止血。结论解剖变异的骶中动脉的损伤是先天性巨结肠。Rehbein改良根治术中直肠分离异常出血止血困难的重要原因，该动脉损伤引起的出血，应作骶中动静脉结扎。     

中国人的腰神经丛

观察了320侧中国成年人的腰神经丛。以分叉神经为标准,将腰丛分为八型,其中以分叉神经为L_4,加入腰丛的纤维量多于骶丛的Ⅰ型出现率最高,占69.37％。分析了腰丛各神经的组成型式和参加组成各神经的神经纤维量。各神经组成的常见型如下:股神经由L_(1-4)组成的占73.75％,闭孔神经由L_(2-4)组成的占84.06％,股外侧皮神经以L_(1,2)(40.63％)或L_(2,3)(39.37％)组成的较多,生殖股神经由L_(1,2)组成的占72.19％。依髂腹下神经与髂腹股沟神经合、分情况分为三型:分干型占36.87％,共干型占50.63％,合并型占12.5％。讨论了副股神经和副闭孔神经的命名问题,本文副股神经的出现率为7.5％,副闭孔神经出现率为3.44％。     

骶外侧静脉的应用解剖研究

目的 通过骶外侧静脉的解剖研究,为临床提供形态学资料。方法 选用50具新鲜尸体,经乳胶灌注后,在体视显微镜下观察。结果 骶外侧静脉多为2支型,占51.9％,其中以直接注入髂内静脉的最多见 骶外侧静脉管径左侧为(1.03±0.33)mm,右侧为(1.04±0.28)mm。骶外侧静脉脊支在第1骶前孔多为2支型,在第2～4骶前孔以1支型为多见。在第1骶前孔内脊支多位于外上象限,占52.11％ 在第2～4骶前孔内多位于内上象限,各占63.33％,64.71％和80％。结论 骶前出血是多源性出血,骶外侧静脉出血时要依据其解剖学特点进行有效地止血     

骶管的应用解剖学观察

观察骨性骶管246个,带软组织骶管100个。结果表明,骶管上宽下窄,高位穿刺操作较易,但上端有硬膜囊,静脉丛较丰富,管径也较大,引起出血可能性也较大。有些骶管腔宽大,常规药液量充盈不足,第1—3骶神经外包有较厚的神经鞘和脂肪,均可导致上位骶神经阻滞不全。硬膜囊与终丝前后方,纤维索及脂肪形成的“中隔”,可能引起单侧阻滞。     

骶骨前孔区应用解剖学研究

目的 :为后路骶神经管扩大减压术提供解剖学资料。方法 :对 2 6具 (5 2侧 )成人尸体进行骶前孔区血管、神经走行特点的观察 ,对具有临床意义的数据进行解剖学测量。结果 :①骶外侧动脉的分支进入骶前孔 ,S1多在骶前孔外上缘 (5 6.3 %) ,S2 多在骶前孔内上缘 (73 .1%) ;②臀上动脉与骶丛相交点水平线上距S1AB线 (横线与骶前孔内侧缘交点的垂线 ) (3 0 .0± 7.3 )mm ,S1水平线下方 (-11.3± 9.9)mm ;③骶外侧静脉与臀上静脉及出骶前孔的静脉存在吻合支 ,骶前静脉丛与椎体静脉有广泛吻合 ;④S1、S2 、S3 、S4神经与AB线的夹角分别为 (63 .1± 11.7)° ,(71.2± 11.8)° ,(70 .2± 11.3 )° ,(79.7± 16.2 )° ;⑤梨状肌多起自S2～ 4椎体侧方 ,梨状肌上缘与S1、S2 的垂直距离为 (-11.5± 11.0 )mm ,(12 .7± 10 .0 )mm。S1神经与梨状肌上缘相交点与S1的距离为 (2 2 .9± 9.8)mm。结论 :后路骶神经管扩大减压术是相对安全的 ,但应避免损伤骶前孔区的血管 ;后路骶神经管扩大减压术最好沿骶神经走行方向进行 ,到达梨状肌上缘即可。     

轴向腰椎椎间融合术入路的应用解剖

目的　探讨经骶前间隙轴向腰椎椎间融合术入路的安全性。 方法　(1) 12具（24侧）防腐固定成人骨盆段标本,解剖骶前间隙,观察骶前的筋膜层次,骶直肠筋膜,盆内脏神经等,测量骶直肠筋膜和盆内脏神经的相关解剖数据。(2) 参照Marotta方法,模拟手术置入导针,测量导针在骶前间隙中的相关解剖学数据。 结果　(1)骶前的筋膜可分为5层;(2)骶直肠筋膜的出现率是91.7%,在骶前壁层筋膜的起始部位：S2为16.7%,S3为41.7%,S4为33.3%,它将骶前间隙分为上、下两部分; (3)盆内脏神经限制直肠下段的解剖分离,可作为骶前间隙“矢状安全区域”的指标,其长度是（22.9±3.2）mm; (4)模拟手术时,导针到盆内脏神经的最短距离是（7.8±1.9）mm,到S3/4横线的垂直距离是（15.0±3.6）mm。 结论　经骶前间隙轴向腰椎椎间融合术入路的安全性是相对的,由于骶直肠筋膜、骶前静脉丛横干和骶前血管变异的存在,手术入路面临着较大的风险。     

Cesarean section before the onset of labor and subsequent motor function in infants with meningomyelocele diagnosed antenatally

Background. Meningomyelocele can now be detected before birth. Few data are available on its natural history, however, and optimal management at the time of delivery is controversial, although it has been suggested that labor and vaginal delivery may cause pressure on exposed nerve roots, resulting in additional loss of neural function. Methods. To assess the effect of labor and the type of delivery on the level of motor function in fetuses with uncomplicated meningomyelocele, we identified 200 cases of this disorder, accounting for 95 percent of the cases that occurred in the state of Washington during our 10-year study period. We compared the outcomes of 47 infants delivered by cesarean section before labor began, 35 delivered by cesarean section after a period of labor, and 78 who were delivered vaginally (another 40 were ineligible for the study). In cases of meningomyelocele detected prenatally, cesarean section was performed before the onset of labor if isolated meningomyelocele without severe hydrocephalus was present. The infants delivered in this manner were compared with those who were delivered either vaginally or by cesarean section after labor began. Results. At two years of age, the infants who had been exposed to labor were 2.2 times more likely to have severe paralysis than those delivered by cesarean section without labor (95 percent confidence interval, 1.7 to 2.8). Infants delivered by cesarean section before the beginning of labor had a mean (+/- SD) level of paralysis 3.3 +/- 3.0 segments below the anatomical level of the spinal lesion at two years of age, as compared with 1.1 +/- 2.3 for infants delivered vaginally and 0.9 +/- 4.1 for infants delivered by cesarean section after the beginning of labor (P less than 0.001 for both comparisons). Exposure to labor did not affect the frequency of neonatal complications or later intellectual performance. Conclusions. For the fetus with uncomplicated meningomyelocele, delivery by cesarean section before the onset of labor may result in better subsequent motor function than vaginal delivery or delivery by cesarean section after a period of labor.     

Information system for labor and delivery surveillance.

An on-line information system has been developed and implemented at St. Mary Medical Center in Long Beach, California, to support a ten-bed labor and delivery suite. A Digital Equipment Corporation VAX 750 was programmed to provide on-line multi-terminal clinical surveillance. The reports implemented include an obstetrical summary report, labor record, obstetrical clinical record, and the birth certificate. Computer terminals and monitors are placed at the nursing station and other work areas, such as the anesthesia on-call room, obstetrical supervisor's office, on-call room, neonatal ICU, O.R., admission room, and M.D. conference room. The system includes computer databases used to store information for medical quality assurance, management reports, obligatory statutory reports, and research, and to provide comparison of patient data with data from other hospitals.     

2009年度昆明市孕产妇死因及相关因素分析

目的分析2009年度昆明市孕产妇死亡原因及相关因素,为制定干预措施提供科学依据。方法利用孕产妇死亡报告卡及死亡评审资料进行统计分析。结果 1.2009年度在昆明市辖区内共发生孕产妇死亡28例,死亡率为40.24/10万。其中,直接产科原因占64.3%,妊娠合并内科疾病占21.4%,其它疾病占14.3%。（χ2=12.286,P=0.002）;2.直接产科原因中,产科出血居第一位,占32.1%;3.年龄、文化程度、产检次数、产次、人流引产次数、死亡地点和接生者为孕产妇死亡相关因素（P〈0.05）。结论加强孕产妇监管,降低孕产妇死亡率。     

腰硬联合阻滞分娩镇痛对产程的影响及产程中使用缩宫素对镇痛效果的影响

目的探讨腰硬联合阻滞分娩镇痛对产程的影响及产程中缩宫素的使用。方法 2010年11月至2011年2月在本院足月阴道分娩、无妊娠合并症和并发症、无手术助产的初产妇82例,其中,41例产妇实施分娩镇痛（分娩镇痛组）,41例未行分娩镇痛（对照组）,分别记录并比较两组产妇各产程时间、产时缩宫素的使用率、镇痛效果、产后2h及24h出血量、新生儿Apgar评分及分娩镇痛组产时使用缩宫素的镇痛效果等。结果分娩镇痛组第一产程较对照组明显延长（P〈0.05）;分娩镇痛组较对照组缩宫素使用率增加;分娩镇痛组较对照组镇痛效果显著（P〈0.05）;产后出血及新生儿Apgar评分两组比较差异无统计学意义;分娩镇痛时使用缩宫素对镇痛效果无影响。结论分娩镇痛效果显著,但可能会使第一产程延长;产程中可适当使用缩宫素,其对镇痛效果无影响;分娩镇痛对产妇及新生儿无不良影响。     

Compared characteristics of peripheral facial paralysis according to HIV status in Bobo-Dioulasso (Burkina Faso)

Facial paralysis is a well-described manifestation of HIV infection. We report 27 cases of peripheral facial paralysis observed at Bobo-Dioulasso Hospital in a prospective study over a period of 9 months: 55 of the cases were HIV positive and 12/15 (80%) were in the 20-39 age group. Nine out of 11 females and 6 out of 16 males were seropositive. 13 of the cases were at stage B of CDC classification and 2 at stage C. ESR was elevated in all the HIV patients. CSF examination revealed lymphocytic pleiocytosis, elevated proteins and a positive HIV serology. CD4 counts were obtained in 8 cases and were under 400/mm3 in 4 cases. The clinical presentation was more severe in HIV seropositives with a longer duration of symptoms. Isolated peripheral facial paralysis associated with an elevated ESR in young adults suggest HIV infection and should lead to HIV counselling and testing.     

急症产科子宫切除治疗产科出血23例分析

目的分析产科急症子宫切除的原因、价值、预防措施,降低急症产科子宫切除的可能性。方法对我院产科近11年间所做的急症产科子宫切除术作回顾性分析。结果急症产科子宫切除术发生率为0.27%,剖宫产子宫切除率为1.00%,阴道分娩子宫切除率为0.05%。首位原因为是胎盘因素(43.48%),其次为子宫收缩乏力(30.43%),子宫破裂居第三(13.04%)。结论胎盘因素及子宫收缩乏力是产科急症子宫切除的主要原因。产科急症子宫切除在挽救某些危重产科大出血患者的生命中起到关键作用。加强孕期保健和计划生育,提高产科质量,可以有效地降低急症产科子宫切除率。     

甲状腺手术的围手术期并发症及其预防

目的探讨甲状腺手术围手术期并发症的相关因素和预防方法,降低并发症的发生率。方法回顾性分析1997年1月至2004年12月收治的甲状腺肿块350例的临床资料,分析其主要并发症的发生情况及其临床相关因素,总结甲状腺手术技巧。结果全组350例中术后单侧喉返神经麻痹14例(4%),不显露喉返神经组的喉返神经麻痹发生率(7.3%)高于显露返神经组(1.5%),P=0.011;恶性肿瘤组(9.4%)高于良性肿瘤组(3.0%),P=0.045,而肿瘤大小、合并症、局部敷药与术后喉返神经麻痹无关。术后出血7例,有合并症组的术后出血发生率7.4%(5/68),高于无合并症组的0.7%(2/282),P=0.004;术后出血与是否显露喉返神经及病变性质无关。甲状旁腺功能一过性低下1.1%(4/350),均发生于双侧甲状腺次全切除术。结论解剖显露喉返神经有利于降低甲状腺手术喉返神经麻痹发生率。对合并高血压病、糖尿病、甲亢患者应注意术前控制血压、血糖和血清T3、T4水平,术中彻底止血。双侧甲状腺手术在解剖甲状腺背面应紧贴真包膜充分剥离,对可疑甲状腺组织应尽量保留。     

Anatomical study concerning the origin and course of the pectoral branch of the thoracoacromial trunk for the pectoralis major flap

The patterns of the feeding vessels to each muscle determine the extent of their safe transposition and the muscles value as a pedicled flap in reconstructive surgery. This study aimed to demonstrate the point of origin and the intra- and submuscular course of the pectoral branch of the thoracoacromial trunk (TAT) for pectoralis major (PM) flap surgery. Seventy sides of the PM were dissected based on a clinical reference line that has been used for several decades. The branching point of the TAT from the axillary artery was located lateral to the midclavicular line on the right-sided specimens (100%) and medial to the midclavicular line on the left sides (86%). The branching patterns of the pectoral branch to the PM muscle from the TAT were classified into three types. In type I the pectoral branches originated directly from the TAT (55 cases, 78.6%). In type II (11 cases, 15.7%) and type III (4 cases, 5.7%) the pectoral branch divided from the medial and lateral pedicle of the TAT, respectively. The course of the pectoral branch from the TAT in the PM was categorized into three patterns according to the degree of proximity to the midclavicular line. In 49 cases (70%), the pectoral branch in the PM ran within 1 cm of the midclavicular line. The other cases ran 2 cm (20 cases, 29%) and 3 cm (1 case, 1%) from the midclavicular line, respectively. These results provide topographic data of the pectoral branch based on anatomical landmarks, and will be useful in surgical planning as well as the procedure for PM flap surgery.H.-D. Park and Y.-S. Min equally contributed to this study     

Applying the new concept of maternal near-miss in an intensive care unit

OBJECTIVES:

The World Health Organization has recommended investigating near-misses as a benchmark practice for monitoring maternal healthcare and has standardized the criteria for diagnosis. We aimed to study maternal morbidity and mortality among women admitted to a general intensive care unit during pregnancy or in the postpartum period, using the new World Health Organization criteria.

METHODS:

In a cross-sectional study, 158 cases of severe maternal morbidity were classified according to their outcomes: death, maternal near-miss, and potentially life-threatening conditions. The health indicators for obstetrical care were calculated. A bivariate analysis was performed using the Chi-square test with Yate''s correction or Fisher''s exact test. A multiple regression analysis was used to calculate the crude and adjusted odds ratios, together with their respective 95% confidence intervals.

RESULTS:

Among the 158 admissions, 5 deaths, 43 cases of maternal near-miss, and 110 cases of potentially life-threatening conditions occurred. The near-miss rate was 4.4 cases per 1,000 live births. The near-miss/death ratio was 8.6 near-misses for each maternal death, and the overall mortality index was 10.4%. Hypertensive syndromes were the main cause of admission (67.7% of the cases, 107/158); however, hemorrhage, mainly due to uterine atony and ectopic pregnancy complications, was the main cause of maternal near-misses and deaths (17/43 cases of near-miss and 2/5 deaths).

CONCLUSIONS:

Hypertension was the main cause of admission and of potentially life-threatening conditions; however, hemorrhage was the main cause of maternal near-misses and deaths at this institution, suggesting that delays may occur in implementing appropriate obstetrical care.     

Superior thyroid artery origin in Caucasian Greeks: A new classification proposal and review of the literature

Studies on the origin of the superior thyroid artery, define that it could originate either from the external carotid artery, (at the level of common carotid bifurcation), or from the common carotid artery. However, there is a classical anatomic knowledge that the superior thyroid artery is a branch of the external carotid artery. Variability in the anatomy of the superior thyroid artery was studied on 100 carotids. Moreover, a review about the origin of superior thyroid artery between recent and previous cadaveric, autopsy, and angiographic studies, on adults and fetuses, was carried out. The superior thyroid artery originated from the external carotid artery in 39% and at the level of carotid bifurcation and common carotid artery in 61% of cases. The anterior branches of the external carotid artery were separate in 76% of cases, while common trunks between the arteries were found in 24% of the specimens. A new classification proposal on the origin of the superior thyroid artery is also suggested. In this study, the origin of superior thyroid artery is considered at the level of the carotid bifurcation and not from the external carotid artery as stated in many classical anatomy textbooks. This has a great impact on the terminology when referring to the anterior branches of the external carotid artery, which could be termed as anterior branches of the cervical carotid artery. Head and neck surgeons must be familiar with anatomical variations of the superior thyroid artery in order to achieve a better surgical outcome.