胸椎火器伤后椎管内子弹存留1例报告

<正>脊柱火器伤后引起脊髓损伤的机理包括直接损伤和间接震荡伤。伤后子弹存留尤其是步枪子弹尾端造成脊髓损伤并长期存留在椎管内的病例罕见。我们在维和期间收治1例胸椎火器伤后椎管内子弹存留患者,报道如下。患者女性,15岁,南苏丹难民。因"背部枪伤后双下肢瘫痪伴大小便失禁4个月"于2014年8月14日入院。患者受伤时子弹从背部射入,当即出现双下肢瘫痪,伤口有血性液体流出。在无国界医生组织给予清创后伤口瘢痕愈     

脊柱脊髓锐器伤合并异物存留的救治

[目的] 探讨脊柱脊髓锐器伤合并异物存留的诊疗特点及预后。[方法] 回顾了1995年1月～2005年11月本科收治的128例脊柱脊髓锐器伤的临床资料，对其中19例合并有异物存留患者的诊治、术后恢复情况进行分析总结。[结果] 19例均行急诊手术清创，术后死亡1例（5．3％），椎管内感染1例，发生脑脊液漏1例。14例合并有脊髓损伤患者中，13例术后经综合康复治疗脊髓损害程度ASIA评分较手术前提高（P〈0．05）。[结论] 脊柱脊髓锐器伤合并异物存留时需在充分地术前准备下急诊手术治疗，必要的术前检查，制定详细的手术计划是提高抢救成功率的关键。     

脊柱脊髓开放性损伤21例救治

目的探讨脊柱脊髓开放性损伤的临床特点、治疗及预后情况。方法21例脊柱脊髓开放性损伤患者,男17例,女4例;年龄15~47岁,平均25岁。损伤部位胸脊髓15例,腰脊髓5例,颈脊髓1例。术前ASIA分级A级8例,B级5例,C级6例,D级2例。6例伤口内有异物存留。21例均行急诊手术清创,根据损伤具体情况,行椎管探查、血肿清除、异物取出术。结果术后死亡1例(占4.8%),椎管感染1例(占4.8%),发生脑脊液漏2例(占9.5%)。1例术后脊髓损伤程度加重,2例术后神经功能有不同程度的恢复。术后ASIA分级A级9例,B级4例,C级5例,D级2例,E级1例。结论脊柱脊髓开放性损伤需在充分地术前准备下急诊手术治疗,术前应了解是否有异物存留,手术探查可以减少感染、出血等并发症的发生。     

椎管内异物存留4例报告

椎管内异物存留４例报告黄宏前，曹根洪，葛庆木，杨海涛椎管内容积有限，脊髓非常娇嫩，决不能容忍任何异物的存在。作者在１９９２．４－１９９３．３一年中遇到椎管内异物存留４例，均经手术全部取出，效果满意，现报告如下：１临床资料本组４例全为男性，年龄２２～１...     

脊柱脊髓开放性损伤急诊手术治疗体会

目的总结脊柱脊髓开放性损伤急诊手术治疗原则和临床疗效。方法回顾性分析自2010-01—2018-12行急诊手术治疗的24例脊柱脊髓开放性损伤,根据损伤具体情况行椎管探查、血肿清除、冲洗引流、异物取出术。结果24例均顺利完成手术,均未行内固定。18例获得了10~38个月的随访,随访时间平均26个月,4例失访,1例术后死亡,为猎枪伤,死亡原因为重度肺挫伤、呼吸衰竭。术前3例瘫痪呈进行性加重,术中证实为椎管内血肿压迫,及时手术减压,术后第2天神经根功能恢复到入院时状态。术后发生脑脊液漏2例,经过充分引流、抗感染治疗、维持电解质平衡等治疗后治愈。术后1个月1例出现受伤部位椎间隙感染,经非手术治疗后治愈。未出现伤口感染、伤口不愈合、颅内感染等并发症。末次随访时ASIA等级:A级1例,C级1例,D级6例,E级10例。结论急诊手术是治疗脊柱脊髓开放性损伤的有效方法,有助于清除残留异物、清除椎管内血肿彻底减压、促进脊髓功能恢复、减少污染等相关并发症的发生。     

脊柱脊髓火器伤金属异物存留的处理

作者统计170例脊柱脊髓火器伤中资料完整者100例,其中有金属异物存留者65例.手术取除异物35例未发生附加损伤.认为由于弹头(片)停留在体内形成的盲管伤破坏性较大,并可引起继发性损伤和感染,因此手术取出异物越早越好.并对手术指征及术中注意事项做了讨论.     

手术治疗胸腰段脊柱脊髓损伤56例临床观察

目的探讨胸腰段脊柱脊髓损伤治疗方法的选择及其临床疗效。方法根据患者的病情及骨折类型选用前路或后路椎管减压、钉板或钉棒系统内固定、植骨融合术并结合甲基强的松龙冲击疗法治疗胸腰段脊柱脊髓损伤,观察术前术后椎体高度和脊髓损伤平面以下感觉、运动恢复程度。结果 56例经12～36月随访,术后椎体高度和脊髓损伤平面以下皮肤感觉、下肢运动功能不同程度恢复,未见内固定物松动、断裂,无明显后突畸形发生。结论选用前路或后路椎管减压、钉板或钉棒系统内固定、植骨融合术并结合甲基强的松龙冲击疗法治疗胸腰段脊柱脊髓损伤可以有效恢复脊柱序列和椎管容积,为受伤脊髓修复创造条件。     

后路减压及AF内固定治疗胸腰椎骨骨折并脊髓损伤

目的探讨胸腰段椎骨骨折并脊髓损伤的后路减压及AF内固定手术方法和临床疗效。方法对我院自1998年6月至2002年6月收治的19例胸腰段椎骨骨折,伴有不同程度脊髓损伤患者,经一期后路减压及AF内固定进行回顾性分析：结果19例患者术后随访10个月～5年,平均18个月,本组病人脊柱畸形均得到满意的矫正及椎管减压,骨折均于1年内全部愈合,16例神经功能恢复良好,2例大部分恢复,1例愈合差。结论对胸腰段椎骨骨折并脊髓损伤患者一期后路减压及AF内固定术,可获得满意的脊柱矫形、良好的椎管减压和神经功能恢复的疗效。     

脊柱脊髓火器伤的救治：（附50例报告）

脊柱脊髓火器伤是一种很危重的战伤,常合并胸腹部脏器伤,伤口受污染,可发生严重并发症。我们从1979～1986年收治脊柱脊髓火器伤50例,经过积级的救治,无1例死亡,并有26例脊髓部分损伤的伤员功能恢复满意。现报告如下。1临床资料 本组50例均为男性青年战士。全部为危重伤员,伴有严重休克的13例,经过前方急救后转入我院。炮弹炸伤29例,枪弹伤21例。受伤椎体:颈椎9例,胸椎30例,腰椎11例。本组26例发生骨折,其中单一骨折8例,其余均为多处骨折。部位:椎体4处,椎板30处,椎弓根9处,关节实14处,棘突13处,横突9处。椎管贯通伤!5例,椎管盲管伤13例,椎管…     

后路翻修术治疗PVP后并发椎管内骨水泥渗漏伴脊髓损伤

[目的]探讨后路手术治疗胸腰椎骨质疏松骨折经皮椎体成形术(PVP)并发椎管内骨水泥渗漏所致脊髓损伤的临床效果。[方法]回顾性分析2013年7月~2016年7月收治4例胸腰椎骨质疏松性压缩性骨折PVP治疗后并发椎管内骨水泥渗漏所致脊髓损伤患者的临床资料,院外转入3例、本院1例,均为女性,年龄65~75岁,平均70岁。发生在T111例、T122例、L11例,骨水泥渗漏至椎管内硬脊膜外3例、硬脊膜内1例,4例患者均有不同程度的胸腰背部及双下肢疼痛、腹部束带感、双下肢肌力下降、感觉减退等脊髓损伤表现。4例患者翻修均采取后路全椎板切除减压、经椎弓根截骨取出骨水泥、椎间植骨支撑、后方长节段内固定术。术后随访12~22个月,平均18个月,通过观察脊髓功能恢复情况、疼痛缓解程度、椎间骨性融合情况等判定其疗效。[结果]渗漏至硬脊膜外3例患者翻修术后临床症状完全缓解,渗漏至硬脊膜内的1例患者仍遗留排尿困难及双下肢疼痛,但肌力已恢复至IV级。4例患者均获得18个月随访,未见内固定物松动、脱出,椎间骨性融合良好。[结论]后路手术治疗PVP并发椎管内骨水泥渗漏所致脊髓损伤减压彻底、骨水泥取出方便安全、椎间植骨支撑后方长节段内固定更加符合胸腰椎骨质疏松性骨折内固定生物力学,临床疗效满意。     

A case report of firearm bullet settling into the thoracic spinal canal without causing neurological deficit or vertebral bone destruction

Objective The main objective of this study was to present a case of gunshot injury in which a bullet particle settled into the inferior-thoracic epidural canal, which was neurologically intact, without causing any vertebral bone destruction. Summary of background data There has been no previous report in the literature regarding a foreign body settling into the vertebral canal following gunshot injury without causing any bony destruction. Case report A 40-year-old male patient was hospitalized in emergency service with the complaints of severe pain in his back and both legs secondary to a gunshot wound. The entrance wound of the traversing projectile was located at the level of the tenth costa at the inferior of the right scapula. Neurological examination revealed no motor deficit. His lung X-ray was normal at radiological examination. Direct radiograph determined a bullet nucleus on the medium line at thoracolumbar level T-12. Intracanalicular bullet nucleus was found at posterior epidural at the T-12 level on thoracic CT, myelography and CT myelography. No vertebral bone destruction was seen in the direct radiograph studies and serial CT. T12 total laminectomy was performed and epidural foreign body removed. The patient, whose pains ameliorated during the postoperative process, was discharged without any neurological deficit. Conclusion We prefer removal of firearm particles settling into the spinal canal in view of possible later complications such as infection and the toxic effect of the metallic particles, unless there appears any risk of neurological detriment to the patient.     

Brown-Séquard syndrome caused by a high velocity gunshot injury: a case report

STUDY DESIGN: Case report. OBJECTIVE: To present an unusual traumatic neurologic pathology caused by gunshot injury. SETTING: Spine unit of Department of Trauma and Orthopaedic Surgery, University Medical School, Charité - Campus Benjamin Franklin, Berlin, Germany. METHOD AND RESULT: A 35-year-old male sustained a gunshot injury from a machine gun. The projectile caused a fracture of the left pedicle of Th10. The spinal cord was indirectly damaged by cavitation that caused a Brown-Séquard syndrome (BSS). After a microscopically assisted posterior revision at T9/10 with removal of bullet and bone fragments from the spinal canal and debridement of the bullet cavity via extended fenestrectomy the patient gained his motor function back. The sensory deficit remained unchanged. CONCLUSION: BSS can be caused by bullet-related injury of the spinal canal with no direct damage of neural structures. The initial treatment is always based on the total injury pattern. Possible spinal cord injuries are only clarified after restitution of vital functions. Decompression of neural structures in shotgun injury is indicated in incomplete paraplegia, injury of intra-abdominal hollow organs or high velocity bullet wounds. Through debridement and decompression of neural structures and chronic damage caused by foreign body granulomas can be prevented. Secondary destabilization of the spine should be avoided.     

Effect of bullet removal on subsequent pain in persons with spinal cord injury secondary to gunshot wound

The prevention or minimization of future pain is often cited as a reason for removal of the bullet from patients who have incurred a spinal cord injury secondary to a gunshot wound. In an attempt to examine this assumption, multimodal pain ratings were recorded for 14 patients with spinal cord injury due to a gunshot wound in whom the bullet was still present, 14 neurologically matched patients with spinal cord injury due to a gunshot wound in whom the bullet was removed, and 28 control patients with spinal cord injury unrelated to a gunshot wound who were neurologically matched to the first two groups. The results suggest that persons who sustain a spinal cord injury secondary to gunshot wounds report more pain than those injured in other ways. In addition, there was no indication that surgical removal of the bullet was helpful in reducing subsequent pain either early in the rehabilitation process or at 1 year postinjury. The location of the bullet and the type of pain that subsequently developed were not correlated with the initial decision to surgically remove the bullet. Implications for further study and clinical practice are discussed.     

Syndrome of intramedullary gunshot wound with incomplete neurologic deficit: case report

A patient with a gunshot wound to the spinal cord with an incomplete neurologic deficit is presented. The neurologic examination revealed a combination of a central cord injury and the Brown-Séquard Syndrome. The authors suggest that the Brown-Séquard portion of the syndrome was caused by compression of tracts within the spinal cord caused by the mass of the bullet and the central cord injury was produced by the kinetic energy of the bullet during penetration into the spinal canal. They conclude that with incomplete neurologic lesions following gunshot wounds the bullet be removed.     

Magnetic resonance imaging in the evaluation of a gunshot wound to the cervical spine

A patient in the second trimester of pregnancy sustained a gunshot wound of the upper cervical spine with a partial Brown-Séquard syndrome. The patient's condition was evaluated by conventional roentgenography, computed axial tomography (CT), and magnetic resonance imaging (MRI). The MRI alone clearly demonstrated the relationship of the bullet and the spinal cord, whereas the CT image was obliterated by metal artifacts. The bullet was removed from the spinal canal by a posterior approach with the patient in the sitting position and in skeletal cervical traction. The neurological status of the patient improved markedly after the surgery.     

The effects of removal of bullet fragments retained in the spinal canal. A collaborative study by the National Spinal Cord Injury Model Systems

Serial motor and sensory examinations were conducted on 90 patients with bullet fragments lodged in the spinal canal. Annual follow-up examinations were completed on 66 patients. Despite the fact that approximately 20% of the bullets had perforated the alimentary canal, no cases of infection were noted. Statistical analyses indicated that removal of the bullet fragments made no significant difference with regard to reducing pain or improving the recovery of sensation. However, bullet removal did have an effect on motor recovery, depending on the level at which the lesion occurred. Among those patients with lesions between vertebral levels T12 and L4, there was significantly greater (P less than 0.001) motor recovery in those patients from whom the bullet was removed from than in patients not having bullet removal. Bullet removal from the canal between T1 and T11 had no significant effect on motor recovery.     

椎板成形术治疗椎管内疾病的研究进展

外科手术是治疗椎管内疾病的首选方法 ,手术方式有单纯椎板切除术和椎板成形术等。理想的椎管内手术既要充分显露椎管、完整切除占位并解除脊髓压迫,还要维持脊柱生物力学稳定性。由于临床医师对椎管内疾病手术过程中脊柱稳定性的保护与重建存在不同认识,手术方式的选择及如何保持脊柱生物力学的稳定性成为该领域研究的热点。为减少椎板切除对脊柱稳定性的影响,许多学者进行了积极的探索。椎板成形术可通过增加或重建椎管体积对脊髓进行直接减压并允许脊髓向背侧迁移离开椎间盘和椎体从而完成间接减压,既能做到术中充分显露和减压,又可防止脊柱术后失稳,除病变广泛、严重骨质破坏或合并骨质疏松外,是目前理论上单纯椎管内病变最理想的术式。     

老年骨质疏松引起椎管狭窄症的原因及治疗方法（附61例报告）

因老年骨质疏松椎间盘髓核中蛋白粘多糖及水份的减少、纤维环松弛、椎间隙变窄、椎间盘膨出，加上黄韧带肥厚皱折，后纵韧带钙化增生，使椎管容积缩小是造成颈、腰椎管狭窄的主要原因。８年来收治颈、腰椎管狭窄症６１例，最大年龄７６岁，最小年龄５８岁，对颈狭窄症采用颈后路单开门椎管扩大成形术，本法优点既保护大部椎板起保护脊髓的作用，又起到椎管扩大充分减压的作用，对有要椎管狭窄症采用保留关节突，棘突完整取下，将椎管     

Brown-Sequard syndrome following firearm injury with a bullet lodged in the upper cervical canal

A case of stray bullet injury in a child is reported who presented with Brown-Sequard syndrome and CSF leak from the wound at the nape of neck. Patient was assessed by plain radiography and CT scans showing bullet lying in the cervical spinal canal under the C1 and C2 laminae. Laminectomy at C1/C2 level was done and bullet was carefully removed. Patient improved neurologically and CSF discharge stopped. The case report indicated the atypical neurological presentation and possibility of survival in high cervical spinal firearm injury.     

Penetrating injury of the upper cervical spine by a chopstick--case report

A 35-year-old man presented with penetrating spinal injury after attempting suicide by stabbing a wooden chopstick into his mouth. The object penetrated the pharynx, and the tip entered the spinal canal of the atlantoaxial vertebrae. Emergent surgery disclosed that the tip of the chopstick had penetrated between the dural sac and the vertebral artery. There was no dural tear or vertebral artery injury. The foreign body was removed successfully from the oral side. He recovered without neurological sequelae.