组织工程脊髓修复脊髓损伤的研究进展

脊髓损伤可以导致损伤平面以下神经功能的破坏性丢失,严重地影响身体多个系统.脊髓损伤的效应随着损伤部位不同而不同,这是脊神经有序地按照脊髓排列的缘故.除了损伤平面以下运动功能受损,同时还伴有感觉异常.其造成的功能缺陷包括心血管系统功能、呼吸系统功能、胃肠道消化功能、排汗功能、性功能以及排尿功能,这些缺陷可继发泌尿系感染、褥疮、肌肉痉挛、慢性神经性疼痛和感觉异常等,更严重的可致命.因此,脊髓损伤成为人类急需解决的医学难题之一,至今仍困扰着无数医学工作者。     

Neurovascular injuries of the spinal cord

Neurovascular spinal cord injuries are very prevalent and in a busy trauma center radiology practice these injuries are commonly seen. Imaging neurovascular injuries has been greatly facilitated by magnetic resonance imaging (MRI) and magnetic resonance angiography (MRA). The histopathological changes that occur with spinal cord trauma have been found to correlate well with what is seen on MRI examinations. The MRI findings in spinal cord trauma have also been found to be useful in determining patient prognosis. Spinal cord infarcts due to arterial injury from trauma are relatively rare, but it has been shown by imaging that vertebral artery injuries are not an unusual occurrence. The specific findings associated with neurovascular injuries will be described with an emphasis on the findings on MRI and MRA examinations. MRI and MRA techniques have become the procedure of choice for evaluating neurovascular injuries because of their proven accuracy and because they are non-invasive. Conventional angiography, although, does remain quite useful for evaluating arterial injuries.     

Cervical spinal cord injuries in patients with cervical spondylosis

Eighty-eight patients over age 40 with traumatic cervical spinal cord injuries were clinically and radiographically evaluated, and comparison was made with 35 spinal cord injury patients under age 36. While most older patients sustained obvious bony and/or ligamentous damage commensurate with their neurologic findings, 25 (28%) of the 88 patients had no demonstrable bony abnormalities and 17 (20%) of the 88 patients had only minimal evidence of bony injury. Of particular interest are the patients with severe cord injuries, yet no bony abnormalities, who seem to form a distinct subgroup of the cervical spinal cord injury patient on the basis of radiographic and clinical features. Of these 25 patients, 24 (96%) had severe cervical spondylosis. Fourteen (56%) of the 25 patients were injured in falls, five (36%) of these 14 being of a seemingly trivial nature. Of the 42 patients with minimal or no demonstrable bony abnormalities, 33 (79%) were evaluated with plain tomography and no occult fractures or other significant pathology was demonstrated. Pantopaque myelography in 27 (64%) of the 42 cases revealed no extruded disk or other surgical lesion in any patient. In large measure, these injuries can be attributed to cervical spondylosis, which narrows the canal and makes the cord more susceptible to compression by the bulging ligamenta flava during hyperextension.     

Thermoregulation during exercise in individuals with spinal cord injuries

The increased participation in wheelchair sports in conjunction with environmental challenges posed by the most recent Paralympic venues has stimulated interest into the study of thermoregulation of wheelchair users. This area is particularly pertinent for the spinal cord injured as there is a loss of vasomotor and sudomotor effectors below the level of spinal lesion. Studies within this area have examined a range of environmental conditions, exercise modes and subject populations. During exercise in cool conditions (15-25 degrees C), trained paraplegic individuals (thoracic or lumbar spinal lesions) appear to be at no greater risk of thermal injury than trained able-bodied individuals, although greater heat storage for a given metabolic rate is evident. In warm conditions (25-40 degrees C), trained subjects again demonstrate similar core temperature responses to the able-bodied for a given relative exercise load but elicit increased heat storage within the lower body and reduced whole-body sweat rates, increasing the risk of heat injury. The few studies examining a wide range of lesion levels have noted that, for paraplegic individuals where heat production is matched by available sweating capacity, excessive heat strain may be offset. Studies relating to tetraplegic subjects (cervical spinal lesions) are fewer in number but have consistently shown this population to elicit much faster rates of core and skin temperature increase and thermal imbalance in both cool and warm conditions than paraplegic individuals. These responses are due to the complete absence or severely reduced sweating capacity in tetraplegic subjects. During continuous exercise protocols, the main thermal stressor for tetraplegic subjects appears to be environmental heat gain, whereas during an intermittent-type exercise protocol it appears to be metabolic heat production. Fluid losses during exercise and heat retention during passive recovery from exercise are related to lesion level. Future research is recommended to focus on the specific role of absolute and relative metabolic rates, sweating responses, training status and more sport- and vocation-specific exercise protocols.     

Gallbladder contractility in patients with spinal cord injuries: a sonographic investigation

Approximately 30% of all patients who have spinal cord injuries have gastrointestinal symptoms. One cause is gallstone disease; indeed the literature suggests that gallstones are more common in patients with spinal cord injuries because these patients have impaired contractility of the gallbladder with a reduced ejection fraction. To test this hypothesis, we obtained gallbladder sonograms in 30 patients with spinal cord injuries (16 quadriplegics and 14 paraplegics) and in 32 uninjured age-matched control subjects. Four patients and four asymptomatic control subjects had gallstones and were excluded. The remaining 26 patients and 28 control subjects fasted for 12 hr. Longitudinal and transverse sonograms of the gallbladder were made immediately before the ingestion of 25 g of fat, and at 10, 20, 30, 45, and 60 min thereafter. Gallbladder volumes were measured by using the ellipsoid method. Resting and residual volumes and the emptying times were determined and the ejection fractions were calculated. The ejection fractions were significantly lower (p = .003) in the patients than in the control subjects because the resting volumes were lower than in the control subjects (p = .013). However, the emptying times and residual volumes were the same in the two groups. We conclude that gallbladder contractility is normal in patients with spinal cord injuries and that the lower ejection fraction found in such patients is due to a smaller resting volume.     

Ultrasonic evaluation of the urinary tract in patients with spinal cord injuries. Systematic comparison with intravenous urography in 50 cases

Intravenous urography and ultrasonography were performed routinely, and at the same time, in 50 patients with spinal cord injuries, to compare diagnostic efficacy. Ultrasound was found to be as reliable as intravenous urography in 92% of renal and bladder explorations and to supply additional data on these regions in 6% of cases. It was also found to be equally effective for ureteral dilatation cases, although the site and nature of the obstacle could not be established except in 66% of patients. Ultrasound imaging should therefore play an important role in the urologic surveillance of these patients.     

Rugby injuries of the spine and spinal cord

This article analyzes the type and circumstances of injury in 50 rugby players who sustained cervical spinal cord injury with paralysis. Specific mechanisms of injury occurring during certain phases of the game are identified as being responsible for the majority of injuries. Each phase of the game is discussed in detail, emphasizing the vulnerability of the cervical spine to certain maneuvers, the dangers of illegal play, and the importance of preventive measures to decrease the incidence of these catastrophic injuries.     

Chronic injuries of the spinal cord: assessment with MR imaging

Seventy-six patients with persistent myelopathy secondary to chronic spinal cord injuries underwent examination with magnetic resonance (MR) imaging, the results of which were correlated with neurologic findings. Twenty-one patients received follow-up study during and after the acute stage; 55 patients were examined only at a chronic stage. Spinal cord abnormalities were seen in 48 patients according to five patterns: (a) normal signal intensity on T1- and T2-weighted images (pattern N/N, n = 28), (b) normal signal intensity on T1-weighted and hyperintensity on T2-weighted images (pattern N/Hi, n = 18), (c) hypointensity on T1-weighted and hyperintensity on T2-weighted images (pattern Lo/Hi, n = 17), (d) cord atrophy (n = 5), and (e) longitudinal syrinx formation with hypointensity on T1- and hyperintensity or isointensity on T2-weighted images (n = 8). Patients with pattern N/N had only slight neurologic damage and an excellent prognosis. Patients with pattern N/Hi had mild neurologic impairment, frequently associated with cord compression. Patients with pattern Lo/Hi had the worst prognosis. Atrophy was observed in patients with a long history of myelopathy.     

核磁共振成像在脊髓损伤中的应用

核磁共振成像（ＭＲＩ）在脊髓损伤的诊台中具有重要的意义：ＭＲＩ上表现为出血者较单纯水肿者的病情重,预后差,且均与病灶的大小有关;有脊髓压迫者的病情重,预后差;ＭＲＩ对指导创伤性脊髓空洞症的治疗也有重要的价值。     

Basic science of closed head injuries and spinal cord injuries

Traumatic CNS injury is one of the most important health issues in our society and is a risk to all athletes, both in competitive and recreational sports. Our understanding of the pathophysiology has improved tremendously in the last 20 years. This progress has led to the identification of several possible treatments for improving outcome following spinal cord injury and traumatic brain injury. As no panacea exists, improvements in experimental models have empowered researchers in their search for novel therapeutic strategies.     

Upper urinary tract changes in patients with spinal cord injury

Two hundred and six intravenous urograms on 119 patients with spinal cord injury were reviewed and the findings correlated with the clinical data. Fifty (42%) of 119 patients had pathological changes in their upper urinary tracts. The most common feature was impaired renal emptying. Patients with normal and pathological upper tracts had similar findings according to the number of positive urine cultures during the first post-injury year, but in the follow-up those with pathological urograms showed bacteriuria significantly more often. Febrile urinary tract infections at least once a year were encountered in the follow-up of 40% of the patients with pathological urograms, as compared with 8% with normal urograms. All patients with severe renal changes had impaired emptying from the kidneys. This supports the view that the basic patho-physiological mechanism leading to upper tract deterioration in patients with spinal cord injury is a functional or mechanical obstruction of the lower urinary tract. This should be treated actively before irreversible renal changes develop.     

胰岛素治疗脊髓损伤的研究进展

胰岛素样生长因子（insulin—like growth factor system，IGFS）包括胰岛素、胰岛素样生长因子-Ⅰ（IGF—Ⅰ）、胰岛素样生长因子-Ⅱ（IGF—Ⅱ）及3个相应的受体即胰岛素受体（insulin receptor，IR）、胰岛素样生长因子-Ⅰ受体（IGF—Ⅰ receptor，IGF—IR）、胰岛素样生长因子-Ⅱ受体（IGF—ⅡR），同时还有6个结合蛋白（IGF binding protein，IGFBP）。     

急性脊髓损伤临床研究进展

急性脊髓损伤可导致终身残疾和功能障碍，造成沉重的家庭和社会负担。在美国，其初次医疗费用约为28万美元，而残障引起的社会损失约为每人每年5．7万美元。因而，对急性脊髓损伤的研究始终是脊柱外科的热点。手术减压促进神经功恢复、重建脊柱正常序列和稳定性，已被广泛接受作为脊柱脊髓损伤的标准治疗方式。但急性脊髓损伤的治疗现状仍远不尽如人意。目前，研究重点集中在脊髓损伤的病理生理和神经修复再生，并取得了许多重要成就，手术治疗和康复重建也有了新的进展，但其中很多内容尚不成熟、存在争议。笔者就近期的临床研究进展进行综述。     

Physical performance during rehabilitation in persons with spinal cord injuries.

PURPOSE: The objective of the present study was to evaluate the effect of rehabilitation on physical capacity, mechanical efficiency of manual wheelchair propulsion, and performance of standardized activities of daily living (ADL). METHODS: Nineteen recently injured subjects with spinal cord injuries were tested on a wheelchair ergometer (maximal isometric strength, sprint and maximal power output, and peak oxygen uptake) and during standardized ADL (physical strain and performance time) at the beginning (t1) and at the end (t2) of the active rehabilitation period. RESULTS: Paired Student t-tests showed significant increases for maximal isometric strength (24%, P < 0.01), sprint power output (l7%, P < 0.001) and maximal power output (38%, P < 0.001). Peak oxygen uptake showed no statistically significant improvement (11%, P = 0.06). Mechanical efficiency of submaximal wheelchair exercise was significantly higher at t2 (9.0%) compared to t1 (7.9%, P < 0.01). No significant differences were found for physical strain during ADL, except for passing a door (P < 0.05). Performance time showed a significant decrease for most tasks. CONCLUSIONS: The results of this study show considerable improvements in physical capacity and mechanical efficiency of manual wheelchair propulsion during rehabilitation, and a concomitant lower performance time during standardized ADL. The higher mechanical efficiency and the decrease in performance time during standardized ADL suggest improvement in wheelchair propulsion technique.     

多发伤中脊柱脊髓损伤的治疗对策

目的探讨多发伤中脊柱脊髓损伤早期治疗的意义. 方法回顾我院1998年6月-2003年6月间急诊收治的多发伤伴脊柱脊髓损伤患者116例,其中男97例,女19例;年龄15～69岁,平均38.5岁.损伤严重度评分(ISS)10～51分,平均18.5分.应用伤害控制骨科学观念和VIP 程序救治,对符合条件的脊柱脊髓损伤患者早期采用大剂量甲基强的松龙冲击治疗,病情相对稳定后早期行手术减压和内固定78例,其中前路手术30例,后路手术37例,前后联合入路11例. 结果116例中,生存113例;死亡3例,ISS均≥30分;随访3～48个月,平均24个月.随访时感觉和运动美国脊柱脊髓损伤学会(ASIA)评分较伤后明显改善,无神经功能恶化者.2例椎弓根螺钉断裂,4例伤口深部感染,其中2例换药愈合,2例再次手术清创后愈合. 结论应用伤害控制骨科学和VIP 程序救治合并脊柱脊髓损伤的多发伤的同时,对脊柱脊髓损伤采用临时固定、大剂量甲基强的松龙,病情相对稳定后早期手术治疗,有利于改善预后.多发伤的手术治疗原则为抢救生命--先脏器,后骨折;遵循原则--先开放,后闭合;手术顺序--先四肢,后盆脊;固定选择--优髓内,辅髓外;手术时间--早手术,少并发;治疗目的--利康复,便护理.     

严重多发创伤合并脊柱脊髓损伤的早期诊治体会

探讨降低严重多发创伤合并脊柱脊髓损伤病例的伤残率、死亡率的有效措施。本组31例,临床治愈21例,好转5例,死亡5例。早期检查、诊断及早期治疗至关重要,对降低伤残率、死亡率有重要的临床意义。     

Foot cooling reduces exercise-induced hyperthermia in men with spinal cord injury

The number of individuals with spinal cord injury (SCI) participating in sports at recreational and elite levels is on the rise. However, loss of autonomic nervous system function below the lesion can compromise thermoregulatory capacity and increase the risk of heat stress relative to able-bodied (AB) individuals. PURPOSE: To test the hypotheses that exercise in a heated environment would increase tympanic temperature (TTY) more in individuals with SCI than AB individuals, and that foot cooling using a new device would attenuate the rise in TTY during exercise in both groups. METHODS: Six subjects with SCI (lesions C5-T5) and six AB controls were tested in a heated environment (means +/- SEM, temperature = 31.8 +/- 0.2 degrees C, humidity = 26 +/- 1%) for 45 min at 66% +/- 5 of arm cranking VO2peak and 30 min of recovery on two separate occasions with foot cooling (FC) or no foot cooling (NC) in randomized order. RESULTS: During exercise and recovery in both trials, SCI TTY was elevated above baseline (P < 0.001) but more so in the NC versus FC trial (1.6 +/- 0.2 degrees C vs 1.0 +/- 0.2 degrees C, respectively, P < 0.005). Within the AB group, TTY was elevated above baseline for both trials (P < 0.001) with peak increases of 0.5 +/- 0.2 degrees C and 0.3 +/- 0.2 degrees C for NC and FC, respectively. TTY, face, and back temperature were higher in both SCI trials compared with AB trials (P < 0.05). Heart rate during exercise and recovery was lower in the SCI FC versus SCI NC (P < 0.05). CONCLUSION: These results suggest that extraction of heat through the foot may provide an effective way to manipulate tympanic temperature in individuals with SCI, especially during exercise in the heat.