颈部创伤无骨折脱位的颈脊髓损伤

颈脊髓损伤多继发于头颈部创伤引起的颈椎骨折脱位，但也有一部分颈脊髓损伤，经X线检查未见骨折或脱位的征象，由于对其认识不足，往往不能得到正确的诊断和治疗。自1983年4月至2002年4月，我院收治此类患者150例，通过临床资料分析，对临床的相关问题进行讨论。     

扩大半椎板切除术治疗颈脊髓损伤

OBJECTIVE: To treat cervical spinal cord injury (SCI) accompanied with narrowing spinal canal by expanded hemilaminectomy. METHODS: From 1995 January to 1998 April 51 patients of cervical SCI were treated by expanded hemilaminectomy. Spinal injury classified in to 3 types: no fracture-dislocation (39 patients) fracture dislocation at the lower cervical spine (11), and burst fracture (1). The types of SCI included central cord injury (18 patients) incomplete cord injury (19), and complete cord injury (14). MR imaging in 23 patients showed degenerative changes with normal intensity of the cord in 14 patients, multiple level hyperintensity in 3, cystic changes in 3, myelomalasia in 3, and cord brocken in 1. Expanded hemilaminectomy was performed in 24 hours in 3 patients, in 48 hours in 9, in one week in 2, after one week in 35, and after one year in 2. The left or right laminae were removed from C(7) to C(3) in 42 patients, C(3) - T(1) in 3, C(2) - C(7) in 2, C(3) - C(6) in 3 and C(4) - C(7) in 3. Hemilaminectomy was expanded lateral to the inner of apophyseal joint and medial to the inner lamina beneath the spinal process. RESULTS: Follow-up lasted for 1 year and 7 months. Six patients with complete cord injury had of the no recovery lower extremity but recovery of the brachialis and extensor radial longus. 12 patients of central cord injury had full recovery except intrinsic muscles of the hand (5). They operated were on 2 weeks after injury. 17 patients of incomplete cord injury recovered to Frankel IV. CONCLUSIONS: Expanded hemilaminectomy is indicated for patients of cervical SCI with narrowing spinal canal or without fracture dislocation. Best results can be obtained in patients of central cord injury, and incomplete cord injury. Even in complete cord injury, 1 - 2 forearm muscle may recover (24.8%), securing a pinch grip reconstruction.     

Pressure changes in spinal canal and evaluation of spinal cord injuries in spinal section subjected to impact

ＴＤｅｐａｒｔｍｅｎｔｏｆＯｒｔｈｏｐｅｄｉｃｓ ,2 5 4ｔｈＨｏｓｐｉｔａｌｏｆＰＬＡ ,Ｔｉａｎｊｉｎ30 0 142 ,Ｃｈｉｎａ (ＸｉｅＢＧ ,ＷｕＭＹａｎｄＹａｎｇＪＸ)ｈｏｒａｃｏｌｕｍｂａｒｂｕｒｓｔｆｒａｃｔｕｒｅｓａｒｅｏｆｔｅｎｓｅｅｎｉｎｆａｌｌｉｎｇａｎｄｔｒａｆｆｉｃａｃｃｉｄｅｎｔｉｎｊｕｒｉｅｓ ,ｉｎｗｈｉｃｈａｘｉａｌｌｏａｄｉｎｇａｃｔｓｏｎｔｈｅｖｅｒｔｅｂｒａｌｃｏｌｕｍｎ .Ｔｈｅｐｒｅｓｓｕｒｅｉｎｓｐｉｎａｌｃａｎａｌｉｓｒｅｌａｔｅｄｔｏｉｎｊｕｒｙｐａｔｔｅｒｎ ,ｓｅ…     

Imaging diagnosis of cervical spine and spinal cord injuries in children

ＣＤｅｐａｒｔｍｅｎｔｏｆＯｒｔｈｏｐｅｄｉｃＳｕｒｇｅｒｙ ,ＸｉｎｈｕａＨｏｓｐｉｔａｌ,ＳｈａｎｇｈａｉＳｅｃｏｎｄＭｅｄｉｃａｌＵｎｉｖｅｒｓｉｔｙ ,Ｓｈａｎｇｈａｉ 2 0 0 0 92 ,Ｃｈｉｎａ(ＤａｉＬＹ)ｅｒｖｉｃａｌｓｐｉｎｅａｎｄｓｐｉｎａｌｃｏｒｄｉｎｊｕｒｉｅｓｉｎｃｈｉｌｄｒｅｎａｒｅｒａｒｅ .Ｔｈｅｃｌｉｎｉｃａｌｓｐｅｃｔｒｕｍｖａｒｉｅｓｄｅｐｅｎｄｉｎｇｏｎｔｈｅｌｅｖｅｌａｎｄｓｅｖｅｒｉｔｙｏｆｔｈｅｉｎｊｕｒｙ .Ｔｈｅｐａｔｉｅｎｔｓｗｉｔｈｍｉｌｄｉｎｊｕｒｙｍａｙｏ…     

无X线异常的颈脊髓损伤分类外科治疗探讨

目的 探讨无X线异常的颈脊髓损伤(spinal cord injury without radiographic abnormality,SCIWORA)的致伤特点、形成因素及经分类的外科治疗近、远期神经功能疗效.方法 回顾性分析2000年3月至2004年7月间81例经外科治疗的颈SCIWORA病例.男55例,女26例;年龄43～68岁,平均57.3岁.根据颈椎倾向损伤的运动形式和颈椎本身的病理基础将SCIWORA的形成因素归纳为三类,Ⅰ类:屈曲运动为主短节段(一或两个节段)致伤,具有节段性颈椎间盘退变性突出或脱出者19例;Ⅱ类:过伸运动为主多节段(≥三个节段)致伤,具有多节段(≥三个节段)颈椎管狭窄者41例;Ⅲ类:挥鞭样复合(过伸及屈曲并重)致伤,具有多节段椎管狭窄以及节段性椎间不稳定,或前方节段性椎间盘退变性突出或脱出者21例.在有效维持患者生命体征的前提下,针对不同形成因素分别采用前路减压融合、后路多节段椎管扩大成形及后路椎管扩大成形+不稳定节段内固定融合(或+前路减压融合)的手术方式进行早期治疗,观察近期神经功能改善情况并进行远期随访.结果 经术后1个月、3个月、1年及终末(54～118个月,平均78.5个月)随访,神经功能日本矫形外科协会(Japanese Orthopaedic Association,JOA)评分改善率分别为25.1%、41.3%、63.6%及60.9%;远期随访神经功能改善优良率为80.2%.结论 SCIWORA为一类急性、动态且有限的脊髓损伤,虽然有共性的临床表现,但其致伤特点及形成因素并非单一,故经归类并早期进行具有针对性外科治疗,仍可取得较明显的神经功能改善.     

颈椎脊髓损伤患者自主神经性反射异常的临床处理

目的 探讨颈椎脊髓损伤患者自主神经性反射异常（autonomic dysreflexia,AD）的临床诊治措施.方法 2006年9月～2011年9月,共诊治23例颈椎脊髓损伤后发生自主神经性反射异常的患者,主要措施为去除对张力感受器和痛觉感受器的不良刺激.结果 19例患者在去除不良刺激后1-5 min内症状完全缓解,其余4例患者经Ca2＋通道阻滞剂治疗后血压降致正常.结论对于颈椎脊髓损伤的患者,应注意观察并解除可能导致AD发生的因素;一旦诊断为AD,应尽快消除诱因并对症处理,避免出现并发症.     

冲击载荷造成椎管内压力变化与脊髓损伤程度的评估

目的 观察脊柱遭受轴向撞击时椎管内的压力变化,从撞击－压力变化－脊髓损伤的角度分析脊柱骨折类型与脊髓损伤程度间的关系,为脊髓损伤程度的早期评估提供实验依据。方法 应用ＢＩＭ－Ｉ型立式生物撞击机高速准静态轴向加载和应力遮挡技术建立脊椎爆裂型骨折模型,观察８具新鲜尸体的脊柱标本Ｔ１０￣Ｌ４节段受垂直撞击瞬间椎管内的压力变化,将大体解剖观察与放射影像学技术相结合,记录脊柱骨折类型及脊柱损伤程度。结果 发     

无骨折脱位型急性中央颈脊髓损伤的手术疗效分析

目的分析评价无骨折脱位型中央颈脊髓损伤的手术治疗效果。方法自2000年5月至2005年4月,手术治疗了52例无颈椎骨折脱位型中央颈脊髓损伤患者,均经术前影像学检查证实。所有患者都接受损伤段颈椎前路或后路减压、融合和内固定手术。住院期间每日进行症状和体征的观测,脊髓功能采用美国脊柱损伤协会（ASIA）标准进行评分,以线性回归分析方法评价手术对患者ASIA评分的影响。随访患者的最终脊髓功能恢复情况,时间从12～42个月,平均29个月。结果手术后ASIA恢复曲线明显较手术前抬升（P〈0．01）。最终随访时所有患者的ASIA运动、针刺觉和轻触觉评分分别为（91±7）,（107±6）和（107±6）分,均较术前有明显好转（P〈0．01）。结论对损伤水平的脊柱充分减压和固定,可以给水肿的脊髓创造一个宽松和稳定的膨胀空间,加速脊髓功能的早期恢复,改善远期效果。     

改良颈椎管扩大连体棘突重建术临床研究

自1996年10月-2001年3月我们收治的56例脊髓型颈椎病术后的患者进行随访,其中20例改良研究组获得手术前后的完整资料和随访;36例对照组其中有14例资料不全或失访,得到随访20例,资料如下.……     

不同程度颈脊髓损伤后低钠血症的临床分析

 目的回顾性总结急性颈脊髓损伤后低钠血症的发生特点,并分析其可能的发生原因,以及脊髓损伤严重程度、性别、年龄等因素对血钠变化的影响。方法研究对象为2005年6月至2011年3月急诊收治的一组颈椎外伤患者,排除合并颅脑外伤及慢性疾病的患者,入选病例分为完全性脊髓损伤组、不完全性脊髓损伤组及无神经功能障碍组,回顾性分析各组病例的血钠变化情况。结果入选病例共102例,男83例,女19例;年龄17~68岁,平均45.6岁。完全性脊髓损伤组23例,不完全性脊髓损伤组60例,无神经功能障碍组19例。共发生低钠血症共39例,完全性脊髓损伤组15例(65%),不完全性脊髓损伤组23例(38%),无神经功能障碍组1例(5%)。低钠血症发生率在三组间两两比较,差异有统计学意义,完全性脊髓损伤组低钠血症的发生率明显高于不完全性脊髓损伤组和无神经功能障碍组。Logistic逐步回归分析结果显示低钠血症与患者脊髓损伤程度有明确相关关系,而与患者的年龄、性别、脊髓损伤节段无相关关系。结论急性颈脊髓损伤后具有较高的低钠血症发生率,虽然影响钠盐平衡的因素及相互作用非常复杂,但颈脊髓损伤致自主神经功能障碍、神经内分泌功能异常以及血液动力学改变可能是导致颈脊髓损伤后电解质系统异常的重要原因。     

Therapeutic systemic hypothermia for a pediatric patient with an isolated cervical spinal cord injury

Context: While uncommon, spinal cord injuries most frequently occur in adolescent and young adult males. Established treatment options are limited and focused on supportive care. Therapeutic systemic hypothermia is an emerging experimental treatment currently undergoing clinical trials in adults.

Findings: Here we report a case of a 13-year-old male with an American Spinal Injury Association Impairment Scale grade C traumatic cervical spinal cord injury treated with 48 hours of therapeutic systemic hypothermia who made a complete neurological recovery. To our knowledge, this is the youngest such case report.

Clinical relevance: This case suggests that consideration should be given to including pediatric patients in future clinical trials of therapeutic hypothermia for spinal cord injury.     

Damage control of multiple injuries headed by cervica spinal cord injury

Objective ： To explore the strategy of damage control in clinical treatment of multiple injuries headed by cervical spinal cord injury. Methods： A retrospective analysis was performed in 32 patients. Cervical fractures associated with tetraplegia occurred in 18 patients, traumatic intervectebral disk hernia associated with tetraplegia in 2 patients, and cervical fractures and dislocation associated with tetraplegia in 12 patients. Seventeen cases were combined with craniocerebral injury, 7 combined with pulmonary contusion, multi-fractures of rib or hemopneumothorax, 2 combined with pelvic fracture and other 8 combined with fracture of limbs. The neural function was assessed by the American Spinal Injury Association （ASIA） scale. Results： Thirty-one patients were followed up for an average of 14 months. Of them, 10 got complete recovery, 13 obtained improvement of more than one ASIA grade, 8 did not improve, and 1 died. Conclusions ： For the emergency treatment of multiple injuries headed by cervical spinal cord injury, the damage control strategy is the principle to follow. The final operations are preferably performed within 5 to 10 days after injury so as to raise the successful rate of remedy.     

单开门椎管扩大术治疗无骨折脱位颈脊髓损伤的疗效评价

目的：通过分析无骨折脱位颈脊髓损伤的临床特点及诊断方法，评价单开门椎管扩大术对其进行治疗的疗效。方法：40例无骨折脱位颈脊髓损伤患者通过x线平片测量颈椎椎管矢状径，32例存在发育性颈椎管狭窄。MR检查40例均见不同程度椎间盘突出、退行性颈椎管狭窄，16例脊髓前、后受压。本组40例均采用单开门椎管扩大术（中野式）治疗。结果：平均随访2～8年，后路较大范围减压未见不稳现象及再关门。神经功能按Frankel分级：30例恢复至E级，6例恢复至D级，2例恢复至C级，2例术前A级无恢复。上肢功能据颈脊髓神经根支配的肌肉功能分5级：Ⅳ级30例，Ⅲ级6例，Ⅱ级2例，Ⅰ级2例。38例患者能独立或通过辅助支具站立，不需帮助。结论：无骨折脱位颈脊髓损伤多合并颈椎管狭窄、多节段椎间盘突出，存在脊髓受压、水肿，应早期手术治疗。MRI对脊髓损伤的早期诊断、预后及正确制定治疗与康复计划有重要价值。单开门椎管扩大术减压彻底，持续地扩大颈椎管，未破坏椎间关节的稳定性，神经功能恢复满意，是值得推荐的优良术式之一。     

Post-traumatic growth following spinal cord injury

Context/objective

Examine the relationship of post-traumatic psychological growth (PTG), depression, and personal and injury characteristics in persons with spinal cord injury (SCI).

Design

Cross-sectional survey.

Setting

Community.

Participants

Eight hundred and twenty-four adults with SCI.

Interventions

None.

Outcome measures

Five items from the Post-traumatic Growth Inventory, reflecting positive change after injury in life priorities, closeness to others, new opportunities being available, stronger faith, and personal strength.

Results

Initial structural equation model testing of a conceptual model of personal and injury characteristics, violent etiology, depression, and PTG resulted in a poor fit. Model modifications resulted in an improved fit, but explained only 5% of the variance in PTG. Being female, younger, having less formal education, and less time since injury had significant relationships with PTG, whereas depression, violent etiology, and injury level/severity did not. In each PTG domain, between 54 and 79% of the sample reported at least some positive change after injury.

Conclusions

The results of this study, while promising, explained only a small portion of the variance in PTG. A majority of the sample experienced some positive change after injury, with the greatest change in discovering that they were stronger than they thought they were. Comparing means previously reported in a non-SCI sample of those who experienced trauma, positive change after injury was comparable for each PTG item except for new opportunities being available, which was significantly lower for those with SCI. Future directions of research include the development of theoretical models of PTG after SCI.     

下颈椎骨折脱位并脊髓损伤的前路手术治疗

目的探讨前路手术在治疗下颈椎骨折脱位并脊髓损伤中的价值。方法168例下颈椎骨折脱位并脊髓损伤患者均在全麻下行颈前路减压、复位、钛网或自体髂骨植骨及颈椎带锁钢板固定。结果完全复位151例,复位90%以上17例。平均随访80.7个月,颈椎椎间高度和生理曲度维持良好,无钢板螺钉并发症。140例脊髓损伤者神经功能获改善。结论下颈椎骨折脱位并脊髓损伤选择前路手术治疗可获得满意的疗效。     

Anorectal functions in patients with lumbosacral spinal cord injury

Objective: To investigate the anorectal status in patients with lumbosacral spinal cord injury (SCI). Methods: Twenty six patients (23 males, 3 females) with lumbosacral SCI and 13 normal volunteers were enrolled into this study as controls. The median age was 43.7 years (ranging 17-68 years) and the median time of patients since injury was 59.1 months (ranging 8 months-15 years). They were diagnosed as complete lumbosacral SCI (n=2, American Spinal Injury Association (ASIA) score A), or incomplete lumbosacral SCI (n =24, ASIA score B-D) with mixed symptoms of constipation and/or fecal incontinence, and were studied by anorectal manometry. None of the patients had any medical treatments for neurogenic bowel prior to this study. Results: The maximum anal resting pressure in lumbosacral SCI patients group was slightly lower than that in control group (One-way ANOVA: P =0.939). During defecatory maneuvers, 23 of 26 (88. 5%) patients with lumbosacral SCI and 1 of 13 (7.7%) in the control group showed pelvic floor dysfunction ( PFD) ( Fisher' s exact test: P<0.0001). Rectoanal inhibitory reflex (RAIR) was identified in both patients with lumbosacral SCI and the controls. The rectal volume for sustained relaxation of the anal sphincter tone in lumbosacral SCI patients group was significantly higher than that in the control group (Independent-Samples t test: P <0.0001). The mean rectal volume to generate the first sensation was 92.7 ml±57.1 ml in SCI patients, 41. 5 ml±13. 4 ml in the control group (Independent-Samples t test: P < 0.0001). Conclusions: Most of the patients with lumbosacral SCI show PFD during defecatory maneuvers and their rectal sensation functions are severely damaged. Some patients exhibit abnormal cough reflex. Anorectal manometry may be helpful to find the unidentified supraconal lesions. RAIR may be modulated by central nervous system (CNS).     

大剂量甲基强地松龙治疗颈椎无骨折脱位脊髓损伤的临床研究

作者对应用大剂量甲基强地松龙、外科减压及两者联合使用对颈椎无骨折脱位脊髓损伤患者的治疗效果进行了比较研究。将３２例颈椎无骨折脱位脊髓损伤患者分为三组：甲基强地松龙（ＭＰ）组８例,在伤后８小时内给予大剂量甲基强地松龙;外科减压组１２例,在伤后４８小时内给予手术减压;ＭＰ＋外科减压组１２例,在伤后８小时内给予大剂量甲基强地松龙及伤后４８小时内行手术减压。根据脊髓损伤的神经和功能评分标准,评定脊髓损伤程度和疗效。随访１年,结果显示ＭＰ＋外科减压对感觉及运动的恢复,不论对完全性脊髓损伤者,还是不完全性脊髓损伤者均明显优于单纯大剂量甲基强地松龙或外科减压组,而三组之间并发症发生率无明显差异。     

无骨折脱位型颈脊髓损伤的诊治现状

近些年来,由于各种辅助检查手段的提高,国内外对无骨折脱位型颈脊髓损伤的发生机理、诊治等研究有了长足的进展.笔者结合有关文献进行回顾性综述.     

胸、腰段脊柱脊髓损伤外科治疗失误的处理

目的:分析急性胸、腰段脊柱脊髓损伤外科治疗失误的主要原因,探讨处理原则。方法:对104例首次外科治疗失误的急性胸、腰段脊柱脊髓损伤患者的临床资料和影像学资料进行分析,并根据临床具体情况进行外科处理。结果:104例患者中,残存腰痛45例次,脊柱畸形30例次,脊柱不稳35例次,脊髓神经受压8例次,坐位失平衡8例次。经再次手术治疗后脊柱畸形患者明显改善;椎管残存压迫的不完全性脊髓损伤患者椎管减压术后运动指数和感觉指数均增加;30例脊柱不稳定患者重建了脊柱稳定性;45例腰痛患者中40例腰痛消失或基本消失,5例仍有轻度腰痛需应用止痛药物,但不影响轮椅活动。结论:胸、腰段脊柱脊髓损伤手术治疗失误的主要因素包括手术适应证选择不当、手术技术失误和保守治疗不当。再处理方案主要参考首次治疗主要失误因素来确定。     

非压迫性髓核致脊神经根和脊神经节损伤的实验研究进展

腰椎间盘髓核（nucleus pulposus，NP）突出引起下腰痛和坐骨神经痛的确切机制尚不清楚。临床和影像学资料表明腰椎间盘突出患者的神经根受压程度与患者的临床症状和疼痛并无直接关系，提示机械性压迫并非是惟一的因素。近年来大量的研究提示：NP的炎症反应可能在根性神经痛的发生中起着重要作用。