退变性脊柱畸形患者经第2骶椎骶髂螺钉骨盆固定术中与术后骨盆入射角的变化

【摘要】 目的：探讨退变性脊柱畸形患者经第2骶椎骶髂（S2 alar-iliac,S2AI）螺钉骨盆固定术中与术后骨盆入射角（pelvic incidence,PI）的变化。方法：回顾性分析2016年11月～2020年10月期间在我院接受后路矫形长节段融合固定术治疗的退变性脊柱畸形患者,其中22例患者采用双侧S2AI螺钉固定至骨盆,男性3例,女性19例;年龄45~74岁（62.3±7.9岁）。术中使用计算机辅助下O型臂X线机导航系统引导螺钉置入。收集患者术前、术后1周及末次随访时站立位全脊柱正侧位X线片,测量冠状面侧凸Cobb角、PI、腰椎前凸角（lumbar lordosis,LL）、PI与LL差值（PI-LL）、骨盆倾斜角（pelvic tilt,PT）、骶骨倾斜角（sacral slope,SS）、矢状面平衡（sagittal vertical axis,SVA）;导出术中俯卧位下O型臂X线机导航系统扫描的患者骨盆矢状面图像,并测量PI、PT、SS。结果：22例患者内固定节段数为5~17个（11.1±2.21个）,随访5~13个月（6.64±1.43个月）。术前、术后1周和末次随访时冠状面侧凸Cobb角分别为38.04°±21.12°、19.16°±12.49°、19.01°±11.99°,LL分别为28.48°±28.12°、40.61°±15.25°、39.25°±15.51°,SVA分别75.64±64.66mm、21.82±19.42mm、23.18±19.12mm,PI分别为55.55°±14.68°、50.47°±13.35°、53.94°±13.37°,PI-LL分别为27.10°±22.00°、9.86°±10.41°、12.92°±13.02°,PT分别为31.55°±10.25°、19.69°±7.7°、24.25°±8.28°,SS分别为24.00°±16.61°、30.78°±10.27°、29.55°±11.23°。术后1周和末次随访时的侧凸Cobb角、LL、SVA、PI、PI-LL、PT和SS与术前比较均有显著性差异（P<0.05）;末次随访时的PI和PT与术后1周比较有显著性差异（P<0.05）。术中PI、PT、SS分别为45.17°±14.20°、21.56°±6.71°、23.61°±12.86°,PT和PI与术前、术后1周及末次随时比较均有显著性差异（P<0.05）,SS与术前比较无显著性差异（P>0.05）,与术后1周及末次随访时比较有显著性差异（P<0.05）。其中21例（95%）患者术中PI与术前比较减少大于5°,13例（59%）患者术后站立位PI较术前下降大于5°。结论：应用S2AI螺钉进行骨盆固定的退变性脊柱畸形患者术中俯卧位下PI较术前站立位PI显著性降低,术后站立位PI较术中回升,但仍较术前站立位降低。     

不对称经椎弓根截骨矫治成人先天性脊柱侧后凸畸形

【摘要】 目的：分析应用不对称经椎弓根截骨技术矫治成人先天性脊柱侧后凸畸形的临床疗效。方法：2009年9月~2013年10月采用不对称经椎弓根截骨矫治成人先天性脊柱侧后凸畸形患者16例,男9例,女7例。年龄18～42岁,平均23.6岁。均有腰背痛,无神经受压症状。16例患者脊柱侧凸Cobb角43°~97°,后凸Cobb角15°~70°。侧凸畸形和后凸畸形顶椎均位于同一节段,其中顶椎位于胸椎10例、腰椎6例。于术前、术后及末次随访时在X线片上测量脊柱冠状面主弯Cobb角、矢状面后凸角、冠状面平衡及矢状面平衡,比较术前、术后及末次随访时影像学参数评估手术矫形效果。于术前、末次随访时填写SRS-22问卷量表,评估患者术后的生活质量变化。结果：手术融合节段5~12个,平均7.23个节段。手术时间3~7h,平均4.26h。术中出血量700～2500ml,平均1265ml。1例L1部位截骨患者术后出现双下肢痛觉过敏,急诊手术探查发现截骨部位硬脊膜皱褶,脊髓受压,对截骨部位椎板切开减压,术后症状明显好转,术后3个月随访神经症状消失。2例患者术后出现一侧胸腔积血,紧急行胸腔闭式引流术,1周后拔除引流管。15例患者获得6～48个月（平均13.4个月）随访。获得随访的15例患者冠状位主弯Cobb角术前为58.67°±20.36°（43°～97°）,术后为20.32°±8.76°（8°～37°）,末次随访时为21.76°±8.34°（10°～41°）,术后与术前比较差异有统计学意义（P<0.01）,矫正率为50.76%~82.36%,平均为65.36%,末次随访时与术后比较丢失率为2.45%。术前矢状位后凸角度为45.62°±16.26°（15°～70°）,术后为16.35°±16.87°（-20°～40°）,末次随访时为18.27°±13.92°（-15°～40°）,术后与术前比较差异有统计学意义（P<0.01）,矫正率为50.97%~79.32%,平均为64.16%,末次随访时与术后比较丢失率为4.2%。15例患者中,6例术前存在冠状面失平衡,术后均恢复平衡;4例术前存在矢状面失平衡,术后3例恢复平衡,1例仍为失平衡。SRS-22问卷量表总得分由术前66.47±12.35分（49～79分）提高至末次随访时的84.13±6.42分（76～92分）（P<0.01）。15例患者均获得骨性融合,无假关节形成或内固定断裂。结论：应用不对称经椎弓根截骨技术矫治先天性脊柱侧后凸畸形,可获得较好的矫形效果,显著改善患者躯体外观及躯体平衡,同时明显改善患者的生活质量。     

Lenke 5C型脊柱侧凸后路选择性矫形术下端融合椎影像学改变对冠状面平衡的影响

【摘要】 目的：探讨下端融合椎（lowest instrumented vertebra,LIV）相关影像学指标对Lenke 5C型特发性脊柱侧凸（adolescent idiopathic scoliosis,AIS）患者术后冠状面平衡的影响。方法：本研究包括30例行后路选择性融合的Lenke 5C型AIS患者,所有患者于术前、术后即刻及末次随访时拍摄站立前后位像及术前仰卧位拍摄左右Bending像。对术前、术后和末次随访时的冠状面平衡与LIV相关影像学指标（LIV偏移、LIV旋转、LIV倾斜度、LIV尾侧椎间盘开角）进行分析。结果：所有患者平均随访33个月（24~50个月）,其中LIV为L3者20例,L4者10例。30例Lenke 5C型AIS患者术前冠状面胸腰弯/腰弯Cobb角平均为49.8°±5.1°,术前冠状面胸弯Cobb角平均为25.6°±7.1°。相关性检验发现以下3个指标与术后即刻冠状面平衡（coronal trunk balance,CTB）有显著相关性：（1）术前CTB（r=0.69,r2=0.48,P<0.01）;（2）术前LIV倾斜度（r=0.63,r2=0.40,P<0.01）;（3）术后即刻LIV倾斜度（r=0.60,r2=0.36,P<0.01）。在末次随访时,不管是术前还是术后的LIV相关影像学指标均与末次随访时CTB无显著相关（P>0.05）。结论：对行后路选择性融合术的Lenke 5C型AIS患者而言,术前冠状面平衡与否及术前LIV倾斜度大小对预测术后即刻冠状面平衡有重要的作用。术前LIV倾斜大于25°的患者容易发生术后即刻冠状面失平衡。然而,LIV倾斜度对Lenke 5C型AIS患者术后冠状面平衡无显著影响。     

后路病灶清除植骨融合内固定手术治疗跳跃性脊柱结核的疗效分析

【摘要】 目的：总结跳跃性脊柱结核的临床特点,探讨一期后路病灶清除植骨融合内固定手术治疗跳跃性脊柱结核的疗效。方法：回顾性分析2016年7月~2022年5月我院手术治疗的31例跳跃性脊柱结核患者的临床资料,其中患者男18例,女13例,年龄49.5±27.5岁。其中2处病灶24例,3处病灶7例。对每例患者明确责任椎,确定手术病灶、融合节段、内固定方式,以制定个体化手术方案,随访29.7±14.7个月（15～85个月）。记录患者手术时间、术中出血量,并记录术中及术后并发症情况;术前和术后1个月、3个月、1年及末次随访的红细胞沉降（ESR）和C-反应蛋白（CRP）;术前及术后1周、1个月、3个月、1年及末次随访的疼痛视觉模拟评分（VAS）;术前及术后1周、末次随访时病灶后凸Cobb角;记录术前及末次随访时美国脊髓损伤协会（ASIA）分级;末次随访时采用Bridwell骨愈合标准分级以评估术后结核活动性、症状改善、畸形矫正及骨愈合。结果：31例患者中20例（65.4%）只有1处病灶出现临床症状,23例（74.2%）以疼痛为主诉入院,15例（48.4%）在病程中只有疼痛症状,而11例（35.5%）只有1处病灶出现疼痛症状,18例（58.1%）患者初诊时至少有1处病灶漏诊。所有患者手术顺利,手术时间280.0±52.2min（165～330min）,失血量567.7±332.0mL（150～1000mL）。术后出现脑脊液漏4例,切口感染3例,经对症处理后痊愈;所有结核病灶均治愈,未出现复发。术前及术后1个月、3个月、1年、末次随访时ESR为41.5±26.3mm/h、16.3±13.4mm/h、12.5±6.3mm/h、11.4±5.2mm/h、9.2±3.1mm/h;CRP为32.8±23.2mg/L、7.3±5.6mg/L、6.2±4.1mg/L、5.1±3.7mg/L、2.8±2.3mg/L;术前及术后1周、1个月、3个月、1年、末次随访时VAS评分为6.4±2.4分、2.4±1.7分、2.3±1.3分、1.6±0.9分、0.9±0.7分、0.4±0.3分。术后各个时间点CRP、ESR、VAS评分较术前均有显著改善（P＜0.05）。术前Cobb角25.7°±4.9°,术后1周15.4°±2.1°,末次随访时17.1°±2.3°,术后均较术前有统计学差异（P＜0.05）;10例存在术前神经功能损伤患者,末次随访时1例术前A级患者恢复至C级;4例术前B级患者1例恢复至C级,3例恢复至D级;5例术前C级患者2例恢复至D级,3例恢复至E级;术后6～12个月42处植骨病灶均获得骨融合,末次随访时34处病灶Bridwell Ⅰ级愈合,8处病灶Bridwell Ⅱ级融合。结论：对跳跃性脊柱结核患者,明确责任椎及各处病灶病变特点,一期后路病灶清除植骨融合内固定手术治疗安全且高效,能得到满意的疗效。     

不同入路手术治疗成人胸腰椎结核的中远期临床疗效分析

【摘要】 目的：对比分析后路（Wiltse′s入路）、前路及后前路联合入路手术治疗成人胸椎和腰椎结核中远期疗效。方法：2008年1月～2016年1月共有421例胸椎和腰椎结核患者在我科行手术治疗,其中获得中远期随访者341例,男性190例,女性151例;年龄18～73岁（42.1±15.1岁）。330例术前接受标准化抗结核治疗至少2周（异烟肼+利福平+吡嗪酰胺+乙胺丁醇）,11例行急诊手术。T1~T10 82例,T11~L2 165例,L3~L5 94例。179例采用经后路（Wiltse′s入路）病灶清除椎体间植骨融合内固定术（A组）;98例采用经前路病灶清除椎体间植骨融合内固定术（B组）,64例经Wiltse′s入路内固定+前路病灶清除椎体间植骨融合术（C组）。术后采用规范抗结核药物治疗1.5~2.0年。收集三组患者手术时间、术中出血量和住院天数,术前、术后1周的血沉（ESR）和C-反应蛋白（CRP）;术前、术后1周和末次随访时的胸腰背部疼痛VAS评分,在X线片上测量胸腰椎后凸Cobb角,计算胸腰椎后凸畸形矫正率、末次随访矫正丢失角度;末次随访时脊髓神经功能恢复状况、植骨融合率和术后并发症。结果：所有患者均顺利完成手术,随访5~13年（8.4±2.1年）。A组手术时间、术中出血量、住院时间均小于B组和C组（A组分别为207.8±50.0min、570.0±309.6ml、12.5±2.5d,B组分别为249.9±47.7min、745.5±394.6ml、16.8±9.7d,C组分别为274.3±59.3min、792.0±282.8ml、17.3±3.4d,P＜0.001）。A组术前、术后1周时的ESR和CRP分别68.8±26.1mm/h、31.4±13.0mm/h和53.0±14.6mg/L、27.9±7.1mg/L;B组分别为63.7±22.4mm/h、27.9±10.0mm/h和53.4±20.3mg/L、27.6±9.4mg/L;C组分别为65.4±24.2mm/h、31.1±11.1mm/h和55.2±16.9mg/L、26.0±7.8mg/L。三组术后1周的ESR、CRP均较术前显著性下降（P＜0.001）。A组术前、术后1周和末次随访时的VAS评分为5.1±1.1分、2.5±0.8分、1.8±0.7分;B组为5.2±1.0分、2.6±1.0分、2.0±0.6分;C组为4.9±1.0分、2.5±1.1分、2.0±0.7分。三组术后1周和末次随访VAS评分均较术前显著性改善（P＜0.001）。A组术前、术后1周和末次随访时的Cobb角为27.0°±3.1°、9.8°±2.0°、13.0°±1.9°;B组为27.5°±1.9°、10.4°±0.8°、14.4°±0.9°;C组为28.3°±4.8°、10.6°±2.4°、13.9°±2.3°。三组后凸畸形均得到显著性矫正（P＜0.001）。末次随访时矫正角度丢失：A组3.2°±1.1°、B组4.0°±0.7°、C组3.3°±1.0°,B组矫正角度丢失大于A组和C组（P<0.001）。末次随访时三组未达到1级和2级融合共15例,A组10例（5.6%）,B组2例（3.1%）,C组3例（3.1%）（P>0.05）。24例伴有脊髓神经功能损害患者末次随访时均有明显改善。术后A组6例（3.4%）、B组6例（6.1%）、C组5例（7.8%）发生并发症（P>0.05）,均经对症治疗治愈。B组1例术后2年结核复发,采用经后路Wiltse′s病灶清除椎间植骨融合内固定术治愈。结论：在抗结核药物治疗基础上三种入路手术治疗成人胸椎和腰椎结核均能够取得较满意的中远期疗效,经Wiltse′s入路组在手术时间、术中出血量、住院时间优于单纯前路组和后前路联合组,经Wiltse′s入路组和后前路联合组对后凸畸形的矫正和维持优于单纯前路组。     

退变性脊柱侧凸的选择性手术治疗

【摘要】 目的 评价选择性手术治疗退变性脊柱侧凸的临床疗效。 方法 2005年1月~2009年9月共手术治疗22例患者。记录所有患者术前、术后3个月及末次随访时的Oswestry功能评分;记录实施内固定治疗患者术前、术后3个月及末次随访时的侧凸Cobb角、腰椎前凸角以及融合时间。 结果 平均随访19个月（8~36个月）。椎管减压3例;椎管减压并内固定植骨融合术19例,其中长节段固定6例。Oswestry功能评分术前为39.25±10.47,术后3个月为13.85±7.73,末次随访时为17.95±6.18。实施内固定的患者侧凸Cobb角术前为21.05°±8.51°,术后3个月为12.13°±4.83°,末次随访时为14.03°±5.25°;腰椎前凸角术前为 14.40°±14.72°,术后3个月为26.62°±11.48°,末次随访时为24.27°±11.03°;术后6个月,均达到骨性融合。上述各组术后3个月及末次随访的数据与术前比较差异均有统计学意义（P＜0.05）。 结论 退变性脊柱侧凸的治疗主要以缓解症状为目的,依据不同的临床及影像学表现制定个体化治定方案能够取得满意的临床疗效。     

支撑棒技术在后路胸腰椎矫形融合术治疗伴严重冠状面失衡和骨盆倾斜脊柱侧凸中的临床应用

【摘要】 目的：评价应用支撑棒（kickstand rod,KR）技术的后路胸腰椎矫形融合术治疗伴有严重冠状面失衡（coronal imbalance,CI）和骨盆倾斜（pelvic obliquity,PO）脊柱侧凸患者的矫正效果及其并发症。方法：回顾性分析2019年1月~2020年12月在我院接受后路胸腰椎矫形融合术（脊柱-骨盆融合手术）治疗的45例伴严重CI和PO的脊柱侧凸的患者资料。男性6例,女性39例,年龄51.2±17.5岁（12~73岁）,随访时间16.4±5.3个月（11~26个月）。按骨盆固定的方式将使用经S2骶髂螺钉（S2 alar-iliac,S2AI）而未应用支撑棒技术行骨盆固定的患者纳入非KR组（25例）,将使用支撑棒内固定技术行骨盆固定的患者纳入KR组（20例）。术前、术后7d和末次随访时在全脊柱正侧位X线片测量冠状面平衡距离（coronal balance distance,CBD）、骨盆倾斜角（pelvic obliquity angle,POA）、侧凸Cobb角、腰骶半弯（lumbosacral fractional curve,LFC）和骨盆入射角（pelvic incidence,PI）,比较两组患者脊柱骨盆参数矫正率以及末次随访时的矫正丢失率,记录患者术后及随访期间的并发症发生情况。结果：两组患者术前的侧凸Cobb角、POA、CBD、LFC和PI均无统计学差异（P＞0.05）。两组患者侧凸Cobb角、POA、CBD、LFC术后7d时与术前相比均有明显改善（P＜0.05）,KR组患者末次随访时与术后7d相比无统计学差异（P＞0.05）,非KR组患者在末次随访时POA出现明显矫正丢失（P＜0.05）。KR组和非KR组患者术后POA的矫正率分别为（66.9±13.4）%和（44.2±23.4）%,CBD的矫正率分别为（58.5±20.9）%和（42.9±20.9）%,有统计学差异（P＜0.05）;其余影像学参数在两组患者间均无统计学差异（P＞0.05）。随访期间KR组1例发生断棒,非KR组3例发生术后CI,两组并发症发生率的差异无统计学意义（χ2=0.672,P=0.412）。结论：对于合并严重CI和PO的脊柱侧凸患者,与传统骨盆固定方式相比,应用KR技术的后路矫形脊柱-骨盆融合手术可以在矫正脊柱侧凸的同时维持良好的骨盆水平和冠状面平衡。     

后路松解复位侧块关节植骨融合枕颈内固定术治疗颅底凹陷合并难复性寰枢椎脱位的疗效分析

【摘要】 目的：探讨后路松解复位侧块关节植骨融合枕颈内固定术治疗颅底凹陷症合并难复性寰枢椎脱位的临床疗效。方法：回顾性分析2010年1月~2020年1月于我院行后路松解复位侧块关节植骨融合枕颈内固定术治疗颅底凹陷症合并难复性寰枢椎脱位患者的资料,其中男11例,女8例,年龄37.4±13.9岁（13~69岁）,随访时间为54.7±29.4个月（25～131个月）。术前、术后1周、术后6个月、末次随访时分别通过视觉模拟（visual analogue scale,VAS）评分和日本骨科协会（Japanese Orthopaedic Association,JOA）评分评估患者的疼痛和神经功能情况。术前、术后1周、术后6个月、末次随访时在颈椎正中矢状位CT上测量寰齿前间距（atlantodental interval,ADI）、齿突尖至Chamberlain线的距离（distance of the top of odontoid to Chamberlain′s line,DOCL）,在颈椎MRI上测量延髓脊髓角（cervico-medullary angle,CMA）。通过CT评估植骨融合情况,记录术后并发症。结果：所有患者手术顺利,手术时间136.1±29.0min（95～210min）,出血量为189.7±85.0mL（100～455mL）。术前、术后1周、术后6个月及末次随访时VAS评分分别为6.06±1.21分、2.35±0.76分、1.24±0.81分、1.12±0.90分,JOA评分分别为9.26±2.24分、14.05±2.01分、15.05±1.57、15.16±1.42分;与术前相比,患者术后1周、术后6个月和末次随访时的VAS评分和JOA评分均显著改善（P<0.05）。影像学方面,术前、术后1周、术后6个月及末次随访时ADI分别为9.63±1.93mm、1.21±1.10mm、1.16±1.09mm、1.26±1.02mm,DOCL分别为11.47±3.93mm、2.53±3.30mm、2.32±3.20mm、2.26±2.73mm,CMA分别为114.31°±11.00°、144.16°±9.33°、145.31°±8.83、143.42°±9.12°;与术前相比,患者术后1周、术后6个月和末次随访时的ADI、DOCL和CMA均显著性改善（F=41.05,P＜0.001）。所有患者均实现骨性融合,融合时间为10.3±2.7个月（5～15个月）。术后发生并发症2例（脑脊液漏1例,切口深部组织感染1例）,给予对症支持治疗后均治愈。结论：后路松解复位侧块关节植骨融合枕颈内固定术是治疗颅底凹陷症合并难复性寰枢椎脱位安全有效的手术方式。     

青少年特发性脊柱侧凸术后肩部外观可塑性与融合策略

【摘要】 目的：本研究旨在探讨青少年特发性脊柱侧凸（adolescent idiopathic scoliosis,AIS）术后肩部外观可塑性,分析基于该现象的胸弯融合上端椎选择策略。方法：对56例Lenke Ⅰ型AIS患者进行回顾性研究,术后随访2～5年。术前Cobb角主胸弯57.65°±12.28°、上胸弯20.34°±9.52°。根据术前肩部平衡、上胸弯柔韧度情况,主胸弯融合上端椎选择方案为：术前右肩抬高非僵硬性上胸弯（柔韧度＞30%）患者10例,选择端椎下位椎（端椎－1）;僵硬性上胸弯（柔韧度≤30%）患者7例,选择端椎。术前双肩平衡非僵硬性上胸弯患者,7例选择端椎上位椎（端椎＋1）,7例选择T3;僵硬性上胸弯患者,5例选择T4,6例选择T3。术前左肩抬高非僵硬性上胸弯患者4例,选择端椎上位椎（端椎＋1）;僵硬性上胸弯患者,1例选择T4,9例选择T3。配对t检验比较术后即刻、末次随访外观肩高（CSD）,评估术后肩部外观可塑性。并对术后肩部平衡进行主观评价,其中患者和家属一方或双方认为肩部外观未恢复平衡,为主观评价不满意。通过分析外观CSD变化,影像学冠状面平衡及T2～T5后凸角,患者及家属主观评价,总结基于肩部外观可塑性的上端椎选择策略。结果：末次随访Cobb角主胸弯19.16°±10.34°、上胸弯11.83°±8.65°,冠状面平衡0.67±0.56cm,T2～T5后凸角17.23°±7.28°。1例患者2年内随访主观评价左肩抬高,其余患者无并发症发生。术前、术后即刻、末次随访时,CSD值：1.04±0.24cm、0.92±0.22cm、0.63±0.16cm;CSD≥1cm患者例数：31例、23例、5例。术后即刻与末次随访CSD存在显著差异（t=7.98,P＜0.001）,最大肩部外观可塑值ΔCSD为1.69cm。随访中肩部恢复平衡的上端椎选择方案：术前右肩抬高非僵硬性上胸弯患者选择端椎－1,右肩抬高僵硬性上胸弯患者选择端椎,双肩平衡非僵硬性上胸弯患者选择端椎＋1或T3,双肩平衡僵硬性上胸弯患者选择T3后,患者末次随访CSD均＜1cm,主观评价满意;术前左肩抬高非僵硬性上胸弯患者选择端椎＋1后1例末次随访CSD为1.06cm,左肩抬高僵硬性上胸弯患者选择T3后1例末次随访CSD为1.02cm,主观评价满意。随访中肩部未恢复平衡的上端椎选择方案：术前双肩平衡僵硬性上胸弯患者选择T4后,2例CSD分别为1.45cm、1.54cm,其中1例随访2年内主观评价左肩抬高;术前左肩高僵硬性上胸弯患者选择T4,1例CSD较大为1.52cm。结论：AIS患者术后肩部外观存在可塑性,基于该特性Lenke Ⅰ型AIS患者胸弯融合上端椎策略为：术前右肩抬高非僵硬性上胸弯患者选择端椎－1,僵硬性上胸弯患者选择端椎;双肩平衡非僵硬性上胸弯患者选择端椎＋1,僵硬性上胸弯患者选择T3;左肩抬高非僵硬性上胸弯患者选择端椎＋1,僵硬性上胸弯患者选择T3。     

胸、腰椎椎体结核病椎置钉短节段内固定的疗效分析

 目的 总结胸、腰椎椎体结核前路一期病灶清除、椎体间植骨融合、病椎置钉短节段内固定的疗效,并探讨其安全性和有效性。方法 2009年6月至2013年11月,行前路一期病灶清除、椎体间植骨融合、病椎置钉短节段内固定治疗胸、腰椎椎体结核患者46例,男25例,女21例;年龄13~69岁,平均39.6岁。病变节段为T6~L4(均≤ 3个节段)。术前Frankel分级：B级3例、C级6例、D级4例、E级33例。术前后凸Cobb角平均为16.34°±3.19°。术前红细胞沉降率为19~81 mm/1 h。术前均行胸、腰椎CT平扫及二维重建,测量残余椎体冠状位及矢状位前、中柱最低有效残留高度,当最低残留有效高度>10 mm时,结合术中测量选择合适的内固定器械行前路病灶清除、植骨融合、病椎置钉内固定。对手术前后Cobb角、视觉模拟评分(visual analogue scale,VAS)、红细胞沉降率、Frankel分级行统计分析,并观察内植物稳定性和植骨融合情况。结果 46例患者随访12~48个月,平均26个月。所有患者结核中毒症状均消失,红细胞沉降率为0~15 mm/1 h。末次随访Frankel分级：D级2例、E级44例。术后1周后凸Cobb角平均为4.16°±2.71°,末次随访平均为4.52°±1.29°;VAS评分由术前(6.85±1.22)分,恢复至术后1周(4.79±0.95)分,末次随访时(2.26±0.93)分;红细胞沉降率由术前(41.25±1.61) mm/1 h,恢复至术后1周(17.36±6.82) mm/1 h,末次随访时(10.67±0.72) mm/1 h。术后6个月植骨融合优44例、良2例。结论 胸、腰椎椎体结核残余椎体有效高度>10 mm时行病椎置钉短节段内固定安全且可靠。     

Vasopressor hormone response following mesenteric traction during major abdominal surgery

Background : We investigated the vasopressor hormone response following mesenteric traction (MT) with hypotension due to prostacyclin (PGI₂) release in patients undergoing abdominal surgery with a combined general and epidural anesthesia. Methods : In a prospective, randomized, placebo-controlled study we administered 400 mg ibuprofen (i.v.) in 42 patients scheduled for abdominal surgery. General anesthesia was combined with epidural anesthesia (T4-L1). Before as well as 5, 15, 30, 45, and 90 min after MT we recorded plasma osmolality, hemodynamics and measured 6-keto-PGFlα (stabile metabolite of PGI₂), TXB₂ (stabile metabolite of thromboxane A₂) active renin, and arginine vasopressin (AVP) plasma concentrations by radioimmunoassay. Catecholamine levels were assessed by high-pressure liquid chromatography (HPLC) with electrochemical detection. Results : Following MT, arterial hypotension occurred along with a substantial PGI₂ release. This was completely abolished by ibuprofen administration. Although plasma levels of 6-keto-PGF_1α (1133 (708) vs. 60 (3) ng/L, median (median absolute deviation), P=0.0001, placebo vs. ibuprofen) remained significantly elevated, blood pressure was restored within 30 min after MT in the placebo group. At the same point in time plasma concentrations of TXB² (164 (87) vs. 58 (1) ng/L, P=0.0001), epinephrine (46 (33) vs. 14 (6) ng/L, P=0.001), AVP (41 ± (18) vs. 12 (7) ng/L, P=0.0004), and active renin (27 (12) vs. 12 (4) ng/L, P = 0.001) were significantly higher in placebo-treated patients. Conclusion : Under combined general and epidural anesthesia arterial hypotension following MT due to endogenous PGI₂ release is associated with enhanced release of AVP, active renin, epinephrine and thromboxane A₂, presumably contributing to hemodynamic stability within 30 min after MT.     

A comparison of the inhibitory effects of four volatile anaesthetics on the metabolism of chlorzoxazone, a substrate for CYP2E1, in rabbits

Background: Halothane inhibits in vitro and in vivo activity of cytochrome P-450 (CYP) 2E1. There are several fluorinated volatile anaesthetics besides halothane, and most of them are defluorinated by CYP2E1. It is unclear whether other fluorinated anaesthetics inhibit the in vivo activity of CYP2E1.
Methods: We compared the inhibitory effects of therapeutic concentrations of four inhalational anaesthetics, halothane, enflurane, isoflurane, and sevoflurane, on chlorzoxazone metabolism in rabbits receiving artificial ventilation.
Results: All four inhalational anaesthetics decreased arterial blood pressure and increased plasma chlorzoxazone concentration. However, no significant differences in the plasma chlorzoxazone concentration were found between the four anaesthetics. The estimated chlorzoxazone clearance increased after beginning inhalation with all four agents, but no significant difference in clearance was noted between agents.
Conclusions: At therapeutic concentrations, the in vivo inhibitory effect on chlorzoxazone metabolism was similar for all four inhalational anaesthetics examined, even though their chemical characteristics and extent of hepatic metabolism differ considerably.     

A Teaspoon Pump for Pumping Blood with High Hydraulic Efficiency and Low Hemolysis Potential

Abstract: Virtually all blood pumps contain some kind of rubbing, sliding, closely moving machinery surfaces that are exposed to the blood being pumped. These valves, internal bearings, magnetic bearing position sensors, and shaft seals cause most of the problems with blood pumps. The original teaspoon pump design prevented the rubbing, sliding machinery surfaces from contacting the blood. However, the hydraulic efficiency was low because the blood was able to "slip around" the rotating impeller so that the blood itself never rotated fast enough to develop adequate pressure. An improved teaspoon blood pump has been designed and tested and has shown acceptable hydraulic performance and low hemolysis potential. The new pump uses a nonrotating "swinging" hose as the pump impeller. The fluid enters the pump through the center of the swinging hose; therefore, there can be no fluid slip between the revolving blood and the revolving impeller. The new pump uses an impeller that is comparable to a flexible garden hose. If the free end of the hose were swung around in a circle like half of a jump rope, the fluid inside the hose would rotate and develop pressure even though the hose impeller itself did not "rotate"; therefore, no rotating shaft seal or internal bearings are required.     

Microspheres Based Detoxification System: A New Method in Convective Blood Purification

Abstract: A variety of protein-bound or hydrophobic substances, accumulating as a result of pathologic conditions such as exogenous or endogenous intoxications, are removed poorly by conventional detoxification methods because of low accessibility (hemodialysis), insufficient adsorption capabilities (hemosorption), low efficiency (peritoneal dialysis), or economic limitations (high-volume plasmapheresis). Combining advantages of existing methods with microspheric technology, a module-based system was designed. Major operating parameters of the latter can be modified to allow for adjustment to individual clinical situations. An extracorporeal blood circuit including a plasmafilter is combined with a secondary high-velocity plasma circuit driven by a centrifugal pump. Different microspheric adsorbers can be combined in one circuit or applied in sequence. Thus, a prolonged treatment can be tailored using specially designed selective adsorber materials. Comparing this system with existing methods (high-flux hemodialysis, molecular adsorbent recycling system), results from our in vitro studies and animal experiments demonstrate the superior efficiency of substance removal.     

Tissue perfusion in relation to cardiac output during continuous positive-pressure ventilation and administration of propranolol or verapamil

Background : Our objective was to determine whether administration of propranolol or verapamil modifies the hemodynamic adaptation to continuous positive-pressure ventilation (CPPV), in particular the regional distribution of cardiac output (CO).
Methods : General hemodynamics and regional blood flows assessed by microsphere technique (15 (μm) were recorded in 16 anesthetized pigs during spontaneous breathing (SB) and CPPV with 8 cm H₂O end-expiratory pressure (CPPV8) before and after intravenous administration of propranolol (0.3 mg · kg⁻¹ followed by 0.15 mg · kg⁻¹ · h⁻¹, n=8) or verapamil (0.1 mg · kg⁻¹ followed by 0.3 mg · kg⁻¹ · h⁻¹, n=8).
Results : CPPV8 depressed CO by 25% without shifts in its relative distribution with the exception of a noteworthy increase in adrenal perfusion. Propranolol increased arterial blood pressure, and due to a fall in heart rate, CO dropped by 25%. The kidneys and, to a lesser extent, the splanchic region and central nervous system received increased fractions of the remaining CO at the expense of skeletal muscle flow. Similar patterns were seen during SB and CPPV8 such that the combination of propranolol and CPPV8 depressed CO by 50%. The circulatory effects of verapamil were less evident but myocardial perfusion tended to increase.
Conclusions : The combination of propranolol or verapamil with CPPV does not result in any specific hemodynamic interaction in anesthetized pigs, except that the combined effect of propranolol and CPPV may severely reduce CO.     

Volatile anaesthetics reduce adhesion of blood platelets under low-flow conditions in the coronary system of isolated guinea pig hearts

Background : Inhibitory effects of volatile anaesthetics on platelet aggregation have been demonstrated in several studies. However, the influence of volatile anaesthetics on intracoronary platelet adhesion has not been elucidated so far.
Methods : Isolated hearts of guinea pigs were perfused with buffer in the absence or presence of volatile anaesthetics (0.5 and 1 MAC) at constant coronary flow rates of 5 ml/min for 25 min, then 1 ml/min for 30 min and again 5 ml/min for 10 min. Before, during and after low-flow perfusion, a bolus of human platelets was applied into the coronary system. To simulate thrombogenic conditions, 0.3 U/ml human thrombin was infused during low-flow perfusion and reperfusion. The number of platelets sequestered to the endothelium was calculated from the difference between coronary in- and output of platelets. The myocardial production of lactate and consumption of pyruvate and coronary perfusion pressure were also determined.
Results : At a flow rate of 5 ml/min only about 3% of the applied platelets did not emerge from the coronary system, in any group. In contrast, 13.1±1.2% (mean±SEM) of infused platelets became adherent in low-flow perfusion in the control group without anaesthetic. The adherence was reduced with each 1 MAC isoflurane (to 6.2±1.2%), sevoflurane (to 4.4±0.9%) or halothane (to 3.2±1.5%) (each P <0.05 vs. control). Volatile anaesthetic, 0.5 MAC, did not inhibit platelet adhesion to a statistically significant extent in any case. Perfusion pressure and metabolic parameters were not statistically different between the control and the hearts exposed to anaesthetics.
Conclusion : Volatile anaesthetics in a concentration of 1 MAC can reduce the adhesion of platelets in the coronary system under reduced flow conditions. This action does not arise from vasodilation or inhibition of ischaemic stress.     

Bariatric Surgery in Some "Central and East-European (former Eastern bloc)"Countries - Current Status and Prediction for the Next Millennium

Background: Obesity is increasing globallly, including in the formerly "Eastern Bloc" countries. Methods: A survey was made of obesity and bariatric surgery. Results: In the 8 East and Central European countries studied, with total population 300 million, roughly 43% of the population was overweight (BMI 25-30), 23% obese (BMI > 30), with about 15 million people morbidly obese (BMI > 40). From 0-10 morbidly obese individuals/100,000/year undergo bariatric surgery. Conclusion: Most countries were found to provide inadequate treatment for obesity.The majority of the morbidly obese are not treated effectively. However, health-care awareness of obesity and bariatric surgeons are slowly increasing.     

Is the recovery profile of mivacurium independent of the rate of decay of its plasma concentration in patients with normal plasma cholinesterase activity?

Background: The duration of action of muscle relaxants is poorly correlated to the rate of decay of their plasma concentration. The plasma concentration of mivacurium may rapidly decrease below its active concentration because of the extensive hydrolysis of mivacurium. By inflating a tourniquet on one upper limb for 3 min after the administration of atracurium, mivacurium or vecuronium, we studied the influence of the initial decline of their plasma concentration on their effect. Methods: In 50 patients anaesthetised with thiopental, isoflurane and fentanyl, the effect of bolus doses of 0.15 or 0.25 mg . kg^?1 mivacurium (MIV 15, MIV 25), 0.3 or 0.5 mg . kg^?1 atracurium (ATR 30, ATR 50) and 0.06 or 0.1 mg . kg^?1 vecuronium (VEC 06, VEC 10) were measured on both arms (evoked response of the adductor pollicis to train-of-four stimulation every 12 s), a tourniquet being applied on one arm just before and during 3 min after the muscle relaxant bolus. Results: Tourniquet inflation of 3 min almost abolished the neuromuscular effect of mivacurium. In the vecuronium groups and in the ATR 50 group, tourniquet inflation did not modify the maximum degree of depression of the twitch response. Also, the duration of action of vecuronium was unaffected by the tourniquet. In the ATR 30 group, times to return of the twitch response to 25% (duration 25%) and 75% (duration 75%) of control response were significantly shorter in the cuffed arm, 23 min vs 27 min, and 41 min vs 45 min, respectively. In the ATR 50 group, only duration 25% was significantly shorter in the cuffed arm (41 min vs 45 min). Conclusion: The results suggest that the rate of decline of the plasma concentration of mivacurium is so rapid, that a very low and almost clinically ineffective concentration is present as soon as 3 min after its administration. The results also indicate that the recovery from a mivacurium-induced neuromuscular blockade is not influenced by the rate of decay of its plasma concentration in patients with genotypically normal plasma cholinesterase.     

Membranes in Artificial Organs

Abstract: Membrane processes play a pivotal and enabling role in modern replacement therapy for acute and chronic organ failure and in the management of immunologic diseases. In fact, virtually all contemporary extracorporeal blood purification methods employ membrane devices, and the next generation of artificial organs and tissue engineering therapies are almost certain to be similarly grounded in membrane technology. In this short essay, we comment on the similarities and differences among synthetic membranes and their natural counterparts and also provide a critical overview of the demographics and technology of hemodialysis, hemofiltration, apheresis, oxygenation, and emerging membrane technologies and applications.     

Synergistic interaction between the effects of propofol and midazolam with fentanyl on phrenic nerve activity in rabbits

Background: It has been shown that the depressive effects of both propofol and midazolam on consciousness are synergistic with opioids, but the nature of their interactions on other physiological systems, e. g. respiration, has not been fully investigated. The present study examined the effect of propofol and midazolam alone and in combination with fentanyl on phrenic nerve activity (PNA) and whether such interactions are additive or synergistic. Methods: PNA was recorded in 27 anaesthetised and artificially ventilated rabbits. In three groups, propofol, fentanyl and midazolam were administered intravenously in incremental doses to construct dose-response curves for the depressant effects of each one on PNA. In another two groups, the effect of pretreatment with either fentanyl 1 μg · kg^?1 i. v. or midazolam 0.05 mg · kg^?1 i. v. on the effects of propofol and fentanyl respectively on PNA were studied. Results: Propofol and fentanyl caused a dose-dependent depression of PNA with complete abolition at the highest total doses of 16 mg · kg^?1 i. v. and 32 μg · kg^?1 i. v., respectively. In contrast, midazolam in incremental doses to a total of 0.8 mg · kg^?1 reduced mean PNA by 63%, but approximately 12% of PNA remained at a total dose as high as 6.4 mg · kg^?1. The mean ED₅₀s, calculated from dose-response curves, were 5.4 mg · kg^?1, 3.9 μg · kg^?1 and 0.4 mg · kg^?1 for propofol, fentanyl and midazolam, respectively. Initial doses of either fentanyl 1 μg · kg^?1 i. v. or midazolam 0.05 mg · kg^?1 i. v. acted synergistically with subsequent doses of either propofol or fentanyl to abolish PNA at total doses of 8 mg · kg^?1 and 8 μg · kg^?1, respectively. Conclusion: Fentanyl has a synergistic interaction with both propofol and midazolam on PNA and hence potentially on respiration.