颈神经后支综合征——解剖与临床研究

目的：从解剖和临床两方面探讨颈神经后支综合征的机制及诊治方法。方法：对17具成人固定尸体中C1～8颈神经后支进行解剖学研究;对24例颈神经后支综合征的患者进行了临床观察和分析。结果：（1）颈神经后支自椎间孔处发出后,穿过由项部肌群附着于颈椎关节突关节囊的交叉纤维、上下关节突关节和内侧椎板组成的骨纤维管,然后发出关节突关节支、肌支、皮支和交通支,穿行于颈后肌群及其腱性纤维组织间。（2）临床发现保守治疗有一定疗效,对保守治疗效果欠佳的患者行颈神经后支松解术可获得满意的疗效。结论：颈神经后支综合征的病因是以颈后肌群为主的腱性交叉纤维压迫颈神经后支所致。对经保守治疗无效的患者行颈神经后支松解术,有可能是解除颈神经后支卡压的切实有效方法。     

患者康复护理干预对颈神经后支源性颈肩痛术后患者的影响

目的分析颈神经后支源性颈肩痛的病理特点,探讨颈神经后支阻滞术后,康复护理干预的作用和影响.方法将121例颈神经后支源性颈肩痛患者,随机分为对照组(60例)予以神经阻滞术治疗,观察组(61例)实施术后康复护理干预.结果121例平均随访9个月,对照组总有效率为81.67%,观察组总有效率为91.8%.经统计学处理,组间比较有显著性差异(P<0.01).结论术后采取相应的康复护理手段,调整颈椎关节突结构紊乱和功能障碍,能有效地缓解或减轻关节、肌肉、韧带以及骨纤维管等因素对颈神经后支的刺激和卡压,是提高治疗效果的重要措施.     

患者康复护理干预对颈神经后支源性颈肩痛术后患者的影响

目的分析颈神经后支源性颈肩痛的病理特点,探讨颈神经后支阻滞术后,康复护理干预的作用和影响。方法将121例颈神经后支源性颈肩痛患者,随机分为对照组(60例)予以神经阻滞术治疗,观察组(61例)实施术后康复护理干预。结果121例平均随访9个月,对照组总有效率为81.67%,观察组总有效率为91.8%。经统计学处理,组间比较有显著性差异(P<0.01)。结论术后采取相应的康复护理手段,调整颈椎关节突结构紊乱和功能障碍,能有效地缓解或减轻关节、肌肉、韧带以及骨纤维管等因素对颈神经后支的刺激和卡压,是提高治疗效果的重要措施。     

腰骶部脊神经后支行经特点及骨纤维管道解剖测量

目的:探讨腰骶背神经后支的行径特点,并测量神经行径的骨纤维管道的位置。方法:解剖8具16侧成人尸体标本,观察测量神经走行经过的骨纤维管道位置。结果:腰神经后外侧支在行径中经过下位椎体横突背面的骨纤维管道,该点至后正中线的距离从L1至L5椎体依次为24.9±1.2,25.7±1.4,30.2±1.7,32.5±1.3,32.2±1.5 mm;所汇成的臀上皮神经分2~3束跨髂嵴入臀,最内侧的入臀点骨纤维管道至后正中线距离为68.4±11.8mm。后内侧支恒定地向后下沿下位椎体横突基部的骨纤维管。臀中皮神经主要由L5~S3的后外侧支组成,经过骶髂长韧带深面的纤维管道,管道内上口至髂后上棘的距离平均为32.4±6.2 mm;外下口至髂后上棘的距离平均为36.8±5.6 mm;髂后上棘至骶骨外侧角的距离平均为67.2±9.3 mm。结论:腰骶神经后支行经的几个骨纤维管道位置基本恒定。这些骨纤维管道是神经卡压的解剖基础,在疼痛诊断和治疗上有重要意义。     

针刀松解术治疗腰椎间盘突出症的机理探讨（附156例临床报告）

本文报告由作者亲自操作，应用针刀松解术治疗的156例腰突症，优65％，优良率为91%，有效率为97％，取得了较高的疗效。目的：通过临床研究，探讨针刀松解椎间管（孔）外口、腰椎棘间韧带、横突间韧带、横突间肌和脊神经后支卡压处等的治疗机理。结果：通过对椎间管精细解剖和生物力学的研究，作者认为，椎间管（孔）外口的针刀松解术，可以将固定在此处的神经根外膜松解，增加神经根的蠕变率，这是缓解或解除神经根受突出间盘压迫的关键；针刀松解棘间韧带、横突间韧带、横突间肌，可以解除椎间韧带的异常紧张度和损伤所致的挛缩改变；针刀松解脊神经后支卡压可以消除竖脊肌的痉挛，后两者结合可更有效的从整体上解除脊柱周围肌肉、韧带对脊柱、间盘和椎间管的压力，也就是横向松解，纵向减压。通过以上针刀松解术的治疗，可以使脊柱和受累的神经根，从整体到局部恢复其生物力学平衡状态。这样，受累神经根的血循环（尤其是微循环）和神经根内外的生化环境将迅速改善，神经根水肿消退，致痛物质将锐减等等，从而消除一切症状，达到了治疗目的。这便是针刀松解术治疗腰突症的治疗机理。结论：事实证明，手术切除间盘与针刀松解术治疗腰突症。虽然施术方法和部位有所不同，但都可以取得较好的疗效，可以说是殊途同归。且针刀松解术较手术疗法要简便、安全得多，又无切口及疤痕粘连之虞，所以针刀松解术是治疗腰突症比较有效的方法，是腰突症治疗学上的一大突破，值得推广应用。     

经颈椎关节突滑膜注药治疗颈肩痛神经形态解剖学机制研究

<正>颈肩痛为临床常见病、多发病,病因错综复杂。研究[1~2]表明颈椎关节突关节病变是导致颈肩痛发生的一个重要原因,约占颈肩痛发生原因的50%左右。颈椎关节突关节滑膜含有丰富的神经末梢,是颈肩痛发生与治疗的重要感受器,其由颈神经后支支配,临床通过行颈椎关节突滑膜注射、银质针导热或颈神经后支射频治疗颈椎关节突源性颈肩痛,效果确切[3~5]。既往研究[6~8]多集中于关节突关节的神经分布上,而关于颈椎关节突滑膜感受器通路的     

颈丛深支一点法阻滞相关结构的研究

摘要 目的：对颈丛神经阻滞入路相关结构及其毗邻关系进行解剖观测，为颈丛神经阻滞入路和预防并发症的发生提供解剖学基础。方法：对50侧尸体颈部与颈丛神经阻滞入路相关结构及其毗邻关系进行了解剖观测。结果：颈丛深支穿刺进针深度：皮肤至第4颈椎横突距离（在前斜角肌与中斜角肌平第4颈椎垂直刺入皮肤）左侧21.0±0.4（18.0—24.0）mm，右侧20.5±0.5（19.0—23.5）mm。获得了与颈丛穿刺相关结构的观测结果。胸膜顶的体表投影，胸膜顶的内侧界距胸骨柄上缘中点，左侧为14.2±0.3(11.0—19.0)mm，右侧为14.5±0.5(10.0—17.0)mm。胸膜顶的外侧界与胸锁关节之间的距离，左侧为55.3±0.6(43.0—70.0)mm，右侧为57.5±0.7(51.5—80.0)mm。胸膜顶的最凸点与锁骨之间的距离，左侧为21.6±0.4(11.0—29.0)mm，右侧为26.5±0.5(11.0—39.0)mm。肺尖与颈正中线的距离，左侧为38.4±0.6(31.0—52.0)mm，右侧为38.3±0.9(31.0—50.0)mm。星状神经节多居于第7颈椎横突基部与第1肋颈之间的前方。结论：为颈丛神经阻滞入路进针深度和预防并发症的发生提供了解剖学依据。 关键词 颈丛；神经阻滞；解剖观测 中图分类号:R223,R614.4 文献标识码:A 文章编号：1001-1242(2008)-03-0248-03     

C型臂定位下颈脊神经后内侧支阻滞治疗颈肩痛

通常认为颈椎病的许多不同的疼痛综合征是由颈椎及其周围支持组织结构紊乱所引起,如钩椎关节及关节突关节的退变导致椎间孔外神经根的压迫,颈神经根受到刺激而导致疼痛.但近年来不少研究认为颈神经后支在椎间孔外压迫是引起头、颈痛及肩、上肢牵涉痛的主要来源之一.我院通过C臂定位下颈神经后内侧支注射治疗颈肩痛30例,现报告如下.     

颈椎及其毗邻结构的超声检查与临床意义

目的探讨颈椎及其毗邻结构的超声检查方法与临床意义。方法对50例健康成人颈部进行超声检查,重点描述颈椎及其毗邻结构的扫查方法与声像图特点。结果 (1)颈椎棘突扫查图像:颈椎棘突呈"栅栏样"声像,寰椎有"拱桥形"的后弓与"山丘状"的后结节,枢椎棘突宽大且末端分叉,而隆椎拥有高大突出的棘突。(2)寰枕关节与寰枢外侧关节扫查图像:颈2背根神经节位于寰枢外侧关节后内侧,椎动脉在寰枢外侧关节后外侧上行,之后走行于寰枕关节下方侧块背侧。(3)颈椎小关节纵切扫查图像:后面观呈"叠瓦状"图像;侧面观呈"波浪线"图像,颈神经后内侧支走行于波谷处。(4)颈椎横突横切扫查图像:颈6横突前、后结节呈"驼峰征",颈6神经根位于两结节间的深沟内;颈7横突仅有一个巨大的后结节,颈7神经根位于后结节前方。(5)颈椎钩突与钩椎关节扫查图像:钩突外侧紧邻椎动脉,内侧为椎间盘;钩椎关节呈"裂缝样"图像。结论超声是检查颈椎及其毗邻结构的理想方法。     

咽旁脓肿的临床诊疗体会

正咽旁间隙位于咽腔的外侧壁(即咽上缩肌)和翼内肌的筋膜之间,是一个圆锥形的间隙,锥底向上至颅底,锥尖向下达舌骨。内侧面以咽缩肌和颊咽筋膜与咽扁桃体相邻,外侧是下颌骨的升支、腮腺深面与翼内肌,后界是颈椎前筋膜。咽旁间隙以茎突和附着其上的肌肉为界分为前隙(茎突前间隙)和后隙(茎突后间隙)。茎突前间隙较小,有颈外动脉及静脉丛通过,内侧和扁桃体相邻,外侧和翼内肌紧密相连;茎突后间隙较大,     

Determination of creatine kinase isoenzyme MB activity in serum using immunological inhibition of creatine kinase M subunit activity. Activity kinetics and diagnostic significance in myocardial infarction.

This is a new method for the determination of creatine kinase isoenzyme MB activity in serum. The method uses direct activity measurement of creatine kinase B subunit activity after blocking of CK-M subunit activity by inhibiting antibodies. The test takes no longer than 15 min. The method yields an intra-serial C.V. of 2.0-12.9%, and a C.V. from day to day of 5.5%. The detection limit is 3.4 U/l creatine kinase MB. In the 95 cases with proven myocardial infarction several types of creatine kinase MB activity kinetics could be determined. The percentage of creatine kinase MB of peak CK-total is 6-25%, with a mean of 11.1%. The amount of creatine kinase MB with respect to total CK activity after reinfarction is higher than the amount after initial infarction.     

俯卧位通气对高海拔地区肺复张治疗无效急性呼吸窘迫综合征患者氧合的影响

目的 探讨俯卧位通气对高海拔地区肺复张术(RM)治疗无效急性呼吸窘迫综合征(ARDS)患者的治疗作用.方法 从海拔2260m的地区医院筛选RM治疗无效的41例ARDS患者[平均氧合指数( PaO2/FiO2)较RM前升高＜20％视为RM无效],依不同病因分为肺内源性ARDS组(ARDSp组)和肺外源性ARDS组(ARDSexp组),每组再按信封法随机分为俯卧位组和仰卧位组,即ARDSp俯卧位组(11例)、ARDSp仰卧位组(9例)、ARDSexp俯卧位组(10例)、ARDSexp仰卧位组(11例).在通气前及通气1、2、3、4h监测动脉血氧分压( PaO2)、PaO2/FiO2、静态顺应性(Cst)、气道阻力(Raw)的变化.结果 通气lh时,ARDSexp俯卧位组PaO2/FiO2( mm Hg,l mm Hg=0.133 kPa)即较通气前显著升高(157.4±40.6比129.3±48.7,P＜0.05),并随通气时间延长呈持续增高趋势,4h达峰值(219.1 ±41.1);且ARDSexp俯卧位组通气3h内PaO2/FiO2较其他3组显著增高,另3组间则差异无统计学意义.ARDSp俯卧位组、ARDSexp俯卧位组通气4h时PaO2/FiO2均较相应仰卧位组显著增高(208.8±39.7比127.4±47.1,219.1±41.1比124.9±50.8,均P＜0.05).4组通气前后Cst无显著改变,各组间差异也无统计学意义.ARDSp俯卧位组通气4h时Raw(cmH2O·L-1·s-1)较通气前显著降低(6.8±1.7比10.7±1.8,P＜0.05),且明显低于其他3组;其他3组各时间点Raw组内及组间比较差异均无统计学意义.结论 俯卧位通气作为ARDS机械通气重要策略之一,可以改善RM无效高原ARDS患者的氧合,为抢救患者赢得宝贵的时间.     

Digital imaging among medical facilities

The Department of Veterans Affairs (VA) in the USA operates a network of 172 medical centres which all utilize a hospital information system (HIS) which has been developed and is currently maintained by the VA. During the past several years, an image management and communication module has been developed, installed and clinically utilized at the Washington DC and Maryland VA Medical Centres. This image management and communication system, referred to as the decentralized hospital computer program (DHCP) imaging system, is fully integrated with a commercial picture archiving and communication system (PACS). The system is utilized to capture, archive, and display all images generated within the hospital including radiology, nuclear medicine, pathology, endoscopy, bronchoscopy, and dermatology, intraoperative photographs, ECG data, and a limited number of paper documents. The ultimate goal of the project is to have all patient text and image data available at any clinical workstation to any authorized user anywhere within the network of medical centres. Clinical requirements for an imaging workstation include ease of use, rapid and reliable access to the complete set of patient information, and images which are of acceptable quality to meet the requirements of the user and the subspecialty. Patient confidentiality and data security must be safeguarded at all times. Integration of the images with the remainder of the patient's database was found to be critical to the success of the project. The experience at the Washington and Maryland facilities suggests that an imaging system that is successfully integrated with a hospital information system can provide substantial clinical and economic benefits both within and among medical centres. Clinical acceptance and utilization of the system has been excellent, particularly in diagnostic radiology where DHCP Imaging has been interfaced to a commercial PAC system. Based upon this initial experience, the VA has begun to deploy the system throughout its large network of medical centres.     

Myocardial elastography at both high temporal and spatial resolution for the detection of infarcts

Myocardial elastography is a novel method for noninvasively assessing regional myocardial function, with the advantages of high spatial and temporal resolution and high signal-to-noise ratio (SNR). In this paper, in-vivo experiments were performed in anesthetized normal and infarcted mice (one day after left anterior descending coronary artery [LAD] ligation) using a high-resolution (30 MHz) ultrasound system (Vevo 770, VisualSonics Inc., Toronto, ON, Canada). Radiofrequency (RF) signals of the left ventricle (LV) in longitudinal (long-axis) view and the associated electrocardiogram (ECG) were simultaneously acquired. Using a retrospective ECG gating technique, 2-D full field-of-view RF frames were acquired at an extremely high frame rate (8 kHz) that resulted in high-quality incremental displacement and strain estimation of the myocardium. The incremental results were further accumulated to obtain the cumulative displacements and strains. Two-dimensional and M-mode displacement images and strain images (elastograms), as well as displacement and strain profiles as a function of time, were compared between normal and infarcted mice. Incremental results clearly depicted cardiac events including LV contraction, LV relaxation and isovolumetric phases in both normal and infarcted mice, and also evidently indicated reduced motion and deformation in the infarcted myocardium. The elastograms indicated that the infarcted regions underwent thinning during systole rather than thickening, as in the normal case. The cumulative elastograms were found to have higher elastographic SNR (SNR(e)) than the incremental elastograms (e.g., 10.6 vs. 4.7 in a normal myocardium, and 6.0 vs. 2.4 in an infarcted myocardium). Finally, preliminary statistical results from nine normal (m = 9) and seven infarcted (n = 7) mice indicated the capability of the cumulative strain in differentiating infracted from normal myocardia. In conclusion, myocardial elastography could provide regional strain information at simultaneously high temporal (>/=0.125 ms) and spatial ( approximately 55 microm) resolution as well as high precision ( approximately 0.05 microm displacement). This technique was thus capable of accurately characterizing normal myocardial function throughout an entire cardiac cycle, at the same high resolution, and detecting and localizing myocardial infarction in vivo.     

手转胎头术失败的原因与分娩结局临床分析

目的 探讨手转胎头术失败的原因与分娩结局.方法 选择2008年1月至2010年12月于我院住院分娩的持续性枕横位、枕后位产妇198例,根据行手转胎头术后结果分为成功组126例、失败组72例.比较两组分娩结局,对比分析失败原因.结果 失败组胎儿体质量≥3500 g的发生率[76.4％(55/72)]明显高于成功组[31.7％(40/126)],差异有统计学意义(x2=30.177,P=0.001)、失败组宫缩乏力发生率[58.3％(42/72)]高于成功组[38.1％ (48/126)],差异有统计学意义(x2=7.569,P=0.006)、失败组骨盆临界或轻度狭窄发生率[38.9％ (28/72)]高于成功组[23.8％(30/126)],差异有统计学意义(x2 =5.030,P=0.002)、失败组手转胎头时机不当(宫口开大＜6 cm、胎头位于坐骨棘上及宫口开大8～10 cm、胎头位于坐骨棘下≥2 cm)发生率[61.1％(44/72)]高于成功组[38.9％(49/126)],差异有统计学意义(x2=9.084,P=0.003).失败组母儿并发症(产后出血、产褥病率、胎儿窘迫、新生儿窒息)发生率高于成功组(x2 =9.586,P=0.002、x2=9.334,P=0.002、x2=5.910,P=0.015、x2=5.240,P=0.022)、失败组剖宫产发生率[72.2％(52/72)]明显高于成功组[34.1 ％(43/126),x2=26.641,P=0.001)].结论 手转胎头术能使难产变顺产,降低剖宫产率,减少母儿并发症,但须积极预防、处理导致手转胎头术失败的原因,对矫正失败后继续矫正及试产应慎重.     

Clinical Pharmacokinetics of Morphine

Morphine, the most widely used mu-opioid analgesic for acute and chronic pain, is the standard against which new analgesics are measured. A thorough understanding of the pharmacokinetics of morphine is required in order to safely and effectively use this analgesic in a wide variety of patients with different levels of organ function. A MEDLINE search was conducted to identify literature published between 1966 and January 2002 relevant to the pharmacokinetics of morphine. These publications were reviewed and the literature summarized regarding unique and clinically important elements of morphine disposition relative to its parenteral administration (including intravenous, intramuscular, subcutaneous, epidural and intrathecal administration), absorption profile (immediate release, controlled release, and sublingual/buccal, and rectal administration), distribution, and its metabolism/ excretion. Special populations, including infants, elderly, and those with renal/liver failure, have a unique morphine pharmacokinetic profile that must be taken into account in order to maximize analgesic efficacy and reduce the risk of adverse events.     

Evidence-Based Pain Management and Palliative Care in Issue Four for 2009 of The Cochrane Library

ABSTRACT

The Cochrane Library of Systematic Reviews is published quarterly. Issue 4 for 2009 contains 4027 complete reviews, 1906 protocols for reviews in production, and 11447 one-page summaries of systematic reviews published in the general medical literature. In addition, there are citations of 600,000 randomized controlled trials, and 12,200 cited papers in the Cochrane methodology register. The health technology assessment database contains over 7500 citations. This edition of the Library contains 90 new reviews, of which 19 have potential relevance for practitioners in pain and palliative medicine.     

Wie zuverlässig sind Angaben zu nichtentzündlichen ausgedehnten Schmerzen?

ZusammenfassungFragestellung Es wurde geprüft, wie sich der Differenziertheitsgrad zweier Schmerzmessmethoden auf Angaben zur Ausgedehntheit klinischer Schmerzen auswirkt. Zugleich wurde der Referenzzeitraum variiert, über den die Patienten berichten sollten.Methode Erfasst wurde der Einfluss zu Lasten der Befragungsdifferenziertheit durch den Vergleich zweier Körperschema-Bildvorlagen. Drei Referenzzeiträume (Schmerz aktuell, letzte Woche, letztes halbes Jahr) wurden vorgegeben.Ergebnisse Patienten mit ausgedehnten Schmerzen gaben bei differenzierter Befragung um so mehr Schmerzen an, je weiter die Schmerzen zurück lagen und je größer der Berichtszeitraum war. Patienten mit gelenknahen Schmerzen gaben bei hoch differenzierter Befragung weniger ausgedehnte Schmerzen in der Vergangenheit an als bei globaler Einschätzung. Patienten mit Rückenschmerzen berichteten bei differenzierter Befragung zum aktuellen Schmerz über weniger ausgedehnte Schmerzen als bei globaler Befragung.Schlussfolgerung Die Angaben zur Schmerzausdehnung variieren vor allem bei Patienten mit ausgedehnten Schmerzen in Abhängigkeit von der Differenziertheit der Befragung. In diesen Fällen ist die Wahrscheinlichkeit erhöht, dass sich die Beschwerdesymptomatik zumindest teilweise erst in der Reaktion auf die situativen Befragungsbedingungen konstituiert und daher nicht auf andere Befragungsbedingungen generalisiert werden kann.