胸腔镜辅助下治疗特发性脊柱侧凸

[目的]评价胸腔镜下前路松解,前路或后路矫形治疗特发性脊柱侧凸的治疗效果。[方法]回顾本院自2003年7月~2005年12月施行的11例胸腔镜辅助下前路松解,前路或后路矫形治疗特发性脊柱侧凸病例。年龄12~16岁,平均14.6岁。LenkeⅠ型9例,术前冠状面Cobb s角54°~68°,平均59.7°;LenkeⅢ型2例,术前冠状面Cobb s角分别为58°和71°,平均64.5°。Bending X线片侧凸矫正率为21.8%~32.4%,平均26.4%。对11例患者在胸腔镜辅助下,采用等离子冷消融切除椎间盘松解,前或后路矫正。对手术后及随访时,冠状面和矢状面的Cobb s角进行测量,并对手术时间,术中出血量,围手术期并发症及矫正丢失等进行分析。[结果]平均手术时间290 min,平均术中出血171 ml。松解节段5~7个,平均4.4个。9例LenkeⅠ型术后Cobb s角平均20.4°,Cobb s角矫正率平均65.8%;2例LenkeⅢ型术后Cobb s角分别为20°和25°,Cobb s角矫正率平均65.1%;1例术后包裹性胸腔积液,术后平均随访18.6个月;1例出现矫正度丢失14°,无神经系统及血管损伤并发症。[结论]与传统开胸前路胸椎侧凸矫形手术相比,胸腔镜辅助下胸椎松解前后路矫形治疗脊柱侧凸是安全有效的微创手术,可达到与开胸手术同样效果。     

经后路多点锚定技术治疗Ⅰ型神经纤维瘤病伴营养不良性脊柱侧凸的临床疗效

[目的]探讨经后路多点锚定技术治疗Ⅰ型神经纤维瘤病伴营养不良性脊柱侧凸的临床疗效。[方法]回顾性研究2005年1月~2013年12月本科收治的Ⅰ型神经纤维瘤病伴营养不良性脊柱侧凸23例;年龄10~22岁,平均13.6岁;其中胸弯13例,胸腰双主弯4例,胸腰弯3例,双胸弯2例,腰弯1例;术前冠状面Cobb角48.9°~91.4°,平均68.3°;凸侧Bending相Cobb角40°~79.2°,平均57.4°;柔韧性8.3%~28.1%,平均15.7%;顶椎旋转度2°~3°,平均2.3°;矢状面胸椎后凸Cobb角46.4°~79.6°,平均58.2°,胸腰段后凸Cobb角21.1°~35.7°,平均28.3°。均采用经后路多点锚定技术进行矫形融合固定。[结果]随访12~96个月,平均52个月。术后冠状面Cobb角16.3°~46.7°,平均28.4°;顶椎旋转度1°~2°,平均1.2°;矢状面胸椎后凸Cobb角16.1°~38.3°,平均25.3°,胸腰段后凸Cobb角-4.3°~18.7°,平均8.9°;术后各指标均获得良好的矫正,侧凸矫正率为46.3%~74.1%,平均56.9%。末次随访时侧凸矫正丢失率仅3.1%,无神经系统并发症,仅1例假关节形成。[结论]经后路多点锚定技术治疗Ⅰ型神经纤维瘤病伴营养不良性脊柱侧凸可获得较满意的矫形融合效果。     

前路半椎体切除截骨后路矫形固定治疗严重先天性脊柱侧凸

目的探讨分期前路半椎体切除截骨后路矫形手术治疗严重先天性脊柱侧凸的临床疗效。方法严重先天性脊柱侧凸14例,男4例,女10例;年龄8～13岁,平均11.2岁。其中形成缺陷2例,分节缺陷6例,混合型6例。半椎体位于T53例,T2、T8、T10、T11、L1、L4各1例。胸弯12例,胸腰弯2例。术前冠状面Cobb角63°～95°,平均72.1°。胸椎后凸减小或前凸8例,胸腰段后凸4例。一期采用前路半椎体切除、多节段椎体间楔形截骨及分节不全松解;二期采用后路椎弓根钉棒系统三维矫形固定。前后路手术均植骨,平均截骨5.5个节段。结果一期前路术后冠状面Cobb角48°～60°,平均51.5°;矫正率19.6%～37.8%,平均28.6%。二期术后冠状面Cobb角5°～45°,平均30.5°;矫正率52.6%～87.5%,平均62.5%。8例存在胸椎后凸减小或前凸的患者均恢复生理性后凸,4例胸腰段后凸患者3例达到矢状面矫正。全部病例随访8～30个月,平均12.1个月。无断钉、断棒及明显的矫正度丢失,植骨融合良好。发生并发症2例,椎弓根钉帽松动1例,T1神经根激惹1例。结论一期前路半椎体切除、多节段椎体间楔形截骨、分节不全松解,二期后路矫形固定及前后路植骨治疗先天性脊柱侧凸能够达到较满意的矫形效果,适合于8～12岁的青春期前患者。     

后路“三棒矫形技术”治疗重度特发性脊柱侧凸

[目的]探讨后路“三棒矫形技术”在治疗重度青少年特发性脊柱侧凸的作用.[方法]回顾性研究自2003年7月～2009年11月,对19例重度特发性脊柱侧弯患者利用“三棒矫形技术”行后路—期非截骨矫形治疗.其中男性5倒,女性14例;年龄13～21岁,平均15.8岁,主弯Cobb角83°～122°,平均97°,胸椎矢状面后凸角度49°～74°,平均62°.手术采用后路一期手术,首先在主弯凹侧顶椎上下置钉,置入1根短棒强力撑开,再于两侧分别置入第2、3根棒,凹侧双棒交替撑开,凸侧单棒加压进行矫形.[结果]所有手术均顺利实施,无脊髓和神经损伤的严重并发症发生,术后主弯Cobb角30°～52°,平均38°,胸椎后凸角度20°～45°,平均30°.平均随访34个月(24～77个月),所有患者在末次随访时均获得良好骨性融合,未见假关节形成、断钉及断棒等手术并发症.[结论]后路“三棒矫形技术”在治疗重度青少年特发性脊柱侧凸中,操作安全,能够取得良好的治疗效果.     

后路单侧经椎弓根半椎体截骨治疗青少年先天性脊柱侧凸

目的评估后路经椎弓根截骨矫形部分半椎体保留治疗先天性半椎体所致脊柱侧凸畸形的临床疗效。方法共18例先天性半椎体合并脊柱侧凸患者纳入随访研究,平均年龄16.17岁（14～21岁）,术前测量半椎体所致脊柱畸形的节段性主弯Cobb角45.39°±6.81°,头侧代偿弯Cobb角27.5°±2.71°,尾侧代偿弯Cobb角为26.44°±6.85°,顶椎偏距为4.28±0.58cm,节段性后/前凸角度为14.11°±18.07°。所有病例均采用后路一期经半椎体椎弓根截骨,双侧固定矫正侧凸畸形。随访时间为14.17±6.56个月。综合评估影像学、临床疗效以及并发症的情况。结果手术时间为2.82±0.74h,术中失血量317.22±65.15ml。术后节段性主弯Cobb角为11.33°±4.68°,矫正34.06°±7.88°,末次随访14.61°±4.96°;头侧代偿弯Cobb角为8.72°±1.44°,矫正18.78°±3.17°,末次随访18.78°±3.17°;尾侧代偿弯Cobb角为7.98°±1.82°,矫正18.47°±5.83°,末次随访18.47°±5.83°;节段性后/前凸角为-1.94°±12.35°,矫正14.94°±10.18°,末次随访-1.5°±12.67°。顶椎偏距的矫正为2.31±0.52cm,末次随访2.1±0.24cm。术中没有血管、神经损伤、骨折等重大并发症发生,术后没有发生冠状面和矢状面的失代偿。结论后路半椎体经椎弓根截骨矫形能有效矫正轻、中度先天性半椎体所致脊柱侧凸畸形,缩短手术时间,创伤小,减少术中失血量,矫形效果满意,所选病例骨骼发育相对成熟者,避免矫形丢失。     

前路ADS联合后路PRSS应用治疗重度僵硬脊柱侧弯

[目的]研究前后路联合矫形治疗僵硬脊柱侧弯畸形。[方法]男6例,女12例;年龄11~18岁,平均15.2岁,先天性胸腰段侧凸8例,胸段侧凸 胸腰段侧凸9例,其中Luque氏棒后路矫形后翻修1例。均采用前路松解后,进行ADS(anterior derotation spondylodese,ADS)前路矫形,2周后再进行后路PRSS(plate-rod system forscoliosis)矫形。[结果]本组病例获得6个月~2年(平均18个月)随访,其矫形效果满意。术前平均Cobb s角99.4°(70°~110°),术后平均Cobb s角42.4°(30°~64°),平均矫正率57.4%。侧弯(冠状面畸形)矫正效果良好,平背或后凸畸形者与腰椎前凸术后基本达到正常的矢状重建。无明显并发症。仅内固定棒断裂1例。[结论]前后路联合矫形治疗重度脊柱侧弯畸形可取得较好的矫正结果。     

经后路胸膜外松解脊椎楔形截骨治疗重度特发性脊柱侧凸

目的:评价经后路胸膜外松解脊椎楔形截骨治疗重度僵硬性特发性脊柱侧凸的安全性和早期临床效果.方法:2004年5月～2007年10月采用经后路胸膜外松解凸侧胸椎间隙、顶椎区楔形截骨、凹侧肋椎关节松解及椎弓根螺钉同定矫正治疗重度僵硬性特发性脊柱侧凸患者19例,男12例,女7例,年龄14～39岁,平均18.9岁.术前侧凸Cobb角890～132°,平均107°;C7中垂线与骶骨中垂线距离3～5.7cm,平均4.1cm;侧凸柔韧性为16.1%～29.6%,平均24.2%;12例合并后凸畸形,后凸Cobb角56°-89°,平均67°.结果:平均松解椎间隙5.2个,楔形截骨平均2.1个椎体.手术时间平均8.9h,术中出血量1200～4700ml,平均3100ml.无脊髓损伤.1例术中发生血气胸,术毕行胸腔闭式引流,2周后痊愈;1例术后第4d并发肠系膜上动脉综合征,采取禁食水、持续胃肠减压、维持水电解质平衡、左侧卧位,术后2周痊愈.术后侧凸Cobb角矫正至12°～59°,平均24.1°,矫正率为77.5%;12例后凸Cobb角22°～460°,平均35.6°,矫正率为46.9%;C7中垂线与骶骨中垂线距离0.3～1.3cm,平均0.7cm.随访8～41个月,平均17.2个月,末次随访时侧凸Cobb角15°～67°,平均27.9.,丢失3.6%;12例后凸Cobb角25°～51°,平均39.4°,丢失5.7%;C7中垂线与骶骨中垂线距离0.4～1.6cm,平均为0.9cm.所有患者植骨愈合良好,内固定无断裂及松动.结论:经后路胸膜外松解、脊椎楔形截骨与胸廓成形及后路脊柱矫形使用同一个手术切口,创伤小,节省了前路经胸的手术时间,对心肺干扰小,降低了手术风险.应用此方法治疗重度特发性脊柱侧凸安全性好,能获得较好的脊柱三维矫正.     

后路广泛松解全椎弓根螺钉矫形治疗成人特发性胸腰椎/腰椎侧凸

[目的]回顾性分析后路广泛松解全椎弓根螺钉矫形治疗成人特发性胸腰椎/腰椎侧凸的疗效.[方法]2005年1月～2008年6月,通过后路广泛松解全椎弓根螺钉矫形治疗成人特发性胸腰椎/腰椎侧凸患者,27例获得随访.术前冠状面主凸cobb角为48.6°(42°～63°),侧凸平均柔韧度34.2%.术后平均随访27.4个月(24～36个月),通过影像学检查对手术矫形效果和躯干平衡情况进行分析,末次随访时进行患者主观疗效评价.[结果]所有患者术后外观明显改善.冠状面主凸平均Cobb角矫正率为62.1%.末次随访冠状面Cobb角平均丢失2.3°.冠状面平衡由术前平均26 mm矫正为术后平均8 mm.腰椎前凸cobb角由术前平均36.7°增加为39.6°.[结论]后路广泛松解全椎弓根螺钉矫形治疗成人特发性胸腰椎/腰椎侧凸可以获得良好的冠状面和矢状面矫形,重建躯干的平衡,主客观疗效满意.     

选择性椎弓根置钉矫形治疗青少年特发性脊柱侧凸

[目的]回顾性观察分析后路选择性椎弓根置钉矫形治疗青少年特发性脊柱侧凸(AIS)的临床疗效。[方法]2005年1月～2009年6月采用后路选择性椎弓根置钉矫形手术治疗AIS,测量术前和术后胸侧凸冠状面Cobb角、矢状面Cobb角,腰侧凸冠状面Cobb角,顶椎椎体旋转和身高变化。分析临床疗效。[结果]手术时间平均186min;术中失血量平均800 ml。术中无脊髓、神经及血管损伤,术后无胸腔积液及切口感染。随访2.1～6.4年,平均3.6年。胸侧凸冠状面Cobb角、胸侧凸矢状面Cobb角和冠状腰弯Cobb角分别由术前57.38°±10.93°、29.3°±7.8°、33.03°±7.75°矫正为12.88°±8.79°、17.9°±10.3°和8.85°±3.65°,手术前后有显著性差异(P<0.01),末次随访分别为:13.89°±9.36°、19.3°±5.4°和9.06°±3.78°,与术后比较无显著性差异(P>0.01)。顶椎椎体旋转由术前2.83°±1.25°矫正为1.37°±1.13°(P<0.01),末次随访(1.32°±1.04°)与术后比较无显著性差异(P>0.05);身高平均增长4.45 c...     

后路椎体截骨内固定治疗僵硬性脊柱侧凸9例报告

[目的]评价后路椎体截骨矫形固定治疗僵硬性脊柱侧凸的临床疗效和适应证的选择。[方法]本院2003年4月~2005年2月采用后路顶椎楔形截骨矫形固定治疗9例僵硬性脊柱侧凸,男5例,女4例;年龄11~23岁,平均14.2岁。先天性侧凸5例,特发性侧凸4例。术前测Cobb s角平均为81.5°,悬吊后平均为67.2°,脊柱柔韧度平均11.5%。伴有神经症状2例,椎管内间隔2例。顶椎截骨平面在T8~11,截骨后采用Scofix器械固定,后路植骨融合。[结果]9例随访6~28个月,平均16.6个月。侧凸Cobb s角平均31.2°,矫正率平均61.3%,矫正丢失率平均2.1%。本组病例全部骨性融合,无断钉、断棒、松动。[结论]后路椎体截骨矫形固定治疗僵硬性脊柱侧凸,适用于中、重度青春期后特发性和重度先天性混合性脊柱侧凸畸形,此方法能一次性完成矫形侧凸,降低神经、血管损伤的发生率,并通过椎弓根系统固定和植骨融合重建脊柱的稳定性,临床疗效肯定。     

Is the reexcision rate higher if breast conservation surgery is performed by surgical trainees?

BACKGROUND: It is essential that surgical trainees obtain adequate operative experience without compromising patient outcome. The aim of this study was to compare the reexcision and local recurrence rates between consultants (attending surgeons) and surgical trainees (residents) after breast conservation surgery. METHODS: Prospective data were obtained from the local breast cancer registry for all patients who had breast-conservation surgery between 1994 and 2000. Reexcision was carried out if the margins were deemed inadequate after taking the clinical and pathologic features into consideration. RESULTS: The primary operation (n = 505) was wide local excision = 377; wire-guided excisions = 107; and quadrantectomy = 21 patients. Sixty-five percent (n = 330) were operated on by consultants and 35% (n = 175) by residents. Second procedures (n = 137) were performed for involved margins in 95 and close margins in 31 patients. The patients in both groups were equally matched. The reexcision rate was similar for both groups of surgeons (P = 0.58). On multivariate analysis, the factors determining reexcision were nodal status, type of first procedure, and tumor type. The local recurrence rate was comparable in both groups (P = 0.33). CONCLUSIONS: In patients with breast cancer treated by conservation surgery during a 7-year period, the reexcision and local recurrence rates were similar for both groups of surgeons.     

Effect of immunosuppressive drugs on the release of metalloproteinases from human polymorphonuclear leukocytes

The concentration of the metalloproteinases type I collagenase and gelatinase was measured in isolated polymorphonuclear leukocytes (PMNLs) of renal transplant recipients treated either with cyclosporin A (CyA) and prednisolone (Pr) (n=8) or azathioprine (Aza) and Pr (n=8), and of healthy subjects (n=12). PMNLs of CyA- and Aza-treated transplant patients displayed markedly higher gelatinase content (2427±489 and 3284±357 ng/10⁷ cells) than PMNLs of controls (528±83 ng/10⁷ cells). There was also a higher content of type I collagenase in PMNLs (3374±292 ng/10⁷ cells) of Aza-treated patients and significantly elevated levels in PMNLs of patients receiving CyA (3625±229 ng/10⁷ cells) compared with healthy subjects (2878±151 ng/10⁷ cells). In contrast, neutrophil lactoferrin content was lower in transplant patients. Thus, immunosuppressive drugs may reduce the release of leukocyte proteinases, which are known for their deleterious role in proteolytic tissue and matrix breakdown. In vitro, the effects of different immunosuppressive drugs on the release of lactoferrin, collagenase and gelatinase were investigated on FMLPNTL-stimulated PMNLs isolated from healthy subjects. CyA but not Aza or Pr caused inhibition of gelatinase, collagenase and lactoferrin release.     

Clinicopathologic Impact of Early Medullary Ray Injury in Patients Following Kidney Transplantation

Background

Previously, we explored the histopathologic characteristics of medullary ray injury (MRI) inducing interstitial fibrosis and tubular atrophy (IF/TA) to determine its etiologies, which include calcineurin inhibitor (CNI) toxicity and urologic complications. However, we did not examine the effects of these etiologies on long-term kidney allograft prognosis, because biopsy timing differed among cases.

Electroencephalographic investigations in sellar tumours,with special regard to different methods of operative treatment

Summary Sixty-six patients with tumours in the sellar region were examined. All were operated on either by the transfrontal or the transsphenoidal route. Pre- and postoperative longitudinal electroencephalographic investigations were performed.Preoperative electroencephalograms showed a normal frequency content in cases of intrasellar tumours or those reaching the chiasma. Nearly all cases had irregularities in the temporal regions. Tumours compressing the third ventricle had slower average frequencies and a general slowing in all cases. Besides these alterations unilateral delta waves or bitemporal dysrhythmic groups were sometimes found.A connection between extension of the tumour and its histological nature could not be found, but the operative approach influenced the electroencephalographic disturbances enormously. After a transfrontal approach and removal of the tumour the electroencephalogram was unchanged. Sometimes a mild transient bitemporal slowing was present. But after a transfrontal operative approach a general slowing was common, usually with focal marked slow activity in the right fronto-temporal area.     

Aspects of personality in patients with pituitary adenomas

Summary In 24 patients suffering from pituitary tumours, aspects of personality as covered by the FPI (Freiburger Personality Inventory), the Gie\en test and the STAI (State-Trait-Anxiety Inventory) were investigated in order to find out changes or problems which demand special treatment.The most interesting result concerns state and trait-anxiety scores being increased pre-surgically and normalizing to some extent after treatment. Most of the other explored aspects did not show but tendencies which demand further investigation.Relationships between hormone levels and tumour size could not be shown. As a result of this investigation, special psychological treatment should be considered in acromegaly and Cushing's disease.Dedicated to Prof. Dr. Friedrich Loew on the occasion of his 65th birthday and the 25th anniversary of the Homburg Neurosurgical University Clinic, which has been founded and built up by him.     

Functional, life-threatening disorders and splenectomy following liver transplantation

Splenectomy (SPL) in cirrhotic patients undergoing liver transplantation (LTx) may resolve specific problems related to the procedure itself, in case of functional and life-threatening clinical situations often occurring as a result of liver cirrhosis and portal hypertension. METHOD: A single-center experience of ten splenectomies in a series of 180 consecutive adult liver transplant patients over a period of 6 yr is reported. The mean patient age was 46.8 +/- 9.5 yr (range 25 57 yr). Indications for SPL were post-operative massive ascitic fluid loss (n = 3), severe thrombocytopenia (n = 3), acute intra-abdominal hemorrhage (n = 2), infarction of the spleen (n = 1), and multiple splenic artery aneurysms (n = 1). RESULTS: Extreme ascites production due to functional graft congestion disappeared post-SPL, with an improvement of the hepatic and renal functions. SPL was also effective in cases of thrombocytopenia persistence post-LTx, leading to an increase in the platelet count after about 1 wk. Bleeding episodes related to left-sided portal hypertension or trauma were also resolved. The rejection rate during hospitalization was 0%, and no other episodes were recorded in the course of the long-term follow-up. However, sepsis with a fatal outcome occurred in 4 patients, i.e. between 2 and 3 wk post-SPL in three cases and 1 yr after the procedure as a result of pneumococcal infection in the last case. Fatal traumatic cranial injury occurred 3 yr post-LTx in another case. Five patients (50%) are still alive and asymptomatic after a median follow-up period of 36 months. CONCLUSION: The lowering of the portal flow appears to resolve unexplained post-operative ascitic fluid loss as a result of functional graft congestion following LTx. However, because of the enhanced risk of SPL-related sepsis, a partial splenic embolization (PSE) or a spleno-renal shunt could be used as an alternative procedure because it allows us to preserve the immunological function of the spleen. SPL is indicated in case of post-transplant bleeding due to left-sided portal hypertension and trauma, spleen infarction, and to enable prevention of hemorrhage in liver transplant patients with multiple splenic artery aneurysms. Severe and persistent thrombocytopenia could be treated with PSE. Because the occurrence of fatal sepsis post-SPL is a major complication in LTx, functional disorders, such as ascites and thrombocytopenia, should be treated with a more conservative approach.     

Macronutrients,minerals, vitamins and energy

Carbohydrates have the general formula C_n(H₂O)_n. Monosaccharides have between three and six carbon atoms and exist as chains or ring structures. As rings, they link with other monosaccharide rings. The major carbohydrate in humans is glucose, which is stored as glycogen: branching chains of glucose molecules. Fat (triglyceride), which makes up adipose tissue, consists of three fatty acids bonded to glycerol, but other lipids include phospholipids and steroids. Proteins are composed of chains of amino acids linked by amide bonds folded on each other to form protein structures. Vitamins and minerals are obtained from the diet and are required in varying quantities for a variety of metabolic processes. Energy is derived from the oxidation of carbohydrate, fat and protein. Energy expenditure and substrate oxidation can be calculated from oxygen consumption, carbon dioxide production and urinary nitrogen excretion.     

Cash transfers for HIV prevention: considering their potential

Introduction

Cash payments to vulnerable households and/or individuals have increasingly garnered attention as a means to reduce poverty, improve health and achieve other development-related outcomes. Recent evidence from Malawi and Tanzania suggests that cash transfers can impact HIV-related behaviours and outcomes and, therefore, could serve as an important addition to HIV prevention efforts.

Discussion

This article reviews the current evidence on cash transfers for HIV prevention and suggests unresolved questions for further research. Gaps include (1) understanding more about the mechanisms and pathways through which cash transfers affect HIV-related outcomes; (2) addressing key operational questions, including the potential feasibility and the costs and benefits of different models of transfers and conditionality; and (3) evaluating and enhancing the wider impacts of cash transfers on health and development.

Conclusions

Ongoing and future studies should build on current findings to unpack unresolved questions and to collect additional evidence on the multiple impacts of transfers in different settings. Furthermore, in order to address questions on sustainability, cash transfer programmes need to be integrated with other sectors and programmes that address structural factors such as education and programming to promote gender equality and address HIV.