陈旧性胸腰椎骨折的术式选择--前路固定与后路椎体截骨术的比较

目的比较前路减压内固定与后路椎体截骨治疗陈旧性胸腰椎骨折的疗效。方法39例伴有神经受损和后凸畸形胸腰椎骨折的患者,采用前路固定19例,后路椎体截骨20例。前路固定组:平均年龄38.3岁(21～64岁),受伤至手术时间平均5.3个月(2～16个月),术前后凸角平均25.2°(10°～43°)。后路椎体截骨组:平均年龄39.9岁(18～68岁),受伤至手术时间平均5.6年(2个月～16年),术前后凸角平均27.6°(5°～60°)。结果前路固定组:平均手术时间为274min(140～395min),平均出血为994mL(300～2000mL),术后平均后凸角为14.7°(0～35°),平均矫正10.5°(5°～16°)。后路椎体截骨组:平均手术时间为283min(190～3950min),平均出血为1654mL(800～3800mL),术后平均后凸角为4.4°(-10°～30°),平均矫正23.2°(7°～40°)。所有的不完全神经损伤的患者神经功能都得到改善。结论后路椎体截骨在不增加手术创伤的同时,可以获得更好的后凸矫正。     

一期后路病灶清除、椎体间钛笼植骨椎弓根钉内固定治疗胸椎结核

目的探讨一期后路病灶清除、椎体间钛笼植骨、椎弓根钉内固定治疗胸椎结核的临床效果。方法对21例胸椎结核患者采用一期后路病灶清除、椎体间钛笼植骨椎弓根钉内固定治疗,术后抗结核药物治疗9～12个月。对患者术前、术后行影像学检查,测量Cobb角以及评价神经功能Frankel分级。结果患者均获随访,时间12～48个月。钛笼植骨平均融合时间6～9(7.8±1.2)个月;Cobb角由术前31°～61°(41.8°±8.2°)矫正至术后10°～29°(21.6°±5.6°)。18例有神经功能障碍者术后15例获得1级以上的恢复。结论一期后路病灶清除椎体间钛笼植骨椎弓根钉内固定治疗胸椎结核可取得较好疗效。     

一期后路固定前路病灶清除植骨治疗胸腰段椎体结核

目的探讨一期后路内固定联合前路病灶清除植骨融合治疗胸腰段椎体结核。方法2003年2月至2011年2月手术治疗胸腰段椎体结核23例,应用一期后路内固定联合经前路结核病灶清除植骨融合治疗胸腰椎体结核,根据术前、术后X线片分析植骨融合及术后畸形矫正效果。结果经14～54个月随访,脊髓功能得到不同程度的恢复,植骨融合满意,无内固定失败和脊柱结核病灶复发。结论一期后路内固定联合经前路结核病灶清除植骨融合治疗胸腰段椎体结核具有脊柱后凸侧弯畸形易于矫正、前路结核病灶减压彻底、内固定远离病灶等优点,是治疗脊柱胸腰段结核的一种有效手术方法。其缺点是手术创伤较大、时间较长、操作相对繁杂。     

胸椎结核合并流注脓肿的外科治疗

目的:分析胸椎结核合并流注脓肿的临床特点,探讨其外科治疗方式。方法:回顾性分析2000年8月～2005年9月间收治的21例合并流注脓肿的胸椎结核患者的临床资料,男13例,女8例,平均年龄37.2岁。结核病灶累及2个椎体12例、3个椎体6例、4个椎体3例,均合并椎旁或流注脓肿。8例出现它处流注脓肿,8例伴神经功能损害,14例合并后凸畸形,平均后凸Cobb角55.3°。病灶仅累及椎间隙和椎体骨膜下且无后凸畸形者,行前路病灶清除和椎间植骨;2个以上椎体中心型破坏和合并后凸畸形者采用后路畸形矫正、一期或分期前路病灶清除和植骨重建。结果:所有患者均顺利完成手术,应用自体髂骨植骨14例,钛网植骨4例,髂骨联合钛网植骨3例。术后伤口窦道形成2例,再次行清创术后2周愈合;合并胸背部疼痛1例,保守治疗半年后好转。术后后凸角平均30.5°。平均随访2.1年,8例伴神经功能损害者术后神经功能得到不同程度改善,无内固定失败和矫正度丢失,植骨均融合。结论:胸椎结核伴脓肿形成者应根据不同情况,采用病灶清除、闭式灌洗、负压引流或分段植骨重建结合合理的后路内固定,均可取得好的手术效果。     

胸腔镜下前路松解结合后路矫形治疗Scheuermann病后凸畸形

目的探讨胸腔镜下前路松解结合后路矫形治疗Scheuermann病后凸畸形的效果。方法对16例Scheuermann病后凸畸形患者在胸腔镜下行前路松解、椎间盘摘除、植骨融合,结合后路矫形内固定。手术前后及随访期间测量后凸畸形Cobb角,了解后凸畸形矫正情况。评定术前及术后Oswestry功能障碍指数,了解背部疼痛缓解情况。结果16例后凸畸形患者均获得满意矫形,术前Cobb角平均788°(70°～92°),术后平均405°(36°～47°),最后一次随访平均417°(36°～50°)。患者背部疼痛症状明显改善,Oswestry功能障碍指数术前平均373(0～72),术后平均64(0～30)。结论胸腔镜下前路松解结合后路矫形是一种较好的治疗Scheuermann病后凸畸形的手术方法。     

一期前后联合入路治疗胸腰段脊柱结核

目的回顾性分析一期后路椎弓根螺钉内固定和前路病灶清除植骨融合术治疗胸腰椎脊柱结核的临床疗效。方法 2004年12月～2010年8月,采用一期后路椎弓根螺钉系统内固定和前路病灶清除、神经减压、自体骨椎间植骨治疗胸腰段脊柱结核患者27例,2个椎体16例,3个椎体8例,4个椎体2例,5个椎体1例。分析术前与术后脊髓神经功能Frankel分级情况以及脊柱融合情况。结果所有患者术后随访9个月～3年,平均16.5个月。脊柱后凸畸形由术前平均46.3°改善到术后平均14.3°(P<0.05)。术后所有病例神经功能均获得改善。结论经后路椎弓根螺钉内固定和前路病灶清除植骨融合术治疗脊柱结核能彻底清除结核病灶,矫正脊柱后凸畸形,促进脊髓及神经功能恢复。     

一期后路病灶清除、截骨矫形治疗伴后凸畸形的腰椎结核

目的探讨一期后路病灶清除、截骨矫形治疗伴明显后凸畸形的腰椎结核的临床效果及意义。方法对2002年1月至2008年11月间我院治疗的21例伴有明显后凸畸形的腰椎结核患者采取一期后路病灶清除、楔形截骨矫形及内固定术。男13例,女8例,年龄25～65岁,平均40.1岁。累及1～2个椎体者12例,3个及以上椎体者9例。术前后凸角38～°106,°平均66.8°。10例合并神经损害,3例为F ranke l C级,7例为F ranke l D级。结果手术时间为2.3～4.1 h,平均3.3 h,术中出血500～2 000 mL,平均900 mL。无严重并发症发生,术后神经功能均获显著改善。术后后凸角度平均15.1,°矫正率为77.4%。随访12～48个月,平均26个月。无内固定松动、断裂及明显矫正度丢失,融合良好。结论对伴有明显后凸畸形的腰椎结核患者采取一期后路病灶清除、截骨矫形术效果满意。     

一期后路病灶清除植骨融合内固定矫形治疗伴后凸畸形的儿童胸腰段脊柱结核的临床初步报告

[目的]探讨经后路一期病灶清除、植骨融合内固定矫形治疗伴后凸畸形的儿童胸腰段脊柱结核的可行性及疗效.[方法]7例胸腰段脊柱结核患儿,均伴有后凸畸形.其中男5例,女2例;年龄9～12岁.术前脊柱后凸角为35°～45°,平均37.9°.Frankel分级:B级2例,C级3例,D级2例.采用经后路一期病灶清除、植骨融合加钉棒系统矫形固定治疗.[结果]术后随访27～42个月,平均34个月.切口均一期愈合,无1例结核复发.Frankel分级:4例恢复2级,3例恢复1级.术后后凸角为2°～9°,较术前明显改善,最后随访时后凸角为2°～12°,较术后无明显丢失.术后3个月血沉均恢复正常;所有患儿均获得满意的植骨融合.[结论]一期后路病灶清除、后方植骨内固定矫形手术治疗伴后凸畸形的儿童胸腰段脊柱结核是矫正后凸畸形和预防晚期后凸畸形发生的有效方法.     

一期前路病灶清除、后路内固定并横突间植骨融合治疗胸腰椎结核

目的:评价一期前路病灶清除、后路内固定并横突间植骨融合治疗胸腰椎结核的临床疗效。方法:采用一期前路病灶清除、后路内固定并横突间植骨融合手术治疗胸、腰椎结核患者17例,按照Frankel分级评定患者手术前后的神经功能,根据X线片评价植骨融合时间,测量术前、术后后凸角度及随访期内的角度丢失。结果:17例患者结核病灶清除彻底,切口均Ⅰ期愈合、无窦道形成,结核治愈无复发。后凸畸形平均矫正19.2°;在随访期内,后凸畸形矫正有1°~4°丢失。X线片示植骨界面骨性融合时间平均5个月。3例出现并发症,对症处理后好转。结论:一期前路病灶清除、后路内固定并横突间植骨融合治疗胸、腰椎结核的疗效确切,具有迅速缓解症状、早期离床活动和较理想的脊柱矫形等优点,是治疗胸、腰椎结核的有效方法。     

侧前方病灶清除人工椎体置换术治疗胸椎结核后凸畸形

目的:探讨脊柱侧前方病灶清除椎间轴套式钛合金人工椎体置换治疗胸椎结核并后凸畸形的疗效。方法:胸椎结核并后凸畸形患者19例,后凸Cobb角15°～30°,平均25°,7例患者合并脊髓压迫,Frankel分级C级3例,D级4例。手术方法为一期侧前方病灶清除椎间轴套式钛合金人工椎体置换,置换的人工椎体内置入松质骨。术后抗结核药物治疗9个月。结果:随访2～3年,平均2年4个月。切口均一期愈合,椎体无滑脱,胸椎结核全部治愈,脊髓功能损害者术后1年内完全恢复。术后后凸Cobb角平均8°,平均矫正17°,随访期间畸形矫正无明显丢失。结论:胸椎结核侧前方病灶清除人工椎体置换术治疗胸椎结核并后凸畸形效果较好,能够一期完成病灶清除、脊髓减压、脊柱稳定性重建和后凸畸形矫正。     

Pseudoaldosteronism with increased serum cortisol associated with pneumonia, hypouricemia, hypocalcemia, and hypophosphatemia

We describe here the interesting case of a 73-year-old hypertensive man with pseudoaldosteronism. He had been taking glycyrrhizin at a dose of 75 mg/day for 12 years because of mild liver damage, but had never experienced any previous symptoms associated with hypokalemia. He was referred to our hospital because of hypokalemic tetraparesis and rhabdomyolysis. At that time, we noted mineralocorticoid excess characterized by hypokalemia due to urinary K loss, exacerbation of hypertension due to increased tubular Na reabsorption, metabolic alkalosis, and suppression of both plasma renin activity and plasma aldosterone concentration. His urinary free cortisol excretion rate and the urinary ratio of free cortisol to free cortisone were markedly elevated. Thus we diagnosed pseudoaldosteronism that was related to the long-term use of glycyrrhizin. When he developed pseudoaldosteronism, he also contracted pneumonia, and exhibited elevated levels of serum cortisol and creatinine clearance (CCr) as well as hypouricemia, hypocalcemia, and hypophosphatemia. All normalized after the recovery from pneumonia and the administration of spironolactone. The extracellular volume expansion associated with increased tubular Na reabsorption by the aldosterone-sensitive distal nephron and the resulting increase in CCr caused an inhibition of proximal tubular reabsorption of uric acid, Ca, and inorganic phosphate, leading to their renal loss and therefore hypouricemia, hypocalcemia, and hypophosphatemia, respectively. In this patient, the increased circulating cortisol associated with the stress of inflammation caused by pneumonia triggered the development of pseudoaldosteronism.     

Adherence and persistence with teriparatide among patients with commercial, Medicare, and Medicaid insurance

Summary

Adherence to, and persistence with, treatments for osteoporosis are low. Adherence with teriparatide decreases over time. Higher copayments in the commercial/Medicare population were associated with worse persistence. Understanding factors such as prior screening, prior treatment history, and out of pocket costs that influence persistence with teriparatide may help clinicians make informed decisions.

Introduction

The purpose of this study was to evaluate adherence and persistence with teriparatide.

Methods

Beneficiaries with at least one claim for teriparatide in 2003 or 2004 and continuous enrollment in the previous 12?months and subsequent 6?months were identified in a national commercial/Medicare and Medicaid administrative claims database (MarketScan?). Adherence was assessed through calculation of the medication possession ratio (MPR). Persistence was measured by time until discontinuation and time until first 60-day gap in treatment. Factors associated with persistence were assessed using Cox proportional hazards models.

Results

The average MPR at 6?months was 0.74 (N?=?2,218) and at 12?months, was 0.66 (N?=?1,303). At 6?months, 64.6% of patients remained on therapy and at 12?months, 56.7% remained. Bone mineral density screening and use of antiresorptive therapy within the 12?months pre-period, and lower patient copayments were associated with increased persistence.

Conclusion

Patients appear to have good adherence with teriparatide over the first 6?months which declines over time. Prior screening and treatment of osteoporosis and out of pocket costs appear to impact persistence. To optimize patient outcomes, clinicians should consider clinical factors that impact persistence, while healthcare decision makers should consider the negative effect of higher patient copayments on persistence.     

Anaesthetic induction with alfentanil: comparison with thiopental, midazolam, and etomidate

The speed, side effects and cardiovascular changes associated with anaesthetic induction and endotracheal intubation following alfentanil (20 micrograms/kg/min, IV), thiopental (84 micrograms/kg/min, IV), etomidate (5 micrograms/kg/min, IV) and midazolam (20 micrograms/kg/min, IV) prior to halothane-nitrous oxide general anaesthesia were evaluated and compared in 80 patients undergoing elective general surgical operations. Anaesthetic induction was fastest with etomidate and thiopental (approximately one minute) and slowest with midazolam (about two minutes). Systolic arterial blood pressure (SBP) was decreased at the moment of unconsciousness with thiopental but unchanged with the other compounds. Heart rate (HR) was increased at unconsciousness with midazolam and thiopental but unchanged with etomidate and alfentanil. After intubation HR was increased in all groups except those induced with alfentanil. Arrhythmias were infrequent (5 per cent or less in all groups). Rigidity during induction only occurred with alfentanil (55 per cent) and pain on injection only with etomidate (35 per cent) and alfentanil (5 per cent). Postoperative vomiting was infrequent in all groups (15 per cent) except etomidate (55 per cent). No patient remembered any aspect of laryngoscopy or the operation and all rapidly regained consciousness at the end of operation. The results of this study demonstrate that with the exception of rigidity (which is easily overcome with succinylcholine) and a slightly slower onset of action, alfentanil compares favourably as an induction agent with thiopental and is better than midazolam and etomidate. Alfentanil is superior to all three other induction agents with respect to cardiovascular stability during induction and intubation.