经皮内窥镜技术治疗老年单节段退行性腰椎椎管狭窄症

腰椎椎管狭窄症（LSS）是骨科常见病之一。随着我国老龄化的加速,老年退行性腰椎椎管狭窄症（DLSS）的发生率逐年增加,腰腿痛和间歇性跛行严重影响患者的生活质量^[1]。DLSS往往由椎间盘突出或合并钙化、小关节骨赘增生及黄韧带肥厚等原因引起,部分患者合并发育性椎管狭窄^[2-3]。临床上根据解剖部位将LSS分为中央管狭窄（椎管中央型狭窄）、关节下管狭窄（神经根管的关节下段,包括侧隐窝）和椎间管狭窄（椎弓根及椎间孔段）^[4-5]。老年DLSS患者一般病史较长,影像学资料提示多节段的椎间盘膨出或突出、黄韧带肥厚、小关节增生、侧隐窝狭窄,有时神经根病变的定位诊断也不明确,是否需要将所有狭窄的间隙部位减压,是否需要广泛的融合固定一直是临床争论的问题^[6]。传统腰椎减压融合术治疗DLSS效果明显,但手术创伤较大,术后感染、切口愈合不良、植骨区不融合、内固定松动断裂、邻椎病等手术并发症使得此类技术的应用受到限制^[7]。近年来,经皮内窥镜技术在治疗DLSS方面优势明显,通过术前病史询问、体格检查及相关影像学资料的反复研究,并根据病情需要可结合椎间盘造影,最终精准定位责任椎间隙及椎管狭窄部位行靶向穿刺,达到定点精准减压。2014年5月-2017年8月,本院采用经皮内窥镜下减压术并射频消融术治疗老年单节段DLSS患者40例,现将诊疗过程报告如下。     

单侧椎弓根螺钉联合对侧椎板关节突螺钉内固定椎间融合术的研究进展

椎弓根螺钉(PS)内固定技术由Roy-Camille等^[1]于1970年首次报道,特别是其联合椎间融合器植骨的应用,具有固定节段短、稳定性好、融合率高、疗效确切等优点,成为腰椎固定融合的标准术式^[2-3]。但双侧PS内固定增加了邻近节段的应力^[4],特别是采用正中切口显露的操作,存在切口大、软组织剥离范围广、出血量大等缺点^[5-6]。虽然经皮和经肌间隙入路明显减小了手术切口、减少了创伤和出血量,但固定方式和力学特性并没有改变^[7-9]。椎板关节突螺钉(TLFS)内固定技术由Magerl^[10]于1984年首次完整地描述,并报道了与PS联合应用的初步实践。TLFS可较好地控制腰椎三维6个方向的运动^[11-12],具有切口小、创伤小、操作简单等优点^[13-14]。单侧PS联合对侧TLFS内固定(联合固定)于2005年由Jang等^[15]首次报道,在临床上获得快速推广应用,成为一种独立、有效的腰椎固定融合方法^[6,16-17]。本文从生物力学、临床应用及适应证等方面对联合固定椎间融合术的进展作如下综述。     

单侧双通道与单通道内窥镜技术治疗腰椎退行性疾病疗效和安全性的荟萃分析

腰椎退行性疾病是骨科常见病，对于经系统非手术治疗无效或效果欠佳的患者须手术干预。传统的开放减压术在临床中取得良好的疗效，但会对周围肌肉和韧带等软组织造成较大的医源性损伤。随着脊柱内窥镜技术的快速发展，该技术逐渐成为治疗腰椎退行性疾病的新方法，其中单通道内窥镜（UE）技术备受关注^[1]，然而该术式存在视野狭窄、减压不彻底及适应证局限等问题，给临床实践造成困扰^[2-5]。2017年，Heo等^[6]首次提出单侧双通道脊柱内窥镜（UBE）技术，即一个通道放入内窥镜，另一个通道放入手术器械，克服了部分UE技术难以解决的难题。本研究对UE与UBE技术治疗腰椎退行性疾病的随机对照研究（RCT）进行荟萃分析，以期为2种术式的远期疗效和安全性提供循证医学证据。     

Quadrant系统下单侧内固定治疗老年腰椎退行性疾病

腰椎退行性疾病是引起腰腿痛的常见原因,在老年人群中发生率超过50%^[1]。腰椎融合术是治疗腰椎退行性疾病的有效方法,可稳定椎体、恢复椎间高度,临床疗效良好^[2-3]。目前椎间融合术的金标准是双侧椎弓根内固定术,可为椎体间接提供坚固内固定,但坚固内固定会导致邻近节段退行性变及骨量丢失^[4]。有研究报道,单侧和双侧内固定治疗腰椎退行性疾病的临床疗效无显著差异^[5]。本院2016年6月—2018年1月采用Quadrant系统下单侧内固定治疗老年腰椎退行性疾病患者33例,疗效满意,现报告如下。     

单侧双通道内窥镜下椎间盘切除术治疗腰椎术后退行性变1例报告

腰椎术后邻近节段退行性变(ASD)是腰椎后路融合术后的常见远期并发症^[1-2],其发生率为4%~31%^[3-5]。ASD由多种因素引起,继而产生新的神经压迫症状。Kambin等^[6]于1986年提出单侧双通道内窥镜下椎间盘切除术(UBED)治疗腰椎椎间盘突出症(LDH)^[7],其兼具了开放手术与微创手术的优点^[8]。本院采用UBED治疗腰椎术后ASD患者1例,现将诊疗过程报告如下。     

多排螺旋CT在腰椎椎体后缘离断症诊断中的应用

<正>腰椎椎体后缘离断症,又称为腰椎后缘软骨结节、腰椎软骨板破裂症等[1-4],是指多种原因引起椎体后缘骨突与椎体分离,向椎管内突出,进而造成椎管狭窄、神经根受压等改变[5]。以往对该病的认识不足,相关的研究报道较少。近年来随着多排螺旋CT的飞速发展以及多平面重组等后处理技术的广泛应用,越来越多的学者开始关注本病,对其研究愈发深入[1-2]。本文对我院收治的35例腰椎椎体后缘离断症患者     

寰枢椎脱位伴齿突后假瘤诊疗的研究进展

齿突后假瘤是由寰枢椎脱位或其他病因引起的炎性肉芽肿或反应性肥大导致齿突后软组织增生病变^[1]。其可压迫脊髓，导致疼痛、感觉异常，甚至瘫痪。引起齿突后假瘤较常见的病因有类风湿关节炎（RA）^[2-3]、寰枢椎脱位^[4]、颈椎退行性疾病^[5]，少见的病因有长期透析^[6]、晶体沉积^[7]、滑膜囊肿^[8]等。     

脊柱夏科特关节病1例报告

夏科特关节病又称神经性关节病,由于各种原发病,患者痛觉和位置觉丧失,不能本能地调整肢体位置,关节失去保护性反射,同时,关节区域的血管及破骨细胞异常增殖导致局部代谢紊乱,最终导致加速的严重关节退行性变,表现为骨与软骨的破坏、关节面崩解和关节脱位^[1-2]。不同的原发病有不同的好发部位,脊髓痨患者好发于脊柱关节,脊髓空洞患者好发于上肢的肩关节、肘关节和腕关节,糖尿病患者则好发于足、踝关节^[3]。脊柱夏科特关节病（CSA）目前国内相关报道较少。本院收治1例胸椎脊髓损伤后继发CSA及髋关节病变的患者,现将诊疗过程报告如下。     

新鲜齿突骨折后路复位固定非融合技术的进展

 齿突骨折是一种危及上颈椎稳定性的严重损伤,文献报道其发病率占所有颈椎骨折的10%~15%^[1]。齿突的解剖形态特别、毗邻结构复杂,骨折处理稍有不慎会加剧脑干、脊髓及神经根的损伤。依靠颅骨牵引后Halo-vest支架外固定难以获得寰枢椎的持续稳定,齿突骨折的不愈合率较高^[2]。传统观点认为前路齿突螺钉固定是治疗新鲜Ⅱ型和浅Ⅲ型齿突骨折的首选方法,然而,并非所有Ⅱ型和浅Ⅲ型齿突骨折均适用于该技术^[3]。手术操作中齿突螺钉的位置不佳、长短选择不当等时有发生,若螺钉穿出齿突会伤及颈髓,术后骨折移位和不愈合的报道并不罕见^[4]。后路寰枢椎融合术多应用于寰枢椎复合损伤,保持上颈椎整体力学稳定的效果尚佳,但同时会丧失寰枢椎的大部分旋转功能^[5]。     

颈椎椎间盘突出致脊髓半切综合征误诊为脑卒中1例报告

脊髓半切综合征(BSS)由Brown-Sequard于1849年首次提出^[1],是由外部压迫和内部病变等原因引起的一种罕见的脊髓不完全性损伤,通常发生在颈部^[2]。可由创伤(如枪伤、刺伤、骨折及椎体脱位)和非创伤(如肿瘤、硬膜外血肿、多发性硬化症、辐射等)引发^[3-5],因椎间盘突出导致的BSS相对较少^[6-7]。BSS表现为病变侧损伤平面以下深感觉障碍及上运动神经元性瘫痪;对侧损伤平面以下疼痛、温觉丧失^[8-9],有轻度到严重的神经功能受损。BSS占创伤性脊髓损伤的1%~4%^[10],国内外相关文献报道较少,主要为个案报道^[2,11]。本院急诊科于2020年10月22日收治1例因存在类卒中症状,初期被误诊为急性脑梗死,在下级医院进行过溶栓治疗的BSS患者,现对诊疗过程进行梳理分析,报告如下。     

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 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.     

Influence of dopexamine hydrochloride on haemodynamics and regulators of circulation in patients undergoing major abdominal surgery

Background: Catecholaminergic support is often used to improve haemodynamics in patients undergoing major abdominal surgery. Dopexamine is a synthetic vasoactive catecholamine with beneficial microcirculatory properties. Methods: The influence of perioperative administration of dopexamine on cardiorespiratory data and important regulators of macro- and microcirculation were studied in 30 patients undergoing Whipple pancreaticduodenectomy. The patients received randomized and blinded either 2 μg · kg^?1 · min^?1 of dopexamine (n=15) or placebo (n=15, control group). The infusion was started after induction of anaesthesia and continued until the morning of the first postoperative day. Endothelin-1 (ET-1), vasopressin, atrial natriuretic peptide (ANP), and catecholamine plasma levels were measured from arterial blood samples. Measurements were carried out after induction of anaesthesia, 2 h after onset of surgery, at the end of surgery, 2 h after surgery, and on the morning of the first postoperative day. Results: Cardiac index (CI) increased significantly in the dopexamine group (from 2.61±0.41 to 4.57±0.78 1 · min^?1 · m^?2) and remained elevated until the morning of the first postoperative day. Oxygen delivery index (DO₂I) and oxygen consumption index (VO₂I) were also significantly increased in the dopexamine group (DO₂I: from 416±91 to 717±110 ml/m² · m²; VO₂I: from 98±25 to 157±22 ml/m² · m²), being significantly higher than in the control group. pHi remained stable only in the dopexamine patients, indicating adequate splanchnic perfusion. Vasopressive regulators of circulation increased significantly only in the untreated control patients (vasopressin: from 4.37±1.1 to 35.9±12.1 pg/ml; ET-1: from 2.88±0.91 to 6.91±1.20 pg/ml). Conclusion: Patients undergoing major abdominal surgery may profit from prophylactic perioperative administration of dopexamine hydrochloride in the form of improved haemodynamics and oxygenation as well as beneficial influence on important regulators of organ blood flow.