皮层体感诱发电位术中监护脊髓损伤的实验研究与临床应用

为开展皮层体感诱发电位(CSEP)术中监护脊髓损伤,确定脊髓损伤的临界值及有效的评价预后,采用30只中国家犬,造成不同程度的脊髓损伤,术中CSEP动态监测,并观察伤后1—3个月脊髓功能恢复情况。结果显示:脊髓损伤CSEP术中监护临界值为P_1潜伏期较术前延长不超过1.5倍。波幅下降〈50％;波幅变化灵敏,其恢复早于形态学及功能变化。临床应用35例,结果表明CSEP术中监护脊髓损伤准确、可靠。     

保留后结构环状减压手术治疗急性胸腰段脊柱损伤

目的探讨保留脊柱后结构环状减压复位内固定的手术方法,治疗急性胸腰段脊柱脊髓损伤的临床效果.方法对38例急性脊柱脊髓损伤伴不全瘫痪的病例进行椎管内骨块复位,环状的脊髓及神经根减压,保留棘突、棘间韧带、小关节的手术方法治疗.结果随访31例,时间10～42个月,平均16个月,按Frankel分级,术后神经功能恢复3级者5例,2级者24例,1级者2例.结论对于急性脊柱脊髓务的病例,应用保留脊柱后结构环状减压内固定的方法,是兼顾脊髓减压的彻底性和保持脊柱稳定性较为合理、有效的手术方法.     

The Effects of Hypertonic Saline on Spinal Cord Blood Flow Following Compression Injury

Summary  7.5% hypertonic saline was administered following spinal cord injury to test its effect on spinal cord blood flow. Four different groups of rats underwent 10 minutes of spinal cord compression (45g) at the C3 to C5 levels. A fifth group was not injured, but received hypertonic saline (5 ml/kg) at 5, 15 and 60 minutes following injury. Somatosensory evoked potentials and spinal cord blood flow were measured prior to and for 4 hours following the injury. The administration of hypertonic saline caused a significant increase in flow when administered 5 minutes following injury. Topical nitroprusside administration did not cause any increase in spinal cord blood flow during this time period. Hypertonic saline administration at the later time periods did not increase spinal cord blood flow. The group of animals which were not injured, but received hypertonic saline also showed no significant change in flow. The somatosensory evoked response of the treated animals was maintained for 4 hours after the injury where as the untreated animals began to lose their evoked responses 3 hours after injury.     

Surgical treatment of idiopathic transdural spinal cord herniation: a new technique to untether the spinal cord

Summary Idiopathic transdural spinal cord herniation is a rare but treatable cause of thoracic myelopathy caused by herniation of the spinal cord through a defect in the dura. The diagnosis is frequently missed or delayed, but the latest imaging techniques can document spinal cord herniation through a dural defect. Surgical treatment, consisting of reducing the herniation by closing the dural defect or widening the aperture to prevent spinal cord compression, is rather successful. We describe a new technique to untether the spinal cord by wrapping a dura graft around the myelum to prevent recurrent transdural herniation. Two patients and a review of the literature are discussed. We conclude that high-resolution T2 magnetic resonance imaging is the best imaging modality to detect the entity, and wrapping the myelum is an effective surgical technique to untether the spinal cord.     

医源性脊髓液压冲击伤3例报告

目的 探讨医源性脊髓液压冲击伤的机制与治疗。方法 对2例颈前路减压植骨术及1例胸11椎管肿瘤造影过程中发生的医源性脊髓液压冲击伤进行分析。结果 3例均属医源性突变意外,经及时发现并采取有效救治措施,脊髓功能均获满意恢复。结论 脊髓医源性液压冲击损伤的机制及转是与受损脊髓的直接受压、再灌注、楔入嵌顿等有关;及时解除致压因素、早期扩血管、激素、高压氧等可有效阻断继发损伤,促进脊髓功能恢复。     

脊髓前方减压与高压氧治疗胸腰椎骨折合并脊髓损伤

作者采用脊髓前方塌陷减压加高压氧治疗胸腰椎骨折合并脊髓损伤42例,单纯减压术22例。结果按Frankel分级,脊髓前方塌陷减压组恢复到D级以上者9例（平均改善2.1级）;脊髓前方塌陷减压加高压氧组恢复到D级以上者29例（平均改善2.8级）。作者认为脊髓前方塌陷减压加高压氧治疗脊髓损伤优于单纯塌陷减压术,高压氧具有促进神经功能恢复的作用。     

前后路联合手术治疗伴结构异常的颈脊髓损伤

目的 探讨伴结构异常的颈脊髓损伤患者的临床治疗效果。方法从2002年4月-2007年8月对伴结构异常的颈脊髓损伤患者进行一期或分期前后路联合减压固定手术。结果11例患者术后随访5～27个月，以Sunnybrook分级判定脊髓功能，平均提高3．7分。结论伴有结构异常的颈脊髓损伤患者，颈髓前后方同时有压迫和椎间不稳，需进行前后路联合减压和颈椎稳定性重建。     

金田前方固定器的临床应用

本文报告了应用金田前方固定器治疗胸腰椎疾病13例,结果神经功能恢复良好,脊柱重新获得稳定性,可早期进行功能锻炼。我们的治疗包括①椎体部分或全切除前方减压;②脊柱侧弯、后凸畸形的矫正;③脊柱稳定性的重建。本文对手术方法及金田固定器的结构及其生物力学要点进行了叙述,并对手术适应症进行了探讨。认为胸腰椎骨折有前方骨块压迫脊髓者;椎体肿瘤及其他椎体病变压迫脊髓并脊柱不稳定者为其适应症。     

Exophytic ependymomas of the spinal cord

Summary Intramedullary ependymomas of the spinal cord with exophytic components are rare outside the filum or conus region. Two cases of combined intradural intramedullary and extramedullary ependymomas of the spinal cord are presented. At operation, the tumours proved to be primarily intramedullary but had a contiguous exophytic component that extruded either through a defect in the ventral pia to encase the anterior spinal artery in one patient, or through the dorsal root entry zone in the second patient. When removing intramedullary spinal tumours with an exophytic component, separate removal of the intramedullary and extramedullary components is recommended, rather than en bloc resection, to prevent possible injury to the vascular supply of the spinal cord.     

显微手术治疗脊髓髓内占位性病变——附23例报告

目的:探讨显微手术切除脊髓髓内占位性病变的技巧。方法:系统分析经显微手术切除的23例髓内占位性病变(髓内肿瘤21例;髓内炎症性病变2例。)患者手术经过并发症及疗效。结果:髓内肿瘤全切15例,占71.4％;次全切或大部切除6例;炎症性病变2例获全切。全组无手术死亡,术后早期神经系统状态均无恶化。随访1月—3年,神经功能改善者19例,占82.6％。结论:对于绝大多数髓内占位性病变,手术治疗是目前最根本的治疗方法,并应强调对不同病变采用相应的微创性手术技巧,而早期治疗是必要的。     

Restoration of motor function after operative reconstruction of the acutely transected spinal cord in the canine model

Background

Cephalosomatic anastomosis or what has been called a “head transplantation” requires full reconnection of the respective transected ends of the spinal cords. The GEMINI spinal cord fusion protocol has been developed for this reason. Here, we report the first randomized, controlled study of the GEMINI protocol in large animals.

Prognostic factors and optimal management for patients with cervical spinal cord injury without major bone injury

Background

Even though the number of patients with cervical spinal cord injury (CSCI) without major bone injury is increased, the treatment with either surgery or conservative measures remains controversial. The aim of this study was to assess its prognostic value in the prediction of useful motor recovery and to clarify whether the patients should be treated surgically are present.

Ventral Transdural Herniation of the Thoracic Spinal Cord: Surgical Treatment in Four Cases and Review of Literature

Summary  Background. A specific cause of progressive Brown-Sequard syndrome has been identified: a ventral herniation of the thoracic spinal cord through the dural sleeve on one side. Method. Four female patients who were affected by a progressive Brown Sequard syndrome related to a transdural spinal cord herniation have been investigated and were submitted to surgery and postoperative evaluation. Findings. The MRI scan showed atrophy and forward displacement of the spinal cord on one side and adhesion of the spinal cord to the dura mater. CT myelography demonstrated the disappearance of the premedullar rim at the level of the herniation and the shadow of the extradural herniation. Surgical treatment consisted in the excision of the arachnoid cyst when there was one, section of the dentate ligament, release of the adhesions, detachment of the spinal cord from the hernial orifice, and lastly suture of the dural tear or placement by a patch. Follow-up examination showed motor improvement with persistent sensory deficit in two cases and stabilisation in two cases. Interpretation. The cause of the dural tear, either traumatic or congenital could not be confirmed in the four cases. Symptoms probably occur when herniation fills the orifice and strangulation happens which explains the late appearance and progressive evolution of this myelopathy. Mobilisation of the herniated spinal cord back into the intradural space can be achieved by surgery and may stop the evolution of the symptoms and signs.     

Acute spinal cord compression in hereditary multiple exostoses

Summary Osteocartilaginous exostoses are benign bone tumors frequently found in the metaphysis of long bones but rarely in the spine. Four patients with acute spinal cord decompensation due to vertebral exostoses spinal cord compression have been previously described in the literature. We report an additional case of rapidly evolving spinal cord compression due to a cervical osteochondroma in a patient with hereditary multiple exostoses (HME), also known as Bessel Hagen disease. Careful analysis of the 5 cases suggested to us that patients with HME should have a systematic spinal imaging screening, in order to prevent rapid neurological decompensation. A minimal risk surgical procedure can be performed at a time of election.     

Prevention of Ischemic Spinal Cord Injury Following Aortic Cross-Clamping: Use of Corticosteroids

Prior to proximal aortic cross-clamping, baseline measurements of spinal cord blood flow and function were done. Blood flow was evaluated with radioactive microspheres and function determined by assessment of somatosensory evoked potential (SEP). Group 1 (N = 6) animals had aortic cross-clamping for 5 minutes after ischemic spinal cord dysfunction (SEP loss) was documented. Group 2 (N = 9) underwent aortic cross-clamping for 10 minutes after loss of SEP. Group 3 (N = 6) also underwent 10 minutes of cross-clamping after initial SEP loss, but were treated intravenously with methylprednisolone (30 mg per kilogram of body weight) 10 minutes prior to cross-clamping and again 4 hours postoperatively. After release of the cross-clamp, the animals were allowed to recover and serial evaluations of spinal cord blood flow and neurological status were carried out for seven days. Group 1 animals recovered uneventfully without evidence of neurological injury. Group 2 animals sustained a 67% incidence of permanent spastic paraplegia (p = 0.02 versus Group 1). In contrast, methylprednisolone-treated animals sustained no clinically detectable neurological injury (p = 0.02 versus Group 2). Measurements of spinal cord blood flow at the time of SEP loss revealed similar degrees of spinal cord ischemia in all groups. No significant differences were observed in the duration of aortic cross-clamping prior to SEP loss among the three groups. The data indicate that short periods of cross-clamping (5 minutes) following SEP loss are well tolerated, whereas longer periods (10 minutes) are associated with a high incidence of paraplegia. This injury can be prevented if an adequate dose of methylprednisolone is given before and after cross-clamping. Beneficial effects of steroid administration do not appear to be related to changes in spinal cord blood flow, but may be related to protective effects on cellular and subcellular components. Clinical investigations employing this regimen of corticosteroid protection during surgical procedures on the thoracoabdominal aorta appear to be indicated.     

Idiopathic Spinal Cord Herniation: Case Report and Literature Review

Summary  We report one case of spontaneous thoracic spinal cord herniation presenting with a progressive spastic paraparesis for 4 years in a 55 years old man. From preoperative MRI, showing a ventrally displaced atrophic spinal cord at T2–T3 level, a dorsal intradural arachnoid cyst was suspected. At operation, after a 3 level laminectomy, no arachnoid cyst was found and spinal cord herniation into a meningeal diverticulum was confirmed. The herniated myelon was replaced intradurally and the lumen of the diverticulum was filled with Teflon? settled with fibrin glue to prevent recurrence. Postoperatively some neurological recovery was achieved.  The literature was reviewed, regarding clinical and epidemiological features, proposed pathophysiological mechanisms, treatment options and outcome. Only 32 surgically proved cases of thoracic spinal cord herniation with no past history of spine trauma, injury or surgery were found.     

Intradural metastatic spinal cord compression from ACTH-secreting pituitary carcinoma

Summary. Pituitary carcinomas are uncommon and intradural metastatic spread to the spine is rarer still. We describe a 27-year old man with metastatic spinal cord compression from an adrenocorticotrophic hormone (ACTH) cell pituitary carcinoma, 16 years following the initial presentation. He had three previous resections of the pituitary tumour and post-operative radiotherapy. The intradural, extramedullary spinal metastases causing thoracic and lumbar cord compression were excised, with neurological improvement.Spinal metastases in pituitary carcinoma are uncommon, but aggressive surgical resection of the spinal metastases produces good symptomatic relief.     

Effect of mannitol in a patient with spinal cord injury

Summary Relief of spinal cord compression following mannitol infusion is reported in a patient with a thoracic compression fracture.     

Role of temozolomide in spinal cord low grade astrocytomas: results in two paediatric patients

Summary Background. The optimal treatment of low grade intramedullary spinal cord tumours remains controversial. In many cases the tumours continue to progress even after surgery and radiation. Effective chemotherapy may be an important therapeutic adjunct in this setting. Temozolomide is widely used for brain gliomas, yet its role in the management of spinal cord tumours has not been reported. Procedure. Two paediatric patients with low grade spinal cord astrocytomas were diagnosed to have progression of the tumour in spite of surgery and radiotherapy. They received temozolomide, 200 mg/m² daily for five days every four weeks for 10 cycles, and were followed serially. Results. Stabilization of the spinal tumour in both patients was observed at 18 months of follow-up. One of the patients developed haematological toxicity requiring platelet transfusion and dose reduction. Conclusion. Based on our findings in two paediatric patients, temozolomide may be a useful agent in the management of progressive recurrent low grade spinal cord astrocytomas.     

经颅磁刺激运动诱发电位监测脊髓创伤的实验研究

目的：观察脊髓创伤与运动诱发电位的关系，了解运动诱发电位在脊髓中的传导通路。方法：对３９只猫采用脊髓Ａｌｅｎ损伤模型和部分切断伤模型进行经颅磁刺激运动诱发电位（ＴＭＳ－ＭＥＰ）监测。结果：脊髓轻度打击伤时，ＭＥＰ潜伏期即有明显延长，但恢复良好；中度打击伤时，ＭＥＰ潜伏期延长更明显，且不能完全恢复；重度打击伤时，大部分动物ＭＥＰ不能引出，至２４ｈ不能恢复。ＭＥＰ的改变与后肢功能变化及镜下脊髓病理改变一致。ＴＭＳ－ＭＥＰ对脊髓前索和外侧索的损伤敏感，并可间接反应脊髓柱后索损伤。结论：ＴＭＳ－ＭＥＰ经脊髓前索和外侧索传导，可敏感而准确地反映脊髓损伤后功能改变，是一种有效的监测脊髓功能的手段