膝骨关节炎与腰椎间盘突出症关系的临床研究

[目的]探讨膝骨关节炎与腰椎间盘突出症的关系,明确腰椎间盘突出症是膝骨关节炎的致病因素,提高防治膝骨关节炎效果.[方法]采用对比分析的方法:(1)对确诊骨关节炎患者50例行腰椎CT或MRI检查,确定其腰椎间盘突出症的发生率,同时确定其中L3、4突出的发生率;同时比较L3、4腰椎间盘突出程度与膝骨关节炎病情严重程度的关系;(2)对确诊无骨关节炎的对照组30例行腰椎CT或MRI检查,比较其腰椎间盘突出症的发生率,同时确定其中L3、4突出症的发生率;(3)对确诊腰椎间盘突出症患者50例,进行膝关节检查,确定其骨关节炎的发生率.确定其中L3、4腰椎间盘突出症发生率,确定L3、4突出症合并骨关节炎的发生率;(4)对排除腰椎间盘突出症的对照组30例,进行膝关节检查,确定其骨关节炎的发生率.[结果](1)确诊骨关节炎的50例患者中有43例并发腰椎间盘突出症(86％).其中L34突出35例(70％).L3、4椎间盘突出程度与膝骨关节炎病情严重程度相关,P1=0.02;(2)对确诊无骨关节炎的患者30例,其腰椎间盘突出症5例,L3、4突出症者1例.骨关节炎组及非骨关节炎组中腰椎间盘突出症发生率不同,有明显统计学差异,P1 =0.002;(3)确诊有腰椎间盘突出症的患者50例中骨关节炎31例(62％),其中L3、4腰椎间盘突出症患者21例中,合并骨关节炎21例,发生率100％.非L3、4腰椎间盘突出症患者29例,合并骨关节炎10例,非L3、4椎间盘突出症和L3、4腰椎间盘突出症患者合并骨关节炎发生率有统计学差异,P2 =0.04;(4)排除腰椎间盘突出症的对照组30例中确定骨关节炎6例(20％).腰椎间盘突出症与非腰椎间盘突出症合并骨关节炎的发生率有明显统计学差异性,P1 =0.03.[结论]腰椎间盘突出症与膝骨关节炎发生有高度相关性,尤其是L3、4椎间盘突出症更明显,L3、4椎间盘突出症是骨关节炎的重要致病因素.     

椎间盘镜治疗腰椎间盘突出症80例分析

目的 探讨椎间盘镜系统治疗腰椎间盘突出症的手术适应症、手术方法及近期疗效。方法 应用Rudolf椎间盘镜系统手术治疗腰椎间盘突出症80例,87个椎间盘。L3-4 6间隙、L4-5 33间隙、L5-S1 48间隙。双间隙突出7例,合并椎管狭窄8例,纤维环破裂18例。平均椎间盘手术55分钟,平均椎间盘出血量45ml。结果 手术随访平均13个月,（3～26个月）,优67例、良10例、可3例、优良率96．25％,并发症：硬膜破裂1例,神经牵拉伤1例,椎间盘感染1例,遗漏游离髓核1例。结论 椎间盘镜系统治疗腰椎间盘突出症手术视野清楚,出血少,术后恢复快,对脊柱稳定结构损伤小,疗效佳。     

椎间盘镜髓核摘除术治疗腰椎间盘突出症

目的：总结第二代椎间盘镜手术系统治疗腰椎间盘突出症的效果。方法：1999年2月至2000年6月采用显微椎间盘镜髓核摘除术共治疗137例、153个间隙腰椎间盘突出症,单间隙突出者121例,双间隙突出症16例,合并侧隐窝狭窄者61例。突出间隙：L3／421个,L4／569个,L5／S163个。突出位置：后外侧型127间隙,中央型21间隙,极外侧型5间隙,结果：所有病例均获得2－18个月随访,平均7．5个月。优良率93．4％。术后椎间盘炎1例,同间隙椎间盘突出复发1例。结论：显微椎间盘镜髓核摘除术具有手术创伤小、神经根减压彻底、术后恢复快的特点,选择合适的适应证和仔细的操作是手术成功的关键。     

有限化手术治疗多间隙腰椎间盘突出症的疗效观察

目的探讨多间隙腰椎间盘突出的临床定位诊断和手术方法的选择。方法对50例多间隙腰椎间盘突出症患者行X线摄片和CT检查,根据影像学诊断和临床症状体征,确定"责任间隙",进行有限的手术治疗。结果多间隙腰椎间盘突出以L4、5、L5S1最为多见,行单间隙手术40例,双间隙、双侧手术10例,其中使用内固定12例。术后随访1～5年,疗效优40例,良6例,尚可3例,差1例,优良率为92%。结论通过对多间隙椎间盘突出的影像学分析,结合临床表现,确定引起症状的"责任间隙",从而进行有限的手术治疗,尽量少使用内固定。     

改良经椎板间隙法腰椎间盘髓核摘除术52例报告

1998年7月～2001年7月采用改良经椎板间隙法腰椎间盘髓核摘除术治疗腰椎间盘突症52例，取得良好效果。报告如下。临床资料男38例，女14例，年龄19～67岁，平均36岁。均经临床、CT和/或MRI确诊。腰椎间盘突出部位：L4/524例，L5/S120例，L4/5并L5/S18例。旁侧型突出40例，中央型突出12例。13例合并侧隐窝狭窄。双侧手术8例，余均为单侧手术。从52例腰椎正侧位片上测量椎板间隙与椎间盘后缘的对应关系，椎间盘后缘中点与椎板间隙正相对者：L4/56例，L5/S119例。椎间盘后缘中点与椎板间隙上部相对者：L4/524例，L5/S18例。椎间盘后缘中…     

极外侧型腰椎间盘突出症的诊治特点

目的：探讨极外侧型腰椎间盘突出症的诊治特点。方法：回顾性分析16例病人的症状,体征,影像学表现和手术。结果：坐骨神经痛11例,腰痛3例,股神经牵拉试验阳性9例,直腿抬高试验阳性4例,椎间盘突出L4／5间隙9例,结论：极外侧型腰椎间盘突出症腿痛多较腰痛严重,直腿抬高试验阳性率低,好发于L4／5且压迫同节段的神经根,影像学表现是主要诊断依据。手术入路依突出位置和病理类型而定。     

骨化型腰椎间盘突出症（附16例临床报告）

腰椎间盘突出症为临床常见病。传统分型对诊断和治疗有较大的指导意义，但我们在临床实践中发现，有难以完全归类于传统分型的椎间盘突出症，即突出的椎间盘发生钙化或骨化。我们称之为骨化型或钙化型腰椎间盘突出症。在CT片和术中均可观察到，其临床表现与治疗有一定的特殊性。我院自1988年1月至1995年12月手术治疗的167例腰椎间盘突出症中，发现骨化16例，占9．58％。1临床资料1．1一般资料16例共17个突出椎间盘发生骨化，L4-58个，L5-S19个。其中男9例，女7例；年龄最大60岁，最小17岁，平均43．5岁。病程最短的仅1个月，最长者20余年…     

CT引导椎间盘造影术在多节段腰椎间盘退变中的临床价值

[目的]探讨CT引导下椎间盘造影术在治疗多节段腰椎间盘退变疾患中的临床价值.[方法]2005年1月～2008年1月对28例多节段腰椎间盘退变疾患行CT引导下椎间盘造影术,其中男12例,女16例;年龄30～56岁,平均38.2岁.腰椎间盘退变节段:L3、4和 L4、5突出9例,L4、5和 L5S1突出15例,L3、4、L4、5和 L5S1三节段突出4例.造影节段:28例共计92个椎间盘,L2、3间隙10例,L3、4间隙28例,L4、5间隙28例,L5S1间隙26例.按照阳性椎间盘造影的诊断标准,筛选出致痛性椎间盘(责任间盘),对这些病变间隙行相应的椎间融合术治疗.[结果]28例患者92个间隙共筛选出32个责任间盘.VAS≥6分组中Ⅱ+Ⅲ级间盘(Dallas分级)和退变间盘(Pearce分级)所占的百分比明显高于VAS<6分组(P<0.05).手术前后ODI指数评分比较有显著性差异(P<0.05).随访12～36个月,平均25.2个月.Charles疗效评定,术后优22例(78.6%),良5例(17.9%),一般1例(3.6%),差0例.所有病例均未发生与椎间盘造影有关的并发症.1例椎间融合器下沉,1例植骨融合不良,1例术后病变侧伸母肌力减退,再次手术行椎弓根螺钉调整术,术后2个月肌力恢复.[结论]CT引导下椎间盘造影术对于多节段腰椎间盘退变疾患中责任间盘的选择具有重要的临床意义.     

改良椎板间隙入路显微内窥镜下髓核摘除治疗治疗腰椎间盘突症

腰椎间盘髓核摘除术后椎管内粘连是较严重的并发症,直接影响到手术效果。有人用保留黄韧带的方法预防椎间盘术后疤痕粘连,取得良好效果[1]。我院自2000年11月以来,采用显微内窥镜下椎间盘切除术(MED)治疗腰椎间盘突出症340例,其中61例选择了保留黄韧带的“改良椎板间隙入路”,近期临床效果满意。报道如下。临床资料全组共61例,其中L3/42例,L4/536例,L5/S123例。单纯腰椎间盘突出症45例,伴侧隐窝狭窄者16例。后外侧型突出50例,中央型突出11例。突出型35例,破裂型20例,游离型6例。全组病例均经CT或MRI证实病变间隙与临床症状和体征相符。…     

腰椎间盘突出症的再手术问题

本文报告16年手术治疗腰椎间盘突出症431例,再手术18例,再手术率4.17％。分析其原因有:术中马尾神经损伤3列;原椎间盘摘除不彻底3例。定位失误及双间隙突出造成椎间盘遗漏4例;术后外伤再复发4例;术后严重粘连、疤痕压迫脊髓造成严重症状者4例。主张在腰椎间盘突出症手术中应用硬膜外麻醉,反对片面强调小切口,强调准确定位及术后引流。腰椎间盘突出症再手术难度较大,应慎重考虑,必要时可经椎管造影或CT检查明确手术指征。     

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.     

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.     

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.     

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.     

A comparison of the inhibitory effects of four volatile anaesthetics on the metabolism of chlorzoxazone, a substrate for CYP2E1, in rabbits

Background: Halothane inhibits in vitro and in vivo activity of cytochrome P-450 (CYP) 2E1. There are several fluorinated volatile anaesthetics besides halothane, and most of them are defluorinated by CYP2E1. It is unclear whether other fluorinated anaesthetics inhibit the in vivo activity of CYP2E1.
Methods: We compared the inhibitory effects of therapeutic concentrations of four inhalational anaesthetics, halothane, enflurane, isoflurane, and sevoflurane, on chlorzoxazone metabolism in rabbits receiving artificial ventilation.
Results: All four inhalational anaesthetics decreased arterial blood pressure and increased plasma chlorzoxazone concentration. However, no significant differences in the plasma chlorzoxazone concentration were found between the four anaesthetics. The estimated chlorzoxazone clearance increased after beginning inhalation with all four agents, but no significant difference in clearance was noted between agents.
Conclusions: At therapeutic concentrations, the in vivo inhibitory effect on chlorzoxazone metabolism was similar for all four inhalational anaesthetics examined, even though their chemical characteristics and extent of hepatic metabolism differ considerably.     

Systemic analgesia adapted to the children's condition

A concept of balanced analgesia using nonsteroidal anti-inflammatory drugs (NSAIDs), paracetamol (acetaminophen), opioids, and corticosteroids can also be used in patients with pre-existing illnesses. NSAIDs are the most effective treatment for acute pain of moderate intensity in children; however, these drugs should be avoided in patients at increased risk for serious side effects, e.g. patients with renal impairment, bleeding tendency, or extreme prematurity. NSAIDs can be given with minimal risks to the younger child with mild to moderate asthma, and, in these patients, the use of steroids can be encouraged; in addition to their antiemetic and analgesic action, a beneficial effect on asthma symptoms can be expected. In the non-intubated child with cerebral trauma, exaggerated sedation caused by opioids and increased bleeding tendency caused by NSAIDs must be avoided. In neonates and small infants, the oral administration of sucrose or glucose is helpful to minimize pain reaction during short uncomfortable interventions.