腰椎间盘髓核摘除术后症状重现原因分析

笔者１９８９年～１９９４年收治腰椎间盘突出症６８例，行手术经后路椎间盘髓核摘除２４例，术后１周～５个月症状不同程度复发或症状未除者７例，经追踪随访、二次手术、ＣＴ复查等，总结原因分析如下。手术性因素１．椎间盘再突出：术中髓核摘除未尽，或破裂突入椎管内的纤维环切除不彻底或未切除，术后残余髓核突出或纤维环水肿、粘连而压迫神经根。２．神经根损伤：术中不同程度的神经根损伤，如电烙损伤、钳夹损伤、神经根牵拉过度过久，致神经根充血、水肿，乃至损伤后粘连，术后均有不同程度的神经根症状再现。３．错切椎间盘：术中…     

椎间盘镜下腰椎间盘髓核摘除术的疗效

目的 探讨椎间盘镜下腰椎间盘髓核摘除术的手术要点和早期疗效。方法 在椎间盘镜直视下对50例单间隙腰椎间盘突出症患者行突出髓核摘除术，并进行疗效分析。结果 患者均在术后10天出院，平均随访9.34个月，临床疗效优良率96%，无严重手术并发症，术后CT检查显示突出椎间盘已摘除，脊髓及神经根已获得充分减压。结论 椎间盘镜下腰椎间盘髓核摘除术创伤小，患者术后恢复快，疗效肯定，是治疗腰椎间盘突出症的有效方法之一。     

42例椎间盘镜下髓核摘除术早期疗效

目的：探讨椎间盘镜下腰椎间盘髓核摘除术的手术要点和早期疗效。方法：显微内窥镜椎间盘切除术(microendoscopic discectory,MED)在椎间盘镜直视下对42例单间隙腰椎间盘突出症患者行突出髓核摘除术，并进行疗效分析。结果：42例获随访，时间3—24个月(平均10个月)。疗效优38例，良3例，可1例。无差级疗效及相关并发症发生。结论：椎间盘镜下腰椎间盘髓核摘除术创伤小，患者术后恢复快，疗效肯定，是治疗腰椎间盘突出症的有效方法之一。     

改良显微椎间盘镜下腰椎间盘摘除术

目的：报告应用改良显微椎间盘镜行腰椎间盘髓核除术，治疗腰椎间盘突出症。方法：对86例椎间盘突出症病人，行改良显微椎间盘镜下，腰椎间盘髓核除术。所有病人均在硬膜外或局部麻醉下，于椎间盘突出间隙用显微椎间盘镜，在电视引导或直视下，通道内将突出的髓核除并对骨性受压的神经根与硬膜囊进行松解。对使用注意事项及术后疗效进行分析。结果：本组病人在术后24h下床活动，平均8d可出现，无术后并发症，术后病人症状，体征均缓解。结论：经后路改良显微椎间盘镜下腰椎间盘除术，治疗腰椎间盘突出症，半圆形通道比圆形通道视野清楚，有可直视术野，减少神经根损伤，创伤小（1．8cm切口），恢复快，疗效好等特点，同时可根据病情行椎板减压，侧隐窝、椎间孔扩大等优点。     

腰椎间盘突出症手术疗效与突出类型及纤维环完整性的关系

目的探讨腰椎间盘突出症手术疗效与突出类型及纤维环完整性的关系。方法回顾性分析经后路椎板开窗髓核摘除术治疗的260例腰椎间盘突出症患者的疗效。病例选择条件:均为下腰椎单节段突出,侧突型(单侧坐骨神经症状),不伴有椎管狭窄。随访6～14年,平均8.5年。根据术中所见椎间盘突出的髓核形态及纤维环破损大小,将椎间盘突出症分为四种类型,并对不同类型的术后疗效进行统计学分析比较。结果椎间盘髓核突出较大、纤维环破损较小者,术后疗效佳,复发率低;反之,髓核突出较小或纤维环破损大者,术后疗效差,复发率高。结论腰椎间盘突出症的手术效果与椎间盘突出类型及纤维环的完整性有密切的联系。对临床症状较轻、间盘突出较小且突出物基底较宽的患者应尽量避免开放式手术。椎间盘突出摘除术中除应注意保持脊柱骨性结构的稳定性,还应尽量避免过多地破坏椎间盘纤维环的完整性。     

髓核成形术治疗颈、腰椎间盘突出症的疗效分析

目的：探讨髓核成形术治疗颈、腰椎间盘突出症的手术技术、适应证及疗效。方法：采用ArthroCare 2000射频汽化仪对颈、腰椎间盘突出症患者实施髓核成形术。其中颈椎间盘突出症患者43例(A组)，平均年龄47岁；腰椎间盘突出症患者39例(B组)，平均年龄36岁。术前及术后随访时采用症状缓解率(VAS评分)和患者主观满意度分级进行疗效评估。结果：A组术后即刻症状缓解率平均为68％，主观满意度优良率达95％，B组术后即刻症状缓解率平均为61％，主观满意度优良率为87％。A组平均随访17．6个月，症状缓解率为49％，主观满意度优良率为63％。末次随访时B组39例中16例症状接近术前，主观满意度优良率为3l％，其中5例接受了开放手术。结论：髓核成形术创伤小、安全，治疗包含性颈椎间盘突出症疗效较好，但治疗腰椎间盘突出症疗效欠稳定。     

治疗腰椎间盘突出症三种术式的疗效比较

目的 比较经皮腰椎间盘髓核摘除术(automated pereutaneous lumbardiscectomy，APLD)、经后路显微内窥镜椎间盘髓核摘除术(microendoscopic discectomy，MED)、传统开窗椎间盘髓核摘除术3种术式对腰椎间盘突出症的治疗效果。方法 在相同时间段内，3组病例采用统一的选择标准、疗效评定标准、手术由专人操作。结果 均获12个月以上的随访，用Ridit分析法对3种治疗结果进行比较。结论 APLD是治疗包容性腰椎间盘突出症的较好方法；MED治疗腰椎间盘突出症是传统手术的微创化，其手术技能基本同传统开窗椎间盘髓核摘除术，可作为单间隙旁侧型腰椎间盘突出症手术治疗的首选术式。     

腰椎间盘突出症术后近期复发再手术临床分析

目的 探讨腰椎间盘突出症近期复发再手术的原因,减少术后复发率.方法 对7例腰椎间盘突出症术后近期复发再手术的临床资料进行回顾性分析.结果 患者随访平均33.1个月(6～75个月),效果优6例,良1例.结论 腰椎间盘突出症术后近期复发的原因有初次手术摘除髓核不彻底致使髓核碎片残留、椎间盘纤维环突出、瘢痕组织粘连、椎间盘髓核突出合并椎管狭窄未解除椎管狭窄、年龄、体重等有关.     

突出的腰椎间盘与神经根粘连的原因分析及处理措施

目的探讨腰椎间盘突出症术中神经根粘连的原因及处理措施。方法回顾性分析2002年12月～2008年12月,经手术治疗证实的突出椎间盘组织与神经粘连的腰椎间盘突出症85例90个间隙。单间隙80例,双间隙5例,其中行椎间盘镜下髓核摘除术5例,椎板开窗髓核摘除术30例,半椎板切除髓核摘除30例,全椎板切除髓核摘除20例;其中30例同时行植骨融合内固定术。结果腰椎间盘突出钙化30例(35.3%);腰椎间盘突出破裂25例(29.4%);椎间盘软骨板破裂症10例(11.8%);腰椎间盘突出复发5例(5.9%);一般腰椎间盘突出症15例(17.6%)。其中既往行过椎管内封闭或行经皮溶核术的5例;合并椎间隙狭窄30例;合并腰椎不稳15例。患者随访1～6年,平均2.5年,2例术后残留麻木,2例足下垂,1例术后椎间隙感染,经非手术治疗痊愈。3例术中有硬膜撕裂,1例行修补术,术后无脑脊液漏,融合内固定患者无内固定松动及断裂,融合率86.3%。按Nakai疗效评定标准:优67例,良10例,可5例,差3例,优良率90.6%。结论腰椎间盘突出症患者突出椎间盘与神经根粘连常见的原因为:腰椎间盘突出破裂、腰椎间盘突出钙化、腰椎间盘突出复发及椎间盘突出合并腰椎不稳和腰椎间盘突出既往行过椎管内注射治疗者。充分的显露、彻底松解粘连、髓核摘除及合理选择内固定可获得满意的疗效。     

开放手术观察腰椎间盘突出症溶核失败45例分析

目的 通过开放手术观察分析椎间盘髓核化学溶解术治疗腰椎间盘突出症失败原因。方法 收集溶核失败的腰椎间盘突出症45例行开放手术治疗。结果 术中见45例硬膜外脂肪完全消失，43例髓核未见溶解，2例髓核溶解呈糊状但未被吸收，21例伴有侧隐窝狭窄，15例突出物与神经根粘连，20例黄韧带增厚，2例椎管骨性狭窄，14例突出物钙化。结论 腰椎间盘突出症病变间隙合并有侧隐窝狭窄、神经根粘连、椎管狭窄、突出物钙化等，不是溶核治疗的适应证。     

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.     

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.     

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.     

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.