经椎间孔腰椎体间融合术在腰椎翻修术中的应用

目的探讨应用经椎间孔腰椎椎体间融合术(transforaminal lumbar interbody fusion,TLIF)治疗腰椎术后失败综合征(failed back surgery syndrome,FBSS)的临床效果。方法 2003年10月-2007年12月,应用TLIF治疗36例腰椎FBSS患者。男19例,女17例;年龄46～68岁,平均52.6岁。病程3个月～15年,平均1.6年。2次手术者25例,3次手术者10例,5次手术者1例。共融合50个节段,其中L4、512例,L5、S110例,L3、4和L4、5双节段8例,L4、5和L5、S1双节段6例。术前常规行腰椎正侧位和屈伸动力位X线片、CT及MRI检查,诊断为腰椎全椎板减压术后继发腰椎不稳12例,腰椎间盘突出症术后复发18例,腰椎滑脱术后复发6例。结果 1例术中发生硬膜破裂,经缝合修补,术后无脑脊液漏发生。1例术后1周发生切口深部金黄色葡萄球菌感染,1例术后3d因切口形成血肿出现一过性单根刺激症状,经对症治疗均治愈;其余患者切口均Ⅰ期愈合。无永久性神经损伤或症状加重者。33例获随访,随访时间18～72个月,平均35.2个月。术后12个月患者均达椎间融合,无螺钉断裂和椎间融合器移位、沉陷。术前日本骨科协会(JOA)评分为(14.2±4.1)分,术后18个月为(23.9±2.6)分,差异有统计学意义(t=2.45,P=0.01)。临床效果评价获优23例,良7例,可3例,改善率为90.9%。结论应用TLIF技术治疗腰椎FBSS,简化了腰椎翻修手术的操作环节,降低了手术危险,减少了术后并发症。     

UL形截骨侧隐窝开窗腰椎间盘切除术

采用自行设计的“田氏骨刀”行UI形截骨侧隐窝开窗腰椎间盘切除术，治疗500例具有单侧下肢症状的腰椎间盘突出症。此手术入路创伤小，功能恢复早；尤其适用于停有根管狭窄的椎间盘突出症。经4～30年的远期随访，疗效优良率为93．25％。     

VASCULAR SURGERY

Recent developments in vascular surgery have occurred in many areas. The topics of intimal hyperplasia and reperfusion injury are the subject of much current research and possible methods of treatment are at an early stage of development. Advances in perioperative care have contributed to a reduction in mortality and morbidity. Endovascular techniques are being employed widely but the indications for their use are not yet agreed. The laboratory assessment of patients has been enhanced by the availability of duplex ultrasound scanning. The indications for carotid endarterectomy are becoming less controversial and a more aggressive approach is being taken in patients with abdominal aortic aneurysm. In patients with chronic lower limb ischaemia, long bypass grafts to the level of the ankle are being performed more frequently. The use of temporary shunts in patients with major arterial injuries appears to improve the results of treatment.     

THE CHANGING PATTERN OF VASCULAR SURGERY THE EFFECT OF PERCUTANEOUS TRANSLUMINAL ANGIOPLASTY

The pattern of vascular surgery at westmead hospital from 1979 to 1985 has been reviewed. There has been an upward trend in the number of patients having repair of abdominal aortic aneurysm and carotid endarterectomy. However, the number of operations for peripheral vascular disease has not increased. This may be due to the increasing usc of percutaneous transluminal angioplasty (pta), but it may also be associated with the inmasing difficulty in obtaining hospital admission for patients with conditions not immediately life or limb threatening.     

SMALL AREA ANALYSIS OF LUMBAR SPINE SURGERY IN SOUTH AUSTRALIA

The hospital separation records for 1987 in the health planning regions of South Australia were reviewed using a selection algorithm to identify all hospitalizations involving a lumbar spine surgery (LSS) for low back or leg pain. Among 16 health planning regions (two additional regions were excluded from the analysis because of the low number of observations) the LSS rate varied almost four-fold, from 25 to 92/100000, with a mean of 55/100000. The effect of 24 socioeconomic and health care supply characteristic variables upon observed differences in rates were tested. The unemployment rate was the only significant variable in the analysis, explaining 11 % of the variation in the surgery rates for the 16 regions. This finding is in agreement with studies from other countries that suggest that characteristics of small areas do not substantially predict the rates of elective surgical procedures. The decision-making processes of surgeons and their patients remain poorly defined; the contributions to the rate of lumbar spine surgery by the health care delivery system, physician behaviours or patient expectations are not yet identified.     

化学性腰交感神经切除术治疗下肢缺血性疾病

腰文感神经切除术在治疗下肢动脉闭塞性疾病方面起着重要作用。但手术创伤较大,术后并发症及死亡率较高,尤其是伴有脑或冠心病的患者难以耐受。1991年以来,我们采用了化学性腰交感神经切除术治疗7例下肢缺血性疾病,5例(71.4％)获满意效粟,特别是对雷诺氏病患者可收到立杆见影的效果。本法具有操作简单、损伤小及易于被患者接受等优点,值得推广。     

极外侧型腰椎间盘突出症的诊断与治疗

目的 探讨极外侧型腰椎间盘突出症的诊断与治疗方法。方法回顾分析1999年1月～2004年1月收治16例极外侧型腰椎间盘突出症患者资料。其中椎间孔型8例，椎间孔外型2例，椎间孔内外混合型6例。L2.3 1例，L3,4 5例，L4,5例，L5、S1 2例。CT扫描显示在相应椎间孔内、椎间孔外、椎间孔内外有与椎间盘相同的CT值密度影像。手术采用椎板间入路10例，椎板侧方入路3例，椎板间和椎板侧方联合入路3例。结果术后16例均获随访6个月～5年，平均9个月。根据中华骨科学会脊柱组腰背痛手术评定标准：优8例，良5例，可3例。术后CT显示相应节段椎间盘突向椎间孔或椎间孔外的占位消失，同节段神经根压迫解除。结论CT是目前诊断腰椎间盘突出症的较好方法。手术入路应依突出椎间盘组织占位、病理类型及是否合并椎管内病变而定。     

孤立性腰椎间盘吸收症

介绍一种不可忽视而又被矫形外科医师所知甚少的引起腰背痛的原因之一──孤立性腰间盘吸收。ＨｅｎｒｙＣｒｏｃｋ首先揭示出了此症的发病机理，并确切地论述了本综合征的临床症状，体征、Ｘ线特征及其手术治疗。据此为４例患者施行了手术治疗，并在平均１８个月后作了随访，复习文献井提出了该综合征的临床特征，以期引起同道对本症的注意。     

对腰椎间盘突出症分类的建议：附100例报告

本文报告１００例腰椎间盘突出症手术病例的回顾性分析。作者将三种不同程度的突出（Ｐ．Ｉ．Ｄ．Ｅ．Ｉ．Ｄ．＆．Ｓ．Ｉ．Ｄ．）与继发性病变（神经根管狭窄与严重粘连）相结合依照病变单一的或复合的原则分成二类：单纯型４５例（４５％）与复杂型５５例（５５％）作为临床分类的病理基础，建议在手术前尽可能获得确切的临床分类诊断。将有利于明确手术指征入提高手术成功率。     

PROGNOSTIC FACTORS IN ELECTIVE AORTIC RECONSTRUCTIVE SURGERY

Background : The present study was carried out to determine the risk factors associated with peri-operative mortality and long-term survival in patients undergoing abdominal aortic reconstructive surgery (ARS). Methods : A retrospective review was performed of the case notes of all patients having ARS at a university teaching hospital during a 5.5-year period, and their details entered onto a pro forma. Results : A total of 252 patients underwent ARS between July 1989 and December 1994. The peri-operative mortality was 7.5%. The most frequent adverse events were cardiac events, accounting for 8 (42%) of the peri-operative deaths. The risk of a peri-operative cerebrovascular accident was low (n = 3, 1.2%) as was the risk of peri-operative renal failure requiring dialysis (n = 3, 1.2%). Factors independently linked to increased peri-operative mortality included moderate-to-severe hypertension (P= 0.05, odds ratio = 3.54), those with renal impairment (P= 0.05, odds ratio = 2.69), and blood transfusion requirements (P < 0.001, odds ratio = 1.26). Long-term survival was independently shortened by occlusive disease (P= 0.004, hazard ratio = 2.78) and ischaemic heart disease (P < 0.001, hazard ratio = 3.58). Conclusions : The risks of ARS were significantly increased in patients with severe hypertension, those with renal impairment and those requiring blood transfusion. Long-term survival was shortened for those patients with occlusive aortic disease and ischaemic heart disease. These risk factors should be carefully assessed in each patient before performing elective ARS.     

THE RATIONAL USE OF HOMOLOGOUS BLOOD IN ELECTIVE SURGERY

The supply of homologous blood in Australia is limited, but the demand for blood and blood products is steadily increasing. Elective surgery is a major part of this demand. In many institutions the blood ordering practices for elective surgery have been haphazard. This study was undertaken to document current patterns of blood use in a major city teaching hospital. A retrospective analysis of blood ordering and transfusion for elective surgical procedures was carried out over a 12 month period. As in several previous studies, an inefficient use of blood was demonstrated. Possible strategies to rationalize the use of blood in elective surgery have been proposed. These include the use of a ‘group and screen’ procedure instead of a full cross-match when transfusion is unlikely to be necessary, and ordering according to a ‘maximum blood order schedule’ when transfusion is usually required for a procedure.     

A COMPARATIVE STUDY OF TWO TYPES OF LATEX SURGICAL GLOVES IN ELECTIVE ORTHOPAEDIC SURGERY

Glove perforation during surgery represents a potential risk of infection for the surgeon. The authors postulated that thicker latex gloves may offer greater protection. The perforation rates for the Ansell Gammex? glove and the thicker Baxter Triflex? gloves were compared in single- and double-glove usage and no difference was found between the two brands, in either usage. The authors recommend double-gloving for all orthopaedic operations with regular glove changes during major procedures.     

TRENDS IN THE PRACTICE OF ARTERIAL SURGERY IN WESTERN AUSTRALIA

An overview of arterial surgery in Western Australia and the Department of Vascular Surgery at Royal Perth Hospital was undertaken for the ten year period from 1983 to 1992. The annual number of arterial procedures increased 116% from 937 to 2027 and lower limb amputations increased 44% from 335 to 483. Five arterial procedures were examined in detail. There was a marked increase in carotid endarterectomy and angioplasty, a moderate increase in aortic aneurysm repair and a small increase in aortofemoral and femoropopliteal bypass surgery. The major amputation rate was not influenced by bypass surgery. It rose from 113 per million population in 1983 to a peak of 148 in 1986, and then fell to 113 per million population in 1992. From June 1982 to June 1992 the population of Westem Australia rose 24%, from 1.34 to 1.66 million (and for persons 60 years and over, rose 38% from 0.16 to 0.23 million). At Royal Perth Hospital similar trends were observed. Mean duration of operation for all vascular procedures and for the individual procedures of carotid endarterectomy, angioplasty, aortic aneurysm repair and aortofemoral and femoropopliteal bypass remained unchanged. Average length of stay decreased for carotid endarterectomy (29%) and angioplasty (74%), but remained unchanged for aortic aneurysm repair and aortofemoral and femoropopliteal bypass.     

经皮穿刺腰椎间盘切除术与透明质酸钠联合治疗腰椎间盘突出症

目的　研究经皮穿刺腰椎间盘切除术 (PL D)与透明质酸钠联合治疗腰椎间盘突出症的疗效。方法　 48例患者随机分为两组 ,采用经皮穿刺 PL D联合透明质酸钠骶管注射 (治疗组 ) 2 6例 ,单纯经皮穿刺 PL D(对照组 ) 2 2例。术后每 3个月随访一次 ,至术后 2年 ,根据改良的 Macnab标准判断疗效。结果　治疗组痊愈 16例 ,显效 5例 ,有效 4例 ,无效 1例。显效率为 80 .77%。对照组痊愈 8例 ,显效 7例 ,有效 5例 ,无效 2例。显效率为6 8.18%。两组疗效比较 ,有统计学意义 (P<0 .0 5 )。结论　腰椎间盘切除术与透明质酸钠联合治疗具有疗程短、见效快及安全等优点 ,是穿刺治疗腰椎间盘突出症的一种理想方法     

经皮激光汽化颈椎间盘减压术的临床应用

目的评价经皮激光汽化椎间盘减压术（percutaneous laser disc decompression,PLDD）治疗颈椎间盘突出症的临床应用效果和应用前景。方法2003年3月-2005年12月,对47例颈椎间盘突出症患者96个椎间盘实施PLDD治疗。男25例,女22例;年龄37-72岁,平均56岁。突出椎间盘节段：单节段3例,多节段44例。C3、420个、C4、527个、C5、631个、C6、718个。通过激光对髓核组织的汽化,凝固减少髓核组织,降低椎间盘压力。激光汽化1次治疗3个椎间隙者5例,2个椎间隙者39例,1个椎间隙者3例。结果42例获随访3-31个月,平均13个月。疗效评价参考丁亮华等评定标准,优18例（42.9%）,良14例（33.3%）,中6例（14.3%）,差4例（9.5%）,有效率90.5%,优良率76.2%,无并发症发生。结论PLDD能有效缓解颈椎间盘突出症的症状和体征,创伤小、安全、有效。     

有限潜行减压术治疗多节段腰椎间盘突出症疗效分析

目的 分析多节段腰椎间盘突出症患者的临床特征及影像学改变，并对有限潜行减压术疗效进行回顾性评价。方法1999年3月～2004年3月，收治22例（L1-S1共49个节段）多节段腰椎间盘突出症患者，男14例，女8例，年龄49～68岁。以L4，5及L5、S1为主，共35个节段。均行有限潜行减压加髓核摘除术。结果术后22例患者获随访4～21个月，平均7个月。术后x线片检查腰椎稳定。按Nakai等评定标准评价：优16例、良5例、可1例。无神经根损伤和硬脊膜损伤等并发症。结论有限潜行减压术治疗多节段腰椎间盘突出症是一种有效的手术方法，能解决多节段腰椎间盘突出症引起的突出和狭窄，并最大限度地保持了脊柱的稳定性。     

腰椎间盘切除与人工椎间盘置换前后上位关节突关节内压力改变

目的测量腰椎间盘完整时、切除后及人工椎间盘置换后上一关节突关节内压力变化,探讨椎间盘切除及人工椎间盘置换对上一节段的影响,为人工椎间盘的临床应用提供理论依据。方法在7具成人新鲜尸体标本上,分别以200～2000N的轴向、1～10Nm的后伸、侧弯加载,测量L4、5椎间盘完整时、切除后及人工椎间盘置换后L3、4关节突关节内的压力并进行统计学分析。结果相同载荷(轴向、后伸、侧弯)下,上一关节突关节内平均压力:椎间盘切除后与椎间盘完整时差异有统计学意义(P<0.01);人工椎间盘置换后与椎间盘完整时无统计学意义(P>0.05);人工椎间盘置换后与椎间盘切除后差异有统计学意义(P<0.01)。结论腰椎间盘切除后上一关节突关节内压力降低,单纯椎间盘切除可影响腰椎的力学分布,进一步导致继发性腰椎结构的退行性改变;人工椎间盘置换后上一关节突关节内压力与正常一致,对腰椎结构具有保护作用,并提供了一定的生物力学基础和理论依据。     

Iatrogenic vascular injury during to lumbar disc surgery

Summary We report two patients who sustained vascular injury while undergoing intervertebral disc surgery at the lumbar four and five level. Each patient suffered from massive bleeding and shock, urgent laparatomy was performed, and the vascular injuries were successfully primarily repaired. The experience prompted us to review reports in the literature since 1965 of vascular complications associated with surgical excision of hernia disc via a posterior approach. From our analysis, we highlight the clinical features and management, emphasising that rapid diagnosis and immediate intervention can result in a favourable outcome, as in our patients.     

髓核摘除联合Isobar非融合内固定治疗腰椎间盘突出症

目的评价髓核摘除联合Isobar非融合内固定治疗腰椎间盘突出症的近期疗效。方法 2006年5月-2008年5月,对65例单间隙腰椎间盘突出症患者分别采用髓核摘除联合Isobar非融合内固定(A组,34例)和单独髓核摘除(B组,31例)治疗。A组男18例,女16例;年龄23～51岁,平均38.8岁。责任节段:L2、3 1例,L3、4 4例,L4、5 20例,L5、S1 9例。分型:突出型11例,脱出型16例,游离型7例。病程1～66个月,平均7.2个月。B组男19例,女12例;年龄21～49岁,平均39.2岁。责任节段:L3、4 2例,L4、5 24例,L5、S1 5例。分型:突出型13例,脱出型15例,游离型3例。病程3周～72个月,平均6.5个月。两组患者一般资料比较差异无统计学意义(P>0.05),有可比性。手术前后采用疼痛视觉模拟评分(VAS)及Oswestry功能障碍指数(ODI)进行比较评价,并动态观察术后责任椎间隙高度变化情况。结果两组患者均获随访,随访时间24～49个月,平均32个月。术后A、B组患者腰、腿痛症状均明显改善,B组1例发生术后脑脊液漏,经处理后治愈。随访期间两组均无内固定物松动、断裂等并发症发生。A、B组术后3周、3、6个月和1、2年腰、腿痛VAS均较术前显著改善(P<0.05);术后1、2年,A、B组间腰痛VAS比较差异有统计学意义(P<0.05),其余各时间点腰痛VAS及手术前后各时间点腿痛VAS A、B组间比较差异均无统计学意义(P>0.05)。术后2年两组ODI与术前比较差异均有统计学意义(P<0.05),但A、B组间比较差异无统计学意义(P>0.05)。术后各时间点A组责任椎间隙高度均较术前增加(P<0.05);B组较术前下降,术后3周及3个月与术前比较差异无统计学意义(P>0.05),术后6个月、1年及2年与术前比较差异有统计学意义(P<0.05)。A、B组间术后各时间点责任椎间隙高度比较差异均有统计学意义(P<0.05)。结论髓核摘除联合Isobar非融合内固定治疗节段隙腰椎间盘突出症的近期疗效满意,患者术后腰痛缓解程度较单独髓核摘除术更明显,可能与其能维持术后责任椎间隙高度有关。     

COMPLICATIONS OF TRANS‐SPHENOIDAL SURGERY: THE WELLINGTON EXPERIENCE

Background : All patients who underwent trans‐sphenoidal surgery between January 1984 and December 1998 were reviewed to assess morbidity resulting from this operation. Methods : There were 185 operations on 165 patients. The operative approach was sublabial in 80 cases and transnasal in 105. One surgeon (VB) performed the vast majority of operations. Results : Complications included nasal perforation (7.6%), transient diabetes insipidus (4.9%), permanent diabetes insipidus (3.8%), cerebrospinal fluid fistula (4.3%), donor site haematoma (2.2%) and residual tumour haemorrhage (1.6%) causing ophthalmoplegia (1.1%) and loss of vision (1.1%). Other complications included epistaxis (1.1%), meningitis (0.5%) and sinusitis (0.5%). Injury to the anterior superior alveolar nerve also occurred in the sublabial approach in 6.3% of patients. There were no perioperative deaths. Conclusions : There is a small but significant risk of a number of complications that should be considered for informed consent of this procedure.