腰椎术后脑脊液漏的处理

1993年7月～2007年5月,我科共行腰椎手术429例,其中18例术后发生脑脊液漏,发生率4．2％,经积极处理后均治愈。     

Defining the Origins of the Iliofemoral, Ischiofemoral, and Pubofemoral Ligaments of the Hip Capsuloligamentous Complex Utilizing Computer Navigation

Purpose  

To use computer navigation software to investigate the specific origins of the hip capsuloligamentous complex.     

Average 7-Year Survivorship and Clinical Results of a Newer Primary Posterior Stabilized Total Knee Arthroplasty

We evaluated the average 7-year survivorship and clinical results of a newer primary posterior stabilized total knee arthroplasty (TKA). The modifications in this design included a deeper patellar sulcus aimed at reducing contact stresses, improving patellar tracking, and achieving greater maximum flexion. A consecutive group of 137 patients (171 knees) who underwent TKAs using the Optetrak PS knee prosthesis between October 1997 and March 2004 were followed for an average of 6.8?years (range 4.0-11.5?years). Preoperative range of motion (ROM) and Knee Society scores were obtained and compared to that of the patients' most recent follow-up. Manipulation under anesthesia (MUA) and revision of the implant for any reason were considered endpoints for Kaplan-Meier survival analysis of all knees. Twenty-one knees (12.3%) underwent MUA. Three knees (1.8%) underwent revision, resulting in a 97.2% survival at a mean 10?years follow-up. Pain scores and ROM significantly improved after surgery (from preoperative average of 5.3 and 105° respectively to 44.6 and 120° postoperatively). These findings suggest that this posterior stabilized knee design is both a safe and effective option for patients undergoing primary TKA.     

Physician attitudes to the concept of ‘men''s health’ in Asia

BackgroundMen's health is an emerging medical and public health concept, but it is confronted by special challenges in the Asia-Pacific medical and cultural context.MethodsA telephone survey was conducted with physicians in Korea, Taiwan and Singapore. The interview was conducted in Korean (Korea), Mandarin (Taiwan) or English (Singapore) by trained interviewers. The physicians interviewed were drawn from a variety of medical specialties including urology, primary care, endocrinology and cardiology.ResultsIn total, 810 physicians from various medical specialities took part in the survey. There was only broad general agreement (>50%) between the physicians in the various countries on a range of questions relating to men's health, such as the conditions most associated with men's health, the predictability of illness/disability with age etc, and physician willingness to discuss problems in sexual health.ConclusionsThe data from this survey suggest that, although not as clearly defined as women's health, the treatment of men's health cuts across many different medical specialties and takes in a broad spectrum of health conditions. Therefore, there is a clear opportunity for the medical community to define, refine and improve the treatment and understanding of men's health in Asia.     

Instant Vertebral Assessment: A Noninvasive Dual X-ray Absorptiometry Technique to Avoid Misclassification and Clinical Mismanagement of Osteoporosis

The presence of a vertebral fracture significantly increases the risk of future fracture, classifies a patient with "clinical" osteoporosis, and usually results in treatment for osteoporosis. However, the majority of vertebral fractures are silent, and lateral X-rays (the standard method for identification) are not routinely obtained. Instant vertebral assessment (IVA), a technology that utilizes dual X-ray absorptiometry (DXA), provides rapid assessment of vertebral fractures and is highly correlated with vertebral fractures, as assessed on standard lateral spine X-rays. To assess the role of IVA in patient management, we examined standard bone mineral density (BMD) of the spine, total hip, and femoral neck and spine IVA by DXA in 482 participants screened for an osteoporosis study, who had no previous knowledge of vertebral fractures. Using World Health Organization (WHO) guidelines, subjects were classified using BMD at the spine, total hip, femoral neck, or any combination of these central sites. In addition, we considered subjects as osteoporotic if they had vertebral fractures independent of low bone density. We found that vertebral fractures assessed by IVA were present in 18.3% of asymptomatic postmenopausal women recruited for this study. The sensitivity of BMD alone to diagnose osteoporosis based on either a vertebral fracture or low BMD using WHO criteria ranged from 40 to 74%. This means that between 26 and 60% of osteoporotic individuals could have potentially been missed. Furthermore, 11.0-18.7% of clinically osteoporotic individuals would have been classified as normal by BMD criteria alone. We conclude that IVA is a useful adjunct in the clinical identification of osteoporosis and may prevent mismanagement of osteoporotic patients.     

甲状腺再手术的时机及入路方式探讨

目的探讨甲状腺再手术的时机及手术入路方式。方法对我院2000年1月至2006年1月收治的94例甲状腺再手术患者的临床资料进行回顾性分析,主要分析再手术的时机及手术入路方式与操作难易程度的关系。结果本组病例行双侧甲状腺全切除术16例,一侧甲状腺切除并峡部切除术27例,一侧甲状腺切除术并对侧大部切除45例,单侧残余甲状腺切除加部分颈前肌群切除5例,单侧全切加同侧颈淋巴结清扫1例,再手术时间与初次手术相距4d～28年。手术入路:正中入路34例,胸锁乳突肌内侧入路23例,经胸骨舌骨肌、胸骨甲状肌间侧入路25例,正中入路加侧入路12例。手术时间1.5～2.5h,平均2.0h。结论甲状腺包块切除术后病理诊断甲状腺癌的再手术患者尽早手术。结节性甲状腺肿复发再手术的患者应作好充分术前准备,合并呼吸困难的甲状腺再手术患者采用正中入路易于松解气管前瘢痕粘连,缓解气管压迫症状;无呼吸困难症状者采用侧入路或正中入路与侧入路结合,简化手术操作、减少手术并发症。     

db/db mice exhibit severe wound-healing impairments compared with other murine diabetic strains in a silicone-splinted excisional wound model

The pathophysiology of diabetic wound healing and the identification of new agents to improve clinical outcomes continue to be areas of intense research. There currently exist more than 10 different murine models of diabetes. The degree to which wound healing is impaired in these different mouse models has never been directly compared. We determined whether differences in wound impairment exist between diabetic models in order to elucidate which model would be the best to evaluate new treatment strategies. Three well-accepted mouse models of diabetes were used in this study: db/db, Akita, and streptozocin (STZ)-induced C57BL/6J. Using an excisional model of wound healing, we demonstrated that db/db mice exhibit severe impairments in wound healing compared with STZ and Akita mice. Excisional wounds in db/db mice show a statistically significant delay in wound closure, decreased granulation tissue formation, decreased wound bed vascularity, and markedly diminished proliferation compared with STZ, Akita, and control mice. There was no difference in the rate of epithelialization of the full-thickness wounds between the diabetic or control mice. Our results suggest that splinted db/db mice may be the most appropriate model for studying diabetic wound-healing interventions as they demonstrate the most significant impairment in wound healing. This study utilized a novel model of wound healing developed in our laboratory that stents wounds open using silicone splints to minimize the effects of wound contraction. As such, it was not possible to directly compare the results of this study with other studies that did not use this wound model.     

Single center experience with third-generation cryosurgery for management of organ-confined prostate cancer: critical evaluation of short-term outcomes, complications, and patient quality of life

BACKGROUND AND PURPOSE: Technical refinements such as improved ultrasonographic localization and the routine use of urethral warmers and small-gauge needle delivery systems have renewed interest in cryosurgical treatment as a minimally invasive option for selected patients with localized prostate cancer. Only three reports of quality of life (QoL) in prostate cryoablation exist, and none report on patients treated with third-generation cryoablative technology. We critically examine our initial series of consecutive patients at a single institution undergoing primary third-generation cryosurgical treatment of localized prostate cancer with respect to treatment outcome, morbidity profile, and QoL parameters. To our knowledge, this is the first QoL report on third-generation cryoablation of the prostate. PATIENTS AND METHODS: We retrospectively review the records of 89 consecutive patients with median followup of 11 months (1-32) who have undergone third-generation cryosurgical ablation of the prostate as primary treatment for localized prostate cancer with intention to cure. Patients were risk stratified according to preprocedural parameters of prostate-specific antigen (PSA), clinical stage, and Gleason score. PSA trends were recorded and treatment effectiveness was observed using different definitions of biochemical failure. Charts were reviewed for postprocedure complications. Quality of life was measured prospectively using the University of California, Los Angeles, Prostate Cancer Index as well as American Urological Association symptom scores. We compare a percent of baseline score (%BS) for various domains between our series of patients treated with primary cryoablation with a series of patients undergoing brachytherapy for localized prostate cancer. RESULTS: Treatment success was defined by achievement of a PSA nadir of < or =0.1 ng/mL and by biochemical disease-free survival (BDFS) assessed with both a PSA threshold of < or =0.4 ng/dL over time and the American Society for Therapeutic Radiology and Oncology (ASTRO) definition of three consecutive rises in PSA. According to risk stratification, 86%, 81.5%, and 78% of low-, intermediate-, and high-risk patients, respectively, achieved a PSA nadir of < or =0.1 ng/mL. Overall, at 12 months follow-up, 94% of patients achieved BDFS using ASTRO criteria while 70% achieved BDFS using a PSA threshold of < or =0.4 ng/mL. With risk stratification, 74%, 70%, and 60% of low-, intermediate-, and high-risk patients, respectively, achieved BDFS defined by PSA threshold of < or =0.4 ng/mL. Complications were rare. The response rate for Health Related Quality of Life (HRQoL) questionnaires was 71% for cryoablation patients and 51% for brachytherapy patients. At 12 months follow-up, patients undergoing cryoablation on average achieved urinary and bowel domain scores comparable to baseline, but sexual domains remained well below baseline. When compared with a brachytherapy series with better baseline sexual function (P = 0.04) and urinary function (P = 0.03), cryotherapy patients experienced more negative impact on sexual function steadily for up to 12 months (P = 0.02). Urinary function was similar between the groups until 18 months, at which time cryoablation patients fared better (P = 0.01); this was sustained up to 24 months (P = 0.04). CONCLUSIONS: Treatment success with cryosurgery varies with definition; however, our results are comparable to other series with regard to short-term cancer control. Complication rates in this series of third-generation cryosurgical patients are low. QoL characteristics of third-generation cryoablation are similar to those described in second-generation cryoablation series. Compared with brachytherapy, cryotherapy results in less irritative and obstructive voiding symptoms in the early post-treatment period and may improve urinary function up to 24 months after treatment. In a small group of older patients with baseline erectile dysfunction undergoing cryoablation, sexual function returns to 20% of its baseline value with up to 12 months follow-up.     

A Clinical Pathway for Total Shoulder Arthroplasty—A Pilot Study

Background

Appropriate pain management after total shoulder arthroplasty (TSA) facilitates rehabilitation and may improve clinical outcomes.

Questions/purposes

This prospective, observational study evaluated a multimodal analgesia clinical pathway for TSA.

Methods

Ten TSA patients received an interscalene nerve block (25 cm³ 0.375% ropivacaine) with intraoperative general anesthesia. Postoperative analgesia included regularly scheduled non-opioid analgesics (meloxicam, acetaminophen, and pregabalin) and opioids on demand (oral oxycodone and intravenous patient-controlled hydromorphone). Patients were evaluated twice daily to assess pain, anterior deltoid strength, handgrip strength, and sensory function.

Results

The nerve block lasted an average of 18 h. Patients had minimal pain after surgery; 0 (median score on a 0–10 scale) in the Post-Anesthesia Care Unit (PACU) but increased on postoperative day (POD) 1 to 2.3 (0.0, 3.8; median (25%, 75%)) at rest and 3.8 (2.1, 6.1) with movement. Half of the patients activated the patient-controlled analgesia four or fewer times in the first 24 h after surgery. Operative anterior deltoid strength was 0 in the PACU but returned to 68% by POD 1. Operative hand strength was 0 (median) in the PACU, but the third quartile (75%) had normalized strength 49% of preoperative value.

Conclusions

Patients did well with this multimodal analgesic protocol. Pain scores were low, half of the patients used little or no intravenous opiate, and some patients had good handgrip strength. Future research can focus on increasing duration of analgesia from the nerve block, minimizing motor block, lowering pain scores, and avoiding intravenous opioids.