双节段人工腰椎间盘置换术的疗效与探讨

[目的]观察采用以双段SB Charite Ⅲ人工椎间盘置换术治疗退变性腰椎间盘疾病的l临床结果并探讨其可行性。[方法]自2000年10月至2006年8月，对22例L4-S1退变的病例采用双节段人工腰椎间盘置换术，男16例，女6例；年龄43～54岁，平均48岁；均获得随访，随访时间10—61个月（平均37．4个月），分别于手术前后对患者的情况进行JOA评分和影像学对比。[结果]术后病例JOA评分较术前显著提高（P〈0．05）。按FRANKLE标准，JOA评分改善率1年后优12例，良7例，可3例；3年后共获得随访18例，其中优10例，良5例，可3例。术后X线片显示人工椎间盘位置正确，椎间隙高度恢复正常，椎间活动度得到维持。15例患者返回原工作，2例变换工作，1例退休。所有病例无假体功能并发症发生，无假体松动、半脱位、下沉。[结论]在严格适应证的前提下，双节段人工椎间盘置换术是可以获得满意临床疗效的，可在有条件的医院积极开展。     

椎弓根螺钉联合椎间植骨融合器治疗腰椎滑脱症的远期疗效分析

[目的]探讨椎弓根螺钉系统联合椎间植骨融合器治疗峡部不连性腰椎滑脱症的远期疗效。[方法]自1996年10月~2002年10月本组收治峡部不连性腰椎滑脱症105例,随访资料齐全者86例。所有患者均行椎弓根螺钉系统复位滑脱,椎间植骨融合器行椎间融合固定。62例患者中1枚融合器从后斜向前呈45°植入,24例为2枚融合器从后向前垂直植入。随访测定固定节段的椎体间有无移位、滑脱有无复发,比较术前、术后2周及随访时固定椎间隙高度与近端第2椎间隙高度比值的变化。[结果]随访2~8年,平均35个月。根据NaKai评分标准,本组优56例,良13例,可17例,优良率为80.23%。Ⅰ度腰椎滑脱19例术后全部解剖复位;Ⅱ度腰椎滑脱51例中5例遗留Ⅰ度滑脱;Ⅲ度腰椎滑脱16例中4例留有Ⅰ度滑脱。末次随访时使用1枚融合器或2枚融合器所固定的椎间隙高度与近端第2椎间隙高度的比值与术后2周时的比值相比有所减低,滑脱无复发。[结论]椎弓根螺钉加椎间植骨融合器治疗腰椎滑脱症手术疗效满意,显著提高融合率,预防神经根管狭窄、神经卡压的发生,减少术后断钉和滑脱复发等问题。     

Surgical strategy of one stage surgery of anterior release combined with posterior correction in treatment of severe scoliosis

Objective: Severe scoliosis refers to scoliosis with serious and stiff curve. It always combins with trunk imbalance in coronal and sagittal contour. Besides complex pathological changes, cardiopulmonary deficits and other concomitant diseases increase treatmental difficulties. So the treatment of severe scoliosis is always a great challenge to spine surgeon. Methods :Thirty-six patients with severe scoliosis received one stage posterior correction followed by anterior release during July 1997 to January 2003, including 9 males and 27 females. Mean age was 17.2 years. Of them, 33 was idiopathic scoliosis and 3 was neurofibromatosis scoliosis( Cobb angle: 85-116 degree); 20 cases were abnormal in sagital plane. Three-dimensional devised instrumentation were applied such as CD, CD-Horizon, TSRH or Isola in posterior procedure followed by anterior release during the same anesthesia. 31 cases of this group received thorac icplasty. Results: The correction in the frontal plane achieved an average of 48.5%. In the sagittal plane, the pathological shape of the spine was reduced and distinctly ameliorated. 80. 6% of the patients maintained or achieved balance of sagittal plane. There were no complications of severe neurological deficit, hook displacement, rod broken, and deep infection at follow-up. One case occurred traumatic pleurisy after operation and another appeared pseudarthrosis 2 years later. One case demonstrated imbalance 11 months after operation. One patient was presented loss of correction more than 10 degree at one year follow-up and 5.2 degree in average. Conclusion:The study indicates that the one stage posterior correction combined with anterior release in treatment of severe scoliosis can achieve satisfactory correction. Appropriate choice of cases, preoperational detailed assessment and application of SEP and wake-up test during operation can possibly reduce severe complication. The long-term outcomes still need further observation.     

冠心病患者CRP水平与肾动脉狭窄的关系

【论文特点介绍】本研究观察了CRP是否可以作为肾动脉粥样硬化狭窄（ARAs）的独立危险因子。通过对危险因素进行多变量Logistic回归分析，结果表明年龄、冠脉病变严重程度、外周血管疾病是ARAS的独立危险因素，而CRP水平、高血压、高脂血症、肾功能不全并非ARAS的独立危险因素。     

The carotid endarterectomy: Experience with 260 cases and discussion of the indications

Summary During 1978 to 1989, 235 patients were operated upon with 260 procedures for cervical carotid endarterectomy. The patients were classified according to the presence or absence of ischaemic symptomatology, and for symptomatic patients, according to the reversibility or persistance of ischaemic symptoms. So the selection of patients was: reversible ischaemia 46%, stroke 29%, asymptomatic patients 25%. In the stroke group, no patient was operated on as an emergency, the endarterectomy was only performed after stabilization of the clinical state. Three subgroups were included in patients operated on for asymptomatic carotid stenosis: casual discovery 40%, treatment of the second carotid artery (previous endarterectomy for symptomatic contralateral stenosis) 34%, and treatment of the second carotid artery (previous ECIC by-pass for contralateral carotid occlusion) 26%. All patients were operated upon after angiographic exploration (femoral catheterisation in most cases), and after cerebral CT scan. The surgical technique included general anaesthesia, systematic shunting, endarterectomy after longitudinal arteriotomy, closure without patch. The operating microscope has been used since 1985.The surgical results were studied in terms of uneventful postoperative course (87%), reversible complications (8%) and long lasting complications (5%). The long lasting complications were of local origin (1%), of neurological origin (2%), of general origin (1%). Overall the operative outcome at 6 months was: return to previous clinical state 95%, neurological sequelae 2%, death 3%. In the patients operated on for asymptomatic carotid stenosis the overall outcome was: previous clinical state 97%, death 3%. The legitimacy of carotid endarterectomy procedure is discussed in relation to some recent pertinent literature.     

Myocardial perfusion imaging and cardiac events in a cohort of asymptomatic patients with diabetes living in southern France.

AIMS: To assess the association between abnormal stress myocardial perfusion imaging (MPI) and cardiac events (CE) in asymptomatic patients with diabetes and with > or = 1 additional risk factor. Predictors of abnormal stress MPI were also evaluated. METHODS: Four hundred and forty-seven consecutive patients who underwent stress MPI were prospectively followed for 2.1 [0.5-4.1] years for the subsequent occurrence of hard CE (myocardial infarction and sudden or coronary death) and soft CE (unstable angina and ischaemic heart failure requiring hospitalization). Re-vascularization procedures performed as a result of the screening protocol were not included in the analysis. RESULTS: Follow-up was successful in 419 of 447 patients (94%), of whom 71 had abnormal MPI at baseline. Medical therapy was intensified in all subjects and especially in those with abnormal MPI. Twenty-three patients with abnormal MPI underwent a re-vascularization procedure. CEs occurred in 14 patients, including six of 71 patients (8.5%) with abnormal MPI and eight of 348 patients (2.3%) with normal MPI (P < 0.005). Only two patients developed a hard CE and 12 a soft CE. In multivariate analysis, abnormal MPI was the strongest predictor for CEs [odds ratio (OR) (95% CI) = 5.6 (1.7-18.5)]. Low-density lipoprotein cholesterol > or = 3.35 mmol/l [OR (95% CI) = 7.3; 1.5-34.7] and age > median [OR (95% CI) = 6.0 (1.2-28.6)] were additional independent predictors for CE. The independent predictors for abnormal MPI were male gender, plasma triglycerides > or = 1.70 mmol/l, creatinine clearance < 60 ml/min and HbA1c > 8%, with male gender the strongest [OR (95% CI) = 4.0 (1.8-8.8)]. CONCLUSIONS: Asymptomatic patients with diabetes in this study had a very low hard cardiac event rate over an intermediate period. This could be explained by the effects of intervention or by the low event rate in the background population. Randomized studies of cardiac heart disease screening are required in asymptomatic subjects with diabetes to determine the effectiveness of this intervention.     

Spinal anaesthesia in a child with Job''s syndrome, pneumatoceles and empyema

We present a case of acute bowel obstruction in an immunocompromised child, who also had lobar pneumonia and a giant unilateral pneumatocele. She was successfully managed with subarachnoid anaesthesia for exploratory laparotomy to relieve a colonic obstruction. This proved to be a safe alternative to general anaesthesia with tracheal intubation in this patient and should be considered in infants and children in selected cases whenever a contraindication to general anaesthesia exists.     

Nociceptin (Orphanin FQ) abolishes gestational and ovarian sex steroid-induced antinociception and induces hyperalgesia

Nociceptin (Orphanin FQ) is a newly discovered endogenous heptadecapeptide substrate for the opioid-receptor-like 1 receptor, a G protein coupled receptor that bears striking amino acid sequence homology to opiate receptors. In rats, intrathecal (i.t.) administration of nociceptin is without effect on basal thresholds for responsiveness to electric foot shock. However, during either late gestation or its hormonal simulation, when nociceptive thresholds are elevated by approximately 70%, i.t. nociceptin substantially attenuates jump thresholds in a dose-dependent fashion. This hypoalgesic effect of nociceptin is not limited to attenuating the gestational or sex steroid-induced increment in pain thresholds. Following the highest i.t. dose of nociceptin employed (20 nmol), the gestational or sex steroid-induced increment in jump thresholds is not only abolished but a significant hyperalgesia is observed. These results underscore the importance of the hormonal milieu to nociceptin hypoalgesic sensitivity. The potential contribution of spinal nociceptive pathways that utilize nociceptin to the etiology of extraordinary painful pregnancy and labor should not be ignored.     

Primary spinal paragangliomas: a clinicopathological and immunohistochemical study of 30 cases

Aims: Extra-adrenal paragliomas are neoplasms which have been the subject of much debate regarding parameters to establish their biological behaviour. This study describes the clinicopathological and immunohistochemical features of 30 cases of spinal paragliomas. Methods and results: There were 15 male and 15 female patients. The median age at diagnosis was 46 years (range 20–74 years). Fourteen patients presented with back pain, two with numbness of the lower extremities, one with difficulty in walking and one with spinal cord compression. Nineteen tumours were located in the lumbar region, six in the cauda equina, two in the filum terminale, two in the thoracic region and one in the cervical region. All patients underwent gross total excision. The size of the tumours ranged from 10 to 50 mm. Histologically, 18 neoplasms showed alveolar (Zellballen) pattern, seven a spindle component, two eosinophilic granular cells suggestive of oncocytic metaplasia, two melanin pigment and one ganglion cells. Positive immunohistochemical results include: neuron-specific enolase 23/23 (100%), synaptophysin 21/23 (91%), S100 protein 22/23 (95%, sustentacular cells), leu-enkephalin 11/23 (47%), somatostatin 8/23 (34%), focal glial fibrillary acidic protein 7/23 (30%), focal keratin 5/23 (21%), neurofilament proteins 3/23 (13%) and adrenocorticotrophic hormine (ACTH) 1/23 (4%). Follow-up information obtained in 20 patients show 17 patients alive over a period of 6–216 months. One patient had bone metastases. Two patients died of unrelated causes, including one of congestive heart failure and one of myocardial infarction. Conclusions: In our experience, spinal paragangliomas behave as slow-growing tumours susceptible to potential cure by total excision. We agree with the current World Health Organization (WHO) classification as grade I tumours. Less than 1% may be locally aggressive. Spinal paragangliomas immunoreact not only for conventional neuroendocrine markers but also for peptides including somatostatin and ACTH and focally for the epithelial marker keratin.