第一骶椎骶前区应用解剖学研究

目的：明确第一骶椎骶前区周围结构,为腹腔镜下阴道-骶骨固定术手术安全性提供应用解剖学资料。方法：选用16具成年女性尸体,对其骶前区血管灌注后,对S1骨盆面周围结构进行观察及测量。方差分析及配对t减检验分析数据。结果：骶正中血管43．75％通过骶岬中点,而18．75％通行于右侧;在S1椎体前面,12．50％的骶正中血管行走于S1椎体中线,31．25％行走于中线偏左,而56．25％行走于中线偏右。位置变异的第一横干静脉位于骶岬下方10mm之内。在骶岬水平,骶正中血管与左右输尿管的距离分别为：（33．73±9．53）mm、（33．43±7．00）mm,其左侧距离最近的血管是左髂总静脉（22．00±10．60）mm、左髂内静脉（25．06±9．23）mm,右侧距离最近的血管是右髂内动脉（21．33±6．91）mm、右髂内静脉（23．76±7．04）mm;两两比较,P〈0．05,在第一骶前孔水平,骶正中血管与左右输尿管的距离分别为：（44．05±11．70）mm、（43．08±6．23）mm,而距离最近的血管是左右髂内静脉（31．85±11．89）mm、（27．50±14．60）mm,两两比较,P〈0．05。结论：S1的骶前区解剖结构复杂,特别是骶正中血管及第一横干静脉位置变异较大。对于骶前血管异常分布的患者,进行阴道-骶前固定手术可能增加骶前区血管损伤的几率。     

退变性腰椎不稳症手术治疗的疗效分析

目的:探讨退变性腰椎不稳症手术治疗的疗效。方法:随访我院60例腰椎不稳症患者运用椎板扩大开窗或全椎板切除减压,摘除髓核,椎体间植骨,后路钉棒系统加压内固定及腰椎间融合术。结果:术后随访半年到3.5年,平均12个月,复查X线示骨性融合,2例出现断钉及松动现象,患者症状完全消失48例,基本消失7例,无明显缓解5例(可3例,差2例)。根据日本骨科学会(JOA)评分法,优良率91.3%。结论:椎弓根螺钉内固定加椎管减压,椎体间植骨融合可使不稳节段即刻稳定,骨性融合率高,是治疗腰椎不稳症的较好方法。     

复发性腰椎间盘突出症的研究进展

腰椎间盘突出症是骨科常见病,手术是治疗该病的有效方式,但是仍有5．0％～20．0％的患者发生腰椎手术失败综合征,其中以复发性腰椎间盘突出症为主。该文综述了复发性腰椎间盘突出症的定义、病因、诊断、治疗和预防等方面的研究进展。     

Effects of using the posterior or anterior approaches to the lumbar plexus on the minimum effective anesthetic concentration (MEAC) of mepivacaine required to block the femoral nerve: a prospective, randomized, up-and-down study

BACKGROUND AND OBJECTIVES: To evaluate if psoas compartment block requires a larger concentration of mepivacaine to block the femoral nerve than does an anterior 3-in-1 femoral nerve block. METHODS: Forty eight patients undergoing anterior cruciate ligament repair were randomly allocated to receive an anterior 3-in-1 femoral block (femoral group, n = 24) or a posterior psoas compartment block (psoas group, n = 24) with 30 mL of mepivacaine. The concentration of the injected solution was varied for consecutive patients using an up-and-down staircase method (initial concentration: 1%; up-and-down steps: 0.1%). RESULTS: The minimum effective anesthetic concentration of mepivacaine blocking the femoral nerve in 50% of cases (ED(50)) was 1.06% +/- 0.31% (95% confidence interval [CI], 0.45%-1.68%) in the femoral group and 1.03% +/- 0.21% (95% CI, 0.6%-1.45%) in the psoas group (P = .83). The lateral femoral cutaneous and obturator nerves were blocked in 4 (16%) and 5 (20%) femoral group patients as compared with 20 (83%) and 19 (80%) psoas group patients (P = .005 and P = .0005, respectively). Intraoperative analgesic supplementation was required by 15 (60%) and 5 (20%) patients in the femoral and psoas groups, respectively (P = .01). CONCLUSIONS: Using a posterior psoas compartment approach to the lumbar plexus does not increase the minimum effective anesthetic concentration of mepivacaine required to block the femoral nerve as compared with the anterior 3-in-1 approach, and provides better quality of intraoperative anesthesia due to the more reliable block of the lateral femoral cutaneous and obturator nerves.     

AF椎弓根系统治疗胸腰椎骨折的临床观察

目的 探讨AF椎弓根系统治疗胸腰椎骨折的效果.方法 2000年1月～2006年9月应用AF椎弓根系统手术治疗胸腰椎骨折48例.结果平均随访13个月,48例患者惟体高度恢复良好,神经功能、神经损伤的恢复按ASIA分级,术前E级以上的有7例无变化,余22例均有1～2级恢复,术前E级无变化.结论 AF椎弓根钉多系统能达到很好的复位固定、椎管减压效果.是一种治疗胸腰椎骨折的理想方法.     

Measurement of peak CSF flow velocity at cerebral aqueduct, before and after lumbar CSF drainage, by use of phase-contrast MRI: utility in the management of idiopathic normal pressure hydrocephalus

OBJECTIVE: Since it was first described, normal pressure hydrocephalus (NPH) and its treatment by means of cerebrospinal fluid (CSF) shunting have been the focus of much investigation. Whatever be the cause of NPH, it has been hypothesized that in this disease there occurs decreased arterial expansion and an increased brain expansion leading to increased transmantle pressure. We cannot measure the latter, but fortunately the effect of these changes (increased peak flow velocity through the aqueduct) can be quantified with cine phase-contrast magnetic resonance imaging (MRI). This investigation was thus undertaken to characterize and measure CSF peak flow velocity at the level of the aqueduct, before and after lumbar CSF drainage, by means of a phase-contrast cine MRI and determine its role in selecting cases for shunt surgery. PATIENTS AND METHODS: 37 patients with clinically suspected NPH were included in the study. Changes in the hyperdynamic peak CSF flow velocity with 50 ml lumbar CSF drainage (mimicking shunt) were evaluated in them for considering shunt surgery. RESULTS: 14 out of 15 patients who were recommended for shunt surgery, based on changes peak flow velocity after lumbar CSF drainage, improved after shunt surgery. None of the cases which were not recommended for shunt surgery, based on changes in CSF peak flow velocity after lumbar CSF drainage, improved after shunt surgery (2 out of 22 cases). CONCLUSION: The study concluded that the phase-contrast MR imaging, done before and after CSF drainage, is a sensitive method to support the clinical diagnosis of normal pressure hydrocephalus, selecting patients of NPH who are likely to benefit from shunt surgery, and to select patients of NPH who are not likely to benefit from shunt surgery.     

X-Tube辅助下微创后路腰椎椎体间融合术的价值研究

目的 探讨扩张通道管系统(METRX X-Tube)辅助下后路腰椎椎体间融合术(PLIF)治疗下腰椎疾患的临床价值.方法 2005年5月至2006年3月,应用X-Tube辅助下微创PLIF治疗下腰椎病变患者31例,其中男性17例,女性14例;年龄38-75岁,平均54.2岁;腰椎滑脱症14例(其中Ⅰ度8例,Ⅱ度6例),椎管狭窄症8例,椎体后缘离断症5例,椎间盘突出症伴椎间隙狭窄4例.病变节段:L4,5 17例,L5～S1 13例,L3,4 1例.记录手术时间及术中出血量.每例患者术前、术后1 d及术后7 d检查生化全套,测定肌酸激酶水平变化,并与同期在本院行开放PLIF的31例患者的肌酸激酶水平变化进行比较.对所有患者进行定期随访和影像学检查,并进行Oswestry功能障碍评分.结果 31例患者手术时间140～225 min,平均(176±22)min;术中出血量270～750 ml,平均(406±96)ml.微创PLIF术后1 d肌酸激酶水平明显低于开放手术(P＜0.01).术后2例患者2枚螺钉置入位置欠佳,但无神经损伤并发症和不影响固定效果而无需翻修;1例 L4,5节段椎管狭窄症患者术后主诉左侧L5神经根支配区域麻木,经对症治疗2周后症状消失,其余患者无固定不良和神经损伤等相关并发症发生.31例均获随访,随访时间7～17个月,平均12.2个月.随访病例均经腰椎X线检查,部分病例经螺旋CT三维重建,提示手术节段均在术后半年内获得良好的节段融合.Oswestry功能障碍评分由术前平均(40.6±5.1)分降至术后平均(17.4±6.5)分,末次随访时平均(9.5±4.0)分,手术疗效优良.结论 X-Tube辅助下微创PLIF治疗下腰椎疾患具有术中出血少、创伤小、术后康复快、骨融合时间短和临床疗效确切等优点.     

针刀松解法对第三腰椎横突综合征大鼠血管活性物质的影响

目的:探讨针刀松解法对第三腰椎横突综合征模型大鼠的治疗机制。方法:将40只SD大鼠随机分为正常组、模型组、电针组和针刀组4组,每组10只。后3组首先采用在第三腰椎横突尖部埋置明胶海绵的方法制作第三腰椎横突综合征模型,电针组和针刀组分别给予电针患侧"肾俞"腰阳关"和针刀松解干预治疗。造模后第28天,应用放射免疫分析法和酶联免疫分析法观察4组动物血中降钙素基因相关肽(CGRP)、内皮素(ET)、6-酮-前列腺素F1α(6-keto-PGF1α)、血栓素A2(TXA2)含量的变化。结果:模型组大鼠血浆中ET、CGRP、TXA2、6-keto-PGF1α含量与正常组比较均呈上升趋势(P<0.01);经电针和针刀松解法治疗后,血浆中ET含量与模型组比较差异无显著性意义(P>0.05),CGRP、TXA2、6-keto-PGF1α含量较模型组明显降低(P<0.05,0.01);电针组与针刀组比较,除TXA2含量两者差异有显著性意义外,其余3项指标两组间差异无显著性意义。结论:针刀松解法对第三腰椎横突综合征大鼠血管活性物质的合成与分泌具有良性调节作用,使其恢复到正常水平,从而使炎症局部循环障碍得到改善。     

虚拟人的腰丛神经断层解剖学及可视化研究

目的观测“虚拟中国人”（virtual Chinese human,VCH）女性Ⅰ号、男性Ⅲ号腰丛神经连续横断面的走行,建立腰丛神经的可视化数字模型。方法应用“虚拟中国人”女性Ⅰ号（VCH—FⅠ）和男性Ⅲ号（VCH．Mm）数据集,在薄层断面图像上观察腰丛神经的构成及其与腰大肌和周围血管的关系,应用Amira3．1（WGS）软件对腰丛神经及其周围结构进行计算机三维重建并立体显示。结果在VCH-FⅠ和VCH—MⅢ的薄层断面图像上可以清楚地显示腰丛神经的主要结构,重建的数字化模型可准确地反映腰丛神经解剖学结构特点。结论VCH—FⅠ和VCH—MⅢ数据集能够提供完整精确的腰丛神经断面解剖,重建的数字化模型为腰丛神经损伤的影像诊断和外科治疗提供了良好的形态学依据。     

Effect of lumbar flexion on the extent of epidural blockade

BACKGROUND AND OBJECTIVES: This study examined the effect of lumbar flexion on the extent of the epidural block during lumbar epidural anesthesia. METHODS: The epidural catheter was introduced at the L3-4 interspace with the patient in the lateral decubitus position with the surgical side down. After administering a test drug (3 mL of 2% lidocaine and 15 mug of epinephrine), the patients were randomly allocated to 1 of 2 groups: Group F (n = 16, lumbar spine flexed) and Group N (n = 17, lumbar spine in the neutral position). In both groups, 2% lidocaine (16 mL) mixed with sodium bicarbonate (2 mL) was administered through the epidural catheter while the patient maintained the lateral decubitus position with the lumbar spine either flexed or in the neutral position. All the patients maintained their respective positions for 5 minutes and were subsequently turned to the supine position. The pinprick block level and the degree of motor blockade were assessed every 10 minutes for 60 minutes after administering the local anesthetics. A 2-dermatomal difference in uppermost block between groups was determined to be clinically significant. RESULTS: The median difference between groups in the uppermost pinprick block level was only 1.5 dermatomes and it did not satisfy our criteria for clinical significance. There were no significant differences between the 2 groups in the lowermost pinprick block level and the degree of motor block. CONCLUSIONS: Lumbar flexion has no clinically relevant effect on sensory spread during epidural anesthesia.