一期切开高位挂线治疗后马蹄形脓肿

采用后位一期切开高位挂线两侧坐骨直肠间隙开窗对口引流治疗后马蹄形脓肿30例，全部一次治愈，疗程20－32d，平均23．6d。术后随访1－4年无遗留肛瘘、肛门狭窄、肛门失禁及肛门畸形。     

Incidence of cerebrospinal fluid leak after microsurgical removal of vestibular schwannomas

Summary.  Objectives: Cerebrospinal fluid (CSF) leak still remains an unresolved problem after microsurgical removal of vestibular schwannomas (VS).  Methods: 14 (6%) Cases of cerebrospinal fluid rhinorrhea and 3 cases with subcutaneous retro-auricular CSF collection, occurring in a series of 224 patients operated on by the senior author (JMG) on VS between 1989–2000 via the suboccipital retrosigmoidal approach were studied retrospectively. Prophylaxis of CSF leak was usually attempted by packing the unroofed posterior wall of internal acoustic meatus with muscle. The mastoid air cells were packed first with collagen then with muscle and bone dust.  Results: All CSF leaks were diagnosed within 2–7 days after surgery. We found no relation to tumour size. Treatment was initiated in all patients with continuous external lumbar cerebrospinal fluid drainage (CELCFD) for 7 days. In 11 cases with CSF rhinorrhea and all cases with retro-auricular CSF collection, the CSF leak was stopped. However, in 3 cases the CSF leak persisted despite the lumbar drain. These patients were operated on again with sealing the IAM and the mastoid cells again with muscle and collagen. No recurrence of CSF leak was noted after the second operation. There was no case of late onset CSF leak during the follow-up of one year.  Conclusion: Although CSF leak is a common complication (6%) after vestibular schwannoma removal, aggressive treatment is required only in a few cases (1%). Most of the cases are successfully treated by (CELCFD). The suboccipital approach offers an advantage of opening only a part of mastoid air cells, which are in our opinion the second most common site of CSF leakage. Published online October 10, 2002 Correspondence: A. Bani M.D., Neurochirurgische Klinik, Klinikum Duisburg, Wedau Kliniken, Zu den Rehwiesen 9, 47055 Duisburg, Germany.     

椎体切除截骨矫形术治疗胸腰段脊柱后凸的疗效观察

目的观察椎体切除截骨矫形术治疗胸腰段脊柱后凸的矫正效果。方法2004年8月至2008年7月,采用后路椎体切除截骨矫形椎弓根钉棒固定植骨融合术治疗15例脊柱后凸患者,男10例,女5例;年龄12～62岁,平均32.3岁;后凸角度45°～110°,平均78.5°。病因：椎体肿瘤术后3例,先天性脊柱畸形5例,创伤后脊椎后凸4例,椎体结核术后3例。受累节段：均位于胸腰段,T_（11） 3例,T_（12） 5例,L_1 5例,L_2 2例。椎体切除：部分切除4例,单节段切除8例,2节段切除2例,4节段切除1例。术前,术后1周、3个月、1年摄全脊柱X线片,同时行MR及CT检查。结果全部获得随访,随访时间为10个月～3年,平均26个月。术后后凸角为0°～40°,平均20°,平均改善68.5°。术后患者腰痛均消失。脊髓功能：13例E级无明显变化,1例由Frankel C级恢复至D级,另1例由D级恢复至E级。8～12个月X线片示截骨融合,无一例出现钉棒松动、断裂、假关节形成及矫正度数丢失等。结论椎体切除截骨矫形是治疗脊柱后凸畸形的有效手段,能达到矢状面和冠状面的同时矫正且矫形彻底。     

Choice of surgical approach for ossification of the posterior longitudinal ligament in combination with cervical disc hernia

Ossification of the posterior longitudinal ligament (OPLL) is a common spinal disorder that presents with or without cervical myelopathy. Furthermore, there is evidence suggesting that OPLL often coexists with cervical disc hernia (CDH), and that the latter is the more important compression factor. To raise the awareness of CDH in OPLL for spinal surgeons, we performed a retrospective study on 142 patients with radiologically proven OPLL who had received surgery between January 2004 and January 2008 in our hospital. Plain radiograph, three-dimensional computed tomography construction (3D CT), and magnetic resonance imaging (MRI) of the cervical spine were all performed. Twenty-six patients with obvious CDH (15 of segmental-type, nine of mixed-type, two of continuous-type) were selected via clinical and radiographic features, and intraoperative findings. By MRI, the most commonly involved level was C5/6, followed by C3/4, C4/5, and C6/7. The areas of greatest spinal cord compression were at the disc levels because of herniated cervical discs. Eight patients were decompressed via anterior cervical discectomy and fusion (ACDF), 13 patients via anterior cervical corpectomy and fusion (ACCF), and five patients via ACDF combined with posterior laminectomy and fusion. The outcomes were all favorable. In conclusion, surgeons should consider the potential for CDH when performing spinal cord decompression and deciding the surgical approach in patients presenting with OPLL.     

One-stage posterior instrumentation surgery for the treatment of osteoporotic vertebral collapse with neurological deficits

The number of reports describing osteoporotic vertebral fracture has increased as the number of elderly people has grown. Anterior decompression and fusion alone for the treatment of vertebral collapse is not easy for patients with comorbid medical problems and severe bone fragility. The purpose of the present study was to evaluate the efficacy of one-stage posterior instrumentation surgery for the treatment of osteoporotic vertebral collapse with neurological deficits. A consecutive series of 21 patients who sustained osteoporotic vertebral collapse with neurological deficits were managed with posterior decompression and short-segmental pedicle screw instrumentation augmented with ultra-high molecular weight polyethylene (UHMWP) cables with or without vertebroplasty using calcium phosphate cement. The mean follow-up was 42 months. All patients showed neurologic recovery. Segmental kyphotic angle at the instrumented level was significantly improved from an average preoperative kyphosis of 22.8–14.7 at a final follow-up. Spinal canal occupation was significantly reduced from an average before surgery of 40.4–19.1% at the final follow-up. Two patients experienced loosening of pedicle screws and three patients developed subsequent vertebral compression fractures within adjacent segments. However, these patients were effectively treated in a conservative fashion without any additional surgery. Our results indicated that one-stage posterior instrumentation surgery augmented with UHMWP cables could provide significant neurological improvement in the treatment of osteoporotic vertebral collapse.     

增加胫骨平台后倾角度、后交叉韧带部分松解对全膝关节置换术后膝关节运动影响的实验研究

目的通过增加胫骨平台后倾角度或后交叉韧带（PCL）部分松解对全膝关节置换术（TKA）中屈曲间隙过紧进行处理,分析这两种方法对TKA术后膝关节运动学的影响。方法测量6例新鲜尸体膝关节标本在完整状态下、正常TKA、屈曲间隙过紧、增加胫骨平台后倾角以及PCL部分松解TKA术后膝关节屈曲0°、30°、60°、90°、120°时的前后松弛度、内外翻松弛度、旋转松弛度及最大屈曲度。结果屈曲过紧TKA与正常TKA相比,在屈曲30°、60°、90°和120°时前后松弛度、内外翻松弛度及旋转松弛度均显著较小（P〈0．05）。与屈曲过紧TKA相比,增加胫骨后倾角后,在屈曲30°、60°、90°和120°时前后松弛度、内外翻松弛度和旋转松弛度均明显增大（P〈0．05）。PCL部分松解与屈曲过紧TKA相比,在屈曲30°、60°、90°和120°时前后松弛度明显增加（P〈0．05）;旋转松弛度在屈曲30°、60°、90°时明显增加（P〈0．05）。与PCL部分松解相比,增加胫骨后倾角的内外翻松弛度在屈曲30°、60°、90°时明显较大（P〈0．05）;旋转松弛度在屈曲0°、30°、60°和90°时明显较大（P〈0．05）。屈曲过紧TKA的最大屈曲度（120．4°）与正常TKA（130．3°）及增加胫骨后倾角（131．1°）相比明显较小（P〈0．05）。增加后倾角与PCL部分松解（124．0°）相比,最大屈曲度较大,但差异无统计学意义（P=0．0816）。结论屈曲间隙过紧TKA术后膝关节的前后松弛度、内外翻松弛度、旋转松弛度和最大屈曲度均减小;增加胫骨平台后倾角后,前后松弛度、内外翻松弛度、旋转松弛度和最大屈曲度均明显增大;PCL部分松解仅能明显增大前后松弛度。因此对于TKA术中屈曲紧张的膝关节,增加胫骨平台后倾角比PCL部分松解能更好地改善膝关节的运动学。     

颈椎间盘与后纵韧带上交感神经分布的特点及临床意义

目的观察颈椎间盘及后纵韧带上交感神经分布特点及其临床意义。方法按节段（C2／3、C3／4、C4／5、C5／6、C6／7）分别切取16只兔颈椎间盘及颈椎后纵韧带，其中8只通过NF200对其神经纤维进行荧光组织化学染色，另8只通过冰冻切片．乙醛酸（SPG）法对交感神经纤维进行染色，通过荧光显微镜观察及图像分析软件（Image—pro plus 5．0软件）描述分析其分布特点。结果在颈椎间盘纤维环外环分布有少量交感神经节后纤维。在颈椎后纵韧带上分布有大量交感神经节后纤维，主要呈网状分布，且以椎间盘区分布相对密集。分布于后纵韧带浅层的交感神经较深层密集，分布于C2／3、C3／4、C4／5的交感神经较C5／6、C6／7密集。结论颈椎间盘及后纵韧带上分布的交感神经可能是引发颈性眩晕的另一重要因素。     

腮腺手术中耳大神经后支保留的临床意义

目的 探讨腮腺手术中耳大神经后支保留的可行性、方法及临床价值。方法 我们对48例腮腺肿瘤患者，按常规隐蔽切口腮腺手术方法进行治疗，保留或不保留耳大神经后支。分别于术后10d及1、6、12个月进行随访，检测耳廓上部、耳垂、耳下区、耳前区和耳后区的触觉、痛觉，并观察其感觉变化情况。结果 48例中35例耳大神经后支保留，耳廓上部及耳后区感觉无减退。术后早期耳前、耳垂及耳下区感觉有不同程度的减退，以耳前区最明显，随着时间延长症状逐步好转，6个月时感觉接近正常。另13例耳大神经切断患者感觉减退症状更加明显，恢复时间延长。结论 腮腺手术中耳大神经后支保留是可行的，所采用的方法可靠，可减轻局部麻木感，提高患者术后早期生活质量，降低神经切断后产生局部永久性麻木的可能性。     

Feasibility and efficacy of placement of continuous sciatic perineural catheters solely under ultrasound guidance in children: a descriptive study

Background: Placement of sciatic catheters with ultrasound and stimulating catheters is known. Literature regarding catheter placements with only ultrasound is limited. We aimed to investigate the feasibility of performing continuous sciatic nerve block exclusively with ultrasound guidance and minimal equipment. Method: Forty ASA 1 and 2 patients aged 8 months–10 years posted for congenital talipoequinovarus surgery were included in the study. Continuous sciatic catheters were placed under ultrasound guidance with 18‐ gauge Tuohy needle at the infragluteal fold. Then, 0.25% of bupivacaine 0.5 ml·kg^?1 bolus was injected followed by continuous infusion later. Half the volume of the drug was injected prior to catheter insertion to improve visibility. The sciatic nerve, needle tip and shaft, catheter tip and the drug spread were visualized. The efficacy of the block intraoperatively and postoperatively was evaluated. Results: The sciatic nerve, needle shaft, and tip were well visualized in all 40 patients. The catheter tip was seen in 72.5% of patients. The effect of block was complete intraoperatively and postoperatively. Clinically significant complications were absent. Conclusion: We conclude that in children, continuous sciatic catheters can be accurately and efficaciously placed with minimal equipment with ultrasound alone.     

Computational analysis of the safe zone for the antegrade lag screw in posterior column fixation with the anterior approach in acetabular fracture: A cadaveric study

ObjectiveThe fluoroscopically-guided procedure of antegrade posterior lag screw in posterior column fixation through anterior approach is technique-dependent and requires an experienced surgeon. The purpose of this study was to establish the safe zone for the antegrade posterior lag screw by using computational analysis.MethodThe virtual three-dimensional model of 178 hemi-pelvises was created from the CT data (DICOM format) by using Mimics^® program, and were used to measure the safe zone of antegrade lag screw fixation on the inner table of the iliac wing, and the largest diameter of cylindrical implant inside safe zone. The central point (point A) of the cylinder was assessed and was compared with the intersection point (point B) between the linea terminalis and the anterior border of the sacroiliac articulation.ResultsThe safe zone was triangular with an average area of 670.4 mm² (range, 374.8–1084.5 mm²). The largest diameter of the cylinder was a mean 7.4 mm (range, 5.0–10.0 mm). When height was under 156.3 cm, the diameter of the cylindrical implant was smaller than 7.0 mm (p < 0.001, regression coefficient = 0.09). The linear distance between points A and B was 32.5 mm (range, 19.2–49.3 mm). Point A was far enough away from the well-positioned anterior column plate to prevent collision between the two.ConclusionThe safe zone was shaped like a triangle, and was large enough for multiple screws. Considering the straight-line distance between points A and B, the central screw can be fixed without overlapping with the well-positioned anterior column plate at the point between holes 2 and 3.