目的介紹一種采用Photoshop CS16.0軟件（PS軟件）輔助下行強直性脊柱炎后凸畸形（ankylosing spondylitis kyphosis，ASK）矯正術前截骨設計，探討其應用價值。 方法2009年3月－2013年3月，對21例ASK患者行改良椎弓根閉合截骨術前，采用PS軟件輔助設計截骨角度及范圍。男16例，女5例；年齡23～50歲，平均34.2歲。后凸畸形節段：單純胸段2例，胸腰段14例，單純腰段5例。比較術前設計截骨角度及術后實際截骨角度；術前、術后1周及末次隨訪時測量脊柱骨盆矢狀面參數：全脊柱后凸角（global kyphosis,GK）、腰椎前凸角（lumbar lordosis,LL）、矢狀位垂直軸（sagittal vertical axis,SVA）、骨盆入射角（pelvic incidence,PI）、骨盆傾斜角（pelvic tilt,PT）及頜眉角（chin brow-vertical angle,CBVA）；采用Oswestry功能障礙指數（ODI）和脊柱側凸研究會-22項問卷（SRS-22）評分評價患者功能改善情況。 結果術中出現硬脊膜破裂1例，術后出現神經損害癥狀1例；其余患者均無并發癥發生，切口Ⅰ期愈合。患者均獲隨訪，隨訪時間14～45個月，平均26.3個月。術后1周及末次隨訪時，ODI及SRS-22評分均較術前顯著改善（P＜0.05）；末次隨訪和術后1周時比較，差異無統計學意義(P＞0.05)。術前計劃截骨角度為（34.2±10.5）°，術后實際截骨角度為（33.7±9.7）°，比較差異無統計學意義（t=0.84，P=0.42）。術后1周及末次隨訪時脊柱骨盆矢狀面參數GK、SVA、PT、LL及CBVA較術前明顯改善（P＜0.05），且達理想范圍；術后1周和末次隨訪比較，差異均無統計學意義（P＞0.05）。末次隨訪時X線片示無內固定失效及斷裂，截骨部位均獲得骨性融合。 結論通過PS軟件術前輔助截骨設計，可精確恢復ASK患者脊柱矢狀面平衡以及水平視角，有效避免矯正過度或矯正不足，獲得較好療效。
目的探討椎弓根螺釘內固定術中椎弓根外側壁穿破后，向內側重新定向后打入矯正螺釘（redirectionally correctly placed pedicle screw,RS）對脊柱內固定的生物力學影響。 方法6只市售家豬，體重95～105 kg，雌雄不限。取其新鮮腰椎標本30個（L1～5椎體各6個）。每個椎體標本一側椎弓根打入最佳位置的椎弓根螺釘（optimum placed pedicle screw，OS）；對側在椎弓根和椎體連接處破壞椎弓根外側壁，然后擰入RS螺釘。分別測量每個椎弓根釘最大擰入扭矩、鎖緊扭矩、螺釘松動力和軸向拔出力。 結果OS螺釘和RS螺釘的最大擰入扭矩分別為（111.4±8.2） N·cm和（78.9±6.4） N·cm，差異有統計學意義（Z=3.038，P=0.002）；OS螺釘和RS螺釘的鎖緊扭矩分別為（86.3±7.7） N·cm和（59.7±5.3） N·cm，差異有統計學意義（Z=2.802，P=0.005）。OS螺釘和RS螺釘的螺釘松動力分別為（76.3±6.2）N和（53.0±5.8）N，差異有統計學意義（Z=2.861，P=0.004）；OS螺釘和RS螺釘的軸向拔出力分別為（343.0±12.6）N和（287.0±10.5）N，差異有統計學意義（Z=2.964，P=0.003）。 結論與OS相比，椎弓根外側壁破壞后RS在最大擰入扭矩、鎖緊扭矩、螺釘松動力和軸向拔出力方面均顯著降低，強化螺釘可能是較好的補救方法。
目的 探討右美托咪定在脊柱矯形手術患者喚醒試驗的應用效果。方法 將80例脊柱矯形手術患者隨機分為試驗組和對照組，每組40例，兩組均采用氣管插管全麻，麻醉誘導方式相同，試驗組在誘導前給予右美托咪定0.8 μg/（kg·h）（10 min內輸注完），術中繼予0.5 μg/（kg·h）速率輸注至縫合切口。對照組給予等量的生理鹽水，喚醒試驗開始前15 min停止泵注所有麻醉藥，喚醒試驗結束后繼續泵注。比較兩組患者的喚醒時間、喚醒質量，喚醒前15 min（T1）、自主呼吸恢復時（T2）、喚醒即刻（T3）、喚醒后15 min（T4）的血液動力學變化，麻醉藥的用量以及不良事件的發生率。結果 兩組喚醒前手術時間差異無統計學意義（P=0.07）。試驗組的喚醒前七氟醚、舒芬太尼的用量顯著少于對照組（P=0.03，P=0.00）。試驗組的喚醒時間、喚醒期間出血量顯著少于對照組，喚醒質量顯著高于對照組（P=0.04，P=0.00，P=0.03）。試驗組喚醒時的血壓和心率顯著低于對照組（P=0.00，P=0.00）。試驗組喚醒不良事件的發生率顯著少于對照組（P=0.04）。結論 右美托咪定應用于脊柱矯形手術，能顯著提高患者的喚醒質量，縮短喚醒時間，減少喚醒時的出血量和喚醒后的不良事件，且能維持血液動力學的穩定，具有較好的保護效應。
目的 針對一例晚期肺癌脊柱轉移患者病情和治療預期，結合最新的循證醫學證據，制定治療決策。方法 按照PICO原則，對患者在治療中面臨的問題進行轉換并制定檢索策略后，在多個數據庫中進行文獻檢索。按照循證醫學5級證據分級標準，選擇最佳的臨床證據進行解讀，并指導治療決策。結果 檢出相關文獻148篇，最終納入4篇系統評價/Meta 分析。針對患者關心的4個方面的問題均獲得1級證據支持，包括恢復脊髓功能（行走和括約肌功能）、局部疼痛控制、遠期生存率和治療并發癥。根據患者意愿，最終選擇了治療后并發癥相對高發，但能夠更好恢復神經功能，顯著緩解疼痛，提高遠期生存率的手術減壓治療。術后患者行走功能完全恢復。結論 采用循證治療方法，能為肺癌脊柱轉移伴脊髓壓迫患者選擇合理的治療方案。對于惡性脊髓壓迫患者，如出現行走功能障礙，且具備手術條件，應盡早進行減壓手術，以盡早恢復脊髓功能，緩解疼痛，提高遠期生存率。但醫患雙方均應對手術治療存在較高的并發癥風險有充分的共識和諒解。
目的 評價微創椎弓根釘內固定技術治療胸腰椎爆裂骨折的中期臨床療效。 方法 2002年9月－2007年9月，采用微創椎弓根釘內固定技術治療胸腰椎爆裂骨折30例。其中男16例，女14例;年齡18～65歲，平均39.8歲。骨折節段:胸11者3例， 胸12者13例， 腰1者12例， 腰者22例。所有骨折按AO分型，均為A3型。受傷至手術時間6 h～6 d，平均45 h。分析術后影像學指標、疼痛評分及功能障礙指數。 結果 患者均獲隨訪，隨訪時間3～9年，平均5.2年。術后各時間點傷椎前緣高度及后凸Cobb角均較術前明顯恢復（P＜0.01）。術后傷椎高度隨隨訪時間延長逐漸下降，后凸Cobb角逐漸增大。取出內固定物后、術后2年、末次隨訪時動力位X線片上骨折椎體前后相對滑移距離分別為（1.9 ± 0.3）、（2.1 ± 0.2）、（2.1 ± 0.3）mm，兩兩比較差異無統計學意義（P＞0.05）。術后1、2年及末次隨訪時疼痛視覺模擬評分分別為（2.5 ± 1.2）、（2.5 ± 1.1）、（2.4 ± 1.3）分，兩兩比較差異無統計學意義（P＞0.05）。末次隨訪時Denis腰痛分級：P1級13例，P2級12例，P3級5例。功能障礙指數為（11.4 ± 3.1）分，獲優23例、良5例、可2例。 結論 單純微創椎弓根釘內固定技術治療胸腰椎爆裂骨折中期臨床效果滿意，脊柱穩定性良好。Objective To mid-term efficacy of the technique of minimally invasive pedicle screw fixation on thoracolumbar burst fracture. Methods From September 2002 to September 2007, 30 patients were treated with minimally invasive pedicle screw fixation for thoracolumbar fracture. There were 16 males and 14 females with the mean age of 39.8 years (range,18-65 years). The injured level of was T11 in 3 cases, T12 in 13 cases, L1 in 12 cases, and L2 in 2 cases. The type of thoracolumbar fractures of all the patients was A3 according to AO classification. The during from injury to operation was 6 hours to 6 days with an average of 45 hours. The index of image and pain and disability index were evaluated after operation. Results All patients were followed up for 3 to 9 years with the mean of 5.2 years. Their average sliding distance after operation for removing internal fixation was (1.9 ± 0.3), and (2.1 ± 0.2) mm 2 years after the operation and (2.1 ± 0.3) mm at the latest follow-up. There was no significant difference (P＞0.05). Their average score was (2.51 ± 1.2) 1 year after the operation, was (2.42 ± 1.1) 2 year after the operation, and was (2.36 ± 1.3) at the latest follow-up (P＞0.05). According to Denis score system to evaluate index of lumbago, there was P1 in 13 cases, P2 in 12 cases, and P3 in 5 cases. The score of Oswestry Disability Index (ODI) was 11.4 ± 3.1 at the latest follow-up. Twenty-one cases gotexcellent therapeutic result, five cases got good and two were moderate. Conclusions Minimally invasive pedicle screw fixation for the treatment of thoracolumbar burst fracture provide satisfactory clinical results. The vertebral body and adjacent vertebral body have a good stability.
目的 評價微創椎弓根釘內固定技術治療胸腰椎爆裂骨折的中期臨床療效。 方法 2002年9月－2007年9月，采用微創椎弓根釘內固定技術治療胸腰椎爆裂骨折30例。其中男16例，女14例;年齡18～65歲，平均39.8歲。骨折節段:胸11者3例， 胸12者13例， 腰1者12例， 腰者22例。所有骨折按AO分型，均為A3型。受傷至手術時間6 h～6 d，平均45 h。分析術后影像學指標、疼痛評分及功能障礙指數。 結果 患者均獲隨訪，隨訪時間3～9年，平均5.2年。術后各時間點傷椎前緣高度及后凸Cobb角均較術前明顯恢復（P＜0.01）。術后傷椎高度隨隨訪時間延長逐漸下降，后凸Cobb角逐漸增大。取出內固定物后、術后2年、末次隨訪時動力位X線片上骨折椎體前后相對滑移距離分別為（1.9 ± 0.3）、（2.1 ± 0.2）、（2.1 ± 0.3）mm，兩兩比較差異無統計學意義（P＞0.05）。術后1、2年及末次隨訪時疼痛視覺模擬評分分別為（2.5 ± 1.2）、（2.5 ± 1.1）、（2.4 ± 1.3）分，兩兩比較差異無統計學意義（P＞0.05）。末次隨訪時Denis腰痛分級：P1級13例，P2級12例，P3級5例。功能障礙指數為（11.4 ± 3.1）分，獲優23例、良5例、可2例。 結論 單純微創椎弓根釘內固定技術治療胸腰椎爆裂骨折中期臨床效果滿意，脊柱穩定性良好。Objective To mid-term efficacy of the technique of minimally invasive pedicle screw fixation on thoracolumbar burst fracture. Methods From September 2002 to September 2007, 30 patients were treated with minimally invasive pedicle screw fixation for thoracolumbar fracture. There were 16 males and 14 females with the mean age of 39.8 years (range,18-65 years). The injured level of was T11 in 3 cases, T12 in 13 cases, L1 in 12 cases, and L2 in 2 cases. The type of thoracolumbar fractures of all the patients was A3 according to AO classification. The during from injury to operation was 6 hours to 6 days with an average of 45 hours. The index of image and pain and disability index were evaluated after operation. Results All patients were followed up for 3 to 9 years with the mean of 5.2 years. Their average sliding distance after operation for removing internal fixation was (1.9 ± 0.3), and (2.1 ± 0.2) mm 2 years after the operation and (2.1 ± 0.3) mm at the latest follow-up. There was no significant difference (P＞0.05). Their average score was (2.51 ± 1.2) 1 year after the operation, was (2.42 ± 1.1) 2 year after the operation, and was (2.36 ± 1.3) at the latest follow-up (P＞0.05). According to Denis score system to evaluate index of lumbago, there was P1 in 13 cases, P2 in 12 cases, and P3 in 5 cases. The score of Oswestry Disability Index (ODI) was 11.4 ± 3.1 at the latest follow-up. Twenty-one cases gotexcellent therapeutic result, five cases got good and two were moderate. Conclusions Minimally invasive pedicle screw fixation for the treatment of thoracolumbar burst fracture provide satisfactory clinical results. The vertebral body and adjacent vertebral body have a good stability.
【摘要】 目的 探討脊柱外科手術患者術后發生譫妄的危險因素和有效防治措施。 方法 2007年1月-2009年10月應用ICU譫妄診斷的意識狀態評估法觀察1 835例脊柱外科術后患者。對于發生術后譫妄的患者隨機分為治療組和未治療組，治療組于譫妄診斷明確時即靜脈注射氟哌利多5 mg。 結果 術后3 d，136例發生譫妄，譫妄發生率為7.41%。篩選出術后譫妄的可能高危因素包括高齡、術前合并高血壓、術前合并糖尿病、術中出血量gt;600 mL、手術時間gt;4 h、術中應用激素、術后電解質紊亂和低氧血癥、術后疼痛。發生譫妄的患者中，治療組（68例）住院時間短于未治療組（68例），差異有統計學意義（Plt;0.05）。 結論 高齡，術前合并高血壓、糖尿病，術中出血量gt;600 mL，手術時間gt;4 h，術中應用激素，術后電解質紊亂、低氧血癥及疼痛是脊柱外科手術患者術后發生譫妄的主要高危因素。氟哌利多治療術后譫妄有效。【Abstract】 Objective To analyze the related factors influencing postoperative phrenitis in patients who have undergone spine surgery. Methods Postoperative phrenitis was evaluated with the confusion assessment method for the intensive care unit in 1 835 patients underwent spine surgery between January 2007 and October 2009. All the patients with postoperative phrenitis were randomly divided into two groups: treatment group and control group. The patients in treatment group underwent intravenous injection with droperidol (5 mg). Results Three days after the operation, 136 patients were diagnosed with postoperative phrenitis. The pre-operative complications of hypertension and diabetes, hemorrhage amount (gt;600 mL) during the operation, operative time (gt;4 hours), hormone usage during the operation, postoperative electrolyte disturbances, hyoxemia and pain were the factors influencing the morbidity of postoperative phrenitis. The length of hospital stay was shorter in the treatment group than that in the control group (Plt;0.05). Conclusions Senility, pre-operative complications of hypertension and diabetes, hemorrhage amount (gt;600 mL) during the operation, operative time (gt;4 hours), hormone usage during the operation, postoperative electrolyte disturbances, hyoxemia and pain were the factors influencing the morbidity of postoperative phrenitis. Droperidol is effective on postoperative phrenitis.
【摘要】 目的 探討低位下頸椎前方入路聯合胸骨柄劈開術治療頸胸段脊柱結核的手術方式及術后療效。 方法 2002年3月-2009年7月收治頸胸段脊柱結核16例，男11例，女5例；年齡18~52歲，平均38歲。其中位于頸6-胸1者2例，頸7-胸1者5例，胸1-2者4例，胸2-3者3例，胸1-3者2例。神經功能Frankel分級為：B級4例，C級7例，D級3例，E級2例。手術行低位下頸椎前方入路聯合胸骨柄劈開術，術中徹底清除結核肉芽組織、膿液、死骨并進行脊髓減壓，取自體髂骨塊植骨重建中前柱、前方鈦板內固定。術后佩戴頭頸胸支具6個月，正規抗癆18個月。術前后凸Cobb角為25~60°，平均為37.5°。 結果 全部患者均獲得隨訪，隨訪時間2~8年，平均3年。均獲得骨性融合，融合時間為5～8個月，無螺釘松動、脫落及鋼板斷裂等并發癥發生。神經功能恢復按Frankel分級，平均改善3.6個級別；結核病變無復發，術后后凸Cobb角明顯改善，為15～35°，平均22.6°，末次隨訪后凸角無明顯丟失。1例術后出現暫時性聲音嘶啞，術后1個月恢復。 結論 低位下頸椎前方入路聯合胸骨柄劈開術治療頸胸段脊柱結核，病灶顯露充分，植骨內固定，重建脊柱穩定性，矯正后凸畸形可靠。【Abstract】 Objective To explore the clinical characteristics of cervico-thoracic junction spinal tuberculosis (CTJST) and to observe the therapeutic effect of lower anterior cervical approach combined with presternum-splitting approach on CTJST. Methods The clinical data of 16 patients with cervicothoracic junction spinal tuberculosis from Match 2002 to July 2008 were retrospectively analyzed. According to the Frankel grades, four patients were in grade B, seven were in grade C, three were in grade D, and two were in grade E. There were 11 males and five females with a average age of 38 years ranging from 18 to 52 years. All patients underwent radical excision of epidural granulation tissue/abscess and necrotic bone, whilst a proper tricortical iliac crest autograft and anterior titanium plate were placed to reconstruct the anteromedian spinal column, followed by chemotherapy for 18 months and immobilization in a brace for six months. The mean Cobb angle was 37.5° (ranged from 25° to 60°) before surgery. Results All patients were followed up for two to eight years (three years on average), and got complete bone fusion within five to eight months postoperatively. There were no pull out and breakage of screws or plates.Spinal cord functional recovery improved on average 3.6 degree according Frankel standard, without recurrence of the disease or loss of Cobb angle till the last follow up. There was a statistically significant improvement in the Cobb angles from 22.6° to 37.5° (Plt;0.01) in average. However, two patients appeared transient hoarse voice after surgery, and the symptoms were alleviated one month after the operation. Conclusion Lower anterior cervical approach combined with presternum-splitting approach for CTJST may provide adequate exposure to the lesion, keep the bone graft with internal fixation and spinal stability, and correct the kyphosis.
目的:分析脊柱外科患者術后并發譫妄綜合征的原因,總結其診斷、預防、治療。方法:回顧性分析我科2008年10月至2009年4月脊柱手術167例,其中11例患者術后發生譫妄綜合征。結果:11例患者均給予氟哌啶醇5mg im bid治療,平均使用5.6天,癥狀緩解;并獲3~6月隨訪,無一例復發譫妄綜合征。結論:譫妄綜合征是脊柱外科患者術后常見并發癥,其發生與年齡,性別,低血糖等有關,目前治療首選氟哌啶醇。
目的:探討脊柱轉移瘤患者的手術切除與脊柱穩定性重建的適應證與效果。方法：2003年4月至2008年4月，收治了脊柱轉移癌患者32例。腫瘤轉移部位:胸椎轉移22例，腰椎轉移7例，頸椎轉移3例。男性13例，女性19例。出現神經系統受損者27例，其中完全癱瘓者7例，不完全癱瘓者20例。全組患者均做了椎體切除、內固定術或后路椎板切除、椎管減壓內固定術或前后路聯合行360°脊椎切除固定一期重建脊柱穩定性。觀察術后局部疼痛緩解，神經功能恢復及脊柱穩定性情況。結果：隨訪時間為6～60個月，32例患者中，30例術后痛疼得到緩解。27例有神經功能損害的患者中，25例術后麻痹癥狀改善。3例完全癱瘓的患者中，2例在減壓術后ASIA分級提高了1~2個等級。術后影像學提示脊柱序列和椎間高度恢復。術后存活1年以上的患者22例，約占患者總數的69%。結論：外科切除與重建治療轉移癌所致椎體塌陷或不穩定造成嚴重的神經損害或機械性脊柱痛疼的外科療效肯定，能夠增加脊椎穩定性，提高生存質量。
