椎间孔外神经鞘膜瘤1例报告

椎管内神经鞘膜瘤常见,但位于椎间孔外的神经鞘膜瘤却较为少见,文献报道更少.腰骶神经根鞘膜瘤的临床表现与腰椎间盘突出症、腰骶神经节异位畸形有很多相似之处,鉴别存在一定的难度,易引起误诊.我科收治1例椎间孔外神经根鞘膜瘤,报告如下.     

伴腰骶神经节椎管内异位的腰椎间盘突出症

伴腰骶神经节椎管内异位的腰椎间盘突出症王培增，桑仲亮，苏炜腰骶神经节（即腰骶神经后根节）可因发育因素内移至椎管内致异位畸形。神经节因位置异常，可被退变狭窄的神经根管或变性突出的椎间盘卡压而发病［１］。陈伯华［２］将椎管内异位的神经节列为椎管内型。我院...     

腰骶神经节椎管内异位畸形的诊断与手术治疗

目的：再认识腰骶神经节椎管内异位的应用解剖和探讨腰骶神经节椎管内异位畸形的诊断与手术治疗。方法：１９９１～１９９６年对２７例腰骶神经节椎管内异位畸形的病人进行了诊断与手术治疗。结果：术后对所有病人进行了４月～４年的随访，平均２５年，手术优良率为９２６％。结论：该类病人主要表现为下腰痛和根性腿痛，其诊断依赖于临床表现、腰椎管造影术、ＣＴ或ＭＲＩ及手术探查，该类病人的腰骶神经节异位于神经根管或侧隐窝内，并因组织退变或间盘突出而遭受卡压。手术治疗包括神经根管的探查、矫形、减压，并注意异位神经节与神经根肿瘤的鉴别，以免发生腰骶神经节误伤或误切     

腰骶神经节异位致腰腿痛(附5例报告)

论文对５例腰骶神经节变异和１例神经鞘膜瘤的诊治，目的：对其神经节变异的认识，以及与神经鞘膜瘤的鉴别加以讨论。方法：从１９９４－１９９６年，搜集到５例神经节异位，另有１例为神经鞘膜瘤，全部病例均为男性，年龄２３－５８岁，平均４２岁，职业均为体力劳动者，异位的部位，Ｌ３，４间隙左侧１例，Ｌ４，５间隙右侧１例，Ｌ５Ｓ１间隙右侧２例，Ｌ５Ｓ１间隙左侧１例，全部病例均手术治疗，结果：认为腰骶神经节变异是解剖生理变异，一般不会产生症状，只有合并侧隐窝狭窄时才会出现症状，所以常误诊为“腰椎间盘突出症”，结论对神经节异位ＣＴ有助于诊断，而磁共振要高于ＣＴ，与神经鞘膜瘤的鉴别影像学者很难将两者区分开来，手术是较好的鉴别方法，对于神经节不能冒然切除     

腰椎间盘突出合并腰骶管内其他疾病的诊治

目的探索腰椎间盘突出症并发腰骶管其他疾病的漏诊和误诊原因，提出合理的诊治方法。方法分析1996年3月至2001年10月1571例腰椎间盘突出患者的临床资料，共发现6例腰椎间盘突出患者并发有腰骶管其他疾病，其中漏诊2例，误诊1例。结果6例患者均以腰椎间盘突出收入院，其中合并神经根脓肿者1例，合并神经鞘瘤者2例，合并骶管囊肿者3例。均经CT和MRI检查得以确诊(1例例外)。6例患者均在摘除突出的椎间盘的同时或以后，处理了并发的其他疾病。结论CT及MRI检查是正确诊断腰椎间盘突出并发腰骶管其他疾病的有力手段；同时处理突出的髓核和并发的其他疾病能收到较好的疗效。     

无椎间盘突出的腰骶神经根压迫症的临床分型与治疗

目的 探讨无椎间盘突出的椎骶神经根压迫症的临床分型与诊治方法。方法 对43例无椎间盘突出的腰骶神经根压迫症行椎板切除或椎间孔减压术。结果 在43例手术患者中，随访33例，平均随访时间3年，其中32例下肢症状全部消失，1例残留下肢放射痛、足背伸力弱。结论 无椎间盘突出的腰骶神经根压迫症原因复杂，有7种类型，分别为不合并椎间透突出的神经根管狭窄症、神经根畸殂、神经根节异位畸形、神经根鞘膜瘤、神经根囊肿、椎间静脉曲张畸形、椎间盘吸收综合征。其临床表现类似椎间盘突出症，易造成误诊及术中失误，手术治疗应根据不同的临床分型采用相应的手术方式。     

后路椎板切除手术治疗脊柱椎管内神经鞘瘤的疗效分析

目的探讨后路椎板切除手术治疗脊柱椎管内神经鞘瘤的临床疗效。方法 35例椎管内神经鞘瘤患者,颈段6例,胸段10例,腰骶段19例。4例位于脊髓髓内,21例位于髓外硬膜下,10例位于硬膜外,其中呈哑铃状8例。均行后路椎板切除手术治疗,其中9例肿瘤及带瘤神经根因不能分离或神经根变形坏死而一并切除,28例采用脊柱椎弓根或侧块内固定。术后随访观察临床疗效,复查X线和CT观察脊柱稳定性及植骨融合情况,复查MRI平扫+增强观察肿瘤有无复发。结果 35例患者肿瘤均被完整切除,术后病理结果证实均为神经鞘瘤。手术时间2～6小时,平均3. 6小时。术中出血量300～900 ml,平均450 ml。术后1例麻醉清醒后24小时内出现双下肢感觉、运动功能障碍,MRI未见明显血肿及脊髓压迫,考虑脊髓缺血再灌注损伤,及时予大剂量甲强龙激素冲击及脱水、营养神经治疗,症状明显改善。术后21例患者出现了不同程度的脑脊液漏。术后随访时间3～34个月,平均18. 2个月,所有患者的临床症状和神经功能均有明显改善,肿瘤无复发。随访期间,所有采用脊柱内固定术患者均未见椎体不稳的表现。结论后路椎板切除手术能有效治疗脊柱椎管内神经鞘瘤,结合显微镜技术能够更好地暴露及完全切除肿瘤,采用此方法治疗脊柱椎管内神经鞘瘤疗效满意。     

非椎间盘性腰椎管内病变与腰腿痛关系(附23例分析)

从1978年1月至1982年10月,我们以腰椎部位开窗、半椎板、全椎板切除术式,治疗腰腿痛患者247例。其中非腰椎间盘突出症,而属椎管内其他病变者23例。术前虽经多种检查,有时仍难确诊,本文就腰段椎管内非椎间盘突出引起的腰腿痛讨论如下: 1.肿瘤:良性7例,马尾神经纤维瘤1例,马尾神经鞘瘤2例。恶性:腰_5骶_1椎管内粘液脂肪肉瘤1例。转移性肿病3例。 2.创伤:椎间盘突出软骨化2例,椎体或关节突骨赘6例,关节突骨折游离片1例,单纯黄韧带肥厚5例。 3.炎症:单发性神经根炎1例,蜘网膜炎1例。 以上各例的主要症状也是腰痛,伴有下肢痛。     

腰骶神经根异常综合征

目的：报道临床所见腰骶神经根异常综合征。方法：５２３例诊断为腰椎间盘突出症而行手术治疗中发现１４例为腰骶神经根变异而致病。予以手术治疗。结果；通过手术所见，腰骶神经根变异，解剖上可分为：１．腰骶神经根畸形，２．腰骶神经后根节异位。结论：腰骶神经根异常综合生，临床不多见，术前影像学检查确诊率较低，术中应注意去除一切对异常神经根造成嵌压的因素，包括轻度的椎间盘突出，小关节内聚，增生，黄韧带肥厚，退变等     

腰骶神经根异常综合征(临床14例报告)

目的：报道临床所见腰骶神经根异常综合征。方法：５２３例诊断为腰椎间盘突出症而行手术治疗中发现１４例为腰骶神经根变异而致病，（占２６８％）。予以手术治疗。结果：通过手术所见，腰骶神经根变异，解剖上可分为：１腰骶神经根畸形，２腰骶神经后根节异位。结论：腰骶神经根异常综合征，临床不多见，术前影像学检查确诊率较低，术中应注意去除一切对异常神经根造成嵌压的因素，包括轻度的椎间盘突出，小关节内聚、增生、黄韧带肥厚、退变等可收到较好的临床治疗效果     

Is the recovery profile of mivacurium independent of the rate of decay of its plasma concentration in patients with normal plasma cholinesterase activity?

Background: The duration of action of muscle relaxants is poorly correlated to the rate of decay of their plasma concentration. The plasma concentration of mivacurium may rapidly decrease below its active concentration because of the extensive hydrolysis of mivacurium. By inflating a tourniquet on one upper limb for 3 min after the administration of atracurium, mivacurium or vecuronium, we studied the influence of the initial decline of their plasma concentration on their effect. Methods: In 50 patients anaesthetised with thiopental, isoflurane and fentanyl, the effect of bolus doses of 0.15 or 0.25 mg . kg^?1 mivacurium (MIV 15, MIV 25), 0.3 or 0.5 mg . kg^?1 atracurium (ATR 30, ATR 50) and 0.06 or 0.1 mg . kg^?1 vecuronium (VEC 06, VEC 10) were measured on both arms (evoked response of the adductor pollicis to train-of-four stimulation every 12 s), a tourniquet being applied on one arm just before and during 3 min after the muscle relaxant bolus. Results: Tourniquet inflation of 3 min almost abolished the neuromuscular effect of mivacurium. In the vecuronium groups and in the ATR 50 group, tourniquet inflation did not modify the maximum degree of depression of the twitch response. Also, the duration of action of vecuronium was unaffected by the tourniquet. In the ATR 30 group, times to return of the twitch response to 25% (duration 25%) and 75% (duration 75%) of control response were significantly shorter in the cuffed arm, 23 min vs 27 min, and 41 min vs 45 min, respectively. In the ATR 50 group, only duration 25% was significantly shorter in the cuffed arm (41 min vs 45 min). Conclusion: The results suggest that the rate of decline of the plasma concentration of mivacurium is so rapid, that a very low and almost clinically ineffective concentration is present as soon as 3 min after its administration. The results also indicate that the recovery from a mivacurium-induced neuromuscular blockade is not influenced by the rate of decay of its plasma concentration in patients with genotypically normal plasma cholinesterase.     

Membranes in Artificial Organs

Abstract: Membrane processes play a pivotal and enabling role in modern replacement therapy for acute and chronic organ failure and in the management of immunologic diseases. In fact, virtually all contemporary extracorporeal blood purification methods employ membrane devices, and the next generation of artificial organs and tissue engineering therapies are almost certain to be similarly grounded in membrane technology. In this short essay, we comment on the similarities and differences among synthetic membranes and their natural counterparts and also provide a critical overview of the demographics and technology of hemodialysis, hemofiltration, apheresis, oxygenation, and emerging membrane technologies and applications.     

Dilemma of Membrane Biocompatibility and Reuse

Abstract: Numerous articles have been published on the multiple use of dialyzers and on the effect of different reprocessing chemicals and techniques on the dialyzer biocompatibility and performance. The results often appear contradictory, especially those comparing standard biocompatibility parameters. Despite this confusion, a discerning review of the published works allows certain limited conclusions to be drawn. Reprocessing of used hemodialyzers changes the biocompatibility profile of a dialyzer as defined by the parameters complement activation. leukopenia, and cytokine release. The effect of reprocessing depends on the chemicals and reprocessing technique applied and also on the type of membrane polymer being subjected to the reprocessing procedure. Reports of pyrogenic reactions indicate that the flux of the membrane also influences how suitable it is for safe reuse. An increased risk of allergic and pyrogenic reactions appears to be associated with dialyzer reuse. Furthermore, there has been a lack of investigations into the immunologic effect of the layer of adsorbed and chemically altered proteins that remains on the inner surface of reprocessed dialyzers. We conclude that the clinical benefit of dialyzer reuse cannot be generally accepted from a biocompatibility point of view.     

The analgesic effect of racemic ketamine in patients with chronic ischemic pain due to lower extremity arteriosclerosis obliterans

Background : Ketamine in sub-dissociative doses has been shown to have analgesic and phantom-Limb pain, where conventional treatment has often failed. Chronic ischemic pain due to lower extremity arteriosclerosis obliterans often responds poorly to analgesics, and the pain-generating mechanisms are not well understood.
Methods : Eight patients with rest pain in the lower extremity due to arteriosclerosis obliterans were given sub-dissociative doses of 0.15, 0.30, or 0.45 mg/kg racemic ketamine and morphine 10 mg as a 5-min infusion on four separate days in a cross-over, double-blind, randomised protocol. Plasma levels of (S)- and (R)-ketamine and their nor-metabolites were analysed with an enantioselective high-performance liquid chromatography (HPLC) method. Pain levels were evaluated with a visual analogue scale (VAS).
Results : Individual pain levels were highly variable during and after all the infusions but the pooled pain levels showed a dose-dependent analgesic effect of ketamine with a transient but complete pain relief in all patients at the highest dose (0.45 mg/ kg). Side-effects, mainly disturbed cognition and perception, were pronounced and dose-dependent. Morphine 10 mg had an analgesic peak at 20 min and 5/8 patients had complete pain relief. The remaining 3 patients also had high baseline pain scores, indicating a higher analgesic potency for the 0.30 and 0.45 mg/ kg ketamine doses than for morphine 10 mg.
Conclusion : We have demonstrated a potent dose-dependent analgesic effect of racemic ketamine in clinical ischemic pain. Due to a narrow therapeutic window, this analgesic effect is probably best utilised in combination with other analgesics.     

Intravenous endotoxin does not increase tissue extravasation of albumin in rats

Background : It is unclear whether activation of the inducible nitric oxide synthase (iNOS) increases or decreases the extravasation of plasma.
Methods : Chloralose anaesthetised male Wistar rats received E. coli lipopolysacharide (LPS), 3 mg kg^-1 i.v., or the corresponding volume of saline, 3 or 5 h before the end of the experiment. Mean arterial pressure (MAP) and heart rate (HR) were recorded. Tissue clearance of radio-labelled albumin, during the last 2 h of each experiment, was determined by a double-isotope method. In separate animals, the serum concentration of nitrite and nitrate was determined, 5 h after LPS or the solvent.
Main Results : LPS initially decreased MAP and lastingly increased HR. In the 3-h LPS animals (n=8), tissue plasma clearance was lower in the heart and calf muscle and increased only in diaphragm, compared to corresponding control animals (n=8). In the 5-h LPS rats, clearance was lowered (n=8) in the entire gastrointestinal tract and in testes, compared to controls (n=8). The serum nitrite/nitrate concentration was higher in animals given LPS (n=6) than in controls (n=6).
Conclusion : After LPS, tissue clearance of albumin was not increased in any major tissue, in spite of increased serum levels of NO end products. Apparently, after activation of iNOS, the augmented release of NO is not necessarily associated with increased albumin extravasation.     

Adrenaline markedly improves thoracic epidural analgesia produced by a low-dose infusion of bupivacaine, fentanyl and adrenaline after major surgery: A randomised, double-blind, cross-over study with and without adrenaline

Background: Basic pharmacological research indicates that there are synergistic antinociceptive effects at the spinal cord level between adrenaline, fentanyl and bupivacaine. Our clinical experience with such a mixture in a thoracic epidural infusion after major surgery confirms this. The objectives of the present study were to evaluate the effects on postoperative pain intensity, pain relief and side effects when removing adrenaline from this triple epidural mixture. Methods: A prospective, randomised, double-blind, cross-over study was carried out in 24 patients after major thoracic or abdominal surgery. Patients with only mild pain when coughing during a titrated thoracic epidural infusion of about 10 ml · h^?1 of bupivacaine 1 mg · ml^?1, fentanyl 2 μg · ml^?1, and adrenaline 2 μg · ml^?1 were included. On the 1^st and 2^nd postoperative days each patient was given a double-blind epidural infusion, at the same rate, with or without adrenaline. The effect was observed for 4 h or until pain when coughing became unacceptable in spite of a rescue analgesic procedure. Rescue analgesia consisted of up to two epidural bolus injections per hour and i.v. morphine if necessary. All patients received rectal paracetamol 1 g, every 8 h. Fentanyl serum concentrations were measured with a radioimmunoassay technique at the start and end of each study period. Main outcome measures were extent of sensory blockade and pain intensity at rest and when coughing, evaluated by a visual analogue scale, a verbal categorical rating scale, the Prince Henry Hospital pain score, and an overall quality of pain relief score. Results: The number of hypaesthetic dermatomal segments decreased (P <0.001) and pain intensity at rest and when coughing increased (P <0.001) when adrenaline was omitted from the triple epidural mixture. This change started within the first hour after removing adrenaline. After 3 h pain intensity when coughing had increased to unacceptable levels in spite of rescue analgesia (epidural bolus injections and i.v. morphine). Within 15–20 min after restarting the triple epidural mixture with adrenaline, pain intensity was again reduced to mild pain when coughing. Serum concentration of fentanyl doubled from 0.22 to 0.45 ng · ml^?1 (P <0.01), and there was more sedation during the period without adrenaline. Conclusions: Adrenaline increases sensory block and improves the pain-relieving effect of a mixture of bupivacaine and fentanyl infused epidurally at a thoracic level after major thoracic or abdominal surgery. Serum fentanyl concentrations doubled and sedation increased when adrenaline was removed from the epidural infusion, indicating more rapid vascular absorption and systemic effects of fentanyl.     

Utilisation des médicaments prokinétiques en réanimation : indications et limites ?

Enteral feeding is often limited by gastric and intestinal motility disturbances in critically ill patients, particularly in patients with shock. So, promotility agents are frequently used to improve tolerance to enteral nutrition. This review summaries the pathophysiology, presents the available pharmacological strategies, the clinical data, the counter-indications and the principal limits. The clinical data are poor. No study demonstrates a positive effect on clinical outcomes. Metoclopramide and erythromycin seems to be the more effective. Considering the risk of antibiotic resistance, the first line use of erythromycin should be avoided in favor of metoclopramide.     

Anesthésie générale chez l’enfant : quid des pratiques en 2010 ?

Introduction

The practice of pediatric anesthesia requires a regular update of scientific knowledge and technical skills. To provide the most adequate Continuing Medical Education programs, it is necessary to assess the practices of pediatric anesthesiologists. Thus, the objective of this survey was to draw a picture of the current clinical practices of general anesthesia in children, in France.

Material and methods

One thousand one hundred and fifty questionnaires were given to anesthesiologists involved in pediatric cases. These questionnaires collected information on various aspects of clinical practice relative to induction, maintenance, recovery from general anaesthesia and also classical debated points such as children with Upper Respiratory Infection (URI), emergence agitation, epileptoid signs or anaesthetic management of adenoidectomy. Differences in practices between CHG (general hospital), CHU (teaching hospital), LIBERAL (private) and PSPH (semi-private) hospitals were investigated.

Results

There were 1025 questionnaires completed. Fifty-five percent of responders worked in public hospitals (CHG and CHU); 77% had a practice that was 25% or less of pediatric cases. In children from 3 to 10 years: 72% of respondents used always premedication and two thirds performed inhalation induction in more than 50% of cases. For induction, 53% used sevoflurane (SEVO) at 7 or 8%. Respondents from LIBERAL used higher SEVO concentrations. Tracheal intubation was performed with SEVO alone (37%), SEVO and propofol (55%) and SEVO with myorelaxant (8%), 93% of respondents used a bolus of opioid. For maintenance, the majority of respondents used SEVO associated with sufentanil; desflurane and remifentanil were more frequently used in CHU. Two thirds of respondents used N₂O. Depth of anesthesia was commonly assessed by hemodynamic changes (52%), end tidal concentration of halogenated (38%) or automated devices based on EEG (7%). In children with URI, 98% of respondents used SEVO for anesthesia. To control the airway 42% used a tracheal tube, 30% a laryngeal mask and 20% a facial mask. Emergence agitation was an important concern for two thirds of respondents, while epileptoid signs were considered as important by only 20%. Eighty-nine percent of respondents practiced anesthesia for adenoidectomy. Anesthesia was induced by inhalation of SEVO 7–8% (41%), 6% (39%) or 4% (12%), 66% put an intravenous line (less frequently in LIBERAL). 67% of the responders managed adenoidectomy without any device to control the airway (more frequently in LIBERAL), 32% administrated a bolus of opioid (less frequently in LIBERAL).

Discussion

This survey demonstrated that the practices regarding general anesthesia in children are relatively homogenous. Most of the differences appeared between LIBERAL and the others structures; the anaesthetic management for adenoidectomy illustrates these findings.     

Intérêt d’une rééducation précoce pour les patients neurologiques

Rehabilitation improves the functional prognosis of patients after a neurologic lesion, and tendency is to begin rehabilitation as soon as possible. This review focuses on the interest and the feasibility of very early rehabilitation, initiated from critical care units. It is necessary to precisely assess patients’ impairments and disabilities in order to define rehabilitation objectives. Valid and simple tools must support this evaluation. Rehabilitation will be directed to preventing decubitus complications and active rehabilitation. The sooner rehabilitation is started; the better functional prognosis seems to be.     

Risiko Schlaganfall — Öffentlichkeitsarbeit und Aufklärung dringend erforderlich

Zusammenfassung Das wesentliche — und zugleich noch wenig ausgeschöpfte — Potenzial der Schlaganfallmedizin liegt in der langfristigen Prophylaxe. Durch Beeinflussung von Lifestylefaktoren wie Ernährungsgewohnheiten, Zigarettenkonsum und körperlichem Training durch entsprechende Aufklärung ließe sich ein erheblicher Teil an zerebralen Ereignissen vermeiden. Ein weiterer in Deutschland noch zu wenig beachteter Faktor ist die konsequente Blutdruckeinstellung. Breitgestreute Aufklärung könnte außerdem potenziellen Patienten helfen, bereits auftretende Warnsymptome wie die transiente ischämische Attacke richtig einzuschätzen, um eine rechtzeitige Behandlung zu ermöglichen.