颈椎髓外硬膜下结核瘤1例

患者,男,38岁,以颈项部疼痛1个月,突发左上肢麻木无力3d入院。1个月前,无明显诱因,出现颈部疼痛,无双上肢感觉障碍,无活动受限,无头晕头痛,就诊于当地医院(具体治疗不详),症状无改善。3d前突然出现左上肢麻木无力,右上肢麻木感,排尿无力。既往:3年前无明显诱因出现颈部皮肤溃烂     

特发性脊柱侧凸King型和型远端融合椎的选择

目的回顾采用椎弓根钩和螺钉CD技术治疗特发性脊柱侧凸King型和型患者,分析选择性缩短融合节段的治疗效果。方法2000年3月~2003年1月,治疗58例特发性脊柱侧凸单胸弯患者,男17例,女41例,年龄12~18岁,平均14岁。其中King型40例,King型18例。胸弯Cobb角平均64°(50~83°),柔韧性62%;腰弯Cobb角平均37°(16~48°),柔韧性105%。腰弯腰骶角平均为17°(10~22°)。所有患者C7重力垂线均不同程度地偏离骶骨中线。采用椎弓根钩和螺钉CD技术矫形治疗,以中立椎为基础选择远端融合椎,所有远端融合节段均未超过中立椎。术后随访摄站立前后位和侧位X线片,观察各项指标的变化。结果患者均获随访1年8个月~3年2个月,平均2.4年,均未出现明显的躯干侧方移位和双肩不平衡。术后Cobb角平均丢失3.1°(-1~5°);最后随访时,胸弯矫正率68%;除2例C7重力垂线偏离骶骨中线1~2cm外,其余均通过骶骨中线;腰弯腰骶角减少至平均8°(2~13°),矫正率为53%;48例远端融合椎为非稳定椎者术后成为稳定椎。与Harrington远端融合椎选择原则相比,患者远端融合椎平均节省1.4个节段(1~2个节段)。结论采用三维节段性器械内固定系统治疗特发性单胸弯时,以中立椎为基础选择远端融合椎,可获得较好的临床效果。     

颈椎前路钢板椎间融合器系统治疗颈椎间盘突出症

颈椎前路手术在颈椎间盘疾病中已广泛应用，手术方法主要为颈前路减压加椎间植骨融合术。但不管是早期的自体骨融合的颈前路手术，还是后来进一步发展的颈前路钢板以及椎间融合器技术，都存在着诸如融合失败率高、植骨块移位、塌陷、螺钉断裂、钢板松动等并发症，造成手术疗效不佳以致于二次手术。自2002年2月-2004年1月采用颈椎间盘摘除、颈椎前路钢板椎间融合器（PCB）系统内固定、植骨融合术治疗颈椎间盘突出症后均无前述并发症的发生，疗效满意，现报道如下。     

血管内支架移植物治疗胸-腹主动脉瘤

目的　评价内支架移植物 (ESG)植入术治疗胸、腹主动脉瘤的有效性和安全性。方法　 2 8例胸、腹主动脉夹层动脉瘤 (AD或AAA) ,全麻下行血管内支架移植物治疗 ,其中 5例AD植入TALENT移植物 ,9例植入国产ESG ;7例AAA植入Zenith和TALENT分叉型ESG ,7例植入国产ESG。结果　 2 5例动脉假腔及动脉瘤得到有效隔绝。2例AD封堵失败 ;1例AAA移植物遮盖右肾动脉开口 ,术后肾体积缩小 ;1例AAA因多器官衰竭死亡。平均随访 18.5± 15 .1个月( 1～ 5 9个月 ) ,2 5例生活及工作情况良好。结论　ESG植入术可有效治疗StanfordB型AD和肾下AAA ;严格掌握适应证有助于减少并发症     

Left thoracotomy approach in reoperative off-pump coronary revascularization

Objective: Reoperative coronary bypass grafting is at high risk. Particularly in redo cases where the patent graft is running near the midline of the sternum, the graft may be exposed to injury by a median sternotomy and subsequent dissection. Whereas, off-pump bypass grafting from the left axillary artery or descending thoracic artery by a left thoracotomy approach is safe for preventing graft damage.Methods: From March 1998 to February 2002, we performed off-pump coronary artery bypass grafting by a left thoracotomy approach in 9 patients. The left axillary artery was used as the inflow vessel in 4 cases, and the descending thoracic, aorta in 5.Results: The radial artery was anastomosed proximally to the axillary artery in 4 cases and the descending thoracic aorta in one case. The saphenous vein graft was anastomosed, proximally to the descending thoracic aorta in 4 cases. Transdiaphragmatic minimally invasive bypass grafting for the right coronary artery was simultaneously performed in 3 cases. Postoperative cardiac events were ventricular arrhythmia in 6 cases and supraventricular arrhythmia in 3 cases. There was no damage to the patent grafts. Postoperative coronary angiography performed, in 8 cases revealed all the grafts to be patent without stenosis. Cardiac symptoms were not found after the operation in any of the cases.Conclusions: These procedures can prevent the injury to patent grafts caused by a median sternotomy, and will be one of the useful strategies for reoperative off-pump coronary artery bypass grafting.     

颈椎损伤合并截瘫100例总结

本文回顾我院20年来所收治的100例颈椎损伤合并截瘫伤员,试图对诊断和处理方法上若干主要问题提出探讨。     

Central cardiovascular and oxygen variables during haemorrhage in the pig

Background: We evaluated the ability of the standards issued by the Danish Society of Anaesthesiologists to reflect a blood loss.
Methods: In 9 pigs bled (0–24 ml kg^-1) and retransfused (to 28 ml kg^-1) during halothane anaesthesia, central cardiovascular, thoracic electrical impedance (TI), oxygen, acid-base and temperature variables were recorded.
Results: With the recommendation for minor surgery (mean arterial pressure (MAP) and heart rate (HR)), the correlation to the blood loss was 0.74 ( P < 0.001) and with that for major surgery (MAP, HR, central venous pressure (CVP) and rectal temperature (Temp_r)) it was 0.79 ( P < 0.001). With the recommendation for extensive surgery (MAP, HR, CVP, pulmonary artery catheter variables and the central-peripheral temperature difference (ΔTemp_r-t)), the correlation was 0.84 ( P < 0.001). Non-invasive monitoring (MAP, HR, ΔTemp_r-t TI and near-infrared spectroscopy of the brain (S_invosO₂)) was only slightly better than basal monitoring (r=0.76, P < 0.001). However, adding arterial base excess (BE), TI and peripheral temperature (Temp_t) to the recommendation for major surgery resulted in a correlation of 0.87 ( P < 0.001), while adding BE and TI to the recommendation for extensive surgery raised correlation to only 0.88 ( P < 0.001).
Conclusion: When the recommendations were followed the correlation to the blood loss ranged from 0.74–0.84. However, with the recording of MAP, HR, CVP, ΔTemp_r-t, BE and TI a correlation of 0.87 was achieved, indicating that a pulmonary artery catheter may not be in need for patients undergoing surgical procedures with expected haemorrhage.     

PHA胸导管来源诱生的LAK细胞的作用

利用胸导管引流治疗哮喘病的机会,研究了PHA在rIL-2诱导胸导管淋巴细胞成为LAK细胞中的作用。结果表明:PHA和rIL-2共同诱导TDL2周,细胞数量扩增约34倍。同时明显促进了DL的~3H-TdR和~3H-Leucine的参入,较对照组有明显差异(P<0.01)。其中rIL-2 100～1000U/ml和PHA组作用最佳,但PHA和rIL-2的协同作用持续时间短,第6d即开始下降,而且PHA参与诱导的TDL-LAK细胞的杀伤活性有所下降。     

Extension of the “Elephant Trunk” Technique in Complex Aortic Pathology: The “Bidirectional” Option

Background. The “elephant trunk” technique, using a free-floating vascular prosthesis, was originally described to facilitate a subsequent operation on the downstream aorta. We developed an additional refinement of this technique, called the “bidirectional elephant trunk.” This option may represent an interesting tool in more complex aortic operations, especially when the descending aorta has to be replaced first in patients with concomitant pathology of the ascending aorta or of the aortic arch.

Methods. The initial operation is performed through a left thoracotomy. The proximal elephant trunk is created by invaginating the future aortic arch graft into the descending aortic graft. The proximal anastomosis between the doubled graft and the proximal descending aorta is performed first. During construction of the distal anastomosis, a distal elephant trunk may be inserted likewise. If the aortic arch and ascending aorta have to be replaced later, this second step is performed through a median sternotomy. The free-floating arch graft is pulled out of the proximal descending aorta with a nerve hook, unfolded, and used for total arch replacement.

Results. This technique was used successfully in 3 patients without mortality. No major complications were observed excepted persistent hoarseness in a patient with preoperative paresis of the recurrent nerve. No perfusion problems due to the unfolding of the free-floating graft occurred during the second operation.

Conclusions. The bidirectional elephant trunk technique is an interesting option that may be suitable for patients presenting with a complex pathology of the whole thoracic aorta when the descending segment has to be replaced first.     

Bilateral continuous paravertebral block used for postoperative analgesia in an infant having bilateral thoracotomy

We describe the successful postoperative pain management in an 11-month-old infant who underwent bilateral thoracotomy, using continuous infusions of bupivacaine into two directly placed paravertebral catheters. Haemodynamic parameters and pain scores were measured 1–2 h for 60 h while the infusions were continued and, intermittently, blood samples were taken for subsequent measurement of serum bupivacaine concentrations. The technique provided effective pain relief and the infant required no other analgesia postoperatively. There were no adverse haemodynamic consequences or complications relating to either catheter placement or drug infusions. Serum concentrations of bupivacaine remained below toxic levels throughout the study period, though accumulation did occur.