2010年 · 第13卷第03期

Abstract：Objective:To prospectively evaluate the feasibility,safety and efficacy of the percutaneous pedicle screw fixation through the pedicle of fractured vertebra in the treatment of type A thoracolumbar fractures using Sextant system in the retrospective non-randomized case-control study.Methods:A total of 38 consecutive non-randomized patients with type A thoracolumbar fractures, which had been stabilized posteriorly from December 2006 to March 2009,were examined retrospectively more than 9 months after surgery.Twenty-one patients had been treated conventionally with open pedicle screw fixation (OPSF) and 17 patients received minimally invasive treatment with Sextant percutaneous pedicle screw fixation (SPPSF). As a method of evaluation, the incision size, the intraoperation and postoperative volume of blood loss, operation time, postoperative hospital stay, blood transfusion, the radiological assessment of the sagittal Cobb's angle, vertebral body angle and vertebral body height were recorded and compared.Results: All patients were followed up for 8-24 months (average 11.6 months). There were significant differences in the incision size, surgical blood loss, surgical draining loss, operation time, hospital stay after operation, blood transfusion, the proportion of antalgic supplement and postoperative incisional VAS between the two groups (P<0.05). Mean preoperative kyphotic deformity was 16.0°and improved by 9.3° after surgery in OPSF group, but 15.2° and 10.3° respectively in SPPSF group. Mean preoperative angle of the fractured vertebral body was 15.9°and improved by 7.9° after surgery in OPSF group, but 14.9° and 6.6° respectively in SPPSF group. Mean anterior vertebral body height (% of normal) was 67.3% before surgery and 95.8% after surgery, but 69. 1% and 90.1% respectively in SPPSF group. Mean posterior vertebral body height (% of normal) was 93.3% before surgery and 99.5% after surgery,but 88.9% and 93.3% respectively in SPPSF group. Among the patients whose 9-month follow-up films were available,3.0° of kyphosis correction was lost in OPSF group, but 3.2°in SPPSF group. And 1.0° of the angle of the fractured vertebral body correction was lost in OPSF group, but 1.5° in SPPSF group. Then 3.0% of the anterior vertebral body height correction was lost in OPSF group, but 2.2% in SPPSF group. And 3.0% of the posterior vertebral body height correction was lost in OPSF group, but 2.5% in SPPSF group.The sagittal Cobb's angle, vertebral body angle and anterior height of the fractured vertebra were all significantly different in each group before and after operation (P<0.05).There were no significant differences in the postoperative sagittal Cobb's angle, vertebral body angle and the improvement of the vertebral body height and the kyphotic deformity correction between OPSF and SPPSF groups (P>0.05),but there was significant difference in the postoperative anterior height of the fractured vertebra between the two groups (P<0.05).Conclusion: The percutaneous pedicle screw fixation through the pedicle of fractured vertebra using Sextant system is a good minimally-invasive surgical therapeutic choice for patients with type A thoracolumbar fracture except for that the SPPSF has a little insufficiency in resuming the anterior height of the fractured vertebra compared with OPSF。

Abstract：Objective:To evaluate the effect of the treatment modality guided by intraventricular intracranial pressure (ICP) monitoring on patients with severe traumatic brain injury (TBI).Methods:The clinical data of a group of 136 severely brain-injured patients admitted to Shanghai Neurosurgical Emergency Center from December 2004 to February 2006 were studied.Results:The intraventricular ICP monitor was placed in all the 136 patients via Kocher's pathway, Paine's pathway or intraoperative opened ventricle. In this series, the probe was placed during the procedure of craniotomy in 98 patients; for other 38 patients, the probe was placed initially to measure or to monitor ICE A stepwise protocol targeting at ICP control (≤20 mm Hg) and optimal cerebral perfusion pressure (CPP) maintenance (60-90 mm Hg) was deployed.Among them, 76 patients survived with good recovery, 14 with moderate disability, 24 with severe disability, 10 with vegetative state, and 12 died. Complications associated with intraventricular ICP monitoring included hemorrhage and infection. Hemorrhage occurred in 1 patient and infection in 5 patients. There were no unacceptable complications related to ICP monitoring.Conclusions:Ventricular access for ICP monitoring can be safely and accurately achieved. ICP monitoring via ventriculostomy may facilitate an early and accurate intervention for severely brain-injured patients. The intraventricular ICP monitoring is a low-risk procedure and can yield great benefits for management of patients with severe TBI。

Abstract：Objective:Measurement of biomarkers is a potential approach to early prediction of the risk of mortality in patients with sepsis. The aim of the present study was to evaluate the prognostic value of pro-atrial natriuretic peptide (pro-ANP) and pro-adrenomedullin (proADM) levels in a cohort of medical intensive care patients and to compare it with that of other known biomarkers and physiological scores.Methods:Blood samples of 51 consecutive critically ill patients admitted to the intensive care unit and 53 age-matched healthy control people were evaluated in this prospective study. The prognostic value of pro-ANP and pro-ADM levels was compared with that of acute physiology and chronic health evaluation (APACHE) Ⅱ scores and various biomarkers such as C-reactive protein, interleukin-6 and procalcitonin. Pro-ANP and pro-ADM were detected by a new sandwich immunoassay.Results: On admission, 25 patients had systemic inflammatory response syndrome (SIRS), 12 sepsis, 9 severe sepsis and 5 septic shock. At that time, the median levels (ng/ml) of pro-ANP and pro-ADM were 87.22 and 0.34 respectively in patients with SIRS, 1533.30 and 2.23 in those with sepsis, 1098.73 and 4.57 in those with severe sepsis, and 1933.94 and 8.21 in those with septic shock.With the increasing severity of disease, the levels of pro-ANP and pro-ADM were gradually increased. On admission,the circulating levels of pro-ANP and pro-ADM in patients with sepsis, severe sepsis,or septic shock were significantly higher in non-survivors than in survivors (P<0.05). In a receiver operating characteristic curve analysis for the survival of patients with sepsis, the areas under the curve (AUCs) for pro-ANP and pro-ADM were 0.89 and 0.87 respectively, which was similar to the AUCs for procalcitonin and APACHE Ⅱ scores.Conclusion: Pro-ANP and pro-ADM are valuable biomarkers for prediction of severity of septic patients。

Abstract：Objective:To explore the effects of Xingnaojing injection on cerebral edema and blood-brain barrier (BBB) in rats following traumatic brain injury (TBI).Methods: A total of 108 adult male Sprague-Dawley rats were used as subjects and randomly assigned to three groups:sham-operation,TBI and Xingnaojing injection was set up by the improved device of Feeney's weightcontent and BBB permeability expressed as Evans blue content were measured at 1, 3, 5 and 7 days after surgery.Results: In sham-operation group, brain water content and Evans blue content in brain tissue were 78.97%±1.22%and 5.13μg±0.71μg. Following TBI, water content in brain tissue was increased significantly at 1, 3, 5 and 7 days (83.49%±0.54%, 82.74%±0.72%, 80.22%±0.68%, 79.21%±0.60%), being significantly higher than that in sham operation group (P<0.05). Evans blue content was increased in TBI group (16.54 μg±0.60 μg, 14.92μg±0.71μg, 12.44 μg ±0.92μg, 10.14μg±0.52 μg) as compared with sham-operation group(P<0.05). After treatment with Xingnaojing injection, brain water content decreased as compared with TBI group (81.91%±1.04%, 80.38%±0.72%, 79.54%±0.58%,78.60%±0.77%, P<0.05). Xingnaojing injection also reduced the leakage of BBB as compared with TBI group (15.11 μg± 0.63 μg, 13.62 μg±0.85μg, 10.06 μg±0.67 μg, 9.54 μg±0.41 μg,P<0.05).Conclusion: Xingnaojing injection could alleviate cerebral edema following TBI via reducing permeability ofBBB。

Abstract：Objective:To study the surgical treatment for distal humeral fractures in adults according to the follow-up results.Methods: Twenty-one cases (16 males and 5 females)of distal humeral fracture were included in this study. The average age was 42.5 years (range: 37-52 years). Fractures were classified according to the AO classification system.Nine cases of C1,8 C2 and 4 C3-type fractures were identified.Open reduction and internal fixation were performed in all cases. A tricep-reflecting approach was adopted, and either the AO orthogonal plating or parallel plating technique was chosen,based on the fracture type. The plaster cast was removed 3 weeks after operation. Rehabilitation was encouraged during this period and afterwards. The average follow-up time was 12.2 months (range: 8-28 months). The outcome was scored according to Aitken and Rorabeek system.Results:No nerve injury,nonunion or failure of fixation was encountered during the operation and follow-up.However, ossifying myosifis occurred in one case.Conclusions:A triceps-reflecting approach can provide adequate exposure to the joint. The use of AO orthogohal plating or parallel plating techniques based on the type of fractures can provide rigid fixation for the fracture。

Abstract：Objective:To elucidate the relationship between surgical time and postoperative complications in senile patients with hip fractures, and try to find out other factors which are related to these complications.Methods: Sixty-two patients, 28 males aged from 65 to 72 years with a mean age of 76.3 years and 34 females aged from 65 to 95 years with a mean age of 78.1 years, who had undergone orthopedic surgery because of hip fractures,were enrolled in a retrospective cohort study. The surgical time and pattern, the type of fracture, preoperative comorbidities, American Society of Anesthesiologists (ASA) score and the volume of blood transfusion during operation were obtained from these patients who were followed up by telephone calls for postoperative complications.All the patients were followed up at least for 1 year and were divided into subgroups according to their clinical characteristics and the results were analyzed by the Statistical Analysis System software.Results:There was no significant difference in the morbidity of postoperative eomplications with the gender,age,surgical time and pattern,or ASA score. There was significant difference in the morbidity of postoperative complications related to preoperative comorbidities and the volume of blood transfusion. There was a significant causality between preoperative comorbidities and postoperative complications. The morbidity of postoperative complications was 1.651 times higher in patients with preoperative comorbidities than those without.Conclusions:There is no relationship between the surgical time and postoperative complications in senile patients who received surgery for hip fracture within 1 year.No correlation is found between the postoperative complications and gender,age,type of fracture, surgical pattern,ASA score and the volume of blood transfusion. Preoperative comorbidities are an independent predictor for postoperative complications。

Abstract：Objective:To label rat bone marrow mesenchymal stem cells (BMSCs) with superparamagnetic iron oxide (SPIO) in vitro, and to monitor the survival and location of these labeled BMSCs in a rat model of traumatic brain injury (TBI) by susceptibility weighted imaging (SWI)sequence.Methods:BMSCs were cultured in vitro and then labeled with SPIO. Totally 24 male Sprague Dawley (SD) rats weighing 200-250 g were randomly divided into 4 groups: Groups A-D (n=6 for each group). Moderate TBI models of all the rats were developed in the left hemisphere following Feeney's method. Group A was the experimental group and stereotaxic transplantation of BMSCs labeled with SPIO into the region nearby the contusion was conducted in this group 24 hours after TBI modeling. The other three groups were control groups with transplantation of SPIO, unlabeled BMSCs and injection of nutrient solution respectively conducted in Groups B, C and D at the same time. Monitoring of these SPIO-labeled BMSCs by SWI was performed one day,one week and three weeks after implantation.Results: Numerous BMSCs were successfully labeled with SPIO. They were positive for Prussian blue staining and intracytoplasm positive blue stained particles were found under a microscope (×200). Scattered little iron particles were observed in the vesicles by electron microscopy (×5000). MRI of the transplantation sites of the left hemisphere demonstrated a low signal intensity on magnitude images,phase images and SWI images for all the test rats in Group A, and the lesion in the left parietal cortex demonstrated a semicircular low intensity on SWI images, which clearly showed the distribution and migration of BMSCs in the first and third weeks. For Group B, a low signal intensity by MRI was only observed on the first day but undetected during the following examination. No signals were observed in Groups C and D at any time points.Conclusion:SWI sequence in vivo can consecutively and noninvasively trace and demonstrate the status and distribution of BMSCs labeled with SPIO in the brain of TBI model rats。

Abstract：Objective:To explore the clinical manifestation,diagnosis and surgical treatment of cerebrospinal fluid rhinorrhea in sphenoidal sinus.Methods: Nine cases of cerebrospinal fluid rhinorrhea in spenoidal sinus from 2007 to 2009 were retrospectivelyanalyzed consisting of their possible etiological factors,clinical manifestations, localization of the leakage site and treatment methods. Among them, there were 3 cases of traumatic rhinorrhea, 4 postoperative rhinorrhea and 2 spontaneous rhinorrhea. All 9 patients underwent 3-dimensional CT scan in sellar region including all para-nasal sinus. Leakage site was identified and repairing procedure was performed through trans-sphenoidal approach.Results:All cases were cured with the trans-sphenoidal microsurgical procedure. They were followed up for 9 months to 2 years. No recurrence, no infection and epilepsy complications were observed.Conclusion:For the cerebrospinal fluid rhinorrhea at sphenoidal sinus, it is critical to identify the leakage site accurately and the trans-sphenoidal approach is a microinvasive and effective way to repair the leakage, which is worthy to be advocated。

Abstract：Objective:To investigate the efficacy and safety of polyethylene glycol 4000 (Forlax(R)) on adult patients with functional constipation due to posttraumatic confinement to bed.Methods: A total of 201 posttraumatic bedridden patients were studied in this prospective,open-labeled, singlegroup study. Polyethylene glycol 4000 was administered orally for 14 days and the dosage was adjusted according to the Bristol stool types. Demographic characteristics, disease status, treatment period and factors affecting clinical outcome, especially the concomitant medications, were recorded.Results:After administration of polyethylene glycol 4000, 194 cases (96.52%) showed remission of constipation,including 153 (76.12%)persistent remission. The average defecation frequency increased significantly after treatment and the percentage of patients with stools of normal types (Bristol types 3-5) increased as well. Genders, ages and concomitant medications showed no significant influence on the persistent remission rate. After consecutive treatment for two weeks, patients with slight movement showed a significantly higher remission rate than those without movement (95% vs 80%). At the end of treatment, most accompanying symptoms were relieved obviously. Patients with a medical history of constipation or ever taking laxatives showed a lower remission rate. Sixty cases (29.85%) developed diarrhea during the observational period, among whom 6 (10%) withdrew from the clinical observation voluntarily at the first onset of diarrhea. Two cases suffered from abdominal pain.Conclusions:Polyethylene glycol 4000 (Forlax(R)) has efficacy on functional constipation in posttraumatic bedridden patients. Furthermore, patients with milder symptoms,more movement in bed, and longer duration of treatment but without accompanying symptoms can achieve a higher remission rate。

Abstract：Objective:To study the expression changes of matrix metal loproteinases (MMPs) in traumatic deep vein thrombosis (TDVT) in a rat model with the aid of gene chip technology and to explore the roles of MMPs in TDVT.Methods:Totally 150 Sprague Dawley rats were randomly divided into control group (n=10) and model group (n=140). Rat models of TDVT were established by clamping the femoral vein and fixing the bilateral hind limbs. Then fixation of the hip spica with plaster bandage was conducted.According to the observation phases and/or biological situations of the femoral vein thrombosis, the model rats were further divided into 7 groups. Vascular tissues were obtained from each group through noninvasive incision into the femoral vein at corresponding time points. We adopted the Trizoi one-step method for total RNA extraction,Affymetrix RAT 230 2.0 array for detection of RNA expressions and fold change (FC) analysis for changes of differential expressions of MMPs in each group. The main outcome parameters measured included expressions of MMP-2,MMP-3, MMP-7, MMP-8, MMP-9, MMP-10, MMP-11,MMP- 12, MMP-13, MMP- 14, MMP- 16, MMP-23 and MMP-24. Gene array data of these MMPs were analyzed by the Affymetrix Microarray Analysis software (Version 5.0).Results:FC analysis showed differential expressions of MMPs in each group during the course of TDVT. At the initial period of thrombosis, MMP-2, MMP-3, MMP-7,MMP-8, MMP-9, MMP- 10, MMP-11, and MMP-24 had significantly high expression, while MMP-12, MMP-13,MMP-14, MMP-16 and MMP-23 had relatively low expression. MMPs were all highly expressed at the peak time of thrombosis. In the process of thrombus resolution,MMP-2, MMP-10, MMP-16 and MMP-24 have relatively low expression, while MMP-12, MMP-13, MMP-14,MMP-16 and MMP-23 have significantly high expression.Conclusion:MMPs may affect the process of TDVT through transcription regulation of the fibrinolysis-anti-fibrinolytic system during the course of thrombosis and thrombus resolution。

Abstract：To review the challenges and countermeasures in the hospital care for Wenchuan earthquake casualties and draw lessons for the protective response in the future. Medical records and laboratory findings of the victims admitted in West China Hospital (WCH) were retrospectively analyzed. Related data were compared between beforemath and aftermath of the earthquake and between WCH and frontier county hospitals. One thousand and thirty-one earthquake survivors were hospitalized, 1358 victims underwent surgery and 142 victims were transferred to intensive care unit. The incidence of infection, crush syndrome and multiple organ dysfunction syndrome (MODS)was 39.6%, 20.7% and 2.3% respectively. Wound classification showed that the incidence of extremity damage was 72%, while the incidence of chest trauma, abdominal trauma and brain trauma was less than 10% respectively. Isolating rates of environmental pathogens were increased in the aftermath of earthquake, and the spectrum of the pathogens and related antibiotic sensitivities were quite different from those in the beforemath of earthquake. The social economic and population conditions in the earthquake-stricken areas affected the composition of the victims and the geographic features restricted the efficiency of rescue. Trauma-induced MODS, crush syndrome and severe infections all constituted the dilemma for the hospital care, to resolve whether the multidiscipline team work was proved to be an optimizing choice. For a more effective disaster protective response in the future,the study on rescue plan and the ladder therapies for massive casualties should be potentiated。