内镜下单侧小关节分级切除对颈椎节段稳定性影响

目的 探究颈椎内镜下不同范围小关节切除对颈椎节段稳定性的影响,为临床手术提供生物力学理论基础。方法 基于CT数据建立颈椎C5~6正常有限元模型,并模拟颈椎内镜手术操作获得不同范围(0、25%、50%、75%、100%)单侧小关节切除椎板开窗模型(模型1~5),分析比较各组模型节段活动度(range of motion, ROM)及椎间盘von Mises应力情况。结果 除前屈工况外,模型1、2较正常模型各方向下ROM及椎间盘von Mises应力改变不明显,模型3较正常模型各方向下ROM及椎间盘von Mises应力出现较为明显增加,前屈、后伸、左侧弯、右侧弯、左旋转及右旋转时ROM分别增加27%、4%、3%、13%、5%、16%,von Mises应力分别增加32%、4%、2%、5%、9%、5%。模型4、5较正常模型各方向下ROM及椎间盘von Mises应力增加显著,模型4的ROM分别增加27%、14%、6%、24%、7%、167%,von Mises应力分别增加33%、13%、3%、32%、10%、130%;模型5的ROM分别增加27%、17%、6%、25%、7%、167%,von Mises应力分别增加33%、29%、8%、33%、12%、138%。结论 随着单侧小关节切除范围的增加,颈椎节段ROM和椎间盘von Mises应力极值逐渐增加。当单侧小关节切除超过1/2时,颈椎出现较大的ROM增加及应力改变。临床手术中应尽量保留1/2以上颈椎小关节,避免医源性失稳。

小关节分级切除对腰椎间盘突出症稳定性影响的生物力学研究

目的：研究腰椎间盘突出症手术中小关节、椎间盘切除对腰椎稳定性的影响。方法：采用八具新鲜腰椎尸体标本进行生物力学应力分析，比较前屈、后伸、左侧屈、右侧屈等不同工况下Ｌ４～５双侧小关节分级切除后的稳定性的变化。结果：试验表明腰椎间盘突出症手术中小关节切除范围在侧隐窝减压至小关节１／２切除内应变强度、位移、 ＲＯＭ与正常标本相比有显著性差异（ｐ＜０．０５）。结论：（１）腰椎间盘突出症手术中小关节切除范围应以侧隐窝减压为最大切除范围。（２）如手术需要切除１／２小关节时应考虑加用内固定以提高稳定性。

有限元模拟单节段腰椎小关节分级切除对腰椎稳定性的影响

目的探讨腰椎后路椎板减压小关节切除范围对腰椎病变节段稳定性的影响。方法利用有限元方法建立腰椎单节段退变（K4-L5）的L3-S1完整三维模型，在MIMICS软件下模拟腰椎后路椎板减压术，建立切除病变节段椎板及分级切除双侧椎间关节（切除内侧1／3、1／2、2／3及全部下关节突）的L3-S1术后失稳模型，对不同模型施加正常生理载荷，记录病变节段（L4-5）在前屈、后伸、左右侧弯、左右侧旋6个工况的相对位移（运动范围）变化。结果当双侧小关节切除达到1／3时，与术前完整模型相比，模型前屈运动范围增加18％，后伸运动范围增加27％，侧向旋转运动范围增加45％，且随着椎间关节切除范围的增大，运动范围变化也增大。各模型在侧向弯曲时运动范围变化不显著。结论腰椎椎间关节对腰椎节段的稳定性起重要作用，当双侧椎问关节切除范围达到1／3时，即可能引起退变腰椎节段的稳定性丢失。

关节突关节切除范围对下颈椎稳定性影响的生物力学研究

研究保留椎旁肌肉情况下,下颈椎单侧关节突关节分级切除对颈椎稳定性的影响,为临床手术提供理论依据。取5具新鲜山羊颈椎标本,先后分5组进行操作,即完整标本组,左侧C4-5关节突关节25%、50%、75%、100%切除组。先后测量每组每个颈椎标本在三维空间六个方位(前屈、后伸、左右侧屈、左右轴向旋转)随载荷增加而变化的活动度。最后将所得数据进行统计分析。结果表明:随关节突关节切除范围的增大,在相同载荷条件下的位移也增大,其中增长幅度最大发生在50%～75%切除组之间,增长幅度平均在46.7%(前驱、后伸、左右侧弯四个方向)和71.5%(左右轴向旋转)。在保留椎旁肌肉情况下,单侧关节突关节切除范围大于50%时,颈脊柱稳定性丧失。

良性脑膜瘤术后复发的相关因素及预后分析

目的探讨良性脑膜瘤患者术后复发的危险因素及对其预后的影响。方法收集2015年4月至2019年4月于徐州医科大学附属医院神经外科接受手术治疗的915例良性脑膜瘤患者的临床资料,所有患者术后门诊或电话随访1年,根据术后1年内脑膜瘤复发情况将其分为复发组(n=44)和未复发组(n=871)。进行单因素分析和多因素Logistic分析,筛选对患者复发有统计学意义的因素。结果单因素分析结果显示,年龄、肿瘤部位、肿瘤最大直径、肿瘤形状、瘤周水肿情况、肿瘤切除程度、Ki-67表达情况、FASN表达情况、PCNA表达情况是影响良性脑膜瘤术后复发的相关因素(P<0.05)。多因素Logistic分析结果显示,年龄>57岁、肿瘤侵犯静脉窦及大脑镰旁、部分切除及Ki-67表达≥8%是脑膜瘤术后复发的独立危险因素(P<0.05)。结论肿瘤侵犯静脉窦及大脑镰旁、边界不清、部分切除、年龄>57岁、Ki-67表达≥8%的良性脑膜瘤患者术后复发风险更高。临床治疗时应尽可能完全切除,即使对于病理诊断为WHOⅠ级的脑膜瘤患者,也应进一步做免疫组化检测,Ki-67表达情况,以评估预后。

恶性脑膜瘤的诊断及治疗(附16例分析)

目的探讨恶性(WHOⅢ级)脑膜瘤的诊断及治疗方法。方法回顾性分析16例WHOⅢ级脑膜瘤患者的临床资料。结果本组患者临床表现主要为头痛、头晕等高颅内压症状。MRI或CT表现主要为肿瘤分叶、不均匀强化、边界不清、瘤周水肿重,少数有脑膜尾征等。16例患者共行30次显微手术。病理类型为间变型10例,横纹肌样型2例,乳头状型2例,砂粒体型术后恶变2例。手术切除分级为SimpsonⅠ级7例、Ⅱ级8例、Ⅳ级1例,手术切除分级与肿瘤部位、是否复发、瘤周水肿程度、基底宽窄、术中出血量有关(P均<0.05),而与病理类型、Ki-67值、肿瘤大小无关。14例患者完成随访,术后1年,肿瘤复发6例、死亡3例;术后3年,肿瘤复发11例、死亡8例;术后5年,肿瘤复发11例、死亡10例;术后10年,肿瘤复发13例、死亡11例。结论恶性脑膜瘤临床表现无特异性,MRI或CT检查有助于术前诊断,确诊主要依靠病理诊断,治疗首选显微手术切除,预后较差。

Classification of right hepatectomy for special localized malignant tumor in right liver lobe

AIM： To describe a new classification method of righth epatectomy according to the different special positionsof tumors.METHODS： According to positions, 91 patients with malignant hepatic tumor in the right liver lobe were divided into six groups： tumors in the right posterior lobe and （or） the right caudate lobe compressing the right portal hilum （n = 14, 15.4%）, tumors in the right liver lobe compressing the inferior vena cava and （or） hepatic veins （n = 11, 12.9%）, tumors infiltrating diaphragmatic muscle （n = 7, 7.7%）, tumors in the hepatorenal recess （infiltrating the right fatty renal capsule, transverse colon and right adrenal gland, n = 8, 8.8%）, tumors deeply located near the vertebral body （n = 3, 3.3%）, tumors at other sites in the right liver lobe （the control group, n = 48,52.75%）. The values of intraoperative blood loss （IBL）, tumor＇s maxim cross-section area （TMCSA）, and time of hepatic hilum damping （THHC） and incidence of postoperative complications were compared between five groups of tumor and control group, respectively.RESULTS： The THHC in groups 1-4 was significantly longer than that in the control group, the IBL in groups 1-4 was significantly higher than that in the control group, the TMCSA in groups 2-4 was significantly larger than that in the control group, and the ratio of IBL/TMCSA in group 1 was significantly higher than that in the control group. There was no significant difference in the indexes between group 5 and the control group.CONCLUSION： The site of tumor is the key factor that determines IBL.

窦旁脑膜瘤术后复发的分析

目的：观察窦旁脑膜瘤术后复发临床表现并对影响其复发的危险因素进行分析。方法：选取113例在我院接受治疗的窦旁脑膜瘤患者,对其进行手术治疗,之后进行随访,一旦检查出现复发状况立即给予再次治疗。记录所有患者的临床表现及肿瘤的手术切除程度、病理分型、性别、年龄、肿瘤的大小等相关资料。结果：经检查发现52例复发患者均有不同程度的头痛、恶心、呕吐、视乳头水肿、视力下降等症状。窦旁脑膜瘤的复发和患者的年龄、性别及术前有无癫痫发作并没有显著相关性。肿瘤直径〉4 cm、WHOⅡ~Ⅲ级、Simpson切除Ⅱ~Ⅲ级患者复发率显著高于其他患者（P〈0.05）。结论：影响窦旁脑膜瘤术后复发的重要因素是手术切除程度、病理级别以及肿瘤大小,而患者年龄、性别及术前是否有癫痫发作等对复发的影响尚未证实。

“Three-Grade Criteria” of Radical Resection for Primary Liver Cancer

OBJECTIVE The present study was designed to develop the “Three- Grade Criteria” for radical resection of primary liver cancer （PLC） and to evaluate its clinical significance. METHODS Criteria for radical resection of PLC were summed up to 3 grades based on criterion development. Grade Ⅰ： complete removal of all gross tumors with no residual tumor at the excision margin. Grade Ⅱ： on the basis of Grade Ⅰ, additional 4 requirements were added： （1） the tumor was not more than two in number; （2） no tumor thrombi in the main trunks or the primary branches of the portal vein, the common hepatic duct or its primary branches, the hepatic veins or the inferior vena cava; （3）no hilar lymph nodes metastases; （4）no extrahepatic metastases. Grade Ⅲ ： in addition to the above criteria, negative postoperative follow-up result including AFP dropping to a normal level （with positive AFP before surgery） within 2 months after operation, and no residual tumor upon diagnostic imaging.The clinical data from 354 patients with PLC who underwent hepatectomy were reviewed retrospectively. Based on the “Three-Grade Criteria” these patients were divided into 6 groups： Grade Ⅰ radical group, Grade Ⅰ palliative group, Grade Ⅱ radical group, Grade Ⅱ palliative group, Grade Ⅲ radical group, Grade Ⅲ palliative group. The survival rate of each group was calculated by the life-table method and the rates compared among the groups. RESULTS The survival rate of patients receiving radical treatment was better than those receiving palliative treatment （P〈0.01）. Survival improved as more criteria were applied. The 5-year survival rate of the patients in Grade Ⅰ, Ⅱ and Ⅲ who underwent radical resection was 43.2%, 51.2% and 64.4%, respectively （P〈0.01）. CONCLUSION The “Three-Grade Criteria” may be applied for judging the curability of resection therapy for PLC. The stricter the criterion used, the better the survival would be. Adopting high-grade criteria to select cases and guide operations and strengthening postoperative follow-up would improve the results of hepatectomy for PLC.