腰椎间盘营养扩散途径的DCE-MRI研究进展

椎间盘退变是颈、腰椎病发生发展的根本原因，不同程度的影响患者的生活质量[1]。流行病学研究表明营养供应减少、细胞凋亡失衡、基质酶活性改变、生物力学机制及自身免疫反应等均可能是导致椎间盘退变的重要因素[2]，营养物质缺乏被认为是诸多因素中导致椎间盘退变的首要影响因素并被体外研究所证实[3]。当某些病因引起营养椎体的血液供应减少时，影响了髓核营养的输送，终导致椎间盘退变的发生。既往检测扩散途径的方法较多，但主要集中在离体研究上[4]，如何无创检测活体对于早期预防和干预治疗具有重要意义。磁共振成像(magneticresonanceimaging，MRI)应用于医学领域已有20多年历史，动态增强磁共振扫描(dynamiccontrastenhanced-MRI，DCE-MRI)通过MRI对比剂进入椎间盘的快慢及多少反映椎间盘的营养扩散过程，具有可重复、无创的优点，是一种新的分析椎间盘营养机制的方法，现将其机制进行综述。

骶椎隐球菌骨髓炎一例报告

骶椎隐球菌骨髓炎临床上非常罕见，容易误诊为骶椎原发性肿瘤和转移瘤。2012年我院收治1例骶椎隐球菌骨髓炎，现报道如下。

Degenerative constrictions of the spinal canal with compression of neural elements arise as a result of bony, disk, capsular or ligament structures. The most frequent causes are disk herniations and spinal stenoses. The lumbar and cervical spine is the most prominent cause. After conservative treatments have been exhausted, surgical intervention may be necessary. Today, microsurgical or microscopically-assisted decompression is regarded as the standard procedure for disk herniation and spinal stenosis in the lumbar region, while in the cervical spine, microsurgical or microscopically-assisted anterior decompression and fusion are standard. Both procedures demonstrate good clinical results but present problems associated with the operation. Decompressions in the area of the spine must be carried out under continuous visualization and must entail the possibility of adequate bone resection. Taking this into account, completely new endoscopes and instrument sets has been developed for full-endoscopic operations in tandem with the development of the lateral transforaminal and interlaminar approaches for the lumbar spine and the posterior, contralateral and anterior approaches for the cervical spine. The possibilities and results of comparable and established standard procedures have been used as a benchmark in the course of clinical validation. The development of surgically created approaches and the new rod lens endoscopes combined with appropriate instrument sets have laid the technical foundations for full-endoscopic operation in the lumbar spine on all primary and recurrent disk herniations inside and outside the spinal canal and on spinal stenoses. This development has also permitted resection of soft disk herniations in the cervical spine. The use of the relevant approaches depends on anatomical and pathological inclusion and exclusion criteria. The clinical results of standard procedures are achieved, which must be regarded as a minimum criterion for the introduction of new technologies. On the basis of evidence-based medicine ( EBM ) criteria, it can be established that using the full-endoscopic techniques developed, adequate decompression is achieved in the deifned indications with reduced traumatization, improved visibility conditions and positive cost beneifts. Today, full-endoscopic operations may be regarded as an expansion and alternative within the overall concept of spinal surgery.

经皮侧后路腰椎间孔成形与经椎间孔完全内镜下腰椎间盘摘除术

一、背景
　　1992年，报道经侧后路内窥镜下进行腰椎间盘摘除术以来，许多学者报告了经椎间孔内窥镜下腰椎间盘摘除术的技术及疗效[1-3]。完全内镜下腰椎间盘摘除术是指使用带工作通道的硬杆状内镜在持续生理盐水灌洗下进行的微创腰椎间盘摘除手术，分为经椎间孔入路和经椎板间入路两类技术[4]。Yeung等[5-7]发明的YESS(yeungendoscopicspinesystem)系统是早的完全内镜手术系统，早的完全内镜下腰椎间盘摘除术是使用YESS系统经后外侧椎间孔入路进行的由盘内至盘外的操作技术，适用于椎间孔型及极外侧型椎间盘突出，对椎管内包含型突出及韧带下型椎间盘脱出也可以有效处理，但对椎管内脱出及游离髓核无法有效切除。Ruetten等[8]采用侧方入路技术可以将内镜经椎间孔置入椎管内，摘除脱出及游离髓核组织，使经椎间孔完全内镜下腰椎间盘摘除术适应证进一步扩大，但L5～S1节段由于侧方髂骨的阻挡，使该技术无法实施；对于高位腰椎间盘突出症使用该技术有损伤腹腔脏器的风险。随着腰椎间孔成型技术的出现及内窥镜手术系统的改进，可以对腰椎间孔有效扩大，使内镜可以经椎间孔进入椎管内，对合并腰椎侧隐窝或椎间孔狭窄者也可一起处理，对L5～S1椎间盘突出症亦可适用，大大扩展经皮经椎间孔完全内镜下腰椎间盘摘除术的适应证，提高疗效及安全性[9-11]。但我们也要记住：尽管经椎间孔入路完全内镜技术经过上述技术改进，用于椎管内巨大型脱出及高度移位型椎间盘突出症时，仍然有高达15.7%的失败率，所以经椎板间入路完全内镜下腰椎间盘摘除术是必要的补充，尤其适用于L5～S1节段及其他节段椎间盘突出并高度移位者[12-14]。

医者当怀一颗好奇之心--兼评：骶椎隐球菌骨髓炎一例报告

常言道：医者仁心，也就是说医生需要有高尚的医德，正如古语“心不近佛不可为医”。现代社会，作为一名优秀的医生，除了有德，还要有术，又如“才不近仙不可为医”。如何拥有高超的医术？答案一定包含很多，但笔者以为，常怀一颗好奇心，也是其中的一个要素。