甲基强的松龙在脊柱非创伤性病治疗中的应用.ppt

甲基强的松龙在脊柱非创伤性疾病治疗中的应用MethylprednisoloneUseinOrthopedicConditions(Non-traumaticSpinalDiseases),北京大学第三医院骨科孙宇YuSun,MDProfessorofOrthopaedicSurgeryPekingUniversityThirdHospitalBeijing,PeoplesRepublicofChina,MP的药理作用PharmacologicEffectofMPinSCI(Hall1981-85),抑制SCI后脂质过氧化的程度减轻SCI后损伤部位脊髓血流量下降的程度提高SCI后Na+-K+ATP酶的活性支持SCI后的能量代谢1.Inhibitslipidperoxidation2.Increasesbloodflowtositeofinjury3.StimulatesNa+-K+ATPaseactivity4.Promotesenergymetabolism,MP的药理作用PharmacologicEffectofMPinSCI(Hall1981-85),5.减少局部乳酸含量，提高丙酮酸含量6.抑制Ca+内流，减轻纤维蛋白的降解7.抑制中性粒细胞和巨噬细胞向损伤部位的浸润8.抑制损伤后炎症介质及炎症性细胞因子的产生5.Reduceslocallacticacidcontent,increasingpyruvicacidcontent6.SuppressesCa+influx,reducingfibrindegradation7.Inhibitsneutrophilandmacrophageinfiltrationintotheinjuredsite8.Depressestheproductionofinflammatorymediatorsandcytokinesafterinjury,1、减轻脊髓和神经根细胞膜水肿2、抑制神经细胞膜和轴突、树突的脂质过氧化进程3、抑制一般性炎症反应和作用RelievingedemaofcellmembranesofspinalcordandnerverootsInhibitinglipidperoxidationofnervecellmembrane,axonsanddendritesSuppressinggeneralinflammatoryreaction,MP在脊柱非创伤性疾患中应用的理论依据TheoreticalSupportforMPinTreatingNon-traumaticSpinalDiseases,4、间接改善局部血液循环5、抑制细胞的凋亡6、减轻再灌注损伤4.Indirectlyimprovinglocalbloodcirculation5.Inhibitingapoptosis6.Relievingreperfusioninjury,MP在脊柱非创伤性疾患中应用的理论依据TheoreticalSupportforMPinTreatingNon-traumaticSpinalDiseases,常见的脊柱非创伤性疾患CommonNon-traumaticSpinalDiseases,1、慢性压迫性颈脊髓病2、胸椎管狭窄症3、腰椎间盘突出症及腰椎管狭窄症4、脊柱肿瘤5、脊柱结核ChroniccompressivecervicalmyelopathyStenosisofthoracicspinalcanalLumbardiscprotrusionandstenosisoflumbarspinalcanalSpinaltumorsTuberculosisofspine,MP应用现状及方法CurrentUseofMP,指征：1.脊髓或神经严重受压者2.术中或术后可疑有神经系统损伤Indication1.Severecompressionofspinalcordornerves2.Suspectednerveinjuryduringoraftertheoperation,MP应用现状及方法CurrentUseofMP,方法：1.术中或术后可疑有神经系统损伤时，按照NASCISII方案应用MP冲击疗法。2.其他情况时，应用剂量无统一认识。Methods1.MPtherapyasperNASCISIIproposalcanbeappliedincasesofsuspectednerveinjuryduringoraftertheoperation2.Noconsensusonthedosageinothersituations,脊柱外科疾病（颈椎）SurgicalTreatmentofSpineDiseases(cervicalspine),临床常见疾病及治疗方法1.颈椎骨折脱位切开复位内固定2.颈椎病前路、后路减压、固定、融合3.颈椎肿瘤切除Commondiseasesandtreatments1.Openreductionandinternalfixationoffracture-dislocationofcervicalspine2.Anteriororposteriordecompression,fixationandfusionforcervicalspondylosis3.Resectionofcervicalspinaltumors,脊柱外科疾病（颈椎）DiseasesofSpineSurgery(cervicalspine),车祸伤左侧C6神经根损伤CarcrashinjuryNeurologicallydeficitofC6nerverootonleftside,碎骨片Smallpieceofbonegraft,小关节交锁Lockedfacetjoint,椎间盘碎片Discfragment,后路切开复位，经椎弓根螺钉内固定PosteriorapproachforORIFandtrans-pediclescrewfixation,前路椎间盘切除、植骨、内固定AnteriorACDFandplating,脊髓型颈椎病，发育性颈椎管狭窄,C4-5椎间盘突出Cervicalspondyloticmyelopathy,DevelopmentalcervicalSpinalstenosis,C4-5discprotrusion,脊柱外科疾病（颈椎）DiseasesofSpineSurgery(cervicalspine),脊柱外科疾病（颈椎）DiseasesofSpineSurgery(cervicalspine),后路C3-7椎管成形术+前路C4-5椎间盘切除+CAGE植入PosteriorC3-7laminoplasty+AnteriorC4-5discectomy+CAGEimplantation,颈椎管内肿瘤，压迫脊髓Cervicalintraspinaltumor,compressedspinalcord,脊柱外科疾病（颈椎）DiseasesofSpineSurgery(cervicalspine),脊柱外科疾病（颈椎）SurgicalTreatmentofSpineDiseases(cervicalspine),4.颈椎后纵韧带骨化、黄韧带骨化减压手术5.颈椎畸形的矫正6.颈椎结核病灶清除术4.Decompressionofossificationofposteriorlongitudinalligamentandligamentaflavaofcervicalspine5.Correctionofcervicalspinemalformation/deformity6.Focusclearanceoftuberculosisofcervicalspine,颈椎后纵韧带骨化，脊髓严重受压,单开门术后Ossificationofposteriorlongitudinalligamentofcervicalspine,severelycompressedspinalcord，post-opendoorlaminoplasty,脊柱外科疾病（颈椎）DiseasesofSpineSurgery(cervicalspine),颈椎结核，椎管内脓肿Tuberculosisofcervicalspine,intraspinalabscess,脊柱外科疾病（颈椎）DiseasesofSpineSurgery(cervicalspine),颈椎椎板切除术后后凸畸形Post-laminectomycervicalKyphosis,脊柱外科疾病（颈椎）DiseasesofSpineSurgery(cervicalspine),颈椎前路松解+后路松解+前后路固定、矫正、融合Combinedanteriorandposteriorrelease,fixation,correctionandfusion,脊柱外科疾病（颈椎）DiseasesofSpineSurgery(cervicalspine),手术常见并发症*喉上神经、喉返神经水肿*神经根牵拉损伤*反应性脊髓水肿*脊髓损伤CommoncomplicationsEdemaofsuperiorlaryngealnerveandrecurrentlaryngealnerveStretchinjuryofnerverootsResponsiveedemaofspinalcordSpinalcordinjury,脊柱外科疾病（颈椎）SurgicalTreatmentofSpineDiseases(cervicalspine),甲强龙对颈前路术后耳鼻喉并发症的影响EffectsofMPonENTComplicationsAfterAnteriorCervicalDecompression,给药方法分别于术后即刻，术后12小时，24小时按1mg/kg的剂量静脉注射MPMedication:1mg/kgMPisadministeredintravenouslyattheendofoperation,12hr,and24hrafteroperationseparately,Eur-Spine-J200312(1)84-90,甲强龙对颈前路术后耳鼻喉并发症的影响EffectsofMPonENTComplicationsAfterAnteriorCervicalDecompression,评价指标:-客观指标:根据内窥镜评价咽、喉黏膜受损的范围-主观指标:患者自觉手术对吞咽的影响Evaluationindicators:Objectiveindicators:AccessingtherangeofthroatmucousmembranelesionaccordingtoendoscopeSubjectiveindicators:Patientsperceptionsabouttheinfluenceofoperationonswallowing,Eur-Spine-J200312(1)84-90,甲强龙对颈前路术后耳鼻喉并发症的影响EffectsofMPonENTComplicationsAfterAnteriorCervicalDecompression,结论：甲强龙可减轻颈前路术后咽、喉黏膜受损的程度、减少呼吸系统并发症的发生。Conclusions:MPcanrelievethedamageofthroatmucousmembraneafteranteriorcervicaldecompressionandreducethecomplicationsofrespiratorysystem,Eur-Spine-J200312(1)84-90,北医三院的治疗方案RegimensinPekingUniversityThirdHospital,甲强龙用法:(1)未发生急性脊髓损伤120mg,静脉输入，小壶给药持续3-5天不需要逐渐减量TreatmentwithMP(1)Noacutespinalcordinjury120mg,intravenousinjection,administeredviaAct-o-VialOnceperdayfor3to5daysNeednotgraduallydecreasethedosage,北医三院的治疗方案RegimensinPekingUniversityThirdHospital,甲强龙用法:(2)术中发生急性脊髓损伤按照急性脊髓损伤治疗方案30mg/kg（冲击量），静注，持续20分钟5.4mg/kg/小时（持续量），静注，持续23小时TreatmentwithMP(2)IncaseofacutespinalcordinjuryoccurredduringOPAccordingtotheregimensofMPforASCI30mg/kg（bolus),iv,for20min.5.4mg/kg/hr(infusion),iv,for23hr.,解放军总医院骨科应用MP于颈椎病的外科治疗UseofMPintheSurgicalTreatmentofCervicalSpondylosisinDepartmentofOrthopaedics,GeneralHospitalofPLA*,入选标准：年龄60岁确诊为脊髓型颈椎病手术方式为颈前路减压固定InclusionCriteria:Age60yearsoldFinaldiagnosisiscervicalspondyloticmyelopathyTreatment:anteriorcervicaldecompressionandfixation,*PeoplesLiberationArmy,排除标准：有脑部疾患者有胸、腰段脊髓或神经根病变合并神经根型颈椎病或OPLL先天性颈椎管狭窄MRIT2加权像有高信号ExclusionCriteria:ThosewhohaveBraindiseaseThoracicandlumbarmyelopathyorradiculopathyCervicalspondyloticradiculopathyorOPLLSimultaneouscongenitalcervicalspinalstenosisHighsignalintensityatMRIT2WI,解放军总医院骨科应用MP于颈椎病的外科治疗UseofMPintheSurgicalTreatmentofCervicalSpondylosisinDepartmentofOrthopaedics,GeneralHospitalofPLA*,病例资料：A组（N=22)小剂量。MP80-240mg/次，每天2次，术后应用持续5-7天。Dataofthecases:GroupA(N=22)Lowdose,MP80-240mg,b.i.d,5-7daysafteroperation,解放军总医院骨科应用MP于颈椎病的外科治疗UseofMPintheSurgicalTreatmentofCervicalSpondylosisinDepartmentofOrthopaedics,GeneralHospitalofPLA*,B组（N=25)：大剂量。MP首剂1000mg，术中减压前30min应用，术后每日递减200mg，共5天GroupB(N=25)Highdose,initialdoseof1000mgMP,administered30minbeforedecompression;decreaseprogressively200mg/dafteroperation;total5days,解放军总医院骨科应用MP于颈椎病的外科治疗UseofMPintheSurgicalTreatmentofCervicalSpondylosisinDepartmentofOrthopaedics,GeneralHospitalofPLA*,C组（N=24)：大剂量。MP首剂1000mg，术后当天应用，术后每日递减200mg，共5天。GroupC(N=24)Highdose,initialdoseof1000mgMP,administeredimmediatelyafteroperation;decreaseprogressively200mg/d;total5days,解放军总医院骨科应用MP于颈椎病的外科治疗UseofMPintheSurgicalTreatmentofCervicalSpondylosisinDepartmentofOrthopaedics,GeneralHospitalofPLA*,病例资料：D组（N=16)对照组，未用MPDataofthecases:GroupD(N=16)Control;noMP,解放军总医院骨科应用MP于颈椎病的外科治疗UseofMPintheSurgicalTreatmentofCervicalSpondylosisinDepartmentofOrthopaedics,GeneralHospitalofPLA*,NeurologicalfunctionscoreafteroperationGroupAGroupBGroupCGroupDNear-term(1week)39.713.653.814.656.615.341.716.6Long-term(6months)51.414.474.816.276.814.853.118.2TherecoveryoffunctionafteroperationofGroupBandCissignificantlybetterthanthatofGroupAandD,解放军总医院骨科应用MP于颈椎病的外科治疗UseofMPintheSurgicalTreatmentofCervicalSpondylosisinDepartmentofOrthopaedics,GeneralHospitalofPLA*,术后神经功能评分恢复率A组B组C组D组近期（1周）39.713.653.814.656.615.341.716.6远期(半年)51.414.474.816.276.814.853.118.2B组和C组术后神经功能的改善明显优于A组及D组,结论：大剂量MP应用于颈椎病患者有助于术后神经功能改善Conclusions:High-doseMPimprovesrecoveryofneurologicalfunctioninpatientswithcervicalspondylosisaftertheoperation,解放军总医院骨科应用MP于颈椎病的外科治疗UseofMPintheSurgicalTreatmentofCervicalSpondylosisinDepartmentofOrthopaedics,GeneralHospitalofPLA*,疾病类型：胸椎骨折、脱位胸椎管狭窄胸椎畸形（侧凸、后凸）Diseases:Fracture-dislocationofthoracicspineStenosisofthoracicspinalcanalDeformityofthoracicspine(scoliosis,kyphosis),脊柱外科疾病（胸椎）SurgicalTreatmentofSpineDiseases(thoracicspine),胸椎后纵韧带骨化、黄韧带骨化胸椎椎管内肿瘤胸椎结核OssificationofposteriorlongitudinalligamentandligamentaflavaofthoracicspineIntraspinaltumorsofthoracicspineTuberculosisofthoracicspine,脊柱外科疾病（胸椎）SurgicalTreatmentofSpineDiseases(thoracicspine),疾病类型：腰椎间盘突出症腰椎骨折、脱位腰椎管狭窄Diseases:LumberdiscprotrusionFracture-dislocationoflumberspineStenosisoflumberspinalcanal,脊柱外科疾病（腰椎）SurgicalTreatmentofSpineDiseases(thoracicspine),疾病类型：腰椎畸形（侧凸、后凸）腰椎椎管内肿瘤腰椎结核Diseases:Deformityoflumberspine(scoliosis,kyphosis)IntraspinaltumorsoflumberspineTuberculosisoflumberspine,脊柱外科疾病（腰椎）SurgicalTreatmentofSpineDiseases(lumberspine),MP在腰间盘突出症手术治疗中的应用UseofMPinSurgeryforLumbarDiscProtrusion,Mechanicalandchemicalstimulationofouterlayersofannulusfibrosusandsinuovertebralnerveinposteriorlongitudinalligamentbyprotrudednucleuspulposusbeckpain,Mechanicalandchemicalstimulationofnerverootsbyprotrudednucleuspulposusanditsinflammatoryreactionsciatica,突出的髓核对纤维环外层及后纵韧带上的窦椎神经的机械性、化学性刺激腰痛,突出的髓核及其引起的炎症反应对神经根的机械性、化学性刺激坐骨神经痛,神经根性疼痛产生的原因CausesofNerveRootPain,正常的神经根对于压迫和牵拉有一定的耐受性。髓核突出后的病理生理改变：Normalnerverootshavesometolerancetocompressionandstretch.Pathophysiologicalchangesinnucleuspulposusprotrusion:,神经根性疼痛产生的原因CausesofNerveRootPain,McCarron(1967)髓核可以引起硬膜外的炎症反应Saal(1990)腰椎间盘突出症的患者间盘组织内PLA2活性增高ByrodG（2000）硬膜外放置髓核组织可引发局部炎症反应，增加神经根血管的通透性McCarron(1967)NucleuspulposuscouldcauseepiduralinflammatoryreactionSaal(1990)PLA2activityincreasinginintervertebraldiscofpatientswithlumbardiscprotrusionByrodG(2000)Nucleuspulposusplacedepidurallycouldcauselocalinflammatoryreactionandincreasevascularpermeabilityofnerveroots.,神经根性疼痛产生的原因CausesofNerveRootPain,炎症反应的存在可降低神经根对机械性作用的耐受性。InflammatoryreactioncouldreducethetoleranceofnerverootstomechanicalforcesMurphy,etal.ClinNeurosurg.1997;15:343-351.,间盘组织产生化学性物质的刺激及自身免疫反应使神经根产生炎症。Stimulationofchemicalsubstanceproducedbyintervertebraldiscandautoimmunereactioncauseinflammatoryreactionofnerveroots.Surgery.WUZaide.Eds.PeoplesMedicalPublishingHouse,2000.,神经根性疼痛产生的原因CausesofNerveRootPain,突出的髓核压迫或牵张已有炎症的神经根，使其静脉回流受阻，进一步增加水肿，从而对疼痛的敏感性增高。受压的神经根缺血。Protrudednucleuspulposuscompressorstretchinflamednerveroots,resultintheobstructionofvenousreturn,furtheraggravateedema,andincreasethesensitivitytopain.IschemiaofcompressednerverootsSurgery.WUZaide.Eds.PeoplesMedicalPublishingHouse,2000.,神经根性疼痛产生的原因CausesofNerveRootPain,手术方法：单侧椎板间开窗，髓核摘除Surgicalprocedures:Singlelevellaminotomy,removalofnucleuspulposus,MP在腰椎间盘突出症手术治疗中的应用UseofMPinSurgeryforLumbarDiscProtrusion,JNeurosurg.1993Mar;78(3):383-7.,手术方法：单侧椎板间开窗，髓核摘除Surgicalprocedures:Singlelevellaminotomy,removalofnucleuspulposus,MP在腰椎间盘突出症手术治疗中的应用UseofMPinSurgeryforLumbarDiscProtrusion,JNeurosurg.1993Mar;78(3):383-7.,JNeurosurg.1993Mar;78(3):383-7,MP在腰椎间盘突出症手术治疗中的应用UseofMPinSurgeryforLumbarDiscProtrusion,Completeremissionofnerverootpainafteroperation,0,1,2,3,4,5,6,7,8,9,1day,1week,1month,Group1,Group2,Group3,JNeurosurg.1993Mar;78(3):383-7.,术后神经根性疼痛完全缓解情况NerveRootPainReliefAfterOP,术后时间TimeofPost-OP,结论腰椎间盘突出症手术中应用MP可缩短腰间盘突出症病人的住院时间，减少术后止痛药的应用，更快的缓解根性疼痛症状ConclusionsMPadministrationduringsurgeryforlumbardiscprotrusionshortenedhospitalization,reducedtheuseofanalgesia,andrelievesthesymptomsofnerverootpainfaster.,MP在腰椎间盘突出症手术治疗中的应用UseofMPinSurgeryforLumbarDiscProtrusion,大剂量MP在脊柱手术后的应用UseofHigh-doseMPAfterSpinalSurgery,用药方法：MP组：术后1小时甲强龙按30mg/kg加入0.9%生理盐水1小时内滴注，以后23小时按5.4mg/kg维持滴注。Treatment:MPGroup30mg/kgMPaddedin0.9%normalsalineintravenousdripforthefirsthouraftersurger