医学资料甲基强的松龙在脊柱非创伤性疾病治疗中的应用VIP

1、甲基强的松龙在脊柱非创伤甲基强的松龙在脊柱非创伤 性疾病治疗中的应用性疾病治疗中的应用 Methylprednisolone Use in Orthopedic Conditions (Non-traumatic Spinal Diseases) MPMP的药理作用的药理作用 Pharmacologic Effect of MP in SCI (Hall 1981-85) 1. 抑制SCI后脂质过氧化的程度 2. 减轻SCI后损伤部位脊髓血流量下降的程度 3. 提高SCI后Na+-K+ATP酶的活性 4. 支持SCI后的能量代谢 1. Inhibits lipid peroxidation 2

2、. Increases blood flow to site of injury 3. Stimulates Na+-K+ATPase activity 4. Promotes energy metabolism MP的药理作用 Pharmacologic Effect of MP in SCI (Hall 1981-85) 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. Reduces local lactic acid content, increasin

3、g pyruvic acid content 6. Suppresses Ca+ + influx, reducing fibrin degradation 7. Inhibits neutrophil and macrophage infiltration into the injured site 8. Depresses the production of inflammatory mediators and cytokines after injury 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 1.Relieving

4、edema of cell membranes of spinal cord and nerve roots 2.Inhibiting lipid peroxidation of nerve cell membrane, axons and dendrites 3.Suppressing general inflammatory reaction MPMP在脊柱非创伤性疾患中应用的理论依据在脊柱非创伤性疾患中应用的理论依据 Theoretical Support for MP in Treating Non-traumatic Spinal Diseases 4、间接改善局部血液循环 5、抑制

5、细胞的凋亡 6、减轻再灌注损伤 4. Indirectly improving local blood circulation 5. Inhibiting apoptosis 6. Relieving reperfusion injury MPMP在脊柱非创伤性疾患中应用的理论依据在脊柱非创伤性疾患中应用的理论依据 Theoretical Support for MP in Treating Non-traumatic Spinal Diseases MPMP应用现状及方法应用现状及方法 Current Use of MP 方法： 1. 术中或术后可疑有神经系统损伤时， 按照NASCIS II

6、方案应用MP冲击疗法。 2. 其他情况时，应用剂量无统一认识。 Methods 1. MP therapy as per NASCIS II proposal can be applied in cases of suspected nerve injury during or after the operation 2. No consensus on the dosage in other situations 脊柱外科疾病（颈椎）脊柱外科疾病（颈椎） Surgical Treatment of Spine Diseases (cervical spine) 临床常见疾病及治疗方法 1.颈

7、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 Common diseases and treatments 1. Open reduction and internal fixation of fracture-dislocation of cervical spine 2. Anterior or posterior decompression , fixation and fusion for cervical spondylosis 3. Resection of cervical spinal tumors 脊柱外科疾病（颈椎）脊柱外科疾病（颈椎）

8、Diseases of Spine Surgery (cervical spine) 车祸伤 左侧C6神经根损伤 Car crash injury Neurologically deficit of C6 nerve root on left side 碎骨片 Small piece of bone graft 小关节交锁 Locked facet joint 椎间盘碎片 Disc fragment 后路切开复位，经椎弓根螺钉内固定 Posterior approach for ORIF and trans-pedicle screw fixation 前路椎间盘切除、植骨、内固定 Anter

9、ior ACDF and plating 脊髓型颈椎病，发育性颈椎管狭窄,C4-5椎间盘突出 Cervical spondylotic myelopathy, Developmental cervical Spinal stenosis,C4-5 disc protrusion 脊柱外科疾病（颈椎）脊柱外科疾病（颈椎） Diseases of Spine Surgery (cervical spine) 脊柱外科疾病（颈椎）脊柱外科疾病（颈椎） Diseases of Spine Surgery (cervical spine) 后路C3-7椎管成形术+前路C4-5椎间盘切除+CAGE植入 P

10、osterior C3-7 laminoplasty+ Anterior C4-5 discectomy + CAGE implantation 颈椎管内肿瘤，压迫脊髓 Cervical intraspinal tumor, compressed spinal cord 脊柱外科疾病（颈椎）脊柱外科疾病（颈椎） Diseases of Spine Surgery (cervical spine) 脊柱外科疾病（颈椎）脊柱外科疾病（颈椎） Surgical Treatment of Spine Diseases (cervical spine) 4. 颈椎后纵韧带骨化、黄韧带骨化减压手术 5.

11、颈椎畸形的矫正 6. 颈椎结核病灶清除术 4. Decompression of ossification of posterior longitudinal ligament and ligamenta flava of cervical spine 5. Correction of cervical spine malformation/deformity 6. Focus clearance of tuberculosis of cervical spine 颈椎后纵韧带骨化，脊髓严重受压,单开门术后 Ossification of posterior longitudinal liga

12、ment of cervical spine, severely compressed spinal cord，post-open door laminoplasty 脊柱外科疾病（颈椎）脊柱外科疾病（颈椎） Diseases of Spine Surgery (cervical spine) 颈椎结核，椎管内脓肿 Tuberculosis of cervical spine, intraspinal abscess 脊柱外科疾病（颈椎）脊柱外科疾病（颈椎） Diseases of Spine Surgery (cervical spine) 颈椎椎板切除术后后凸畸形 Post-laminec

13、tomy cervical Kyphosis 脊柱外科疾病（颈椎）脊柱外科疾病（颈椎） Diseases of Spine Surgery (cervical spine) 颈椎前路松解+后路松解+前后路固定、矫正、融合 Combined anterior and posterior release, fixation, correction and fusion 脊柱外科疾病（颈椎）脊柱外科疾病（颈椎） Diseases of Spine Surgery (cervical spine) 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 Com

14、mon complications Edema of superior laryngeal nerve and recurrent laryngeal nerve Stretch injury of nerve roots Responsive edema of spinal cord Spinal cord injury 脊柱外科疾病（颈椎）脊柱外科疾病（颈椎） Surgical Treatment of Spine Diseases (cervical spine) 甲强龙对颈前路术后耳鼻喉并发症的影响甲强龙对颈前路术后耳鼻喉并发症的影响 Effects of MP on ENT Comp

15、lications After Anterior Cervical Decompression 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MP Medication: 1mg/kg MP is administered intravenously at the end of operation, 12hr, and 24hr after operation separately Eur-Spine-J 2003 12(1) 84-90 甲强龙对颈前路术后耳鼻喉并发症的影响甲强龙对颈前路术后耳鼻喉并发症的影响 Effects of MP on ENT Comp

16、lications After Anterior Cervical Decompression 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 Evaluation indicators: Objective indicators: Accessing the range of throat mucous membrane lesion according to endoscope Subjective indicators: Patients perceptions about the influence of operation

17、on swallowing Eur-Spine-J 2003 12(1) 84-90 甲强龙对颈前路术后耳鼻喉并发症的影响甲强龙对颈前路术后耳鼻喉并发症的影响 Effects of MP on ENT Complications After Anterior Cervical Decompression 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: MP can relieve the damage of throat mucous membrane after anterior cervical decompression an

18、d reduce the complications of respiratory system Eur-Spine-J 2003 12(1) 84-90 北医三院的治疗方案北医三院的治疗方案 Regimens in Peking University Third Hospital 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 Treatment with MP (1)No acute spinal cord injury 120mg, intravenous injection, administered via Act-o-Vial

19、 Once per day for 3 to 5 days Need not gradually decrease the dosage 北医三院的治疗方案北医三院的治疗方案 Regimens in Peking University Third Hospital 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 Treatment with MP (2) In case of acute spinal cord injury occurred during OP Accor

20、ding to the regimens of MP for ASCI 30mg/kg（bolus), iv, for 20min. 5.4mg/kg/hr (infusion), iv, for 23hr. 解放军总医院骨科应用解放军总医院骨科应用MPMP于颈椎病的外科治疗于颈椎病的外科治疗 Use of MP in the Surgical Treatment of Cervical Spondylosis in Department of Orthopaedics, General Hospital of PLA* 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 I

21、nclusion Criteria: Age 60 years old Final diagnosis is cervical spondylotic myelopathy Treatment: anterior cervical decompression and fixation* Peoples Liberation Army 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 MRI T2加权像有高信号 Exclusion Criteria: Those who have Brain disease Thoracic and lumba

22、r myelopathy or radiculopathy Cervicalspondylotic radiculopathy or OPLL Simultaneous congenital cervical spinal stenosis High signal intensity at MRI T2WI 解放军总医院骨科应用解放军总医院骨科应用MPMP于颈椎病的外科治疗于颈椎病的外科治疗 Use of MP in the Surgical Treatment of Cervical Spondylosis in Department of Orthopaedics, General Hos

23、pital of PLA* 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。 Data of the cases: Group A (N=22) Low dose, MP 80-240mg, b.i.d, 5-7days after operation 解放军总医院骨科应用解放军总医院骨科应用MPMP于颈椎病的外科治疗于颈椎病的外科治疗 Use of MP in the Surgical Treatment of Cervical Spondylosis in Department of Orthopaedics, General Hospit

24、al of PLA* 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 Group B (N=25) High dose, initial dose of 1000mg MP, administered 30 min before decompression; decrease progressively 200mg/d after operation; total 5 days 解放军总医院骨科应用解放军总医院骨科应用MPMP于颈椎病的外科治于颈椎病的外科治 疗疗 Use of MP in the Surgical Treatmen

25、t of Cervical Spondylosis in Department of Orthopaedics, General Hospital of PLA* 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。 Group C (N=24) High dose, initial dose of 1000mg MP, administered immediately after operation; decrease progressively 200mg/d; total 5 days 解放军总医院骨科应用解放军总医院骨科应用MPMP于颈椎病

26、的外科治于颈椎病的外科治 疗疗 Use of MP in the Surgical Treatment of Cervical Spondylosis in Department of Orthopaedics, General Hospital of PLA* 病例资料： D组（N=16) 对照组，未用MP Data of the cases: Group D (N=16) Control; no MP 解放军总医院骨科应用解放军总医院骨科应用MPMP于颈椎病的外科治于颈椎病的外科治 疗疗 Use of MP in the Surgical Treatment of Cervical Spo

27、ndylosis in Department of Orthopaedics, General Hospital of PLA* Neurological function score after operation Group A Group B Group C Group D Near-term (1 week) 39.713.6 53.814.6 56.615.3 41.716.6 Long-term (6 months) 51.414.4 74.816.2 76.814.8 53.118.2 The recovery of function after operationof Grou

28、p B and C is significantly better than that of Group A and D 解放军总医院骨科应用解放军总医院骨科应用MPMP于颈椎病的外科治于颈椎病的外科治 疗疗 Use of MP in the Surgical Treatment of Cervical Spondylosis in Department of Orthopaedics, General Hospital of PLA* 术后神经功能评分恢复率 A组组 B组组 C组组 D组组 近期（近期（1 1周）周）39.739.713.6 53.813.6 53.814.6 56.614.

29、6 56.615.3 41.715.3 41.716.616.6 远期远期( ( 半年半年) 51.4) 51.414.4 74.814.4 74.816.2 76.816.2 76.814.8 53.114.8 53.118.218.2 B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-dose MP improves recovery of neurological function in patients with cervical spondylosis after the operation

30、 解放军总医院骨科应用解放军总医院骨科应用MPMP于颈椎病的外科治于颈椎病的外科治 疗疗 Use of MP in the Surgical Treatment of Cervical Spondylosis in Department of Orthopaedics, General Hospital of PLA* 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-dislocation of thoracic spine Stenosis of thoracic spinal canal Deformity of thoracic sp

31、ine (scoliosis, kyphosis) 脊柱外科疾病（胸椎）脊柱外科疾病（胸椎） Surgical Treatment of Spine Diseases (thoracic spine) 胸椎后纵韧带骨化、黄韧带骨化 胸椎椎管内肿瘤 胸椎结核 Ossification of posterior longitudinal ligament and ligamenta flava of thoracic spine Intraspinal tumors of thoracic spine Tuberculosis of thoracic spine 脊柱外科疾病（胸椎）脊柱外科疾病（

32、胸椎） Surgical Treatment of Spine Diseases (thoracic spine) 疾病类型： 腰椎间盘突出症 腰椎骨折、脱位 腰椎管狭窄 Diseases: Lumber disc protrusion Fracture-dislocation of lumber spine Stenosis of lumber spinal canal 脊柱外科疾病（腰椎）脊柱外科疾病（腰椎） Surgical Treatment of Spine Diseases (thoracic spine) 疾病类型： 腰椎畸形（侧凸、后凸） 腰椎椎管内肿瘤 腰椎结核 Diseas

33、es: Deformity of lumber spine (scoliosis, kyphosis) Intraspinal tumors of lumber spine Tuberculosis of lumber spine 脊柱外科疾病（腰椎）脊柱外科疾病（腰椎） Surgical Treatment of Spine Diseases (lumber spine) MPMP在腰间盘突出症手术治疗中的应用在腰间盘突出症手术治疗中的应用 Use of MP in Surgery for Lumbar Disc Protrusion Mechanical and chemical stim

34、ulation of outer layers of annulus fibrosus and sinuovertebral nerve in posterior longitudinal ligament by protruded nucleus pulposus beck pain Mechanical and chemical stimulation of nerve roots by protruded nucleus pulposus and its inflammatory reaction sciatica 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

35、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神经根性疼痛产生的原因 Causes of Nerve Root Pain 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： Normal nerve roots have some tolerance to compression and stretch. Pathophysiological changes in nucleus pulposus protrusion : 神经根性疼痛产生的原因神经根性疼痛产生的原因 Causes of Nerve Root Pain McC

36、arron(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 Byrod G（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) Nucleus pulposus could cause epidural inflammatory reaction Saal (1990) PLA2 activity increasing in intervertebral disc of patients with lumbar disc protrusion Byrod G (2000) N

37、ucleus pulposus placed epidurally could cause local inflammatory reaction and increase vascular permeability of nerve roots. 神经根性疼痛产生的原因神经根性疼痛产生的原因 Causes of Nerve Root Pain 炎症反应的存在可降低神经根对机械 性作用的耐受性。 Inflammatory reaction could reduce the tolerance of nerve roots to mechanical forces Murphy, et al.

38、Clin Neurosurg. 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。 Stimulation of chemical substance produced by intervertebral disc and autoimmune reaction cause inflammatory reaction of nerve roots. Surgery. WU Zaide. Eds. Peoples Medical Publishing House, 2000. 神经根性疼痛产生的原因神经根性疼痛产生的原因 Causes of Ner

39、ve Root Pain 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。 Protruded nucleus pulposus compress or stretch inflamed nerve roots, result in the obstruction of venous return, further aggravate edema, and increase the sensitivity to pain. Ischemia of compressed nerve roots Surgery. WU Zai

40、de. Eds. Peoples Medical Publishing House, 2000. 神经根性疼痛产生的原因神经根性疼痛产生的原因 Causes of Nerve Root Pain Inclusion Criteria 入选标准入选标准 Acute episode Single level protrusion Inefficiency of 6 weeks conservative therapy Having operation within 6 months after episode Final diagnosis dependent on CT and MRI scan

41、 急性发作 单一节段间盘突出 保守治疗6周无效 发作后6个月内接受手术治疗 确诊依赖CT及MRI检查 手术方法：单侧椎板间开窗，髓核摘除 Surgical procedures: Single level laminotomy, removal of nucleus pulposus MPMP在腰椎间盘突出症手术治疗中的应用在腰椎间盘突出症手术治疗中的应用 Use of MP in Surgery for Lumbar Disc Protrusion J Neurosurg. 1993 Mar;78(3):383-7. 剔除病例剔除病例 Exclusion Criteria 病史超过6个月 多

42、节段间盘突出 椎管狭窄 症状与影像学表现不符 有过椎管内手术史 More than 6 months history Multiplelevel protrusion Stenosis of spinal canal Symptoms not consistent with image manifestation Having history of intraspinal operation 手术方法：单侧椎板间开窗，髓核摘除 Surgical procedures: Single level laminotomy, removal of nucleus pulposus MPMP在腰椎间盘突

43、出症手术治疗中的应用在腰椎间盘突出症手术治疗中的应用 Use of MP in Surgery for Lumbar Disc Protrusion J Neurosurg. 1993 Mar;78(3):383-7. 手术开始时 At the beginning of operation 手术结束时 At the end of operation 第一组 Group 1 250mg MP 静脉注射 160mg MPA 肌肉注射 30ml0.25% 普鲁卡因皮下及肌肉注射 250mg MP IV 160mg MPA IM 30ml 0.25% procaine subcutaneous inj

44、ection and IM 30ml0.25% 普鲁卡因皮下及肌肉注射 浸泡有80mgMPA的脂肪覆盖神经根 30ml 0.25% procaine subcutaneous injection and IM Fat marinated with 80mg MPA covering nerve roots 第二组 Group 2 30ml0.25% 普鲁卡因皮下及肌肉注射 30ml 0.25% procaine subcutaneous injection and IM 30ml0.25% 普鲁卡因皮下及肌肉注射30ml 0.25% procaine subcutaneous injectio

45、n and IM 第三组 Group 3 10ml0.5%利多卡因皮下及肌肉注射 10ml 0.5% procaine subcutaneous injection and IM J Neurosurg. 1993 Mar;78(3):383-7 MPMP在腰椎间盘突出症手术治疗中的应用在腰椎间盘突出症手术治疗中的应用 Use of MP in Surgery for Lumbar Disc Protrusion Complete remission of nerve root pain after operation 0 1 2 3 4 5 6 7 8 9 1 day 1 week 1 mo

46、nth Group 1Group 2Group 3 J Neurosurg. 1993 Mar;78(3):383-7. 术后神经根性疼痛完全缓解情况 Nerve Root Pain Relief After OP 术后时间 Time of Post-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 Conclusions MP administration during surgery for lumbar disc protrusion shortened hospitalization, reduced the u

47、se of analgesia, and relieves the symptoms of nerve root pain faster. MPMP在腰椎间盘突出症手术治疗中的应用在腰椎间盘突出症手术治疗中的应用 Use of MP in Surgery for Lumbar Disc Protrusion 大剂量MP在脊柱手术后的应用 Use of High-dose MP After Spinal Surgery 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: MP Group 30m

48、g/kg MP added in 0.9% normal saline intravenous drip for the first hour after surgery, 5.4mg/kg continuous infusion in subsequent 23hr 陈旸 颈腰痛杂志2003年第24卷第1 期35-36 Chen Yang, 2003 MP methylprednisolone; DX dexamethasone 大剂量MP在脊柱手术后的应用 Use of High-dose MP After Spinal Surgery DX组：术后地塞米松10mg 加入20%甘露醇 25

49、0ml。每日两次，持续一周 DX Group DX 10mg added in 20% mannitol 250ml intravenous drip after peraton, bid, lasting for 1 week 陈旸 颈腰痛杂志2003年第24卷第1期35- 36 Chen Yang, 2003 MP methylprednisolone; DX dexamethasone 大剂量MP在脊柱手术后的应用 Use of High-dose MP After Spinal Surgery MP methylprednisolone; DX dexamethasone 脊柱侧弯 S

50、coliosis 脊柱滑脱 Spondylolisthesis 腰间盘突出 Lumbar disc protrusion 腰椎管狭窄 Stenosis of lumbar spine MP组 MP group0 21613 DX 组 DX group 161211 病例资料： Cases： 陈旸 颈腰痛杂志2003年第24卷第1期35-36 Chen Yang, 2003 结果： 术后1天、2周、3个月 感觉运动评分及患者自主满意度评估。 Results: Time frame: 1 day, 2 weeks and 3 months post-OP Endpoints: Sensory mo

51、tor score and self- satisfaction evaluation 大剂量MP在脊柱手术后的应用 Use of High-dose MP After Spinal Surgery 结果： 术后1天： MP组症状改善或消失占90%，DX组73.3%， 术后2周及3个月：无差异。 Results: 1 day after operation: 90% of patients with symptoms relieved or vanished in MP group, versus 73.3% in DX group. There were no differences bet

52、ween the two groups at 2 weeks and 3 months after the surgery. 大剂量MP在脊柱手术后的应用 Use of High-dose MP After Spinal Surgery MPMP在非创伤性脊柱疾患手术后的应用存在问在非创伤性脊柱疾患手术后的应用存在问 题题 Post-surgical Problems in Use of MP for Non-traumatic Spinal Diseases After Operation 适应症？ 药物剂量的确定？ 用药方法？ 可能的并发症的防治？ Indications? Determi

53、nation of drug dosage? Methods of drug administration? Prevention and treatment of possible complications? 需要多中心双盲对照研究! Multi-center, double blind, case control studies are needed! 谢 谢 颈椎后纵韧带骨化，脊髓严重受压,单开门术后 Ossification of posterior longitudinal ligament of cervical spine, severely compressed spinal cord，post-open door laminoplasty 脊柱外科疾病（颈椎）脊柱外科疾病（颈椎） Diseases of Spine Surgery (cervical spine) 甲强龙对