医学资料-甲基强松龙在脊柱非创伤性疾病治疗中应用

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第一页，共61页。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第二页，共61页。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,axonsand

dendritesSuppressinggeneralinflammatoryreactionMP在脊柱非创伤性疾患中应用的理论依据

TheoreticalSupportforMPinTreating

Non-traumaticSpinalDiseases第三页，共61页。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

TheoreticalSupportforMPinTreating

Non-traumaticSpinalDiseases第四页，共61页。常见的脊柱非创伤性疾患

CommonNon-traumaticSpinalDiseases1、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ChroniccompressivecervicalmyelopathyStenosisofthoracicspinalcanalLumbardiscprotrusionandstenosisoflumbarspinalcanal

Spinaltumors

Tuberculosisofspine第五页，共61页。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

Indication

1.Severecompressionofspinalcordornerves2.Suspectednerveinjuryduringoraftertheoperation第六页，共61页。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。Methods

1.MP

therapyasperNASCISIIproposal

canbeappliedincasesofsuspectednerveinjuryduringoraftertheoperation

2.Noconsensusonthedosageinothersituations

第七页，共61页。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.Resection

ofcervicalspinal

tumors第八页，共61页。脊柱外科疾病（颈椎）

DiseasesofSpineSurgery(cervicalspine)车祸伤左侧C6神经根损伤CarcrashinjuryNeurologicallydeficitofC6nerverootonleftside第九页，共61页。碎骨片Smallpieceofbonegraft第十页，共61页。小关节交锁Lockedfacetjoint第十一页，共61页。椎间盘碎片Discfragment第十二页，共61页。后路切开复位，经椎弓根螺钉内固定PosteriorapproachforORIFandtrans-pediclescrewfixation第十三页，共61页。第十四页，共61页。前路椎间盘切除、植骨、内固定AnteriorACDFandplating第十五页，共61页。第十六页，共61页。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)第十七页，共61页。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+Anterior

C4-5discectomy+CAGEimplantation第十八页，共61页。颈椎管内肿瘤，压迫脊髓Cervicalintraspinaltumor,compressedspinalcord脊柱外科疾病（颈椎）

DiseasesofSpineSurgery(cervicalspine)第十九页，共61页。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.Decompressionofossificationofposteriorlongitudinalligament

andligamentaflavaofcervicalspine5.Correction

ofcervicalspinemalformation/deformity6.Focusclearanceoftuberculosisofcervicalspine第二十页，共61页。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)第二十一页，共61页。颈椎结核，椎管内脓肿Tuberculosisofcervicalspine,intraspinalabscess脊柱外科疾病（颈椎）

DiseasesofSpineSurgery(cervicalspine)第二十二页，共61页。颈椎椎板切除术后后凸畸形Post-laminectomycervicalKyphosis

脊柱外科疾病（颈椎）

DiseasesofSpineSurgery(cervicalspine)第二十三页，共61页。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)第二十四页，共61页。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CommoncomplicationsEdemaofsuperiorlaryngealnerve

andrecurrentlaryngealnerveStretchinjuryofnerverootsResponsiveedemaofspinalcordSpinalcordinjury

脊柱外科疾病（颈椎）

SurgicalTreatmentofSpineDiseases(cervicalspine)

第二十五页，共61页。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第二十六页，共61页。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:

Patients’perceptionsabouttheinfluenceofoperationonswallowingEur-Spine-J200312(1)84-90第二十七页，共61页。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:

MPcanrelievethedamageofthroatmucousmembraneafteranteriorcervicaldecompressionandreducethecomplicationsofrespiratorysystemEur-Spine-J200312(1)84-90第二十八页，共61页。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

第二十九页，共61页。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.第三十页，共61页。解放军总医院骨科应用MP于颈椎病的外科治疗

UseofMPintheSurgicalTreatmentofCervicalSpondylosis

inDepartmentofOrthopaedics,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:Age≤60

yearsoldFinaldiagnosisiscervicalspondyloticmyelopathyTreatment:anteriorcervicaldecompressionandfixation*People’sLiberationArmy第三十一页，共61页。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:ThosewhohaveBraindiseaseThoracicandlumbar

myelopathyorradiculopathyCervicalspondyloticradiculopathyorOPLLSimultaneouscongenitalcervicalspinalstenosisHighsignalintensityatMRIT2WI

解放军总医院骨科应用MP于颈椎病的外科治疗

UseofMPintheSurgicalTreatmentofCervicalSpondylosis

inDepartmentofOrthopaedics,GeneralHospitalofPLA*第三十二页，共61页。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:Group

A

(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

UseofMPintheSurgicalTreatmentofCervicalSpondylosis

inDepartmentofOrthopaedics,GeneralHospitalofPLA*第三十三页，共61页。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)

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

UseofMPintheSurgicalTreatmentofCervicalSpondylosis

inDepartmentofOrthopaedics,GeneralHospitalofPLA*第三十四页，共61页。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)

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

UseofMPintheSurgicalTreatmentofCervicalSpondylosis

inDepartmentofOrthopaedics,GeneralHospitalofPLA*第三十五页，共61页。

病例资料：D组（N=16)对照组，未用MPDataofthecases:Group

D(N=16) Control;noMP解放军总医院骨科应用MP于颈椎病的外科治疗

UseofMPintheSurgicalTreatmentofCervicalSpondylosis

inDepartmentofOrthopaedics,GeneralHospitalofPLA*第三十六页，共61页。Neurologicalfunctionscoreafteroperation

GroupA

Group

B

Group

C

Group

D

Near-term(1

week)39.7±13.653.8±14.656.6±15.341.7±16.6

Long-term(6months)51.4±14.474.8±16.276.8±14.853.1±18.2TherecoveryoffunctionafteroperationofGroupBandC

issignificantlybetter

thanthatofGroupAandD解放军总医院骨科应用MP于颈椎病的外科治疗

UseofMPintheSurgicalTreatmentofCervicalSpondylosis

inDepartmentofOrthopaedics,GeneralHospitalofPLA*

术后神经功能评分恢复率

A组B组C组D组近期（1周）39.7±13.653.8±14.656.6±15.341.7±16.6

远期(半年)51.4±14.474.8±16.276.8±14.853.1±18.2

B组和C组术后神经功能的改善明显优于A组及D组

第三十七页，共61页。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

UseofMPintheSurgicalTreatmentofCervicalSpondylosis

inDepartmentofOrthopaedics,GeneralHospitalofPLA*第三十八页，共61页。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

ofthoracicspineStenosisofthoracicspinalcanalDeformityofthoracicspine(scoliosis,kyphosis)脊柱外科疾病（胸椎）

SurgicalTreatmentofSpineDiseases(thoracicspine)第三十九页，共61页。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)第四十页，共61页。疾病类型：腰椎间盘突出症腰椎骨折、脱位腰椎管狭窄Diseases:LumberdiscprotrusionFracture-dislocation

oflumberspineStenosisoflumberspinalcanal脊柱外科疾病（腰椎）

SurgicalTreatmentofSpineDiseases(thoracicspine)第四十一页，共61页。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)第四十二页，共61页。MP在腰间盘突出症手术治疗中的应用

UseofMPinSurgeryforLumbarDiscProtrusion

第四十三页，共61页。Mechanicalandchemicalstimulation

ofouterlayersofannulusfibrosus

andsinuovertebralnerveinposteriorlongitudinalligamentbyprotruded

nucleuspulposus——beckpainMechanicalandchemicalstimulationofnerverootsbyprotruded

nucleuspulposusanditsinflammatoryreaction——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——坐骨神经痛第四十四页，共61页。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.Pathophysiological

changesinnucleuspulposusprotrusion:

第四十五页，共61页。神经根性疼痛产生的原因

CausesofNerveRootPainMcCarron(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)

Nucleuspulposuscouldcauseepiduralinflammatoryreaction

Saal(1990)

PLA2activityincreasinginintervertebraldisc

ofpatientswithlumbardiscprotrusion

ByrodG(2000)

Nucleuspulposusplacedepidurallycouldcauselocalinflammatoryreactionandincreasevascularpermeabilityofnerveroots.第四十六页，共61页。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。Inflammatoryreactioncouldreducethetoleranceofnerverootstomechanicalforces

Murphy,etal.ClinNeurosurg.1997;15:343-351.第四十七页，共61页。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.

People’sMedicalPublishingHouse,2000.神经根性疼痛产生的原因

CausesofNerveRootPain第四十八页，共61页。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

nucleuspulposuscompressorstretchinflamednerveroots,resultintheobstructionofvenousreturn,furtheraggravateedema,andincreasethesensitivitytopain.Ischemiaofcompressednerveroots

Surgery.WUZaide.Eds.

People’sMedicalPublishingHouse,2000.神经根性疼痛产生的原因

CausesofNerveRootPain第四十九页，共61页。

InclusionCriteria

入选标准AcuteepisodeSinglelevel

protrusionInefficiencyof6weeksconservativetherapyHavingoperationwithin6monthsafterepisodeFinaldiagnosisdependentonCT

andMRIscan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

Surgicalprocedures:Singlelevellaminotomy,removalofnucleuspulposusMP在腰椎间盘突出症手术治疗中的应用

UseofMPinSurgery

forLumbarDiscProtrusionJNeurosurg.1993Mar;78(3):383-7.第五十页，共61页。

剔除病例ExclusionCriteria

病史超过6个月多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Morethan6monthshistory

Multiplelevelprotrusion

Stenosis

ofspinalcanal

Symptomsnotconsistentwithimagemanifestation

Havinghistoryofintraspinaloperation手术方法：单侧椎板间开窗，髓核摘除

Surgicalprocedures:Singlelevellaminotomy,removalofnucleuspulposusMP在腰椎间盘突出症手术治疗中的应用

UseofMPinSurgery

forLumbarDiscProtrusionJNeurosurg.1993Mar;78(3):383-7.第五十一页，共61页。手术开始时Atthebeginningofoperation

手术结束时Attheendofoperation第一组Group1250mgMP静脉注射160mgMPA肌肉注射

30ml0.25%普鲁卡因皮下及肌肉注射250mgMPIV160mgMPAIM30ml0.25%procainesubcutaneousinjectionandIM30ml0.25%普鲁卡因皮下及肌肉注射浸泡有80mgMPA的脂肪覆盖神经根30ml0.25%procainesubcutaneousinjectionandIMFatmarinatedwith80mgMPAcoveringnerveroots

第二组Group230ml0.25%普鲁卡因皮下及肌肉注射30ml0.25%procainesubcutaneousinjectionandIM30ml0.25%普鲁卡因皮下及肌肉注射30ml0.25%procainesubcutaneousinjectionandIM第三组Group310ml0.5%利多卡因皮下及肌肉注射10ml0.5%procainesubcutaneousinjectionandIMJNeurosurg.1993Mar;78(3):383-7MP在腰椎间盘突出症手术治疗中的应用

UseofMPinSurgery

forLumbarDiscProtrusion第五十二页，共61页。

Completeremissionofnerve

rootpainafteroperation01234567891day1week1monthGroup1Group2Group3JNeurosurg.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第五十三页，共61页。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

MPadministrationduringsurgery

forlumbardiscprotrusionshortenedhospitalization,reducedtheuseofanalgesia,andrelievesthesymptomsofnerverootpainfaster.MP在腰椎间盘突出症手术治疗中的应用

UseofMPinSurgery

forLumbarDiscProtrusion第五十四页，共61页。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:

MPGroup

30mg/kgMPaddedin0.9%normalsalineintravenousdripforthefirsthouraftersurgery,5.4mg/kgcontinuousinfusioninsubsequent23hr

陈旸颈腰痛杂志2003年第24卷第1期35-36ChenYang,

2003MP