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-北京大学第三医院骨科-孙宇.ppt

1、甲基强的松龙在脊柱非创伤性疾病治疗中的应用Methylprednisolone Usein Orthopedic Conditions(Non-traumatic Spinal Diseases),北京大学第三医院骨科 孙宇 Yu Sun, MD Professor of Orthopaedic Surgery Peking University Third Hospital Beijing, Peoples Republic of China,MP的药理作用 Pharmacologic Effect of MP in SCI (Hall 1981-85),抑制SCI后脂质过氧化的程度 减轻S

2、CI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. Inhibits lipid peroxidation 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

3、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, increasing 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

4、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 Relieving edema of cell membranes of spinal cord and nerve roots Inhibiting lipid peroxidation of nerve cell membrane, axons and dendrites Suppressing general inflammatory reaction,MP在脊柱非创伤性疾患中应用的理论依据Theoretical Support for MP in Tr

5、eating Non-traumatic Spinal Diseases,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. Indirectly improving local blood circulation 5. Inhibiting apoptosis 6. Relieving reperfusion injury,MP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,MP应用现状及方法Current Use of MP,方法： 1. 术中或术

6、后可疑有神经系统损伤时， 按照NASCIS II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） Surgical Treatment of Spine Diseases (cervical spine),临

7、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 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（

8、颈椎） 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 A

9、nterior 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） Diseases of Spine Surgery (cervical spine),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 Posterior C3-7 la

10、minoplasty+ 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） Diseases of Spine Surgery (cervical spine),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. 颈椎畸形的矫正 6. 颈椎结核病灶清除术 4. Decompressio

11、n 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 ligament of cervical spine, severely com

12、pressed spinal cord，post-open door laminoplasty,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） Diseases of Spine Surgery (cervical spine),颈椎椎板切除术后后凸畸形 Post-laminectomy cervical Kyphosis,脊柱外科疾病（颈椎） Diseases of Spine Surg

13、ery (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） 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 Common complications Edema of superior laryngeal nerve and recurrent laryngeal

14、nerve Stretch injury of nerve roots Responsive edema of spinal cord Spinal cord injury,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 Effects of MP on ENT Complications 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

15、/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 Effects of MP on ENT Complications 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:

16、Objective indicators: Accessing the range of throat mucous membrane lesion according to endoscope Subjective indicators: Patients perceptions about the influence of operation 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 Effects of MP on ENT Complications After Anterior Cervical Deco

17、mpression,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 and reduce the complications of respiratory system,Eur-Spine-J 2003 12(1) 84-90,北医三院的治疗方案Regimens in Peking University Third Hospital,甲强龙用法: (1)未发生

18、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 Once per day for 3 to 5 days Need not gradually decrease the dosage,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

19、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 According 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MP于颈椎病的外科治疗Use of MP in the Surgical Treatment of C

20、ervical 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 Inclusion 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

21、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 lumbar 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MP于颈椎病的外科治疗Use of MP i

22、n the Surgical Treatment of Cervical Spondylosis in Department of Orthopaedics, General Hospital 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MP于颈椎病的外科治疗Use of MP in the Surgical Treatment o

23、f Cervical Spondylosis in Department of Orthopaedics, General Hospital 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M

24、P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*,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

25、; total 5 days,解放军总医院骨科应用MP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*,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MP于颈椎病的外科治疗Use of MP in the Surgical Treatment of Cervical Spondy

26、losis 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 Group B

27、 and C is significantly better than that of Group A and D,解放军总医院骨科应用MP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*,术后神经功能评分恢复率 A组 B组 C组 D组 近期（1周）39.713.6 53.814.6 56.615.3 41.716.6 远期( 半年) 51.414.4 74.816.2 76.814.8 53.1

28、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,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,解放军总医院骨科应用MP于颈椎病的外科治疗Use of MP in the Surgical Treatment of Cervical Spondylosis in Department of Orthopaedics, Gen

29、eral 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 spine (scoliosis, kyphosis),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 post

30、erior 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） 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 Ste

31、nosis of lumber spinal canal,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 Diseases: Deformity of lumber spine (scoliosis, kyphosis) Intraspinal tumors of lumber spine Tuberculosis of lumber spine,脊柱外科疾病（腰椎） Surgical Treatment of Spine Diseases (lumb

32、er spine),MP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 stimulation 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

33、 protruded nucleus pulposus and its inflammatory reactionsciatica,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 change

34、s in nucleus pulposus protrusion :,神经根性疼痛产生的原因Causes of Nerve Root Pain,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 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 reactionSaal (1990) PLA2 activity increasing in int

35、ervertebral disc of patients with lumbar disc protrusionByrod G (2000) Nucleus 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 to

36、lerance of nerve roots to mechanical forces Murphy, et al. 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 Pu

37、blishing House, 2000.,神经根性疼痛产生的原因Causes of Nerve 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. Ischem

38、ia of compressed nerve roots Surgery. WU Zaide. Eds. Peoples Medical Publishing House, 2000.,神经根性疼痛产生的原因Causes of Nerve Root Pain,手术方法：单侧椎板间开窗，髓核摘除 Surgical procedures: Single level laminotomy, removal of nucleus pulposus,MP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.

39、 1993 Mar;78(3):383-7.,手术方法：单侧椎板间开窗，髓核摘除 Surgical procedures: Single level laminotomy, removal of nucleus pulposus,MP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.,J Neurosurg. 1993 Mar;78(3):383-7,MP在腰椎间盘突出症手术治疗中的应用Use of MP in Surgery for Lumbar

40、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 month,Group 1,Group 2,Group 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 Concl

41、usions MP administration during surgery for lumbar disc protrusion shortened hospitalization, reduced the use of analgesia, and relieves the symptoms of nerve root pain faster.,MP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 Group30mg/kg MP added in 0.9% normal saline intravenous drip for the first hour after surgery, 5.4mg/kg continuous infusion in subsequent 23hr