胸椎管狭窄症的治疗现状及研究进展

胸椎管狭窄症(thoracicspinalstenosis，TSS)是指由于先天、退变或内分泌及全身系统性疾病等因素导致胸椎管容积变小，胸脊髓、神经根受压，从而引起相应临床症状和体征的疾病，可分为原发性胸椎管狭窄症(primarythoracicstenosis)和继发性胸椎管狭窄症(secondarythoracicstenosis)。原发性胸椎管狭窄症指先天性的椎管矢状径＜10mm，加之后天退变等因素造成胸脊髓、神经根受压，出现临床症状的疾病。继发性胸椎管狭窄症与内分泌或全身系统性疾病有关，典型表现为全脊柱的环形狭窄[1]。TSS多发生于中老年人，以下胸椎为主，上胸椎次之。与熟知的颈椎病、腰椎管狭窄症等疾病相比，TSS发生率相对较低[2-6]，许多TSS的患者同时合并颈椎病或腰椎疾病，往往容易误诊和漏诊[7-10]。随着CT与MRI技术逐步应用于临床及手术技术的发展，TSS进一步为人们所认识[11]，但由于其特殊的生理及解剖结构，其手术高致瘫率仍是一大难题，笔者就其近年来的治疗现状及进展作一简要综述。

成骨不全症合并股骨头坏死一例

临床资料
　　患者，男，24岁，汉族，身高143 cm，主因“双髋关节疼痛、活动受限5个月”入院。入院查体：患者身材矮小，发育不良(图1)，巩膜蓝染(图2)，左耳失聪，右耳听力减弱。骨盆未见明显畸形，双侧“4”字试验(+)，四肢关节松弛，Beighton 评分9分。辅助检查：髋关节正轴位平片检查示：股骨头骨质疏松，部分区域骨质密度相对增高，双股骨屈曲短缩畸形(图3)。双髋关节MRI示：右股骨头、颈骨质见广泛水肿，相邻髋臼关节面下亦见小片水肿信号影，右髋关节滑膜囊水肿增厚。左股骨头关节面下见斑片状水肿信号影。双侧股骨头区均有硬化缘围绕较低、不均匀信号的坏死区(图4)。实验室检查：甲状腺素312 nmol/L ( T4)、血清ALP 110 U/L。既往史：0.5米处坠落伤致右锁骨骨折，后双上肢反复骨折2次。左耳4年前失聪，右耳先天性听力弱。个人史及家族史：无酗酒、激素过度使用等病史。其父亦有蓝巩膜、多发骨折、进行性耳聋等症状。

关于“成骨不全症合并股骨头坏死一例”诊断的讨论

本刊2014年第3卷第1期第76～79页，发表了吴李菲医师的“成骨不全症合并股骨头坏死一例”一文后，读者马云青医师对文中“股骨头坏死”的诊断有异议。根据“鼓励争鸣”的学术思想和办刊原则，我们欢迎并倡导这种不同学术观点的争鸣，也希望有更多的读者能参与到这种不同观点争鸣的讨论中来！

关于“成骨不全症合并股骨坏死一例”诊断的再讨论

吴李菲医生，您好！首先感谢您对我提出疑问的回复，并将更清楚的影像学资料上传给读者[1]。本人仍有以下几个问题需要与您进一步探讨。

BACKGROUND: Core decompression alone for osteonecrosis of femoral head easily causes fovea of femoral head and colapse of inner microstructure. Therefore, autologous bone is needed for filing and supporting. Moreover, bone marrow stem cel transplantation can decrease the incidence of femoral head colapse. OBJECTIVE:To discuss the clinical effects of core decompression and bone grafting combined with autotransplantation of bone marrow mesenchymal stem cels for osteonecrosis of femoral head. METHODS: A total of 33 patients were treated by core decompression and bone grafting combined with autotransplantation of bone marrow mesenchymal stem cels in the Fourth Department of Bone Surgery, Central Hospital Affiliated to Shenyang Medical Colege in China from December 2012 to May 2013. RESULTS AND CONCLUSION:After the treatment by core decompression and bone grafting combined with autotransplantation of bone marrow mesenchymal stem cels, Harris hip function score increased and pain disappeared in patients with osteonecrosis of femoral head. They could do various labors. Radiographs or CT examination displayed normal femoral head in 30 hips, accounting for 79%. Pain significantly reduced. Normal or slight limp walking was found in 15 hips, accounting for 40%. There were 35 hips in patients, whose walking distance was extended, accounting for 92%. 24 hips dysfunction was improved markedly, accounting for 63%. Al results suggested that core decompression and bone grafting combined with autotransplantation of bone marrow mesenchymal stem cels improved the local blood supply of femoral head, and played a positive role in promoting the necrotic bone absorption and bone repairing.

Objective: To study the mechanism of rabbit lunginjury caused by explosive decompression.Methods: A total of 42 rabbits and 10 rats were served as the experimental animals. A slow recompressiondecompression test and an explosive decompression test were applied to the animals, respectively. And the effects of the given tests on the animals were discussed.Results: The slow recompression-decompression did not cause an obvious lung injury, but the explosive decompression did cause lung injuries in different degrees. The greater the decompression range was, the shorter the decompression duration was, and the heavier the lung injuries were.Conclusions: Explosive decompression can cause a similar lung injury as shock wave does. The primary mechanical causes of the lung injury might be a tensile strain or stress in the alveolar wall and the pulmonary surface's impacts on the inside wall of the chest.