◇◇新语丝(www.xys.org)(xys4.dxiong.com)(www.xysforum.org)(xys2.dropin.org)◇◇   从北大医院案谈医务工作者应当总结吸取的经验教训   作者:放射科医生   因为自己从事的不是骨科专业,想当然的就会犯一些低级错误。我在给于峥 嵘辩护一文中,提到手术适应症及溶栓的问题,说了些外行话,我在此表示深刻 反省。其实医疗无小事,病人的生命安全永远是第一位的,从这个案件中我们要 吸取的教训真的是太多太多。   如果做一回事后诸葛亮,用现在的眼光看看当时的北大医院治疗决策是否有 合理,肯定有些苛刻了。浏览一下大众比较容易获得的循证医学的指南网页,就 这个脊柱手术适应症的选取,无论国内国外,还是有一些原则的。无症状的腰椎 滑脱一般不需手术治疗,即使有了症状,多数应先行保守治疗。手术只适用于那 些保守治疗无效,或有下肢神经根症状者。一般情况下,出现下列病情有手术指征: 持续性腰背痛,经保守治疗不缓解,严重影响患者生活者;伴持续性神经根压迫症 状或椎管狭窄症状者;严重腰椎滑脱伴有腰骶部畸形者;X线片证实滑脱进展者 《创伤外科杂志》> 2009年6月11卷3期>综 述> 详见 http://journal.shouxi.net/html/qikan/wkx/cswkzz/20096113/z%20%20%20%20 s/20090531094654358_479241.html,   英文的可以参考上有关腰背疼的指南《Adult low back 》 painhttp://www.guideline.gov/summary/summary.aspx?doc_id=13479   "The decision to operate is a clinical decision based on the presence of severe, uncontrolled pain, profound or progressive neurological symptoms, or a failure to respond to conservative therapy."   《Diagnosis and treatment of degenerative lumbar spondylolisthesis》 North American Spine Society (NASS); 2008. 133p http://www.guideline.gov/summary/summary.aspx?doc_id=12680   "Do surgical treatments improve outcomes in the treatment of degenerative lumbar spondylolisthesis compared to the natural history of the disease?   Surgery is recommended for treatment of patients with symptomatic spinal stenosis associated with low grade degenerative spondylolisthesis whose symptoms have been recalcitrant to a trial of medical/interventional treatment.   Grade of Recommendation: B"   What is the long-term result (four+ years) of surgical management of degenerative lumbar spondylolisthesis?   Decompression and fusion is recommended as a means to provide satisfactory long-term results for the treatment of patients with symptomatic spinal stenosis and degenerative lumbar spondylolisthesis.   Grade of Recommendation: C"   简单理解就是症状严重经保守治疗无效的,建议手术并认为具有长期疗效, 证据等级B和C显示研究可信度一般。其实就是手术适应症和疗效还有争议。 guidline上还有各种术式的适应症及评价,总结的很详细,有兴趣的自己看吧。 注意到这些文件发布时间多是06年以后的了,总的看就是对腰椎滑脱的治疗趋于 保守。   关于术后溶栓的问题,从近几年报道看,手术导致深静脉血栓以致肺栓塞死 亡的引起重视,在哪些人哪类手术中进行预防性溶栓也形成了一些共识。对高危 人群的划分一般人并不了解,美国胸科协会有一些提示。Prevention of venous thromboembolism. American College of Chest Physicians evidence-based clinical practice guidelines (8th edition).Chest 2008 Jun;133(6 Suppl):381S-453Shttp://www.guideline.gov/summary/summary.aspx?doc_id=1 2956   Elective Spine Surgery 选择性脊柱手术   1. For patients undergoing spine surgery who do not have additional thromboembolic risk factors, the guideline developers suggest that clinicians not routinely use specific thromboprophylaxis other than early and frequent ambulation (Grade 2C). 对于没有附加危险 因素的病人,不建议常规抗凝,而应早期下床活动。   2. For patients undergoing spine surgery who have additional thromboembolic risk factors建议有以下附加危险因素的药物或机械预防, such as advanced age(高龄), malignancy,(怀孕) presence of a neurologic deficit, previous VTE(既往有静脉栓塞), or an anterior surgical approach(手术史), the guideline developers recommend that one of the following thromboprophylaxis options be used: postoperative LDUH 低剂量未分馏肝素(Grade 1B), postoperative LMWH低分子量肝素 (Grade 1B), or optimal use of perioperative IPC间歇性气囊压迫 (Grade 1B). An alternative consideration is GCS 逐步加压弹性袜(Grade 2B).   3. For patients undergoing spine surgery who have multiple risk factors for VTE, the guideline developers suggest that a pharmacologic method (i.e., LDUH or LMWH) be combined with the optimal use of a mechanical method (i.e., GCS and/or IPC) (Grade 2C).静脉栓塞多个危险因 素的,建议药物及机械方法同时预防。   个人危险因素包括:高龄、肥胖、血管曲张、VTE 病史或癌症、含雌激素或 激素替代疗法。>40岁和肥胖(体重指数>30)大约属于中危或高危(请专家指 正)。能看出在溶栓预防上趋势是比较积极的,注意证据等级都是中等,尚缺乏 大样本统计数据。   现在看如果当初选择保守的治疗或积极的预防栓塞,也许悲剧就不会发生。 我们也要反思,我们今天掌握的知识是否就能保证不会再有类似情况发生呢?医 学太复杂了,我们依然任重而道远。 (XYS20091125) ◇◇新语丝(www.xys.org)(xys4.dxiong.com)(www.xysforum.org)(xys2.dropin.org)◇◇