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Analysis of Misdiagnosis of Spinal Tumor and Spinal Tuberculosis

Spinal tumors and spinal tuberculosis are more common in clinical cases. Spinal tuberculosis has a high disability rate and has a great impact on the quality of life of patients. Spinal tumors and spinal tuberculosis are often difficult to distinguish. Unclear identification can easily lead to misdiagnosis and delay in treatment. The diagnosis and treatment cannot be obtained as soon as possible, and the disease condition or misdiagnosis is delayed. Therefore, this article mainly discusses some problems in the diagnosis of spinal tumors and spinal tuberculosis, hoping to make certain references in clinical work.

  1. Common causes of misdiagnosis of spinal tumors and spinal tuberculosis

1) The clinical manifestations of vertebral tuberculosis and tumors are similar to those of fatigue, weight loss, poor appetite, pain, and anemia. Individual tumor patients also have symptoms of low fever and night sweats. In physical examination, there are more signs of kyphosis, local percussive pain, and limited mobility, and the course of the disease is chronic. Therefore, the diagnosis is difficult and easy to be confused.

2) In some cases of spinal tuberculosis, there are no obvious symptoms and signs of tuberculosis poisoning such as weight loss, hot flashes, night sweats, fatigue, etc., and low back pain is a common clinical symptom and the earliest symptom of spinal tumor; l Whether it is spinal tumor or spinal tuberculosis Mild to severe spinal nerve dysfunction can occur due to the progression of the disease, including nerve root pain, sensory motor disorder, urinary incontinence, and even paraplegia, bone destruction, and can cause vertebral body collapse, wedge-shaped changes, and kyphotic deformity. In addition, some spine tumors can also have symptoms similar to tuberculosis poisoning, physical examination pick-up test, Thomas’ sign positive, differential diagnosis is difficult.

3) Insufficient understanding of the clinical features of this disease, thinking of tumors for gradually worsening lesions, ignoring the possibility of tuberculosis. The author believes that most spinal tuberculosis is primary tuberculosis, and the diagnosis of spinal tuberculosis cannot be denied clinically because there is no tuberculosis.

4) Unfamiliar with the significance and limitations of CT and MRI examinations, blindly relying on the results of medical examinations, causing misdiagnosis and missed diagnosis.

5) Inadequate understanding of the medical history, poor imaging examination quality, or inaccurate reading of imaging examination materials, resulting in diagnostic errors. The necessary differential diagnosis was not performed. Spinal tuberculosis and spinal tumors have similar symptoms and signs. If imaging is difficult to distinguish, the differential diagnosis is difficult. Experimental anti-tuberculosis treatment is of differential value.

  1. The value of MRI in the identification of spinal diseases

The anatomical structure of the spine overlaps significantly. MRI is one of the indispensable imaging examinations. There will be more and more MRI examinations for patients with spinal diseases. MRI has gradually become more and more important in the differential diagnosis of spinal tumors and tuberculosis. M RI is a non-invasive imaging examination method with high resolution of soft tissues and multi-directional imaging. M RI can well show the spatial relationship between the soft tissues and lesions around the spine and adjacent blood vessels and nerves, and can also judge the various components of the tumor and necrosis or bleeding. The advantages of MRI in the differential diagnosis of spinal tumors and tuberculosis: (1) Vertebral body: It can clearly show vertebral body abnormalities, even if there is no bone destruction, only bone marrow abnormalities can be displayed. This is what other imaging methods cannot do so far; (2) Intervertebral disc: Uninvolved intervertebral disc is an important feature of spinal tumors, while intervertebral disc stenosis caused by intervertebral disc involvement is an important feature of spinal tuberculosis. MRI shows whether the intervertebral disc is involved is more reliable; (3) Soft tissue: Although both tumors and tuberculosis will have soft tissue abnormalities, the formation of cold abscess is one of the important points of distinguishing spinal tumors and tuberculosis. With the help of the application of contrast agent, it is possible to clearly determine whether there is abscess formation and the shape and location of the abscess; (4) Blood supply: M RI soft tissue resolution is high, and there are obvious advantages in observation enhancement, and the enhancement mode directly reflects the blood supply of the lesion. . After spinal tuberculosis and tumor enhancement, the lesion showed mixed enhancement to varying degrees, which shows that the blood supply of tuberculosis and tumor is uneven.

  1. Prevention measures for misdiagnosis of spinal tumors and spinal tuberculosis

In view of the common causes of misdiagnosis, we can prevent it from the following aspects: 1) When distinguishing spinal tumors from most primary tuberculosis of the spine, the diagnosis of spinal tuberculosis cannot be denied because there is no history of tuberculosis. 2) In the clinical work, the young and middle-aged patients with low back pain are diagnosed as tuberculosis when the tumor or tuberculosis cannot be clearly identified by the imaging examination, and the bone marrow findings suggest infection. Anti-tuberculosis treatment is of differential value. 3) In the diagnosis of this type of disease, we must be careful about the medical history, and at the same time, we should carefully read the imaging materials. 4) Correctly understand the imaging manifestations of atypical spinal tuberculosis and spinal tumors, strive to improve the reading ability, comprehensively and systematically observe the imaging signs, and combine with clinical analysis to reduce misdiagnosis.

  1. Summary

In summary, in medical practice, we must adhere to a serious and meticulous scientific attitude, conduct scientific diagnosis, scientific treatment, and implement targeted inspections to provide reliable evidence for diagnosis. In clinical work, attention should be paid to the diagnosis of spinal diseases. For patients who are suspected of unclear spinal diseases, only careful medical history, careful physical examination, reasonable application of auxiliary examinations, and broadening of diagnostic ideas should not only pay attention to the changes in the patient’s spinal lesions, but also Pay attention to the lesions in other relevant parts, and make comprehensive consideration and three-dimensional analysis, which can help us establish the correct diagnosis.

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Diagnosis and treatment of acute cerebral infarction

Treatment principles

Restore blood supply to cerebral ischemic area as soon as possible

Prevention and treatment of ischemic brain edema

Prevent and treat complications

Give systematic and individualized rehabilitation early

Control blood pressure

Hypertension is the most important risk factor for cerebral hemorrhage and cerebral infarction;

After controlling for other risk factors, for every 10mmHg increase in systolic blood pressure, the relative risk of stroke increased by 49%, and for every 5mmHg increase in diastolic blood pressure, the relative risk of stroke increased by 46%;

A clinical randomized controlled trial of systolic hypertension in the elderly in China showed that after 4 years of follow-up, the blood pressure treatment group had a 58% reduction in stroke mortality compared with the placebo control group.

(1) Further strengthen publicity and education, strive to raise residents’ awareness of stroke prevention, and take the initiative to care about their blood pressure; it is recommended that people ≥35 years old measure blood pressure every year1, and patients with hypertension should measure blood pressure frequently (at least every 2 to 3 months) 1 time) to adjust the dosage

(2) Hospitals at all levels should establish a blood pressure measurement system for the first diagnosis of adults as soon as possible

(3) All localities should actively create conditions to establish demonstration communities of a certain scale, regularly screen hypertensive patients in the population and provide appropriate treatment and follow-up

(4) For early or mild patients, first adopt lifestyle change treatment, and those whose effect is still not good for 3 months should be treated with antihypertensive drugs.

General treatment-blood pressure

Elevated blood pressure in the acute phase of ischemic stroke usually does not require special treatment

When systolic blood pressure>220mmHg or diastolic blood pressure>120mmHg and mean arterial pressure>130mmHg, appropriate antihypertensive treatment

If persistent low blood pressure (systolic blood pressure <90mmHg) occurs, blood volume needs to be supplemented and cardiac output increased first

After the acute phase (4 weeks), if the patient can tolerate it, keep it below 140/90mmHg as much as possible

Control blood sugar

Diabetes is an important risk factor for cerebrovascular disease. The risk of stroke in patients with type 2 diabetes is doubled

(1) People with risk factors for cardiovascular and cerebrovascular diseases should check their blood sugar regularly, and if necessary, measure glycosylated hemoglobin (HbAlc) and glycosylated plasma albumin.

(2) Diabetes patients should first control their diet and strengthen physical exercise. Those who are still unsatisfied with blood sugar control for 2 to 3 months should use oral hypoglycemic drugs or insulin treatment

(3) It is more important to actively treat high blood pressure, control weight and lower cholesterol levels

blood sugar

Diabetes and stress can raise blood sugar. When it exceeds 11.1mmol/L, insulin therapy should be given immediately to control blood sugar below 8.3mmol/L;

When you start using insulin, you should monitor your blood sugar once every 1 to 2 hours to prevent hypoglycemia.

Brain edema

Cerebral edema is more common in large area infarction

Reducing intracranial pressure, maintaining adequate cerebral perfusion and preventing brain herniation are the goals of treatment. Available 20% mannitol, furosemide, glycerol fructose and albumin, etc.

infection

Stroke patients (especially those with impaired consciousness) are prone to respiratory and urinary tract infections in the acute stage

Turn over and knock your back frequently to prevent aspiration and pneumonia

Avoid intubation and indwelling catheters as much as possible. Intermittent catheterization and acidification of urine can reduce urinary tract infections

If it occurs, select sensitive antibiotics based on bacterial culture and drug sensitivity test

Stress ulcer

The elderly and severe stroke patients are prone to stress ulcers in the acute stage;

It is recommended to routinely use intravenous antiulcer drugs (H2 receptor antagonists or proton pump inhibitors);

For patients with gastrointestinal bleeding, ice salt water gastric lavage and local application of hemostatic drugs (Yunnan Baiyao, thrombin, etc.) should be performed.

Control body temperature

The hypothalamic body temperature regulation center is damaged, complicated by infection or heat absorption, dehydration and increased body temperature, which can increase brain metabolism, oxygen consumption and free radical production, thereby increasing the mortality and disability rate of stroke patients;

Physical cooling (alcohol rubbing bath, ice cubes, etc.) should be the main method, and artificial sub-hibernation should be given when necessary.

Deep vein thrombosis

Old age, severe paralysis and atrial fibrillation all increase the risk of deep vein thrombosis and increase the risk of pulmonary embolism

Encourage patients to move as soon as possible, raise the lower limbs, and avoid intravenous infusion of the lower limbs

Special treatment-ultra-early thrombolysis

If the time window is within 3 hours, the screening criteria for patients, thrombolytic indications, and the patient’s consent, intravenous and intraarterial thrombolysis is possible

Commonly used drugs are urokinase and tissue plasminogen activator (rtPA)

Thrombolytic therapy recommendations

(1) Intravenous thrombolytic therapy should be actively used for patients with acute ischemic stroke within 3 hours after the onset of strict selection. RTPA is the first choice. When rTPA is used unconditionally, urokinase can be used instead

(2) Patients with acute ischemic stroke whose onset is 3 to 6 hours can be treated with intravenous urokinase thrombolysis, but the selection of patients should be stricter

(3) For patients with acute ischemic stroke whose onset is 3 to 6 hours, in experienced and qualified units, research on intra-arterial thrombolysis can be considered

(4) The time window and indications for thrombolysis of basilar artery thrombosis can be appropriately relaxed

(5) Thrombolysis beyond the time window will not increase the therapeutic effect, and will increase reperfusion injury and bleeding complications. Thrombolysis is not suitable, and thrombolytic therapy should be disabled for patients during recovery.

Anti-platelet aggregation treatment recommendations

Most patients with acute cerebral infarction who have not undergone thrombolysis without contraindications should take aspirin 100-325 mg/d or oral clopidogrel 75 mg/d within 48 hours

Patients with thrombolysis should take aspirin 24 hours after thrombolysis

The recommended dose of aspirin is 150~300mg/d, divided into two doses, and changed to the preventive dose after 4 weeks

Anticoagulant treatment recommendations

(1) Patients with general acute cerebral infarction are not recommended to use anticoagulants routinely immediately;

(2) For patients using thrombolytic therapy, it is not recommended to use anticoagulants within 24 hours;

(3) When there are no contraindications in the following situations (such as bleeding tendency, severe liver and kidney disease, blood pressure >180/100mmHg), you can consider the selective use of anticoagulants: ① Cardiac infarction (such as artificial valve, atrial fibrillation, Patients with myocardial infarction accompanied by mural thrombosis, left atrial thrombosis, etc.) are prone to relapse stroke. ②Patients with ischemic stroke accompanied by protein C deficiency, protein S deficiency, and active protein C resistance; patients with symptomatic extracranial dissecting aneurysms; patients with intracranial and extracranial artery stenosis. ③ Patients with cerebral infarction in bed can use low-dose heparin or corresponding dose of LMW to prevent deep vein thrombosis and pulmonary embolism.

Recommendations for defibrosis treatment

(1) Early stage cerebral infarction (especially within 12 hours) can be treated with defibrinating treatment; patients with hyperfibrinogenemia should be actively treated with defibrinating

(2) Strictly grasp the indications and contraindications

(3) Commonly used drugs: Batroxobin; defibrase; other defibrase preparations: such as lumbrokinase, acutin, etc.

Other treatments

Brain protection therapy: including free radical scavengers (edaravone), opioid receptor blockers, which reduce ischemic brain damage by reducing brain metabolism and intervening in ischemia-induced cytotoxic mechanisms

Surgical treatment: Cerebral infarction caused by the main artery of the cerebral hemisphere, severe cerebral edema and life-threatening, or large-scale infarction of the cerebellum compresses the brainstem, surgical decompression treatment

Rehabilitation treatment: should be carried out early and follow the principle of individualization. Short-term and long-term treatment plans should be developed. Patients should be given targeted physical and technical training to reduce the disability rate, improve the recovery of nerve function and improve the quality of life

prevention

Actively look for vascular risk factors and deal with them accordingly

Control blood pressure

Control diabetes

Lower blood lipid

Quit smoking, alcohol, obesity

Treat heart disease etc.

Referral indications

Those who cannot be distinguished from cerebral hemorrhage, cerebral embolism, brain tumor, subdural hematoma and brain abscess

Within 3 hours of onset, meet the thrombolytic standard, and the patient agrees to thrombolysis without thrombolytic conditions

Large-area cerebral infarction with severe edema, obvious space-occupying effect combined with disturbance of consciousness, or brain herniation

Patients with large-area cerebellar infarction and signs of brain stem compression requiring emergency surgery

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Surgery cooperation norms for radical resection of colon cancer

  1. Indications
  2. Proximal colon (cecum, ascending colon, transverse colon) cancer.
  3. Distal colon (descending colon, sigmoid colon) cancer.
  4. Patients with no distant metastases such as liver or lung and intraoperative peritoneal metastasis in B-ultrasound and CT examination before operation.
  5. There is no severe heart, lung, liver, or kidney insufficiency.
  6. Operation method
  7. Radical right hemicolectomy
  8. Radical transverse colectomy
  9. Radical left colectomy
  10. Radical sigmoid colectomy
  11. Radical total colectomy
  12. Anesthesia: general anesthesia

Fourth, surgical position

  1. Radical resection of the right colon, transverse colon, and left colon (the tumor is located near the splenic flexure) in the supine position
  2. Radical sigmoid colon (tumor is located on the distal side), total colectomy with lithotomy position

Five, preoperative preparation

  1. General equipment and materials: general equipment package, surgical dressing package, laparotomy dressing package, rectal single package. 22# blade 11# blade 3-0#2-0#0#丝线14# urinary tube urine bag 20ml syringe aspirator tube aspirator head glove electric knife.
  2. Special instruments and objects: large purse-string pliers, 64mm purse-string, ultrasonic knife
  3. Prepare according to doctor’s advice: use Hemlock forceps for abdominal laparotomy, Hemlock (544243, 544253) Xinpihu (180MM) stapler, closure, cutting stapler, staple cartridge, antibiotics, chemotherapy drugs
  4. Special equipment: ultrasonic knife 23CM, high frequency electric knife
  5. Itinerant nurses: check whether all the instruments and equipment in the operating room are in good condition and in standby state, check patients, establish intravenous access, and strictly implement the tripartite verification system before anesthesia
  6. Matters needing attention: Reverse verification should be used when verifying the identity of the patient, and at least two verification methods should be used. Pay attention to verify the label of the surgical site, and sign the surgical safety checklist in time

Six, set-up specifications

  1. Surgical steps and cooperation (taking radical right hemicolectomy as an example)
  2. Skin disinfection and disinfection methods: 2% iodine twice, 75% alcohol deiodine twice, and perineal iodine disinfection twice. Disinfection range: from the bottom of the nipple to the upper 1/3 of the thigh to the mid-axillary line and the perineum. Instrument nurse: prepare disinfectants (three iodine cotton balls in the small blue bowl, five alcohol cotton balls in the big blue bowl, two iodine cotton balls in the curved plate, 2 sponge forceps); then check the dressings with the visiting nurse : Two people sing points according to the cards in the equipment. After the inventory is correct, the pre-division of instruments: 6 middle bends, 2 needle holders, 2 leather tweezers, 1 scissors, small knife handle No. 11 blade, a set reserved on the side of the sterile table away from the surgical area, covered by the treatment towel spare. Inside the isolation tray: spread treatment towels, 2 large straight forceps and 3 tissue forceps. Itinerant nurse: assist the surgeon to correctly position the patient, maintain the functional position, and avoid excessive pulling of blood vessels and nerves; cooperate with the hand-washing nurse to open various items needed for the operation; choose the muscle-rich place to paste the electrosurgical negative plate; count the number of equipment dressings, duo Record the points one by one; if it is a stone cutting position, you should prepare a silicone pad and a posture frame in advance, and remove the head plate; standardize the use of antibiotics.
  3. Spread sterile sheets in the order of use and deliver sterile sheets such as treatment towels to assist doctors in spreading sterile sheets. Put on a sterile film. Instrument nurse: prepare 4 treatment towels, covering the incision in the order of perineal side-contralateral side-head side-proximal side. The first layer of treatment towel is handed to the doctor’s shop (the first treatment towel is folded inward, the second treatment towel is folded outward, the third treatment towel is folded inward, and the fourth treatment towel is folded inward) , And then lay the surgical drapes with the surgeon who put on sterile gowns and sterile gloves, in the same order as the treatment towel, covering the anesthesia head frame and the side of the foot. Note: When handing the treatment towel, the surgeon’s hands must not touch the hands of the hand washing nurse; when placing the surgical drape, turn it inward to cover the back of the hand and not expose it; the surgical incision and instrument tray should cover at least 4-6 layers ; The transparent film sticks smoothly and without bubbles.
  4. Connect the electric knife, aspirator, and ultrasonic knife to the instrument, and fix it properly. Device nurse: Properly fix it to prevent the patient from being pinched. Do not wind the electric knife cord around metal instruments. Install the ultrasonic knife correctly, and spare it for self-check. Itinerant nurse: Connect the electric knife and ultrasonic knife, and adjust the power from low to high. Connect the suction tube and turn on the shadowless lamp to fully illuminate the surgical area.
  5. Open the abdomen: take the midline incision on the right side, and cut the skin with the 22nd knife. The electric knife cuts the subcutaneous tissue, the anterior and posterior sheath of the rectus abdominis and the peritoneum. Instrument nurse: accurately pass 22# blade-leather tweezers-electric knife pen-large curved pliers-gauze. Replace the open gauze. Note: The electrosurgical cap, iron wire, and the visiting nurse will check and deal with them. The sharps are transmitted without contact; the nurses, anesthesiologists, and surgeons in the operating room once again check the patient’s information together before the operation.
  6. Exploring the abdominal cavity: install an incision protector, if the tumor breaks through the serosal surface, do a sealing treatment, and replace the gloves after the exploration. Instrument nurse: prepare incision protector, automatic pull hook, suspension hook, abdominal cavity pull hook, and prepare deep instruments. Prepare to replace the required gloves. Note: Check the integrity of the incision protector and the automatic pull hook before use. Itinerant nurse: Use chemotherapy drugs as directed by your doctor. Remind the doctor to change gloves. Check the specifications and models of the incision protector in advance.
  7. Separate the right peritoneum and free the right colon. Instrument nurse: pass the large curved forceps, electric knife, and ultrasonic knife in turn. Spare pliers with No. 4 silk thread.
  8. Dissociate the roots of the right mesocolon, cut off the main vascular trunks that innervate the corresponding intestinal segments (ileocolonic arteries and veins, left colonic arteries and veins, right branch of the middle colonic arteries and veins), free with large curved vascular forceps, electric knife, ultrasonic knife No. 1 silk thread ligation or small round needle No. 4 silk thread ligation. Instrument nurse: accurately deliver large curved forceps, electrosurgical knife, and ultrasonic knife. Prepare pliers with No. 4 silk thread (or No. 1 silk thread) and small round needle No. 4 silk thread. Handling blood vessels: vascular forceps-electrosurgical knife or tissue cutting off-4th silk thread ligation-thread cutting. Itinerant nurse: According to different positions operated by the surgeon, adjust the light and electric knife power in time. Prepare Hemlock according to the habit of the surgeon.
  9. Free the right mesocolon and greater omentum: Use greater curved vascular forceps, electrosurgical knife, and ultrasonic knife to free it. No. 4 silk thread, No. 1 silk thread ligation or small round needle No. 4 silk thread ligation. Instrument nurse: accurately transfer large curved forceps-electric knife, ultrasonic knife. Prepare pliers with No. 4 silk thread (or No. 1 silk thread) and small round needle No. 4 silk thread. Handling blood vessels: vascular forceps-electrosurgical knife or tissue cutting off-4th silk thread ligation-thread cutting. Itinerant nurse: communicate with the surgeon in advance about the model of the stapler and turn it on for use. Prepare purse-string pliers and purse-string for spare.
  10. Resection of the right colon and the mass: the proximal end is 10cm away from the ileocecal area from the severed ileum, and the distal end is 10cm away from the lower edge of the tumor. Instrument nurse: add a sterile sheet and put an isolation disc on the end. Proximal end: small purse-string pliers-purse string-large straight pliers-electrosurgical disconnection-iodophor cotton ball disinfection of intestines-tissue forceps 3 holding intestinal lumen-put into the stapler at the bottom of the stapler. Far end: large straight pliers-extra large bend-electric knife cut off-iodophor cotton ball disinfection. Prepare the specimen basin to collect specimens. Strictly implement surgical isolation techniques. Pay attention to the number and completeness of disinfection cotton balls. Itinerant nurse: prepare stump closure or linear cutting closure according to doctor’s order. Communicate with the surgeon in advance to prepare the stump closure.
  11. Anastomosis of the intestine and embed the anastomosis: the distal end of the stump is inserted into the stapler gun, and after the proximal end is anastomosed end-to-side, the stump closer closes the distal stump, and the small round needle No. 1 silk thread embeds the anastomosis and the broken end. Instrument nurse: 3 tissue forceps (distal broken ends)-iodophor cotton ball sterilization-stapler gun anastomosis-closing device closed stump-iodophor cotton ball disinfection treatment towel stapler, confirm whether the stapler is cut completely. Remove the isolation tray and the sterile sheet added. Small round needle No. 1 silk thread is embedded. The needles and instruments used for embedding the stump should not be used for other operations. Itinerant nurse: Prepare sutures for embedding as directed by the doctor. Prepare anastomosis objects in advance according to the anastomosis method.
  12. Close the mesentery and arrange the small intestine homing equipment. Nurse: Prepare small round needle No. 1 silk thread
  13. Flush the abdominal cavity, check hemostasis, replace the gauze and equipment. Nurse: count the equipment, remove the equipment and items in the surgical field, prepare 37-42℃ distilled water, replace all the equipment, needles, and gauze after washing, wipe the electric knife handle, and add Spread sterile towels and use the reserved instruments to perform the following operations after changing gloves. Itinerant nurse: Pay attention to the temperature of the washing fluid and strictly implement the inventory system. Prepare 37-42℃ warm distilled water. Remind the surgical staff to use the reserved instruments to perform the following operations after changing their gloves.
  14. Placement and fixation of drainage tube equipment nurses: surgical staff change gloves and add sterile sheets. 11#Blade—2 large curved pliers—drainage tube—large leather needle No. 4 silk thread to fix. Spread the treatment towel and replace the equipment. Verify the side hole fragments of the drainage tube cutter. Itinerant nurse: prepare a suitable type of drainage tube according to the needs of the surgeon.
  15. Close 6 middle peritoneal curved forceps, large round needle No. 7 silk suture, 1 large forceps, and check the dressings. After the instrument nurses and the visiting nurses count the instruments and items together, prepare sutures according to the needs of the surgeon. Before and after closing the body cavity, count in time after sewing the skin. Before and after closing the body cavity, count in time after sewing the skin, and inform the doctor after correctness.
  16. Suture the front sheath with a large round needle No. 7 silk suture. 16. Suture the skin with alcohol cotton ball to sterilize the skin, use 2 skin tweezers and suture with a large skin needle No. 4 silk thread. The application covers the incision. Before and after closing the body cavity, count in time after sewing the skin, and inform the doctor after correctness. After the instrument nurses and the visiting nurses count the instruments and items together, prepare sutures according to the needs of the surgeon. Before and after closing the body cavity, count in time after sewing the skin. Before and after closing the body cavity, count in time after sewing the skin, and inform the doctor after correctness.
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Prevent skin necrosis during calcaneal fracture surgery

The incidence of calcaneal fractures accounts for 60% of the incidence of tarsal fractures, and 2% of systemic fractures. For displaced calcaneal fractures, surgical treatment is often used in clinical practice. The most common surgical approach is to expand the outside of the foot. Type incision approach for reduction and plate fixation. The surgical field of this operation is well exposed, but the probability of skin necrosis is high. It is reported that about 25% of patients with calcaneal fractures will have complications such as skin necrosis around the incision after surgery. If there is a large area of ​​skin Necrosis, soft tissue defects, and exposed steel plates can cause catastrophic consequences. How can we reduce the probability of skin necrosis?

In order to reduce the probability of skin necrosis, the following points need to be paid attention to:

  1. Avoid high-risk factors; diabetes and smoking are high-risk factors that lead to postoperative skin necrosis. For smoking patients, they should be informed in detail of the possible adverse consequences before the operation, and they should be banned from smoking before the incision is healed. Diabetes patients should control their fasting blood sugar below 8.0mmol/L and postprandial blood sugar below 10.0mmol/L.
  2. Assessment of soft tissue conditions; for severe calcaneal fractures, the soft tissue damage is severe, and tension blisters will form on the skin surface. Do not puncture the blisters, because the blister will lose its barrier when the epidermis ruptures, and bacteria will easily cover the surface and increase infection Probability. In addition, the blisters should be avoided when designing the skin incision.
  3. Selection of the timing of surgery; the timing of surgery can be selected within 12-24 hours after injury, because soft tissue edema is still relatively mild at this time, if emergency surgery cannot be performed, the surgery time should be postponed to 7-14 days later, until the swelling subsides , Surgery is performed when the skin appears wrinkled. For severe soft tissue damage, the time can be extended appropriately, and surgery must not be performed before the swelling has subsided.
  4. Preoperative treatment of the affected area; patients with calcaneal fractures should be given a plaster cast or brace for fixation before the operation to prevent the fracture from stimulating the soft tissue and aggravate the damage. At the same time, encourage the patient to move the toe, which is beneficial to reduce swelling. Preoperative local cold compresses and intermittent compression pump treatment can promote the swelling to subside and shorten the waiting time for surgery.
  5. Surgical technique

(1) The design of the surgical incision The most commonly used clinically expanded L-shaped incision on the outside of the foot should be composed of two parts. The distal end starts from the base of the fifth metatarsal and runs horizontally along the border between the dorsum of the foot and the sole of the foot, starting from the longitudinal incision From 6-8 cm above the heel, the Achilles tendon and fibula extend to the distal midpoint. Because such an incision is located at the watershed of the two different blood supply distribution areas on the outside of the foot, it does little damage to the blood supply of the skin and can reduce the probability of skin necrosis. In addition, if technical conditions permit, try to choose minimally invasive surgery, such as sinus tarsi incision. road.

(2) The subperiosteal dissection incision should go straight to the cortex, and perform subperiosteal separation forward and upward to form a full-thickness flap, which must not be separated layer by layer.

(3) To control the operation time, you should master surgical reduction techniques, avoid unnecessary operations, and try to complete the operation within one expulsion band time, which can effectively reduce postoperative soft tissue swelling and reduce the probability of skin necrosis. (4) The suture technique recommends using the Allgower-Donati method to suture the incision. This suture method has little effect on the blood supply of the skin around the incision and helps reduce the probability of skin necrosis.

(5) Intraoperative negative pressure drainage should be placed after the operation is completed. After the operation, the accumulated blood should be fully drained to avoid the formation of subcutaneous hematoma and affect the healing of the incision.

(6) Dressing change and suture removal Periodically change the dressing, keep the skin around the incision dry, remove the sutures about 2-3 weeks after the operation, and ask the patient to avoid activities before removing the sutures to avoid excessive suture tension affecting the skin blood supply.

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Be alert to syringomyelia due to cerebrospinal fluid circulation disorders

Syringomyelia is a chronic and progressive disease of the spinal cord. Its pathological features are the formation of a tubular cavity in the spinal cord (mainly gray matter) and the proliferation of glial (non-neuronal cells). The tubular cavity expands from the inside to the outside over time, compressing and injuring the spinal cord, leading to weakness, numbness, loss of bladder and sphincter function, headache, loss of warm feeling and other clinical manifestations. Syringomyelia mainly includes communicative syringomyelia. Non-communicating syringomyelia, syringomyelia parenchyma, atrophic syringomyelia, and neoplastic syringomyelia have their characteristic pathogenesis and imaging manifestations. Among them, communicative syringomyelia refers to the enlargement of the central canal of the spinal cord caused by the obstruction of the outlet of the fourth ventricle and the cerebrospinal fluid circulation. Common pathogenic factors are meningitis and subarachnoid hemorrhage caused by hydrocephalus and hindbrain malformations such as Chiari II malformation, occipital meningocele, Dandy-Walker malformation and so on.

Is it acute myelitis or communicative syringomyelitis?

Here is a selection of a clinical case encountered by the author to talk about the diagnosis and treatment of communicative syringomyelia:

  1. Summary of medical records:

The patient, a male, 72 years old, a farmer, was admitted to the hospital because of “unstable walking, blurred vision for 20 days, and numbness and weakness of his limbs for 3 days”.

Twenty days ago, the patient had no obvious inducement to walk instability, widened stride, with unresponsiveness, urinary incontinence, blurred vision, no headache, nausea, or vomiting, which gradually aggravated and did not pay attention to it; three days ago, the patient developed limbs Numbness and weakness, unable to stand alone and holding objects, lying in bed, and going to our hospital, head CT showed dilation of the whole ventricle system, changes after interventional embolization of anterior communicating aneurysm, income from “numbness of limbs, weakness waiting for diagnosis, hydrocephalus” My department. One month ago, he was cured and discharged from the hospital due to “anterior communicating artery aneurysm, subarachnoid hemorrhage” underwent interventional embolization and lumbar drainage. At that time, the head CT showed that the ventricle was normal. During the course of the disease, the patient had a cough, a small amount of white sticky sputum, no hemoptysis, headache, no dizziness, convulsions, no diarrhea, no diet, and normal bowel movements.

He has previously denied high blood pressure, diabetes history, surgical trauma and blood transfusion history, food drug allergy history, hepatitis tuberculosis and other infectious diseases history, and special bad habits.

Admission examination: T36.2℃ P70 beats/minute R19 beats/minute BP110mmHg/70mmHg Shenqing, no yellowing of the skin and mucous membranes, no swelling of superficial lymph nodes. Both pupils are equal to 3 mm in diameter, reflect light, lips are not cyanotic, tonsils are not enlarged, neck is soft, trachea is in the middle, and thyroid is not enlarged. Breath sounds in both lungs were clear, no wet rales were heard, the heart rate was uniform, and no pathological murmurs were heard in the auscultation area of ​​each valve. The abdomen is flat and soft, the liver and spleen are not under the ribs, and there is no edema in both lower limbs. The bilateral pathological signs were negative. Specialist examination: lack of fluency in speech. The pupils on both sides are erect and equi-circular, and are sensitive to light reflection. Forehead lines and nasolabial folds are symmetrical on both sides, and the tongue is centered. Muscle strength of both lower limbs was level 2 and both upper limbs were level 3. The tendon reflexes were active in the extremities, the bilateral Pap sign was positive, and the depth of sensation below C6 was absent. Urinary retention.

Auxiliary examination: head CT: dilation of the whole ventricle system, changes after interventional embolization of anterior communicating aneurysm. Cervical MRI showed: (1) Cervical 2-3, 3-4, 4-5, 5-6 intervertebral disc protruding backward or both sides, cervical 3-4, 4-5, 5-6 intervertebral disc horizontal spinal stenosis, The spinal cord is compressed and deformed. (2) Abnormal signals of the spinal cord at the level of the medulla oblongata-cervical 6 vertebral body. Consider exudation and edema. Please exclude myelitis in combination with clinical practice.

Preliminary diagnosis: (1) numbness and weakness of the extremities. Acute myelitis? (2) Communication hydrocephalus; (3) After aneurysm

  1. Diagnosis and treatment process:

The patient’s admission diagnosis considers the possibility of acute myelitis. He was given intravenous human immunoglobulin immunomodulation and methylprednisolone sodium succinate pulse therapy. The patient’s clinical symptoms did not improve significantly, and headache, nausea, and vomiting appeared gradually. Fundus examination showed bilateral papilledema. Considering the patient’s high intracranial pressure, he was transferred to brain surgery for lateral ventricle puncture and external drainage. The postoperative headache, nausea, vomiting and other symptoms of intracranial hypertension were quickly relieved. 4 days after the operation, the muscle strength of the lower limbs of the patient recovered to 4+, and the muscle strength of the upper limbs recovered to 5, and the head CT showed that the ventricle shape was better than before. The patient’s family refused to perform another neck MRI examination. Combined with the patient’s medical history, imaging findings and treatment effects, the revised diagnosis was made as: communicating hydrocephalus communicating syringomyelia; after interventional aneurysm.

The main manifestations of this patient were unstable walking, blurred vision, and numbness and weakness of the limbs. Combined with physical examination and analysis, the muscle strength of both lower limbs was level 2, the muscle strength of both upper limbs was level 3, and the muscle tension of the limbs was low. Active tendon reflexes in limbs. Positive bilateral Pap sign is located in the corticospinal tracts of the bilateral corticospinal tract; blurred vision in both eyes, can be located in the optic nerve, optic chiasm, optic tract, optic radiation, etc.; bilateral deep and shallow sensory loss below C6, consider bilateral spinal thalamus The fascicles, thin fascicles, and fascicles are affected; urine retention is located in the autonomic nervous system. The patient’s acute onset is mainly manifested by involvement of the motor system, sensory system, and autonomic nervous system, accompanied by a clear sensory plane, combined with the patient’s cervical MRI performance, so myelitis has become the first consideration for diagnosis. The patient has blurred vision in both eyes, except for neuromyelitis optica. Admission to the hospital to complete related auxiliary examinations, and to give intravenous human immunoglobulin immune conditioning and methylprednisolone sodium succinate therapy. The clinical symptoms did not improve significantly, and headache, nausea, and vomiting gradually appeared. The ophthalmological consultation found bilateral papilledema. Increased internal pressure, transferred to brain surgery for lateral ventricle puncture and external drainage. Postoperative headache, nausea, vomiting and other symptoms of intracranial hypertension were relieved quickly. 4 days after the operation, the muscle strength of both lower limbs recovered to grade 4+, and the muscle strength of both upper limbs recovered to grade 5. Reexamination of the head CT showed that the ventricle shape was better than before. Finally, lateral ventricle-intra-abdominal drainage was performed, and the prognosis was good.

Final diagnosis: communicating hydrocephalus communicating syringomyelia; after aneurysm intervention

Three, summary

Syringomyelia mainly affects the motor system, sensory system, and autonomic nervous system. Its clinical manifestations include: sensory symptoms, characterized by segmental dissociative sensory disturbances, pain, temperature sensation decreased or disappeared, and deep sensation exists; motor symptoms, upper limbs Lower motor neuron paralysis, upper motor neuron paralysis, dizziness, gait instability and nystagmus, etc.; autonomic nervous system, Horner syndrome, abnormal sweat secretion on the skin of the limbs and trunk, urinary disorders and recurrent urinary system Infection etc. The severity of symptoms is closely related to the speed and time of cavity development. Early symptoms can be relatively limited and mild, and late symptoms can be severe or even paraplegia. MRI is relatively specific for the diagnosis of syringomyelia. Typical MRI manifestations are: abnormal tubular signal in the center of the spinal cord, low signal on T1 (equal to the signal of cerebrospinal fluid in the adjacent subarachnoid space), high signal on T2, and most of the spinal cord in the hollow area. Thickened, the spinal cord is thin. On the cross-sectional image, most of the cavities are round or oblate, and a few with glial hyperplasia may have a double cavity shape.

The low incidence of traffic syringomyelia, the lack of vigilance of clinicians, and the lack of systematic understanding of the MRI manifestations of syringomyelitis and acute myelitis are the main reasons for misdiagnosis. (1) MRI manifestations of acute myelitis myelitis: ①The lesion is long, usually more than 5 vertebral body segments, and the upper boundary of the lesion is often higher than the clinical sensory level; ②The spinal cord is uniformly swollen and thickened; ③The lesion is fragmentary Long T1, long T2 signal, high signal in the lesion area T2, sagittal image can clearly show the lesion area. The cross-sectional T2 signal is uniform or uneven; ④The lesions on enhanced scan are generally not enhanced, or show patchy light enhancement. The patient had an acute onset, and the motor, sensory, and autonomic nervous systems were all involved with a clear sensory level. Myelitis seemed acceptable for the first diagnosis. (2) The clinical manifestations and onset forms of patients are different from most patients with syringomyelia. Syringomyelia is more chronic onset and progresses slowly. Acute disease with clear sensory level and paraplegia are relatively rare. The patient had an acute onset with paraplegia. Cervical spinal MRI showed that the central canal of the cervical spinal cord was dilated and exuded significantly. It is considered to be related to acute or subacute obstruction of the fourth ventricle, and belongs to a patient with relatively specific clinical manifestations of syringomyelia. (3) The patient was admitted without optic nerve and fundus examination, which became another reason for delayed diagnosis. During treatment, the patient’s lumbar puncture pressure was normal but the imaging showed hydrocephalus, and the diagnosis of normal intracranial hydrocephalus was made. As everyone knows, the patient had a history of SAH, subarachnoid adhesion, cerebrospinal fluid circulation path is not smooth, lumbar puncture pressure It does not reflect the true level of the patient’s intracranial pressure, which excludes the diagnosis of communicating hydrocephalus and communicating syringomyelia.

Therefore, for patients with hydrocephalus and abnormal intramedullary signals, especially patients with a history of intracranial infection or subarachnoid hemorrhage, it is necessary to be alert to the possibility of syringomyelia due to cerebrospinal fluid circulation disorders and include them in the differential diagnosis. Early detection, early diagnosis, reasonable treatment, and timely removal of spinal cord compression can significantly improve the prognosis of patients with communicative syringomyelia and reduce the occurrence of sequelae.

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Myasthenia gravis after thymectomy: a case report

Myasthenia gravis (mg) is an acquired autoimmune disease, which occurs at the neuromuscular junction and is mediated by antibodies against acetylcholine receptor and dependent on cellular immunity. Its pathogenesis is related to genetic factors, pathogenic autoantibodies, cytokines, complement participation and thymic muscle cells and other complex factors.

In clinical practice, myasthenia gravis is easy to fatigue after activity, which can be relieved by resting or using cholinesterase inhibitors. It is usually characterized by light in the morning and heavy in the evening with obvious fluctuation. About 2 / 3 cases involved extraocular muscles, often early symptoms, 10% of them were confined to ocular muscles for a long time, while facial muscles, throat muscles, trunk muscles and limb muscles were all involved. The course of the disease is prolonged and can be relieved, relapsed or worsened. Infection, fatigue and so on often aggravate the condition, even appear crisis. In general, the early diagnosis of myasthenia gravis with thymic abnormalities mainly depends on thymic imaging. Although thymic CT can detect lesions early with good histological features, it is difficult to accurately distinguish between thymoma and thymic hyperplasia.

At present, thymectomy is still the basic treatment for myasthenia gravis. It is suitable for patients with systemic myasthenia gravis who have poor drug efficacy or can not tolerate drug treatment, or patients with thymoma. Whether ocular myasthenia gravis should be treated surgically is still controversial. Relevant studies have shown that the earlier the operation is performed after the diagnosis of myasthenia gravis, the greater the benefit of patients. Therefore, it is generally considered that surgical treatment within 3 years after the diagnosis is clear is more appropriate. At present, the surgical approaches of thymectomy for myasthenia gravis include neck incision, partial sternotomy incision and whole sternotomy incision. In recent years, video-assisted thoracoscopic or robot assisted thymectomy has been widely used. Because of the extensive distribution of ectopic thymus tissue in mediastinum, although it is emphasized that thymus and adipose tissue in mediastinum are completely removed during operation, it is difficult to achieve 100% resection. Some literatures have shown that the resection rate of extended thymectomy with cervical incision and sternotomy can reach 85% ~ 95%.

But there are also new cases of myasthenia gravis after thymectomy. We once met a 54 year old female patient who was diagnosed as mediastinal mass with uniform density and intact capsule, with a diameter of about 4 cm × 3 The patients were considered as thymoma without myasthenia and physical activity was the same as that of normal people. The relevant examination should be improved and the operation contraindication should be excluded. Thoracoscopic thymectomy was performed. The postoperative pathology showed thymoma. On the 2nd day, the patient had difficulty in breathing, and had no dyspnea. On the fourth day after the operation, the symptoms were not relieved, and the limbs were weak, accompanied by chest tightness and asthma. Myasthenia gravis was considered, and the neostigmine test was positive, so the diagnosis was confirmed. The patients were given bromopyrimethamine tablets. They could get out of bed on the second day of medication. The symptoms of myasthenia such as choking and weakness of limbs gradually improved. After 5 days, the general symptoms improved and discharged. They continued to take medicine outside the hospital and myasthenia occurred one week after discharge The symptoms disappeared, and bromadine was gradually reduced to discontinuation within 1 month after discharge. No myasthenia recurred during the follow-up.

After operation, the time of ventilator assistance should be prolonged according to the patient’s condition, and the tracheal intubation should be pulled out after the recovery of muscle strength and consciousness. Early postoperative application of anticholinesterase drugs can help patients recover muscle strength, promote active sputum excretion and reduce respiratory tract infection. Tracheotomy should be performed in time if extubation is difficult. 72 hours after operation, the incidence of myasthenia crisis was high. In case of crisis, endotracheal intubation and tracheotomy should be carried out as soon as possible, and the dosage of anticholinesterase drugs and hormones should be adjusted. After the condition is completely stable, the patient will gradually leave the ventilator. After operation, when patients have respiratory fatigue and hypoxemia, whether it is myasthenia crisis or cholinergic crisis, tracheal intubation should be given decisively to improve the ventilation function of patients. At present, most scholars believe that timely use of mechanical ventilation is the main means to reduce the mortality of myasthenia crisis.

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Clinical diagnosis of blepharoptosis

Blepharoptosis is one of the common clinical symptoms in neurology department. It is often accompanied by eye movement disorder and diplopia. It can be divided into unilateral blepharoptosis and bilateral blepharoptosis. The former can be seen in Horner syndrome, oculomotor nerve palsy and trauma, while the latter can be seen in Fisher syndrome and myasthenia gravis. The etiology of blepharoptosis is complicated. How to make a positioning and qualitative diagnosis is one of the basic skills of neurologists. Combined with my clinical experience, the clinical diagnosis ideas of blepharoptosis are summarized as follows.

Clinical diagnosis of blepharoptosis

The main cause of blepharoptosis is extraocular muscle paralysis, which may be accompanied by diplopia, ocular dyskinesia, orbital pain and other clinical manifestations. The location diagnosis of extraocular muscle paralysis can be divided into neurogenic, neuromuscular junction lesions, myogenic lesions and congenital lesions. Neurogenic disease is the most common, and can be divided into supranuclear, nuclear, inter nuclear and peripheral neuropathy. Myasthenia gravis is the most common cause of ptosis caused by neuromuscular junction lesions. Myogenic lesions are more common in thyroid myopathy, muscular dystrophy and mitochondrial myopathy. Congenital extraocular muscle paralysis is more common in congenital orbital fibrosis and senile degenerative changes.

The qualitative diagnosis of extraocular muscle paralysis can be divided into inflammatory, vascular, space occupying, traumatic, metabolic and so on. Extraocular muscle paralysis caused by inflammation is more common in painful ophthalmoplegia, cerebral neuritis, Guillain Barre syndrome, cavernous sinus thrombosis, orbital cellulitis, etc.; extraocular muscle paralysis caused by space occupying, common intracranial aneurysms, skull base tumors, etc.; extraocular muscle paralysis caused by vascular diseases can be seen in brainstem infarction and hemorrhage. Metabolically induced extraocular muscle paralysis is more common in diabetes, hyperthyroidism and cancerous peripheral neuropathy; there are some uncommon causes of extraocular muscle paralysis, which can not be ignored clinically, such as leakage of internal carotid cavernous sinus, multiple sclerosis, etc.; trauma is more common in orbital fracture and surgery, which can also lead to extraocular muscle paralysis; extraocular muscle paralysis with ipsilateral pupil narrowing is found in Horner’s syndrome Symptomatic, cervical sympathetic nerve damage.

What are the auxiliary examinations needed for differential diagnosis of extraocular muscle paralysis? Clinical diagnosis should first consider common diseases and frequently occurring diseases. Since I was engaged in clinical work, extraocular muscle paralysis is the most common in diabetic peripheral neuropathy (oculomotor nerve is most commonly involved), brainstem stroke, intracranial aneurysms, intracranial tumors. Diabetic oculomotor nerve paralysis is the most common, but some patients have no history of diabetes, fasting blood glucose is normal, need to monitor 2 hours postprandial blood glucose, glycosylated hemoglobin, if necessary, OGTT test to diagnose diabetes or abnormal glucose tolerance. Brain stem lesions or space occupying lesions of skull base can be excluded by MRI scan. The extraocular muscle paralysis caused by intracranial aneurysm compression of oculomotor nerve usually has mydriasis, which should be excluded by MRA / CTA as soon as possible. Suspected intracranial infection, extraocular muscle paralysis caused by Guillain Barre syndrome needs lumbar puncture for definite diagnosis; for extraocular muscle paralysis caused by other reasons, thyroid function, ENA, ANCA series, tumor markers, immunity, rheumatism series should be examined, and cerebrovascular angiography should be performed for differential diagnosis if necessary. Myasthenia gravis caused by extraocular muscle paralysis, mostly bilateral ptosis, no abnormal eye movement, mild morning and evening heavy phenomenon, fatigue test, neostigmine test positive, some patients with positive acetylcholine receptor antibody, patients with hyperthyroidism, thymoma and other autoimmune diseases. If the extraocular muscle paralysis caused by myogenic lesions is considered, electromyography can be performed, and muscle biopsy can be performed if necessary. In addition, there are a small number of extraocular muscle paralysis is unknown, but in clinical work, we should first consider common diseases, frequently occurring diseases and treatable diseases.

For the treatment of extraocular muscle paralysis, the first is etiological treatment, removing the cause is the basis of treatment, symptomatic treatment is mainly to nourish the nerve, reduce edema, improve microcirculation treatment, followed by acupuncture treatment, strengthen rehabilitation training.