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甲基强的松龙在脊柱非创伤性疾病治疗中的应用MethylprednisoloneUseinOrthopedicConditions(Non-traumaticSpinalDiseases)MP的药理作用PharmacologicEffectofMPinSCI(Hall1981

-85)1.抑制SCI后脂质过氧化的程度2.减轻SCI后损伤部位脊髓血流量下降的程度3.提高SCI后Na+-K+ATP酶的活性4.支持SCI后的能量代谢1.Inhibitslipidperoxidation2.Increasesbloodflowt

ositeofinjury3.StimulatesNa+-K+ATPaseactivity4.PromotesenergymetabolismMP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,increas

ingpyruvicacidcontent6.SuppressesCa++influx,reducingfibrindegradation7.Inhibitsneutrophilandmacrophageinfi

ltrationintotheinjuredsite8.Depressestheproductionofinflammatorymediatorsandcytokinesafterinjury1、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1.Relievingedemaofcellmembranesofspinalcordandnerveroots2.Inhibitinglipidperox

idationofnervecellmembrane,axonsanddendrites•SuppressinggeneralinflammatoryreactionMP在脊柱非创伤性疾患中应用的理论依据TheoreticalSupportforMPinTreatingNon-traumat

icSpinalDiseases4、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.RelievingreperfusioninjuryMP在脊柱

非创伤性疾患中应用的理论依据TheoreticalSupportforMPinTreatingNon-traumaticSpinalDiseases常见的脊柱非创伤性疾患CommonNon-traumaticSpinalDiseas

es1、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1.Chroniccompressivecervicalmyelopathy2.Stenosisofthoracicspinalcanal3.Lu

mbardiscprotrusionandstenosisoflumbarspinalcanal4.Spinaltumors5.TuberculosisofspineMP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Indication1.Severecompressionofspinalcordornerves2.Suspectednerveinjuryduringoraftertheop

erationMP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。Methods1.MPtherapyasperNASCISIIpro

posalcanbeappliedincasesofsuspectednerveinjuryduringoraftertheoperation2.Noconsensusonthedosageinothersituations脊柱外科疾病（颈椎）Surgic

alTreatmentofSpineDiseases(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Commondi

seasesandtreatments1.Openreductionandinternalfixationoffracture-dislocationofcervicalspine2.Anteriororposteriordecompression,fixati

onandfusionforcervicalspondylosis3.Resectionofcervicalspinaltumors脊柱外科疾病（颈椎）DiseasesofSpineSurgery(cervicalspine)•车祸伤•左侧C6神经根损伤•Ca

rcrashinjury•NeurologicallydeficitofC6nerverootonleftside碎骨片Smallpieceofbonegraft小关节交锁Lockedfacetjoint椎间盘碎片Discfragment后路切开复位，经椎弓根螺钉内固定Po

steriorapproachforORIFandtrans-pediclescrewfixation前路椎间盘切除、植骨、内固定AnteriorACDFandplating脊髓型颈椎病，发育性颈椎管狭窄,C4-5椎间盘突出Cervicalspondyloti

cmyelopathy,DevelopmentalcervicalSpinalstenosis,C4-5discprotrusion脊柱外科疾病（颈椎）DiseasesofSpineSurgery(cerv

icalspine)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+AnteriorC4-5discectomy+CAG

Eimplantation颈椎管内肿瘤，压迫脊髓Cervicalintraspinaltumor,compressedspinalcord脊柱外科疾病（颈椎）DiseasesofSpineSurgery(cervicalspine)脊柱外科疾病（颈椎）SurgicalTreatment

ofSpineDiseases(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.Decompressionofossificationofposteriorlongitudinalli

gamentandligamentaflavaofcervicalspine5.Correctionofcervicalspinemalformation/deformity6.Focusclearanceoft

uberculosisofcervicalspine颈椎后纵韧带骨化，脊髓严重受压,单开门术后Ossificationofposteriorlongitudinalligamentofcervicalspine,severelycompressedspinalcord，post-opendoo

rlaminoplasty脊柱外科疾病（颈椎）DiseasesofSpineSurgery(cervicalspine)颈椎结核，椎管内脓肿Tuberculosisofcervicalspine,intraspinalabscess脊柱外科疾病（颈椎）DiseasesofSpineSurg

ery(cervicalspine)颈椎椎板切除术后后凸畸形Post-laminectomycervicalKyphosis脊柱外科疾病（颈椎）DiseasesofSpineSurgery(cervic

alspine)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）DiseasesofSpine

Surgery(cervicalspine)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Commoncomplications•Edemaofsuperiorlaryngealnerveandrecurrentlaryngealnerv

e•Stretchinjuryofnerveroots•Responsiveedemaofspinalcord•Spinalcordinjury脊柱外科疾病（颈椎）SurgicalTreatmentofS

pineDiseases(cervicalspine)甲强龙对颈前路术后耳鼻喉并发症的影响EffectsofMPonENTComplicationsAfterAnteriorCervicalDecompres

sion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,and24hrafteroperationseparatelyEur

-Spine-J200312(1)84-90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:Accessingtherangeofthroatmucous

membranelesionaccordingtoendoscope–Subjectiveindicators:Patients’perceptionsabouttheinfluenceofoperati

ononswallowingEur-Spine-J200312(1)84-90甲强龙对颈前路术后耳鼻喉并发症的影响EffectsofMPonENTComplicationsAfterAnteriorCerv

icalDecompression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:MPcanrelievethedamageofthroatmucousmembraneafteranteriorcervic

aldecompressionandreducethecomplicationsofrespiratorysystemEur-Spine-J200312(1)84-90北医三院的治疗方案RegimensinPekingUn

iversityThirdHospital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)Noacutespinalcordinjury•120mg,intrave

nousinjection,administeredviaAct-o-Vial•Onceperdayfor3to5days•Neednotgraduallydecreasethedosage北医三院的治疗方案RegimensinPekingUniversityThirdHospita

l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)Incaseofacutespi

nalcordinjuryoccurredduringOP•AccordingtotheregimensofMPforASCI•30mg/kg（bolus),iv,for20min.•5.4mg/kg/hr(infusion),iv,for23hr.解放军总医院骨科应用MP于颈椎

病的外科治疗UseofMPintheSurgicalTreatmentofCervicalSpondylosisinDepartmentofOrthopaedics,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≤60yearsold•Finaldiagnosisiscervicalspondyloticmyelopathy•Treatment:anteriorcervicaldecompressionan

dfixation*People’sLiberationArmy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:Thosewhohave•Braindisease•Thoracican

dlumbarmyelopathyorradiculopathy•CervicalspondyloticradiculopathyorOPLL•Simultaneouscongenitalcervicalspinalstenos

is•HighsignalintensityatMRIT2WI解放军总医院骨科应用MP于颈椎病的外科治疗UseofMPintheSurgicalTreatmentofCervicalSpondylosisinDepartmentofOrthopaedics,

GeneralHospitalofPLA*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:•GroupA(N=22)Lowdose,MP80-240mg,b.i.d,5-7daysafterop

eration解放军总医院骨科应用MP于颈椎病的外科治疗UseofMPintheSurgicalTreatmentofCervicalSpondylosisinDepartmentofOrthopaedics,GeneralHospitalofPLA*•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GroupB(N=25)Highdose,initialdoseof1000mgMP,administered30minbeforedeco

mpression;decreaseprogressively200mg/dafteroperation;total5days解放军总医院骨科应用MP于颈椎病的外科治疗UseofMPintheSurgicalTreatme

ntofCervicalSpondylosisinDepartmentofOrthopaedics,GeneralHospitalofPLA*•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UseofMPintheSurgicalTreatmentofCervicalSpondylosisinDepartmentofOrthopaedics,GeneralHospitalofPLA*病例资料：•D组（N=16)对照组，未用MPDa

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

DepartmentofOrthopaedics,GeneralHospitalofPLA*NeurologicalfunctionscoreafteroperationGroupAGroupBGroupCGroupDNear-term(1wee

k)39.7±13.653.8±14.656.6±15.341.7±16.6Long-term(6months)51.4±14.474.8±16.276.8±14.853.1±18.2TherecoveryoffunctionafteroperationofGroupBandCissignif

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

isinDepartmentofOrthopaedics,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±18.2B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-doseMPimprov

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

ntofCervicalSpondylosisinDepartmentofOrthopaedics,GeneralHospitalofPLA*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-dislocationofthoracicspine•Stenosisofthoracicspinalcanal•Deformityofthoracicspine(scoliosis,kyphosis)脊柱外科疾病（胸椎）Surgi

calTreatmentofSpineDiseases(thoracicspine)•胸椎后纵韧带骨化、黄韧带骨化•胸椎椎管内肿瘤•胸椎结核•Ossificationofposteriorlongitudinalligamentandligamentaflavaofthoracic

spine•Intraspinaltumorsofthoracicspine•Tuberculosisofthoracicspine脊柱外科疾病（胸椎）SurgicalTreatmentofSpineDiseases(thoracicspi

ne)疾病类型：•腰椎间盘突出症•腰椎骨折、脱位•腰椎管狭窄Diseases:•Lumberdiscprotrusion•Fracture-dislocationoflumberspine•Stenosisoflumberspinalcanal脊柱外科疾病（腰椎）

SurgicalTreatmentofSpineDiseases(thoracicspine)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)•Intraspinaltumorsof

lumberspine•Tuberculosisoflumberspine脊柱外科疾病（腰椎）SurgicalTreatmentofSpineDiseases(lumberspine)MP在腰间盘突出症手术治疗中的应用UseofMPinSurgeryforLumbar

DiscProtrusionMechanicalandchemicalstimulationofouterlayersofannulusfibrosusandsinuovertebralnerveinposteriorlongitudinalligamentbypr

otrudednucleuspulposus——beckpainMechanicalandchemicalstimulationofnerverootsbyprotrudednucleuspulposusanditsinflam

matoryreaction——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.•Pathophysiologicalchangesinnucleuspulpos

usprotrusion:神经根性疼痛产生的原因CausesofNerveRootPain•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•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)NucleuspulposuscouldcauseepiduralinflammatoryreactionSaal(1990)PLA2activi

tyincreasinginintervertebraldiscofpatientswithlumbardiscprotrusionByrodG(2000)Nucleuspulposusplacedepidurallycouldcauselocalinflammatoryre

actionandincreasevascularpermeabilityofnerveroots.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。•Inflammatoryreactioncouldreducet

hetoleranceofnerverootstomechanicalforcesMurphy,etal.ClinNeurosurg.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。•Stimulati

onofchemicalsubstanceproducedbyintervertebraldiscandautoimmunereactioncauseinflammatoryreactionofnerveroots.Surgery.WUZaide.

Eds.People’sMedicalPublishingHouse,2000.神经根性疼痛产生的原因CausesofNerveRootPain•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。•Protrudednucleuspulposuscompressorstretchinflamednerveroots,resultintheobstructionofvenousreturn,furtheraggr

avateedema,andincreasethesensitivitytopain.•IschemiaofcompressednerverootsSurgery.WUZaide.Eds.People’sMedicalPublish

ingHouse,2000.神经根性疼痛产生的原因CausesofNerveRootPain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UseofMPinSurgeryforLumbarDiscProtrusionJNeurosurg.1993Mar;78(3):383-7.手术方法：单侧椎板间开窗，髓核摘除Surgicalprocedure

s:Singlelevellaminotomy,removalofnucleuspulposusMP在腰椎间盘突出症手术治疗中的应用UseofMPinSurgeryforLumbarDiscProtrusionJNeurosurg.1993Mar;78(3):383-7.JNe

urosurg.1993Mar;78(3):383-7MP在腰椎间盘突出症手术治疗中的应用UseofMPinSurgeryforLumbarDiscProtrusionCompleteremissionofnerverootpainafterope

ration01234567891day1week1monthGroup1Group2Group3JNeurosurg.1993Mar;78(3):383-7.术后神经根性疼痛完全缓解情况NerveRootPainReliefAfter

OP术后时间TimeofPost-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ConclusionsMPadministrationdurin

gsurgeryforlumbardiscprotrusionshortenedhospitalization,reducedtheuseofanalgesia,andrelievesthesymptom

sofnerverootpainfaster.MP在腰椎间盘突出症手术治疗中的应用UseofMPinSurgeryforLumbarDiscProtrusion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:MPGroup30mg/kgMPaddedin0.9%normalsalineintr

avenousdripforthefirsthouraftersurgery,5.4mg/kgcontinuousinfusioninsubsequent23hr陈旸颈腰痛杂志2003年第24卷第1期35-36ChenYang,2003MP–methylpredn

isolone;DX–dexamethasone大剂量MP在脊柱手术后的应用UseofHigh-doseMPAfterSpinalSurgeryDX组：术后地塞米松10mg加入20%甘露醇250ml。每日两次，持续一周DXGroupDX10mgaddedin20%mann

itol250mlintravenousdripafterperaton,bid,lastingfor1week陈旸颈腰痛杂志2003年第24卷第1期35-36ChenYang,2003MP–methylprednisolone;D

X–dexamethasone大剂量MP在脊柱手术后的应用UseofHigh-doseMPAfterSpinalSurgeryMP–methylprednisolone;DX–dexamethasone病例资料：Cases：陈旸颈腰痛杂志2003年

第24卷第1期35-36ChenYang,2003结果：术后1天、2周、3个月感觉运动评分及患者自主满意度评估。Results:Timeframe:1day,2weeksand3monthspost-OPEndpoints:Senso

rymotorscoreandself-satisfactionevaluation大剂量MP在脊柱手术后的应用UseofHigh-doseMPAfterSpinalSurgery结果：术后1天：MP组症状改善或消失占90%，DX组73.3%，术后2周及3个月：无差异。

Results:1dayafteroperation:90%ofpatientswithsymptomsrelievedorvanishedinMPgroup,versus73.3%inDXgroup.Therewerenod

ifferencesbetweenthetwogroupsat2weeksand3monthsafterthesurgery.大剂量MP在脊柱手术后的应用UseofHigh-doseMPAfterSpinalSurgeryMP在非

创伤性脊柱疾患手术后的应用存在问题Post-surgicalProblemsinUseofMPforNon-traumaticSpinalDiseasesAfterOperation•适应症？•药物剂量的确定？•用药方法？•可能的并发症的防治？•Indicatio

ns?•Determinationofdrugdosage?•Methodsofdrugadministration?•Preventionandtreatmentofpossiblecomplications?需要多中

心双盲对照研究!!!Multi-center,doubleblind,casecontrolstudiesareneeded!!!谢谢