2016年5月5日,NEJM杂志(新英格兰医学杂志,影响因子55.873)临床实践栏目(Clinical Practice)发表了美国波特兰俄勒冈健康与科学大学Richard A. Deyo等的文章:腰椎间盘突出的诊治规范[1]。西京医院骨科王海强、张军教授择其精华择期精华,呈现给学界同仁和大众。有兴趣者,可点击如下链接:http://mp.weixin.qq.com/s?__biz=MzI1NDA1NzU5OQ==&mid=2651147603&idx=1&sn=442763d2a1eca4958b951ddc25e803f2&scene=0#wechat_redirect
发表者:成惠林(南京军区南京总医院.全军神经外科研究所.脊柱脊髓治疗中心)[中英文对照]Neurosurgeon or Orthopedic Surgeon?Does it Matter?选择神经外科医师还是矫形外科医师?问题重要么?(选择脑外科医师还是骨科医师?问题重要么?)“如果我咨询一个脊柱方面的问题,或者我需要接受脊柱外科手术,我是应该去看神经外科医师呢,还是去看矫形外科医师?”几个简单的事实将有助于感兴趣的患者加深了解。重要的是,患者应认识到神经外科和矫形外科医生都做脊柱手术。现在,结合两个专业而出现了一个新兴领域“脊柱外科”。未来可能会出现“脊柱专家”这一有自己委员会认证的明确的医学专业。但目前情况并非如此。在当今,神经外科医师的专业资格认证是由美国神经外科委员会实施的,而矫形外科医师资格则由美国矫形外科委员会认证,目前作为委员会的“父辈” ——美国医学专业委员会并没有开始要对“脊柱外科专家”进行认证。对患者来说,更重要的是应该清楚其主治医师是否通过了高标准的执业考试并获得专业认可。神经外科医师培训美国的神经外科医师,一般是在完成了在6到7年的住院医师培训之后,才系统地学习脊柱疾病的诊断及治疗(包括手术和非手术)。有些医师顺利地完成了神经外科培训,他们通常已经比较了解脊柱疾病的诊治程序。如果他们希望获得更高阶的训练,他们可以选择在脊柱外科进行进一步的研究。这种密集的,有重点的培训通常是在住院医师培训一、两年后进行。大多数患者错误地认为神经外科医师就是“脑外科医生”,其实,大多数神经外科手术是脊柱外科手术。当然在某些医院特别是大学附属医院中,也有些医生只专注于脑部手术很少进行脊柱手术。但是在这些分工明确的科室中,同时会有擅长脊柱外科的医师共同工作。矫形外科医师的培训所有的矫形外科医师在他们4-5年的培训计划中也接触到脊柱外科。一些矫形外科的住院医师会在拥有1名或多名比较擅长脊柱外科的矫形外科医师的机构学习。在这些机构中,住院医师要进行的脊柱外科训练不比神经外科医师少。有些矫形外科住院医师培训着重于外伤或骨关节手术及运动医学。一些希望专门从事脊柱外科和想要获得进一步培训的矫形外科医师可以在住院医生学习后继续从事脊柱外科研究,这和神经外科的情况是相似的。神经外科医师和矫形外科医师双方都可以从事脊柱外科现在,在矫形外科和神经外科都有很多在脊柱外科方面比较擅长的医师,这与许多年前的情况不同。我们愈发经常相互称呼对方为“脊柱外科医生”,两科医生间越来越看不出有什么差别。擅长脊柱外科手术的神经外科医师和矫形外科医师都能够诊治椎间盘膨出、椎间盘退变、椎管狭窄、脊柱骨折、脊柱滑脱、脊柱侧弯、脊柱骨肿瘤等诸多疾病。对于15岁以下年轻患者而言,还有一群专攻儿科脊柱方面的专家。神经外科医师和矫形外科医师的区别这两者之间在某些领域还是有区别的。只有神经外科医师在其6到7年的住院医师培训中接触到硬脊膜以内的疾病。因此,脊髓肿瘤,蛛网膜囊肿,脊髓空洞症, Chiari畸形,脊髓动静脉畸形,脊髓纵裂畸形,脊髓栓系,脊柱裂或脊髓脊膜膨出,脂肪脊髓脊膜膨出、颅颈交界区及上颈髓肿瘤、神经根肿瘤及其他一些疾病的诊治仍然归属于神经外科医师。同样,小儿及成人的脊柱侧弯,还有其他脊柱畸形仍由矫形脊柱外科专业医师诊治。共同的专业兴趣令人振奋的消息是,矫形外科和神经外科医生在脊柱外科领域已有卓有成效的合作。我们不再视对方为竞争对手,而是具有共同追求的合作者。目前许多国际学科组织包括北美脊柱学会,脊柱侧弯协会,颈椎病协会等,都向这两个专业的医师敞开了大门。两者之间的友谊和专业协作将大大有利于患者。患者享有选择权当前,患者没有必要局限于找一个“主要是做脑部手术而很少涉及脊柱手术”的神经外科医师或是一个“主要做关节手术而很少做脊柱手术”的矫形外科医师去治疗你的脊柱方面的疾病。今天,患者可以向经过脊柱外科住院专科培训或者可能专门从事脊柱疾病诊治的医师寻求咨询。无论他原先是在神经外科还是矫形外科。换句话说,这些医生日日夜夜、月月年年,都在诊治脊柱方面的疾病。推进脊柱医疗进步的共同目标打破了分隔这两个专业的界限。不要害怕询问您的医师的培训经历、工作重点、所推荐手术的受训练情况,以及是否告知所有治疗方案以供选择(不管你的手术医生是否能够实行这些方案)。不要害怕说出来你的想法,因为这是你的身体,你的脊柱。医生应尽全力让病人完全知情,这样双方才能做出一个满意的决定并开始实行治疗。(翻译:茅磊,戴嵬,王笑亮,校对:成惠林)If I need to be evaluated for a spinal problem, or, if I need spinal surgery, should I see a neurosurgeon or an orthopedic surgeon?A few simple facts will help educate the interested patient.It is important for patients to realize that both neurosurgeons and orthopedic surgeons perform spine surgery. Today, there is an emerging field of "spine surgery" that incorporates both specialties. In the future, there may be a well-defined medical specialty of "spine specialists" defined by its own board certification. This is not currently the case. Currently, neurosurgeons seek board certification from the American Board of Neurological Surgery and orthopedic surgeons seek certification from the American Board of Orthopedic Surgery. There is no certification process at the present time that is recognized by the "father" board, the American Board of Medical Specialties. It is very important that patients make sure that their doctor is certified by the appropriate board. This ensures that the doctor has met the highest standards set by his or her peers and passed both oral and written examinations.Neurosurgeon TrainingAll neurosurgeons trained in the United States (and many places abroad) gain experience in the diagnosis and nonsurgical and surgical treatment of spinal disorders during a six or seven year residency training program (after medical school). When physicians graduate from an accredited neurosurgery training program, they usually have assisted in many hundreds of spinal procedures. If they wish to gain even more advanced training, they may elect to do a post-graduate fellowship in spine surgery. This intensive, focused training is typically one or two years after residency training. Though most patients think of neurosurgeons as "brain surgeons", it may be interesting to know that the majority of operations performed by neurosurgeons across the country are spine surgeries. In large group practices and certainly in academic (university-based) neurosurgery departments, there are some neurosurgeons that specialize in brain surgery and do very little spine surgery. In these settings, they will have a colleague who specializes in spine surgery.Orthopaedic Surgeon TrainingAll orthopedic surgeons are also exposed to spine surgery during their four or five year training program. Some orthopedic residencies are at institutions where there are one or more orthopedic surgeons who specialize in spine surgery. At these institutions, orthopedic residents in-training may be exposed to a volume of spine surgeries comparable to many neurosurgery programs. In some orthopedic training programs, the emphasis is on trauma or joint surgery or on sports medicine. As in neurosurgery, some orthopedic surgeons who wish to specialize in spine surgery and gain further training may pursue a post-graduate (after residency) fellowship in spine surgery.Both Can Specialize in Spine SurgeryThough things were different many years ago, today there are a large number of both orthopedic surgeons and neurosurgeons who specialize in spine surgery. More and more, we are referring to each other as "spine surgeons" as the distinction between us is becoming nonexistent. Both neurosurgeons and orthopedic surgeons specializing in spine surgery are skilled in taking care of disc herniations, disc degenerations,spinal stenosis, fractures of the spine, slippage of the spine (spondylolisthesis),scoliosis, bone tumors of the spine, etc. For younger patients, there is a subset of spine specialists that is devoted to the pediatric patient (usually defined by patients below age 15 or so).DifferencesThere are a few areas where there still is a difference. Only neurosurgeons are trained during their six or seven year residency to perform procedures inside the lining of the spinal canal called the dura. Thus, spinal cord tumors, arachnoid cysts, syringomyelia, Chiari malformation, spinal cord arteriovenous malformation, diplomyelia or diastematomyelia, tethered spinal cord,spina bifidaor myelomeningocele, lipomyelomeningocele, tumors at the junction of the base of the skull and upper cervical spine, nerve root tumors, and a few other diagnoses still fall under the domain of the neurosurgeon. Similarly, both pediatric and adultscoliosisand other spinal deformities are still primarily treated surgically by orthopedic spine specialists.Sharing the Same InterestsPerhaps the most exciting news to report is that there is a terrific, productive collegiality developing between orthopedic surgeons and neurosurgeons who wish to devote their careers to the advancement of spine care. We no longer look at each other as competitors; rather, we look at each other as colleague with the same interests. Many international scientific organizations now open their doors to physicians from both specialties such as the North American Spine Society, theScoliosisResearch Society, the Cervical Spine Research Society, and others. This friendship and professional association of orthopedic surgeons and neurosurgeons will be of great benefit to patients.Patients Have ChoicesCurrently, a patient does not have to settle on a neurosurgeon who does "mostly brain surgery and a little bit of spine surgery" or an orthopedic surgeon who does mostly "joint surgery and a little bit of spine surgery." A patient today can seek consultation with either a neurosurgeon or an orthopedic surgeon appropriately trained in residency and, possibly, in a post-graduate fellowship in spine surgery who has devoted his or her practice to spinal disorders. In other words, they take care of spine problems day to day, week to week, month to month, and year to year. The old walls separating these two specialties have been broken down by the shared goal of advancing the field of spine care. Don\"t be afraid to ask your surgeon about his or her training, practice focus, experience with whatever operation has been recommended, and whether you the patient have been presented all of the options that exist (regardless of whether your surgeon performs all of them or not). Don\"t be afraid to speak up. It\"s your body, your spine. Physicians place great value on educating patients to the best of their ability so that satisfactory decisions can be made and acceptable treatment initiated.(from spineuniverse)
发表者:李维新(第四军医大学 唐都医院.全军神经外科研究所.脊柱脊髓治疗中心) 脊柱神经外科是诊断及治疗脊髓及其支撑结构的医学,是神经外科学的一个重要分支,其治疗范围主要包括:1、脊柱退行性疾病,如颈椎病、腰椎间盘突出等,这些最为常见疾病占各种脊柱手术的80%以上;2、脊柱、脊髓外伤;3、椎管肿瘤;4、脊柱畸形。 脊柱神经外科手术始于20世纪初,1905年,Cushing报道第1例髓内肿瘤切除术;1909年,Openheim报道1例L5/S1椎间盘切除术。之后各种脊柱、脊髓疾病手术治疗及各种入路方法相继报道,脊柱神经外科手术逐渐得以开展。早期由于影像学技术、手术器械、照明设备的落后以及神经外科医生对脊柱稳定性认识的不足,临床工作中诊断脊柱脊髓疾病准确性差,手术治疗效果不好,手术后经常出现脊髓损伤、脊柱医源性畸形等并发症。1973年Hounsfield发明了CT,这是脊柱神经外科发展史上的第一个重大的飞跃;1977年,MRI在神经领域的应用成为脊柱神经外科的第2次飞跃。可以说CT和MRI的出现给脊柱神经外科带来了里程碑式的发展。1983年Denis提出的“脊柱三柱理论”,成为指导脊柱神经外科的力学基础。在此理论基础上,随着工程学与材料学的发展和结合、手术器械的革新,新材料、新技术和新方法不断涌现并得以应用临床,脊柱神经外科取得了快速的发展,尤其是近10余年来脊柱神经外科的发展可谓日新月异,速度之快令人惊叹。 脊柱神经外科的定义来源于美国神经外科医师协会对神经外科的定义,其内容为:诊断及治疗中枢、周围及自主神经系统及其支撑结构的医学。 中国神经外科学会也明确指出,脊柱脊髓疾病的诊断与治疗属神经外科职业范畴。这为神经外科医生开展脊柱手术奠定了基础。众所周知、脊柱与脊髓是密不可分、相依存在的,就如同颅骨与脑的关系一样。脑和脊髓都属于中枢神经系统,颅骨做为脑的支撑结构,属于神经外科的诊治范畴。而脊柱做为脊髓的支撑结构,也应该属于神经外科的重要分支。并且基于神经外科医生对神经解剖和神经生理更为熟悉,更加重视神经组织的保护。特别是显微操作技术在神经外科的广泛使用,神经外科医生的手术操作更加精细,手术的安全性更高。因此,在欧美国家脊柱、脊髓手术大部分由神经外科医生承担。 一直以来,关于脊柱脊髓疾病,在很多人的概念中,硬脊膜外的病变属于骨科治疗范畴,硬脊膜内的病变归属神经外科。其实脊柱神经外科属于典型的交叉学科,既包含脊柱骨性结构、也包含脊髓中枢神经和脊神经结构。由于神经外科在我国起步较晚,过去脊柱神经外科疾病的治疗基本上都是由骨科医生承担,虽然建国之初就有神经外科前辈开始了脊柱手术,但其中所占的比例很少,并且手术主要集中在椎管内肿瘤的切除。其中主要的原因是,神经外科医生更多关注于脊髓、神经的保护,对脊柱的稳定性方面考虑的较少,或者说对脊柱生物力学结构和内固定技术了解甚少。过去多为简单的咬除椎板,甚至是咬除多个节段的椎板,多年后发现很多此类患者出现了脊柱畸形。所以忽视脊柱稳定性成为过去神经外科医生在此类手术方面最大的问题。神经外科医生开始反思,开始站在全面、整体的角度认识脊柱脊髓疾病,开始学习脊柱固定方面的新技术新理论。目前国内一些大医院已经成立了脊柱神经外科治疗中心,结合神经显微外科技术和内固定技术,在脊柱、脊髓疾病的手术治疗方面取得了优异的成绩。 在欧美国家,脊柱疾病多归属神经外科,神经外科医生致力于脊柱神经外科这一领域,脊柱脊髓疾病的手术量在许多大的神经外科中心,占手术总量的40-60%以上,脊柱神经外科的发展历史中不乏神经外科医生的身影,Cushing、Cloward、Goel、Bryan、Laheri等神经外科医生在脊柱固定材料的发展中做出了巨大的贡献。2000年美国神经外科医师协会杂志J Neurosurgery,正式出版脊柱分册J Neurosurgery:Spine,从而使脊柱神经外科成为继功能神经外科、介入神经外科等的又一重要分支。 脊柱神经外科手术可概括为两个方面,即减压与固定。有报告指出,减压不彻底是颈椎病手术疗效欠佳的主要原因,高颈段手术造成的严重并发症、甚至死亡也多与手术操作有关,而神经外科医生正是在这一方面可以通过显微操作技术充分发挥自己的特长。 神经外科与骨科在脊柱手术方面各具所长,神经外科医生擅长对脊髓、神经的保护,而骨科医生更擅长脊柱的稳定。脊柱神经外科必须将两者完美结合,站在整体的角度来分析和治疗。从事脊柱神经外科必须经过正规的专业训练,而神经外科医生从脊髓髓内的显微手术过渡到椎间盘手术,与骨科医生从椎间盘手术过渡到脊髓显微手术,两者难易程度显然是不同的。神经外科医生拥有显微外科技术,加上培训背景的不同,对脊髓神经的解剖、生理等有更深入的理解,在处理脊髓及神经减压方面,神经外科医生有着独特的优势。脊柱稳定性方面似乎是神经外科的弱项,实际上神经外科医生不仅可以通过内固定器械维护及恢复脊柱的稳定,还可以通过显微外科技术,减小椎管开窗范围,降低脊柱的手术创伤,从而最大程度的减少对脊柱稳定性的影响。可以说,神经外科医生虽然也需要脊柱内固定方面的训练,但相比较显微技术而言并非难事,而从骨科过渡到脊柱神经外科则需要特殊的训练。 勿用讳言,脊柱神经外科属于交叉学科,神经外科与骨科各有所长,两科之间不应该是孤立、竞争甚至是对立的关系,而应该相互学习、取长补短、相互促进、和谐发展。对于神经外科医生而言,应该采取积极的态度开展脊柱神经外科工作,但是开展脊柱神经外科工作必须虚心向骨科医生学习脊柱固定技术,务必经过严格的脊柱内固定技术培训,切勿盲目自大、急功近利。目前我国脊柱神经外科规模还远远落后于欧美发达国家,我国神经外科医生应该本着“一切为了病人出发”的思想,和骨科医生互相学习,贯彻科学的微创理念,充分发挥神经外科显微技术优势,积极推动我国脊柱神经外科的发展,最终为广大患者带来更多的帮助。
原创 2016-11-13 黄学成、陈国铭 前言 在异地求诊中,您是否遇到过这种情况:一些患者因行动不便或因时间和空间的限制不能到医院找医生就诊,此时患者家属往往需要将影像资料带到医院咨询医生或寄给医生查看。随着网络诊疗的进步和远程会诊的需要,一种简单易行的方法可以帮到您。 以CT为例,方法如下 1材料:电脑一台、可拍照手机一部、透明胶布一卷、剪刀一把 2 步骤 1 电脑屏幕变“阅片灯” 打开电脑,新建一个PPT文档(幻灯片),点击幻灯,在电脑右下角处点击全屏播放按钮,这时电脑屏幕摇身一变成为阅片灯。 2 如何确定片子的正反顺序 在“电脑屏幕”上放X光或CT片(确保片子上的文字是顺的,就说明片子方向是正确的。),用胶布在电脑屏幕固定,片子就很会清晰地显示了! 3 片子的正反和方向 片子的正反和方向可依据片子上的文字方位来调整 备注 确保片子上的文字是顺的,拍摄时也确保文字可以阅读,这样的图片质量大多数可用于诊断。 4 关闭手机闪光灯 用手机的相机拍照时要关闭“闪光灯”,建议每次以“四小格”的形式拍照,保证图像的清晰度。然后按顺序发送即可。