【作者】 黄剑侯；

【导师】 贾连顺；

【作者基本信息】 第二军医大学 ， 外科学， 2010， 博士

【摘要】 在近代战争中脊柱脊髓火器伤约占伤员的0.3-4.6%,在美国,每年因火器伤而致脊髓损伤的约占总数的13-17%。脊髓火器伤的特点是病情急、创伤重、变化快,对机体影响比较大,残废率、死亡率均比较高。军事作战及长时间剧烈运动将大量产热,在高温高湿环境下机体汗液蒸发困难,加之持续暴露于高温环境下接受大量的外加热,导致体热平衡失调、水盐代谢紊乱、血液循环衰竭等,进而造成体内温度增高、代谢率增加、体液丧失和内环境失衡紊乱等；在此基础上合并脊髓火器伤,脊髓病理损害将更显著,同时损伤又加重了内环境的紊乱和全身重要脏器的负荷与损害,使脊髓火器伤后伤情更重、更为复杂。我国东南部沿海常形成典型的高温高湿气候,台海的危机、南海领地的保卫,面临着医疗保障的迫切需要。因此脊柱脊髓火器伤在高温高湿条件下的研究,对于未来南方战区军事作战及伤病员救治具有十分重要的意义。目的1、建立满意的脊髓火器伤模型。2、探讨脊髓火器伤在高温高湿环境下早期生命体征和肺功能的变化。3、观察脊髓火器伤在高温高湿环境下早期的病理变化。方法1、建立胸腰段猪脊髓火器伤的全瘫模型,进行麻醉和非麻醉下的生命体征观察。2、建立高温高湿条件下胸腰段猪脊髓火器伤的全瘫模型,对动物进行生命体征、血气分析进行监测及肺部病理学检查。3、对火器伤脊髓进行超微结构改变的及病理学检查(GFAF、NSE、S-100蛋白和CD34)。结果1、麻醉组与清醒组对照研究(1)MAP变化：两组动物伤后MAP进行性下降,在伤后4小时麻醉组MAP下降比清醒组明显。(2)HR变化：两组动物伤后HR进行加快,伤后6h麻醉组的心率加快比清醒组明显。(3)肛温变化：麻醉组伤后平均体温在伤后两小时较伤前下降近2℃。(4)PaO2和PaCO2变化：PaO2在伤后均持续下降,PaCO2在伤后2小时内因过度通气,PaCO2短暂下降,2小时后进行性增高。2、高温高湿环境下脊髓火器伤的生命体征及肺功能变化(1)MAP变化：两组动物伤后MAP均进行性下降(P<0.05)。对照组在伤后两小时与伤前差别存在统计学差异(P<0.05),在伤后各时间点H组的MAP下降与对照组差别具有统计学(P<0.05)。(2)HR变化：伤后两组动物的HR都进行加快,与伤前相比,心率在伤后各时间点均与伤前存在差别(P<0.05)；H组心率在伤后不同时间变化均比对照组快(P<0.05)。(3)肛温变化：对照组肛温在伤后有轻微波动,但伤后各时间点与伤前比较无差异(P>0.05)；H组的平均肛温在伤后进行性增高,伤后6h较伤前增高2.4℃,P<0.05,存在明显差别具有统计学意义。(4)PaO2和PaCO2变化：PaO2在伤后均持续下降(P<0.05)。H组的PaO2在伤后个时间点均比对照组低(P<0.05)。对照组在伤后2小时内因过度通气,PaCO2短暂下降,2小时后进行性增高,H组PaCO2伤后持续性增高并比对照组组高(P<0.05)。(5)大体标本两组均出现大量点、片状出血,高温高湿环境组出血明显。镜下观察高温高湿组：肺泡结构消失,肺泡上皮溶解变性,可见片状出血及炎性细胞浸润。支气管上皮变性脱失,管腔内出血物及分泌物明显。常温组：肺泡间质血管广泛性充血,肺泡腔大小不一,伴有少量出血及炎性细胞浸润,支气管轻度扩张。3、高温高湿组(H)与常温常湿组(C)损伤脊髓病理改变对照研究(1)光镜检查：两组脊髓硬脊膜血管明显扩张,硬膜下淤血明显,部分蛛网膜破裂,脊髓白质外露,组织疏松、水肿,小血管扩张,伴散在单核细胞浸润,白质轴突以纤维变性为主,病变不明显,脊髓灰质中神经元细胞变性,部分尼氏体消失,严重者神经元消失溶解,形态不规则,部分标本脊髓中央管附近部分组织广泛出血变性,正常结构消失H组病变相对严重。(2)电镜检查：两组均可见不同程度细胞核增大,染色质边集部分空洞形成,线粒体轻至重度水肿溶酶体增多,部分细胞内线粒体明显消失；髓鞘板层结构增厚、扭曲、松散、分层、破裂及出现不规则排列,轴索与髓鞘之间由于水肿出现间隙,轴索肿胀,部分轴浆溢出,可见较多水肿、髓内出血、坏死区及炎性细胞浸润。C组明显轻于H组。(3)尼氏体：两组均有损伤表现：出现尼氏体数目的减少、淡染,C组明显轻于H组。(4) NSE:H组表达明显比C组下调。(5) GFAP:H组表达明显比C组上调。(6) S-100:H组表达明显比C组上调。(7)CD34两组均可见零星散在阳性标记物,H组单个视野平均血管数明显少于C组。结论1、麻醉对猪脊髓火器伤早期生命体征存在影响,随着实验动物的体重的增加其伤后早期的存活时间也逐渐延长。2、高温高湿环境下,机体通过对流、传导和辐射排热障碍,代偿性出汗排热增加,导致机体代谢率增加、体热平衡失调、水盐代谢紊乱和血液循环改变等,高温高湿环境引起脊髓火器伤动物体温升高,呼吸频率和心率增加等明显生命体征改变,加剧了火器伤所带来的肺功能损害及加重脊髓火器伤的病理损害但脊髓损伤的同时也存在着脊髓损伤的修复。更多还原

【Abstract】 The number of the spinal cord injury (SCI) from gunshot in the modern times wars accounted for 0.3-4.6%.In USA, the number of the SCI from gunshot constitutes 13-17% total number of spinal cord injury. SCI from gunshot is characterized by emergency, high disability rate and mortality. When people live in the hot and humid environment, especially in military fight and long-time high intensity work, the body has great heat production, eccrine sweat glands evaporation difficulty and accepts large apposition heat, which results in body heat disequilibrium, water-electrolyte metabolism disturbance and blood circulation collapse, and finally causes body temperature raise, metabolic rate increase, body fluid loss and internal environment chaos. When combined with spinal cord firearm wound。Spinal cord tissue pathological lesion becomes more severe and aggravates internal environment turbulence and importance organs’loading and damage including bleeding, cell hurt, brain edema and nerve endocrine system change, which fastens the development of the illness. The study of SCI from gunshot under hot and humid environment have important significance to the patient treatment in the South war zone in the future, in the Taiwan Strait crisis, South China Sea territory guard, as well as the working and living crowd in the district.Objective1. To establish the porcine satisfy models of spinal cord injury to thoracolumbar from gunshot.2. To study vital sign and pathology of lung in the hot and humid environment of SCI from gunshot.3. To investigate the pathological and histological change in the damaged spinal cord.Methods1. To establish the porcine satisfy models of spinal cord injury to thoracolumbar from gunshot in Drugged and waking state.2. To study vital sign and pathology of lung in the hot and humid environment of SCI from gunshot.3. To investigate the pathological and histological change in the damaged spinal cord (GFAF、NSE、S-100 protein and CD34).Results1. Drugs groups and waking group (1)Mean artery blood pressure (MAP):Both MAP level of two groups decreased progressively, but the level of drugs’get more in the 6th hour.(2) Mean heart rate (HR):Both HR level of two groups increased progressively, but the level of hot and drugs’get more in the 6th hour.(3) Rectal temperature:Mean rectal temperature level of drugs’increased.at the level of 2℃in the 2th hour.(4) PaO2 and PaC02:Both PaO2 level of two group decreased progressively, but level of two decreased in two hour because of hyperventilation, and increased after 2th hour。2、vital sign and respire function in the hot and humid environment(1)Mean artery blood pressure (MAP):Both MAP level of two groups’ decreased progressively(P<0.05) after gunshot.The difference between pre-injuries’and post-injuries’ in control group at 4th hour after gunshot and groups H occurred just after gunshot at every observational time.(2) Mean heart rate (HR):Both HR level of two groups increased progressively after gunshot at every observational time (P＜0.05), and the level of H group’s get more at every observational time (P＜0.05)(3) Rectal temperature:Mean rectal temperature level of control changed little after gunshot, otherwise the level of H group’s increased.at the level of 2.4℃at the 6th hour.(4) PaO2 and PaC02:Both of two groups’PaO2 level decreased progressively after gunshot, and the H group’s got more obviously (P<0.05).The PaC02 of H group’s decreased progressively after gunshot, but level of control group’s decreased in two hour because of hyperventilation, and increased after 2th hour。(5) There were obvious spotty and patchy bleeding areas in lungs in two group’s, especially in H group. Disappearance of alveolar structure, dissolution and degeneration of alveolar epithelial, infiltration of inflammatory cell, patchy bleeding, degeneration and shedding of Bronchial epithelial, substances from hemorrhage and secretions in lumen were all pronounced under Microscope in H group compared with extensive alveolar interstitial vascular congestion with alveolar cavity in different sizes accompanied by less bleeding and inflammatory cell infiltration and mild Bronchial expansion in control group。3 Controlled studies of pathological changes in spinal cord with injury in hot and humid group and control group(1) Optical microscopy:notable expansion of the spinal dural vascular obvious subdural hematoma, partial tear of the arachnoid, exposion of white matter, loosening and swelling of tissue structure, expansion of small blood vessels accompanied by scattered mononuclear cell infiltration were all observed in both groups. Fibrosis were main pathological finding in white matter axis without severe lesion., Degeneration of neurons and disappearance of some Nissl bodies were observed in gray matter. Neuron dissolution with irregular shape appeared in severe conditions. Extensive bleeding appeared in some specimens. Disappearance of normal structure was relatively obvious in tissues near the central canal of the spinal cord in high temperature and humidity group.(2) Electron microscope examination:Enlargement of nuclei in varying degrees and cavity formation in some part of the chromatin margination, mild to severe edema in mitochondrial, increased lysosomes, were all seen in both groups. Mitochondria apparently disappeared with thicken, twisted, loose, ruptured and irregularly layered myelin lamellar structure. Gap formed between axon and myelin sheath due to edema. Axon swelled with some axoplasm overflowed. Edema, intramedullary hemorrhage, necrosis and inflammatory cell infiltration were obvious. These findings were significantly obvious in high temperature and humidity group than in room temperature group.(3) The Nissl bodies:There were reduction in the number of Nissl body with pale staining in both groups which was significant in control group than H group(4) NSE:Expression was reduced significantly in H group than in control group。(5) GFAP:expression was reduced significantly in H group than in control group.(6) S-100:expression was reduced significantly in H group than in control group.(7) CD34:Positive markers were seen scattered in both groups. The number of vessels was significantly small in a single field of vision in H group than in control group.Conclusion1. It was good for pig to survive longer and get less influence in wake. 2.Spinal cord injury from gunshot in the hot and humid environment, the body has great heat production, eccrine sweat glands evaporation difficulty and accepts large apposition heat, which results in body heat disequilibrium, water-electrolyte metabolism disturbance and blood circulation collapse, and finally causes body temperature raise, metabolic rate increase, body fluid loss and internal environment chaos. It woud do more imparement to the pulmonary function and spinal cord injury.更多还原