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The study showed a case of missed diagnosis of Leriche syndrome. Patients with intermittent claudication were diagnosed as lumbar spinal stenosis by local hospital with lumbar MRI. When conservative treatment was ineffective, the patients were treated in our spine clinic. However, the lumbar MRI showed no significant stenosis, and arteriovenous ultrasound also showed no abnormality. Vascular surgeons believed that patient’s symptoms had little correlation with vascular lesions. After careful reading of lumbar spine MRI, we found that the signal intensity of abdominal aorta increased unevenly below L2 vertebral level. CTA examination of abdominal aorta revealed sclerosis of abdominal aorta and common iliac artery, stenosis and occlusion of abdominal aorta and common iliac artery lumen below the level of renal artery orifice. The patient was finally diagnosed as Leriche syndrome.
ABSTRACT
The study showed a case of missed diagnosis of Leriche syndrome.Patients with intermittent claudication were diagnosed as lumbar spinal stenosis by local hospital with lumbar MRI.When conservative treatment was ineffective,the patients were treated in our spine clinic.However,the lumbar MRI showed no significant stenosis,and arteriovenous ultrasound also showed no abnormality.Vascular surgeons believed that patient's symptoms had little correlation with vascular lesions.After careful reading of lumbar spine MRI,we found that the signal intensity of abdominal aorta increased unevenly below L2 vertebral level.CTA examination of abdominal aorta revealed sclerosis of abdominal aorta and common iliac artery,stenosis and occlusion of abdominal aorta and common iliac artery lumen below the level of renal artery orifice.The patient was finally diagnosed as Leriche syndrome.
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Objective@#To analyze the necessity of routinely performing foraminoplasty during percutaneous transforaminal endoscopic discectomy (PETD).@*Methods@#A total of 412 patients including 231 males and 181 females with an average age of 39.1±13 (20-80) years were enrolled in the present study. All patients were preoperatively diagnosed with single-segment lumbar disc herniation and underwent PETD by the same surgical group. The affected segments were at L3-4 in 32 cases, L4-5 in 289 cases, and L5S1 in 91 cases. Among them, 306 cases had no prolapse, 89 had mild up/down prolapse, and 17 had severe prolapse. MRI sagittal imaging was used to measure the height and width of the intervertebral foramen of L3, 4, L4, 5 and L5S1 segments, the distance between the lower edge of vertebral pedicle and the upper edge of the lower vertebral pedicle and the distance between the point 3 mm to the ventral side of the intervertebral space to the superior articular process. The necessity of performing foraminoplasty was evaluated by measuring the change of intervertebral foramen width using dynamic X-ray and verified during operation.@*Results@#The height of the intervertebral foramen of L3,4, L4,5 and L5S1 segments were 1.99±0.25, 1.89±0.15 and 1.52±0.26 cm, respectively. The width of the intervertebral foramen was 0.78±0.14, 0.75±0.13 and 0.64±0.13 cm, respectively. The distance between the lower edge of vertebral pedicle and the upper edge of the lower vertebral pedicle were 1.14±0.17, 1.05±0.16, and 0.98±0.19 cm, respectively. The distance between the point 3 mm to the ventral side of the intervertebral space to the superior articular process were 1.11±0.31, 1.17±0.20, and 0.95±0.14 cm, respectively. The width of the intervertebral foramen of the L3, 4 and L4,5 segments was significantly greater at the over-flexion position than at the over-extension position (P<0.05). Intraoperative verification showed that 347 cases (group A) did not need foraminoplasty. However, the other 65 patients (group B) needed foraminoplasty, including 31 at L4, 5 segment and 34 at L5S1 segment. One patient in group A and one in group B underwent revision operation due to residual intervertebral disc. At 2 years of follow-up, recurrence occurred in 4 patients in group A and 2 patients in group B. The ODI score and JOA score in group A and B were 18%±9%, 24.2±1.3 and 16%±7%, 23.9±1.3, respectively. There were not significantly different between patients in group A and B (t=1.70, P=0.090; t=1.71, P=0.088). The VAS score of lumbar pain of patients in group A was better than that of patients in group B (P<0.05).@*Conclusion@#Most of PETD of L3-S1 segments can reach the therapeutic target without performing foraminoplasty with half-half technique combined with far lateral access technique. Due to the special anatomical position of L5-S1 segment, the probability of performing foraminoplasty during operation is much higher. Performing foraminoplasty or not depends on the preoperative measurement of foramina and verification during the operation.
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Objective To analysis causes of surgical failure of percutaneous lumbar endoscopic discectomy (PLED) for lumbar degenerative diseases.Methods Forty-six patients (31males,15 females),who underwent unsuccessful PLED (including percutaneous transforaminal endoscopy discectomy,PTED;percutaneous interlamina endoscopy discectomy,PIED) or percutaneous endoscopic lumbar decompression,were included in this study.Unsuccessful surgeries included no relieve of lumbar and limb pain and numbness right after surgeries;aggravated after surgeries that need revision 1～3 moths after surgeries;new symptoms appeared after surgeries;still had severe low back pain (VAS ＞5 points) 3 months after surgeries;had recurrence of lumbar disc herniation at the same level.The average age was 46±11 years old (20-81 years old).The primary diagnosis was lumbar disc herniation in 43 cases,and lumbar spinal canal stenosis in 3 cases.Forty-two cases accepted single level surgeries,others accepted twolevel surgeries.One case underwent PLED twice,others underwent one-time surgery.Results The causes of surgical failure included misdiagnosis in 10 cases,inappropriate surgical indication in 10 cases,inappropriate surgical technique in 12 cases,recurrent disc herniation in 9 cases,and persistent low back pain in 6 cases.Misdiagnosis cases included avascular necrosis of femoral head in 2 cases,missed diagnosis of cervical myelopathy in 1 case,mental disorder in 1 case,severe central spinal canal stenosis in 3 cases,and unidentified diagnosis in 3 cases.Inappropriate surgical indication cases included performing PLED for severe central spinal canal stenosis in 3 cases,PLED for only low back pain in 6 cases,untreated responsible disc herniation at adjacent level in 1 cases.Inappropriate surgical technique cases included incomplete removal of protruded disc in 11 cases,nerve root injuryin 1 case.Conclusion The causes of surgical failure of PLED mainly included misdiagnosis,inappropriate surgical indication,incomplete removal of protruded disc,and recurrent disc herniation.Improving diagnosis and indication selecting ability may help to avoid surgical failure.
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Objective To review and analyze the clinical effect of combined posterior mini-invasive fixation with anterior debridement via small incision for the treatment of single segment lumbar vertebral tuberculosis. Methods Totally 31 cases with single segment lumbar tuberculosis (both borderline tuberculosis) without attachment involvement underwent one-stage anterior debridement, interbody fusion and posterior mini-invasive fixation from July 2010 to July 2015. Among these patients, 19 were male and 12 were female. The average age was (36.1±17.8) years old (ranged 21-61 years old). The average course of disease was 11(9, 12) months (ranged from 2 to 16 months). All were single segment involvement, and the involved segment was L2-3 in 7 cases, L3-4 in 10 cases, L4-5 in 6 cases, and L5-S1 in 8 cases. The clinical manifestations included lumbar back pain in 31 cases with an average pain visual analog score (VAS) of 7(6, 8) points. ASIA grade of spinal cord injury was E in 25 cases and D in 6 cases. Paravertebral abscess occurred in 22 cases and iliac fossa gravity abscess appeared in 9 cases. Kyphosis was observed in 12 cases and the average Cobb angle was 21° ± 6° . Quadruple anti-tuberculosis chemotherapy was used for at least 2 weeks preoperatively. Posterior mini-invasive fixation was fulfilled on prone position, including mini-invasive percutaneous screws in 18 cases and pedicle screw fixation via Wiltse approach in 13 cases. Posterior distraction and deformity correction were performed simultaneously for patients with kyphosis. Then the patients were changed to lateral position for anterior debridement, bone grafting and/or titanium mesh fusion. Results The average operation time was (204±54) min (ranged 160-240 min) in 31 patients, and the mean blood loss was (168±73) mL (ranged 100-300 mL). Delayed healing of anterior incision occurred in 1 case and the incision healed after two-week dressing of wound. The incision healed well in the rest 30 cases. No complications such as nerve function, blood vessel injury were found in patients. The VAS scores of the 3 days after operation were 1.3 ± 0.3 and 2.1 ± 1.4 in percutaneous group and Wiltse approach group, respectively, and the difference between them was statistically significant ( P<0.05). The VAS score of low back pain was 2(1, 3) points in all the 31 patients three months after operation, which was significantly lower than that before surgery (P<0.05). The six patients with neurological symptoms recovered to E grade after operation. The average Cobb angle correction was 15°±5° in 12 patients with kyphosis (P<0.05), which was significantly decreased compared with that before surgery (P<0.05). All patients were followed up for an average of (36.8 ± 9.3) months (ranged from 12 to 72 months). The clinical healing of tuberculosis was achieved at the final follow-up in all the 31 patients. No complications were observed, such as lumbar kyphosis, internal fixation loosening and breakage, dislocation and titanium mesh subsidence. Conclusion Mini-invasive posterior internal fixation and anterior debridement via small incision is effective for the treatment of single segment lumbar vertebral tuberculosis in lesion debridement and spine stability reconstruction by short segment fixation. This technique can reduce fused segments, surgical trauma of anterior approach and related complications.
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Objective To report the results using endoscopic techniques in ce rvical discectomy and intervertebral fusion. Methods From October 2002 to August 2003, 26 patients underwent cervical discectomy and intervertebral fusion using endoscopic techniques. 16 patients had been followed-up more than 3 months, inc luding 4 females and 12 males. The average age was 53.2 years (range, 23 to 65 y ears). The disorders lasted from 3 to 14 months before surgery. There were 3 cas es of cervical injury associated cervical disc herniation (CDH), 8 of cervical s pondylotic myelopathy (CSM), 2 of solitary ossification of the posterior longitu dinal ligament (OPLL), and 3 of radiculopathy. The mean preoperative ADL of Japa nese Orthopedic Association (JOA) score was 7.2. The working channel was inserte d through a 2 cm long incision, the protruded discs or ossified posterior longit udinal ligaments were excised for complete decompression, then an appropriate in tervertebral PEEK fusion cage was implanted. Results All patients obtained endos copic cervical discectomy and interbody fusion successfully. None of cases was c onverted to open procedures. The surgery lasted an average of 120 min (range, 50 to 150 min), mean blood loss was 110 ml (range, from 40 to 140 ml). There was n o complication during operation and no any stimulating symptoms on laryngopharyn x after surgery. However, postoperative hemorrhage of the incision occurred in 1 case, then an injury of a thyroid vessel was found during immediate exploration . The follow-up period extended from 3 to 8 months (mean, 6.5 months), the aver age preoperative ADL of JOA score was 13.1 while the improvement rate was 60.2%. Conclusion The cervical discectomy and intervertebral fusion through endoscopi c approach is able to reduce the soft tissue injury and the incidence of stimula ting symptoms on laryngopharynx, which makes the surgery more safe. The indicati ons for this procedure include cervical disc herniation, cervical myelopathy, ra diculopathy, and traumatic cervical disc injury on C3,4 to C5,6 segments.