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Objective:To explore the feasibility and clinical efficacy of oblique lateral interbody fusion (OLIF) in the treatment of adjacent segment disease (ASDis).Methods:Retrospective analysis was conducted on the data of 31 patients with ASDis treated by OLIF in four medical centers from June 2015 to December 2018. There were 17 males and 14 females. The average age was (65.7±3.4) years (range, 59 to 75 years). 19 cases received single-segment fixed fusion, 11 cases received double-segment fixed fusion and 1 case received three-segment fixed fusion. Original fixed fusion site: 1 case of L 1, 2, 3 cases of L 3, 4, 11 cases of L 4, 5, 4 cases of L 5S 1, 6 cases of L 3-L 5, 5 cases of L 4-S 1, and 1 case of L 3-S 1. The time from the initial fixation and fusion to this admission was 82.5±45.5 months (rang, 24 to 180 months). ASDis occurred at the proximal end of the fixed fusion segment in 28 cases and at the distal end in 3 cases. The types of ASDis: degenerative disc disease in 11 cases, lumbar spinal stenosis in 15 cases, degenerative spondylolisthesis in 2 cases, and degenerative scoliosis in 3 cases. The location of ASDis: 6 cases of L 2, 3, 12 cases of L 3, 4, 6 cases of L 4, 5, 3 cases of L 1-L 3, 1 case of L 2-L 4, and 3 cases of L 1-L 4. At admission, 3 cases of lumbar internal fixation had been removed and 28 cases of internal fixation remained. Stand-alone OLIF was performed in 19 cases, OLIF combined with pedicle screw fixation in 8 cases, and OLIF combined with cortical screw fixation in 4 cases. Visual analogue scale (VAS) and Oswestry disability index (ODI) were used to evaluate the low back pain and lumbar function before operation and at the last follow-up, and the imaging results and complications were observed. Results:All patients were followed up. The follow-up time was 23.6±9.6 months (range, 12 to 60 months). The operation time was 73.8±25.3 mins (range, 40 to 180 min), and the intraoperative blood loss was 86.2±67.4 ml (range, 20 to 310 ml). The average blood loss in each segment was 24.8 ml. During the operation, there were 1 case of segmental vein injury, 7 cases of endplate injury, 2 cases of transient iliopsoas muscle weakness, 1 case of thigh pain and numbness, and 1 case of incomplete intestinal obstruction. There was no incision necrosis and infection. The VAS score of low back pain decreased from 5.9±1.9 before operation to 1.4±0.6 at the last follow-up, with a statistically significant difference ( t=8.47, P<0.001). The ODI index recovered from 45.2%±5.7% before operation to 13.8%±4.7% at the last follow-up, with a statistically significant difference ( t=7.92, P<0.001). The height of intervertebral space increased from 8.7±1.6 mm before operation to 11.4±1.9 mm after operation and 9.9±1.8 mm at the last follow-up. There was a statistically significant difference between postoperative and preoperative height of intervertebral space ( F=4.15, P=0.007). There was a statistically significant difference between the last follow-up and postoperative height of intervertebral space ( P=0.011). During the follow-up, there were 13 cases of fusion cage subsidence, 1 case of fusion cage displacement, and no case of internal fixation loosening or fracture. The intervertebral fusion rate was 94%(29/31) and the complication rate was 42%(13/31). Conclusion:ASDis is a common complication after lumbar fixation and fusion, and requires surgical treatment. OLIF is a reliable method to treat ASDis as it has advantages of small trauma, high fusion rate and low complication rate.
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We reported a clinical caseof gas gangrene in the lower back and buttocks due to local intramuscular injection. A 43-year-old male was treated by local private clinic for low back pain. He underwent local intramuscular injection in his lower back and buttocks. 5 or 6 hours after the treatment,he felt worsen of low back pain (VAS 5 points)with a fever. After one day of treatment, the lower back pain was even worse(VAS 8 points). And he had soy-sauce urine and a high fever. The results of laboratory examination and clinical manifestation suggested multiple organ failure within a short period of time. Imaging (CT) suggested large area of gas and muscle necrosis in the lower back and buttocks. Considering the progress of the disease, emergency surgery on lumbar back and right buttocks was performed after hospitalization. Rapid bacterial smear reported gram-positive coarse bacteria. Anaerobic culture suggested clostridium perfringens. Aerobic culture result did not show any bacterial growth. According to the clinical manifestation, imaging (CT), intraoperative judgment and postoperative anaerobic culture results, the clinical diagnosis was gas gangrene. Gas gangrene is a special infectious disease in clinic, which can be characterized by low morbidity, difficult early diagnosis,rapid disease progression and high mortality. Sinceintramuscular injection leaded to this disease in our case, the importance of standardized aseptic procedures should be emphasized.
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Charcot Spinal Arthropathy (CSA) is a rare and progressive serious degenerative spinal disease. The clinical manifestations of CSA are concealed and atypical, which could lead to missed misdiagnosis, disease prognosis, and a huge burden on patients. However, there is no systematic review of CSA in China. The causes of CSA are mainly divided into spinal cord injury and non-injury neuropathy. The risk factors for CSA caused by spinal cord injury include long-segment fixation, scoliosis, laminectomy, overload spinal exercise and obesity. CSA usually occurs in the lower thoracic or lumbar spine. The symptoms of CSA include spinal deformity, unbalanced sitting posture and local pain. The CSA can be diagnosed after excluding non-specific chronic inflammation in histology and other inflammatory diseases or tumor based on the following items, damage to proprioception, pain and temperature perception, bone destruction, absorption and new bone formation on imaging. Conservative treatment can be considered for patients with CSA who have good stability without infections, stable nerve function, skin fistulas, balanced sitting posture, and autonomic dysfunction. Surgery is recommended for patients with symptoms lasting for more than 6 months with spinal instability, skin fistulas or complicated infections. Before surgery, it is recommended to evaluate the heterotopic ossification or rigidity of both hip joints. During operation, more attention should be paid to the adequate removal of necrotic tissue and inflammatory tissue in the lesion and sufficient bone grafting. Spinal fusion is recommended at the sacrum or pelvis. Postoperative complications include failure of internal fixation, new Charcot joint formation, difficulty in wound healing and infection. The authors emphasize that the overall thoracolumbar spine should be followed up for patients with spinal cord injury and paraplegia for the long-term. The typical symptoms of CSA are helpful for early diagnosis and selection of appropriate interventions.
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Objective:To investigate the characteristics and causes of endplate injury in the oblique lateral interbody fusion for the treatment of lumbar diseases, and summarize the precaution of endplate injury.Methods:Thirty-five cases of endplate injury were observed, which were originally treated with oblique lateral interbody fusion with or without pedicle screw fixation from October 2014 to December 2017. There were 7 males and 28 females, and the age ranged from 51 to 78 years old (averagely 62.8±8.13 years). There were 2 cases of lumbar disc degeneration, 10 cases of lumbar canal stenosis, 17 cases of lumbar degenerative spondylolisthesis, 2 cases of lumbar spondylolysis with or without spondylolisthesis, and 4 cases of lumbar degenerative scoliosis. Lesion sites contained L 3,4 in 2 cases, L 4,5 in 21 cases, L 2-4 in 3 cases, L 3-5 in 4 cases, L 2-5 in 3 cases and L 1-5 in 2 cases. Preoperative bone mineral density examination revealed there were 7 cases of T>-1 SD, 24 cases of -2.5 SD<T<-1 SD and 4 cases of T<-2.5 SD. There were 5 cases of high iliac crest. There were 25 cases of single segment, 5 cases of double segment, 3 cases of three segments, and 2 cases of four segments. Endplate injury occurred in all cases, and a total of 40 endplates occurred in 39 intervertebral spaces, of which the upper and lower endplates of 1 intervertebral space were injured, and the rest were single endplate injuries. There were 35 cases of upper endplate injury, 5 cases of lower endplate injury and 3 cases combined with vertebral fracture. The cage location where the endplate injury occurred: 3 cases in zone Ⅰ-Ⅱ, 31 cases in zone Ⅱ-Ⅲ and 5 cases in zone Ⅲ-Ⅳ. The main observation indicators were Visual Analog Scale (VAS) for low back pain, Oswestry disability index (ODI), intervertebral space height, and position of cage. Results:The reasons for endplate injury were: osteopenia or osteoporosis 28 cases, improper surgical steps 9 cases, high iliac crest 5 cases, endplate anatomical morphology variation 5 cases, obvious stenosis of the intervertebral space 4 cases, large cage 3 cases and mixed factors 12 cases. The follow-up time was 18.5±8.1 months. There was no pedicle screw loosen during the follow-up. There were 3 cases of lateral displacement of cage, including 1 case of Stand-alone OLIF, 2 cases of OLIF combined with pedicle screw fixation. In all cases, different degrees of cage subsidence occurred. Among them, 7 cases of Stand-alone OLIF were supplemented with posterior pedicle screw fixation. The intervertebral height of diseased segment was well restored postoperatively, which was statistically significant compared with preoperative. But there was significant loss during the follow-up, and the difference was statistically significant at the last follow-up. The low back pain VAS score was from 6.6±2.2 preoperative to 1.3±0.74 at the last follow-up, which was statistically different. The ODI was from 36.3%±7.4% preoperative to 9.6%±3.5% at the last follow-up, which was statistically different. Except 3 cases, the remaining had well interbody fusion, with the fusion rate of 91.4%.Conclusion:The incidence of endplate injury during oblique lateral interbody fusion is high. The reasons of endplate injury include both the patient's factors and the surgical factors. Endplate injury is closely related to the decreased intervertebral space height during the follow-up period, as well as the settlement or displacement of cage. Some cases may require reoperation. The prevention of endplate injury should be strengthened. Once it occurs, timely and effective treatment should be taken, and follow-up should be done closely.
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Circular RNA (circRNA) is a kind of RNA with a circular structure. The unique structure of circRNA endows it with various cell biological functions and characteristics. It has become a research hotspot recently. CircRNA can play a role via mechanisms, such as microRNA (miRNA) sponge, RNA binding protein, peptide translation and regulation of gene transcription. CircRNA was found to be associated with disc degeneration, spinal cord injury, scoliosis, and facet arthritis. Some techniques, including bioinformatics and molecular biology techniques, microarray and high-throughput sequencing, can be used to predict and to discover disease-related circRNA, aiming to evaluate whether circRNA can be used as a molecular biomarker for spinal and spinal cord diseases. Based on the current role of circRNA, the corresponding therapeutic strategies have been carried out in experimental animals, which can provide theoretical basis for gene therapy. At present, the researches in circRNA for spinal and spinal cord diseases are still insufficient compared with those in other fields. Currently, the main direction focuses on the miRNA sponge mechanism of circRNA. Due to the variety of diseases in spinal surgery, the research progress of circRNA is also varied. In addition, the development of microarray and high-throughput sequencing technology have greatly promoted the researches in circRNA. The availability of public database is of great significance in the study. The present review summarized the current researches status of circRNA in spinal and spinal cord diseases, aiming to deepen understanding of circRNA in spinal and spinal cord diseases.
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Objective:To compare the efficacy of oblique lumbar interbody fusion (OLIF) and minimally invasive interbody fusion (MI-TLIF) for degenerative lumbar spondylolisthesis.Methods:Data of 40 patients with I-II degree single level degenerative lumbar spondylolisthesis from January 2018 to December 2018 were retrospectively analyzed. According to the operation procedure, they were divided into two groups: OLIF group and MI-TLIF group, and each group had 20 patients. There were 15 males and 5 females in the OLIF group, aged 50.3±8.8 years; and there were 13 males and 7 females in the MI-TLIF group, aged 51.7±8.7 years. According to the Meyerding's grade system, there were 16 patients of type I in the OLIF group and 15 cases in the MI-TLIF group; and there were 4 patients of type II in the OLIF group and 5 cases in the MI-TLIF group. The operation time, intra-operative hemorrhage, postoperative drainage, recessive blood loss and albumin loss were recorded. The CRP and ESR on the third day after operation, the VAS score and ODI score before and after operation were recorded. The lumbar lordosis (LL), fused segmental lordosis (FSL) and disc height (DH) before and after operation were recorded. The time of getting out of bed and walking and the hospital stay were recorded. Paired t-test was used to analyze the data.Results:Forty patients successfully underwent the operation. The operation time of OLIF group was 96±20 min, with intraoperative blood loss of 61±32 ml and postoperative drainage volume of 18±8 ml. The operation time of MI-TLIF group was 132±26 min, with intraoperative blood loss of 262±102 ml and postoperative drainage volume of 95±42 ml; and there was statistical difference between the two groups ( t=4.901, 8.404, 8.064; P< 0.001). On the third day after operation, the occult blood loss was 139±47 ml in the OLIF group and 486±192 ml in the MI-TLIF group; the albumin loss was 4.2±1.9 g/L in the OLIF group and 10.2±3.9 g/L in the MI-TLIF group; CRP was 34±11 mg/L in the OLIF group and 106±39 mg/L in the MI-TLIF group; ESR was 41±15 mm/1 h in the OLIF group and 71±24 mm/1 h in the MI-TLIF group, and there all were statistical differences between the two groups ( t=7.838, 6.184, 7.983, 4.675; P< 0.001). The VAS scores were 2.2±1.5, 1.8±1.3 and ODI scores were 14%±11%, 59%±17%, respectively. There was no significant difference between the two groups. The LL were 33.41°±9.25°, 32.07°±9.54°, FSL were 11.59°±5.09°, 10.61°±4.56° and DH were 10.35±2.30 mm, 10.85±1.85 mm, respectively. There was no significant difference between the two groups. The follow-up time was 13.5±2.3 months in the OLIF group and 14.1±2.8 months in the MI-TLIF group. Three patients in the MI-TLIF group had radiation pain in the lower extremity on the third day after operation, which relieved after NSAID drugs and mannitol treatment. In the group of OLIF, the skin temperature of the left lower extremity increased in 1 case on the first day after operation, in which sympathetic chain injury was considered, and the patient recovered after 2.5 months; in the group of OLIF, the numbness in the front of the left thigh and the weakness of flexion of the hip was found in 3 cases, in which the edema or injury of the psoas major muscle was considered. Conclusion:Compared with MI-TLIF in the treatment of I, II degree single segment degenerative lumbar spondylolisthesis, OLIF has the advantages of shorter operation time, less intraoperative and postoperative blood loss, lower inflammation index, earlier time to get out of bed and shorter hospital stay. However, the outcomes of the two surgeries were similar.
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Objective:To investigate the safety, key techniques and clinical efficacy of OLIF (oblique lumbar interbody fusion) corridor combined with lumbar intervertebral debridement, fusion with two interbody and internal fixation for the treatment of single-level lumbar pyogenic spondylodiscitis.Methods:From February 2016 to March 2017, data of 12 patients with single-level lumbar intervertebral pyogenic infection diagnosed in our hospital who had undergone oblique lumbar interbody fusion with two interbody and posterior pedicle screw fixation via Wiltse approach were retrospectively analyzed. Among them, there were 10 males and 2 females, aged from 49 to 79 years, with an average age of 65.4±9.5 years. The white blood cells (WBC), erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) were recorded and analyzed before operation and at the last follow-up. Lumbar pain was assessed by visual analogue acale (VAS), Oswestry disability index (ODI), and clinical efficacy was assessed by the MOS 36-item short-form health survey (SF-36) and Kirkaldy-Willis criteria. The hospitalization time, operation time, intraoperative blood loss, pathological reports, etiological results and complications were recorded. Disc height (DH), segmental angle (SA) and Lumbar Lordosis (LL) were measured before operation and at the last follow-up. The fusion time was recorded. Paired t-test and ANOVA was used for data analysis. Results:All patients underwent surgery successfully, including 6 cases using two titanium meshes and 6 cases using two autologous tricortical iliac bones. Pathogenic culture was positive in 10 cases, with a positive rate of 83.3%, including 4 cases of streptococcus, 4 cases of Staphylococcus aureus, 1 case of Escherichia coli, and 1 case of Klebsiella pneumoniae. All patients were followed up for 16.1±5.1 months. At the last follow-up, WBC ([6.25±2.02] ×10 9/L) was lower than that before operation ([4.89±1.28] ×10 9/L), CRP (preoperation 58.73±52.56 mg/L vs postoperation 8.48±8.79 mg/L) and ESR (preoperation 51.88±19.04 mm/1 h vs postoperation 9.25±5.50 mm/1 h) were significantly lower ( P< 0.01). The VAS score was preoperation 6.67±1.63 and postoperation 1.50±0.55, ODI score was preoperation 72.57%±3.41% and postoperation 18.00%±2.31%, and both were significantly lower postoperatively ( P < 0.01). SF-36 score (preoperation 56.33±4.93 vs postoperation 73.73±5.86) was significantly higher ( P< 0.01) respectively. The postoperative height of intervertebral space ([11.68±2.64] mm) was significantly higher than that before operation ([5.18±1.58] mm). The disc height at the last follow-up was (11.22±2.25) mm, and the loss rate was 1.89% compared with that of the immediate postoperatively; The postoperative lumbar lordosis angle (32.89°±14.52°) was significantly increased compared with that of the preoperative (24.16°±13.49°), and maintained well at the last follow-up (32.27°± 14.21°); The postoperative segmental angle (10.8°±8.51°) was significantly increased compared with that of the preoperative (5.81°±7.44°), and maintained well at the last follow-up (9.94°±7.87°). The fusion time ranged from 6 to 16 months, with an average of 9.2±3.5 months. The clinical efficacy was excellent in 10 cases (83.3%) and good in 2 cases (16.7%). The excellent and good rate was 100%. One case of pulmonary infection and pulmonary embolism occurred 2 days after operation, and recovered after use of antibiotics and anticoagulation treatment in ICU; one case of intramuscular venous thrombosis was found 1 day after operation, and recovered after anticoagulation treatment; no loosening of internal fixation was found, and no complications related to OLIF corridor occurred. Conclusion:The treatment of single-level lumbar intervertebral pyogenic infection with OLIF corridor combined with lumbar intervertebral debridement, fusion with two interbody and internal fixation has the advantages of less blood loss, shorter operation time, more direct clearance of intervertebral space and left paravertebral focus, no disturbance of intraspinal canal and posterior structure, higher positive rate of etiology detection, shorter bedrest time and better restore of disc height and lumbar lordosis after operation. What’s more, the fusion rate is high and the clinical efficacy is satisfactory.
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Objective To compare the long-term effect between minimally invasive (MIS) and open approaches in one-level posterior lumbar interbody fusion (O-PLIF) after more than 10 years follow up. Methods All 131 patients (lumbar spine le-sions) in our hospital were randomized into MIS-PLIF group and O-PLIF group from March 2006 to March 2008. In MIS-PLIF group, there are 66 patients, 34 males and 32 females, with the average of 52.3 ± 6.7 years old (range from 40 to 63). In O-PLIF group, there are 65 patients, 29 males and 36 females, with the average of 51.1 ± 6.9 years old (range from 46 to 63). Regarding March 2018 as last follow-up, differences in intervertebral disc height and segmental lordosis restoration of the operation segment , lumbar lordosis restoration, multifidus cross section area (CSA), multifidus atrophy rate, fusion rate, visual analogue scale (VAS) for back and leg pain, Oswestry Disability Index(ODI), Japanese Orthopaedic Association cores (JOA) and postoperative long-term compli-cations were evaluated between the two groups. The related risk factors of postoperative long-term complications were evaluated in further analysis. Results Complete follow-up data were available on 37 patients in MIS-PLIF group and 35 patients in O-PLIF group, with the follow-up rate of 56.1％and 53.8％respectively,and with the mean follow-up time of 134.5 ±8.4 and 137.1±5.8 months respectively. At three time nodes of one year after operation, five years after operation and last follow-up after operation, there were significant differences in lumbar lordosis restoration (one year after operation and last follow-up after operation)( 5.0°± 2.3° vs. 3.9°±1.4°;4.7°±2.4° vs. 3.7°±1.5°), multifidus CSA (965.4±164.9 mm2 vs. 884.9±168.2 mm2;891.1±155.9 mm2 vs. 783.2± 163.0 mm2; 764.8 ± 148.3 mm2 vs. 643.5 ± 150.0 mm2), multifidus atrophy rate (8.5％± 2.5％ vs. 16.6％± 5.8％; 15.6％± 3.5％ vs. 26.2％±7.4％;27.6％±6.5％vs. 39.3％±9.3％), postoperative VAS for back pain (2.2±1.0 vs. 2.9±1.2;1.7±0.9 vs. 2.2±1.0;1.4±1.0 vs. 2.2±1.2), JOA score (22.3±3.8 vs. 19.9±4.2;23.1±4.3 vs. 19.3±3.9;22.4±4.2 vs. 19.6±4.0) and ODI (11.6％±4.8％vs. 22.0％± 7.7％;9.4％±3.9％vs. 12.3％±4.9％;8.6％±4.0％vs. 11.0％±4.6％) between the two groups (P<0.05). However, there were no sig-nificant differences in segmental lordosis, intervertebral height restoration, lumbar lordosis restoration (one year after operation), fusion rate or postoperative VAS for leg pain between MIS-PLIF and O-PLIF(P>0.05). Intractable back pain and adjacent segment disease were the major postoperative long-term complications for MIS-PLIF group (3 cases and 2 cases) and O-PLIF group (10 cas-es and 7 cases), and the difference was statistically significant in the intractable back pain incidence rate ( 8.5％vs. 28.6％,χ2=5.090, P=0.024), but not in the adjacent segment disease(5.4％vs. 20％,χ2=0.002, P=0.061). What's more, patients with intracta-ble back pain suffered more obviously multifidus atrophy than patients without intractable back pain at three time nodes of one year after operation (19.4±4.4％vs. 10.9±5.1％, P<0.05), five years after operation (30.2±5.4％vs. 18.7±6.7％, P<0.05) and last fol-low-up after operation (44.5±5.7％vs. 30.8±8.9％, P<0.05) . Conclusion In the long-term follow up, compared with O-PLIF, MIS-PLIF had advantages in better maintenance of lumbar lordosis, protection of the multifidus muscle, reduced lower back pain, JOA score, ODI score and intractable back pain incidence rate. Multifidus atrophy may be a related risk factor of intractable back pain.
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Objective To evaluate and discuss the clinical outcomes and advantages of midline lumbar fusion (MIDLF) with cortical bone trajectory (CBT) screw in the reoperation of lumbar disease. Methods From June 2014 to August 2015, a total of 12 patients, 5 male and 7 female with an average age of 68.5±5.6 years old (ranged from 56-76 years). The indications of reoper-ation including:5 cases of adjacent segment disease, 2 cases of discogenic back pain after lumbar dynamic stabilization, 5 cases of recurrent disc herniation. The interval time from primary surgery to second surgery was 3-9.5 years (average 6.0±2.0 years). Dis-ease level:L2/31 case, L3/42 cases, L4/57 cases, L5/S12 cases. All cases were got the X-ray, CT scan and MRI examination before surgery. The operative duration, blood loss, complications were all evaluated. Back and leg pain were recorded by visual analogue scale (VAS) scores. Functional recovery was evaluated by Oswestry disability index (ODI). Results Operative time was 110-210 min, and mean duration was (158.3±36.4) min. Blood loss was 150-310 ml, and mean loss was (231.7±51.0) ml. There was 1 case of cerebrospinal fluid leakage which treated with pillow supine for 1 week after surgery, and strengthened the prevention of antibi-otics, incision healing, with no headache and other low intracranial pressure of dizziness, the remaining patients had no intraopera-tive and postoperative complications. The time of follow-up was 12-25 months, with an average of (17.9 ± 4.6) months. The back pain of VAS score of preoperative was 3.9±1.4, and the last follow-up was 1.9±0.5, the difference was statistically significant (t=4.506, P=0.001). The VAS score of preoperative leg pain (4.9±1.4) was significant higher than the last follow-up (1.2±0.6, t=9.134, P=0.000). The preoperative ODI was 32.9±3.4, and last follow-up was 13.3±3.2, and the difference was statistically significant (t=15.002, P=0.000). Conclusion MIDLF was applicable with good clinical outcome and technical advantages in current cases, and it might be a choice of reoperation for lumbar disease.
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Objective To observe the outcomes of one-stage posterior short-level pedicle screw fixation combined with anterior fixation of severe thoracolumbar fractures.Methods A retrospective case series study was performed on 21 patients with severe thoracolumbar fractures stabilized by posterior short-level pedicle fixation combined with anterior internal fixation at one stage from January 2012 to December 2014.There were 16 males and 5 females,at age of 17 and 64 years [(38.7 ± 11.4) years].The involved segments included T11 in 2 patients,T12 in 5,Lt in 6 and L2 in 8.For AO fracture classification,type A fractures were seen in 4 patients,type B in 7 and type C in 10.Thoracolumbar injury classification and severity score (TLICS) was (8.12 ± 0.87) points (range,7-10 points).Frankel neurological performance scale was Grade B in 8 patients,Grade C in 11 and Grade D in 2.Operation time,blood loss,nerve function,kyphosis correction and complications were reported.Results Operation time was (234.5 ±57.3)min (range,180-360 min),and blood loss was (387.4 ± 124.4) ml (range,260-950 ml).Time of follow-up was (19.8 ± 3.5)months (range,14-25 months).Nerve function of 18 patients was improved by at least one Frankel scale.Cobb angle was (4.1 ±5.3)° at postoperative 3 days and (4.0 ± 4.9)°at the final follow-up,showing significant differences from that before operation [(-9.3 ± 4.2) °] (P ＜ 0.05).While the difference of Cobb angle did not differ significantly at postoperative 3 days and at final follow-up.No cerebrospinal fluid leakage,vascular injury,incision infection or nerve function deterioration occurred.Conclusion One-stage posterior short-level pediele screw fixation combined with anterior decompression and bone graft fixation is characterized by short operation time,few blood loss,good correction of traumatic kyphosis and good neurological recovery,indicating a good surgical choice for severe thoracolumbar fractures.
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Objective To investigate the indirect decompression effect of oblique lateral interbody fusion (OLIF) in the treatment of mild to moderate degenerative lumbar stenosis.Methods From October 2014 to November 2016,23 patients with mild to moderate lumbar spinal stenosis underwent OLIF combined with or without posterior pedicle screw fixation;9 males and 14 females with average age of 59.2±11.6 years old;8 cases at L3,4 segment and 15 cases at L4,5 segment.All cases were followed up for more than 6 months.Thin layer scanning of CT and two-dimensional reconstruction images were used to measure the vertical diameter and area of intervertebral foramen.Intervertebral disc height and spinal canal anteroposterior diameter were measured on median sagittal MRI sequence,and the anteroposterior diameter and the cross-sectional area of the spinal canal were measured on cross-sectional MRI sequence.The clinical effects were assessed by the visual analogue score (VAS) and the Oswestry disability index (ODI) for low back pain,lower limb pain and lower limb numbness.Results Compared with those measurements pre-operatively,the post-operative intervertebral disc height increased by 78.6％±13.4％.The post-operative left vertical diameter of intervertebral foramen increased by 36.7％±7.8％,and the post-operative left area of intervertebral foramen increased by 36.6％± 8.7％,and the post-operative right vertical diameter of intervertebral foramen increased by 40.7％±9.6％,and the post-operative right area of intervertebral foramen increased by 40.0％±8.9％.The post-operative anteroposterior diameter of sagittal spinal canal were increased 32.6％ ± 5.9％,and the post-operative anteroposterior diameter of cross-sectional spinal canal were increased 34.4％±6.8％,and the post-operative cross-sectional area of the spinal canal were increased 47.5％±7.2％.All of the differences were statistically significant between pre-operative and post-operative measurements.The VAS score for low back pain was 6.2± 1.7 pre-operatively,and 1.1±0.5 post-operatively.The ODI for low back pain was 81.2％± 18.2％ pre-operatively,and 6.1％±2.0％ post-operatively.The VAS score for lower limb pain was 5.6±1.4 pre-operatively,and 0.8±0.3 post-operatively.And the VAS score for lower limb numbness was 6.6±2.0 pre-operatively,and 3.4± 1.2 post-operatively.All of the differences were statistically significant between pre-operative and post-operative evaluations.Conclusion There were obvious radiological evidences and remarkable clinical effect of indirect decompression using OLIF technique in treatment of mild to moderate lumbar spinal stenosis at early post-operative stage.However further long-term follow-up studies with multicenter large sample were still needed.
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Objective To evaluate the early clinical outcomes and complications of oblique lateral interbody fusion (OLIF) in the treatment of degenerative lumbar diseases.Methods All of 83 patients,29 males and 54 females with ages from 32 to 83 (average 60.8± 13.7 y),underwent OLIF with or without posterior pedicle screw-rod instrumentations from October 2014 to February 2017.The index diagnosis was discogenic back pain in 17 cases,spondylolisthesis in 23,lumbar spinal canal stenosis in 25,and degenerative lumbar spinal kyphoscoliosis in 18 cases.The distribution of operative level was 5 at L1,2,13 at L2,3,38 at L3,4,and 69 at L4,5.The mean number of fusion level for each case was 1.5 segments.The operative duration,blood loss during operation,intra-operative and post-operative complications,the length of post-operative hospital stay were recorded.Clinical outcomes were evaluated using visual analogue scale (VAS) and Oswestry disability index (ODI).All patients were followed up for at least 3 months.Lumbar X-ray and CT scans were taken and the clinical outcomes were re-assessed during follow-up.Results Fifty-one in the 83 patients underwent supplementary posterior pedicle screw-rod instrumentation with OLIF procedures.The operation lasted for 43-295 min,with a mean duration of (153 ± 72) min.Mean operation time for each OLIF segment was 43± 12 min.Blood loss during the operation was 30-800 ml,with a mean of 125±74 ml.Mean blood loss for each OLIF segment was 27±13 min.Average length of stay was 5.6 ± 3.2 d,ranging from 3-15 d.The VAS for back pain and leg pain and ODI scores were decreased apparently for each patient.The total incidence of complications was 22.9％ (19/83),including 6.0％ (5/83) of intra-operative complications (4 cases of cage subsidence,1 case of segmental artery injury) and 16.9％ (14/83) of post-operative ones.The latter consisted of ipsilateral hip flexor weakness in 6,ipsilateral anterolateral thigh pain in 2,ipsilateral lateral thigh numbness in 1,contralateral pain in flexion of hip in 1,ipsilateral sympathetic chain injury in 2,and pain in area of iliac bone donor site in 2.All symptoms were released or disappeared during follow-up.Conclusion OLIF as a novel minimally invasive technique can act as a safe and effective treatment for degenerative lumbar diseases,which can also reduce approach-related complications.
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Objective To evaluate the clinical outcomes of oblique lateral interbody fusion (OLIF) in the treatment of adult degenerative scoliosis (ADS).Methods From January 2015 to May 2016,17 ADS patients,4 males and 13 females were enrolled with ages from 46 to 80 (average 69.5±9.2 years).The Cobb angle of all was greater than 10°.According to Lenke-Silva classification systems:Ⅰ level,2 cases,decompression alone;Ⅱ level,2 cases,decompression and limited instrumented spinal fusion;Ⅲ levels,4 cases,decompression and lumbar curve instrumented fusion;Ⅳ levels,5 cases,decompression with anterior and posterior spinal instrumented fusion;Ⅴ level,4 cases,thoracic instrumentation and fusion extension.The operation time,blood loss,blood transfusion,and preoperative and postoperative complications were recorded.Clinical and radiological outcomes were evaluated using visual analogue scale (VAS),Oswestry disability questionnaire (ODI) scores,sagittal vertical axis (SVA) and coronal Cobb.All cases were followed up in 3,6,12 and 24 months.Results All of 17 cases underwent OLIF,one level 4 cases,two levels 2 cases,three levels 7 cases and four levels 4 cases.Alone OLIF was 5 cases (2 case of Ⅰ level,1 case of Ⅱ level,1 case of Ⅲ level and 1 case of Ⅳ level).OLIF combined with posterior approach was 12 cases and the interval time were 1-2 weeks,the mean were 1.7±0.5 weeks.Among these 12 cases,posterior fixation was 6 cases,posterior fixation and decompression was 2 cases,and L5/S1 interbody fusion was 4 cases.The operation lasted for 50-460 min,with a mean duration of 230.6± 132.0 min.Blood loss during the operation was 30-640 ml,with a mean of 306.5±213.8 ml.No patient had blood transfusion.The follow-up was 12-28 months and the mean was 17.9±4.5 months.The preoperative Cobb angles were 16.2°-37.7°,the mean was 29.1°±6.4°.The postoperative Cobb angle were 1.5°-10.2°,and the mean were 5.6°±2.4°.The Cobb of all cases improved significantly.The SVA was returned to the normal level in 4 cases of Lenke-Silva V level.The VAS and ODI score decreased from 7.1 ±0.7 preoperatively to 2.4±0.9 at last follow-up,and from 37.9±2.5 to 10.9±3.0,respectively,and both of them were improved significantly.2 cases of OLIF had cage malposition.Left hip flexor weakness occurred in 5 cases and recovered completely within 2 weeks.Left anterior thigh pain occurred in 1 case and disappeared within 2 weeks.Left sympathetic chain injury happened in 1 case and recovered at last follow-up.Conclusion OLIF as a management of ADS showed excellent short-term outcomes.Clinical and radiological results,such as VAS,ODI and Cobb angle,were improved in all cases.OLIF will be a good choice for the treatment of ADS.
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Objective To evaluate and discuss the clinical outcomes and advantages of midline lumbar fusion (MIDLF) with cortical bone trajectory (CBT) screw in the reoperation of lumbar disease. Methods From June 2014 to August 2015, a total of 12 patients, 5 male and 7 female with an average age of 68.5±5.6 years old (ranged from 56-76 years). The indications of reoper-ation including:5 cases of adjacent segment disease, 2 cases of discogenic back pain after lumbar dynamic stabilization, 5 cases of recurrent disc herniation. The interval time from primary surgery to second surgery was 3-9.5 years (average 6.0±2.0 years). Dis-ease level:L2/31 case, L3/42 cases, L4/57 cases, L5/S12 cases. All cases were got the X-ray, CT scan and MRI examination before surgery. The operative duration, blood loss, complications were all evaluated. Back and leg pain were recorded by visual analogue scale (VAS) scores. Functional recovery was evaluated by Oswestry disability index (ODI). Results Operative time was 110-210 min, and mean duration was (158.3±36.4) min. Blood loss was 150-310 ml, and mean loss was (231.7±51.0) ml. There was 1 case of cerebrospinal fluid leakage which treated with pillow supine for 1 week after surgery, and strengthened the prevention of antibi-otics, incision healing, with no headache and other low intracranial pressure of dizziness, the remaining patients had no intraopera-tive and postoperative complications. The time of follow-up was 12-25 months, with an average of (17.9 ± 4.6) months. The back pain of VAS score of preoperative was 3.9±1.4, and the last follow-up was 1.9±0.5, the difference was statistically significant (t=4.506, P=0.001). The VAS score of preoperative leg pain (4.9±1.4) was significant higher than the last follow-up (1.2±0.6, t=9.134, P=0.000). The preoperative ODI was 32.9±3.4, and last follow-up was 13.3±3.2, and the difference was statistically significant (t=15.002, P=0.000). Conclusion MIDLF was applicable with good clinical outcome and technical advantages in current cases, and it might be a choice of reoperation for lumbar disease.
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Objective To investigate a reliable and practicable model of intraoperative neurophysiological monitoring (IONM) in oblique lateral interbody fusion (OLIF) combined with posterior transpedicle internal fixation.Methods A total of 34 consecutive patients who underwent OLIF combined with posterior transpedicle internal fixation with IONM at the SRRSH from November 2014 to July 2016 were collected and follow-up at least for 3 months postoperative.The intraoperative somatosensory evoked potentials (SEP),motor evoked potentials (MEP),dermatomal somatosensory evoked potential (DSEP) and spontaneous electromyography (sEMG) were used and evaluated,besides,triggered electromyography (tEMG) was used to monitor the implantation of pedicle screws,the possible reasons and treating procedures of monitoring alerts were summarized.Results A total of 34 cases of patients were effectively monitored during OLIF combined with posterior transpedicle internal fixation.SEP monitoring was successful in all patients,and no abnormal SEPs were observed in all cases.DSEP monitoring was successful in 20 cases (58.8％),and no abnormal DSEPs were observed in these patients.MEP was successfully monitored in all cases,eliminating the anesthesia factor,no abnormal MEPs were observed in all cases.The sensitivity and positive predictive value of SEP,MEP,DSEP were 0％.3 cases had abnormal sEMG reactions during the channel establishment which disappeared after adjustment of channel,and 2 cases which appeared abnormal wave recovered after brief observation.Among the 5 patients with abnormal wave,one case got numbness,one patient felt pain in front of the thigh postoperative.Among the other 29 patients without abnormal wave during channel establishment,one case appeared numbness.These 3 patients with neurologic symptoms recovered in 3 months after conservative treatment.The sensitivity and specificity of sEMG was 66.7％ and 90.3％ respectively,negative predictive value and positive predictive value were 96.6％ and 40％ respectively.6 screws got tEMG response after tapping even the intensity was less than 10mA,which showed broken codex of pedicle according to postoperative CT scan.Cornclusion Intraoperative application of sEMG monitoring in OLIF can obviously reduce the incidence of the neurological deficit,which was an effective method,tEMG monitoring during lumbar pedicle screw fixation can detect the mal-positioned screws and protect the nerve roots.SEP,MEP and DSEP did not seem well suited for OLIF.
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Objective To investigate the clinical effect of modified anterior approach to manage fracture of the ulnar coronoid process via the space of brachial artery and vein with median nerve.Methods From June 2012 to January 2013,11 patients with ulnar coronoid fracture were fixed via the modified anterior approach.The operation time,intraoperative blood loss and postoperative complications were recorded.Flexion and rotation range of motion about the injured and normal elbow were observed during postoperative follow-up period.Function of elbow joint was evaluated by mayo elbow performance index (MEPI).Results There was approximate 8 cm in length and 5 cm in width between the brachial vessels and median nerve.Operated angle from radial to ulnar side was fifty degrees and from proximal to distal end was sixty degrees.All the patients were available for follow-up.The fracture healed,that is the elbow flexion restored [(130.7 ±5.0) °] was 96.6％ of the unaffected elbow,elbow extension restored [(7.6 ± 8.1) °] was 84.0％ of the unaffected elbow,pronation restored [(86.9 ± 3.8) °] was 98.2％ of the unaffected side,and supination restored [(85.6 ± 6.0) °] was 96.7％ of the unaffected side.MEPI of the elbow joint was over 75 points.Conclusion Modified anterior approach is relatively safe and simple in operation and results in satisfactory function recovery of the elbow joint,providing a new surgical approach for treatment of coronoid process fracture.
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Objective To evaluate the effects of mini-open anterior lumbar interbody fusion (ALIF) in the treatment of recurrent lumbar disc herniation (RLDH).Methods From February 2001 to February 2012,20 patients of RLDH who underwent mini-open ALIF were retrospectively analyzed.There were 8 male and 12 female with an average age of 53.1±5.9 years (range,44-68 years).The SynFrame retractor system and SynFix-LR interbody cage were used in operation.The operative time,intraoperative blood loss,blood drainage of 24 hours postoperatively and hospital stay were recorded.In addition,visual analogue scale (VAS)and Oswestry disability index (ODI) of pre-operation,2 days,3,6 and 12 months postoperatively were evaluated.Results All patients were followed up for 12-110 (average,45.6±29.6) months,postoperative VAS score and ODI percent decreased significantly comparing with that of pre-operation (P＜0.05).However,no remarkable difference (P＞0.05) was found among that of 2 days,3,6,12 months postoperatively.Average VAS score was 7.7±0.7 before operation and 1.7±0.9 at 12-month follow-up.Average ODI percent was 80.6％±3.9％ before operation and 6.6％± 1.3％ at 12-month follow-up.Intraoperative blood loss was 90-220 ml (average,126.0±40.3 ml) and postoperative blood drainage at 48 h was 35-63 ml (average,47.5±7.6 ml).Hospital stay was 4-11 days (average,6.7± 1.8 days).All patients had achieved solid fusion after 6 months' follow-up.All these implants were in good places without displacement or hardware failure.Conclusion Mini-open ALIF can result in fewer invasions,significantly relieve symptoms and improve patients' function in the treatment of RLDH.Moreover,it can increase fusion rate with fewer complications,which can obtain a satisfactory short-or mid-term effect.
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Objective To observe the correlation between bone mineral density (BMD) and surgical outcomes of posterior lumbar interbody fusion (PLIF) for lumbar degenerative spondylolisthesis (DS).Methods From January 2006 to December 2010,69 patients with DS had undergone PLIF by the same surgical team.According the BMD,the cases were divided into two groups.Normal group (T ≥-1.0) had 33 cases [Male 16 cases,Female 17 cases; mean age,(56.5±9.0) yrs; L,,5 20 cases,L5S1 13 cases].The osteopenia group (T ＜-1.0) had 36 cases [Male 13 cases,Female 23 cases; mean age,(60.5±7.8) yrs; L4.5 21 cases,L5S1 15 cases].Blood loss,surgical duration,intra-and post-operative complications were collected.The clinical improvement was quantified by measurement of pain (visual analogue scale,VAS) and Roland-Morris (RM) Disability Questionnaire.Between two groups,the differences of age,body mass index,blood loss,VAS improvement,and RM improvement were compared.The correlation between BMD and sex,age,segment,screw loose,nonunion,and cage subsidence was analyzed.Results In two groups,the difference between pre-and post-operative RM and VAS was significant respectively.The blood loss was 415.5± 105.8 ml in normal group,significantly less than 528.3±128.7 ml in osteopenia group.There was no significant difference in the duration between normal group (169.7±44.3 min) and osteopenia group (176.4±42.6 min).The improvement of VAS and RM between two groups had no significant difference.There was a negative correlation between the BMD and blood loss (r=-0.407,P=0.001).The other surgical outcomes (surgical duration,VAS improvement,RM improvement,cage subsidence,nonunion,screw loose and etc.) had no correlation with BMD.Conclusion There is a negative correlation between the BMD and blood loss in DS patients managed by PLIF.BMD has no effect on other surgical outcomes.
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Objective To evaluate the distribution of Schmorl's nodes (SN) in patients with low back pain or radiculopathy,and to analyze the correlation between SN and degeneration of lumbar intervertebral discs.Methods In 2012,1024 patients with low back pain or sciatica were examined by magnetic resonance (MR) scan and plain film.There were 448 males and 576 females,with an average age of (54.3 ± 12.7) years (range,22-90).The features distribution of SN in lumbar endplate on age,sex,segment and the type and grade of intervertebral disc degeneration were analyzed retrospectively.Results Among 5120 lumbar intervertebral segments of the 1024 patients,295 (28.8％) cases and 532 (5.2％) endplates were involved with SN,302 located in the cranial and 230 in the caudal endplate.According to percent prevalence per lumbar segment,L1,2 was the most common level (29.1％),followed by L3,4 (23.7％) and L2,3 (21.1％).The incidence of SN was positively correlated with elder age,but not with sex,body weight,height,or body mass index.SN occurred more often in bulging,extrusion,Modic changes,spondylolisthesis and osteophyte comparing with normal disc or protrusion or high intensity zone.The distributions of the grade of intervertebral disc degeneration were significantly different between groups with and without adjacent SN.Intervertebral discs with adjacent SN were more degenerated than those without adjacent SN.The number,size and volume of SN were associated with the degrade of intervertebral discs degeneration.SN was divided into two types,i.e.,acute edematous SN and non-acuteSN,according to the signal type on T1-and T2-weighted MR images,and the degeneration of the corresponding intervertebral discs was more severe in the latter than the former group.Conclusion SN occurred more often in the upper lumbar spine and cranial endplate in patients with low back pain or radiculopathy.SN were correlated with elder age and the degeneration of lumbar intervertebral discs.The number,size,volume and signal type on MR images of SN impacted on its correlation with lumbar intervertebral disc degeneration.
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Objective To study the anatomy of the innervation of hallucis longus muscle,and discuss the clinical value of the innervation.Methods Nineteen limbs of 10 cadavers were studied.There were 4 female cadavers and 6 male cadavers.Nine were left legs and 10 were right legs.The specimens were anatomied to confirm the tibialis anterior,extensor digitorum longus and hallucis longus muscle.The innervation of hallucis longus muscle was been observed along the deep peroneal nerve.Measuring the muscular branches length (nerve length,NL),the distance from the tip of the fibular head to the muscular brance (nerve-fibula head length,NFL),and fibular length (fibula length,FL).The hematoxylin and eosin stain was used to observe the numbers of nerve fascicle for each branch of EHL.Results Twenty-three muscle branches of hallucis longus muscle were found in 19 limbs,15 limbs had a single branch,4 limbs had the double branches.All branches were originated in the deep peroneal nerve.Fourteen branches were into hallucis longus muscle from the fibular side,3 from anterior side,6 from the tibial side.The fibula length was 37.0±1.9 cm (range,34.5-40.6 cm); the nerve-fibula head length was 89.0±5.2 mm (range,75.4-97.2 mm);nerve length was 48.5±5.0 mm (range,33.6-57.4 mm); the nerve-fibula head length/fibula length was 0.245±0.020 (range,0.211-0.280).Among 15 specimens with single branch,3 branches had a unique nerve fascicle and 12 had two fascicles.Among 4 specimens with doulbe branches,only 1 branch had two fascicles,7 branches had a unique fascicle.Conclusion Special anatomical features of muscular branches might be the reason of isolated extensor hallucis longus dysfunction.