Comparison of long-term effect between minimally invasive and open approaches in one-level posterior lumbar inter-body fusion: a 10-12 year prospective study / 中华骨科杂志

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.

Clinical value of oblique lateral interbody fusion in the treatment of adult degenerative scoliosis / 中华骨科杂志

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.

The indirect decompression effect of oblique lateral interbody fusion in the treatment of degenerative lumbar stenosis / 中华骨科杂志

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.

Early complications associated with oblique lateral interbody fusion in the treatment of degenerative lumbar diseases / 中华骨科杂志

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.

An important factor for cage retropulsion after lumbar interbody fusion——the injury of the posterior part of endplate cranial-adjacent to fusion / 中华骨科杂志

Objective To investigate causes and treatment strategy of cage retropulsion after lumbar interbody fusion,in particular the correlations between the injury of the posterior part of endplate cranially adjacent to fusion and cage retropulsion.Methods Data of 7 patients with cage migration after lumbar interbody fusion from August 2011 to July 2014 in our hospital were retrospectively analyzed.There were 4 males and 3 females,aged from 45-74 years (average,53.6 years).All patients took X-ray and CT scans examinations 3 d postoperatively,and they were followed up at 3,6,12 months after operation.The characteristics of the patients and the injury of the endplate adjacent to fusion were analyzed to identify possible risk factors of cage retropulsion.Moreover,corresponding managements were performed and outcomes were recorded.Results All 7 cases of cage retropulsion occurred within 3 months post-operatively (rang,15-67 d).Posterior part of the endplate superiorly neighboring to fusion was found injured on the decompression side in all cases with cage retropulsion,and that led to an increase in the posterior intervertebral space height at the fusion segment.Other factors,including pear-shape type endplate,and improper operative manipulations may add the risk of cage retropulsion.These 7 patients complained mild back pain or no back pain,and received corresponding treatments including bed rest,activity limitation,and oral administration of anti-inflammatory analgesics.The clinical symptoms and degrees of cage retropulsion were not aggravated during follow-up.Conclusion The injury of the posterior margin of end-plate superiorly neighboring to fusion on the decompression side which caused increased posterior intervertebral space height may be key to postoperative cage retropulsion.Prevention of possible iatrogenic injury to the endplate may be effective to reduce the risk of cage retropulsion.

The distribution of Schmorl's nodes in patients with low back pain or radiculopathy and their correlation with degeneration of lumbar intervertebral discs / 中华骨科杂志

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.

Comparison of adjacent segment degeneration following one-level mini-open or conventional open posterior lumbar interbody fusion / 中华骨科杂志

Objective To compare the difference of adjacent segment degeneration (ASD) following one-level mini-open or conventional open posterior lumbar interbody fusion (PLIF).Methods From October 2005 to September 2008,108 patients underwent one-level instrumented PLIF using two different approaches: mini-open approach in 56 patients including 32 males and 23 females,aged from 32 to 68 years (average,53.8 years) and conventional open approach in 52 patients including 24 males and 28 females,aged from 27 to 69 years (average,52.6 years).The follow-up rates of the mini-open and conventional open groups were 91.1％ and 88.5％,respectively.The visual analog scale (VAS),Oswestry disability index (ODI),multifidus muscle injury and ASD were evaluated.Results There were no significant differences in VAS and ODI scores between two groups preoperatively,but the two scores in the mini-open group were significantly lower than those in conventional open group after surgery.Compared with the conventional open approach,less decrease of cross sectional area and less severe fatty degeneration of the multifidus muscle were observed in mini-open group.There were 4 cases of radiographic ASD in the mini-open group including two symptomatic cases,and 11 cases in the conventional open group including 4 symptomatic cases among them 2 required surgical intervention.Both radiographic and symptomatic ASD were correlated with the decrease of cross sectional area and degree of fatty degeneration of the multifidus muscle,but only symptomatic ASD was associated with the clinical results.Conclusion Compared with the conventional open approach,the mini-open PLIF has many advantages,such as better clinical outcomes,lower incidence of multifidus muscle atrophy,and lower incidence of radiographic ASD.

The Study of Trial Labor Following Previous Cesarean Section / 上海第二医科大学学报

ObjectiveThe aim of this study was to establish women previously undergoing cesarean section again puerperal ways.Methods170 pregnant women who had previously undergone 1 or 2 cesarean section were studied. ResultsAmong the 170 cases, 93 cases were trial of labor. The success was 81 cases, the success rate was 87%. One patient with preuterine scar ruptured. There was no maternal death. When the repeat cesarean group was compared with the trial of labor group, in the blood loss and after delivery febrile morbidity were significantly higher in women with repeat cesarean (P＜0.05). The Apgar score of newborns was no difference (P＞0.05). ConelusionWe should control the indications for cesarean section. A trial of labor after previous cesarean is safe, less damage and can be rceommended in the majority of cases. All eligible women would allowed to deliver vaginally after previous cesarean.