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Objective:To investigate the clinical outcomes of minimally invasive lateral lumbar interbody fusion (LLIF) and the necessity to perform LLIF plus posterior direct decompression in the treatment of severe degenerative lumbar spinal stenosis (DLSS).Methods:In this prospective randomized, controlled trial, we assigned 71 patients, who were 50 to 80 years old, and diagnosed with severe DLSS (Schizas Classification grade C on magnetic resonance imaging), in a 1∶1 ratio to undergo either one-stage LLIF plus posterior internal fixation (treatment group) or CLIF plus posterior internal fixation with laminectomy (control group). Demographic and perioperative data were collected and compared. The clinical outcome measures included Oswestry Disability Index (ODI), Zurich Claudication Questionnaire (ZCQ) score as well as visual analogue scale (VAS). Patients were followed up for at least 1 year.Results:The treatment group included 36 patients with 46 surgical levels, while the control group included 35 patients with 46 surgical levels. The baseline demographic data of the 2 groups were equivalent in preoperative central canal areas, spinal canal anteroposterior diameter, disc height, ODI, ZCQ score for symptom severity and physical function, as well as VAS scores for back and leg pain. The mean operative time, blood loss, drainage volume and hospital stay of the treatment group are significantly less than the control group (157.2±29.1 min vs. 180.6±26.8 min, 75.6±39.1 ml vs. 108.6±43.3 ml, 136.9±73.9 ml vs. 220.5±121.3 ml, 5.3±1.1 d vs. 6.6±2.3 d). There were 2 cases with dura tear and 1 case with wound infection in control group. Thus, the surgical trauma and complications of the control group were more than the treatment group. At 1-year follow-up, the mean ODI score of treatment group improved from 42.24%±10.70% preoperatively to 18.21%±11.49%, the mean ZCQ symptom severity from 2.89±0.38 to 1.61±0.41, the mean ZCQ physical function from 2.31±0.45 to 1.50±0.37, the mean VAS for back from 5.56±1.19 to 1.97±1.13 and the mean VAS for leg from 4.44±1.81 to 0.94±1.26. At 1-year follow-up, the mean ODI score of the control group improved from 43.65%±14.93% preoperatively to 17.36%±12.15%, the mean ZCQ symptom severity from 2.92±0.52 to 1.65±0.39, the mean ZCQ physical function from 2.37±0.52 to 1.55±0.39, the mean VAS for back from 5.63±1.40 to 2.34±1.47, and the mean VAS for leg from 4.37±2.14 to 0.83±1.20. The ZCQ satisfactory score of both groups were not significant different (1.25±0.45 vs. 1.26±0.43, t=0.07, P=0.944). The mean improvement rate of both groups for ODI, ZCQ symptom severity, ZCQ physical function, VAS back and VAS leg at 1-year follow-up were not significant different (55.43%±27.74% vs. 58.36%±25.06%, 43.07%±17.22% vs. 42.66%±12.95%, 32.25%±23.65% vs. 31.71%±23.24%, 62.65%±21.25% vs. 58.37%±22.44%, 78.94%±26.41% vs. 85.45%±20.53%). One adjacent segment disease was found in each group at 1 year follow-up. Conclusion:CLIF+ posterior internal fixation in the treatment of Schizas Grade C DLSS has satisfactory clinical outcome at 1-year follow-up. Laminectomy increases surgical trauma, but does not significantly improve the clinical outcome at 1-year follow-up.
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Osteoporotic vertebral compression fracture (OVCF) can lead to lower back pain and may be even accompanied by scoliosis, neurological dysfunction and other complications, which will affect the daily activities and life quality of patients. Vertebral augmentation is an effective treatment method for OVCF, but it cannot correct unbalance of bone metabolism or improve the osteoporotic status, causing complications like lower back pain, limited spinal activities and vertebral refracture. The post-operative systematic and standardized rehabilitation treatments can improve curative effect and therapeutic efficacy of anti-osteoporosis, reduce risk of vertebral refracture, increase patient compliance and improve quality of life. Since there still lack relevant clinical treatment guidelines for postoperative rehabilitation treatments following vertebral augmentation for OVCF, the current treatments are varied with uneven therapeutic effect. In order to standardize the postoperative rehabilitation treatment, the Spine Trauma Group of the Orthopedic Branch of Chinese Medical Doctor Association organized relevant experts to refer to relevant literature and develop the "Guideline for postoperative rehabilitation treatment following vertebral augmentation for osteoporotic vertebral compression fracture (2022 version)" based on the clinical guidelines published by the American Academy of Orthopedic Surgeons (AAOS) as well as on the principles of scientificity, practicality and advancement. The guideline provided evidence-based recommendations on 10 important issues related to postoperative rehabilitation treatments of OVCF.
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Objective:To investigate the influence of different degrees of facet joint arthropathy on the indirect decompression effect of crenel lumbar interbody fusion (CLIF), and the clinical outcomes of CLIF for the treatment of lumbar spinal stenosis with severe facet joint arthropathy (grade 3).Methods:This study reviewed a total of 269 surgical segments in 156 patients with lumbar spinal stenosis treated with CLIF technique from November 2016 to February 2020. According to preoperative CT images, the facet joint was graded according to Pathria classification. There are 19 segments with grade 0, 156 segments with grade 1, 67 segments with grade 2, and 27 segments with grade 3. Radiographic parameters included disc angle, anterior and posterior disc height, and bilateral intervertebral foramen height on CT, and the midsagittal canal diameter and axial central canal area. In 30 patients with at least one segment of grade 3, the clinical efficacy was assessed using visual analogue scale (VAS) and Oswestry disability index (ODI).Results:The average the anterior and posterior intervertebral space height, intervertebral space angle, height of bilateral intervertebral foramina, spinal canal sagittal diameter and spinal canal area were significantly improved after the operation of grade 3 facet joint degeneration segment compared to preoperation. The preoperative mean spinal canal sagittal diameter and spinal canal area of grade 3 facet joint degeneration segment were significantly less than grade 1 and grade 2. The average change of spinal canal area after grade 3 articular degeneration was significantly less than that of grade 1 and 2, but there was no significant difference with that of grade 0. The posterior decompression rate was 55.56% (15/27) for grade 3, 35.82% (24/67) for grade 2, 16.03% (25/156) for grade 1, and 21.05% (4/19) for grade 0. The posterior decompression rate of grade 3 articular process degeneration was significantly higher than that of other grades ( P<0.001). Severe lateral recess stenosis and 24.24% of severe intervertebral foraminal stenosis were found in 81.48% of grade 3 degenerative segment. The 23 patients were followed up with an average of 21.62±6.52 months, and the average improvement of ODI was 24.10%±11.09%; the average VAS for leg pain and back pain were improved significantly. Conclusion:The degrees of facet joint degeneration do not prevent intervertebral space distraction of CLIF. However, because segments with severe facet joint arthropathy were usually associated with severe spinal canal stenosis, CLIF had a high rate of second-stage posterior decompression in the treatment of lumbar spinal stenosis with severe facet joint arthropathy.
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Objective:To explore the clinical effect of the application of intraoperative psoas major intramuscular block therapy on the complications related to the approach after multi-segmental crenel lumbar interbody fusion (CLIF).Methods:All of 68 degenerative lumbar scoliosis patients who had received multi-segmental crenel lumbar interbody fusion during January 2020 and June 2020 were retrospectively reviewed. Patients were divided into two groups according to whether the psoas major muscle was treated with block therapy during the operation. The psoas muscle inblock group were filled with gel sponge infiltrated with a mixture of Betamethasone and lidocaine for local block therapy before closing the incision while that in the control group were not filled with gel sponge. There were 33 patients in the control group, 7 males and 26 females with an average of 65.8±7.1 years old (range: 54-81 years old); 35 cases in the block group, 9 males and 26 females with an average of 68.0±6.5 years old (range: 54-85 years old). The complications related to the approach (mainly includes pain, numbness in the front of the thigh, as well as psoas major, quadriceps muscle strength) were recorded respectively 1 day, 1 week, 1 month and 3 months after surgery. The main indicators of outcome including visual analog scale (VAS) of pain, the visual analog scale (VAS) of numbness, muscle strength of psoas major and quadriceps femoris, and the incidence of complications related to the approach were compared between the two groups of patients at different time points after surgery. The clinical outcomes were assessed using the Oswestry disability index (ODI), VAS for low back pain. The radiological outcome was evaluated with Cobb angles and sagittal balance parameters (sagittal vertical axis, SVA).Results:There were no significant differences in age, gender, body mass index (BMI), number of fusion segments, operation time, and intraoperative blood loss between the two groups. The incidence of approach-related complications was 17.1% in the block group and 39.4% in the control group, with statistically significant difference between the two groups ( χ2=4.177, P=0.041). The incidence of postoperative pain, numbness in the front of the thighs, and muscle strength of psoas major in the block group (11.4%, 14.3%) were lower than those in the control group (33.3%, 36.4%) ( χ2=4.740, P=0.029; χ2=4.416, P=0.036). And for numbness in the front of thigh, the block group (14.3) was lower than control group (21.2%), but no significant difference was shown between two groups ( χ2=0.561, P=0.454). However, there was no quadriceps weakness in either group. The VAS scores of painof the block group were lower than those of the control group at 1 day, 1 week, and 1 month after surgery, and the difference was statistically significant ( t=2.220, P=0.031; t=2.235, P=0.031; t=2.086, P=0.044). The difference at 3 months was not statistically significant ( t=0.385, P=0.701). The muscle strength of psoas major of the block group, meanwhile, was higher than those of the control group on the 1day and 1 week after surgery, the difference was statistically significant as well ( t=2.208, P=0.032; t=2.171, P=0.034). The difference at 1 and 3 months was not statistically significant ( t=0.923, P=0.359; t=1.437, P=0.160). No statistically significant differences were found in VAS scores of numbness at 1 day, 1 week, 1 month, and 3 months after surgery. Postoperative low back pain and lumbar spine function were significantly improved in both groups, and there was no statistical significance between the two groups. Coronal Cobb angle and sagittal balance were significantly improved in both groups after surgery, and there was no statistical significance between the two groups. Conclusion:Psoas major intramuscular block therapy can reduce the incidence of early postoperative complications of multi-segmental CLIF. Furthermore, it was found to be effective to alleviate anterior thigh pain within 1 month, and improve psoas major muscle weakness within 1 week.
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Objective:To analyze the incidence and epidemiological characteristics of traumatic spinal cord injury in China in 2018.Methods:Multi-stage stratified cluster sampling was used to randomly select hospitals capable of treating patients with spinal cord injury from 3 regions，9 provinces and 27 cities in China to retrospectively investigate eligible patients with traumatic spinal cord injury admitted in 2018. National and regional incidence rates were calculated. The data of cause of injury，injury level，severity of injury，segment and type of fracture，complications，death and other data were collected by medical record questionnaire，and analyzed according to geographical region，age and gender.Results:Medical records of 4，134 patients were included in this study，with a male-to-female ratio of 2.99∶1. The incidence of traumatic spinal cord injury in China in 2018 was 50.484 / 1 million （95% CI 50.122-50.846）. The highest incidence in the Eastern region was 53.791 / 1 million （95% CI 53.217-54.365）. In the whole country，the main causes of injury were high falls （29.58%），as well as in the Western region （40.68%），while the main causes of injury in the Eastern and Central regions were traffic injuries （31.22%，30.10%）. The main injury level was cervical spinal cord in the whole country （64.49%），and the proportion of cervical spinal cord injury in the Central region was the highest （74.68%），and the proportion of lumbosacral spinal cord injury in the Western region was the highest （32.30%）. The highest proportion of degree of injury was incomplete quadriplegia （55.20%），and the distribution pattern was the same in each region. A total of 65.87% of the patients were complicated with fracture or dislocation，77.95% in the Western region and only 54.77% in the Central region. In the whole country，the head was the main combined injury （37.87%），as well as in the Eastern and Central regions，while the proportion of chest combined injury in the Western region was the highest （38.57%）. A total of 32.90% of the patients were complicated with respiratory complications. There were 23 patients （0.56%） died in hospital，of which 17（73.91%） died of respiratory dysfunction. Conclusions:The Eastern region of China has a high incidence of traumatic spinal cord injury. Other epidemiological features include high fall as the main cause of injury cervical spinal cord injury as the main injury level，incomplete quadriplegia as the main degree of injury，head as the main combined injury，and respiratory complications as the main complication.
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Objective:To compare the effect of robot navigation system (Tian Ji robot system) plus 3D printing and traditional C-arm X-ray fluoroscopy in assisting percutaneous kyphoplasty (PKP) or percutaneous vertebroplasty (PVP) for treatment of Kümmell disease.Methods:A retrospective case-control study was conducted to analyze the clinical data of 40 patients with Kümmell disease treated at Honghui Hospital Affiliated to Xi'an Jiaotong University School of Medicine from December 2017 to February 2019, including 12 males and 28 females, with an average age of 56.4 years (range, 42-71 years). In observation group, 20 patients underwent PKP or PVP assisted by the robot navigation system and 3D printing. In control group, 20 patients underwent PKP or PVP assisted by the traditional C-arm X-ray fluoroscopy. The operation time and incidence of complications were observed. The visual analogue scale (VAS), Oswestry disability index (ODI), Cobb angle and anterior vertebral height were compared before operation, 1 day and 3 months after operation.Results:All patients were followed up for 3.5-8.6 months (mean, 6.7 months). The operation time in control group was (32.2±5.8)minutes, compared with (26.7±3.6)minutes in observation group ( P<0.05). The incidence of cement leakage was 0% (0/20) in the observation group and 5% (1/20) in control group ( P>0.05). One day after operation, in observation group and control group, the VAS was (2.1±0.3)points and (3.7±0.8)points, the ODI was 14.3±1.8 and 25.5±5.7, the Cobb angle was (20.6±1.2)° and (22.4±0.6)°, and the anterior height of vertebral body was (21.2±0.8)mm and (17.6±0.7)mm, respectively, showing significant improvement compared with those before operation ( P<0.01). Three months after operation, in observation group and control group, the VAS was (1.8±0.4)points and (2.8±0.8)points, the ODI was 12.3±1.5 and 21.6±2.3, the Cobb angle was (18.1±0.8) ° and (20.5±1.6)°, and the anterior height of vertebral body was (20.1±1.8)mm and (16.8±1.3)mm, showing no significant difference compared with those at day 1 after operation ( P>0.05). There were significant differences in the VAS, ODI, Cobb angle and anterior vertebral height between the two groups 1 day and 3 months after operation ( P<0.01). Conclusion:For Kümmell disease, with assistance with the robot navigation system combined with 3D printing, PKP or PVP can more effectively reduce the pain of patients, improve the quality of life, restore the anterior height of vertebral body, and realize the individualized treatment in comparison with the traditional C-arm X-ray fluoroscopy.
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According to the pathological characteristics of symptomatic chronic thoracic and lumbar osteoporotic vertebral fracture (SCOVF), the different clinical treatment methods are selected, including vertebral augmentation, anterior-posterior fixation and fusion, posterior decompression fixation and fusion, and posterior correction osteotomy. However, there is still a lack of a unified understanding on how to choose appropriate treatment method for SCOVF. In order to reflect the new treatment concept and the evidence-based medicine progress of SCOVF in a timely manner and standardize its treatment, the clinical guideline for surgical treatment of SCOVF is formulated in compliance with the principle of scientificity, practicability and advancement and based on the level of evidence-based medicine.
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Objective@#To investigate the preliminary clinical efficacy of modified minimally invasive lateral interbody fusion in the anterior support and reconstruction for thoracolumbar fracture combined with intervertebral disc injury.@*Methods@#A retrospective case series study was conducted to analyze the clinical data of 14 patients with single-segment thoracolumbar fracture combined with intervertebral disc injury admitted to the Second Affiliated Hospital of Zhejiang University School of Medicine from December 2017 to May 2018. There were 12 males and two females, aged 22-56 years [(37.4±10.2)years]. The injured segments were at L1 in nine patients and L2 in five patients. Twelve patients had upper disc injury and two patients had lower disc injury. Before operation, American Spinal Injury Association (ASIA) classification was grade A in five patients, grade B in four, grade C in three, and grade D in two. All patients received modified minimally invasive lateral interbody fusion to reconstruct the stability of the anterior and middle columns of the spine one week after posterior short-segment fixation. The operation time, intraoperative bleeding, postoperative hospital stay and complications were recorded. Pain visual analogue scale (VAS) and ASIA nerve injury grading were used to evaluate the clinical efficacy. The Cobb angle changes of the operative segment and lumbar lordosis were compared before operation and during the last follow-up.@*Results@#The patients were followed up for 6-14 months[(12.1±3.6)months]. The operation time was 65-210 minutes [(138.9±39.4)minutes], and the intraoperative blood loss was 250-600 ml [(407.1±119.1)ml], respectively. The total postoperative length of stay ranged from 3 to 13 days [(7.8±2.5)days]. The incisions healed well at stage I in all patients. VAS for back pain and leg pain before operation were (6.3±2 .4)points and (4.1±1.3)points respectively. The final VAS for back pain and leg pain were (2.2±0.6)points and (2.3±0.8)points, which were significantly lower than the preoperative VAS (both P<0.01). At the last follow-up, there was one patient with grade A, two with grade B, five with grade C, one with grade D, and five with grade E. Postoperative CT showed that decompression was complete, implants were in good position and internal fixation was reliable. Preoperative Cobb angles of lumbar lordosis and the injury segment were (-7.8±3.9)° and (24.8±6.9)° respectively. The final Cobb angles of lumbar lordosis and the injury segment were (3.1±2.7)° and (30.7±9.6)°, which were significantly restored compared with preoperative values (both P<0.01). One patient had postoperative pain in the front thigh, and another patient had numbness in the front thigh, whose symptoms were alleviated after non-surgical treatment. No serious surgical complications such as quadriceps femoris and weakness, pleural tear, vascular injury, nerve root injury, sympathetic nerve injury, retroperitoneal hematoma and artificial vertebral body displacement occurred in these patients.@*Conclusions@#For anterior reconstruction of the thoracolumbar fracture with intervertebral disc injury, the modified minimally invasive lateral interbody fusion has the advantages of less invasive, less blood loss, shorter hospitalization time, low incidence of complications. Significant pain relief, neurological function improvement, and anterior and middle column reconstruction can be achieved postoperatively.
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Upper cervical spine injury is a common spine injury in the clinic,which mainly refers to the fracture,ligament tear,and dislocation of atlantoaxial and its accessory structures due to violence.The injury of upper cervical ligament complex is the main cause of instability after injury.The controversy lies in how to evaluate the effect of ligaments on stability.The injuries of different sports units may involve different ligament composite structures which show different instability characteristics and types,requiring special attention.In addition to the shape and location of the fracture,fixation method and range of the surgical treatment should be selected mainly based on whether there are stable or unstable types.The author mainly expounds the characteristics of upper cervical injury,clinical classification,diagnosis and treatment measures to discusses the difficulties and focus of the treatment of upper cervical injury,so as to provide reference for clinical treatment.
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Objective To explore the impact of cage position on indirect decompression and cage subsidence in crenel lateral interbody fusion (CLIF).Methods Retrospectively,18 mens and 16 womens with a mean age of 63.98±5.99 years (range:52-75 years) who underwent CLIF for lumbar stenosis by our surgical group during November 2016 and Feburary 2018 were reviewed.Sixty-two segments were included for radiographic evaluation.Endplates thickness was measured using high resolution computed tomography.By image processing,endplate thickness was measured at 10 equally distributed points on the mid-sagittal and mid-coronal planes,and two further planes were measured at an angle of 45° to both the first and second planes.Contour plots representing an isoline of endplate thickness was drawn based on those data.The cages were classified into anterior group and medium-posterior group.Radiographic evaluation included segmental angle,anterior and posterior disk heights,intervertebral foramen heights,and cross-sectional area of the spinal canal.To assess the factors affecting the postoperative segmental angle and cross-sectional area of the spinal canal,univariate and multivariate analysis were performed using the regression analysis model.Cage subsidence was recorded at the last follow-up.Results The mean follow-up time of those patients were 10.88±3.73 months (range:6-18 months).At each spot,the mean thickness was significantly greater for the cranial endplate of disc than the caudal endplate.Contour plots show more areas of thick bony endplates in the anterior and anterolateral part of the endplate than the lateral and posterior part,especially for the cranial endplate.The cage was placed in the anterior area for 19 levels and medium-posterior for 41 levels.The mean increase of anterior disk height was 3.38±3.38 mm in anterior group and 1.83±3.08 mm in medium-posterior group(P=0.04).The mean increase of segmental angle was 2.93°±3.47°in anterior group and 0.73°±3.60° in medium-posterior group(P=0.04).No significant difference was found with mean increase of posterior disk height,mean increase of intervertebral foramen heights,as well as increase ratios of cross-sectional area of the spinal canal between groups.Multivariate analysis showed that the increase of segmental angle was affected by cage position (β=1.24,P=0.03),but the increase ratios of cross-sectional area of the spinal canal was not affected.The subsidence rate of anterior group was 15.79％ (3/19) and medium-posterior group was 24.39％ (10/41),which was not significantly different (x2=0.56,P=0.45).Conclusion There are more areas with thick bony endplates in the anterior and anterolateral parts of the lumbar endplate than the lateral and posterior parts.The cage position at the anterior 1/3 of disk space is better for achieving the restoration of the segmental angle and having lower subsidence rate,without compromising the indirect neural decompression in crenel lateral interbody fusion.
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In researches on osteoporotic vertebral compression fractures,the present focuses are their treatments and complications rather than the sagittal balance of the spine in the patients.The previous researches on the sagittal balance of the spine have demonstrated that the sagittal line of the spine plays an important role in the occurrence and development of many spinal diseases and the recent researches have further shown that the onset and treatment of osteoporotic vertebral fractures are associated with the sagittal line of the spine.This article reviews the researches on the spinal balance in the patients with osteoporotic vertebral compression fracture and the related treatments of the patients.
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Objective To evaluate the precise percutaneous sacroplasty (PSP) assisted by a Renaissance robot for sacral insufficiency fractures (SIF).Methods The clinical data of 12 SIF patients were retrospectively analyzed who had been treated from March 2016 to March 2018 at Department of Spinal Surgery,Honghui Hospital.They were 5 males and 7 females,aged from 55 to 76 years (average,67.5 years).They all received PSP assisted by a Renaissance robot.Their operation time,hospital stay and intraoperative radiation were recorded.The clinical efficacy was evaluated by comparing their visual analogue scale (VAS) and Oswestry disability index (ODI) before surgery,1 day,3 and 12 months after surgery.Results All the 12 patients underwent surgery successfully with no complications like cement leakage.Their operation time ranged from 32 to 47 minutes (mean,36.8 minutes),their hospital stay from 12 to 25 hours (mean 17.5 hours) and their intraoperative exposure to radiation from 0.87 to 1.53 mSv (mean,1.27 mSv).All the patients were followed up for 12 to 18 months (mean,15.8 months).Their VAS (1.7 ± 0.7) and ODI (22.8 ± 4.1) one day after surgery were significantly decreased than the preoperative values (7.6 ±0.9 and 43.7 ±4.6) (P ＜ 0.05).At 3 and 12 months after surgery,their VAS scores were 2.0 ± 0.8 and 2.4 ±0.8 and their ODI scores 21.5 ±4.3 and 23.0 ±4.6,respectively,showing no significant differences from the values at 1 day after surgery (P ＞ 0.05).Conclusion The PSP assisted by a Renaissance robot is safe and leads to satisfactory clinical efficacy for SIF as bone cement can be accurately injected into the target area of the fracture.
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Objective To investigate the preliminary clinical efficacy of modified minimally invasive lateral interbody fusion in the anterior support and reconstruction for thoracolumbar fracture combined with intervertebral disc injury. Methods A retrospective case series study was conducted to analyze the clinical data of 14 patients with single-segment thoracolumbar fracture combined with intervertebral disc injury admitted to the Second Affiliated Hospital of Zhejiang University School of Medicine from December 2017 to May 2018. There were 12 males and two females, aged 22-56 years [(37. 4 ± 10. 2)years]. The injured segments were at L1 in nine patients and L2 in five patients. Twelve patients had upper disc injury and two patients had lower disc injury. Before operation, American Spinal Injury Association ( ASIA) classification was grade A in five patients, grade B in four, grade C in three, and grade D in two. All patients received modified minimally invasive lateral interbody fusion to reconstruct the stability of the anterior and middle columns of the spine one week after posterior short-segment fixation. The operation time, intraoperative bleeding, postoperative hospital stay and complications were recorded. Pain visual analogue scale ( VAS) and ASIA nerve injury grading were used to evaluate the clinical efficacy. The Cobb angle changes of the operative segment and lumbar lordosis were compared before operation and during the last follow-up. Results The patients were followed up for 6-14 months[(12.1 ±3.6)months]. The operation time was 65-210 minutes [(138.9 ±39.4)minutes],and the intraoperative blood loss was 250-600 ml [(407. 1 ± 119. 1) ml], respectively. The total postoperative length of stay ranged from 3 to 13 days [(7. 8 ± 2. 5)days]. The incisions healed well at stage I in all patients. VAS for back pain and leg pain before operation were (6. 3 ± 2 . 4)points and (4. 1 ± 1. 3) points respectively. The final VAS for back pain and leg pain were (2. 2 ± 0. 6)points and (2. 3 ± 0. 8)points, which were significantly lower than the preoperative VAS (both P<0. 01). At the last follow-up, there was one patient with grade A, two with grade B, five with grade C, one with grade D, and five with grade E. Postoperative CT showed that decompression was complete, implants were in good position and internal fixation was reliable. Preoperative Cobb angles of lumbar lordosis and the injury segment were ( -7. 8 ± 3. 9)° and (24. 8 ± 6. 9)° respectively. The final Cobb angles of lumbar lordosis and the injury segment were (3. 1 ± 2. 7)° and (30. 7 ± 9. 6)°, which were significantly restored compared with preoperative values (both P<0. 01). One patient had postoperative pain in the front thigh, and another patient had numbness in the front thigh, whose symptoms were alleviated after non-surgical treatment. No serious surgical complications such as quadriceps femoris and weakness, pleural tear, vascular injury, nerve root injury, sympathetic nerve injury, retroperitoneal hematoma and artificial vertebral body displacement occurred in these patients. Conclusions For anterior reconstruction of the thoracolumbar fracture with intervertebral disc injury, the modified minimally invasive lateral interbody fusion has the advantages of less invasive, less blood loss, shorter hospitalization time, low incidence of complications. Significant pain relief, neurological function improvement, and anterior and middle column reconstruction can be achieved postoperatively.
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OBJECTIVE: To investigate the potential risk of approach-related complications at different access angles in minimally invasive lateral lumbar interbody fusion.METHODS: Eighty-six axial magnetic resonance images were obtained to analyze the risk of approach-related complications. The access corridor were simulated at different access angles and the potential risk of neurovascular structure injury was evaluated when the access corridor touching or overlapping the corresponding structures at each angle. Furthermore, the safe corridor length was measured when the corridor width was 18 and 22 mm.RESULTS: When access angle was 0°, the potential risk of ipsilateral nerve roots injury was 54.7% at L4–L5. When access angle was 45°, the potential risk of abdominal aorta, contralateral nerve roots or central canal injury at L4–L5 was 79.1%, 74.4%, and 30.2%, respectively. The length of the 18 mm-wide access corridor was largest at 0° and it could reach 44.5 mm at L3–L4 and 46.4 mm at L4–L5. While the length of the 22 mm-wide access corridor was 42.3 mm at L3–L4 and 44.1 mm at L4–L5 at 0°.CONCLUSION: Changes in the access angle would not only affect the ipsilateral neurovascular structures, but also might adversely influence the contralateral neural elements. It should be also noted to surgeons that alteration of the access angle changed the corridor length.
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Aorta, Abdominal , Magnetic Resonance Imaging , SurgeonsABSTRACT
Objective To present the modified surgical technique of lateral lumbar interbody fusion and investigate its approach related complications.Methods Fifty-eight patients treated with novel surgical technique of lateral lumbar interbody fusion(LLIF)from June 2016 to January 2017 were studied retrospectively.There were 24 males and 34 females,aged from 45 to 82 years old(averaged at 66.1±12.1).The diagnosis was as following:degenerative spinal scoliosis in 24 cases,degenerative lum-bar spinal stenosis in 16,lumbar spinal spondylolisthesis in 14,spinal infection and spinal trauma in 2 respectively.The modified surgical technique included operation under direct visualization,the"safety"transpsoas approach and the adjustable microretrac-tor.The patient was placed in a lateral decubitus position,and a transverse or oblique skin incision was planned using fluoroscopy to target the center of the desired disc spaces.The 3 abdominal layers were split longitudinally along the muscle fiber.The psoas major was split longitudinally along the muscle fiber according to the"safety"working window.The adjustable microretractor was used as working corridor to carry out interbody fusion. Oswestry disability index (ODI) was used to assess the clinical outcome. The surgical time,estimated blood loss and approach related complications(pain/numbness at anterior thigh,weakness of psoas muscle and quadriceps)were recorded.Results All patients were followed up from 6-12months,the mean follow-up time(9.1± 2.3)months.A total of 132 levels were performed with novel surgical technique of LLIF,one level in 19 cases,2 levels in 10,3 lev-els in 23 and 4 levels in 6 cases.The mean surgical time was(57.2±13.3)min for 1 level,(94.5±31.3)min for 2 levels,(129.8± 42.1)min for 3 levels and(208.3±22.7)min for 4 levels.The estimated blood loss during surgery was less than 10ml every level. Preoperative ODI was 61.8%±20.1%,it was 22.5%±18.3%(t=7.572,P=0.000)at the last time follow-up.The incidence rate of ap-proach related complications was 12.1%(7/58),with anterior thigh pain in 6 cases(10.3%),numbness 5 cases(8.6%)and psoas major weakness 3 cases(5.2%).No quadriceps weakness,vascular injury,sympathetic nerve injury,visceral injury and ureteral in-jury was found in these series.The incidence rate of complications increased significantly in patients underwent three or more lev-els interbody fusion(χ2=4.453,P=0.035).Conclusion The modified surgical technique reduces the approach related complica-tions of traditional lateral lumbar interbody fusion through the operation under the direct visualization, the"safety"transpsoas approach and the adjustable microretractor.
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Objective To investigate the relationship between the facet angle (FA) and facet violation in percutaneous pedicle screw placement in lumbar vertebrae.Methods From December 2013 to November 2016,atotal of 115 lumbar fracture or degenerative disease patients who had undertaken percutaneous pedicle screw operation was retrospectively analyzed.There were 56 males and 59 females,with an average age of 53.71±12.19 years (ranged from 15 to 77 years).Measure the FA at the level of pedicle through CT scan,diagnosis and evaluate the grade of facet joint violation after the operation.Analyzed the effect of variant FA and lumbar segment (L-L5) on the facet violation (FV) with two-way analysis of variance,and evaluate the correlation between the FA and FV in percutaneous pedicle screw placement.Results There was no significant difference between the two groups on age,gender,and body mass index.476 percutaneous pedicle screws were operated in this study:L1 144 screws,L2 136 screws,L3 64 screws,L,72 screws and L5 60 screws.The total FV rate was 30.46％ (145/476).344 screws in the upper lumbar group,and the FV rate was 28.78％ (99/344);132 screws in lower lumbar group,and the FV rate was 34.85％ (46/132).There was no significant difference of FV rate between the two groups (x2=1.66,P=0.20).The result of two-way analysis of variance indicated that the FV rate increased dramatically when FA ＞ 35° (F=20.12,P ＜ 0.001),but FV rate was not related to the lumbar segment statistically (F=0.93,P=0.45).Spearman rank correlation analysis was performed between FA and FV rate,FV grade.The result was both positive (r=0.25,P ＜ 0.001 and r=0.27,P ＜ 0.001).Conclusion The traditional C-arm fluoroscopy percutaneous pedicle screw placement technique has a high rate of FV,and the size of FA significantly affects the incidence and severity of FV.
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Objective To explore the clinical effects of C2 dome-like expansive laminoplasty and C2 expansive opendoor laminoplasty in upper cervical(involve or above C2 segment) ossification of the posterior longitudinal ligament.Methods All of 39 patients (22 males and 17 females) withcervical ossification of the posterior longitudinal ligament up to C2 which causedcompression symptoms were operated with posterior cervical surgery in ourhospital from January 2013 to June 2017.The average age was 55.74+7.91 years old,ranging from 39 to 71 years.Among these patients,21 patients underwent C2 domelike expansive laminoplasty and 18 underwent C2 expansive open-door laminoplasty,the patients in both groups underwent the C3-C7 expansive open-door laminoplasty.The preoperative and postoperative Neck Disability Index (NDI),Japanese Orthopedic Association (JOA) score,the xisual analog scale(VAS) and the space available for the spinal cord (SAC) of C2 segment in X-ray were measured and statistically analyzed.Results All patients were followed up,the follow-up time was from 15 to 63 months (mean 42.3±17.7 months).There was no significant difference in the general condition,NDI,JOA score and JOA score improvement rate between preoperative and postoperative follow-up in 2 groups.There were significant differences in the NDI,JOA,VAS and SAC between preoperative and postoperative follow-up in 2 groups.The VAS score in C2 dome-like expansive laminoplasty group 1.52± 1.2 was significantly lower than that in C2 expansive open-door laminoplasty group 2.06±0.87(t=-2.23,P＜0.05),while the SAC in C2 expansive open-door laminoplasty group 14.11±1.023 was significantly higher than that in C2 dome-like expansive laminoplasty group 1 L86± 1.014(t=-6.89,P＜0.05).No failure of internal fixation or recurrent compression was found during follow-up.Conclusion For patients with ossification of posterior longitudinal ligament up to C2 or higher level,both C2 dome-like expansive laminoplasty and C2 expansive open-door laminoplasty can achieve good results.The SAC in C2 expansive open-door laminoplastygroup was superior to that in C2 dome-like expansive laminoplasty group,while the postoperative pain was more obvious.There was no significant difference in postoperative neurological recovery between the two groups.Using C2 dome-like expansive laminoplasty could reduce postoperative axial pain than the C2 expansive open-door laminoplasty surgery.For patients withossified tissue in the spinal canal,which occupies more than 50％ of the sagittal diameter of the spinal canal,or with developmental spinal stenosis,C2 expansive open-door laminoplasty may berecommend to get more adequate decompression.
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OBJECTIVE: To investigate the potential risk of approach-related complications at different access angles in minimally invasive lateral lumbar interbody fusion. METHODS: Eighty-six axial magnetic resonance images were obtained to analyze the risk of approach-related complications. The access corridor were simulated at different access angles and the potential risk of neurovascular structure injury was evaluated when the access corridor touching or overlapping the corresponding structures at each angle. Furthermore, the safe corridor length was measured when the corridor width was 18 and 22 mm. RESULTS: When access angle was 0°, the potential risk of ipsilateral nerve roots injury was 54.7% at L4–L5. When access angle was 45°, the potential risk of abdominal aorta, contralateral nerve roots or central canal injury at L4–L5 was 79.1%, 74.4%, and 30.2%, respectively. The length of the 18 mm-wide access corridor was largest at 0° and it could reach 44.5 mm at L3–L4 and 46.4 mm at L4–L5. While the length of the 22 mm-wide access corridor was 42.3 mm at L3–L4 and 44.1 mm at L4–L5 at 0°. CONCLUSION: Changes in the access angle would not only affect the ipsilateral neurovascular structures, but also might adversely influence the contralateral neural elements. It should be also noted to surgeons that alteration of the access angle changed the corridor length.
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Aorta, Abdominal , Magnetic Resonance Imaging , SurgeonsABSTRACT
Objective To determine the outcome of unstable atlas fractures combined with rupture of transverse ligament treated by posterior atlantoaxial transpedicular screw fixation.Methods A retrospective case series study was made on 17 patients with unstable atlas fractures combined with rupture of transverse ligament treated by posterior atlantoaxial transpedicular screw fixation and fusion from January 2008 to December 2015.There were 13 males and 4 females,with age range of 34-69 years (mean,47.8 years).All atlas fractures were Jefferson fractures (Levine-Edwards type Ⅲ).Classification of transverse ligament rupture was type Ⅰ in 12 patients and type Ⅱ in 5 patients.No patients had neurologic deficit [American spinal injury association (ASIA) classification grade E].Operation time,blood loss,implant failure,bone fusion and visual analogue scale (VAS) were recorded after operation.Results Operation time was 85-120 min (mean,102 min).Blood loss was 90-150 ml (mean,115 ml).All patients were followed up for 10-20 months (mean,17.8 months).At the final follow-up,all patients achieved bone union,with no implant loosening or breakage happened.VAS was improved from preoperative (5.5 ± 1.8) points to (2.4 ± 1.5) points at tbe final follow-up (P ＜ 0.05).ASIA Grade E remained in all patients.Conclusion Posterior atlantoaxial transpedicular screw fixation of unstable atlas fractures combined with rupture of transverse ligament is a safe and effective surgical procedure that is able to restore the atlanto-axial vertebral stability and relieve pain.
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Objective To investigate the effect of percutaneous lordorizing screws fixation for correcting kyphosis in thoracolumbar burst fractures and treatment strategies.Methods A retrospective case control study was designed to analyze data of 97 patients with single-level thoracolumbar burst fractures without neurological deficits undergone percutaneous lordorizing screw fixation from April 2010 to March 2015.According to the different surgical procedures,the patients were divided into Group A (percutaneous transpedicle fixation,n =47) and Group B (percutaneous transpedicle fixation combine lordorizing screw fixation,n =50).Each group was subdivided based on the preoperative segmental kyphosis:Group A consisted subgroups A1 (kyphosis angle≤ 10°,n =11),A2 (kyphosis angle between 10° and 20°,n =20) and A3 (kyphosis angle ≥ 20°,n =16),and Group B consisted of subgroups B1 (kyphosis angle ≤ 10°,n =16),B2 (kyphosis angle between 10° and 20°,n =16) and B3 (kyphosis angle ≥ 20°,n =18).Length of hospital stay,operation time,blood loss,visual analogue scale (VAS) and Oswestry disability index (ODI) were compared between groups.Segmental kyphosis angle and vertebral wedge angle were compared between subgroups before operation,after operation and at the final follow-up.Results All patients were followed-up for 12-37 months (mean,21.2 months).There were no significant differences between the two groups in aspects of length of hospital stay,blood loss,VAS and ODI (P ＞ 0.05).Operation time was (60.62 ± 9.59) min in Group A,significantly less than that in Group B [(74.78 ± 17.66) min] (P ＜ 0.05).No breakage or malfunction of fixation occurred.There were no significant differences between the two groups in preoperative segmental kyphosis angle (P ＞ 0.05),while the correction of segmental kyphosis angle in Group B was better than Group A at the final follow-up [(7.97 ± 5.09) ° vs.(3.76 ± 1.67) °] (P ＜ 0.05).At the final follow-up,the correction of segmental kyphosis angle was similar between Group A1 and Group B1 (P ＞ 0.05),but the correction in Group B2 was better than GroupA2 (P ＜0.05) and the correction in Group B3 better than Group A3 (P ＜ 0.05).Besides,the correction of vertebral wedge angle was similar between Group A1 and Group B1 (P ＞ 0.05),but the correction in Group B2 was better than Group A2(P ＜0.05) and the correction in Group B3 was better than Group A3 (P ＜ 0.05).Loss of segmental kyphosis angle and vertebral wedge angle in Group A were greater than these in Group B (P ＜ 0.05).Conclusions Combined use of lordorizing screw with percutaneous transvertebral fixation improves the correction of thoracolumbar kyphosis angle in single-level thoracolumbar burst fractures.When the preoperative segmental kyphosis over 20°,lordorizing screw fixation should be recommended so as to achieve better correction of kyphotic deformity.