Clinical efficacy of three different minimally invasive procedures for far lateral lumbar disc herniation / 中华医学杂志(英文版)

<p><b>BACKGROUND</b>Far lateral lumbar disc herniation (FLLDH) accounts for 2.6% to 11.7% of all lumbar herniated discs. Numerous surgical approaches have been described for treating this condition. The purpose of this study was to evaluate minimally invasive surgical techniques for the treatment of FLLDH.</p><p><b>METHODS</b>From June 2000 to March 2006, 52 patients with FLLDH were treated with minimally invasive procedures. All patients were assessed by anteroposterior and lateral roentgenography and computed tomography (CT). Some patients underwent myelography, discography, and magnetic resonance imaging. Procedures performed included Yeung Endoscopy Spine System (YESS) (n = 25), METRx MicroDiscectomy System (n = 13), and X-tube (n = 14). Patients were followed up for a mean of 13.5 months. Clinical outcomes were assessed using a visual analog scale (VAS) and Nakai criteria.</p><p><b>RESULTS</b>All 3 procedures significantly improved radiating leg symptoms (P < 0.005). After surgery, 84.0%, 84.6%, and 92.8% of patients in the YESS, METRx, and X-tube groups had excellent or good outcomes. There were no statistically significant differences of VAS scores between the groups. The YESS procedure was associated with the shortest operation time, simplest anesthesia, and least trauma compared with the other 2 procedures, especially for type I herniations. The METRx procedure was the most suitable for type II herniations and posterior endoscopic facetectomy. Posterior lumbar interbody fusion and unilateral pedicle screw instrumentation with X-tube was the most suitable for herniations combined with degenerative lumbar instability (type III).</p><p><b>CONCLUSION</b>Minimally invasive strategies and options should be determined with reference to the type of FLLDH.</p>

Clinical study on lumbar spondylolisthesis treated by minimally invasive transforaminal lumbar interbody fusion / 中华外科杂志

<p><b>OBJECTIVES</b>To retrospectively analyze the treatment of lumbar spondylolisthesis using minimally invasive and open transforaminal lumbar interbody fusion (TLIF), and compare the clinical results of two techniques.</p><p><b>METHODS</b>From June 2006 to May 2010, 371 patients with lumbar spondylolisthesis grade 1 and 2 were treated with TLIF, pedicle screw fixation and followed up. The mean age was 50.4 years (range, 37 - 85 years). There were 172 patients who underwent minimally invasive TLIF and percutaneous pedicle screw fixation were set as the MIS-TLIF group, 199 patients who underwent open TLIF and pedicle screw fixation were set as the OTLIF group. The operative time, blood loss, X-ray exposure time and complications were compared between the two groups. Clinical outcome was assessed using the visual analog scale (VAS) and the Oswestry disability index (ODI). Fusion rates were determined by using CT scan reconstruction and dynamic lumbar radiography in last fellow-up.</p><p><b>RESULTS</b>The average follow-up duration was 32.7 months with a range of 12-58 months. The gender, age, classification of spondylolisthesis and level of fusion showed a identical pattern in both groups. The mean intra-operative blood loss (310 ± 75) ml and postoperative blood loss (38 ± 13) ml in MIS-TLIF group were significantly superior to the intra-operative blood loss (623 ± 156) ml and postoperative blood loss (184 ± 72) ml in OTLIF group (t = 2.836 and 3.274, P < 0.01). Comparing with the OTLIF group (20 ± 10) s, the MIS-TLIF group had a significantly longer radiation time (51 ± 19) s (t = 2.738, P < 0.01). There was no statistical difference in operating time, lower back pain VAS scores, ODI scores and incidence of complication between the two groups.</p><p><b>CONCLUSIONS</b>Comparing with open TLIF, minimally invasive TLIF is a safe and reliable procedure for treatment of lumbar spondylolisthesis grade 1 and 2 with potential advantages.</p>

X-ray observation on how axial compression stimulates tibial fracture healing / 中华创伤杂志(英文版)

<p><b>OBJECTIVE</b>To validate the hypothesis that there exists an optimal axial compression stress range to enhance tibial fracture healing.</p><p><b>METHODS</b>Rabbits with a surgically induced V-shaped tibial fracture were separated into 2 main groups: the control group (C Group, n equal to 6) without application of any axial compression stress stimulation postoperatively and the stimulation group (S Group, n equal to 90). The S Group was further divided into 20 subgroups (S11 to S54) in terms of 5 axial compression stress stimulation levels (112.8 kPa, 289.8 kPa, 396.5 kPa, 472.7 kPa, and 602.3 kPa) and 4 experimental endpoints (1, 3, 5 and 8 weeks after operation). A custom made circular external fixator was used to provide the axial compression stress of the fracture sites. Based on X-ray observation, a fracture healing scoring system was created to evaluate the fracture healing process.</p><p><b>RESULTS</b>At 8 weeks after operation, there existed a "arch shape" relationship between healing score and axial compression stress stimulation level of fracture site. The optimal axial compression stress stimulation ranged from 289.8 kPa to 472.7 kPa, accompanying the best fracture healing, i.e. the fracture line became indistinct or almost disappeared, and a lot of callus jointed the two fracture ends. Meanwhile, at 5 weeks after operation, corresponding to the relatively low healing scores, there was a fracture healing performance similar to that at 8 weeks. Besides, at 1 or 3 weeks after operation, for all the axial compression stress levels (0-602.3 kPa), no obvious healing effect was found.</p><p><b>CONCLUSIONS</b>It is implied from the stated X-ray observation results in this study that the potential optimal axial compression stress stimulation and optimal fracture healing time are available. The axial compression stress level of 289.8-472.7 kPa and fracture healing time of more than 8 weeks jointly comprise the optimal axial compression stress stimulation conditions to enhance tibial fracture healing.</p>

Percutaneous pedicle screw fixation through the pedicle of fractured vertebra in the treatment of type A thoracolumbar fractures using Sextant system: an analysis of 38 cases / 中华创伤杂志(英文版)

<p><b>OBJECTIVE</b>To prospectively evaluate the feasibility, safety and efficacy of the percutaneous pedicle screw fixation through the pedicle of fractured vertebra in the treatment of type A thoracolumbar fractures using Sextant system in the retrospective non-randomized case-control study.</p><p><b>METHODS</b>A total of 38 consecutive non-randomized patients with type A thoracolumbar fractures, which had been stabilized posteriorly from December 2006 to March 2009, were examined retrospectively more than 9 months after surgery. Twenty-one patients had been treated conventionally with open pedicle screw fixation (OPSF) and 17 patients received minimally invasive treatment with Sextant percutaneous pedicle screw fixation (SPPSF). As a method of evaluation, the incision size, the intraoperation and postoperative volume of blood loss, operation time, postoperative hospital stay, blood transfusion, the radiological assessment of the sagittal Cobb;s angle, vertebral body angle and vertebral body height were recorded and compared.</p><p><b>RESULTS</b>All patients were followed up for 8-24 months (average 11.6 months). There were significant differences in the incision size, surgical blood loss, surgical draining loss, operation time, hospital stay after operation, blood transfusion, the proportion of antalgic supplement and postoperative incisional VAS between the two groups (P less than 0.05). Mean preoperative kyphotic deformity was 16.0 degree and improved by 9.3 degree after surgery in OPSF group, but 15.2 degree and 10.3 degree respectively in SPPSF group. Mean preoperative angle of the fractured vertebral body was 15.9 degree and improved by 7.9 degree after surgery in OPSF group, but 14.9 degree and 6.6 degree respectively in SPPSF group. Mean anterior vertebral body height (% of normal) was 67.3% before surgery and 95.8% after surgery, but 69.1% and 90.1% respectively in SPPSF group. Mean posterior vertebral body height (% of normal) was 93.3% before surgery and 99.5% after surgery, but 88.9% and 93.3% respectively in SPPSF group. Among the patients whose 9-month follow-up films were available, 3.0 degree of kyphosis correction was lost in OPSF group, but 3.2 degree in SPPSF group. And 1.0 degree of the angle of the fractured vertebral body correction was lost in OPSF group, but 1.5 degree in SPPSF group. Then 3.0% of the anterior vertebral body height correction was lost in OPSF group, but 2.2% in SPPSF group. And 3.0% of the posterior vertebral body height correction was lost in OPSF group, but 2.5% in SPPSF group. The sagittal Cobb's angle, vertebral body angle and anterior height of the fractured vertebra were all significantly different in each group before and after operation (P less than 0.05). There were no significant differences in the postoperative sagittal Cobb's angle, vertebral body angle and the improvement of the vertebral body height and the kyphotic deformity correction between OPSF and SPPSF groups (P larger than 0.05), but there was significant difference in the postoperative anterior height of the fractured vertebra between the two groups (P less than 0.05).</p><p><b>CONCLUSION</b>The percutaneous pedicle screw fixation through the pedicle of fractured vertebra using Sextant system is a good minimally-invasive surgical therapeutic choice for patients with type A thoracolumbar fracture except for that the SPPSF has a little insufficiency in resuming the anterior height of the fractured vertebra compared with OPSF.</p>

Controlled clinical trials on the pathological expressions of VEGF in patients with active ankylosing spondylitis / 中国骨伤

<p><b>OBJECTIVE</b>To investigate the pathological expression and significance of VEGF in patients with active ankylosing spondylitis.</p><p><b>METHODS</b>The expression of VEGF in the synovial tissues of cacroiliac joint of patients with active AS was detected by using in situ hybridization and the results were compared with those in the patients with pelvic fracture using image analysis system.</p><p><b>RESULTS</b>The positive expressions of VEGF in the synovial tissues of cacroiliac joint of patients with active AS were stronger than those in the control group (P<0.01).</p><p><b>CONCLUSION</b>VEGF are important factors in patients with active AS. They are tightly correlated with the process of osteoclasia and pathological new bone formation in the cacroiliac joint of patients with active AS. If we can reduce the expressions of VEGF in the patients with active AS, the process of osteoclasia and pathological new bone formation will be interrupted and this provides a new strategy for the treatment of ankylosing spondylitis.</p>

Micro-endoscopic strategies and options for recurrent lumbar disc herniation / 中华外科杂志

<p><b>OBJECTIVE</b>To evaluate the results of micro-endoscopic revision surgery for recurrent disc herniation, and compare the results of disc excision with and without interbody fusion.</p><p><b>METHODS</b>A total of 32 patients included who had undergone micro-endoscopic revision discectomy for recurrent disc herniation with or without interbody fusion has been surveyed to assess their clinical outcome. The 27 patients who had been followed were divided into two groups; the micro-endoscopic discectomy alone 14 cases, the micro-endoscopic discectomy with interbody fusion 13 cases. With an average follow-up of 25.5 months. Clinical symptoms were assessed based on the VAS scores and Nakai criteria. All medical and surgical records were examined and analyzed, including intraoperative blood loss, length of surgery, and postsurgery hospital stay et al.</p><p><b>RESULTS</b>The statistical difference in the postoperative back pain and leg pain score compared with preoperative score were significant (P < 0.05) or very significant (P < 0.01). Clinical outcomes were excellent or good in 92.8% of patients undergoing a micro-endoscopic discectomy alone, and in 85.5% of patients with interbody fusion. The statistical difference between the fusion and non-fusion groups was insignificant (P = 0.793). But the two groups intraoperative blood loss, length of surgery, length of hospitalization and expenses were significantly less in patients undergoing discectomy alone than in patients with interbody fusion.</p><p><b>CONCLUSIONS</b>Micro-endoscopic revision surgery for recurrent disc herniation is very effective and safety. Micro-endoscopic discectomy alone is first choice for managing recurrent disc herniation.</p>

Vascular endothelial growth factor and its receptor expression during the process of fracture healing / 中华创伤杂志(英文版)

<p><b>OBJECTIVE</b>To study the expression regularity of vascular endothelial growth factor (VEGF) during the process of fracture healing, and the type of VEGF receptor expressed in the vascular endothelial cells of the fracture site.</p><p><b>METHODS</b>The fracture model was made in the middle part of left radius in 35 rabbits. The specimens from the fracture site were harvested at 8, 24, 72 hours and 1, 3, 5, 8 weeks, and then fixed, decalcified, and sectioned frozenly to detect the expression of VEGF and its receptor at the fracture site by in situ hybridization and immunochemical assays.</p><p><b>RESULTS</b>VEGF mRNA and VEGF expression was detected in many kinds of cells at the fracture site during 8 hours to 8 weeks after fracture. Flt1 receptor of VEGF was found in the vascular endothelial cells at the fracture site during 8 hours to 8 weeks after fracture, and strong expression of flk1 receptor was detected from 3 days to 3 weeks after fracture.</p><p><b>CONCLUSIONS</b>The expression of VEGF and flt1 receptor appears during the whole course of fracture healing, especially from 1 to 3 weeks. Flk1 receptor is highly expressed in a definite period after fracture. VEGF is proved to be involved in the vascular reconstruction and fracture healing.</p>

The initial approach of two sides hypogastric artery ligation and isolation with laparoscope before excision of presacral tumor / 中华外科杂志

<p><b>OBJECTIVE</b>To observe the significance of excision of presacral tumor after two sides hypogastric artery ligation and tissue dissociation with laparoscope.</p><p><b>METHODS</b>Twenty-one patients with sacral tumor were performed excision of presacral tumor after two sides hypogastric artery ligation and tissue dissociation with laparoscope.</p><p><b>RESULTS</b>All sacral tumor were removed successfully, the mean volume of operative blood was 800 ml (range 500-1900 ml), and all the patients were followed up 3-25 months, averaged time 11 months. One patient was recurred after 2 months of operation (the patient was Ewing's sarcoma, and refused to accept radiotherapy and chemotherapy after operation), 1 patents died of brain metastases after 9 months of operations. There were no recurrence in the others patients.</p><p><b>CONCLUSIONS</b>The excision of presacral tumor after two sides hypogastric artery ligation and tissue dissociation with laparoscope is an effective operation method, with the advantages of decreasing the operative blood and difficulty of sacral tumor excision, and diminishing the operation wound.</p>

Endoscopic transforaminal lumbar decompression, interbody fusion and pedicle screw fixation-a report of 42 cases / 中华创伤杂志(英文版)

<p><b>OBJECTIVE</b>To evaluate the surgical procedure of endoscopic transforminal discectomy, bone grafting and Dynalok pedicle screw fixation under X-Tube operation system in the treatment of lumbar disc herniation combined with segmental instability and/or pars defected spondylolithesis.</p><p><b>METHODS</b>From June 2004 to May 2006, 42 patients with classic features of lumbar disc herniation combined with segmental instability and/or pars defected spondylolithesis underwent endoscopic transforminal lumbar interbody fusion (TLIF). Under the guidance of fluoroscopy, a 2.8 to 3.0 cm incision with 4.5 to 5.0 cm apart from the posterior middle line was made on the symptomatic side and the working portal (X-Tube) was docked unilaterally on the facet joint. A total facetectomy was then performed to expose neural foramina and nerve root. Discectomy and endplate preparation were completed through the tube. A Telamon cage was placed obliquely into the intervertebral space after interbody grafting, and then the Dynalok pedicle screw fixation system was performed. This procedure was accomplished on the lateral side when it is necessary.</p><p><b>RESULTS</b>Clinical outcomes were determined using the Oswestry Disability Index (ODI) which revealed that 62.2% of patients got excellent results, 29.2% good and 8.6% fair. The average hospital stay was 12.5 days (5-25 days). Operation time averaged 240 min (110-320 min), blood loss averaged 140 ml (80-420 ml) and incision length averaged 3 cm (2.8-3.2 cm). Five patients had complications including wound infection in 1 case, incision dehiscence and focal skin necrosis in 1, progressive radicular pain of contralateral leg in 1 and residual radicular numbness after transient radicular pain in 2.</p><p><b>CONCLUSIONS</b>This surgical procedure of endoscopic transforminal diskectomy, bone grafting, cage placement and pedicle screw fixation can be effectively accomplished under X-Tube operation system with predominant benefits such as small incision, less stripping of paraspinal muscles, minimal blood loss and rapid postoperative recovery.</p>

Minimally invasive strategies and options for far-lateral lumbar disc herniation / 中华创伤杂志(英文版)

<p><b>OBJECTIVE</b>To investigate the surgical procedures, options and surgical indications for far-lateral lumbar disc herniation between three different minimally invasive procedures.</p><p><b>METHODS</b>From January 2000 to October 2006, 52 patients with far-lateral lumbar disc herniation (29 males and 23 females, with the average age of 41.5 years) were treated with minimally invasive procedures. All the patients were assessed by X-ray and CT. Some were given additional myeography, discography, Computerized tomography mye-lography (CTM) and MRI examination. Yeung Endoscopy Spine System (YESS), METRx and X-tube procedures were performed in 25, 13 and 14 cases, respectively. All patients were followed up for a mean period of 13.5 months. Clinical outcomes were assessed by visual analog score (VAS) and Nakai criteria.</p><p><b>RESULTS</b>The results indicated that the three procedures could significantly improve the radiating leg symptoms (P less than 0.05). The postoperative overall excellent and good rates of YESS, METRx and X-tube procedures were 84.0%, 84.6% and 92.8% respectively, with no statistical difference among three groups (P larger than 0.05). The YESS procedure had several advantages including shortest operation time, simplest anesthesia and least trauma as compared with the other two procedures, especially for simple type I far-lateral lumbar disc herniation. METRx procedure was specially suitable for simple type II. And the procedure of posterior endoscopic facetectomy, posterior lumbar interbody fusion and unilateral pedicle screw instrumentation with X-tube was designed for far-lateral disc herniation combined with degenerative lumbar instability.</p><p><b>CONCLUSION</b>Minimally invasive strategies and options should be determined by different types of far-lateral lumbar disc herniation.</p>

Endoscopic transforaminal lumbar decompression, bone graft fusion and pedicle screw fixation under X-tube system: report of 42 cases / 中华外科杂志

<p><b>OBJECTIVE</b>To evaluate the surgical procedure of unilateral transforaminal discectomy, bone grafting, cage (Telamon) insertion and Dylanok pedicle screw fixation using X-tube operation system for the treatment of lumbar disc herniation combined with segmental instability and Spondylolysis with pars defect.</p><p><b>METHODS</b>From 2004 to 2006, 42 patients including 17 male and 25 female were treated in our department. The age range from 22 to 77 (mean: 51.6). Etiologies including lumbar disc herniation combined with segmental instability and Spondylolysis with pars defect.</p><p><b>RESULT</b>Of these 42 patients, the mean operation time was 240 min (110 - 320 min), the average blood loss was 140 ml (80 - 420 ml), the average incision length was 3 cm (2.8 - 3.2 cm) and the average hospitalization time was 12.5 days (5 - 25 days). Nakai criteria, Excellent in 23 cases (62.2%), good in 11 cases (29.2%) and fair in 3 cases (8.6%). 5 patients had postoperative complication (complication rate: 16.3%).</p><p><b>CONCLUSIONS</b>The surgical procedure has shown predominant benefits: small incision, less stripping of paraspinal muscles, minimal blood loss and rapid postoperative recovery which makes it a valuable alternative to conventional surgical procedures.</p>

Identification of a novel regeneration-related gene H3 and its protein from the differential expression cDNA library of spinal cord injury in neonatal rats / 中华创伤杂志(英文版)

<p><b>OBJECTIVE</b>To clone and identify one novel regeneration related gene H(3) (CA854305) from the differential expression genes library we had set up before.</p><p><b>METHODS</b>Use the method of Northern blot to detect the different expressions of the novel gene under different situations, employ the technique of in silico cloning to scan the span of the novel gene, and analyze their sequences. Also we used reverse transcription PCR to validate the largest open reading frame.</p><p><b>RESULTS</b>Northern blotting results of H(3) (CA854305) showed that the transplanted group had more efficient and extensive expression than untreated and uninjured groups 5 days after spinal cord injury, while the untreated group had more extensive expression than uninjured group. It implied that H(3) might have some relationship with nerve regeneration after spinal cord injury. From the results of in silico cloning we got a longest contig of 1635 bp and an largest open reading frame of 542 bp from 49 to 591 bp correspondent with the Cozak rules. Reverse transcription PCR validated the largest open reading frame sequence primarily.</p><p><b>CONCLUSIONS</b>We got the sequence of novel gene H(3) which might be one of the regenerationjrelated genes. Key words:Gene library; Genes; Nerve regeneration; Spinal cord injuries.</p>

Regulation of vascular endothelial growth factor on the expression of fracture healing-related factors / 中华创伤杂志(英文版)

<p><b>OBJECTIVE</b>To study the effect of vascular endothelial growth factor (VEGF)and anti-VEGF on the expression of fracture healing-related factors and observe pathological changes at fractured sites.</p><p><b>METHODS</b>Fracture models were established in 105 New Zealand white rabbits and they were randomly divided into control group, VEGF group and anti-VEGF group. The relevant factors expression at fractured sites was assayed and pathological changes were observed in decalcified samples at 8, 24, 72 hours and 1,3,5,8 weeks after fracture.</p><p><b>RESULTS</b>After application of VEGF, the expression of BMP appeared earlier and expression time lasted longer. On the contrary, anti-VEGF completely inhibited the expression of BMP. The fractured sites were filled with fibrous callus, cartilaginous callus and bony callus at the 3rd week and woven bone was constructed at the 5th week. Fracture healing was accomplished at the 8th week in VEGF group. In anti-VEGF polyclonal antibody group, cellular necrosis increased at early period. Continuous focal necrosis was seen in the fractured sites from the 1st week to 5th week. Vascularization reduced obviously at the 3rd week.</p><p><b>CONCLUSIONS</b>Fracture healing is a result of mutual regulation and coordination among many factors. VEGF may be an important factor in fracture healing.</p>

The clinical comparison of microendoscopic lumbar diskectomy with and without preservation of the ligamentum flavum / 中华外科杂志

<p><b>OBJECTIVE</b>To discuss the surgical technique, indication and the clinical effects of the Microscope Endoscopic Tubular Retractor System (METRx) for microendoscopic lumbar diskectomy with the preservation of the ligamentum flavum.</p><p><b>METHODS</b>Two hundred and eleven patients underwent single-segment METRx, with ligamentum flavum preservation in 65 patients (Group A), and without preservation in 146 patients (Group B). The two groups were compared clinically. All the patients suffered from low back pain and radicular syndrome to some extent, and the diagnosis was affirmed by CT and/or MRI. After exposed the interlaminar space regularly, the superior, inferior and lateral edge of the ligamentum flavum was released, the 3-sided dissociative ligament pacth was retracted medially during the spinal manipulation and restored anatomically after disc removal and the decompression of the nerve root.</p><p><b>RESULTS</b>According to the results of two groups, ligamentum flavum preservation technique was feasible under endoscope and helpful in reducing the scar formation in the spinal canal.</p><p><b>CONCLUSIONS</b>The ligamentum flavum preservation technique enable the surgeons to preserve the natural barrier. It is feasible to perform METRx, and it is helpful in reducing the epidural fibrosis.</p>