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1.
Chinese Journal of Orthopaedics ; (12): 697-704, 2023.
Article in Chinese | WPRIM | ID: wpr-993493

ABSTRACT

Objective:To investigate the diagnostic efficacy of MRI-based or CT-based measurements and the combined evaluation methods for preoperative bone quality assessment in patients with cervical degenerative diseases.Methods:Patients who underwent spine surgery for cervical degenerative diseases at the Department of Orthopedics, Huashan Hospital, Fudan University from September 2020 to March 2022 with available preoperative X-ray, CT, MRI and dule energy X-Ray absorptiometry (DEXA) data were included in this study. Vertebral bone quality score (VBQ) based on MRI T1-weightedimages and CT Hounsfiled unit (HU) values of the cervical spine were measured, and a combined diagnostic formula based on the binary logistic regression was constructed. The patients were divided into normal bone mass (T≥-1.0) and osteopenia/osteoporosis groups (T<-1.0). The student's t-test and Chi-square test were performed for comparisons between groups. The Pearson correlation coefficient was also used to investigate the correlation between DEXA-T scores, cervical VBQ and CT HU values. In addition, receiver operating characteristic curve (ROC) were plotted to explore the diagnostic efficacy of VBQ, CT HU and their combined diagnosis. Meanwhile, the corresponding sensitivity and specificity were obtained. Results:A total of 71 patients were included in this study (17 in the normal group and 54 in the osteopenia/osteoporosis group). The student's t-test showed that VBQ (2.90±0.70 vs. 3.83±0.83, t=4.23, P<0.001) and CT HU values (370.26±85.38 vs. 295.20±67.96, t=3.73, P=0.002) were significantly different between the two groups. The area under the ROC curve (AUC) for VBQ and CT values of the cervical spine were 0.81 and 0.75, respectively, and the AUC for the combined diagnostic value constructed on the basis of both was 0.85. Applying VBQ scores alone had a diagnostic sensitivity of 80% and a specificity of 70%, and the combined diagnosis with VBQ and CT HU had a sensitivity of 90% and a specificity of 75%. Person correlation analysis showed a significant correlation between DEXA T value, cervical VBQ value and CT HU value. The detailed formula was: DEXA T score=-0.63×cervical VBQ+0.64 ( r=-0.55, P<0.001), CT HU value=-40.20×cervical VBQ+458.40 ( r=-0.45, P<0.001), DEXA T score=0.006×CT HU-3.47 ( r=0.45, P<0.001). Conclusion:This study confirmed the feasibility of using cervical VBQ values, CT HU values and combined diagnostics for preoperative bone density screening in patients with degenerative cervical spine diseases. This method allows surgeons to perform an initial preoperative bone density screening based on the patient's existing imaging data, and thus could aid in confirming the indication and scheme of surgery. The method could be a powerful tool for preoperative bone density assessment screening in patients with cervical degenerative diseases.

2.
Chinese Journal of Trauma ; (12): 299-308, 2023.
Article in Chinese | WPRIM | ID: wpr-992602

ABSTRACT

The acute combination fractures of the atlas and axis in adults have a higher rate of neurological injury and early death compared with atlas or axial fractures alone. Currently, the diagnosis and treatment choices of acute combination fractures of the atlas and axis in adults are controversial because of the lack of standards for implementation. Non-operative treatments have a high incidence of bone nonunion and complications, while surgeries may easily lead to the injury of the vertebral artery, spinal cord and nerve root. At present, there are no evidence-based Chinese guidelines for the diagnosis and treatment of acute combination fractures of the atlas and axis in adults. To provide orthopedic surgeons with the most up-to-date and effective information in treating acute combination fractures of the atlas and axis in adults, the Spinal Trauma Group of Orthopedic Branch of Chinese Medical Doctor Association organized experts in the field of spinal trauma to develop the Evidence-based guideline for clinical diagnosis and treatment of acute combination fractures of the atlas and axis in adults ( version 2023) by referring to the "Management of acute combination fractures of the atlas and axis in adults" published by American Association of Neurological Surgeons (AANS)/Congress of Neurological Surgeons (CNS) in 2013 and the relevant Chinese and English literatures. Ten recommendations were made concerning the radiological diagnosis, stability judgment, treatment rules, treatment options and complications based on medical evidence, aiming to provide a reference for the diagnosis and treatment of acute combination fractures of the atlas and axis in adults.

3.
Chinese Journal of Trauma ; (12): 204-213, 2023.
Article in Chinese | WPRIM | ID: wpr-992589

ABSTRACT

Ankylosing spondylitis (AS) combined with spinal fractures with thoracic and lumbar fracture as the most common type shows characteristics of unstable fracture, high incidence of nerve injury, high mortality and high disability rate. The diagnosis may be missed because it is mostly caused by low-energy injury, when spinal rigidity and osteoporosis have a great impact on the accuracy of imaging examination. At the same time, the treatment choices are controversial, with no relevant specifications. Non-operative treatments can easily lead to bone nonunion, pseudoarthrosis and delayed nerve injury, while surgeries may be failed due to internal fixation failure. At present, there are no evidence-based guidelines for the diagnosis and treatment of AS combined with thoracic and lumbar fracture. In this context, the Spinal Trauma Academic Group of Orthopedics Branch of Chinese Medical Doctor Association organized experts to formulate the Clinical guideline for the diagnosis and treatment of adult ankylosing spondylitis combined with thoracolumbar fracture ( version 2023) by following the principles of evidence-based medicine and systematically review related literatures. Ten recommendations on the diagnosis, imaging evaluation, classification and treatment of AS combined with thoracic and lumbar fracture were put forward, aiming to standardize the clinical diagnosis and treatment of such disorder.

4.
Chinese Journal of Orthopaedics ; (12): 1312-1320, 2022.
Article in Chinese | WPRIM | ID: wpr-957126

ABSTRACT

Fusion surgery has been an effective modality for the treatment of spinal disorders for more than 100 years. With the increasing understanding of the disease and the increasing maturity of surgical techniques, lumbar fusion has become more widely performed and its efficacy has been conclusively proven. However, fusion surgery inevitably disrupts the original physiologic motion of the spine and limits segmental motion, resulting in a significant increase in disc and joint protrusion stress in adjacent segments. When a newly identified degenerative change on imaging is present in an adjacent segment or an existing degeneration is more aggravated, this is known as adjacent segment degeneration. When clinical symptoms such as pain and numbness in the lower extremities are present that are consistent with degeneration, this is known as adjacent segment disease. Real world studies (RWS) have become a major focus in medical research in recent years. Since it is closer to clinical practice and more practical for decision-making compared with randomized controlled trail (RCT), it is gaining importance in clinical practice. By searching major national and international databases, this article provides a review of risk factors as well as advances in the treatment of lumbar adjacent segment disease in RWS. According to the retrieved literature, there are many factors that contribute to the development and progression of adjacent segment degeneration and disease, which are mainly divided into patient-related factors and surgery-related factors. In general, patient age, weight, spinal-pelvic sagittal parameters, and internal diseases influence the progression of adjacent segment degeneration. Surgery-related risk factors include the number of segments operated on, the surgical approach, interference with adjacent segments, and whether the spinal-pelvicsagittal imbalance is corrected. To prevent the development of adjacent segment disease, patients can slow the progression of adjacent segment degeneration by reducing their own weight and controlling their internal diseases. The physician can also avoid the influence of surgery-related factors through adequate surgical planning and careful intraoperative management. At the same time, surgeries may be performed in patients who have developed adjacent segmental disease and for whom conservative treatment has failed. The current revision surgical approaches include endoscopic simple decompression and posterior decompression with extended internal fixation.Short-term RWS revealed that the efficacy of endoscopic treatment of adjacent spondylosis might be equivalent to re-fusion internal fixation surgery. Studies with large samples and long-term follow-up are still needed to guide the treatment of adjacent segment disease in the future, in order to improve clinical decision-making.

5.
Chinese Journal of Orthopaedics ; (12): 1301-1311, 2022.
Article in Chinese | WPRIM | ID: wpr-957125

ABSTRACT

Objective:To investigate the influence of interbody cage height during oblique lumbar interbody fusion (OLIF) on lumbar biomechanics with different degrees of degeneration and to provide a reference for cage choice.Methods:The finite element model of normal lower lumbar spine (L 3-S 1) was built and validated, then constructed three different degenerative segments in L 3, 4, and the cages with different height (8, 10,12, 14 mm) were implanted into L 4, 5 disc. All the twelve models were loaded with pure moment of 7.5 N·m to produce flexion, extension, lateral bending and axial rotation motions on lumbar spine, and the effects of cage height on range of motion (ROM), intervertebral pressure in adjacent segments and stress in facet joints were investigated. Results:The ROM of adjacent segments and the maximum stress of intervertebral discs increased with the increase of cage height, but this trend was not obvious in moderate and severe degeneration groups. After implantation of 4 different height cages (8, 10, 12, 14 mm), the ROM of L 3, 4 segment reached the maximum during extension. The ROM of mild degeneration group was 2.68 °, 2.71 °, 2.94 °, 2.98 °, moderate degeneration group was 2.33°, 2.37°, 2.41°, 2.49°, and severe degeneration group was 1.94 °, 1.99 °, 2.14 °, 2.21 °. The stress of L 3, 4 intervertebral disc reached the maximum during right bending. The maximum stress of L 3, 4 intervertebral disc was 23.95 MPa, 24.60 MPa, 24.90 MPa and 25.34 MPa in mild group, 25.57 MPa, 25.60 MPa, 25.82 MPa and 25.89 MPa in moderate group, and 25.95 MPa, 25.99 MPa, 26.48 MPa and 27.13 MPa in severe group. The maximum stress of L 3, 4 facet joint was 15.87 MPa, 15.78 MPa, 16.29 MPa and 16.43 MPa in mild group, 15.97 MPa, 16.31 MPa, 16.53 MPa and 16.79 MPa in moderate group, and 16.17 MPa, 16.49 MPa, 16.95 MPa and 17.35 MPa in severe group. Conclusion:For patients with mild lumbar degeneration requiring OLIF surgery, the intervertebral height of the surgical segment should not be overstretched. But for patients with moderate to severe lumbar degenerative disease who need to undergo OLIF surgery, it is recommended that the cage height be 0-2 mm higher than the original intervertebral space height.

6.
Chinese Journal of Orthopaedics ; (12): 1292-1300, 2022.
Article in Chinese | WPRIM | ID: wpr-957124

ABSTRACT

Objective:To investigate the correlation between paraspinal muscle atrophy, morphological changes of facet joints and adjacent segment disease (ASDis) after lumbar fusion operation.Methods:A retrospective study was conducted among 195 patients who underwent posterior lumbar fusion again for ASDis at this institution from January 2014 to December 2020, including 29 patients with ASDis whose initial surgical fusion segment was L 4,5. According to Roussouly's staging, there were 5 cases of type I, 9 cases of type II, 10 cases of type III, and 5 cases of type IV. Another 29 cases were selected from patients without ASDis after lumbar fusion as a control group. The control group was paired 1∶1 with the ASDis group according to gender, fusion segment, and Roussouly typing of the lumbar spine. The cross-sectional area (CSA) and fat infiltration (FI) of paravertebral muscle, facet joint angle (F-J) and pedicle facet (P-F) angle before the first (second) operation were measured and compared between the two groups. Then logistic regression analysis was used to determine the predictors of ASDis after posterior lumbar fusion. Finally, the receiver operation characteristic (ROC) curve was described, and the area under the curve (AUC) and cut-off point were calculated. At the same time, the paraspinal muscle atrophy before the second operation in ASDis group was measured. Results:The average follow-up time of 98 patients was 59.25±6.38 months (range, 49-73 months). The average body mass index (BMI) of ASDis group was 24.76±3.64 kg/m 2, which was higher than that in control group (22.24±2.92 kg/m 2) ( t=2.481, P=0.041). The average CSA and relative cross-sectional area (rCSA) of paraspinal muscle in ASDis group were 3 214.32± 421.15 mm 2 and 1.69±0.36 respectively, which were less than 3 978.91±459.87 mm 2 and 2.26±0.29 in control group ( t=10.22, P=0.012; t=9.47, P=0.038). The FI degree of paraspinal muscle in ASDis group (21.95%±5.89%) was significantly higher than that in control group (14.64%±7.11%) ( t=7.32, P=0.002). The F-J angle in ASDis group was 35.06°±3.45°, which was less than 38.39°±4.67° in control group ( t=4.76, P=0.027). The P-F angle in ASDis group was 117.39°±8.13°, which was greater than 111.32°±4.78° in control group ( t=5.25, P=0.031). Multivariate logistic regression analysis showed that higher BMI ( OR=1.34, P=0.038), smaller rCSA of paraspinal muscle ( OR=0.02, P=0.017) and higher FI of paraspinal muscle ( OR=1.58, P=0.032) were the risk factors of postoperative ASDis. The ROC curve showed that the AUC of BMI was 0.680 and the cut-off point was 22.58 kg/m 2; The AUC of the FI of paraspinal muscle was 0.716 and the cut-off point was 15.69%; The AUC of rCSA of paraspinal muscle was 0.227 and the cut-off point was 1.92. For ASDis patients, the paraspinal muscle before the second operation had a higher degree of FI (25.47%±6.59% vs. 21.95%±5.89%, t=3.99, P=0.042) and a smaller rCSA (1.52±0.28 vs. 1.69±0.36, t=3.85, P=0.038) than that before the first operation. The difference between the FI degree of paraspinal muscle before the second operation and the first operation was negatively correlated with the occurrence time of ASDis ( r=-0.53, P=0.039) , and the difference of rCSA was positively correlated with the occurrence time of ASDis ( r=0.64, P=0.043) . Conclusion:When BMI >22.58 kg/m 2, FI of paraspinal muscle >15.69%, and rCSA of paraspinal muscle <1.92, it suggests that ASDis is more likely to occur after operation. And the more obvious paraspinal muscle atrophy after the first operation, the earlier ASDis may occur. Morphological changes of facet joints cannot be used as an index to predict the occurrence of ASDis.

7.
Chinese Journal of Orthopaedics ; (12): 1249-1253, 2022.
Article in Chinese | WPRIM | ID: wpr-957119

ABSTRACT

Adjacent segment disease (ASDis) is a kind of mid- or long-term complication after lumbar spinal fusion. Although natural degenerative factors and patients' characteristics play a major role in the development of ASDis, iatrogenic related factors, especially surgical related factors, are also important factors affecting ASDis. The research shows that injury of posterior ligament complex, insufficient recovery of the disc height and lumbar alignment, and violation of the implant on adjacent segments will accelerate ASDis. Therefore, attention should be paid to the protection of the posterior lumbar structure, suitable reconstruction of the disc height and alignment of the lumbar spine, and avoiding the violation of the implant on adjacent segments. In addition, the quality of clinical research on ASDis has gradually improved in recent years, but there are still many problems, including small sample size, short follow-up time, low evidence level, and poor clinical values. To solve these problems, randomized controlled trial (RCT) should be conducted to evaluate the impact of specific factors on ASDis in order to obtain high level evidence. On the other hand, real world studies (RWS) should also be conducted, focusing on the actual problems encountered in clinical practice, through the real medical environment and medical process, to obtain the results with guidance and value for clinical problems.

8.
Chinese Journal of Trauma ; (12): 911-918, 2021.
Article in Chinese | WPRIM | ID: wpr-909956

ABSTRACT

Objective:To establish a radiological classification system for acute cervical spinal cord injury without fracture or dislocation in adults and evaluate its credibility.Methods:A retrospective case series study was performed to analyze the clinical and radiological data of 132 patients with acute cervical spinal cord injury without cervical fracture or dislocation admitted to Huashan Hospita,Fudan University from January 2010 to December 2018. There were 97 males and 35 females,aged 18-82 years[(57.4±17.8)years]. The radiological classification system of acute cervical spinal cord injury without fracture and dislocation in adults was established based on spinal cord compression and its compressors,and the disco-ligamentous complex(DLC)injury. The number,age and causes of injury of each subtype were further analyzed. Another 24 patients with acute cervical spinal cord injury without fracture and dislocation were collected and assessed to calculate the Kappa coefficient for credibility assessment in the radiological classification by orthopedic surgeons who did not participate in the establishment of the classification.Results:The radiological classification system of acute cervical spinal cord injury without fracture or dislocation in adults included types I-IV. Type I was the cervical spinal cord significantly compressed by the existed pathological factors such as the ossification of the posterior longitudinal ligament of the cervical spine and/or cervical spinal canal stenosis before the injury;Type II was the cervical spinal cord significantly compressed by traumatic disc herniation and/or epidural hematoma;Type III was the spinal cord without obvious compression,but with definite DLC injury;Type IV was the spinal cord without obvious compression,accompanied with no or only suspicious DLC injury. Type I and type II could be with or without DLC injury. Eighty-three patients(62.9%)were classified as type I,with the age of(62.2±15.7)years,and the main cause of injury was fall injury(37 patients,44.6%),followed by traffic injury(31 patients,37.3%). Seventy patients(12.9%)were classified as type II,with the age of(55.8±13.4)years,and the traffic injury(9 patients,52.9%)and fall injury(5 patients,29.4%)were more common. Twenty-four patients(18.2%)were classified as type III,with the age of(53.6±16.3)years,and the main causes of injury were fall injury(9 patients,37.5%)and traffic injury(8 patients,33.3%). Eight patients(6.1%)were classified as type IV,with the age of(37.4±11.6)years,and the main causes of injury were traffic injury(4 patients,50.0%)and sports injury(3 patients,37.5%). The credibility assessment of the radiological classification of acute cervical spinal cord injury without fracture or dislocation in adults showed that the consistency percentage was 79.2%-87.5%(mean,81.2%)among different observers. The Kappa coefficient was 0.691-0.866(mean,0.789),and the credibility was basically credible(0.61-0.80).Conclusions:The established radiological classification system of acute cervical spinal cord injury without fracture or dislocation in adults has a good degree of credibility. Variances in age and causes of injury of each type suggest a good guidance value for clinical classification of acute cervical spinal cord injury without fracture and dislocation in adults.

9.
Chinese Journal of Orthopaedics ; (12): 769-777, 2020.
Article in Chinese | WPRIM | ID: wpr-869024

ABSTRACT

Objective:To investigate the operational impact of the curve laterality of degenerative lumbar scoliosis on oblique lateral lumbar interbody fusion (OLIF).Methods:Data of 40 cases with degenerative lumbar scoliosis and 20 cases without degenerative lumbar scoliosis treated in our hospital from January to December 2017 were retrospectively analyzed. There were 20 cases in left convex group (male 5, female 15, 70.62±5.45 years old) and 20 cases in left concave group (male 3, female 17, 69.73±7.24 years old), and there were 20 cases of lumbar degenerative diseases without scoliosis (lumbar spinal stenosis 13 cases, lumbar disc herniation 7 cases; male 5, female 15, 71.48±5.73 years old). The following OLIF operation-related anatomical parameters were measured on MR axial T2 weighted image and lumbar spine X-ray image: distance from the left edge of the abdominal aorta to the anterior medial edge of the left psoas muscle; distance from the left edge of the abdominal aorta to the left lumbar sympathetic trunk; distance from the anterior medial edge of the left psoas muscle to the transverse axis of the vertebral body; distance between the midpoints of adjacent vertebral bodies in L 2-5; angle of rotation of the vertebral body and angle of the OLIF operating channel. One-way analysis of variance(ANOVA) and least significant difference (LSD) were used for statistical analysis of measurement parameters of different groups. Results:There were statistically significant differences between the distance from the left edge of the abdominal aorta to the anterior medial edge of the left psoas muscle, and the distance from the left edge of the abdominal aorta to the left lumbar sympathetic trunk in the three groups of cases (All P<0.05). The L 2, 3 segment (24.41±9.54 mm, 18.18±7.1 mm) and L 3, 4 segment (18.54±7.94 mm, 13.73±6.73 mm) in the left concave group were significantly larger than those in the no scoliosis group; and the above values of the L 4, 5 segment of the left convex group (19.16±7.04 mm, 11.67±3.63 mm) were significantly larger than those in the no scoliosis group. For the distance from the anterior medial edge of the left psoas muscle to the transverse axis of the vertebral body, the values of L 2, 3 and L 3, 4 (13.76±2.98 mm, 15.87±3.53 mm) in the left convex group were significantly greater than those in the no scoliosis control group; but in the left concave group, the corresponding values (9.97±3.14 mm, 10.75±5.03 mm) were significantly smaller than those in the no scoliosis group. The distances between the midpoints of adjacent vertebral bodies of L 2, 3 and L 3, 4 (37.67±3.45 mm, 38.18±3.54 mm) in the left convex group were greater than those in the no scoliosis group and left concave group, and the differences between the three groups were statistically significant ( P<0.05). Pearson correlation analysis between the absolute value of vertebral rotation angle and OLIF surgical passage angle showed that there was a negative correlation between them in the left convex group and a positive correlation in the left concave group. Conclusion:The curve laterality of degenerative lumbar scoliosis had a certain influence on the anatomical parameters of oblique lateral lumbar interbody fusion. It was recommended to design and adjust the operation skills according to the curve laterality before surgery.

10.
Chinese Journal of Trauma ; (12): 577-586, 2020.
Article in Chinese | WPRIM | ID: wpr-867755

ABSTRACT

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.

11.
Chinese Journal of Orthopaedics ; (12): 1507-1513, 2019.
Article in Chinese | WPRIM | ID: wpr-824521

ABSTRACT

Objective To summarize the clinical features of cervical spondylosis with distal upper extremity amyotrophy;and further analyze the clinical efficacy of cervical anterior decompression and fusion on cervical spondylosis with distal upper extremity amyotrophy.Methods Thirty cases of cervical spondylosis with distal upper extremity amyotrophy were analyzed retrospectively from June 2006 to June 2015.nineteen males and eleven females with an average age of 55.20±9.08 years (41 to 72 years) were included.The preoperative course was 1 to 108 months with a median of 6 months.The muscle extent of the affected group,the segmentation and location of spinal canal stenosis,and the results of neurophysiological examination were analyzed.The muscular strength recovery of atrophic muscles was evaluated by Manual Muscle Testing (MMT),and the clinical satisfaction was assessed at the last followed up.Results The muscles involved in patients of cervical spondylosis with distal upper extremity amyotrophy are mainly the thenar muscle (17 cases,56.7%),interosseous muscle (15 cases,50.0%),and shypothenar muscles (13 cases,43.3%).Most cases of imaging findings showed multi-segmental degeneration,of which C5.6 (24 cases,80.0%),C6.7 (21 cases,70.0%) segments were most common,and the types of anterior compression:23 segments (33.5%) of the central type,37 segments (54.4%) of the lateral-central type,and 8 segments (11.8%) of the foramen type.Neuroelectrophysiological examination showed that cervical spinal cord anterior horn cells or nerve root damage,the most commonly involved segments of C7,C8,T1(18 cases,60.0%).The average follow-up time was 36.8 months.At the last follow-up,MMT assessment showed that thirteen patients (43.3%) in this group had muscle strength recovery for more than one grade at the last follow-up.The average clinical satisfaction was 73.4%.Conclusion The clinical diagnosis of cervical spondylosis with distal upper extremity amyotrophy requires a combination of clinical symptoms,imaging findings and neurophysiological examination results for comprehensive judgment.Cervical anterior decompression and fusion can effectively prevent the progression of cervical spondylosis in distal upper extremity amyotrophy patients,and some patients can get a good muscle recovery.

12.
Chinese Journal of Orthopaedics ; (12): 1507-1513, 2019.
Article in Chinese | WPRIM | ID: wpr-803379

ABSTRACT

Objective@#To summarize the clinical features of cervical spondylosis with distal upper extremity amyotrophy; and further analyze the clinical efficacy of cervical anterior decompression and fusion on cervical spondylosis with distal upper extremity amyotrophy.@*Methods@#Thirty cases of cervical spondylosis with distal upper extremity amyotrophy were analyzed retrospectively from June 2006 to June 2015. nineteen males and eleven females with an average age of 55.20±9.08 years (41 to 72 years) were included. The preoperative course was 1 to 108 months with a median of 6 months. The muscle extent of the affected group, the segmentation and location of spinal canal stenosis, and the results of neurophysiological examination were analyzed. The muscular strength recovery of atrophic muscles was evaluated by Manual Muscle Testing (MMT), and the clinical satisfaction was assessed at the last followed up.@*Results@#The muscles involved in patients of cervical spondylosis with distal upper extremity amyotrophy are mainly the thenar muscle (17 cases, 56.7%), interosseous muscle (15 cases, 50.0%), and shypothenar muscles (13 cases, 43.3%). Most cases of imaging findings showed multi-segmental degeneration, of which C5, 6 (24 cases, 80.0%), C6,7 (21 cases, 70.0%) segments were most common, and the types of anterior compression: 23 segments (33.5%) of the central type, 37 segments (54.4%) of the lateral-central type, and 8 segments (11.8%) of the foramen type. Neuroelectrophysiological examination showed that cervical spinal cord anterior horn cells or nerve root damage, the most commonly involved segments of C7, C8, T1(18 cases, 60.0%). The average follow-up time was 36.8 months. At the last follow-up, MMT assessment showed that thirteen patients (43.3%) in this group had muscle strength recovery for more than one grade at the last follow-up. The average clinical satisfaction was 73.4%.@*Conclusion@#The clinical diagnosis of cervical spondylosis with distal upper extremity amyotrophy requires a combination of clinical symptoms, imaging findings and neurophysiological examination results for comprehensive judgment. Cervical anterior decompression and fusion can effectively prevent the progression of cervical spondylosis in distal upper extremity amyotrophy patients, and some patients can get a good muscle recovery.

13.
Chinese Journal of Orthopaedics ; (12): 1222-1228, 2019.
Article in Chinese | WPRIM | ID: wpr-803033

ABSTRACT

Oblique lateral interbody fusion (OLIF) surgery uses the retroperitoneal gap between the abdominal aorta and left psoas as the surgical approach to perform discectomy and interbody fusion. It has the advantages of shorter operation duration and hospital stay, less blood loss, lighter postoperative pain and quicker recovery compared with traditional lumbar interbody fusion surgery. OLIF surgery has been gradually applied in treating degenerative diseases of the lumbar spine. However, the complications, such as the injury of blood vessels, sympathetic nerves, lumbosacral plexus, peritoneum and ureteral, cannot be negligible. Previous studies reported that the overall incidence of complications about OLIF surgery was 3% to 53.1% with an average of 15.5%, which can be divided into intraoperative and postoperative complications. The incidence of iliac vascular injury was found to be 0.3%-15.4% in OLIF at the L5S1 segments. The anatomy about vascular in this area is complex because the aorta is branched into the left and right iliac artery. The surgical approach in L5S1 segments is also different from the traditional OLIF but similar to the lateral anterior lumbar interbody fusion, which could increase the risk of vascular injury. The other complications which do not show significant segmental difference were based on the previous literatures. The incidence of abdominal aortic injury is 0.1%, which is related to direct damage caused by the narrow operation window of OLIF. The incidence of lumbar segmental arterial injury was 0.7% to 5%, which may be caused by the anatomical variation of L4, 5 lumbar segmental artery. The incidence of lumbar sympathetic nerve injury is 1.7%. More attention should be paid to protect the lumbar sympathetic trunk which lying in the front of the psoas muscle. The incidence of cage-related complications ranges from 2.9% to 13.4%, which perhaps is associated with older age, osteoporosis and use of large-sized cages. Although the incidence of ureteral injury is 0.3% to 1.6%, care should also be taken due to not obvious injury without urinary tube.

14.
Chinese Journal of Orthopaedics ; (12): 975-981, 2019.
Article in Chinese | WPRIM | ID: wpr-802799

ABSTRACT

Objective@#To investigate the effect of modified transforaminal lumbar interbody fusion (TLIF) on coronal degenerative lumbar scoliosis (DLS) in adults with mild Drum Tower Hospital Classification type B and C coronal imbalance.@*Methods@#From January 2011 to December 2015, 31 patients with mild coronal imbalance underwent long-segment fusion for DLS, 27 females and 4 males, with an average age of 63.1±5.5 years (52-76 years), were retrospectively analyzed. According to the coronal balance classification of Drum Tower degenerative scoliosis, there were 20 patients with type B and 11 patients with type C. The average follow-up time was 38.5±9.3 months. Sagittal parameters includingpelvic tilt (PT), PI-LL (pelvic incidence, PI; lumbar lordosis, LL), sagittal vertical axis (SVA) and coronal parameters includingCobb angle, coronal balance distance (CBD), lumbosacral inclination angle (when L 5 is the lower fusion vertebra, the angle between L4 upper endplate and horizontal line was measured; when S1 or S2 was the lower fusion vertebra, the angle between L 5 upper endplate and horizontal line is measured), and clinical scores including Visual Analogue Scale (VAS) and Oswestry Disability Index (ODI) (excluding sexual life assessment)were recorded before and during the last follow-up. Complications such as internal fixation displacement, fracture and loss of correction were evaluated at the last follow-up. The main method of surgical correction was the modified TLIF operation on the distal compensatory curve and concave side. After the soft tissue is released, the ipsilateral intervertebral fusion cage was implanted to distract the intervertebral space. SPSS 20.0 was used for statistical analysis. All data were expressed as mean ±standard deviation. Paired t-test was used to evaluate the imaging measurement and clinical scores. Independent sample t-test was used to compare the databetween type B and C. P value less than 0.05 has statistical significance.@*Results@#The mean operating time was 4.4±0.9 h (3.1-6.0 h) and the mean intraoperative bleeding was 777±249 ml (500-1 300 ml). For Sagittal balance, PI-LL was 21.7°±5.3° in 31 patients before operation, and the last follow-up was 7.4°±2.4° (t=16.41, P<0.001); PT was 32.6°±7.6° before operation, and the last follow-up was 24.1°±8.5° (t=15.32, P<0.001); SVA was 52.2±16.2 mm before operation, and the last follow-up was 25.5±13.8 mm (t=10.20, P<0.001). For coronal balance, the lumbosacral tilt angle was 8.8°±3.4°, and the last follow-up was 3.9°±2.1°. The average correction rate was 56.0%. The preoperative scoliosis Cobb angle was 41.5°±9.6°, and the last follow-up was 19.7°±6.7° (t=17.90, P <0.001). The average correction rate was 52.7%. The preoperative CBD was 4.3 ±0.7 mm, and last follow-up was 1.6 ± 0.8 mm (t=33.76, P < 0.001). In terms of clinical scores, the VAS score of 31 patients before operation was 6.5±1.0, and the last follow-up was 2.7±1.0 (t=15.97, P <0.001); the ODI score before operation was 34.8%+5.6%, and the last follow-up was 18.0%±5.4% (t=12.42, P <0.001). There were no significant differences in sagittal parameters, coronal parameters and clinical efficacy scores between group B and group C.@*Conclusion@#In adult DLS patients with mild coronal B-type and C-type imbalances, the application of modified TLIF interbody fusion and cage insertion in the distal convex side of lumbar scoliosis can achieve the levelization of lumbosacral region and correct coronal imbalance.

15.
Chinese Journal of Orthopaedics ; (12): 975-981, 2019.
Article in Chinese | WPRIM | ID: wpr-755242

ABSTRACT

Objective To investigate the effect of modified transforaminal lumbar interbody fusion (TLIF) on coronal de?generative lumbar scoliosis (DLS) in adults with mild Drum Tower Hospital Classification type B and C coronal imbalance. Meth?ods From January 2011 to December 2015, 31 patients with mild coronal imbalance underwent long?segment fusion for DLS, 27 females and 4 males, with an average age of 63.1±5.5 years (52-76 years), were retrospectively analyzed. According to the coronal balance classification of Drum Tower degenerative scoliosis, there were 20 patients with type B and 11 patients with type C. The average follow?up time was 38.5 ± 9.3 months. Sagittal parameters includingpelvic tilt (PT), PI-LL (pelvic inci?dence, PI; lumbar lordosis, LL), sagittal vertical axis (SVA) and coronal parameters includingCobb angle, coronal balance dis?tance (CBD), lumbosacral inclination angle (when L 5 is the lower fusion vertebra, the angle between L 4 upper endplate and hor?izontal line was measured; when S1 or S2 was the lower fusion vertebra, the angle between L 5 upper endplate and horizontal line is measured), and clinical scores including Visual Analogue Scale (VAS) and Oswestry Disability Index (ODI) (excluding sexual life assessment)were recorded before and during the last follow?up. Complications such as internal fixation displace?ment, fracture and loss of correction were evaluated at the last follow?up. The main method of surgical correction was the modi?fied TLIF operation on the distal compensatory curve and concave side. After the soft tissue is released, the ipsilateral interver?tebral fusion cage was implanted to distract the intervertebral space. SPSS 20.0 was used for statistical analysis. All data were expressed as mean ±standard deviation. Paired t?test was used to evaluate the imaging measurement and clinical scores. Inde?pendent sample t?test was used to compare the databetween type B and C. P value less than 0.05 has statistical significance. Results The mean operating time was 4.4±0.9 h (3.1-6.0 h) and the mean intraoperative bleeding was 777±249 ml (500-1 300 ml). For Sagittal balance, PI-LL was 21.7°±5.3°in 31 patients before operation, and the last follow?up was 7.4°±2.4°(t=16.41, P<0.001); PT was 32.6°±7.6°before operation, and the last follow?up was 24.1°±8.5°(t=15.32, P<0.001); SVA was 52.2±16.2 mm be?fore operation, and the last follow?up was 25.5±13.8 mm (t=10.20, P<0.001). For coronal balance, the lumbosacral tilt angle was 8.8°±3.4°, and the last follow?up was 3.9°±2.1°. The average correction rate was 56.0%. The preoperative scoliosis Cobb angle was 41.5°±9.6°, and the last follow?up was 19.7°±6.7°(t=17.90, P<0.001). The average correction rate was 52.7%. The preoperative CBD was 4.3 ±0.7 mm, and last follow?up was 1.6 ± 0.8 mm (t=33.76, P<0.001). In terms of clinical scores, the VAS score of 31 patients before operation was 6.5±1.0, and the last follow?up was 2.7±1.0 (t=15.97, P<0.001); the ODI score before operation was 34.8%+5.6%, and the last follow?up was 18.0%±5.4% (t=12.42, P<0.001). There were no significant differences in sagittal param?eters, coronal parameters and clinical efficacy scores between group B and group C. Conclusion In adult DLS patients with mild coronal B?type and C?type imbalances, the application of modified TLIF interbody fusion and cage insertion in the distal con?vex side of lumbar scoliosis can achieve the levelization of lumbosacral region and correct coronal imbalance.

16.
Chinese Journal of Orthopaedics ; (12): 510-517, 2019.
Article in Chinese | WPRIM | ID: wpr-745417

ABSTRACT

Objective To investigate the efficacy of neurological injury in patients with Hirayama disease using threshold tracking technique.Methods This study included 17 patients with Hirayama disease who visited the Department of Orthopaedics of Huashan Hospital from June 2017 to October 2017(patient group,16 males and 1 female,the average age was 18.06±0.50 years,ranging from 16 to 22 years,the average course of disease was 27.2±18.81 months,ranging from 1 to 60 months.Mean-while,a total of 20 healthy volunteers(control group,19 males and 1 female,the average age is 20.05±1.30 years,ranging from 17 to 23 years)were also enrolled in this study.In patient group,the median motor nerve conduction examination,needle EMG examination,and threshold tracking examination were performed on the severe side;while in control group,the median motor nerve conduction examination and threshold tracking examination were performed on either side.We evaluate the changes in peripheral motor nerve conduction of Hirayama disease by comparing CMAP(compound muscle action potential)and median motor nerve conduction velocity evaluate the changes in motor nerve excitability by comparing the rheobase,SDTC(Strength-duration time constant),threshold electrotonus,current-threshold I/V slope,superexcitability,and subexcitability.The upper limb function was assessed by disabilities of arm,shoulder and hand(DASH)score.The differences in threshold tracking parameters between groups were compared by independent t test,and the correlation between SDTC and DASH score was tested by Pearson correlation analysis.Results In the peripheral motor nerve conduction examination,the median nerve CMAP in patients with Hirayama disease was 4.12±1.43 mV in average,which is lower than healthy controls 8.23±1.61 mV(t=-3.8,P<0.01).There was no significant difference in the peripheral motor nerve conduction velocity(t=-0.86,P=0.39).In the threshold tracking examination,SDTC in patients with Hirayama disease was 0.48±0.09 ms,which was prolonged than healthy controls 0.39±0.06 ms(t=3.75,P<0.01).The absolute values of TEh(10-20)and TEh(20-40)decreased significantly(P<0.01),hence,the hyperpolarized part of the threshold-electrotonus curve showed "fanning-in" pattern.The slope of the current-threshold(I/V)curve had a decreasing trend.The hyper-polarized l/V slope in patients with Hirayama disease was 0.27±0.09 in average,which was lower than the healthy controls which was 0.34±0.07(t=-2.73,P=0.01).The DASH score of patients ranged from 0.86 to 19.44,with an average of 6.99±5.79.There was a correlation between SDTC and DASH score,R2=0.36,which met the F test(P=0.01).Conclusion Threshold tracking technique can be adapted in evaluating nerve injury in Hirayama disease to determine the degree of injury and potential pathogenesis.

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Chinese Journal of Orthopaedics ; (12): 496-503, 2019.
Article in Chinese | WPRIM | ID: wpr-745415

ABSTRACT

Objective To investigate the predictive value of dynamic F wave in the treatment of Hirayama disease(HD)after anterior cervical fusion and internal fixation.Methods From February 2014 to January 2016,thirty-six patients with HD were included in this study(age:17.9±2.6 years,height:173.1±6.2 cm,disease duration:20.1±13.1 months;male to female ratio:35:1),and all of these 36 patients underwent anterior cervical autogenous iliac fusion and internal fixation.All of these patients underwent bilateral dynamic F-wave detection(The F-wave was tested on the cervical standard position and at least 30 minutes after cervical flexion)on the median nerve before operation and 3-5 days after operation.The latency and maximum amplitude of M-wave,the persistence of F-wave,the shortest latency of F-wave,the ratio of F/M and the persistence of repeated F-wave were measured.Dynamic F-wave abnormalities were defined when repeated F-wave was only found during neck flexion or the standard-flexion difference of each measurements of F-wave was more than 2 standard deviations from the normal value(the shortest latency of F-wave:0.6±0.5 ms,persistence of F-wave:7.3%±5.7%,the ratio of F/M:1.1±1.0).Furthermore,these patients with HD accepted both bilateral grip strength and hand function score(disabilities of arm,shoulder and hand,DASH)before and 1 year after operation.According to the presence of abnormal dynamic F-wave before operation,patients were divided into abnormal dynamic F-wave group and normal dynamic F-wave group.Fisher exact test was used to compare the percentage of the patient with improved DASH score in both patient groups after operation.Both DASH score and bilateral grip strength were analyzed by paired sample t test before and after operation.Results Before operation,eleven(11/36,30.6%)patients with HD had abnormal dynamic F-wave,and there was no significant difference of age(t=-0.849,P=0.412),duration(t=1.110,P=0.282),DASH scores(t=2.002,P=0.055)and handgrips(more-symptomatic side:t=-0.673,P=0.507;symptomatic side:t=-1.729,P=0.094)between the patients with or without preoperative dynamic F-wave abnormalities.One-year follow-up demonstrated that significantly greater number of the patients presented with reduced DASH scores in the patients with preoperative dynamic F-wave abnormalities(10/11,90.9% vs 12/25,48.0%;P=0.025).Compared with the patients without preoperative dynamic F-wave abnormalities,the patients with preoperative dynamic F-wave abnormalities showed reduced DASH scores after operation(t=2.347,P=0.041).Furthermore,abnormal dynamic F-waves disappeared soon after operation in ten patients(90.9%,10/11)with preoperative dynamic F-wave abnormalities,and DASH scores reduced significantly in these ten patients after operation(4.4±3.8 vs 1.5±0.4,t=3.094,P=0.013),and the DASH score in another patient whose dynamic F wave did not disappear after operation increased significantly one year after operation(preoperative vs.postoperative:6.66 vs 9.87).Conclusion Dynamic F-wave can be used as a preoperative evaluation method for HD to predict the recovery of upper limb function after operation.At the same time,the comparison of dynamic F-wave before and after operation is an effective and immediate method to evaluate the effectiveness of surgical treatment of HD.

18.
Chinese Journal of Orthopaedics ; (12): 466-473, 2019.
Article in Chinese | WPRIM | ID: wpr-745411

ABSTRACT

Objective To investigate the impact of the loss of attachment on the outcomes in Hirayama disease(HD)patients treated with anterior cervical discectomy and fusion(ACDF).Methods A total of 26 patients(23 males and 3 females)who were diagnosed as HD and received 2 levels of ACDF surgery from February 2014 to November 2016 were enrolled in the present study.All patients took the MRI at both flexion and neutral position pre-operation and MRI at flexion position post-operation.The measured parameters related to performance of "loss of attachment" include:the distances between the posterior edge of the spinal cord and the cervical spinal canal(x),the anterior and posterior wall of the cervical spinal canal(y),the anterior-posterior(a)and the transverse diameter(b)of spinal cord cross sections.The value of the cervical spinal cord deformation(flexion position a/b)and the cervical spinal cord forward movement(flexion position x/y-neutral position x/y)were calculated,and the centrums refer to the performance of "loss of attachment" were also recorded.DASH scores and grip strength on both sides were recorded before and 1 year after operation.The 26 patients were divided into two groups,17 patients(17/26,65.4%)in improvement group with the decreased DASH scores and the other 9 patients(9/26,34.6%)in no improvement group.Logistic regression and ROC curve were used to analyze the influence factor of anterior cervical discectomy and fusion(ACDF)surgery on patients with Hirayama disease.Results After surgery,the value of a/b significantly increased(t=4.27,P=0.001)and x/y significantly decreased(t=10.25,P=0.001).The performance of "loss of attachment" in 88.5%(23 of 26)patients disappeared after surgery,while the DASH score(P=0.06),and the grip strength of severe and mild side(P=0.36 and P=0.42)shew no obvious change.65.4%(17 of 26)patients shew a decrease in DASH scores after operation,the remaining 34.6%(9 of 26)patients shew no obvious change,several even with a mild increase.The segments refer to performance of "loss of attachment",the value of the cervical spinal cord de-formation and the cervical spinal cord forward movement shew a difference between the two group(t=-5.56,P=0.001;t=3.06,P=0.005;t=-3.76,P=0.001).The logistics regression analysis with the above three independent variable confirmed that the value of segments that refer to "loss of attachment" was the factor of the post-operative efficacy of ACDF surgery on patients with Hirayama disease(OR=6.963,P=0.001).And the ROC curve shew AUC=0.902,Jordan index=0.83,critical value=4.5.Conclusion The anterior cervical discectomy and fusion(ACDF)surgery can effectively improve the loss of attachment at the surgical segments,and prevent the progress of upper limb dyskinesia.And range of the longitudinal separation refers to "loss of attachment" can impact the outcomes of ACDF surgery,more segments for fusion may be need in order to improve the outcomes of those patients with the range more than 5 segments.

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Chinese Journal of Orthopaedics ; (12): 458-465, 2019.
Article in Chinese | WPRIM | ID: wpr-745410

ABSTRACT

Objective To establish Huashan diagnostic criteria and clinical classification system for Hirayama disease.Methods Retrospective analysis 359 cases of puberty onset,upper extremity muscle atrophy as main clinical manifestations,and complete clinical data from September 2007 to August 2018.There were 348 males and 11 females(31.6:1 male and female)in this group.The average age of onset was 16.7±2.2 years,the average age of visits was 19.2±4.5 years,and the average duration of treatment was 29.3±45.4 months.Descriptive study of the clinical manifestations,radiologic and neurophysiological findings of this group of patients,the Huashan clinical diagnostic criteria of Hirayama disease were established by including 100% of the clinical manifestations,imaging and neurophysiological findings.According to the following parameters,the clinical classification system of Hirayama disease was proposed.The parameters specifically included:the muscle atrophy involves the upper limbs,whether the quadriplegia was active or hyperactive,the Babinski sign positive and other pyramidal tract damage,whether it was accompanied by sensory dysfunction such as upper limb numbness,muscle atrophy location,and the progress of clinical symptoms or electrophysiological examination within 6 months.Thirty patients were randomly selected from the above 359 cases.Four orthopedic surgeons who were not involved in the classification system completed the clinical classification within the specified time.The Kappa value was used for the credibility evaluation.Results The Huashan diagnostic criteria of Hirayama disease included clinical manifestations,imaging examinations and neurophysiological examinations.The main diagnostic indicators were:1)occult onset puberty,more common in men;2)localized muscle atrophy and weakness in the upper extremities;3)compared with the cervical neutral MRI,the MRI of cervical flexion showed that spinal cord was significantly shift forward and the anterior spinal cord was narrowed or disappeared.4)MRI T2 weighting of the cervical flexion showed cyst-wall separation behind the spinal cord;5)Neurophysiological examination showed that the affected muscles were neurogenic damage.6)The affected parts are limited to the middle and lower neck segment.At the same time,it was necessary to combine imaging and neurophysiological manifestations to distinguish cervical spondylosis with upper limb muscle atrophy and motor neuron disease.According to the clinical characteristics of different patients,Hirayama disease can be divided into type I-III.Type I:72.1%,one-sided upper limb or one upper limb-based hand inner muscle and forearm muscle atrophy.According to whether progress of symptoms or electrophysiological examination was seen in the past 6 months,type I can be divided into:Ia.stable period.Regular follow-up assessment was recommended.If the disease progressed,to wear a cervical collar was suggested;surgery could be done if necessary;Ib.progression period,it was recommended to use a cervical collar,and regularly evaluate,if patients could not wear cervical collar for long,it was recommended to operate.Type II:14.2%,unilateral upper limb or one upper limb-based hand inner muscle and forearm muscle atrophy with pyramidal tract injury.Surgery was recommended.Type II:13.7%,atypical Hirayama disease,including upper limb proximal muscle atrophy,symmetrical double upper limb muscle atrophy,and sensory disturbances associated with upper limb numbness.Wear a cervical collar,and follow-up and assess closely,and choose surgical treatment if necessary.The credibility evaluation showed that the average Kappa value of the classification was 0.732(0.688-0.834),which is a basic credibility.Conclusion The Huashan diagnostic criteria of Hirayama disease was conducive to the early diagnosis.The clinical classification system of Hirayama disease has good credibility and good clinical intervention guidance value.

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Chinese Journal of Orthopaedics ; (12): 150-155, 2018.
Article in Chinese | WPRIM | ID: wpr-708520

ABSTRACT

Objective To investigate the mechanisms of sacroiliac joint pain after lumbar fusion surgery and to present the clinical outcomes after a combining intra-and peri-articular injection.Methods Totally 20 male and 15 female patients (48-75 years old) from January 2013 to December 2016 were retrospectively included in the present study.The patients were all with sustained low back and hip pain after prior posterior lumbar interbody fusion surgery.Nine cases were diagnosed with lumbar disc herniation,22 cases with lumbar stenosis,and 4 cases with degenerative lumbar spondylolisthesis.Ten cases were performed with single level fusion,16 cases with two level fusion,9 cases with 3 or more level fusion.Autogenous iliac bone graft was not applied in any of those patients.The pain of the patients was confirmed from the sacroiliac joint through specific symptoms and signs.They were divided into two groups and were treated with either standard intra-articular injection (17 cases) or a combine of intra-and peri-articular sacroiliac injection (18 cases).Peri-articular injection was conducted at 1 cm above the inferior margin of the sacroiliac joint.Recover ratios of visual analogue scale (VAS) and Oswestry disability index (ODI) at 2 weeks post-operatively were recorded and were compared between the two groups.Results No statistical difference was found in gender,fusion location,fusion levels,pre-operative VAS and ODI score between the two groups (P > 0.05).The combination of intra-and peri-articular sacroiliac injection showed significantly better results than the single intra-articular injection in VAS score immediately after injection (t=2.159,P=0.038),VAS score at 2 weeks after injection and ODI score at 2 weeks after the injection (t=2.705,P=0.011;t=2.156,P=0.039,respectively).Conclusion Both intra-and extra-sacroiliac joint diseases may lead to sacroiliac joint pain after lumbar fusion surgery.A single intra-articular sacroiliac injection could not provide optimistic outcomes.Further extra-articular injection is required at approximate 1 cm above the inferior margin of the sacroiliac joint.The technique combining intra-and peri-articular injection could guarantee improved early clinical outcomes.

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