Efficacy of full-endoscopic interlaminar and transforaminal discectomy for lumber disc herniation / Eficácia da discectomia interlaminar e transforaminal totalmente endoscópica na hérnia de disco lombar

ABSTRACT A previous study has reported the therapeutic effects of interlaminar/transforaminal approaches under full-endoscopic visualization to treat L5-S1 lumber disc herniation (LDH). However, the comparison of interlaminar/transforaminal approaches to treat other segments of LDH remains unclear. Objective: To evaluate the clinical efficacy of full-endoscopic interlaminar and transforaminal lumbar discectomy to treat LDH. Methods: A total of 93 patients with LDH who underwent fully-endoscopic lumbar interlaminar/transforaminal discectomy were retrospectively collected. Patients were divided into a Transforaminal group (n=41) and an Interlaminar group (n=52). Clinical efficacy was evaluated by visual analogue scale (VAS), the Oswestry disability index (ODI), and the modified MacNab scoring system. Results: Of the 93 patients, involving segments in LDH referred to L3-4, L4-5, and L5-S1. The fluoroscopy times in the Interlaminar group were smaller than that of the Transforaminal group. We found no obvious significances between the Transforaminal and Interlaminar groups regarding operation time, incision length, postoperative landing time, hospitalization, and incision healing time. Postoperative VAS and ODI scores notably improved at follow-up. Besides, almost 90% LDH patients achieved excellent/good outcomes. Conclusion: The full-endoscopic visualization technique via interlaminar and transforaminal approaches safely and effectively treat LDH. Level of Evidence III, Retrospective Study.

RESUMO Um estudo anterior relatou os efeitos terapêuticos das abordagens interlaminar/transforaminal sob visualização totalmente endoscópica para tratar a hérnia de disco lombar (HDL) L5-S1. No entanto, a comparação das abordagens interlaminar/transforaminal para o tratamento de outros segmentos de HDL permanece pouco clara. Objetivo: Avaliar a eficácia clínica da discectomia lombar interlaminar e transforaminal totalmente endoscópica no tratamento da HDL. Métodos: Foram recolhidos retrospetivamente 93 pacientes com HDL submetidos a discectomia lombar interlaminar/transforaminal totalmente endoscópica. Os pacientes foram divididos em um grupo transforaminal (n=41) e um grupo interlaminar (n=52). A eficácia clínica foi avaliada através da escala visual analógica (EVA), do índice Oswestry de incapacidade (ODI) e do sistema de pontuação de MacNab modificado. Resultados: Dos 93 pacientes, os segmentos envolvidos na HDL referiam-se a L3-4, L4-5 e L5-S1. Os tempos de fluoroscopia no grupo Interlaminar foram menores do que no grupo Transforaminal. Não encontramos significâncias óbvias entre os grupos Transforaminal e Interlaminar em relação ao tempo de operação, comprimento da incisão, tempo de pós-operatório, hospitalização e tempo de cicatrização da incisão. As pontuações EVA e ODI pós-operatórias melhoraram notavelmente no acompanhamento. Além disso, quase 90% dos pacientes com HDL obtiveram resultados excelentes/bons. Conclusão: A técnica de visualização totalmente endoscópica através de abordagens interlaminar e transforaminal trata a HDL de forma segura e eficaz. Nível de Evidência III, Estudo Retrospectivo.

Comparative analysis of clinical efficacy between posterior percutaneous endoscopic discectomy and anterior cervical discectomy and fusion in the treatment of cervical spondylotic radiculopathy / 中国骨伤

OBJECTIVE@#To explore the clinical efficacy of posterior percutaneous endoscopic discectomy(PPECD) in the treatment of cervical spondylotic radiculopathy.@*METHODS@#A total of 56 patiens with single segment cervical spondylotic radiculopathy from December 2017 to October 2020, were randomly divided into observation group and control group. In observation group, there were 16 males and 11 females, including 8 cases of C4,5, 13 cases of C5,6 and 6 cases of C6,7 performed posterior percutaneous endoscopic discectomy, aged from 34 to 61 years old with an average of (51.15±6.29) years old. In control group, there were 19 males and 10 females with single segment cervical spondylotic radiculopathy including 10 cases of C4,5, 14 cases of C5,6 and 5 cases of C6,7 performed anterior cervical discectomy and fusion, aged from 40 to 65 years old with an average of (53.24±5.31) years old. The operative time, intraoperative blood loss, postoperative time of lying in bed and length of postoperative hospital stay were recorded. Visual analogue scale(VAS) and neck disability index(NDI) were used to evaluate the clinical efficacy. Cervical plain films or MRIs, CTs were taken for re-visiting patients.@*RESULTS@#All patients were followed up more than 2 years. The observation group patients were followed up, the duration ranged from 24 to 42 months with an average of (30.48±4.91) months. The control group patients were followed up, the duration ranged from 25 to 47 months, with an average of (32.76±4.53) months. Compared with control group, operative time, intraoperative blood loss, postoperative time of lying in bed and length of postoperative hospital stay were decreased(P<0.05). Compared with pre-operation, VAS of neck and upper limb and NDI at the latest follow-up between two groups were significantly improved(P<0.05). Compared with control group, VAS of neck and upper limb at 1 day after operation in observation group were significantly reduced(P<0.05). There was no significant difference in VAS of neck and upper limb and NID at 1, 3 months and the latest follow-up after operation between two groups(P>0.05). In the observation group, one patient's deltoid muscle strength was weakened to grade 4 after operation, and returned to normal after 12 weeks of conservative treatment. In control group, there was 1 case of postoperative adjacent spondylosis with symptoms of spinal compression after 2 years operation, then underwent cervical artificial intervertebral disc replacement. And there was 1 case of dysphagia after operation in control group and improved after 1 year. There was no significant difference in incidence of complications between two groups.@*CONCLUSION@#PPECD has advantages of shortening operative time, decreasing intraoperative blood loss, reducing postoperative time of lying in bed and length of postoperative hospital stay. However, applicable age range of patients and long-term clinical efficacy needs further study.

Influential factors related to functional status after full-endoscopic lumbar discectomy / 北京大学学报(医学版)

OBJECTIVE@#To explore the influential factors associated with functional status of those patients who undertook a full-endoscopic lumbar discectomy operation.@*METHODS@#A prospective study was conducted. A total of 96 patients who undertook a full-endoscopic lumbar discectomy operation and met inclusive criteria were enrolled in the study. The postoperative follow-up was held 1 month, 3 months and 6 months after operation. The self-developed record file was used to collect the patient's information and medical history. Visual analogue scale (VAS) score, Oswestry disability index (ODI) score, Gene-ralised anxiety disorder-7 (GAD-7) scale score and patient health questionnaire-9 (PHQ-9) scale score were applied to measure pain intensity, functional status, anxiety status and depression status. Repeated measurement analysis of variance was used to explore the ODI score 1 month, 3 months and 6 months after operation. Multiple linear regression was recruited to illuminate the influential factors associated with functional status after the operation. Logistic regression was employed to explore the independent risk factors related to return to work 6 months after operation.@*RESULTS@#The postoperative functional status of the patients improved gradually. The functional status of the patients 1 month, 3 months and 6 months after operation were highly positively correlated with the current average pain intensity. The factors influencing the postoperative functional status of the patients were different according to the recovery stage. One month and 3 months after operation, the factors influencing the postoperative functional status were the current average pain intensity; 6 months after operation, the factors influencing the postoperative functional status included the current average pain intensity, preoperative average pain intensity, gender and educational level. The risk factors influencing return to work 6 months after operation included women, young age, preoperative depression status and high average pain intensity 3 months after operation.@*CONCLUSION@#It is feasible to treat chronic low back pain with full-endoscopic lumbar discectomy operation. In the process of postoperative functional status recovery, medical staffs should not only take analgesic mea-sures to reduce the pain intensity experienced by the patients, but also pay attention to the impact of psychosocial factors on the recovery. Women, young age, preoperative depression status, and high average pain intensity 3 months after operation may delay return to work after the operation.

A review of patients with dysphagia after anterior cervical discectomy and fusion / 中国实用护理杂志

Anterior cervical discectomy and fusion is one of the classic procedures for the treatment of cervical spondylosis, and dysphagia is a common perioperative complication of this procedure, which affects patients′ recovery to different degrees. This paper summarizes and analyzes the perioperative assessment and interventions in the care of patients with dysphagia after anterior cervical discectomy and fusion, aiming to improve clinical nursing staff′s attention to dysphagia in patients after anterior cervical discectomy and fusion, and provide scientific basis for the prevention and treatment of high-risk groups.

Effect of acupotomy on the fat infiltration degree of lumbar multifidus muscle in patients with lumbar disc herniation after percutaneous transforaminal endoscopic discectomy / 中国针灸

OBJECTIVE@#To observe the effect of acupotomy on the fat infiltration degree of lumbar multifidus muscle (LMM) in patients with lumbar disc herniation after percutaneous transforaminal endoscopic discectomy (PTED).@*METHODS@#A total of 104 patients with lumbar disc herniation treated with PTED were randomly divided into an observation group (52 cases, 3 cases dropped off) and a control group (52 cases, 4 cases dropped off). Patients of both groups received rehabilitation training of two weeks 48 h after PTED treatment. The observation group was treated with acupotomy (L3-L5 Jiaji [EX-B 2]) once within 24 h after PTED. In the two groups, the fat infiltration cross sectional area (CSA) of LMM was compared before and 6 months after PTED, the visual analogue scale (VAS) score and Oswestry disability index (ODI) score were observed before and 1, 6 months after PTED. The correlation between fat infiltration CSA of LMM in each segment and VAS score was analyzed.@*RESULTS@#Six months after PTED, the fat infiltration CSA of LMM in L4/L5 and the total L3-S1 segments of the observation group was lower than that before PTED (P<0.05), and the fat infiltration CSA of LMM in L4/L5 of the observation group was lower than the control group (P<0.01). One month after PTED, the ODI and VAS scores of the two groups were lower than those before PTED (P<0.01), and those in the observation group were lower than the control group (P<0.05). Six months after PTED, the ODI and VAS scores of the two groups were lower than those before PTED and 1 month after PTED (P<0.01), and those in the observation group were lower than the control group (P<0.01). There was a positive correlation between the fat infiltration CSA of LMM in the total L3-S1 segments and VAS scores in the two groups before PTED (r = 0.64, P<0.01). Six months after PTED, there was no correlation between the fat infiltration CSA of LMM in each segment and VAS scores in the two groups (P>0.05).@*CONCLUSION@#Acupotomy can improve the fat infiltration degree of LMM, pain symptoms and activities of daily living in patients with lumbar disc herniation after PTED.

Biomechanical Study on Contiguous Three-Level Cervical Hybrid Surgery and Anterior Cervical Discectomy and Fusion / 医用生物力学

Objective To compare the biomechanical effects of contiguous three-level cervical Hybrid surgery[anterior cervical discectomy and fusion (ACDF) + cervical disc arthroplasty ( CDA)] and three-level ACDF. Methods The finite element model of C1-T1 cervical-thoracic spine was developed based on CT data. Three models were simulated by the implantation of Prestige LP and Zero-P prostheses, including two Hybrid models (AFA, Prestige LP implanted at C3-4 and C5-6 segments and Zero-P implanted at C4-5 segment; FAF, Zero-P implanted at C3-4 and C5-6 segments and Prestige LP implanted at C4-5 segment) and three-level ACDF model(FFF). The changes in range of motion (ROM) of adjacent levels during flexion, extension, lateral bending and axial rotation, the overall ROM, as well as the intradiscal pressure ( IDP) and facet contact force ( FCF) of adjacent levels were compared. Results The ROM in adjacent levels and the overall ROM of the AFA modelwere closer to the intact model, and the maximum increases in the ROM of the adjacent levels for the FAF and FFF models were 15. 0% and 23. 4% , respectively. For AFA, FAF and FFF models, the maximum increases in the maximum IDP of adjacent levels were 19. 0% , 66. 7% , 147. 6% , and the maximum increases in FCF were 17. 4% , 55. 7% , 80. 1% , respectively. Conclusions This study provides biomechanical basis for three-level cervical Hybrid surgery in treating patients with the contiguous three-level cervical degenerative disc disease.

Evaluation of Fenestration and Discectomy for Prolapsed Lumbar Intervertebral Disc by Minimally Invasive Procedure

Background: Prolapsed lumbar intervertebral disc is one of the most common problems encountered in medical practice. In orthopaedic practice patients having lesions of lumbosacral region causing low back pain with sciatica are not uncommon since the begdatainning of recorded history. To evaluate the fenestration and discectomy for prolapsed lumbar intervertebral disc by minimally invasive procedure.Material & Methods:This prospective observational study was conducted at National Institute of Traumatology and Orthopaedic Rehabilitation (NITOR), Dhaka, Bangladesh during July 2015 to June 2017. A total of 31 patients with prolapsed lumbar intervertebral disc were included for the study. A 3cm incision was made in midline on back centering the desired space of the spine. The analysis was done according to the standard statistical analysis system. Prior to commencement of this study, the research protocol was approved by the Institutional Review Board of ethics of National Institute of Traumatology and Orthopaedic Rehabilitation (NITOR).Results:Mean age was (35.98 ± 8.50) years with the range from 17 to 50 years. Out of 31 patients, 26 (83.87%) patients were male and 05(16.12%) were female. Out of 31 patients 01(03.22 %) had prolapse at the level of L3-L4, 23(74.19%) had at the level of L4-L5 and 07(22.58%) had at the level of L5-S1. In this series the most common causes of muscle weakness in EHL. Out of 31 patients, 22 (70.96 %) patients had weakness in EHL. 08 (25.80%) cases had weakness in FHL and both muscle weakness in 01 (3.22%). Out of 31 patients, 30 (96.78%) patients had preoperative sensory deficit and 03(09.67%) patients had postoperative sensory deficit, which is statistically significant. In preoperative period, moderate pain in 27(83.87%) patients, severe pain in 04(12.90%) patients. In postoperative period had no pain in 22(70.96%) patients, mild pain was noted in 08(25.08%) patients, moderate pain in 01(03.22%) patient. 20(64.51%) patients had para spinal muscle spasm in the preoperative period. Postoperative mean SLR was 81.94 ± 4.774 degree and range was 70?-90?, which was significantly improved. 29 (93.54%) patients had normal spine movement and 02 (06.45%) patients had restricted movement after 3 months of follow up. The minimum period of duration for follow up was 3 months and maximum duration of follow up was 12 months..Conclusions:By considering all aspects fenestration and discectomy is a better technique in the context of our country with the advantage of less tissue injury, good spinal function, smooth patient recovery, improve working status with early rehabilitation and maintain clinical efficacy.

Prone spine surgery in a morbidly obese patient: Anesthesia challenges and management

India is seeing a rapid epidemiological transition from underweight to overweight, with an overall prevalence of obesity reported to be 40.3%. Anesthesiology concerns in an obese patient are well known. We elaborate on the anesthesia management in a 68-year-old male patient with a body mass index of 66.3 kg/m2 who underwent spine surgery in prone position. Challenges faced ranged from the size of the table to the difficult airway, difficulty in positioning, maintenance of airway and ventilation, maintaining a free abdomen, and anesthesia management with meticulous use of anesthetic drugs for an uneventful recovery.

Pain intensity and functional status 30 days after surgery: difference between transforaminal and interlaminar percutaneous endoscopiclumbar discectomies / Intensidade da dor e estado de funcionalidade aos 30 dias de pós-operatório: diferença entre a discectomia endoscópica lombar percutânea transforaminal e interlaminar / Intensidad del dolor y estado funcional a los 30 días del procedimiento quirúrgico: diferencia entre discectomía endoscópica lumbarpercutánea transforaminal e interlaminar

ABSTRACT Objective: To compare the differences between transforaminal and interlaminar endoscopic approaches in terms of pain intensity and functionality 30 days after the surgical procedure. Methods: A retrospective cohort study, with patients treated by percutaneous interlaminar or transforaminal endoscopic discectomy at the Spine Service of the ISCMPA, in southern Brazil. Data were collected from the patients' electronic medical records by two independent physicians. The clinical outcomes of pain intensity and lumbar functionality were evaluated, respectively, using the visual analogue scale and the Oswestry Disability Index. Results: Thirty-six patients were included in the study, with a mean age of 50.8 ± 15.3 years, 19 (52.8%) of whom were males. As for the clinical outcomes for both transforaminal and interlaminar percutaneous endoscopic approaches, we observed a statistically significant reduction in pain intensity (mean difference of 3.5 points, p < 0.001) and a statistically significant improvement in functionality (mean difference of 33.2 points, p < 0.001) when we compared the pre- and 30-day postoperative periods, with no significant differences in terms of approaches. The type of technical approach also differed in relation to the patients' age, the location, type, and migration of the herniated disc, and the patient's time in the operating room. Conclusion: There was a similar effect on pain reduction and restoration of lumbar functions, 30 days after percutaneous endoscopic discectomy, in both technical approaches, with no significant differences between them. Level of Evidence III; Retrospective comparative study.

RESUMO Objetivo: Comparar as diferenças entre as abordagens endoscópicas transforaminal e interlaminar quanto à intensidade da dor e a funcionalidade 30 dias depois do procedimento cirúrgico. Métodos: Estudo de coorte retrospectivo, com pacientes tratados por discectomia endoscópica percutânea interlaminar ou transforaminal, em acompanhamento no Serviço de Coluna da ISCMPA, sul do Brasil. Os dados foram coletados do prontuário eletrônico dos pacientes por dois médicos independentes. Os desfechos clínicos de intensidade de dor e funcionalidade lombar foram avaliados, respectivamente, pela pontuação da escala visual analógica e do Oswestry Disability Index. Resultados: Trinta e seis pacientes foram incluídos no estudo; a média de idade foi 50,8 ± 15,3 anos, sendo 19 (52,8%), do sexo masculino. Quanto aos desfechos clínicos, observou-se diferença estatisticamente significativa para as abordagens endoscópicas percutânea transforaminal e interlaminar na redução da intensidade da dor (média da diferença 3,5 pontos, p < 0,001) e na melhora da funcionalidade (média da diferença 33,2 pontos, p < 0,001) quando comparados os momentos pré e em 30 dias pós-operatórios, sem diferença significativa com relação às abordagens. O tipo de abordagem técnica diferiu também com relação à idade dos pacientes, à localização, ao tipo e à migração da hérnia de disco e ao tempo do paciente em sala cirúrgica. Conclusões: Observou-se efeito semelhante na redução da dor e na restauração das funções lombares, 30 dias depois da discectomia endoscópica percutânea, em ambas as abordagens técnicas, sem diferenças significativas entre si. Nível de Evidência III;Retrospectivo comparativo.

RESUMEN Objetivos: Comparar las diferencias entre los abordajes endoscópicos transforaminal e interlaminar en cuanto a la intensidad y funcionalidad del dolor a los 30 días del procedimiento quirúrgico. Métodos: Estudio de cohorte retrospectivo, con pacientes tratados por discectomía endoscópica percutánea interlaminar o transforaminal, en acompañamiento en el Servicio de Columna - ISCMPA, sur de Brasil. Los datos fueron recopilados de las historias clínicas electrónicas de los pacientes por dos médicos independientes. Los resultados clínicos de la intensidad del dolor y la funcionalidad lumbar se evaluaron, respectivamente, utilizando la escala visual analógica y el Oswestry Disability Index. Resultados: Se incluyeron en el estudio 36 pacientes, con una edad promedio de 50,8 ± 15,3 años, 19 (52,8%) varones. En cuanto a los resultados clínicos, se observó una diferencia estadísticamente significativa para los enfoques endoscópicos percutáneos transforaminal e interlaminar en la reducción de la intensidad del dolor (diferencia media 3,5 puntos, p <0,001) y en la mejora de la funcionalidad (diferencia media 33,2 puntos, p <0,001) al comparar los períodos preoperatorios y postoperatorios a los 30 días, sin diferencia significativa en cuanto a los enfoques. El tipo de enfoque técnico también difirió con respecto a la edad de los pacientes, la ubicación, el tipo y la migración de la hernia de disco, y el tiempo del paciente en el quirófano. Conclusiones: Hubo un efecto similar en la reducción del dolor y la restauración de las funciones lumbares, 30 días después de la discectomía endoscópica percutánea, en ambos enfoques técnicos, sin diferencias significativas entre ellos. Nivel de Evidencia III; Estudio retrospectivo comparativo.

Analysis of the effect and influencing factors of different surgical methods in the treatment of multi-level cervical spondylotic myelopathy / 中国综合临床

Objective:To explore the use of anterior cervical corpectomy and fusion (ACCF) combined with anterior cervical discectomy and fusion (ACDF) in patients with multilevel cervical spondylopathy myelopathy (CSM).Methods:The clinical data of 83 patients with multi-segment CSM admitted to the Department of Spinal Surgery of Hubei Liuqi2 Orthopaedic Hospital of Integrated Traditional Chinese and Western Medicine from January 2018 to January 2021 were retrospectively analyzed. According to the different surgical methods used in their treatment, they were divided into group A and group B. In group A, 44 patients were treated with anterior cervical ACCF combined with ACDF, and 39 patients in group B were treated with posterior single-door laminoplasty. The general clinical indexes such as operation time, perioperative bleeding volume and hospitalization time were collected.The neurological function and cervical dysfunction improvement effect of the patients before and 6 months after operation were evaluated by using the Japanese Orthopaedic Association (JOA) score and neck disability index (NDI) scale. The cervical curvature of the patients before and 6 months after operation was compared, The complications of the two groups were observed 6 months after operation. The patients were divided into improved group (72 cases) and non improved group (11 cases). Comparison between count data groups χ 2 inspection. Independent sample t-test was used for comparison between measurement data groups conforming to normal distribution. According to the results of univariate analysis, the meaningful factors were included in the binary Logistic regression to analyze the influencing factors related to the surgical efficacy. Result:The perioperative blood loss ((153.36±10.68) mL) and hospital stay ((10.11±2.30) d) in group A were lower than those in group B ((171.47±11.32) mL, (15.58±3.76) d). There were significant differences between the two groups ( t values were 7.50 and 8.10; both P<0.001). Six months after operation, the JOA score (13.70±1.49, 12.94±1.63) and cervical curvature (22.10±3.23, 13.38±3.12) of patients in groups A and B were all higher than those before operation (9.40±1.32, 9.36±1.51; 11.16±2.60, 11.23±2.71), and group A was higher than group B, the difference was statistically significant (JOA scores before and after operation: t values were 14.33 and 10.07, respectively; cervical curvature: t values were 17.50 and 3.25, respectively; t values between groups were 2.22 and 12.47, respectively, and the P values were <0.001, <0.001, <0.001, 0.002, 0.029 and <0.001, respectively). Six months after the operation, the NDI indexes of groups A and B (11.38±4.76, 14.79±4.85) were lower than those before the operation (39.56±9.43, 39.74±9.51), and those in group A were lower than in group B, and the difference was statistically significant ( t values were 17.70, 14.60, and 3.23; all P<0.001). Binary Logistic regression showed that the duration of disease ≥6 months ( OR=59.045, 95% CI: 6.485-537.629), the presence of cervical spinal cord MRI signal changes ( OR=0.031, 95% CI: 0.002-0.587), the surgical approach (posterior approach single-door laminoplasty) ( OR=6.300, 95% CI: 1.269-31.273) was an independent risk factor affecting the surgical outcome ( P values were <0.001, 0.021, and 0.024, respectively). Conclusion:Anterior cervical ACCF combined with ACDF has an ideal surgical effect in the treatment of patients with multi-segment CSM, which can significantly improve the cervical spinal nerve function and cervical curvature, shorten the operation time and reduce the perioperative blood loss. It isstill necessary to pay attention to the patient's disease course, MRI signals changes of cervical spinal cord and the effect of surgical methods on their surgical outcomes.

Effect of iliac crest on L5-S1 transforaminal puncture and catheterization evaluated by CT scan and 3D reconstruction / 西安交通大学学报(医学版)

【Objective】 To analyze the effect of iliac crest on the difficulty of L5-S1 transforaminal puncture and catheterization by using CT images and oblique sagittal reconstruction images. 【Methods】 We made a retrospective analysis of the CT images and oblique sagittal reconstruction images of the adults aged from 30 to 50 years who underwent abdominopelvic CT examination in Affiliated Hospital of Nantong University. Based on the feasibility of puncture and catheterization， all the subjects were divided into two groups： group Ⅰ （suitable for puncture and catheterization） and group Ⅱ （unsuitable for puncture and catheterization）. We compared and analyzed differences in the rostral puncture inclination angle （α）， the abaxial angle of iliac crest （β）， the distance between the highest iliac crests （a）， the distance between sacroiliac joints （b）， the height of the superior articular process of sacral （c）， the height of iliac crest （d）， and the height of the superior articular process of sacral （c’） in the oblique sagittal images between the two groups. We explored the effect of anatomical indexes and iliac crests in oblique sagittal images on puncture and catheterization. 【Results】 The number of high/low iliac crests for group Ⅰ and group Ⅱ was （117/58 vs. 63/0）， and the number of men/women was 64/111 vs. 56/7， respectively. Variables α， b and c were higher in group Ⅰ than in group Ⅱ （34.77±4.86 vs. 31.11±5.16， P<0.001； 137.19±19.24 vs. 128.56±20.73， P = 0.003； 14.34±2.38 vs. 13.02±2.68， P<0.001）， and d was lower than that in group Ⅱ （27.51±6.73 vs. 37.65±6.35， P<0.001）. In addition， no statistically significant difference was found in the height of c of coronal CT scan and c’ of oblique sagittal reconstruction images （13.99±2.53 vs. 13.93±2.40， P = 0.465）. 【Conclusion】 It is more comprehensive and effective to evaluate preoperatively the influence of iliac crest on L5-S1 puncture and catheterization of TF-PELD by using CT scan and CT 3D reconstruction oblique sagittal images. The key factors in the evaluation of iliac crest are the degree of “cohesion” and the height. It is more easily to successfully puncture and catheterize when the shape of iliac crest is wider and lower. Therefore， it has higher probability to successfully puncture and catheterize in women.

Anesthetic effect of ultrasound-guided retrolaminar block during percutaneous transforaminal lumbar spine endoscopic surgery / 西安交通大学学报(医学版)

【Objective】 To compare the anesthestic effects of ultrasound-guided retrolaminal block （RLB） and local anesthesia during posterior approach vertebral surgery. 【Methods】 Forty patients （ASA physical status Ⅰ or Ⅱ） scheduled for transforaminal lumbar spine endoscopic surgery were recruited and randomly divided into two groups （n=20）： RLB group and local anesthesia group （Group C）. RLB group received the ultrasound-guided retrolaminar block using parasagittal in plane method by an anesthesiologist while Group C received layer-by-layer local infiltration anesthesia according to the operation location； 0.5% ropivacaine of 20 mL was used in the two groups. We recorded visual analogue score （VAS） and Ramsay sedation score at admission （T0）， during skin incision （T1）， puncture （T2）， foraminoplasty （T3）， nerve root decompression （T4） and suture （T5）. We also recorded remedial analgesia rate， scores of the patients’ satisfaction and the intraoperative occurrence of side effects （respiratory depression， tachycardia and hypertension）. The patients were followed up. Their functional status was assessed by the Oswestry Disability Index （ODI） score before surgery and three months after surgery. 【Results】 Compared with Group C， RLB group had significantly decreased visual analogue score at T2-4 and lower remedial analgesia rate （P<0.05）. The patients’ satisfaction was higher in group RLB than in Group C （P<0.05）. The intraoperative occurrence of hypertension and tachycardia were significantly lower in RLB group than in Group C （P<0.05）. ODI score was significantly decreased three months after surgery in both groups （P<0.05）， but it did not differ significantly between the two groups （P>0.05）. 【Conclusion】 Ultrasound-guided RLB can provide satisfactory analgesia with greater safety when trasforaminal endoscopic surgery is used.

Risk factors of hidden blood loss during percutaneous endoscopic interlaminar discectomy / 西安交通大学学报(医学版)

【Objective】 To explore the relationship between hidden blood loss （HBL） and risk factors in percutaneous endoscopic interlaminar discectomy （PEID）. 【Methods】 We retrospectively analyzed 113 patients （67 males and 46 females， aged 21-71 years old） with lumbar disc herniation （L5-S1 level） who underwent PEID with complete clinical data in the Department of Spinal Surgery of Subei People’s Hospital Affiliated to Yangzhou University from January 2018 to August 2020. The collected data included general patient indicators （age， body mass index and gender）， underlying diseases （hypertension and diabetes）， laboratory tests （prothrombin time， activated partial thromboplastin time， fibrinogen， hematocrit and hemoglobin level）， imaging related parameters （grade of intervertebral disc degeneration， interlaminar space height and soft tissue thickness of interlaminar approach）， intraoperative significant blood loss and operation time. According to the Gross formula， total blood loss and HBL during operation were calculated. And the risk factors of HBL was analyzed. 【Results】 The total perioperative blood loss was （394.85±130.50） mL， and HBL was （337.09±124.98） mL which accounted for 85.4% of the total blood loss. Multivariate linear regression analysis showed that operation time （P<0.001） and disc degeneration grade （P=0.020） were independent risk factors of HBL. 【Conclusion】 HBL is the main cause of blood loss during PEID， and operation time and disc degeneration grade are independent risk factors that affect the amount of HBL.

Perioperative blood loss in different approaches by percutaneous endoscopic discectomy / 西安交通大学学报(医学版)

【Objective】 To compare the perioperative blood loss between interlaminar and transforaminal approaches by percutaneous endoscopic discectomy in order to provide more reference for guiding the proper choice of surgical methods clinically. 【Methods】 We retrospectively analyzed the clinical data of 160 patients who underwent percutaneous endoscopic lumbar discectomy from June 2019 to November 2020， with 80 patients in interlaminar approach group and 80 in transforaminal approach group. The blood loss was calculated according to Gross formula. 【Results】 The perioperative total blood loss （mL）， hidden blood loss （mL） and hemoglobin loss （g/L） were significantly lower in interlaminar approach group than in transforaminal approach group （119.73±179.26 vs. 158.6±190.65， 109.73±179.53 vs. 148.78±190.19， 3.76±8.12 vs. 4.31±7.62） （P<0.05）. However， there was no significant difference in visible blood loss between the two groups. 【Conclusion】 The perioperative hidden blood loss accounts for a large proportion in percutaneous endoscopic lumbar discectomy. In addition， the interlaminar approach causes less blood loss than the transforaminal approach.

Clinical observation of selective nerve block combined with percutaneous posterior endoscopic cervical discectomy in the treatment of cervical spondylotic radiculopathy / 西安交通大学学报(医学版)

【Objective】 To observe the short-term clinical effect of selective nerve block combined with percutaneous posterior endoscopic cervical discectomy （PPECD） in the treatment of cervical spondylotic radiculopathy. 【Methods】 We reviewed 22 patients who received selective nerve block combined with percutaneous posterior endoscopic cervical discectomy （PPECD） for cervical spondylotic radiculopathy from June 2018 to January 2020. We recorded Japanese Orthopaedic Association （JOA） score for treatment evaluation， visual analogue scale （VAS）， the neck disability index score （NDI） preoperative 1 day， postoperative 1 day， 1 month， 3 months， 6 months and 1 year. All data were imported into SPSS26.0 software for analysis and processing. Quantitative data are expressed as mean ± standard deviation. The scores of neck VAS， arm VAS， JOA and NDI were compared at different time points by repeated measurement analysis of variance. Paired t-test was used to compare each time point after operation and the first day before operation. P<0.05 was considered statistically significant， and the modified MacNab standard was used to evaluate the clinical effect at the last follow-up. 【Results】 All operations were successfully completed under ultrasound-guided selective nerve block combined with endoscopic operation. The average operation time was 125.6 minutes. The intraoperative blood loss was 2-100 mL and the average blood loss was 19.1 mL. All patients were followed up for 15-33 months， with an average follow-up of 24.1 months. No patients had spinal cord， nerve root and vascular injury， dural tear or other complications. Compared with the preoperative VAS score， the VAS score of neck and upper arm decreased significantly （P<0.05）， while the JOA score increased significantly （P<0.05）， and the preoperative NDI score decreased significantly （P<0.05）. At the last follow-up， the modified Macnab criteria showed there were 15 excellent cases， 5 good cases， 2 medium cases and 0 poor case. The excellence rate was 91%. Postoperative magnetic resonance imaging and 3D computed tomography reconstruction of the cervical spine showed that the disc had been fully removed and the nerve root compression at the surgical segment was relieved. 【Conclusion】 Ultrasound-guided selective nerve block combined with percutaneous posterior endoscopic cervical discectomy is a safe and effective minimally invasive surgical method for the treatment of cervical spondylotic radiculopathy with reliable short-term efficacy.

Comparison of the efficacy of unilateral biportal endoscopic and microscopic discectomy in treatment of lumbar disc herniation / 西安交通大学学报(医学版)

【Objective】 To compare the clinical efficacy of unilateral biportal endoscopic （UBE） and microscopic discectomy in the treatment of lumbar disc herniation （LDH） and to explore the safety and effectiveness of this operation. 【Methods】 A total of 87 LDH patients from July 2018 to July 2021 were analyzed retrospectively， including 42 cases of unilateral biportal endoscopic discectomy and 45 cases of microscopic discectomy. Analysis was based on comparison of perioperative metrics， operation time， and estimated blood loss. Clinical outcomes were evaluated using visual analogue scale （VAS）， Oswestry disability index （ODI） and modified Macnab criterion. 【Results】 All patients were followed up for 13.3±1.18 months. In UBE group， operation time （57.12±6.35） min was shorter than that in the microscope group （62.21±7.09） min and estimated blood loss （29.31±3.62） mL was smaller than that in the microscope group （51.77±8.43） mL， with a significant difference （P0.05）. Dural sac tear occurred in 2 cases in UBE group and 3 cases in the microscope group； the incidence was not statistically significant （P>0.05）. Modified MacNab criterion evaluation at the last follow-up showed that 32 cases were excellent in UBE group， 7 cases were good， and 3 cases were fair， with the excellent and good rate of 92.9% （39/42）. The microscope group was excellent in 31 cases， good in 10 cases， and fair in 4 cases， with the excellent and good rate of 91.1% （41/45）. 【Conclusion】 UBE for LDH has a satisfactory short-term clinical efficacy， with the advantages of less trauma， greater efficiency， clear vision， and large operating space. Both UBE and microscopic discectomy can achieve good clinical results in treating LDH， but the former has the advantages of less trauma， high efficiency， and quick postoperative recovery.

Buckling of the Ligamentum Flavum as a Rare Complication of Anterior Cervical Corpectomy and Fusion: A Case Report

Introduction and Importance Neurological deterioration due to buckling of the ligamentum flavum (LF) is an uncommon complication after anterior cervical corpectomy or discectomy with fusion. Case Presentation In this report, we present the case of a 66-year-old male who underwent anterior cervical partial corpectomy of C5 and discectomy of prolapsed C5- C6 with fusion. Postsurgery, the patient displayed signs of neurological deterioration. Upon immediate cervical magnetic resonance imaging (MRI), posterior canal stenosis and severe compression with cord signal due to LF buckling were detected. A posterior laminectomy procedure and canal decompression at the C5-C6 level with bone fusion were performed. Clinical Discussion Patient presented with walking difficulty, then walking disability, followed by bilateral upper and lower limb paresthesia with burning sensation. Examination showed ⅘ muscle strength in both handgrips. Further investigation showed brisk deep tendon reflexes, positive Hoffman sign unilaterally, equivocal Babinski sign, and progressive quadriparesis. Magnetic resonance imaging showed mild and diffuse building of some cervical discs, with spinal cord progression. We performed an anterior cervical corpectomy and fusion (ACCF) and anterior cervical discectomy and fusion (ACDF); a titanium mesh with plates and screws was used for fusion, with removal of a calcified and herniated subligamentous disc. Postoperatively, upper and lower limb strength deteriorated; immediate cervical and thoracic MRI showed LF buckling, which caused canal stenosis and severe compression. Urgent posterior laminectomy and canal decompression with bone fusion was scheduled on the same day. The patient underwent physiotherapy and regained upper and lower limb strength and his ability to walk. Conclusion This indicates the possibility of neurological deterioration as a result of LF buckling, whichmay be a result of LF thickening accompanied by hyperextension in the cervical region. In this regard, immediate imaging following signs of neurological complications after anterior cervical corpectomy or discectomy warrants early detection, which results in a better prognosis.

The use of dexmedetomidine in puncture techniques for degenerative diseases of the lumbar spine / Uso de dexmedetomidina em técnicas de punção para doenças degenerativas da coluna lombar / Uso de dexmedetomidina en técnicas de punción para enfermedades degenerativas de la columna lumbar

ABSTRACT Objective To analyze the results of the use of dexmedetomidine (D) in the treatment of patients with degenerative diseases of the lumbar spine using puncture techniques. Methods The study included 77 patients who underwent surgical puncture for degenerative diseases of the lumbar spine with the use of alpha-2-adrenomimetic D: percutaneous laser denervation of the facet joints (n = 46) and posterolateral transforaminal endoscopic discectomy (n = 31). We assessed: the level of sedation using the Ramsay Sedation Scale (RSS) and the Richmond Agitation Sedation Scale (RASS); intraoperative dynamics of the cardiovascular and respiratory system parameters; the level of pain syndrome according to VAS. Results A high intraoperative level of sedation was determined, with RASS -2, -3 and Ramsay III, IV; when transferring a patient to a department (in 90 minutes) this parameter was RASS 0 and Ramsay II. There were no significant changes in central hemodynamics and respiratory depression. The minimum level of pain was determined immediately after surgery, at 30 and 60 minutes after surgery, and before transfer to the department (90 minutes): 6 (4;9); 10 (8;12); 12 (9;13); 16 (13;19) respectively. The absence of the need for additional analgesia on the first postoperative day was verified. Conclusion The use of D significantly reduces the level of pain, while maintaining the necessary verbal contact with the patient, and provides the necessary neurovegetative protection without respiratory depression or lowered hemodynamic parameters during the perioperative period. Level of evidence II; Prognostic Studies - Investigating the Effect of a Patient Characteristic on Disease Outcome. Case series, retrospective study.

RESUMO Objetivo Analisar os resultados do uso de dexmedetomidina (D) no tratamento de pacientes com doenças degenerativas da coluna lombar com técnicas de punção. Métodos O estudo incluiu 77 pacientes submetidos à punção cirúrgica em doenças degenerativas da coluna lombar com o uso de um agonista alfa-2 adrenérgico: denervação percutânea das articulações facetárias com laser (n = 46) e discectomia endoscópica transforaminal posterolateral (n = 31). Foram avaliados o nível de sedação usando a Escala de Sedação de Ramsay (RSS) e a Escala de Sedação e Agitação de Richmond (RASS); a dinâmica intraoperatória dos parâmetros dos sistemas cardiovascular e respiratório; o nível de síndrome de dor de acordo com a EVA. Resultados Determinou-se um alto nível intraoperatório de sedação pela RASS (-2, -3) e pela Ramsay (III, IV). Ao transferir um paciente para outro setor (depois de 90 minutos), esse parâmetro era 0 em RASS e II em Ramsay. Não houve alterações significativas na hemodinâmica central e na depressão respiratória. O nível mínimo de dor foi determinado imediatamente após a cirurgia, 30 e 60 minutos depois da cirurgia e antes da transferência para o outro setor (90 minutos depois): 6 (4; 9); 10 (8; 12); 12 (9; 13); 16 (13; 19), respectivamente. Constatou-se que não era necessária analgesia adicional no primeiro dia pós-operatório. Conclusões O uso de D reduz significativamente o nível de dor mantendo a comunicação verbal necessária com o paciente e fornece a proteção neurovegetativa necessária sem depressão respiratória e os parâmetros hemodinâmicos reduzidos durante o período perioperatório. Nível de evidência II; Estudos prognósticos - Investigação do efeito de característica de um paciente sobre o desfecho da doença. Série de casos, Estudo retrospectivo.

RESUMEN Objetivo Analizar los resultados del uso de dexmedetomidina (D) en el tratamiento de pacientes con enfermedades degenerativas de la columna lumbar con técnicas de punción. Métodos El estudio incluyó a 77 pacientes con enfermedades degenerativas de la columna lumbar que se sometieron a punción quirúrgica mediante el uso de un agonista adrenérgico alfa-2: denervación percutánea de las articulaciones facetarias con láser (n = 46) y discectomía endoscópica transforaminal posterolateral (n = 31). Fueron evaluados el nivel de sedación mediante la Escala de Sedación de Ramsay (RSS) y la Escala de Sedación y Agitación de Richmond (RASS); la dinámica intraoperatoria de los parámetros de los sistemas cardiovascular y respiratorio; el nivel del síndrome de dolor según la EVA. Resultados Se determinó un alto nivel de sedación intraoperatoria en RASS (-2, -3) y por Ramsay (III, IV)Al transferir un paciente a otro sector (después de 90 minutos), este parámetro fue 0 en RASS y II en Ramsay. No hubo cambios significativos en la hemodinámica central y la depresión respiratoria.El nivel mínimo de dolor se determinó después de la cirugía, 30 y 60 minutos después de la cirugía y antes del traslado al otro sector (90 minutos después): 6 (4; 9); 10 (8; 12); 12 (9; 13); 16 (13; 19), respectivamente. Se verificó que no era necesaria analgesia adicional el primer día postoperatorio. Conclusiones El uso de D reduce significativamente el nivel de dolor al mismo tiempo que se mantiene la necesaria comunicación verbal con el paciente y brinda la protección neurovegetativa necesaria sin depresión respiratoria y parámetros hemodinámico reducidos durante el período perioperatorio. Nivel de evidencia II; Estudios de pronóstico: Investigación del efecto de la característica de un paciente sobre el desenlace de la enfermedad. Serie de casos, Estudio retrospectivo.

Análisis biomecánico de la ligamentoplastía interespinosa con fibra de poliéster posterior a discectomía / Biomechanical analysis of interespinous ligamentoplasty with polyester fiber after discectomy

Resumen: Introducción: Existen diferentes patologías de la columna lumbar que condicionan una inestabilidad biomecánica y clínica para su tratamiento, se han efectuado diversas técnicas de estabilización que tratan de preservar el movimiento y la transmisión de carga del segmento afecto como la ligamentoplastía interespinosa con fibra Dallos®. Objetivo: Mostrar las variaciones biomecánicas de segmento funcional de columna lumbar de porcino, antes y después de realizar la discetomía y ligamentoplastía con fibra Dallos®. Material y métodos: El segmento lumbar se montó en un simulador multiaxial servo-hidráulico. Se simularon rangos de movilidad de flexión, extensión, flexiones laterales y rotaciones axiales en tres condiciones: 1) segmento natural; 2) segmento discectomizado; y 3) segmento disectomizado más ligamentoplastía con fibra Dallos®. Los rangos de movilidad se realizan hasta un torque de 7.5 N-m. La data de los torques y rangos de movilidad se recolectó en el programa del simulador y se graficaron los resultados de los cambios biomecánicos entre las tres condiciones descritas. Resultados: Se demostró que la biomecánica lumbar es afectada después de la discectomía principalmente en la flexión y la extensión. En los movimientos de flexión y rotación axial izquierdas, se comprobó una alteración del torque y los rangos de movilidad. Conclusiones: La ligamentoplastía recupera parte de la estabilidad perdida postdiscectomía, preservando parte de la altura discal sin llegar a igualar los movimientos como en el segmento natural. Posterior a la discectomía, la distribución de la fuerza sugiere que la inestabilidad residual con ligamento plastía puede representar sobrecarga facetaria.

Abstract: Introduction: There are different pathologies of the lumbar spine that condition a biomechanical and clinical instability for its treatment, various stabilization techniques have been carried out that try to preserve the movement and the transmission of load of the affected segment such as the interspinatus ligamentplasty with Dallos® fiber. Objective: To show the biomechanical variations of functional segment of lumbar spine of pigs, before and after performing the discectomy and ligamentoplasty with Dallos® fiber. Material and methods: The lumbar segment was mounted in a servo-hydraulic multiaxial simulator. Mobility ranges of flexion, extension, lateral flexion and axial rotations were simulated under three conditions: 1. Natural segment, 2. Discectomy segment, and 3. Disectomized segment plus ligamentoplasty with Dallos® fiber. The mobility ranges are made up to a torque of 7.5 N-m The data of the torques and mobility ranges was collected in the simulator program and the results of the biomechanical changes between the three conditions described were plotted. Results: It was shown that lumbar biomechanics is affected after discectomy mainly in flexion and extension. In the left axial bending and rotation movements, an alteration of torque and mobility ranges was found. Conclusions: The ligamentoplasty recovers part of the stability lost after discectomy preserving part of the disc height without reaching to equalize the movements as in the natural segment. After discectomy the distribution of force suggests that residual instability with ligament plasty may represent facet overload.

Analysis of surgical strategy of percutaneous endoscopic lumbar discectomy in young and middle-aged double-segment patients with lumbar disc herniation / 北京大学学报(医学版)

OBJECTIVE@#To investigate clinical efficacy and safety of single and double segmental percutaneous lumbar discectomy for young and middle-aged patients with double-segment disc herniation.@*METHODS@#Retrospective analysis was undertaken for 32 young and middle-aged patients with percutaneous endoscopic lumbar discectomy (PELD) in the treatment of double-segment lumbar disc herniation from January 2015 to October 2018 in Peking University First Hospital. In the study, 18 cases were treated with single-segment treatment and 14 cases with double-segment treatment. Visual analogue score (VAS) and oswestry disability index (ODI) assessment were used to compare clinical symptom outcomes before surgery, 3 months after surgery and at the last follow-up. Macnab criteria were used to assess the patients' overall satisfaction after surgery. Imaging parameters included lumbar lordosis, intervertebral height at each segment and endplate angle of lesion segment on the X-ray. And Michigan State University(MSU) rating and Pfirrmann scoring system were used to evaluate the grade of disc herniation and disc degeneration respectively on magnetic resonance imaging (MRI). The perioperative parameters included the surgeon, anesthesia method, operation time, postoperative hospital stay, postoperative bracing time and perioperative complications.@*RESULTS@#The mean follow-up time was (26.78±10.64) months. There was no significant difference in the follow-up time and baseline information between the two groups(P > 0.05). ODI scores 3 months post-operatively and at the last follow-up were lower in the double segment (P < 0.05). The ODI improvement was also more significant in the double-segment group at the last follow-up (P < 0.05). There was no significant difference in radiographic parameters at baseline (P>0.05). MSU scale for the primary segment was significantly lowered after both operations (P < 0.05). MSU scale for secondary segment was significantly lowered in double segment group but not in single segment group. Other imaging parameters were similar between the two groups (P > 0.05). The operation time of the single-segment group was significantly shorter than that of the double-segment group(P < 0.001). No perioperative complications were found in either group, but three patients underwent secondary lumbar surgery during the postoperative follow-up period in the single-segment group.@*CONCLUSION@#For young and middle-aged patients with double-segment disc herniation, this study suggests double-segment PELD may be more advantageous than single-segment PELD in terms of asuring clinical efficacy without increasing perioperative risks.