Risk factors for multiple debridements of the patients with deep incisional surgical site infection after spinal surgery / 北京大学学报(医学版)

OBJECTIVE@#To investigate the risk factors that contribute to multiple debridements in patients suffering from deep incisional surgical site infection after spinal surgery and advise medical personnel to pay special attention to these risk factors.@*METHODS@#We retrospectively enrolled 84 patients who got deep incisional surgical site infection after spinal surgery from Jan. 2012 to Dec. 2017. The infections occurred within 30 days after the surgery, and the identification met the criteria of deep incisional surgical site infection of Centers of Disease Control (CDC). Early debridement with first stage closure of the wound and a continuous inflow-outflow irrigation system was used, and reasonable antibiotics were chosen according to the bacterial culture results. During the treatment, the vital signs, clinical manifestations, blood test results, drainage fluid colour and bacterial culture results were acquired. If the infection failed to be controlled or relapsed, a second debridement was performed. Of the 84 cases, 60 undergwent single debridement which included 36 male cases and 24 female cases, and the age ranged from 36 to 77 years, with a mean of 57.2 years. Twenty four had multiple debridements (twice in 14 cases, three times in 6 cases, four times in 1 case, five times in 2 cases, six times in 1 cases) which included 17 male cases and 7 female cases, and the age ranged from 21 to 70 years, with a mean of 49.5 years. Risk factors that predispose patients to multiple debridements were identified using univariate analysis. Risk factors with P values less than 0.05 in univariate analysis were included together in a multivariate Logistic regression model using back-forward method.@*RESULTS@#Multiple debridements were performed in 28.6% of all cases. The hospital stay of multiple debridements group was (82.4±46.3) days compared with (40.4±31.5) days in single debridement group (P=0.018). Instrumentation was removed in 6 cases in multiple debridements group and 4 cases in single debridement group (P=0.049). Flap transplantation was performed in 7 cased in multiple debridements group while none in single debridement group (P < 0.001). Diabetes, primary operation duration longer than 3 hours, primary operation blood loss more than 400 mL, bacteriology examination results, distant site infection were significantly different between the two groups in univariate analysis. In multivariate analysis, primary operation duration longer than 3 hours (OR=3.60, 95%CI: 1.12-11.62), diabetes (OR=3.74, 95%CI: 1.06-13.22), methicillin-resistant Staphylococcus aureus (MRSA) infected (OR=16.87, 95%CI: 2.59-109.73) were the most important risk factors related to multiple debridements in the patients with deep incisional surgical site infection after spinal surgery.@*CONCLUSION@#Diabetes, primary operation duration more than 3 hours, MRSA infected are independent risk factors for multiple debridements in patients suffering from deep incisional surgical site infection after spinal surgery. Special caution and prophylaxis interventions are suggested for these factors.

Efficacy and safety of antifibrinolytic agents in spinal surgery: a network meta-analysis / 中华医学杂志(英文版)

BACKGROUND@#Significant blood loss is still one of the most frequent complications in spinal surgery, which often necessitates blood transfusion. Massive perioperative blood loss and blood transfusion can create additional risks. Aprotinin, tranexamic acid (TXA), and epsilon-aminocaproic acid (EACA) are antifibrinolytics currently offered as prophylactic agents to reduce surgery-associated blood loss. The aim of this study was to evaluate the efficacy and safety of aprotinin, EACA, and low/high doses of TXA in spinal surgery, and assess the use of which agent is the most optimal intervention using the network meta-analysis (NMA) method.@*METHODS@#Five electronic databases were searched, including PubMed, Cochrane Library, ScienceDirect, Embase, and Web of Science, from the inception to March 1, 2018. Trials that were randomized and compared results between TXA, EACA, and placebo were identified. The NMA was conducted with software R 3.3.2 and STATA 14.0.@*RESULTS@#Thirty randomized controlled trial (RCT) studies were analyzed. Aprotinin (standardized mean difference [SMD]=-0.65, 95% credibility intervals [CrI;-1.25, -0.06]), low-dose TXA (SMD = -0.58, 95% CrI [-0.92, -0.25]), and high-dose TXA (SMD = -0.70, 95% CrI [-1.04, -0.36]) were more effective than the respective placebos in reducing intraoperative blood loss. Low-dose TXA (SMD = -1.90, 95% CrI [-3.32, -0.48]) and high-dose TXA (SMD = -2.31, 95% CrI [-3.75, -0.87]) had less postoperative blood loss. Low-dose TXA (SMD = -1.07, 95% CrI [-1.82, -0.31]) and high-dose TXA (SMD = -1.07, 95% CrI [-1.82, -0.31]) significantly reduced total blood loss. However, only high-dose TXA (SMD = -2.07, 95% CrI [-3.26, -0.87]) was more effective in reducing the amount of transfusion, and was significantly superior to low-dose TXA in this regard (SMD = -1.67, 95% CrI [-3.20, -0.13]). Furthermore, aprotinin (odds ratio [OR] = 0.16, 95% CrI [0.05, 0.54]), EACA (OR = 0.46, 95% CrI [0.22, 0.97]) and high dose of TXA (OR = 0.34, 95% CrI [0.19, 0.58]) had a significant reduction in transfusion rates. Antifibrinolytics did not show a significantly increased risk of postoperative thrombosis. Results of ranking probabilities indicated that high-dose TXA had the greatest efficacy and a relatively high safety level.@*CONCLUSIONS@#The antifibrinolytic agents are able to reduce perioperative blood loss and transfusion requirement during spine surgery. And the high-dose TXA administration might be used as the optimal treatment to reduce blood loss and transfusion.

The posterior surgical treatment of old tuberculous kyphosis / 中华外科杂志

<p><b>OBJECTIVE</b>To observe the results of posterior osteotomy and correction in the surgical treatment of old tuberculous kyphosis.</p><p><b>METHODS</b>From June 2004 to December 2008, 31 cases of old tuberculous kyphosis with posterior osteotomy and correction technique were treated. There were 12 cases of male and 19 cases of female. The average age was 33.4 years. Pedicle subtraction osteotomy or vertebral column resection were applied in surgery. The kyphosis angle, lumbar lordosis angle and sagittal balance condition of the spine were measured before and after surgery, as well as follow-up. The Frankel grading system for neurological function of lower extremities, the Oswestry disability index (ODI) for life quality, and patient satisfactory index (PSI) for satisfaction of surgery were applied before surgery and at follow-up.</p><p><b>RESULTS</b>The average kyphosis angle was 94° ± 27°, the average lumbar lordosis angle was 71° ± 20°, and the average sagittal C(7) plumb line was (-15 ± 44) mm away from the balance region before surgery. The average kyphosis angle decreased to 26° ± 11° in one week after surgery, with an improvement rate of 71.4%. The average follow-up time was 22.5 months. The average kyphosis angle was 28° ± 12° at the final follow-up, with an improvement rate of 70.0%. The average lumbar lordosis angle was 46° ± 11°, with an improvement rate of 35.1%. The postoperative kyphosis angle and lumbar lordosis angle were significantly different with that of pre-operation (for kyphosis angle: t = 16.3, P < 0.05; for lumbar lordosis angle: t = 8.1, P < 0.05). The average sagittal C(7) plumb line was (-4 ± 22) mm away from the balance region at the final follow-up, with an improvement rate of 73.4%. The Frankel grading were E in 13 cases, D in 13 cases, and C in 5 cases before surgery, and were E in 20 cases, D in 8 cases, and C in 3 cases at the final follow-up. The average ODI was 13 ± 12 before surgery, and was 7 ± 8 at the final follow-up, with an improvement rate of 45.2%. The PSI results showed a satisfied rate of 90.3%.</p><p><b>CONCLUSION</b>Good results can be achieved by applying proper posterior osteotomy and correction technique according to the severity of old tuberculous kyphosis.</p>

Longterm outcome after the decompressive surgery for thoracic myelopathy due to the ossification of the ligamentum flavum / 中华外科杂志

<p><b>OBJECTIVES</b>To investigate the long-term surgical outcome of thoracic myelopathy caused by the ossification of the ligamentum flavum (OLF) and evaluate the related risk factors.</p><p><b>METHODS</b>Forty-four patients who underwent decompressive laminectomy with thoracic OLF between January 1990 and December 2005 and got more than 5 years follow-up were retrospectively reviewed. Among these 44 cases, there were 29 male and 15 female whose ages at operation were 52 years averagely (27-68 years). The 2-year follow-up results and long-term outcomes were classified according to the modified Epstein's standard, and then the rates of excellent or good (REG) were calculated. The correlation between the long-term REG and the patients' ages, durations of symptoms, decompressed levels, and dural leak were analyzed.</p><p><b>RESULTS</b>The mean follow-up period of these 44 cases was 8.5 years (5-19 years). The REG at 2 years after laminectomy was 77.3% (34/44), while the long-term REG was 65.9% (29/44). There was one case who had suffered from an acute spinal cord injury got a poor post-operative outcome. The other 43 cases had chronic durations, including 22 cases whose pre-operative durations of symptoms were less than 12 months and 21 cases whose durations were equal to or more than 12 months. And the long-term REG of these two groups were 77.3% (17/22) and 57.1% (12/21) respectively (P>0.05). The REG of those cases whose decompression levels were limited in T1-T9 was 78.9% (15/19), while that of those cases whose laminectomy was relevant to thoracolumbar segment (T10-L2) was 58.3% (14/24) (P>0.05). There were 7 cases who had excellent or good short-term results and poor long-term outcomes. The reasons of these changes included coexistence of lumbar spinal stenosis in three cases and the growth of the OLF at the adjacent levels in four cases.</p><p><b>CONCLUSIONS</b>Although the short-term results of the decompressive surgery for thoracic OLF is good, the regular long-term follow-up is necessary because the symptoms may reoccur or deteriorate secondary to lumbar spinal stenosis or the growth of OLF at the adjacent levels near former decompressive levels; the duration of symptoms which is more than one year and the decompression levels that is involved to T10-L2 segments are possibly related to the poor long-term outcomes.</p>

Comparison of adjacent segment degeneration five years after single level cervical fusion and cervical arthroplasty: a retrospective controlled study / 中华医学杂志(英文版)

<p><b>BACKGROUND</b>Cervical arthroplasty is indicated to preserve cervical motion and prevent accelerated adjacent segment degeneration. Whether accelerated adjacent segment degeneration is prevented in the long term is unclear. This trial compared adjacent segment degeneration in Bryan disc arthroplasty with that in anterior cervical decompression and fusion five years after the surgery.</p><p><b>METHODS</b>We studied patients with single level degenerative cervical disc disease. The extent of adjacent segment degeneration was estimated from lateral X-rays.</p><p><b>RESULTS</b>Twenty-six patients underwent single level Bryan disc arthroplasty and twenty-four patients underwent single level anterior cervical decompression and fusion. All patients were followed up for an average of sixty months. In the Bryan arthroplasty group, nine (17.6%) segments developed adjacent segment degeneration, which was significantly lower than that (60.4%) in the anterior cervical decompression and fusion group. Eleven segments in the Bryan arthroplasty group developed heterotopic ossification according to McAfee's classification and two segments had range of motion less than 2°. In the heterotopic ossification group, four (19.5%) segments developed adjacent segment degeneration, similar to the number in the non-heterotopic ossification group (16.7%). Adjacent segment degeneration rate was 50% in grade IV group but 11.8% in grade II to III.</p><p><b>CONCLUSIONS</b>Adjacent segment degeneration was accelerated after anterior cervical decompression and fusion. However, Bryan disc arthroplasty avoided accelerated adjacent segment degeneration by preserving motion. Patients with grade IV heterotopic ossification lost motion, and the rate of adjacent segment degeneration was higher than that in patients without heterotopic ossification.</p>

Circumspinal decompression through a single posterior incision to treat thoracolumbar disc herniation / 中华医学杂志(英文版)

<p><b>BACKGROUND</b>Various surgical approaches have been successfully used in the treatment of thoracolumbar disc herniation (TLDH). Although the anterior transthoracic approach has a reputation for better visualization than the posterolateral and lateral approaches, it involves the manipulation of the thoracic and pulmonary structures. Thus, this approach is technically demanding and prone to compromising the respiratory system. An ideal approach would involve adequate visualization and be accomplished through the posterior midline approach that is familiar to spine surgeons. The objective of this retrospective preliminary clinical study was to introduce a new surgical procedure, circumspinal decompression through a single posterior incision, for the treatment of TLDH (T10/11-L1/2) and to evaluate the surgical outcome of this procedure by comparing it to the conventional anterior transthoracic approach.</p><p><b>METHODS</b>In this study, 15 patients (10 males, 5 females; mean age 51 years) with symptomatic TLDH underwent the circumspinal decompression through a single posterior incision procedure between January 2008 and December 2009. Altogether, 17 herniated discs were excised, with 2 discs at T10/11, 4 discs at T11/12, 5 discs at T12/L1 and 6 discs at L1/2. Of these patients, 13 were followed up with a mean follow-up period of 23.5 months. Clinical outcomes, including operative time, blood loss, perioperative complications, postoperative time of hospitalization, neurologic status improvement, back pain and correction of local kyphosis, were investigated by comparing these data with the results from patients who underwent the anterior transthoracic approach for TLDH during the same period. The patients' neurologic status was evaluated by a modified Japanese Orthopedic Association (JOA) scoring system of 11 points. Neurologic status improvement after the surgery was assessed by calculating the recovery rate, which was equal to the (postoperative JOA score-preoperative JOA score)/(11-preoperative JOA score)×100%. The rates of patients who improved at the final follow-up were also assessed.</p><p><b>RESULTS</b>The mean operative time was 183 minutes, the mean blood loss was 1067 ml, and the mean postoperative hospitalization time was 8.4 days. Three patients suffered perioperative complications, but none of these complications involved the respiratory system. Local kyphotic angles at the fusion levels were reduced. Of the 13 patients that were followed up, 12 improved at the final follow-up, with a mean recovery rate of 52.8%. Patients who underwent the circumspinal decompression procedure showed a higher percentage of improvement at the final follow-up, a higher degree of local kyphosis correction and a lower percentage of complications (especially respiratory complications) compared to patients who underwent the anterior transthoracic decompression procedure.</p><p><b>CONCLUSIONS</b>The circumspinal decompression through a single posterior incision procedure is an effective and safe technique that is comparable to anterior tranthoracic approach for the surgical treatment of TLDH patients. It could be an attractive choice in certain circumstances.</p>

The impact of thoracic and thoracolumbar angular kyphosis on pelvic shape and sagittal alignment / 中华外科杂志

<p><b>OBJECTIVE</b>To analyze the impact of thoracic and thoracolumbar angular kyphosis on pelvic shape and sagittal alignment.</p><p><b>METHODS</b>From May 2002 to June 2010, the sagittal spino-pelvic parameters were analyzed in lateral standing radiographs of 32 patients (mean age 29.6 years) with thoracolumbar angular kyphosis. The parameters included Cobb angle of kyphosis, lumbar lordosis (LL), pelvic incidence (PI), sacrum slope (SS), pelvic tilt (PT) and sagittal vertical axis (SVA). All pelvic parameters in the patients were compared with those reported in historical normal subjects. All patients were treated by using kyphotic correction and fusion. The preoperative and postoperative parameters were compared. The pelvic parameters were also compared between the patients with kyphotic apex located at T(1-8) and those located at T(9-12) and thoracolumbar junction. The linear regression analysis was used to investigate the independent factors of PI.</p><p><b>RESULTS</b>The mean kyphosis was 90.1° (31° - 138°). The mean age of kyphosis occurrence was 6.1 years. The mean PI, SS and PT were 34.8°, 35.8° and -0.7° respectively. The PI and PT were significantly smaller (P < 0.001) in the patients than those in normal subjects while the SS was similar. The kyphosis was improved to 27.9° post-operatively. There was no difference in PI values between pre-operation and postoperation (P > 0.05). The PI and SS in patients whose kyphosis located at thoracic spine (T(1-8)) were significantly higher than those at T(9)-L(2). Instead of patients' age and LL, the preoperative Cobb angle of kyphosis and the levels where kyphosis located were two independent impact factors of PI.</p><p><b>CONCLUSIONS</b>The kyphosis occurred at childhood may influence pelvic shape and alignment significantly. The lower kyphotic apex located and the bigger kyphosis, the greater impact on the pelvic morphology. The surgery can improve the kyphosis, but can not change the sagittal pelvic morphology. Early treatment of thoracolumbar angular kyphosis is beneficial not only to reconstruction of spine alignment but also to the formation of sagittal pelvic morphology.</p>

Characteristics of clinical findings and radiological assessment of high grade developmental spondylolisthesis / 中华外科杂志

<p><b>OBJECTIVES</b>To investigate clinical appearance and radiological characteristics of high grade developmental spondylolisthesis and their significance.</p><p><b>METHODS</b>In a retrospective study, a group of 6 female patients, who were diagnosed as high grade developmental spondylolisthesis and treated in Peking University third hospital from March 2007 to December 2008 were included. Clinical and radiological characteristics of the 6 patients were investigated and the following parameters were measured on standing lateral X-ray: PI (pelvic incidence), SK (sacral kyphosis) and LL (Lumbar lordosis). A series of 44 patients who came to out-patient department due to LBP and had no positive findings on lateral lumbar X-ray were selected as the control group. The four parameters were compared between study group and control group. Clinical meanings of significant difference were discussed.</p><p><b>RESULTS</b>Clinical findings of high grade developmental spondylolisthesis included bending of knees, deformity of trunk and sciatica. Radiological appearances were characterized with kyphosis of lumbo-sacral joint, retroverted pelvis and domed sacrum. Spondylolisthesis patients has an average PI of (52 +/- 7) degrees which was significant higher than the control group [(43 +/- 8) degrees ] (P < 0.01). LL of study group [(51 +/- 10) degrees ] was higher than that of the control group [(18 +/- 9) degrees ] (P < 0.01) and SK of the study group [(12 +/- 11) degrees ] were lower than that of the control group [(21 +/- 10) degrees ] (P < 0.05).</p><p><b>CONCLUSIONS</b>Characteristics of clinical findings of spondylolisthesis patients have obvious cosmetic appearance, significant pain and lower neurological deficits. Radiological characteristics display deformity of lumbo-sacral joint. PI, LL and SK are significant parameters for high grade spondylolisthesis.</p>

Morphological features of complicated thoracolumbar fractures and fixation technology of injured vertebra / 中华外科杂志

<p><b>OBJECTIVES</b>To study the morphological feature of complicated thoracolumbar fractures and the fixation technology of injured vertebra.</p><p><b>METHODS</b>From January 2005 to December 2007, 61 patients with type B and C thoracolumbar fractures according to AO classification were treated. There were 53 males and 8 females, with a mean age of 33.2 years (range, 9 to 65 years). Based on ASIA grading system of neurologic deficit, Grade A was found in 41 cases, grade B in 5 cases, Grade C in 5 cases, Grade D in 6 cases and Grade E in 4 cases. The injured vertebra located at thoracic region in 13, thoracolumbar in 39 and lumbar in 9 cases. The patients were divided into two groups: 32 cases with pedicle screws in the injured vertebra and 29 cases without pedicle screw in the injured vertebra. The analyses on the morphological features of injured vertebra were performed, and comparisons were carried out on the outcome regarding the reduction and correction of the injured vertebra, and the difference of Denis scale in pain domain and work status domain, between the two groups.</p><p><b>RESULTS</b>All the patients were followed up for an average of 3 years (range, 1.5 to 4.5 years). There were significance statistical difference in the correction loss of Cobb angle, sagittal index, correction of dislocation index, and the Denis pain scale between the two groups (P < 0.05). A better outcome was observed in the injured vertebra fixation group than the injured vertebra non-fixation group.</p><p><b>CONCLUSIONS</b>Inserting pedicle screws in the injured vertebra is effective and useful in the correction of complicated thoracolumbar fractures. It improves biomechanical stability of the spine after the operation.</p>

Clinical outcomes of surgical correction for ankylosing spondylitic kyphosis / 中华外科杂志

<p><b>OBJECTIVE</b>To evaluate the clinical outcomes of posterior surgical corrective methods for ankylosing spondylitic kyphosis.</p><p><b>METHODS</b>From June 2003 to June 2008, 21 cases of ankylosing spondylitic kyphosis received posterior surgical correction. There were 17 male and 4 female, and the average age was 39.5 years (range, 20 to 57 years). The total spine X-ray and CT were used to evaluate sagittal balance and thoracolumbar spine kyphosis angle, and chin brow-vertical angle was obtained from clinical lateral photograph. The surgical goal was to correct sagittal imbalance and chin brow-vertical angle. The simulated osteotomy was performed in computer before surgery to determine the correction methods. The surgical methods included: 16 cases of monosegmental closing osteotomy correction, 3 cases of anterior opening-posterior closing osteotomy correction, and 2 cases of combined pedicle subtraction osteotomy in thoracolumbar spine and Smith-Peterson osteotomy in lumbar spine. All patients were followed up after surgery, and the improvement of sagittal imbalance, chin brow-vertical angle and thoracolumbar spine kyphosis angle were assessed. The symptoms relief and satisfied rate were also evaluated.</p><p><b>RESULTS</b>The average operation time was 4.4 hours, and the average blood loss was 1770 ml. Before surgery, the average thoracolumbar kyphosis angle was 62.1°, the average anterior shift of C(7) plumb line was 172.9 mm, and the average chin brow-vertical angle was 34.9°. The average follow-up was 28.8 months after surgery. The average correction rate of thoracolumbar kyphosis angle was 60%, the average improvement rate of anterior shift of C(7) plumb line was 64%, and the average correction rate of chin brow-vertical angle was 98%. The improvement rate of back pain was 64% during follow-up. The total surgical satisfactory rate was 95%.</p><p><b>CONCLUSION</b>Based on the simulated osteotomy in computer before surgery, according to the characteristics of ankylosing spondylitic kyphosis, different posterior osteotomy and correction methods can achieve good results.</p>

Application of cervical arthroplasty with Bryan cervical disc: long-term X-ray and magnetic resonance imaging follow-up results / 中华医学杂志(英文版)

<p><b>BACKGROUND</b>Cervical disc arthroplasty is a new technique for treating degenerative cervical disease. Its goal is to avoid the degeneration of adjacent levels by preserving motion at the treated level. The aims of this study were to evaluate the radiologic outcomes of Bryan cervical disc replacement and the degenerative status of adjacent segments.</p><p><b>METHODS</b>Twenty-two patients at a single center underwent discectomy and implantation of Bryan cervical disc. The mean follow-up period was 60 months (57 - 69 months). Twenty patients underwent single-level arthroplasty and two underwent arthroplasty at two levels. The levels of surgery included C3/4 (3 levels), C4/5 (2 levels), C5/6 (18 levels) and C6/7 (1 level). Radiographic evaluation included dynamic X-ray examination and magnetic resonance imaging (MRI) at baseline and at final follow-up.</p><p><b>RESULTS</b>On X-ray examination, the range of motion (ROM) at the operated level was 7.2° (2.5° - 13.0°) at baseline and 7.8° (1.0° - 15.0°) at final follow-up (P > 0.05). Heterotopic ossification around the prosthesis was observed in eight levels, and two levels showed loss of motion (ROM < 2°). MRI showed worsening by a grade at the upper level in 2/22 patients, and worsening by a grade at the lower level in 3/22, according to Miyazaki's classification. No further impingement of the ligamentum flavum into the spinal canal was observed at adjacent levels, though the disc bulge was slightly increased at both the adjacent upper and lower levels at final follow-up.</p><p><b>CONCLUSIONS</b>Arthroplasty using Bryan cervical disc prosthesis resulted in favorable radiologic outcomes in this study. Disc degeneration at adjacent levels may be postponed by this technique.</p>

Sagittal plane analysis of the spine and pelvis in adult idiopathic scoliosis / 中华医学杂志(英文版)

<p><b>BACKGROUND</b>There has been an increasing recognition of the importance of sagittal spinopelvic alignment in patients with scoliosis as it relates to clinical outcomes. However, the changes seen in sagittal spinopelvic alignment in adult idiopathic scoliosis patients is poorly defined. This study was conducted to evaluate the sagittal alignment of pelvis and spine in adult idiopathic scoliosis patients.</p><p><b>METHODS</b>The sagittal parameters of the spine and pelvis were analyzed in lateral standing radiographs of 124 patients (mean age 47.4 years) with adult idiopathic scoliosis, including thoracic kyphosis (TK), thoracolumbar junction kyphosis (TLJ), lumbar lordosis (LL), pelvic incidence (PI), sacrum slope (SS), pelvic tilt (PT) and C7 plumb line (C7PL). The patients were divided into three groups according to the age: 20 - 40 years, 41 - 64 years, and ≥ 65 years. The parameters were compared with those in normal adults and adolescent idiopathic scoliosis (AIS) patients. The relationship between all parameters as well as age and sagittal parameters were analyzed.</p><p><b>RESULTS</b>The PI in patients with adult idiopathic scoliosis was 58.1° ± 13.0°, which was significantly higher than that in normal adults. The PT (19.9° ± 10.6°) was also higher than that in both normal adults and AIS patients, while the SS (38.1° ± 12.0°) was similar or smaller. As age increased, C7PL, PT and TJL increased while LL decreased. There was no relationship between age and both PI and TK. PT had the strongest statistical association with the C7PL.</p><p><b>CONCLUSIONS</b>PI is higher in adult idiopathic scoliosis than normal subjects. The PT is the most relevant pelvic parameter to the global sagittal alignment of the spine. Age significantly influences sagittal parameters of the spine and pelvis except the PI and TK.</p>

The study on correlation between intrusion of nucleus gelatinosus into vertebral body and low back pain after thoracolumbar fractures / 中华外科杂志

<p><b>OBJECTIVE</b>To study the correlation between intrusion of nucleus gelatinosus into vertebral body and low back pain after thoracolumbar fractures.</p><p><b>METHODS</b>One hundred and two patients who were treated in Peking university third hospital from January 2005 to September 2007 were evaluated retrospectively and included into this study. They were followed up for an average of 18 months and complete data were kept. Fifty-four patients were treated operatively and forty-eight patients were treated conservatively. VAS questionnaire was applied to evaluate the low back pain. Spearman Correlation Coefficients module and Wilcoxon 2-Sample Test module of SAS software were used to analyze the relation between intrusion of nucleus gelatinosus, different treatments, kyphotic Cobb angles and VAS.</p><p><b>RESULTS</b>There were strong correlations between intrusion of nucleus gelatinosus and VAS in both operative group, P < 0.01 and non-operative group, P < 0.01; there were poor correlations between different treatments and VAS in both intrusion group, P > 0.05 and non-intrusion group, P > 0.05; and there were also poor correlations between Cobb angles and VAS, gamma = 0.2584, P > 0.05.</p><p><b>CONCLUSION</b>There is correlation between the intrusion of nucleus gelatinosus into vertebral body and the low back pain after thoracolumbar fractures.</p>

Combined segmental resection osteotomy with dual axial rotation correction, fixation and fusion for the treatment of severe angular kyphosis / 中华外科杂志

<p><b>OBJECTIVE</b>To design a new surgical correction and fixation technique for the treatment of severe angular kyphosis, observe the feasibility, safety and effectiveness of the technique.</p><p><b>METHODS</b>From May 2004 to February 2007, 16 cases with severe kyphosis (average 90.8 degrees, range 50 degrees-130 degrees) were treated with segmental resection osteotomy, section distraction, dual axial rotation correction and instrumentation fusion technique. The patients were inspected by local and total spine anteroposterior and lateral radiography pre-and postoperatively. The kyphotic Cobb angle was measured and 7 cases combined scoliosis Cobb angle was also measured. The Frankel Grading for neurological function, Oswestry Disability Index (ODI) and Patients Satisfactory Index (PSI) were evaluated preoperatively, postoperatively and at follow-up. The back pain relief was also observed.</p><p><b>RESULTS</b>The average surgical duration was 6.9 hours. The average blood loss was 4000 ml. The complications include 1 shifting of artificial vertebrae, 3 nerve root injury, 3 dural tear and 1 transitory dysfunction of lower extremity. All of these complications were relieved greatly after feasible treatment. The average follow-up time was 25 months. The average kyphotic angle was 90.8 degrees preoperatively, which was improved to 26.9 degrees immediately after surgery, and got an average correction rate of 72.5%. At follow-up, the average kyphotic angle was 28.9 degrees, and correction rate was 70.1%. The 7 cases who combined with scoliosis had an average Cobb angle of 35.9 degrees preoperatively, which decreased to 4.4 degrees immediately after surgery, and the correction rate was 87.2%. The correction rate was kept until follow-up (78.6%). Some patients got an improved neurological function. The Frankel Grading were E in 5 cases, D in 5 cases, C in 5 cases, and B in 1 case preoperatively. There were 10 cases of E grade, 3 cases of D grade, and 3 cases of C grade at follow-up. Except 3 cases who had no symptoms before surgery, the average ODI was 18.9 preoperatively, and 10.8 postoperatively. The average improvement of ODI was 52.7%. The PSI result showed a satisfied rate of 93.8%. The back pain of 3 cases were totally relieved after surgery.</p><p><b>CONCLUSIONS</b>Segmental resection osteotomy with dual axial rotation correction and fusion technique is an effective way to treat severe angular kyphosis. It is a safe technique and has high correction rate. The long-term results is acceptable.</p>

The height of the osteotomy and the correction of the kyphotic angle in thoracolumbar kyphosis / 中华医学杂志(英文版)

<p><b>BACKGROUND</b>This study investigated the relationship between the height of osteotomy and the correction of the kyphotic angle during posterior closing wedge osteotomy with instrumentation and the spinal osteotomy with cage inserting into the intervertebral gap and closing posteriorly by a single posterior approach in thoracolumbar kyphosis, and using this relationship as the basis of the preoperative design.</p><p><b>METHODS</b>From April 1996 to June 2007, 30 thoracolumbar kyphosis patients with complete medical records and clear X-ray photograms have undergone operation. Of these 30 cases, 16 cases underwent posterior closing wedge osteotomy with instrumentation while the height of the osteotomy and the correction of the angle have been measured; 14 cases underwent spinal osteotomy with cage inserting into the intervertebral gap and closing posteriorly by a single posterior approach while the height of the osteotomy, the height and the place of the cage and the correction of the angle were also measured. A simple geometrical model was simulated to calculate the relationship between the height of the osteotomy and the correction of the angle and these results are finally compared with the data coming from the actual measuring by the Wilcoxon statistic method.</p><p><b>RESULTS</b>The distribution of data from the 16 cases by posterior closing wedge osteotomy with instrumentation was as such: 9 male and 7 female, the mean age was 49.2 years (range 38-70), the kyphosis improved from an average of 30 degrees (range 15 degrees-45 degrees) preoperatively to 4 degrees (range -26 degrees-30 degrees) postoperatively, the kyphosis was corrected on average 2.5 degrees per 1 mm in the height of the osteotomy. The results from the simple geometrical model were that the mean of the correction of the angle per 1 mm was 2.2 degrees. As a result, there was no significant difference (P > 0.05) when comparing the measurement collected with the result simulated from the geometric model. The distribution of data from the 14 cases by spinal osteotomy with cage inserting into the intervertebral gap and closing posteriorly by a single posterior approach was as such: 5 male and 9 female, the mean age was 35.3 years old (range 15 - 57), the kyphosis improved from an average of 64 degrees (range 34 degrees-95 degrees) preoperatively to 8.7 degrees (range -10 degrees-22 degrees) postoperatively. The kyphosis was corrected on average of 6.2 degrees per 1 mm in the height of the osteotomy. The results from the simple geometrical model is that the mean of the correction of the angle per 1 mm was 6.6 degrees . There was also no significant difference (P > 0.05) when comparing the measurement collected with the result simulated from the geometric model.</p><p><b>CONCLUSIONS</b>The therapeutic effect is significant for both posterior closing wedge osteotomy with instrumentation and spinal osteotomy with cage inserting into the intervertebral gap and closing posteriorly by a single posterior approach. The posterior closing wedge osteotomy with instrumentation is an easier approach with the mean angle of the correction per 1 mm of 2.5 degrees and the maximum angle of correction of 45 degrees . The spinal osteotomy with cage inserting into the intervertebral gap and closing posteriorly by a single posterior approach is more efficient with the mean angle of correction per 1 mm of 6.2 degrees . It should be reserved for the severe cases of thoracolumbar kyphosis. We can also use the formula to help us constructing preoperative design.</p>

Treatment of cervical dislocation with locked facets / 中华医学杂志(英文版)

<p><b>BACKGROUND</b>Lower cervical dislocation with locked facets is common in cervical injury. The locked facets include unilateral and bilateral types. Different successful closed reduction rates has been achieved between unilateral and bilateral types by using rapid skull traction, which was commonly used to reduce the cervical dislocation. It is important to investigate a suitable management specific to patients with different types of cervical locked facets.</p><p><b>METHODS</b>A total of 38 patients with cervical dislocation with locked facet due to cervical injury treated by rapid skull traction and operation from 1988 to 2005 were reviewed. Rapid skull traction was used in all the patients. Successful closed reduction rate was 88.0% in patients with bilateral cervical locked facets and that was 15.4% in those with unilateral cervical locked facets. These data were then statistically compared by Chi-square test. Patients who were reduced successfully underwent anterior cervical discectomy and fusion at the injured level, and those who failed in closed reduction received posterior open reduction and fixation.</p><p><b>RESULTS</b>In this series, there was statistically significant difference (P < 0.05) in the rate of successful closed skull traction reduction between unilateral and bilateral locked facets dislocation. Unilateral cervical locked facets dislocation was not easily reduced by skull traction which was suitable for reduction of bilateral cervical locked facets dislocation. However, unilateral cervical locked facets dislocation can be reduced by posterior open reduction.</p><p><b>CONCLUSIONS</b>Unilateral cervical locked facets dislocation should be treated immediately with posterior open reduction and instrumentation. Bilateral cervical locked facets dislocation can be reduced by rapid skull traction firstly and anterior cervical discectomy and interbody fusion later.</p>

Icariine stimulates proliferation and differentiation of human osteoblasts by increasing production of bone morphogenetic protein 2 / 中华医学杂志(英文版)

<p><b>BACKGROUND</b>Icariine is a flavonoid isolated from a traditional Chinese medicine Epimedium pubescens and is the main active compound of it. Recently, Epimedium pubescens was found to have a therapeutic effect on osteoporosis. But the mechanism is unclear. The aim of the study was to research the effect of Icariine on the proliferation and differentiation of human osteoblasts.</p><p><b>METHODS</b>Human osteoblasts were obtained by inducing human marrow mesenchymal stem cells (hMSCs) directionally and were cultured in the presence of various concentrations of Icariine. 3-(4, 5-dimethylthiazol-2-yl)-2, 5-diphenyltetrazolium bromide (MTT) test was used to observe the effect of Icariine on cell proliferation. The activity of alkaline phosphatase (ALP) and the amount of calcified nodules were assayed to observe the effect on cell differentiation. The expression of bone morphogenetic protein 2 (BMP-2) mRNA was detected by reverse transcriptase-polymerase chain reaction (RT-PCR).</p><p><b>RESULTS</b>Icariine (20 microg/ml) increased significantly the proliferation of human osteoblasts. And, Icariine (10 microg/ml and 20 microg/ml) increased the activity of ALP and the amount of calcified nodules of human osteoblasts significantly (P < 0.05). BMP-2 mRNA synthesis was elevated significantly in response to Icariine (20 microg/ml).</p><p><b>CONCLUSIONS</b>Icariine has a direct stimulatory effect on the proliferation and differentiation of cultured human osteoblast cells in vitro, which may be mediated by increasing production of BMP-2 in osteoblasts.</p>

Analysis the reasons of pulmonary embolism after spine surgery in eleven patients / 中华外科杂志

<p><b>OBJECTIVE</b>To discuss the clinical characteristics, early diagnosis and treatment for pulmonary embolism after spine surgery.</p><p><b>METHODS</b>From January 1995 to May 2006, 11 cases suffered pulmonary embolism after spine surgery in the total of 10 993 patients. The clinical characteristics, diagnosis and treatment of these 11 cases were retrospectively analyzed.</p><p><b>RESULTS</b>The incidence of pulmonary embolism was 0.1% after spine surgery. Pulmonary embolism was found during 5 to 14 days after spine surgery (mean 9.8 days). All of them show characteristic syndrome of pulmonary embolism, such as difficult breathe, cardiopalmus, thoracodynia, hemoptysis. Five patients died, and the mortality was 45.5%. The earlier use of pulmonary angiography and embolectomy by catheter device, the lower mortality will be. It is significantly.</p><p><b>CONCLUSIONS</b>Pulmonary embolism is one of the serious complications after spine surgery. It is the period of high happening on deadly PE and the mortality during 1 to 2 weeks after spine surgery. Pulmonary angiography and interventional therapy take an important part in the early diagnosis and treatment.</p>

New type spinal osteotomy with cage inserting anteriorly and closing posteriorly to correct thoracolumbar kyphosis by a single posterior approach / 中华外科杂志

<p><b>OBJECTIVE</b>To evaluate the feasibility, safety and efficacy of surgical correction of thoracolumbar kyphosis, using the new type spinal osteotomy with cage inserting into the intervertebral gap anteriorly and closing posteriorly by a single posterior approach.</p><p><b>METHODS</b>Since 2003, eight consecutive patients with thoracolumbar kyphosis were treated surgically. There were 4 male and 4 female with the mean age of 35 years old (from 14 to 58 years old). There were 3 cases of congenital kyphosis with scoliosis, 1 case of old spinal tuberculosis kyphosis, 2 cases of post-traumatic kyphosis, 1 case of ankylosing spondylitic kyphosis with old stress fracture and 1 case of iatrogenic kyphosis post-op of laminectomy due to the removal of ependymoma from cauda equina. The apex level of kyphosis was T(11) in 1 case, T(12) in 2 cases, L(1) in 3 cases and L(2) in 2 cases. The average preoperative Cobb angle of kyphosis was 73 degrees (range from 42 degrees to 90 degrees), there were 3 cases associated with scoliosis, with the mean preoperative Cobb angle of scoliosis was 25.7 degrees (range from 20 degrees to 36 degrees). According to the Frankel grading system, 2 cases were classified as Grade C, 2 cases as Grading D and 4 cases as Grading E preoperatively. All the patients had severe thoracolumbar dorsum pain with difficulty of sitting. The bladder sphincter function disturbance were also found in 3 cases. The main procedures of the new type spinal osteotomy consisted of temporary rod installation, trans-intervertebral spinal osteotomy, circumferential decompression of the spinal cord, dissection and complete cut of the anterior longitudinal ligament, spreading the intervertebral gap with the distraction forceps during the instrumentation correction maneuver and replaced by the cage filled with autograft bone inserting into the intervertebral gap, then the closing maneuver followed.</p><p><b>RESULTS</b>The average operation time was 4.5h (range from 3.5 to 6 h), and the mean blood loss volume during the operation was 2280 ml (range from 700 to 4200 ml). All patients underwent surgery safely and there were no major complications related to the surgical procedures, apart from CSF leakage of 1 case postoperatively and transient low blood pressure of 1 case intraoperatively. Localized kyphosis, scoliosis were reduced from an average of 73 degrees to 8.3 degrees and 25.7 degrees to 18.7 degrees respectively with an average 12.8 months follow-up. Bony fusion were achieved in all patients and there was no correction loss. Neurologic improvement occurred in 1 case from Frankel Grade C to Grade D, and 1 case from Frankel Grade D to Grade E after the surgery. The bladder sphincter function were also found improved in 2 cases postoperatively.</p><p><b>CONCLUSIONS</b>The new type spinal osteotomy with cage inserting anteriorly and closing posteriorly by a single posterior approach was a safe, reliable and effective surgical procedure for the treatment of the thoracolumbar kyphosis with the Cobb angle from 40 degrees to 90 degrees. Compared with the other common spinal wedge osteotomies, the deformation danger, such as hanging down, kinking or dural buckling could be effectively prevented, a better correction rate is also achieved significantly with this new type procedure.</p>

Clinical characteristics and treatment of flexion-distraction stage I injuries in subaxial cervical spine / 中华外科杂志

<p><b>OBJECTIVE</b>To study the clinical characteristics and treatment of flexion-distraction stage I injuries in subaxial cervical spine.</p><p><b>METHODS</b>Twelve cases of flexion-distraction stage I injuries with delayed symptoms, admitted in our hospital between January 1995 and December 2004, were studied retrospectively. In acute phase, all of 12 cases had neck pain and limited neck movements, neurological deficits were found in 6 of 12 cases. Eight cases had a correct diagnosis, and 2 cases had a error diagnosis, 2 cases missed. All cases were satisfactory by the primary conservative treatment. After 274 days average asymptomatic intervals, all of 12 cases had recurrence of neck pain, delayed neurological deficits were found in 10. MRI showed that all of 12 cases were unstable injuries.</p><p><b>RESULTS</b>All of the 12 patients were treated operatively. Decompression, fusion and fixation were performed by anterior approach in 9 cases, and by combined anterior and posterior approach in 3 cases. The average follow-up period was 33.1 months. Neck pain had great recovery in all cases, 10 cases with neurological deficits, 7 returned normal. Radiographic evidences of intervertebral bony fusion and good cervical alignment were observed in all of 12 cases.</p><p><b>CONCLUSIONS</b>Flexion-distraction stage I injuries is often caused by ligament and disc injuries, and often missed with subtle symptoms and radiographic changes. Inadequate primary treatment options are often due to failure to recognize the instability, and maybe result in delayed injuries. MRI is helpful for the early accurate evaluation of spinal stability. Unstable injury require early surgical treatment. The anterior approach operation is recommended to most of these patients with acute and old injuries. Combined anterior and posterior approach operation should be considered in these patients who have old injuries with stiff kyphosis.</p>