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The acute combination fractures of the atlas and axis in adults have a higher rate of neurological injury and early death compared with atlas or axial fractures alone. Currently, the diagnosis and treatment choices of acute combination fractures of the atlas and axis in adults are controversial because of the lack of standards for implementation. Non-operative treatments have a high incidence of bone nonunion and complications, while surgeries may easily lead to the injury of the vertebral artery, spinal cord and nerve root. At present, there are no evidence-based Chinese guidelines for the diagnosis and treatment of acute combination fractures of the atlas and axis in adults. To provide orthopedic surgeons with the most up-to-date and effective information in treating acute combination fractures of the atlas and axis in adults, the Spinal Trauma Group of Orthopedic Branch of Chinese Medical Doctor Association organized experts in the field of spinal trauma to develop the Evidence-based guideline for clinical diagnosis and treatment of acute combination fractures of the atlas and axis in adults ( version 2023) by referring to the "Management of acute combination fractures of the atlas and axis in adults" published by American Association of Neurological Surgeons (AANS)/Congress of Neurological Surgeons (CNS) in 2013 and the relevant Chinese and English literatures. Ten recommendations were made concerning the radiological diagnosis, stability judgment, treatment rules, treatment options and complications based on medical evidence, aiming to provide a reference for the diagnosis and treatment of acute combination fractures of the atlas and axis in adults.
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Ankylosing spondylitis (AS) combined with spinal fractures with thoracic and lumbar fracture as the most common type shows characteristics of unstable fracture, high incidence of nerve injury, high mortality and high disability rate. The diagnosis may be missed because it is mostly caused by low-energy injury, when spinal rigidity and osteoporosis have a great impact on the accuracy of imaging examination. At the same time, the treatment choices are controversial, with no relevant specifications. Non-operative treatments can easily lead to bone nonunion, pseudoarthrosis and delayed nerve injury, while surgeries may be failed due to internal fixation failure. At present, there are no evidence-based guidelines for the diagnosis and treatment of AS combined with thoracic and lumbar fracture. In this context, the Spinal Trauma Academic Group of Orthopedics Branch of Chinese Medical Doctor Association organized experts to formulate the Clinical guideline for the diagnosis and treatment of adult ankylosing spondylitis combined with thoracolumbar fracture ( version 2023) by following the principles of evidence-based medicine and systematically review related literatures. Ten recommendations on the diagnosis, imaging evaluation, classification and treatment of AS combined with thoracic and lumbar fracture were put forward, aiming to standardize the clinical diagnosis and treatment of such disorder.
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Objective:To explore the application of high-throughput sequencing (HTS) technology in pathogens detection for spinal infection.Methods:From January 2019 to May 2020, a total of 41 patients including 31 males and 10 females with an average age of 59.7±11.9 years (29-75 years) were suspected of spinal infections. There were 37 patients with local pain, 15 with fever (≥38 ℃) and 18 with neurological dysfunction. The infected sites were as follows, 4 cases of cervical spine, 8 cases of thoracic spine and 29 cases of lumbar spine. There were 36 patients met the surgical indications and underwent open debridement, bone grafting, fusion and internal fixation, while the other 5 patients underwent conservative treatment (three received drug therapy and two were transferred to the internal department for chemotherapy). Lesions obtained from open surgery patients were underwent pathology and HTS examination. In 5 cases with conservative treatment, two of them underwent CT guided percutaneous puncture for samples, while one case underwent ultrasound guided percutaneous puncture for pus, one case for venous blood, and one case received lumbar puncture for cerebrospinal fluid. The samples were sent for pathological and HTS examination, while liquid specimens were sent for bacterial culture and HTS. The sensitivity and specificity of HTS results were determined according to pathological examination which was regarded as the "gold standard". Based on HTS results combined with the clinical manifestations, imaging examination and pathological results of the patients, targeted antibiotics or anti-tuberculosis drugs were selected for postoperative drug therapy. Patients with bacterial infection received anti-infection treatment for 3 months after operation. For tuberculosis patients, "tetrad" (isoniazid+rifampicin+pyrazinamide+ethambutanol) anti-tuberculosis treatments were underwent for one year. Inflammation indicators from the blood samples were observed before and after treatment, including white blood cell count (WBC), C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR). These indicators were used to monitor disease progression and the curative effects. All patients were followed up for at least 3 months after surgery.Results:A total of 41 patients with suspected spinal infection were included in this study. The HTS pathogen detection results were obtained within 48 h. For the initial 5 patients, first-generation sequencing verification was conducted with coincidence rate 100%. Further, no further verification was conducted in the rest patients. Among the 41 cases, a total of 26 cases had positive results with a positive rate of 63.4%(26/41). Among them, thirteen cases were with mycobacterium tuberculosis (31.7%) and 6 cases with staphylococcus (14.6%). Fungi and Brucellosis were diagnosed in 2 cases respectively, accounting for 4.9% respectively. The test were negative in 15 patients (36.6%), including 2 patients with tumor or tumor-like lesions (1 hematologic tumor and 1 eosinophilic granuloma). A total of 38 patients underwent pathological examination, which confirmed 7 cases of suppurative infection, 12 cases of tuberculosis, 2 cases of tumor or tumor-like lesions and the remaining 17 cases of inflammatory lesions. The sensitivity and specificity of HTS were 80%(16/20) and 55.6% (10/18) with positive predictive value (PPV) 66.7% (16/24) and negative predictive value (NPV) 71.4% (10/14). All patients were followed up for 3 months. The inflammation indicators of blood at 3 months were all lower than that at admission. WBC decreased from (7.50±3.26)×10 9/L at admission to (6.22±2.53)×10 9/L at 3 months after treatment without statistically significant difference ( t=1.082, P=0.290). The CRP decreased from (32.2±34.1) mg/L to (4.5±10.5) mg/L, and ESR from (44.2±26.5) mm/1 h to (18.6±12.1) mm/1 h with statistically significant difference ( t=8.963, P<0.001; t=5.421, P<0.001). Conclusion:High-throughput sequencing technology can be used in detection of spinal infection pathogens, due to its relatively high positive rate, satisfied sensitivity and good diagnostic value.
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Objective@#To investigate the long-term outcomes of posterior long segment instrumentation and fusion in adult degenerative scoliosis (ADS), and to explore the correlative factors of sagittal imbalance after long segment instrumentation and fusion, and to summarize the impacts of different lowest instrumented vertebra (LIV) on sagittal complication rates.@*Methods@#ADS patients who underwent long segment instrumentation and fusion between January 2008 and January 2014 were retrospectively reviewed and divided into two groups depended on LIV (L 5 group and S1 group). The follow-up time was at least five years. Radiographic parameters, Visual Analogue Score (VAS), Oswestry Disability Indexscore(ODI), the 12-item Short Form Health Survey-Physical Component Summary (SF-12 PCS)and sagittal complications were analyzed. And the correlation between sagittal imbalance and sagittal complications were calculated. Patients were divided into two groups(sagittal imbalance group and sagittal balance group) to explore the correlative factors of sagittal imbalance.@*Results@#All of 56 patients were included and evaluated in this study, and 35 cases stopped at L 5, 21 cases at S1. The mean follow-up time was 6.6±1.6 years. No significant difference were found in age, gender, follow-up time and surgery method (P>0.05) between two groups. No significant differences were found in Cobb angle(11.8°±7.3° vs 12.6°±6.4°), coronal balance distance(CBD) (0.7±0.6 cm vs 1.0±0.5 cm), sagittal vertebral axis(SVA)(3.0±3.1 cm vs 2.6±5.6 cm), thoracic kyphosis(TK) (21.4°±9.6° vs 22.5°±6.9°), lumbar lordosis(LL) (-32.7°±7.3° vs-34.8°±9.1°), pelvic tilt (PT) (23.4°±9.8° vs 23.3°±8.1°), VAS score(2.0±1.2 vs. 2.2±0.9), ODI score(18.5%±6.4% vs 19.3%±5.2%) and SF-12 PCSscore(45.5±5.2 vs 42.4±7.0) between two groups at final follow-up time(P>0.05). Radiographic parameters including Cobb angle, CBD, SVA and health related quality of life scores including VAS score, ODI score and SF-12 PCS scores were improved significantly at two weeks postoperatively, two-year follow-up time andfinal follow-up time in two groupscompared with those preoperatively (P<0.05). And no significant difference were found in radiographic parameters and health related quality of life scores between those at two years follow-up time and those at final follow-up time; Sagittal complication rates at final follow-up were higher than these at two years follow-up (82.1% vs 33.9%, P=0.000). Sagittal imbalance was related to internal fixation failure in L 5 group (r=0.691, P=0.011), internal fixation failure in S1 group (r=0.691, P=0.001) and pseudoarticulation formation (r=0.499, P=0.021). 10 patients in the sagittal imbalance group were with preoperative sagittal imbalance, 9 with preoperative coronal imbalance, 6 with internal fixation failure, 5 with proximal junctional kyphosis (PJK), 4 with adjacent segment degeneration during the follow-up periods, the incidence rates of which were higher than those in the sagittal balance group. LL in the sagittal imbalance group was lower than that in the sagittal balance group at two years follow-up time and final follow-up time. Compared with the sagittal imbalance group, the sagittal balance group achieved a higher SF-12 PCS (45.4±5.1 vs 41.6±7.4, P<0.05) and lower ODI scores (17.8%±6.1% vs 21.5±4.6%, P<0.05), and no significant difference was found in VAS scores between two groups (1.9±1.2 vs 2.4±0.8, P>0.05). The incidence of adjacent segment degeneration in L 5 group was higher than that in S1 group (P<0.05) at final follow-up time, and the incidence of pseudojoint in S1 group was higher than that in L 5 group (P=0.002) at final follow-up time.@*Conclusion@#Posterior long segment instrumentation and fusion for adult degenerative spinal deformity can obtain satisfying long-term clinical outcomes, and postoperative sagittal imbalance was related to preoperative sagittal/coronal imbalance, postoperativeinternal fixation failure, PJK, pseudoarticulation formation and adjacent segment degeneration. Distal fusion at L 5 or S1 may lead to high risk of adjacent segment degeneration or pseudoarticulation formation respectively.
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Objective To investigate the long?term outcomes of posterior long segment instrumentation and fusion in adult degenerative scoliosis (ADS), and to explore the correlative factors of sagittal imbalance after long segment instrumentation and fusion, and to summarize the impacts of different lowest instrumented vertebra (LIV) on sagittal complication rates. Meth?ods ADS patients who underwent long segment instrumentation and fusion between January 2008 and January 2014 were retro?spectively reviewed and divided into two groups depended on LIV (L 5 group and S1 group). The follow?up time was at least five years. Radiographic parameters, Visual Analogue Score (VAS),Oswestry Disability Indexscore(ODI), the 12?item Short Form Health Survey?Physical Component Summary (SF?12 PCS)and sagittal complications were analyzed.And the correlation between sagittal imbalance and sagittal complications were calculated. Patients were divided into two groups(sagittal imbalance group and sagittal balance group) to explore the correlative factors of sagittal imbalance. Results All of 56 patients were included and evaluat? ed in this study, and 35 cases stopped at L 5, 21 cases at S1. The mean follow?up time was 6.6±1.6 years. No significant difference were found in age, gender, follow?up time and surgery method (P>0.05) between two groups.No significant differences were found in Cobb angle(11.8°±7.3°vs 12.6°±6.4°), coronal balance distance(CBD) (0.7±0.6 cm vs 1.0±0.5 cm), sagittal vertebral axis (SVA)(3.0±3.1 cm vs 2.6±5.6 cm), thoracic kyphosis(TK) (21.4°±9.6°vs 22.5°±6.9°), lumbar lordosis(LL) (-32.7°±7.3°vs -34.8°± 9.1°), pelvic tilt (PT) (23.4°±9.8°vs 23.3°±8.1°), VAS score(2.0±1.2 vs. 2.2±0.9), ODI score(18.5%±6.4% vs 19.3%±5.2%) and SF?12 PCSscore(45.5±5.2 vs 42.4±7.0) between two groups at final follow?up time( P>0.05). Radiographic parameters including Cobb angle, CBD, SVA and health related quality of life scores including VAS score, ODI score and SF?12 PCS scores were improved significantly at two weeks postoperatively, two?year follow?up time andfinal follow?up time in two groupscompared with those preop?eratively (P<0.05). And no significant difference were found in radiographic parameters and health related quality of life scores be?tween those at two years follow?up time and those at final follow?up time; Sagittal complication rates at final follow?up were higher than these at two years follow?up (82.1% vs 33.9%, P=0.000). Sagittal imbalance was related to internal fixation failure in L 5 group (r=0.691, P=0.011), internal fixation failure in S1 group (r=0.691, P=0.001) and pseudoarticulation formation (r=0.499, P=0.021). 10 patients in the sagittal imbalance group were with preoperative sagittal imbalance, 9 with preoperative coronal imbalance, 6 with internal fixation failure, 5 with proximal junctional kyphosis (PJK), 4 with adjacent segment degeneration during the follow?up periods, the incidence rates of which were higher than those in the sagittal balance group. LL in the sagittal imbalance group was lower than that in the sagittal balance group at two years follow?up time and final follow?up time. Compared with the sagittal imbal?ance group, the sagittal balance group achieved a higher SF?12 PCS (45.4 ± 5.1 vs 41.6 ± 7.4, P<0.05) and lower ODI scores (17.8%±6.1% vs 21.5±4.6%, P<0.05), and no significant difference was found in VAS scores between two groups (1.9±1.2 vs 2.4± 0.8, P>0.05). The incidence of adjacent segment degeneration in L 5 group was higher than that in S1 group (P<0.05) at final follow?up time, and the incidence of pseudojoint in S1 group was higher than that in L 5 group (P=0.002) at final follow?up time. Conclu?sion Posterior long segment instrumentation and fusion for adult degenerative spinal deformity can obtain satisfying long?term clinical outcomes, and postoperative sagittal imbalance was related to preoperative sagittal/coronal imbalance, postoperativein?ternal fixation failure, PJK, pseudoarticulation formation and adjacent segment degeneration. Distal fusion at L 5 or S1 may lead to high risk of adjacent segment degeneration or pseudoarticulation formation respectively.
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Objective To evaluate the clinical outcomes of K-line(-) ossification of posterior longitudinal ligament (OPLL) between single open-door posterior decompression with instrumented in situ fusion(PDF) and laminoplasty (LMP).Methods From February 2008 to February 2015,38 cases including 30 males and 8 females underwent posterior decompression due to K-line(-) OPLL in our institution.The age ranged from 48 to 76 years,mean 56.3±9.7 years.The OPLL canal occupation ratio ranged from 38.6％ to 72.5％,mean 58.1％± 13.6％.According to surgical procedures,26 cases were in PDF group and 12 cases were in LMP group.The data collected from both groups included complications,C2-C7 Cobb angle and neurologic symptoms evaluated based on the Japanese Orthopedic Association (JOA) score and JOA score recovery rate,and were analyzed with statistics in and between groups.Results All the patients were completed follow up with a mean of 3.6±2.1 years (range,2.5 to 7.0 months).At the final follow-up,the postoperative JOA score was 11.8± 1.9 points on average,improved from preoperative 7.7± 1.6 points (t=3.757,P＜0.05),the mean JOA score recovery rate was 44.2±6.7％in PDF group;and the postoperative JOA score was 9.1 ±2.1 points,improved from preoperative 7.9± 1.5 points (t=1.327,P＜0.05),the mean JOA score recovery rate was 29.5±5.0％ in LMP group.No significant difference was found in preoperative JOA score between the two groups (t=0.365,P＞0.05),however,there were significant differences in the postoperative JOA score (t=3.941,P＜0.05) and JOA score recovery rate (t=6.741,P＜0.05) at the final follow-up.In PDF group,the C2-C7 Cobb angle was 4.1±2.0°,similar with preoperative 3.8±1.6° (t=0.587,P＞0.05).On the contrary,the C2-C7 Cobb angle was-2.1°±1.8°,lower than preoperative 3.9°±1.2° (t=6.824,P＜0.05) in LMP group.Ten cases occurred C5 palsy (PDF:7;LMP:3),and 3 cases occurred wound infection (PDF:2;LMP:1).The complication rate was 34.6％ and 33.3％ (x2=0.003,P＞0.05),respectively.Conclusion Compared with LMP,PDF without correcting cervical alignment for patients with K-line(-) OPLL showed better neurological recovery and clinical efficacy.
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Objective To evaluate the safety and efficacy of the mini-open anterolateral lumbar interbody fusion (MO-ALLIF) in lumbar revision surgery.Methods Seventeen patients,seven male and ten female,who underwent revision lumbar surgeries using MO-ALLIF with self-anchored stand-alone polyetheretherketone (PEEK) cage in a single center between April 2013 and April 2016 were studied retrospectively.There were 14 of sing-level cases and 3 of double-level cases.Among them,11 cases were L4.5,4 cases were L3,4,5 cases were L5S1.There were 2 cases of cage migration,3 cases of pseudarthrosis,6 cases of recurrent lumbar disc herniation of the same level,and 6 cases of lumbar disc herniation on the adjacent level.The average age was 53.9±7.2 years (range,41-65 years).The clinical manifestation was low back pain and/or leg pain.The operation time,blood loss,and perioperative complications were evaluated.Oswestry disability index (ODI) and visual analog scale (VAS) score of leg and back pain were analyzed preoperatively and at each time point of follow-up postoperatively.Radiological evaluation including fusion,global lumbar lordosis,disc height on the operation level,foraminal height on the operation level,and subsidence were assessed.Results The average follow-up time was 22.7±8.6 months(12-48 months).Among the seventeen patients that participated in this study with a total of 20 segments,only one patient suffered from peritoneal rupture,but no symptom was observed after suturing.No other approach-related complications were found in all cases.The mean operation time was 74.0± 15.5 minutes.The average blood loss was 122.4±28.8 ml.All patients involved achieved solid fusion at the last followup (12 months post-operation) with no cage migration.Significant differences were observed between the pre-and post-operation status,with respect to the back pain VAS,leg pain VAS and ODI scores.The post-operative lumbar lordosis,disc height on the operation level and foraminal height on the operation level,were also significantly improved when compared with the pre-operative ones.Conclusion MO-ALLIF with self-anchored stand-alone PEEK cage is a modification of both anterior lumbar interbody fusion and oblique lumbar interbody fusion,which is safe and effective in some revision lumbar surgery with minor surgical trauma,low access-related complication rates,and satisfactory clinical and radiological results.
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Objective To investigate the efficiency of intraoperative neurophysiological monitoring in cervical spinal tumor surgery.Methods Retrospective case-control study comparing 23 cervical spinal tumor patients received surgery under neurophysiological monitoring (case) and 23 cases without neurophysiological monitoring (control).Results All of 46 cases,there were no significant differences of age,gender and preoperative neurological function.Duration of operation and estimated blood loss in the IONM cohort was less than the control group with significant difference.The preoperative JOA score of IONM group and control group were 12.0±2.4 and 12.7±2.1,with no significant difference.The postoperative JOA score of each group were 15.0±1.5 and 15.2±1.7,with no significant difference.The rate of cervical cord neurological improvement of IONM group was higher than control group,but there was no significant difference.In the IONM cohort,abnormal signal appeared in 8 cases,with 1 case developed new postoperative deficit,and the sensitivity and specificity of SEP were 100％ and 77.3％,the sensitivity and specificity of MEP were 100％ and 86.4％.Compared with preoperative SEP,4 cases showed major improvement (baseline increase ＞ 40％),2 cases showed moderate improvement (baseline increase:15％-40％).The coincidence rate of the SEP improvement and the AISA grade was 66.7％.Conclusion IONM could reduce the duration of operation and intraoperative blood loss.Changes of IONM were correlated with postoperative neurological function improvement.