Evidence-based guideline for clinical diagnosis and treatment of acute combination fractures of the atlas and axis in adults (version 2023) / 中华创伤杂志

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.

Clinical guideline for diagnosis and treatment of adult ankylosing spondylitis combined with thoracolumbar fracture (version 2023) / 中华创伤杂志

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.

Predictive effect of the preoperative ratio of C reactive protein to albumin on perioperative delirium in geriatric patients with femoral intertrochanteric fracture / 中华创伤骨科杂志

Objective:To explore the clinical predictive effect of the preoperative ratio of C reactive protein to albumin (CAR) on perioperative delirium (POD) in geriatric patients with femoral intertrochanteric fracture.Methods:The clinical data were analyzed retrospectively of the 398 patients who had undergone surgery for femoral intertrochanteric fractures at Department of Orthopedics, Xuanwu Hospital from January 2013 to March 2016. According to the presence or absence of POD, all the patients were divided into 2 groups: a delirium group and a normal group. The 2 groups were compared in terms of general clinical data like gender, age, body mass index, blood routine, CAR, biochemical indicators, blood coagulation indicators and concomitant internal diseases. After a single factor logistic regression analysis of the general clinical data of the patients, factors with P<0.10 were introduced into the multivariate logistic binary regression model to screen out the risk factors for POD in geriatric patients with femoral intertrochanteric fracture. The receiver operating characteristic (ROC) curve was drawn to analyze the predictive value and optimal cut-off point of CAR for POD in geriatric patients with femoral intertrochanteric fracture. Results:The incidence of POD in this cohort was 14.32%(57/398). The age, C-reactive protein, CAR, platelet and probability of pulmonary infection in the delirium group were significantly higher than those in the normal group, but the hemoglobin, albumin and prealbumin in the former were significantly lower than those in the latter ( P< 0.05). The multivariate logistic binary regression analysis showed that hemoglobin ( OR=0.975, 95% CI: 0.957 to 0.993, P=0.006) and CAR( OR=53.713, 95% CI: 17.713 to 162.876, P<0.001) were risk factors for POD in geriatric patients with femoral intertrochanteric fracture. The area under ROC of CAR in predicting POD in geriatric patients with femoral intertrochanteric fracture was 0.906 (95% CI: 0.873 to 0.933, P<0.001), and the cut-off point was 2.06. When CAR>2.06, its predicted incidence of POD was 50.50%, with a sensitivity of 89.47% and a specificity of 85.34%. Conclusion:As CAR is a risk factor for POD in geriatric patients with femoral intertrochanteric fracture, it can be used as an effective indicator to predict POD.

Clinical guideline for surgical treatment of symptomatic chronic osteoporotic vertebral fractures / 中华创伤杂志

According to the pathological characteristics of symptomatic chronic thoracic and lumbar osteoporotic vertebral fracture (SCOVF), the different clinical treatment methods are selected, including vertebral augmentation, anterior-posterior fixation and fusion, posterior decompression fixation and fusion, and posterior correction osteotomy. However, there is still a lack of a unified understanding on how to choose appropriate treatment method for SCOVF. In order to reflect the new treatment concept and the evidence-based medicine progress of SCOVF in a timely manner and standardize its treatment, the clinical guideline for surgical treatment of SCOVF is formulated in compliance with the principle of scientificity, practicability and advancement and based on the level of evidence-based medicine.

Asymmetric degeneration of paravertebral muscles in degenerative lumbar scoliosis and potential significance / 中华骨科杂志

Objective@#To measure the cross-sectional area (CSA) and fatty infiltration (FI) of lumbar paravertebral muscles in patients with degenerative lumbar scoliosis (DLS), and to analyze the mechanism and clinical significance of paravertebral muscles degeneration.@*Methods@#A retrospective study was performed on 118 patients with DLS who were enrolled in our hospital from September 2016 to September 2017. All patients had complete preoperative image data. Preoperative lumbar lordosis (LL), Cobb angle, and vertebral rotation were measured on spinal X-ray plain film. The CSA and FI of the paravertebral muscle on the upper and lower intervertebral level of the scoliosis apical vertebrae were measured by lumbar MRI, and the CSA, FI and their correlation with the Cobb angle were compared.@*Results@#This study enrolled 118 DLS patients, including 49 males and 69 females. The mean age of the patients was 65.4 ± 7.2 years, with an average BMI of 24.7 ± 3.4 and lumbar symptoms including LBP, sciatica, numbness and intermittent claudication, decreased myodynamia and other symptoms. The lasting time of symptoms were 21 months (3-60 months). The Cobb angle of the patients averaged 18.5°±6.7°. Of all patients, 60 patients had a scoliosis to the left, and 58 patients had a scoliosis to the right. The number of patients with lateral apical vertebrae located at L1-L4 were: 12 cases of L1, 41 cases of L2, 49 cases of L3, 16 cases of L4. The CSA of the concave side psoas muscle was significantly larger than that of the convex side(upper intervertebral level, concave side 3.74±2.17 cm2, convex side 3.56±1.91 cm2; lower intervertebral level, concave side 6.54±3.08 cm2, convex side 6.31±3.302 cm2. And the CSA of the concave side multifidus muscle and the extensor muscle group was significantly smaller than the convex side, multifidus muscle: upper intervertebral level, concave side 9.47±3.86 cm2, convex side 10.25±4.20 cm2; lower intervertebral level, concave side 9.30±3.61 cm2, convex side 10.21±3.81 cm2; extensor muscle group: upper intervertebral level, concave side 18.35±4.94 cm2, convex side 19.37±5.17 cm2; lower intervertebral level, concave side 18.98±4.73 cm2, convex side 19.81±5.16 cm2. The concave side FI of extensor muscle group is significantly larger than the convex side, upper intervertebral level, concave side 30.63±15.09, convex side 23.48±15.00; lower intervertebral level, concave side 37.87±19.38, convex side 30.43±16.89. There was a correlation between the degree of asymmetry of CSA and FI in the multifidus, dorsal extension muscles, paravertebral muscle and the scoliosis Cobb angle.@*Conclusion@#The paravertebral muscles of lumbar vertebrae are not a whole in the degenerative changes of DLS. There are different anatomical and physiological effects of lumbar flexion and extension muscle groups. The extensor muscles play an important role in antagonizing the progression of DLS. Improving paravertebral muscle function is an important element in the treatment of DLS.

Asymmetric degeneration of paravertebral muscles in degenerative lumbar scoliosis and potential significance / 中华骨科杂志

To measure the cross?sectional area (CSA) and fatty infiltration (FI) of lumbar paravertebral mus?cles in patients with degenerative lumbar scoliosis (DLS), and to analyze the mechanism and clinical significance of paravertebral muscles degeneration. Methods A retrospective study was performed on 118 patients with DLS who were enrolled in our hospi?tal from September 2016 to September 2017. All patients had complete preoperative image data. Preoperative lumbar lordosis (LL), Cobb angle, and vertebral rotation were measured on spinal X?ray plain film. The CSA and FI of the paravertebral muscle on the upper and lower intervertebral level of the scoliosis apical vertebrae were measured by lumbar MRI, and the CSA, FI and their correlation with the Cobb angle were compared. Results This study enrolled 118 DLS patients, including 49 males and 69 fe?males. The mean age of the patients was 65.4 ± 7.2 years, with an average BMI of 24.7 ± 3.4 and lumbar symptoms including LBP, sciatica, numbness and intermittent claudication, decreased myodynamia and other symptoms. The lasting time of symptoms were 21 months (3-60 months). The Cobb angle of the patients averaged 18.5°±6.7°. Of all patients, 60 patients had a scoliosis to the left, and 58 patients had a scoliosis to the right. The number of patients with lateral apical vertebrae located at L1-L4 were: 12 cases of L1, 41 cases of L2, 49 cases of L3, 16 cases of L4. The CSA of the concave side psoas muscle was significantly larger than that of the convex side(upper intervertebral level, concave side 3.74±2.17 cm2, convex side 3.56±1.91 cm2; lower intervertebral lev?el, concave side 6.54±3.08 cm2,convex side 6.31±3.302 cm2. And the CSA of the concave side multifidus muscle and the extensor muscle group was significantly smaller than the convex side, multifidus muscle: upper intervertebral level, concave side 9.47±3.86 cm2, convex side 10.25±4.20 cm2; lower intervertebral level, concave side 9.30±3.61 cm2, convex side 10.21±3.81 cm2; extensor muscle group: upper intervertebral level, concave side 18.35±4.94 cm2, convex side 19.37±5.17 cm2; lower intervertebral level, concave side 18.98±4.73 cm2, convex side 19.81±5.16 cm2. The concave side FI of extensor muscle group is significantly larger than the convex side, upper intervertebral level, concave side 30.63±15.09, convex side 23.48±15.00; lower intervertebral level, concave side 37.87±19.38, convex side 30.43±16.89. There was a correlation between the degree of asymmetry of CSA and FI in the multifidus, dorsal extension muscles, paravertebral muscle and the scoliosis Cobb angle. Conclusion The paravertebral mus?cles of lumbar vertebrae are not a whole in the degenerative changes of DLS. There are different anatomical and physiological ef?fects of lumbar flexion and extension muscle groups. The extensor muscles play an important role in antagonizing the progression of DLS. Improving paravertebral muscle function is an important element in the treatment of DLS.

An imaging study on effect of total artificial disc replacement on lumbar sagittal alignment / 中华外科杂志

<p><b>OBJECTIVE</b>To investigate effect of Activ L total lumbar disc replacement on lumbar sagittal alignment.</p><p><b>METHODS</b>The imaging data of patients with degenerative disc disease received Activ L total lumbar disc replacement at Department of Orthopedics, Beijing Chao-Yang Hospital, Capital Medical University from March 2009 to March 2013 were retrospectively analyzed. The average age was 45.6 years(range, 35-60 years)and the surgery levels were as follows: L3-4 2 cases, L4-5 15 cases, L5/S1 5 cases, L3-4+ L4-5 3 cases, L4-5+ L5/S1 7 cases. All patients were followed up for 15 to 63 months(average, 32 months). Radiographic parameters such as lumbar lordosis angle(LL), segment lordosis angle(SL) and sacral slope angle(SS) were recorded. All the radiographic parameters were compared using one-way ANOVA at different stage. Lumbar lordosis angle of the two-level was compared with the one of one-level by using independent sample t-test before and after the operation. A partial correction test was carried out to determine the corrections between the parameters preoperatively, one month after the operation and at final follow-up.</p><p><b>RESULTS</b>One month after the operation, the lumbar lordosis angle decreased by an average of 1.8°, but there was no statistically significant(P>0.05). Compared with one month postoperation, the lumbar lordosis angle increased by an average of 6.8°(P<0.05), which also increased a lot compared with preoperation(P<0.05). The value of segment lordosis angle was rising up from preoperation to the final follow-up(P<0.05), so was the value of sacral slope angle, but there was no statistically significant between different stage(P>0.05). The lumbar lordosis angle showed no significant difference between double-level ones and single-level ones at different stage(P<0.05). The lumbar lordosis angle showed positive correlation with the sacral slope(P<0.001), however, the lumbar lordosis angle showed no corrected with the segment angle all the time(P>0.05).</p><p><b>CONCLUSIONS</b>The total lumbar disc replacement with Activ L prosthesis had contributed to maintain and improve the lumbar alignment in the short and medium term. Double- or single-level total lumbar disc replacement had no significant effect on the value of lumbar lordosis angle. The lumbar lordosis angle showed positive correlation with the sacral slope all the time with no correlation between lumbar lordosis angle and sacral slope.</p>

Study on the morphology of sagittal of lumbar endplate in healthy adult / 中华外科杂志

<p><b>OBJECTIVE</b>To provide a theoretical basis for designing of lumbar intervertebral disc prosthesis by collecting the data of the lumbar endplate morphology.</p><p><b>METHODS</b>A total of 100 healthy adults were measured about the following parameters: lumbar lordosis, the Cobb angle of each segment, the concavity depth (ECD) of the endplate, the location of concavity apex (ECA) of the endplate. And a correlation analysis on lumbar lordosis and ECD, ECA was made, respectively.</p><p><b>RESULTS</b>In total, 100 volunteers were measured. The mean age of the volunteer was 40 years (range 20 - 50 years); the average depth of ECD was (2. 37 ± 1. 42) mm, the average location of ECA was (52. 21 ± 9. 70) %; the average depth of ECD of inferior endplate (IEP) was (2. 81 ± 1. 52) mm (0. 54 - 7. 60 mm), and the parameter of the superior endplate (SEP) was (1. 94 ± 1. 16)mm(0. 39 - 6. 10 mm). The average depth of ECD of the IEP was bigger than of the SEP for each lumbar vertebral body. Most of the location of ECA was at the back of the intervertebral body, the average location of ECA of IEP was (49. 60 ± 8. 78) % (22. 57% - 75. 58%), and the parameter of the SEP was (55. 03 ± 9. 90) % (16. 03% -75. 58%); the mean angle of lumbar lordosis was 39. 760 11. 25°(13. 8° - 72. 00°). There was no obvious correlation between the lumbar lordosis and the ECD (r -0. 193, P =0. 195), neither was the location of ECA(r =0. 080, P =0. 592).</p><p><b>CONCLUSION</b>Most of the location of ECA is at the back of the intervertebral body, the average depth of ECD is 2. 37 mm, the average location of ECA is 52. 21%.</p>

Cervical radiculopathy treatment experts' consensus to establish radiculopathy type by using the modified Delphi meth-od / 中华骨科杂志

Objective Cervical radiculopathy treatment experts' consensus to establish radiculopathy type by using the modified Delphi method. Methods Use document retrieval method to review information and articles about the treatment guidelines and articles of cervical radiculopathy including domestic and international areas, established a protocol about clini?cal consensus of the treatments for cervical radiculopathy. This protocol included 23 questions (the effective proportion of non?operating therapy, neck immobilization, physiotherapy, pharmacologic treatment, surgical indications, contraindications, anteri?or surgical decompression, anterior surgical implants). We performed a modified Delphi survey in which current professional opinions from experienced experts, representing from almost all of the Chinese provinces, were gathered. And then we modi?fied the protocol according to those professional opinions. Three rounds were performed and finally we established consensus. Consensus was achieved with ≥70% agreement. Results The panel included 30 experienced experts. The recycling question?naire's quantity of three rounds were 30(100%), 24(80%) and 16(53.3%) respectively. After three expert assessments, there were 18 questions which achieved with≥70%agreement and these questions accounted for 64.3%(18/28) of all the questions. Consen?sus of the treatments for cervical radiculopathy was reached on 7 aspects, including:the effective proportion of non?operating thera?py (1 question), neck immobilization (1 question), physiotherapy (1 question), pharmacologic treatment (5 questions), surgical indi?cations (3 questions), contraindications (4 questions), surgery (3 questions). Conclusion This modified Delphi study had reached a consensus concerning several treatment issues on cervical radiculopathy which had strong representativeness of experts and good convergence of opinions. In the absence of high?level evidence, at present, these experts' opinion findings will guide health care providers to define appropriate treatment in their regions. Areas with no consensus provide excellent insight for future research.

The optimal insertion position of the lumbar interspinous dynamic stabilization device (Coflex): a biomechanical evaluation / 中华外科杂志

<p><b>OBJECTIVE</b>To evaluate the optimal insertion position of the Coflex lumbar interspinous dynamic stabilization device.</p><p><b>METHODS</b>Six fresh adult human cadaveric lumbar spine specimens (L1-L5) were mounted in a materials testing machine by embedding to clamps with L1 and L5 vertebrae. L3-4 motion segment of each specimen was operated by selective decompression and Coflex interspinous device insertion. The L3 and L4 vertebrae was inserted one needle attached with four marker points respectively, which were used to record the range of motion (ROM). Each lumbar spine specimen was tested according to the loading sequence at 5 groups: intact (keeping lumbar ligamenta and facet joints intact) group, partial destabilized (resection of L3-4 interspinous ligamenta, ligamentum flavum, facet capsule, and bilateral resection 50% of L3 inferior facets) group, 10 mm insertion (distance between apex of U-shaped Coflex and dural sac was 10 mm)group, 5 mm insertion (distance was 5 mm)group, and 0 mm insertion (distance was 0 mm)group. Each lumbar spine specimen was tested repeatedly 3 times according to a loading sequence consisting of flexion, extension, left/right lateral bending, left/right axial rotation, loaded with pure moments of 8 N·m, and was recorded the ROM of operative segment at the third time. ROM of 5 groups in 6 directions respectively were analyzed with one-way ANOVA test and multiple comparisons were based on LSD method.</p><p><b>RESULTS</b>The means ROM of 5 groups were not all equal in flexion, extension, left/right lateral bending, left/right axial rotation (F = 8.472, 18.301, 7.700, 12.473, 16.809, 6.624; all P < 0.01). The 10 mm insertion group had significant high ROM in 6 directions than the intact group (t = 3.80, 3.82, 4.49, 5.60, 4.96, 2.98, all P < 0.01), but it was no difference comparing with the partial destabilized group (P > 0.05). The ROM of the 5 mm and 0 mm insertion group were no significant differences comparing with the intact group in flexion, extension, left/right axial rotation (P > 0.05), but it were significant differences comparing with the partial destabilized group in the same directions (5 mm insertion group: t = 3.19, 6.34, 5.26, 3.43, all P < 0.01; 0 mm insertion group: t = 4.21, 6.68, 5.81, 3.72, all P < 0.01). There were significant differences in the ROM of left/right lateral bending between the 5mm/0mm insertion groups and the intact group (5 mm insertion group: t = 3.71 and 5.22, all P < 0.01; 0 mm insertion group: t = 3.44 and 4.95, all P < 0.01), but there were no differences comparing with the partial destabilized group in the same directions (P > 0.05).</p><p><b>CONCLUSIONS</b>The insertion of Coflex interspinous dynamic stabilization device can maintain the stability of a partially destabilized specimen back to an intact one in flexion, extension and axial rotation when distance between apex of U-shaped Coflex and dural sac was ≤ 5 mm, but can't return the stability in lateral bending. The Coflex can't return the stability of a partially destabilized specimen back to an intact one in 6 directions when distance between apex of U-shaped Coflex and dural sac was ≥ 10 mm.</p>

Cervical spinal cord injuries without radiographic abnormality: classification and surgical treatment / 中华骨科杂志

Objective To investigate the traumatic characters, the causative factors and the outcomes of surgical treatments of cervical spinal cord injuries without radiographic abnormality(SCIWORA).Methods From March 2000 to July 2004, 81 patients of cervical SCIWORA undergone surgery were evaluated retrospectively. There were 55 males and 26 females, with a mean age of 57.3 years. According to the mechanisms of injuries and pathological changes of the cervical spine, the causative factors were divided into 3 groups: hyper-flexion type of injury (1 or 2 segments) with protrusion or prolapse of the cervical intervertebral discs (19 cases), hyper-extension type injury with multiple (≥3 segments) cervical spinal stenosis (41cases), and whiplash injury with multiple cervical spinal stenosis and segmental intervertebral instability or anterior protrusion of the cervical intervertebral discs (21 cases). A variety of surgeries as anterior discectomy with interbody fusion, multiple posterior decompressions with cervical laminoplasty, and multiple posterior decompressions with internal fixation at the facet joints were performed based the classification. Results The average follow-up period was 78.5 month (54-118 months). During the follow-up of 1 month, 3 months,1 year and last visit post-operatively, the rate of JOA improvement were 25.1%, 41.3%, 63.6% and 60.9%respectively. In the long-term follow-up, the good ratio of neurological function was obtained with 80.2%.Conclusion SCIWORA is considered as a course of acute, dynamic and limited injury. In spite of common clinical manifestation, its traumatic characters and causative factors are different indeed. The distinct improvement of neurological function can also be achieved with proper classification and surgery.

Exogenous carbon monoxide protects against the lung injury induced by ischemia-reperfusion of hind limbs in rats / 中国病理生理杂志

AIM: To study the mechanism of protective effect of exogenous carbon monoxide (CO) in the lung injury induced by ischemia-reperfusion (IR) of hind limbs in rats. METHODS: Thirty-two SD rats were randomly divided into 4 groups: control, control+CO, IR and IR+CO. A rat model of ischemia in hind limbs and the reperfusion lung injury was made. The rats in IR+CO and control+CO groups were exposed to air containing 2.5?10~ -8 CO for 1 h before reperfusion or the corresponding control time point, while the other two groups were exposed to the routine air. The lung tissue structure, polymorphonuclear leukocyte (PMN) count, wet-to-dry weight ratio (W/D), malondialdehyde (MDA) content and the animal survival rate were observed. The carboxyhemoglobin (COHb) levels in artery blood were detected with CO-oximeter and the expression of intercellular adhesion molecule-1 (ICAM-1) in the lung was detected by Western blotting. RESULTS: Compared to control, the animal mortality, lung PMNs number, W/D , MDA content and ICAM-1 expression were all significantly increased in IR group. Compared with the IR group, the blood COHb level was significantly increased and the animal mortality, lung PMNs number, W/D, MDA content and ICAM-1 expression were all significantly decreased in IR+CO group. CONCLUSION: These data suggest that exogenous CO attenuate limb IR- induced lung injury by down-regulatiny ICAM-1 expression and suppressing PMN sequestration in the lung following limb IR in rats.