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Objective:To simulate the placement of percutaneous cortical bone trajectory (CBT) screws on reconstructed CT images and three-dimensional lumbar model and to measure the morphometric parameters for guiding the placement of percutaneous CBT screws.Methods:The CT images of 100 adult patients with lumbar spine diseases were studied. The CT images were reconstructed using Mimics software. Taking the projection point on the lamina at the junction of the inner and lower edge of the smallest coronal section of lumbar pedicle as the entry point, the cephalad angle, lateral angle, maximum screw length, maximum screw diameter, distance between trajectory and spinous process were measured. At the same time, the relationship between the trajectory and spinous process was observed by using the reconstructed three-dimensional image.Results:The lateral angle of the trajectory from L 1 to L 5 were 9.3° (8.9°, 9.8°), 9.6° (8.9°, 9.8°), 10.4° (9.5°, 11.3°), 11.81°±1.24° and 13.6° (12.5°, 14.5°), respectively. The cephalad angle from L 1 to L 5 were 26.6° (26.0°, 27.0°), 26.2° (25.7°, 26.5°), 26.9° (26.5°, 27.4°), 25.94°±0.92° and 24.3° (22.7°, 25.4°), respectively. Significant statistic differences were found among all levels in the cephalad angles and lateral angles. The mean diameters of the trajectory from L 1 to L 5 were 5.65±0.49 mm, 6.38±0.60 mm, 6.91±0.67 mm, 7.42±0.76 mm and 8.33 (7.59, 9.01) mm, respectively. Except L 1 and L 5, there were significant differences among all levels in the maximum screw diameters. The mean length of the trajectory from L 1 to L 5 were 36.4 (35.4, 37.0) mm, 36.7 (35.8, 37.3) mm, 37.6 (37.1, 38.1) mm, 37.8 (37.3, 38.1) mm and 36.2 (35.2, 36.9) mm, respectively, and there were also significant differences among all levels. The ration in superior endplate for each segment were 41.08% (34.36%, 45.60%), 37.94% (32.97%, 43.63%), 40.18% (34.56%, 44.49%), 38.61% (34.80%, 46.24%) and 40.9% (35.32%, 46.02%), respectively and statistical differences were significant between L 1 and L 2 and L 2 and L 5. The mean distance between the trajectory and the spinous process from L 1 to L 5 were 7.27±1.23 mm, 7.19 (5.97, 8.28) mm, 7.32 (6.01, 8.28) mm, 7.31±1.36 mm and 7.45 (6.32, 8.23) mm, respectively. In the sagittal CT image, the tip of the trajectory located near the posterior two-fifths of the superior end plate, and the extended line of the trajectory located at the inferior edge of spinous process. In the three-dimensional reconstruction model, no obstruction was found between the simulated screws and the spinous process. Conclusion:Lumbar CBT screw can be implanted percutaneously, and spinous process will not hinder the implantation process. Spinous process and upper endplate can be used as a sign to guide the percutaneous CBT screw implantation. Digital analog screw placement can offer a useful reference for the clinical application of percutaneous cortical bone trajectory screw.
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Objective:To investigate CT classification of diffuse idiopathic skeletal hyperostosis (DISH), and to analyze the correlation between the position of ossification in the anterolateral spine and the sagittal configuration of the spine.Methods:The medical records of 109 patients (70 male and 39 female) who underwent whole spine computerized tomography (CT) from October 2018 to October 2020 were retrospectively analyzed. The average age was 68.4±6.9 years old, ranging from 60 to 88 years old. High resolution CT volume rendering technique images were used to assess the degree of anterolateral spinal ossification in each vertebral space, and a CT grading system was established. Sagittal parameters such as thoracic kyphosis (TK), lumbar lordosis(LL), cervical lordosis (CL), sacral slope (SS), and thoracolumbar junction angle (TLJ) of the patients were measured. The sagittal morphology of the spine was divided into four types using the modified Abelin-Genevois (AG) sagittal classification. In AG type 1 patients, the kyphotic vertex was located in the middle of the thoracic spine (T 4-T 11). In AG type 2 patients, there was no significant kyphotic vertex. In AG type 3 patients, the kyphotic vertex was located in the thoracolumbar segment (T 12-L 2). In AG type 4 patients, the kyphotic vertex was located in the upper thoracic segment (T 1-T 3). Inter-observer and intra-observer reliability were calculated by intra-group correlation coefficient ( ICC). Statistical analysis was conducted to investigate the correlation between different AG types and ossification location and severity. Results:The new DISH grading system classifies the severity of anterolateral spinal ossification in each intervertebral space into grades 0 to 3 with an intra-observer ICC value of 0.871 and inter-observer ICC value of 0.874. Combined with Resnick's DISH diagnostic criteria, 97 patients (89.0%) in this study had four consecutive intervertebral spaces with ossification grade 1 or above. For these patients, in T 4-T 11, the standardized ossification grade of AG type 1 was 1.24±0.69, greater than that of AG type 2 (0.84±0.71) and AG type 3 (1.00±0.70), and the differences were statistically significant ( F=23.101, P<0.001). In T 12-L 2, the standardized ossification grade of AG type 3 was 1.44±0.87, which was higher than AG type 1 (1.06±0.84) and AG type 2 (0.72±0.63), the differences were statistically significant ( F=14.008, P<0.001). In this study, no patients with kyphosis apex in the cervicothoracic region (AG type4) were found. In T 1-T 3, there was no statistical difference between the three groups ( F=0.303, P=0.738); in the whole thoracic and lumbar spine (T 1-L 5), there was statistically significant difference in the total ossification grade ( F=14.374, P<0.001), there was no statistical difference between AG type 1 and AG type 3 ( P=0.254), both of which were higher than AG type 2 ( P<0.001). Conclusion:The new DISH ossification grading system proposed in this study has high credibility, which can be used in DISH's study. This study confirmed that the region where the apex of kyphosis is located is prone to anterolateral ossification of the spine.
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Objective To review and analyze the clinical effect of combined posterior mini-invasive fixation with anterior debridement via small incision for the treatment of single segment lumbar vertebral tuberculosis. Methods Totally 31 cases with single segment lumbar tuberculosis (both borderline tuberculosis) without attachment involvement underwent one-stage anterior debridement, interbody fusion and posterior mini-invasive fixation from July 2010 to July 2015. Among these patients, 19 were male and 12 were female. The average age was (36.1±17.8) years old (ranged 21-61 years old). The average course of disease was 11(9, 12) months (ranged from 2 to 16 months). All were single segment involvement, and the involved segment was L2-3 in 7 cases, L3-4 in 10 cases, L4-5 in 6 cases, and L5-S1 in 8 cases. The clinical manifestations included lumbar back pain in 31 cases with an average pain visual analog score (VAS) of 7(6, 8) points. ASIA grade of spinal cord injury was E in 25 cases and D in 6 cases. Paravertebral abscess occurred in 22 cases and iliac fossa gravity abscess appeared in 9 cases. Kyphosis was observed in 12 cases and the average Cobb angle was 21° ± 6° . Quadruple anti-tuberculosis chemotherapy was used for at least 2 weeks preoperatively. Posterior mini-invasive fixation was fulfilled on prone position, including mini-invasive percutaneous screws in 18 cases and pedicle screw fixation via Wiltse approach in 13 cases. Posterior distraction and deformity correction were performed simultaneously for patients with kyphosis. Then the patients were changed to lateral position for anterior debridement, bone grafting and/or titanium mesh fusion. Results The average operation time was (204±54) min (ranged 160-240 min) in 31 patients, and the mean blood loss was (168±73) mL (ranged 100-300 mL). Delayed healing of anterior incision occurred in 1 case and the incision healed after two-week dressing of wound. The incision healed well in the rest 30 cases. No complications such as nerve function, blood vessel injury were found in patients. The VAS scores of the 3 days after operation were 1.3 ± 0.3 and 2.1 ± 1.4 in percutaneous group and Wiltse approach group, respectively, and the difference between them was statistically significant ( P<0.05). The VAS score of low back pain was 2(1, 3) points in all the 31 patients three months after operation, which was significantly lower than that before surgery (P<0.05). The six patients with neurological symptoms recovered to E grade after operation. The average Cobb angle correction was 15°±5° in 12 patients with kyphosis (P<0.05), which was significantly decreased compared with that before surgery (P<0.05). All patients were followed up for an average of (36.8 ± 9.3) months (ranged from 12 to 72 months). The clinical healing of tuberculosis was achieved at the final follow-up in all the 31 patients. No complications were observed, such as lumbar kyphosis, internal fixation loosening and breakage, dislocation and titanium mesh subsidence. Conclusion Mini-invasive posterior internal fixation and anterior debridement via small incision is effective for the treatment of single segment lumbar vertebral tuberculosis in lesion debridement and spine stability reconstruction by short segment fixation. This technique can reduce fused segments, surgical trauma of anterior approach and related complications.
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Objective To compare the clinical outcome of minimally invasive transforaminal lumbar interbody fusion (M-TLIF) and Wiltse-approach TLIF (W-TLIF) in treating single-level degenerative lumbar disease.Methods A retrospective review was performed on the 57 patients with single-level degenerative lumbar disorder managed via M-TLIF (n =27) and W-TLIF (n =30) from December 2009 to December 2010.In M-TLIF group degeneration at the L4-5 disc were noted in 11 cases and at the L5-S1 disc in 16 cases.And 19 cases were diagnosed with lumbar isthmus spondylolisthesis (17 with Grade Ⅰ spondylolisthesis and 2 with Grade Ⅱ spondylolisthesis),4 lumbar spinal stenosis and instability,2 lumbar disc herniation combined with huge posterior osteophytes,1 recurrent lumbar disc herniation after lumbar fenestration,and 1 recurrent lumbar spinal stenosis after decompression.In W-TLIF group degeneration at L4～5 disc were noted in 12 cases and at the L5-S1 disc in 18 cases.There were 19 cases diagnosed with lumbar isthmus spondylolisthesis (18 with Grade Ⅰ spondylolisthesis and 1 with Grade Ⅱ spondylolisthesis),3 with lumbar disc herniation,and 8 with lumbar spinal stenosis.Japanese Orthopedic Association (JOA) score and Visual Analogue Scale (VAS) were used to measure low back and leg pain.Modified Brantigan score was used to assess lumbar interbody fusion.Results Operative time was not significantly different between the two groups (P ＞ 0.05).Incision length and mean blood loss were (5.1 ± 0.7) cm and (90.1 ± 10.5) ml in M-TLIF group,but were (6.9 ± 1.0)cm and (155.3 ±21.2)ml in W-TLIF group (P＜0.05).At postoperative 1 and 3 days VAS in M-TLIF group was (2.1 ± 0.5) points and (1.0 ± 0.1) points respectively,but in W-TLIF group was (3.6 ± 0.1) points and (2.4 ± 1.0) points respectively (P ＜ 0.05).Intraoperative X-ray fluoroscopy frequencies were (46 ± 9) times in M-TLIF group and (7 ± 2) times in W-TLIF group (P ＜ 0.05).Mean period of follow-up was 26.7 months (range,24-36 months).At final follow-up,JOA score,VAS for leg pain and lumbar interbody fusion rate revealed no significant differences between the two groups (P ＞ 0.05),but VAS for lumbar pain was (1.0 ± 0.2) points in M-TLIF group versus (1.9 ± 0.3) points in W-TLIF group (P ＜0.05).Twenty-four cases (89％) had Brantigan score of 3 or over in M-TLIF group and 27 cases (90％) in W-TLIF group,indicating a similar interbody fusion rate (P ＞ 0.05).Conclusions Both lumbar fusion methods are effective in treatment of lumbar degenerative disease.M-TLIF lumbar fusion results in small amount of bleeding,small incision and significantly improved lower back pain as compared with W-TLIF,but W-TLIF involves less exposure to the X-rays.