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.

Analysis of reoperation rate and risk factors of adjacent segment disease after transforaminal lumbar interbody fusion / 中华骨科杂志

Objective:To explore the reoperation rate and risk factors of adjacent segment disease (ASDis) in patients with lumbar degenerative diseases after transforaminal lumbar interbody fusion (TLIF).Methods:The clinical data of 460 patients who underwent TLIF for lumbar degenerative diseases in our hospital from January 2011 to December 2013 were retrospectively analyzed. There were 204 males and 256 females with an age of 54.6±12.6 years (range, 20-85 years). Divided into ASDis group and None ASDis (N-ASDis) group according to the occurrence of ASDis and received surgical treatment. The age of ASDis group was 57.9±12.2 years, with 14 males and 12 females, while the age of N-ASDis group was 54.4±12.5 years, with 188 males and 246 females. Count the reoperation rate of ASDis. Compare the age, body mass index (BMI), comorbidities, surgery-related parameters, length of stay, imaging parameters before and after surgery between the two groups, and use univariate analysis and logistic regression analysis to explore risk factors for ASDis.Results:Among 460 patients who underwent TLIF due to lumbar degenerative diseases, 26 patients developed ASDis and received surgical treatment, the reoperation rate was about 5.7%. Among them, the reoperation rate of ASDis with above Pfirrmann grade III in the adjacent intervertebral disc was about 53.1% (17/32). The average onset time of adjacent segment disease was 76.3±25.0 months (range, 30-111 months). Univariate analysis showed that BMI ( t=3.86, P<0.001), history of hypertension (χ 2=5.30, P=0.021), preoperative adjacent vertebral disc degeneration (χ 2=85.90, P<0.001), preoperative adjacent spinal canal stenosis (χ 2=25.35, P<0.001), and preoperative intervertebral space height of adjacent segments ( t=4.33, P<0.001) were statistically different among patients with or without ASDis. Incorporating the above indicators into the logistic regression model, the analysis results showed that body mass index (BMI) >24.9 kg/m 2 and preoperative adjacent intervertebral disc degeneration ≥III degree were risk factors for ASDis after TLIF. Conclusion:The reoperation rate of ASDis after TLIF in patients with lumbar degenerative disease is about 5.7%. BMI>24.9 kg/m 2 and preoperative adjacent intervertebral disc degeneration ≥III degree are risk factors for ASDis and received surgical treatment after TLIF.

Single-stage posterior total En bloc spondylectomy for the treatment of metastatic tumors of the lower lumbar spine / 中华骨科杂志

Objective:To investigate the feasibility and clinical outcome of single-stage posterior total en bloc spondylectomy via posterior approach for lowerlumbar spinal malignant tumors.Methods:The clinical data of 23 patients with metastatic tumors of the lower lumbar spine who underwent single-stage posterior total En bloc spondylectomy in our hospital from January 2012 to June 2018 were analyzed retrospectively. There were 14 males and 9 females, age 57.9±10.8 years old (range, 37-74 years old). All patients were treated with single-stage posterior total en blocspondylectomy, titanium mesh implantation and posterior pedicle screw fixation. Observation items included operation time, intraoperative blood loss, postoperativehospital stays,the visual analogue scale (VAS) and the Eastern Cooperative Oncology Group (ECOG) physical condition score of the patients before operation,1 month after operationand 6 months after operation, the American spinal injury association (ASIA) spinal cord injury grade pre-operation andpostoperation, perioperative complications, local recurrence and survival state.Results:The median fellow-up time of this group was 20 months (range 6-56 months). At the end of the last follow-up, there were 3 patients who survived, the average follow-up time of the three patients who survived to the last follow-up was 37.3±11.7 months. One of them had local recurrence, but survived with tumor. The operative time was 155-510 min, with an average of 258±96 min, the intraoperative blood loss was 750-2 500 ml, with an average of 1 258.7±528.6 ml, and the postoperative hospital stay was 10-30 d, with an average of 18.4±4.6 d. VAS score decreased from 7.4±0.8 before operation to 2.6±0.6 1 month after operation, and ECOG score decreased from 1.6±0.9 before operation to 0.9±0.76 months after operation, showing statistically significant differences ( P<0.05). 6 patients presented with postoperative acute nerve root stimulation, 3 patients presented with postoperative cerebrospinal fluid leakage, 3 patients presented with postoperative surgical site infection, 1 with pulmonary infection, and 3 patients presented with titanium mesh displacement. Conclusion:Single-stage posterior total En bloc spondylectomy is feasible for the treatment of metastatic tumors of the lower lumbar spine. Although the operation is quite challenging due to its special anatomical structure and biomechanical characteristics,the long-term follow-up effect is satisfactory.

A surgical classification system for the management of axial primary malignant and aggressive benign tumors and its application in multiple tertiary centers / 中华骨科杂志

Objective:To propose and verify a surgical classification system for the axial primary malignant and aggressive benign tumor.Methods:The CZH surgical classification system was originally developed for the axial primary malignant and aggressive benign tumor. The CZH surgical classification system includes seven types, according to the anatomic features and the extension of tumor violation. A total of 136 patients (79 males and 57 females) with axial primary malignant and aggressive benign tumor from multiple tertiary centers who received surgery from July 2006 to July 2019 were included. The average age was 44.40±17.55 years (8-83 years) old. There were 99 malignant tumors and 37 aggressive benign tumors included. The number of patients with each classification was presented as followed, Type I 13, Type II 15, Type IIIa 3, Type IIIb 20, Type IVa 43, Type IVb 12, Type Va 21, Type Vb 3, Type VI 2, Type VIIa 3 and Type VIIb 1. Surgical procedures were selected according to different types in classification. The inter- and intra-observer consistencies were evaluated by the Kendall's W test. The VAS, Frankel score, overall survival and recurrence free survival were recorded during the follow-up. Results:The inter- and intra-observer consistent coefficient was 0.973 and 0.996, respectively ( P<0.05). The single posterior approach was adopted for the Type II tumors. Other patients underwent surgery by the combined antero-posterior approach. The majority in anterior approach (113 cases) was the modified submandibular approach. The reconstruction modes included anterior "T" shape titanium mesh (112 cases) or the 3D printed prothesis (7 cases) combined with the posterior occipto-cervical fusion (92 cases) or the pedicle screw system (44 cases). The average surgical duration and the volume of intraoperative bleeding was 348.40±136.14 min (60-760 min) and 1 225.69±859.40 ml (80-4 000 ml), respectively. The operation duration and volume of intraoperative bleeding among each type were with statistical difference. The patients with Type IV, V tumors had longer operation duration than those with Type II tumors. Those with Type V and VII tumors had longer operation duration than those with Type I tumors. The patients with Type V tumors had more intraoperative bleeding than those with Type I-IV tumors. The average preoperative VAS score was 4.15±2.25 and then was reduced significantly to 0.62±0.71 and 0.38±0.59 at one and three months after operation, respectively. The Frankel score was also significantly ameliorated at one and three months postoperatively. There were 22 postoperative complications (16.2%). The complications included cerebral spinal fluid leak (12.5%), dysphagia and/or dysphonia (7.4%), dyspnea (5.1%), wound infection (3.7%), wound hemorrhage (2.2%) and pharyngeal dehiscence (1.5%). The incidence of postoperative complication was 25.9% in Type IV-VII tumors, while 11.8% in Type I-III tumors. Conclusion:CZH surgical classification system was verified with high observer consistency. This classification system could assist surgeons to select proper surgical approaches, resection modes and reconstruction modes, and thus ensure the safety of surgery and reduce the recurrence. The tumors in Type IV, V and VII may be with more challenging for surgeons. The incidence of postoperative complication in Type IV-VII tumors may be higher than that in Type I-III tumors.

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.

Primary pathological changes of spinal cord tissues of human complete spinal cord injury and their significance / 中华创伤杂志

Objective To investigate the pathological changes of spinal cord tissues after spinal cord injury and their significance for clinical diagnosis and treatment of complete spinal cord injury.Methods Patients with complete spinal cord injury were selected.Mter rigorous ethical review and patient informed consent,damaged section of the spinal cord and necrotic tissue were removed and transplanted with the function biological material with autologous stem cell.The specimen of injured spinal cord collected during the operation were divided into three phases according to injury time:3 cases of acute phase (≤ 3 days),3 cases of subacute phase (4-14 days),and 1 case of chronic phase (＞ 14 days).The pathological changes of injured spinal cord tissue were observed through HE staining,and the expression of hypoxia inducible factor 1α (HIF-1α),tumor necrosis factor (TNF-α),microtubule-associated protein(MAP2) were detected by immunofluorescence.Results (1) HE staining showed that the acute injury mainly manifested as diffuse hyperemia and liquefaction,subacute injury infiltration of inflammatory cells and spinal cord liquefaction,and chronic injury mainly scar repair.(2)The fluorescence intensity (24.67 ±0.51) of HIF-1o in chronic injury was higher than acute (3.17 ± 0.40) and subacute injury (4.62 ± 0.48) (P ＜ 0.05),and the fluorescence intensity of subacute injury was higher than that of acute injury (P ＜ 0.05).(3) The fluorescence intensity (17.60 ± 1.17) of TNF-α in subacute injury was higher than that of acute injury (5.35 ± 0.33) and chronic injury (1.81 ± 0.17) (P ＜0.05);(4) The fluorescence intensity of MAP2 was 9.46 ±0.41 in acute injury,higher than 3.25 ± 0.42 in subacute injury and 1.16 ± 0.08 in chronic injury (P ＜ 0.05).Conclusions There are hypoxia,inflammation,neuronal apoptosis and repair in the spinal cord tissues after complete spinal cord injury,such as hyperemia,liquefaction,necrosis and gradual scar repair.The severity of inflammation and hypoxia significantly differs among different injury phases.The inflarmnatory cytokines are mainly active in the microenvironment during subacute injury.Hypoxia is mainly involved in the pathological changes of chronic injury.This can provide a new theoretical basis for the clinical treatment of complete spinal cord injury and the timing of surgical treatment.

Effect of lung cancer bone metastasis on serum osteocalcin levels in Chinese population:a meta-analysis of case-control studies / 局解手术学杂志

Objective To evaluate the effect of lung cancer bone metastasis on serum osteocalcin(OC)in Chinese population using me-ta-analysis.Methods Searched the date of PubMed,Web of science,Embase,Cochrane Library,CBM,CNKI,VIP database and Wanfang da-tabase to identify potentially studies which involved the correlation between bone metastasis and serum OC in Chinese patients with lung canc-er.Standardized mean difference(SMD)and 95%CI was used to access the results.Results 8 studies were included.The study showed that the OC in serum would increase significantly when bone metastases happened in Chinese lung cancer patients.SMD(95%)CI was 0.58 [0.15,1.01]and 0.776[0.20,1.34]compared with controls and BM-,respectively.SMD and 95%CI of BM-compared with controls was -0.15[-0.54,0.23],insignificantly.Conclusion Lung cancer bone metastases may raise serum osteocalcin levels in Chinese popu-lation meanwhile this phenomenon will not happen without bone metastasis.

Study on the accuracy of thoracolumbar pedicle screw installation assisted by O-arm navigation / 中华创伤杂志

Objective To evaluate the accuracy and reliability of O-arm-based thoracolumbar pedicle screw installation.Methods A retrospective review was conducted on 75 patients who had undergone thoracolumbar pedicle screw fixation assisted with O-arm navigation (navigation group,n =32) and C-arm fluoroscopy (fluoroscopy group,n =43) from March to October 2014.All the patients were assessed with X-ray and CT images after operation.Accuracy of screw installation in both groups was compared.In navigation group,screw directions were measured on the sagittal and axial images of intraoperative navigation and post-operative CT scanning to evaluate the concordance.Results In fluoroscopy group,a total of 206 pedicle screws were placed with the one-time success rate of 93.2％ and accuracy of 90.8％ for screw placement,and one misplaced screw (grade llⅢ) led to L3 nerve root symptom.In navigation group,a total of 226 pedicle screws were placed with the one-time success rate of 100％ and accuracy of 96.9％ for screw placement,and no screw was grade Ⅲ.Further,there were no significant differences in screw directions on the sagittal and axial images between intraoperative navigation and postoperative CT scanning (P ＞ 0.05).Conclusion O-arm navigation that provides high-resolution images and high precision improves the accuracy of thoracolumbar pedicle screw installation,and possesses good reliability.

Jagged1 promotes osteoclast differentiation and inhibits proliferation by activating of Notch signaling pathway induced / 中国免疫学杂志

Objective:To study the role of Jagged1 and Notch signaling pathway played in the differentiation and proliferation of RAW 264.7 cells.Methods: RAW 264.7 cells were divided into three groups to culture:The control group:RAW 264.7 cells were threated with culture and RANKL.The Jagged1 group:RAW 264.7 cells were threated with recombinant protein Jagged 1 besides the control group.The DAPT group:RAW 264.7 cells were threated with DAPT besides the Jagged 1 group.The mRNA expression of osteoclast markers(TRAP,CK,CTR) and Notch key target genes (HES-1 and HEY-1) were measured by real-time PCR.The formation of osteoclast , bone resorption , Notch expression and proliferation of RAW 264.7 cells were detected by TRAP staining , scanning electron microscope ,immunofluorescence and cell counting kit-8 ( CCK-8 ).Results: TRAP, CK, CTR , HES-1 and HEY-1 mRNA expression were significantly higher than the control group and DAPT group in Jadded 1 group ( P<0.05 ).TRAP+cell count ,osteolytic area was significantly increased in Jagged 1 group compared with control and DAPT group , and no significant difference observed between the last two groups.Immunofluorescence results showed high expression of N ICD in cell membrane and cytoplasm in all groups and additionally expressed in nucleus in Jadded 1 group.Cell proliferation was inhibited in Jagged 1 group also ( P<0.05 ).Conclusion:Jagged1 promotes RAW264.7 cells osteoclast differentiation and inhibits proliferation by activating Notch signaling pathway .

Histopathological and ultrastructural observation of the supraspinal ligaments in ankylosing spondylitis / 中华风湿病学杂志

Objective To observe the histopathological and ultrastructural changes of the supraspinal ligaments in ankylosing spondylitis (AS).Methods The supraspinal ligaments were stained with HE,Sirius Red/saturated carbazotic acid and then observed nuder microscope,electyonic scanning microscope and transmission electron microscope respectively.The density of blood vessel and collagen fibril were analy-zed.Statistical analysis was carried out by using t test.Results In the AS group,under the microscope,the arrangement of in collagen fibers was in chaos,and hyalinosis,fatty infiltration could be seen.Vascular proliferation was predominant.Collagen-Ⅲ expression could be detected in this group.Under electron microscope,the distribution of collagen fibril was sparse,and the periodic strita was indistinct,the matrix was degraded,and some matrix vesicle could be seen.While in the control group,orderly arrangd collagen fibrils could be seen,and no change of blood vessels could be seen.The density of vascular structures in the AS group was (6.8±0.7)/HP,and (1.0±0.4)/HP of the control group.The density of collagen fibrils in the AS group was (122±22)/μm2,and that of the control group was (218±10)/μm2,the difference between the two groups was statistically significant (P＜0.05).Conclusion A series of histopathological changes have occurred in the supraspinal ligaments in AS patients.

Study on the construction of training base and teaching model of minimally invasive spine surgery / 中华医学教育探索杂志

Based on the analysis of the current status and limited factors of MISS at home and aboard,this paper discussed on the importance of MISS training base construction and explored the construction from the aspects of infrastructure constructing,teaching staff training,teaching materials compiling and teaching practice(teaching forms,contents and evaluation)researching.

Posterior transpedicular-intervertebral disc wedge resection osteotomy for correction of thoracolumbar kyphotic deformity / 中华创伤杂志

Objective To explore a safe and effective posterior surgical operation for correction of the horacolumbar kyphotic deformity. Methods The study involved 16 patients with thoracolumbar kyphotic deformity treated with the modified posterior transpedicular-intervertebral disc wedge resection osteotomy and screws-rods internal fixation apparatus.There were 11 males and 5 females at an average age of 26.5 years(13-53 years).The kyphosis deformity was caused by ankylosing spondylit in four patients,old lumbothoracic fracture in nine,vertebral dysplasia in two and vertebral body in one.The preoperative kyphosis Cobb angle was 58.1(45°-85°),with the kyphosis deformity at T10 in two patients,at Thin two,at T12in six,at L1 in three and at L2 in three.The main clinical manifestations were different degrees of lower back pain and progressive aggravation of the deformity,influencing the work and living.The course of disease was 8.5 years(4-17 years).All patients underwent pesteriortotal vertebral osteotomy on the apex vertebra,trails-pedicular fixation combined with correction and fusion,after which the patients stayed in bed for four weeks and received orthosis fixation for three months after operation. Resuits The operation lasted for average 190 minutes(125-240 minutes),with average blood loss of 750 ml(450-1 900 m1).All patients were with single segment cut bone,with no spinal cord injury,neurological injury or hardware failure.The post-operative vertical plane facial deformity was corrected for average 55(44°-76°),wit average correction rate of 83%.The follow-up for 10-24 months showed firm internal fixation on the X-ray film and good fusion ofthe vertebral column,with no pseudoarticulation formation,loosening internal fixation or loss of correction.All the patients obtained obvious improvement in appearance of the deformity,with disappearance of the lower back pain and improvement of the quality of life. Conclusion One stage posterior transpedicular-interverte-bral disc wedge resection osteotomy is all effect and safe surgical technique for correction of horacolumbar kyphotic deformity.

Clinical outcome of cervical disc replacement and adjacent cage fusion for multi-segmental cervical disc herniation / 中华创伤杂志

Objective To evaluate the clinical outcome of artificial cervical disc replacement and cage fusion in the treatment of multi-segmental cervical disc herniation. Methods A total of 39 patients with multi-level cervical disc herniation were treated with disc replacement and adjacent segment cage fusion at one stage. There were 29 patients with two level cervical disc herniation, nine with three level cervical disc herniation and one with four level cervical disc herniation. Of the patients, there were 17 male and 22 female, aged between 35 and 63 years ( mean age 47 years). The herniated disc was located at C3-4 and C4-5 in two patients, C4-5 and C5-6 in 15, C5-6 and C6-7 in nine, C4-5 and C6-7 in three, C3-4,C4-5 and C5-6 in four, C4-5, C5-6 and C6-7 in five and C3-4, C4-8 , C5-6 and C6-7 in one. There were 18 patients with myelopathy and 21 with radieulopathy. The stabilization and the range of motion of implanted disc,the fusion of cage and the displacement of cage were observed on dynamic radiograph postoperatively. The clinical symptom and the neurological function were evaluated according to JOA score and odom' s criteria. Postoperative clinical symptoms and daily function were evaluated by using neck disability index (NDI) scale. Results Twenty-nine patients with bi-level cervical disc herniation underwent single level disc replacement and cage fusion on adjacent segment. Nine patients with three level disc herniation underwent single level disc replacement in seven and level cage fusion on adjacent segment in two. Twopatients underwent two level disc replacement and one level cage fusion. One patient with four level disc herniation was treated with two level disc replacement and two level cage fusion. The patients were followed up for from 6 moths to 3 years, which showed that definite stabilization was achieved for all disc with average range of motion for 9.3 degrees postoperatively. Solid fusion was achieved in all cage, with no subsidence or displacement of cage. The JOA score was increased from 9.1 to 13.2 at final follow up and the NDI (neck disability index) score decreased from 41.8 reduced to 29.5 at final follow up. The clinical success rate (excellent/good/fair) according to Odom' s Criteria was 85%. Conclusion Cervical disc replacement and cage fusion can attain definite stabilization and satisfactory mobility and provide a new effective treatment for cervical disc herniation. The long-term outcome needs further clinical followup.

Percutaneous anterior screw fixation in the treatment of odontoid fractures / 中华骨科杂志

ObjectiveTo retrospectively analyze the treatment of odontoid fractures using percutaneous and open anterior screw fixation,and compare the clinical and radiographic results of the two techniques.MethodsFrom March 2003 to May 2010,115 patients with odontoid fracture were treated with anterior screw fixation,and all patients were followed up.The mean age of the patients was 43.5 years (range,16-71).Forty-seven patients who underwent percutaneous anterior screw fixation were set as the percutaneous fixation group,including 42 cases of type Ⅱ odontoid fracture and 5 of rostral type Ⅲ fracture.Sixtyeight patients who received open anterior screw fixation were set as the open fixation group,composing of 61cases of type Ⅱ odontoid fracture and 7 of rostral type Ⅲ fracture.We compared the operative time,intraoperative blood loss,X-ray exposure time,fracture union and complications between the two groups.Results The average follow-up duration was 37.6 months with a range of 12-70 months.The gender,age,classification of odontoid fractures,time after the injuries and concomitant spinal injuries showed a similar pattern in both groups.The operating time and intra-operative blood loss in percutaneous fixation group were (40.3±9.5)min and (5.6±4.1) ml respectively,and in open fixation group were (62.9±15.3) min and (47.1±28.6) ml respectively,both of them were significantly superior in percutaneous fixation group than in open fixation group (P＜0.05).There was no statistical difference in radiation exposure time,fracture union and incidence of complication between the two groups.ConclusionComparing with open screw fixation,percutaneous anterior screw fixation is a safe and reliable procedure for treatment of type Ⅱ and rostral type Ⅲ odontoid fractures with potential advantages.

Management of severe rotational throracolumar fracture and dislocation with posterior decompression by vertebral body resection, interbody bone fusion and transpedicular screw internal fix-ation / 中华创伤杂志

Objective To explore feasibility and therapeutic effect of posterior decompression by vertebral body resection, interbody bone fusion and transpedicular screw internal fixation in treatment of severe rotational throracolumar fracture and dislocation. Methods From October 2007 to July 2008, nine patients with severe rotational throracolumar fracture and dislocation classified as AO C types under-went decompression by vertebral boby resection, intervertebral bone fusion and transpedicular screw inter-nal fixation via a posterior midline small incision. There were eight males and one female, at age range from 23 to 54 years. All patients involved levels at T_(11)-L_2. According to AO classification, there were three patients with type C1 bursting fractures with rotational dislocation, five with distraction fracture com-bined with rotational dislocation and one with rotational distraction shear fracture/dislocation. The preop-erative Frankel Grading was Grade A in three patients, Grade B in one, Grade C in four and Grade D in one. Postoperative neurological status, the correction and loss of dislocation and the location and union of bone graft were reviewed. Results All patients received successful operation, with operation time of 3.5-5.8 hours (mean 4.4 hours), blood loss of 1 200-3 500 ml (mean 1 800 ml). The follow- up period in nine patients was 3-12 months (mean seven months). Postoperative X-ray photographs showed that the dislocation in all patients was reduced, the spine curvature was recovered to normal and the intervertebral bone graft was well fixed. Three patients at Frankel Grade A had no improvement, one at Grade B was improved to Grade C. Of four patients at Grade C, three patients were improved to Grade D. The follow-up showed bony fusion in all patients, with no loosening, dislocation or breakage of the internal fixation or implants. Conclusions For severe rotational throracolumar fracture and dislocation, decompression, reduction, fusion and fixation are rather difficult, while sufficient posterior decompression by vertebral body resection, rigid interbody bone fusion and transpadicular screw internal fixation can be an effective alternative measure.

Minimally invasive surgical treatment of post-traumatic thoracolumbar kyphosis / 中华创伤杂志

Objective To determine the safety and efficacy of minimally invasive surgical treatment for post-traumatic thoracolumbar kyphosis. Methods A retrospective review was performed on seven patients with post-traumatic thoracolumbar kyphosis admitted from April 2009 to February 2010.There were four males and three females, at average age of 45.3 years. After general anesthesia, minimally invasive transarticular osteotomy and multi-level SextantTM percutaneous reduction and internal fixation were performed under QuadrantTM working tube system. The status of pain and ability was evaluated by using visual analogue scale (VAS) and Oswestry disability index (ODI). The kyphotic deformity was evaluated by using the Cobb's angle. Results The operation lasted for mean 135 minutes, with mean perioperative blood loss of 106 ml but with no any complications occurred. The mean follow -up period was 5.5 months ( range 4 -16 months ). The mean VAS score was improved from preoperative ( 7.6 ±3.5) points to postoperative (2.5 ± 1.3) points, with statistical difference (P ＜0.01 ). The mean ODI was improved from preoperative 53.6 ± 24.2 to postoperative 20.6 ± 6.3, with statistical difference ( P ＜0.01 ). The Cobb angle was also improved from preoperative ( 32. 1 ± 4.5 ) ° to postoperative ( 7.3 ±2.9 ) °, with statistical difference ( P ＜ 0. 01 ). Conclusion Minimally invasive transarticular osteotomy under QuadrantTM working tube system is a safe and effective alternative for dealing with post-traumatic thoracolumbar kyphosis.

Clinical evaluation of percutaneous transforaminal endoscopic discectomy in the treatment of far lateral lumbar disc herniation / 中华创伤杂志

Objective To evaluate surgical techniques and clinical results of percutaneous transforam-inal endoscopic discectomy in the treatment of far lateral lumbar disc herniation. Methods Thirty-sev-en patients (24 males and 13 females) with far-lateral lumbar disc herniation were treated by percutane-ous transforaminal endoscopic discectomy from September 2005 to October 2008. The mean age of the pa-tients was 40.6 years. There were 19 patients (51.4%) with foraminal lumbar disc herniation, 11 (29.7%) with extraforaminal lumbar disc herniation and 7 (18.9%) with mixed lumbar disc herniation. The mean operation time, stay-in-bed time, postoperative hospital stay were 70 minutes, 9 hours and 5.0 days respectively. The mean operation costed mean 9 800 ￥ RMB. Results All the patients were fol-lowed up for an average period of 11.5 months. The efficacy of percutaneous transforaminal endoscopic discectomy was determined by Visual Analog Score (VAS), Oswestry Disability Index (ODI) and Nakai criteria. The mean value of VAS was significantly decreased from preoperative 8.3±2.3 to 3.1±1.6 at postoperative month 3, and to 2.9±1.9 at postoperative month 6 (P < 0.01). The mean value of ODI was significantly decreased from preoperative 64.5±23 to 23.6±12.0 at postoperative month 3, and to 12.9±7.0 at postoperative month 6 (P < 0.01). According to the Nakai criteria, the outcome of the op-eration was excellent in 19 patients (51%), good in 13 (35%), fair in 2 (5%) and poor in 3 (8%), with overall excellence rate of 87%. Conclusions Transforaminal percutaneous endoscopic discecto-my is safe and efficacious in the treatment of far lateral lumbar disc herniations, and proper selection of patients is the key factor to ensure the outcome of the operation.

Pedicle screw reduction and fixation for thoracolumbar fractures via or not the injured vertebra:a comparative study / 中华创伤杂志

Objective To compare the clinical curative effect of pedicle screw reduction and fix-ation via or not the injured vertebra in treatment of thoracolumbar fractures. Methods A retrospective study was performed on 27 patients with single thoracolumbar fractures admitted from March 2006 to Feb-ruary 2008. There were 12 patients treated with pedicle screw fixation (Group A) and 15 with traditional two-level fixation (Group B). Group A involved 11 males and 5 females, aged average 43 years (25-56 years); Group B included 10 males and 5 females, aged from 23 to 61 years (mean 42 years). All pa-tients had fresh fractures with intact pedicles on either unilateral or bilateral sides. With body position re-duction under anesthesia, the patients in Group B were treated with posterior routine distraction and lordo-sis restoration, while those in Group A were treated with the methods used in Group B as well as pedicle screw reduction and fixation. The kyphosis (Cobb angle) and recovery of injured vertebral height were observed. Results The mean follow-up period was 9 months (6-22 months). After operation, the op-timal Cobb angle and anterior column restoration were achieved through the ventral reduction from the in-jured vertebral body. The degree in anterior movement of injured vertebrae pre- and post-operatively was (0.089±0.036)° in Group A and (0.023±0.048)° in Group B, with statistical difference (P < 0.01). Cobb angle was (9.88±7.69)° in Group A and (5.19±3.24)° in Group B (P < 0.05). Changes of distance between the anterior- upper edge of the cephalad vertebrae to the anterior - lower edge of the caudal vertebral body was (39.3±5.2) % in Group A and (20.6±6.5)% in Group B (P < 0.05). Over distraction of the contiguous discs was also avoided efficiently. Conclusions Selective pedicle screw fixation into the injured vertebrae can help correct the kyphosis and maintain the reduction and en-hance the stiffness of the posterior short-segment instrumentation in single thoracolumbar fractures.

Treatment of upper cervical spine injuries via the high anterior cervical retropharyngeal approach / 中华创伤杂志

Objective To study the indications and clinical outcome of the upper cervical spine via the high anterior cervical retropharyngeal approach in treatment of upper cervical spine injuries. Methods There were 41 patients including 32 males and 9 females, at age of 12-67 years. Of all patients, there were 21 patients with Hangman fractures, two with fracture of C2 vertebral body, 12 with irreducible atlantoaxial dislocation secondary to os odontoideum, four with C1,2 tuberculosis and two with C2 gaint cell tumor. All patients underwent the high anterior cervical retropharyngeal approach to expose C1C3. C2,3 fusion followed by self-locking plate was performed for Hangman fractures and C2 fractures. Ventral reduction plud posterior aflantoaxial fusion was done for irreducible atlantoaxial dislocation secondary to os odontoideum. Lesion was cleared for tuberculosis and the tumor was resected and reconstructed. The neurological funcation was evaluated according to the ASIA criteria, the JOA score and Odom' s criteria. Results Successful exposure of arch of atlas to C3 was achived in all 41 patients, with satisfactory reducation, decompression, fusion, lesion resection and reconstruction. The trauma patients with normal neurological function showed no neurological deficit postoperatively, but those with quadriparesis had partial recovery. While the patients with illness obtained marked recovery of neurological function, with the JOA score from preoperative 8.9 to 12.5 at final follow-up. The clinical success rate (excellent/good/fair) reached 94. % according to Odom' s Criteria. Hypoglossal symptom was found in three patients and facial nerve symptom in two, without wound infection. Conclusions Via the high anterior cervical retropharyngeal approach, the upper cervical spine can be thoroughly exposed to facilitate reduction, decompression and reconstruction and maximally restore physiological function of the cervical spine in treatment of the upper cervical spine injuries.