Case control study on two different surgical approaches combined fixation with lumbar interbody fusion for the treatment of single segmental lumbar vertebra diseases / 中国骨伤

<p><b>OBJECTIVE</b>To discuss the advantages and disadvantages of two different surgical approaches combined fixation with lumbar interbody fusion in treating single segmental lumbar vertebra diseases.</p><p><b>METHODS</b>The clinical data of 86 patients with single segmental lumbar vertebra diseases treated from June 2011 to June 2013 was retrospectively analyzed. There were 33 males and 53 females, aged from 28 to 76 years old with an average of 53.0 years. Among them, there were 39 cases of lumbar disc degeneration, 22 cases of lumbar disc herniation complicated with spinal canal stenosis, 9 cases of huge lumbar disc herniation and 16 cases of lumbar degenerative spondylolisthesis (Meyerding degree I ). Lesion sites contained L3, 4 in 5 cases, L4, 5 in 70 cases and L5S1 in 11 cases. All the patients were treated with internal fixation and lumbar interbody fusion with 45 cases by midline incision approach (median incision group) and the other 41 cases by channel-assisted by muscle-splitting approach(channel group). Incision length, operation time, intraoperative bleeding and postoperative drainage were recorded in two groups. Visual analogue scale(VAS) was used to assess lumbar incision pain 72 h after operation. Depended on imaging results to compare the changes of the disc space height in lesion in preoperative, postoperative and final follow-up, the coronal and sagittal Cobb angle in preoperative and final follow-up, the area of multifidus and the degree of multifidus fat deposition before and after operation between two groups. Loosening or fragmentation of internal fixation, displacement of intervertebral cage and interbody fusion were observed in each group. Japanese Orthopedic Association (JOA) scoring system was used to evaluate the function before operation and at the final follow-up.</p><p><b>RESULTS</b>The channel group was superior to the median incision group in incision length and postoperative drainage while the median incision group was less than the channel group in the operation time and intraoperative bleeding. The average VAS score of lumbar incision 72 h after operation was 1.50 points in median incision group and 0.97 points in channel group, and there was significant difference between two groups(<0.05). No incision infection was found, but there were 4 cases of incisional epidermal necrosis, 1 case of incision healed badness, and 3 cases of nerve injury in channel group. The incidence of cacothesis of pedicle screw were 5.0% and 3.6% in median incision group and channel group respectively, and there was no significant difference between two groups(>0.05). The incidence of cacothesis of translaminar facet screw were 6.6% and 12.2% in median incision group and channel group respectively, and there was significant difference between two groups(<0.05). All the patients were followed up for 12 to 36 months with a mean of 22.8 months. The changes of disc space height had statistical difference between preoperative and postoperative(<0.05) in all patients, but there was no significant difference between postoperative and final follow-up(>0.05), however, there was no significant difference 3 days after operation and final follow-up between two groups(>0.05). At final follow-up, coronal and sagittal Cobb angle were obviously improved in all patients(<0.05), but there was no significant difference between two groups(>0.05). One year after operation, the area of multifidus in median incision group was (789.00±143.15) mm² less than preoperative(1 066.00±173.55) mm² (<0.05), and in channel group, was(992.00±156.75) mm² at 1 year after operation and(1 063.00±172.13) mm² preoperatively, there was no significant difference between them(>0.05), however, there was significant difference one year after operation between two groups (<0.05) . About the degree of multifidus fat deposition, there was significant difference between one year after operation and preoperation in median incision group (<0.05), but there was no significant difference between one year after operation and preoperation in channel group (>0.05), and there was significant difference at one year after operation between two groups(<0.05). During the follow-up period, neither pedicle screw and/or translaminar facet screw loosening, displacement or fragmentation nor displacement of intervertebral cage were found. The lumbar interbody fusion rate was 95.6% in median incision group and was 95.1% in channel group, and there was no significant difference between two groups(>0.05). No obvious adjacent segmental degeneration was observed in fixed position. JOA score in median incision group was significantly increased from 8-16 points (average: 12.77±2.56) preoperative to 21-29 points (average: 25.20±2.43) at final follow-up(<0.05); and in channel group was significantly increased from 8-16 points (average: 12.64±2.37) preoperative to 23-29 points(average: 26.7±1.82) at final follow-up(<0.05); there was also significant difference between two groups at final follow-up.</p><p><b>CONCLUSIONS</b>Compared to the median incision approach, unilateral pedicle screw combined with contralateral translaminar facet screw fixation using channel-assisted by muscle-splitting approach has advantages of small incision, less trauma, fast recovery and so on. However, it also has shortages such as high surgical complications incidence, especially in cases that.</p>

Unilateral pedicle screw fixation versus its combination with contralateral translaminar facet screw fixation for the treatment of single segmental lower lumbar vertebra diseases / 中国骨伤

<p><b>OBJECTIVE</b>To compare the advantages and disadvantages of unilateral pedicle screw fixation plus lumbar interbody fusion and unilateral pedicle screw fixation combined with contralateral translaminar facet screw fixation plus lumbar interbody fusion in treating single segmental lower lumbar vertebra diseases.</p><p><b>METHODS</b>Sixty-two patients with single segmental lower lumbar vertebra disease who received treatment between January 2008 and June 2009. These patients were consisted of 16 males and 46 females, ranging in age from 27 to 72 years old, with a mean age of 51.6 years old. Among these patients, lumbar degenerative disease had in 22 patients, recurrence of lumbar intervertebral disc protrusion in 13 patients, lumbar intervertebral disc protrusion accompany with spinal canal stenosis in 12 patients, massive lumbar intervertebral disc protrusion in 5 patients and lumbar degenerative spondylolisthesis with degree I in 10 patients. The lesions occurred at L3,4 segment in 5 patients, at L4,5 segment in 42 patients, and at L5S1 segment in 15 patients. Thirty patients underwent unilateral pedicle screw fixation (unilateral screw fixation group, group A) and thirty-two patients received unilateral pedicle screw fixation combined with contralateral translaminar facet screw fixation (bilateral screw fixation group, group B). Lumbar interbody fusion with intervertebral cages was also performed in all patients. Incision length, operation time, intraoperative blood loss and postoperative wound drainage were compared between two groups. Loosening or breakage of internal fixations, displacement of intervertebral cages and interbody fusion conditions were observed in each group. Preoperative and postoperative intervertebral height, coronal and sagittal Cobb angle and wound pain at 72 h after operation were compared between two groups. The Japanese Orthopedic Association (JOA) scoring system was used to evaluate the cinical effects.</p><p><b>RESULTS</b>Neither wound infection, skin necrosis, nerve root or cauda equia injury, nor worsened neurological dysfunction in the lower limb occurred in each group. There were no significant differences in incision length, intraoperative blood loss and postoperative wound drainage between two groups. The operation time in group A was significantly shorter than that of group B (P < 0.05). There were no significant differences in visual analogue scale value of the wound pain at postoperative 72 h between two groups (P > 0.05). All patients were followed up for 12-48 months,with a mean of 27.5 months. The intervertebral height of all patients had obviously recovered at 5 days after operation, furthermore, at the final follow-up, it still had well maintained. During follow-up, no pedicle screw and/or translaminar facet screw loosening, displacement or breakage and displacement of intervertebral cages were found. The lumbar interbody fusion rate was 96.7% and 96.9% in group A and group B, respectively, and there was no significant difference between two groups (P > 0.05). JOA score of all patients got obviously improved after operation (P < 0.05) and there was no significant difference between two groups (P > 0.05).</p><p><b>CONCLUSION</b>Both unilateral pedicle screw fixation plus lumbar interbody fusion and unilateral pedicle screw fixation combined with contralateral translaminar facet screw fixation plus lumbar interbody fusion have advantages of small incision, minimal invasion, simple operation, reliable stability, high interbody fusion rate,rapid recovery, encouraging clinical effects and less complications. Compared with unilateral pedicle screw fixation combined with contralateral translaminar facet screw fixation, the operation of unilateral pedicle screw fixation is simpler and can avoid using special equipments. Therefore, unilateral pedicle screw fixation plus lumbar interbody fusion can be used in treating single-segmental lower lumbar vertebra diseases under the precondition of strictly grasping indications for surgery and improving surgical skills.</p>

Injury characteristics and surgical treatment of lower lumbar vertebral burst fractures / 中国骨伤

<p><b>OBJECTIVE</b>To investigate the feasibility of utilizing self-designed score system for lower lumbar vertebral burst fractures to select surgical approach.</p><p><b>METHODS</b>From January 2006 to December 2011, the clinical data of 56 patients with lower lumbar vertebra burst fractures who underwent surgical treatment were retrospectively analyzed. There were 42 males and 14 females with an average age of 43.1 years old (ranged, 19 to 65). Causes of injury included falling down (40 cases), traffic accidents (12 cases), and crashing injury by heavy objects(4 cases). Injury site was L3 in 37 cases, L4 in 16 cases, and L5 in 3 cases. According to the AO classification, 17 cases were type A3.1, 14 cases were type A3.2, 25 cases were type A3.3. According to Frankel grade of nerous function, 2 cases were grade B, 5 cases were grade C, 9 cases were grade D and 40 cases were grade E. Surgical methods and approaches were chosen based on the comprehensive evaluation of AO classification, condition of posterior column injury and spinal canal encroachment. Surgical methods and approaches included trans-vertebra fixation (15 cases), intra-vertebra pedicle screw fixation (21 cases), combination of anterior and posterior approaches (11 cases), one-stage posterior approaches (9 cases). Cobb angles, restorations of the affected vertebral anterior border height, and conditions of spinal canal encroachment were compared before and after surgery. Conditions of bone graft fusion and internal fixation (if bending, loosening or breakage existed) were observed. Spinal cord functions were assessed according to Frankel grade. Localized pain and working status of patients were also assessed at the last follow-up.</p><p><b>RESULTS</b>No incision infection was found and no spinal nerve symptoms improved in all of 56 patients. All patients were followed up for 12 to 60 months with a mean of 28.5 months, without internal fixation loosening or breakage. There was significant differences in Cobb angle, vertebral anterior border height and recovery of spinal canal encroachment between preoperative and postoperative instantly (P < 0.05), however, there was no significant difference between postoperative instantly and final follow-up (P > 0.05). Thirteen cases obtained fusion by trans-vertebra fixation, 20 cases obtained fusion by intra-vertebra fixation, and 20 cases were treated by the combination of anterior and posterior approaches or one-stage posterior approaches all of patients obtained fusion. Spinal nervous function recovered I to II grade, 1 case was grade C, 3 cases were grade D, 52 cases were grade E. Localized pain was assessed as P1 in 52 cases, P2 in 3 cases, and P3 in 1 case. Working status was classified into W1 in 12 cases, W2 in 39 cases, and W3 in 5 cases.</p><p><b>CONCLUSION</b>The lower lumbar vertebra and thoracolumbar junction exhibit different injury characteristics due to variations in anatomy and biomechanics. A comprehensive score of the AO classification, posterior column injury and degree of spinal canal encroachment will guide the selection of surgical method and approach for the treatment of lower lumbar vertebra burst fractures.</p>

Surgical treatment of thoracolumbar fractures using pedicle screws fixation at the level of the fracture: results for following up more than 2 years / 中国骨伤

<p><b>OBJECTIVE</b>To explore clinical efficacy of thoracolumbar fractures fixation with pedicle screws fixation at the level of the fracture and monosegment bone graft simultaneously.</p><p><b>METHODS</b>Retrospective analysis of 32 patients with thoracolumbar fractures underwent surgical procedure of pedicle screws fixation at the level of the fracture and monosegment bone graft simultaneously from January 2006 to December 2008. All the patients were followed up more than two years. There were 25 males and 7 females with an average age of 39.1 years (ranged, 25 to 60 years). According to the AO classification, type A1.3 was in 5 cases, type A3.1 in 17, type A3.3 in 8, type C1.1 in 1, and type C1.3 in 1. Load scoring was from 4 to 7 points with average of 5.8 points. The spinal cord function according to Frankel grade, grade A was in 2 cases, grade B in 2, grade C in 5, grade D in 9 and grade E in 14. Cobb angle, the height of anterior border of vertebral body, spinal canal stenosis rate were observed by X-ray films. Meanwhile, pain and work ability were evaluated by Denis scale.</p><p><b>RESULTS</b>All the patients were followed-up from 30 to 48 months (averaged, 39.2 months). No internal fixation loosening or breakage were found. Three cases occurred with floating callus and other obtained well bone fusion. Compared with preoperation, Cobb angle, the height of anterior border of vertebral body, and spinal canal stenosis rate improved obviously (P < 0.05); but Cobb angle had lost partially at the last follow-up (P > 0.05). Meanwhile, anterosuperior part of vertebral body of 25 cases existed cavity phenomenon. The nerve function of all cases recovered for 1-2 grades, except for 2 cases without change whose spinal cord function was degree A preoperatively. According to Denis scale, lower back pain scoring, P1 was in 22 cases, P2 in 7, P3 in 3; state of work scoring, W1 was in 18 cases, W2 in 8, W3 in 3, W5 in 3.</p><p><b>CONCLUSION</b>It can help to correct the kyphosis and improve low back pain in thoracolumbar fractures through pedicle screws fixation at the level of the fracture and monosegment bone graft simultaneously, but it can not improve the cavity phenomenon of injured vertebral body and avoid partially lost of Cobb angle.</p>