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Objective:To investigate the clinical efficacy of full-endoscopic technique through the posterior cervical Delta large portal for the treatment of cervical spondylotic myelopathy and radiculopathy.Methods:The clinical data were analyzed retrospectively of the 15 patients who had been treated for cervical spondylotic myelopathy or radiculopathy at Orthopedics Department, Jiaxing Xiuzhou District People's Hospital from January 2020 to June 2021. There were 6 males and 9 females, aged from 54 to 76 years (average, 66.2 years). Responsible levels: 3 cases of C3, 4, 4 cases of C4, 5, 7 cases of C5, 6 and 1 case of C6, 7. They were all treated by full-endoscopic technique through the posterior cervical Delta large portal. The therapeutic efficacy was assessed by comparing the neck disability indexes (NDI) and Japanese Orthopaedic Association (JOA) cervical scores at preoperation, 1 and 3 months post-operation, and the last follow-up, and the modified MacNab scores at the last follow-up. The operative effects on cervical curvature and segmental stability were assessed by comparing the C2-7 cobb angles and operative ranges of motion (ROM) at preoperation, 1 and 3 months postoperation, and the last follow-up.Results:All cases completed their operation successfully. The operation time ranged from 56 to 82 min (average, 65.7 min), and the intraoperative blood loss from 10 to 30 mL (average, 20.7 mL). Tissue infection, intraspinal infection, dural tear, nerve root injury or perioperative anesthesia-related complications occurred in none of the patients. All patients were followed up for 6 to 18 months (average 10.8 months). The NDIs at 1 and 3 months post-operation, and the last follow-up (18.54%±3.06%, 14.96%±2.33%, and 12.89%±2.33%) were significantly lower than that before operation (34.19%±3.83%), and those at 3 months postoperation and the last follow-up significantly lower than that at 1 month postoperation ( P<0.05), but there was no significant difference between 3 months postoperation and the last follow-up in NDI ( P>0.05). The JOA scores at 1 and 3 months postoperation, and the last follow-up [(12.28±1.65), (13.30±1.57) and (13.54±1.41) points] were significantly higher than the preoperative value [(9.25±1.49) points] ( P<0.05), but there was no such a significant difference between postoperative time points ( P>0.05). Comparisons between preoperation, 1 and 3 months postoperation, and the last follow-up showed no significant difference in the C2-7 cobb angle or operative ROM ( P>0.05). The modified MacNab scores at the last follow-up resulted in 9 excellent, 5 good and 1 fair cases. Conclusion:In the treatment of cervical spondylotic myelopathy and radiculopathy, the full-endoscopic technique through the posterior cervical Delta large portal shows the advantages of limited invasion and complications, rapid recovery after operation, and little impact on the cervical curvature and segmental stability.
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【Objective】 To investigate the feasibility of full-endoscopic posterolateral odontoidectomy through morphological analysis and cadaver specimen surgery. 【Methods】 We collected the DICOM data of 20 normal cervical CT patients （10 males and 10 females） from the PACS Image Library of our hospital. The Mimics software was used for cervical CT reconstruction and anatomical measurements were made to measure the maximum sagittal diameter， coronal diameter and height of the odontoid process. The C1 lateral mass could provide the maximum working height and width of endoscopic operation with a diameter of 7 mm， as well as the angle between the anchor point of C1 lateral mass and the notch on both sides of the odontoid process. The feasibility of endoscopic surgery was analyzed based on the measured data. The fresh frozen corpse was used for the operation in prone position under the guidance of C-arm. Kirschner wire was anchored at the midpoint of the lower surface of the C1 lateral mass. Part of the C1 lateral mass was removed by the grinding drill and endoscopic tools， and then the odontoid process and adjacent ligaments were removed. 【Results】 The maximum sagittal diameter， coronal diameter and height of the odontoid process were （11.73±0.74）mm， （10.97±0.71）mm and （14.51±0.91）mm， respectively. The working height and width of the C1 lateral mass were （13.53±0.57）mm and （10.00±1.27）mm， respectively. The angle between the anchor point and the double-edge notch of the odontoid process was （28.3±3.1）°， with no statistical difference between the male and female patients （P>0.05）. All the measurements met the requirements of 7 mm endoscopic implantation and surgical operation， and the space for swing could be provided for complete or partial removal of the odontoid process to meet the requirements of ventral spinal decompression. In cadaver surgery， a fully endoscopic posterolateral approach enabled complete removal of the odontoid process by grinding part of the C1 lateral mass. Postoperative cervical CT confirmed that the odontoid process had been completely resected， and there were no signs of dural sac or vertebral artery injury. 【Conclusion】 The odontoid process can be completely resected through a posterolateral endoscopic approach via the lateral mass approach of C1， providing a new surgical method for clinical odontoidectomy to decompress the spinal cord in craniovertebral junction.
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BACKGROUND:Minimally invasive endoscopic decompression is currently used in the treatment of lumbar spinal stenosis, but there are few studies on the scope of precise laminectomy under the microscope. OBJECTIVE: To explore the influence of precise decompression with different laminectomy zones on lumbar range of motion and stress distribution using the entire degenerative lumbar finite element model. METHODS: A patient with lumbar spinal stenosis was randomly selected. Based on CT data, the lumbar L4-5 segment finite element model (M1) was established using relevant biomechanical software, and the validity was verified. After that, the finite element simulation of fully endoscopic precisely laminectomy decompression operation was performed. Combined with pathological classification of lumbar spinal stenosis, personalized laminectomy decompression aiming at different L4-5 segment stenosis was established, specifically including L4 lamina margin and partial facet joint resection model (M2), L5 lamina margin and partial facet joint resection model (M3), L4/5 lamina margin and partial facet joint resection model (M4), M4+"Over-the-Top" contralateral partial facet joint resection model (M5), and L4/5 lamina margin and over 50% facet jointresection model (M6). The same boundary loading was applied to the various finite element models. The lumbar range of motion and equivalent stress of intervertebral discs were compared under six conditions including flexion, extension, left and right flexion, left and right rotation. RESULTS AND CONCLUSION: (1) Compared with the entire M1 model, ranges of motion of M2, M3, M4 and M5 models were similar under various conditions, but range of motion of M6 model was significantly increased to 151 %-264% scope, especially in the extension and rotational conditions. (2) In terms of the equivalent stress of disc, the M2, M3, M4 and M5 models showed no obvious increasing trend at the anterior, left and right regions under various working conditions. The largest increase of the equivalent stress at posterior and middle disc regions was 53% maximally, but with no significant stress concentration. However, the equivalent stress in total disc regions showed a significant increasing trend in M6 model, especially in flexion condition with the maximum three times of M1 model. (3) Results suggest that extensive laminectomy can significantly affect the stability of the lumbar spine, with the intervertebral disc stress increase at the corresponding segment which is more likely to accelerate segmental degeneration. Minimally invasive endoscopic decompression is precise and controllable. The personalized decompression schemes can be adopted for different types of lumbar spinal stenosis to ensure the surgery effect and effectively maintain the biomechanical characteristics of the segments.
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OBJECTIVE@#To investigate the clinical efficacy and advantages of the full endoscopic I See technique for the single-segment degenerative lumbar spinal stenosis.@*METHODS@#The clinical data of 38 patients with the single-segment degenerative lumbar spinal stenosis treated by full endoscopic I See technique from January 2017 to March 2018 were analyzed retrospectively. There were 16 males and 22 females, aged from 35 to 79 years with an average of(53.45±12.56) years. Five cases were L, 23 cases were L, 10 cases were LS. The clinical efficacy was evaluated by VAS, ODI and Macnab scores.@*RESULTS@#All the patients were followed up for more than 12 months after operation. The length of operation was from 55 to130 (86.0± 17.5) min. Intraoperative blood loss was ranging from 10 to 50 (17±6) ml, and the hospitalization length was from 3 to 7 days with an average of 4.6 days. The VAS scores of low back pain assessed before operation, and 3 d, 3 months, 12 months post operation were 6.67 ±1.25, 3.87 ±1.35, 2.55 ±1.21, 2.05 ±0.97, respectively, and the differences were statistically significant (P < 0.05);VAS scores of leg pain at these time points were 7.85±2.62, 3.31±1.42, 2.02±1.13, 1.85±0.86, respectively, and the differences were statistically significant (<0.05);ODI scores were 40.32±5.38, 25.76±4.81, 12.66±4.64, 9.32±2.91, respectively, and the differences were statistically significant (<0.05). Tevaluate the lumbar vertebrae function according to the Macnab criteria, 15 cases obtained excellent results, 19 cases were good, and 4 cases were fair.@*CONCLUSION@#Full endoscopic I See technique is effective in the treatment of single-segment degenerative lumbar spinal stenosis, with the advantages of less trauma, shorter hospital stay, and faster recovery.
Assuntos
Adulto , Idoso , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Descompressão Cirúrgica , Vértebras Lombares , Estudos Retrospectivos , Fusão Vertebral , Estenose Espinal , Resultado do TratamentoRESUMO
BACKGROUND: Minimally invasive endoscopic decompression is currently used in the treatment of lumbar spinal stenosis, but there are few studies on the scope of precise laminectomy under the microscope. OBJECTIVE: To explore the influence of precise decompression with different laminectomy zones on lumbar range of motion and stress distribution using the entire degenerative lumbar finite element model. METHODS: A patient with lumbar spinal stenosis was randomly selected. Based on CT data, the lumbar L4-5 segment finite element model (M1) was established using relevant biomechanical software, and the validity was verified. After that, the finite element simulation of fully endoscopic precisely laminectomy decompression operation was performed. Combined with pathological classification of lumbar spinal stenosis, personalized laminectomy decompression aiming at different L4-5 segment stenosis was established, specifically including L4 lamina margin and partial facet joint resection model (M2), L5 lamina margin and partial facet joint resection model (M3), L4/5 lamina margin and partial facet joint resection model (M4), M4 + "Over-the-Top" contralateral partial facet joint resection model (M5), and L4/5 lamina margin and over 50% facet jointresection model (M6). The same boundary loading was applied to the various finite element models. The lumbar range of motion and equivalent stress of intervertebral discs were compared under six conditions including flexion, extension, left and right flexion, left and right rotation. RESULTS AND CONCLUSION: (1) Compared with the entire M1 model, ranges of motion of M2, M3, M4 and M5 models were similar under various conditions, but range of motion of M6 model was significantly increased to 151%-264% scope, especially in the extension and rotational conditions. (2) In terms of the equivalent stress of disc, the M2, M3, M4 and M5 models showed no obvious increasing trend at the anterior, left and right regions under various working conditions. The largest increase of the equivalent stress at posterior and middle disc regions was 53% maximally, but with no significant stress concentration. However, the equivalent stress in total disc regions showed a significant increasing trend in M6 model, especially in flexion condition with the maximum three times of M1 model. (3) Results suggest that extensive laminectomy can significantly affect the stability of the lumbar spine, with the intervertebral disc stress increase at the corresponding segment which is more likely to accelerate segmental degeneration. Minimally invasive endoscopic decompression is precise and controllable. The personalized decompression schemes can be adopted for different types of lumbar spinal stenosis to ensure the surgery effect and effectively maintain the biomechanical characteristics of the segments.
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BACKGROUND: The effective treatment of lumbar spinal stenosis with total endoscopic decompression is a breakthrough frontier technology. Compared with open surgery, it has the characteristics of fewer traumas, controllable operation, and fewer complications, but it reported less in finite element biomechanics. OBJECTIVE: To establish a finite element model of full endoscope lumbar fenestration and to investigate the effects of decompression range and nucleus pulposus removal on lumbar range of motion and stress distribution of disc. METHODS: CT scan data of a case of L4-5 segmental lumbar spinal stenosis were collected and imported in Mimics 20.0 software. A finite element model M of L4-5 lumbar spinal stenosis in degenerative lumbar spine was established. The model M was imported into 3-matic for surgical simulation, i.e., unilateral disc resection of the small joints 1/2 and 1/4 model M1, bilateral joints 1/2 and 1/2 resection of intervertebral disc model M2, and unilateral disc and articular process of 1/4 model M3. In the ANSYS software, the mechanical comparative analysis was conducted in four kinds of models under six working conditions of the same pure couple moment, including forward bending, backward extension, left bending, right bending, left rotation and right rotation, and the same load of the intervertebral disc. RESULTS AND CONCLUSION: (1) Compared with the spinal M model, the range of motion of M1 model was similar under six working conditions, but the range of motion of M2 and M3 was significantly increased than that of M, especially under the left/right flexion and forward/backward flexion working conditions, which was 130%-200% of the overall activity of M model. (2) In terms of the stress of intervertebral disc, M1 model showed no obvious upward trend of the effect force in the posterior region, central region and right region of intervertebral disc under various working conditions. The equivalent stress in the left region and front region of intervertebral disc increased to a maximum of 63%, but there was no significant stress concentration. In the M2 and M3 models, the equivalent stress of intervertebral discs in all regions showed a significant increased trend. (3) Endoscopic minimally invasive surgery is accurate and controllable for different types of lumbar spinal stenosis decompression surgery. The resection of facet joints and the removal of nucleus pulposus by less than 1/2 have little influence on the biomechanical stability of the corresponding segments. The successful and reliable finite element modeling of lumbar lamina fenestration can provide an important method and basis for the follow-up biomechanical study of lumbar surgery.
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Objective: To design the method of posterior percutaneous full-endoscopic cervical foraminotomy (P-PECF) for treating cervical osseous foraminal stenosis and analyze its feasibility in clinical application. Methods: The clinical data of 12 patients with cervical osseous foraminal stenosis who met the selection criteria between October 2015 and June 2017 were retrospectively analysed. There were 7 males and 5 females with an age of 52-63 years (mean, 57.6 years). The disease duration ranged from 15 days to 6 months (mean, 3.7 months). The segments included C 4, 5 in 2 cases, C 5, 6 in 6 cases, and C 6, 7 in 4 cases; all showing root pain or numbness caused by nerve root compression. All patients were treated with the P-PECF technique. At preoperation, immediately after operation, and at last follow-up, visual analogue scale (VAS) scores and neck disability index (NDI) were respectively recorded to assess the patient's quality of life and the pain of neck and arm. The clinical outcomes were evaluated by the modified Macnab criteria. Results: All operations were successful. The operation time was 71-105 minutes (mean, 82 minutes); the intraoperative blood loss was about 5 mL. The CT of the cervical spine at 1 week postoperatively showed that the cervical root canal was enlarged and the nerve root compression was relieved. The symptoms of neck and arm pain and numbness were relieved; the hospitalization time was 2-5 days (mean, 3 days). All patients were followed up 6-18 months (mean, 12.3 months). Except for 1 patient's feeling transient hypoesthesia postoperatively, there was no complication such as hematoma, nerve root injury, or incision infection. The VAS scores and NDI at immediate postoperatively and at last follow-up were significantly improved when compared with preoperative scores ( P<0.05); and the scores also improved significantly at last follow-up when compared with the scores at immediate postoperatively ( P<0.05). According to modified Macnab criteria, the results were excellent in 9 cases, good in 2 cases, and fair in 1 case, with an excellent and good rate of 91.7%. Conclusion: The P-PECF technique can enlarge the nerve root canal and relieve nerve root compression, and obtain better effectiveness by minimally invasive methods. It is a safe and feasible procedure.