Percutaneous foraminal endoscopy for the treatment of lumbar lateral recess stenosis in elderly / 中国骨伤

OBJECTIVE@#To investigate the clinical efficacy and safety of percutaneous foraminal endoscopy in the treatment of lumbar lateral recess stenosis in elderly.@*METHODS@#The clinical data of 31 elderly patients with lumbar lateral recess stenosis treated by percutaneous foraminal endoscopic decompression from March 2018 to August 2019 were retrospectively analyzed. Including 16 males and 15 females, aged from 65 to 81 years with an average of (71.13±5.20) years, the course of disease ranged from 3 months to 7 years with an average of (14.36±6.52) months. Visual analogue scale (VAS) and Oswestry disability index (ODI) were used to assess clinical symptom and functional status before operation and 1, 6, 12 months after operation. At the final follow-up, the modified Macnab standard was used to evaluate clinical efficacy.@*RESULTS@#All patients were completed the operation successfully. The operation time was from 75 to 120 min with an average of (97.84±11.22 ) min. All 31 patients were followed up from 12 to 28 months with an average of (17.29±5.56) months. Postoperative lumbago-leg pain VAS and ODI were significantly improved at 1, 6, and 12 months(P<0.01). At the final follow-up, according to the modified Macnab standard to evaluate the effect, 23 got excellent results, 5 good, 3 fair. One patient had severe adhesions between peripheral tissues and nerve root, and postoperative sensory abnormalities in the lower extremities were treated conservatively with traditional Chinese medicine and neurotrophic drugs, which recovered at 2 weeks after surgery. No complications such as nerve root injury and infection occurred.@*CONCLUSION@#The intervertebral foraminal endoscopy technique, which is performed under local anesthesia for a short period of operation, ensures adequate decompression while minimizing complications, and is a safe and effective surgical procedure for elderly patients with lumbar lateral recess stenosis.

Treatment of degenerative lumbar lateral recess stenosis with full endoscopic lamina fenestration discectomy / 中国骨伤

OBJECTIVE@#To compare the clinical efficacy of full endoscopic lamina fenestration discectomy (Endo-LOVE) with full endoscopic transforaminal approach discectomy in the treatment of degenerative lumbar lateral recess stenosis.@*METHODS@#A retrospective analysis of 48 patients with degenerative lumbar lateral recess stenosis between March 2018 and March 2019 was performed. There were 32 males and 16 females, aged from 60 to 83 years old with an average of (72.9±6.5) years, course of disease ranged from 5 to 16 years with an average of (8.0±2.8) years. The patients were divided into observation group and control group according to surgical approaches. There were 28 cases in observation group, underwent Endo-LOVE surgery;and 20 cases in control group, underwent full endoscopic foraminal approach discectomy. The operation time, intraoperative blood loss, hospitalization day and complications were observed between two groups. Visual analgue scale (VAS), Japanese Orthopaedic Association(JOA), Oswestry Disability Index(ODI), lateral crypt angle were compared between two groups. And clinical effects were evaluated by modified Macnab standard.@*RESULTS@#There was no significant difference in follow-up and operation time between two groups (P>0.05). Intraoperative blood loss was from 5 to 15 ml with an average of (8.4±3.6) ml in observation group and 5 to 25 ml with an average of (11.5±5.4) ml in control group. The hospitalization day was from 5 to 8 days with an average of (6.0±1.0) days in observation group and 6 to 9 days with an average (7.2±1.1) days in control group. Intraoperative blood loss and hospitalization day were significantly lower in observation group(P<0.05). There were no serious complications in both groups. The VAS, JOA scores, and ODI at 3-month and final follow-up were significantly improved in both groups (P<0.05), and observation group was significantly better than control group (P<0.05). The skeletal lateral crypt angle and soft lateral crypt angle were significantly greater than the preoperative angle at 3 days postoperatively(P<0.05), and observation group was significantly better than control group(P<0.05). At the final follow-up, the modified Macnab criteria was used to assess clinical efficacy, in observation group, 22 patients obtained excellent results, 5 good and 1 fair;while 11 excellent, 4 good and 5 fair in control group;the clinical efficacy of observation group was significantly better than that of control group(P<0.05).@*CONCLUSION@#Both surgical methods are performed under direct vision, with high safety and good clinical efficacy. However, Endo-LOVE enlarged the lateral crypt more fully.

Observation of early clinical efficacy of unilateral biportal endoscopy technique in the treatment of lumbar postoperative adjacent segmental diseases / 中国骨伤

OBJECTIVE@#To investigate early clinical efficacy of unilateral biportal endoscopy technique for the treatment of lumbar postoperative adjacent segmental diseases.@*METHODS@#Fourteen patients with lumbar postoperative adjacent segmental diseases were treated with unilateral biportal endoscopy technique from June 2019 to June 2020. Among them, there were 9 males and 5 females, aged from 52 to 73 years old, and the interval between primary and revision operations ranged from 19 to 64 months. Adjacent segmental degeneration occurred after lumbar fusion in 10 patients and after lumbar nonfusion fixation in 4 patients. All the patients received unilateral biportal endoscopy assisted posterior unilateral lamina decompression or unilateral approach to the contralateral decompression. The operation time, postoperative hospital stay and complications were observed. The visual analogue scale (VAS) of low back pain and leg pain, Oswestry Disability Index (ODI), modified Japanese Orthopaedic Association (mJOA) score were recorded before operation and at 3 days, 3 months, and 6 months after operation.@*RESULTS@#All procedures were successfully completed. Surgical duration ranged from 32 to 151 min. Postoperative CT showed adequate decompression and preservation of most joints. Out of bed walking 1 to 3 days after surgery, postoperative hospital stay was 1 to 8 days, and postoperative follow-up was 6 to 11 months. All 14 patients returned to normal life within 3 weeks after surgery, and VAS, ODI, and mJOA scores improved significantly at 3 days and 3, 6 months after surgery. One patient occurred cerebrospinal fluid leak after operation, received local compression suture, and the wound healed after conservative treatment. One patient occurred postoperative cauda equina neurologic deficit, which was gradually recovered about 1 month after rehabilitation therapy. One patients advented transient pain of lower limbs after surgery, and the symptoms were relieved after 7 days of treatment with hormones, dehydration drugs and symptomatic management.@*CONCLUSION@#Unilateral biportal endoscopy technique has a good early clinical efficacy in the treatment of lumbar postoperative adjacent segmental diseases, which may provide a new minimally invasive, non-fixation option for the treatment of adjacent segment disease.

Comparison of clinical effect and muscle injury imaging between oblique lateral lumbar interbody fusion and transforaminal lumbar interbody fusion in the treatment of single-segment degenerative lumbar spinal stenosis / 中国骨伤

OBJECTIVE@#To compare the efficacy and muscle injury imaging between oblique lateral lumbar interbody fusion (OLIF) and transforaminal lumbar interbody fusion (TLIF) in the treatment of single-segment degenerative lumbar spinal stenosis.@*METHODS@#The clinical data of 60 patients with single-segment degenerative lumbar spinal stenosis who underwent surgical treatment from January 2018 to October 2019 was retrospectively analyzed. The patients were divided into OLIF groups and TLIF group according to different surgical methods. The 30 patients in the OLIF group were treated with OLIF plus posterior intermuscular screw rod internal fixation. There were 13 males and 17 females, aged from 52 to 74 years old with an average of (62.6±8.3) years old. And 30 patients in the TLIF group were treated with TLIF via the left approach. There were 14 males and 16 females, aged from 50 to 81 years old with an average of (61.7±10.4) years old. General data including operative time, intraoperative blood loss, postoperative drainage volume, and complications were recorded for both groups. Radiologic data including disc height (DH), the left psoas major muscle, multifidus muscle, longissimus muscle area, T2-weighted image hyperintensity changes and interbody fusion or nonfusion were observed. Laboratory parameters including creatine kinase (CK) values on postoperative 1st and 5th days were analyzed. Visual analogue scale(VAS) and Oswestry disability index(ODI) were used to assess clinical efficacy.@*RESULTS@#There was no significant difference in the operative time between two groups(P>0.05). The OLIF group had significantly less intraoperative blood loss and postoperative drainage volume compared to the TLIF group(P<0.01). The OLIF group also had DH better recovery compared to the TLIF group (P<0.05). There were no significant differences in left psoas major muscle area and the hyperintensity degree before and after the operation in the OLIF group (P>0.05). Postoperativly, the area of the left multifidus muscle and longissimus muscle, as well as the mean of the left multifidus muscle and longissimus muscle in the OLIF group, were lower than those in the TLIF group (P<0.05) .On the 1st day and the 5th day after operation, CK level in the OLIF group was lower than that in the TLIF group(P<0.05). On the 3rd day after operation, the VAS of low back pain and leg pain in the OLIF group were lower than those in the TLIF group (P<0.05). There were no significant differences in the ODI of postoperative 12 months, low back and leg pain VAS at 3, 6, 12 months between the two groups(P>0.05). In the OLIF group, 1 case of left lower extremity skin temperature increased after the operation, and the sympathetic chain was considered to be injured during the operation, and 2 cases of left thigh anterior numbness occurred, which was considered to be related to psoas major muscle stretch, resulting in a complication rate of 10% (3/30). In the TLIF group, one patient had limited ankle dorsiflexion, which was related to nerve root traction, two patients had cerebrospinal fluid leakage, and the dural sac was torn during the operation, and one patient had incision fat liquefaction, which was related to paraspinal muscle dissection injury, resulting in a complication rate of 13% (4/30). All patients achieved interbody fusion without cage collapse during the 6- month follow-up.@*CONCLUSION@#Both OLIF and TLIF are effective in the treatment of single-segment degenerative lumbar spinal stenosis. However, OLIF surgery has obviously advantages, including less intraoperative blood loss, less postoperative pain, and good recovery of intervertebral space height. From the changes in laboratory indexes of CK and the comparison of the left psoas major muscle, multifidus muscle, longissimus muscle area, and high signal intensity of T2 image on imaging, it can be seen that the degree of muscle damage and interference of OLIF surgery is lower than that of TLIF.

Research progress of different minimally invasive spinal decompression in lumbar spinal stenosis / 中国修复重建外科杂志

OBJECTIVE@#To review the application and progress of different minimally invasive spinal decompression in the treatment of lumbar spinal stenosis (LSS).@*METHODS@#The domestic and foreign literature on the application of different minimally invasive spinal decompression in the treatment of LSS was extensively reviewed, and the advantages, disadvantages, and complications of different surgical methods were summarized.@*RESULTS@#At present, minimally invasive spinal decompression mainly includes microscopic bilateral decompression, microendoscopic decompression, percutaneous endoscopic lumbar decompression, unilateral biportal endoscopy, and so on. Compared with traditional open surgery, different minimally invasive spinal decompression techniques can reduce the operation time, intraoperative blood loss, and postoperative pain of patients, thereby reducing hospital stay and saving treatment costs.@*CONCLUSION@#The indications of different minimally invasive spinal decompression are different, but there are certain advantages and disadvantages. When patients have clear surgical indications, individualized treatment plans should be formulated according to the symptoms and signs of patients, combined with imaging manifestations.

Early-effectiveness of unilateral biportal endoscopic laminectomy in treatment of two-level lumbar spinal stenosis / 中国修复重建外科杂志

OBJECTIVE@#To analyze the early effectiveness of unilateral biportal endoscopy (UBE) laminectomy in the treatment of two-level lumbar spinal stenosis (LSS).@*METHODS@#The clinical data of 98 patients with two-level LSS treated with UBE between September 2020 and December 2021 were retrospectively analyzed. There were 53 males and 45 females with an average age of 59.9 years (range, 32-79 years). Among them, there were 56 cases of mixed spinal stenosis, 23 cases of central spinal canal stenosis, and 19 cases of nerve root canal stenosis. The duration of symptoms was 1.5- 10 years, with an average of 5.4 years. The operative segments were L 2, 3 and L 3, 4 in 2 cases, L 3, 4 and L 4, 5 in 29 cases, L 4, 5 and L 5, S 1 in 67 cases. All patients had different degrees of low back pain, among of which 76 cases were with unilateral lower extremity symptoms and 22 cases were with bilateral lower extremity symptoms. There were 29 cases of bilateral decompression in both segments, 63 cases of unilateral decompression in both segments, and 6 cases of unilateral decompression and bilateral decompression of each segment. The operation time, intraoperative blood loss, total incision length, hospitalization stay, ambulation time, and related complications were recorded. Visual analogue scale (VAS) score was used to assess the low back and leg pain before operation and at 3 days, 3 months after operation, and at last follow-up. The Oswestry disability index (ODI) was used to evaluate the functional recovery of lumbar spine before operation and at 3 months and last follow-up after operation. Modified MacNab criteria was used to evaluate clinical outcomes at last follow-up. Imaging examinations were performed before and after operation to measure the preservation rate of articular process, modified Pfirrmann scale, disc height (DH), lumbar lordosis angle (LLA), and cross-sectional area of the canal (CAC), and the CAC improvement rate was calculated.@*RESULTS@#All patients underwent surgery successfully. The operation time was (106.7±25.1) minutes, the intraoperative blood loss was (67.7±14.2) mL, and the total incision length was (3.2±0.4) cm. The hospitalization stay was 8 (7, 9) days, and the ambulation time was 3 (3, 4) days. All the wounds healed by first intention. Dural tear occurred in 1 case during operation, and mild headache occurred in 1 case after operation. All patients were followed up 13-28 months with an average of 19.3 months, and there was no recurrence or reoperation during the follow-up. At last follow-up, the preservation rate of articular process was 84.7%±7.3%. The modified Pfirrmann scale and DH were significantly different from those before operation ( P<0.05), while the LLA was not significantly different from that before operation ( P=0.050). The CAC significantly improved ( P<0.05), and the CAC improvement rate was 108.1%±17.8%. The VAS scores of low back pain and leg pain and ODI at each time point after operation significantly improved when compared with those before operation, and the differences between each time points were significant ( P<0.05). According to the modified MacNab criteria, 63 cases were excellent, 25 cases were good, and 10 cases were fair, with an excellent and good rate of 89.8%.@*CONCLUSION@#UBE laminectomy is a safe and effective technique with little trauma and fast recovery for two-level LSS and the early effectiveness is satisfactory.

Development and clinical application of a new transverse process retractor based on computer-aided design and 3D printing technology / 中国骨伤

OBJECTIVE@#To manufacture a new type of transverse process retractor by using computer-aided design(CAD) combined with 3D printing technology and investigate its clinical application effect.@*METHODS@#A new type of transverse protrusion retractor was developed by CAD combined with 3D printing technology. From September 2018 to September 2019, the new transverse process retractor was applied in clinic. Sixty patients with lumbar single segment lesions who needed treatment by pedicle screw fixation, bone grafting and interbody fusion were divided into new transverse process retractor group and control group, with 30 cases in each group. There were 14 males and 16 females in new type transverse process retractor group, the age was (68.0±4.3) years old on average; lesion segment of 8 cases were L3,4, 9 cases were L4,5, 13 cases were L5S1;5 cases of lumbar disc herniation, 20 cases of lumbar spinal stenosis, 5 cases of degenerative lumbar spondylolisthesis;new transverse process retractor was used to pedicle screw placement. While there were 15 males and 15 females in control group, with an average age of (69.2±4.5) years old;lesion segment of 8 cases were L3,4, 10 cases were L4,5, 12 cases were L5S1;5 cases of lumbar disc herniation, 21 cases of lumbar spinal stenosis, 4 cases of degenerative lumbar spondylolisthesis;the traditional lamina retractor was used for soft tissue pulling and finished pedicle screw placement by freehand. The length of surgical incision, the time required for inserting a single screw, fluoroscopy times, the times of adjusting the positioning needle or screw in insertion process, and the visual analogue scale (VAS) of surgical incision 72 hours after operation were compared between two groups.@*RESULTS@#Using CAD and 3D printing technology, a new type of transverse protrusion retractor was developed quickly. The length of surgical incision, the time required for inserting a single screw, fluoroscopy time, and the times of adjusting the positioning needle or screw in insertion process in new transverse process retractor group were less than those in control group(P<0.05). There was no significant difference in VAS of lumbar incision pain at 72 hours after operation between two groups(P>0.05).@*CONCLUSION@#Using CAD combined with 3D printing technology to develop a new transverse protrusion retractor has the advantages of convenient design, short development cycle and low cost. It provides a new idea for the research and development of new medical devices. The new transverse process retractor has the advantages of easy operation, reliable fixation, less damage to paravertebral muscle, convenient pedicle screw placement, reducing fluoroscopy time and so on.

Current status and progress of percutaneous spinal endoscopy in the treatment of degenerative lumbar spinal stenosis / 中国骨伤

Percutaneous endoscopic spine decompression(PSED) in recent years in the treatment of degenerative lumbar spinal stenosis(DLSS) achieved excellent results.Compared with traditional open surgery, which is characterized by large trauma, much bleeding, longer bed stay and slow recovery, the rapid development of PSED technology has greatly reduced the surgical trauma, postoperative recovery time and complications of DLSS patients. PSED core as the target therapy, with minimal trauma at the same time to achieve satisfactory decompression effect for lumbar spinal stenosis. Depending on the level, location, and degree of lumbar spinal stenosis, it is important to determine the ideal treatment. However, in practice, PSED has insufficient understanding of the treatment of different pathological types of lumbar spinal stenosis, such as indication selection, surgical approach selection, advantages and limitations of various approaches, and endoscopic vertebral fusion.At present, with the deepening of PSED research and the improvement of endoscopic instruments, great progress has been made in the treatment of DLSS.In this paper, the research progress in the treatment of DLSS by PSED in recent years will be described from four aspects, namely, the grasp of indications, the selection of approaches, the advantages and disadvantages of endoscopic approaches, and endoscope-assisted vertebral fusion, in order to provide certain guidance for the clinical treatment of DLSS by PSED.

Influence of degenerative scoliosis on the treatment of lumbar spinal stenosis by MIS-TLIF / 中国骨伤

OBJECTIVE@#To evaluate the effect of degenerative scoliosis on the difficulty and efficacy of minimally invasive transforaminal lumbar interbody fusion(MIS-TLIF) in the treatment of lumbar spinal stenosis.@*METHODS@#From September 2016 to September 2019, 52 patients with lumbar spinal stenosis treated by MIS-TLIF were retrospectively analyzed, including 16 males and 36 females, aged from 42 to 71(63.44±5.96) years old, the course of disease from 1.5 to 6.5 years, with an average of (3.69±1.10) years. All patients had lower extremity root pain or numbness, 41 patients had intermittent claudication. There were 31 cases of L@*RESULTS@#All patients were followed up for 12 to 36 months, with an average of (19.58±5.33) months. The operation time and intraoperative bleeding in stenosis group were better than those in scoliosis group (@*CONCLUSION@#For patients with lumbar spinal stenosis undergoing MIS-TLIF, degenerative scoliosis can lead to prolonged operation time and increased bleeding. However, it has no significant effect on therelief of postoperative symptoms, postoperative complications and the recovery of lumbar function.

Case-control study on the treatment of single-segment lumbar spinal stenosis with modified interlaminar approach and traditional approach / 中国骨伤

OBJECTIVE@#To explore the clinical effect of modified interlaminar approach for the treatment of single-segment lumbar spinal stenosis.@*METHODS@#From February 2015 to August 2017, 80 patients with single-segment lumbar spinal stenosis planned to undergo endoscopic surgery were selected, including 38 males and 42 females;aged 33 to 69 (47.6±9.5) years old. Using random number table method, the patients were divided into study group and traditional group, 40 cases in each group, and underwent surgical treatment through modified translaminar approach and traditional approach respectively. The operation time, intraoperative blood loss, and hospital stay were recorded;visual analogue scale (VAS) and Oswestry Disability Index (ODI) before and after operation were compared between two groups;spinal canal arca, spinal canal diameter, disc yellow space and surgical complications were observed.@*RESULTS@#All 80 patients were followed up for at least 3 months. Two patients had incision infection, both of them were in traditional group;there was no significant difference in operation time between two groups(@*CONCLUSION@#Compared with the traditional approach, the modified interlaminar approach has advantages of less trauma, faster recovery and better postoperative spinal space recovery in the treatment of single-segment lumbar spinal stenosis.

Clinical observation of transforaminal endoscopy combined with interspinous fusion in the treatment of lumbar spinal stenosis with instability in the elderly / 中国骨伤

OBJECTIVE@#To observe the clinical effect of transforaminal endoscopy combined with interspinous fusion in the treatment of lumbar spinal stenosis with instability in the elderly.@*METHODS@#From February 2018 to February 2019, 82 elderly patients with lumbar spinal stenosis and instability were divided into control group and observation group. In the control group, there were 23 males and 18 females;the age was (68.9±4.1) years;the course of disease was (14.1±5.7) months;there were 5 cases of single segment lesions and 36 cases of multi segment lesions;simple bacfuse interspinous fusion was used. In the observation group, there were 22 males and 19 females;the age was (69.1±4.0) years;the course of diseasewas (14.4±5.5) months;there were 6 cases of single segment lesions and 35 cases of multi segment lesions;they were treated with transforaminal endoscopic surgery combined with Bacfuse interspinous fusion. The clinical efficacy, visual analogue scale (VAS), Japanese Orthopaedic Association scores (JOA), Oswestry disability index (ODI), Lehmann lumbar function score, posterior disc height and intervertebral foramen height, complication rate and recurrence rate of the two groups were compared.@*RESULTS@#The clinical efficacy of the observation group was better than that of the control group;the VAS score of the observation group was lower than that of the control group, the JOA score was higher than that of the control group, and the ODI index at 3 months after operation and at the last follow-up was lower than that of the control group, the Lehmann lumbar function score was higher than that of the control group;the posterior edge height of intervertebral disc and intervertebral foramen height were higher than those of the controlgroup;the incidence of complications and recurrence rate (4.9% and 0.0%) of the observation group were lower than those of the control group (19.5%, 9.8%), the difference was statistically significant (@*CONCLUSION@#The clinical effect of transforaminal endoscopy combined with interspinous process fusion in the treatment of lumbar spinal stenosis with instability in the elderly is ideal. It can reduce postoperative pain, improve lumbar function, improve the height of posterior edge of intervertebral disc and intervertebral foramen, and reduce the incidence and recurrence rate. It is worthy of clinical promotion.

Treatment of senile lumbar spinal stenosis by unilateral approach and bilateral decompression with large channel endoscopy / 中国骨伤

OBJECTIVE@#To evaluate clinical effect of unilateral approach and bilateral decompression via large channel endoscopic system for the treatment of lumbar spinal stenosis.@*METHODS@#The clinical data of 32 patients with lumbar spinal tenosis treated by unilateral approach and bilateral decompression via large channel endoscopy from February 2018 to February 2019 were retrospectively analyzed. There were 18 males and 14 females, aged 65 to 84 years old with an average of (70.6± 8.4) years. The course of disease was from 1 to 12 years. All 32 cases were accompanied by numbness or pain in the lower limbs, of which 28 cases were accompanied by intermittent claudication. Narrow segments were L@*RESULTS@#All the patients were followed up for 12-24 (17.68±2.43) months and all operations were successfully completed with the operation time of 70-160(85.64±11.94) min. Spinal dural tear occurred in 1 case during the operation, and sensory disturbance in the other side of lower limb in a short period of time occurred in 2 cases, all improved after corresponding treatment. Postoperative imaging showed that the spinal canal was significantly enlarged and the nerve root was fully released. Before operation and 3 days, 3 months, 1 year after operation, VAS scores of low back pain were 4.62 ±1.41, 2.73 ±1.35, 1.21 ±1.17, 1.11 ±0.34, respectively;VAS scores of leg pain were 6.83 ± 1.71, 3.10±1.50, 1.08±0.19, 0.89±0.24, respectively. VAS scores of low back pain and leg pain each time point after operation were obvious improved (@*CONCLUSION@#It is a safe and effective way to treat lumbar spinal stenosis with unilateral approach and bilateral decompression via large channel endoscopic system. It has the advantages of sufficient decompression, less trauma, fast recovery, high safety and low incidence of postoperative complications. It can minimize the damage to the stable structure of the lumbar spine and is an ideal minimally invasive operation for the treatment of lumbar spinal stenosis.

Ligamentum flavum in lumbar spinal stenosis, disc herniation and degenerative spondylolisthesis. An histopathological description / Ligamento amarillo en estenosis lumbar espinal, hernia de disco y espondilolistesis degenerativa. Una descripción histopatológica

Abstract: Introduction: Changes in ligamentum flavum (LF) related to degeneration are secondary to either the aging process or mechanical instability. Previous studies have indicated that LF with aging shows elastic fiber loss and increased collagen content, loss of elasticity may cause LF to fold into the spinal canal, which may further narrow of the canal. Material and methods: A total of 67 patients operated with the surgical indications of lumbar spinal stenosis (LSS), lumbar disc herniation (LDH) and lumbar degenerative spondylolisthesis (LDS) were included. LF samples were obtained from patients who had LSS (39), LDH (22) and LDS (6). Specimens were examined with regard to chondroid metaplasia, calcification, fragmentation of collagen fibers, cystic degeneration, fibrillar appearence, and hypercellularity. Results: The most frequent histopathological changes were hyalinization and fragmentation of collagen fibers occur in 34%, neovascularization in 40.3% and irregular arrangement of elastic fibers is the most prevalent change with 56.7% of the total samples. There is a difference in the presence of certain changes in the LF according to the diagnosis, being statistically significant for fragmentation of collagen fibers (p = 0.045), cystic degeneration (p = 0.001), fibrillar appearance (p = 0.007) and hypercellularity (p = 0.005) all of these, being more prevalent in LDS group. LHD group presented fragmentation of collagen fibers in 45.5% (p = 0.045) and fibrillar appearance in 4.5% (p = 0.009). Conclusions: There is not evidence of cellular hyperthophy in the histhopatological analyses, thickening of the LF can be seen by bulking of LF followed by collapse of motion segment.

Resumen: Introducción: Los cambios en el ligamento flavum (LF) relacionados con la degeneración son secundarios al proceso de envejecimiento o a la inestabilidad mecánica. Estudios anteriores han indicado que LF con envejecimiento muestra pérdida de fibras elásticas y aumento del contenido de colágeno, la pérdida de elasticidad puede hacer que el LF se pliegue en el canal espinal, disminuyendo su espacio. Material y métodos: Se incluyeron 67 pacientes operados de estenosis lumbar espinal (LSS), hernia de disco lumbar (LDH) y espondilolistesis degenerativa (LDS). Se obtuvieron muestras de LF de pacientes que tenían LSS (39), LDH (22) y LDS (6). Se examinaron especímenes con respecto a metaplasia condroide, calcificación, fragmentación de fibras de colágeno, degeneración quística, apariencia fibrilar e hipercelularidad. Resultados: Los cambios histopatológicos más frecuentes fueron la hialinización y la fragmentación de las fibras de colágeno (34%), neovascularización en 40.3%, y la disposición irregular de las fibras elásticas es el cambio más frecuente con 56.7% del total de muestras. Existe una diferencia en la presencia de cambios en el LF, de acuerdo con el diagnóstico, siendo estadísticamente significativo para la fragmentación de las fibras de colágeno (p = 0.045), la degeneración quística (p = 0.001), la apariencia fibrilar (p = 0.007) y la hipercelularidad (p = 0.005) todos ellos, siendo más frecuentes en el grupo LDS. El grupo LHD presentó fragmentación de las fibras de colágeno en 45.5% (p = 0.045) y la apariencia fibrilar en 4.5% (p = 0.009). Conclusiones: No hay evidencia de hipertrofia celular en los análisis histopatológicos, el engrosamiento del LF se puede ver por abultamiento del mismo, seguido de colapso del segmento de movimiento.

Efficacy and safety of percutaneous transforaminal endoscopic discectomy in the treatment of lumbar spinal stenosis combined with osteoporosis

SUMMARY OBJECTIVE: To investigate the efficacy and safety of percutaneous transforaminal endoscopic discectomy (PTED) in the treatment of lumbar spinal stenosis (LSS) combined with osteoporosis. METHODS: Eighty patients with LSS combined with osteoporosis were divided into a control and PTED group, which received conventional transforaminal lumbar interbody fusion and PTED, respectively. The surgical indications, incision visual analogue scale (VAS), lumbar and leg pain VAS, lumbar Japanese Orthopaedic Association (JOA) and Oswestry disability index (ODI) scores, bone mineral density (BMD), and adverse reactions were observed. RESULTS: Compared with the control group, in the PTED group, the operation time, bleeding loss and hospitalization duration, incision VAS scores at postoperative 12, 24 and 48 h and lumbar and leg pain VAS and lumbar ODI scores on postoperative 6 months were significantly decreased (P < 0.01), and the lumbar JOA score on postoperative 6 months was significantly increased (P < 0.05). There was no significant difference in BMD between two groups (P > 0.05). Compared with the control group, in the PTED group, the total effective rate was significantly higher (P < 0.05), and the incidence of adverse reactions was significantly lower (P < 0.05). CONCLUSIONS: PTED is safe and effective in the treatment of LSS combined with osteoporosis.

RESUMO: OBJETIVO: Investigar a eficácia e segurança da discectomia endoscópica percutânea transforaminal (DEPT) no tratamento da estenose lombar (EL) combinada à osteoporose. MÉTODOS: Oitenta pacientes com EL combinada à osteoporose foram divididos entre um grupo de controle e um grupo de DEPT, que receberam tratamento convencional com fusão intersomática lombar transforaminal e DEPT, respectivamente. As indicações cirúrgicas, a escala analógica visual (VAS) da incisão e de dor lombar e nas pernas, os escores lombares de acordo com a Associação Ortopédica Japonesa (JOA) e o Oswestry Disability Index (ODI), a densidade mineral óssea (DMO) e possíveis reações adversas foram observados. RESULTADOS: Em comparação com o grupo de controle, no grupo de DEPT o tempo de operação, a perda de sangue e duração de internação, os escores VAS da incisão no pós-operatório após 12, 24 e 48 h, o VAS para dor lombar e nas pernas e os escores ODI lombares após 6 meses de pós-operatório foram significativamente menores (P < 0,01); já o escore JOA lombar após 6 meses de pós-operatório foi significativamente maior (P < 0,05). Não houve diferença significativa na densidade mineral óssea entre os dois grupos (P > 0,05). Em comparação com o grupo de controle, o grupo de DEPT teve uma taxa efetiva total significativamente maior (P < 0,05), e a incidência de reações adversas foi significativamente menor (P < 0,05). CONCLUSÕES: A discectomia endoscópica percutânea transforaminal é segura e eficaz no tratamento de EL combinada à osteoporose.

Lumbar spinal stenosis: evaluation of pain and life quality after surgical treatment / Estenose de canal lombar: avaliação de dor e qualidade de vida após tratamento cirúrgico / Estenosis de canal lumbar: evaluación del dolor y de la calidad de vida después de tratamiento quirúrgico

ABSTRACT Objective: The objective of this study was to present an analysis of progression of the quality of life and pain in patients undergoing surgical treatment of LSS and the potential correlations between individual factors and the clinical outcome observed. Methods: We studied 111 patients undergoing surgical treatment of LSS from January 2009 to December 2011 using the functional capacity (ODI) and pain (VAS) questionnaires. The preoperative data were compared statistically with the results obtained during the postoperative follow-up at one month, six months, one year, and two years. Results: The population consisted of 60 men and 51 women. The mean age was 61.16 years at the time of surgery, 33.33% were 60 years or older. When the questionnaires were applied, we found improvement in the progressive disability assessment with a mean drop of 23.65 ODI points after 6 months of the surgical treatment and 27.47 at the end of one year of surgery compared to preoperative for this scale. There was a decline of 3.84 points (mean) in the VAS at first postoperative month. Conclusion: Surgical treatment of LSS presented favorable postoperative evolution in a 2-year follow-up regarding pain and quality of life through VAS and ODI. Level of Evidence IV; Case series.

RESUMO Objetivo: O objetivo deste estudo foi apresentar uma análise evolutiva da qualidade de vida e da dor em pacientes submetidos ao tratamento cirúrgico da ECL, e possíveis correlações entre fatores individuais e o desfecho clínico observado. Métodos: Foram avaliados 111 pacientes submetidos ao tratamento cirúrgico da ECL, no período de Janeiro de 2009 a Dezembro de 2011, através de questionários de capacidade funcional (ODI) e dor (EVA). Os dados do período pré-operatório foram comparados estatisticamente com os resultados obtidos durante o seguimento pós-operatório de um mês, seis meses, um ano e dois anos. RESULTADOS: A população foi constituída de 60 homens e 51 mulheres. A média de idade foi de 61,16 anos no momento da cirurgia, 33,33% tinham 60 anos ou mais. Aplicados os questionários, encontramos melhora na avaliação progressiva da incapacidade, com uma queda média de 23,65 pontos do ODI após 6 meses do tratamento cirúrgico e de 27,47 ao final de um ano da cirurgia, em comparação com os valores de pontuação pré-operatória para esta escala. Houve um declínio de 3,84 pontos (média) na EVA já no primeiro mês de pós-operatório. Conclusão: O tratamento cirúrgico da ECL apresentou evolução pós-operatória favorável em acompanhamento de 2 anos, em análise de dor e qualidade de vida através de VAS e ODI. Nível de Evidência IV; Série de casos.

RESUMEN Objetivo: El objetivo de este estudio fue presentar un análisis evolutivo de la calidad de vida y del dolor en pacientes sometidos a tratamiento quirúrgico de la ECL y posibles correlaciones entre factores individuales y el desenlace clínico observado. Métodos: Se evaluaron 111 pacientes sometidos al tratamiento quirúrgico de la ECL en el período de enero de 2009 a diciembre de 2011 a través de cuestionarios de capacidad funcional (ODI) y dolor (EVA). Los datos del período preoperatorio se compararon estadísticamente con los resultados obtenidos durante el seguimiento postoperatorio de un mes, seis meses, un año y dos años. Resultados: La población del estudio consistió en 60 hombres y 51 mujeres. La edad promedio fue de 61,16 años en el momento de la cirugía, el 33,33% tenían 60 años o más. Cuando los cuestionarios fueron aplicados, encontramos una mejora en la evaluación de la incapacidad progresiva, con una caída media de 23,65 puntos del ODI después de 6 meses del tratamiento quirúrgico y de 27,47 al final de un año de la cirugía, en comparación con los valores de puntuación preoperatoria para esta escala. Se observó un descenso de 3,84 puntos (promedio) en la EVA ya en el primer mes de postoperatorio. Conclusión: El tratamiento quirúrgico de ECL presentó evolución postoperatoria favorable en el seguimiento de dos años con respecto al análisis de dolor y a la calidad de vida a través de EVA y ODI. Nivel de Evidencia IV; Serie de casos.

Factors associated with persistence of pain in lumbar stenosis surgery / Fatores associados á persistência da dor na cirurgia de estenose lombar / Factores asociados a la persistencia del dolor en la cirugía de estenosis lumbar

ABSTRACT Objective: The objective of this study was to determine the factors associated with the persistence of pain in patients operated on for lumbar stenosis. Method: One hundred and fifty-three patients were studied, divided into two groups: 1) Patients with persistent pain in varying degrees, 2) Patients without pain. Age, sex, affected levels, comorbidities, surgical risk, and type of surgical procedure were evaluated. Results: There were 108 patients in the group with pain and 45 in the group without pain. In the group with pain, there were 28 patients with diabetes mellitus, 31 smokers, and 28 alcohol-dependent patients, with a significant difference of p = 0.001 and an RR = 1.1. A simple widening procedure was performed in 48 patients in the group with pain and 12 patients in the group without pain, with RR = 0.8, and widening plus instrumentation was performed in 7 patients in both the with and without pain groups. Conclusion: The indication of a surgical procedure in patients with spinal stenosis must take many factors into account in addition to clinical factors and the segments affected, since these factors impact patient prognosis. In the multivariate analysis, the variable most closely associated with persistent pain was the procedure performed. Level of Evidence III; Case-control study.g

RESUMO Objetivo: Determinar os fatores associados à persistência da dor em pacientes operados por estenose lombar. Método: 153 pacientes foram estudados em dois grupos: 1) Pacientes com dor persistente em graus variados; 2) Pacientes sem dor. Idade, sexo, níveis afetados, comorbidades, risco cirúrgico e tipo de procedimento cirúrgico foram avaliados. Resultados: 108 pacientes no grupo com dor e 45 no grupo sem dor. Diabetes Mellitus em 28 pacientes no grupo da dor. Grupo com dor positivo em relação ao tabagismo em 31 pacientes, 28 pacientes com alcoolismo, com diferença significativa de p=0,001 e um RR=1,1. Os procedimentos realizados foram: Aumento Simples em 48 pacientes dentro do grupo com dor e em 12 pacientes no grupo sem dor, com RR=0,8, Extensão mais instrumentação em sete pacientes no grupo com dor e em sete pacientes no grupo sem dor. Conclusão: A indicação do procedimento cirúrgico em pacientes com estenose espinhal deve levar em consideração muitos fatores, não apenas os segmentos clínicos ou afetados, uma vez que esses fatores têm um efeito prognóstico no paciente. Na análise multivariada, a condição mais associada à dor persistente foi o procedimento realizado. Nível de Evidência III; Estudo de caso-controle.g

RESUMEN Objetivo: Determinar los factores asociados a la persistencia del dolor en pacientes operados por estenosis lumbar. Métodos: Se estudiaron 153 pacientes, en dos grupos: 1) Pacientes con persistencia del dolor en grados variables, 2) Pacientes sin dolor. Se evaluó edad, sexo, niveles afectados, comorbilidades, riesgo quirúrgico y tipo de procedimiento quirúrgico. Resultados: Ciento ocho pacientes en el grupo con dolor y 45 en el grupo sin dolor. Diabetes Mellitus en 28 pacientes del grupo con dolor. Grupo positivo tabaquismo con dolor en 31 pacientes, 28 pacientes con alcoholismo, con diferencia significativa de p=0,001 y un RR=1,1. Los procedimientos realizados fueron: aumento simple en 48 pacientes dentro del grupo con dolor y en 12 pacientes en el grupo sin dolor con RR=0,8, extensión más instrumentación en siete pacientes en el grupo con dolor y en siete pacientes en el grupo sin dolor. Conclusiones: La indicación del procedimiento quirúrgico en pacientes con estenosis espinal debe tomar en cuenta numerosos factores, no únicamente los clínicos o los segmentos afectados, ya que esos factores tienen un efecto pronóstico en el paciente. En el análisis multivariado la condición mayormente asociada a la persistencia del dolor fue el procedimiento realizado. Nivel de Evidencia III; Estudio de caso-controlg.

Evolución clínica de la cirugía descompresiva en el tratamiento del canal lumbar estrecho degenerativo / Clinical results of decompressive surgery in degenerative lumbar spinal stenosis

Resumen: Antecedentes: Diversos autores y publicaciones se han enfocado en comparar la evolución clínica de la cirugía descompresiva de las raíces, ya sea con o sin fusión, para el tratamiento del canal lumbar estrecho degenerativo. Sin embargo, no existen muchos reportes que analicen la evolución clínica tras la cirugía descompresiva de una sola raíz nerviosa (la más sintomática) contra la descompresión de todas las raíces de un segmento. El presente estudio pretende comparar la evolución clínica de la liberación radicular lumbar de la raíz más sintomática con respecto a la liberación de múltiples raíces lumbares para el alivio del dolor neuropático en el canal lumbar estrecho degenerativo. Material y métodos: Se realizó un estudio prospectivo observacional, descriptivo, longitudinal con 38 pacientes divididos en dos grupos de 19 casos a quienes se les practicó recalibraje de una sola raíz o de múltiples raíces de un segmento; se obtuvieron porcentajes, t de Student y coeficiente de correlación de Pearson. Resultados: En el grupo A, se evidenció una disminución de 46.63 puntos en la escala de Oswestry, lo que traduce una mejoría del dolor de 66.73%. En el grupo B, en cambio, se observó una disminución promedio de 34.54 puntos en la escala de Oswestry, equivalente al 47.23%, con una t de Student donde p = 0.11 y el coeficiente de correlación de Pearson, 0.08. Conclusiones: No se encontraron diferencias estadísticamente significativas entre ambos grupos de estudio.

Abstract: Background: Several authors and publications have focused on comparing the clinical course of nerve root decompressive surgery, with or without fusion, to treat degenerative lumbar stenosis. However, there are not many reports analyzing the clinical course after decompressive surgery of a single nerve root (the most symptomatic one) comparing it with decompression of all the roots in a segment. This study intends to compare the clinical course after decompressing the most symptomatic lumbar nerve root with the release of multiple lumbar nerve roots to relieve neuropathic pain resulting from degenerative lumbar stenosis. Material and methods: A prospective, observational, descriptive longitudinal study was performed. A total of 38 patients were divided into two groups that included each 19 cases. Patients underwent recalibration of either a single nerve root or multiple nerve roots of a segment. Percentages were calculated as well as the Student t test and the Pearson correlation. Results: In group A, a decrease of 46.63 points was seen in the Oswestry scale, representing a 66.73% improvement in pain. In group B, in turn, a mean decrease of 34.54 points was seen in the Oswestry scale, equivalent to a 47.23% improvement in pain, with a Student t in which p = 0.11 and a Pearson correlation coefficient of 0.08. Conclusions: No statistically significant differences were found between both study groups.

Lumbar Lordosis of Spinal Stenosis Patients during Intraoperative Prone Positioning

BACKGROUND: To evaluate the effect of spondylolisthesis on lumbar lordosis on the OSI (Jackson; Orthopaedic Systems Inc.) frame. Restoration of lumbar lordosis is important for maintaining sagittal balance. Physiologic lumbar lordosis has to be gained by intraoperative prone positioning with a hip extension and posterior instrumentation technique. There are some debates about changing lumbar lordosis on the OSI frame after an intraoperative prone position. We evaluated the effect of spondylolisthesis on lumbar lordosis after an intraoperative prone position. METHODS: Sixty-seven patients, who underwent spinal fusion at the Department of Orthopaedic Surgery of Gwangmyeong Sungae Hospital between May 2007 and February 2012, were included in this study. The study compared lumbar lordosis on preoperative upright, intraoperative prone and postoperative upright lateral X-rays between the simple stenosis (SS) group and spondylolisthesis group. The average age of patients was 67.86 years old. The average preoperative lordosis was 43.5degrees (+/- 14.9degrees), average intraoperative lordosis was 48.8degrees (+/- 13.2degrees), average postoperative lordosis was 46.5degrees (+/- 16.1degrees) and the average change on the frame was 5.3degrees (+/- 10.6degrees). RESULTS: Among all patients, 24 patients were diagnosed with simple spinal stenosis, 43 patients with spondylolisthesis (29 degenerative spondylolisthesis and 14 isthmic spondylolisthesis). Between the SS group and spondylolisthesis group, preoperative lordosis, intraoperative lordosis and postoperative lordosis were significantly larger in the spondylolisthesis group. The ratio of patients with increased lordosis on the OSI frame compared to preoperative lordosis was significantly higher in the spondylolisthesis group. The risk of increased lordosis on frame was significantly higher in the spondylolisthesis group (odds ratio, 3.325; 95% confidence interval, 1.101 to 10.039; p = 0.033). CONCLUSIONS: Intraoperative lumbar lordosis on the OSI frame with a prone position was larger in the SS patients than the spondylolisthesis patients, which also produced a larger postoperative lordosis angle after posterior spinal fusion surgery. An increase in lumbar lordosis on the OSI frame should be considered during posterior spinal fusion surgery, especially in spondylolisthesis patients.