[Surgical strategy for the treatment of thoracolumbar metastatic tumor and its clinical outcomes].

OBJECTIVE: To evaluate surgical strategy and clinical outcomes for the treatment of thoracolumbar metastatic tumor. METHODS: From January 2009 to December 2010,42 patients with thoracolumbar metastatic tumor were treated surgically. Among the patients, 30 patients were male, and 12 patients were female, ranging in age from 28 to 76 years old, with an average age of 56.8 years old. Twenty-five patients had metastatic tumor in thoracic vertebraes, and 17 patients had metastatic tumor in lumbar vertebraes. Thirty-four patients had metastatic tumor in 1 segment, 6 patients had metastatic tumor in 2 segments and 2 patients had metastatic tumor in 3 segments. Two patients had no symptoms and 40 patients had back or leg pain. Eighteen patients had neurologic deficits, and 5 patients had injuries of A degree, 3 patients had injuries of B degree, 4 patients had injuries of C degree, 6 patients had injuries of D degree according to ASIA grading system. The operation goal was made according to Tomita evaluation. The surgical procedures included pallative decompression, tumor curettage and total vertebrectomy, which were decided based on Tomita classification. The pain, spinal cord function,part control of tumor,survival rate and conditions of internal fixation were evaluated at 1 week, 3 months, 6 months, 1 year and 2 years after operation. RESULTS: One patient died in the operation. Pain relief was obtained in 38 patients after operation. Among 18 patients suffering from spinal cord compromise, 17 patients improved 1 to 4 grades after surgery according to the ASIA grading system. All the patients were followed up and the duration ranged from 24 to 48 months, with a mean time of 34.2 months. Five patients got recurrence. The postoperative survival rates at 3 months, 6 months, 1 year and 2 years were 95.2%, 85.7%, 58.2%, 37.6% respectively. CONCLUSION: According to Tomita system, the different surgical treatments can be selected for patients with spinal metastatic tumors, which can relieve pain, improve the neurological status and spine stabilization, maintain local control, improve quality of life.

[Complication and treatment of the lumbar intervertebral disc herniation using percutaneous endoscopic lumbar discectomy].

OBJECTIVE: To summarize and discuss the lapsus and the treatment of the lumbar intervertebral disc herniation using percutaneous endoscopic lumbar discectomy (PELD). METHODS: Between July 2002 and October 2010, 689 patients with lumbar intervertebral disc herniation treated by PELD were analyzed, including 448 males, and 241 females. Single lumbar intervertebral disc herniation were 669 cases. double lumbar intervertebral disc herniation were 19; three lumbar intervertebral disc herniation were 1. Central type in 66, side central type in 365, lateral type in 242, extreme lateral type in 10, sequestered type in 6. These cases with complications in operation and postoperation were studied retrospectively. RESULTS: There were nucleus pulposus omissions in 5 patients and 2 patients underwent open resection of nucleus pulposus during operation immediately and the second operation was needed in 3 cases, 1 case with transforaminal lumbar interbody fusion (TLIF) and the others with open resection of nucleus pulposus. Two patients had nerve root injury, but all completely recovered in 3 - 6 months after operation. Spinal dura mater disruption was in 2 patients, recovered after suturing of skin wound. All 689 patients were followed up for 6 - 96 months, mean follow-up time was 33 months. Postoperative spondylodiscitis was in 7 patients, recovery after expectant treatment in 1, percutaneous puncture irrigation and drainage for continued use of local antibiotics in 4, posterior infective lumbar discectomy in 2. Postoperative relapse was in 6 patients, operated secondly by PELD in 4 and by TLIF in 2, recovery after the second operation. Nerve root induced hyperalgesia and burning-like nerve root pain was seen in 19 patients, the symptom was improved by analgesic drug, neurotrophy drug and physiotherapy. The effect of single segment PELD was not good in 10 patients with spinal stenosis, who underwent multiple segment TLIF later. CONCLUSIONS: The complications during operation usually are nucleus pulposus omissions, nerve root injury, spinal dura mater disruption. Accordingly the complications after operation include spondylodiscitis, recurrence, nerve root induced hyperalgesia or burning-like nerve root pain. Strict indication, aseptic technique, skilled operation and proper rehabilitation exercise are effective ways to reduce complications.

Treatment of lumbar and lumbosacral spinal tuberculosis with minimally invasive surgery.

OBJECTIVE: To evaluate the outcome of computed tomography (CT)-guided percutaneous puncture and local chemotherapy for tuberculosis (TB) of the lumbar or lumbosacral spine. METHODS: From January 2002 to August 2006, 49 patients with lumbar or lumbosacral spinal TB in whom conservative treatment had failed were treated by minimally invasive surgery. There were 21 female and 28 male patients. The mean age of the patients was 47 ± 18 years (range from 12 to 78 years). There were 40 cases with lumbar TB, and 9 with lumbosacral TB. From L(1) to S(1), the involved vertebral numbers were 8, 26, 19, 19, 21 and 10, respectively. In 3 patients the spinal TB involved a single vertebra, in 39 patients two, in 6 patients three and in only one case four vertebrae. According to the Frankel scale, three patients had grade E incomplete paralysis preoperatively. The outcome, after treatment by CT-guided percutaneous puncture and local chemotherapy, was retrospectively analyzed according to the preoperative and postoperative kyphotic angles and the Oswestry disability index (ODI). RESULTS: Forty-nine patients were followed up for from one year to 5 years and 8 months (average 35 months). All cases recovered, and there was no recurrence. Preoperatively, the kyphotic angle was 16.47°± 8.74°, and it had decreased to 13.35°± 8.02° by the final follow-up (t= 5.79, P < 0.001). The average ODI score had improved from 70.12 ± 22.24 to 12.72 ± 8.62 (t= 21.42, P < 0.001). CONCLUSION: The majority of cases of lumbar and lumbosacral spinal TB can achieve satisfactory results with minimally invasive surgery. Its clinical application is therefore strongly recommended.

[Characteristics of nerve root compression caused by degenerative lumbar stenosis with scoliosis].

OBJECTIVE: To investigate the factors that may contribute to radiculopathy in degenerative lumbar stenosis with scoliosis (DLSS) and their association with the pattern of the scoliosis. METHODS: Twenty-seven patients with DLSS were examined in our hospital. The symptomatic nerve roots were determined by pain distribution, and neurological findings. The compressive factors were diagnosed by magnetic resonance imaging and myelography or radiculography. The pattern of scoliosis was determined by plain radiographs. Correlation between the affected nerve root and the compressive factors or the pattern of the scoliosis were then analyzed. RESULTS: Among the 27 patients, L3 root was affected in 6 patients, L4 root in 13 patients, L5 root in 15 patients, and S1 root in 9 patients. L3 and L4 roots were more compressed by foraminal or extraforaminal stenosis on the concave side of the curve, whereas L5 and S1 roots were commonly affected by lateral recess stenosis on the convex side. CONCLUSION: In DLSS, nerve root compression is not only seen on the concave side of the scoliosis, but also equally involved on the convex side. Most radiculopathy in DLSS distributes close to central sacral vertical line, which may be due to the abnormal weight-bearing for the pattern of scoliosis.

[Anterior cervical diskectomy and fusion with allograft and internal fixation].

OBJECTIVE: To evaluate the effect of cylindrical titanium mesh packing cancellous allograft in the anterior cervical fusion for the cervical spondylosis with anterior titanium plate. METHODS: Ninety-eight patients with cervical spondylosis underwent diskectomy and cancellous allograft contained in cylindrical titanium mesh enhanced by anterior titanium plate system. Sixty-four patients were followed up clinically and radiographically. The mean follow-up time was (15.2 +/- 1.7) months. JOA scores and Nurick myelopathy grading system were used for clinical assessment. Roentgenograms were analyzed to identify the stability of fused levels. RESULTS: In all patients of 98 cases, the wounds were normally healed without acute or chronic infection. In statistical analysis of 64 patients followed up, the mean JOA scores was (11.6 +/- 1.8) preoperatively and improved to (16.0 +/- 1.2) at final follow-up (P < 0.05). And the mean Nurick grades were (2.7 +/- 0.7) and (0.7 +/- 0.8) before and after surgery respectively (P < 0.05). The X-ray films demonstrated that no meshes were found displacing or subsiding. New bone formation occurred in the back of meshes at 5 months after surgery. The final follow-up fusion rate was 95%. CONCLUSION: The cancellous allograft impacted into titanium meshes for cervical fusion has gained excellent or good results clinically and radiographically in short term follow-up.

[Freeze-dried allograft of posterior spinal fusion in patients with scoliosis].

OBJECTIVE: To observe the effectiveness and safety of allograft in posterior spinal fusion in patients with scoliosis. METHODS: 41 cases of 54 scoliosis patients with allograft for spinal fusion were followed up. The mean follow-up time is 16 months. Foreign body reaction was studied clinically and fusion status was assessed radiographically. RESULTS: There was no foreign body reaction significantly in all patients. Acute deep wound infection happened in one patient and no chronic deep wound infection occurred. There was no disease transferred by allograft in followed patients. New bone formation appeared after 4 months postoperatively in radiogram. At final follow-up, the mean angle of 3.4 degrees lost and minimal -1 degrees and maximal 6 degrees . Implants were fastened and did not loosen and fracture. CONCLUSIONS: Allograft for posterior spinal fusion in scoliosis patients was useful and safe.