[Clinical efficacy and technical characteristics of percutaneous endoscopic lumbar discectomy in the treatment of upper lumbar disc herniation].

OBJECTIVE: To analyze the clinical efficacy and technical characteristics of percutaneous endoscopic lumbar discecomy in the treatment of upper lumbar disc herniation. METHODS: The clinical data of 9 patients with upper lumbar disc herniation underwent percutaneous endoscopic lumbar discecomy from January 2012 to October 2019 were retrospectively analyzed. There were 6 males and 3 females, aged 26 to 79 years, including 2 patients with L1,2 disc herniation and 7 patients with L2, 3 disc herniation. Visual analogue scale (VAS) and Japanese Orthopeadic Association (JOA) score were recorded before and after surgery. The clinical efficacy was evaluated according to the modified Macnab standard. RESULTS: All 9 patients were followedup, and the follow-up time was 1 day and 3 months after surgery. The operation time was 1.5 to 2.9 h and postoperative hospital stay was 5 to 8 d. No cerebrospinal fluid leakage or spinal cord injury occurred during the operation. Preoperative and postoperative at 1 day, 3 months, the VAS scores of 9 patients were 7 to 8 scores, 1 to 3 scores, 0 to 1 case, JOA scores were 5 to 7 scores, 15 to 24 scores, 21 to 26 scores, respectively. The improvement rate of JOA was 36.4% to 78.3% on the first day and 65.2% to 87.5% three months after operation. According to modified Macnab standard to evaluate effect, 4 cases got excellent results, 4 good, 1 fair. CONCLUSION: Percutaneous endoscopic lumbar discecomy has reliable therapeutic effect for upper lumbar disc herniation in line with the indications, and it has the characteristics of small trauma and short operation time, so it is more suitable for middle aged and elderly patients with poor physique and can replace part of transforaminal lumbar interbody fusion.

Posterior Lumbar Interbody Fusion with Interspinous Fastener Provides Comparable Clinical Outcome and Fusion Rate to Pedicle Screws.

OBJECTIVE: To investigate the clinical feasibility and validity of interspinous fastener (ISF) for lumbar degenerative diseases. METHODS: From October 2013 to March 2014, a total of 46 patients suffering from lumbar degenerative diseases underwent posterior lumbar interbody fusion (PLIF) randomly augmented by ISF or pedicle screws. The clinical outcome was primarily measured by Oswestry Disability Index (ODI) score. The minimal clinical important difference (MCID) was defined as an eight-point decrease in ODI. The second clinical outcome measurement was Japanese Orthopedic Association (JOA) score. Interbody fusion rates were evaluated by lumbar plain radiograph and computed tomography (CT) scan. Complications were also compared between groups. Statistical analyses were performed by SPSS version 13.0. Sample size calculation was performed before the study. The type I error α was set at 0.05 and the type II error ß at 0.1. Based on these assumptions and adding 10% for possible drop-outs, sample size calculations indicated that a total of 46 patients were required for the study. Parametric data was compared by independent t-test and categorical variables were compared using χ2 -tests or Fisher exact tests depending on the sample size. A P-value of less than 0.05 was considered significantly statistically different. Fleiss kappa coefficients were calculated for intra-observer and inter-observer reliability. RESULTS: A total of 43 patients completed the follow-up, with 22 cases in the ISF group and 21 patients in the pedicle screws group, respectively. Less intraoperative blood loss and shorter operation time were observed in the ISF group. The mean ODI significantly declined in both groups, with the ISF group's decreasing from preoperative 43.3 ± 8.2 to 21.4 ± 3.5 at 24-month follow-up and the pedicle screws group's decreasing from preoperative 42.9 ± 7.9 to 22.5 ±3.8 at 24-month follow-up, respectively. The ODI changes between groups had no statistical difference (P > 0.05). Of the 43 patients, 33 patients achieved an MCID. The bone fusion rate was 77.3% according to X-rays and 68.2% according to CT scans in the ISF group, and 81.0% according to X-rays and 76.2% according to CT scans in the pedicle screws group at the final follow-up. The intra-observer and inter-observer reliability assessed by the kappa value were 0.93 and 0.89, respectively. One patient in the pedicle screws group demonstrated screw loosening at the 6-month follow-up but was asymptomatic. One patient with spondylolisthesis in the ISF group demonstrated cage subsidence during the follow-up but also without related symptoms. CONCLUSION: The less invasive ISF combined with PLIF provided comparable clinical outcome and a similar bone fusion rate to pedicle screws. The ISF could potentially serve as a new alternative for lumbar degenerative diseases.

Impacts of Tumor Location, Nature and Bone Destruction of Extremity Osteosarcoma on Selection of Limb Salvage Operative Procedure.

OBJECTIVE: To study the impacts of tumor location, nature and extent of bone destruction on selection of operative protocol for extremity osteosarcoma (OS). METHODS: The medical records of 201 patients with extremity OS treated in our institute from December 1999 to June 2014 were retrospectively reviewed. Ninety eligible patients (56 males and 34 females) of average age 20 ± 11 years (range, 4-40 years) were enrolled. Tumor locations were categorized as diaphyseal (4; diaphysis group) or juxta-articular (86); the latter being subclassified as with (51, type III, epiphysis group) or without invasion beyond the epiphyseal line or plate (35, type I and II, metaphysis group) according to MRI images. Tumor nature (osteogenic, 51; osteolytic, 39) was determined radiologically. Extent of bone destruction was quantitated according to Mirel's scoring system to obtain an "invasion score". Regular postoperative follow-up included physical examination and imaging evaluation. RESULTS: Fifty-four patients underwent biological reconstruction and 36 mechanical reconstruction. The mean follow-up duration was 51 months (range, 6-176 months, including four deaths within 12 months). Biological reconstruction was performed more frequently in the diaphysis and metaphysis groups (31/39, 79.5%) than mechanical reconstruction (8/39, 20.5%, P < 0.05). Biological reconstruction and articular preservation were associated with more satisfactory limb function (MSTS scores: 25.0 ± 3.3 and 25.1 ± 3.6) than mechanical reconstruction and articular resection (MSTS scores: 23.4 ± 3.7 and 23.1 ± 3.4, P < 0.05). Reconstruction methods and articular preservation had no relationship with overall or tumor-free survival (P > 0.05). Osteolytic lesions were associated with more extensive bone destruction than osteogenic lesions according to invasion scores (P < 0.05). Following biological reconstruction, high invasion scores (>8) had a 13.5-fold risk of fracture compared with low scores (≤8) (P < 0.05). Twenty-one subjects had recurrences, 30 metastases and 26 died. Postoperative complications included infection (6), fracture (10), and prosthesis loosening (4). Kaplan-Meier analysis indicated 5- and 10-year survival rates of 68.9% and 62.8%, respectively, and 5- and 10-year tumor-free survival rates of 66.7% and 57.8%, respectively. CONCLUSION: Selection of limb salvage operative protocol for extremity OS should rely on tumor location, nature and extent of bone destruction. Regardless of tumor site, mechanical reconstruction is indicated for tumors with high invasion scores (>8), whereas biological reconstruction is preferred for those with low invasion scores (≤8). Tumors sparing the epiphyseal line or plate are ideal candidates for articular preservation.

Triptolide (TPL) improves locomotor function recovery in rats and reduces inflammation after spinal cord injury.

In this study, we studied the effect of triptolide (TPL) on locomotor function in rats with spinal cord injury. A total of 40 rats were studied after dividing them in two major groups, one was experimental group denoted as TPL group while other was control group denoted as PBS group. Each group was subdivided in four subgroups having five rats each (n = 5). TPL was given intraperitonially at the rate of 5 mg/kg/day in TPL group while PBS was given at the same time interval in the same manner in control group for comparison. A reduction in the cavity area of tissue sections was observed by bright field microscopy from 0.22 ± 0.05 to 0.12 ± 0.05 mm(2) in experimental group after 28 days of treatment while BBB score also improved from 1 to 5 after 14 days of treatment. SPSS software, one way ANOVA, was used for recording statistical analysis and values were expressed as mean ± SEM where P value of <0.01 was considered significant. The expression of I-kBα and NF-kB p65 was also studied using western blotting and after recording optical density (OD) values of western blots. It was observed that treatment with TPL significantly reduced the expression of these factors after 28 days of treatment compared with controls.

Alcohol-inactivated autograft replantation with joint preservation in the management of osteosarcoma of the distal femur: a preliminary study.

AIM: To evaluate clinical outcomes in patients who underwent alcohol-inactivated autograft replantation with joint preservation for the treatment of osteosarcoma of the distal femur. PATIENTS AND METHODS: 10 patients (7 men, 3 women; mean age: 20.1 years) were treated. 9 patients had Enneking stage IIb tumors and 1 patient had stage III. The mean follow-up time was 34 months. All patients obtained first-stage healing. RESULTS: 1 patient died of local recurrence and multiple metastases 13 months after surgery; 3 patients died of multiple metastases 9, 12, and 24 months after surgery, respectively. 3 patients required second surgery because of fracture of the inactivated autograft, 1 patient died 6 months later, 1 patient experienced bony healing 4 months later with no further complications, and 1 patient required subsequent open reduction and bone implantation with internal fixation (bony healing was evident 6 months later; however, joint instability and limited knee flexion were apparent). At final follow-up, the mean International Society of Limb Salvage (ISOLS) graft score was 31 (87%), whereas the mean Musculoskeletal Tumour Society (MSTS) function score was 23 (77%). CONCLUSIONS: These preliminary findings indicate that alcohol-inactivated autograft replantation with joint preservation may be effective in treating osteosarcoma of the distal femur in some patients. Larger-scale studies are needed to fully evaluate the efficacy/safety of this approach.

[Clinical efficacies of skipping two-level transpedicular wedge osteotomy for correction of severe kyphosis in ankylosing spondylitis].

OBJECTIVE: To explore the clinical efficacies of skipping two-level transpedicular wedge osteotomy in the correction of severe kyphotic deformity in ankylosing spondylitis (AS). METHODS: From January 2003 to December 2009, a total of 38 consecutive patients with AS and severe kyphosis (chin-brow vertical angle (CBVA) or global thoraco-lumbar kyphosis angle (TLKA) over 70°) undergoing skipping two-level transpedicular wedge osteotomy at the Department of Orthopedics of Chinese PLA General Hospital were reviewed retrospectively. There were 32 males and 6 females with an average age of 38.0 years (range: 22 - 65). The preoperative parameters of TLKA, T11-L2 kyphotic angle, L1-S1 lordosis angle, sagittal imbalance and CBVA were obtained from the total spine radiography or computed tomography and clinical lateral photograph. According to the characteristic curves and normal spinal alignment, their profiles of osteotomy location and angle were determined and confirmed by computer simulations. Improvement in postoperative parameters was observed and treatment satisfaction evaluated RESULTS: The average operating duration was 309 minutes and the average volume of blood loss was 2050 ml. The parameters of TLKA, T11-L2 kyphotic angle and L1-S1 lordosis angle improved from 101.0° ± 21.3°, 45.2° ± 13.6°, -28.2° ± 23.3° at preoperation to 26.0° ± 12.1°, 2.8° ± 11.6°, 28.9° ± 13.3° postoperation respectively (P < 0.01). CBVA improved from 79.4° ± 15.9° to 13.6 ° ± 10.9° (P < 0.01). The sagittal imbalance distance improved from (49 ± 13) to (15 ± 7) cm (P < 0.01). All patients could walk with orthophoria and lie horizontally postoperatively. The average follow-up was 32 months (range: 24 ∼ 78 months). Fusion of osteotomy was achieved in all patients and there was no event of loss of correction or implant failure. The SRS-22 average score improved from 1.8 to 4.2. CONCLUSION: For severe kyphosis in AS, skipping two-level transpedicular wedge osteotomy is a satisfactory and reliable approach for the correction of kyphotic deformity and it may improve appearance and function significantly.

[One-stage total en bloc spondylectomy and reconstruction via a single posterior approach for thoracic vertebral symptomatic hemangioma associated with spinal cord dysfunction].

OBJECTIVES: To investigate the surgical results of one-stage total en bloc spondylectomy (TES) and reconstruction via a single posterior approach for thoracic symptomatic vertebral hemangioma associated with spinal cord dysfunction and evaluate its curative effect. METHODS: A total of 9 patients treated with one-stage TES (7 cases) and total vertebrectomy (2 cases) by posterior approach from March 2006 to January 2010 were retrospectively reviewed. The cases included 2 males and 7 females with a median age of 33.6 years (range 14 to 77 years), and with 1 case of Grade A, 3 cases of Grade B, 3 cases of Grade C, 2 cases of Grade D according to Frankel grade system. All patients suffered from moderate to severe pain and neurological deficit with an average symptom duration of 14.4 months (range 3 - 24 months) MRI revealed severe spinal cord compression. The spinal reconstruction was obtained by titanium mesh filled with autograft and posterior internal fixation with rod-screw system. RESULTS: The operation time was 210 minutes on average (180 - 270 minutes) and the average blood loss was 1800 ml (1000 - 5000 ml). The follow-up period lasted from 18 months to 5 years. All cases with preoperative pain relieved after operation. The visual analogue scale pain scores decreased to 1.1 from 8.3 at 3 months after surgery. No disruption of dural mater, cerebrospinal fluid leakage, iatrogenic spinal cord injury and major vessel damage occurred. Up to now, there was no local recurrence in all cases. Significant neurological function improvement was achieved in all patients with one to three grades in Frankel grade system. Fusion of the autograft was well achieved and no internal fixation failure in all patients. CONCLUSIONS: One-stage TES and spine reconstruction by a single posterior approach is feasible, safe and effective to this disease. It is favourable in decreasing the hemangioma recurrence and improvement of the neurological function.

Long-term outcomes of epiphyseal preservation and reconstruction with inactivated bone for distal femoral osteosarcoma of children.

OBJECTIVES: To study the long-term outcomes of inactivated bone reimplantation with preservation of the epiphysis in children with distal femoral osteosarcomas. METHODS: Over 10 years, five children (mean age 9.2 years, one boy and four girls) with distal femoral osteosarcomas underwent inactivated bone reimplantation with preservation of the epiphysis following chemotherapy in our hospital. Three patients were type I on MRI classification (one with pathological fracture), and two type II. The therapeutic regime was two cycles of preoperative chemotherapy, surgery and six cycles of postoperative chemotherapy. RESULTS: Five patients were followed up for 60-126 months (mean 82 months). No local tumor recurrences or metastases occurred. Three patients with fractures of inactivated bone were treated by open reduction, bone grafting and internal fixation; their fractures had united by 6 months after reoperation. The mean functional score of the affected limbs was 25.6 points (13-30 points). CONCLUSIONS: Inactivated bone reimplantation with preservation of the epiphysis for distal femoral osteosarcomas in children optimizes recovery of limb function and preservation of limb length. The main measures for improving clinical outcomes include preoperative analysis of the lesion's boundaries and extent of tumor invasion, bone grafting between inactivated and host bone, and timely treatment of complications.

Long-term outcome of giant cell tumors of bone around the knee treated by en bloc resection of tumor and reconstruction with prosthesis.

OBJECTIVE: To study the long-term outcomes and complications of giant cell tumors around the knee treated with en bloc resection and reconstruction with prosthesis. METHODS: From January 1991 to March 2005, 19 patients (11 men, 8 women, average age 35.4 years) were treated in our hospital with en bloc resection and reconstruction with domestic prosthesis (15 hinge knee and 4 rotating-hinge knee). The distal femur was involved in 12 and the proximal tibia in 7 cases. Nine tumors were primary and 10 recurrent. All cases were Campanacci grade III. The affected limb functions were evaluated by the Musculoskeletal Tumor Society scoring system. RESULTS: All patients underwent operation successfully with no complications. The mean follow-up time was 128.9 months (60 to 216 months). Apart from one patient who underwent amputation because of wound infection two years after reoperation, the range of knee motion of 18 patients was 30°-110°. The mean functional score of the affected limb was 22.7 (15 to 27 points). The length of the lower extremities was equal in nine cases; the affected limb was 2-9 cm shorter in the other ten cases. Prosthesis fracture and loosening developed in one, prosthesis aseptic loosening in three, and delayed deep infection and prosthesis loosening in two cases. The prosthesis loosening rate was 31.6%. One patient developed a proximal femur fracture. CONCLUSION: En bloc resection and reconstruction with prosthesis is a feasible method for treating giant cell tumor of bone around the knee. Complications related to the prosthesis, mainly prosthesis loosening and limb shortening, increase gradually with longer survival time.

Marginal resection for osteosarcoma with effective preoperative chemotherapy.

OBJECTIVE: To present the clinical results of marginal resection with effective preoperative chemotherapy for treatment of osteosarcoma. METHODS: Thirty-eight patients (20 male and 18 female, average age 17 years), underwent marginal resection after confirmation of effective preoperative chemotherapy between 1999 and 2008 and the results were analyzed retrospectively. The distal femur was involved in 22 cases, proximal tibia in 11, proximal humerus in 4, and proximal fibula in 1. Thirty-seven patients were stage IIB and one IIIB. Twenty-nine patients were treated with the DIA, and 9 with the MMIA protocol. Twenty-one patients underwent tumor resection and bone allograft transplantation. The epiphysis was preserved in 9 patients, and not in the other 12. Eleven patients underwent tumor resection and prosthetic replacement, and 4 tumor resection with autograft implantation. One patient underwent tumor resection and allograft with preservation of the epiphysis; another underwent marginal tumor resection only. RESULTS: All patients received effective preoperative chemotherapy. At a median follow-up of 52 months, local recurrence had developed in one patient (2.6% local recurrence rate). Pulmonary metastases developed in 9 patients (23.7%). Five patients died of metastases, one died of intracranial hemorrhage due to thrombocytopenia caused by postoperative chemotherapy. The overall 2-year survival rate was 87.3%, and event-free survival rate 75.5%. The overall 5-year survival rate was 74.7%, and event-free survival rate 60.8%. Excellent to good function of affected limbs was achieved in 60.5%. CONCLUSIONS: With careful preoperative evaluation and effective preoperative chemotherapy marginal resection of osteosarcoma can produce good results. Marginal resection of osteosarcoma should be performed by an experienced surgeon who is familiar with the limb salvage rules for osteosarcoma.