An evidence-based guideline on treating lumbar disc herniation with traditional Chinese medicine.

BACKGROUND: Lumbar disc herniation (LDH), as one of the most common causes of lower back pain, imposes a heavy economic burden on patients and society. Conservative management is the first-line choice for the majority of LDH patients. Traditional Chinese medicine (TCM) is an important part of conservative treatment and has attracted more and more international attention. STUDY DESIGN: Evidence-based guideline. METHODS: We formed a guideline panel of multidisciplinary experts. The clinical questions were identified on the basis of a systematic literature search and a consensus meeting. We searched the literature for direct evidence on the management of LDH and assessed its certainty-generated recommendations using the grading of recommendations, assessment, development, and evaluation (GRADE) approach. RESULTS: The guideline panel made 20 recommendations, which covered the use of Shentong Zhuyu decoction, Shenzhuo decoction, Simiao San decoction, Duhuo Jisheng decoction, Yaobitong capsule, Yaotongning capsule, Osteoking, manual therapy, needle knife, manual acupuncture, electroacupuncture, Chinese exercise techniques (Tai Chi, Baduanjin, or Yijinjing), and integrative medicine, such as combined non-steroidal anti-inflammatory drugs, neural nutrition, and traction. Recommendations were either strong or weak, or in the form of ungraded consensus-based statement. CONCLUSION: This is the first LDH treatment guideline for TCM and integrative medicine with a systematic search, synthesis of evidence, and using the GRADE method to rate the quality of evidence. We hope these recommendations can help support healthcare workers caring for LDH patients.

What is the Preferable Method for the C3 and C7 Segments in Unilateral Open-Door Laminoplasty for Patients Diagnosed with Cervical Spondylotic Myelopathy?

BACKGROUND: Traditional C3-C7 unilateral open-door laminoplasty (UOLP) often leads to various postoperative complications as a result of damage of cervical posterior muscles and nuchal ligaments. We aimed to thoroughly evaluate postoperative outcomes after our modified UOLP versus traditional UOLP in treating multilevel cervical spondylotic myelopathy (MCSM). METHODS: Seventy-six patients with MCSM who underwent the modified UOLP with C3 laminectomy and C7 upper hemilaminectomy (40 patients) or traditional C3-C7 UOLP (36 patients) were included. Preoperative and postoperative cervical radiologic parameters, as well as clinical and surgical outcomes, were evaluated. RESULTS: Postoperatively, Japanese Orthopaedic Association scores improved significantly more in the modified UOLP group than in the traditional UOLP group (P = 0.028), whereas visual analog scale scores and Neck Disability Index improved similarly in both groups. Follow-up scores for Japanese Orthopaedic Association, Neck Disability Index, and visual analog scale were not significantly different between the 2 groups. At the final follow-up, the C2-C7 sagittal vertical axis and T1 slope increased in the traditional UOLP group and did not change in the modified UOLP group and were unchanged in the modified UOLP group. The C2-C7 Cobb angle decreased significantly in the traditional UOLP group and did not change in the modified UOLP group. The modified UOLP group lost less cervical posterior muscle area compared with the traditional UOLP group (3.72% ± 3.54% vs. 6.67% ± 2.81%; P < 0.001). The range of motion in the modified UOLP group was significantly greater than in the traditional UOLP group at the final follow-up (P < 0.001). Also, the modified UOLP group experienced a notable reduction in operative time, blood loss volume, and postoperative hospital stay. CONCLUSIONS: We recommend performing our modified UOLP with C3 laminectomy and C7 upper hemilaminectomy instead of traditional C3-C7 UOLP.

The incidence and risk factors for extensive epidural cement leakage in cement-augmented pedicle screw fixation: a multicenter retrospective study.

INTRODUCTION: In cement-augmented pedicle screw fixation (CAPSF), epidural cement leakage (CL) is a frequently reported complication with the potential for neural injury, especially when it is extensive. To date, there has been no reports discussing basivertebral foramen morphology and pedicle screw placement, which is critical in the analysis of the risk of extensive epidural CL. Thus, this study aimed to identify the incidence and risk factors for extensive epidural CL in osteoporotic patients with CAPSF. MATERIALS AND METHODS: 371 osteoporotic patients using 1898 cement-augmented screws were included. Preoperative computed tomography (CT) was utilized to characterize basivertebral foramen morphology. Following CAPSF, the severity of epidural CL, the implantation position of pedicle screw and cement extension within the vertebral body were determined by postoperative CT. In this study, significant risk factors for extensive epidural CL were identified through logistic regression analysis. RESULTS: There were 19 patients (5.1%) and 32 screws (1.7%) with extensive epidural CL. Nine patients (involving 19 screws) had neurological symptoms. The independent risk factors for patients with extensive epidural CL were decreased BMD and increased number of augmented screws. Significant predictors for extensive epidural CL were a magistral type of basivertebral foramen, more volume of cement injected, solid screw, a shallower screw implantation, and the smaller distance between the tip of the screw and the midline of vertebral body. CONCLUSION: Extensive epidural CL risk was significant in CAPSF when a magistral basivertebral foramen was present; solid screws and more volume of cement were used; and screw tip was implanted shallower or closer to the midline.

Lower ratio of adjacent to injured vertebral bone quality scores can predict augmented vertebrae recompression following percutaneous kyphoplasty for osteoporotic vertebral fractures with intravertebral clefts.

BACKGROUND: Despite the favorable clinical outcome of percutaneous kyphoplasty (PKP) in symptomatic osteoporotic vertebral fractures (OVFs) patients with intravertebral clefts (IVCs), previous studies have demonstrated a high incidence of augmented vertebrae recompression (AVR). We aim to evaluate the usefulness of the adjacent and injured vertebral bone quality scores (VBQS) based on T1-weighted MRI images in AVR after PKP for OVFs with IVCs. METHODS: Patients who underwent PKP for single OVFs with IVCs between January 2014 and September 2020 were reviewed and met the inclusion criteria. The follow-up period was at least 2 years. Relevant data affecting AVR were collected. Pearson and Spearman correlation coefficients were used to calculate the correlation between the injured and adjacent VBQS and BMD T-score. We determined independent risk factors and critical values using binary logistic regression analysis and receiver operating characteristic curves (ROC). RESULTS: A total of 165 patients were included. Recompression group was found in 42 (25.5%) patients. The independent risk factors for AVR were lumbar BMD T-score (OR = 2.53, p = 0.003), the adjacent VBQS (OR = 0.79, p = 0.016), the injured VBQS (OR = 1.27, p = 0.048), the ratio of adjacent to injured VBQS (OR = 0.32, p < 0.001), and cement distribution pattern. Among these independent significant risk factors, the prediction accuracy of the ratio of adjacent to injured VBQS was the highest (Cutoff = 1.41, AUC = 0.753). Additionally, adjacent and injured VBQS were negatively correlated with lumbar BMD T-scores. CONCLUSION: For the patients after PKP treatment for OVFs with IVCs, the ratio of adjacent to injured VBQS had the best prediction accuracy in predicting recompression and when the ratio of adjacent to injured VBQS was <1.41, the augmented vertebrae were more likely to have recompression in the future.

Prediction of subsequent vertebral compression fractures after thoracolumbar kyphoplasty: a multicenter retrospective analysis.

OBJECTIVE: Second fractures at the cemented vertebrae (SFCV) are often seen after percutaneous kyphoplasty, especially at the thoracolumbar junction. Our study aimed to develop and validate a preoperative clinical prediction model for predicting SFCV. METHODS: A cohort of 224 patients with single-level thoracolumbar osteoporotic vertebral fractures (T11-L2) from 3 medical centers was analyzed between January 2017 and June 2020 to derive a preoperative clinical prediction model for SFCV. Backward-stepwise selection was used to select preoperative predictors. We assigned a score to each selected variable and developed the SFCV scoring system. Internal validation and calibration were conducted for the SFCV score. RESULTS: Among the 224 patients included, 58 had postoperative SFCV (25.9%). The following preoperative measures on multivariable analysis were summarized in the 5-point SFCV score: bone mineral density (≤-3.05), serum 25-hydroxy vitamin D3 (≤17.55 ng/mL), standardized signal intensity of fractured vertebra on T1-weighted images (≤59.52%), C7-S1 sagittal vertical axis (≥3.25 cm), and intravertebral cleft. Internal validation showed a corrected area under the curve of 0.794. A cutoff of ≤1 point was chosen to classify a low risk of SFCV, for which only 6 of 100 patients (6%) had SFCV. A cutoff of ≥4 points was chosen to classify a high risk of SFCV, for which 28 of 41 (68.3%) had SFCV. CONCLUSION: The SFCV score was found to be a simple preoperative method for identification of patients at low and high risk of postoperative SFCV. This model could be applied to individual patients and aid in the decision-making before percutaneous kyphoplasty.

Establishment of a novel risk prediction model for recompression of augmented vertebrae at the thoracolumbar junction and modified puncture technique for prevention: a multicenter retrospective study.

OBJECTIVE: Recompression of augmented vertebrae (RCAV) is often seen after percutaneous kyphoplasty (PKP), especially at the thoracolumbar junction. The authors aimed to develop and validate a risk prediction model (nomogram) for RCAV and to evaluate the efficacy of a modified puncture technique for RCAV prevention after PKP for thoracolumbar osteoporotic vertebral fractures (OVFs). METHODS: Patients who underwent PKP for single thoracolumbar OVFs (T10-L2) between January 2016 and October 2020 were reviewed and followed up for at least 2 years. All patients were randomly divided into a training group (70%) and a validation group (30%). Relevant potential data affecting recompression were collected. Predictors were screened by using binary logistic regression analysis to construct the nomogram. Calibration and receiver operating characteristic curves were used to evaluate the consistency of the prediction models. Finally, the efficacy of the modified puncture technique for prevention of RCAV in OVF patients with a preoperative intravertebral cleft (IVC) was further demonstrated through binary logistic regression analysis. RESULTS: Overall, 394 patients were included and 116 of them (29.4%) sustained RCAV. The independent risk factors included decreased bone mineral density, lower level of serum 25-hydroxy vitamin D3, larger C7-S1 sagittal vertical axis (SVA), preoperative IVC, and solid-lump cement distribution. The area under the curve (AUC) of the prediction model was 0.824 in the training group and 0.875 in the validation group patients. The calibration curve indicated the predictive power of this nomogram, with the preoperative IVC having the highest prediction accuracy (AUC 0.705). The modified puncture technique significantly reduced the incidence of RCAV by enhancing bone cement distribution into a sufficiently diffused distribution in OVF patients with preoperative IVC. CONCLUSIONS: The nomogram prediction model had satisfactory accuracy and clinical utility for identification of patients at low and high risk of postoperative RCAV. Patients at high risk of postoperative RCAV might benefit from the target puncture technique and vitamin D supplementation as well as effective antiosteoporotic therapies.

The Potential Impact of Basivertebral Foramen Morphology and Pedicle Screw Placement on Epidural Cement Leakage With Cement-Augmented Fenestrated Pedicle Screw Fixation: A Multicenter Retrospective Study of 282 Patients and 1404 Augmented Screws.

BACKGROUND: Epidural cement leakage (CL) is a common complication in cement-augmented fenestrated pedicle screw fixation (CAFPSF) with the potential for neural injury. However, there are no reports discussing basivertebral vein morphology and pedicle screw placement, which are critical in the analysis of the risk of epidural CL after CAFPSF. OBJECTIVE: To identify the incidence and risk factors of epidural CL in osteoporotic patients during CAFPSF. METHODS: Two hundred and eighty-two osteoporotic patients using 1404 cement-augmented fenestrated screws were included. Preoperative computed tomography (CT) was used to characterize the morphology of posterior cortical basivertebral foramen. After CAFPSF, the severity of epidural CL, the implantation position of the screw tip, and cement extension within the vertebral body were determined by postoperative CT scans. In this study, significant risk factors for epidural CL were identified through logistic regression analysis. RESULTS: In total, 28 patients (18.8%) and 108 screws (7.7%) had epidural CL and 7 patients (13 screws) experienced neurological symptoms. Although local epidural CL was generally not clinically significant, extensive epidural leakage posed a higher risk of neurological symptoms. Significant predictors for extensive epidural CL were a magistral type of basivertebral foramen and the smaller distance between the tip of the screw and the posterior wall of the vertebral body. CONCLUSION: In osteoporotic patients receiving CAFPSF, epidural CL is relatively common. The morphology of basivertebral foramen should be taken into account when planning a CAFPSF procedure. It is important to try and achieve a deeper screw implantation, especially when a magistral type of basivertebral foramen is present.

[Clinical observation of acupuncture at Huiyin (CV 1) for chronic severe functional constipation].

OBJECTIVE: To compare the effect of acupuncture at Huiyin (CV 1) and oral administration of western medication in treatment of chronic severe functional constipation (CSFC). METHODS: A total of 64 patients with CSFC were randomly divided into an acupuncture group (32 cases, 5 cases dropped off) and a western medication group (32 cases, 4 cases dropped off). Both groups were given routine basic treatment. The acupuncture group was treated by directly puncture of 20-30 mm at Huiyin (CV 1), once a day for the first 4 weeks, 5 times a week, once every other day for the next 4 weeks, 3 times a week, totally for 8 weeks. The western medication group was treated with 2 mg prucalopride succinate tablets orally before breakfast every day for 8 weeks. The average number of weekly spontaneous bowel movement (SBM) of the two groups were observed before treatment and 1-8 weeks into treatment. The constipation symptom score before and after treatment, and in follow-up of 1 month after treatment, as well as quality of life [patient assessment of constipation quality of life questionnaire (PAC-QOL) score and the proportion of patients of PAC-QOL score difference before and after treatment≥1] before and after treatment were compared in the two groups. The clinical effects of the two groups were evaluated after treatment and in follow-up. RESULTS: Compared before treatment, the average number of weekly SBM in the two groups was increased 1-8 weeks into treatment (P<0.05). The average number of weekly SBM in the acupuncture group was less than that in the western medication group 1 week into treatment (P<0.05), and the average number of weekly SBM in the observation group was more than that in the western medication group 4-8 weeks into treatment (P<0.05). The scores of constipation symptom after treatment and in follow-up and scores of PAC-QOL after-treatment in the two groups were lower than those before treatment (P<0.05), and those in the acupuncture group were lower than the western medication group (P<0.05). The proportion of patients of PAC-QOL score difference before and after treatment≥1 in the acupuncture group was higher than that in the west medication group (P<0.05). The total effective rates after treatment and in follow-up in the acupuncture group were 81.5% (22/27) and 78.3% (18/23), respectively, which were better than 42.9% (12/28) and 43.5% (10/23) in the western medication group (P<0.05). CONCLUSION: Acupuncture at Huiyin (CV 1) can effectively increase the number of spontaneous defecation in patients with CSFC, reduce constipation symptoms, improve the quality of life, and the effect after treatment and in follow-up is better than oral western medication.

Metformin protects against ethanol-induced liver triglyceride accumulation by the LKB1/AMPK/ACC pathway.

BACKGROUND: Hepatic lipid accumulation is one of the main pathological features of alcoholic liver disease (ALD). Metformin serves as an AMPK activator and has been shown to have lipids lowering effects in non-alcoholic fatty liver disease (NAFLD), but its role in ALD remains unclear. The purpose of this study was to explore the potential mechanism of metformin regulating lipid metabolism in ALD. METHODS AND RESULTS: In vitro and in vivo ALD models were established using AML12 cells and C57BL/6 mice, respectively. To determine the effect of metformin on ALD in vitro, the concentration of cellular triglyceride was examined by Nile red staining and a biochemical kit. To further reveal the role of metformin on ALD in vivo, liver tissues were examined by HE and oil red O staining, and the levels of ALT and AST in serum were determined via an automatic biochemical analyzer. The expression of mRNA and proteins were measured using qRT-PCR and Western blot, respectively. The role of the LKB1/AMPK/ACC axis on metformin regulating ethanol-induced lipid accumulation was evaluated by siRNA and AAV-shRNA interference. The results showed metformin reduced the ethanol-induced lipid accumulation in AML12 cells through activating AMPK, inhibiting ACC, reducing SREBP1c, and increasing PPARα. In addition, compared with control mice, metformin treatment inhibited ethanol-induced liver triglyceride accumulation and the increase of ALT and AST in serum. Interference with LKB1 attenuated the effect of metformin on ethanol-induced lipid accumulation both in vitro and in vivo. CONCLUSION: Metformin protects against lipid formation in ALD by activating the LKB1/AMPK/ACC axis.

[Clinical application of lumbar hyperextension MRI in the diagnosis of lumbar spinal stenosis].

OBJECTIVE: To evaluate the diagnostic value of lumbar hyperextension MRI, through studying the changes of spinal stenosis degree in lumbar hyperextension position. METHODS: From September 2018 to February 2020, 26 patients with lumbar spinal stenosis did lumbar spine neutral and hyperextension MRI scans. There were 11 males and 15 females, aged from 43 to 85 (64.00±10.37) years. As 6 patients induced and aggravated the symptoms of low back and leg pain in the hyperextension position, qualified MRI data could not be collected. Because of that, a total of 20 patients' qualified data were collected. Mimics Medical 21.0 medical image processing software was used to measure the relevant diagnostic parameters of lumbar spinal stenosis, analyze the change rules statistically, and evaluate the degree of lumbar spinal stenosis and changes in nerve compression in the hyperextension position. RESULTS: The sagittal diameter and cross sectional area of the lumbar spinal bony canal do not change significantly with the body position;the sagittal diameter of the dural sac, the sagittal diameter of the dural sac, and the disc yellow space all have different degrees of decline in the hyperextension position. CONCLUSION: For the imaging diagnosis of lumbar spinal stenosis, lumbar spine hyperextension position MRI can be a good complement for the routine neutral MRI examination, and it is more sensitive to the clinical diagnosis of lumbar spinal stenosis.

[Clinical observation of dry eye syndrome treated with acupuncture].

OBJECTIVE: To compare the therapeutic effect between acupuncture and hyaluronic acid sodium eye drops for dry eye syndrome. METHODS: A total of 60 patients with dry eye were randomized into an acupuncture group and a western medication group, 30 cases in each one. In the acupuncture group, acupoints around the eyes, abdomen and limbs were selected, such as Jingming (BL 1), Cuanzhu (BL 2), Fengchi (GB 20), Taiyang (EX-HN 5), Guanyuan (CV 4), Qihai (CV 6) and Hegu (LI 4), once 2 days for 1 month, 15 times in total. In the western medication group, hyaluronic acid sodium eye drops was applied, 3 times a day, one drop every time, for 1 month. The tear meniscus height (TMH), tear break-up time (BUT) and conjunctival congestion scores were observed before and after treatment in the two groups, and the clinical effects of the two groups were compared. RESULTS: The total effective rate in the acupuncture group was 68.3% (41/60), which was superior to 30.0% (18/60) in the western medication group (P<0.05). Compared before treatment, the TMH was increased, BUT was prolonged and conjunctival congestion score was reduced after treatment in the acupuncture group (P<0.05, P<0.01). After treatment, the TMH and BUT in the acupuncture group were higher (P<0.05, P<0.01), and the conjunctival congestion score was lower than those in the western medication group (P<0.05). CONCLUSION: The therapeutic effect of acupuncture is superior to hyaluronic acid sodium eye drops. Acupuncture can promote lacrimal gland secretion and increase the tear film stability.

Cement Distribution Patterns in Osteoporotic Vertebral Compression Fractures with Intravertebral Cleft: Effect on Therapeutic Efficacy.

OBJECTIVE: To determine cement distribution patterns on therapeutic efficacy after percutaneous vertebroplasty treatment of osteoporotic vertebral compression fractures (OVCFs) with intravertebral cleft (IVC). METHODS: Patients who were treated with percutaneous vertebroplasty for single OVCFs with IVC and met this study's inclusion criteria were retrospectively reviewed. The follow-up period was at least 2 years. Distribution patterns of cement in the IVC area were respectively specified into 2 groups: group 1: solid lump distribution pattern (n = 22); group 2: the comparatively diffused pattern (n = 90). Radiologic and clinical parameters were analyzed and compared. Then, associations of recollapse with covariates and a risk score were further analyzed and developed to predict recollapse of the augmented vertebrae. RESULTS: At the immediate postoperative period, all patients benefited from significant improvement in vertebrae height and kyphotic angle correction. However, significant recollapse was observed at the 2 years postoperative follow-up for the patients in group 1. Furthermore, we found that preoperative severe kyphotic deformity (a cutoff value of 12.5°), solid lump cement distribution pattern, and larger reduction angle (a cutoff value of 8.3°) was significantly associated with increased risk for recollapse. A risk score was developed based on the number of risk factors present in each patient and the receiver operating characteristic curve of the risk score generated an area under the curve of 0.788 (95% confidence interval 0.702-0.873, P = 0.000). CONCLUSIONS: The comparatively diffused pattern shows better long-term radiologic and clinical outcomes for the treatment for OVCFs with IVC. A risk score can be used to predict the incidence of recollapse.

[Study the degree of cervical spinal canal stenosis by MRI in flexion and extension of the cervical vertebrae].

OBJECTIVE: To study the degree and changes of cervical spinal canal stenosis by MRI scans in flexion and extension of the cervical vertebrae. METHODS: Thirty cases of cervical stenosis included 13 male and 17 female with an average age of 39 years ranging from 28 to 66 years. The sagittal diameter of cervical spinal canal were below 10 mm (absolute stenosis) in 12 cases,within 10 to 12 mm (correspondence stenosis) in 18 cases. MRI scans in neutrality, flexion, extension performanced and the degree of cervical spinal canal stenosis and the changes of spinal cord compression were evaluated after MRI scans obtained. RESULTS: Nineteen patients of extension occurrenced stenosis more serious, 8 patients of flexion occurrenced (P < 0.05). CONCLUSION: For the cervical stenosis imaging diagnostic, flexion and extension of cervical MRI scan can be used to supplement conventional MRI examination neutral position, and the extension of MRI is more sensitivity than neutral position and flexion bit.

[Effects of a combined regime of auricular-plaster and body acupuncture in treatment of cervical spondylosis of vertebral artery type].

OBJECTIVE: To study effects of a combined regime of auricular-plaster and body acupuncture in treatment of cervical spondylosis of vertebral artery type and make a preliminary revelation of the mechanism. METHODS: Ninety-two patients were randomly divided into 2 groups, the treatment group (n = 56) received the combined regime of auricular-plaster and body acupuncture, and the control group (n = 36) received treatment with body acupuncture. Clinical symptoms and signs, therapeutic effect and some indexes about vertebrobasilar hema-kinetics and hema-rheology were investigated before and after treatment. RESULTS: The treatment group was better than the control group in the clinical overall effective rate (89.29%) and the clinically control rate (17. 85%), and in improving the following indexes, including dizziness and headache, the vertebrobasilar volume and rate of blood flow etab and IR (P < 0.05). CONCLUSIONS: A combined regime of auricular-plaster and body acupuncture ameliorates not only main signs but also some indexes about vertebrobasilar hema-kinetics and hema-rheology. This treatment is an effective therapy for cervical spondylosis of vertebral artery type both in Malaysia and in China.