Delayed neurological dysfunction following posterior laminectomy with lateral mass screw fixation: A case report and review of literature.

BACKGROUND: While most complications of cervical surgery are reversible, some, such as symptomatic postoperative spinal epidural hematoma (SEH), which generally occurs within 24 h, are associated with increased morbidity and mortality. Delayed neurological dysfunction is diagnosed in cases when symptoms present > 3 d postoperatively. Owing to its rarity, the risk factors for delayed neurological dysfunction are unclear. Consequently, this condition can result in irreversible neurological deficits and serious consequences. In this paper, we present a case of postoperative SEH that developed three days after hematoma evacuation. CASE SUMMARY: A 68-year-old man with an American Spinal Injury Association (ASIA) grade C injury was admitted to our hospital with neck pain and tetraplegia following a fall. The C3-C7 posterior laminectomy and the lateral mass screw fixation surgery were performed on the tenth day. Postoperatively, the patient showed no changes in muscle strength or ASIA grade. The patient experienced neck pain and subcutaneous swelling on the third day postoperatively, his muscle strength decreased, and his ASIA score was grade A. Magnetic resonance imaging showed hypointense signals on T1 weighted image (T1WI) and T2WI located behind the epidural space, with spinal cord compression. Emergency surgical intervention for the hematoma was performed 12 h after onset. Although hypoproteinemia and pleural effusion did not improve in the perioperative period, the patient recovered to ASIA grade C on day 30 after surgery, and was transferred to a functional rehabilitation exercise unit. CONCLUSION: This case shows that amelioration of low blood albumin and pleural effusion is an important aspect of the perioperative management of cervical surgery. Surgery to relieve the pressure on the spinal cord should be performed as soon as possible to decrease neurological disabilities.

Spine-Related Malpractice Claims in China: A 2-year National Analysis.

STUDY DESIGN: Retrospective cross-sectional study. OBJECTIVE: To investigate the prevalence, characteristics, and risk factors of spine-related malpractice claims in China in a 2-year period. METHODS: The arbitration files of the Chinese Medical Association (CMA) were reviewed for spine-related malpractice claims. Descriptive statistics and correlation analysis were conducted on claim characteristics, clinical data, plaintiff's main allegations, and arbitration outcomes. RESULTS: A total of 288 cases of spinal claims filed in the CMA between January 2016 and December 2017 were included. Most claims were found in lumbar degenerative disorders (59.4%), lumbar trauma (13.2%), and cervical degenerative disorders (11.8%). The most common adverse events (AEs) leading to claims were new neurologic deficit (NND) (47.6%), infection (11.5%), and insufficient symptom relief (10.4%). The most common patient allegation was surgical error (66.0%), although the main arbitrated cause of AEs was disease/treatment itself (49.0%), while providers were judged as mainly responsible in only 47.3% cases. In multivariate regression analysis, cervical spine, misdiagnosis/mistreatment, and unpredictable emergency correlated with more severe damage to patients; minimally invasive surgery was predictive of judgment in plaintiff's favor, while claims in the eastern region and unpredictable emergencies were predictive of defendant's favor; only NND was associated with being arbitrated as surgical error in surgical cases where surgeons accepted major liability. CONCLUSION: The current study provided a descriptive overview and risk factor analysis of spine-related malpractice claims in China. Gaining improved understanding of the facts and causes of malpractice claims may help providers reduce the risk of claims and subsequent litigation.

Radiological and clinical outcomes of midline lumbar fusion on sagittal lumbar-pelvic parameters for degenerative lumbar diseases.

BACKGROUND: Improving the sagittal lumbar-pelvic parameters after fusion surgery is important for improving clinical outcomes. The impact of midline lumbar fusion (MIDLF) on sagittal lumbar-pelvic alignment for the management of degenerative lumbar diseases is still unknown. AIM: To analyze the effects of short-segment MIDLF and minimally invasive transforaminal lumbar interbody fusion (MIS-TLIF) on sagittal lumbar-pelvic parameters. METHODS: We retrospectively analyzed 63 patients with degenerative lumbar diseases who underwent single-segment MIDLF or MIS-TLIF. The imaging data of patients were collected before surgery and at the final follow-up. The radiological sagittal parameters included the lumbar lordosis (LL), lower LL, L4 slope (L4S), L5 slope (L5S), L5 incidence (L5I), L1 axis and S1 distance (LASD), pelvic incidence (PI), pelvic tilt (PT), sacral slope (SS), and PI-LL mismatch (PI-LL). Additionally, the clinical outcomes, including lower back and leg pain visual analog scale (VAS) and Oswestry disability index (ODI) scores, were also analyzed. RESULTS: In both groups, LL and Lower LL significantly increased, while L5I and LASD significantly decreased at the final follow-up compared to that recorded prior to operation (P < 0.05). In the MIDLF group, L4S significantly decreased compared to that recorded prior to operation (P < 0.05), while the mean SS significantly increased and the PT significantly decreased compared to that recorded prior to operation (P < 0.05). In the MIS-TLIF group, SS slightly increased and the mean PT value decreased compared to that recorded prior to operation, but without a statistically significant difference (P > 0.05). However, the PI-LL in both groups was significantly reduced compared to that recorded prior to operation (P < 0.05). There was no significant difference in the sagittal lumbar-pelvic parameters between the two groups prior to operation and at the final follow-up (P > 0.05). In addition, the change in sagittal lumbar-pelvic parameters did not differ significantly, except for ΔLASD within the two groups (P > 0.05). The mean lower back and leg pain VAS and ODI scores in both groups were significantly improved three months after surgery and at the final follow-up. Though the mean ODI score in the MIDLF group three months after surgery was slightly higher than that in the MIS-TLIF group, there was no significant difference between the two groups at the final follow-up. CONCLUSION: Short-segment MIDLF and MIS-TLIF can equally improve sagittal lumbar parameters such as LL, Lower LL, L5I, and LASD in the treatment of lumbar degenerative diseases. However, MIDLF had a larger impact on pelvic parameters than MIS-TLIF.

Thoracolumbar surgery for degenerative spine diseases complicated with tethered cord syndrome: A case report.

BACKGROUND: Tethered cord syndrome (TCS) secondary to split cord malformation (SCM) is rare in adulthood. There is as yet no consensus about the optimal treatment method for adult patients with SCMs and degenerative spine diseases such as lumbar stenosis, spondylolisthesis and ossification of the ligamentum flavum (OLF). The tethered cord poses a great challenge to the decompression and fusion procedures for the intraoperative stretching of the spinal cord, which might lead to deteriorated neural deficits. Here, we report on a case to add our treatment experience to the medical literature. CASE SUMMARY: We treated a 67-year-old female patient with type II SCM suffering from lumbar disc herniation, degenerative lumbar spondylolisthesis and thoracic OLF. The patient underwent thoracolumbar spinal fusion and decompression surgery for severe lower back pain, extensive left lower limb muscle weakness and intermittent claudication. After the thoracolumbar surgery, without stretching the tethered cord, the patient achieved complete relief of pain and lower extremity weakness at final follow-up. CONCLUSION: For adult patients with underlying TCS secondary to SCM coupled with thoracic OLF and lumbar spondylolisthesis, a thoracolumbar fusion surgery could be safe and effective with the tethered cord untreated. It is critical to design individualized surgical protocols to reduce the stretch of the low-lying spinal cord.

Impact of intraoperative intravenous magnesium on spine surgery: A systematic review and meta-analysis of randomized controlled trials.

BACKGROUND: The effectiveness and safety of intraoperative intravenous magnesium (IIM) on spine surgery remain uncertain, as recent randomized controlled trials (RCTs) yielded conflicting results. The purpose of this study was to determine the impact of IIM on spine surgery. METHODS: A literature search was performed on multiple electronic databases, ClinicalTrial.gov and Google Scholar on July 12th 2021, and reference lists were examined. We selected RCTs comparing the effects of IIM with placebo treatment on spine surgery. We calculated pooled standard mean difference (SMD) or risk ratio (RR) with 95% confident interval (CI) under a random-effect model. We assessed risk of bias using Cochrane risk-of-bias tool and Jadad score was applied to assess the quality of each included trial. Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) was used to determine the confidence in effect estimates. Sensitivity analysis was conducted by omitting each included study one by one from the pooled analysis. PROSPERO Registration: CRD42021266170. FINDINGS: Fourteen trials of 781 participants were included. Low- to moderate-quality evidence suggested that IIM reduces postoperative morphine consumption at 24 h (SMD: -1·61 mg, 95% CI: -2·63 to -0·58) and intraoperative remifentanil requirement (SMD: -2·09 ug/h, 95% CI: -3·38 to -0·81). High-quality evidence suggested that IIM reduces the risk of postoperative nausea and vomiting compared with placebo (RR: 0·43, 95% CI: 0·26 to 0·71). Besides, moderate-quality evidence suggested that recovery orientation time in the IIM group is longer than control group (SMD: 1·13 min, 95% CI: 0·83 to 1·43). INTERPRETATION: IIM as adjuvant analgesics showed overall benefits on spine surgery in terms of reducing analgesic requirement and postoperative nausea and vomiting; however, potential risks of IIM, such as delayed anesthetic awakening, should not be ignored. Future evidence will inform the optimal strategy of IIM administration for patients undergoing spine surgery. FUNDING: This study was funded by Beijing Municipal Natural Science Foundation (Grant No :7212117).

Acute deep venous thrombosis induced by May-Thurner syndrome after spondylolisthesis surgery: A case report and review of literature.

BACKGROUND: Deep venous thrombosis (DVT) is a serious complication of lumbar spine surgery. Current guidelines recommend pharmacomechanical prophylaxis for patients at high risk of DVT after spine surgery. May-Thurner syndrome (MTS), a venous anatomical variation that may require invasive intervention, is an often overlooked cause of DVT. To date, no case reports of symptomatic MTS caused by isthmic spondylolisthesis or subsequent acute DVT after posterior lumbar surgery have been published. CASE SUMMARY: We here present a case of a patient who developed acute DVT 4 h after spondylolisthesis surgery, and MTS was only considered after surgery, during a review of a gynecological enhanced computed tomography image taken before the procedure. CONCLUSION: In conclusion, clinicians should consider MTS in the presence of a dangerous triad: spondylolisthesis, elevated D-dimer levels, and sonographically indicated unilateral deep vein dilation. Consultation with a vascular surgeon is also essential to MTS management.

Low-intensity extracorporeal shock wave therapy for midshaft clavicular delayed union: A case report and review of literature.

BACKGROUND: One of the most common complications following surgery for midshaft clavicle fracture is nonunion/delayed union. Extracorporeal shock wave therapy (ESWT) is an alternative to promote new bone formation without surgical complications. To date, no literature has reported low-intensity ESWT (LI-ESWT) in delayed union of midshaft clavicle fracture. CASE SUMMARY: We reported a 66-year-old Chinese amateur cyclist with clavicle delayed union treated with 10 sessions of LI-ESWT (radial, 0.057 mJ/mm2, 3 Hz, 3000 shocks). No anesthetics were applied, and no side effects occurred. At the 4 mo and 7 mo follow-ups, the patient achieved clinical and radiographical recovery, respectively. CONCLUSION: In conclusion, our findings indicated that LI-ESWT could be a good option for treating midshaft clavicular delayed union.

Comparison of the effect of posterior lumbar interbody fusion with pedicle screw fixation and interspinous fixation on the stiffness of adjacent segments.

BACKGROUND: Adjacent segment degeneration could seriously affect the long-term prognosis of lumbar fusion. Dynamic fixation such as the interspinous fixation, which is characterized by retaining the motion function of the spinal segment, has obtained satisfactory short-term effects in the clinical setting. But there are few reports about the biomechanical experiments on whether dynamic fixation could prevent adjacent segment degeneration. METHODS: The surgical segments of all 23 patients were L4/5. Thirteen patients with disc herniation of L4/5 underwent Wallis implantation surgery, and 10 patients with spinal stenosis of L4/5 underwent posterior lumbar interbody fusion (PLIF). L3-S1 segmental stiffness and displacement were measured by a spine stiffness gauge (SSG) device during surgery when the vertebral plate was exposed or during spinal decompression or internal fixation. Five fresh, frozen cadavers were used in the self control experiment, which was carried out in four steps: exposure of the vertebral plate, decompression of the spinal canal, implantation of a Wallis fixing device, and PLIF of L4/5 after removing the Wallis fixing device. Then, L3-S1 segment stiffness was measured by an SSG device. RESULTS: The experiments showed that the average stiffness of the L4/5 segment was (37.1 ± 8.9) N/mm after exposure of the vertebral plate, while after spinal decompression, the average stiffness fell to (26.2 ± 7.1) N/mm, decreasing by 25.8% (P < 0.05). For the adjacent segments L3/4 and L5/S1, their stiffness showed no significant difference between the L4/5 segment decompression and the exposure of the vertebral plate (P > 0.05). After Wallis implantation of L4/5, the stiffness of the cephalic adjacent segment L3/4 was (45.8 ± 10.7) N/mm, which was 20.5% more than that after the exposure of the vertebral plate (P < 0.05); after L4/5 PLIF surgery, the stiffness of L3/4 was (35.3 ± 10.7) N/mm and was decreased by 12.4% more than that after the exposure of the vertebral plate (P < 0.05). The stiffness of the cephalic adjacent segment L3/4 after fixation in the Wallis group was significantly higher than that of the PLIF group (P < 0.05). Cadaver experiments showed that the stiffness of the cephalic adjacent segment in the Wallis group was significantly higher than that of the PLIF group after L4/5 segment fixation (P < 0.05); the stiffness of the L5/S1 segment showed no significant difference between PLIF surgery and Wallis implantation (P > 0.05). CONCLUSIONS: After interspinous (Wallis) fixation, the stiffness of the cephalic adjacent segment increased. After PLIF with pedicle screw fixation, the stiffness of the cephalic adjacent segment decreased. An interspinous fixation system (Wallis) has a protective effect for cephalic adjacent segments for the immediate post-operative state.

[Retrospective study of complication of interspinous implants for degenerative lumbar disease].

OBJECTIVE: To summarize and analyze the complications of interspinous implants for degenerative lumbar disease. METHODS: From September 2007 to September 2011, 177 cases with degenerative lumbar diseases were treated with interspinous implants. There were 99 male patients and 78 female patients, the average age was 44.5 years (26 - 71 years). According to the application interspinous dynamic stabilization system type were divided into the Wallis group (136 cases) and Coflex group (41 cases). The clinical results were assessed by visual analog scale (VAS) of pain on lumbar and lower limbers, lumbar Japanese Orthopedic Association (JOA) score and Prolo functional score. The radiological results including segmental lodosis and segement movement degree were assessed by lumbar X ray and dynamic X ray. Summarize and analyze the complications both during operation and post operation. Quantitative datas were compared by paried-samples t test and complication rate was compared by χ(2) test. RESULTS: There were 168 cases had completed follow-up and the average time was 34.7 months (3 - 50 months). In the final follow-up, lumbar pain VAS, lower limber pain VAS, lumbar JOA score and Prolo functional score were better than pre-operation (t = 10.7, 7.9, 13.4 and 8.8, P < 0.01). Segment lodosis angles was 14° ± 4° which was less than pre-operation 19° ± 4° (t = 9.4, P < 0.01).Segment movement degree was larger in Coflex group (12.6° ± 3.1°) than in Wallis group (9.7° ± 2.7°) (t = 8.6, P < 0.05). Complication rate was 10.7% (18/168), which of Wallis group was 6.2% (8/130) and Coflex group was 26.3% (10/38) (χ(2) = 12.5, P < 0.01). In Wallis group, there were 3 cases with dura tear and cerebrospinal fluid leakage, 1 case with nerve root injury and foot drop, 2 cases with spacer breakage when implantation and change the implants and 2 cases with recurrence of lumbar disc herniation. In Coflex group, there was 1 case with dura tear and cerebrospinal fluid leakage, 2 cases with mild displacement post operation, 1 case with debridement for aseptic wound exudates, 1 case with implant removal for breakage 1 week post operation, 4 cases with recurrence of lumbar disc herniation and 1 case with lumbar disc herniation 6 months post operation of lumbar stenosis. CONCLUSIONS: The application of interspinous implants for degenerative lumbar diseases is effective and relative safe, but would suffer from the risk of complications.

[Clinical characteristics and reoperation of symptomatic adjacent segment degeneration postoperation of lumbar fusion].

OBJECTIVE: To evaluate the clinical characteristics and reoperation of symptomatic adjacent segment degeneration postoperation of lumbar fusion. METHODS: In the study, 28 cases of symptomatic adjacent segment degeneration postoperation of lumbar fusion from May 2007 to April 2012 were retrospectively reviewed,with an average age of (64.3±8.7) years. The mean period between reoperation and primary fusion surgery was (47.5±30.8) months. Symptomatic adjacent segment degeneration located in cephalic segments in 12 cases, in caudal segments in 14 cases and in both segments in 2 cases. Of all the 28 patients, 12 suffered from lumbar stenosis, other 13 from lumbar disc herniation and still other 3 from both lumbar stenosis and disc herniation, of whom 11 were together with segment instability. Localization diagnoses of 19 cases were clear and other 9 received diagnostic nerve root block. The cases were divided into two groups by the type of reoperation,of which 8 cases were in adjacent degenerative segment nonfusion group and the other 20 cases in adjacent degenerative segment fusion group. The clinical results were assessed by lumbar pain visual analog score (VAS) and lower limber pain VAS,lumbar Japanese Orthopedic Association (JOA) score and Prolo functional score before operation and in the final follow-up. RESULTS: In adjacent degenerative segment nonfusion group, the average operation time was (86.3±17.1) min and average blood volume was (125.0 ±37.8) mL of reoperation and 1 case with dural injury; and in adjacent degenerative segment fusion group, the average operation time was (201.6 ±71.0) min and average blood volume was (313.6±218.9) mL of revision surgery and 4 cases with dural injury. The average follow-up period was 25.5 months. In the final follow-up,lumbar pain VAS,lower limber pain VAS,lumbar JOA score and Prolo functional score of adjacent degenerative segment nonfusion group were 2.4±1.2, 2.8±1.4,23.5±4.2 and 8.2±1.5,which were better than preoperation 5.5±2.9, 6.8±2.5, 13.7±5.2 and 4.3±2.1, P<0.001; lumbar pain VAS, lower limber pain VAS,lumbar JOA score and Prolo functional score of adjacent degenerative segment nonfusion group were 3.3±1.9, 3.1±1.2, 22.2±4.4 and 7.7±1.6, which were better than preoperation 5.4±2.7, 7.0±2.4, 13.0±5.6 and 3.9±1.9, P<0.001.In the final follow up, lumbar pain VAS of adjacent degenerative segment nonfusion group was better than that adjacent degenerative segment fusion group(P=0.028). CONCLUSION: Symptomatic adjacent segment degeneration postoperation of lumbar fusion is difficult for diagnosis and treatment. Appropriate reoperation could get the good results.

[Biomechanical study of interspinous fixational effect on the stiffness of adjacent segments].

OBJECTIVE: To discuss the effect of interspinous fixation (Wallis) on the stiffness of adjacent segments by biomechanical measurements. METHODS: The surgical segments of all 23 patients were L4/5 lumbar disc herniation with or without lumbar stenosis. Thirteen patients (experimental group) underwent interspinous (Wallis) fixation, and ten patients (control group) underwent PLIF. L3/4 and L5/S1 segmental stiffness and displacement were measured by a spine stiffness gauge (SSG) device during surgery when the vertebral plate was exposed or during spinal decompression or internal fixation. RESULTS: Stiffness of adjacent segments L3/4 and L5/S1 showed no significant difference between the L4/5 segment decompression and the exposure of the vertebral plate. After interspinous (Wallis) fixation of L4/5, the stiffness of the cephalad adjacent segment L3/4 was (45.8 ± 10.7) N/mm, which was 20.5% more than that after exposure of the vertebral plate (P=0.025); After L4/5 PLIF, the stiffness of L3/4 was (35.3 ± 10.7) N/mm and was decreased by 12.4% less than that after exposure of the vertebral plate (P=0.033). The stiffness of the cephalad adjacent segment L3/4 after fixation in the Wallis group was significantly higher than that of the PLIF group (P=0.037). CONCLUSION: After interspinous (Wallis) fixation, the stiffness and the stability of the cephalad adjacent segment increased. The interspinous fixation system (Wallis) has a protective effect on cephalad adjacent segments.

[Retrospective analysis of effect of type 2 diabetes mellitus on lumbar intervertebra disc herniation].

OBJECTIVE: To analyze the influence of type 2 diabetes mellitus on incidence and severity of lumbar disc herniation. METHODS: A total of 575 cases of lumbar disc herniation (40-70 years) from Orthopedic Department of Peking University First Hospital from October 1998 to October 2008 were retrospective studied, and the number and ratio of cases of type 2 diabetes mellitus identified. The control group included 219 cases of hallus valgus, carpal tunnel syndrome, cubital tunnel syndrome or ganglion. The number and ratio of cases of type 2 diabetes mellitus were also identified and the ratios of the two groups compared. Then we divided the lumbar disc herniation operation group into two subgroups, one with type 2 diabetes mellitus and the other without, and compared between the two subgroups the numbers of operation segments,the types of lumbar disc herniation (contained type and uncontained type) and the ratio of relapse with revision surgery by t test or χ² test. RESULTS: The ratio of lumbar disc herniation group with type 2 diabetes mellitus was 15.3%(88/575) and significantly higher than 7.76%(17/219)of the control group (χ² =7.861,P=0.005), and also significantly higher than 9.94%(188/1892 ) of the incidence of type 2 diabetes mellitus in 40-70 years old people of Beijing (χ² =12.788, P=0.000 4). The operation segments were 1.19 in subgroup with type 2 diabetes mellitus and 1.15 in subgroup without type 2 diabetes mellitus(t=0.703, P=0.483);the ratios of different types of lumbar disc herniation were 65.7%(58/88)with contained type and 34.3% (30/88) with uncontained type in subgroup with type 2 diabetes mellitus as well as 70.5% (343/487) contained type and 29.5% (144/487) uncontained type in subgroup without type 2 diabetes mellitus(χ² =0.722, P=0.395); the ratios of relapse cases with revision surgery were 3.41%(3/88) in subgroup with type 2 diabetes mellitus and 3.89% (19/487) in subgroup without type 2 diabetes mellitus ( χ² =0.034,P=0.854). CONCLUSION: People who received operation with lumbar disc herniation had the higher ratio concomitant with type 2 diabetes mellitus than the control group. Type 2 diabetes mellitus may increase the risk of suffering from lumbar disc herniation.

[Retrospective study of combined application of interspinous process fixation system and rigid fixation system for degenerative lumbar diseases].

OBJECTIVE: To assess the efficacy and safety of combined application of interspinous process fixation system and rigid fixation system for degenerative lumbar diseases. METHODS: From September 2007 to September 2008, 16 cases with degenerative lumbar diseases were treated with combined application of interspinous process fixation system and rigid fixation system. The clinical results were assessed by VAS of pain of lumbar and lower limbs, lumbar JOA score and Prolo functional score. The radiological results including implant position (interspinous process, pedicle screws and plates), spinous process fracture, segmental range of motion (the non-fusion fixation segment, and the intermediate segments between fused and non-fused segments) which were assessed by lumbar static and dynamic X rays. RESULTS: All 16 cases obtained an average follow-up of 17.6 months. At final follow up, lumbar VAS, lower limbers VAS, lumbar JOA score and Prolo functional score were significant improved than those of pre-operation (lumbar VAS: 1.9 +/- 1.4 vs. 4.5 +/- 3.1; lower limbs VAS: 1.7 +/- 1.2 vs. 6.3 +/- 2.9; lumbar JOA score: 22.8 +/- 3.3 vs. 12.5 +/- 4.7; Prolo functional score: 8.3 +/- 1.2 vs. 4.0 +/- 2.3). Range of motion of the non-fusion fixation segment was (9.8 +/- 4.2) degrees and that of the intermediate segments between fused and non-fused segments was (13.2 +/- 3.5) degrees . CONCLUSIONS: Combined application of interspinous process fixation system and rigid fixation system for degenerative lumbar diseases provides a new idea to avoid the multi-segment fusion fixation and pertinent potential problems. Short-term clinical results are successful.