Genetic ablation of receptor for advanced glycation end products promotes functional recovery in mouse model of spinal cord injury.

Spinal cord injury (SCI) results in a loss of normal motor and sensory function, leading to severe disability and reduced quality of life. The aim of this work was to investigate the effect of receptor for advanced glycation end products (RAGE) deficiency on the function recovery in a mouse model of SCI. Mice received a mid-thoracic spinal contusion injury. Upregulation of RAGE protein expression in spinal cord tissue was evident at 12 h after SCI and continued at 2 and 5 days. Furthermore, we showed that locomotor recovery was improved and lesion pathology was reduced after SCI in RAGE-deficient mice. RAGE deficiency in mice attenuated apoptosis after SCI through inhibiting p53/Bax/caspase-3 pathway. RAGE deficiency in mice inhibited inflammation after SCI, marked by reduced myeloperoxidase activity, NFκB nuclear translocation, and TNF-α, IL-1ß, and IL-6 mRNA and protein levels. RAGE deficiency in mice exposed to SCI suppressed the upregulation of inducible nitric oxide synthase (iNOS) and gp91-phox and attenuated oxidative and nitrosative stresses, marked by reduced formation of malondialdehyde, reactive oxygen species, peroxynitrite (OONO(-)), and 3-nitrotyrosine. RAGE deficiency in mice exposed to SCI attenuated glial scar at the injury site, marked by decreased expression of glial fibrillary acidic protein. These data indicate that the RAGE plays an important role in the development of SCI and might provide a therapeutic target to promote recovery from SCI.

Technical Notes and Clinical Outcomes of Full-Endoscopic Interbody Fusion Via Transforaminal Approach for Hard Disc Herniations in Thoracolumbar Junction.

OBJECTIVE: Obtaining sufficient decompression and solid fusion and avoiding approach-related injuries simultaneously are still challenging for the treatment of hard disc herniation in thoracolumbar junction. A combined full-endoscopic decompression and interbody fusion via a transforaminal approach was used to achieve this goal. The purpose of this study was to introduce the technical notes and clinical outcomes of this novel technique. METHODS: Twenty segments of hard disc herniations in the thoracolumbar junction of 14 patients treated with full-endoscopic interbody fusion via the transforaminal approach between January 2018 and September 2021 were analyzed. The patients were an average age of 43.3 years. Full-endoscopic interbody fusion and discectomy via the transforaminal approach were performed under local anesthesia, followed by percutaneous pedicle screw system fixation under general anesthesia. Imaging, including magnetic resonance imaging (MRI), computed tomography (CT), and X-ray, was carried out. MRI was performed on the second day and 3 months postoperatively. CT was performed on the second day, 6 months, and 1 year (as needed) postoperatively. Back and radicular pain, neurological function, and thoracic spine function were scored using a visual analog scale, the Nurick scale, and modified Japanese Orthopaedic Association (mJOA) scale, and the Oswestry disability index at 1 week, 3 months, 6 months, and 1 year postoperatively. RESULTS: All the operations were successfully completed, and no intraoperative conversion of the surgical methods occurred. Postoperative thoracolumbar junction MRI and CT examinations of all the patients revealed a sufficiently decompressed spinal cord or cauda equina, without any residual compression. At the 1-year follow-up, all the surgical segments were fused. Back and radicular pain was relieved in all the patients, and neurological function was restored. The average recovery rate of the mJOA was 72.5%, including seven excellent, five good, and two fair cases. Although dural tears occurred in two cases during the operation, no cerebrospinal fluid leakage or pseudomeningocele occurred during follow-up. No other surgical complications were noted. CONCLUSIONS: A combined full-endoscopic decompression and interbody fusion via a transforaminal approach can achieve complete spinal canal decompression and solid interbody fusion with fewer approach-related injuries. It is a safe and effective minimally invasive spine surgery for treating hard disc herniation in the thoracolumbar junction.

Modified Unilateral Biportal Endoscopic Lumbar Discectomy Results in Improved Clinical Outcomes.

OBJECTIVE: To evaluate and describe the clinical efficacy and safety of a modified unilateral biportal endoscopic lumbar discectomy. METHODS: From February 2019 to February 2020, patients who met the inclusion criteria were treated using a modified unilateral biportal endoscopic lumbar discectomy. During the operation, the herniated disc was removed and the ligamentum flavum was preserved. Clinical efficacy was assessed via postoperative imaging and follow-up. RESULTS: A total of 70 patients were followed up for more than 2 years, including 51 males and 19 females, aged 49.4 ± 16.0 years. All operations were completed and no complications were noted. Postoperative lumbar magnetic resonance imaging showed that the decompression of the nerve root was sufficient and the ligamentum flavum was preserved in all patients. Postoperative lumbar CT showed that the caudal lamina and inferior articular process of the cephalad vertebral were partially removed. Lower back and leg pain were significantly relieved after surgery, and the Oswestry Disability Index was significantly improved compared to presurgery measurements (P ＜ 0.01). After 2 years of follow-up, the sensory and muscle strength of nerve roots were significantly recovered (P ＜ 0.01). According to the MacNab score of the patients, 40 cases were defined as "excellent," 26 cases were "good," 2 cases were "fair," and 2 cases were "poor." CONCLUSIONS: Modified unilateral biportal endoscopic lumbar discectomy can completely remove a lumbar herniated disc; relieve lower back and leg pain; improve lumbar function; reduce the risk of dural tearing, cerebrospinal fluid leakage, and epidural hematoma; and reduce the epidural adhesion and arachnoiditis caused by ligamentum flavum resection.

Simvastatin protects osteoblast against H2O2-induced oxidative damage via inhibiting the upregulation of Nox4.

Statins, 3-hydroxy-3-methylglutaryl coenzyme A reductase inhibitors, have been used clinically as a cholesterol-lowering drug to treat hyperlipidemia. In recent years, accumulating evidence indicates the possible beneficial effect of statins on osteoporosis. However, the underlying molecular mechanism remains to be elucidated. In the present study, we investigated the therapeutic effects of simvastatin on cell viability, apoptosis, and alkaline phosphatase activity in murine osteoblastic MC3T3-E1 cells treated by hydrogen peroxide (H(2)O(2), 100 µM). It was shown that simvastatin suppressed H(2)O(2)-induced oxidative stress and attenuated H(2)O(2)-induced cell injury including increasing osteoblastic viability, inhibiting apoptosis, and promoting differentiation. Then, we examined the effects of simvastatin (10(-7) M) on Nox1, Nox2, and Nox4 expressions in osteoblastic cells treated by H(2)O(2) (100 µM). We found that in MC3T3-E1 cells, H(2)O(2)-induced upregulation of Nox4 expression was inhibited by simvastatin, which was restored by farnesyl pyrophosphate (5 µM) as well as geranylgeranyl pyrophosphate (5 µM). RNAi approach was used to reduce Nox4 protein levels in osteoblastic cells to explore its biological effects against H(2)O(2)-induced oxidative damage. When Nox4 expression was reduced in osteoblastic cells, H(2)O(2)-induced cell injury was attenuated markedly. We concluded that simvastatin protected osteoblast against H(2)O(2)-induced oxidative damage, at least in part, via inhibiting the upregulation of Nox4.

Sirt1 overexpression protects murine osteoblasts against TNF-α-induced injury in vitro by suppressing the NF-κB signaling pathway.

AIM: Sirtuin 1 (Sirt1) is the class III histone/protein deacetylase that interferes with the NF-κB signaling pathway, thereby has anti-inflammatory function. This study was undertaken to investigate whether Sirt1 could protect osteoblasts against TNF-α-induced injury in vitro. METHODS: Murine osteoblastic cell line, MC3T3-E1, was used. Overexpress of Sirt1 protein in MC3T3-E1 cells was made by transfection the cells with Sirt1-overexpressing adenovirus. The levels of mRNAs and proteins were determined with qRT-PCR and Western blotting, respectively. The activity of NF-κB was examined using NF-κB luciferase assay. The NO concentration was measured using the Griess method. RESULTS: Treatment of MC3T3-E1 cells with TNF-α (2.5-10 ng/mL) suppressed Sirt1 protein expression in a concentration-dependent manner. TNF-α (5 ng/mL) resulted in an increase in apoptosis and a reduction in ALP activity in the cells. Overexpression of Sirt1 in the cells significantly attenuated TNF-α-induced injury through suppressing apoptosis, increasing ALP activity, and increasing the expression of Runx2 and osteocalcin mRNAs. Furthermore, overexpression of Sirt1 in the cells significantly suppressed TNF-α-induced NF-κB activation, followed by reducing the expression of iNOS and NO formation. Sirt1 activator resveratrol (10 µmol/L) mimicked the protection of the cells by Sirt1 overexpression against TNF-α-induced injury, which was reversed by the Sirt1 inhibitor EX-527 (5 µmol/L). CONCLUSION: Overexpression of Sirt1 protects MC3T3-E1 osteoblasts aganst TNF-α-induced cell injury in vitro, at least in part, via suppressing NF-κB signaling. Sirt1 may be a novel therapeutic target for treating rheumatoid arthritis-related bone loss.

[Clinical safety about repairing the peripheral nerve defects with chemically extracted acellular nerve allograft].

OBJECTIVE: To discuss the clinical safety about repairing the peripheral nerve defects with the acellular allogeneic nerve. METHODS: The 41 patients (male 38, female 3, age 10 - 55 years old, average 28.9 years old) who were performed chemically extracted acellular nerve allograft transplanting to repair nerve defects from 2002 to 2011. The average interval from injury to nerve repairing was 4.1 months (range, 10 hours to 9 months). There were 41 cases nerve defects including 10 brachial plexus nerves, 3 radial nerves of upper arm, 4 ulnar nerves of forearm, 12 digital and toe nerves, 2 sciatic nerves, 2 femoral nerves, 3 tibial nerves and 5 common peroneal nerves. There were 12 cases combined fractures and 20 soft tissue injury or defects. The average length of the nerve allograft to bridge the nerve defects was 6.1 cm (range, 2 - 10 cm). No immunosuppressive drugs were used in all cases. The clinical safety was evaluated through physical examination, blood biochemistry and immunity detection. RESULTS: All cases were followed up post-operation. They got primary wound healing except 2 superficial infection who got delay healing through dressings changing. No any adverse effects happened including immunological rejection, hypersensitivity reaction, deep infection, hepatotoxicity and nephrotoxicity. CONCLUSIONS: It is safe and feasible to repairing human peripheral nerve defects with chemically extracted acellular nerve allograft.

Full-Endoscopic Lumbar Interbody Fusion Versus Minimally Invasive Transforaminal Lumbar Interbody Fusion with a Tubular Retractor System: A Retrospective Controlled Study.

OBJECTIVE: The objective of this study was to compare the safety and clinical efficacy of full-endoscopic lumbar interbody fusion (FE-LIF) and minimally invasive transforaminal lumbar interbody fusion (MIS-TLIF). METHODS: A total of 70 patients with single-level lumbar degenerative diseases underwent FE-LIF or MIS-TLIF with a tubular retractor system from August 2018 to August 2020. Postoperatively, the efficacy and safety were compared using several clinical and radiological indices. RESULTS: A total of 32 patients underwent FE-LIF and 38 received MIS-TLIF with a tubular retractor system, and all patients had no apparent complications. The FE-LIF group had higher radiation exposure, longer operation time, and less bleeding than the MIS-TLIF group (P < 0.05). Postoperative lumbar magnetic resonance imaging showed that the nerve decompression was sufficient. The pain in the lower back and legs was significantly relieved, and the Oswestry Disability Index (ODI) score was greatly improved after surgery (P < 0.01) in both the groups. The sensory and motor functions of nerve roots were remarkably recovered in both the groups at the 1-year follow-up (P < 0.05), and there was no significant difference in MacNab scores between the 2 groups. As per Mannion's fusion classification, the interbody fusion rate was significantly better in the FE-LIF group than in the MIS-TLIF group. CONCLUSIONS: FE-LIF, which is safe, effective, and minimally invasive, exhibits the same clinical efficacy as MIS-TLIF but with longer operation time and increased radiation exposure.

[Comparison of the grafting technique in treatment of thoracolumbar burst fractures:transpedicular intracorporeal versus posterolateral].

OBJECTIVES: To retrospectively investigate the outcome of transpedicular intracorporeal grafting and posterolateral grafting in treatment of thoracolumbar burst fractures. METHODS: Forty-six patients treated with transpedicular intracorporeal grafting from January 1999 to December 2009 and followed up for 19-119 months (average 67 ± 13 months) were reviewed retrospectively, and were compared with 18 patients who had underwent posterolateral fusion during the same period through radiographic analysis. Radiographic measurements included Cobb angle, vertebral wedge angle (VWA), ratio between anterior and posterior vertebral height (APHR), upper inter-vertebral angle, lower inter-vertebral angle on X-ray, CT and MRI. RESULTS: In transpedicular intracorporeal grafting group, the VWA was corrected from 27.2° ± 6.5° to 7.0° ± 3.0° and the APHR from (53.3 ± 11.8)% to (92.3 ± 2.4)%. In posterolateral fusion group, the VWA was corrected from 23.9° ± 4.4° to 8.8° ± 2.1° and the APHR from (60.7 ± 10.0)% to (88.5 ± 3.3)%. Transpedicular intracorporeal grafting group showed better postoperative correction results than posterolateral fusion group (P < 0.05), and had less loss of correction of Cobb angle, VWA and APHR at final follow-up (P < 0.05). CONCLUSIONS: The transpedicular intracorporeal grafting can improve injured vertebral body morphology recovery better than posterolateral bone grafting, but can not prevent the late loss of correction after implant removal.

[Both the medial and lateral meniscal allograft transplantation following the anterior cruciate ligament reconstruction by arthroscopic surgical technique].

OBJECTIVE: To discuss the minimal invasive arthroscopic surgery technique and clinical results of both the medial and lateral meniscal transplantation following the anterior cruciate ligament reconstruction with double bundles and bone tunnels. METHODS: In August 2008 a minimal invasive surgery of both the medial and lateral meniscal allograft transplantation following anterior cruciate ligament reconstruction was preformed for 1 case with both the medial and lateral meniscectomy by arthroscopic surgery. The method of two bone plugs attached on tibial plateau was employed for medial meniscal allograft transplantation and the technique the bridge in slot for lateral meniscal allograft transplantation. The VAS, Lysholm score and IKDC rating were recorded before and after operation. The stability of knee was assessed by Lachman test, drawer sign and pivot shift test. RESULTS: The patient was followed up 26 month after the operations. The degrees of knee flexion, extension and function of walk were normal. The Lachman test, drawer sign and pivot shift test were nearly normal. The VAS after operation was 2 points lower than that before operation. The Lysholm score post-operation was 20 points higher than pre-operation. The IKDC became B degree in late following-up from C degree before the operation. MRI revealed anterior cruciate ligament graft was continuous and the meniscal allograft was normal shape on year 1 after the operation. The posterior horn of medial meniscal allograft and anterior corner of lateral meniscal allograft showed slightly shrunk. The second-look arthroscopy showed that the healing occurring between meniscal allograft and the capsule and meniscal allograft was normal shape on month 18 after the operation. The anterior horn of medial and lateral meniscus was slightly worn. CONCLUSIONS: Both the medial and lateral meniscal transplantation following the anterior cruciate ligament reconstruction in appropriately selected patients with the medial and lateral meniscus-deficient knee may recover the knee mechanic balance and stability, which is a option of treatment for that young and activity patients. It is proposed that the medial and lateral meniscal grafts harvested from a single donator. Attention should be paid to the direction of the bone tunnels fixing the horns of the meniscus in order to avoid communication with the tunnels of anterior cruciate ligament reconstruction.

Ultrasonic Osteotome Assisted Full-Endoscopic en Block Resection of Thoracic Ossified Ligamentum Flavum: Technical Note and 2 Years Follow-up.

BACKGROUND: Conventional open laminectomy is considered to be the standard procedure for the treatment of thoracic ossified ligamentum flavum, but multi-segment thoracic laminectomy extensively removes the facet joints and ligamentous tissue, destroying the thoracic spine biomechanics and stability, may lead to delayed thoracic spine kyphosis deformities, which in turn can lead to potential neurological deterioration and local intractable pain. OBJECTIVE: To introduce the technical notes and clinical outcome of ultrasonic osteotome assisted full-endoscopic en block resection of thoracic ossified ligamentum flavum. STUDY DESIGN: A prospective cohort study. SETTING: Hospital and outpatient surgery center. METHODS: From January 2017 to March 2018, 15 patients with 1 - 2 segment thoracic ossified ligamentum flavum were treated with ultrasonic osteotome assisted full-endoscopic en block resection of thoracic ossified ligamentum flavum under local anesthesia. The magnetic resonance imaging and computed tomography of the thoracic spine was reexamined after the operation to evaluate the completeness of ossified ligamentum flavum resection and spinal cord decompression. The patients were followed up on the visual analog scale of back pain and radicular pain, Nurick score and mJOA score of neurological function, and Oswestry Disability Index at 1 week, 3 months, 6 months, one year, and 2 years after operation. RESULTS: All operations of 17 segments thoracic ossified ligamentum flavum in 15 patients were successfully completed without intraoperative conversion to open surgery. There were no intraoperative spinal cord injuries, dura tears, postoperative cerebrospinal fluid leakage, postoperative infections, and postoperative spinal cord injury aggravated symptoms. Postoperative thoracic spine magnetic resonance imaging and computed tomography examinations of all patients showed that the spinal cord was fully decompressed without any residual pressure. Back pain and radicular pain were relieved significantly, and spinal cord function (Nurick, mJOA, and Oswestry Disability Index scores) was obviously restored. The mJOA recovery rate at the 2-year follow-up was 78.3% in average. LIMITATIONS: This is an observational cohort study with relative small sample and short-term follow-up. CONCLUSIONS: Ultrasonic assisted full-endoscopic en block resection of ossified ligamentum flavum is a safe and effective minimally invasive spine surgery for thoracic myelography caused by thoracic ossified ligamentum flavum.

[Clinical efficacy of different rehabilitation modes for lumbar degenerative diseases after operation].

OBJECTIVE: To compare clinical effects of different postoperative rehabilitation modes on lumbar degenerative diseases, and explore influence of rehabilitation mode and other factors on postoperative effect. METHODS: From June 2013 to July 2016, totally 900 patients were admitted from nine tertiary hospitals in Beijing to perform single segment bone grafting and internal fixation due to lumbar degenerative diseases were prospectively analyzed. There were 428 males and 472 females, the age of patient over 18 years old, with an average of (51.42±12.41) years old;according to patients' subjective wishes and actual residence conditions, all patients were divided into three groups, named as observation group 1 (performed integrated rehabilitation approach and orthopedic treatment model intervention), observation group 2 (performed integrated rehabilitation approach and orthopedic treatment, classified rehabilitation model intervention), and control group(performed routine rehabilitation model intervention). Visual analogue scale(VAS), Oswestry Disability Index(ODI) and Japanese Orthopaedic Association (JOA) were used to evaluate postoperative efficacy among three groups at 24 weeks. Possible factors affecting the postoperative efficacy including age, age grouping, gender, body mass index (BMI), BMI grouping, education level, visiting hospital, payment method of medical expenses, preoperative complications, preoperative JOA score, clinical diagnosis, surgery section, operative method, intraoperative bleeding volume, postoperative complications and rehabilitation mode were listed as independent variables, and postoperative ODI score at 24 weeks as dependent variables. Univariate analysis was used to analyze relationship between influencing factors and postoperative efficacy. Multiple linear regression was used to analyze relationship between influencing factors, rehabilitation mode and postoperative ODI score at 24 weeks, in further to find out the main reasons which affect postoperative efficacy, and to analyze impact of rehabilitation mode on postoperative efficacy. RESULTS: All patients were followed up for 24 weeks after operation. All incisions healed at stage I with stable internal fixation. (1)Evaluation of postoperative efficacy:① There were no statistical differences in preoperative VAS and ODI among three groups(P>0.05), the degree of pain and dysfunction decreased among three groups after operation, and had differences in postoperative VAS and ODI among three groups (P<0.05). There were no significant differences between observation group 1 and observation group 2(P>0.05); while compared with observation group 1 and control group, observation group 2 and control group, there were significant differences (P<0.05). ②The function among three groups were improved in varying degrees after operation. There was difference in JOA score among three groups before operation and 24 weeks after operation (P<0.05). There were no difference in JOA score among three groups between observation group 1 and observation group 2 (P>0.05);while compared with observation group 1 and control group, observation group 2 and control group, there were significant differences (P<0.05). (2)Influencing factors at 24 weeks after operation:①Univariate analysis showed gender, age, age grouping, education level, preoperative complications, clinical diagnosis, operative section, operative method, preoperative JOA score and rehabilitation mode had statistical significance with postoperative ODI score at 24 weeks (P<0.05). BMI, BMI grouping, payment method of medical expenses, visiting hospital, intraoperative bleeding volume, postoperative complications had no statistical significance with postoperative ODI score at 24 weeks (P<0.05).②Multivariate analysis results showed gender, rehabilitation mode, age, preoperative JOA score entered the equation eventually, stepwise multiple linear equation obtained had statistical significance (F=12.294, P= 0.000). Among rehabilitation mode, standardized regression coefficient of the integrated rehabilitation approach and orthopedic treatment with classified rehabilitation model was absolute value of the largest (0.176), which had the greatest influence on postoperative curative effect. The degree of dysfunction in control group was higher than that in observation group 1 and observation group 2. Postoperative dysfunction was more severe in males than that of in females. Older age has higher degree of dysfunction after operation. Lower preoperative JOA score has higher degree of dysfunction after operation. CONCLUSION: Preoperative JOA score, gender, age could predict postoperative clinical effects of lumbar degenerative diseases in varying degrees treated with single level bone graft fusion and internal fixation. Different rehabilitation modes could improve clinical effects. Intergrated rehabilitation orthopedic treatment model and integrated rehabilitation approach and orthopedic treatment with classifiedrehabilitation model are superior to conventional rehabilitation model in improving patients' postoperative function and relieving pain, which is worthy of promoting in clinical.

Genetics of osteoporosis: accelerating pace in gene identification and validation.

Osteoporosis is characterized by low bone mineral density and structural deterioration of bone tissue, leading to an increased risk of fractures. It is the most common metabolic bone disorder worldwide, affecting one in three women and one in eight men over the age of 50. In the past 15 years, a large number of genes have been reported as being associated with osteoporosis. However, only in the past 4 years we have witnessed an accelerated pace in identifying and validating osteoporosis susceptibility loci. This increase in pace is mostly due to large-scale association studies, meta-analyses, and genome-wide association studies of both single nucleotide polymorphisms and copy number variations. A comprehensive review of these developments revealed that, to date, at least 15 genes (VDR, ESR1, ESR2, LRP5, LRP4, SOST, GRP177, OPG, RANK, RANKL, COLIA1, SPP1, ITGA1, SP7, and SOX6) can be reasonably assigned as confirmed osteoporosis susceptibility genes, whereas, another >30 genes are promising candidate genes. Notably, confirmed and promising genes are clustered in three biological pathways, the estrogen endocrine pathway, the Wnt/beta-catenin signaling pathway, and the RANKL/RANK/OPG pathway. New biological pathways will certainly emerge when more osteoporosis genes are identified and validated. These genetic findings may provide new routes toward improved therapeutic and preventive interventions of this complex disease.

[The anatomic and radiographic morphometry of thoracic pedicle rib unit].

OBJECTIVES: To investigate the spatial structure of pedicle rib units in normal thoracic human spines and to compare the dimensions of the pedicle rib unit with corresponding dimensions. METHODS: Thoracic spine specimens in four fresh adult cadaveric were used. Computerized tomographic (CT) images (including two-dimensional, three-dimensional reconstruction) of the thoracic spines were obtained. Measurement parameters include:the width, the height, the chord length and the sagittal angles of the pedicle rib unit compared with pedicle, especially for the pedicle-rib overlapping height. RESULTS: The pedicle rib unit was not a simple two-dimensional structure but a three-dimensional structure. The shortest height of pedicle rib unit was (12.6 ± 0.8) mm (T(1)), while the longest was (16.9 ± 1.1) mm (T(11)). The shortest height of pedicle-rib overlap was (7.2 ± 0.3) mm (T(1)), while the longest was (11.8 ± 1.0) mm (T(10)). The height of pedicle rib unit and the height of pedicle were significantly larger than that of the pedicle-rib overlap (P < 0.05), while there was no significantly difference between the height of pedicle rib unit and the height of pedicle (P > 0.05). CONCLUSIONS: The pedicle rib unit is a complicated spatial structure, and the longitudinal height of pedicle-rib overlap should be taken as the real height of the unit.

A Pilot Study of Full-Endoscopic Annulus Fibrosus Suture Following Lumbar Discectomy: Technique Notes and One-Year Follow-Up.

BACKGROUND: An annulus fissure or defect will inevitably be left on the posterior annulus fibrosus after almost all kinds of lumbar discectomy, which may lead to unsatisfying postoperative pain relief and recurrence of the disc herniation. OBJECTIVE: The objective of this research is to introduce the technique of full-endoscopic annulus fibrosus suture following lumbar discectomy through the transforaminal or interlaminar approach, and to analyze the clinical outcome of full-endoscopic lumbar discectomy and annulus fibrosus suture. STUDY DESIGN: This study used a prospective cohort design. SETTING: The research was conducted in a hospital and outpatient surgery center. METHODS: A total of 50 patients with noncontained lumbar disc herniation treated with full-endoscopic lumbar discectomy and annulus fibrosus suture were treated in our department between January 2018 and November 2018. Full-endoscopic single-stitch suture via the transforaminal approach (Group T) or double-stitch suture via the interlaminar approach (Group I) was selected according to the level of lesion. Lumbar magnetic resonance imaging (MRI) was reexamined on the second day and 3 months after operation to evaluate the completeness of the discectomy and the adequacy of nerve decompression. Patients were followed up on the second day, 3 months, 6 months, and one year after operation to evaluate the relief of low back pain and leg pain, using a visual analog scale (VAS, 100-point scale). At 3 months, 6 months, and one year after operation, the patients were followed up for recovery of lumbar spine function, using the Oswestry Disability Index (ODI). At the one-year follow-up, the MacNab score was used to evaluate the clinical outcome, and the recovery of nerve root function (sensation, muscle strength, and reflex) was recorded. RESULTS: All operations were successfully completed, including 27 cases in Group T and 23 cases in Group I. There were no surgical complications and no recurrence of lumbar disc herniation. Lumbar MRI reexaminations of all patients showed that the herniated disc was completely removed and the nerves were fully decompressed. Postoperative low back pain and leg pain were significantly relieved, and the ODI score was significantly improved (P < .01) in both groups. At the one-year follow-up, the excellent and good rates as measured by the MacNab score were 92.6% in Group T and 91.3% in Group I with no significant difference between the 2 groups (P > .05). The impaired sensation and muscle strength in the low extremities of evolved nerve root of the 2 groups of patients recovered significantly at the one-year follow-up (P < .01), but the tendon reflex did not recover significantly (P > .05). LIMITATIONS: This is an observational cohort study with relatively small sample sizes and short-term follow-up. CONCLUSIONS: Full-endoscopic lumbar discectomy and annulus fibrosus suture through either the transforaminal or interlaminar approach are safe and effective minimally invasive spinal surgery techniques that can reduce the recurrence rate of lumbar disc herniation after full-endoscopic lumbar discectomy.

[Analysis of the technical key points and clinical effect of full-endoscopic lumbar annulus fibrosus suture].

OBJECTIVE: To introduce the technical key points of lumbar annulus fibrosus suture under full-endoscope and analyze the clinical efficacy of full-endoscopic lumbar discectomy and annulus fibrosus suture. METHODS: A total of 50 patients with non contained lumbar disc herniation treated with full-endoscopic lumbar discectomy and annulus fibrosus suture in our department between January 2018 and November 2018 were included. Full-endoscopic single-stitch suture through transforaminal approach or double-stitch suture through interlaminar approach was selected according to lesion level. The lumbar MRI and CT were reexamined on the second day and 3 months after surgery to evaluate the completeness of the discectomy and the adequacy of nerve decompression respectively. The patients were followed up on the second day, 3 months, 6 months, and 1 year after surgery for pain relief using visual analogue scale (VAS, 100 -point scale). The patients were followed up at 3 months, 6 months, and 1 year postoperatively for the recovery of lumbar spine function using Oswestry Disability Index(ODI). At the 1-year follow-up, the Macnab standard of lumbar spine function was evaluated, and the recovery of nerve root function (sensory, muscular and reflex) was recorded. RESULTS: All operations were successfully completed, of which 27 patients were treated with transforaminal approach(including 8 cases of L3, 4 and 19 cases of L4, 5), and 23 patients(including 11 cases of L4, 5 and 12 cases of L5S1) with interlaminar approach. The average operation time was 43.2 minutes. There were no surgical complications and no recurrence of lumbar disc herniation. Postoperative lumbar MRI and CT examinations of all patients showed that the herniated disc was completely removed and the nerveswere fully decompressed. All patients had significant relief of low back pain and lower extremity radiation pain, and the ODI score improved significantly(P<0.01). At 1 year postoperative follow up, 17 patients got an excellent result, 29 good and 4 fair according to Macnab evaluation system. On the first year after surgery, the sense of damaged nerve roots and muscle strength were significantly restored (P<0.01), but tendon reflexes were not significantly restored (P>0.05). CONCLUSION: Full-endoscopic lumbar discectomy and annulus fibrosus suture are safe and effective techniques for minimally invasive spinal surgery, which can reduce the recurrence rate of lumbar disc herniation after full endoscopic lumbar discectomy.

[Transplantation of large anterior latissimus dorsi muscular flap combination with musculus rectus abdominis flap].

OBJECTIVE: To study the value and surgical techniques of transplantation of large anterior latissimus dorsi muscular flap combination with musculus rectus abdominis flap. METHODS: Three cases (2 male and 1 female) with skin defect and bone exposed were reviewed from May 2005 to January 2007. Two patients suffered from trauma, and 1 suffered from tumor resection. Flaps size were: 60 cm x 32 cm, 55 cm x 30 cm and 50 cm x 25 cm, flaps pattern including: 1 free flap with 2 ends of vascular, 1 flap with pedicle and free vascular end, 1 flap with 2 ends of pedicle. RESULTS: Two flaps survived completely, 1 flap with necrosis edge eventually healed after change of dressing. The infection had been effectively controlled and ready for function recovered. One case caused by trauma recovered with fracture healing, full weight-bearing and restore the original work. CONCLUSIONS: Large anterior latissimus dorsi muscular flap combination with musculus rectus abdominis flap can be used for repair of large skin defect. For the difficulty and technical requirements, surgical indications should be strictly controlled.

[The role of capsaicin-sensitive primary afferents in experimental sciatic pain].

OBJECTIVES: To determine the effect of destroying capsaicin-sensitive primary afferents (CSPA) fibers on paw withdrawal mechanical threshold (PWMT) induced by the direct compression of L5 nerve root with autologous disc. METHODS: The procedure used autologous disc of the rats from the coccygeal intervertebral discs to apply direct pressure to the L5 dorsal root. PWMT was measured at the different time points post-surgery and pre-surgery. The changes in spatial expression pattern of c-fos protein in the spinal cord were also determined at 3 weeks when PWMT decreased to the peak. RESULTS: The pretreatment with capsaicin produced a complete prevention of mechanical hyperalgesia induced by disc compression. The direct compression of L5 nerve root produced an obvious expression of fos-like immunoreactivity neurons in the dorsal horn of the spinal cord, which was significantly decreased by pretreatment with capsaicin. CONCLUSIONS: The study shows that CSPA fibers, which mainly terminated in superficial layers of dorsal horn, may play a key role in mechanical hyperalgesia in the new sciatica model.

[The application of external fixator for complex tissue defect in the forearm].

OBJECTIVE: To discuss the curative effect of the external fixator for complex tissue defect in the forearm. METHODS: From May, 2005 through December, 2008, the external fixators were used in 17 patients to treat the complex tissue defect in the forearm caused by trauma. There were 11 male and 6 female, with a mean age of 25.6. All patients were accompanied with the exposure of tendon, muscle or screw. The skin defect ranged from 7 cm x4 cm to 19 cm x9 cm. All patients underwent pedicle flap repair. The flap ranged from 10 cm x 6 cm to 20 cm x 15 cm. The proximal pedicle of the flap was sutured into a tubular. The position of the pedicle was fixed by the external fixator. The pin was at the ulnar and the iliac (n=5), and the radius and the iliac (n=12). The immobilization lasted 3 to 8 weeks, 5.1 weeks in average. RESULTS: All patients were followed up for 3 to 20 months, 11.3 in average. All pedicle flaps survived with no pressure ulcer, or no erosion in the axilla. No compartment syndrome or osteomyelitis occurred. Four to six week after surgery, the pedicle was cut. Infection occurred at the cutting end in 1 patient. The wound healed after addressing. The wound in the other 16 patients healed successfully. The fracture of the ulnar and the radius healed 8.5 or 15 weeks after surgery, 13.5 weeks in average. Eleven patients underwent second stage reshape and function restoration. The function of the hands and forearms recovered satisfactorily. Eleven patients returned to their work. Six patients can live with basic function for living. CONCLUSIONS: The external fixator used for complex tissue defect in the forearm can keep the position of the pedicle, replacing plaster fixation. It can reduce the incidence of flap and vessel spasm, and get good outcomes.

[Studying the influence of age and short or long segments of pedicle screw instrumentation to the clinical efficacy of early single thoracolumbar fracture].

OBJECTIVE: To study the influence of different age and short or long segments of pedicle screw fixation to the clinical efficacy of early single thoracolumbar fracture. METHODS: From June 2005 to June 2008, 27 patients of early single thoracolumbar fracture were treated using short or long segments pedicle screw instrumentation, fracture vertebral (AO classification: type A1 or A2) was between T11 or L2. All patients were divided into A or B group according to age. A group: 12 cases mean age (32.6+/-10.7) years old (range, 16-55 years old). B group: 15 cases mean age (66.8+/-9.2) years old (range, 56-78 years old). All patients were treated with bony autograft by transpedicular of fracture vertebral and internal fixation by pedicle instrumentation. Pedicle screws were inserted in the pedicles of above and lower adjacent vertebral body of fracture vertebral, and others were inserted in the pedicles of above and lower two vertebral bodies of injured vertebral. Recorded operation time, blood loss and occurrence of complications. All patients took X radiograph plane examination (anterior-posterior position and lateral position) before operation and during 1 week of post operation and more than 1 year of follow up. Measured percentage of anterior compression vertebral high and kyphosis angle of the fracture vertebral by the same one group doctors. RESULTS: Mean follow up time was (29.6+/-9.1) months (range, 10 - 34 months). The patients using short segments pedicle screw fixation in A and B group, mean operation time were (102+/-16) min and (118+/-24) min (P=0.072), mean volume of loss blood were (315+/-87) ml and (331+/-87) ml (P=0.064) respectively. The patients using long segments pedicle screw fixation in A and B group, Mean operation time were (138+/-22) min and (159+/-31) min (P=0.052), Mean volume of loss blood were (446+/-102) ml and (482+/-148) ml (P=0.055) respectively. There was no statistic different significantly between A and B group. The patients using short segments fixation, preoperative, during one week of post operation, one year of follow up, in A group the percentage of anterior compression vertebral high were 41.3+/-14.0, 5.4+/-1.0, 13.6+/-1.1, and 38.5+/-11.2, 8.3+/-2.1, 21.4+/-5.2 in B group. The patients using long segments fixation, at some time of preoperative, during one week of post operation and one year of follow up the percentage of anterior compression vertebral high were 40.8+/-11.5, 4.6+/-1.2, 8.3+/-1.0 in group A, and 44.3+/-10.2, 9.7+/-2.1, 11.2+/-3.0 in group B. In group A and B the kyphosis angle of fracture segment was 17.5 degrees+/-1.0 degrees and 16.3 degrees+/-3.1 degrees before operation, 4.2 degrees+/-1.0 degrees and 6.0 degrees+/-1.1 degrees in one week of postoperation and 11.5 degrees+/-1.0 degrees, 13.4 degrees+/-3.0 degrees in one year later postoperation. All the compression vertebral high was recovered and kyphosis was corrected significantly during one week and one year after operation (P<0.05), but there was some loss of kyphosis correction rate in follow up. CONCLUSION: There is better clinical efficacy of short segments pedicle instrumentation for treating early thoracolumbar fracture in the young group, but long segments fixation of pedicle instrumentation is more suitable for the older group.

[Correlation between high intensity zone on MRI and positive pain response on lumbar discography in the diagnosis of discogenic low back pain].

OBJECTIVE: To study correlation between high intensity zone (HIZ) of lumbar disc and positive pain response on lumbar discography for the diagnosis and treatment of discogenic low back pain. METHODS: Thirty-seven cases with chronic low back pain without neurologic symptoms and lumbar disc herniation on CT scan underwent lumbar discography and MRI examination. X-ray and CT after discography with positive pain response were analyzed to correlate with HIZ on MRI. RESULTS: Ninety-eight discs underwent discography in 37 patients. Twenty-one discs presented positive pain response; including 10 have HIZ (47.6%). Seventy-seven discs presented negative pain response; including 29 had HIZ (37.6%). The higher grade of annular disruption group had the higher proportion of HIZ on lumbar MRI. There was a positive correlation between HIZ and degree of annular disruption. However, there was no correlation between HIZ and positive pain response on lumbar discography. CONCLUSIONS: HIZ on lumbar MRI only can be a filtrated and suggestive image sign and can not replace discography in the diagnosis and treatment of discogenic low back pain.