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Objective:To investigate the effect of Ponte osteotomy combined with bony bridge dissection and intervertebral bone grafting in the treatment of rigid degenerative scoliosis.Methods:From March 2017 to October 2021, this method was used to treat 21 cases of rigid degenerative scoliosis, including 7 males and 14 females, aged 59-76 years, with an average age of 67.6 years. All patients had intractable low back pain and limited standing and walking, while 15 patients had radiation pain in lower limbs. The preoperative standing X-ray film showed that the average Cobb angle of lumbar scoliosis was 51.3°±24.1°, the average lumbar lordosis was 5.4°±13.6°. The coronal balance distance (CBD) was 4.3±2.0 cm (range, 0.5-6.2 cm), and the sagittal vertical axis (SVA) was 5.9±3.1 cm (range, 1.5-6.8 cm). The bending images showed huge osteophyte with bone bridge formation in the vertebral body of the apex region, with poor mobility. Ponte osteotomy was performed according to the degeneration of the deformity. The bone bridge at apex area was cut off, and the intervertebral spaces at apex area and slipped or subluxated levels were release and grafted with granular autogenous decompression bone. During follow-up, the efficacy and deformity improvement were evaluated with visual analogue scale (VAS), Oswestry disability index (ODI) and standing X-ray films.Results:All patients successfully completed the operation. The operation time was 190-330 min, with an average of 250±68 min. The intraoperative bleeding was 700-1600 ml, with an average of 970±260ml. The patients were followed up for 12-36 months, with an average of 20.6±7.2 months. No internal fixation failure, fracture or revision occurred. At the last follow-up, the VAS of low back pain decreased from preoperative 6.1±2.2 to 2.1±1.8 ( t=6.45, P<0.001), and the leg pain decreased from 5.5±3.4 to 1.2±1.0 ( t=5.56, P<0.001).ODI decreased from 52.2%±22.2% to 16.4%±10.6% ( t=6.67, P<0.001). The Cobb angle of lumbar scoliosis was 19.3°±10.5°, with an average correction rate of 62.4%; lumbar lordosis was 34.4°±15.6 °, with average correction of 30°. CBD was 1.9±1.1 cm, with an average correction of 2.4 cm ( t=4.42, P<0.001); and SVA was 1.6±2.1 cm, with an average correction of 4.3 cm ( t=4.90, P<0.001). Conclusion:Ponte osteotomy combined with bone bridge dissection and intervertebral bone grafting is an effective method to treat rigid degenerative scoliosis, which can improve spinal sequence, CBD and SVA, avoid vertebral osteotomy and reduce fusion segments.
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Intervertebral disc degeneration is the most common cause of chronic low back pain and the leading cause of disability in adults. The fact that lacking of effective treatment methods often causes a serious economic and social burden. Intervertebral disc degeneration is the result of multifactorial factors. The prevalence of intervertebral disc degeneration increases drastically with age, what is more, mechanical trauma, genetic predisposition,lifestyle factors and certain metabolic disorders. At present, the main treatment methods both pharmacological and surgical interventions just aim at relieving symptoms and improving function, and can not fundamentally reverse the process of intervertebral disc degeneration, which not only bring inevitable side effects and high cost, but also the long-term curative effect is limited. In theory, biological therapy can not only reverse or delay the process of it, but also can maximize preservation and restore the normal physiological function of the disc, which has been the focus and hot spot areas of research in recent years. The methods of inhibiting inflammation, promote the proliferation and division of residual cells, stem cell transplantation, cell scaffolds and new biomaterials all provide new ideas and direction for the treatment of intervertebral disc degeneration. This paper makes a review of the research progress in related fields, in order to provide a valuable reference for the selection of intervertebral disc degeneration treatment options.
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Objective:To investigate the effect of unilateral biportal endoscopy (UBE) through extraforaminal approach in the treatment of extra canal lumbosacral nerve entrapment.Methods:Seventeen patients with extra canal lumbosacral nerve root entrapment were treated by UBE through extraforaminal approach in Tianjin Hospital from January 2020 to March 2022, including 9 males and 8 females with an average age of 59.2 years (range 45-71 years). All 17 patients had lower limb radiation pain, numbness, and weakness with or without intermittent claudication. MRI imaging examination showed L 4, 5 foramen stenosis with far lateral disc herniation in 2 case, and L 5S 1 foramen stenosis with far lateral disc herniation in 15 cases, and the height of intervertebral space decreased, resulting in the compression of exiting nerve root and ganglion. Among them, far-out syndrome was diagnosed in 7 cases and transitional lumbarsacral vertebrae was found in 12 cases. The incisions were designed 2 cm away form the projection of adjacent pedicles, while incision at S 1 was designed at the inner edge of the iliac bone due to the shielding of the ilium, taking the outer edge of the isthmus at the outer opening of the intervertebral foramen as the target of channels. The ventral and apical part of superior articular process (SAP) was gradually removed with high-speed burr from its outer edge and isthmus, and the occluded sacral ala and the lower edge of transverse process were removed when necessary. The hyperplastic ligament was removed to expose the exiting nerve root. The protruding intervertebral disc was removed at the ventral side of the nerve root. The far-out syndrome was decompressed laterally along the exiting nerve root until it is completely released. The results and stability were evaluated with visual analogue scale (VAS), Oswestry disability index (ODI), Macnab scores and dynamic X-ray film during follow-up. Results:The operation time was 45-85 min, with an average of 60 min. After remove of the SAP tip and enlarge of the intervertebral foramen, the exiting nerve root and disc protrusion were fully exposed, the exiting nerve root was exposed and released laterally until totally release without entrapment in far out syndrome, and the nerve could be decompressed completely. The symptoms were significantly relieved after operation, and imaging examination showed that facet joints were preserved. During follow-up, the pain and function improved continuously. At final follow-up, the improve rate of VAS and ODI were 85.2% and 86.2%, respectively, and the results were excellent in 15 cases and good in 2 case according to Macnab score, and there was no lumbar instability on dynamic lumbar X-ray film.Conclusion:Extra canal lumbosacral nerve entrapment can be treated by UBE through extraforaminal approach, with sufficient exposure, complete decompression and better preservation of lumbar stability.
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Bone defects caused by different causes such as trauma, severe bone infection and other factors are common in clinic and difficult to treat. Usually, bone substitutes are required for repair. Current bone grafting materials used clinically include autologous bones, allogeneic bones, xenografts, and synthetic materials, etc. Other than autologous bones, the major hurdles of rest bone grafts have various degrees of poor biological activity and lack of active ingredients to provide osteogenic impetus. Bone marrow contains various components such as stem cells and bioactive factors, which are contributive to osteogenesis. In response, the technique of bone marrow enrichment, based on the efficient utilization of components within bone marrow, has been risen, aiming to extract osteogenic cells and factors from bone marrow of patients and incorporate them into 3D scaffolds for fabricating bone grafts with high osteoinductivity. However, the scientific guidance and application specification are lacked with regard to the clinical scope, approach, safety and effectiveness. In this context, under the organization of Chinese Orthopedic Association, the Expert consensus for the clinical application of autologous bone marrow enrichment technique for bone repair ( version 2023) is formulated based on the evidence-based medicine. The consensus covers the topics of the characteristics, range of application, safety and application notes of the technique of autologous bone marrow enrichment and proposes corresponding recommendations, hoping to provide better guidance for clinical practice of the technique.
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Low back pain (LBP) is a common clinical condition, and non-specific LBP is believed to be associated with lumbar instability caused by paraspinal muscle (PSM) degeneration. Therefore, MRI evaluation of PSM degeneration can help predict the progression of low back pain-related diseases. At present, the most commonly used MRI parameters are the cross-sectional area (CSA) and fat infiltration (FI) of PSM. In order to assess the degree of PSM degeneration more accurately, modified parameters including functional CSA, relative CSA and muscle-fat infiltration index (MFI), have been designed. Advancements in MRI technology,such as the application of IDEAL-IQ, allow for early detection of changes in fat infiltration. Additionally, the proton density fat fraction (PDFF) derived from chemical shift encoding based water-fat MRI (CSE-MRI), also shows promise in studying PSM. Numerous MRI studies, both domestically and internationally, have aimed to establish the relationship between PSM degeneration and non-specific LBP, lumbar degenerative diseases, degenerative lumbar scoliosis, and osteoporosis. It has been found that PSM degeneration is affected by other factors such as intervertebral disc, articular process and endplate degeneration. Furthermore, PSM degeneration and scoliosis/kyphosis are also reciprocal causation. Higher fat content in the vertebral body and PSM is associated with increased bone fragility, while vertebroplasty following osteoporotic vertebral fracture can delay PSM degeneration and improve quality of life.
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Objective:To explore the application value of graded surgical strategy and balanced load concept for thoracolumbar osteoporotic compression fractures (OVCFs) with kyphosis.Methods:All of 56 patients of thoracolumbar OVCFs with kyphosis were studied, including 11 males and 45 females, with an average of 75.6±9.3 years old. All patients had back pain, and 32 patients had nerve compression, including 5 patients with aggravation of vertebral collapse after conservative treatment, and 1 patient with cement loosening after percutaneous kyphoplasty (PKP) in another hospital. A graded surgical strategy was developed according to the concept of balanced load, including whether there existed nerve compression, kyphosis, sagittal index (SI), vertebral collapse, load capacity of anterior and middle columns, and fracture reducibility. All patients were treated with anti osteoporosis therapy. 24 patients without nerve compression underwent posture reduction and PKP; 32 patients with nerve compression underwent open surgery: 5 patients with arcuate ky-phosis and SI≤15° underwent Ponte osteotomy; 15 patients with angular kyphosis or SI>15° underwent posterior pedicle subtraction osteotomy (PSO) or/and modified PSO including intervertebral space; 11 patients with SI>15° and severe vertebral collapse (the height of anterior and middle vertebral bodies <1/3 of the average height of adjacent vertebral bodies) or cement loosen after PKP underwent vertebrectomy and reconstruction, of which 4 patients underwent posterior vertebral column resection (PVCR), and 8 patients underwent combined surgery including anterior subtotal vertebrectomy with support and posterior pedicle fixation. The clinical efficacy was evaluated by pain visual analog score (VAS) and Oswestry dysfunction index (ODI).Results:All patients were followed up for 12-60 months, with an average of 24.2 months. For the 24 patients with PKP, the symptoms improved significantly, and 1 case had adjacent vertebral fracture that was improved after PKP again. For the 32 patients with open surgery, the intraoperative blood loss was 400-1 800 ml, with an average of 960 ml (PVCR > PSO and combined surgery > Ponte); the operation time was 2-7 h, with an average of 4.3±1.9 h. The neurological symptoms improved after the operation. During follow-up, the artificial vertebral body and titanium mesh collapsed in 3 cases, but did not continue to deteriorate, no vertebral fracture, internal fixation displacement or loosening failure occurred on X-ray films. At the last follow-up, the VAS score and ODI score of 56 patients decreased from 7.0±2.6 and 60.4±16.2 pre-operation to 1.4±1.1 and 9.5+5.8 respectively, and local kyphosis angle improved from 18.1±4.3 pre-operation to 5.6±4.3. According to the overall satisfaction of patients, the effect was fair in 12 cases, good in 30 cases, excellent in 14 cases, and the excellent and good rate was 78.6%.Conclusion:The graded surgical strategy for thoracolumbar OVCFs with kyphosis based on the concept of balanced load can restore the balanced load of the anterior and middle columns of the spine, reduce the fixation and fusion segments, and reduce the risk of internal fixation displacement and loosening failure.
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Objective:To evaluate the safety and validity of enriched autologous bone marrow mesenchymal stem cells (BMSCs) and annular suture for repairing defect after lumbar discectomy.Methods:Enrichment of autologous BMSCs: autologous bone marrow blood was collected from 5 patients undergoing lumbar surgery, and nucleated cells were enriched on gelatin sponge particles by selective cell retention technique. From October 2016 to March 2019, 109 patients with lumbar disc herniation underwent discectomy with mobile microendoscopic discectomy technique, including 61 males and 48 females, aged 24-59 years. Discectomy group: 26 cases received simple discectomy. Suture group: 39 cases received annular suture after discectomy. BMSCs+suture group: 44 cases received intradisc transplantation of gelatin sponge particles enriched with autologous BMSCs and annular suture after discectomy. The perioperative conditions were recorded, with visual analogue scale (VAS), Oswestry dysfunction index (ODI), Pfirrmann grade of disc degeneration, disc height and degree of herniationevaluated after operation.Results:In enrichment test with flow cytometry, the enrichment multiple of nucleated cells and target cells was 6.4±0.9 and 4.2±0.6 respectively, and BMSCs grew well in vitro. The operation time was 35-55 mins. 7 cases in the suture group were transferred to the discectomy group and 10 cases in the BMSCs+suture group were transferred to BMSCs group due to unsuccessful suture. There were no significant differences in VAS, ODI, Pfirrmann grade of disc degeneration, disc height and degree of herniation among the groups. There was no significant difference in intraoperative bleeding, postoperative drainage and length of hospital stay. The incision was healed without redness and swelling. 18 patients were followed up for 6 months, and 91 cases were followed up for 1-3 years (25.0±5.6 months). There was no interbody fusion, heterotopic ossification or infection during follow-up. VAS and ODI decreased significantly after operation in all patients. At final follow-up, the VAS improvement rate of BMSCs+suture group (81.7%±7.9%) was higher than discectomy group (73.0%±8.9%), suture group (74.0%±6.9%) and BMSCs group (75.3%±8.4%); the ODI improvement rate of BMSCs+suture group (91.9%±8.8%) was higher than discectomy group (86.2%±8.1%) and suture group (86.4%±5.5%). According to MRI, the Pfirrmann grade of disc increased 0.7 in discectomy group, 0.6 in suture group, while it did not increased significantly in BMSCs+suture group and BMSCs group, and the progress of Pfirrmann grade in BMSCs+suture group and BMSCs group were lighter than discectomy group and suture group.The disc height decreased in each group, the loss rate of disc height in BMSCs+suture group (17.2%±4.3%) was less than discectomy group (29.3%± 6.3%) and suture group (20.6%±5.7%); and suture group was less than discectomy group. The degree of herniation was reduced by more than 50% in all groups, while 1 case in discectomy group had herniation without clinical symptoms.Conclusion:Autologous BMSCs and annulus suture are safe and effective in repairing the defect after lumbar discectomy, which may help to slow down the degeneration of intervertebral disc.
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Objective:To evaluate the value and efficacy of microscope-assisted minimally invasive anterior lumbar discectomy and zero-profile fusion (ALDF) for lumbar degenerative diseases.Methods:Anterior lumbar distractors were designed to maintain the distraction of intervertebral space and expose the posterior edge of the intervertebral space. From June 2018 to December 2020, 41 cases of lumbar degenerative diseases were treated with this operation, including 19 men and 22 women, aged 29-71 years old (average 42.1 years old). All patients had intractable low back pain. Imaging examination showed lumbar disc degeneration with narrow intervertebral space, including disc herniation with Modic changes in 7 cases, spinal stenosis with instability in 16 cases and spondylolisthesis in 18 cases. The involved levels included L 2,3 in 1 case, L 3,4 in 3 cases, L 2-L 4 in 1 case, L 4,5 in 17 cases and L 5S 1 in 19 cases. An incision was taken that was pararectus for L 2-L 4 and transverse for L 4-S 1, with the intervertebral disc exposed via extraperitoneal approach. The intervertebral space was released and distracted after discectomy in intervertebral space, and self-made distractors were used to maintain the space. Under microscope, the herniation, posterior annulus and osteophyte were removed for sufficient decompression, with a suitable self-anchoring cage implanted into the intervertebral space. The visual analogue score (VAS), Oswestry dysfunction index (ODI), intervertebral space height, lordosis angle and spondylolisthesis rate were evaluated. Results:Operations were performed successfully in all the patients. The operation time was 70-120 min with an average of 90 min, and the intraoperative blood loss was 15-70 ml with an average of 30 ml. No severe complication such as nerve or blood vessel injury occurred. The patients were followed up for 12 to 36 months, with an average of 18 months. At the last follow-up, VAS decreased from 6.4±2.3 to 1.1±0.9, and ODI decreased from 44.9%±16.9% to 5.8%±4.7%. Intervertebral space height recovered from 7.2±2.8 mm to 12.1±2.1 mm and lordosis angle recovered from 6.9°±4.8° to 10.1°±4.6°. X-ray showed significant recovery of intervertebral space height, lordosis angle and spondylolisthesis rate, with obvious interbody fusion and no displacement of cage. For 18 patients of spondylolisthesis, the slippage recovered from 16.6%±9.3% to 7.6%±5.3%, with an average improvement of 54.2%.Conclusion:Microscope-assisted minimally invasive ALDF can provide sufficient decompression and zero-profile fusion for lumbar degenerative diseases with satisfactory results during short-term follow-up.
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Objective:To explore the ideal method of minimally invasive anterior lumbar extraperitoneal approach.Methods:Twenty-one adult embalmed cadavers underwent longitudinal incision near the left rectus abdominis, the extraperitoneal space and peritoneal characteristics were observed; the L 2-S 1 disc was exposed through extraperitoneal approach, and the relationship between the anterior large vessels and the disc was observed. One hundred adult abdominal CT were collected to measure the distance between the extraperitoneal fat of anterior abdominal wall and the rectus abdominis and the anterior midline at L 2-S 1 segment. One hundred and fifty adult lumbar MRI were collected to measure the distance between the anterior great vessels and the anterior midline of the intervertebral disc. Fifty-six cases of lumbar fusion were performed by minimally invasive anterior lumbar extraperitoneal approach, including 25 males and 31 females, aged 29-71 years. L 2-L 4 in 8 cases was performed by left rectus abdominis oblique incision, and L 4-S 1 in 48 cases was performed by median left transverse incision, with a length of about 8 cm, the complications related to the surgical approach were evaluated. Results:L 2-L 4 was proximal to the arcuate line, the posterior sheath of rectus abdominis adhered to the peritoneum, which was easy to rupture when separated; the peritoneum gradually thickened from the outer edge of the sheath of rectus abdominis and extraperitoneal fat appears. L 4-S 1 could be exposed distal to the arcuate line, the posterior side of rectus abdominis was extraperitoneal fat, the extension of arcuate line to the lateral abdominal wall would be slightly separated proximally, and there were multiple iliopsoas veins in the medial side of psoas major muscle. L 5S 1 was between the right common iliac artery and the left common iliac vein far, the median sacral vessel was small or absent, and the sympathetic nerve was to the left. Extraperitoneal fat appeared 36.2±9.9 mm, 35.2±11.6 mm and 27.6±11.2 mm away from the outer edge of rectus abdominis at L 2, 3, L 3, 4 and L 4, 5 segments respectively, and covered the posterior side of rectus abdominis and reached the midline at L 5S 1 segment. The left edge of abdominal aorta was 14.9±5.1 mm, 13.9±4.6 mm and 19.7±5.9 mm away from the midline at L 2, 3, L 3, 4 and L 4, 5 level respectively; the inferior vena cava was located on the right side of the midline at L 2, 3 and L 3, 4 level, crossed the midline 4.6±8.7 mm at L 4, 5 level. At L 5S 1 level, the left common iliac vein and the right common iliac artery were 14.6±6.8 mm and 17.6±5.3 mm away from the midline respectively. Seventy-six patients were successfully and fully exposed by small incision through extraperitoneal approach. 1 case of L 4, 5 had iliac lumbar vein tear and hemostasis with bipolar electrocoagulation. The operation time was 70-120 min, with an average of 90 min; Intraoperative bleeding was 15-70 ml, with an average of 30 ml. No severe complication such as nerve and great vessel injury occurred. Conclusion:Minimally invasive lumbar anterior retroperitoneal approach has small trauma and sufficient exposure with good feasibility. L 2-L 4 can be exposed with supine position and oblique incision next to the left rectus abdominis muscle, and L 4~S 1 with French position and median left transverse incision.
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Objective:To compare the clinical effects of percutaneous curved vertebroplasty (PCVP) and unilateral percutaneous kyphoplasty (PKP) in the treatment of osteoporotic vertebral compression fracture (OVCF).Methods:A retrospective cohort study was used to analyze the clinical data of 104 patients with single vertebral OVCF treated in Tianjin Hospital from September 2019 to September 2020, including 21 males and 83 females; aged 50-91 years [(70.3±7.7)years]. AO classification of the fracture was type A1 in 65 patients and type A2 in 39. The patients received PCVP (PCVP group, n=51) or unilateral PKP surgery (unilateral PKP group, n=53). The operation time, bone cement injection volume, intraoperative fluoroscopy frequency, effective dispersion times of bone cement and excellent rate of bone cement distribution were compared between the two groups. In evaluation of the therapeutic effects of the two groups, visual analogue scale (VAS) and Oswestry dysfunction index (ODI) were measured preoperatively and at postoperative 24 hours, 3 months and 6 months; Beck index was measured preoperatively and at postoperative 24 hours and 3 months. The rate of bone cement leakage and rate of refracture of adjacent vertebral bodies were compared between the two groups. Results:All patients were followed up for 6-8 months [(6.4±0.7)months]. The operation time, bone cement injection volume and intraoperative fluoroscopy frequency in PCVP group was (12.15±1.63)minutes, (2.13±0.28)ml and (24.74±1.71)times, shorter or less than (22.09±1.62)minutes, (5.30±0.52)ml and (30.09±1.86)times in unilateral PKP group (all P<0.01). The effective dispersion times of bone cement in PCVP group was (1.42±0.04)times, higher than (1.18±0.02)times in unilateral PKP group ( P<0.01). The excellent rate of bone cement distribution in PCVP group was 94%, higher than 70% in unilateral PKP group ( P<0.01). There were no significant differences in VAS, ODI and Beck index between the two groups before operation and at 24 hours and 3 months after operation (all P>0.05). VAS and ODI in PCVP group were (1.20±0.49)points and 16.52±5.22 at 6 months after operation, lower than (1.49±0.58)points and 20.16±5.16 in unilateral PKP group (all P<0.01). VAS and ODI in the two groups were significantly improved at 24 hours, 3 months and 6 months after operation when compared with those before operation (all P<0.05). Beck index in the two groups detected at 24 hours and 3 months after operation was improved from that before operation (all P<0.05). Unilateral PKP group showed Beck index was 0.75±0.07 at 3 months after operation, significantly lower than 0.79±0.07 at 24 hours after operation ( P<0.05), but there was no significant change in PCVP group ( P>0.05). The leakage rate of bone cement in PCVP group was 16% (8/51), lower than 47% (25/53) in unilateral PKP group ( P<0.01). There was no significant difference in the incidence of refracture of adjacent vertebral bodies between the two groups during follow-up ( P>0.05). Conclusion:For OVCF, PCVP is superior to unilateral PKP in terms of operation time, amount of bone cement injection, intraoperative fluoroscopy frequency, dispersion effect of bone cement in vertebral body, pain, function improvement, maintenance of injured vertebral height and incidence of bone cement leakage.
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Objective:To investigate the feasibility and clinical effects of thoracic endoscopic-assisted anterior-lateral decompression and fusion for thoracolumbar or upper lumbar disc herniation (LDH) associated with vertebral osteochondrosis (VO).Methods:From December 2017 to December 2019, 10 patients of thoracolumbar or upper LDH associated with VO were treated with thoracic endoscopic-assisted anterior-lateral decompression and fusion, including 6 men and 4 women, with an average 49.2 years old (range, 37 to 65 years old). The involved levels included T 12L 1 in 5 cases, L 1, 2 in 2 cases and L 2, 3 in 3 cases. There were 4 cases of simple thoracolumbar or upper LDH associated with VO and 6 cases of thoracolumbar or upper LDH associated with VO combined with ligamentum flavum hyperplasia and ossification or kyphosis (combined with posterior decompression and internal fixation or posterior correction surgery). The visual analogue scale (VAS), Oswestry disability index (ODI) and anterior and posterior height of intervertebral space were evaluated at follow-up. The clinical effects were evaluated according to the modified MacNab criteria. Results:The operation was performed successfully in all the patients. During the operation, the herniated disc and ossification were clearly exposed and completely removed, with the sufficient decompression of spinal cord, nerve root and dural sac. The operation duration was 115.4±23.8 minutes (range, 70 to 180 mins). Intraoperative bleed loss was 122.6±21.3 ml (range, 40 to 310 ml). The patients were followed up for averagely 21.6 months (range, 12 to 36 months). At the final follow-up, VAS score decreased from preoperative 7.2±1.9 to 1.8±1.1, and ODI decreased from preoperative 64.3%±13.9% to 16.3%±5.1% ( P<0.05). The anterior height of intervertebral space recovered from preoperative 7.8±1.5 mm to 11.9±2.3 mm, and the posterior height of intervertebral space recovered from preoperative 4.5±1.1 mm to 7.4±1.6 mm ( P<0.05). According to modified MacNab criteria, the results were excellent in 9 cases and good in 1 case. Conclusion:For thoracolumbar or upper LDH associated with VO, thoracic endoscopic-assisted anterior-lateral decompression and fusion provided clear vision of the surgical field, fully exposed and completely removed the herniated disc and ossification, which achieved satisfactory short-term results.
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Objective:To evaluate the value and efficacy of self-anchored anterior lumbar discectomy and fusion (SA-ALDF) for L 5 isthmic spondylolisthesis. Methods:From June 2018 to December 2019, a total of 11 cases of L 5 isthmic spondylolisthesis were treated with SA-ALDF, including 4 men and 7 women, aged 43.2±12.6 (range 29-63) years. All patients had intractable low back pain aggravating during standing activities and alleviating during rest, without lower extremity radicular symptoms. Imaging examination showed bilateral isthmus cleft of L 5 with spondylolisthesis of 1 degree in 10 cases and 2 degree in 1 case according to Meyerding grading system. Under general anesthesia and supine French position, transverse 6 cm incision was made. Then, the L 5S 1 intervertebral disc was exposed via extraperitoneal approach between the bifurcation of abdominal aorta and vena cava. The intervertebral disc was sufficiently removed. The intervertebral space was released and distracted followed by canal ventral decompression and sequential mold testing. Suitable self-anchoring cage filled with auto iliac cancellous bone was implanted to restore intervertebral height and lordosis as well as reduction of spondylolisthesis. Under fluoroscopic guidance, the distal anchoring plate was knocked into the sacrum followed by direct reduction and proximal anchoring plate locking in the L 5 vertebral body. The patients were followed up for 12.1±4.7 (range 6-18) months. The visual analogue score (VAS) and Oswestry dysfunction index (ODI) were evaluated. The reduction and fusion were evaluated on the X-ray films. Furthermore, the rate of spondylolisthesis, the height and the lordosis of intervertebral space were measured. Results:The operation was performed successfully in all the patients with operation duration 90±18 (range 70-120) min, intraoperative blood loss 30±16 (range 10-60) ml. No severe complication such as nerve and blood vessel injury occurred. All patients experienced alleviation of symptom during follow-up. X-rays confirmed that the spondylolisthesis and alignment were recovered obviously without obvious cage displacement. However, the loss of reduction was 63.2% for the grade 2 spondylolisthesis. At the final follow-up, VAS decreased from 6.1±2.1 to 0.9±0.5, ODI decreased from 43.6%±14.2% to 6.0%±3.4%. The spondylolisthesis recovered from 17.7%±10.3% to 8.0%±7.2% with reduction rate of 54.8%±21.6%. The interverbral height recovered from 6.4±2.1 mm to 9.8±3.9 mm and intervertebral lordosis recovered from 4.8°±2.9° to 9.6°±4.7°.Conclusion:SA-ALDF can provide satisfactory outcomes for selected L 5 isthmic spondylolisthesis of degree 1 without neurological compromise. However, its mechanical stability may be insufficient for isthmic spondylolisthesis of degree 2.
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Objective:To evaluate the efficacy of self-anchored lateral lumbar interbody fusion (SA-LLIF) for lumbar degenerative diseases.Methods:During January to December in 2019, a total of 41 patients with lumbar degenerative disease were treated with SA-LLIF, included 18 males and 23 females, aged 59.6±11.3 (range 49-77) years. There were lumbar stenosis and instability in 17 cases, disc degenerative disease in 8 cases, degenerative spondylolisthesis in 8 cases, degenerative scoliosis in 5 cases, postoperative revision in 3 cases. And osteoporosis was diagnosed in 5 of them. The index level included L 2, 3 in 2 cases, L 3, 4 in 11 cases, L 4, 5 in 20 cases, L 2-L 4 in 3 cases and L 3-L 5 in 5 cases. After general anesthesia, the patient was placed in decubitus position. The anterior edge of psoas major muscle was exposed through 6 cm incision and extraperitoneal approach. Further, the psoas major muscle was properly retracted to expose the disc. After discectomy, the intervertebral space was prepared and moderately distracted. A suitable fusion cage filled with auto iliac graft was implanted. Two anchoring plates were inserted into the cage. Then, the caudal and cephalic vertebral body and the fusion cage were locked. Results:The operation was performed successfully in all the patients. The operation duration was 79.0±19.5 (range 60-100) min. Intraoperative bleed loss was 38.0±28.2 (range 15-70) ml. The patients were followed up for averagely 10.6±4.6 (range 4-15) months. The visual analogue scale decreased from preoperative 6.2±2.1 to 1.6±1.1 and Oswestry disability index decreased from 47.8%±15.1% to 11.0%±7.3%. X-ray showed that the spine alignment recovered satisfactorily. No cage displacement was found. Sinking (2-3 mm) of cage was found in 7 patients without obvious symptom despite transient lumbar pain in an obesity woman. The lumbar lordosis recovered from 36.4°±10.2° to 48.0°±10.7°, and intervertebral height recovered from 8.3±2.5 mm to 11.3±3.3 mm. The rate of spondylolisthesis recovered from 19.7%±4.4% to 9.3%±5.3%.Conclusion:SA-LLIF can provide immediate stability and good results for lumbar degenerative diseases with stand-alone anchoring cage without posterior internal fixation.
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Objective To evaluate the factors related to contralateral hip fracture in the elderly patients with hip fracture by meta analysis.Methods Pubmed,Cochrane,CBMdisc,CNKI Chinese Journal Full Text Database and Wan Fang Database were searched for publications at home and abroad from January 2005 to April 2018 on factors related to contralateral hip fracture after hip fractures in the elderly.The publication quality was strictly evaluated before the data were extracted concerning gender and age(＞ 65years) of the patients,concomitant osteoporosis (Singh sign ≥ 4),primary fracture type,concomitant Parkinson disease,concomitant stroke,concomitant senile dementia,concomitant cataract,concomitant rheumatoid arthritis,concomitant diabetes,type of internal fixation for primary fracture and therapeutic compliance.Revman5.0 was used to perform the statistical analysis and the OR value and 95％ CI were calculated fore each index.Results A total of 17 studies were included involving 1,504 patients with contralateral hip fracture among 13,717 elderly patients with hip fracture.The factors related to the refracture of the contralateral hip were the age of the patients (OR ＝-3.55,95％ CI:-5.60 ～-1.50,P ＜ 0.001),osteoporosis (OR=2.38,95％CI:1.36～4.17,P=0.002),Parkinson disease (OR=4.54,95％CI:2.74～7.53,P ＜0.001),stroke (OR=0.33,95％ C I:0.18～0.59,P ＜ 0.001),senile dementia (OR=0.43,95％CI:0.29～0.62,P ＜0.001),cataract (OR=0.37,95％CI:0.22～0.63,P ＜0.001),rheumatoid arthritis (OR =0.32,95％ CI:0.21 ～ 0.50,P ＜ 0.001),diabetes (OR =0.65,95％ CI:0.47～0.91,P=0.01),type of internal fixation for primary fracture (OR=0.51,95％ CI:0.30 ～ 0.85,P =0.01),and therapeutic compliance (OR =0.36,95％ CI:0.21 ～ 0.64,P ＜ 0.001).However,the refracture of the contralateral hip was not related to gender (OR =1.07,95％ CI:0.45 ～2.56,P=0.88),smoking (OR=0.86,95％CI:0.40～1.86,P=0.70),fracture type (OR=0.97,95％ CI:0.60～1.57,P=0.90),or hypertension (OR=0.70,95％ C I:0.41～1.21,P=0.20).Conclusions In elderly patients with hip fracture,the risks for contralateral hip fracture may be advanced age,concomitant osteoporosis,Parkinson disease,stroke,senile dementia,cataract,rheumatoid arthritis and diabetes,type of internal fixation for primary fracture,and poor therapeutic compliance.However,no sufficient evidence has suggested that gender,smoking,type of hip fracture or concomitant hypertension might be associated with the contralateral hip fracture.
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Objective@#To investigate the clinical effect of combined anterior and posterior approach revision on complex acetabular fractures.@*Methods@#A retrospective case series study was performed on the clinical data of 21 patients with complex acetabular fractures who underwent failed surgery through single approach from June 2012 to June 2017. There were 16 males and five females, averagely aged 34.6 years (range, 24-45 years). According to Letournel-Judet classification, there were seven patients with transverse+ posterior wall fracture, five patients with anterior column+ posterior semi-transverse fracture, four patients with double column fracture and five patients with "T" fracture. The first operation was performed by ilioinguinal approach in nine patients and by Kocher-Langebeck (K-L) approach in 12 patients. Revision surgery was performed using a combined anterior and posterior approach. The operation time and intraoperative blood loss were recorded, and the fracture healing was observed. The quality of fracture reduction was assessed according to Matta reduction criteria, and hip function by the modified D Aubigne and Postel score. The complications during and after operation were recorded. Heterotopic ossification was evaluated according to Brooker's criteria.@*Results@#The patients were followed up for 12 to 36 months, with an average of 27 months. The operation time ranged from 180 to 360 minutes, with an average of 270 minutes. Intraoperative bleeding was 1 000-3 800 ml, with an average of 2 000 ml. Fractures were healed, with the healing time ranging from 3.5 to 7 months, with an average of 5 months. According to Matta reduction criteria, there were eight patients with anatomical reduction, 12 with satisfactory reduction and one with unsatisfactory reduction. The improved D Aubigne and Postal score was (11.1±1.9)points preoperatively and (15.6±1.7)points six months after operation (P<0.05), the outcome of hip function was excellent in three patients, good in 14, fair in three, and poor in one, with the excellent and good rate of 81%. There were three patients with transient injury of sciatic nerve, one patient with traumatic arthritis and one with heterotopic ossification of Brooker II. No femoral head necrosis or deep venous thrombosis in the lower extremities was found.@*Conclusion@#For complex acetabular fractures, combined anterior and posterior approach revision can promote fracture reduction, fracture healing, and functional recovery, with low incidence of complications.
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Objective To investigate the clinical effect of combined anterior and posterior approach revision on complex acetabular fractures. Methods A retrospective case series study was performed on the clinical data of 21 patients with complex acetabular fractures who underwent failed surgery through single approach from June 2012 to June 2017. There were 16 males and five females, averagely aged 34. 6 years (range, 24-45 years). According to Letournel-Judet classification, there were seven patients with transverse+posterior wall fracture, five patients with anterior column+posterior semi-transverse fracture, four patients with double column fracture and five patients with "T" fracture. The first operation was performed by ilioinguinal approach in nine patients and by Kocher-Langebeck ( K-L ) approach in 12 patients. Revision surgery was performed using a combined anterior and posterior approach. The operation time and intraoperative blood loss were recorded, and the fracture healing was observed. The quality of fracture reduction was assessed according to Matta reduction criteria, and hip function by the modified D Aubigne and Postel score. The complications during and after operation were recorded. Heterotopic ossification was evaluated according to Brooker 's criteria. Results The patients were followed up for 12 to 36 months, with an average of 27 months. The operation time ranged from 180 to 360 minutes, with an average of 270 minutes. Intraoperative bleeding was 1000-3800 ml, with an average of 2000 ml. Fractures were healed, with the healing time ranging from 3. 5 to 7 months, with an average of 5 months. According to Matta reduction criteria, there were eight patients with anatomical reduction, 12 with satisfactory reduction and one with unsatisfactory reduction. The improved D Aubigne and Postal score was ( 11. 1 ± 1. 9 ) points preoperatively and ( 15. 6 ± 1. 7 ) points six months after operation (P<0. 05), the outcome of hip function was excellent in three patients, good in 14, fair in three, and poor in one, with the excellent and good rate of 81％. There were three patients with transient injury of sciatic nerve, one patient with traumatic arthritis and one with heterotopic ossification of Brooker II. No femoral head necrosis or deep venous thrombosis in the lower extremities was found. Conclusion For complex acetabular fractures, combined anterior and posterior approach revision can promote fracture reduction, fracture healing, and functional recovery, with low incidence of complications.
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Objective Retrospective study and report on cases of "symptomatic facet of residual bone mass" caused by percutaneous transforaminal endoscopic discectomy (PTED),to analysis of its causes and revision strategies.Methods Seven cases of "symptomatic facet of residual bone mass" after PTED were found in six medical centers from July 2015 to November 2017.Weintroduced the course of diagnosis and treatment,to analysis of the causes,clinical features and revision strategies of the rare complication.Results Seven patients came from different medical centers (2 cases in Ningbo No.6 Hospital and 1 case in each of the other medical centers).The average age of the subject is 67.29±9.64 years (range from 57-83 years).Among them there were 1 male and 6 female.PTED was performed for all cases with lumbar disc herniation or stenosis.The operative segments were 1 of L2,3,2 of L3,4,3 of L4,5,1 of L5S1.Symptoms occurred immediately after surgery in all cases except one after a week of operation and another one month later.Two cases were appeared symptom of contralateral irritation,and the rest were aggravated by the original symptoms.Two cerebrospinal fluid leakage caused by bone mass piercing the dural sac.The bone mass compressed the nerve root and caused 1 case of lower limb muscle weakness.Foraminoplasty was performed during PTED in all patients.After CT scan,5 cases of bone mass were found on the same side of operation,and 2 cases were in the contralateral side.The shortest time for revision was 2 days and the longest 3 months.After conservative treatment,the symptoms were relieved in only one case.Revision surgeries were performed for all the other 6 cases,2 with microendoscopic discectomy (MED),1 mobile microendoscopic discectomy (MMED),1 small incision operation,1 PTED and 1 with minimal invasive surgery of transforaminal lumbar intervertebral fusion (MIS-TLIF).The VAS scores of low back pain and leg pain was significantly relieved from 8.67±0.52 to 1.50±0.55.Conclusion FTED may lead to residual bone mass in lumbar foraminoplasty.The penetration of the bone mass block into the spinal canal can cause the compression symptoms of the corresponding segment.The patients showed the corresponding spinal canal stenosis and nerve root irritation symptoms.A revision operation is required to remove the oppressed bone mass to relieve the symptoms as soon as possible if the conservative treatment not effective.
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Objective To evaluate the strategy and clinical effects of percutaneous endoscopic surgery for cervical disc herniation.Methods Fifty-one patients with cervical disc herniation were treated with percutaneous endoscopic surgery from June 2015 to March 2017,including 32 men and 19 women,with an average age of 52.2 years (range,28-66 years).Radicular symptoms were present in all patients,while 23 patients had mild myelopathy (Nurick Grade:0-3) and 3 patients of multilevel stenosis had severe myelopathy (Nurick Grade:4-5).According to axial image of preoperative magnetic resonance imaging (MRI),31 patients had lateral herniation that was located lateral to the edge of spinal cord,20 patients had central herniation that was located within the lateral edge of spinal cord.Among them,48 patients had soft herniation and 3 patients had ossified lateral herniation combined with foraminal stenosis.All surgery was carried out under general anesthesia,while posterior and anterior percutaneous endoscopic surgeries were performed for lateral herniation and central herniation respectively.Posterior endoscopic surgery was performed with "keyhole" fenestration at "V" point (the junction of lateral edge of lamina space and inner edge of facet).Lateral edge of thecal sac and nerve root were exposed and decompressed,soft herniation was explored and removed.Anterior endoscopic surgery was performed through puncture and 4mm tube between the visceral sheath and vascular sheath.The tube was inserted through disc to the base of herniation under fluoroscopy.The herniation was removed until the dura sac was exposed and relaxed.One stage open-door laminoplasty was performed for 3 patients with severe multiple segmental stenosis and huge central herniation.The operative time and blood loss were recorded,and patients were followed-up (range,6-18 months,average 12.1 months) to evaluate the clinical efficacy.Results The mean operative time of posterior endoscopic surgery was 90 min (range,45-150 min).The nerve root was not well exposed,and the fenestration was too lateral in 1 patient,with partial relieve of symptoms;and simple nerve root decompression was performed for 3 patients of ossified herniation combined with foraminal stenosis.Herniated or sequestered nucleus pulposus was removed for 27 patients,one of them had transient paralysis ipsilateral limb and 2 of them had linkage of cerebrospinal fluid.The Visual Analogue Score (VAS) score improved form preoperative 8.9±1.6 to 0.5±0.4,and the Oswestry Disability Index (ODI) score improved form 32.8±4.2 to 2.3± 1.9 at final follow-up.For anterior percutaneous endoscopic surgery,the mean operative time was 80 min (range,45-120 min).Herniated or free nucleus was successfully removed for all patients.The thecal sac was lacerated due to unclear exposure in 1 case.The VAS score improved form preoperative 6.9±2.3 to 0.9±0.8,and the ODI score improved form 40.1±8.6 to 5.6±3.0 at final follow-up,with improvement of myelopathy at least one Nurick Grade.During follow-up,the alignment of cervical spine was well preserved without kyphosis for two groups,while the height of intervertebral space decreased with 0.4±0.3 mm and 0.9±0.6 mm in posterior and anterior surgery respectively.Conclusion Percutaneous endoscopic surgery provides minimally invasive alternatives for some cervical disc herniation with predominant radicular pain.Posterior endoscopic surgery is suitable for lateral herniation,and anterior endoscopic discectomy is suitable for some central soft herniation without obvious collapse and instability.However,the long-term results of disc space collapsed after anterior approach remains unclear.
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Objective To explore the feasibility of anterior cervical decompression assisted with the microscope and mobile microendoscopic discectomy (MMED),and to compare their clinical efficacy.Methods From May 2015 to February 2017,thirty patients with cervical spondylotic myelopathy (CSM) underwent anterior cervical decompression assisted with microscope or MMED.Among them,conventional transverse anterior cervical incisions were used,and intervertebral distractors were placed in order to complete the decompression,then the fusion and fixation procedure were conducted under direct vision,and the operative time and intraoperative blood loss were recorded.Of 30 cases,15 cases were in microscope cohort (anterior cervical discectomy and fusion,ACDF 12 cases;anterior cervical corpectomy and fusion,ACCF 3 cases),including 4 males and 11 females with a mean age of 54.00±11.10 years (range,32-71 years).Another 15 cases were in MMED cohort (ACDF 13 cases,ACCF 2 cases),including 9 males and 6 females with a mean age of 59.60± 11.10 years (range,39-73 years).Neurological and cervical function were evaluated before surgery and at the follow-up according to the Japanese Orthopaedic Association (JOA) and the neck disability index (NDI) scores,and the neurologic improvement grade (NIG) was used to evaluate the neurological function.Results Both the microscope and MMED cohort underwent decompression successfully,and the visual field was clear.No neurological symptoms became worse.For the microscope,its lens and the instrument had to be adjusted separately,whereas MMED lens could move synchronously with the instrument.It was easier for MMED to reveal the posterior edge of the vertebral body and the left and right side of the spinal canal.The operation time of the microscope cohort was 90-180 min,with an average of 124.67±36.42 min;the M MED cohort was operated for 80-130 min with an average of 110.00± 15.12 min,and there was no significant difference between the two cohorts (t=1.440,P=0.161).The intraoperative blood loss for microscope cohort was 20-200 ml,with an average of 66.00±49.11 ml;MMED cohort was 30-150 ml with an average of 60.00±35.25 ml;there was no significant difference between the two cohorts (t=0.384,P=0.704).The JOA score of the microsurgery cohort improved from 8.67±3.20 preoperatively to 15.93± 1.53 at the latest follow-up,and its difference was significant (t=8.687,P=0.000).According to NIG,neurological improvement was excellent in 12 cases and good in 3 cases,giving an excellent to good rate of 100％.NDI was reduced from 18.00％±9.75％ preoperatively to 5.93％±2.58％ at the latest follow-up,with significant difference (t=5.137,P=0.000).The JOA score in MMED cohort improved from 8.87±3.11 preoperatively to 15.53±1.69 at the latest follow-up,and its difference was significant (t=9.413,P=0.000).and Among these 15 patients,11 were excellent and 4 were good,giving an excellent-good rate 100％.NDI decreased from 17.13％± 8.00％ preoperatively to 5.80％±2.43％ at the latest follow-up,and its difference was significant (t=5.592,P=0.000).There was no significant difference in JOA (t=0.680,P=0.502),NIG (P=1.000) and NDI (t=0.146,P=0.885) between the two cohorts at the latest follow-up.Conclusion Both microscope and MMED could provide a clear and magnified field of view,which was beneficial for adequate decompression during the anterior cervical surgery to ensure better clinical results.Compare to the microscope,MMED has relatively narrow indications and steep learning curve,so the surgeon should select cases strictly.
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Objective To analyze the causes of revision surgery after percutaneous transforaminal endoscopic discectomy (PTED) for lumbar spinal stenosis,and to provide references for indications and operative methods.Methods From January 2015 to October 2017,206,491 and 60 patients of lumbar spinal stenosis were treated with PTED in Tianjin Hospital,Shanxi People's Hospital,Ningbo Sixth Hospital,respectively;among them,4,10 and 4 cases received revision surgery.Another 13 patients of lumbar spinal stenosis were treated with revision surgery due to poor results after PTED in other hospitals.Among 31 cases of reoperation,there were 16 males and 15 females,aged 27-82 years (average,66.2±12.7 years).The lesion segments included 1 case of L3,4,23 cases of L4,5,5 cases of L5S1,1 cases of L3-L5,and 1 cases of L4-S1.Patients were followed up after reoperation from 3 to 24 months (average,12.1 months).The causes of poor result and revision surgery were analyzed according to preoperative,intraoperative and postoperative data.Results All of 757 cases of lumbar spinal stenosis were treated with PTED in three hospitals,of which 18 cases (2.4％) were re-operated.The causes of reoperation included:bone slice displacement in 1 case;nerve injury in 4 cases;lumbar instability in 4 cases;disc protrusion in 10 cases (residual or recurrence);insufficient decompression in 21 cases;planed staging operation in 4 cases with bilateral or two-level stenosis.32 revision surgeries were performed for 31 patients,including PTED in 15 cases,microendoscopic discectomy (MED) in 1 case,mobile MED (MMED) in 5 cases,MMED assisted fusion in 2 cases,transforaminal lumbar interbody fusion (TLIF) in 4 cases,Minimally invasive TLIF (Mis-TLIF) in 2 cases,and open decompression and fusion in 3 cases.All patients experienced relieve of symptoms after revision surgery.At final follow-up,VAS leg pain deceased form 7.1±3.9 before revision surgeries to 1.9±1.2,VAS low back pain decreased form 6.3±3.2 to 1.8±1.3,ODI score decreased from 35％± 14％ to 7.6％±5％.According to the MacNab score,the result was excellent in 11 cases,good in 16 cases,and fair in 4 cases.Conclusion The treatment of lumbar stenosis with PTED has high technical requirements,the indications of PTED for lumbar stenosis should be strictly controlled according to technical conditions,and appropriate operative methods should be chosen according to the specific conditions of the lesions.Insufficient decompression,disc protrusion,lumbar instability and nerve injury are the common causes of reoperation.Suitable indications and proper operation should be selected.