[Long-term clinical outcomes of selective segmental transforaminal lumbar interbody fusion and posterior spinal fusion for degenerative lumbar scoliosis].

OBJECTIVE: To explore the surgical techniques and long-term clinical outcomes of degenerative scoliosis (DS) with selective segmental transforaminal lumbar interbody fusion (TLIF) and posterior spinal fusion. METHODS: Ninety-five patients with adult degenerative lumbar scoliosis undergoing posterior long fusion at our department from January 1999 to December 2007 were analyzed retrospectively. The average follow-up period was 7.8 (5-13) years. The clinical outcomes of Oswestry disability index (ODI), visual analog scale (VAS), patient satisfaction and such radiographic parameters as Cobb angle, apical vertebra translation (AVT), Nash-Moe grade, lumbar lordosis (LL) and thoracolumbar kyphosis (TLK) were evaluated. RESULTS: The clinical outcomes of ODI score and VAS significantly improved at the last visit (P < 0.05). The ODI score was 32.2 ± 8.6 before surgery and 11.1 ± 6.8 at the last visit. The VAS was 8.9 ± 2.0 before surgery and 2.0 ± 1.2 at the last visit. Patient satisfaction was 88.2% (84/95) at the last visit. At the final evaluation, Cobb's angle, apical vertebra translation and Nash-Moe grades decreased with a statistically significant difference (P < 0.001) compared with preoperative parameters.Lordotic angle had a significant increase than preoperative angle (P < 0.001). Thoracolumbar kyphosis showed no significant change (P > 0.05). Besides, a significant positive correlation existed between the decrease of ODI score and the increment of lumbar lordotic angle (r = 0.62, P = 0.01) .Long-term complications included broken rod (n = 2), coronal junctional scoliosis (n = 4), L5-S1 spondylolisthesis (n = 2), L5-S1 restenosis (n = 5). And 11 patients underwent reoperation. CONCLUSION: A combination of selective segmental TLIF and posterior spinal fusion is both safe and effective for degenerative scoliosis and excellent long-term clinical outcomes may be achieved. And selective segmental TLIF can facilitate solid fusion, improvement of lumbar lordosis, better correction of lateral spondylolisthesis and asymmetric disc space so as to yield better corrective effects and long-term clinical outcomes.

[Effects of intrathecal injection of methylprednisolone sodium succinate in acute spinal cord injury rabbits].

OBJECTIVE: To investigate the effects and apoptosis of intrathecal injection of Methylprednisolone Sodium Succinate (MPss) for acute spinal cord injury (SCI) in New Zealand rabbits. METHODS: Seventy-two healthy New Zealand rabbits were used for the procedure and were randomly divided into two groups: SCI group and SHAM group, which was both divided into 6 subgroups, such as the vehicle group, the MPss intrathecal injection groups (1.5 mg/kg, 3.0 mg/kg, 6.0 mg/kg group), the MPss intravenous injection group and the combined injection group. TARLOV score was tested daily to evaluate the motor function. The rabbits were sacrificed 7 days after the surgery and the thoracic spinal cord sections and the sacral sections where MPss was injected were harvested for HE and TUNEL staining. Two-Factors Repeated Measures analysis of variance for TARLOV scores tested at various times and One-Way ANOVA analysis of variance for data between groups were used. RESULT: Seven days after surgery in SCI group, there was no statistical difference between the TARLOV scores of intrathecal injection of MPss 3.0 mg/kg group, 6.0 mg/kg group and MPss intravenous injection group (P > 0.05), which were all better than the vehicle group (F = 4.762, P < 0.05). Referring to the lymphocyte infiltration at the injury site in SCI group, there was statistical difference between MPss intrathecal injection 6.0 mg/kg group (1.33 ± 0.21) and the vehicle group (2.67 ± 0.21) (F = 5.793, P < 0.05) and no statistical difference between intrathecal injection of MPss 6.0 mg/kg group and MPss intravenous injection group (P > 0.05). As for the lymphocyte infiltration at the intrathecal injection site in SHAM group, there was statistical difference between MPss intrathecal injection 6.0 mg/kg group (2.50 ± 0.55) and the vehicle group (0.50 ± 0.55) (F = 17.333, P < 0.05). TUNEL staining in SCI group showed statistical difference between MPss intrathecal injection 6.0 mg/kg group (6.3 ± 1.5) and the vehicle group (20.3 ± 2.2) (F = 71.279, P < 0.05). CONCLUSIONS: Intrathecal injection of MPss can improve the functional recovery of lower limb and decrease apoptosis of neuron cells,which can provide same effects as the traditional intravenous injection of MPss in New Zealand rabbits.

[The effect of Topping-off surgery on preventing adjacent segment degeneration, a retrospective study].

OBJECTIVE: To investigate the early-middle stage clinical results of Topping-off surgery in preventing adjacent segment degeneration when mild or moderate adjacent segment degeneration exists before surgery. METHODS: All the cases that received L(5)-S(1) posterior lumbar interbody fusion (PLIF)+L(4)-L(5) interspinous process (ISP) surgeries between April 2008 and March 2010 (Topping-off group) were analyzed retrospectively. The cases received L(5)-S(1) PLIF surgery and whose intervertebral disc degeneration using modified Pfirrmann's grading system were grade 4 - 6 were analyzed retrospectively at the same time (PLIF group). Both groups matched in gender, age, body mass index and Pfirrmann's grading of disc. All the patients were evaluated with visual analogue scale (VAS) and Japanese orthopaedic association (JOA) scores before the surgery and in the last follow-up. The X-ray films before and after surgery were measured. RESULTS: There were 25 patients in Topping-off group and 42 patients in PLIF group were included in the final analysis. The follow-up averaged 24.8 and 23.7 months. No symptomatic or radiological adjacent segment degeneration was observed. The average surgery time was (120 ± 24) min and (106 ± 21) min. There was no significant difference in the blood loss during surgery or post-operation drainage (P > 0.05). VAS and lumbar JOA score improved in both groups (P < 0.01). In the lateral view of lumbar spine, neither of anterior or posterior disk height was significantly changed (P > 0.05), segmental lordosis of L(4)-L(5), total lordosis were all increased (Topping-off group: t = -2.30 and -2.24, P < 0.05; PLIF group: t = -2.76 and -1.83, P < 0.05). In the hyperextension and hyperflexion view, Topping-off group's range of motion (ROM) and olisthesis in the L(4-5) segment did not significantly change in flexion (P > 0.05), but decreased in extension (t = 5.83 and 4.92, P < 0.01). In PLIF group, the ROM (t = -7.82 and -4.90, P < 0.01) and olisthesis (t = -15.67 and -18.58, P < 0.01) both significantly increased in extension and flection. CONCLUSIONS: Compared with single segmental PLIF surgery, Topping-off surgery can achieve similar symptomatic improvement in cases with pre-existing mild or moderate adjacent segment degeneration, restrict the adjacent segment's range of motion in extension and prevent excessive olisthesis of adjacent segment in both extension and flexion. Topping-off surgery has a potential effect of preventing adjacent segmental degeneration.

[Clinical outcomes of Hybrid-surgery to treat the two-level cervical disease].

OBJECTIVE: To evaluate the clinical and radiologic outcomes of the Hybrid surgery (cervical artificial disc replacement combined with anterior cervical discectomy and fusion (ACDF)) and the effective of the adjacent segment. METHODS: Between December 2007 to June 2010, 34 patients underwent 2-level cervical disc surgery. There were 17 patients underwent Hybrid surgery (Hybrid group), 17 patients underwent 2-level ACDF (ACDF group). Japanese orthopaedic association (JOA), neck disability index (NDI), and Odom's standards were evaluated. Dynamic flexion and extension lateral cervical radiographs were obtained in the standing position before surgery and at routine postoperative intervals of 1, 3, 6 months. RESULTS: Both of the two groups had significantly improvement than preoperative in JOA (t = -8.790 - -5.803, P < 0.05) and NDI scores (t = 10.717 - 13.514, P < 0.05), but no significantly difference between the two groups (P > 0.05). Both of the two groups had significantly decreased in the mean C(2-7) range of motion (ROM). The Hybrid group decreased from 46° ± 11° preoperative to 41° ± 8° at the 6 mouths after surgery (t = 3.170, P < 0.05). The ACDF group decreased from 45° ± 13° preoperative to 38° ± 15° at the 6 mouths after surgery (t = 6.709, P < 0.05). But there were no significantly difference between the two groups (P > 0.05). In the Hybrid group, both the superior adjacent segment ROM and the inferior adjacent segment ROM were decreased in the follow-up, there had significantly difference at the 1 and 3 months after surgery (superior adjacent segment: t = 5.622 and 4.032, P < 0.05; inferior adjacent segment: t = 2.879 and 2.207, P < 0.05), but no significantly difference after 6 months (P > 0.05). In the ACDF group, the ROM of the inferior adjacent segment was significantly increased at 3 and 6 months after surgery (t = -7.038 and -13.540, P < 0.05), the ROM of the superior adjacent segment was significantly increased at 6 months after surgery (t = -2.453, P < 0.05). CONCLUSIONS: Hybrid surgery has excellent clinical results and decreases the ROM of the adjacent segment in the following 6 months, meanwhile 2-level ACDF increases the ROM of the adjacent segment. The long-term clinical outcomes of the Hybrid surgery need more study.

[Pathogenesis analysis of proximal junctional lordosis after short-level posterior pedicle screw fixation in lumbar spine].

OBJECTIVE: To analyze the possible reasons for proximal junctional lordosis (PJL) after short-segment posterior pedicle screw fixation in lumbar spine and discuss its proper management. METHODS: From December 2001 to August 2005, 345 patients were treated by short-segment pedicle screw fixation and these patients were reviewed. Clinical outcome was evaluated according to Oswestry Disability Index (ODI). Proximal junctional lordosis was assessed evaluated on radiographs, by measuring lumbar lordosis angle, segmental angle at proximal level and lumbar-sacral angle. Risk factors of proximal junctional lordosis were analyzed. RESULTS: All patients were followed-up for 2 to 6 years (average 3.8 years). ODI after lumbar surgery was 9.7-46.2 ( average 19.6 +/- 10.7). PJL was noted in 78 patients (22.6%), 37 (10.7%) of whom were symptomatic and 21 (6.1%) received revision surgery. PJL was more commonly occurred in patients over 60 years old, with reduced lumbar lordosis or vertical sacrum. The number of fusion-segment was not correlated to the occurrence of PJL. CONCLUSIONS: Short-segment posterior pedicle screw fixation can not improve lumbar sagittal alignment. Age over of 60 years, reduced lumbar lordosis and vertical sacrum are possible risk factors of PJL sacrum.

[Long-term follow-up after posterior corrective operation for degenerative scoliosis].

OBJECTIVE: To evaluate the clinical outcome of posterior corrective operation for degenerative scoliosis and analyze the possible reasons for its late complications and their proper management. METHODS: Thirty-five patients with degenerative scoliosis, who were treated by posterior pedicle screw fixation and interbody fusion with cage implantation from September 1997 to September 2002, were reviewed. Their clinical outcomes were determined according to Oswestry Disability Index (ODI). The fusion area and its adjacent segments were evaluated through radiographic measurements of coronal Cobb angle, lumbar lordosis and coronal balance of the spine. The association of late complications, spinal alignment, and range of fusion was analyzed. RESULTS: At final follow-up, ODI was 17.8 - 62.2 (average 34.7). Late complications occurred in 13 patients, accounting for 37.1%. Among the 13 cases, 10 were symptomatic and 6 received revision surgery. The late complications were proximal junctional scoliosis in 4 patients, proximal junctional kyphosis in 4 patients, proximal compressed vertebral fracture in 1 patient, pseudarthrosis in 1 patient, pedicle screw loosening in 1 patient, and distal segment degeneration in 1 patient. Junctional kyphosis had no obvious relationship with abnormality of spinal alignment. Adjacent segment degeneration occurred more commonly in the cases with the proximal ultimate vertebra below L1 (9/ 18) than above T12 (4/17). CONCLUSIONS: The rate of late complications is relatively high after posterior corrective operation for degenerative scoliosis. Spinal alignment should be evaluated carefully in preoperative planning. The proximal ultimate vertebra should be extended to the level above T12 to avoid late complications.

[Treatment of cervical spondylotic myelopathy by decompression of spinal canal and internal fixation with the combination of anterior and posterior approaches].

OBJECTIVES: To evaluate the clinical results of treatment of cervical spondylotic myelopathy by decompression of spinal canal and internal fixation with the combination of anterior and posterior approaches, and to study the methodology to prevent operative complications. METHODS: 28 consecutive cases with cervical spondylotic myelopathy, aged 65.3 (49 ~ 73) were treated by decompression of spinal canal and internal fixation with the combination of anterior and posterior approaches from December 2001 to December 2005. The surgical methods included decompression of spinal canal, spinal fusion, and internal fixation with the combination of anterior and posterior approaches. The patients were followed up for 16 months (6 ~ 52 months). The clinical results and complications were analyzed retrospectively. The clinical effects were evaluated by the Japanese Orthopedic Association (JOA) scoring system and Odom's criteria. The outcome of cervical spinal fusion was evaluated by X-ray plate. RESULTS: There were no neural injury and wound healing problems in all patients. All postoperative patients ambulated three days after the operation. CSF leak occurring in 3 cases was cured by conservative treatment. The recovery rate by the JOA scoring system was 50% when the patients were discharged. According to the Odom scoring system, 83.3% of the patients had excellent and good effects. No evidence of implant failure was found according to the Brantigan's criteria. Interbody fusion was achieved in 3 approximately 6 months after operation in all followed-up patients. No additional operation was needed for the involved segments, the spinal cord function of the patients had been improved in a certain extent, and the surgical outcomes could be maintained. CONCLUSION: Decompression of spinal canal and internal fixation with the combination of anterior and posterior approaches is necessary and effective in the treatment of severe and multi-level cervical spondylotic myelopathy, but the operative trauma is relatively serious, surgeons must carefully design the operative plan and pay enough attention to the methods to prevent operative complications, especially for the elderly patients.

[Effects of lower extremity joints' disease on lumbar surgical outcomes].

OBJECTIVE: To study the effects of lumber operation on patients with pathologic changes of the lumbar vertebrae combined with degenerative diseases of lower extremity joints. METHODS: 237 patients with pathologic changes of the lumbar vertebrae combined with pain and/or limited activity of hip or knee joint, 153 (64.56%) with degenerative knee joints and 84 (35.44%) with degenerative hip joints received lumbar surgery. 160 patients with lower extremity joint pain and negative physical examination and imagology before the surgery were used as controls. The joint pain value was assessed on all patients with Visual Analog Scale before and after treatment and the joint pain relief rate was calculated. RESULTS: The average pain relief rate of the control group was 90.54%, significantly higher than those of the degenerative knee joint group (55.20%) and the degenerative hip joint group (46.88%, both P < 0.05). CONCLUSION: Diseases of lower extremity joints influence the lumbar surgical outcomes. It is very important to make a definite diagnosis of the lower extremity joint pain pre-operationally and take appropriate measures to treat the pain according to its pathogenesis.

[Experience in reoperation of lumbar spinal surgery using posterior lumbar interbody fusion cage].

OBJECTIVE: To investigate the indications and surgical techniques of reoperative lumbar spinal surgery using posterior lumbar interbody fusion cage. METHODS: Seventeen cases underwent reoperative lumbar spinal surgery using posterior lumbar interbody fusion cage. The surgical methods included decompression of lumbar canal, dural and radicular conglutination release, discectomy, posterior insertion of lumbar interbody fusion cage, pedicle screw instrumentation, posterolateral lumbar fusion. Periodical follow-up was conducted for 18 months (12 - 43 months). The clinical effect was evaluated by the Macnab's criterion, and the outcome of lumbar interbody fusion was evaluated according to the Brantigan's criterion. RESULTS: Twenty-seven cages were implanted into twenty-three disc spaces (cage at L(3 - 4) in 5 cases, cage at L(4 - 5) in 8 cases, and cage at L(5)-S(1) in 4 cases). All postoperative patients ambulated after two weeks. No wound healing problems and nerve injury were found. Dural rupture occurred in 5 cases, but without occurrence of cerebrospinal fluid leakage. According to the Macnab's criterion, the preoperative lower extremity radicular symptoms and neurogenic claudication were effectively relieved in 15 cases (88.2%), and the outcomes were good or excellent in 15 cases (88.2%). According to the Brantigan's criterion no evidence of implant failure was found, and interbody fusion could be achieved about 6 months in all patients. No additional operation was needed for involved segments, and the surgical outcomes could be maintained. CONCLUSION: A good and effective method, use of posterior lumbar interbody fusion cage in reoperative lumbar spinal surgery eliminates neural compression and the discogenic pain, restore the lumbar alignment, and accomplish the internal fixation and anterior column fusion of lumbar vertebrae simultaneously.

Comparison of Topping-off and posterior lumbar interbody fusion surgery in lumbar degenerative disease: a retrospective study.

BACKGROUND: Topping-off surgery is a newly-developed surgical technique which combines rigid fusion with an interspinous process device in the adjacent segment to prevent adjacent segment degeneration. There are few reports on Topping-off surgery and its rationality and indications remains highly controversial. Our study aims to investigate the short-term and mid-term clinical results of Topping-off surgery in preventing adjacent segment degeneration when mild or moderate adjacent segment degeneration existed before surgery. METHODS: The 25 cases that underwent L5-S1 posterior lumbar interbody fusion (PLIF) + L4-L5 interspinous process surgeries between April 2008 and March 2010 formed Topping-off group. The 42 cases undergoing L5-S1 PLIF surgery formed PLIF group. Both groups matched in gender, age, body mass index and Pfirrmann grading (4 to 6). The patients were evaluated with visual analogue scale (VAS) and Japanese orthopaedic association (JOA) scores before surgery and in the last follow-up. Modic changes of endplates were recorded. RESULTS: The follow-up averaged 24.8 and 23.7 months. No symptomatic or radiological adjacent segment degeneration was observed. There was no significant difference in intraoperative blood loss or postoperative drainage. VAS and lumbar JOA scores improved significantly in both groups (t = 12.1 and 13.5, P < 0.05). Neither anterior nor posterior disc height was significantly changed. Segmental lordosis of L4-L5 and total lordosis were all increased significantly (Topping-off group: t = -2.30 and -2.24,P < 0.05; PLIF group: t = -2.76 and -1.83, P < 0.01). In the hyperextension and hyperflexion view, Topping-off group's range of motion (ROM) and olisthesis in the L4-L5 segment did not significantly change in flexion, but decreased in extension. In PLIF group, ROM (t = -7.82 and -4.90, P < 0.01) and olisthesis (t = -15.67 and -18.58, P < 0.01) both significantly increased in extension and flexion. CONCLUSIONS: Compared with single segment PLIF surgery, Topping-off surgery can achieve similar symptomatic improvement in cases with pre-existing mild or moderate adjacent segment degeneration, restrict the adjacent segment's ROM in extension and prevent excessive olisthesis of adjacent segment in both extension and flexion.