Repair of symptomatic bilateral L5 spondylolysis with autogenous iliac crest graft and temporary intersegmental pedicle screw fixation in youth.

BACKGROUND: When symptomatic spondylolysis fail to respond to nonoperative treatment, surgical management may be required. A number of techniques have been described for repair by intrasegmental fixation with good results; however, there are still some problems. We reported a repair technique with temporary intersegmental pedicle screw fixation and autogenous iliac crest graft. The aim of present study is to assess the clinical outcomes of L5 symptomatic spondylolysis with this technique. METHODS: A retrospective analysis of 128 patients with L5 spondylolysis treated with this method was performed. According to CT scan, the spondylolysis were classified into 3 categories: line, intermediate, and sclerosis type. The diagnostic block test of L5 bilateral pars defect was done in all patients preoperatively. The sagittal and axial CT images were used to determine the bone union. The healing time, complications, number of spina bifida occulta, Japanese Orthopedic Association (JOA) score, and VAS for back pain were recorded. After fixation removal, the rate of ROM preservation at L5S1 was calculated. RESULTS: There were 97 patients (194 pars) followed with mean follow-up of 23 months (range, 12-36 months). The union rate of pars was 82.0% at 12 months and 94.3% at 24 months postoperatively. Low back pain VAS significantly (P < 0.05) improved from preoperative mean value of 7.2 to 1.3 at the final follow-up postoperatively (P < 0.05). JOA score increased significantly postoperatively (P < 0.05) with average improvement rate of 79.3%. The rates of L5S1 ROM preservation were 79.8% and 64.0% after fixation removal at 1 and 2 years postoperatively. There were 3 patients of delayed incision healing without other complications. CONCLUSIONS: Although sacrificing L5S1 segment motion temporarily, more stability was obtained with intersegmental fixation. This technique is reliable for spondylolysis repair which has satisfactory symptom relief, high healing rate, low incidence of complications, and preserve a large part of ROM for fixed segment.

Comparison of Functional and Radiological Outcomes Between Two Posterior Approaches in the Treatment of Multilevel Cervical Spondylotic Myelopathy.

BACKGROUND: Posterior cervical decompression is an accepted treatment for multilevel cervical spondylotic myelopathy (CSM). Each posterior technique has its own advantages and disadvantages. In the present study, we compared the functional and radiological outcomes of expansive hemilaminectomy and laminoplasty with mini titanium plate in the treatment of multilevel CSM. METHODS: Forty-four patients with multilevel CSM treated with posterior cervical surgery in Department of Orthopedic Surgery, Beijing Army General Hospital from March 2011 to June 2012 were enrolled in this retrospective study. Patients were divided into two groups by surgical procedure: Laminoplasty (Group L) and hemilaminectomy (Group H). Perioperative parameters including age, sex, duration of symptoms, operative duration, and intraoperative blood loss were recorded and compared. Spinal canal area, calculated using AutoCAD ® software(Autodesk Inc., San Rafael, CA, USA), and neurological improvement, evaluated with Japanese Orthopedic Association score, were also compared. RESULTS: Neurological improvement did not differ significantly between groups. Group H had a significantly shorter operative duration and significantly less blood loss. Mean expansion ratio was significantly greater in Group L (77.83 ± 6.41%) than in Group H (62.72 ± 3.86%) (P < 0.01). CONCLUSIONS: Both surgical approaches are safe and effective in treating multilevel CSM. Laminoplasty provides a greater degree of enlargement of the spinal canal, whereas expansive hemilaminectomy has the advantages of shorter operative duration and less intraoperative blood loss.

Percutaneous Nucleoplasty Using Coblation Technique for the Treatment of Chronic Nonspecific Low Back Pain: 5-year Follow-up Results.

BACKGROUND: This study evaluated the efficacy of percutaneous nucleoplasty using coblation technique for the treatment of chronic nonspecific low back pain (LBP), after 5 years of follow-up. METHODS: From September 2004 to November 2006, 172 patients underwent percutaneous nucleoplasty for chronic LBP in our department. Forty-one of these patients were followed up for a mean period of 67 months. Nucleoplasty was performed at L3/4 in 1 patient; L4/5 in 25 patients; L5/S1 in 2 patients; L3/4 and L4/5 in 2 patients; L4/5 and L5/S1 in 7 patients; and L3/4, L4/5, and L5/S1 in 4 patients. Patients were assessed preoperatively and at 1 week, 1 year, 3 years, and 5 years postoperatively. Pain was graded using a 10-cm Visual Analogue Scale (VAS) and the percentage reduction in pain score was calculated at each postoperative time point. The Oswestry Disability Index (ODI) was used to assess disability-related to lumbar spine degeneration, and patient satisfaction was assessed using the modified MacNab criteria. RESULTS: There were significant differences among the preoperative, 1-week postoperative, and 3-year postoperative VAS and ODI scores, but not between the 3- and 5-year postoperative scores. There were no significant differences in age, sex, or preoperative symptoms between patients with effective and ineffective treatment, but there were significant differences in the number of levels treated, Pfirrmann grade of intervertebral disc degeneration, and provocative discography findings between these two groups. Excellent or good patient satisfaction was achieved in 87.9% of patients after 1 week, 72.4% after 1 year, 67.7% after 3 years, and 63.4% at the last follow-up. CONCLUSIONS: Although previously published short- and medium-term outcomes after percutaneous nucleoplasty appeared to be satisfactory, our long-term follow-up results show a significant decline in patient satisfaction over time. Percutaneous nucleoplasty is a safe and simple technique, with therapeutic effectiveness for the treatment of chronic LBP in selected patients. The technique is minimally invasive and can be used as part of a stepwise treatment plan for chronic LBP.

[Clinical classification and surgical options of the far-lateral lumbar disc herniation].

OBJECTIVES: To suggest the clinical classification of the far-lateral lumbar disc herniation and offer the considerations for clinical choice of different surgical procedures. METHODS: According to the locations of the herniated disc and relevant clinical symptoms, the far-lateral lumbar disc herniation was divided into three types: Type I: posterolateral and foraminal herniation(double herniations); Type II: foraminal disc herniation and Type III: extraforaminal herniation. From January 2002 to January 2007, 38 patients with far lateral lumbar disc herniation underwent surgery in the institute. The surgical options were decided by means of the classification. The surgical procedures included (1) discectomy by inter-TP (transverse process) approach, (2) discectomy with partial facetectomy and (3) discectomy with facetectomy and PLIF (posterior lumbar interbody fusion). Among the 38 patients, there were 25 males and 13 females. The mean age was 58.4 years old. The herniated discs located at L(3-4) in 17, L(4-5) in 13, and 8 cases at L(5)S(1). Twenty-three patients were simple disc herniation, 15 cases with concomitant lumbar spinal stenosis. The symptoms and signs of exiting root compression at herniated disc level were presented in all patients and passing root compression presented in 7 Type I cases as well; while intermittent claudication being presented in 15 and low back pain in 21 patients. The VAS (visual analog pain scale) of radicular leg pain was taken before and after the operation. The postoperative outcomes were evaluated through the MacNab's method in all the patients. RESULTS: By using the new classification system, the 38 patient were divided into Type I 10 cases, Type II 19 cases and Type III 9 cases. The adopted surgeries included discectomy by intertransverse approach in 5, discectomy with partial facetectomy in 7, and discectomy with facetectomy and PLIF in the rest 26 cases. The mean follow-up period was ranging from 6 months to 4 years and 10 months, average 2 years and 11 months. The mean VAS scores of radicular pain was 7.4 preoperatively, 2.7 at 2 weeks after the operation and 3.1 at final follow-up. The final clinical outcomes by MacNab's method were as follow: excellent results in 20 cases, good in 12, fair in 5 and poor in 1 case. The overall improvement ratio was 84.2%. The postoperative complications included superficial wound infection in 1 case, insufficient decompression in 1 case and leakage of cerebrospinal fluid in 1 case respectively. No breakage and loosening of internal fixation were detected. CONCLUSIONS: A new clinical classification of far lateral lumbar disc herniation was suggested, which is significant to understanding the relevant pathology and choosing the surgical procedures.

[An experimental study on percutaneous autologous bone marrow mesenchymal stem cell grafting for bone defect].

OBJECTIVES: To investigate in vive osteogenic potential in size-critical bone defect after percutaneous autologous grafting of culture-expanded rabbit autologous BMSCs, osteo-induced BMSCs and combination of both. METHODS: BMSCs were cultured and then induced with osteogenic supplement (OS) medium. BMSCs with and without OS induction were collected and percutaneously autologously injected respectively into the 15 mm bone defect of 20 experimental rabbit model. The grafts were BMSCs, osteo-induced BMSCs, BMSCs and osteo-induced BMSCs, BMP combined with fibrin sealant, and 0.9% NaCl solution. Osteogenesis at the defect areas were observed by regular radiography, histology and biomechanics. RESULTS: The group transplanted with BMSCs + osteo-induced BMSCs achieved complete bone healing with medullary cavity united, which showed the largest quantity of new bone measured by X-ray analysis, and also their maximal load were better than those in other groups. CONCLUSION: The bone-forming ability of rabbit osteo-induced BMSCs combined with BMSCs in bone defect is superior to those of BMSCs and osteo-induced BMSCs.