Occipitocervical Revision Surgery Using the Bicortical Screw and Plate System for Failed Craniovertebral Junction Stabilization.

BACKGROUND: To evaluate the clinical efficacy and safety of the modified technique utilizing the occipital bicortical screws and plate system in occipitocervical revision surgery. METHODS: Between October 2010 and May 2018, 12 consecutive patients were retrospectively evaluated. All patients had posterior occipitocervical resurgery utilizing modified technique of bicortical screws and occipital plate. The measurements of extracranial occiput on midline were conducted on computed tomography (CT) scans. The thickness of the occipital bone at the location of external occipital protuberance and below 15 mm were evaluated, respectively. For the procedure, the trajectory was drilled perpendicular to the external occipital protuberance for the specified depth with a depth-limited drilling, 2 mm away from the internal bone plate, then the trajectory was deepened at intervals of 1 mm each time until reaching the internal bone plate. Meanwhile, a probe was used to explore all the walls of the trajectory. Bicortical screws were inserted to the occipital plate and the depth of penetration was less than 2 mm from the internal bone plate. Clinical efficacy and radiographic evaluation were followed up. RESULTS: The thickest point was the external occipital protuberance, which was 15.49 ± 1.47 mm and decreased gradually on the midline to 13.41 ± 1.60 mm at below 15 mm. Twelve cases (mean age 41.17 years; range, 24-62 years), including five males and seven females, were followed up for 24.08 months (14-32 months). The interval time was 40.42 months (3-156 months) after the initial operation. At the final follow-up, JOA score increased from 8.58 ± 2.53 before surgery to 12.67 ± 1.84 (P < 0.05) and VAS score improved from 6.17 ± 1.21 to 2.08 ± 1.32 (P < 0.05). Besides, clinical symptoms were relieved in all patients after revision surgery. All patients had rigid internal fixations with bone fusion and no major complications occurred. CONCLUSIONS: Posterior occipitocervical plate-screw system with bicortical screws had the advantages of safety, simple and promising efficacy without excessive tissue release or intraspinal manipulation, proving that it's valuable as a modified technique for occipitocervical revision surgery.

[Analysis of clinical efficacy of unilateral open-door cervical laminoplasty combined with foraminotomy for cervical ossification of posterior longitudinal ligament].

OBJECTIVE: To explore the clinical efficacy of unilateral open-door laminoplasty combined with foraminotomy for cervical ossification of posterior longitudinal ligament(OPLL). METHODS: The clinical data of 45 patients with OPLL underwent surgical treatment between September 2011 and September 2015 were retrospectively analyzed. There were 26 males and 19 females with a mean age of 53.6 years old(ranged from 28 to 71 years). Among them, 24 cases received the surgery of unilateral open-door cervical laminoplasty combined with foraminotomy(combined group), and 21 cases received a single unilateral open-door cervical laminoplasty(single group). Operation time, intraoperative blood loss, complications including C5 nerve root palsy and axial symptoms were compared between two groups. Pre-and post-operative Japanese Orthopedic Association(JOA) score, improvement rate of neurological function, Neck Disability Index(NDI) score, and cervical Cobb angle were recorded and analyzed between the two groups. RESULTS: All the patients were followed up for 12-24 months, with an average of (14.3±2.8) months for combined groups and (13.7±3.1) months for single group, and no significant difference was found between the two groups(P>0.05). There was no significant difference in operation time and intraoperative blood loss between two groups(P>0.05). Postoperative JOA scores obtained obvious improvement in all patients(P<0.05). However, there was no significant difference between two groups for the improvement rate of neurological function(P>0.05). At final follow-up, NDI scores of combined group and single group were 13.6±1.8 and 16.1±2.4 respectively, there was significant difference between two groups(P<0.05). The incidence of C5 nerve root palsy was lower in combined group(4.2%) than that of single group (28.6%). There was no significant difference in incidence rate of axial symptoms between two groups(P>0.05). There was no significant difference in cervical Cobb angle between pre-and post-operative conditions, or between two groups(P>0.05). CONCLUSIONS: Unilateral open-door cervical laminoplasty combined with foraminotomy is an effective method to treat cervical OPLL, which could provide sufficient decompression of spinal cord and nerve root, prevent the C5 nerve root palsy.

[Effect of Buyanghuanwu decoction on the expression of platelet activating factor after acute spinal cord injury in rats].

OBJECTIVE: To investigate the effect and mechanism of Buyanghuanwu decoction on platelet activating factor expression in spinal cord tissue of model of acute upper cervical spinal cord injury in rats. METHODS: Sixty SPF grade 3-month-old female Wistar rats were randomly divided into sham operation group, model group, methylprednisolone group and Buyanghuanwu decoction (Traditional Chinese Medicine group, TCM), with 15 rats in each group. The first day after the modeling, the methylprednisolone group were treated by injection of the tail vein for a total of 24 h, the first dose of 30 mg/kg, followed by a dose of 5.4 mg/kg·h, and 1 time per 4 h. The traditional Chinese medicine group was prepared with a medium dose of Buyanghuanwu decoction granules which were prepared into a solution containing 2 g/ml of granules, 3.5 g/kg per day gavage, was equivalent to 1 time the amount of adult consumption. The model group and the sham operation group were given equal volume of normal saline for 2 times a day for 2 weeks. The recovery of nerve function was evaluated by BBB classification at 1, 3, 7, 14 days after treatment. The expression of PAF in the segment of spinal cord injury was detected by double antibody sandwich (ELISA) method at 1, 7, and 14 d postoperatively. RESULTS: At the first day after treatment, BBB score in model, TCM and methylprednisolone groups were lower than that of sham operation group(P<0.01), but there was no difference among the three groups(P>0.05). At 7, 14 days afer treatment, BBB score in TCM and methylprednisolone groups were higher than that of model group significantly(P<0.01); but there were no significant difference between TCM group and methylprednisolone group(P>0.05). PAF expression in TCM group and methylprednisolone group were lower than that of model group at 7, 14 day afer treatment significantly (P<0.05); but there were no significant difference between TCM group and methylprednisolone group (P>0.05). CONCLUSIONS: Buyanghuanwu decoction treatment after acute upper cervical spinal cord injury can significantly improve locomotor recovery by inhibiting the expression of PAF.

[Clinical study on spinal cord decompression combined with traditional Chinese medicine for the treatment of cervical spondylotic myelopathy].

OBJECTIVE: To compare the clinical effect between spinal card decompression combined with traditional Chinese medicine and simple spinal card decompression for cervical spondylotic myelopathy. METHODS: From June 2012 to June 2015, 73 patients with cervical spondylotic myelopathy were treated, including 42 males and 31 females, aged from 29 to 73 years old with a mean of 50.9 years old. The patients were divided into the simple operation group (34 cases) and the operation combined with traditional Chinese medicine group(39 cases) according to the idea of themselves. The anterior discectomy or subtotal corpectomy with internal fixation or posterior simple open-door decompression with lateral mass screw fixation were performed in the patients. Among them, 39 cases were treated with traditional Chinese medicine after surgery. The Japanese orthopedic association (JOA) score of spinal cord function, the improvement rate of neural function, the neck dysfunction index (NDI) score and the governor vessel stasis syndrome score were compared between two groups preoperative and postoperative 1 week, 1 month and the final follow-up respectively. The internal fixation and the condition of spinal cord decompression were observed by CT, MRI and X-rays before and after operation. RESULTS: All the operations were successful, no injuries such as dura mater, spinal cord and nerve root were found. All the wounds were healed without infection except one patient had a superficial infection. It was solved after intermittent debridement and anti-infective therapy. Hematoma occurred in 1 case, complicated with spinal cord compression, caused incomplete paralysis, and promptly performed the re-operation to remove the hematoma without any obvious sequelae. All the patients were followed up from 12 to 24 months, (14.6±0.8) months for simple operation group and (13.5±0.7) months for operation combined with traditional Chinese medicine group, and there was no significant difference(P>0.05). The scores of JOA, NDI and the governor's vessel stasis syndrome in simple operation group were 8.31±3.15, 29.91±4.52, 6.58±1.31 before operation, and 10.21±2.58, 18.67±4.31, 8.24±1.18 one week after operation, and 11.38±2.85, 16.11±3.18, 8.91±2.11 one month after operation, and 12.21±3.12, 14.61±3.28, 9.12±1.56 at final follow-up, respectively; and in operation combined with traditional Chinese medicine group were 8.29±3.47, 30.83±4.14, 6.38±1.81before operation, and 10.48±2.39, 17.59±5.14, 8.33±1.57 one week after operation, and 12.14±3.12, 13.14±3.21, 9.55±2.49 one month after operation, and 13.85±3.34, 12.11±2.51, 10.33±1.95 at final follow-up, respectively. Postoperative JOA , NDI, and the governor vessel stasis syndrome score of two groups were significantly higher than preoperativee(P<0.05). There was no significant difference in JOA, NDI, and the governor vessel stasis syndrome score between two groups one week after operation (P>0.05). The above items in operation combined with traditional Chinese medicine group was better than that of simple operation group one month and final follow-up after operation (P<0.05). The improvement rate of neural function in simple operation group was (67.59±10.78)%, and in operation combined traditional Chinese medicine group was (66.88±12.15)%, there was no significant difference between two groups(P>0.05). There were no complications such as internal fixation failure or re-dislocation of atlas by postoperative CT, MRI and X-rays examination. CONCLUSIONS: Spinal card decompression for the treatment of cervical spondylotic myelopathy can extend the spinal canal, relieve the compression of nerve, achieve the deoppilation of governor vessel, the regulation of qi and blood, the restore of Yangqi, combined with traditional Chinese medicine of activating blood removing stasis, warming yang and activating meridians, reinforcing liver benefiting kidney, which may obtain better clinical effect.

[Effects of decompression combined with electro-acupuncture on rat with acute severe upper cervical spinal cord compression injury].

OBJECTIVE: To explore the effect and underlying mechanism of decompression(DE)combined with Governor Vessel(GV)electro-acupuncture(EA) on rats with acute severe upper cervical spinal cord compression injury. METHODS: Thirty SPF rats were randomly divided into 5 groups(control group A, B and experiment group C, D, E), 6 rats in each group. The model of acute severe upper cervical spinal cord compression injury were made by forcing a balloon catheter put in atlas pillow clearance. The group A was blank one, the group B put balloon catheter in atlas pillow clearance without forcing, and the group C, D, E sustained compressed for 48 h. The group C received electric acupuncture intervention, selecting the Baihui and Dazhui point, having the continuous wave and frequency of 2 Hz, with the treatment time of 15 min and continuous treatment for 14 d; the group D received methylprednisolone intervention, injected by caudal vein; the group E did not received any intervention again. The arterial blood and injured spinal cord tissue of all the rats were obtained after 14 days' treatment, and BBB score was used to evaluate the change of each group hind limbs motor function, the contents of platelet activating factor(PAF) in injured spinal cord tissue and blood serum were assess by ELISA method; the Caspase-9 expression for each group after 14 days' treatment was assess by Western blot method. RESULTS: BBB scores were(21.000±0.000) points at the 6 time points, that was, 1 h, 48 h after forcing in control group, 24 h, 3 d, 7 d, 14 d after treating in experiment group; the score of experimental groups (group C, D, E) were always lower than control groups(group A, B); compared with group E, group C and D were significantly higher(P<0.05); and there was no significant difference between group C and group D(P>0.05). The results of PAF by ELISA method to measure:the concentration of serum PAF, there was no statistical difference among group A, B, D, E (P>0.05), group C was lower than the other groups (P<0.05); the concentration of tissue PAF, there was no significant difference between group A and group B(P>0.05), group D was significantly higher than that of group A, B, and C(P<0.05), group E was the highest one than that of the other groups(P<0.05). Western blot med tests showed that the Caspase-9 protein expression in group A and B was similar (P>0.05), group C was higher than that of group A and B(P<0.05), group D was higher than group A, B and C(P<0.05), group E was the highest than that of group A, B, C and D (P<0.05). CONCLUSIONS: Decompression and Governor Vessel electro-acupuncture on acute severe upper cervical spinal cord compression injury had a better effect compare with decompression and methylprednisolone or simple decompression only, its mechanism may be related to lower the PAF levels and downregulating Caspase-9 protein expression in spinal injury tissue.

Improved Intermittent-clamped Drainage in Lower Lumbar Internal Fixation: A Randomized Prospective Study.

BACKGROUND: Continuous negative pressure drainage (CNPD) is widely used after lower lumbar internal fixation; however, it may cause tremendous blood loss and lead to postoperative hemorrhagic anemia. The present study explored the efficacy and safety of improved intermittent-clamped drainage (ICD) for lower lumbar internal fixation. METHODS: This was a prospective study that included 156 patients with decompression of the spinal canal and internal fixation for the first time from January 2012 to December 2014. The patients were randomly divided into ICD group and CNPD group, and each group had 78 cases. A drainage tube was placed under the deep fascia in all patients within 10 min after the commencement of wound closure. The postoperative drainage amount at different time points, the hemoglobin level, and postoperative complications were recorded and compared between the two groups. Shapiro-Wilk test, independent samples t-test, and Mann-Whitney U-test were used in this study. RESULTS: The drainage amount was significantly reduced in the ICD group, as compared with the CNPD group (Z = 10.74, P < 0.01). The mean total drainage amount (in ml) of the single-segment and two-segment procedures was significantly greater in the CNPD group than the ICD group (Z = 10.63 and 10.75, respectively; P < 0.01). For the adverse events, there was no significant difference in postoperative temperature, wound problem, and complications between the two groups. CONCLUSIONS: The present study showed a statistically significant reduction in postoperative drainage amount between ICD and CNPD groups, and ICD is an effective, convenient, and safe method for routine use in lower lumbar surgery. It is essential to focus on the effect of clamping drainage with long-segment surgical procedure and complex lumbar disease in the further investigation, as well as the effect of clamping on long-term functional outcomes.

Footprint mismatch of cervical disc prostheses with Chinese cervical anatomic dimensions.

BACKGROUND: The footprint of most prostheses is designed according to Caucasian data. Total disc replacement (TDR) has been performed widely for cervical degenerative diseases in China. It is essential to analyze the match sizes of prostheses footprints and Chinese cervical anatomic dimensions in our study. METHODS: The anatomic dimensions of the C4-C7 segments of 138 patients (age range 16-77 years) in a Chinese population were measured by computed tomography scans. We compared the footprints of the most commonly used cervical disc prostheses (Bryan: Medtronic, Minneapolis, MN, USA; Prestige LP: Medtronic, Fridley, Minnesota, USA; Discover: DePuy, Raynham, MA, USA; Prodisc-C: Synthes, West Chester, PA, USA) in China with Chinese cervical anatomic dimensions and assessed the match of their size. RESULTS: The mismatch of available dimensions of prostheses and anatomic data of cervical endplates ranged from 17.03% (C4/C5, Prestige LP, Prodisc-C) to 57.61% (C6/C7, Discover) in the anterior-posterior (AP) diameter, and 35.51% (C4/C5, Prodisc-C, Prestige LP) to 94.93% (C6/C7, Bryan) in the center mediolateral (CML) diameter. About 21.01% of endplates were larger than the largest prostheses in the AP diameter and 57.25% in the CML diameter. All available footprints of prostheses expect the Bryan with an unfixed height, can accommodate the disc height (DH), however, 36.23% of the middle DH was less than the smallest height of the prostheses. The average disc sagittal angles (DSAs) of C4-C7 junctions were 5.04°, 5.15°, and 4.13° respectively. Only the Discover brand had a built-in 7° lordotic angle, roughly matching with the DSA. CONCLUSIONS: There is a large discrepancy between footprints of prostheses and Chinese cervical anatomic data. In recent years, possible complications of TDR related with mismatch sizes are increasing, such as subsidence, displacement, and heterotopic ossification. Manufacturers of prostheses should introduce or produce additional footprints of prostheses for Chinese TDR.