Surgical treatment of severe multilevel circumferential compressive myelopathy of the cervical spine: is circumferential procedure necessary?

OBJECTIVE: To determine the necessity of circumferential decompression and fusion in patients with severe multilevel cervical spondylotic myelopathy with circumferential cord compression. METHODS: This prospective study involved 51 patients with severe multilevel circumferential cervical myelopathy underwent two-stage circumferential procedure between July 2008 and June 2010. VAS scores, satisfaction surveys and JOA scores and imaging studies were obtained. Twenty-three patients (45.1%) underwent two-stage surgery (group A); the other 28 patients (54.9%) were satisfied with the outcomes after first-stage surgery, and the second-stage surgery was avoided (group B). Age, sex and symptom duration did not differ between the groups. RESULTS: Patients were followed up for 3-5 years (mean, 42.5 months). In group A, VAS and JOA scores significantly improved from 63.3 and 7.9 to 38.3 and 10.4, respectively, at 3 months after the first-stage operation and 10.2 and 12.7, respectively, at 3 months after the second-stage operation. In group B, the VAS and JOA scores significantly improved from 62.7 and 7.9 to 31.1 and 11.2 respectively, at 3 months and 18.2 and 12.4, respectively at 6 months. Patient satisfaction rate significantly increased from 43.5% after the first-stage operation to 82.6% after the second-stage operation in group A. In group B, this rate was 89.3%. In group A, cervical spine lordosis increased from 12.8° preoperatively to 18.5° (p < .0001) and 19.1° (p > .05) at 3 months after the first-stage and second-stage operations, respectively. In group B, lordosis significantly increased from 12.5° preoperatively to 18.8° at 3 months. The total complication rate did not significantly differ from the rates after a single surgery (either anterior or posterior). CONCLUSION: Only 45.1% patients required surgery via both approaches. Therefore, a two-stage procedure is a rational choice and safe procedure. If outcomes are unsatisfactory after the first-stage operation, a second-stage operation can be performed.

Single segment of posterior lumbar interbody fusion for adult isthmic spondylolisthesis: reduction or fusion in situ.

OBJECTIVE: We prospectively compared surgical reduction or fusion in situ with posterior lumbar interbody fusion (PLIF) for adult isthmic spondylolisthesis in terms of surgical invasiveness, clinical and radiographical outcomes, and complications. METHODS: From January 2006 to June 2008, 88 adult patients with isthmic spondylolisthesis who underwent surgical treatment in our unit were randomized to reduced group (group 1, n = 45) and in situ group (group 2, n = 43), and followed up for average 32.5 months (range 24-54 months). The clinical and radiographical outcomes were compared between the two groups. RESULTS: The average operative time and blood loss during surgery showed insignificant difference (p > 0.05) between two groups. The radiological outcomes were significantly better in group 1, but there was no significant difference between two groups of clinical outcomes, depicting as VAS, ODI, JOA and patients' satisfaction surveys. Incident rate of surgical complications was similar in two groups, but in group 1 the complication seemed more severe because of two patients with neurological symptoms. CONCLUSIONS: For the adult isthmic spondylolisthesis without degenerative disease in adjacent level, single segment of PLIF with pedicle screw fixation is an effective and safe surgical procedure regardless of whether additional reduction had been conducted or not. Better radiological outcome does not mean better clinical outcome.

[Clinical manifestation and surgical treatment of spinal osteoblastoma].

OBJECTIVE: To investigate the clinical manifestation and surgical outcome of spinal osteoblastoma. METHODS: From June 2006 to July 2010, 11 patients with spinal osteoblastoma treated surgically were analyzed retrospectively. There were 7 males and 4 females with an average age of 23.5 years (range, 16 - 34 years). The tumors were located at C(5) in 3, C(6) in 4, C(7) in 2, C(6) ~ T(1) in 1 and T(11) in 1. Based on WBB classification, 9 were 1 - 3 or 10 - 12 and 2 were 4 - 9 and 1 - 3. All the operations had been performed with en-bloc resection. The posterior approach was used for 9 patients, and combined posterior and anterior approach was used for 2 patients. Reconstruction using instrumentation and fusion was performed using spinal instrumentation in 8 patients. To evaluate the change of pain before and after the operation by visual analogue scales (VAS), and to assess functional status of the spine by McCormick scale. Imaging test was used to review the stability and recurrence rate of spine cord, and the confluence of graft bones. RESULTS: All cases were followed up for 12 - 64 months (average, 28.4 months). The average surgical time was 130.5 minutes (range, 90 - 210 minutes), with the average intraoperative blood loss of 560 ml (range, 300 - 1000 ml). During the follow-up period, the VAS grade reduced from 6.3 ± 1.1 to 2.5 ± 1.0 (t = 8.48, P < 0.05). There were 8 patients had neurological function improved and 3 remained no change which was evaluated by McCormick scale for spinal function status at final follow-up. CONCLUSIONS: Spinal osteoblastoma has its own specific radiographic feature. There are some recurrence in simple curettage of tumor lesion. The thoroughly en-bloc resection of tumor or spondylectomy, bone fusion and strong in ter fixation are the key points for successful surgical treatment.

An MRI study of psoas major and abdominal large vessels with respect to the X/DLIF approach.

Extreme/direct lateral interbody fusion (X/DLIF) has been used to treat various lumbar diseases. However, it involves risks to injure the lumbar plexus and abdominal large vessels when it gains access to the lumbar spine via lateral approach that passes through the retroperitoneal fat and psoas major muscle. This study was aimed to determine the distribution of psoas major and abdominal large vessels at lumbar intervertebral spaces in order to select an appropriate X/DLIF approach to avoid nerve and large vessels injury. Magnetic resonance imaging scanning on lumbar intervertebral spaces was performed in 48 patients (24 males, 24 females, 54.2 years on average). According to Moro's method, lumbar intervertebral space was divided into six zones A, I, II, III, IV and P. Thickness of psoas major was measured and distribution of abdominal large vessels was surveyed at each zone. The results show vena cava migrate from the right of zone A to the right of zone I at L1/2-L4/5; abdominal aorta was located mostly to the left of zone A at L1/2-L3/4 and divided into bilateral iliac arteries at L4/5; Psoas major was tenuous and dorsal at L1/2 and L2/3, large and ventral at L3/4 and L4/5. Combined with the distribution of nerve roots reported by Moro, X/DLIF approach is safe via zones II-III at L1/2 and L2/3, and via zone II at L3/4. At L4/5, it is safe via zones I-II in left and via zone II in right side, respectively.

Noncontiguous anterior decompression and fusion for multilevel cervical spondylotic myelopathy: a prospective randomized control clinical study.

Anterior decompression and fusion is an established procedure in surgical treatment for multilevel cervical spondylotic myelopathy (MCSM). However, contiguous corpectomies and fusion (CCF) often induce postoperative complications such as nonunion, graft subsidence, and loss of lordotic alignment. As an alternative, noncontiguous corpectomies or one-level corpectomy plus adjacent-level discectomy with retention of an intervening body has been developed recently. In this study, we prospectively compared noncontiguous anterior decompression and fusion (NADF) and CCF for MCSM in terms of surgical invasiveness, clinical and radiographic outcomes, and complications. From January 2005 to June 2007, 105 patients with MCSM were randomized to NADF group (n = 55) and CCF group (n = 50), and followed up for average 31.5 months (range 24-48 months). Average operative time and blood loss decreased significantly in the NADF group as compared with those in the CCF group (p < 0.05 and <0.001, respectively). For VAS, within 3 months postoperatively, there was no significant difference between the two groups. But at 6 months after surgery and final follow-up, VAS improved significantly in NADF group than that in CCF group (p < 0.05). No significant difference of JOA score was observed between the two groups at every collection time. In NADF group, all 55 cases obtained fusion at 1 year after operation (average 5.1 months). In CCF group, 48 cases achieved fusion 1 year postoperatively, but the other 2 cases were performed posterior stabilization and achieved fusion 6 months later. The differences of cervical lordosis between two groups were insignificant at the same follow-up time. But the loss of lordosis and height of fusion segments in 6 months postoperatively and final follow-up were significantly more in CFF group than in NADF group (p < 0.001). Complications were similar in both groups. But in CCF group three cases needed reoperation, one case with extradural hematoma was immediately re-operated after anterior decompression and two cases mentioned above were performed posterior stabilization at 1 year postoperatively. In conclusion, in the patients with MCSM, without developmental stenosis and continuous or combined ossification of posterior longitudinal ligaments, NADF and CCF showed an identical effect of decompression. In terms of surgical time, blood loss, VAS, fusion rate and cervical alignment, NADF was superior compared with CCF.

Novel three-dimensional nerve tissue engineering scaffolds and its biocompatibility with Schwann cells.

OBJECTIVE: To develop a novel scaffolding method for the copolymers poly lactide-co-glycolide acid (PLGA) to construct a three-dimensional (3-D) scaffold and explore its biocompatibility through culturing Schwann cells (SCs) on it. METHODS: The 3-D scaffolds were made by means of melt spinning, extension and weaving. The queueing discipline of the micro-channels were observed under a scanning electronic microscope (SEM).The sizes of the micropores and the factors of porosity were also measured. Sciatic nerves were harvested from 3-day-old Sprague Dawley (SD) rats for culture of SCs. SCs were separated, purified, and then implanted on PLGA scaffolds, gelatin sponge and poly-L-lysine (PLL)-coated tissue culture polystyrene (TCPS) were used as biomaterial and cell-supportive controls, respectively. The effect of PLGA on the adherence, proliferation and apoptosis of SCs were examined in vitro in comparison with gelatin sponge and TCPS. RESULTS: The micro-channels arrayed in parallel manners, and the pore sizes of the channels were uniform. No significant difference was found in the activity of Schwann cells cultured on PLGA and those on TCPS (P larger than 0.05), and the DNA of PLGA scaffolds was not damaged. CONCLUSION: The 3-D scaffolds developed in this study have excellent structure and biocompatibility, which may be taken as a novel scaffold candidate for nerve-tissue engineering.

[Correlation between magnetic resonance T2-weighted increased signal intensity position and prognosis of cervical spondylotic myelopathy].

OBJECTIVE: To investigate the correlation between position of the spinal cord with increased signal intensity (ISI) on magnetic resonance images (MRI) and the outcome of surgical treatment for cervical spondylotic myelopathy (CSM). METHODS: Seventy-two patients with CSM who underwent preoperative MRI were selected. Pre- and post-operative clinical status was evaluated by modified Japanese Orthopedic Association (JOA) score. ISI was evaluated according to the T2-weighted sequences. The JOA score and the recovery ratios among patients with ISI in gray matter (group A), in both gray and white matter (group B) and ISI-negative group were compared. RESULTS: Forty patients were in ISI-negative group. ISI presenting only in gray matter included 21 cases (group A) and 11 cases were in both gray and white matter group (group B). Preoperative JOA score of ISI positive and negative group had significant difference, but the recovery ratios had no significant difference [recovery ratios of two groups at week 1, week 14, and week 52 were (20.8 +/- 14.5)%, (51.1 +/- 15.6)%, (60.1 +/- 14.2)% and (20.3 +/- 14.3)%, (54.4 +/- 22.3)% and (61.2 +/- 22.3)% respectively; P > 0.05]. The recovery ratios of negative group and group A in week 104 were superior to group B [recovery ratios of negative group, group A, and group B in week 52 were (61.2 +/- 22.3)%, (64.3 +/- 13.3)% and (50.1 +/- 11.2)% respectively; P < 0.05]. CONCLUSION: Patients with ISI in the gray matter alone on T2-weighted MR images have no significantly different surgical outcomes as compared with those without ISI. Patients with ISI in both gray and white matter have worse surgical outcomes than those without ISI.

[Comparison of clinical effects between anterior cervical discectomy combined with corpectomy and cervical posterior single open-door laminoplasty in treating three-segment cervical spondylotic myelopathy].

OBJECTIVE: To compare the clinical effects between anterior cervical discectomy and fusion(ACDF) combined with anterior cervical corpectomy and fusion(ACCF) and cervical posterior single open-door laminoplasty with mini-titanium plate fixation in treating three-segment cervical spondylotic myelopathy. METHODS: The clinical data of 63 patients (39 males and 24 females) with three-segment cervical spondylotic myelopathy underwent surgical treatment from March 2014 to March 2016 were retrospectively analyzed. Among them, 43 cases were treated by ACDF combined with ACCF(anterior group), and 20 cases were treated by cervical posterior single open-door laminoplasty with mini-titanium plate fixation(posterior group). Operative time, intraoperative blood loss, postoperative complications were compared between two groups. And according to JOA score to evaluate the clinical effect. RESULTS: All the patients were follow-up from 16 to 40 months with an average of 25.8 months. Operative time of anterior group and posterior group were (123.70±6.21) min and(118.70±5.41) min, respectively, there was no significant difference between two groups(P>0.05). Intraoperative blood loss of anterior group and posterior group were (85.23±7.51) ml and (107.18±9.41) ml, respectively, there was significant difference between two groups(P<0.05). In anterior group, axial symptoms occurred in 6 cases, dysphagia in 1 case, and no C5 nerve root palsy, hoarseness and choking cough were found, the incidence rate of complication was 16.3%(7/43); and in posterior group, axial symptoms occurred in 5 cases, C5 nerve root palsy in 1 case, and no dysphagia, hoarseness and choking cough were found, the incidence rate of complication was 30.0%(6/20); there was significant defference in incidence rate of complication between two group(P<0.05). At 1 week after operation and final follow-up, the JOA scores of anterior group were obviously better than that of posterior group(P<0.05). CONCLUSIONS: Above-mintioned two surgical treatment for cervical spondylotic myelopathy can provide instantly stability, the method of ACDF combined with ACCF was obviously better that of the method of cervical posterior single open-door laminoplasty in intraoperative blood loss, the incidence rate of complications, clinical effect.Thus, for the treatment of three-segment cervical spondylotic myelopathy, the method of ACDF combined with ACCF would be firstly chosen.

[The efficacy of third-generation instrumentation for the treatment of adult scoliosis].

OBJECTIVE: To evaluate the efficacy of third generation spinal instrumentation such as TSRH, CD and ISOLA for the treatment of adult scoliosis. METHODS: Thirty-five adult scoliosis patients including adult idiopathic and degenerative scoliosis were all surgically treated with third generation instrumentation such as TSRH, CD and ISOLA from July 1999 to January 2003. Preoperative mean cobb angles of major curves of the frontal plane was 58.1 degrees (42 degrees -95 degrees ). The patients received anterior combined with posterior correction or single posterior procedure. Mean follow-up was 20 months (10 - 48 months). Preoperative and postoperative Cobb angles of the frontal plane and sagittal plane and distance between C(7) and CVSL were measured. We assessed the subjective efficacy by questionnaire. RESULTS: Clinical appearance of all patients improved significantly. Mean correction of major curves of the coronal plane was 53.2%. Mean lost of correction of the coronal plane in the last follow-up was 4.3 degrees , distance between the midline of C(7) and CVSL was corrected from 2.6 cm to 0.24 cm. Questionnaire in the follow-up showed that 89.3% patients were satisfied with operation results. Two cases occurred pneumatothorax and haematothorax. Three cases still complained about low back pain in 1 year after operation, among which 2 were adjacent degeneration and 1 was pseudarthrosis. CONCLUSION: Imageology assessment and patients self-evaluation shows that the third generation instrumentation could gain good correction and trunk balance in the treatment for adult scoliosis. And patients are more satisfied and have less complications.

Cationic liposome-mediated GDNF gene transfer after spinal cord injury.

Glial cell line-derived neurotrophic factor (GDNF) has been shown to protect cranial and spinal motoneurons, which suggests potential uses of GDNF in the treatment of spinal cord injury (SCI) and motor neuron disease. We examined neuroprotective effect of cationic liposome-mediated GDNF gene transfer in vivo on axonal regeneration and locomotor function recovery after SCI in adult rats. The mixture of DC-Chol liposomes and recombinant plasmid pEGFP-GDNF cDNA was injected after SCI. RT-PCR confirmed the increased expression of GDNF mRNA in the injected areas at 7 days after injection. The expression of EGFP-GDNF was observed in the cells around the injection locus by fluorescence microscope at least 4 weeks after injection. Four weeks after GDNF gene transfer, regeneration of the corticospinal tracts was assessed using anterograde tract tracing. There are more HRP labeling of corticospinal tract axons across the lesion in GDNF group compared with control group. In GDNF group, the maximum distance these labeled axons extended varied in different animals and ranged from 5 mm to approximately 9 mm from the lesion. In control group, no HRP labeled axons extended caudal to the lesion. The locomotion function of hindlimbs of rats was evaluated using inclined plane test and BBB locomotor scores. The locomotion functional scores in GDNF group were higher than that in control group within 1-4 weeks after SCI (p < 0.05). These data demonstrate that in vivo transfer of GDNF cDNA can promote axonal regeneration and enhance locomotion functional recovery, suggesting that cationic liposome-mediated delivery of GDNF cDNA may be a practical gene transfer method for traumatic SCI treatment.

Protective effect of liposome-mediated glial cell line-derived neurotrophic factor gene transfer in vivo on motoneurons following spinal cord injury in rats.

OBJECTIVE: To investigate the effect of liposome-mediated glial cell line-derived neurotrophic factor (GDNF) gene transfer in vivo on spinal cord motoneurons after spinal cord injury (SCI) in adult rats. METHODS: Sixty male Sprague-Dawley rats were divided equally into two groups: GDNF group and control group. The SCI model was established according to the method of Nystrom, and then the DC-Chol liposomes and recombinant plasmid pEGFP-GDNF cDNA complexes were injected into the injured spinal cord. The expression of GDNF cDNA 1 week after injection was detected by RT-PCR and fluorescence microscope. We observed the remaining motoneurons in the anterior horn and the changes of cholinesterase (CHE) and acid phosphatase (ACP) activity using Nissl and enzyme histochemistry staining. The locomotion function of hind limbs of rats was evaluated using inclined plane test and BBB locomotor scale. RESULTS: RT-PCR and fluorescence observation confirmed the presence of expression of GDNF cDNA 1 week and 4 weeks after injection. At 1, 2, 4 weeks after SCI, the number of motoneurons in the anterior horn in GDNF group (20.4+/-3.2, 21.7+/-3.6, 22.5+/-3.4) was more than that in control group (16.8+/-2.8, 17.3+/-2.7, 18.2+/-3.2, P<0.05). At 1, 2 weeks after SCI, the mean gray of the CHE-stained spinal motoneurons in GDNF group (74.2+/-25.8, 98.7+/-31.6) was less than that in control group (98.5+/-32.2, 134.6+/-45.2, P<0.01), and the mean gray of ACP in GDNF group (84.5+/-32.6, 79.5+/-28.4) was more than that in control group (61.2+/-24.9, 52.6+/-19.9, P<0.01). The locomotion functional scales in GDNF group were higher than that in control group within 1 to 4 weeks after SCI (P<0.05). CONCLUSIONS: GDNF gene transfer in vivo can protect motoneurons from death and degeneration induced by incomplete spinal cord injury as well as enhance locomotion functional restoration of hind limbs. These results suggest that liposome-mediated delivery of GDNF cDNA might be a practical method for treating traumatic spinal cord injury.

[Clinical observation of dynamic cervical implant (DCI) internal fixation in the surgical treatment of cervical spondylosis].

OBJECTIVE: To investigate the early clinical effects and radiological outcome of dynamic cervical implant (DCI) internal fixation in treating cervical spondylosis, and evaluate its safety and efficiency. METHODS: From June 2009 to December 2011, 19 patients with cervical spondylosis correspond to the indication of DCI internal fixation in the study, including 5 cases of cervical spondylotic myelopathy and 14 cases of cervical spondylotic radiculopathy. There were 8 males and 11 females, aged from 35 to 54 years with a mean of 43.2 years. Pathological segments included C3,4 in 1 case, C4,5 in 6, C5,6 in 6, C6,7 in 4, C3,4 and C5,6, C6,7 in 2. All patients were treated with anterior discectomy and decompression and DCI internal fixation, meanwhile, 2 cases of them with anterior cervical corpectomy and fusion plate fixation. Clinical evaluation included Modified Japanese orthopedics association (mJOA), neck disability index (NDI), visual analogue scale (VAS) score and patient satisfaction index (PSI) at pre-operation and final follow-up. Radiographic evaluation included flexion/extension lateral view at operative level and adjacent segment. The adjacent level degeneration was analyzed according to Miyazaki classification on MRI images. RESULTS: All patients were followed up from 12 to 42 months with an average of 19.8 months. Preoperative mJOA score was 13.6±1.1 and at final follow-up was 16.3±1.2 with improvement rate of 85.0%. Preoperative VAS,NDI was 6.6± 1.4, 17.1±7.4 and at final follow-up was 1.4±0.8, 6.1±3.9, respectively; there was statistical significance in all above-mentioned results between preoperative and final follow-up (P<0.05). Preoperative ROM at operation level was (7.6±1.9)° and final follow-up was (7.8+2.1)°; preoperative ROM at C2-C7 was (38.6±7.2)° and final follow-up was (39.9±6.4)°; there was no statistical significance in all above-mentioned results between preoperative and final follow-up (P>0.05). Preoperative DHI at operation level was (6.3±1.1) mm and final follow-up was (7.1±0.8) mm, there was statistical significance in DHI between preoperative and final follow-up (P<0.05). No heterotopic ossification was found. All patients followed up MRI, degeneration of 3 segments aggravated 1 degree in 38 adjacent segments, without clinical symptom. CONCLUSION: Treatment of cervical spondylosis with dynamic cervical implant can got satisfactory outcome in early follow-up. Activity of operative segment obtain reservation in some degree. The incidence of adjacent segment degeneration is lower and no adjacent segment disease occur. Nevertheless a longer follow-up time should be needed to assess the long term functionality of the DCI and the influence on adjacent levels.

Posterior lumbar interbody fusion for aged patients with degenerative spondylolisthesis: is intentional surgical reduction essential?

BACKGROUND CONTEXT: Surgical reduction and posterior lumbar interbody fusion (PLIF) is commonly used to recover segmental imbalance in degenerative spondylolisthesis. However, whether intentional reduction of the slipped vertebra during PLIF is essential in aged patients with degenerative spondylolisthesis remains controversial. PURPOSE: We compared the outcomes of surgical reduction and fusion in situ among aged patients who underwent PLIF for degenerative spondylolisthesis. STUDY DESIGN: A prospective randomized clinical trial on the surgical treatment of degenerative spondylolisthesis patients aged older than 70 years. PATIENT SAMPLE: Between January 2006 and December 2009, 73 patients aged 70 years or older with single-level degenerative spondylolisthesis requiring surgical treatment were included in this study. OUTCOME MEASURES: Clinical outcomes were assessed using the visual analog scale, Oswestry Disability Index, and Japanese Orthopedic Association scores. Radiographic outcomes included percentage of vertebral slippage, focal lordosis, and disc height. METHODS: The 73 patients were randomly assigned to two groups treated using surgical reduction (Group A, n=36) and fusion in situ (Group B, n=37). Both groups were followed up for an average of 33.2 months (range, 24-54 months). The clinical and radiographic outcomes were compared between the two groups. RESULTS: Surgical complications were similar in the two groups. The average operative time and blood loss during surgery did not insignificantly differ (p>.05) between the two groups. Spondylolisthesis, disc height, and focal lordosis were significantly improved postoperatively in both groups. There was no obvious difference in clinical outcomes, as assessed using the visual analog scale, Oswestry Disability Index, and Japanese Orthopedic Association scores, although the radiographic outcomes were considerably better in Group A than in Group B. CONCLUSIONS: Posterior lumbar interbody fusion with pedicle screws fixation, with or without intraoperative reduction, provides good outcomes in the surgical treatment of aged patients with degenerative spondylolisthesis. Better radiological outcomes by intentional reduction do not necessarily indicate better clinical outcomes.

[Posterior debridement for the treatment of iatrogenic purulent lumbar spinal infection].

OBJECTIVE: To discuss diagnosis and treatment of iatrogenic purulent lumbar spinal infection. METHODS: From December 2006 to January 2010, 4 patients with iatrogenic purulent lumbar spinal infection were treated with posterior debridement. There were 2 males and 2 females, ranging in age from 50 to 66 years (respectively in 52, 66, 58, 50 years); in course of disease from 2 weeks to 2.5 months (respectively in 21, 14, 60, 75 days ). All patients had fever, lumbago, local tenderness and limited lumbar activity before operation. White blood cell count (WBC), erythrocyte sedimentation rate (ESR) were abnormal. The clinical effects were evaluated by symptoms and laboratory examination. RESULTS: Symptoms of lumbago and fever vanished in 4 patients, of which wounds were primary healing without complications. The patients were followed up for 3 months, no infection (WBC, C-reactive protein and ESR were normal) and lumbar instability were found. CONCLUSION: Iatrogenic purulent lumbar spinal infection can be diagnosed according to course of disease, clinical symptoms and signs, imaging finding. In the items, magnetic resonance imaging finding have necessarily specificity, once finding abscess-formation, will promptly operate.

[Spinal fusion combined with dynamic interspinous fixation with Coflex system for lumbar degenerative disease].

OBJECTIVE: To summarize the effect of the implantation of Coflex interspious stabilization device combined with pinal fusion for the treatment of lumbar degenerative disease. METHODS; From March 2008 to March 2010, 18 patients with two levels lumbar degenerative disease were treated with spinal fusion and dynamic interspinous fixation with Coflex system. There were 11 males and 7 females. The average age was 50.2 years (range 41 to 62 years). The VAS and the Oswestry Disability Index (ODI) were used to assess clinical symptoms preoperatively and postoperatively. All patients underwent flexion/extension radiographs examinations before surgery and at last follow-up. Range of motion (ROM) and disc height index (DHI) were recorded. RESULTS: All patients were followed up for 12 months averagely (range 6-30 months). At final follow-up, leg VAS, back VAS and ODI functional score were significant improved than those of preoperation [back VAS: 1.50 +/- 0.90 vs 7.20 +/- 0.90; leg VAS: 1.10 +/- 0.80 vs 5.20 +/- 0.90; ODI functional score: (15.90 +/- 5.80)% vs (52.50 +/- 5.90)%]. The DHI increased from 0.23 +/- 0.05 preoperatively to 0.35 +/- 0.06 postoperatively and to 0.33 +/- 0.04 at final follow-up, the height of intervertebral space were not found significant loss. The ROM at the Coflex stabilized levels on the X-ray views was (8.90 +/- 1.80) degrees preoperatively, (8.30 +/- 1.90) degrees postoperatively, and (8.10 +/- 1.80) degrees at final follow-up. There was no significant difference between final follow-up and preoperative (P = 0.19). The ROM of the lumbar spine (L2-S1) was (20.20 +/- 5.60) degrees preoperatively, (14.40 +/- 5.70) degrees postoperatively, and (15.50 +/- 5.20) degrees at final follow-up. There was significant reduction of the [E-S, ROM at final follow-up (P = 0.01). CONCLUSION: Posterior interspinous stabilization with Coflex system combined with spinal fusion can obtain satisfactory outcomes for patients with two levels lumbar degenerative disease in the short follow-up duration. Nevertheless,no overwhelming evidence suggested that the system is better than traditional fusion at present. The selection of surgical indication is important for the treatment of lumbar degenerative disease.

Position of increased signal intensity in the spinal cord on MR images: does it predict the outcome of cervical spondylotic myelopathy?

BACKGROUND: Increased signal intensity (ISI) in the spinal cord on T2-weighted MR images has been reported in some previous researches, however no study focused on the position of the ISI in the spinal cord and its potential value. The aim of this study was to investigate the correlation between ISI position and the outcome of surgical treatment for cervical spondylotic myelopathy (CSM) patients. METHODS: A retrospective study was conducted. Pre- and post-operative clinical status was evaluated by modified Japanese Orthopaedic Association (JOA) score. ISI was evaluated according to the T2-weighted sequences. The JOA score and the recovery ratios among patients with ISI in gray matter (group A), in both gray and white matter (group B), and ISI-negative group were compared. RESULTS: Totally 64 patients were enrolled in this retrospective study. Preoperative JOA score of ISI positive and negative group had significant difference, but the recovery ratios had no significant difference (the recovery ratios of the two groups in week 1, week 26, and week 104 were (21.54 +/- 14.65)%, (50.56 +/- 14.76)%, (59.23 +/- 13.08)% and (20.25 +/- 14.32)%, (54.46 +/- 23.16)% and (61.26 +/- 29.4)%, respectively; P > 0.05). The recovery ratios of negative group and group A in week 104 were superior to group B (the recovery ratios of negative group, group A, and group B in week 104 were (61.26 +/- 29.49)%, (65.35 +/- 11.36)%, and (50.33 +/- 10.20)%, respectively; P < 0.05). CONCLUSIONS: Patients with ISI in the gray matter alone on T2-weighted MR images did not have significantly different surgical outcomes compared with those without ISI. Patients with ISI in both gray and white matter had surgical outcomes that were worse than those without ISI.

Anterior debridement and bone grafting of spinal tuberculosis with one-stage instrumentation anteriorly or posteriorly.

Between 2000 and 2004, 40 cases (average age 38, range 16-65 years) of spinal tuberculosis were treated with anterior debridement and iliac bone graft with one-stage anterior or posterior instrumentation in our unit. All patients received at least 2 weeks of regular antituberculous chemotherapy before surgery. We followed up all patients for 12-48 months (mean 22 months). Local symptoms of all patients were relieved significantly 1-3 weeks postoperatively; 23 of 25 cases (92%) with neurogical deficit had excellent or good clinical results. Erythrocyte sedimentation rates (ESR) returned from 51 mm/h to 32 mm/h (average) two weeks postoperatively. Kyphosis degrees were corrected by a mean of 16 degrees . Fusion rate of the grafting bone was 72.5% one year postoperatively and 90% two years postoperatively. Severe complications did not occur. We therefore believe that patients undergoing anterior debridement and iliac bone grafting with one-stage anterior or posterior instrumentation achieve satisfactory clinical and radiographic outcomes.

The treatment for multilevel noncontiguous spinal fractures.

We report the outcome of 30 patients with multilevel noncontiguous spinal fractures treated between 2000 and 2005. Ten cases were treated conservatively (group A), eight cases were operated on at only one level (group B), and 12 cases were treated surgically at both levels (group C). All cases were followed up for 14-60 months (mean 32 months). Initial mobilisation with a wheelchair or crutches in group A was 9.2 +/- 1.1 weeks, which was significantly longer than groups B and C with 6.8+/-0.7 weeks and 3.1 +/- 0.4 weeks, respectively. Operative time and blood loss in group C were significantly more than group B. The neurological deficit improved in six cases in group A (60%), six in group B (75%) and eight in group C (80%). Correction of kyphotic deformity was significantly superior in groups C and B at the operated level, and increasing deformity occurred in groups A and B at the non-operated level. From the results we believe that three treatment strategies were suitable for multilevel noncontiguous spinal fractures, and individualised treatment should be used in these patients. In the patients treated surgically, the clinical and radiographic outcomes are much better.