目的 探討前路小切口頂椎切除聯合后路矯形手術治療重度僵硬性脊柱側凸的可行性及療效。 方法 2009 年7月－2010年9月，采用前路小切口頂椎切除聯合后路矯形手術治療重度僵硬性脊柱側凸18例。其中男9例，女9例，年齡10～24歲，平均14.5歲。其中15 例特發性脊柱側凸（Lenke 2型6例，Lenke 3型1例，Lenke 4型8例），2 例脊髓空洞合并脊柱側凸，1 例Chiari畸形合并脊柱側凸。術前剃刀背高度（6.8 ± 2.3）cm，主胸彎Cobb角（99.6 ±10.0）°，主胸彎頂椎偏距（7.3 ± 1.3）cm。 結果 前路手術切口10～13 cm，平均（11.4 ± 1.0）cm；前路手術時間170～300 min，平均（215.3 ± 36.8）min；失血量300～1 300 mL，平均（662.5 ± 274.8） mL。所有患者隨訪25～39個月，平均30.7個月。末次隨訪時，剃刀背高度（1.0 ± 0.6）cm，矯正率86.7%；主胸彎Cobb角（31.4 ± 11.4）°，矯正率68.7%；主胸彎頂椎偏距（2.2 ± 0.9） cm，矯正率69.6%。上胸彎、胸腰彎/腰彎的Cobb 角及頂椎偏距亦明顯矯正，冠狀面及矢狀面平衡與術前相比，差異無統計學意義（P＞0.05）。未發生神經系統并發癥，1例患者在前路手術后入ICU行呼吸支持治療12 h，1例患者出現椎弓根螺釘穿透椎弓根上壁，2例患者出現鈦網位置不佳，隨訪未見鈦網位置改變。 結論 采用前路小切口頂椎切除聯合后路矯形治療重度僵硬性脊柱側凸安全可行，矯形效果滿意。
ObjectiveTo investigate the optimal surgical opportunity timing of posterior hemivertebra resection by comparing the outcomes of surgical treatment for congenital spinal deformity in patients at different ages. MethodsBetween January 2007 and Februay 2013, 36 cases of congenital hemivertebra scoliosis underwent one-stage posterior hemivertebra resection and segmental instrumentation fixation and fusion. There were 22 males and 14 females, with an average age of 16.8 years (range, 5-48 years). The patients were divided into 3 groups:group A (≤10 years, n=7), group B (10-20 years, n=22), and group C (>20 years, n=7). There was no significant difference in gender, segment, type, and complication among 3 groups (P>0.05). Anteroposterior and lateral X-ray films were taken before and after operation to measure the scoliosis Cobb angle, kyphosis Cobb angle, and C7 plumb line-center sacral vertical line (C7PL-CSVL). The improvement rate was calculated. And the perioperative and long-term complications were recorded. ResultsThe operation time of group A was significantly less than that of group C (P<0.05); the intraoperative blood loss of group B and group C were significantly more than that of group A (P<0.05); and the fixed segments of group B and group C were significantly more than those of group A (P<0.05). Thirty-six cases were followed up 7-62 months (mean, 31.3 months). No poor wound healing, pedicle cutting, pseudoarticulation formation, and other complications occurred during the follow-up. At last follow-up, 31 patients obtained a balance of double shoulders and double hips. The scoliosis Cobb angle, kyphosis Cobb angle, and C7PL-CSVL at immediate after operation and last follow-up were significantly improved when compared with preoperative ones in 3 groups (P<0.05). The scoliosis Cobb angle at last follow-up of group B was significantly larger than that of group C, the kyphotic correction rate at immediate after operation was significantly larger in groups A and C than in group B, the kyphotic correction rate of group B at last follow-up was significantly less than that of group C, and C7PL-CSVL correction rate of group A at immediate after operation was significantly larger than that of group B, all showing significant differences (P<0.05). ConclusionEarly one stage posterior hemivertebra resection is safe and effective, especially in patients who had no formation of structural compensatory bending and spinal stiffness, which can shorten the operation time and reduce the fixed segments and intraoperative hemorrhage. Influence on the growth and activity of the spine is relatively small.
ObjectiveTo evaluate the effectiveness of cervical single open-door laminoplasty with the unilateral C4,5 foraminotomy for cervical myelopathy in preventing postoperative C5 palsy. MethodsBetween January 2008 and June 2012, 200 consecutive patients with cervical myelopathy and unilateral C4,5 foraminal stenosis were treated, and the clinical data were retrospectively analyzed. Of them, 89 patients underwent cervical single open-door laminoplasty combined with unilateral C4,5 foraminotomy (group A), and 111 patients underwent simple cervical single open-door laminoplasty (group B). There was no significant difference in gender, age, disease duration, segmental lesions, and diagnosis distribution between 2 groups (P>0.05). The operation time, intraoperative bleeding volume, and the incidence of C5 palsy were recorded. The Japanese Orthopaedic Association (JOA) score before and after operation was used for neurological assessment, and the JOA recovery rate was calculated. ResultsThe operation time was (122±29) minutes and the intraoperative bleeding volume was (165±50) mL in group A, which were significantly higher than those in group B[(109±31) minutes and (145±32) mL] (t=3.033, P=0.010;t=3.429, P=0.003). All patients were followed up; the follow-up time was 3-48 months (mean, 25 months) in group A, and was 4-50 months (mean, 27 months) in group B. C5 palsy occurred in 1 patient of group A (1.12%), and in 9 patients of group B (8.11%), showing significant difference between 2 groups (χ2=3.709, P=0.045). The JOA score was significantly improved at 2 weeks and last follow-up after operation when compared with preoperative JOA scores in 2 groups (P<0.05), but no significant was found between at 2 weeks and at last follow-up (P>0.05) in each group. Between group A and group B, no significant difference was found in JOA score and the recovery rate (P>0.05). During follow-up, no persistent axial pain for a long time and obvious spinal instability occurred in 2 groups. ConclusionCervical single open-door laminoplasty with unilateral C4,5 foraminotomy can reduce the incidence of the C5 palsy for patients with cervical myelopathy combined with unilateral C4,5 foraminal stenosis.
Objective To compare the effectiveness of cortical bone trajectory screw (CBTS) and conventional pedicle screw for posterior lumbar interbody fusion (PLIF) in the treatment of single segment lumbar degenerative disease. Methods Between May 2013 and May 2016, a total of 97 patients with single segment lumbar degenerative disease were treated with PLIF. Fifty-one patients were fixed with CBTS in PLIF (trajectory screw group) and 46 with pedicle screw (pedicle screw group). There was no significant difference in age, gender, body mass index, preoperative diagnosis, lesion segment, and preoperative visual analogue scale (VAS) score, Oswestry dysfunction index (ODI) between 2 groups (P>0.05). The operation time, intraoperative blood loss, postoperative drainage, bed rest time, length of hospital stay, serum creatine kinase (CK) concentration, total amount of diclofenac sodium, perioperative complications, ODI, VAS score, and interbody fusion rate were recorded and compared between 2 groups. Results All patients were followed up 12 months. The patients in trajectory screw group had a significantly less operation time, intraoperative blood loss, postoperative drainage, and serum CK concentration when compared with the patients in pedicle screw group (P<0.05). Thirty-five patients (68.6%) in trajectory screw group and 46 patients (100%) in pedicle screw group were given diclofenac sodium within 48 hours after operation, showing significant difference between 2 groups (χ2=89.334, P=0.000). There was no significant difference in the incidence of perioperative complications between trajectory screw group and pedicle screw group (3.9% vs. 8.7%, P=0.418). There was no significant difference in the VAS score, ODI, and interbody fusion rate at 12 months after operation between 2 groups (P>0.05). Conclusion For the single segment degenerative lumbar disease, the use of CBTS or conventional pedicle screw for PLIF can obtain satisfactory clinical function and interbody fusion rate. But the former has the advantages of less blood loss, less intraoperative muscle damage, less perioperative pain, shorter length of hospital stay and bed rest time.
ObjectiveTo compare the complications and clinical scores of posterior lumbar intervertebral fusion (PLIF) in middle-aged and older patients of different ages, and to assess the risk of complications of PLIF in different ages, providing a reference for clinical treatment.MethodsThe clinical data of 1 136 patients, who were more than 55 years old and underwent PLIF between June 2013 and June 2016, were retrospectively analyzed. According to the age of patients undergoing surgery, they were divided into 3 groups as 55-64 years old, 65-74 years old, and ≥75 years old. The general characteristics, comorbidities, and surgical data of the three groups were compared, with comparison the morbidity of complications. According to the minimal clinical important difference (MCID), the improvement of patient’s pain visual analogue scale (VAS) score and the Oswestry disability index (ODI) score were compared. Univariate logistic regression analysis was used to analyze the difference of complications and the improvement of VAS and ODI scores. Multivariate logistic regression analysis was performed for the risk factors of complications.ResultsThere were significant differences in the number of surgical fusion segments and osteoporosis between groups (P<0.05); there was no significant difference in gender, body mass index, operation time, preoperative American Society of Anesthesiologists (ASA) classification, and comorbidities between groups (P>0.05). All patients were followed up 6-62 months with an average of 27.4 months. Among the results of postoperative complications, there were significant differences in the total incidence of intraoperative complications, systemic complications, minor complications, and the percentage of improvement of ODI score to MCID between groups (P<0.05); but there was no significant difference in the total incidence of complications at the end of long-term follow-up and the percentage of improvement of VAS score to MCID between groups (P>0.05). Univariate logistic regression analysis showed that after adjusting the confounding factors, there were significant differences in intraoperative complications and the percentage of improvement of ODI score to MCID between 55-64 and 65-74 years old groups (P<0.05); systemic complications, minor complications, complications at the end of long-term follow-up, and the percentage of improvement of ODI score to MCID in ≥75 years old group were significantly different from those in the other two groups (P<0.05). Multivariate logistic regression analysis showed that age was a risk factor for systemic complications, minor complications, and complications at the end of long-term follow-up. Except for age, long operation time was a risk factor for intraoperative complications, increased number of fusion segments was a risk factor for systemic complications, the number of comorbidities was a risk factor for minor complications, and osteoporosis was a risk factor for complications at the end of long-term follow-up.ConclusionThe risk of surgical complications is higher in the elderly patients (≥75 years) with lumbar degenerative diseases than in the middle-aged and older patients (<75 years), while the improvements of postoperative VAS and ODI scores were similar. Under the premise of fully assessing surgical indications, PLIF has a positive effect on improving the elderly patients’ quality of life.
Objective To compare the effectiveness and radiological changes of posterior decompression combined with Coflex interspinous dynamic reconstruction or lumbar 360° fusion for degenerative lumbar spinal disorders at L4, 5. MethodsBetween October 2008 and November 2010, a comparative study was carried out on patients with degenerative lumbar spinal disorders at L4, 5. In group A, 29 patients underwent posterior decompression combined with Coflex interspinous dynamic reconstruction; there were 20 males and 9 females with an average age of 45.1 years (range, 21-67 years); and the disease duration was 2 months to 4 years. In group B, 31 patients underwent posterior decompression combined with lumbar 360° fusion treatment; there were 16 males and 15 females with an average age of 56.2 years (range, 32-86 years); and the disease duration was 3 months to 6 years. Except the age, there was no significant difference in gender, disease duration, and etiology etc. between 2 groups (P gt; 0.05). The results were assessed by Japanese Orthopaedic Association (JOA), visual analogue scale (VAS) scores, and Oswestry disabil ity index (ODI). The range of motion (ROM) and intervertebral height of affected and adjacent segments, and the ROM of lumbar were measured before operation and last follow-up. Results Significant differences were found in the operative time and blood loss between 2 groups (P lt; 0.05). Intraoperative dural tear occurred in 1 case of group B, spinal canal venous plexus hemorrhage in 1 case of group B, and postoperative cerebrospinal fluid leakage in 2 cases of group A and B respectively, showing no significant difference (χ2=0.119, P =0.731). The follow-up was 12-21 months in group A and was 12-23 months in group B. At the last follow-up, the JOA, VAS scores, and ODI of groups A and B were significantly improvedwhen compared with the preoperative values (P lt; 0.05). The VAS score of group A was significantly higher than that of group B (P lt; 0.05). There was no significant difference in the intervertebral height of L4, 5 and L5, S1 of groups A and B between pre- and post-operation (P gt; 0.05). In group B, the intervertebral height of L3, 4 was significantly reduced (P lt; 0.05) compared with the preoperative one. There was no significant difference in the ROM of L5, S1 and ROM of lumbar in groups A and B between preand post-operation (P gt; 0.05). At last follow-up, the ROM of L4, 5 was significantly reduced in group A (P lt; 0.05), and the ROM of L3, 4 was significantly increased in group B (P lt; 0.05). Except significant differences in the intervertebral height and ROM of L3, 4 between 2 groups (P lt; 0.05), no significant difference was found in other parameters (P gt; 0.05). Conclusion Posterior decompression combined with Coflex interspinous dynamic reconstruction has the same effectiveness as lumbar 360° fusion in treating degenerative lumbar spinal disorders at L4, 5, but the former has a protective effect on the adjacent segments of fusion and is recommended for initial treatment of young adults and the elderly and frail patients with recurrent.
ObjectiveTo investigate the effect of prophylactic C4, 5 foraminal dilatation in posterior cervical open-door surgery on postoperative C5 nerve root palsy syndrome.MethodsThe clinical data of patients with cervical spondylotic myelopathy (cervical spinal cord compression segments were more than 3) who met the selection criteria between March 2016 and March 2019 were retrospectively analyzed. Among them, 40 patients underwent prophylactic C4, 5 foraminal dilatation in posterior cervical open-door surgery (observation group) and 40 patients underwent simple posterior cervical open-door surgery (control group). There was no significant difference between the two groups (P>0.05) in gender, age, disease duration, Nurick grade of spinal cord symptoms, and preoperative diameter of C4, 5 intervertebral foramen, Japanese Orthopaedic Association (JOA) score, and visual analogue scale (VAS) score. The occurrence of C5 nerve root paralysis syndrome was recorded and compared between the two groups, including incidence, paralysis time, recovery time, and spinal cord drift. VAS and JOA scores were used to evaluate the improvement of pain and function before operation and at 12 months after operation.ResultsThe incisions of the two groups healed by first intention, and there was no early postoperative complications such as cerebrospinal fluid leakage. Patients of both groups were followed up 12-23 months, with an average of 17.97 months. C5 nerve root paralysis syndrome occurred in 8 cases in the observation group (3 cases on the right and 5 cases on the left) and 2 cases in the control group (both on the right). There was significant difference of the incidence (20% vs. 5%) between the two groups (χ2=4.114, P=0.043). Except for 1 case in the observation group who developed C5 nerve root palsy syndrome at 5 days after operation, the rest patients all developed at 1 day after operation; the recovery time of the observation group and the control group were (3.87±2.85) months and (2.50±0.70) months respectively, showing no significant difference between the two groups (t=–0.649, P=0.104). At 12 months after operation, the JOA score and VAS score of cervical spine in the two groups significantly improved when compared with those before operation (P<0.05); there was no significant difference in the difference of the cervical spine JOA score and VAS score between at 12 months after operation and before operation and the degree of spinal cord drift between the two groups (P>0.05).ConclusionProphylactic C4, 5 foraminal dilatation can not effectively prevent and reduce the occurrence of postoperative C5 root palsy, on the contrary, it may increase its incidence, so the clinical application of this procedure requires caution.
Objective To evaluate the clinical effects of surgical treatment for 30 patients with discogenic low back pain. Methods A total of 30 patients with 36 intervertebral discs were treated with posterior approach lumbar discectomy and interbody fusion with internal fixation by strict criteria. All patients were followed up for one year. The low back pain before and one year after surgery was evaluated by Japanese Orthopaedic Association (JOA) score and Visual Analogue Scale (VAS) score. Results The patients’ JOA score increased from 14.6±2.3 (before operation) to 27.1±0.9 (one year after operation) (t=–26.936, P<0.001), while the patients’ VAS score decreased from 6.2±1.6 (before operation) to 1.4±0.9 (one year after operation) (t=16.335, P<0.001), and the differences were significant. Conclusion When the conservative treatment is invalid, the operation of posterior lumbar intervertebral fusion is an effective method for the patinets with discogenic low back pain.
ObjectiveTo evaluate the feasibility and effectiveness of one-stage posterior retaining part facet joint in laminectomy, bone graft and debridement combined with short segmental pedicle screw fixation for lumbosacral spinal tuberculosis. MethodsBetween January 2010 and December 2014, 32 cases of lumbosacral spinal tuberculosis (L4-S1) were treated by one-stage posterior retaining part facet joint in laminectomy, bone graft and debridement combined with short segmental pedicle screw fixation. There were 20 males and 12 females, aged 17-62 years (mean, 43 years). The disease duration was 12-48 months (mean, 18 months). The involved segments included L5, S1 level in 19 cases and L4, 5 level in 13 cases. The effectiveness was evaluated by Oswestry disability index (ODI) and imaging parameters (lumbar-sacral angle correction and Bridwell classification and CT fusion criteria) after operation. ResultsThe operation was successfully completed in all patients; the average operation time was 180 minutes, and the average intraoperative blood loss was 400 mL. All cases were followed up 12 to 67 months (mean, 15.6 months). At last follow-up, common toxic symptom of tuberculosis disappeared, and no internal fixation failure occurred. Neurological function was recovered to normal in 7 patients with neurological symptoms, and American Spinal Injury Association (ASIA) scale was improved to grade E from grade C (2 cases) and grade D (5 cases) before operation. At 1 year and last follow-up, the ODI scores were significantly improved when compared with preoperative score (P < 0.05), but no significant difference was found between at 1 year and last follow-up (P>0.05). The lumbarsacral angle was significantly increased at 7 days, 1 year and last follow-up when compared with preoperative one (P < 0.05), but there was no significant difference between different time points after operation (P>0.05). The bone graft fusion time was 9-24 months (mean, 12 months). At 1 year after operation and last follow-up, X-ray Bridwill bone fusion rates were 87.50% (28/32) and 93.75% (30/32) respectively, and CT fusion rates were 87.50% (28/32) and 90.63% (29/32) respectively; and there was significant difference in interbody fusion between at 1 year and last follow-up (P < 0.05). Drug resistance was observed in 4 cases; Bridwill gradeⅢand gradeⅣfusion was shown in 3 cases and 1 case after adjusting the anti-tuberculosis scheme after 1 year. ConclusionOne-stage posterior retaining part facet joint in laminectomy and debridement can effectively clear the tuberculose focus, intervertebral bone graft combined with short segment pedicle screw fixation can maintain postoperative spinal reliable stability and get satisfactory bone fusion rate, so it is an effective method for the treatment of lumbosacral tuberculosis.
Objective To explore the effectiveness and related issues in the treatment of multiple segments of thoracolumbar tuberculosis through posterior unilateral debridement with bone graft and internal fixation. Methods The clinical data of 29 patients with multiple segments of thoracolumbar tuberculosis who met the selection criteria were retrospective analyzed between January 2012 and July 2015. There were 17 males and 12 females, with age of 21-62 years (mean, 37.4 years). Lesions contained 3-8 vertebral segments, including 3 segments in 6 cases, 4-6 segments in 17 cases, and 7-8 segments in 6 cases. The center lesions located at thoracic spine in 8 cases, lumbar spine in 10 cases, and thoracolumbar segment in 6 cases, and thoracic lumbar skip lesions in 5 cases. The complications included vertebral abscess in 7 cases, psoas major abscess in 6 cases, sacral spine muscle abscess in 7 cases, iliac fossa and the buttocks abscess in 1 case, spinal canal abscess in 2 cases. Preoperative neurological function was assessed according to the American Spinal Injury Association (ASIA) classification: 1 case of grade B, 3 cases of grade C, 8 cases of grade D, and 17 cases of grade E. The disease duration was 6-48 months (mean, 19.3 months). All the patients were treated with posterior unilateral transpedicular or transarticular debridement with bone graft fusion and internal fixation under general anesthesia. Pre- and post-operative visual analogue scale (VAS) score, Oswestry disability index (ODI), and sagittal Cobb angle were recorded and compared. Bridwell classification standard was used to evaluate bone graft fusion. According to the number and the center of the lesion, the necessity to placement of titanium mesh cage was analyzed. Results All the patients were followed up 18-30 months (mean, 24 months). Cerebrospinal fluid leakage occurred in 3 cases, intercostal neuralgia in 2 cases, wound unhealed and fistula formation in 1 case, and ofiliac fossa abscess recurred in 1 case, and all recovered after symptomatic treatment. During follow-up, no fracture or loosing of internal fixation was found and all the lesions were cured at last follow-up. According to Bridwell classification standard, bone graft achieved bony fusion during 4-9 months after operation. The VAS score, ODI, and Cobb angle at immediate after operation and at last follow-up were significantly improved when compared with preoperative ones (P<0.05). At last follow-up, the neural function of all patients improved significantly when compared with preoperative one (Z= –3.101, P=0.002). The ratio of no placement of titanium mesh cage was significantly higher in patients with more than 6 lesion segments (6/6, 100%) than in patients with less than 6 lesion segments (4/23, 17.4%) (χ2=14.374, P=0.000). And the ratio of placement of titanium mesh cage was not significantly different between the patients with the different locations of center focus (χ2=0.294, P=0.863). Conclusion For treating multiple segments of thoracolumbar tuberculosis, the method of posterior unilateral debridement with bone graft and internal fixation can decrease the damage of posterior spinal structures and surgical trauma.