ObjectiveTo compare the clinical and radiological effectiveness of oblique lumbar interbody fusion (OLIF) and posterior lumbar interbody fusion (PLIF) in the treatment of Cage dislodgement after lumbar surgery.MethodsThe clinical data of 40 patients who underwent revision surgery due to Cage dislodgement after lumbar surgery betweem April 2013 and March 2017 were retrospectively analyzed. Among them, 18 patients underwent OLIF (OLIF group) and 22 patients underwent PLIF (PLIF group) for revision. There was no significant difference between the two groups in age, gender, body mass index, intervals between primary surgery and revision surgery, number of primary fused levels, disc spaces of Cage dislodgement, and visual analogue scale (VAS) scores of low back pain and leg pain, Oswestry disability index (ODI), the segmental lordosis (SL) and disc height (DH) of the disc space of Cage dislodgement, and the lumbar lordosis (LL) before revision (P>0.05). The operation time, intraoperative blood loss, hospital stay, and complications of the two groups were recorded and compared. The VAS scores of low back pain and leg pain were evaluated at 3 days, 3, 6, and 12 months after operation, and the ODI scores were evaluated at 3, 6, and 12 months after operation. The SL and DH of the disc space of Cage dislodgement and LL were measured at 12 months after operation and compared with those before operation. CT examination was performed at 12 months after operation, and the fusion of the disc space implanted with new Cage was judged by Bridwell grading standard.ResultsThe intraoperative blood loss in the OLIF group was significantly less than that in the PLIF group (t=?12.425, P=0.000); there was no significant difference between the two groups in the operation time and hospital stay (P>0.05). Both groups were followed up 12-30 months, with an average of 18 months. In the OLIF group, 2 patients (11.1%) had thigh numbness and 1 patient (5.6%) had hip flexor weakness after operation; 2 patients (9.1%) in the PLIF group had intraoperative dural sac tear. The other patients’ incisions healed by first intention without early postoperative complications. There was no significant difference in the incidence of complications between the two groups (χ2=0.519, P=0.642). The VAS scores of low back pain and leg pain, and the ODI score of the two groups at each time point after operation were significantly improved when compared with those before operation (P<0.05); there was no significant difference between the two groups at each time point after operation (P>0.05). At 12 months after operation, SL, LL, and DH in the two groups were significantly increased when compared with preoperative ones (P<0.05); SL and DH in the OLIF group were significantly improved when compared with those in the PLIF group (P<0.05), and there was no significant difference in LL between the two groups (P>0.05). CT examination at 12 months after operation showed that all the operated disc spaces achieved bony fusion. According to the Bridwell grading standard, 12 cases were grade Ⅰ and 6 cases were grade Ⅱ in the OLIF group, and 13 cases were grade Ⅰ and 9 cases were grade Ⅱ in the PLIF group; there was no significant difference between the two groups (Z=–0.486, P=0.627). During follow-up, neither re-displacement or sinking of Cage, nor loosening or fracture of internal fixation occurred.ConclusionOLIF and PLIF can achieve similar effectiveness in the treatment of Cage dislodgement after lumbar surgery. OLIF can further reduce intraoperative blood loss and restore the SL and DH of the disc space of Cage dislodgement better.
ObjectiveTo explore the fusion effect of allograft Cages on transforaminal lumbar interbody fusion (TLIF).MethodsThe clinical data of 30 patients (38 vertebral segments) who underwent TLIF with allograft interbody fusion Cages between January 2015 and January 2017 were retrospectively analysed. There were 25 males and 5 females with an average age of 56.9 years (range, 44-72 years). The lesions included 20 cases of lumbar disc herniation, 7 cases of lumbar spondylolisthesis, and 3 cases of lumbar spinal stenosis. The operation section included 4 cases of L3, 4, 13 cases of L4, 5, 5 cases of L5, S1, 6 cases of L4, 5-L5, S1, and 2 cases of L3, 4-L4, 5. The disease duration was 6-36 months (mean, 12 months). The clinical effectiveness was evaluated by visual analogue scale (VAS) score, Oswestry disability index (ODI), and Japanese Orthopaedic Association (JOA) score at preoperation, 3 months and 6 months after operation, and last follow-up. The fusion rate was evaluated by anteroposterior and lateral X-ray films and CT three-dimensional reconstruction at 3 and 6 months after operation. The intervertebral space height was measured on anteroposterior and lateral X-ray films at preoperation, 3 days, 3 months, and 6 months after operation.ResultsThe operation time was 2.1-4.3 hours (mean, 3.1 hours), and the intraoperative blood loss was 150-820 mL (mean, 407.5 mL). The follow-up time was 8-25 months (mean, 16.4 months). One Cage split at 6 months after operation without Cage movement and neurologic symptoms; none of the other patients had Cage prolapse, displacement, and fragmentation. No local or systemic allergy or infection signs was found in all patients. No nerve compression or symptoms was observed during the follow-up. The postoperative VAS score, ODI score, and JOA score improved significantly when compared with preoperative scores (P<0.05); and the scores at 6 months and at last follow-up were significantly improved when compared with those at 3 months after operation (P<0.05); but no significant difference was found between at 6 months and at last follow-up (P>0.05). The fusion rate was 55.3% (21/38), 92.1% (35/38), and 100% (38/38) at 3 months, 6 months, and last follow-up postoperatively. The intervertebral space height was increased significantly at 3 days, 3 months, 6 months, and last follow-up postoperatively when compared with preoperative ones (P<0.05); and the loss of intervertebral space height was significant at last follow-up when compared with postoperative at 3 days (P<0.05).ConclusionThe allograft interbody fusion Cage contributes to the spine interbody fusion by providing an earlier stability and higher fusion rate.
ObjectiveTo investigate the advantage and short- and medium-term effectivenesses of paramedian incision minimally invasive transforaminal lumbar interbody fusion (mini-TLIF) by comparing with open TLIF. MethodsA retrospective analysis was made on the clinical data of 54 patients with single segmental lumbar degenerative disease who accorded with the inclusion criteria between January 2012 and March 2014. Open TLIF was performed in 26 patients (open group), mini-TLIF in 28 cases (minimally invasive group). There was no significant difference in gender, age, disease duration, etiology, and affected segments between 2 groups (P>0.05). The indexes of surgical trauma, systemic inflammatory response, clinical outcome, and interbody fusion rate were compared between 2 groups. ResultsDural rupture occurred in 1 case of open group, L5 nerve root injury in 1 case of minimally invasive group. All patients obtained primary healing of incision. The operation time, intraoperative blood loss, and postoperative drainage of minimally invasive group were significantly lower than those of open group (P<0.05). C-reactive protein, leucocyte count, and creatine kinase-MM (CK-MM) of open group were significantly higher than those of minimally invasive group at 24 hours after operation (P<0.05). At 7 days after operation, the CK-MM of minimally invasive group was significantly lower than that of open group (P<0.05), but no significant difference was found in C-reactive protein and leucocyte count between 2 groups (P>0.05). The follow-up time was 1.2-3.1 years in open group and 1.4-2.9 years in minimally invasive group. At 1 year after operation, the Oswestry disability index (ODI) and visual analogue scale (VAS) scores were significantly improved in 2 groups (P<0.05). Minimally invasive group was better than open group in ODI and VAS score of back pain (P<0.05), but VAS score of leg pain showed no significant difference (P>0.05). According to the Suk interbody fusion standard, solid fusion was obtained in 18 cases, probable fusion in 4 cases, and nonunion in 4 cases, and the fusion rate was 84.61% in open group; solid fusion was obtained in 21 cases, probable fusion in 3 cases, and nonunion in 4 cases, and the fusion rate was 85.71% in minimally invasive group; and the interbody fusion rates showed no significant difference between 2 groups (χ2=0.072, P=0.821). ConclusionCompared with open TLIF, paramedian incision mini-TLIF has advantages of minimal surgical trauma and little blood loss for single-level lumbar degenerative disease. The short- and medium-term effectivenesses are satisfactory.
ObjectiveTo systematically review the effectiveness and safety of dynamic neutralization system (Dynesys) versus posterior lumbar interbody fusion (PLIF) for lumbar degenerative disease. MethodsDatabases including PubMed, EMbase, The Cochrane Library (Issue 5, 2016), CNKI, CBM, VIP and WanFang Data were searched to collect studies about Dynesys versus PLIF for lumbar degenerative disease from inception to May 31st 2016. Two reviewers independently screened literature, extracted data, and evaluated the methodological quality of included studies. Then, meta-analysis was performed using RevMan 5.3 software. ResultsA total of 22 studies involving 1 482 patients were included. The results of meta-analysis showed that, compared with PLIF, Dynesys could reduce operative time (MD=-29.62, 95%CI -36.67 to -22.57), operative blood loss (MD=-112.10, 95%CI -130.60 to -93.61), length of hospital stay (MD=-2.62, 95%CI -4.96 to -0.28), postoperative adjacent segment ROM (MD=-1.29, 95%CI -1.72 to -0.86) and maintain postoperative operated segment ROM (MD=3.53, 95%CI 1.99 to 5.08). There were no significant differences between two groups in postoperative ODI (MD=-1.51, 95%CI -3.58 to 0.55), postoperative back VAS (MD=-0.15, 95%CI -0.38 to 0.08), postoperative leg VAS (MD=-0.09, 95%CI -0.22 to 0.04) and postoperative complications (OR=0.69, 95%CI 0.45 to 1.06). ConclusionThe current evidence shows that compared with PLIF, Dynesys for lumbar degenerative disease has shorter operative time, less operative blood loss, shorter hospitalization days, and Dynesys can also maintain operated segment ROM and delay the degeneration of adjacent segment. Due to the limited quality of the included studies, more studies are needed to verify the above conclusion.
Objective To discuss the key issues in the diagnosis and treatment of degenerative disc disease and thetherapeutic effect of transforaminal lumbar interbody fusion on it. Methods From September 2004 to August 2006, 15 cases of degenerative disc disease were treated by transforaminal lumbar interbody fusion, including 8 males and 7 females with the age of 33-46 years. All cases were single-level degenerative disc diseases, including 1 case of L3,4, 8 cases of L4,5 and 6 cases of L5, S1. The course of the disease was 2 -10 years. Preoperatively, the score of visual analogue scale (VAS) was 8.9 ± 1.8 and the score of Oswestry disabil ity index (ODI) was 51.4 ± 8.3. All patients had received normal conventional treatment for at least 3 months and had no therapeutic effect before operation. Results The operation time was 120-180 minutes (150 minutes on average) and the intra-operative blood loss was 200-500 mL (360 mL on average). There was no severe compl ication, except that the muscle tone of anterior tibia in one case decreased to the third level, which recovered to the 5- level 3 months after operation. A total of 15 cases were followed up for 12-24 months (18 months on average). All patients got interbody bony fusion 12 months after operation with the fusion rate of 100%. Postoperatively, the score of VAS was 2.8 ± 1.6 and the score of ODI was 19.1 ± 3.2, indicating there were significant difference in comparison with postoperative ones (P lt; 0.05). The improvement rates of postoperative VAS and ODI were 61.8% ± 7.3% and 64.3% ± 5.5%, respectively. For the therapeutic effect, 6 cases were regardedas excellent, 8 good, 1 fair, and the choiceness rate was 93.3%. All patients resumed their jobs and normal l ives. Conclusion Transforaminal lumbar interbody fusion is effective for the treatment of lumbar degenerative disc disease, but the indications for operation must be strictly defined.
Objective To compare the short-term effectiveness between dynamic neutralization system (Dynesys) and posterior lumbar interbody fusion (PLIF) in the treatment of lumbar degenerative disease. Methods The clinical data were retrospectively analyzed, from 14 patients undergoing Dynesys and 18 patients undergoing PLIF to treat lumbar degenerative disease between February 2009 and March 2011. No significant difference in gender, age, duration of disease, and lesion segments was found between 2 groups (P gt; 0.05). The visual analogue scale (VAS) score, Oswestry disability index (ODI), and radiographic results were compared between 2 groups at preoperation and last follow-up. Results Thirty-one cases were followed up 12-21 months (mean, 17 months). No internal fixation loosening, broken screws, and broken rods was found during follow-up. The mean interbody fusion time was 15 months (range, 13-19 months) in PLIF group. The VAS score and ODI were significantly improved in 2 groups at last follow-up when compared with the preoperative ones (P lt; 0.05); but there was no signficant difference between 2 groups (P gt; 0.05). Imaging assessment: the range of motion (ROM) of operated segment in PLIF group was (0.1 ± 0.4)° at last follow-up, showing significant difference when compared with preoperative ROM (7.8 ± 0.6)° (t=28.500, P=0.004); the ROM in Dynesys group (5.0 ± 1.5)° decreased, but showing no significant difference when compared with preoperative ROM (7.5 ± 0.8)° (t=0.480, P=0.113); and significant difference was found between 2 groups (t=5.260, P=0.008) at last follow-up. The ROM of adjacent segment in Dynesys group at last follow-up (7.2 ± 0.7)° decreased when compared with preoperative ROM (7.3 ± 1.8)°, but showing no significant difference (t=0.510, P=0.108); however, ROM of adjacent segment in PLIF group (8.7 ± 0.4)° increased significantly when compared with preoperative ROM (7.0 ± 1.6)°, showing signifcant difference (t=3.440, P=0.042); and there was significant difference between 2 groups (t= — 2.100, P=0.047) at last follow-up. Conclusion Dynesys and PLIF have equivalent short-term effectivness in the treatment of lumbar degenerative disease. However, the Dynesys could retain ROM of operated segment without increased ROM of the adjacent segment, which will promote the disc recovery of operated segment and prevent degeneration of adjacent segment.
ObjectiveTo investigate the correlation between CT value and Cage subsidence in patients with lumbar degenerative disease treated with stand-alone oblique lumbar interbody fusion (OLIF). MethodsThe clinical data of 35 patients with lumbar degenerative diseases treated with stand-alone OLIF between February 2016 and October 2018 were retrospectively analyzed. There were 15 males and 20 females; the age ranged from 29 to 81 years, with an average of 58.4 years. There were 39 operative segments, including 32 cases of single-segment, 2 cases of double-segment, and 1 case of three-segment. Preoperative lumbar CT was used to measure the CT values of the axial position of L1 vertebral body, the axial and sagittal positions of L1-4 vertebral body, surgical segment, and the axial position of upper and lower vertebral bodies as the bone mineral density index, and the lowest T value was recorded by dual-energy X-ray absorptiometry. The visual analogue scale (VAS) and Oswestry disability index (ODI) scores were recorded before operation and at last follow-up. At last follow-up, the lumbar interbody fusion was evaluated by X-ray films of the lumbar spine and dynamic position; the lumbar lateral X-ray film was used to measure the subsidence of the Cage, and the patients were divided into subsidence group and nonsubsidence group. The univariate analysis on age, gender, body mass index, lowest T value, CT value of vertebral body, disease type, and surgical segment was performed to initially screen the influencing factors of Cage subsidence; further the logistic regression for multi-factor analysis was used to screen fusion independent risk factors for Cage subsidence. The receiver operating characteristic (ROC) curve and area under curve (AUC) were used to analyze the CT value and the lowest T value to predict the Cage subsidence. Spearman correlation analysis was used to determine the correlation between Cage subsidence and clinical results. Results All the 35 patients were followed up 27-58 months, with an average of 38.7 months. At last follow-up, the VAS and ODI scores were significantly decreased when compared with preoperative scores (t=32.850, P=0.000; t=31.731, P=0.000). No recurrent lower extremity radiculopathy occurred and no patient required revision surgery. Twenty-seven cases (77.1%) had no Cage subsidence (nonsubsidence group); 8 cases (22.9%) had at least radiographic evidence of Cage subsidence, the average distance of Cage subsidence was 2.2 mm (range, 1.1-4.2 mm) (subsidence group). At last follow-up, there was 1 case of fusion failure both in the subsidence group and the nonsubsidence group, there was no significant difference in the interbody fusion rate (96.3% vs. 87.5%) between two groups (P=0.410). Univariate analysis showed that the CT value of vertebral body (L1 axial position, L1-4 axial and sagittal positions, surgical segment, and upper and lower vertebral bodies axial positions) and the lowest T value were the influencing factors of Cage subsidence (P<0.05). According to ROC curve analysis, compared with AUC of the lowest T value [0.738, 95%CI (0.540, 0.936)], the AUC of the L1-4 axis CT value was 0.850 [95%CI (0.715, 0.984)], which could more effectively predict Cage subsidence. Multivariate analysis showed that the CT value of L1-4 axis was an independent risk factor for Cage subsidence (P<0.05). Conclusion The CT value measurement of the vertebral body based on lumbar spine CT before stand-alone OLIF can predict the Cage subsidence. Patients with low CT values of the lumbar spine have a higher risk of Cage subsidence. However, the Cage subsidence do not lead to adverse clinical results.
Objective A prospective randomized controlled trial was conducted to study the effectiveness and safety of intravenous different doses tranexamic acid (TXA) in single-level unilateral minimally invasive transforaminal lumbar interbody fusion (MIS-TLIF). Methods The patients treated with single-level unilateral MIS-TLIF between September 2019 and October 2020 were enrolled and randomly classified into low-dose TXA (LD) group (n=39), high-dose TXA (HD) group (n=39), and placebo-controlled (PC) group (n=38). The LD, HD, and PC groups received intravenous TXA 20 mg/kg, TXA 50 mg/kg, the same volume of normal saline at 30 minute before skin incision after general anesthesia, respectively. There was no significant difference on baseline characteristics and preoperative laboratory results among 3 groups (P>0.05), including age, gender, body mass index, surgical segments, hematocrit (HCT), hemoglobin (HGB), prothrombin time (PT), international normalized ratio (INR), D-dimer, fibrin degradation products (FDP), activated partial prothromboplastin time (APTT), alanine aminotransferase (ALT), aspartate aminotransferase (AST), creatinine (Cr), urea. The intraoperative blood loss (IBL), postoperative drainage volume, operation time, total blood loss (TBL), hidden blood loss (HBL), blood transfusion, hematological examination indexes on the first day after operation, and the incidence of complications within 1 month were compared among the 3 groups. Results There were 3, 2, and 4 patients in the LD, HD, and PC groups who underwent autologous blood transfusion, respectively, and there was no allogeneic blood transfusion patients in the 3 groups. There was no significant difference in IBL, postoperative drainage volume, and operation time between groups (P>0.05). The TBL, HBL, and the decreased value of HGB in LD and HD groups were significantly lower than those in PC group (P<0.05), and TBL and HBL in HD group were significantly lower than those in LD group (P<0.05); the decreased value of HGB between LD group and HD group showed no significant difference (P>0.05). On the first day after operation, D-dimer in LD and HD groups were significantly lower than that in PC group (P<0.05); there was no significant difference between LD and HD groups (P>0.05). There was no significant difference in other hematological indexes between groups (P>0.05). All patients were followed up 1 month, and there was no TXA-related complication such as deep venous thrombosis of lower extremity, pulmonary embolism, and epilepsy in the 3 groups. ConclusionIntravenous administration of TXA in single-level unilateral MIS-TLIF is effective and safe in reducing postoperative TBL and HBL within 1 day in a dose-dependent manner. Also, TXA can reduce postoperative fibrinolysis markers and do not increase the risk of thrombotic events, including deep venous thrombosis and pulmonary embolism.
Objective To review the progress in the features, early cl inical outcomes, and cl inical appl ication of axial lumbar interbody fusion (AxiaLIF) for the minimally invasive treatment of lumbosacral degenerative diseases. Methods The l iterature about the features, early cl inical outcomes, and cl inical appl ication of AxiaLIF for the minimally invasive treatment of lumbosacral degenerative diseases in recent years was reviewed. Results Almost 9 000 procedures performed globally in recent years, AxiaLIF has shown its safety and effectiveness because of high fusion rates, short hospital ization days, and less iatrogenic compl ications in comparison with standard fusion procedures. ConclusionPostoperative long-term outcomes, biomechanics stabil ity, and extended appl ication of AxiaLIF still need a further study,though it suggests an original minimally invasive treatment of lumbosacral degenerative diseases.
ObjectiveTo explore the value of modified subcutaneous lumbar spine index (MSLSI) as a predictor for short-term effectiveness of transforaminal lumbar interbody fusion (TLIF) in treatment of lumbar degenerative disease (LDD).MethodsBetween February 2014 and October 2019, 450 patients who were diagnosed as LDD and received single-segment TLIF were included in the study. Based on the MSLSI measured by preoperative lumbar MRI, the patients were sorted from small to large and divided into three groups (n=150). The MSLSI of group A was 0.11-0.49, group B was 0.49-0.73, and group C was 0.73-1.88. There was no significance in gender, age, disease duration, diagnosis, surgical segment, and improved Charlson comorbidity index between groups (P>0.05). There were significant differences in the subcutaneous adipose depth of the L4 vertebral body and body mass index (BMI) between groups (P<0.05). The operation time, intra-operative blood loss, length of incision, drainage tube placement time, drainage volume on the 1st day after operation, drainage volume on the 2nd day after operation, total drainage volume, antibiotic use time after operation, walking exercise time after operation, hospital stay, the incidences of surgical or non-surgical complications in the three groups were compared. Pearson correlation analysis was used to analyze the correlation between MSLSI and BMI, and partial correlation analysis was used to study the relationship between MSLSI, BMI, improved Charlson comorbidity index, subcutaneous adipose depth of the L4 vertebral body and complications. The Receiver Operating Characteristic (ROC) curve was used to evaluate the value of SLSI and MSLSI in predicting the occurrence of complications after TLIF in treatment of LDD.ResultsThere was no significant difference in operation time, length of incision, antibiotic use time after operation, walking exercise time after operation, drainage tube placement time, drainage volume on the 1st day after operation, drainage volume on the 2nd day after operation, and total drainage volume between groups (P>0.05). The amount of intra-operative blood loss in group C was higher than that in groups A and B, and the hospital stay was longer than that in group B, with significant differences (P<0.05). Surgical complications occurred in 22 cases (14.7%), 25 cases (16.7%), and 39 cases (26.0%) of groups A, B, and C, respectively. There was no significant difference in the incidence between groups (χ2=0.826, P=0.662). The incidences of nerve root injury and wound aseptic complications in group C were higher than those in groups A and B, and the incidence of nerve root injury in group B was higher than that in group A, with significant differences (P<0.05). There were 13 cases (8.7%), 7 cases (4.7%), and 11 cases (7.3%) of non-surgical complications in groups A, B, and C, respectively, with no significant difference (χ2=2.128, P=0.345). There was no significant difference in the incidences of cardiovascular complications, urinary system complications, central system complications, and respiratory system complications between groups (P>0.05). There was a correlation between MSLSI and BMI in 450 patients (r=0.619, P=0.047). Partial correlation analysis showed that MSLSI was related to wound aseptic complications (r=0.172, P=0.032), but not related to other surgical and non-surgical complications (P>0.05). There was no correlation between BMI, improved Charlson comorbidity index, subcutaneous adipose depth of the L4 vertebral body and surgical and non-surgical complications (P>0.05). ROC curve analysis showed that the area under ROC curve (AUC) of MSLSI was 0.673 (95%CI 0.546-0.761, P=0.025), and the AUC of SLSI was 0.582 (95%CI 0.472-0.693, P=0.191). ConclusionMSLSI can predict the short-term effectiveness of TLIF in treatment of LDD. Patients with high MSLSI suffer more intra-operative blood loss, longer hospital stay, and higher incidence of nerve root injury and postoperative incision complications.