Objective To investigate the surgical method and prel iminary cl inical result of managing the patient with lumbar burst fracture but not suitable for single-level fixation and fusion surgery with the reservation of the fractured vertebral body and the anterior decompression. Methods From September 2007 to December 2008, 11 patients with lumbar burst fracture underwent the removal of the posterior superior corner of the injured vertebral body, the removal of the inferior intervertebral disc adjacent to the injured vertebral body, bone graft fusion, and internal fixation. There were 8 males and3 females aged 21-48 years old (average 29.4 years old). All the fractures caused by fall ing from high places. Imaging exams confirmed all the fractures were Denis type B burst fracture. The fracture level was at the L1 in 4 cases, the L2 in 4 cases, the L3 in 2 cases, and the L4 in 1 case. Before operation, the nerve function was graded as grade B in 4 cases, grade C in 3 cases, and grade D in 4 cases according to Frankel scales; the visual analogue scale (VAS) was (7.30 ± 0.98) points; lateral X-ray films displayed the kyphosis Cobb angel was (24.94 ± 12.21)°; the adjacent superior and inferior intervertebral disc height was (12.78 ± 1.52) mm and (11.68 ± 1.04) mm, respectively; CT scan showed the vertebral canal sagittal diameter was (9.56 ± 2.27) mm; CT three-dimensional reconstruction revealed that the intact part of the injured vertebra was less than 50% vertebra body height and the fracture l ine crossed the pedicle. The time from injury to operation was 3-11 days (average 4.8 days). The neurological and radiological evaluations were carried out immediately and 3 months after operation, respectively, and compared with the condition before operation. Results All the patients successfully underwent the surgery. The wound all healed by first intention. All the patients were followed up for 6-18 months (average 14 months). All the patients had a certain degree of nerve function recovery. The Frankel scales in all the patients were increased by 1-2 grade immediately and 3 months after operation. The VAS score was (2.80 ± 1.49) points immediately after operation and (1.54 ± 0.48) points 3 months after operation, suggesting there were significant differences among three time points (P lt; 0.05). The vertebral canal sagittal diameter was significantly enlarged to (18.98 ± 4.82) mm immediately after operation and was (19.07 ± 4.37) mm 3 months after operation. The Cobb angle was (7.78 ± 4.52)° immediately after operation and (8.23 ± 3.57)° 3 months after operation. There were significant differences between before and after operation (P lt; 0.05). For the adjacent superior and inferior intervertebral disc height, there was no significant difference when the value immediately or 3 months after operation was compared with that of before operation (P gt; 0.05). X-ray films and CT scan 3 months after operation showed good internal fixation without theoccurrence of loosing and displacement. Conclusion For the treatment of lumbar burst fracture, the method of reserving the injured vertebral body and anterior decompression can decompress the vertebral canal and shorten the duration for bony fusion.
In recent years, enhanced recovery after surgery (ERAS) has been widely used in spine surgery and achieved satisfactory results. In order to standardize the ERAS implementation process and application in percutaneous endoscopic interlaminar lumbar decompression/discectomy (PEID), we reviewed the literatures and cited evidence-based medicine data, and had a national comprehensive discussion among experts of the Group of Minimally Invasive Spinal Surgery and Enhanced Recovery, Professional Committee of Orthopedic Surgery and Enhanced Recovery, Association of China Rehabilitation Technology Transformation and Promotion. Altogether, the up-to-date expert consensus have been achieved. The consensus may provide the reference for clinical treatment in aspect of the standardization of surgical operations, the reduction of surgical trauma and complications, the optimization of perioperative pain and sleep management, the prevention of venous thrombosis, and the guidance of patients’ functional training and perioperative education.
Objective To investigate the feasibility and effectiveness of robot-assisted posterior minimally invasive access in treatment of thoracolumbar tuberculosis via transforaminal expansion approach. Methods A clinical data of 40 patients with thoracolumbar tuberculosis admitted between January 2017 and May 2022 and met the selection criteria was retrospectively analyzed. Among them, 15 cases were treated with robot-assisted and minimally invasive access via transforaminal expansion approach for lesion removal, bone graft, and internal fixation (robotic group), and 25 cases were treated with traditional transforaminal posterior approach for lesion removal and intervertebral bone grafting (traditional group). There was no significant difference in the baseline data between the two groups (P>0.05) in terms of gender, age, lesion segment, and preoperative American Spinal Injury Association (ASIA) grading, Cobb angle, visual analogue scale (VAS) score, erythrocyte sedimentation rate (ESR), and C reactive protein (CRP). The outcome indicators were recorded and compared between the two groups, including operation time, intraoperative bleeding volume, hospital stay, postoperative bedtime, complications, ESR and CRP before operation and at 1 week after operation, the level of serum albumin at 3 days after operation, VAS score and ASIA grading of neurological function before operation and at 6 months after operation, the implant fusion, fusion time, Cobb angle of the lesion, and the loss of Cobb angle observed by X-ray films and CT. The differences of ESR, CRP, and VAS score (change values) between pre- and post-operation were calculated and compared. Results Compared with the traditional group, the operation time and intraoperative bleeding volume in the robotic group were significantly lower and the serum albumin level at 3 days after operation was significantly higher (P<0.05); the postoperative bedtime and the length of hospital stay were also shorter, but the difference was not significant (P>0.05). There were 2 cases of poor incision healing in the traditional group, but no complication occurred in the robotic group, and the difference in the incidence of complication between the two groups was not significant (P>0.05). There were significant differences in the change values of ESR and CRP between the two groups (P<0.05). All Patients were followed up, and the follow-up time was 12-18 months (mean, 13.0 months) in the traditional group and 12-16 months (mean, 13.0 months) in the robotic group. Imaging review showed that all bone grafts fused, and the difference in fusion time between the two groups was not significant (P>0.05). The difference in Cobb angle between the pre- and post-operation in the two groups was significant (P<0.05); and the Cobb angle loss was significant more in the traditional group than in the robotic group (P<0.05). The VAS scores of the two groups significantly decreased at 6 months after operation when compared with those before operation (P<0.05); the difference in the change values of VAS scores between the two groups was not significant (P>0.05). There was no occurrence or aggravation of spinal cord neurological impairment in the two groups after operation. There was a significant difference in ASIA grading between the two groups at 6 months after operation compared to that before operation (P<0.05), while there was no significant difference between the two groups (P>0.05). Conclusion Compared with traditional posterior open operation, the use of robot-assisted minimally invasive access via transforaminal approach for lesion removal and bone grafting internal fixation in the treatment of thoracolumbar tuberculosis can reduce the operation time and intraoperative bleeding, minimizes surgical trauma, and obtain definite effectiveness.
Objective To investigate the relationship between the expression of apoptosis-related gene Fas and recovery of neurological function after surgical decompression at different time points in acute spinal cord injury (SCI) rat model by cerclage. Methods A total of 100 13-week-old male Sprague Dawley rats (weighing, 255-376 g) were randomly divided into 4 groups (n=25). The rats only received laminectomy in group A as control; the rats were made the acute SCI models by cerclage in groups B, C, and D. The spinal cord decompression was performed in group B at 8 hours and in group C at 72 hours, no spinal cord decompression in group D. At 1, 3, 7, 14, and 21 days, Basso-Beattie-Bresnahan (BBB) score and inclined plane test were used to evaluate the recovery of neurological function; the neuronal apoptosis level of spinal cord was examined by TUNEL staining; HE staining and immunohistochemical staining were applied to analyze the expressions of Fas. Results The BBB score and inclined plane test score in group A were significantly better than those in groups B, C, and D at different time points (P lt; 0.05); group B was significantly better than groups C and D, and group C than group D at 3, 7, 14, and 21 days (P lt; 0.05). In group A, no bleeding, edema, or necrosis was found. The edema, hemorrhage, and neuron death were observed in spinal cord tissue of groups B, C, and D at 1 day after operation, especially in group D. The degree of cell degeneration in group B was lighter than that in groups C and D at 3 and 7 days after operation; few glial cells and fibroblast proliferation were found at damaged zone in group B at 14 and 21 days, but necrosis and cystic cavity in groups C and D. Fas and TUNEL expression was little in group A at different time points. Fas and TUNEL were expressed in groups B, C, and D; the expressions of Fas and TUNEL reached the maximum at 3 days, and then gradually decreased at 7 and 21 days. The number of positive cells was highest in group D, and the number of positive cells in group B was significantly less than that in groups C and D (P lt; 0.05). Conclusion Early decompression of SCI is beneficial to recovering the neurological function. The Fas signal pathway may play an important role in the apoptosis of neuron and glial cells after SCI.
Objective To determine the feasibility, safety, and efficacy of common pedicle screw placement under direct vision combined with dome shaped decompression via small incision for double segment thoracolumbar fracture with nerve injury. Methods A retrospective analysis was performed on the clinical data of 32 patients with double segment thoracolumbar fracture with nerve injury undergoing common pedicle screw placement under direct vision combined with dome shaped decompression via small incision between November 2011 and November 2015 (combined surgery group), and another 32 patients undergoing traditional open pedicle screw fixation surgery (traditional surgery group). There was no significant difference in gender, age, cause of injury, time of injury-to-surgery, injury segments and Frankel classification of neurological function between two groups (P>0.05). The length of soft tissue dissection, the operative time, the blood loss during surgery, the postoperative drainage, the visual analogue scale (VAS) of incision after surgery, and recovery of neurological function after surgery were evaluated. Results All cases were followed up 9 to 12 months (mean, 10.5 months) in combined surgery group, and 8 to 12 months (mean, 9.8 months) in traditional surgery group. The length of soft tissue dissection, the operative time, the blood loss during surgery, the postoperative drainage, and the postoperative VAS score in the combined surgery group were significantly better than those in the traditional surgery group (P<0.05). Dural rupture during surgery and pedicle screw pulling-out at 6 months after surgery occurred in 2 cases and 1 case of the combined surgery group; dural rupture during surgery occurred in 1 case of the traditional surgery group. The X-ray films showed good decompression, and fracture healing; A certain degree of neurological function recovery was achieved in two groups. Conclusion Common pedicle screw placement under direct vision combined with dome shaped decompression via small incision can significantly reduce iatrogenic trauma and provide good nerve decompression. Therefore, it is a safe, effective, and minimally invasive treatment method for double segment thoracolumbar fracture with neurological injury.
Objective To explore the injury mechanism of the severethoracolumbar burst fracture and the necessity of anterior decompression and reconstruction with internal fixation. Methods From January 1999 to January 2004, 21 patients were treated with anterior decompression and reconstruction. The fractures were located at T12 in 6 patients, L1 in12, L2 in 4, L3 in 3,and L4 in 1. Four patients were treated with the “anterior approach” and “posterior approach” surgeries for severe column fractures.Results All the patients were restored to the normal physiological radian, and the spinal canal was decompressed completely. They werefollowed up for 1-6 years, and the bony fusion was observed radiologically.The spinal cord function was improved to the 1-3 Frankel grade in all the patients except 2. There were no such complications as leakage of the cerebrospinal fluid, platescrew loosening or breaking, or segment instability. The clinical effects were satisfactory. Conclusion The operation of the anterior decompression and reconstruction with internal fixation for severe thoracolumbar burst fracture has advantages of complete decompression, full bonegrafting, and firm internal fixation. It canrestore the spinal height and improve the spinal cord function.
Objective To retrospectively analyze the clinical and imaging features of multi-segmental lumbar intervertebral disc protrusion and its treatment with the limited recessive decompression operation. Methods Twenty two patients (14 males and 8 females, aged 49-68 years) were admitted to hospital from March 1999 to March 2004. They suffered from multisegmental lumbar intervertebral disc protrusion that involved L1S1 and were treated with the limited recessive decompression operation. Results The follow-up for 4-21 months showed that 16 of the patients had an excellent outcome, 5 had a good outcome, and 1 had fair outcome. There were nosuch operative complications as nerve root lesions and putamen lesions. Conclusion The limited recessive decompression operation is one of the available good treatments for multi-segmental lumbar intervertebral disc protrusion. It solves problems of herniation and stenosis and maintains stability ofthe spine.
Objective To review the application and progress of different minimally invasive spinal decompression in the treatment of lumbar spinal stenosis (LSS). Methods The domestic and foreign literature on the application of different minimally invasive spinal decompression in the treatment of LSS was extensively reviewed, and the advantages, disadvantages, and complications of different surgical methods were summarized. ResultsAt present, minimally invasive spinal decompression mainly includes microscopic bilateral decompression, microendoscopic decompression, percutaneous endoscopic lumbar decompression, unilateral biportal endoscopy, and so on. Compared with traditional open surgery, different minimally invasive spinal decompression techniques can reduce the operation time, intraoperative blood loss, and postoperative pain of patients, thereby reducing hospital stay and saving treatment costs. Conclusion The indications of different minimally invasive spinal decompression are different, but there are certain advantages and disadvantages. When patients have clear surgical indications, individualized treatment plans should be formulated according to the symptoms and signs of patients, combined with imaging manifestations.
Objective To summarize the progress of percutaneous endoscopic lumbar interbody fusion in the treatment of lumbar degenerative diseases. Methods The relevant literature about percutaneous endoscopic lumbar interbody fusion at home and abroad in recent years was reviewed, the approaches, technical characteristics, short- and long-term effectiveness, and complications of different surgical procedures were summarized. Results Percutaneous endoscopic lumbar interbody fusion is a safe and reliable treatment. At present, the main surgical methods in clinical application can be roughly summarized as percutaneous endoscopic posterior transforaminal lumbar interbody fusion (Endo-PTLIF), percutaneous endoscopic transforaminal lumbar interbody fusion (Endo-TLIF), percutaneous endoscopic oblique lumbar interbody fusion (Endo-OLIF), percutaneous endoscopic lumbar interbody fusion/Z’s percutaneous endoscopic lumbar interbody fusion (Endo-LIF/ZELIF), and unilateral biportal endoscopic transforaminal lumbar interbody fusion (UBE-TLIF). Each surgical method has its own technical characteristics and development. Conclusion Percutaneous endoscopic lumbar interbody fusion is a kind of combined technology based on the individualization of the patient’s anatomical structure and the technical differentiation of the surgeon. Surgical experience, choosing adaptive indication and operative way reasonably are the key for the success.
Objective To evaluate the feasibility, safety, and early effectiveness of percutaneous endoscopic thoracic spine surgery via the trench technique for ventral decompression in central calcified thoracic disc herniation (CCTDH) and thoracic ossification of the posterior longitudinal ligament (T-OPLL). MethodsSeven patients with single-segment CCTDH or T-OPLL admitted between June 2017 and May 2020 and meeting the selection criteria were retrospectively analyzed. There were 3 males and 4 females with an average age of 51.7 years ranging from 41 to 62 years. There were 2 patients with T-OPLL (T1, 2 in 2 cases) and 5 patients with CCTDH (T1, 2 in 1 case, T7, 8 in 1 case, T10, 11 in 2 cases, T11, 12 in 1 case). Five patients with thoracic axial pain and intercostal neuralgia had a preoperative visual analogue scale (VAS) score of 6.0 (5.0, 6.5), and 7 patients had a preoperative Japanese Orthopaedic Association (JOA) score of 21 (21.0, 22.0). Transforaminal approach was used in 4 cases and transpedicular approach in 3 cases. Ventral decompression of thoracic spinal cord was performed by thoracic endoscopy combined with trench technique. The operation time, intraoperative blood loss, postoperative hospital stay, and postoperative complications were recorded. Thoracic spine CT and MRI were performed preoperatively and postoperatively to evaluate the surgical decompression, VAS score was used to evaluate the pain of thoracic back and lower limbs, and JOA score was used to evaluate the functional recovery. Modified MacNab criteria was used to evaluate the effectiveness. ResultsAll surgeries were successfully completed. The operation time ranged from 60 to 100 minutes, with an average of 80.4 minutes; the intraoperative blood loss ranged from 40 to 75 mL, with an average of 57.1 mL; the postoperative hospital stay ranged from 4 to 7 days, with an average of 5.4 days. CT and MRI examinations indicated that the decompression was adequate. All 7 patients were followed up 3-22 months, with an average of 13.3 months. One case developed postoperative wound infection, and 1 case developed pneumonia; the remaining patients did not have any complications such as wound infection or cerebrospinal fluid leakage. Five patients with thoracic axial pain and intercostal neuralgia had VAS scores of 2.0 (1.5, 2.5) at 1 day after operation and 2.0 (1.0, 2.0) at last follow-up, both of which were significantly lower than the preoperative scores (P<0.05). At 1 day after operation, the JOA scores for all 7 patients were 22.0 (21.0, 24.0), which showed no significant difference compared to the preoperative score (P>0.05); however, at last follow-up, the score improved to 24.0 (24.0, 26.0), which was significant compared to the preoperative scores (P<0.05). At last follow-up, the effectiveness was assessed using the modified MacNab criteria, the results were excellent in 2 cases, good in 3 cases, fair in 2 cases, and the excellent and good rate was 71.4%.ConclusionUsing the trench technique, percutaneous endoscopic thoracic spine surgery can achieve the ventral decompression in CCTDH and T-OPLL, providing a new approach for surgical treatment of CCTDH and T-OPLL.