ObjectiveTo investigate the effectiveness of minimally invasive transforaminal lumbar interbody fusion (MI-TLIF) assisted with microscope in treatment of lumbar spondylolisthesis. MethodsBetween January 2011 and June 2012, 52 patients with lumbar spondylolisthesis underwent MI-TLIF assisted with microscope. There were 29 males and 23 females with an average age of 46 years (range, 32-67 years). The median disease duration was 3.2 years (range, 3 months to 6 years). There were 38 cases of lumbar isthmic spondylolisthesis and 14 cases of degenerative spondylolisthesis; 12 cases had stenosis secondary to lumbar spondylolisthesis. The affected segments were L4, 5 (29 cases) and L5, S1 (23 cases). According to the Meyerding evaluating system, 24 cases were classified as degree I and 28 cases as degree Ⅱ. The visual analogue scale (VAS) score and Oswestry disability index (ODI)were used for clinical assessment, and the clinical effects were also analyzed by Macnab criterion at last follow-up. The radiographic data were used to evaluate reduction of spondylolisthesis, including slipping degree, slipping angle, and intervertebral space height. The fusion rate was assessed by Suk criterion. ResultsThe operations were performed successfully in all patients. No dural tear or cerebrospinal fluid leakage occurred during operation. The average operation time was 105 minutes; the average intraoperative blood loss was 225 mL; the average postoperative drainage volume was 75 mL; and the average hospitalization days were 5.5 days. Superficial infection of incision occurred in 1 case and was cured after change dressing, and primary healing of incision was obtained in the others. All patients were followed up 12-26 months (mean, 18 months). No loosening, breakage, and displacement of pedicle screw and no Cage dislocation occurred by X-ray films after operation. The lumbar spondylolisthesis all got good correction. The three-dimensional CT showed continuous bone trabecula between centrums. The VAS score, ODI, and the slipping degree, slipping angle, and intervertebral space height were significantly improved at last follow-up when compared with preoperative ones (P<0.05). According to Macnab criterion at last follow-up, the results were excellent in 20 cases, good in 29 cases, and fair in 3 cases; the excellent and good rate was 94.2%. According to Suk criterion for fusion, 49 cases obtained complete fusion and 3 cases got possible fusion. ConclusionAs long as indications are seized, MI-TLIF assisted with microscope is safe and reliable for treatment of lumbar spondylolisthesis (Meyerding dergee I or Ⅱ), and it has the advantage of less injury, less blood loss, less complications, and definite short-term effectiveness.
Objective To compare the therapeutic effect of conventional discectomy, posterior lumbar interbody fusion (PLIF), and transforaminal lumbar interbody fusion (TLIF) on the recurrent lumbar disc protrusion (RLDP). Methods From January 2000 to January 2008, 65 patients with RLDP underwent different surgical procedures, namely conventional discectomy (group A, 25 cases), PLIF (group B, 22 cases), and TLIF (group C, 18 cases). There were 44 males and 21 females aged 26-65 years old (average 41 years old). All the patients were single-level protrusion, including 33 cases at the L4, 5 level and 32 cases at the L5, S1 level. The primary procedure included laminectomy discectomy in 39 patients, unilateral hemilaminectomy discectomy in 15 patients, and bilateral laminectomy and total laminectomy discectomy in 11patients. The recurrent time to the primary operation was 13-110 months (average 64 months). The location of recurrent disc protrusion was at the ipsilateral side in 47 cases and the contralateral side in 18 cases. No significant differences among three groups were evident in terms of basel ine data (P gt; 0.05). Results The incision all healed by first intention. The incidence of perioperative compl ication in group A (24.0%) and group B (22.3%) was significantly higher than that of group C (5.6%) (P lt; 0.05), and there was no significant difference between group A and group B (P gt; 0.05). The operation time and bleed loss during operation of group B were obviously higher than that of group A and group C (P lt; 0.05), and there was no significant difference between group A and group C (P gt; 0.05). There were no significant differences among three groups in terms of the length of hospital ization (P gt; 0.05). Six-one patients were followed up for 12-36 months (average 20 months). At 1 week after operation, the satisfied rate of patients was 84.0% in group A, 81.8% in group B, and 88.9% in group C (P gt; 0.05). All the patients in group B and group C achieved fusion uneventfully. There were no significant differences among three groups in terms of visual analogue scale (VAS) and Oswestry disabil ity index (ODI) when compared the preoperative value with the final follow-up value (P gt; 0.05). There was significant difference within group A, B, and C in terms of VAS and ODI when compared the preoperative value with the final follow-up value (P lt; 0.05), but there were no significant differences among three groups in the improvement rate (P gt; 0.05). The intervertebral space grading method proposed by Roberts et al. was adopted to evaluate the intervertebral space height (ISH), the preoperative value was 2.04 ± 0.93 in group A, 2.18 ± 0.91 in group B, and 2.11 ± 0.90 in group C, andat the final follow-up, the value was 2.64 ± 0.58 in group A, 1.05 ± 0.59 in group B, and 1.06 ± 0.42 in group C. There were significant differences among three groups in the ISH when compared the properative value with the final follow-up value (P lt; 0.05). Conclusion All of the three surgical procedures are effective for RLDP, but conventional discectomy and PLIF have more compl ications than TLIF. Conventional discectomy may result in the further narrow of the intervertebral space and the occurrence of segment instabil ity, whereas TLIF is safer, more effective, and one of the ideal methods to treat RLDP.
Objective To analyze the effectiveness of transforaminal lumbar interbody fusion (TLIF) for failed back surgery syndrome (FBSS). Methods Between October 2003 and December 2007, 36 patients with FBSS were treated with TLIF. There were 19 males and 17 females with an average age of 52.6 years (range, 46-68 years) and an average disease duration of 1.6 years (range, 3 months-15 years). Of 36 patients, reoperation was performed in 25, 10 received 3 operations,and 1 had 5 operations. A total of 50 segments were involved in fusion, including L4, 5 in 12 cases, L5, S1 in 10 cases, L3, 4 and L4, 5 double segments in 8 cases, and L4, 5 and L5, S1 double segments in 6 cases. According to X-ray films, CT, and MRI examination, 12 patients were diagnosed as having lumbar instabil ity secondary to total laminectomy, 18 as having recurrence of lumbar disc protrusion, and 6 as having recurrence of lumbar spondylol isthesis. Results Dural rupture occurred in 1 case and was repaired by suturing without cerebrospinal fluid leakage was observed; 1 had deep incision infection of Staphylococcus; and 1 had transient single irritation sign because of hematoma formation and was cured after symptomatic treatment. The other incisions healed by first intention. No patients had permanent nerve injury or deterioration. Thirty-three cases were followed up 18-72 months (mean, 35.2 months). At 12 months, all the operated segments reached interbody fusion, and no breakage of screw or Cage dislocation occurred. Japanese Orthopaedic Association (JOA) scores showed significant difference (t=2.45, P=0.01) between before operation (14.2 ± 4.1) and 18 months after operation (23.9 ± 2.6). The rate of cl inical improvement was 90.9% (23 cases of excellent, 7 cases of good, 3 cases of acceptable). Conclusion The TLIF simpl ifies the manipulation of lumbar revision surgery and decreases the operation risk and the operative compl ications for the treatment of FBSS.
ObjectiveTo compare the biomechanical differences between the kidney-shaped nano-hydroxyapatite/polyamide 66 (n-HA/PA66) Cage and the bullet-shaped n-HA/PA66 Cage. MethodsL2-L5 spinal specimens were selected from 10 adult male pigs. L2, L3 and L4, L5 served as a motor unit respectively, 20 motor units altogether. They were divided into 4 groups (n=5):no treatment was given as control group (group A); nucleus pulposus resection was performed (group B); bullet-shaped Cage (group C), and kidney-shaped Cage (group D) were used in transforaminal lumbar interbody fusion (TLIF) through left intervertebral foramen and supplemented by posterior pedicle screw fixation. The intervertebral height (IH) and the position of Cages were observed on the X-ray films. The range of motion (ROM) was measured. ResultsThere was no significant difference in the preoperative IH among 4 groups (F=0.166, P=0.917). No significant change was found in IH between at pre- and post-operation in group B (P>0.05); it increased after operation in groups C and D, but difference was not statistically significant (P>0.05). There was no significant difference in the postoperative IH among groups B, C, and D (P>0.05). The distance from Cage to the left margin was (3.06±0.51) mm in group C (close to the left) and (5.68±0.69) mm in group D (close to the middle), showing significant difference (t=6.787, P=0.000). The ROM in all directions were significantly lower in groups C and D than in groups A and B (P<0.05), and in group A than in group B (P<0.05). The right bending and compression ROM of group C were significantly higher than those of group D (P<0.05), but no statistically significant difference was found in the other direction ROM (P>0.05). ConclusionThe bullet-shaped and kidney-shaped Cages have similar results in restoring IH and maintaining the stability of the spine assisted by internal fixation. Kidney-shaped Cage is more stable than bullet-shaped Cage in the axial compression and the bending load opposite implant, it can be placed in the middle and back of the vertebral body more ideally.
ObjectiveTo evaluate the effectiveness of transforaminal lumbar interbody fusion (TLIF) via Luxor retractor associated with Mantis pedicle screw for the treatment of moderate or severe lumbar spondylol isthesis (LSL). MethodsA retrospective analysis was made on the cl inical data of 32 patients with LSL treated with TLIF via Luxor retractor associated with Mantis pedicle screw between June 2010 and June 2012. There were 20 males and 12 females, with the mean age of 48 years (range, 36-69 years). LSL occurred at the L4, 5 in 17 patients and at the L5, S1 in 15 patients. Of them, 18 cases were rated as Meyerding grade Ⅱ, and 14 cases as grade Ⅲ. The disease duration was 8 months to 6 years (mean, 3.5 years). The operation time, intraoperative blood loss, and preoperative and postoperative (1 week and 1 year) intervertebral height and sl ipping angle were recorded, and the sl ipping rate was calculated; Japanese Orthopaedic Association (JOA) score was used for cl inical efficacy assessment. ResultsThe operation time was 90-130 minutes (mean, 110 minutes); intraoperative blood loss was 120-300 mL (mean, 210 mL). Incisions healed by first intention. All patients were followed up 24-36 months (mean, 28 months), and no complications of leakage of cerebrospinal fluid and nerve root injury occurred; X-ray films showed satisfactory reduction of spondylolisthesis and good position of pedicle screw and interbody fusion cage. The mean bone fusion time was 4.0 months (range, 3.8-6.0 months). The JOA score, sl i pping rate, sl i pping angle, and intervertebral height at 1 week and 1 year after operation were significantly improved when compared with preoperative ones (P<0.05), but no significant difference was found between at 1 week and at 1 year after operation (P>0.05). ConclusionTLIF via Luxor retractor associated with Mantis pedicle screw fixation is a safe and effective minimally invasive technique in treating moderate or severe LSL.
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.
Objective To investigate the effectiveness of surgical treatment for single-level degenerative lumbar instabil ity (DLI) by comparing traditional open transforaminal lumbar interbody fusion (TLIF) with minimally invasive TLIF. Methods Between March 2007 and May 2009，87 patients with single-level DLI were treated by traditional open TLIF (group A, n=45) and by minimally invasive TLIF (group B, n=42), respectively. There was no significant difference in gender, age, disease duration, segment level, combined diseases of lumbar spine, or the proportion of uni- and bilateral symptom between 2groups (P gt; 0.05). The indexes of surgical trauma，systemic inflammatory response, cl inical outcomes, and aravertebral muscle injury were compared between 2 groups. Results Operation was performed successfully in all patients. The patients were followed up 2.9 years on average in group A and 2.8 years on average in group B. The incision, blood loss, and postoperative drainage in group B were significantly less than those in group A (P lt; 0.05), but the operation time in group B was significantly longer than that in group A (P lt; 0.05). There were significant differences (P lt; 0.05) in C-reactive protein, leucocyte count, and creatine kinase MM between 2 groups at 24 hours postoperatively as well as in C-reactive protein at 6 days postoperatively; group B was superior to group A. At last follow-up, the Oswestry disabil ity index (ODI) and visual analogue score (VAS) were significantly improved when compared with the preoperative scores in 2 groups (P lt; 0.05). There were significant differences in ODI and back pain VAS score (P lt; 0.05), but no significant difference in leg pain VAS score (P gt; 0.05) between 2 groups. At last follow-up, no low back pain occurred in 8 and 18 cases, mild in 25 and 18 cases, moderate in 9 and 6 cases, and severe in 3 and 0 cases in groups A and B, respectively, showing that low back pain was significantly l ighter in group B than in group A (Z= —2.574, P=0.010). At last follow-up, the atrophy ratio of multifidus muscle was 37% ± 13% in group A and was 15% ± 7% in group B, showing significant difference (t=12.674, P=0.000). The multifidus muscle atrophy was rated as grade I in 18 and 44 sides, as grade II in 42 and 32 sides, and as grade III in 30 and 8 sides in groups A and B, respectively, showing significant difference (Z= — 4.947, P=0.000). Conclusion Both traditional open TLIF and minimally invasive TLIF are the effective treatments for single-level DLI. Minimally invasive TLIF has less surgical trauma, sl ighter postoperative systemic inflammatory response, less paravertebral muscle injury, and lower incidence of postoperative back pain, but it has longer operation time.
【Abstract】 Objective To investigate the effectiveness of surgical treatment for discogenic low back pain (DLBP) by minimally invasive transforaminal lumbar interbody fusion (TLIF) combined with unilateral pedicle screw fixation (UPSF). Methods Between March 2006 and July 2009, 57 patients with single-level DLBP were treated by minimally invasive TLIF combined with UPSF, including 27 males and 30 females with an average age of 45.6 years (range, 38-61 years) and a disease duration of 3.8 years (range, 9 months to 11 years). The involved segments included L2，3 in 2 cases, L3，4 in 5 cases, L4，5 in 29 cases, and L5, S1 in 21 cases. The operative time, incision length, intraoperative blood loss, postoperative drainage volume, hospitalization times, fusion rate, and complications were observed. The effectiveness were evaluated through Oswestry disability index (ODI) and visual analogue score (VAS), and the operative outcomes were compared in different groups classified according to various pressures of the contrast medium and sensitivities to discoblock after inducing consistent pain. Results The operation time, incision length, blood loss, postoperative drainage volume, and hospitalization times were (84.6 ± 37.4) minutes, (3.4 ± 0.6) cm, (132.5 ± 23.2) mL, (58.7 ± 21.4) mL, and (6.5 ± 0.8) days, respectively. All patients were followed up 2 years and 2 months to 5 years and 4 months (mean, 3.2 years). At last follow-up, ODI and VAS scores were significantly improved when compared with preoperative scores (P lt; 0.05). The effectiveness according to ODI were excellent in 27 cases, good in 22 cases, fair in 6 cases, and poor in 2 cases, with an excellent and good rate of 86.0%. All patients acquired b interbody fusion. At last follow-up according to ODI and VAS scores, better results were found in patients of low-pressure sensitive group and high-sensitive discoblock group (P lt; 0.05). Conclusion Minimally invasive TLIF combined with UPSF is reliable for DLBP with minimal surgical trauma, less paravertebral tissue injury, and fewer complications, but the indications for operation must be strictly followed. Patients being sensitive to low-pressure or high-sensitive to discoblock can achieve better surgical results.
Objective To compare the short-term effectiveness of minimally invasive surgery-transforaminal lumbar interbody fusion (MIS-TLIF) versus open-TLIF in treatment of single-level lumbar degenerative disease. Methods Between February 2010 and February 2011, 147 patients with single-level lumbar degenerative diseases underwent open-TLIF in 104 cases (open-TLIF group) and MIS-TLIF in 43 cases (MIS-TLIF group), and the clinical data were analyzed retrospectively. There was no significant difference in gender, age, disease type, lesion level, disease duration, preoperative visual analogue scale (VAS), and preoperative Oswestry disability index (ODI) between 2 groups (P gt; 0.05). The operation time, intraoperative radiological exposure time, intra- and post-operative blood loss, postoperative hospitalization time, and postoperative complications were compared between 2 groups. The VAS score and ODI were observed during follow-up. The imaging examination was done to observe the bone graft fusion and the locations of internal fixator and Cage. Results There was no significant difference in operation time between 2 groups (t=0.402, P=0.688); MIS-TLIF group had a decreased intra- and post-operative blood loss, shortened postoperative hospitalization time, and increased intraoperative radiological exposure time, showing significant differences when compared with open-TLIF group (P lt; 0.05). Cerebrospinal fluid leakage (2 cases) and superficial infection of incision (2 cases) occurred after operation in open-TLIF group, with a complication incidence of 3.8% (4/104); dorsal root ganglion stimulation symptom (3 cases) occurred in MIS-TLIF group, with a complication incidence of 7.0% (3/43); there was no significant difference in the complication incidence between 2 groups (χ2=0.657, P=0.417). The patients were followed up 18-26 months (mean, 21 months) in MIS-TLIF group, and 18-28 months (mean, 23 months) in open-TLIF group. The VAS scores and ODI of 2 groups at each time point after operation were significantly improved when compared with those before operation (P lt; 0.05). There was no significant difference in VAS score between 2 groups at discharge and 3 months after operation (P gt; 0.05); VAS score of MIS-TLIF group was significantly lower than that of open-TLIF group at last follow-up (t= — 2.022, P=0.047). At 3 months and last follow-up, no significant difference was found in the ODI between 2 groups (P gt; 0.05). The imaging examination showed good positions of Cage and internal fixator, and bone graft fusion in 2 groups. Conclusion The short-term effectiveness of MIS-TLIF and open-TLIF for single-level degenerative lumbar diseases was similar. MIS-TLIF has the advantages of less invasion and quick recovery, but the long-term effectiveness needs more observation.
ObjectiveTo investigate the role of 1,25-dihydroxyvitamin D3 in the posterior transforaminal lumbar interbody fusion (TLIF) for patients with osteoporosis and lumbar degenerative disease. MethodsBetween November 2011 and October 2012,44 patients with osteoporosis and lumbar degenerative disease were treated with TLIF and the clinical data were retrospectively analyzed.The patients were divided into 2 groups based on the administration of 1,25-dihydroxyvitamin D3.After TLIF operation,1,25-dihydroxyvitamin D3 was used in 21 patients (trial group),and was not used in 23 patients (control group).There was no significant difference in gender,age,etiology,affected segment,and disease duration between 2 groups (P>0.05).Lumbar interbody fusion was observed by X-ray and thin-section CT scan reconstruction of lumbar spine according to Brantigan assessment system at 6 months after operation and last follow-up.Clinical outcome was evaluated by Oswestry disability index (ODI) before and after operation. ResultsThe patients of 2 groups were followed up 12-27 months (mean,14.5 months).No fixation loosening or breaking occurred during follow-up.ODI scores in both groups were significantly improved at 6 months after operation and last follow-up (P<0.05) when conpared with preoperative value.Although at preoperation there was no significant difference in ODI score between 2 groups (P>0.05),ODI score of trial group was significantly lower than that of control group at 6 months after operation and last follow-up (P<0.05).At 6 months after operation,the interbody fusion rate was 76.19% (16/21) in trial group and 43.48% (10/23) in control group,showing significant difference (χ2=3.60,P=0.03); at last follow-up,the fusion rate was 95.24% (20/21) in trial group and 65.22% (15/23) in control group,showing significant difference (χ2=4.38,P=0.02). Conclusion1,25-dihydroxyvitamin D3 can improve the lumbar interbody fusion rate and general conditions in the patients with osteoporosis and lumbar degenerative disease.