Objective To study the effect of core decompression combining with autologous cortical sustaining bone and cancellous bone graft in treating osteonecrosis of the femoral head (ONFH). Methods From February 2004 to May 2008, 64 patients (77 hi ps) with ONFH were treated with core decompression combining with autologous cortical sustaining bone and cancellous bone graft, including 45 males and 19 females and aging 23 to 60 years with an average age of 43 years. There were 51 cases of unilateral ONFH and 13 cases of bilateral ONFH. ONFH was caused by alcohol in 39 cases(47 hi ps), by steroid in 21 cases (26 hi ps), and by trauma in 4 cases (4 hi ps). The disease course was 1-12 years. The pain time was 2-14 months (average 7 months). All the cases underwent imageology and postoperation pathology examination to confirm the diagnosis of ONFH. According to Association Research Circulation Osseous (ARCO) international classification of osteonecrosis, 17 cases (23 hips) were classified as stage I A, 2 cases (3 hips) as stage I B, 21 cases (24 hips) as stage II A, 2 cases (2 hips) as stage II B, 4 cases (4 hips) as stage II C, and 18 cases (21 hips) as stage III A. The outcome was evaluated both cl inically by Harris score and radiologically by imageology. Results A total of 59 cases (69 hips) were followed up for 12-62 months with an average of 32.1 months. The Harris score was 87.12 ± 8.68 at 12 months after operation, showing significant difference (P lt; 0.05) when compared with the preoperative one (68.38 ± 14.49). The results were excellent in 39 hips, good in 18 hips, fair in 6 hips, and poor in 6 hip; and the excellent and good rate was 82.6%. Radiographic evaluation was 21 hips (30.4%) of grade I, 42 hips (60.9%) of grade II, and 6 hips (8.7%) of grade III. One case had the compl ication of il ium bone donor site, 21 cases had l ittle pain or numbness, and the other cases had no uncomfortable compl ication. Conclusion The method of core decompression combining with autologous cortical sustaining bone and cancellous bone graft can improve the means of bone grafts, prevent the collapse of the femoral head, and is less traumatic than common procedures. Cl inical effects are obvious and effective.
Objective To evaluate the effectiveness of spinal canal decompression assisted by unilateral biportal endoscopy (UBE) and percutaneous uniplanar pedicle screw internal fixation in the treatment of lumbar burst fractures with neurological symptoms. Methods Between June 2021 and December 2022, 10 patients with single level lumbar burst fracture with neurological symptoms were treated with spinal canal decompression assisted by UBE and percutaneous uniplanar pedicle screw internal fixation. There were 7 males and 3 females with an average age of 43.1 years (range, 21-57 years). The injured vertebrae located at L1 in 2 cases, L2 in 4 cases, L3 in 3 cases, and L4 in 1 case. There were 7 cases of AO type A3 fractures and 3 cases of AO type A4 fractures. The total operation time, the time of operation under endoscopy, and complications were recorded. Pre- and post-operative visual analogue scale (VAS) score and American Spinal Injury Association (ASIA) scale (grading A-E corresponding to assigning 1-5 points for statistical analysis) were used to evaluate effectiveness. X-ray film and CT were performed to observe the fracture healing, and the ratio of anterior vertebral body height, Cobb angle, and rate of spinal canal invasion were measured to evaluate the reduction of fracture.Results All operations was successfully completed, and the spinal canal decompression and the bone fragment in spinal canal reduction completed under the endoscopy. Total operation time was 119 minutes on average (range, 95-150 minutes), and the time of operation under endoscopy was 46 minutes on average (range, 35-55 minutes). There was no complication such as dural sac, nerve root, or blood vessel injury during operation. All incisions healed by first intention. All patients were followed up 18.7 months on average (range, 10-28 months). The VAS score after operation significantly decreased when compared with that before operation (P<0.05), and further improved at last follow-up (P<0.05). The ASIA scale after operation significantly improved when compared with that before operation (P<0.05), and there was no significant difference (P>0.05) in the ASIA scale between at 1 week after operation and at last follow-up. The imaging examination showed that the screw position was good and the articular process joint was preserved. During follow-up, there was no loosening, fracture, or fixation failure of the internal fixation. The ratio of anterior vertebral body height and Cobb angle significantly improved, the rate of spinal canal invasion significantly decreased after operation (P<0.05), and without significant loss of correction during the follow-up (P>0.05). Conclusion Spinal canal decompression assisted by UBE and percutaneous uniplanar pedicle screw fixation is a feasible minimally invasive treatment for lumbar burst fractures with neurological symptoms, which can effectively restore the vertebral body sequence, as well as relieve the compression of spinal canal, and improve the neurological function.
Objective To assess the results of microvascular decompression (MVD) in treating cranial nervehyperactive dysfunction. Methods From October 2002 to January 2007, 106 patients with cranial never hyperactivedysfunction were treated with MVD. Among them, there were 47 males and 59 females with an average age of 62 years (42-85 years), including 56 cases of trigeminal neuralgia, 33 cases of hemifacial spasm and 17 cases of spasmodic torticoll is. MRI showed obvious nerve root compression in 60 patients (56.6%), suspected nerve root compression in 33 patients (31.1%) and no nerve root compression in 13 patients (12.3%). The disease course was 2-300 months with median course of 54 months. The typical manifestations before operation were pain and myospasm in corresponding innervation region. Results The superior cerebellar artery was the most common offending vessel in trigeminal neuralgia (44.6%, 25/56), the anterior inferior cerebellar artery in hemifacial spasm (33.3%, 11/33), and the vertebra-basilar artery in spasmodic torticol is (82.4%, 14/17). Compl ications of facial paralysis, hypoacusia, facial numbness, dizziness, pain of neck and shoulder, muscles weakness of neck and subcutaneous dropsy occurred in 31 patients (29.2%). All patients were followed up for 6-42 months. The total response rate was 90.6%. The curative rate of MVD was 83.9% (47/56) in trigeminal neuralgia, 81.8% (27/33) in hemifacial spasm and 41.2% (7/17) in spasmodic torticol is, respectively. Five patients failed to response (4.7%), 2 of them were cured after re-operation and 3 abandoned further treatrment. Five patients suffered recurrence 3-8 months after operation (4.7%), 2 of them recovered after re-operation, 1 got rel ief by Gamma-knife treatment, and 2 abandoned further treatment. Conclusion MVD has a good therapeutic effect on the disease caused by vascular compression of cranial nerve. Comprehensive preoperative evaluation, skillful operational technique and intraoperative electrophysiological monitoring should be implemented to enhance the therapeutic effects of MVD and to prevent possible compl ications.
To investigate the effectiveness and safety of microendoscopic decompression via unilateral approach for lumbar spinal stenosis. Methods Between May 2006 and June 2009, 79 patients with lumbar stenosis were treated and divided into 2 groups: posterior lamina fenestration decompression (group A, n=37), endoscopic decompression via unilateral approach (group B, n=42). There was no significant difference in age, sex, segment level, and disease duration between 2 groups (P gt; 0.05). The cl inical outcomes were assessed by using the visual analogue scale (VAS) score and Oswestry Disabil ity Index (ODI). The operation time, blood loss, compl ications were compared between 2 groups. Results Operations were successfully performed in all cases. The operation time, blood loss, and drainage volume were (75.0 ± 25.7) minutes, (140.3 ± 54.8) mL, and (46.5 ± 19.7) mL in group A, were (50.4 ± 18.2) minutes, (80.2 ± 35.7) mL, and (12.7 ± 5.3) mL in group B; there were significant differences between 2 groups (P lt; 0.05). All the wounds healed by first intention. All patients were followed up 12-39 months (mean, 16 months). In group A, 1 patient suffered from intervertebral space infection after operation and recovered after conservative treatment; 4 patients had lumbar instabil ity after operation and recovered after lumbar interbody fusion combined with spine system internal fixation. In group B, 2 patients suffered from spinal dural rupture during operation and recovered after corresponding treatment, and no lumbar instabil ity was found. There was no significant difference in VAS score and ODI between 2 groups at preoperation (P gt; 0.05). Both VAS score and ODI were significantly improved at early stage after operation and last follow-up when compared with preoperation in each group (P lt; 0.05). Comparing with group A, there was significant improvement in VAS score at 24 hours postoperatively and in ODI at 1 month postoperatively in group B (P lt; 0.05), but no significant difference was observed at last follow-up (P gt; 0.05). According to cl inical evaluation of ODI mprovement rate, the excellent and good rate was 89.2% in group A and 92.9% in group B, showing no significant difference (χ2=0.896, P=0.827). Conclusion Comparing with posterior decompression surgery, microendoscopic decompression via unilateral approach is one of effective method to treat lumbar stenosis, with less trauma of fenestration yield and good early outcomes.
Objective To observe and evaluate the clinical effect of the new fenestration rammer in the treatment of thoracolumbar burst fracture by posterior internal fixation and reduction of lamina with finite fenestration decompression. Methods Patients with thoracolumbar burst fractures admitted to Zigong Fourth People’s Hospital between September 2017 and January 2020 were retrospectively selected. The patients were divided into observation group and control group according to different surgical methods. The observation group used a new tamping device with finite fenestration rammer of unilateral lamina to reduce the spinal occupying bone mass, and the control group used conventional instruments for reduction of intraspinal fracture masses. The operation time, intraoperative blood loss, CT measurement of sagittal diameter ratio of spinal canal and the number of cases of postoperative vertebral empty shell phenomenon were recorded in the two groups, and Frankel grading evaluation of spinal nerve function was conducted. Results A total of 67 patients were included. There were 33 cases in the observation group and 34 cases in the control group. The patients in both groups were followed up for 12 to 16 months, with an average of (14.45±2.25) months. The improvement rate of Frankel rating in each group was 100%. In the control group and the observation group, except for the sagittal diameter ratio of spinal canal before operation (P=0.616), the operation time [(150.44±26.47) vs. (120.91±20.86) min], the intraoperative blood loss [(244.41±42.97) vs. (183.33±34.56) mL], the sagittal diameter ratio of spinal canal one week after operation [(92.50±2.32)% vs. (93.72±2.40)%], the sagittal diameter ratio of spinal canal at the last follow-up [(91.50±2.96)% vs. (93.17±3.27)%] and the occurrence of empty shell phenomenon (13 vs. 5 cases) were statistically significant (P<0.05). The intragroup comparison showed that the sagittal diameter ratio of spinal canal was improved one week after operation and at the last follow-up compared with that before operation (P<0.05), there was no significant difference in the sagittal diameter ratio of spinal canal between one week after operation and the last follow-up (P>0.05). Conclusions The new fenestration rammer can effectively reduce the spinal occupying bone mass in thoracolumbar burst fracture, effectively restore the volume of the spinal canal, achieve the purpose of decompression, effectively prevent the formation of vertebral shell, maximize the retention of the stable structure of the posterior column, and avoid iatrogenic nerve injury. It is safe and effective.
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.
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.
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.
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 compare the cl inical outcomes of the core decompression combined with autologous bone marrow mesenchymal stem cells (BMSCs) transplantation with the isolated core decompression for the treatment of earlyavascular necrosis of the femoral head (ANFH). Methods From May 2006 to October 2008, 8 patients (16 hips) with earlyANFH were treated. There were 7 males and 1 female with an average age of 35.7 years (range, 19-43 years). According to the system of the Association Research Circulation Osseous (ARCO): 4 hips were classified as stage II a, 2 as stage II b, 1 as stage II c, and 1 as stage III a in group A; 2 hips were classified as stage II a, 2 as stage II b, 3 as stage II c, and 1 as stage III a in group B. The average disease course was 1.1 years (range, 4 months to 2 years). The patients were randomly divided into 2 groups according to left or right side: group A, only the core decompression was used; group B, both the core decompression and autologous BMSCs transplantation were used. The Harris score and visual analogue scale (VAS) score were determined, imaging evaluation was carried out by X-rays and MRI pre- and post-operatively. The erythrocyte sedimentation rate, C-reactive protein, l iver function, renal function, and immunoglobul in were detected for safety evaluation. Results All incisions healed by first intention. Eight patients were followed up 12-42 months (23.5 months on average). The cl inical symptoms of pain and claudication were gradually improved. The Harris scores and VAS scores of all patients were increased significantly at 3, 6, and 12 months after operation (P lt; 0.05). There was no significant difference between groups A and B 3 and 6 months after operation (P gt; 0.05), but there was significant difference between groups A and B 12 months after operation (P lt; 0.05). The necrosis area of femoral head in groups A and B were 18.13% ± 2.59% and 13.25% ± 2.12%, respectively, showing significant difference (P lt; 0.05). In group A, femoral head collapsed 12 months after operation in 1 case of stage III. No compl ication of fever, local infectionoccurred. Conclusion The core decompression and the core decompression combined with BMSCs transplantation are both effective for the treatment of early ANFH. The core decompression combined with BMSCs transplantation is better than core decompression in the rel ief of pain and postponing head collapse.