To probe the etiopathogenisis of adjacent-segment disease by analyzing the imageology data and cl inical neurological function in patients with anterior cervical discectomy and fusion (ACDF) harvested by long-term follow-up. Methods A retrospective study was performed on 52 patients who had undergone ACDF with perfect documents from January 1990 to April 2003. Of the patients, 45 were males and 7 were females with a mean age of 48.5 years (range from 25 to 72 years). There was the fusion of 10 one-levels, 38 two-levels and 4 three-levels. The cervical anterior-posterior and lateral X-ray, CT and MRI examination were performed before the operation. Cl inical neurological function was recorded by the Nurick score, and this score at 6 weeks after the operation was compared with the later follow-up. In the radiological examination, the motion of adjacent vertebrae and osteophyte formation were reviewed on X-ray and CT, and were converted to the semi-quantitative degeneration score according to the Goffin method. The correlation between Nurick score or degeneration score and the age at operation or fusion levels was compared by Spearman correlation coefficients. The cervical canal sizes of adjacent level and remote level on MRI were reviewed and compared with each other by t test. Results The follow-up period was 3 to 10 years, 6.9 years on average. There was difference in the Nurick score between the 6th week after operation (1.07 ± 0.84) and the later follow up (1.92 ± 1.28) by rank test (P lt; 0.05). There was no correlation between the Nurick score change and the age at operation (r = 0.21, P gt; 0.05) or fused levels(r = 0.30, P gt; 0.05) by Spearman correlation coefficients. There was obvious difference in degeneration score between the 6th week after operation (0.73 ± 0.67) and the later follow up (1.58 ± 1.06), (P lt; 0.01). There was no correlation between the degeneration score change and the age at operation (r = 0.35, P gt; 0.05) or fusion levels (r = 0.38, P gt; 0.05) by Spearman correlation coefficients. The cervical canal size reductions were (1.7 ± 1.1) mm at superioradjacent level, (1.2 ± 0.6) mm at inferior adjacent level and (0.30 ± 0.68) mm at remote level. There was obvious difference between superior or inferior and remote level by t test (P lt; 0.01). The adjacent level developed prominent degeneration together with nerve function change after the fusion operation and displayed correlation between degeneration and nerve function change(r = 0.41, P lt; 0.05). Conclusion The adjacent-segment disease after interbody fusion is produced by multiple factors. The natural progression in adjacent disc, biomechanical natural change resulting from interbody fusion, destruction to l igament structure in front of cervical vertebrae by operation, and bone graft model are important factors not to be ignored.
To compare the effectiveness of microdiscectomy and macrodiscectomy on the single-level lumbar disc protrusion (LDP). Methods Between November 2002 and October 2005, 241 patients with LDP underwent 2 surgical procedures: microdiscectomy (group A, 93 cases) and macrodiscectomy (group B, 148 cases). All patients had singlelevel LDP. In group A, there were 51 males and 42 females with an average age of 32.3 yeares (range, 18-47 years); there were 23cases of protrusion, 52 cases of prolapse, and 18 cases of sequestration with an average disease duration of 8.5 months (range, 1-18 months), including 8 cases at L2,3 level, 11 cases at L3,4 level, 35 cases at L4,5 level, and 39 cases at L5, S1 level. In group B, there were 81 males and 67 females with an average age of 31.8 years (range, 16-50 years); there were 37 cases of protrusion, 85 cases of prolapse, and 26 cases of sequestration with an average disease duration of 9.3 months (range, 1-20 months), including 9 cases at L2,3 level, 15 cases at L3,4 level, 63 cases at L4,5 level, and 61 cases at L5, S1 level. There was no significant difference in age, sex, segment level, type, or disease duration between 2 groups (P gt; 0.05). Results Immediate back and sciatic pain rel ief was achieved in 225 (93.4%) patients after operation. The satisfactory rates were 91.4% in group A and 87.8% in group B at 1 week after operation, showing no significant difference (P gt; 0.05). The length of incision, amount of bleeding, amount of drainage, and hospital ization time in group A were significantly fewer than those in group B (P lt; 0.05); while the operative time in group A was longer than that in group B, but showing no significant difference (P gt; 0.05). Dural laceration occurred in 4 cases of groupA and 5 cases of group B, superficial infections of incision occurred in 5 cases of group B and intervertebral space nfections occurred in 4 cases of group B, and epidural hematoma occurred in 1 case of group A. The perioperative compl ication rate (5.4%, 5/93) in group A was significantly lower (P lt; 0.05) than that in group B (9.5%, 14/148). LDP recurred in 4 cases (4.3%) of group A and in 9 cases (6.1%) of group B postoperatively, showing no significant difference (P gt; 0.05); of them, 11 cases received second operation and 2 cases were treated conservatively. All cases were followed up 36-77 months (mean, 51.4 months). There were significant differences in visual analog scale (VAS) and Oswestry disabil ity index (ODI) between 2 groups at the last follow-up and preoperation (P gt; 0.05), but there was significant difference in VAS at 1 week postoperatively between 2 groups (P lt; 0.05). VAS and ODI were obviously improved at 1 week and last follow-up when compared with preoperation (P lt; 0.05). There was no significant difference in the improvement rates of VAS and ODI between 2 groups at last follow-up (P gt; 0.05). According to cl inical evaluation of Modified Macnab criteria, the excellent and good rate was 90.3% in group A and 86.5% in group B at final follow-up (P gt; 0.05). Conclusion Both macrodiscectomy and microdiscectomy are effective for LDP, furthermore microdiscectomy is less invasive than macrodiscectomy. Microdiscectomy is recommended to treat single-level LDP.
Objective To compare microendoscopic discectomy (MED) with open discectomy (OD) for degenerative lumbar spinal stenosis in terms of cl inical outcomes, and provide experience and therapeutic evidence for cl inical appl ication.Methods From May 2002 to October 2007, 215 patients with lumbar spinal stenosis were randomized into two groups, and underwent either MED or OD. In group A, 105 patients underwent MED, including 56 males and 49 females aged 34 to 83 years old (average 45 years old); the duration of the disease ranged from 9 months to 26 years (average 50 months); the spinal stenosis involved one segment in 76 cases, two segments in 27 cases, and three segments in 2 cases. In group B, 110 patients received OD, including 57 males and 53 females aged 35 to 85 years old (average 47 years old); the duration of the disease ranged from 8 months to 25 years (average 48 months); the spinal stenosis involved one segment in 78 cases, two segments in 29 cases, and three segments in 3 cases. No significant difference was evident between two groups in terms of the general information(P gt; 0.05). Results Operation was successfully performed in all cases. Volume of intraoperative blood loss was (82.14 ± 6.18) mL in group A and (149.24 ± 11.17) mL in group B. Length of hospital stay was (7.0 ± 2.1) days in group A and (12.0 ± 2.6) days in group B. Significant difference was noted between two groups in terms of the above parameters (P lt; 0.01). All the wounds healed by first intention. The patients were followed up for 13-54 months (average 27 months) in group A and 12-55 months (average29 months) in group B. Four patients in each group suffered from spinal dural rupture during operation and recovered after corresponding treatment. Three patients in group B had lumbar instabil ity 3 years after operation and recovered using lumbar interbody fusion combined with general spine system internal fixation. No such compl ications as wrong orientation, nerve root injury, cauda equina injury and infection occurred in each group, and radiology exam showed no relapse. Therapeutic effect was evaluated by Nakai standard, 52 cases in group A were graded as excellent, 45 as good, 7 as fair, 1 as poor, and the excellent and good rate was 92.4%; 53 cases in group B were graded as excellent, 48 as good, 8 as fair, 1 as poor, and the excellent and good rate was 91.8%; there was no significant difference between two groups (P gt; 0.05). Conclusion Two methods have the similar therapeutic effect, but MED el iminates the shortcomings of traditional OD, so it is one of ideal minimally invasive operative approaches for degenerative lumbar spinal stenosis.
ObjectiveTo investigate the clinical feasibility of full-endoscopic decompression for the treatment of single-level cervical disc herniation via anterior transcorporeal approach.MethodsAccording to the inclusion and exclusion criteria, 21 patients with cervical disc herniation who received full-endoscopic decompression via anterior transcorporeal approach between September 2014 and March 2016 were retrospectively analyzed. There were 12 males and 9 females with an age ranged from 32 to 65 years, with an average of 48.5 years. The duration of symptoms ranged from 6 to 18 weeks, with an average of 10.5 weeks. According to the Nurick grading of spinal cord symptoms, there were 2 cases with grade 1, 7 cases with grade 2, and 12 cases with grade 3. Operative segment was C3, 4 in 2 cases, C4, 5 in 8 cases, C5, 6 in 9 cases, and C6, 7 in 2 cases. The operation time and related complications were recorded. The central vertical height of the vertebral body and the diseased segment space were measured on the cervical X-ray film. The neck and shoulder pain were evaluated by visual analogue scale (VAS) score; Japanese Orthopaedic Association (JOA) score was used to evaluate the improvement of neurological function in patients. The MRI of cervical spine was reexamined at 3 months after operation, and the CT of cervical spine was reexamined at 12 months after operation. The decompression of spinal cord and the healing of bone canal in the vertebral body were further evaluated.ResultsFull-endoscopic decompression via anterior transcorporeal approach were achieved at all 21 patients. The operation time was 85-135 minutes, with an average of 96.5 minutes. All patients were followed up 24-27 months, with an average of 24.5 months. There was no complication such as residual nucleus pulposus, spinal cord injury, large esophageal vessels injury, pleural effusion, endplate collapse, intraspinal hematoma, cervical spine instability, protrusion of disc in the same segment, or kyphosis. Both VAS scores of neck and shoulder pain and JOA scores were significantly improved at 12 months after operation (P<0.05). At 3 months after operation, it was confirmed by the cervical MRI that neural decompression was sufficient and the abnormal signal was also degraded in the patients with intramedullary high signal at T2-weighted image. The cervical CT showed that bone healing were achieved in the surgical vertebral bodies of all patients at 12 months after operation. At 24 months after operation, the central vertical height of the diseased segment space significantly decreased compared with preoperative one (t=2.043, P=0.035); but there was no significant difference in the central vertical height of the vertebral body between pre- and post-operation (t=0.881, P=0.421).ConclusionFull-endoscopic decompression via anterior transcorporeal approach, integrating the advantages of the endoscopic surgery and the transcorporeal approach, provide an ideal and thorough decompression of the ventral spinal cord with satisfactory clinical and radiographic results.
ObjectiveTo analyze the effectiveness of a new type of decellularized allogeneic bone in the application of anterior cervical discectomy and fusion (ACDF). MethodsA retrospective analysis was made on the clinical data of 73 patients with single segmental cervical spondylosis treated with ACDF between January 2009 and December 2013. Of 73 cases, autologous iliac bone was used in 22 cases (group A), new decellularized allogeneic bone transplantation (Bio-Gene) in 22 cases (group B), and normal allogeneic bone (Xin Kang Chen) in 24 cases (group C). There was no significant difference in gender, age, type of cervical spondylosis, course of disease, and involved segment among 3 groups (P>0.05). The operation time, intraoperative blood loss, and complications were compared between groups; X-ray films and CT images were taken to observe the bone fusion, and Japanese Orthopaedic Association (JOA) score was used to assess the clinical efficacy. ResultsThe operation time and intraoperative blood loss of group A were significantly more than those of groups B and C (P<0.05), but no significant difference was found between groups B and C (P>0.05). Pain and numbness at donor site occurred in 12 cases, and poor healing in 1 case of group A; red swelling and exudate were observed in 1 case of group B and in 6 cases of group C; and there was significant difference in complications among 3 groups (χ2=18.82, P=0.00). All patients were followed up 6-54 months (mean, 30 months). The graft fusion rate was 100% in groups A and B, and was 95.8% in group C, showing no significant difference (χ2=2.04, P=0.36). The JOA score at 6 months after operation were significantly improved when compared with preoperative score in 3 groups (P<0.05), but no significant difference was found among the 3 groups at preoperation and 6 months after operation (P>0.05). The excellent and good rates of groups A, B, and C were 90.9%, 88.9%, and 87.5% respectively, showing no significant difference (χ2=0.14, P=0.93). ConclusionNew type of decellularized allogeneic bone in ACDF has the advantages of shorter operation time, less blood loss, and better early effectiveness. But whether there is a chronic rejection or delayed rejection needs further studies.
ObjectiveTo analyze the clinical outcome of anterior cervical discectomy and fusion using a Zero-profile interbody fusion and fixation device (Zero-P) for cervical spondylotic myelopathy. MethodsBetween April 2011 and September 2013, 26 cases of cervical spondylotic myelopathy underwent anterior cervical discectomy and fusion with the Zero-P. Of 26 cases, 12 were male and 14 were female, aged 43-82 years (mean, 58.3 years). The disease duration was from 3 months to 10 years (mean, 5.9 years). The involved segments included C3,4 in 5 cases, C4,5 in 3 cases, C5,6 in 6 cases, and C6,7 in 12 cases. The clinical outcome was evaluated using visual analogue scale (VAS) score, Japanese Orthopaedic Association (JOA) score, and Neck Disability Index (NDI) score before operation and after operation. ResultsThe operations were successful and the operation time was 75-140 minutes (mean, 105 minutes); and blood loss was 20-150 mL (mean, 45 mL). There was no complications of infection, neural injury, esophageal fistula, prevertebral hematoma, or leakage of cerebrospinal. Dysphagia occurred in 1 case within 1 week after operation,and disappeared after 1 month. All patients were followed up for an average of 15.3 months (range, 12-18 months). The clinical symptoms were relieved after operation. During follow-up, no implant displacement or subsidence, screw breakage, and cervical instability were observed. At 3 and 12 months after operation, the VAS score and NDI reduced significantly (P<0.05); the JOA score increased significantly (P<0.05); and the intervertebral space height and the cervical Cobb angle improved significantly (P<0.05). But there was no significantly difference between at 3 and 12 months (P>0.05). According to JOA evaluation, the results were excellent in 14 cases, good in 10 cases, and fair in 2 cases, with an excellent and good rate of 92.3% at last follow-up. ConclusionThe clinical outcome of anterior cervical discectomy and fusion using a Zero-P is satisfactory and reliable in the treatment of cervical spondylotic myelopathy. It can restore the cervical physiological curve and the intervertebral space height and decrease the incidence of postoperative dysphagia.
Objective To compare the loss of anterior column heightand cervical Cobb angle with three different types of anterior cervical discectomy and fusion(ACDF). Methods A prospective randomized study was performed on 60 patients who had undergone ACDF with the autologous iliac crest graft (group A, n=20), the autogenous bone and the anterior cervical locking plates (group B, n=20), and Syncage-C filled with the local autograft reamings (group C, n=20) from January 1998 to January 2003. The patients diagnosed as having cervical radiculopathy (RP) and cervical spondylotic myelopathy (CSM) were indicated for ACDF. Of the patients, 41 were male and 19 female with a mean age of 57 years (range, 36-68) and their average course of disease was 6.2 months (range, 1-36). There were 36 one-level and 24 two-level fusions from C3,4 to C7,T1. Radiological measurements were performed on the cervical radiographs taken before operation, 7 days and 3 months after operation, and on the last day of the follow-up; then, the height and Cobb angle of the fused segment, functional restoration, and clinical outcome were evaluated in the three groups. Results The followup of more than 2 years (range,2-7) showed that the average loss of anterior column height and Cobb angle of the fused segments in groups A and B, which had not preserved the-endplate, hada greater increase than that in group C, which had preserved the endplate. Of the patients, 12 had autograft collapse, 3 autograft displacement, and 10 postural abnormality between the fused segments, most of which happened in groups A andB. The fusion rate was 93.3% (56 cases) according the strict arthrodesis critera; their excellent and good rate in the functional assessment was 83.3% (RP 90.4%, CSM 79.5%); the overall satisfactory (excellent and good) rates in groups A,B and C were 75%, 85% and 90%, respectively. Conclusion To increase the resistance to graft subsidence, which is a major reason for narrowness of the fused segments, and to maintain normal cervical curvature, we should improve our skills of bone grafting performance, preserve the endplate, carefully evaluate the degree of osteoporosis before operation, and use anterior cervical locking plate and /or fusion with Syncage-C when necessary.
Objective To compare microsurgery lumbar discectomy (MSLD) via posterior approach with traditional open discectomy by fenestration for single-level lumbar disc protrusion in terms of methodology and therapeutic effect. Methods From January 2001 to January 2008, 230 patients with single-level lumbar disc protrusion were randomized into two groups. In group A, 114 patients underwent MSLD, including 77 males and 37 females aged 15-76 years old (average 41 years old); the duration of the disease ranged from 6 months to 28 years (average 51 months); the lumbar disc protrusion involved L4,5 level in 52 cases, and L5 - S1 level in 62 cases; there were 50 cases of lumbar disc protrusion on the left side, 54 onthe right side, and 10 of the central type; preoperative JOA score was 6-18 points (average 11.8 points). In group B, 116 patients underwent traditional posterior open discectomy by fenestration, including 78 males and 38 females aged 14-78 years old (average 42 years old); the duration of the disease ranged from 8 months to 26 years (average 52 months); the lumbar disc protrusion involved L4,5 level in 56 cases, and L5 - S1 level in 60 cases; there were 53 cases of lumbar disc protrusion on the left side, 52 on the right side, and 11 of the central type; preoperative JOA score was 5-19 points (average 12.3 points). No significant difference was evident between two groups in terms of general information (P gt; 0.01). Parameters of operative time, volume of blood loss during operation, length of operative incision, length of hospital stay after operation, and total medical cost of single disease were analyzed. Therapeutic effect was assessed by postoperative JOA score during follow-up period. Results The operative time was (40 ± 9) minutes in group A and (47 ± 11) minutes in group B. The volume of blood loss during operation was (26 ± 5) mL in group A and (60 ± 6) mL in group B. The length of operative incision was (2.6 ± 0.8) cm in group A and (5.6 ± 0.5) cm in group B. The length of hospital stay after operation was (4.0 ± 2.6) days in group A and (8.0 ± 2.9) days in group B. The total medical cost of single disease was (5 500 ± 1 800) ￥ in group A and (6 300 ± 1 500) ￥ in group B. Significant difference was evident between two groups in terms of the above parameters (P lt; 0.01). The incisions in two groups all healed by first intention.No compl ications such as wrong orientation, nerve root injury, cauda equina injury, and infection occurred. The follow-upperiod was 12-37 months (average 26 months) for 102 patients of group A and 12-35 months (average 24 months) for 98 patients of group B. The JOA score 12 months after operation was 21-28 points (average 24.8 points) in group A and 22-27 points (average 25.2 points) in group B, showing a significant difference when compared with preoperative score (P lt; 0.01), and no significant difference between two groups (P gt; 0.01). Conclusion Two methods have similar cl inical outcomes, but MSLD has merits of minimal invasion, less blood loss, shorter operative time, shorter length of hospital stay, and lower medical cost. It is one of ideal minimally invasive operations for single-level lumbar disc protrusion．
Objective To elucidate the relationship between preoperative C7 slope (C7S) and sagittal parameters in anterior cervical discectomy with fusion (ACDF) by imaging. Methods A retrospective analysis of 54 patients (24 males and 30 females) with ACDF for cervical spondylosis between January 2012 and January 2017 was performed. The age ranged from 23 to 71 years (mean, 46.6 years). There were 29 cases of cervical spondylotic radiculopathy and 25 cases of cervical spondylotic myelopathy. The disease duration ranged from 3 to 48 months, with an average of 16.8 months. In the 55 patients, 44 were single-segment ACDF and 10 were double-segment ACDF. Sagittal parameters of cervical spine were measured on cervical X-ray films before operation and at last follow-up, including C2-7 Cobb angle, C2-7 sagittal vertical axis (C2-7 SVA), C7S, and segment Cobb angle (SCobb), and the changes of C2-7 Cobb angle (the difference between the last follow-up and the preoperative angle) were calculated. Pearson correlation was used to analyze the correlation between the parameters before operation and at last follow-up. According to the preoperative median value of C7S (15°), the patients were divided into group A (C7S<15°) and group B (C7S≥15°). The sagittal parameters before and after operation were compared between the two groups. Results All the 54 patients were followed up 6-45 months (mean, 15.5 months). At last follow-up, C7S, C2-7 Cobb angle, C2-7 SVA, and SCobb angle were significantly improved when compared with preoperative values (P<0.05). Correlation analysis showed that the preoperative C7S and SCobb angles were significantly correlated with C2-7 Cobb angle and C2-7 SVA (P<0.05), but there was no significant correlation between C7S and SCobb angle (r=0.049, P=0.724). There was a significant correlation between C7S, C2-7 Cobb angle, and SCobb angle at last follow-up (P<0.05), but there was no significant correlation between C7S and SCobb angles and C2-7 SVA (P>0.05). According to the median value of preoperative C7S, 28 patients in group A had C7S of (11.82±3.60)°, while 26 patients in group B had C7S of (20.77±4.09)°. There was no significant difference in gender and age between the two groups (P>0.05). The preoperative C2-7 Cobb angle and C2-7 SVA in group A were significantly lower than those in group B (P<0.05). There was no significant difference between preoperative SCobb angle and group B (t=0.234, P=0.816). There were no significant differences in C2-7 Cobb angle, C2-7 SVA, and SCobb angle between group A and group B at last follow-up (P>0.05). However, the change of C2-7 Cobb angle in group A was significantly higher than that in group B (t=2.321, P=0.024). Conclusion Preoperative C7S≥15° group has more physiological lordosis before operation, but its postoperative cervical curvature changes less, while ACDF is more conducive to correct the preoperative C7S<15 ° cervical curvature.
Objective To evaluate the safety and effectiveness of anterior cervical discectomy and fusion (ACDF) by using zero-profile anchored cage (ZAC) in treatment of consecutive three-level cervical spondylosis, by comparing with plate-cage construct (PCC). Methods A clinical data of 65 patients with cervical spondylosis admitted between January 2020 and December 2022 and met the selection criteria was retrospectively analyzed. During consecutive three-level ACDF, 35 patients were fixed with ZAC (ZAC group) and 30 patients with PCC (PCC group). There was no significant difference in baseline data between the two groups (P>0.05), including gender, age, body mass index, surgical segment, preoperative Japanese Orthopaedic Association (JOA) score, Neck Disability Index (NDI), visual analogue scale (VAS) score, prevertebral soft tissue thickness (PSTT), cervical lordosis, and surgical segmental angle. The operation time, intraoperative blood loss, hospital stay, clinical indicators (JOA score, NDI, VAS score), and radiological indicators (cervical lordosis, surgical segmental angle, implant subsidence, surgical segment fusion, and adjacent segment degeneration), and the postoperative complications [swelling of the neck (PSTT), dysphagia] were recorded and compared between the two groups. Results Patients in both groups were followed up 24-39 months. There was no significant difference in follow-up duration between the two groups (P>0.05). The operation time and intraoperative blood loss were lower in ZAC group than in PCC group, and the length of hospital stay was longer, but there was no significant difference (P>0.05). At each time point after operation, both groups showed significant improvements in JOA score, VAS score, and NDI compared with preoperative scores (P<0.05), but there was no significant difference between the two groups at each time point after operation (P>0.05). Both groups showed an increase in PSTT at 3 days and 3, 6 months after operation compared to preoperative levels (P<0.05), but returned to preoperative levels at last follow-up (P>0.05). The PSTT at 3 days and 3 months after operation were significantly lower in ZAC group than in PCC group (P<0.05), and there was no significant difference between the two groups at 6 months and at last follow-up (P>0.05). The incidences of dysphagia at 3 days and 3 months were significantly lower in ZAC group than in PCC group (P<0.05), while no significant difference was observed at 6 months and last follow-up between the two groups (P>0.05). There was no postoperative complication in both groups including hoarseness, esophageal injury, cough, or hematoma. Both groups showed improvement in cervical lordosis and surgical segmental angle compared to preoperative levels, with a trend of loss during follow-up. The cervical lordosis loss and surgical segmental angle loss were significantly more in the ZAC group than in PCC group (P<0.05). The incidence of implante subsidence was significantly higher in ZAC group than in PCC group (P<0.05). There was no significant difference between the ZAC group and PCC group in the incidences of surgical segment fusion and adjacent segment degeneration (P>0.05). ConclusionIn consecutive three-level ACDF, both ZAC and PCC can achieve satisfactory effectiveness. The former can reduce the incidence of postoperative dysphagia, while the latter can better maintain cervical curvature and reduce the incidence of implant subsidence.