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.
Objective To investigate the effectiveness of microscope assisted anterior lumbar discectomy and fusion (ALDF) and mobile microendoscopic discectomy assisted lumbar interbody fusion (MMED-LIF) for lumbar degenerative diseases. Methods A clinical data of 163 patients with lumbar degenerative diseases who met the criteria between January 2018 and December 2020 was retrospectively analyzed. Fifty-three cases were treated with microscope assisted ALDF (ALDF group) and 110 cases with MMED-LIF (MMED-LIF group). There was no significant difference between the two groups in terms of gender, age, disease type, surgical segments, preoperative visual analogue scale (VAS) scores of low back pain and leg pain, Oswestry disability index (ODI), intervertebral space height, lordosis angle, and spondylolisthesis rate of the patients with lumbar spondylolisthesis (P>0.05). The operation time, intraoperative blood loss, and hospital stay of the two groups were recorded. The effectiveness was evaluated by VAS scores of low back pain and leg pain and ODI. Postoperative lumbar X-ray films were taken to observe the position of Cage and measure the intervertebral space height, lordosis angle, and spondylolisthesis rate of the patients with lumbar spondylolisthesis. Results The operations were successfully completed in both groups. The operation time, intraoperative blood loss, and hospital stay in ALDF group were less than those in MMED-LIF group (P<0.05). The patients in both groups were followed up 12-36 months, with an average of 24 months. The VAS scores of low back pain and leg pain and ODI after operation were lower than those before operation in the two groups, and showed a continuous downward trend, with significant differences between different time points (P<0.05). There were significant differences between two groups in VAS score of low back pain and ODI (P<0.05) and no significant difference in VAS score of leg pain (P>0.05) at each time point. The improvement rates of VAS score of low back pain and ODI in ALDF group were significantly higher than those in MMED-LIF group (t=7.187, P=0.000; t=2.716, P=0.007), but there was no significant difference in the improvement rate of VAS score of leg pain (t=0.556, P=0.579). The postoperative lumbar X-ray films showed the significant recovery of the intervertebral space height, lordosis angle, and spondylolisthesis rate at 2 days after operation when compared with preoperation (P<0.05), and the improvements were maintained until last follow-up (P>0.05). The improvement rates of intervertebral space height and lordosis angle in ALDF group were significantly higher than those in MMED-LIF group (P<0.05). There was no significant difference in the reduction rate of spondylolisthesis between the two groups (t=1.396, P=0.167). During follow-up, there was no loosening or breakage of the implant and no displacement or sinking of the Cage. Conclusion Under appropriate indications, microscope assisted ALDF and MMED-LIF both can achieve good results for lumbar degenerative diseases. Microscope assisted ALDF was superior to MMED-LIF in the improvement of low back pain and function and the recovery of intervertebral space height and lordosis angle.
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.
ObjectiveTo explore the clinical efficacy of percutaneous endoscopic interlaminar discectomy (PEID) and interlaminar fenestration discectomy in the treatment of lumbar (L) 5-Sacral (S) 1 lumbar disc herniation (LDH).MethodsLDH patients were retrospectively included from January 2016 to Januray 2018. And the patients were divided into the PEID group and the fenestration group according to their choice of different surgical methods. The operation time, intra-operative blood loss, and bed rest time in the two groups were recorded. The preoperative and postoperative [1 week, 1 month, 3 months, and last follow-up (>12 months)] Visual Analogue Score (VAS) of the lumbago and leg pain between the two groups were compared; the preoperative and postoperative [1 week, and last follow-up (>12 months)] Oswestry Disability Index (ODI) and also the postoperative [(>12 months)] therapeutic effect (modified MacNab) between the two groups were compared.ResultsA total of 66 patients were included, with 31 in the PEID group and 35 in the fenestration group. There was no significant difference in age, gender and course of disease between the two groups (P>0.05). There were leakage of cerebrospinal fluid and transient lumbago, leg pain and numbness, which were worse than those before operation in the PEID group (1 and 1 patient, respectively) and the fenestration group (2 and 3 patients, respectively). There were statistically significant differences between the PEID group and the fenestration group, in the operative time [(90.65±9.98) vs. (66.23±16.50) minutes], intra-operative blood loss [(51.77±18.64) vs. (184.29±78.38) mL], and bed time [(2.87±0.92) vs. (7.49±1.20) d] (t=−7.365, t’=−9.697, t=−17.374, P<0.001). There was no significant difference in the preoperative VAS score (lumbar-leg pain) and ODI index, and the ODI index at each postoperative time point, between the two groups (P>0.05). VAS score (lumbago) and VAS score (leg pain) in the PEID group at each postoperative time point were lower than those in the fenestration group (P<0.05); VAS scores (leg pain) at other time points were not statistically significant between the two groups (P > 0.05). VAS (lumbar-leg pain) score and ODI index at each postoperative time point were lower than those before the surgery. The was no statistically significant difference in the PEID group (90.32%) and fenestration group (85.71%) in the excellent rate (χ2=0.328, P=0.713).ConclusionsPEID has less surgical trauma, less bleeding, short bed rest, fast recovery, and better relief of postoperative lumbago symptoms. It is worthy of further promotion in clinical work.
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.
ObjectiveTo identify effect of quantitative indicators of ilium height on approach of percutaneous endoscopic lumbar discectomy (PELD) treatment in patients with L5, S1 lumbar disc herniation.MethodsA retrospective study between May 2014 and March 2016 was conducted, including 100 patients with disc herniation at L5, S1, who were initially enrolled for the PELD treatment. Among them, 66 patients were successfully treated with PELD (group A), and the other 34 patients failed to perform puncture, catheterization, or microscopical operation due to the influence of iliac bone and other peripheral bone structures and treated with alternative surgical plans. By analyzing the X-ray films of lumbar vertebrae (including bilateral ilium) of the two groups before operation, the concept of ilium height rate and ilium angle rate was put forward innovatively. The ilium height rate and ilium angle rate of the two groups were measured and compared, and the diagnostic critical points of ilium height rate and ilium angle rate were determined by ROC curve analysis.ResultsThe ilium height rate was 0.61±0.09, 0.74±0.05 and the ilium angle rate was 0.66±0.08, 0.80±0.08 in groups A and B, respectively, showing significant differences between the two groups (F=69.729, P=0.000; F=65.165, P=0.000). ROC curve analysis showed that the critical point of ilium height rate was 0.71 (area under ROC curve was 0.927, P=0.000), and the critical point of ilium angle rate was 0.75 (area under ROC curve was 0.965, P=0.000).ConclusionPELD is not recommended for patients with L5, S1 intervertebral disc herniation, when the ilium height rate is greater than 0.71 and/or the ilium angle rate is greater than 0.75. Other surgical plans such as transpedicular approach, transpedicular approach, or open surgery, should be recommended to reduce the risk of surgery and the pain of patients.
Objective To investigate the early effectiveness of Zero-profile interbody fusion system (Zero-P) in the treatment of cervical disc protrusion. Methods Between October 2010 and June 2012, 25 patients with cervical disc protrusion underwent anterior cervical discectomy and fusion (ACDF) using the Zero-P system. There were 15 males and 10 females, aged from 35 to 68 years (mean, 49 years). The disease duration was 3-26 months (mean, 10.5 months). Single segment was involved in all cases (2 cases in C3, 4, 5 cases in C4, 5, 11 cases in C5, 6, and 7 cases in C6, 7). The operation time and blood loss were recorded and analyzed. The visual analogue scale (VAS) score, Japanese Orthopaedic Association (JOA) score, and neck disability index (NDI) were used to assess pain and nerve function improvement; the cervical Cobb angle was measured on the X-ray films before and after operation; according to Pitzen’s criteria, intervertebral fusion was evaluated. Results The operation was successful in 25 patients, with no severe complication. The average blood loss was 42.6 mL (range, 20-120 mL). The average operation time was 63.6 minutes (range, 45-90 minutes). Primary healing of incision was obtained in all cases; no injury of spinal cord and nerve root, cerebrospinal leakage, or deep infection occurred. The patients were followed up 6-23 months (mean, 14.5 months). No Cage subsidence and loosening, breaking, or pulling-out were observed. The symptoms and curvature of the cervical spine were obviously improved in all patients after operation. The VAS score, JOA score, NDI, and the cervical Cobb angle at 3 months and last follow-up showed significant differences when compared with preoperative ones (P lt; 0.05), but no significant difference was found between at 3 months and at last follow-up (P gt; 0.05). The interbody fusion was achieved in each operated segment of all patients according to Pitzen’s criteria. Conclusion The early effectiveness of ACDF with Zero-P system is satisfactory in treatment of cervical disc protrusion because it has the advantages of short operation time, less bleeding, good stability and restoration of the cervical alignment.
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.
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.
ObjectiveTo systematically review the efficacy and safety of percutaneous endoscopic lumbar discectomy (PELD) for L5/S1 disc herniation via transforaminal approach (TF-PELD) versus interlaminar approach (IL-PELD).MethodsPubMed, EMbase, The Cochrane Library, CBM, CNKI and WanFang Data databases were electronically searched to collect randomized controlled trials (RCTs) and the cohort studies of TF-PELD versus IL-PELD for L5/S1 disc herniation from inception to October 2017. Two reviewers independently screened literature, extracted data and assessed the risk of bias of included studies, then, meta-analysis was performed by using RevMan 5.3 software.ResultsA total of 1 RCT and 7 cohort studies involving 414 patients were included. The results of meta-analysis indicated that: compared with IL-PELD group, TF-PELD group had longer operative time (MD=17.42, 95%CI 12.86 to 21.97, P<0.000 01) and more frequency of intraoperative fluoroscopy (MD=8.42, 95%CI 6.18 to 10.65,P<0.000 01), respectively. However, there were no significant differences between two groups in the post-operative visual analogue scale (MD=0.01, 95%CI –0.23 to 0.25,P=0.94), the post-operative Oswestry disability index (MD=–0.46, 95%CI –2.42 to 1.49, P=0.64), the excellent and good outcomes rate (RR=1.00, 95%CI 0.89 to 1.12, P=0.96), and the rate of complications (RR=0.73, 95%CI 0.45 to 1.18, P=0.20).ConclusionCurrent evidence shows that TF-PELD and IL-PELD are equally effective and safe for L5/S1 disc herniation, but IL-PELD is superior to TF-PELD in less operative time and less radiation exposure. Due to limited quality and quantity of the included studies, more high quality studies are needed to verify above conclusion.