The intervertebral disc disease is a group of clinical diseases with complex etiology, various clinical symptoms and poor conservative treatment effect. The traditional treatment methods include conservative treatment, local injection and open surgery. In recent years, minimally invasive spine surgery has made great progress and development, and its clinical effect has been fully affirmed. Coblation nucleoplasty (CN) has been mainly used in the treatment of contained disc herniation since it has been used in clinical treatment. Its application is not favorable because of narrow indications, uncertain clinical efficacy and other reasons. At present, the application of CN in the intervertebral disc diseases has been reported in many literatures, and its working principle, operation safety, indications and efficacy have been analyzed and extended. Those literatures play an important role in its clinical application. Therefore, in this paper, the application status of CN in the intervertebral disc diseases is reviewed.

10.3969/j.issn.2095-4344.2013.26.001

BACKGROUND: Minimally invasive transforaminal interbody fusion (Mis-TLIF) for spondylolisthesis has been introduced to reduce muscle trauma, minimize blood loss, and achieve earlier rehabilitation. However, there is a lack of evidence-based medicine concerning the therapeutic efficacy of Mis-TLIF versus open TLIF for spondylolisthesis. OBJECTIVE: To systematically evaluate the clinical efficacy and safety of Mis-TLIF versus open TLIF for spondylolisthesis.METHODS: WanFang, CNKI, PubMed, and Cochrane Library databases were searched using the keywords of spondylolisthesis, minimally invasive transforaminal interbody fusion, open transforaminal interbody fusion in English and Chinese, respectively. The quality evaluation and data extraction of the included literatures were conducted by two authors independently. A meta-analysis was performed on RevMan 5.3 software.RESULTS AND CONCLUSION: Ten literatures were included, including 7 retrospective and 3 randomized controlled trials; 963 cases were enrolled (489 cases of Mis-TLIF, 474 cases of open TLIF). (1) Meta-analysis results showed that there were no significant differences in the operation time, postoperative complication rate, and fusion rate at the last follow-up between two groups, suggesting that the two methods expose analogical effects on the pain relief and functional recovery. (2) There were significant differences in the intraoperative blood loss and radiological times between two methods. (3) To conclude, Mis-TLIF holds similar operation time, incidence of complications and functional recovery with open TLIF, accompanied by minimized trauma, and reduced intraoperative and postoperative blood loss, which is considered as a safe and effective surgical method.

BACKGROUND:Surgical management of sternoclavicular joint dislocation takes relatively larger risks for its adjacent mediastinal and other important structures. However, the surgical methods are varied and remain controversial.
OBJECTIVE:To investigate the feasibility and validity of intramedul ary fixation of the proximal clavicle and sternum for sternoclavicular joint dislocation.
METHODS:On 22 adult cadaver upper limb specimens, the anatomical features of the sternoclavicular joints and associated ligaments, the size of articular surface between the medial clavicle and manubrium and the morphology of articular disc, costoclavicular ligament and sternoclavicular ligament were observed and measured. From January 2009 to July 2012, three patients with sternoclavicular joint dislocation received the intramedul ary fixation with wire rope or absorbable suture in figure-of-eight shape. They were males, aged 9, 45 and 62 years, with an average age of 38.6 years. The outcome was evaluated by upper limb function DASH score.
RESULTS AND CONCLUSION:Anatomic results demonstrated that the anteroposterior and coronal diameters of the surface of the medial clavicle were greater than that of the sternum, so they did not match each other. The minimum thickness of the manubrium sterni was at the superior margin of articular surface and the largest was at the sternal angle. The minimum width of the manubrium sterni was at the superior margin of articular surface and the largest was at the inferior margin. The articular disc, liked an el ipse and matched with the articulating surface of the manubrium sterni more, whose anteroposterior diameter was greater than its coronal diameter. Central thickness was greater than the edge thickness. The costoclavicular ligament was thicker and denser than the anterior and posterior sternoclavicular ligament. The anterior and posterior sternoclavicular ligaments were close in length, width and thickness. Clinical trial results demonstrated that al cases were fol owed up for 14 to 36 months. DASH score was 10-16, 13.3 in average. Effects of internal fixation were satisfactory. Surgical management of sternoclavicular joint dislocation by the fixation of the proximal clavicle and sternum through the intramedul ary cavity with wire rope or absorbable suture is reliable and effective.

Objective To investigate the change of serum Nogo-A protein in patients with acute closed brain injury, and explore its relationship with the severity of neuronal damage and prognosis. Methods Thirty-one patients with acute closed brain injury were enrolled. Venous blood samples (2 mL) were obtained 1, 3 and 5 d after injury. Serum concentrations of Nogo-A protein were determined by ELISA. Patients were divided into mild (n =7), moderate (n = 10) and severe (n = 14) injury groups according to Glasgow coma score (GCS), and were divided into favorable prognosis (n = 23) and poor prognosis (n = 8) groups according to Glasgow outcome score (GOS). Another 20 healthy adults were served as controls. Results The mass concentrations of serum Nogo-A protein in mild, moderate and severe injury groups 1, 3, 5 d after injury were significantly higher than those in control group (P < 0.01), and the mass concentrations of serum Nogo-A protein in moderate and severe injury groups 1, 3, 5 d after injury were significantly higher than those in mild injury group (P <0.05, P <0.01). The mass concentrations of serum Nogo-A protein 1, 3, 5 d after injury were significantly higher in poor prognosis group than those in favourable prognosis group (P < 0.01). Conclusion Serum Nogo-A protein level significantly increases after brain injury, and is related to the degree of injury and prognosis.

Objective To observe the clinical efficacy of transcranial direct current stimulation (tDCS) in the treatment of pain after lumbar fusion operation. Methods Patients underwent lumbar fusion surgery in the Department of Minimally Invasive Spine Surgery, Tianjin Hospital from January 2016 to December 2016 were retrospective analyzed. They were divided into tDCS group and control group according to the postoperative analgesic strategies. Patients in tDCS group were given flurbiprofen injection combined with tDCS to control postoperative pain, and morphine was used if necessary. The control group was only given flurbiprofen injection combined with morphine analgesia to manage postoperative pain. The data of preoperative and postoperative pain visual analogue score (VAS), oswestry disability index (ODI), opioid analgesics usage and complications before and after operation were recorded. Results Forty-two patients were included in this study. There were 22 patients in tDCS group with the mean age (56.7±10.5) years, and 20 in control group with the mean age (60.3± 9.2) years. There were no significant differences in preoperative VAS and ODI scores between two groups. The VAS and ODI scores at postoperative 24 h and hospital discharge significantly improved in two groups compared with preoperative data. Data of postoperative 24 h VAS score (2.0 ± 1.7), VAS score (2.1 ± 0.9) and ODI score (20.9 ± 6.5) at hospital discharge were significantly lower in tDCS group than those in control group (3.3 ± 1.4, 2.9 ± 1.3 and 25.4 ± 5.3). The dosage of opioid medication use in controlling postoperative pain was reduced about 25％ in tDCS group (P < 0.01). The complications reported in tDCS group included itching under the electrodes, pain, scorching hot and stinging. Conclusion The use of tDCS after lumbar fusion operation can decrease the pain sensation, reduce the usage of opioids, promote the rehabilitation and with no increasing the incidence of related complications, which has the potential probability to replace opioids for chronic pain.

Objective:To summarize the clinical manifestations, epidemiological features and progress of diagnosis and treatment of gout in the spinal canal.Methods:A 59-year-old male patient was admitted to the hospital due to back pain, weakness in both lower limbs, hypoaesthesia and feeling of walking and stepping on cotton for more than one month. The preoperative imaging examination showed there were space-occupying lesions in the spinal canal at the T 8, 9 level with severe canal stenosis. The patient underwent posterior T 8, 9 laminectomy decompression, debridement and T 7-T 10 pedicle screw internal fixation under general anesthesia. The thoracic spinal gout was diagnosed by postoperative pathology. Further, the following keywords, "gout", "gout of spinal canal", "gout of spine" and "intraspinal gout", were used to search in the Chinese and English databases. A total of 62 patients with intraspinal gout were retrieved. The age, gender, involved disease, history of gout or hyperuricemia, laboratory indicators and imaging data of 63 patients were collected. Results:A total of 63 patients with intraspinal gout were retrieved. The gender of one patient was unknown. The remaining patients included 54 males (87.1%, 54/62) and 8 females (12.9%, 8/62) with the ratio of male to female 6.75∶1. The average age was 52(35, 67) years (range 20-82 years) and the peak onset period was 60-79 years. Fifty-six cases (88.9%, 56/63) of all patients suffered the disease from one single site of the spine, including 26 cases in the lumbar-sacral (46.4%), 22 cases (39.3%) in the thoracic spine and 8 cases (14.3%) in the cervical spine. However, only 7 patients had the disease at more than two sites at the same time accounting for 11.1% of all patients (7/63). Fifty-three patients (91.4%, 53/58) had a history of hyperuricemia with an average duration of 8.6 years (range 3 months to 28 years). The clinical symptoms of intraspinal gout were not specific. There were 70.5% (43/61) patients had local pain and up to 98.4% (60/61) patients had varying degrees of neurological dysfunction. X-ray examinations often showed no positive results due to technical limitations. Among 41 patients with CT imaging data, 31 cases showed mid-to-high density elliptical or irregular calcifications in the spinal canal and the remaining 10 patients showed medium-low density soft tissue masses. There were 96.2% (51/53) of patients with intraspinal gout showed medium or low signal on T1WI MRI examination but without high signal or low signal on T2WI (40 cases of high signal, 13 cases of high signal or mixed signal). All 63 patients were finally diagnosed by pathological examination and 5 of them with histological features. The main pathological features included foreign body granuloma, red-stained crystal-like deposits in the cytoplasm of foreign body giant cells, birefringent spindle or needle-like crystals under polarized light microscope.Conclusion:Gout in the spinal canal is a rare condition. Dual-energy CT has high sensitivity and specificity in identifying gout and it can provide a more accurate method in diagnosis of spinal gout. However, the final diagnosis depends on postoperative pathology. If case of spinal instability or neurological dysfunction, surgery had to be performed. Hyperuricemia should be treated in order to reduce the risk of acute attacks.

Objective:To retrospectively analyze the patients with spinal metastases who received surgical intervention and summarize the evolution of their clinical and pathological characteristics and surgical methods.Methods:The data of 703 patients with spinal metastases from January 2007 to December 2018 were collected retrospectively. There were 395 males (56.19%, 395/703) and 308 females (43.81%, 308/703) with an average age of 58.14±11.46 years (range 13-84 years). According to the degree of invasion and thoroughness of tumor resection, the surgical methods could be divided into minimally invasive surgery, decompression surgery, separation surgery, piecemeal resection and total en-bloc spondylectomy surgery. The operative methods were minimally invasive surgery in 89 cases (12.66%), decompression surgery in 96 cases (13.66%), separation surgery in 303 cases (43.10%), piecemeal resection in 182 cases (25.89%) and total en-bloc spondylectomy in 33 cases (4.69%). To analyze the trend of the clinical, pathological types and surgical treatment of patients with spinal metastases over the years, and determine the relevant factors affecting the decision-making of surgical methods by multivariate logistic regression.Results:The ratio of male to female was 1.28:1. 39.54% (278/703) of patients with single-segment involvement in 703 patients, 24.04% (169/703) of patients with double-segment metastasis and 36.42% (256/703) of patients with multi-segment metastasis. The most common type of primary tumor was lung cancer (34.57%, 243/703), followed by breast cancer (8.25%, 58/703), myeloma (8.11%, 57/703), gastrointestinal tumor (6.82%, 48/703) and renal malignant tumor (6.40%, 45/703). From 2007 to 2018, there was no significant difference in the percentage change of different age, gender and primary tumor source composition (age: χ 2=14.01, P=0.233; gender: χ 2=35.73, P=0.341; primary tumor: χ 2=120.09, P=0.074). The percentage of patients with sacrococcygeal metastasis decreased from 20.00% in 2008 to 1.89% in 2017 and the difference was statistically significant (χ 2=8.09, P=0.005). The percentage of patients with multi-level metastasis increased from 26.67% in 2008 to 52.83% in 2017, and the difference was statistically significant (χ 2=7.23, P=0.007). The percentage of patients with minimally invasive surgery decreased from 25.00% in 2007 to 5.88% in 2018, and the percentage of patients with segmented resection decreased from 53.33% in 2008 to 10.29% in 2018. The proportion of the two surgical methods showed a significant downward trend, and the differences were statistically significant (minimally invasive surgery: χ 2=1.46, P=0.026; segmented resection surgery: χ 2=19.56, P<0.001). The percentage of patients undergoing separation surgery increased from 13.33% in 2008 to 64.71% in 2018, and the proportion of patients undergoing total en-bloc spondylectomy increased from 0 in 2007 to 10.29% in 2018. Both surgical methods showed a significant growth trend and the differences were statistically significant (separation surgery: χ 2=27.09, P<0.001; χ 2=4.16, P=0.042). Multivariate Logistic regression analysis showed that age, metastatic site, number of metastatic segments, pathological vertebral fractures, Frankel grade, SINS score and VAS score were independent factors influencing surgical decision-making ( P<0.05). Conclusion:With different time and age, the invasiveness and thoroughness of surgery are increasing, which shows that the percentage of patients who underwent separation surgery and to-tal en-bloc spondylectomy is significantly increasing. Age, metastatic site, number of metastatic segments, pathological vertebral fractures, Frankel grade, SINS score and VAS score are independent factors affecting surgical decision-making.

Objective:To evaluate the clinical value of the New England spinal metastasis score (NESMS) in predicting the prognosis of patients with spinal metastases by retrospectively analyzing the medical records of multicenter spinal metastases in China.Methods:The data of 179 patients with spinal metastases from January 2008 to December 2018 were retrospectively collected. There were 108 males (60.3%) and 71 females (39.7%) with an average age of 59.79±10.88 years old (range 27-84 years). The patient demographic characteristics, primary tumor type, spinal metastases and segments, vertebral pathological fractures, neurological Frankel classification, physical function status, Karnofsky performance scale (KPS), visual analogue score (VAS), the spinal instability neoplastic score (SINS), modified Bauer score, NESMS score, Tomita score and modified Tokuhashi score were collected. The clinical value of NESMS score, Tomita score and modified Tokuhashi score in predicting the survival of patients with spinal metastases were compared. The independent factors affecting survival in these patients were analyzed by Cox proportional hazards regression model.Results:Among the 179 patients, the peak incidence of spinal metastases was in the age group of 61-75 years (45.3%, 81/179) of all patients. Lung cancer was the most common primary tumor (46.9%, 84/179). 40.8% (73/179) of patients had multi-segment metastasisand thoracic spine was the most common site with single-site metastasis (26.3%, 47/179). 28.5% (51/179) of the patients had visceral metastases and 52.0% (93/179) of the patients had extraspinal bone metastases. 31.3% (56/179) of the patients had pathological fractures of the involved vertebral bodies.114 patients received surgical treatment (63.4%). The mortality rates in 3-months, 6-months and 1-year were 22.4% (40/179), 51.4% (92/179) and 77.1% (138/179), respectively. The median survival time of patients with NESMS score of 0-3 was 3, 4, 8, and 10 months respectively with the mean survival time was 3.60±2.10, 6.77±3.39, 9.69±5.71 and 10.53±6.25 months. The 1-year mortality rates were 100% (13/13), 87.5% (42/48), 71.6% (63/88) and 66.7% (20/30) respectively. The consistency of NESMS score, Tomita score and modified Tokuhashi score in predicting survival of all patients was 0.63, 0.58 and 0.55, respectively. For patients with spinal metastases, the NESMS score was better than the Tomita score and modified Tokuhashi score in predicting survival at 3-months (AUC=1.00, 0.63, 0.42) and 6-months (AUC=0.71, 0.63, 0.45). But the accuracy of Tomita score was best in predicting survival at 1-year (AUC=0.66, 0.61, 0.38). Multivariate Cox proportional hazards regression model analysis showed that growth rate of primary tumor, neurological function Frankel score, albumin level and surgical treatment were independent factors affecting the survival time of patients with spinal metastases ( P<0.05). Conclusion:The consistency and accuracy of NESMS score in predicting survival of patients with spinal metastases are better than Tomita score and modified Tokuhashi score, especially in predicting 3- and 6-month survival. The growth rate of primary tumor, Frankel classification, albumin level and surgical treatment were independent factors affecting the survival time of patients with spinal metastases.

Objective:To investigate the risk factors for 1-year survival rate in patients with spinal metastasis secondary to lung cancer.Methods:The data of 343 patients with spinal metastases secondary to lung cancer from January 2011 to December 2018 were retrospectively studied. There were 188 males (54.8%) and 155 females (45.2%) with an average age of 59.47±10.21 years old (range 23-91 years). The patients were divided into operation group (150 cases, 43.7%) and non operation group (193 cases, 56.3%). The demographics, types of primary tumor, non spinal metastasis, visceral metastasis, spinal metastasis and segments, pathological fractures of vertebra, Frankel classification, physical function status (Karnofsky performance scale, KPS), visual analogue score (VAS), the spinal instability neoplastic score (SINS) were recorded and analyzed. The impact of different treatments on the survival prognosis of patients with spinal metastasis was evaluated. The independent factors affecting survival in those patients were analyzed by Cox proportional hazards regression model.Results:The peak incidence of spinal metastases was found in the age group of 46-60 years (43.7%, 150/343). 38.5% (132/343) of the patients had pathological fractures of the involved vertebral body. 58.3% (200/343) of the patients had extraspinal bone metastasis. 36.2% (124/343) of the patients had visceral metastasis. Among the primary tumors, adenocarcinoma was the most common tpye (61.5%, 211/343), followed by large cell lung cancer (12.5%, 43/343), small cell lung cancer (6.4%, 22/343), squamous cell cancer (6.1%, 21/343) and mixed cell lung cancer (5.3%, 18/343). The type of lung cancer cells in about 8.2 (28/343) patients was unknown. Among the surgical patients, 21 patients underwent minimally invasive surgery (14.0%), 28 patients underwent simple decompression surgery (18.7%), 76 patients underwent separation surgery (50.7%), and 25 patients underwent radical surgery (16.6%). 59.3% (89/150) of the patients had a better neurological function than before surgery. The average survival time of all patients was 9.88 months with the median survival time of 8 (5,14) months. The survival rates were 62.1% (213/343), 30.0% (103/343), and 3.8% (13/343) at 6, 12, and 24 months, respectively. The average survival time of patients in the operation group was 10.24 months with the median survival time of 9 (5, 15) months, and the average survival time of patients in the non operation group was 9.41 months with the median survival time of 7 (5, 13) months with no significant difference between the groups (χ 2=0.300, P=0.584). Multivariate Cox proportional hazard regression model analysis showed that radiotherapy [ HR=1.913, 95% CI(1.471, 2.488), P<0.001], chemotherapy [ HR=1.313, 95% CI(1.040, 1.658), P=0.022], targeted drug therapy [ HR=1.683, 95% CI(1.221, 2.319), P=0.001], KPS [ HR=1.593, 95% CI(1.140, 2.225), P=0.006] and pathological type (non-small cell lung cancer) were independent factors affecting the 1-year survival rate of patients with spinal metastasis secondary to lung cancer [ HR=0.322, 95% CI(0.225, 0.460), P<0.001] with significant difference. Conclusion:Surgical treatment can improve both the neurological function and general status of patients with spinal metastasis. Treatments of radiotherapy, chemotherapy, and targeted drug therapy can significantly improve 1-year survival rate, while a KPS less than 50 points and a primary lung cancer other than adenocarcinoma were independent risk factors reducing 1-year survival rate.