[Objective]To investagate the anatomic features in the approach to the brachial plexus in neck in order to make the exposure of brachial plexus more convenience and safer.[Method]Neck of six embalmed adult cadavers were made serial sectional specimens,which was observed to identify the border,composition and anatomic relation of fat layer between the superficial and deep layer of cervical fascia in the posterior triangle of neck with the brachial plexus.[Result]There was no branches of superficial cervical plexus in the fat layer between the superficial layer and deep layer of cervical fascia below the middle neck,in which there was no important structures except omohyoid muscle and transverse cervical artery.The deep layer of cervical fascia was dense and was directly superficial to the brachial plexus.[Conclusion]Exposure of brachial plexus in the neck would be more safe and convenience upon the understanding of anatomic relatiowship between cervical fascia and brachial plexus.

Objective To investigate the appropriate incision for intact specimen extraction during retroperitoneoscopic radical nephrectomy. Methods One hundred and nineteen patients in need of retroperitoneoscopic radical nephrectomy were randomized into two groups. One group of 60 patients received intact specimen extraction through a muscle-splitting abdominal incision. The second group of 59 patients received intact specimen extraction through a muscle-cutting lumbar incision. All procedures were performed by the same team of surgeons, and the intact specimens were extracted by the same surgeon. Standard operative features were measured and recorded (operative time, the time of specimen extraction, incision length, specimen weight, the time to get out of bed, the recovery time of gastrointestinal function, postoperative hospital stay, analgesia requirement, and complication rate). Results The two groups were matched in regard to patient age, body mass index, the maximum diameter of the kidney, and the stage of TNM (each P>0.05). There were significant differences between the abdominal incision group and lumbar incision group in terms of operative time (99±14 min vs 115±12 min; P=0.000), incision length (4.9±0.3 cm vs 5.3±0.4 cm; P=0.000), the time of specimen extraction (14±2 min vs 24±6 min; P=0.000), analgesia requirement (35±27 mg vs 52±29 mg; P=0.002), the time to get out of bed (20±2 h vs 21±4 h; P=0.016). The differences were not significant between the 2 groups in terms of the recovery time of gastrointestinal function (21±3 h vs 20±4 h; P=0.457), hospital stay (6±1 d vs 6±1 d; P=0.476), and specimen weight (469±181 g vs 459±169 g; P=0.776). There was no complication of incision in the 2 groups at 12 months′ follow-up (rang, 6 to 18 months). Conclusion A muscle-splitting abdominal incision for intact specimen extraction is more appropriate than a lumbar incision during retroperitoneoscopic radical nephrectomy, with small incision, little injury, short operative time, quick recovery, and less pain.

Objective To analyse the symptoms in discogenic low back pain and their neurological anatomic mechanism,and to explore the theoretical basis of symptomatic diagnosis of discogenic low back pain.Methods From January 2010 to December 2013, 289 patients were primarily diagnosed as discogenic discogenic low pain in our department, of which 164 patients showing only single abnormal segment on MRI were enrolled, including 99 male and 65 female patients, averaging 42 years old.All patients underwent discography.All the symptoms conform to the neurological anatomic mechanism of lumbar disc, i.e.extensive low back pain, posterior ilium pain, lateral thigh pain, groin pain, low abdomen pain, were recorded postoperatively.Then the occurrence rate of each symptom with positive discography was calculated.The positive rate (equal to sensitivity of the symptom to the diagnosis of discogenic low pain) of discography when each symptom occurred and the negative rate (equal to specificity of the diagnosis of the symptom to the discogenic low pain) of discography when each symptom did not occur were calculated respectively.Results The discographies of 129 (78.7％) in 164 patients were positive, of these patients 95 (73.6％) had the symptom of extensive low back pain, 99 (76.7％) had posterior ilium pain, 58 (45.0％) had lateral thigh pain, 29 (22.3％) had groin pain, and 24(18.6％) had low abdomen pain.The positive rate of discography in those with the symptom of extensive low back pain, posterior ilium pain, lateral thigh pain, groin pain and low abdomen pain was 89.6％, 90.8％, 90.6％, 90.6％ and 92.3％ respectively, i.e.the diagnostic sensitivity to the discogenic low back pain of the symptom of extensive low back pain, posterior ilium pain, lateral thigh pain, groin pain and low abdomen pain was 89.6％, 90.8％, 90.6％, 90.6％ and 92.3％ respectively.Conclusion The occurrence of the above-mentioned symptoms in the discogenic low back pain is conform to the neurological anatomic mechanism of efferent nerve of lumbar disc.These symptoms have great diagnostic significance for discogenic low back pain.

Objective To explore the anatomical basis,safty and manipuility of the puncture technique through anterolateral cervical approach.Methods Twenty two embalmed cadavers and 50 patients who underwent operation through anterolateral cervical approach were used to observe the cervical anatomical characteristics.During the cadaver dissection and operation,the following information was observed:the movement of the carotid sheath while the visceral sheath was pushed left,the features of interspace between the two sheaths at each cervical level,the movement of the esophagus and the interfascial space in which the esophagus moved while the trachea was pushed medially,and the movement of the carotid sheath while it was pushed medially and laterally.From January 2007 to December 2011,206 patients diagnosed as cervical discogenic pain or cervical vertigo were treated by radiofrequency using puncture technique through anterolateral cervical approach,including 93 males and 113 females,aged from 22 to 71 years (average,48years).A total of 434 discs were involved.Results Both in cadaver dissection and in operation,the following results were observed:there was no natural interspace between the carotid sheath and visceral sheath below the C4 level,as a result,manual separation was needed to create a interspace between the two sheaths for the puncture; the two layers of the prevertebral fascia could be separated easily; keeping the visceral sheath intact,the esophagus moved following the trachea when the latter was pushed medially,and the movement of the visceral sheath relative to the cervical vertebra occurred between the two layers of prevertebral fascia; the carotid sheath was primarily constituted by continuation of the prevertebral fascia,as a result,the movement of the carotid sheath was limited by its own tension and the prevertebral fascia.A total of 434 cases of puncture to cervical disc were performed smoothly with no complications related to the carotid artery,esophagus and cervical disc.Conclusion The puncture technique through anterolateral cervical approach requires a correct,thorough understanding of the anterior cervical anatomy,based on which this technique is safe and feasible.

Objective To explore the strategy and outcomes of surgical treatment of thoracic ossification of ligamentum flavum(OLF),especially combined with ossification of posterior longitudinal ligament,thoracic kyphosis and epidural adhesion.Methods Fifty-three cases of thoracic OLF from January 2003 to December 2009 were reviewed retrospectively.All patients were treated by the methods of en bloc resection of semi-facet and lamina.All patients were followed up for more than half an year,including 32 males and 21 females,aged from 43 to 73 years(average 54.7 years).The lesions located in upper thoracic for 18 patients,and in thoracolumbar for 35 patients.For multi-level or jumping OLF patients,the responsible levels were determined by combination of images and clinical symptoms.For multi-level OLF with ossification of posterior longitudinal ligament(OPLL)or thoracic kyphosis(＞50°),multi-level pedicle screw fixation and correction of kyphosis were performed.For dural adhesion patients,part of cerebrospinal fluid was released with a caudal incision of dural sac resulting in collapse and epidural arachnoid separation.Ossific and adhesion dura mater were removed with integrity of arachnoid.The surgical outcomes were evaluated with preoperative and postoperative thoracic Japanese Orthopaedic Association(JOA)score,Nurick grade and neurologic functional recovery ratio.Results Fifty-three cases were followed up for 6 months to 6 years,with an average of 18 months.The average preoperative JOA score was 4.3±2.3,which significantly increased to 8.3±1.8 after operation.Postoperative neurologic functional recovery rates were 11% to 80%(average 65.8%),including excellent in 18 cases,good in 20,fair in 10,and poor in 5.The excellent or good rate was 71.7%.The mean preoperative Nurick grade was 3.7(2-5 grade)and decreased to 2.3 grade after operation.Conclusion En bloc resection of semi-facet and lamina is a safe and effective method for treatment of thoracic OLF.For the patients with OPLL or kyphosis,pedicle screws fixation and kyphosis correction was beneficial for recovery of neurologic function of thoracic OLF patients.

Objective:To evaluate the clinical effect of interspinous process fusion (BacFuse) in the treatment of lumbar disc herniation (LDH) with rheumatoid arthritis (RA).Methods:A retrospective analysis of the clinical data of 50 patients with RA and LDH from May 2013 to June 2018 in department of orthopedics, Beijing Friendship Hospital, Capital Medical University was conducted. Among them, there were 9 males and 41 females, aged (66.60±4.23) years, with an age ranging from 54 to 84 years. According to different surgical methods, the patients were divided into posterior lumbar interbody fusion (PLIF) group ( n=26) and BacFuse group ( n=24). Operative time, intraoperative blood loss and operative complications of the two groups were observed. Oswestry disability index (ODI) and Japanese Orthopaedic Association (JOA) scores were used to evaluate the clinical effect at preoperative, 3 days of postoperative and the last follow-up. The measurement data were expressed as mean±standard deviation( Mean± SD), comparison between groups used t test and the count data were expressed as percentage(%), the chi-square test was used for comparison between the two groups. The clinical effect of the two groups were compared by repeated analysis of variance. Results:In the PLIF group, the operation time and bleeding volume were (174.62±55.59) min, (309.62±30.26) mL, respectively. In the BacFuse group, the operation time and bleeding volume were (71.25±12.96) min, (57.92±9.32) mL, respectively. The differences between the two groups were statistically significant ( P<0.05). The operative complications in the PLIF group (8 cases) was significantly higher than that in the BacFuse group (2 cases) , the difference between the two groups was statistically significant ( χ2 = 3.926, P=0.048). There were significant differences between every two scores among the preoperative, 3 days of postoperative and last follow-up in ODI of the PLIF group( F=760.231, P<0.001). The preoperative, 3 days of postoperative and last follow-up ODI scores of the BacFuse group were significant differences between every two scores ( F= 952.525, P<0.001). There were no significant differences in ODI scores between the two groups [( t=-1.13, P=0.263), ( t=0.706, P=0.483), ( t=0.389, P=0.699)]. There were significant differences between every two scores among the preoperative, 3 days of postoperative and last follow-up in JOA of the PLIF group( F=406.012, P<0.001). The preoperative, 3 days of postoperative and last follow-up in JOA scores of the BacFuse group were significant difference between every two scores ( F=457.760, P<0.001). There were no significant differences in JOA scores between the two groups [( t=0.825, P=0.414), ( t=1.909, P=0.062), ( t=1.086, P=0.283). Conclusions:Compared with PLIF, BacFuse has a similar clinical effect in the treatment of LDH with RA, but BacFuse is less invasive and has fewer postoperative complications. BacFuse is an effective minimally surgical method for the treatment of LDH with RA.

Objective:To analyze the clinical efficacy of inter-spinal distraction fusion and fixation and Posterior lumbar interbody fusion in the treatment of lumbar disc herniation with stenosis, and to evaluate the health economics of the two surgical methods.Methods:Retrospectivly analyzed the clinical data of 400 patients with lumbar disc herniation with stenosis, who were enrolled in Beijing Friendship Hospital, Capital Medical University from Jan. 2015 to Jan. 2019, including 190 male cases and 210 female cases, aged from 50 to 87 years old, with the average age of 67.97. All patients were divided into two groups according to different surgical methods. Among them, 200 patients used interspinous process fusion and distraction fixation (ISDFF group), the other 200 cases used posterior lumbar decompression and pedicle internal fixation (PLIF group). All patients completed the follow-up time of more than 1 year after operation. The basic information of patients′ age, gender, total number of days in hospital, intraoperative bleeding, operation time, surgical incision length and other basic information were observed. The Oswestry dysfunction index (ODI), the Japanese Orthopaedic Association Score (JOA) and the visual analog scale (VAS) were used to evaluate the relief of symptoms before and after the two groups of patients. Total medical expenses, anesthesia expenses, surgical expenses and other expenses were analysed. The software of SPSS 20.0 were conducted to analyze data.Results:The patients in the ISDFF group were (70.84±8.93) years old, and the PLIF group was (65.10±10.23) years old ( t=5.98, P=0.008). The operation time in the ISDFF group was (59.21±16.22) min, and the operation time in the PLIF group was (81.31±17.24) min( t=13.20, P<0.001). The bleeding volume of the ISDFF group was (33.24±11.31) mL, and the bleeding volume of the PLIF group was (67.30±17.61) mL ( t=23.02, P<0.001). The length of the surgical incision in the ISDFF group was (8.27±2.53) cm, and the length of the surgical incision in the PLIF group was (11.15±1.91) cm ( t=11.848, P<0.001). The total hospitalization time in the ISDFF group was (15.15±0.54) days, and the total hospitalization time in the PLIF group was (19.86±0.97) days( t=4.26, P<0.001). There was no significant difference in preoperative ODI, JOA and VAS between the two groups ( P>0.05). Symptoms of postoperative patients were significantly improved compared with preoperative. There were statistical differences in ODI, JOA and VAS between the two groups before and after operation ( P<0.05). However, ODI, JOA and VAS were no statistical difference between the two groups after operation. Complications occurred in 5 cases of the two groups of patients, including two cases of superficial infection in the PLIF group, two cases of dural tear in the PLIF group, one case of spinous process fracture in the ISDFF group. The total hospitalization fee for ISDFF was (57 450±8 670) (yuan), and the total hospitalization fee for PLIF was (75 770±1 640) (yuan), with statistical differences ( t=9.92, P<0.001). The cost of ISDFF operation was 1864±38.19 (yuan), and the cost of PLIF operation was 2352±41.39 (yuan) ( t=8.65, P<0.001). ISDFF antibacterial drug usage fee was 635.5±64.69 (yuan), PLIF antibacterial drug usage fee was 1449±307.1 (yuan) ( t=2.59, P<0.001). The one-time medical material cost during the ISDFF operation was (38 990±300) (yuan), and the one-time medical material cost during the PLIF operation was (52 110±150) (yuan) ( t=5.88, P<0.001). The excellent and good rate of ISDFF group was 92%, and that of PLIF group was 86%. In this study, the total cost of hospitalization was used as an indicator to measure the cost, and further cost-effectiveness evaluation was made. For every good patient, the cost of the ISDFF group was 62 450 yuan, and the cost of the PLIF group was 88, 100 yuan. Conclusions:ISDFF is beneficial to reduce the cost of medical insurance in China, which is in line with the direction of national reform to reduce medical expenditure. It is a surgical method worthy of wide promotion and has a good application prospect.

Objective:To analyze the effect of inter-spinal distraction fusion and fixation (ISDFF) combined with limited decompression on the treatment of lumbar spinal stenosis in elderly patients.Methods:A total of 32 elderly patients with lumbar spinal stenosis, aged from 80 to 87 years old (mean age: 82.0±2.0 years) including 10 males and 22 females, in the Department of Orthopedics, Beijing Friendship Hospital, Capital Medical University from January 2016 to January 2020 were enrolled in this retrospective study. Clinical evaluation and imaging measurement were performed before operation, after operation, 6 months and 24 months after operation. SPSS software was used for statistical analysis. Measured data of normal distribution were expressed as means±standard deviation. One way analysis of variance was used for comparison between groups. Paired t-test was used to compare between preoperative and postoperative as well as between preoperative and 24 months′ follow-up. Results:All of the 32 patients had one or more common accompanying diseases, such as hypertension, diabetes, coronary heart disease, and so on. All patients were successfully completed the operation with a total of 32 segments. VAS score was decreased from (6.22±0.91) before operation to (1.94±0.76) at 24 months( t=16.52, P<0.001). ODI score was also demonstrated the similar trend, from (54.17±10.65) preoperatively to (19.91±4.20) at 24 months follow-up( t=15.89, P<0.001). JOA score was significantly increased from (11.69±3.36) before surgery to (23.44±1.66) at the last follow-up ( t=-19.90, P<0.001). In the change of imaging, the intervertebral angle was decreased from preoperation (9.12±4.65) to (6.77±2.70) at 24 months( t=3.53, P=0.001). The posterior disk height was increased from (0.68±0.19) cm to (0.76±0.19) cm at the last follow-up( t=-2.45, P=0.020). Conclusions:As a new type of minimally invasive internal fixator, the ISDFF combined with limited decompression can relieve the pain of elderly patients with lumbar spinal stenosis and improve the quality of life. It is suitable for the treatment of elderly patients with lumbar spinal stenosis.

The cognitive impairment of diabetes mellitus type 2(T2DM)is closely related to neurovascular coupling(NVC)changes,but the exact mechanism remains unclear.Functional MRI(fMRI)technology were able to jointly analyze NVC changes of T2DM,providing new ideas for revealing the mechanism of cognitive dysfunction caused by T2DM.The progresses of fMRI for exploring NVC changes in T2DM were reviewed in this article.

BACKGROUNDInjectable three-dimensional (3D) scaffolds have the advantages of fluidity and moldability to fill irregular-shaped defects, simple incorporation of bioactive factors, and limited surgical invasiveness. Adipose-derived stem cells (ADSCs) are multipotent and can be differentiated toward nucleus pulposus (NP)-like cells. A hypoxic environment may be important for differentiation to NP-like cells because the intervertebral disc is an avascular tissue. Hence, we investigated the induction effects of hypoxia and an injectable 3D chitosan-alginate (C/A) gel scaffold on ADSCs.

METHODSThe C/A gel scaffold consisted of medical-grade chitosan and alginate. Gel porosity was calculated by liquid displacement method. Pore microstructure was analyzed by light and scanning electron microscopy. ADSCs were isolated and cultured by conventional methods. Passage 2 BrdU-labeled ADSCs were co-cultured with the C/A gel. ADSCs were divided into three groups (control, normoxia-induced, and hypoxia-induced groups). In the control group, cells were cultured in 10% FBS/DMEM. Hypoxia-induced and normoxia-induced groups were induced by adding transforming growth factor-β1, dexamethasone, vitamin C, sodium pyruvate, proline, bone morphogenetic protein-7, and 1% ITS-plus to the culture medium and maintaining in 2% and 20% O2, respectively. Histological and morphological changes were observed by light and electron microscopy. ADSCs were characterized by flow cytometry. Cell viability was investigated by BrdU incorporation. Proteoglycan and type II collagen were measured by safranin O staining and the Sircol method, respectively. mRNA expression of hypoxia-inducing factor-1α (HIF-1α), aggrecan, and Type II collagen was determined by reverse transcription-polymerase chain reaction.

RESULTSC/A gels had porous exterior surfaces with 80.57% porosity and 50-200 üm pore size. Flow cytometric analysis of passage 2 rabbit ADSCs showed high CD90 expression, while CD45 expression was very low. The morphology of induced ADSCs resembled that of NP cells. BrdU immunofluorescence showed that most ADSCs survived and proliferated in the C/A gel scaffold. Scanning electron microscopy showed that ADSCs grew well in the C/A gel scaffold. ADSCs in the C/A gel scaffold were positive for safranin O staining. Hypoxia-induced and normoxia-induced groups produced more proteoglycan and Type II collagen than the control group (P < 0.05). Proteoglycan and Type II collagen levels in the hypoxia-induced group were higher than those in the normoxia-induced group (P < 0.05). Compared with the control group, higher mRNA expression of HIF-1α, aggrecan, and Type II collagen was detected in hypoxia-induced and normoxiainduced groups (P < 0.05). Expression of these genes in the hypoxia-induced group was significantly higher than that in the normoxia-induced group (P < 0.05).

CONCLUSIONADSCs grow well in C/A gel scaffolds and differentiate toward NP-like cells that produce the same extracellular matrix as that of NP cells under certain induction conditions, which is promoted in a hypoxic state.

Adipose Tissue ; cytology ; Alginates ; chemistry ; Animals ; Cell Differentiation ; physiology ; Cells, Cultured ; Chitosan ; chemistry ; Glucuronic Acid ; chemistry ; Hexuronic Acids ; chemistry ; Rabbits ; Stem Cells ; cytology ; physiology ; Tissue Engineering ; methods ; Tissue Scaffolds ; chemistry