China ; Evidence-Based Practice ; HIV Infections ; prevention & control ; Humans

Objective To investigate the feasibility of percutaneous transforaminal endoscopic spine system in thoracic discectomy for disc herniation. Methods One patient with thoracic disc herniation involved the level of vertebral segment in T11/12 was treated with percutaneous transforaminal endoscopic spine system and followed up for 1 month. The targeted puncture was performed under local anesthesia and fluoroscopic guidance with patient in prone position. The foramen of T 11/12 was enlarged gradually with four trephinations, and the working cannula was inserted transforaminal into the canal. Then the herniation was exposed and removed with full endoscopic technique, including the loosen nucleus pulposus. The dural sac was exposed and released adequately. Drainage was placed during operation. Results The procedure was successfully carried out and the dural sac was completely released. The drainage was removed in the second day of operation. The patient could walk in the third day after operation with obvious relief of back and leg pain. At the follow-up of one month postoperation, the visual analogue scale of leg pain decreased from 8 to 1, and the Oswestry disability index (ODI) decreased from 64 to 4. According to MacNab scale, excellent result was acquired. Conclusion There is the feasibility of the percutaneous transforaminal endoscopic spine system in thoracic discectomy for disc herniation. It is a good minimal invasive technique with good results and high technical requirements for surgeons.

Objective To investigate the effect of anterior percutaneous endoscopic discectomy (APECD) and open-door laminoplasty (ODLP) through hybrid surgery in the treatment of multisegmental cervical stenosis and giant disc herniation. Methods This study involved 3 patients with multisegmental cervical stenosis and giant disc herniation confirmed by MRI. Among them, there were 2 males and 1 female, with ages from 56-61. All patients showed significant paresthesia or weakness, and were treated between September and November 2016. The surgery was performed by first the ODLP that made spinal cord back shift, and then APECD for the second step. The visual analog scale (VAS) and neck disability index (NDI) were assessed before and after operation. Results The VAS and NDI scores were improved two weeks after operation. No adverse events like spinal cord injury and vascular injury were found during the operation. After operation, no patients were found incision infection, hematoma formation, cerebrospinal fluid leakage, dysphagia, trachyphonia and so on. Conclusion The hybrid surgery of APECD and ODLP for the treatment of the multisegmental cervical stenosis and giant disc herniation can not only decompress the nerve safely and improve the function, but also preserve cervical intervertebral disc and motion segments, therefore delaying the degeneration of adjacent segments with clinical significance.

Objective To provide a minimally invasive surgical treatment using mobile microendoscopy (mobile MED) for limited cervical spine canal stenosis. Methods Eleven patients were collected from February 2015 to February 2016 in Tianjin Hospital, including 6 males and 5 females, aged 51- 77 years, mean (67.4 ± 7.6) years. Clinical treatment was performed on 11 patients of limited cervical spinal stenosis. The levels of stenosis included C3-5 in 5 cases, C4-6 in 4 cases, C5-7 in 2 cases. The working channel of mobile MED (MMED) can be tilted according to the need of operation. The design of surgical methods:the levels of stenosis were located with fluroscopy, through a posterior median 2.5 cm incision, the nachal ligaments was separated and the spinous process was reached. After a little dissection of paraspinal mascle, the working canal was inserted along the spinous process, and the target lamina was exposed. With MMED, the partial laminectomy was performed along the junction groove of lamina and articular process with high-speed burr, and flavum was exposed and resected with ultra-thin Kerisson, and the dural sac was well exposed. Then the working canal was inserted on the contralateral side along the spinous process, and the decompression was performed with the same method. After bilateral direct decompression, the spinous process and posterior ligament complex shift posteriorly with enlargement of spinal canal. The operation time and blood loss were recorded and the efficacy was followed-up. Results There was no serious complications such as neurological injury. The operation time ranged 80-120 min, with an average of (100 ± 18) min. The intraoperative blood loss ranged (50-120) mL, with an average of (80 ± 20) mL. Postoperative CT showed sufficient decompression and enlargement of the canal with the posterior shift of the spinous process and posterior ligament complex. The patients were followed up for 6-18 months. The alignment of cervical spine was well preserved on X-ray. The ODI decreased from 42.2 ± 16.3 preoperatively to 6.2 ± 4.3. The JOA score improved from 8.2 ± 3.3 preoperatively to 15.1 ± 4.2 at the last follow-up. According to the improvement rate [(JOA-preoperative JOA)/(17-preoperative JOA)], the results were excellent in 5 cases, good in 5 cases, and effective in 1 case. Conclusion The cervical canal enlargement with mobile microendoscopic discectomy technique preserving posterior ligament composite provides a minimally invasive procedure for limited cervical stenosis with adequate decompression.

Objective To evaluate the feasibility and clinical efficacy of microendoscopic discectomy-lumbar interbody fusion (MED-LIF) with mobile microendoscopic discectomy (MMED) technique. Methods The MMED includes outer working canal and inner operating canal, and large working canals (12 mm and 14 mm) are fabricated for this operation. The operation was designed as follow:an incision was made between pedicle projection sites and spinous process on the side with prominent symptom. Working canal was inserted along spinous process and a fenestration was performed. After discectomy and ipsilateral decompression, contralateral nerve was decompressed in case of contralateral stenosis. Then the intervertebral space was prepared and grafted. The inner operating canal was removed and the suitable cage was inserted, followed by percutaneous pedicles screws installation, reduction and fixation. A total of 102 patients with lumbar degenerative disc disease were treated by this technique. The index levels included L34 (n=11), L45 (n=64), L5S1 (n=21), L3-5 (n=3), and L4-S1(n=3). The operative data and follow-up results were recorded and evaluated. Results Surgery was successful in all patients, with no nerve injury or conversion to open surgery. The mean operative time was ( 120 ± 30) min (range, 90-200 min), with a mean blood loss of (120 ± 80) mL (range, 50-300 mL). The post-operative X-ray and CT scans showed improvement of spinal alignment with sufficient decompression. Patients were followed up for 6 to 36 months. The Oswestry disability index (ODI) score decreased from the pre-operative 44.2%±16.3%to the last follow-up 4.9%±4.7%. The visual analog pain score (VAS) of lumbar decreased from the pre-operative 5.3±4.1 to the last follow-up 2.1±1.7, and VAS of leg decreased from the pre-operative 6.7 ± 3.5 to 1.0 ± 0.8 at final follow-up. The clinical results were excellent in 46 cases, good in 50 cases and fair in 6 cases according to the Macnab standard. Conclusion MED-LIF can be easily performed with MMED technique, with sufficient decompression and reduction, providing satisfactory results with less invasive procedure.

Objective To evaluate the feasibility and clinical efficacy of microendoscopic discectomy-transforaminal lumbar interbody fusion (MED-TLIF) with mobile microendoscopic discectomy (MMED) technique. Methods The MMED includes outer working canal and inner operating canal. Large working canals and endoscopic chisel were fabricated for MMED-TLIF,which was designed as follow:the pedicles and index level were located with fluoroscopy, and a 2.5 cm incision was made between pedicle punctures sites on the symptomatic side. Working canal was inserted, and the facet was exposed,the inferior articular process and medial part of superior articular process were resected. The disc and cartilage endplates were curettage, and the intervertebral space was released and tested. The inner operating canal was removed and the interbody space was grafted and supported with suitable cage. Percutaneous pedicles screws were inserted and the residual displacement was evaluated under fluoroscopy, followed by the install of connecting rods for reduction and fixation. Fifty-six patients with lumbar stenosis including 32 cases of instability and spondylolisthesis (1 degree in 15 cases and 2 degree in 9 cases) were treated with this technique. The ODI index and VAS score were compared in patients before and after surgery. The efficacy was evaluated by Macnab standard. Results Surgery was successful in all patients, with no nerve injury or conversion to open surgery. The mean operative time was (120±30) min (range, 90–180 min),with a mean blood loss of (120±50) mL (range,50–200 mL). The post-operative X-ray and CT scans showed improvement of spinal alignment with mean reduction ratio of 72%. Patients were followed up for 6 to 36 months. The ODI score decreased from 50.1±11.2 to 5.8±5.6. The VAS score of lumbar decreased from 7.1±4.2 to 1.2±1.0 and VAS score of leg decreased from 4.1±2.5 to 1.1±0.9 at final follow-up. The clinical results were excellent in 36 cases,good in 20 according to the Macnab scale. Conclusion MED-TLIF can easily perform with MMED technique,with sufficient decompression and reduction, and providing satisfactory results with less invasive procedure.

Objective:To evaluate the value and efficacy of self-anchored anterior lumbar discectomy and fusion (SA-ALDF) for L 5 isthmic spondylolisthesis. Methods:From June 2018 to December 2019, a total of 11 cases of L 5 isthmic spondylolisthesis were treated with SA-ALDF, including 4 men and 7 women, aged 43.2±12.6 (range 29-63) years. All patients had intractable low back pain aggravating during standing activities and alleviating during rest, without lower extremity radicular symptoms. Imaging examination showed bilateral isthmus cleft of L 5 with spondylolisthesis of 1 degree in 10 cases and 2 degree in 1 case according to Meyerding grading system. Under general anesthesia and supine French position, transverse 6 cm incision was made. Then, the L 5S 1 intervertebral disc was exposed via extraperitoneal approach between the bifurcation of abdominal aorta and vena cava. The intervertebral disc was sufficiently removed. The intervertebral space was released and distracted followed by canal ventral decompression and sequential mold testing. Suitable self-anchoring cage filled with auto iliac cancellous bone was implanted to restore intervertebral height and lordosis as well as reduction of spondylolisthesis. Under fluoroscopic guidance, the distal anchoring plate was knocked into the sacrum followed by direct reduction and proximal anchoring plate locking in the L 5 vertebral body. The patients were followed up for 12.1±4.7 (range 6-18) months. The visual analogue score (VAS) and Oswestry dysfunction index (ODI) were evaluated. The reduction and fusion were evaluated on the X-ray films. Furthermore, the rate of spondylolisthesis, the height and the lordosis of intervertebral space were measured. Results:The operation was performed successfully in all the patients with operation duration 90±18 (range 70-120) min, intraoperative blood loss 30±16 (range 10-60) ml. No severe complication such as nerve and blood vessel injury occurred. All patients experienced alleviation of symptom during follow-up. X-rays confirmed that the spondylolisthesis and alignment were recovered obviously without obvious cage displacement. However, the loss of reduction was 63.2% for the grade 2 spondylolisthesis. At the final follow-up, VAS decreased from 6.1±2.1 to 0.9±0.5, ODI decreased from 43.6%±14.2% to 6.0%±3.4%. The spondylolisthesis recovered from 17.7%±10.3% to 8.0%±7.2% with reduction rate of 54.8%±21.6%. The interverbral height recovered from 6.4±2.1 mm to 9.8±3.9 mm and intervertebral lordosis recovered from 4.8°±2.9° to 9.6°±4.7°.Conclusion:SA-ALDF can provide satisfactory outcomes for selected L 5 isthmic spondylolisthesis of degree 1 without neurological compromise. However, its mechanical stability may be insufficient for isthmic spondylolisthesis of degree 2.

Objective To discuss the value of thoracolumbar injury classification and severity score (TLICS) and load-sharing scores in guiding selection of the indications of combined anteroposterior surgery for thoracolumbar fractures. Methods A total of 216 patients with thoracolumbar fractures treated surgically from January 2006 to January 2008 were involved in the study. Combined anterior and posterior surgery was carried out in 48 patients including 32 males and 16 females (at average age of 39 years, range 18-55 years). Segments involved T11 in two patients, T12 in eight, L1 in 20 and L2 in 18. According to the classification of Magerl, there were 20 patients with type B1 fractures, 15 with type B2, four with type C1 and nine with type C2. Neurologic status based on ASIA classification was at grade A in five patients, grade B in 16, grade C in 16, grade D in nine and grade E in two. All patients were operated in lateral position at one stage within 14 days after injury, with posterior laminectomy and pedicle fixation, anterior corpectomy, reduction and strut graft. Forty-five patients were followed up for 14-38 months. Plain X-ray radiographs and reconstruction CT were taken to observe the bone healing. Local kyphosis and vertebral canal were also measured. All the patients were evaluated with TLICS and load-sharing scores. Results Lumbar physical lordosis was reconstructed, with no evident correction loss,pseudoarthrosis or implant failure noted during follow-up. The patients treated with combined surgery had TLICS score ≥5 points, load-sharing scores ≥7 points and were combined with posterior ligamentous complex injury, so the fracture could not be sufficiently decompressed and reconstructed with single anterior or posterior surgery. Of all, 45 patients were followed up for 14-38 months (mean 25 months), which showed that all the combined surgeries were performed successfully, with bone fusion and neurological status improved for at least one ASIA grade. No complications like implant breakage, loosening, titanium mesh displacement or subsidence were observed. Conclusions LICS is basically helpful for guiding selection of combined surgery, but does not well evaluate the canal compromise, to which the load-sharing scores can supplement. These two evaluation systems should be applied together. The anteroposterior surgery can be recommended when the patients are with TLICS≥5 points, load-sharing score ≥7 points and combined with ligament complex injury.

Objective To investigate the feasibility and effects of endoscopic surgical treatment of lumbar intervertebral disc herniation associated with veitebral osteochondrosis.Methods From June 2008 to December 2015,276 cases of lumbar intervertebral disc herniation associated with vertebral osteochondrosis were treated with endoscopic surgery,including 185 men and 91 women,with an average 39.2 years old (range,16-65 years old).The involved level included L2.3 in 2 cases,L3.4 in 9 cases,L4,5 in 126 cases and L5S1 in 139 cases.On preoperative axial CT,the diameter of ossification was more than half of the transverse or sagittal diameter of the spinal canal in 89 cases,and no more than half of the transverse and sagittal diameter of the spinal canal in 187 cases.All patients were operated on the side with serious symptom,181 cases were operated with mobile microendoscopic discectomy (MMED),and 95 cases were operated with percutaneous endoscopic surgery,including percutaneous transforaminal endoscopic discectomy (PTED) in 61 cases and the percutaneous interlaminar endoscopic discectomy (PIED) in 34 cases.The operation and complications were analyzed.Results The soft herniation,broken disc material and the periphery of compressing ossification were removed under the endoscope in all cases,until the nerve was well decompressed.However,the ossification was not complete resected.Dural sac tear occurred in 3 cases of MMED.In the early stage of PTED,2 cases converted to MMED because of intraoperative pain and difficulty,and one case had exiting nerve root injury.At the final follow-up of 12-60 months (average,20.6 months),visual analogue scale decreased from preoperative 8.5±1.2 to 1.0±0.9,Oswestry disability index decreased from preoperative 40.2±8.6 to 3.1±3.0.According to Macnab scale,the results were excellent in 89,good in 154 cases,moderate in 33 cases.Conclusion For most lumbar intervertebral disc herniation associated with vertebral osteochondrosis,good results can be achieve by removal of herniated and broken intervertebral disc and decompression of nerve with endoscope.Therefore,we speculate that the soft disc herniation and spinal stenosis are main pathogenic factors,and that the complete resection of ossification is not needed.

Objective To analyze the value of mini-open approach beside costodiaphragmatic recess in thoracolumbar spine surgery. Methods This approach was applied in 31 anterior thoracolumbar spine surgeries, including 22 men and 9 women, with a mean age of 41 years old (range, 26-58 yrs). The diagnosis were burst fractures in 27 cases (T12 level in 12 cas?es and L1 level in 15 cases) and disc herniations with osteochondrosis in 4 cases. An antero-lateral 10-15 (average is 12) cm incision was performed, then the 11th rib was resected and the extraperitoneal space below diaphragma was disconnected. The pleura fold was identified beneath the rib bed, so the gap beside the costdiaphragmatic recess was entered through an in?cision beyond the fold. The diaphragm and medial arcuate ligament were clipped and vertebral body from T11 to L2 were ex?posed. Results The lateral side of T11 to L2 vertebral body was sufficiently exposed in all the 31 patients. In 26 patients, the pleura fold was beyond the bed of the 11th rib, so the 11th intercostals vessel and nerve were exposed and protected, and the costodiaphragmatic recess was reached through the superior border of the 12th rib. Laceration of pleura occurred in 4 cases af?ter it was sutured, but the extra-pleura approach could still be used after repairing without invading into thorax. Fixation and fusion were performed from T11 to L2. Complications include intercostals nerve pain were seen in 3 cases, which resolved with conservative treatment. Conclusion The mini-open approach beside costodiaphragmatic recess can be used in anterior thoraclumbar spine surgery with sufficient explosion and minimum injury in which thoracic cavity.