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One-stage combined anterior and posterior approach for severe thoracolumbar and lumbar spine fracture

Zhenwu ZHANG ; Xiaohua RAO ; Jiqing TIAN

Chinese Journal of Spine and Spinal Cord.2010;20(3):228-234. doi:10.3969/j.issn.1004-406X.2010.03.13

Objective:To investigate the surgical outcome of one-stage combined anterior and posterior ap-proach for severe thoracolumbar and lumbar spine fracture.Method:A total of 62 cases suffered from severe thoracolumbar and lumbar spine fracture undergoing surgery from Jan 2003 to Jan 2008 were reviewed retro-spectively.Of these,there were T11 involved in 2 cases,T12 in 13 cases,L1 in 28 cases,L2 in 10 cases,L3 in 6 cases and L4 in 3 cases.There were 58 fresh fractures and 4 old fractures.Based on Dennis classifica-tion,12 were compression fracture,33 were burst fracture and 17 fracture dislocation.All cases had spine load score≥7 and TLICS score≥5.Of 19 cases with neurological deficit according to Frankel grade,there were 7 A,5 B and 7 C.Combined anterior and posterior approach was performed in all cases,anterior bony graft plus posterior pedicle instrumentation were performed either,of these,52 cases had additional anterior decompres-sion.Result:All operations were performed successfully,with the mean surgical time of 170min (range, 150-210min) ,the average blood loss was 819ml(range,400-2900ml).No iatrogenic neuroinjury,skin infection, dural matter tearing and graft displacement were noted.The preoperative Cobb's angle was 8°-40°(mean, 23.9°), while the postoperative counterpart returning to normal with 5 cases having 2°-10° kyphosis.The preoperative compression rate was 20%-95%(mean,54.5%),while the postoperative counterpart returning to normal in 47 cases,with 15 cases having 2%-30%.The preoperative canal stenosis rate was 5%-90%(mean,51.1%) while the postoperative counterpart was 0-30%(mean,4.7%),which showed significant difference with regarding to these 3 parameters (P<0.05).All cases were followed up for an average of 31 months (range,12-72 months). Bony fusion was evidenced in cases undergoing anterior bony graft.At 10-12 months, the Cobb's angle was 0°-15°(mean,0.62°) ,the vertebral compression rate was 0-30%(mean,4.6%),no significant difference were noted between them and their postoperative counterparts(P>0.05).At final foUow-up,15 of 19 cases with neu-rological deficit had neurofunction improved,while 4 remained unchanged.According to our hospital criteria,of 43 cases with no neurological deficit,there were 30 excellent,9 good,3 fair and 1 bad with the total excel-lent to good rate of 90.6%.Cage subsidence and pedicle screw breaking was noted in 1 case,who developed severe kyphosis presenting with irreducible back pain.Conclusion:One-stage combined anterior and posterior approach for severe thoracolumbar and lumbar spine fracture can ensure three column stability as well as complete decompression,which has good early outcome.

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Treatment of degenerative lumbar spine stenosis by modified unilateral approach for bilateral decompression under microendoscope

Qingchu LI ; Huilin HU ; Yuan YANG

Chinese Journal of Spine and Spinal Cord.2010;20(1):15-18. doi:10.3969/j.issn.1004-406X.2010.01.04

Objective:To evaluate the feasibility and clinical efficacy of the treatment of lumbar spine steno-sis by modified unilateral approach for bilateral decompression under microendoscope.Method:217 cases with degenerative lumbar spine stenosis from September 2003 to December 2008 were treated by modified unilater-al approach for bilateral decompression of central spinal canal and nerve root canal under microendoscope.A-mong them laminectomy of one segment was done in 163 cases,two segments were done in 54 cases.After surgery,the routine radiograph were carried out and the Nakai criterion was used for assessment.Result:The mean operative time was 48±13min (range,25 to 95min),the average blood loss was 37±9ml (range,25 to 180ml),the average skin incision length was 2.2±0.2cm(1.8 to 2.4cm).2 cases had dural matter tearing,which healed after filling with gelatin foam and 2 weeks bed rest,after that no cerebrospinal fluid leakage was noted after surgery.Mislocation was noted in 1 case.No nerve inury and postoperative infection oceurred.Postoperative CT scan demonstrated complete decompression of the central spinal canal and nerve root canal.All patients were followed-up for an average of 14 months (range,3 months to 24 months).The Nakai criterion at final follow-up showed clinical excellent in 134 cases,good in 63 cases,fair in 16 cases and worse in 4 cases, with the excellent and good rate of 90.8%.No lumbar spine instability was noted.Conclusion:Treatment of de-generative lumbar spine stenosis by modified unilateral approach for bilateral decompression under mieroendo-scope has the merit of minimal invasive,less complications and reliable therapeutical effect.

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Debridement and fusion with bone grafting and instrumentation in the treatment of multiple-level contiguous spinal tuberculosis

Jiandang SHI ; Zili WANG ; Xiaomin MA

Chinese Journal of Spine and Spinal Cord.2010;20(2):98-102. doi:10.3969/j.issn.1004-406X.2010.02.03

Objective:To investigate the results of surgical treatment for multi-level spinal tuberculosis with focal debridement ,bone grafting and primary internal fixation.Method:27 cases of multi-level spinal tuberculosis treated by operation from January 1999 to January 2007 were reviewed retrospectively.3 vertebral bodies involved in 15 cases,4 vertebral bodies involved in 7 cases,5 vertebral bodies involved at least in 5 cases.Of these,there were 5 cases in thoracic vertebra,7 cases in lumbar vertebra,11 cases in thoracolumbar vertebra,4 cases in lumbosacral vertebra.11 cases showed neurological deficit before surgery,According to the Frankel classification,Frankel B in 1 case,Frankel C in 2,Frankel D in 8.The preoperative average Cobb angle of kyphosis was 35°±7° (range,26°-43°).The focal debridement,bone grafting and primary internal fixation were performed for all patients.Among these protocols, 16 cases underwent one staged posterior spinal internal fixation and anterior focal debridement,bone grafting.11 cases had anterior spinal internal fixation with focal debridement and bone grafting.All patients received anti-TB chemotherapy before and after operation.Anti-TB chemotherapy protocols consisting of combinations of rifampin,isoniazid,ethambutol and streptomycin were administered for 3 months which including 3 weeks before the operation and 3 months after the operation,followed by rifampin,isoniazid and ethambutol for a total of 9 months.The clinical outcomes were evaluated according to the criteria designed by WU Qiqiu et al.Result:The average surgical time was 240 minutes (range,150-300min),with the average intraoperative blood loss of 1000ml (range,600-1400ml),There was no complication such as nerve injury and cerebrospinal fluid leakage.The incision in 1 case presented sinus which had a secondary healing later on,others obtained primary healing.The average postoperative Cobb angle of kyphosis was 15°±5°(range,12°-20°).All cases were followed up for an average of 18 months(range, 14-48 months).The patients with paraplegia recovered to the normal in 8 months.Bony fusion was achieved in all cases with mean fusion period of 7 months(range,5-14 months) with no incidence of hardware failure.At the final follow-up,all patients had evidence of clinical heal and the solid bony fusion.Conclusion:Focal debridement,bone grafting and primary internal fixation is reliable in dealing with multi -level spinal tuberculosis.

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Analysis of neurologic complications after posterior lumbar interbody fusion

Long GUO ; Jian CHEN ; Jincai TUN

Chinese Journal of Spine and Spinal Cord.2009;19(12):912-915. doi:10.3969/j.issn.1004-406X.2009.12.07

Objective:To evaluate the neurologic complications associated with posterior lumbar interbody fusion (PLIF).Method:From March 2003 to May 2008,a total of 178 patients experienced PLIF procedure due to lumbar disease.Of these,forty two had lumbar disc herniation,39 had lumbar spine stenosis,61 had degenerative spondylolisthesis, 22 had isthmic spondylolisthesis and 14 had post-laminectomy/discectomy syndrome. One hundred and thirty patients had single level fused,of these,8 at L3/4.64 at L4/5 and 58 at L5/S1.Forty six cases had two levels fused,of these, 19 at L3/4 and L4/5,27 at L4/5 and L5/Sl.Two patients had three levels fused,all at the L3/4.L4/5 and L5/S1.A11 causes possibly related to the neurologic complications were documented.Result: 13 cases(7.3%) were noted to have neurologic complications,of these,one at L4,7 at L5 and 5 at S1.6 cases had nerve root stretch injury,3 cases had nerve root injury from instrument maneuver, 1 case had nerve root deformity, 1 case had developed epidural hematoma, 1 case had nerve root injury from pedicle fracture and 1 case had secondary lateral recess stenosis.2 cases had complete neurological injury,and 11 cases had incomplete injury.According to American Spinal Injury Association (ASIA) criteria,there was complete recovery of neurologic function in 7 cases, incomplete recovery in 4 cases and no change in 2 cas-es.Conclusion: Many causes may be associated with the neurologic complications due to posterior lumbar interbody fusion,nerve root stretch injury is the most common.

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Xin JIANG ; Morishita YUICHIRO ; Henry HYMANSON ; C.wang JEFFREY

Chinese Journal of Spine and Spinal Cord.2009;19(11):845-849. doi:10.3969/j.issn.1004-4060.2009.11.12

Objective:To determine the most common patterns in symptomatic lumbar intervertibral disc degeneration at various age period.Method:The lumbar MRI imaging data of 529 patients treated for low back pain with or without skelagia in Santa Monica hospital in USA from 2004 to 2006 were reviewed retrospectively in this study .There were 191 females, 338 males.Degenerative grading was made for all disc levels in the lumbar spine for each patient. The patients were also classified into five age different groups starting from below age 30,with the intervals of a single decade,until over age 60 (≤29 years,30-39 years,40-49 years, 50-59 years and≥60 years).The degenerative grade of all disc levels (L1/2 to L5/S1) in each patient was classified based on Pfirrmann's gading system,and locations and the progressive manner of the degeneration were determined for age groups.SPSS software version 13.0 (SPSS Inc.,Chicago,IL) on a personal computer was used for statistical analyses.Result:The most common pattern in all ages is normal in all the discs and it is described as 1-1-1-1-1 and this normal pattern was found in 71 patients (13.4%).There was rare change to develop severe degeneration (grade 4) for low age groups.The upper levels of the lumbar spine had more commonly lower degenerative grades,and the lower levels had relatively higher grades of advanced disc de-generation.In the age groups of below 29 years and 30-39 years,the most common pattern was normal in all the discs of 5 levels as 1-1-1-1-1.And this pattern was more prominent in the age group below 29 years.In the age group of 40-49 years.it was changed to single level L5-S1 degeneration with 1-1-1-1-3(7.6%) butthe normal discs in all levels had also a similar portion(6.8%).In the age groups of 50-59 years and over 60 years,it was changed to the pattern with all discs abnormal as 3-3-3-3-3.Single level involvement was negatively correlated with age (P<0.01 ).On the contrary,whole symmetrical degenerative involvement of all levels was positively correlated with age (P<0.01).Single L5/S1 involvement was most common in the age group of below 29 years,but in the age group of 30-39 years,the most common pattern was changed to L4/5 and L5/ S1 double involvement(P< 0.05).A relative small portion appeared as the most common pattern with less than two-level involvement in the age groups over 50 years.Conclusion:The rate of unilevel degenerative pattern of lumbar spine in overall population decreases with the progression of age, while that of all-level degenerative pattern increases with the progression of age.

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Correlation between the diameter or angle of thoracic-lumbar pedicle parameters and vertebral number on Chinese adult men

Liangjie DU ; Jianjun LI

Chinese Journal of Spine and Spinal Cord.2009;19(7):545-549. doi:10.3969/j.issn.1004-406X.2009.07.16

Objective:To study the the correlation between the diameter or angle of thoracic-lumber pedicle and vertebral number.Method:X-ray and CT scan were performed on 46 male spine specimens.The length of pediele screw path,the cress-section angle(e) and the sagittal angle(f) of the pedicle,the width of the inner diameter of the pediele and the distance between the two pedicles were measured.The ordinal number of T1-L5 vertebral segment was numbered by 1-17.SPSS 11.5 software was used for statistical analysis.Result:The data showed a positive linear correlation with the vertebral numbers including length of T1-L4 pedicle screw path (R2=0.716),T8-L5 pedicle width (R2=0.673),T4-L5 pedicle distances (R2=0.771),T1-T2 f-angle (R2=0.767) ,T2-T4 f-angle (R2=0.908),T12-L5 pediele e-angle (R2=0.710).The negative linear correlation with thevertebral numbers included T2-T3 pedicle width(R2=0.792),T1-T4 pedicle distances(R2=0.866),T7-L5 f-an-gle(R2=0.931),T1-T6 pedicle e-angle (R2=0.774).However,the T1-T2 and T4-T7 pediele width,the T4-T6 pediele f-angle,as well as the T6-T12 pedicle e-angle had no significant correlation with the vertebral num-bers.Conclusion:Apart from the T1-T2 and T4-T7 pedicle width,the T4-T6 pedicle f-angle and the T6-T12 pedicle e-angle,the diameter or angle of the thoracic-lumbar pedicle have correlation with the vertebral numbers with meaningful linear regression equation.

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The significance of CT multi-planar reconstruction of vertebral artery CT angiography in C2 pedicle screw placement

Yan ZHANG ; Yi LIU ; Xiaohua WANG

Chinese Journal of Spine and Spinal Cord.2014;(3):217-221. doi:10.3969/j.issn.1004-406X.2014.03.05

Objectives: To investigate the significance of CT multi-planar reconstruction of vertebral artery CT angiography(CTA) in C2 pedicle screw placement. Methods: The vertebral artery CTA images of 77 pa-tients were reviewed retrospectively by CT multi-planar reconstruction. The positions in three dimensions were adjusted according to the screw′s ideal direction, and the cross section of the screw passing through the pedicle was displayed based on CT multi-planar reconstruction. A circle was demarcated on the former plane to simulate the cross section of the screw. The diameter of the circle, the accommodation of screw in C2 pedicle, and the positions of the screw related to the vertebral artery were taken into account to assess the feasibility of pedicle screw placement. And meanwhile, the feasibility was assessed by measuring the inner di-ameters of pedicle complex. The results of the two methods were compared. Results: The simulation of place-ment of C2 pedicle screw basing on CT multi-planar reconstruction illustrated the accommodation of screw in C2 and its relationship with surrounding structures. According to this method, 10(13%) cases of left side and 19 (25%) cases of right side could not accommodate the circle with the diameter of 4mm and could not be placed pedicle screw, while operation was unavailable for 12(16%) cases of left side and 20(26%) cases of right side by measurement of inner diameters. The P value of McNamara test was 0.5 in the left and 1 in the right. There was no significant differences between the results of two methods(P>0.05). The result of Kap-pa test was 0.770 in the left and 0.732 in the right, and the P value of the Kappa test in the both sides was 0, which showed good consistency. Conclusions: The simulation of placing pedicle screw in axis basing on CT multi-planar reconstruction can illustrate the screw accommodation in C2 and its relationship with sur-rounding structures, which can provide good reference for the operation.

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The feasibility of the anterior reverse transpedicular screw (ARTPS) fixation at upper thoracic spine

Juliang HE ; Zengming XIAO ; Lijing YANG

Chinese Journal of Spine and Spinal Cord.2014;(4):359-365. doi:10.3969/j.issn.1004-406X.2014.04.13

Objectives: To verify the feasibility and safety of the anterior transpedicular screw(ATPS) fixation of the upper thoracic spine (T1-T4) through the radiological anatomy study on the cadaveric specimens. Methods: The upper thoracic spine thin-section CT data of 40 cases were collected from the radiology de-partment′s database(20 males and 20 females, aged from 18 to 68 years, the mean age was 39.7 years). The data of OPW(outer pedicle width), OPH(outer pedicle height), PAL(pedicle axis length), TPA(transverse section angle), SPA(sagittal section angle), DTIP(distance of transverse intersection point) and DSIP(distance of sagittal intersection point) of each pedicle were measured on the transverse and sagittal sections through the axis of each pedicle. The data were recorded and statistically analyzed. 10 upper thoracic spine(C7-T6) specimens of adults(5 males and 5 females, with unknown ages), with no damage to their appearance, the costovertebral joints and paravertebral soft tissue were completely retained. Then simulate surgical operations were done on the cadaveric specimens based on the obtained data. Screws were implanted anteriorly by free hand. After that, the specimens accepted X-ray fluoroscopy and CT scan. At last, the screws were removed, the speci-mens were sawed along the transaction and sagittal section of the screw channel. Then the success rate of the screw placement was evaluated according to Rao′s worn out classification standard of pedicle screws. Results: From T1 to T4, the OPW decreased from 8.14mm to 3.47mm; the OPH increased from 6.89mm to 10.29mm; the TPA decreased from 32.96° to 11.64°; the DTIP increased from 1.80mm to 5.50mm; the SPA increased from 104.95° to 115.74°; the DSIP increased from 5.95 to 8.76mm; the PAL changed irregularly, from 32.95 to 35.96mm. The pedicle diameters of T3 and T4 were too small to implant ATPS, but the ARTPS can be implanted successfully. The diameter of ATPS was about 4.0mm; the length of ATPS was about 35mm. The diameter of ARTPS was about 5.0mm; the length of ARTPS was about 35mm. 80 pedicle screws were implanted anteriorly, according to Rao′s worn out classification standard of pedicle screws, the fine rate was 90%. The internal walls of 7 pedicles were broken by screws of less than 2mm and no compression to the spinal cord. The internal walls of 5 pedicles were broken of 2 to 4mm, 1 at T1, 1 at T3 and 3 at T4, with varying degrees of spinal cord compression. The internal walls of 2 pedicles were broken of greater than 4mm, 1 at T2 and 1 at T4, with serious spinal cord compression. The external wall of 1 pedicle was broken at T2. Conclusions: The ATPS techniques at T1, T2 and the ARTPS techniques at T3, T4 are feasible, but the safety and clinical practice and further research is needed.

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Association between tumor necrosis factor-alpha 857C/T polymorphism and susceptibility to ankylosing spondylitis：a meta-analysis

Yinhe CHEN ; Xiaomin LIU ; Cailiang SHEN

Chinese Journal of Spine and Spinal Cord.2014;(5):447-453. doi:10.3969/j.issn.1004-406X.2014.05.13

Objectives: To explore the association between the polymorphism in -857 site of tumor necrosis factor (TNF)-α promoter region and the susceptibility to ankylosing spondylitis (AS). Methods: Case-control studies Pubmed, Cochrane Library, Ovid, Chinese Biomedical Database(CBM), Chinese National Knowledge In-frastructure(CNKI), Wanfang and Weipu data bases from inception to October 2013 for the association between TNF-α-857 C/T polymorphism and the susceptibility to AS were collected. Meta-analysis was performed by Revman 5.2 and Stata 12.0 software. Pooled odds ratios (ORs) with 95% confidence intervals (CIs) were de-rived from random-effects or fixed-effects models to assess the strength of the association. Results: Nine case-control studies were included in the final meta-analysis, including a total of 933 AS patients and 1094 controls. Statistically significant differences between AS and control groups were observed in the susceptibility to AS and TNF-α-857 genotype CC [OR=0.46, 95%CI (0.26, 0.81), P=0.007], allele C [OR=0.61, 95%CI (0.41, 0.91), P=0.02] and T [OR=1.64, 95%CI (1.10, 2.43), P=0.02]. But, no statistical difference in the fre-quency of genotype TT [OR=1.49, 95%CI (0.95, 2.34), P=0.08] was observed between AS and control groups. There were obvious heterogeneities among the studies of genotype CC(P<0.00001, I2=87%), allele C(P<0.00001, I2=84%) and allele T(P<0.00001, I2 =84%), except genotype TT(P=0.09, I2=42%). Sensitivity analysis was per-formed by leaving out one study at a time, but the heterogeneity remained obvious. It was symmetric of the funnel plots of genotype CC, allele C and T with AS, but genotype TT. There was no statistical significance in genotype CC[Begg′s test(z=0.52, P=0.602), Egger′s test(t=0.23, P=0.825)], genotype TT[Begg′s test(z=0.94, P=0.348), Egger′s test(t=1.26, P=0.248)], allele C[Begg′s test(z=0.31, P=0.754), Egger′s test(t=0.72, P=0.494)] or allele T[Begg′s test(z=0.31, P=0.754), Egger′s test(t=-0.72, P=0.494)]. Conclusions: Genotype CC, allele C and T of TNF-α-857 are associated with the susceptibility to AS, and T-allele carriers have higher risk of AS.

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Comparison of the analgesic efficacy between the epidural and intravenous analgesia after spinal fusion：a Meta-analysis

Lin LIANG ; Weimin JIANG

Chinese Journal of Spine and Spinal Cord.2014;(5):433-439. doi:10.3969/j.issn.1004-406X.2014.05.11

Objectives: To compare the efficacy of patient-controlled epidural analgesia and patient-controlled intravenous analgesia in postoperative analgesia after spinal fusion. Methods: The CNKI, Wanfang, CBM, Pubmed, Embase, Ovid, Cochrane library databases were searched by computer. The randomized controlled trails with patient-controlled epidural analgesia or patient-controlled intravenous analgesia after spinal fusion published from May 1985 to July 2013 were selected. All of them were assessed by the standard of Cochrane systematic review. Data of postoperative VAS and the rate of side effects after using the analgesic drugs were extracted into an electrical sheet, which was synthesized by a Meta-analysis with RevMan 5.2 software. Re-sult: Eight randomized controlled trails involving 482 patients met the inclusion criteria. And the quality grade of 3 literatures was A, 5 literatures was B. The result of meta-analysis showed that: ①Visual analogue score(VAS). The postoperative first day′s VAS[WMD=-0.47, 95%CI(-0.74, -0.20)], second day′s VAS[WMD=-0.66, 95%CI(-1.14, -0.19)] showed that the patient-controlled epidural analgesia had a good analgesic effect compared with the patient-controlled intravenous analgesia, and both had statistic differences(P<0.05). No dif-ference in the postoperative third day′s VAS[WMD=-0.58, 95%CI(-1.38, 0.21)] was observed between the two methods, and no statistic difference(P>0.05); ②The side effects. The patient-controlled epidural analgesia had a higher incidence of skin itch[RR=1.53, 95%CI(1.08, 2.16)], paresthesia[RR=3.34, 95%CI(1.12, 9.98)] after surgery than the patient-controlled intravenous analgesia, and both had statistic differences(P<0.05). While two groups had no a significant deviation about nausea [RR=1.05, 95%CI (0.79, 1.40)], vomiting [RR=0.80, 95%CI (0.48, 1.31)], and no statistic difference(P>0.05). Conclusions: The patient-controlled epidural analgesia has better analgesic effects on the postoperative first and second day after spinal fusion, but obviously has a high-er incidence of skin itch and paresthesia than the patient-controlled intravenous analgesia.

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