Ankylosing spondylitis (AS) combined with lower cervical fracture is often categorized into unstable fracture, with a high incidence of neurological injury and a high rate of disability and morbidity. As factors such as shoulder occlusion may affect the accuracy of X-ray imaging diagnosis, it is often easily misdiagnosed at the primary diagnosis. Non-operative treatment has complications such as bone nonunion and the possibility of secondary neurological damage, while the timing, access and choice of surgical treatment are still controversial. Currently, there are no clinical practice guidelines for the treatment of AS combined with lower cervical fracture with or without dislocation. To this end, the Spinal Trauma Group of Orthopedics Branch of Chinese Medical Doctor Association organized experts to formulate Clinical guidelines for the treatment of ankylosing spondylitis combined with lower cervical fracture in adults ( version 2024) in accordance with the principles of evidence-based medicine, scientificity and practicality, in which 11 recommendations were put forward in terms of the diagnosis, imaging evaluation, typing and treatment, etc, to provide guidance for the diagnosis and treatment of AS combined with lower cervical fracture.

Objective:To explore the efficacy of stage I modified posterior vertebral column resection (mPVCR) in the treatment of postoperative infection after percutaneous vertebroplasty (PVP) for osteoporotic vertebral compression fracture (OVCF).Methods:A retrospective case series study was conducted to analyze the clinical data of 11 OVCF patients with post-PVP infection who were admitted to Zhengzhou Orthopedics Hospital from January 2016 to June 2022, including 4 males and 7 females, aged 61-81 years [(70.2±6.4)years]. Injured segments included T 9 in 1 patient, T 11 in 2, T 12 in 3, L 1 in 1, L 2 in 2, T 11-T 12 in 1, and T 12-L 1 in 1. American Spinal Injury Association (ASIA) grading was grade D in 5 patients and grade E in 6. All the patients were treated with stage I mPVCR. The operation time and intraoperative bleeding volume were recorded. The values of Visual Analogue Scale (VAS), Oswestry Dysfunction Index (ODI), and Cobb angle of the lesion segments before, at 2 weeks, 3 months after surgery, and at the last follow-up were compared. The loss of Cobb angle of the lesion segments at 2 weeks after surgery and at the last follow-up were compared, and the ASIA grading at the last follow-up was recorded. The infection control, bone healing, and the incidence of complications were observed at the last follow-up. Results:All the patients were followed up for 12-44 months [(26.0±9.4)months]. The operation time and intraoperative bleeding volume were 230-330 minutes [(279.2±28.6)minutes] and 500-1 100 ml [(840.9±184.1)ml] respectively. At 2 weeks, 3 months after surgery and at the last follow-up, the VAS scores were (4.0±0.8)points, (2.7±0.9)points, and (2.4±0.7)points respectively, which were all lower than that before surgery [(8.1±1.2)points] ( P<0.01); the ODI was (45.5±5.1)%, (30.0±6.5)%, and (18.5±3.6)% respectively, which were all lower than that before surgery [(78.7±6.2)%] ( P<0.01); the Cobb angle of the lesion segments were (7.9±1.4)°, (8.5±1.4)°, and (9.2±1.5)° respectively, which were lower than that before surgery [(25.5±9.2)°] ( P<0.01). The VAS and ODI were both improved at 3 months after surgery compared with those at 2 weeks after surgery ( P<0.05), while there was no significant difference in Cobb angle of the lesion segments ( P>0.05). The ODI was further improved at the last follow-up compared with that at 3 months after surgery ( P<0.05), while there were no significant differences in VAS or Cobb angle of the lesion segments ( P>0.05). The loss of Cobb angle correction of the lesion segment at the last follow-up was 0.96 (0.69, 1.45)° compared with that at 2 weeks after surgery and the rate of loss of Cobb angle correction of the lesion segment was 4.4(2.2, 7.4)%. At the last follow-up, the ASIA grading was grade E for all the patients, who were able to walk normally independently. The infection was all cured and good bony fusion was observed in the operated area at the last follow-up. Two patients had pleural effusion and pulmonary atelectasis, 1 incision fat liquefaction, and 1 pneumonia after the surgery. None of the patients had internal fixation failure and serious complications such as worsening neurological symptoms or death. Conclusion:Stage I mPVCR for the treatment of post-PVP infection in patients with OVCF is proved to attain significant pain relief and functional improvement, good correction results, effective reconstruction of spinal stability, complete removal of infected lesions, and few serious complications.

Objective:To investigate the efficacy of one-stage posterior-anterior combined operation for the treatment of abnormal fusion after facet joint dislocation in the subaxial cervical spine.Methods:A retrospective study of case series was conducted to analyze the clinical data of 10 patients with abnormal fusion after facet joint dislocation in the subaxial cervical spine who had been admitted to Department of Spine Surgery, Zhengzhou Orthopedic Hospital from January 2015 to May 2023. There were 7 males and 3 females with an age of (41.2±3.1) years. Preoperative American Spinal Injury Association (ASIA) grading: 5 cases of grade A, 4 cases of grade B, and 1 cases of grade C. All the patients were treated with one-stage posterior-anterior combined operation. The surgical time and intraoperative bleeding volume were recorded. The ASIA grading was used to evaluate the improvements in nerve function of the spinal cord 3 months after surgery. The VAS scores, cervical intervertebral heights, and Cobb angles were compared between pre-surgery, 3 months after surgery, and the last follow-up. The fusion of intervertebral bone graft was evaluated 3 months after surgery using the Bridgell intervertebral fusion criteria. Complications were observed.Results:All patients were followed up for 15.5 (13.8, 20.5) months. The surgical time was (119.5±3.6) minutes, and the intraoperative bleeding volume (141.6±25.6) mL. Significant improvements in VAS score, cervical intervertebral height, and Cobb angle were observed at 3 months after surgery and the last follow-up compared with the pre-surgery values ( P<0.05), but there was no statistically significant difference between 3 months after surgery and the last follow-up ( P>0.05). ASIA grading 3 months after surgery: 4 cases of grade A, 4 cases of grade B, and 2 cases of grade C. By the Bridgell intervertebral fusion criteria at 3 months after surgery: 9 cases of grade Ⅰ and 1 cases of grade Ⅱ, showing good intervertebral fusion. Surgery went on well for all patients, showing no postoperative complications such as aggravation of nerve lesion or vascular injury. Conclusion:In the treatment of abnormal fusion after facet joint dislocation in the subaxial cervical spine, the efficacy of one-stage posterior-anterior combined operation is definite because it can effectively reduce pain, restore the height and physiological curvature of the cervical intervertebral space, and achieve good intervertebral fusion.

BACKGROUND:Stage Ⅲ Kümmell's disease is characterized by a high degree of vertebral compression and posterior wall defects.Most of the patients are elderly people with severe osteoporosis and various medical diseases.Clinically,some surgical methods are often at high risk and are controversial. OBJECTIVE:To investigate the clinical efficacy of screw placement combined with transpedicular impaction bone grafting in the treatment of stage Ⅲ Kümmell's disease. METHODS:The clinical data of injured vertebral screw placement combined with transpedicular impaction bone grafting in treatment of stage Ⅲ Kummell's disease from May 2016 to August 2021 were retrospectively analyzed.Visual analog scale score,Oswestry disability index,anterior vertebral heights,kyphotic Cobb angle and American Spinal Injury Association(ASIA)impairment scale were used to evaluate the effects of surgery.The operation time,intraoperative blood loss and complications were recorded.CT scans were used to evaluate the healing of injured vertebrae at the final follow-up visit. RESULTS AND CONCLUSION:(1)A total of 26 patients were included,with 7 males and 19 females,at the age range of 62-81 years[mean(69.7±4.8)years].The follow-up time was 18-60 months[mean(35.1±8.9)months].The average operative duration was 133.5 minutes(100-165 minutes),and the average intraoperative blood loss was 285.3 mL(210-350 mL).(2)Visual analog scale and Oswestry disability index scores 1 week after surgery were significantly lower than those before surgery.(3)At 1 week after surgery,the anterior vertebral height corrections and the Cobb angle were(9.0±0.7)mm and(16.2±1.0)°,respectively.During the follow-up period,the loss of vertebral height and kyphosis correction were(5.1±0.3)mm and(8.0±0.4)°,respectively.(4)14 patients(54%)had ASIA grade D before operation,which recovered to grade E at the last follow-up.CT scan showed that all patients achieved good osseous union.(5)Complications occurred in seven patients(27%),including hypostatic pneumonia in two cases,postoperative superficial wound tissue liquefaction in two cases,and adjacent vertebral compression fractures in three cases.(6)It is concluded that screw placement of the injured vertebra combined with transpedicular impaction bone grafting can rapidly rebuild spinal stability,effectively relieve pain and improve neurological function in the treatment of stage Ⅲ Kümmell's disease.This technique is an effective and relatively minimally invasive surgical option.

Objective This study aimed to investigate the differential effects of sevoflurane and propofol on perioperative HIF-1α levels and postoperative recovery in patients undergoing bariatric surgery.Methods A total of 40 obese patients(BMI≥44 kg/m2)were randomly allocated into two groups:sevoflurane(n=21)group and propofol(n=19)group.The quantitative measurement of HIF-1α levels in human serum at different time points was conducted using ELISA.The assessment of redness,swelling,pain,exudation,and prognosis-related indicators of the patient's umbilical incision was performed at 24 and 48 hours after surgery.Results On the day following surgery,there was a significant increase in HIF-1α levels in the sevoflurane group and a significant decrease in the propofol group.The frequency and type of opioid analgesics used in the sevoflurane group were signifi-cantly lower than those used in the propofol group after surgery.Conclusions Compared with propofol,sevoflurane is more suitable for maintaining anesthesia in obese patients undergoing bariatric surgery.Sevoflurane can promote enhanced recovery after surgery by reducing postoperative analgesic consumption and upregulating HIF-1α levels.

Objective:To evaluate the application of digital visualization in preoperative planning for surgical clearance of vertebral infection lesions following percutaneous vertebroplasty (PVP).Methods:A retrospective study was conducted to analyze the 13 patients with infectious spondylitis following PVP who had undergone one-stage posterior debridement and interbody bone grafting combined with instrumentation at Department of Spinal Surgery, Zhengzhou Orthopaedics Hospital from January 2016 to December 2022. They were 4 males and 9 females with an age of (71.4±6.5) years. Before surgery, the CT raw data of the patients were imported into software Mimics to reconstruct a three-dimensional model of the spine. After the distribution of bone cement in the model and its relationships with the vertebral plate, pedicle, articular process, and spinal cord were observed, a safe area for spinal canal surgery was designed. Intraoperative operations were carried out according to the preoperative planning. Surgical time, intraoperative blood loss, improvements in American Spinal Injury Association (ASIA) grading, and postoperative complications were recorded. The therapeutic efficacy was evaluated by comparisons of erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), visual analogue scale (VAS), and Oswestry disability index (ODI) between preoperation, 2 weeks and 3 months postoperation, and the last follow-up.Results:Surgery went on successfully in all the 13 patients according to the preoperative planning. The surgical time was (275.9±28.3) min and the intraoperative blood loss (865.4±183.0) mL. All patients were followed up for (24.7±9.4) months. The levels of ESR, CRP, VAS, and ODI at 2 weeks, 3 months and the last follow-up were significantly lower than those before surgery ( P<0.05). At the last follow-up, X-ray and CT examinations showed good positions of internal fixation and sufficient bone graft fusion. The ASIA grading recovered from preoperative D to E in 5 patients. No incision infection, sinus formation, worsening of neurological symptoms, loosening or rupture of internal fixation, or worsening of neurological dysfunction were found. Conclusion:With the assistance of 3D visualization, the spinal cord, bone cement, and debridement area can be visualized directly to reduce nerve injury complications so that a safe and effective preoperative planning can be made for surgical clearance of vertebral infection lesions following PVP.

Background::A phase II trial on recombinant human tenecteplase tissue-type plasminogen activator (rhTNK-tPA) has previously shown its preliminary efficacy in ST elevation myocardial infarction (STEMI) patients. This study was designed as a pivotal postmarketing trial to compare its efficacy and safety with rrecombinant human tissue-type plasminogen activator alteplase (rt-PA) in Chinese patients with STEMI.Methods::In this multicenter, randomized, open-label, non-inferiority trial, patients with acute STEMI were randomly assigned (1:1) to receive an intravenous bolus of 16 mg rhTNK-tPA or an intravenous bolus of 8 mg rt-PA followed by an infusion of 42 mg in 90 min. The primary endpoint was recanalization defined by thrombolysis in myocardial infarction (TIMI) flow grade 2 or 3. The secondary endpoint was clinically justified recanalization. Other endpoints included 30-day major adverse cardiovascular and cerebrovascular events (MACCEs) and safety endpoints.Results::From July 2016 to September 2019, 767 eligible patients were randomly assigned to receive rhTNK-tPA ( n = 384) or rt-PA ( n = 383). Among them, 369 patients had coronary angiography data on TIMI flow, and 711 patients had data on clinically justified recanalization. Both used a –15% difference as the non-inferiority efficacy margin. In comparison to rt-PA, both the proportion of patients with TIMI grade 2 or 3 flow (78.3% [148/189] vs. 81.7% [147/180]; differences: –3.4%; 95% confidence interval [CI]: –11.5%, 4.8%) and clinically justified recanalization (85.4% [305/357] vs. 85.9% [304/354]; difference: –0.5%; 95% CI: –5.6%, 4.7%) in the rhTNK-tPA group were non-inferior. The occurrence of 30-day MACCEs (10.2% [39/384] vs. 11.0% [42/383]; hazard ratio: 0.96; 95% CI: 0.61, 1.50) did not differ significantly between groups. No safety outcomes significantly differed between groups. Conclusion::rhTNK-tPA was non-inferior to rt-PA in the effect of improving recanalization of the infarct-related artery, a validated surrogate of clinical outcomes, among Chinese patients with acute STEMI.Trial registration::www.ClinicalTrials.gov (No. NCT02835534).

Objective:To investigate the efficacy of the classified reduction based on CT two-dimensional images for the surgical treatment of single segment facet joint dislocation in subaxial cervical spine.Methods:A retrospective case series study was made on 105 patients with single segment facet joint dislocation in subaxial cervical spine admitted to Zhengzhou Orthopedic Hospital from January 2015 to October 2022. There were 63 males and 42 females, with the age range of 22-78 years [(47.5±3.6)years]. Preoperative American Spinal Cord Injury Association (ASIA) classification was grade A in 23 patients, grade B in 45, grade C in 22, grade D in 15 and grade E in 0. The classification of surgical approach was based on the presence or not of continuity between anterior and posterior subaxial cervical structures and the movability of the posterior cervical facet joint on CT two-dimensional images, including anterior cervical surgery if both were presented and posterior facet joint resection plus anterior cervical surgery if there was discontinuity between anterior and posterior subaxial cervical structures or posterior facet joint fusion. Reduction procedures were applied in accordance with the type of facet joint dislocation classified based on the position of the lower upper corner of facet joint, including skull traction or manipulative reduction for the dislocation locating at the dorsal side (type A), intraoperative skull traction and leverage technique for the dislocation locating at the top (type B) and intraoperative skull traction and leverage technique with boosting for the dislocation locating at the ventral side (type C). If the dislocation of two facet joints in the same patient was different, the priority of management followed the order of type C, type B and type A. The reduction success rate, operation time and intraoperative blood loss were recorded. The cervical physiological curvature was evaluated by comparing the intervertebral space height and Cobb angle before operation, at 3 months after operation and at the last follow-up. The fusion rate of intervertebral bone grafting was evaluated by Lenke grading at 3 months after operation. The spinal cord nerve injury was assessed with ASIA classification before operation and at 3 months after operation. Japanese Orthopedic Association (JOA) score was applied to measure the degree of cervical spinal cord dysfunction before operation and at 3 months after operation, and the final follow-up score was used to calculate the rate of spinal cord functional recovery. The occurrence of complications was observed.Results:All patients were followed up for 3-9 months [(6.0±2.5)months]. The reduction success rate was 100%. The operation time was 40-95 minutes [(58.6±9.3)minutes]. The intraoperative blood loss was 40 to 120 ml [(55.7±6.8)ml]. The intervertebral space height was (4.7±0.3)mm and (4.7±0.2)mm at 3 months after operation and at the last follow-up, significantly decreased from preoperative (3.1±0.5)mm (all P<0.01), but there was no significant difference in intervertebral space height at 3 months after operation and at the last follow-up ( P>0.05). The Cobb angle was (6.5±1.3)° and (6.3±1.2)° at 3 months after operation and at the last follow-up, significantly increased from preoperative (-5.4±2.2)° (all P<0.01), but there was no significant difference in Cobb angle at 3 months after operation and at the last follow-up ( P>0.05). The fusion rate of intervertebral bone grafting evaluated by Lenke grading was 100% at 3 months after operation. The ASIA grading was grade A in 15 patients, grade B in 42, grade C in 29, grade D in 12 and grade E in 7 at 3 months after operation. The patients showed varying degrees of improvement in postoperative ASIA grade except that 15 patients with preoperative ASIA grade A had partial recovery of limb sensation but no improvement in ASIA grade. The JOA score was (13.3±0.6)points and (13.1±0.6)points at 3 months after operation and at the last follow-up, significantly improved from preoperative (6.8±1.4)points (all P<0.01), but there was no significant difference in JOA score at 3 months after operation and at the last follow-up ( P>0.05). The rate of spinal cord functional recovery was (66.3±2.5)% at the last follow-up. All patients had no complications such as increased nerve damage or vascular damage. Conclusion:The classified reduction based on CT two-dimensional images for the surgical treatment of single segment facet joint dislocation in subaxial cervical spine has advantages of reduced facet joint dislocation, recovered intervertebral space height and physiological curvature, good intervertebral fusion and improved spinal cord function.

Objective:To compare the clinical efficacies of precision targeted and traditional percutaneous vertebroplasty (PVP) in the treatment of refracture of injured vertebra after operation for Kümmell disease.Methods:A retrospective cohort study was conducted to analyze the clinical data of 23 Kümmell disease patients suffering from refracture of injured vertebra after PVP in Zhengzhou Orthopedic Hospital from October 2014 to October 2018. The patients included 7 males and 16 females, aged 53-89 years [(69.3±3.5)years]. There were 11 patients of stage I Kümmell disease and 12 patients of stage II Kümmell disease. The vertebral distribution of fracture was T 11 (3 patients), T 12 (9 patients), L 1 (8 patients) and L 2 (3 patients). Eleven patients received traditional PVP treatment (traditional PVP group) and 12 patients received precision targeted PVP treatment (targeted PVP group). The operation time, amount of bone cement injection and filling of bone cement in the fracture space were compared between the two groups. The visual analogue score (VAS) and Oswestry disability index (ODI) were also compared before operation, at 2 days, 1 month, 3 months, 6 months after operation, and at the last follow-up. The rates of bone cement leakage and re-collapse of injured vertebra were observed in the two groups. Results:The patients were followed up for 12-36 months [(24.2±2.6)months]. There were no significant differences in the operation time or amount of bone cement injection between the two groups (all P>0.05). All the fracture spaces in the targeted PVP group were fully filled with bone cement, while 4 patients in the traditional PVP group showed inadequate filling of the fracture area ( P<0.05). The VAS values in the targeted PVP group were (8.9±0.5)points, (1.6±0.2)points, (1.7±0.1)points, (1.8±0.1)points, (1.9±0.3)points, and (1.8±0.4)points before operation, at 2 days, 1 month, 3 months, 6 months after operation and at the last follow-up; and those in the traditional PVP group were (9.1±0.9)points, (1.8±0.4)points, (1.8±0.2)points, (2.0±0.4)points, (2.1±0.2)points, and (2.4±0.3)points, respectively. The VAS values of both groups were significantly decreased at 2 days, 1 month, 3 months, 6 months after operation, and at the last follow-up compared with those before operation (all P<0.05), but there was no significant difference between different time points after operation (all P>0.05). No significant differences were found in the VAS values between the two groups before operation and at 2 days, 1 month, 3 months and 6 months after operation (all P>0.05). However, the VAS value in the targeted PVP group was significantly lower than that in the traditional PVP group at the last follow-up ( P<0.05). The ODI values in the targeted PVP group were 38.5±4.3, 7.2±2.3, 7.3±2.0, 7.2±1.8, 7.3±2.4, and 7.4±2.5 before operation and at 2 days, 1 month, 3 months, 6 months after operation, and at last follow-up; and those in the traditional PVP group were 37.8±4.1, 7.5±2.5, 7.7±1.9, 7.9±2.4, 8.1±2.6, and 9.6±2.4, respectively. The ODI values of both groups were significantly decreased at 2 days, 1 month, 3 months, 6 months after operation and at the last follow-up compared with those before operation (all P<0.05), but there were no significant differences between different time points after operation (all P>0.05). The ODI values were not significantly different between the two groups before operation and at 2 days, 1 month, 3 months, 6 months after operation (all P>0.05), but the ODI value in the targeted PVP group was significantly lower than that in the traditional PVP group at the last follow-up ( P<0.05). There were no significant differences in the rates of bone cement leakage or re-collapse of injured vertebra between the two groups (all P>0.05). Conclusion:Compared with traditional PVP treatment for refracture of injured vertebra after operation for Kümmell disease, targeted PVP can make bone cement injection fully dispersed, greatly reduce pain and promote functional recovery.

Objective:To compare the efficacies of posterior long segment instrumentation combined with transpedicular impaction bone grafting or with bone cement augmentation in treating stage III Kümmell disease.Methods:A retrospective cohort study was conducted to analyze the clinical data of 38 patients with stage III Kümmell disease who were admitted to Zhengzhou Orthopedic Hospital between January 2016 and December 2020. The study included 8 male and 30 female patients, with ages ranging from 59 to 81 years [(68.9±4.9)years]. The vertebral fractures occurred at T 8 in 1 patient, T 11 in 9 patients, T 12 in 10 patients, and L 2 in 10 patients. Seventeen patients underwent posterior long segment instrumentation combined with transpedicular impaction bone grafting (impaction bone grafting group), and 21 patients underwent posterior long segment instrumentation combined with bone cement augmentation (bone cement group). The surgical duration, intraoperative blood loss, and incidences of postoperative complications were compared between the two groups. Additionally, the visual analogue score (VAS), Japanese orthopedic association (JOA) score, and Cobb angle were compared before the operation, at 1 week and 3 months post-operation, and at the final follow-up for both groups. The study also compared bone healing at the last follow-up and postoperative complication rates between the two groups. Results:All the patients were followed up for 24-35 months [(28.7±2.9)months]. The impaction bone grafting group had a surgical duration of (150.7±25.4)minutes and intraoperative blood loss of (285.3±48.6)ml, significantly different from those in the bone cement group [(132.0±21.1)minutes, (251.4±44.8)ml] (all P<0.05). Before the operation, there were no significant differences in the VAS, JOA score, or Cobb angle between the two groups (all P>0.05).The VAS was (3.2±0.8)points, (2.7±0.5)points and (2.2±0.7)points in the impaction bone grafting group and was (2.7±0.6)points, (2.6±0.7)points and (2.4±0.8)points in the bone cement group at 1 week and 3 months post-operation and at the final follow-up, respectively. The VAS in the impaction bone grafting group was significantly higher than that in the bone cement group at 1 week post-operation ( P<0.05); however, no significant differences were found at 3 months post-operation or at the last follow-up (all P>0.05). There was no significant difference in the JOA score between the two groups at 1 week or 3 months post-operation, or at the final follow-up (all P>0.05). The Cobb angle in the impaction bone grafting group was (5.1±1.3)°, (5.9±1.8)° and (6.5±2.5)° at 1 week and 3 months post-operation, and at the final follow-up, significantly lower than that in the bone cement group [(8.4±1.6)°, (12.6±2.1)°, and (14.5±3.3)°] (all P<0.01). All the patients in the impaction bone grafting group achieved bone healing at the last follow-up. One patient in the impaction bone grafting group experienced delayed incision healing, whereas two patients in the bone cement group had poor bone healing. The complication rate was 5.9% (1/17) in the impaction bone grafting group and 9.5% (2/21) in the bone cement group ( P>0.05). Conclusions:Posterior long segment instrumentation combined with transpedicular impaction bone grafting or with bone cement augmentation are both effective in alleviating pain and improving the spinal function for stage III Kümmell disease. The former procedure is associated with longer surgical duration and increased intraoperative blood loss, but it can provide superior correction and maintenance of kyphosis deformity, promoting the healing of the injured vertebrae.