To investigate the effectiveness and safety of microendoscopic decompression via unilateral approach for lumbar spinal stenosis. Methods Between May 2006 and June 2009, 79 patients with lumbar stenosis were treated and divided into 2 groups: posterior lamina fenestration decompression (group A, n=37), endoscopic decompression via unilateral approach (group B, n=42). There was no significant difference in age, sex, segment level, and disease duration between 2 groups (P gt; 0.05). The cl inical outcomes were assessed by using the visual analogue scale (VAS) score and Oswestry Disabil ity Index (ODI). The operation time, blood loss, compl ications were compared between 2 groups. Results Operations were successfully performed in all cases. The operation time, blood loss, and drainage volume were (75.0 ± 25.7) minutes, (140.3 ± 54.8) mL, and (46.5 ± 19.7) mL in group A, were (50.4 ± 18.2) minutes, (80.2 ± 35.7) mL, and (12.7 ± 5.3) mL in group B; there were significant differences between 2 groups (P lt; 0.05). All the wounds healed by first intention. All patients were followed up 12-39 months (mean, 16 months). In group A, 1 patient suffered from intervertebral space infection after operation and recovered after conservative treatment; 4 patients had lumbar instabil ity after operation and recovered after lumbar interbody fusion combined with spine system internal fixation. In group B, 2 patients suffered from spinal dural rupture during operation and recovered after corresponding treatment, and no lumbar instabil ity was found. There was no significant difference in VAS score and ODI between 2 groups at preoperation (P gt; 0.05). Both VAS score and ODI were significantly improved at early stage after operation and last follow-up when compared with preoperation in each group (P lt; 0.05). Comparing with group A, there was significant improvement in VAS score at 24 hours postoperatively and in ODI at 1 month postoperatively in group B (P lt; 0.05), but no significant difference was observed at last follow-up (P gt; 0.05). According to cl inical evaluation of ODI mprovement rate, the excellent and good rate was 89.2% in group A and 92.9% in group B, showing no significant difference (χ2=0.896, P=0.827). Conclusion Comparing with posterior decompression surgery, microendoscopic decompression via unilateral approach is one of effective method to treat lumbar stenosis, with less trauma of fenestration yield and good early outcomes.
In recent years, enhanced recovery after surgery (ERAS) has been widely used in spine surgery and achieved satisfactory results. In order to standardize the ERAS implementation process and application in percutaneous endoscopic interlaminar lumbar decompression/discectomy (PEID), we reviewed the literatures and cited evidence-based medicine data, and had a national comprehensive discussion among experts of the Group of Minimally Invasive Spinal Surgery and Enhanced Recovery, Professional Committee of Orthopedic Surgery and Enhanced Recovery, Association of China Rehabilitation Technology Transformation and Promotion. Altogether, the up-to-date expert consensus have been achieved. The consensus may provide the reference for clinical treatment in aspect of the standardization of surgical operations, the reduction of surgical trauma and complications, the optimization of perioperative pain and sleep management, the prevention of venous thrombosis, and the guidance of patients’ functional training and perioperative education.
ObjectiveTo observe the effectiveness and safety of percutaneous endoscopic transforaminal bilateral decompression for severe central lumbar spinal stenosis.MethodsA retrospective analysis of 44 patients with single-segment severe central lumbar spinal stenosis with bilateral lower extremity symptoms between October 2015 and December 2017 was performed. Among them, 36 cases underwent bilateral decompression through bilateral transforaminal approach, and 8 cases underwent bilateral decompression through unilateral transforaminal approach. There were 25 males and 19 females, the age ranged from 56 to 89 years with an average of 68.6 years. The disease duration was 5-39 months with an average of 14.5 months. Involved segments: L3, 4 in 6 cases, L4, 5 in 33 cases, and L5, S1 in 5 cases. The dural sac cross-sectional area (DSCA) of the MRI was (66.36±8.48) mm2. Morphological grading (MG) classification: 29 cases of grade C, 15 cases of grade D. The visual analogue scale (VAS) score of preoperative low back pain was 2.3±1.0 and the VAS score of lower extremity pain was 7.8±1.2; the Oswestry disability index (ODI) was 77.8±7.3. Postoperative VAS scores, ODI scores, MG classification, and DSCA were recorded and compared with preoperative ones, and clinical outcomes were assessed by using the modified MacNab criteria.ResultsAll patients successfully underwent surgery and the wounds healed by first intention. All 44 patients were followed up 13-46 months with an average of 24.8 months. One patient developed postoperative lower extremity paralysis and 1 patient developed a dural tear. There was no infection, recurrence, or revision surgery during the follow-up. Postoperative imaging showed that the central spinal canal was enlarged and the area of the dural sac was significantly increased compared with preoperative one. The VAS score of low back pain was 2.4±0.6 and 2.5±0.8 at 1 month after operation and at last follow-up, showing no significant difference when compared with preoperative scores (P>0.05). The VAS of lower limb pain was 2.1±0.6 and 2.0±1.1 at 1 month after operation and at last follow-up, which was significantly improved when compared with preoperative scores (P<0.05); but no significant difference was found between at 1 month after operation and at last follow-up (P>0.05). At last follow-up, the ODI score was 19.7±6.4, and the DSCA was (104.93±12.56) mm2, which was significantly improved when compared with preoperative values (P<0.05). The MG classification was also significantly higher than preoperative one (Z=−5.789, P=0.000). According to the modified MacNab criteria, the results were excellent in 32 cases, good in 9 cases, and fair in 3 cases, with an excellent and good rate of 93.2%.ConclusionPercutaneous endoscopic transforaminal bilateral decompression for treating severe central lumbar spinal stenosis has the advantages of less trauma, adequate decompression, and rapid recovery. The short-term effectiveness is good.
Objective To investigate the operational method of cervical vertebral flavectomy and its cl inical appl ication in the management of cervical canal stenosis. Methods From June 1997 to June 2007, 25 patients suffering from cervical spinal canal stenosis caused by obvious flaval l igament hypertrophy were given flavectomy. There were 22 males and 3 females, with an age range of 32 to 68 years (average 54 years). The course of disease was from 3 weeks to 7 years, with an average of 3 years and 7 months. All patients had degenerative cervical canal stenosis; of them, 5 cases had a history of cervical injury 2 to 3 weeks before operation (3 cases of fall ing injury and 2 cases of traffic accident injury). The X-ray film, CT, and MRI examinations showed that the compression locations were C4-7 in 12 cases, C3-7 in 9 cases, C5-7 in 3 cases, and C6,7 in 1 case. Spinous process and vertebral lamella were exposed by central posterior approach. The insertions of flaval l igaments were cut off at the superior vertebral lamella border, then the starting points of which were cut down from the anterior side of the upper vertebral lamella at their inferior border after l ifting up the flaval l igaments. The residual flaval l igaments in front of the vertebral lamella were scraped off by slope rongeur, the dura mater then could be seen to inflate from the intervertebral lamella space, showing the compression having been rel ieved. Twenty-five cases were all given posterior flavectomy. At 1 week to 3 months after operation, 12 patients received anterior cervical discectomy or vertebral gaining decompression with fusion by bone graft. Results The time for flavectomy was from 60 to 180 minutes, with an average of 95 minutes. The blood loss during operation was from 90 to 360 mL, with an average of 210 mL. The dura maters were lacerated by knife tips during operation with the cervical vertebrae in hyperflexion in 2 cases. Immediate suture and repair were performed and there were no postoperative cerebrospinal fluid leakage. All the incisions healed by first intension after operation. All of the 25 cases were followed up from 2 to 10 years, with an average of 3 years and 9 months. All patients had no compl ication of axial symptoms, and no restenosis at their operation site of cervical canal stenosis. The section area ratios of functional spinal canal to spinal cord were 1.12 ± 0.07 before operation and 2.11 ± 0.19 at 24 months after operation, showing significant difference (P lt; 0.05). The range of motion of cervical vertebrae was (39.4 ± 3.2)º befeore operation and (42.1 ± 2.9)° at 24 months after operation in 13 cases without anterior cervical discectomy fusion, showing no significant difference (P gt; 0.05); was (34.3 ± 3.4)° before operation and (29.2 ± 3.6)° at 24 months after operation in 12 cases with anterior cervical discectomy fusion, showing significant difference (P lt; 0.05). The bone graft achieved bony union 3-5 months after operation (average 3.8 months). The Japanese Orthopaedic Association (JOA) scores were 7.9 ± 2.2 before operation and 15.6 ± 1.4 at 24 months after operation, showing significant difference (P lt; 0.05), with an average improvement rate of 86.3%. Conclusion Cervical flavectomy could rel ieve compression to spinal cord and nerves caused by the flaval l igament hypertrophy without damaging the normal integral ity of bony canal, thus avoiding the compl ication of axial symptoms and so on which are encountered in open-door expansile cervical laminoplasty.
Objective To observe and measure the approach next to the erector spinae in the thoracic and lumbar segments of the spine and adjacent anatomical structures by the topographic method, to clarify the positioning method and safe range so as to provide the anatomical basis of the approach for spinal canal decompression. Methods Twelve formaldehyde-treated adult cadaver specimens were selected, including 6 males and 6 females with an average age of 43 years (range, 27-52 years) and with an average height of 166 cm (range, 154-177 cm). The related data of the approach at T1-S1 levels were respectively measured: the distance between the lateral edge of the erector spinae and the spinous process, the length of the approach, the angle between the approach and the horizontal plane, the size of intervertebral foramen, and the vertical distance between the segmental artery and the upper edge of the vertebrae. Results The distance between the lateral edge of the erector spinae and the spinous process ranged from (41.75 ± 3.29) mm to (74.54 ± 7.08) mm. The length of the approach ranged from (66.75 ± 10.81) mm to (97.13 ± 13.35) mm. The angle between the approach and the horizontal plane ranged from (38.38 ± 6.16)° to (53.67 ± 4.40)°. The vertical distance between the segmental artery and the upper edge of the vertebrae ranged from (9.50 ± 0.60) mm to (18.30 ± 1.56) mm. The size of foraminal was also measured. The spinal canal could reach when iliocostalis lateral edge was used as the starting point in the lumbar segments, and longissimus lateral edge as the starting point in the thoracic segments. It was confirmed that there was enough safe space for the spinal decompression without the resection of the articular process. Conclusion The approach next to the erector spinae can reach spinal canal to achieve the purpose of decompression through the intervertebral foramen. The minimally invasive approach is feasible and safe. It has the value of the operative application.
Objective To compare the effectiveness of unilateral biportal endoscopy (UBE) technique assisted spinal canal decompression combined with percutaneous pedicle screw internal fixation versus traditional open decompression and internal fixation for treatment of lumbar burst fractures. MethodsA retrospective study was conducted on the clinical data of 61 patients with single-segment lumbar burst fractures who met the selection criteria and were admitted between October 2022 and December 2023. Of them, 25 patients received UBE technique assisted decompression combined with percutaneous pedicle screw fixation (UBE group), while 36 patients were treated with traditional posterior unilateral hemilaminectomy decompression and internal fixation (open group). There was no significant difference in baseline data between the two groups (P>0.05), including gender, age, body mass index, fracture segment, cause of injury, AO classification of lumbar fractures, and preoperative height ratio of the anterior margin of injured vertebra, segmental kyphosis angle, rate of spinal canal invasion, the classification of American Spinal Injury Association (ASIA) grading, visual analogue scale (VAS) score, and Oswestry disability index (ODI). The operation time, intraoperative blood loss, and postoperative complications were recorded and compared between the two groups. VAS score, ODI, and ASIA grading were used to evaluate the effectiveness before operation, at 1 week after operation, and at last follow-up. Lumbar anteroposterior and lateral X-ray films and CT were performed to measure the segmental kyphosis angle, height ratio of the anterior margin of injured vertebra, and the rate of spinal canal invasion.ResultsSurgery was successfully completed in both groups. No complication such as dural sac, nerve root, or vascular injury was found during operation, and all incisions healed by first intention. There was no significant difference in operation time between the two groups (P>0.05), the UBE group revealed significant less intraoperative blood loss when compared with open group (P<0.05). Patients in both groups were followed up 6-20 months, with an average of 13 months. There was no loosening, breakage, or failure of internal fixation in all patients. The ASIA grading, VAS score, ODI of the two groups significantly improved at 1 week after operation and further improved at last follow-up (P<0.05). There was no significant difference in ASIA grading at 1 week after operation and last follow-up between the two groups (P>0.05), but the VAS score and ODI in the UBE group were significantly superior to the open group (P<0.05). At 1 week after operation, the height ratio of the anterior margin of injured vertebra, segmental kyphosis angle, rate of spinal canal invasion significantly improved when compared to preoperative ones (P<0.05), the height ratio of the anterior margin of injured vertebra and segmental kyphosis angle significantly decreased at last follow-up when compared to the values at 1 week after operation (P<0.05), but the rate of spinal canal invasion was further significantly improved, and there was no significant difference between the two groups at different time point postoperatively. ConclusionUBE technique assisted spinal canal decompression combined with percutaneous pedicle screw fixation is a safe and effective treatment for lumbar burst fractures, which with little trauma and faster recovery when compared with traditional open decompression and internal fixation.
Objective To investigate the influence of spinal cord decompression on posterior surgical treatment of thoracolumbar fracture, and to provide the practical basis for the indications of posterior spinal cord decompression Methods The cl inical data were retrospectively analyzed from 170 cases of thoracolumbar fracture treated with posterior surgical treatment between January 2005 and January 2009. There were 119 males and 51 females with an average age of42.7 years (range, 17-68 years). The fracture locations included T11 in 22 cases, T12 in 30 cases, L1 in 57 cases, and L2 in 61 cases. According to Denis classification system, there were 65 cases of compression fractures, 44 cases of burst fractures, 25 cases of flexion-distraction injuries, and 36 cases of fracture-dislocations. The time from injury to operation was 3-8 days (mean, 4.4 days). All the cases were divided into 4 groups according to space-occupying rates of spinal cord: group A, ≤20% (n=32); group B, 21%-40% (n=68); group C, 41%-60% (n=37); and group D, ≥ 61% (n=33). Through statistical analysis, the correlation between space-occupying rates and spinal cord function (Frankel grade) was evaluated, and the necessities of spinal cord decompression was studied in the patients who had neurological symptoms with space-occupying rates under 40%. Results There was no positive correlation between the degree of spinal cord injury and the space-occupying rates of bone fragments broken into the spinal canal. All patients were followed up 13-41 months (mean, 23.5 months). During the follow-up period, no secondary neurological damage occurred in the patients who were not given posterior spinal cord decompression with space-occupying rates under 40% (28 cases). And also in the cohort of patients with neurological symptoms whose space-occupying rates were under 40%, the posterior spinal cord decompression (65 cases) could improve the spinal cord function significantly when compared with no decompression cohort (7 cases), (P lt; 0.05). Conclusion The relative indications of posterior spinal cord decompression for thoracolumbar fracture are as follows: the cases having neurological symptoms with space-occupying rates under 40% and the ones having the neurological symptoms or not with space-occupying rates above 40%.
Objective To investigate the effectiveness of spinal canal decompression with microendoscopic disectomy (MED) and pillar vertebral space insertion through pedicle of vertebral arch for thoracolumbar neglected fracture. Methods Between February 2006 and November 2009, 30 patients with thoracolumbar neglected fracture were treated by spinal canal decompression with MED and pillar vertebral space insertion through pedicle of vertebral arch. There were 22 males and 8 females with an average age of 36.2 years (range, 17-58 years). The disease duration was 6 weeks to 14 months with an average of 5.3 months. All patients had single vertebral compression fracture, including T9 in 1 case, T11 in 2 cases, T12 in 5 cases, L1 in 11 cases, L2 in 5 cases, L3 in 5 cases, and L4 in 1 case. The preoperative Cobb angle was (27.5 ± 7.5) ° . The preoperative height of vertebrae was (26.67 ± 5.34) mm. The visual analogue score (VAS) was 5.8 ± 1.4. According to Wolter classification for spinal canal stenosis, there were 17 cases of grade 1, 10 cases of grade 2, and 3 cases of grade 3. According to Frankel grade, 3 cases were in grade A, 8 cases in grade B, 13 cases in grade C, and 6 cases in grade D. Results The average operation time was 70 minutes (range, 40-120 minutes) and the average blood loss was 180 mL (range, 100-400 mL). The hematoma occurred in 1 case, and other incisions healed by first intension. No deep vein thrombosis of the lower extremity occurred. All patients were followed up 26 months on average (range, 24-46 months). The Cobb angle and vertebral height at 3 days and last follow-up were significantly improved when compared with ones before operation (P lt; 0.01). At last follow-up, the spinal canal stenosis was grade 0 in 27 cases and grade 1 in 3 cases according to Wolter classification. At 24 months after operation, the spinal function was obviously improved; 1 case was in grade A, 1 case in grade B, 3 cases in grade C, 9 cases in grade D, and 16 cases in grade E according to Frankle grade, showing significant differences when compared with preoperative ones (P lt; 0.05). The VAS score at 1 month after operation was significantly higher than that before operation (P lt; 0.01), then the score showed downtrend along with time, and it was significantly lower at 24 months after operation than before operation (P lt; 0.01). Conclusion Spinal canal decompression with MED and pillar vertebral space insertion for thoracolumbar neglected fracture has short surgical time, less blood loss, and satisfactory reduction, but higher technical requirement is necessary for MED.
Objective To determine the surgical indications for posterior expansive open-door laminoplasty (EOLP) extended to the C1 level. Methods Seventeen patients undergoing C3-7 or C2-7 open-door laminoplasty were included as the case group between September 2005 and January 2010, whose spinal cord injury symptoms were not alleviated or aggravated again because of the cervical stenosis at C1-4 level, and the causes of the surgery itself were eliminated, all of these patients underwent reoperation with decompress upward to C1 level. Fifteen patients with cervical stenosis who underwent C2-7 laminoplasty and C1 laminectomy were selected as the control group. There was no significant difference in gender, age, and disease duration between 2 groups (P gt; 0.05). The pre- and post-operative cervical curvature and spinal cord compression were evaluated according to the patients’ imaging data; the pre- and post-operative neurological recovery situation was evaluated by Japanese Orthopaedic Association (JOA) 17 score and spinal cord function Frankel grade; the neurological recovery rate (according to Hirabayashi et al. method) was used to assess the postoperative neurological recovery situation. Results In the case group, 8 patients underwent primary C3-7 laminoplasty. In 3 of these patients, there was a cervical stenosis at C1, 2 level, and discontinuous cerebrospinal fluid around the spinal cord was observed; 5 of them with a compression mass which diameter was exceed 7.0 mm in the C2-4 segments. The remaining 9 patients in the case group underwent primary C2-7 laminoplasty, and the diameter of the compression mass was exceed 7.0 mm in the C2-4 segments. In all 17 patients of the case group, reoperation was performed with the decompression range extended to the C1 level, and the follow-up time was 35-61 months with an average of 45.6 months. Cervical curvature: there were 11 cases of cervical lordosis, 4 cases of straight spine, and 2 cases of cervical kyphosis before operation; but after operation, 2 cases of cervical lordosis became straight spine and 1 straight case became kyphosis. The postoperative neurological improvement was excellent in 8 cases, good in 7, and fair in 2. In the control group, all the patients had a compression mass which anteroposterior diameter was exceed 7.0 mm in the C2-4 segments before operation. The follow-up time was 30-58 months with an average of 38.7 months. Cervical curvature: there were 13 cases of cervical lordosis and 2 cases of straight spine before operation; but after operation, 1 case of cervical lordosis became straight spine. The postoperative neurological improvement was excellent in 8 cases, good in 6, and fair in 1. No significant difference was found in the JOA score at pre- and post-operation between 2 groups (P gt; 0.05); however, there were significant differences (P lt; 0.05) in the JOA score between at last follow-up and at preoperation. Conclusion The initially surgical indications which can be used as a reference for EOLP extended to C1 are as follows:① Upper cervical (C1, 2) spinal stenosis: C1 posterior arch above the lower edge part of cerebrospinal fluid around the spinal cord signal is not continuous, and the anteroposterior diameter of the spinal canal actual is less than 8.0 mm as judgment standard. ②There is a huge compression at the lower edge of C2-4 vertebrae, and the most prominent part of the diameter is exceed 7.0 mm, which can not be removed through the anterior cervical surgery, or the operation is high-risk.
ObjectiveTo evaluate the feasibility and the effectiveness of minimally invasive passage in posterior laminotomy decompression and intervertebral bone grafting combined with percutaneous pedicle screw fixation for the treatment of Denis type B thoracolumbar burst fractures. MethodsBetween January 2013 and March 2015, 53 patients with Denis type B thoracolumbar burst fractures were treated by minimally invasive passage in posterior laminotomy decompression and intervertebral bone grafting combined with percutaneous pedicle screw fixation. There were 37 males and 16 females with a mean age of 43 years (range, 16-57 years). The causes included falling injury from height in 23 cases, traffic accident injury in 15 cases, heavy pound injury in 7 cases, and falling injury in 8 cases. The time between injury and operation was 7 hours to 12 days (mean, 6.7 days). The involved segments included T11 in 2 cases, T12 in 7 cases, L1 in 20 cases, L2 in 18 cases, and L3 in 6 cases; based on the neurological classification of spinal cord injury by American Spinal Injury Association (ASIA), 3 cases were rated as grade A, 5 cases as grade B, 12 cases as grade C, 24 cases as grade D, and 9 cases as grade E. The operation time, bleeding volume, and postoperative drainage were recorded; postoperative visual analogue scale (VAS) was used for pain evaluation, and ASIA for neurological function assessment; CT and X-ray films were taken to observe fracture healing, bone fusion, and grafted bone absorption; The vertebral canal patency rate was calculated; the relative height of fractured vertebrae and Cobb angle were measured. ResultsThe operation was successfully completed in all patients; the average operation time was 150 minutes (range, 90-240 minutes); the average bleeding volume was 350 mL (range, 50-500 mL); the average postoperative drainage was 80 mL (range, 20-150 mL); and the average VAS score was 2.3 (range, 1.5-4.7) at 3 days after operation. The incisions healed primarily. All the patients were followed up 12-19 months (mean, 15 months). All fractures healed at 3-9 months (mean, 6 months). No complications of broken nails, broken rod, and screw loosening occurred. At last follow-up, the vertebral canal patency rate was significantly improved when compared with preoperative value (t=27.395, P=0.000). The Cobb angle, and the anterior and posterior heights of of traumatic vertebra were significantly improved at 1 week, 1 year, and last follow-up when compared with preoperative ones (P < 0.05), but there was no significant difference between different time points after operation (P > 0.05). The neurological function was improved in different degrees; 1 case was rated as grade A, 4 cases as grade B, 7 cases as grade C, 15 cases as grade D, and 26 cases as grade E, showing significant difference when compared with preoperative one (Z=-5.477, P=0.000). ConclusionMinimally invasive passage in posterior laminotomy decompression, bone graft in the injured vertebrae combined with percutaneous pedicle screw fixation is an effective method to treat Denis type B thoracolumbar burst fractures, which not only can fully decompression, but also can effectively maintain the postoperative injured vertebral height, reduce the postoperative failure risk of internal fixation and decrease operation trauma.