Objective To study the MRI diagnosis of sacral fracture with sacral neurological damage and its cl inical appl ication. Methods From October 1999 to October 2007, 20 cases of sacral fracture (Denis classification, Type II)with sacral neurological damage were examined by obl ique coronal MRI of sacrum to show the whole length of sacral nerve. There were 17 males and 3 females, aged 30-55 years. The time from injury to hospital ization varied from 1 day to 23 months. The injury was caused by traffic accident in 10 cases, smash of heavy object in 8 cases and crush in 2 cases. Eight cases were accompanied by pubis fracture and 4 cases by urethral disruption. All patients accepted the examination of X-ray, CT and spiral CT 3D reconstruction. X-ray showed the displacement of fracture fragment was backwards and upwards, and sacral-hole l ine was vague, asymmetric and distorted. CT showed that sacral neural tube was left-right asymmetry, the displacement of fracture fragment was backwards and upwards, combining with the compression and intruding to sacrum center at different section levels. The cl inical manifestations, international standards for Neurological Classification of Spinal Cord Injury recommended by American Spinal Injury Association International Spinal Cord Society, comparison between normal and abnormal MRI and Gierada’s results were the basis for cl inical diagnose and MRI diagnose, which was confirmed by operation. Results Nerve injury diagnosed by cl inical manifestation were S1 (17 cases), S2 (14 cases), S3 (7 cases), and S4 (6 cases). Nerve injury diagnosedby MRI were S1 (17 cases), S2 (14 cases), S3 (3 cases), and S4 (2 cases). Nerve injury confirmed by operation were S1 (17 cases), S2 (14 cases), S3 (7 cases), and S4 (1 case). Obl ique coronal MRI of sacrum showed the whole length of sacral nerve and its adjacent relationship, detecting bone fragment compression and route alteration of never were evident in 5 cases, the fat disappearance around the site of nerve root injury in 19 cases, narrowness of sacral nerve canal in 17 cases and the abnormally enlarged sacral nerve in 11 cases. Conclusion Obl ique coronal MRI of sacrum is of great value in the local ization and the qual itative diagnosis of sacral neurological damage.
Objective?To determine the effectiveness and safety of surgical treatment compared to conservative treatment for adult acute nondisplaced scaphoid fractures. Methods?We searched the specialized trials registered in the Cochrane muscle group, The Cochrane Library (CCTR), MEDLINE (1966 to 2007), EMbase (1980 to 2007), PubMed (1966 to 2007), NRR, CCT, and CBMdisc (1979 to July 2007). We also handsearched some Chinese orthopedics journals. Randomized controlled trials (RCTs) of surgical treatment versus conservative treatment for adult acute nondisplaced scaphoid fractures were included. The extraction of data and the methodological assessment of included RCTs were performed by two reviewers independently. RevMan software was used to carry out meta-analysis. Results?Five RCTs including 269 patients met the inclusion criteria. Compared with conservative treatment, the time taken before returning to work or participation in sports was shorter in the surgical treatment group. Because of inadequate extraction data and heterogeneity in the included studies, the results of the time of union and grip strength were not consistent. But all the results showed favorable tendencies. No significant difference was found in wrist motion and complications between the surgical and conservative treatment groups. Conclusion?Compared with conservative treatment for adult acute nondisplaced scaphoid fractures, surgical treatment could decrease the time of returning to work or participation in sports, decrease the time of union, and improve grip strength. But it does not improve the wrist motion or decrease the complications. Because of the small sample size, this conclusion should further tested using well-designed, large scale RCTs.
Objective To assess the efficacy of high-dose chemotherapy versus moderate-dose chemotherapy in the treatment of osteosarcoma. Methods We searched MEDLINE, EMbase, OVID database, CBMdisc, Cochrane CENTRAL Register of Controlled Trials in The Cochrane Library, and handsearched Journal of Chinese Oncology, Journal of Chinese Clinical Oncology and Tumor. The search time was updated to Feburary 2006.The quality of the included studies was evaluated by two reviewers and meta-analyses were performed on the results of homogenous studies. Results Four studies involving 937 participants with primary, high-grade and non-metastatic extremity osteosarcoma were included. All the included studies were judged to be inadequate at reporting randomization and blinding, only one reported allocation concealment. All included studies reported the number of withdrawals and the reasons for these. The meta-analyses showed that there were no significant differences in 5-year event free survival (EFS) (RR 1.10, 95% CI 0.96 to1.25), 5-year overall survival (OS) (RR 1.08, 95% CI 0.97 to1.20), local recurrence rate (RR 0.92, 95% CI 0.54 to 1.57), proportion of good histological response (RR 0.93, 95% CI 0.81 to 1.07), proportion of limb salvage [RR 0.97, 95% CI 0.92 to 1.02) between the high-dose group and the moderate-dose group. The 5-year EFS of the good histological response group was significantly higher than in the poor histological response group [OR 2.45, 95% CI 1.76 to 3.39,Plt;0.00001 ). Conclusions No advantage is shown for high-dose chemotherapy over moderate-dose chemotherapy in 5-year EFS, 5-year OS, local recurrence rate, proportion of good histological response and proportion of limb salvage. Histological response to preoperative chemotherapy is an independent prognosis factor for osteosarcoma. Due to the potential risk of selection bias, performance bias and publication bias, the evidence is not b enough to judge whether high-dose chemotherapy is better than moderate-dose chemotherapy in the treatment of osteosarcoma. Our conclusion suggests that large-scale randomized trials should be performed.
Objictive To evaluate the efficacy of decompression with and without fusion in the treatment of degenerative lumbar disease. Methods We searched the Cochrane Library (Issue 1, 2006), MEDLINE (1966 to April, 2006), EMBASE (1984 to April, 2006), the China Biological Medicine Database (to Dec., 2005), VIP (1989 to April, 2006) and hand-searched several related journals for randomized controlled trials (RCTs) and quasi-randomized controlled trials (quasi-RCTs) involving the comparison of the outcomes between decompression with and without fusion in the treatment of degenerative lumbar disease. The quality of the included trials was assessed. RevMan 4.2.8 software was used for statistical analysis. Results Seven studies involving 412 patients were included. The results of meta-analysis indicated that no statistically significant differences were observed between the two operative procedures in the cumulative clinical outcome (OR1.83, 95%CI 0.92, 3.41), incidence of postoperative leg pain (OR 1.04, 95%CI 0.48, 2.25), incidence of perioperative complications (OR 1.15, 95%CI 0.51, 2.60), incidence of re-operation (OR 0.68, 95%CI 0.30, 1.56) or pre and postoperative pain scores [Pre-op WMD 0.12, 95%CI (-0.44,0.68); Post-op WMD 0.08, 95%CI (-1.08,1.25)]. The only statistical significance was observed in the incidence of postoperative back pain (OR 0.25, 95%CI 0.14, 0.46). Four studies described the length of operation, the intraoperative blood loss, the duration of external fixation postoperative and the total cost in hospital, which revealed that decompression alone was superior to decompression plus fusion. Three studies described the relationships between the clinical outcome and the changes in segmental range of motion/disc height pre- and post-operatively, as well as the flexion-extension radiographs, which revealed that decompression plus fusion was superior to decompression alone. Conclusions There are no significant differences between the two procedures in clinical outcomes, incidences of postoperative leg pain, re-operation and complications. Decompression with fusion leads to fewer patients suffering from postoperative lumbago than that of decompression alone. There is insufficient evidence to demonstrate that the radiographs may predict the clinical outcomes. More high quality, large-scale randomized controlled trials are required.
Objective To assess the effectiveness of surgical interventions for lumbar isthmic spondylolisthesis in adults.Methods RCTs of surgical treatment for adult lumbar isthmic spondylolisthesis were identified from specialized trials registered in Cochrane Back Group, The Cochrane Library (Issue 2, 2004)，additional electronic search (including MEDLINE (1966 to 2004)，EMBASE (1980 to 2004) and CBM), handsearching for Chinese journals. Two reviewers assessed the quality of the trials and extracted data independently. Meta analysis was conducted using RevMan 4.2. Results Four published trials including a total of 277 patients were included. Three trials compared different operative procedures and one trial considered conservative versus surgical treatment for lumbar isthmic spondylolisthesis in adults. Two trials had limitations of trial design which at times gave considerable potential for bias. As very few studies and patients were included, and different score criteria were used to assess the clinical outcomes in the review, we decided to provide a descriptive summary only. All trials drew a conclusion that lumbar posterolateral fusion for adult isthmic spondylolisthesis could relieve pain and improve clinical outcome. There was no significant difference in fusion rate and improvement of clinical outcomes between different operative procedures. One trial showed that the lumbar posterolateral fusion could improve function and relieve pain more efficiently than an exercise program. Three trials indicated there was no difference in fusion rate and improvement of clinical outcomes between different operative methods. One trial suggested that instrumented posterolateral fusion did not improve fusion rate but increased complication rates, operation time and bleeding loss. Two trials considered the role of decompressive laminectomy and reached a conflicting conclusion. Conclusions There is no adequate evidence about the most effective technique of treatment for adult lumbar isthmic spondylolisthesis. There is limited evidence that the lumbar posterolateral fusion for adult isthmic spondylolisthesis can efficiently relieve pain and improve clinical outcome. There is no evidence that the use of pedicle screw fixation can improve the fusion rate or the clinical outcome. At present, there is no enough evidence available from randomised trials to support the routine clinical use of instrumented fusion for lumbar isthmic spondylolisthesis in adults. As very few studies and patients were included in the review, it was cautious to draw any conclusions from the review. More trials with high quality on methodology are needed.
Objective To evaluate the efficacy of artificial total disc replacement for lumbar degenerative disc disease compared with lumbar fusion and other treatment. Methods We conducted electronic searching on The Cochrane Library (Issue 2, 2004) and Specialized Trials Register of Cochrane Back Group, MEDLINE (1966 to 2004)，EMBASE (1980 to 2004) and CBMdisk (2003), some Chinese Journals were handsearched, and researchers in the field were contacted. Data were extracted and evaluated by two reviewers independently. The quality evaluation of studies and data analysis followed the methods of The Cochrane Collaboration. Results Three studies including 152 patients met the inclusion criteria. Two studies used ProDisc Ⅱ, while the other one used SB-Ⅲ. The patients who received the disc replacement reported reduced pain and improved function in early postoperative period, better satisfaction rates at month 6 post operation; complications of operation were reported in two randomized controlled trials. Conclusions The quality of the included trials is inadequate to draw any conclusion about the efficacy of artificial total disc replacement. More trials with high quality on methodology are needed. Artificial discs could preserve motion of diseased level in the short term. Protection of adjacent levels can only be assessed when large studies with long term follow-up are conducted.