Percutaneous Full Endoscopic Lumbar Discectomy for Symptomatic Adjacent Segment Disease after Lumbar Fusion in Elderly Patients

Purpose

Treatment of adjacent segment disease (ASD) is still controversial. The aim of this study was to evaluate the short-term efficacy and safety and to analyze the technical advantages, surgical approach, and indications of percutaneous full endoscopic lumbar discectomy (PELD) in the treatment of ASD after lumbar fusion in elderly patients.

Methods

A retrospective of 32 patients with symptomatic ASD were accepted for PELD from October 2017 to January 2020. All patients used the transforaminal approach and recorded the operation time and intraoperative conditions. Preoperative, 3, 12, 24 months of postoperative and at the last follow-up, the pain of back and leg of visual analog scale (VAS), Oswestry dysfunction index (ODI), and Japanese Orthopaedic Association Assessment Treatment Score (JOA) were performed, and the paired student's t test was used to the compare the continuous variables preoperatively and postoperatively. The clinical efficacy was evaluated according to MacNab standards. The lumbar MRI was performed to evaluate the decompression of the nerve roots, and the lumbar lateral and dynamic X-rays were performed to evaluate the stability of the surgical segment.

Results

A total of 32 patients were included in the study, including 17 males and 15 females. The follow-up time ranged from 24 to 50 months, with an average of (33.2 ± 8.1) months and an average operation time of (62.7 ± 28.1) minutes. Compared to preoperatively, the VAS score of the back and leg pain (p < 0.05), ODI (p < 0.05), and JOA (p < 0.05) postoperatively were significantly improved. At the last follow-up, according to the modified MacNab standard assessment, 24 cases were excellent, five cases were good, and three cases were fair, the excellent and good rate was 90.65%. As for complications, one case had a small rupture of the dural sac during the operation, which was found but not repaired during the operation, and one case recurred after the operation. At the last follow-up, there were three cases of intervertebral instability.

Conclusion

PELD showed satisfactory short-term efficacy and safety in the management of ASD after lumbar fusion in elderly patients. Therefore, PELD might be an alternative choice for elderly patients with symptomatic ASD after lumbar fusion, but surgical indications must be strictly controlled.     

Does Immediate Postoperative Early Ambulation Affect Clinical Results of Full-Endoscopic Lumbar Discectomy? A Historical Control Study of Daytime Operation with a 8-Hour Hospital Stay versus Inpatient Operation

Objective

Full-endoscopic lumbar discectomy (FELD) is a popular operation for the treatment of lumbar disc herniation (LDH) and day surgery mode is increasingly popular. However, only a few studies have reported about day surgery patients undergoing Percutaneous endoscopic lumbar discectomy (PELD). This retrospective study was to evaluate and analyze the clinical outcomes of patients undergoing FELD for LDH as day surgery versus inpatient surgery.

Methods

From January 2020 to January 2022, a retrospective analysis of LDH patients treated with FELD either in day surgery unit (within 8-h hospital stay) or inpatient unit was carried out. All these patients were followed-up for at least 12 months, and were categorized into a FELD-I (inpatient surgery) group or a FELD-D (day surgery) group, according to where the surgical procedures were performed. We assessed and compared the postoperative stand and walk time, postoperative hospitalization stays, time of return to work, modified MacNab criteria, willingness to recommend surgery, complications, revision rate, as well as the visual analogue scale (VAS) and the Oswestry disability index score (ODI). Student t-test was used for continuous variables and chi-square test or Fisher's exact test was used for categorical variables.

Results

There was no statistically significant difference in demographic data and baseline characteristics between two groups. And no significant differences were found in MacNab criteria between two groups. Postoperative VAS and ODI scores at one-day postoperation and final follow-up both improved significantly in both groups, as compared to the preoperative data (p < 0.001). However, no significant difference was found between the two groups on the pre, postoperative, or the last follow-up score for VAS and ODI (p > 0.05). The postoperative first ambulation time and postoperative hospital stays was much longer in FELD-I group than FELD-D group (p < 0.001). However, there were no significant differences in the perioperative complications, revision rate as well as satisfaction rate between two groups (p > 0.05). The overall time of return to work of young patients (<60 years-old) in the FELD-D group was significantly shorter than that in the FELD-I group (p = 0.001). Patients in the FELD-D group were more likely to recommend this kind of surgical model.

Conclusion

These data suggest that FELD-D can be effectively performed as day surgery (within 8 h hospital stay). Early ambulation after FELD-D did not affect the clinical outcomes and the revision rates. Day surgery patients are more likely to recommend this surgery mode to other patients and younger patients may be able to return to work earlier.     

经椎板间内镜椎管减压术治疗老年腰椎侧隐窝狭窄症

目的:探讨经皮椎板间入路内镜下椎管减压术治疗老年腰椎侧隐窝狭窄症的效果。方法:老年腰椎侧隐窝狭窄症患者196例,随机分为观察组和对照组各98例,观察组行经皮椎板间入路内镜下椎管减压术治疗,对照组行经皮椎间孔入路内镜下椎管减压术治疗。分别于术前和术后7 d、1个月、3个月采用视觉模拟评分(VAS)法评估下肢疼痛程度,Oswestry功能障碍指数(ODI)评定腰椎功能,采用侧隐窝角评估侧隐窝狭窄程度,依据MacNab标准评定手术效果,并记录手术并发症。结果:2组术后7 d、1个月、3个月VAS评分、ODI评分均低于术前(P0.05),且观察组均低于对照组(P0.05);观察组、对照组术后7 d软性侧隐窝角[(30.53±9.76)°、(27.27±8.39)°]、骨性侧隐窝角[(33.18±10.36)°、31.52±9.85)°]均大于术前[软性侧隐窝角(14.26±7.92)°、(14.51±6.83)°,骨性侧隐窝角(16.63±6.58)°、(17.02±7.73)°](P0.05),且观察组大于对照组(P0.05);术后3个月,观察组优良率(94%)与对照组(89%)比较差异无统计学意义(P0.05);2组均未出现神经根撕裂、永久性神经损伤等严重并发症。结论:相较于经皮椎间孔入路,经皮椎板间入路镜下椎管减压术对减轻老年腰椎侧隐窝狭窄症患者下肢疼痛、改善侧隐窝狭窄及腰椎功能,效果更明显。     

经皮内窥镜腰椎间盘切除术与开放腰椎间盘摘除术治疗的临床对比研究

目的比较经皮内窥镜腰椎间盘切除术(PELD)和开放腰椎间盘摘除术(OLD)的临床疗效。方法对100例腰椎间盘突出症根据手术方法不同,分为PELD组和OLD组。手术效果按照Oswestry功能障碍指数(ODI)、疼痛视觉类比评分(VAS)和改良的MacNab标准评定。结果PELD组平均随访24.3个月,单个节段平均手术时间60min,失血11ml,术后卧床24h。OLD组平均随访24.5个月,单个节段平均手术时间50min,失血30ml,术后卧床120h。两组采用改良MacNab标准评定随访结果,PELD组优良率为92%,OLD组96%。PELD组和OLD组术后ODI、VAS与术前比较,明显改善(P<0.05)。结论在严格选择手术适应证的情况下,PELD和OLD具有相似的近期临床疗效,但是PELD具有切口小、创伤小和术后恢复较快等优点。     

Does Preoperative Modic Changes Influence the Short-term Fusion Rate of Single Level Transforaminal Lumbar Interbody Fusion?—a Matched-pair Case Control Study

Objective

At present, the influence of Modic changes (MCs) on postoperative fusion rate of lumbar interbody fusion (LIF) is mainly focused on the medium- and long-term fusion rate, while the short-term fusion rate has not been reported. The aim of this study was to compare the short-term fusion rate of lumbar degenerative disease patients with and without MCs after single level transforaminal lumbar interbody fusion (TLIF).

Methods

In this retrospective and matched-pair case control study, we included 100 patients who underwent TLIF from January 2017 to January 2020 and had at least two follow-up visits over a two-year period. Fifty patients with MCs (MCs group) were matched with 50 patients without MCs (non MCs group) for age, sex, surgical level, diagnosis, operative time, and intraoperative blood loss. We collected the X-ray and computed tomography (CT) data of patients from 3 months to 2 years after the operation to assess bony fusion and the cage union ratio. According to the type of cage, the MCs group was further divided into the nano-hydroxyapatite/polyamide 66 (n-HA/PA66) group and polyetheretherketone (PEEK) group, and the fusion performance between the two groups was compared. Finally, age, sex, body mass index (BMI), smoking and cage type were included in the logistic regression model for risk factor analysis.

Results

The bony fusion rates in the MCs group at 3 months, 6 months, 1 year and 2 years after surgery were significantly lower than those in the non MCs group (P < 0.05) (23.8% vs 62.5%, 52.6% vs 78.9%, 61.1% vs 83.3%, 74.0% vs 90.0%). The average coronal cage union ratios of the upper and lower endplates in the MCs group were significantly lower than those in the non MCs group (54.3% ± 17.5% vs 75.0% ± 17.2%, P < 0.05; 73.3% ± 12.0% vs 84.9% ± 8.0%, P < 0.05). Similarly, analogous results were obtained by comparing the MCs and non MCs groups' three-dimensional CT sagittal plane images (62.5% ± 16.5% vs 76.1% ± 12.4%, P < 0.05; 67.0% ± 13.9% vs 79.8% ± 11.5%, P < 0.05).

Conclusion

Short-term fusion rates were lower in the MCs group than in the non MCs group. The coronal and sagittal cage union ratio in the MCs group was lower than that in the non MCs group. The fusion performance of n-HA/PA66 and PEEK cages in the MCs group was comparable.     

Risk factors for the need of surgical treatment of a first recurrent lumbar disc herniation

Purpose

A recurrent lumbar disc herniation (RLDH) is the most prevalent cause for new radicular pain after surgery for disc herniation-induced sciatica. Reported risk factors include age, gender and smoking, while its surgical treatment is associated to a higher rate of complications and costs. The purpose of this study is to identify factors that increase the risk of requiring surgical treatment for a first RLDH in workers’ compensation patients.

Methods

Nested case–control: 109 patients operated for an RLDH (cases) between June 1st 1994 and May 31st 2011 (minimum follow-up 1 year) and 109 randomly selected patients operated for a first disc herniation with no recurrence during the study period (controls). Age, gender, smoking status, type of work and MRI characteristics of the index herniation were statistically evaluated as potential risk factors.

Results

Patient’s age of less than 35 years (p = 0.001) and a subligamentous herniation (p < 0.05) at the time of the index surgery were identified as risk factors for requiring surgical treatment of a first RLDH. No statistical differences were observed between both groups regarding the other evaluated variables.

Conclusion

A subligamentous disc herniation and patient’s age inferior to 35 years at the time of the first surgery are risk factors for requiring surgical treatment of a first RLDH among workers’ compensation patients.

     

A Postoperative Phenomenon of Percutaneous Endoscopic Lumbar Discectomy: Rebound Pain

ObjectiveAfter percutaneous endoscopic lumbar discectomy (PELD), most patients with lumbar disc herniation (LDH) experience relief from the typical symptoms of low back and leg pain. However, for a small number of patients, these symptoms are relieved immediately after surgery but aggravated soon after, and then relieved after short‐term full rest or conservative treatment. The aim of the study was to demonstrate this short‐term recurrent phenomenon, termed rebound pain.MethodsA retrospective study was conducted on 144 patients who underwent single‐segment PELD from May 2017 to June 2020. Postoperative patients were divided into a rebound pain group and a non‐rebound pain group. For the former group, general information, symptom characteristics and visual analogue score (VAS) changes in rebound pain were summarized. For both groups, postoperative efficacy was evaluated by recent VAS of low back and leg pain in the remission stage, the Oswestry disability index (ODI) and the modified MacNab criteria at the last follow‐up. Logistic regression analysis was used to identify predictors for rebound pain.ResultsThe VAS and ODI exhibited significant improvements at the last follow‐up of average 15.4 months (P < 0.001). The successful outcomes according to the modified MacNab criteria reached 94.4%. A total of 15 patients (10.4%) experienced rebound pain. The typical feature was pain that usually began within 1 month after surgery and lasted for less than 1 month. The symptoms were mainly leg pain with or without low back pain. The range of pain was equal to or less than that before surgery. The symptoms were relieved after conservative treatment. In logistic regression model, postoperative return‐to‐work time > 45 days was found as a protective factor for rebound pain (p = 0.031).ConclusionAlthough rebound pain with multiple characteristics and a short duration had no significant effect on long‐term postoperative efficacy, its high incidence often caused unnecessary concern in both patients and doctors. As a result, careful differentiation of rebound pain from other postoperative complications is needed.     

Endoscopic submucosal dissection versus transanal endoscopic microsurgery for the treatment of early rectal cancer

Background

Endoscopic submucosal dissection (ESD) and transanal endoscopic microsurgery (TEM) are minimally invasive procedures that can be used to treat early rectal cancer.

Objective

The aim of this study was to compare clinical efficacy between ESD and TEM for the treatment of early rectal cancer.

Methods

Between July 2008 and August 2011, 24 patients with early rectal cancers were treated by ESD (11) or TEM (13) at the Cancer Institute of São Paulo University Medical School (São Paulo, Brazil). Data were analyzed retrospectively according to database and pathological reports, with respect to en bloc resection rate, local recurrence, complications, histological diagnosis, procedure time and length of hospital stay.

Results

En bloc resection rates with free margins were achieved in 81.8 % of patients in the ESD group and 84.6 % of patients in the TEM group (p = 0.40). Mean tumor size was 64.6 ± 57.9 mm in the ESD group and 43.9 ± 30.7 mm in the TEM group (p = 0.13). Two patients in the TEM group and one patient in the ESD group had a local recurrence. The mean procedure time was 133 ± 94.8 min in the ESD group and 150 ± 66.3 min in the TEM group (p = 0.69). Mean hospital stay was 3.8 ± 3.3 days in the ESD group and 4.08 ± 1.7 days in the TEM group (p = 0.81).

Limitations

This was a non-randomized clinical trial with a small sample size and selection bias in treatment options.

Conclusion

ESD and TEM are both safe and effective for the treatment of early rectal cancer.     

Combined Medial and Lateral Approach Versus Paratricipital Approach in Open Reduction and Internal Fixation for Type C Distal Humerus Fracture: A Randomized Controlled Study

Objective

Olecranon osteotomy and paratricipital approaches were widely used in the treatment of type C distal humerus fracture but some disadvantages exist, so a combined medial and lateral approach was designed. The objective of this study was to investigate and compare the clinical outcomes of combined medial and lateral approach with the paratricipital approach in open reduction and internal fixation of type C distal humerus fractures.

Methods

From May 2018 to April 2020, 37 patients with type C distal humerus fracture who accepted open reduction and internal fixation in our hospital were enrolled in this study. All cases were randomly divided into two groups according to the surgical approach: combined medial and lateral approach group (19 cases), paratricipital approach group (18 cases). All of the patients received open reduction and double vertical plates fixation. The operation and follow-up indexes, including operation time, blood loss, incision length, triceps muscle strength, flexion-extension arc of elbow and forearm rotation arc, were recorded and compared. Caja score was used to assess the quality of fractures reduction. Mayo Elbow Performance Score (MEPS) was used to evaluate the elbow function in the follow-up. Complications such as incision infection, ulnar nerve injury, degenerative osteoarthritis, and heterotopic ossification were analyzed.

Results

The differences in age, gender, and AO classification of fractures between two groups were not statistically significant (p > 0.05). The sum of medial and lateral incision length of combined approach group was longer than the midline incision of paratricipital approach group (15.4 ± 0.8 vs. 14.6 ± 0.8, p < 0.05), but there was no significant difference in operation time (103.5 ± 10.2 vs. 106.0 ± 8.8, p > 0.05), blood loss (71.3 ± 24.5 vs. 72.8 ± 24.6, p > 0.05), and Caja score (16.05 ± 5.67 vs. 15.56 ± 5.66, p > 0.05). During the follow-up, the MEPS of combined approach group was higher than that of paratricipital approach group at 3 months postoperatively (80.5 ± 5.7 vs. 68.9 ± 8.1, p < 0.05), but there was no significant difference in MEPS at 6 months postoperatively (83.9 ± 6.6 vs. 79.7 ± 7.0, p > 0.05) and at the last follow-up (86.8 ± 7.1 vs. 86.9 ± 7.7, p > 0.05) between the two groups. There was no significant difference in triceps muscle strength (p > 0.05), flexion-extension arc (126.8 ± 5.3 vs. 128.9 ± 6.0, p > 0.05), and forearm rotation arc (163.2 ± 5.3 vs. 163.6 ± 4.8, p > 0.05) at the last follow-up. Although the incidence of complication of combined approach group (15.8%) was lower than that of paratricipital approach group (22.2%), the difference was not statistically significant (p > 0.05).

Conclusions

The combined medial and lateral approach was an effective and safe way of open reduction and internal fixation for type C distal humerus fractures. Compared with the paratricipital approach, the combined medial and lateral approach could restore the elbow function more quickly postoperatively, and the long-term results were comparable.     

Safety and Efficacy of Cortical Bone Trajectory Screw Fixation Combined with Facet Fusion for the Treatment of Lumbar Degenerative Disease

Objective

The mainstream lumbar fusion surgeries have various shortcomings, such as complex operation, much invasion, and loss of lumbar function. How to minimize the surgical injury and to achieve better therapeutic effects has become the goal pursued by spine surgeons. This study introduces a cortical bone trajectory (CBT) screw fixation combined with facet fusion (FF), evaluates its safety and efficacy, and explores its advantages, in order to provide a reference for treatment of patients with single-level lumbar stenosis or grade I degenerative spondylolisthesis.

Methods

We retrospectively analyzed the clinical, radiological, and operative data of 167 patients with single-level lumbar stenosis or grade I degenerative spondylolisthesis who underwent FF or transforaminal lumbar interbody fusion (TLIF) from January 2013 to September 2019 in the spine surgery department of the Second Hospital of Shandong University. Patients were divided into four groups according to surgical method: group CBT-FF, CBT screw combined with FF; group PS-FF, pedicle screw (PS) combined with FF; group CBT-TLIF, CBT screw combined with TLIF; and group PS-TLIF, PS combined with TLIF. The operation time, estimated intraoperative blood loss, complications after surgery, visual analog scale (VAS), and Oswestry disability index (ODI) of the four groups were compared. The fusion was evaluated by anteroposterior and lateral X-ray, CT scan, and three-dimensional reconstruction.

Results

Twelve months after surgery, the fusion rate of four groups had no significantly statistical differences (p = 0.914). VAS and ODI scores were lower after surgery than before. Low back pain VAS scores 1 week after surgery in group CBT-FF and group CBT-TLIF were significantly lower than those in group PS-FF and group PS-TLIF (p_CF/PF = 0.001, p_CF/PT = 0.000, p_PF/CT = 0.049, p_CT/PT = 0.000). Low back pain VAS score 3 months after surgery was significantly lower in group CBT-FF than group PS-FF and group PS-TLIF (p_CF/PF = 0.045, p_CF/PT = 0.008). ODI score 1 week after surgery was significantly lower in group CBT-FF than group PS-FF, group CBT-TLIF, and group PS-TLIF (p_CF/PF = 0.000, p_CF/CT = 0.005, p_CF/PT = 0.000, p_CT/PT = 0.015). ODI score 3 months after surgery was significantly lower in group CBT-FF than group PS-FF, group CBT-TLIF, and group PS-TLIF (p_CF/PF = 0.001, p_CF/CT = 0.002, p_CF/PT = 0.000). Incidence of complications did not significantly differ among the groups.

Conclusion

CBT screw fixation combined with FF is a safe and efficacious procedure for patients with single-level lumbar stenosis or grade I degenerative spondylolisthesis. This minimally invasive approach of lumbar fusion can be simply and easily performed. Patients who undergo CBT screw fixation combined with FF recovered faster than TLIF.     

有限髓核摘除结合纤维环缝合治疗腰椎椎间盘突出症的早期疗效

目的观察有限髓核摘除结合纤维环缝合治疗腰椎椎间盘突出症的早期临床疗效。方法对2015年1月—2016年3月在本院行有限髓核摘除术的59例腰椎椎间盘突出症患者临床资料进行回顾性对照研究。缝合组28例行小切口腰椎椎板开窗有限髓核摘除结合纤维环缝合术;对照组31例行小切口腰椎椎板开窗有限髓核摘除,未行纤维环缝合。采用MacNab标准对术后1、3、6个月的治疗效果进行评价,同时采用椎间盘高度及椎间盘夹角对术后6个月时的脊柱稳定性进行评价。结果术后1、3个月2组Mac Nab评分优良率比较差异无统计学意义;术后6个月时缝合组患者优良率高于对照组,差异有统计学意义(P0.05)。术后6个月时缝合组患者椎间盘高度高于对照组,差异有统计学意义(P0.05),椎间盘夹角小于对照组,差异有统计学意义(P0.05)。随访6个月无复发及再手术患者。结论有限髓核摘除结合纤维环缝合术治疗腰椎椎间盘突出症安全、可靠,能获得满意的早期临床疗效且不影响脊柱稳定性,是降低复发率和再手术风险的一种行之有效的方法,值得临床推广应用。     

Clinical and Radiographic Comparison of Oblique Lateral Lumbar Interbody Fusion and Minimally Invasive Transforaminal Lumbar Interbody Fusion in Patients with L4/5 grade-1 Degenerative Spondylolisthesis

Objectives

To compare the clinical and radiographic outcomes of oblique lateral lumbar interbody fusion and minimally invasive transforaminal lumbar interbody fusion in patients with grade-1 L4/5 degenerative spondylolisthesis.

Methods

Based on the inclusion and exclusion criteria, the comparative analysis included consecutive patients with grade-1 degenerative spondylolisthesis who underwent oblique LIF (OLIF, n = 36) or minimally invasive transforaminal LIF (MI-TLIF, n = 45) at the Department of Spine Surgery, Beijing Jishuitan Hospital from January 2016 to August 2017. Patient satisfaction Japanese Orthopaedic Association score, visual analog scale (VAS) scores for back and leg pain, Oswestry disability index (ODI), radiographic outcomes including anterior/posterior disc heights (ADH/PDH), foraminal height (FH), foraminal width (FW), cage subsidence, cage retropulsion, and fusion rate were assessed during a 2-year follow-up. Continuous data are presented as mean ± standard deviation and were compared between groups using the independent sample t-test. Categorical data are presented as n (%) and were compared between groups using the Pearson chi-squared test or Fisher's exact test. Repetitive measurement and analysis of variance was employed in the analysis of ODI, back pain VAS score, and leg pain VAS score. Statistical significance was defined as p < 0.05.

Results

The OLIF and MI-TLIF groups comprised 36 patients (age, 52.1 ± 7.2 years; 27 women) and 45 patients (age, 48.4 ± 14.4 years; 24 women), respectively. Satisfaction rates at 2 years post procedure exceeded 90% in both groups. The OLIF group had less intraoperative blood loss (140 ± 36 vs 233 ± 62 mL), lower back pain VAS score (2.42 ± 0.81 vs 3.38 ± 0.47), and ODI score (20.47 ± 2.53 vs 27.31 ± 3.71) at 3 months follow-up (with trends toward lower values at 2 years follow-up), but higher leg pain VAS scores at all postoperative time points than the MI-TLIF group (all p < 0.001). ADH, PDH, FD, and FW improved in both groups post-surgery. At the 2 year follow-up, the OLIF group had a higher rate of Bridwell grade-I fusion (100% vs 88.9%, p = 0.046) and lower incidences of cage subsidence (8.33% vs 46.67%, p < 0.001) and retropulsion (0% vs 6.67%, p = 0.046) than the MI-TLIF group.

Conclusions

In patients with grade-I spondylolisthesis, OLIF was associated with lower blood loss and greater improvements in VAS for back pain and ODI and radiologic outcomes than MI-TLIF. The OLIF is more suitable for these patients with low back pain as the main symptoms are accompanied by mild or no leg symptoms before operation.     

Correlation between the Coaptation and Regeneration of Tendon Stumps in Endoscopic Assisted Achilles Tendon Rupture Repair

Objective

When the endoscopic Achilles tendon repair technique is utilized, direct stitching of the ruptured site is challenging due to the frayed tendon stumps. To explore whether undesirable coaptation of the tendon stumps influences the generation of the tendons.

Methods

This study is a retrospective analysis of 46 patients who underwent a modified endoscopic Achilles tendon rupture repair from October 2018 to June 2020. Patients were divided into two groups according to the coaptation of tendon stumps on postoperative ultrasonography. Group 1 included 17 cases with undesirable coaptation (<50%), and Group 2 included 29 cases with appropriate coaptation (≥50%). Magnetic resonance imaging (MRI) was obtained postoperatively at 3, 6, and 12 months to evaluate the tendon morphological construction. Clinical evaluations were performed using the American Orthopedic Foot and Ankle Society (AOFAS) ankle-hind foot score, the Achilles Tendon Total Rupture Score (ATRS), muscle power, and the Achilles tendon resting angle at the final follow-up. Complications were also encountered. The Student's t-test and the Mann–Whitney U-test were used to assess differences among both groups.

Results

The mean follow-up time was 37.5 ± 10.6 months in Group 1 and 39.0 ± 11.6 months in Group 2, respectively. The average age in Group 1 is slightly older than in Group 2 (37.3 ± 6.1 vs. 32.7 ± 6.3, p = 0.021). The tendon cross-section areas and thickness increased initially and decreased later on postoperative MRI evaluation. It also showed a significantly higher signal/noise quotient (SNQ) in Group 1 at postoperative 3 months. At postoperative 6 and 12 months, the SNQ between both groups was similar. The AOFAS score (95.9 ± 5.1 vs. 96.2 ± 4.9, p = 0.832), ATRS score (97.0 ± 3.6 vs. 97.7 ± 3.3, p = 0.527), and muscle power (21.38 vs. 24.74, p = 0.287) were not significantly different between both groups. However, the resting angle of Group 1 was significantly larger than that of Group 2 (4.6 ± 2.4 vs. 2.4 ± 2.3, p = 0.004). There was no difference in the complications (p = 0.628).

Conclusion

Although complete regeneration can be finally achieved, the early stage of tendon stump regeneration can be prolonged due to undesirable coaptation when endoscopic Achilles tendon repair technique is applied. The prolonged high signal duration on MRI indicates the less-than-ideal regeneration of the tendon, which might lead to elongation of the tendon.     

椎间孔镜技术治疗腰椎间盘突出症2年以上随访的疗效

目的探讨经皮椎间孔镜椎间盘切除术(percutaneous transforaminal endoscopic discectomy,PTED)治疗腰椎间盘突出症2年以上随访的疗效。方法2013年12月~2015年12月对80例腰椎间盘突出症行经皮穿刺椎间孔镜下腰椎间盘切除术并随访2年以上,比较患者术前后腰腿痛视觉模拟评分(Visual Analogue Scale,VAS)、Oswestry功能障碍指数(Oswestry Disability Index,ODI)、病变节段椎体活动域、病变节段椎间隙高度,采用改良MacNab标准评价疗效。结果80例随访24~35个月(平均28.5月),术前腰痛VAS评分中位数6(1~9)分,显著高于术后3个月3(1~5)分和末次随访时1(0~3)分(P<0.05);术前腿痛VAS评分中位数6(1~9)分,显著高于术后3个月2(0~6)分和末次随访时1(0~3)分(P<0.05);ODI术前(70.8±4.6)%,显著高于术后3个月(16.6±1.6)%和末次随访时(9.9±1.2)%(P均=0.000);病变节段椎体活动域(过伸位角度+过屈位角度),术前L 4~5节段椎体间角度活动域为9.62°±0.78°,显著低于术后3个月9.91°±0.72°(P=0.037),但与末次随访9.91°±0.61°无统计学差异(P=0.058);L 5~S 1节段椎体间角度活动域术前、术后3个月和末次随访分别为10.78°±1.27°、10.84°±1.43°和°,10.92°±0.97°,术前后比较差异无显著性(F=0.260,P=0.771);病变节段椎间隙高度术前(6.52±1.12)mm,与术后3个月(6.38±0.93)mm和末次随访(6.42±1.29)mm无统计学差异(F=0.329,P=0.720)。按改良MacNab标准,末次随访患者术后优良率95.0%(76/80)。结论经皮椎间孔镜治疗腰椎间盘突出症创伤小,恢复快,能明显缓解症状,中期临床疗效可靠。     

Endoscopic resection of large sporadic non-ampullary duodenal polyps: efficacy and long-term recurrence

Background

Endoscopic resection is an alternative to surgery for removal of large duodenal polyps. There are limited data on the safety, efficacy, and long-term recurrence data after endoscopic resection of sporadic, non-ampullary, and large duodenal polyps.

Objective

Our aim was to evaluate the safety and short-term outcomes of the endoscopic removal of the large sporadic duodenal polyps and to determine long-term risk of recurrence and factors predicting recurrence on follow-up.

Methods

Patients with large (>10 mm) sporadic non-ampullary duodenal polyps underwent endoscopic resection from 2001 to 2012 at the Cleveland Clinic. Patients underwent endoscopic polypectomy and argon plasma coagulation. The main outcome measurements were complete polypectomy, complications, short- and long-term recurrence.

Results

A total of 54 patients were included. The mean patient age was 66.4 years. The mean polyp size was 15.1 ± 5.4 mm. Most polyps (N = 48, 88.9 %) were sessile polyps. The median follow-up time was 10.8 (range 0.5–120) months. Most lesions were located in the second part of the duodenum (N = 41, 75.9 %). Adenomas were found in 46 (85.2 %) of lesions overall. Tubular adenoma was the most common histology type found in 33 cases (71.7 %). Tubulovillous and villous were found in 12 (26.1 %) and 1 (2.2 %) cases, respectively. On follow-up, 50 (92.6 %) achieved complete resection with tumor free margins post resection. The 30-day risk of major complications was 5.6 % (N = 3), 1 with perforation and 2 with delayed bleeding. Recurrence was documented in 29 % (N = 16) of patients. All recurrences were managed endoscopically except for one patient who required surgery. The recurrence rate was higher for patients who had villous component in their adenomas compared to those with tubular alone (p = 0.03).

Conclusions

Endoscopic resection is effective for treating large duodenal adenomas. Adenomas with villous features are more likely to recur. Almost all recurrences can be managed endoscopically.     

Platelet-rich plasma supplementation in arthroscopic repair of full-thickness rotator cuff tears: a randomized clinical trial

Background

Results on the effectiveness of PRP supplementation in arthroscopic rotator cuff repair are conflicting, making it difficult to draw definitive conclusions.

Methods

This was a prospective, randomized, and double-blind study with two groups of 20 patients each (PRP group and control group). Degenerative supraspinatus full-thickness tears grade C2–C3 were subjected to arthroscopic repair; PRP supplementation was given to patients in the PRP group. The outcomes were assessed by DASH, Constant scales, and ultrasound before and 6 months after surgery. Pain measured by VAS was evaluated preoperatively and 7 and 30 days after surgery.

Results

The two groups did not differ significantly by age, sex, and dominance of the affected side. In all surgical procedures, a long head of the biceps tenotomy and single-row repair were performed. The preoperative VAS was 5.6 ± 2.4 in PRP group and 6.4 ± 1.5 in the control group (p > 0.05). The group supplemented with PRP reported a VAS significantly better in the first week (2.5 ± 1.9 vs 5.3 ± 2.1, p < 0.05) and during the first month after surgery (1.5 ± 1.0 vs 3.2 ± 1.7, p < 0.05) compared to the control group. The preoperative Constant and DASH scores were 39.95 ± 12 and 51 ± 15.2, respectively, in the PRP group and 41 ± 11 (p > 0.05) and 45 ± 12.6 (p > 0.05) in the control group. The average Constant score improved significantly after 6 months to 81 ± 11.2 (p < 0.05) in the PRP group and 78.5 ± 9 (p < 0.05) in the control group. No differences were noted between the two groups (p > 0.05). The DASH score after 6 months was 17.4 ± 8 (p < 0.05) for the treatment group (the PRP group) and 21 ± 8.4 (p < 0.05) for the control group. No statistically significant differences were found as regards the DASH score in the two groups after 6 months (p > 0.05). The two groups showed no differences in the ultrasound evaluation after 6 months either. No re-ruptures occurred in either group.

Conclusions

PRP leads to a reduction in pain during a short-term follow-up. Pain reduction allows for a more rapid recovery of mobilization and improvement in functionality.

Level of evidence

Randomized controlled trial, Level of evidence, 1.

     

A Novel Free-hand Technique of Pedicle Screw Placement in the Lumbar Spine: Accuracy Evaluation and Preliminary Clinical Results

Objective

Pedicle screw implantation is the most common technique to achieve stability during spinal surgeries. Current methods for locating the entry point do not have a quantified criteria and highly rely on the surgeons' experience. Therefore, we aim to propose a quantified pedicle screw placement technique in the lumbar spine and to investigate its accuracy and safety in clinical practice.

Methods

We conducted a retrospective study involving 110 patients who received spinal surgery in our hospital from August 2018 to August 2021. All patients included had herniation of a single lumbar disc and were consistently treated with posterior discectomy, inter-body fusion, and transpedicular internal fixation. For 54 patients in the observation group, the pedicle screws were placed with our technique, which is located at 4 mm below the superior edge of the transverse process in line with the lateral margin of the superior articular process. For 56 patients in the control group, pedicle screws were placed according to the traditional crista lambdoidalis method. Comparisons were made in terms of the operation time, blood loss, time for exposure, the accuracy of placement, and postoperative complications. Furthermore, we applied our method to 64 patients with indistinguishable crista lambdoidalis and evaluated the accuracy of screw placement and clinical outcomes according to the visual analogue scale (VAS) and the Japanese Orthopaedic Association (JOA) score.

Results

There was no significant difference in intraoperative bleeding, accuracy of placement, and postoperative complications between our technique and the traditional crista lambdoidalis method (P > 0.05). However, the exposure time before screw placement (12.8 ± 0.3 vs. 17.4 ± 0.3, P = 0.001) and the total surgery time (97.2 ± 1.9 vs 102.3 ± 0.9, P = 0.020) were significantly shortened with our method. Additionally, in cases with indistinguishable crista lambdoidalis, our technique showed satisfying accuracy, with 97.6% screws placed in appropriate trajectory on the first attempt and all screws eventually positioned in the safe zone according to the Gertzbein–Robbins grading. All patients experienced steady improvement after surgery.

Conclusion

Placing pedicle screws at 4 mm below the superior edge of the transverse process in line with the lateral margin of the superior articular process is a viable pedicle screw placement method. With this method, we observed a higher success rate and shorter operation time. In addition, this method can be applied in cases with indistinguishable crista lambdoidalis, and have satisfied success rate and clinical outcome.     

Recurrence and survival factors analysis of 171 cases of sacral chordoma in a single institute

Purpose

To evaluate postoperative recurrence, survival and metastasis results and related factors of sacral chordoma.

Methods

Between 1978 and 2013, a total of 171 patients with sacral chordoma were diagnosed at our institution and 162 cases underwent operation. The clinical characteristics, treatment and outcomes of all these patients were reviewed.

Results

The 3-year recurrence free survival rate was 83.1%. The median recurrence free survival time was 73 ± 7.8 months. Tumor level in sacrum and surgical margin were significant factors influencing recurrence. Recurrence was significant factor influencing metastasis. One hundred and fifty-seven cases were followed up for an average of 55.6 months. 135 cases (86%) survived, 37 cases (23.6%) developed recurrence, and 17 cases (10.8%) developed metastasis. The overall 5- and 10-year survival rate was 88.3% and 59.6%, respectively. Age (p = 0.037) and metastasis (p = 0.001) were significant factors influencing survival. The 3-year recurrence free survival rate was 80.1%. The median recurrence free survival time was 69 ± 12.7 months. Tumor level in sacrum (p = 0.035) and surgical margin (p = 0.009) were significant factors influencing recurrence. Seventeen cases (10.8%) had metastasis. Recurrence (p = 0.016) was significant factors influencing metastasis.

Conclusions

Sacral chordoma tended to occur in elderly male patients and locate below sacral 3 level. The recurrence rate was high, especially for tumor above sacral 3 level. Wide surgical margin is very important for good local control. The patients with metastasis had poor prognosis.

     

Comparison of Endoscopic and Robotic Thyroidectomy

Background

Endoscopic thyroidectomy is a technically challenging procedure. Robot-assisted thyroidectomy has been recently introduced and offers improved visualization and dexterity. The present study compared conventional endoscopic and robotic thyroidectomy for thyroid cancer patients in terms of perioperative outcomes and learning curve. All operations were performed by the same surgeon.

Materials and Methods

Between April 2007 and March 2010, 96 patients underwent endoscopic thyroidectomy (endoscopy group) and 163 patients underwent robotic thyroidectomy (robot group). A gasless transaxillary approach was used in both groups. The 2 groups were compared in terms of patient characteristics, perioperative clinical results, complications, and pathologic details. Learning curves for the 2 procedures were compared based on the number of cases required to reach a consistent operation time.

Results

Patient characteristics were similar for both groups. The mean total operation time for thyroidectomy with central compartment neck dissection was 142.7 ± 52.1 min in the endoscopy group and 110.1 ± 50.7 min in the robot group (P = .041). Both patient groups were similar in terms of pathological features including TNM stage, intraoperative blood loss, length of hospital stay, and complication rate. However, the mean number of retrieved central lymph nodes was 2.4 ± 1.9 for the endoscopy group and 4.5 ± 1.5 for the robot group (P = .004). The learning curve was 55–60 cases for endoscopic thyroidectomy and 35–40 cases for robotic thyroidectomy.

Conclusion

Robotic thyroidectomy was found to be superior to endoscopic thyroidectomy in terms of operation time, lymph node retrieval, and learning curve. Complication rates and postoperative hospital stay were similar for the 2 procedures.     

Wiltse入路置钉联合对侧TLIF和传统术式治疗腰椎间盘突出症的病例对照研究

目的:比较Wiltse入路置钉联合对侧经椎间孔腰椎椎间融合术(transforaminal lumbar interbody fusion,TLIF)和传统TLIF治疗腰椎间盘突出症的疗效及其对多裂肌损伤的影响方法:2014年6月至2017年9月收治90例腰椎间盘突出症合并腰椎不稳患者,根据手术方式不同分为Wiltse入路置钉组和传统TLIF组。Wiltse入路置钉组50例,采用一侧Wiltse入路置钉联合对侧TLIF治疗,其中男36例,女14例,年龄45~72岁(60.4±3.1)岁;传统TLIF组40例,采用传统TLIF术式治疗,其中男25例,女15例,年龄45~74(62.1±3.4)岁。记录两组的手术时间、术中出血量、螺钉置入的准确率、术后引流量和引流管拔除时间。评估两组患者术前和术后12个月的腰背痛视觉模拟评分(visual analogue scale,VAS)和Oswestry功能障碍指数(Oswestry Disability Index,ODI)。所有患者术前、术后12个月进行CT检查,并对两组患者两侧多裂肌进行CT值测量。结果:所有患者获得随访,其中传统TLIF组随访时间12~18(15.3±4.3)个月;Wiltse入路置钉组随访时间13~24(16.5±4.1)个月。两组患者手术时间、术中出血量差异无统计学意义(P>0.05),Wiltse入路置钉组置入准确率高于传统TLIF组(P<0.05)。VAS评分和ODI术前两组差异无统计学意义(P>0.05),术后12个月Wiltse入路置钉组明显低于传统TLIF组(P<0.05)。Wiltse入路置钉组术后引流量和引流管放置时间均少于传统TLIF组(P<0.05)。两组患者术前多裂肌CT值比较差异无统计学意义(P>0.05),术后12个月比较差异有统计学意义(P<0.05)。传统TLIF组术后减压侧和非减压侧多裂肌CT值较术前均有明显减少(P<0.05),Wiltse入路置钉组减压侧术后多裂肌CT值较术前明显减少(P<0.05),非减压侧手术前后差异无统计学意义(P>0.05)。结论:Wiltse入路置钉联合对侧TLIF相对于传统术式,具有置钉准确,减少多裂肌的损伤,降低术后顽固性腰背部疼痛的发生率等优点。