双侧小切口椎旁肌间隙入路在下腰椎融合术中应用

[目的]探讨双侧小切口椎旁肌间隙入路在下腰椎融合术中的应用价值。[方法]自2008年6月～2009年10月,选择性对32例单节段下腰椎疾患行椎弓根螺钉加椎间融合器内固定术,均采用双侧小切口椎旁肌间隙即Wilt-se多裂肌和最长肌肌间隙入路。其中男性14例,女性18例;年龄37～65岁,平均51.2岁;病变节段:L3、46例,L4、517例,L5S19例;病种类型:腰椎退行性不稳12例,极外型或椎间孔型椎间盘突出7例,腰椎滑脱5例,椎间盘原位复发5例,椎间盘源性疼痛3例,均表现为严重的下腰痛伴单侧肢体出现放射症状或无双下肢症状。根据Oswe-stry功能障碍指数(ODI)评分和伤口视觉模拟法(VAS)疼痛评分来评估疗效。[结果]手术平均时间106 min,术中平均出血量319 ml,术后平均引流量137 ml,住院平均天数13.5 d。术前ODI评分为(37.3±6.1)分,术后3个月时为(19.1±4.7)分,末次随访时为(11.8±3.7)分;术前VAS疼痛评分为(7.2±1.2)分,术后3个月时为(2.5±0.7)分,末次随访时为(2.1±0.9)分,统计分析显示术前和术后3个月或末次随访时的ODI、VAS评分差异均有统计学意义(P<0.05)。所有病例均获得24个月以上随访,影像学检查示良好的椎间骨性融合现象。[结论]双侧小切口椎旁肌间隙入路行下腰椎融合术能有效地保护椎旁肌,并达到减压、融合目的,是较实用并容易推广的腰椎后路"微创"手术方式。     

单切口Wiltse入路微创经椎间孔椎间融合术与后路椎间融合术治疗复发性腰椎间盘突出症的对比研究

目的 比较单切口Wiltse入路微创经椎间孔腰椎椎体间融合术（minimally invasive transforaminal lumbar interbody fusion,MIS-TLIF）与腰椎后路椎间融合术（posterior lumbar interbody fusion,PLIF）治疗复发性腰椎间盘突出症的临床疗效。方法 回顾性分析2016年1月至2018年10月我科手术治疗的44例复发性腰椎间盘突出症病人的临床资料。采用PIPELINE通道下单切口Wiltse入路MIS-TLIF手术治疗的23例纳入MIS-TLIF组,采用PLIF手术治疗的21例纳入PLIF组。记录手术时间、术中出血量、住院时间、手术前后疼痛视觉模拟量表（visual analogue scale,VAS）评分、Oswestry功能障碍指数（Oswestry disability index,ODI）、肌酸激酶值、并发症及末次随访椎间融合情况。结果 44例均顺利完成手术并定期随访,MIS-TLIF组随访时间为（16.91±3.37）个月,PLIF组随访时间为（16.81±3.04）个月。MIS-TLIF...     

腹腔镜辅助下联合侧前方小切口腹膜后入路治疗腰椎结核

目的 探讨腹腔镜辅助下联合侧前方小切口腹膜后入路治疗腰椎结核的疗效。方法 回顾分析2006年6月-2012年6月,腹腔镜辅助下联合侧前方小切口腹膜后入路行腰椎结核病灶清除、植骨融合及内固定治疗的22例患者临床资料。其中男14例,女8例;年龄26~57岁,平均42.6岁。病程3~10个月,平均7.3个月。结核累及节段:单节段17例,分别为L1、2 3例,L2、3 6例,L3、4 4例,L4、5 2例,L5 2例;双节段5例,分别为L1~3 2例,L2~43例。腰椎Cobb角为5~28°,平均20°;6例有神经压迫症状及体征,神经功能按Frankel分级,C级2例,D级4例。记录手术时间、术中出血量及手术并发症。末次随访时,评估患者术后神经功能恢复情况;于腰椎侧位X线片测量Cobb角;采用Nakai评分标准进行疗效评定;根据Suk标准判断植骨融合率。结果 22例患者均顺利完成手术。手术时间110~250 min,平均140 min;术中出血量120~280 mL,平均180 mL。术后出现股神经损伤和交感神经损伤症状各1例,1~3周后均自行逐渐恢复正常;术后切口均Ⅰ期愈合。22例均获随访,随访时间16~50个月,平均21个月。随访期间未出现内固定物松动及断裂等并发症,均无结核中毒症状及病灶扩散,红细胞沉降率及C反应蛋白正常,未见结核复发。末次随访时,除1例术前神经功能Fankel C级患者恢复至D级外,余均完全恢复至E级;腰椎Cobb角为2~16°,平均7.8°;按Nakai评分标准评估,获优9例、良10例、可3例,优良率86.4%;按Suk标准评定植骨已融合或可能融合21例,融合率95.5%。结论 腹腔镜辅助下联合侧前方小切口腹膜后入路治疗腰椎结核具有创伤小、并发症少的优点,是一种安全有效手术方式。     

前外侧腰椎间融合术与后路经椎间孔腰椎间融合术治疗L4/5Ⅰ度退变性腰椎滑脱的疗效比较

目的:比较单纯前外侧腰椎间融合术(anterolateral lumbar interbody fusion,ALLIF)与后路经椎间孔腰椎间融合术(transforaminal lumbar interbody fusion,TLIF)治疗Ⅰ度退变性腰椎滑脱的疗效。方法:回顾2013年4月~2015年4月在我院行手术治疗的68例L4/5Ⅰ度退变性腰椎滑脱患者,其中32例行ALLIF,男20例,女12例,年龄51.3±11.9岁(40~65岁);36例行TLIF,男22例,女14例,年龄50.3±8.6岁(42~63岁)。对两组患者的一般资料、围手术期参数、并发症、术前和术后1周、6个月、12个月、24个月的腰痛和腿痛视觉模拟评分(visual analog scale,VAS)、Oswestry功能障碍指数(Oswestry disability index,ODI)和影像学参数[腰椎前凸(LL)、手术节段椎间高度(DH)、手术节段前凸角(SLA)和滑脱百分比(Slip%)]进行比较分析。结果:两组患者的年龄、性别比、体重指数、骨盆指数、术前腰腿痛VAS评分、ODI、影像学参数和随访时间等均无统计学差异(P0.05)。ALLIF组手术时间和出血量分别为69.97±11.06min和133.40±23.71ml,TLIF组分别为106.42±8.47min和249.48±30.16ml,ALLIF组均显著性低于TLIF组(P0.05)。术中未出现大血管损伤、硬膜撕裂、神经功能损害、腹膜撕裂、腹部脏器损伤,术后无切口疝、内固定或假体松动、断裂等并发症。两组术后各时间点的腰痛VAS评分、腿痛VAS评分、ODI均较术前有明显改善(P0.05),两组间同时间点比较均无显著性差异(P0.05)。两组术后各时间点的DH、LL、SLA、Slip%均较术前有显著性改善(P0.05),两组术后各个时间点的Slip%比较均无显著性差异(P0.05),ALLIF组术后各个时间点的DH、LL、SLA均优于同时间点TLIF组(P0.05)。末次随访时两组患者均获骨性融合,ALLIF组5例(15.6%)出现融合器沉降。结论:与TLIF相比,ALLIF治疗Ⅰ度退行性腰椎滑脱同样可以获得满意的临床疗效,并具有手术出血量少、手术时间短,可以更好地恢复椎间隙高度以及腰椎前凸角的优势。     

经椎间孔入路与经后方入路椎间融合术治疗退变性腰椎失稳症的疗效比较

目的回顾性研究经后方入路椎体间融合术（posterior lumbar interbody fusion,PLIF）和切除上、下关节突的经椎间孔入路椎体间融合术（transforaminal lumbar interbody fusion,TLIF）治疗腰椎失稳症的疗效及并发症情况。方法采用PLIF和TLIF治疗2004年1月至2008年1月本院收治的退变性腰椎失稳症患者78例,其中PLIF31例,TLIF47例。比较两组手术时间、术中出血量、平均卧床时间、Nakai评分优良率、融合时间（按Suk标准）及术后并发症发生率。对两组术前及末次随访时的椎间隙高度及椎间孔高度进行对比研究。结果 78例患者均获随访,随访时间1.5～4.5年,平均3.5年。所有患者均获椎间骨性融合。对两组卧床时间、Nakai评分优良率、融合时间、同时间点椎间隙高度和椎间孔高度进行比较,差异无统计学意义（P〉0.05）;而在手术时间、出血量以及术后并发症发生率方面,两组之间的差异有统计学意义（P〈0.05）。两组末次随访时的椎间隙高度和椎间孔高度均较术前有明显改善（P〈0.05）。结论 TLIF和PLIF治疗退变性腰椎失稳症效果良好;与PLIF相比,TLIF操作简单,出血量小,并发症少。     

腰椎滑脱的斜外侧椎间融合术入路影像解剖学评估

目的 评估腰椎滑脱的斜外侧椎间融合术(OLIF)入路影像解剖学特点.方法 将40例门诊腰痛行腰椎MRI检查的患者按照是否存在腰椎滑脱分为腰椎滑脱组(均确诊为L4椎体Ⅰ～Ⅱ度退变性滑脱,20例)和非腰椎滑脱组(20例).在腰椎MRI的L4～5椎间隙中央层轴位T2加权像上辨识左侧腰大肌、左侧腹主动脉、左侧腰交感干、节段动脉...     

前路腰椎椎间融合术选择“锁孔”手术还是小切口手术?

近十余年来,随着微创理念和科学技术的发展,以腹腔镜前路锁孔、微创小切口、经皮内固定融合等为代表的新型腰椎前路微创手术取得了长足进步。然而有的技术最初带给人们的欣喜与冲动,为长期临床实践产生的困惑所取代。在当今新理论和新技术日新月异的时代,如何理性、科学发展腰椎前路微创技术更值得人们深思。为此,本期特邀国内几位专家就腰椎前路微创手术技术及相关问题作简要讨论,以达抛砖引玉之作用。     

极外侧入路腰椎间融合术对腰椎矢状面序列的影响

[目的]评估极外侧入路腰椎椎间融合术(XLIF)对腰椎矢状面序列的影响。[方法]回顾2012年6月～2017年1月本科采用极外侧入路微创融合手术(XLIF)治疗的腰椎退变性疾病38例(42个节段)。观察术前及末次随访时手术间隙Cobb角、腰椎整体前凸Cobb角度、手术间隙高度(L1～S1)的变化。[结果]患者手术节段Cobb角由术前平均(11.54±7.67)°增加至末次随访时平均(12.58±8.06)°,腰椎整体前凸Cobb角由术前平均(37.42±15.25)°增加至末次随访时平均(39.46±11.86)°,但两时间点间差异无统计学意义(P0.05);然而,手术间隙前缘高度由术前(11.26±3.95) mm显著增加至末次随访时平均(14.42±7.37) mm(P0.05),手术间隙后缘高度由术前平均(6.37±2.46) mm显著增加至末次随访时平均(8.29±2.89) mm(P0.05)。带角度笼架组18个节段术前手术节段Cobb角为(13.96±7.22)°,末次随访平均为(18.67±4.51)°,有明显改善(P0.05),但不带角度笼架组24个节段手术前Cobb角与末次随访差异无统计学意义,而且两组腰椎(L1～S1)前凸Cobb角术前及末次随访差异亦无统计学意义(P0.05)。[结论]极外侧入路腰椎椎间融合术能明显增加椎间隙高度,实现椎管的间接减压,使用带角度笼架能明显增加手术节段前凸Cobb角,但是对腰椎整体的前凸改善不明显。     

斜外侧椎间融合术联合小切口Wiltse入路椎弓根螺钉固定治疗腰椎滑脱症早期疗效

目的探讨斜外侧椎间融合术(oblique lateral interbody fusion,OLIF)联合小切口Wiltse入路椎弓根螺钉固定治疗腰椎滑脱症的早期疗效。方法2016年1月-12月,采用OLIF联合小切口Wiltse入路椎弓根螺钉固定治疗21例腰椎滑脱症患者。男9例,女12例;年龄57~73岁,平均64.5岁。病程24~60个月,平均34.6个月。患者均为L4椎体滑脱(Ⅰ度15例、Ⅱ度6例);合并椎弓峡部裂1例、椎管狭窄20例。术前及末次随访时采用日本骨科协会(JOA)评分评价临床疗效;术前及术后2 d摄腰椎正侧位X线片及CT,测量椎管矢状径和椎管横截面积,并计算椎间高度和椎体滑脱程度;术后6个月根据CT评价椎间融合情况。结果手术时间120~180 min,平均155 min;术中出血量100~340 mL,平均225.5 mL。1例患者术中下终板轻度损伤,1例术后出现大腿麻木、屈髋无力症状,l例出现腰交感神经干损伤症状。21例均获随访,随访时间12~18个月,平均14.3个月。术后患者下腰痛、腿痛、下肢麻木症状较术前明显改善,无椎间融合器脱出、螺钉断裂、终板塌陷等并发症发生。术后2 d测量椎间高度、椎体滑脱程度、椎管矢状径和椎管横截面积均较术前显著改善(P<0.05)。术后6个月CT检查示1例患者椎间融合欠佳(Ⅲ级),余20例椎间融合良好(Ⅰ、Ⅱ级),椎间融合率为95.2%。末次随访时腰椎JOA评分较术前显著增加,差异有统计学意义(t=24.980,P=0.000)。结论OLIF联合小切口Wiltse入路椎弓根螺钉固定治疗腰椎滑脱症,具有创伤小、并发症少等微创特点以及较高的椎间融合率,是一种安全、有效的治疗术式。     

后路L4/5融合术后邻椎病发生的危险因素

【摘要】 目的：探讨后路L4/5融合术后邻椎病（adjacent segment disease,ASD）发生的危险因素。方法：回顾性分析2012年9月~2021年9月因后路L4/5融合术后ASD于我院接受翻修手术的26例患者,纳入ASD组;采用1∶2匹配的方法,从同期接受腰椎后路融合手术且末次随访时未发生ASD的患者中,按性别、手术时年龄、手术节段、随访时间匹配52例患者作为对照组。收集两组患者术前、术后3d、末次随访时的影像学资料,在腰椎侧位X线片上测量：腰椎前凸角（lumbar lordosis,LL）、节段性前凸（segmental lordosis,SL）、骶骨倾斜角（sacral slope,SS）和L3/4、L4/5、L5/S1的椎间隙相对高度;在初次术前MRI上,采用Pfirrmann分级对融合节段邻近节段椎间盘退变情况进行评估。将两组患者术前基线资料,术前、术后3d、末次随访时的腰椎影像学资料（包括腰椎矢状位参数和初次术后腰椎矢状位参数矫正值）进行比较,将有差异的参数进行多因素Logistic回归分析,通过受试者工作特征（receiver operating characteristic,ROC）曲线确定独立危险因素对ASD的最佳预测阈值。结果：ASD组与对照组在术前第一诊断、术前邻近节段椎间盘的Pfirrmann分级、合并症情况均无统计学差异（P>0.05）。ASD组患者初次接受手术后5.4±2.3年行二次手术,二次手术融合节段L3/4 16例,L5/S1 10例。两组术前SL、SS以及L4/5、L3/4和L5/S1椎间隙相对高度均无显著性差异（P＞0.05）,ASD组患者初次术前LL显著性小于对照组（P=0.031）。初次融合术后3d,ASD组SL和LL显著性小于对照组（P＜0.05）。末次随访时,ASD组SL和LL均显著小于对照组（P<0.001）;ASD组的L3/4椎间隙相对高度明显小于对照组（P=0.002）。两组初次手术各参数的矫正值相比,ASD组的SL相对差值（relative △SL,r△SL）显著性小于对照组（P<0.001）,两组间LL相对差值（relative △LL,r△LL）、L4/5椎间隙高度相对差值（relative △disc height,r△DH）、L3/4 r△DH、L5/S1 r△DH均无显著性差异（P>0.05）。以ASD为因变量的多元回归分析结果显示较小的初次r△SL是发生ASD的独立危险因素（OR=0.031,95%置信区间0.005~0.209）,其曲线下面积（area under curve,AUC）为0.731（95%置信区间0.615~0.848）,最佳预测阈值为-10.5%。结论：后路L4/5融合术中局部曲度纠正不足可能会导致远期邻近节段高度的丢失,是融合术后发生ASD的独立危险因素。     

Mini-open anterior spine surgery for anterior lumbar diseases

Minimally invasive surgeries including endoscopic surgery and mini-open surgery are current trend of spine surgery, and its main advantages are shorter recovery time and cosmetic benefits, etc. However, mini-open surgery is easier and less technique demanding than endoscopic surgery. Besides, anterior spinal fusion is better than posterior spinal fusion while considering the physiological loading, back muscle function, etc. Therefore, we aimed to introduce the modified “mini-open anterior spine surgery” (MOASS) and to evaluate the feasibility, effectiveness and safety in the treatment of various anterior lumbar diseases with this technique. A total of 61 consecutive patients (46 female, 15 male; mean age 58.2 years) from 1997 to 2004 were included in this study, with an average follow-up of 24–52 (mean 43) months. The disease entities included vertebral fracture (20), failed back surgery (13), segmental instability or spondylolisthesis (10), infection (8), herniated disc (5), undetermined lesion for biopsy (4), and hemivertebra (1). Lesions involved 13 cases at T12–L1, 18 at L1–L2, 18 at L2–L3, 22 at L3–L4 and 11 at L4–L5 levels. All patients received a single stage anterior-only procedure for their anterior lumbar disease. We used the subjective clinical results, Oswestry disability index, fusion rate, and complications to evaluate our clinical outcome. Most patients (91.8%) were subjectively satisfied with the surgery and had good-to-excellent outcomes. Mean operation time was 85 (62–124) minutes, and mean blood loss was 136 (minimal-250) ml in the past 6 years. Hospital stay ranged from 4–26 (mean 10.6) days. Nearly all cases had improved back pain (87%), physical function (90%) and life quality (85%). Most cases (95%) achieved solid or probable solid bony fusion. There were no major complications. Therefore, MOASS is feasible, effective and safe for patients with various anterior lumbar diseases.     

微创小切口侧前方腰椎间融合术治疗腰椎退变性疾病的近期疗效和围手术期并发症

目的:评估微创小切口侧前方腰椎间融合术(mini-open lateral-anterior lumbar interbody fusion,La LIF)治疗腰椎退变性疾病的近期疗效和围手术期并发症。方法:分析2016年4月~2017年5月应用La LIF治疗的63例(94个节段)腰椎退变性疾病患者的资料,男23例,女40例,年龄42~86岁(61±15岁)。腰椎间盘突出症8例,腰椎管狭窄症40例,腰椎滑脱症7例,成人退变性侧凸症8例。融合节段为单节段38例,双节段20例,3节段4例,4节段1例。L1/2 3例,L2/3 7例,L3/4 31例,L4/5 53例。不附加内固定即独立的(stand alone)La LIF共56例;同时行二期后路内固定术7例,其中2例非计划内后路手术(1例腰椎管狭窄症因术中终板损伤而行后路内固定术,1例腰椎间盘突出症因术后cage下沉及症状缓解不满意而二期在外院行后路腰椎椎弓根内固定术),另5例退变性侧凸症行计划内后路减压或不减压椎弓根内固定术。记录手术时间、术中出血量、术后并发症,比较术前、术后1个月、术后3个月和末次随访时的腰痛VAS评分及Oswestry功能障碍指数(ODI),比较术前及末次随访时SF-36评分及X线片上手术节段椎间孔高度(intervertebral foramen height,FH)、椎间隙高度(intervertebral disc height,DH)和椎间孔面积(intervertebral foramen area,FA)。结果:63例患者完成随访,随访时间6.0±1.2个月(4~8个月)。单节段平均手术时间81±12min,平均术中出血量30±10ml;双节段平均手术时间130±21min,平均术中出血量50±12ml;3节段平均手术时间198±25min,平均术中出血量150±20ml;4节段手术时间220min,术中出血量300ml。术中出现静脉损伤1例,腹膜损伤1例,终板损伤2例(共3个节段)。术后1例出现切口红肿,对症治疗后缓解;4例出现一过性大腿前方疼痛或感觉异常,均在术后1个月内消失;1例出现下肢乏力,8周恢复正常。术后随访融合器下沉2例,融合器轻度移位8例。无病例因内置物失败、重要脏器损伤、术区感染等并发症而需行翻修手术。所有患者症状在随访过程中均逐渐改善,术后1个月、3个月及末次随访时VAS评分及ODI与术前比较均显著性改善(P0.05)。末次随访时SF-36评分较术前显著性改善(P0.05)。末次随访时手术节段FH、DH和FA较术前均显著性增加(P0.05)。结论:小切口La LIF作为一种微创腰椎融合术式,创伤小,出血少,手术时间短,围手术期并发症少,在治疗腰椎退变性疾病中具有较好的应用价值,严格选择手术适应证,不附加内固定的La LIF可取得较好临床效果。     

Acute pancreatitis complicating anterior lumbar interbody fusion

Postoperative pancreatitis may occur following surgery in regions remote from the pancreas and the biliary tree. Though uncommon, it carries a high mortality rate. Pancreatitis complicating spinal surgery is extremely rare. This report describes a case of acute pancreatitis following an anterior lumbar interbody fusion and discusses the possible mechanisms of pancreatic cellular injury. Received: 17 May 1999/Revised: 6 December 1999/Accepted: 16 December 1999     

Radiological and functional outcome after anterior lumbar interbody spinal fusion

Outcome after anterior spinal fusion has mainly been studied radiologically and reported fusion rates vary greatly. The aim of this study was to investigate radiological and long-term clinical outcome. The study comprised 120 consecutive patients, operated on during the period 1979–1987, with single-or two-level anterior interbody spinal fusion due to disc degeneration or isthmic spondylolisthesis with lumbar instability. In 64 patients a suplemental facet joint fusion was performed. Clinical outcome was evaluated 5–13 years after surgery using the patient-administered Dallas Pain Questionnaire (DPQ). Radiological outcome was determined on the basis of radiographs taken at a 2-year follow-up assessed by independent observers. The radiological follow-up rate was 98%. Complete fusion was found in 52%, questionable fusion in 24%, and definitive pseudoarthrosis in 24% of patients. Radiological results were poor in patients who had undergone previous spinal surgery (P<0.05) and in those with two-level fusion (P<0.05). The DPQ reply rate was 80%. Sixty-six patients claimed improvement in all functional groups. Patients with complete or questionable union had significantly better results than did those with non-union (P<0.01). Poorer functional outcome was found in patients who had undergone previous spinal surgery (P<0.01) or fusion at the L4/L5 level (P<0.05), in those who had responded poorly to the preoperative test brace (P<0.05), and in those above 45 years old at the time of surgery (P<0.05). Radiological and functional outcome did not vary according to whether patients were treated postoperatively with a plaster jacket or with facet screw fixation. The study demonstrated a functional success rate of approximately 66% following anterior lumbar spinal fusion after a mean follow-up of 8 years. There was a clear tendency for poorer prognosis for patients who had undergone previous spinal surgery, those aged above 45 years, those operated at the L4/L5 level and those who had responded poorly to the preoperative test brace. DPQ scores correlated well with radiological outcome.     

腰椎前路椎间融合术临床应用进展

腰椎前路椎间融合术自O’Brien报道以来，目前已成为一种椎间融合的标准技术，广泛应用于椎体滑脱、椎间盘源性疼痛、腰椎失稳等病症的治疗。近年来，腰椎前路椎间融合术在临床应用方面进展很快，小切口术式的临床应用，腹腔镜下手术的开展，使手术趋向微创化；多种内固定器械开始用于临床以增强前路融合的稳定性；椎间融合器自外形到材料等都有很大发展，椎间融合率不断提高，同时，人们对其并发症也有更深刻地认识。本文对腰椎前路椎间融合术的临床应用现状进行综述。     

Anterior lumbar fusion using a memory alloy implant

Surgical Principles The use of a memory alloy implant is a special adjunct to anterior lumbar spine fusion. Primary stabilization is achieved by means of an interbody memory implant made of nickel-titanium (Figure 1). The implant is anchored thanks to a specific memory effect of the alloy [1–4]: Following warming of the inserted implant to at least 45°C, it expands in height, thus wedging itself into a stable position between the two vertebrae (Figures 2a and 2b). Fusion is achieved by applying autologous iliac crest bone into and around the implant. Revised Version from: Operat. Orthop. Traumatol. 2 (1990), 93–104 (German Edition).     

Perioperative thrombotic occlusion of left external iliac artery during anterior lumbar interbody fusion

We report a case of thrombotic occlusion of left external iliac artery during the procedure of anterior lumbar interbody fusion. The diagnosis was confirmed by computed tomography angiography. The patient also developed severe rhabdomyolysis postoperatively. In spite of receiving emergent thromboendarterectomy, the patient expired on postoperative day 3. This report attempts to remind spinal surgeons and anesthesiologists of this rare but potentially fatal complication, and discuss the possible mechanism, management, and prevention.     

Perioperative and short-term advantages of mini-open approach for lumbar spinal fusion

It has been widely reported a vascular and neurologic damage of the lumbar muscles produced in the classic posterior approach for lumbar spinal fusions. The purpose of this study is to demonstrate a better clinical and functional outcome in the postoperative and short term in patients undergoing minimal invasive surgery (“mini-open”) for this lumbar spinal arthrodesis. We designed a prospective study with a 30 individuals cohort randomized in two groups, depending on the approach performed to get a instrumented lumbar circumferential arthrodesis: “classic posterior” (CL group) or “mini-open” approach (MO group). Several clinical and functional parameters were assessed, including blood loss, postoperative pain, analgesic requirements and daily life activities during hospital stay and at the 3-month follow-up. Patients of the “mini-open approach” group had a significant lower blood loss and hospital stay during admission. They also had significant lower analgesic requirements and faster recovery of daily life activities (specially moderate efforts) when compared to the patients of the “classic posterior approach” group. No significant differences were found between two groups in surgery timing, X-rays exposure or sciatic postoperative pain. This study, inline with previous investigations, reinforces the concept of minimizing the muscular lumbar damage with a mini-open approach for a faster and better recovery of patients’ disability in the short term. Further investigations are necessary to confirm these findings in the long term, and to verify the achievement of a stable lumbar spinal fusion.     

Comparison of the early results of transforaminal lumbar interbody fusion and posterior lumbar interbody fusion in symptomatic lumbar instability

Background:

Transforaminal lumbar interbody fusion (TLIF) has been preferred to posterior lumbar interbody fusion (PLIF) for different spinal disorders but there had been no study comparing their outcome in lumbar instability. A comparative retrospective analysis of the early results of TLIF and PLIF in symptomatic lumbar instability was conducted between 2005 and 2011.

Materials and Methods:

Review of the records of 102 operated cases of lumbar instability with minimum 1 year followup was done. A total of 52 cases (11 men and 41 women, mean age 46 years SD 05.88, range 40-59 years) underwent PLIF and 50 cases (14 men and 36 women, mean age 49 years SD 06.88, range 40-59 years) underwent TLIF. The surgical time, duration of hospital stay, intraoperative blood loss were compared. Self-evaluated low back pain and leg pain status (using Visual Analog Score), disability outcome (using Oswestry disability questionnaire) was analyzed. Radiological structural restoration (e.g., disc height, foraminal height, lordotic angle, and slip reduction), stability (using Posner criteria), fusion (using Hackenberg criteria), and overall functional outcome (using MacNab''s criteria) were compared.

Results:

Pain, disability, neurology, and overall functional status were significantly improved in both groups but PLIF required more operative time and caused more blood loss. Postoperative hospital stay, structural restoration, stability, and fusion had no significant difference but neural complications were relatively more with PLIF.

Conclusions:

Both methods were effective in relieving symptoms, achieving structural restoration, stability, and fusion, but TLIF had been associated with shorter operative time, less blood loss, and lesser complication rates for which it can be preferred for symptomatic lumbar instability.     

Retrograde ejaculation after anterior interbody lumbar fusion

Summary Retrograde ejaculation as a complication of anterior interbody lumbar fusion was investigated. The diagnosis of retrograde ejaculation was made on the basis of interviews. Patients were informed of the risk of retrograde ejaculation preoperatively. At the follow-up study the patients were asked if they had noticed retrograde ejaculation after their operation. In one case (anejaculation) testis biopsy and vasography was performed. On average, the incidence of retrograde ejaculation as a complication of anterior interbody lumbar fusion has been very low, ranging from only a few cases up to 5.9% of cases involving male patients. We studied 40 male patients with severe low back pain retrospectively after they had undergone anterior interbody lumbar fusion. The mean age at operation was 31.9 years and the mean follow-up time 5.0 years. Retrograde ejaculation occurred after anterior interbody fusion in nine patients. Permanent retrograde ejaculation developed in seven of these patients (17.5%). These patients were all operated on using a transabdominal approach. Major bleeding during the operation (over 2500 ml) was observed in two patients. Seven patients with retrograde ejaculation had undergone a two-level operation (L4-SI), and eight patients had undergone between one and three previous spine operations. Retrograde ejaculation has been underestimated as a complication of anterior interbody fusion in multioperated low back patients. The possibility of this complication should be kept in mind when planning a transabdominal approach for interbody lumbar fusion in male patients. We do not recommend the transabdominal approach in male patients because of the risk of retrograde ejaculation.