Anterior Cervical Discectomy and Fusion Combined with Foraminotomy Assisted by High‐Definition 3‐Dimensional Exoscope in the Treatment of Cervical Spondylotic Radiculopathy Secondary to Bony Foraminal Stenosis

ObjectiveTo evaluate the outcomes of cervical spondylotic radiculopathy secondary to bony foraminal stenosis treated with anterior cervical discectomy and fusion (ACDF) combined with anterior cervical foraminotomy (ACF) assisted by High‐Definition 3‐Dimensional Exoscope.MethodsIn this retrospective study, a total of 19 consecutive patients (12 males and seven females, with an average of 49.2 years, range from 40 to 59 years) with spondylotic radiculopathy caused by bony foraminal stenosis underwent ACDF combined with ACF assisted by High‐Definition 3‐Dimensional Exoscope in our hospital between January 2019 and December 2019 were included in this study. All patients signed the consent form before the surgery. The patient baseline information such as gender, age, body mass index (BMI), surgery time, blood loss, hospital stay, lesion segment, side, follow‐up time and postoperative complications were recorded. The Japanese Orthopedic Association (JOA), Neck Disability Index (NDI), and Visual Analogue Scale (VAS) were measured and compared before surgery, 1 months and final follow‐up after surgery. The radiographic outcomes were evaluated using the C₂‐C₇ angel, disc height, foraminal height, superior diagonal distance, inferior diagonal distance, and foraminal area.ResultsThe involved levels included C₄‐C₅ (six cases), C₅‐C₆ (10 cases), C₆‐C₇ (three cases). The mean duration of the surgery, mean blood loss, mean hospital stay, and mean follow‐up were 100 ± 11.10 min, 19.4 ± 7.05 mL, 7.1 ± 0.99 days, and 12.1 ± 2.25 months, respectively. The average preoperative JOA score was 11.9 ± 1.31, then improved to 15.7 ± 0.73 (t = −13.45, P < 0.001) and 16.2 ± 0.74 (t = −14.39, P < 0.001) at 1 month after operation and at last follow‐up, respectively. The average preoperative NDI score was 27.3 ± 3.36, then decreased to 5.1 ± 1.79 (t = 20.63, P < 0.001) and 4.5 ± 1.21 (t = 25.53, P < 0.001) 1 month after operation and at last follow‐up, respectively. The average preoperative VAS score was 6.7 ± 0.93, then decreased to 2.4 ± 0.69 (t = 15.05, P < 0.001) and 1.9 ± 0.78 (t = 16.40, P < 0.001) 1 month after operation and at last follow‐up, respectively. As compared with the condition before surgery, there was a significant improvement in the C₂‐C₇ angel, disc height, foraminal height, and foraminal area (P < 0.05). None of the patients developed postoperative vascular injury, nerve injury, loosening and rupture of the internal fixation, displacement of interbody fusion cage, and pseudarthrosis.ConclusionACDF combined with ACF assisted by High‐Definition 3‐Dimensional Exoscope is effective and safe for the treatment of CSR caused by secondary to bony foraminal stenosis.     

Percutaneous Endoscopic Unilateral Laminotomy and Bilateral Decompression for Lumbar Spinal Stenosis

To introduce a new surgery, percutaneous endoscopic unilateral laminotomy and bilateral decompression (Endo‐ULBD) using visual trepan, and investigate its efficacy and safety in elderly patients with lumbar spinal stenosis. In our retrospective study, a total of 69 patients were enrolled between March 2018 and September 2018; 31 patients were treated with Endo‐ULBD and 38 patients were treated with posterior lumbar interbody fusion surgery (PLIF). The operation time, intraoperative blood loss, and hospitalization duration were compared between the two groups. A visual analog scale (VAS) was used to evaluate the degree of pain. The Oswestry Disability Index (ODI) and European Quality of Life‐5 Dimensions (EQ‐5D) were used to evaluate lumbar function and quality of life, respectively. Lumbar X‐ray, computed tomography (CT) and magnetic resonance imaging (MRI) were performed postoperatively at different time points. MacNab''s outcome assessment and perioperative complications were also documented. The surgeon completed all surgeries successfully, and all 69 patients were followed up. The operative time of the Endo‐ULBD group was 60.68 ± 0.47 min, while that of the PLIF group was 120.23 ± 10.24 min. The operative time of the Endo‐ULBD group was shorter than that of the PLIF group, and the difference was statistically significant (P < 0.001). The volume of intraoperative blood loss was 47.25 ± 0.43 mL in the Endo‐ULBD group and 256.90 ± 20.83 mL in the PILF group (P < 0.001). The length of hospital stay in the Endo‐ULBD group was 5.12 ± 1.60 days and that in the PILF group was 10.54 ± 1.82 days (P < 0.001). The VAS scores at postoperative 1 day, 3 months, 6 months, final follow‐up (Endo‐ULBD: 6.58 ± 0.65, 4.55 ± 0.54, 2.78 ± 0.24, 1.31 ± 0.78; PLIF: 7.19 ± 1.14, 4.80 ± 0.13, 2.71 ± 0.83, 1.29 ± 0.56) were significantly improved compared with those before surgery (Endo‐ULBD: 8.63 ± 0.37; PLIF: 8.31 ± 1.34). The ODI and EQ‐5D scores of lumbar function and quality of life at each time point after surgery (Endo‐ULBD ODI: 30.29% ± 0.47%, 23.35% ± 0.95%, 19.45% ± 0.81%, 10.84% ± 0.36%; EQ‐5D: 0.38 ± 0.15, 0.45 ± 0.17, 0.63 ± 0.14, 0.71 ± 0.20; PLIF ODI: 33.56% ± 1.58%, 25.69% ± 2.69%, 20.01% ± 1.49%, 10.72% ± 0.29%; EQ‐5D: 0.33 ± 0.03, 0.39 ± 0.05, 0.62 ± 0.07, 0.72 ± 0.10) were significantly improved compared with those before surgery (Endo‐ULBD: 44.56 ± 1.32, 0.33 ± 0.07; PLIF: 43.79 ± 1.91, 0.31 ± 0.09, respectively), with statistically significant differences (P < 0.05); however, there was no significant difference between the two groups at the last follow‐up (P > 0.05). At the last follow‐up, the excellent and good efficacy rate was 90.3% (28/31) in the Endo‐ULBD group and 89.4% (34/38) in the PILF group (χ² = 0.089, P = 0.993). No mortality, irreversible nerve injury, or even paralysis occurred in either group. Endo‐ULBD for lumbar spinal stenosis has the advantages of less trauma, a shortened operation time, and rapid recovery and is an effective alternative for the treatment of lumbar spinal stenosis. Strict surgical indications, reasonable surgical plans, and experienced surgeons are important factors to ensure safety and satisfactory postoperative efficacy.     

Percutaneous Endoscopic Lumbar Discectomy via Transforaminal Approach Combined with Interlaminar Approach for L4/5 and L5/S1 Two‐Level Disc Herniation

ObjectiveThe purpose of the present study was to discuss a new surgical strategy that combines percutaneous endoscopic transforaminal discectomy (PETD) with percutaneous endoscopic interlaminar discectomy (PEID) for L4/5 and L5/S1 two‐level disc herniation.MethodsThis was a retrospective study. A total of 19 patients with L4/5 and L5/S1 two‐level lumbar disc herniation (LDH) who underwent percutaneous endoscopic lumbar discectomy (PELD) in our hospital from January 2015 to June 2016 were retrospectively examined. The average age of these 19 patients was 42.21 ± 14.88 years old, including 12 men and 7 women. One experienced surgeon who had carried out more than 3000 lumbar surgeries performed PELD for these patients. During the PELD surgery, the transforaminal approach was adopted for L4/5 level disc herniation and the interlaminar approach was adopted for L5/S1 level disc herniation. The demographic data, operation time (min), fluoroscopy times, hospital stay (days), and complications were recorded and analyzed. The visual analogue scale (VAS), Oswestry disability index (ODI) scores, and the modified MacNab criteria were used to evaluate the surgical outcomes. MRI was conducted to evaluate the radiographic improvement.ResultsAll patients underwent PELD via the transforaminal approach combined with the interlaminar approach successfully and achieved satisfactory efficacy. The follow‐up points were 3, 12, and 18 months. The average hospital stay (days) and the average follow up (months) were 3.32 ± 0.98 and 18.63 ± 3.84, respectively. The operation time and fluoroscopy times were 85.79 ± 12.90 min and 39.05 ± 4.59 times, respectively. The fluoroscopy times (frequency) for L4/5 and L5/S1 were 26.95 ± 6.41 and 12.11 ± 3.49 (t = 7.00, P < 0.05). Furthermore, there was no significant difference for fluoroscopy times between male and female patients (t = 0.89, P = 0.99). The preoperative back pain (VAS‐Back) and the last follow‐up VAS‐Back were 5.58 ± 2.01 and 2.37 ± 1.01, respectively (t = 7.14, P < 0.05). The preoperative leg pain (VAS‐Leg) and the last follow‐up VAS‐Leg were 7.00 ± 1.56 and 1.63 ± 1.01, respectively (t = 20.97, P < 0.05). There were significant differences between preoperative VAS‐Back and the last follow‐up VAS‐Back in men (t = 4.61, P < 0.05) and women (t = 6.57, P < 0.05). In addition, there was significant differences between preoperative VAS‐Leg and the last follow‐up VAS‐Leg in men (t = 13.48, P < 0.05) and women (t = 26.87, P < 0.05). There were significant differences between preoperative ODI scores (44.84 ± 10.82%) and the last follow‐up ODI scores (11.12 ± 5.80%) (t = 10.92, P < 0.05). Preoperative ODI scores and the last follow‐up ODI scores were significantly different for men (t = 8.80, P < 0.05) and women (t = 6.63, P < 0.05). All patients received significant pain relief and functional improvement after the surgery. Except for two cases of postoperative dysesthesia and one dural tear, no severe complications occurred. The dysesthesia symptoms of these two patients disappeared within 1 week with the application of dexamethasone and neurotrophic drugs and the dural tear case also recovered well as the dural laceration was small. No poor results were reported and 89.47% of patients achieved excellent or good recovery.ConclusionPercutaneous endoscopic lumbar discectomy via the transforaminal approach combined with the interlaminar approach under epidural anesthesia can treat L4/5 and L5/S1 two‐level disc herniation safely and effectively.     

Impact of dermal matrix thickness on split‐thickness skin graft survival and wound contraction in a single‐stage procedure

Optimal treatment of full‐thickness skin injuries requires dermal and epidermal replacement. To spare donor dermis, dermal substitutes can be used ahead of split‐thickness skin graft (STSG) application. However, this two‐stage procedure requires an additional general anaesthetic, often prolongs hospitalisation, and increases outpatient services. Although a few case series have described successful single‐stage reconstructions, with application of both STSG and dermal substitute at the index operation, we have little understanding of how the physical characteristics of dermal substitutes affects the success of a single‐stage procedure. Here, we evaluated several dermal substitutes to optimise single‐stage skin replacement in a preclinical porcine model. A porcine full‐thickness excisional wound model was used to evaluate the following dermal substitutes: autologous dermal graft (ADG; thicknesses 0.15‐0.60 mm), Integra (0.4‐0.8 mm), Alloderm (0.9‐1.6 mm), and chitosan‐based hydrogel (0.1‐0.2 mm). After excision, each wound was treated with either a dermal substitute followed by STSG or STSG alone (control). Endpoints included graft take at postoperative days (PODs) 7 and 14, wound closure at POD 28, and wound contracture from POD 28‐120. Graft take was highest in the STSG alone and hydrogel groups at POD 14 (86.9% ± 19.5% and 81.3% ± 12.3%, respectively; P < .001). There were no differences in graft take at POD 7 or in wound closure at POD 28, though highest rates of wound closure were seen in the STSG alone and hydrogel groups (93.6% ± 9.1% and 99.8% ± 0.5%, respectively). ADG‐treated wounds demonstrated the least amount of wound contracture at each time point. Increase dermal substitute thickness was associated with worse percent graft take at PODs 14 and 28 (Spearman ρ of −0.50 and −0.45, respectively; P < .001). In this preclinical single‐stage skin reconstruction model, thinner ADG and hydrogel dermal substitutes outperformed thicker dermal substitutes. Both substitute thickness and composition affect treatment success. Further preclinical and clinical studies to optimise this treatment modality are warranted.     

Original Designed Uniportal‐Bichannel Spinal Endoscopic System (UBiSES) for Foraminoplasty in Percutaneous Endoscopic Transforaminal Discectomy

ObjectiveThe study introduced uniportal‐bichannel spinal endoscopic system (UBiSES) and explored the feasibility of applying UBiSES to conduct lumbar foraminoplasty in percutaneous endoscopic transforaminal discectomy (PETD).MethodsThis is a cohort study. 36 patients confirmed as L5/S1 lumbar disc herniation (LDH) in our hospital from March, 2019 to November, 2019 were enrolled. 36 patients were divided into two groups named the UBiSES group (n = 18, male: female = 8:10) and the TESSYS group (n = 18, male: female = 10:8). The average age of the UBiSES group and the TESSYS group were 40.94 ± 12.39 years old and 39.78 ± 13.02 years old respectively. PETD via uniportal‐bichannel foraminoplasty assisted by UBiSES was adopted on the UBiSES group while PETD via conventional foraminoplasty was performed on the TESSYS group. One experienced surgeon with more than 4000 cases of lumbar surgery performed PETD on all patients. The demographic data, the duration of working cannula placement (minutes), decompression time (minutes), radiation exposure time (seconds), complications, Visual Analogue Scale (VAS), Oswestry Disability Index (ODI) scores and modified MacNab criteria were recorded and analyzed. The magnetic resonance imaging (MRI) and computed tomography (CT) were conducted to evaluate the radiographic improvement.ResultsPETD via lumbar foraminoplasty was successfully performed in all cases. The follow‐up points were 3 months, 6 months, and 12 months. The average follow‐up period of all patients was 15.78 ± 2.29 months. There was no statistic difference in age (P = 0.81), sex (P = 0.51) and follow‐up (P = 0.14) between two groups. The duration of working cannula placement was 19.08 ± 2.30 min in the UBiSES group and 24.90 ± 4.71 min in the TESSYS group and there was significant difference between two groups (P < 0.05). There was no statistic difference in decompression time between the UBiSES group (44.18 ± 5.70 min) and the TESSYS group (47.46 ± 5.96 min) (P = 1.70). The radiation exposure time was 28.00 ± 4.70 s in the UBiSES group and 40.50 ± 5.73 s in the TESSYS group respectively, and has significant difference between two groups (P < 0.05). Furthermore, there was significant different in the duration of working cannula placement and radiation exposure time in male or female between the UBiSES group and the TESSYS group (P < 0.05). For male or female, no difference observed in decompression time and follow‐up period between two groups. Postoperative VAS of low back and leg at every follow‐up point (1 day, 3 months, 6 months, 12 months) was improved significantly in both groups compared with their preoperative VAS (P < 0.05). The postoperative ODI (3 months, 6 months, 12 months) has decreased significantly in both the UBiSES group and the TESSYS group compared with their preoperative ODI (P < 0.05). 94.44% patients received an excellent or good recovery in the UBiSES group and 88.89% for the TESSYS group. There was no poor result reported in both groups. The radiographic images showed satisfactory foraminoplasty and sufficient decompression of nerve in both groups. No postoperative complications were observed during follow‐ups in the UBiSES group. Two patients in the TESSYS group experienced postoperative dysesthesia and the symptom was disappeared in 5 days and 7 days respectively with dexamethasone and neurotrophic drugs treatment.ConclusionsThe original designed UBiSES could effectively and safely enlarge the foramen with an extensive surgical view and space under full‐time and real‐time visualization and get satisfactory efficacy.     

Simultaneous or Staged Decompressions for Patients with Tandem Spinal Stenosis

ObjectiveTo compare the clinical effects of cervical decompression first, lumbar decompression first, or simultaneous decompression of both lesions in the treatment of tandem spinal stenosis (TSS).MethodsThis is a retrospective analysis. From January 2013 to December 2018, 51 TSS patients underwent our surgery and postoperative investigation. Among the 51 subjects, 27 females and 24 males, aged 49–77 years with an average age of 66.3 ± 6.8, were selected. According to the different operation sequences, all patients were divided into three groups. In simultaneous operation group, five patients underwent cervical and lumbar vertebrae surgery at the same time. In first cervical surgery group, 28 patients underwent cervical vertebra surgery first, followed by lumbar spine surgery after a period of recovery. And in first lumbar surgery group, 18 patients underwent lumbar vertebrae surgery first. The choice for neck surgery is posterior cervical single‐door vertebroplasty, the surgery of lumber is plate excision and decompression needle‐rod system internal fixation. The outcome measures are visual analogue scale (VAS), Japanese Orthopaedic Association cervical (JOA‐C) and lumbar (JOA‐L) scores, which were assessed at 3 months and 1 year after the operation by telephone interview. In addition, operative time, estimated blood loss, and hospital stay were also recorded.ResultsAll the patients in the study had surgery performed successfully by the same group of orthopaedic surgeons. The preoperative VAS scores of simultaneous operation group, first cervical surgery group, and first lumbar surgery group were 8.00 ± 1.00, 8.36 ± 0.68, and 8.17 ± 0.71 (P > 0.05). The preoperative JOA‐C scores were 7.00 ± 2.35, 6.54 ± 1.53, and 7.83 ± 1.04 (P < 0.05). And the preoperative JOA‐L scores were 7.20 ± 2.17, 4.64 ± 2.36, and 5.78 ± 1.22 respectively (P < 0.05). During the final 1‐year follow‐up, the JOA‐C improvement rates of simultaneous operation group, first cervical surgery group, and first lumbar surgery group were 85.68% ± 5.44%, 84.27% ± 5.02%, and 83.34% ± 10.25%, respectively (P > 0.05), and the JOA‐L improvement rates were 80.04% ± 3.35%, 81.65% ± 3.74%, and 80.21% ± 4.76% (P > 0.05). The difference among them was not statistically significant. In addition, operation time (OP), blood loss (BL), and hospital stay (HS) in the simultaneous operation group were 245.00 ± 5.00 min, 480.00 ± 27.39 mL, and 16.60 ± 0.55 days, respectively. While those parameters in the first cervical surgery group were 342.50 ± 18.18 min, 528.21 ± 43.97 mL, and 22.75 ± 2.15 days, and in the first lumbar surgery group they were 346.11 ± 24.77 min, 519.44 ± 43.99 mL, and 22.89 ± 1.64 days. The average blood loss in simultaneous operation group was less (P > 0.05); meanwhile, the operation time and hospital stay time were significantly shorter in the simultaneous operation group than in the first cervical surgery group and first lumbar surgery group (P < 0.05). Only one case of fat liquefaction occurred in first cervical surgery group, which healed spontaneously after a regular change of dressing for 1 month.ConclusionsUnder the condition of ensuring the surgical effect, the choice of staged surgery or concurrent surgery according to the patients'' own symptoms of cervical and lumbar symptoms could both obtain satisfactory results, and the damage of simultaneous surgery was less than that of staged surgery.     

Psychological and Functional Comparison between Minimally Invasive and Open Transforaminal Lumbar Interbody Fusion for Single‐Level Lumbar Spinal Stenosis

ObjectiveThe aim of this study was to investigate whether treatment with minimally invasive transforaminal lumbar interbody fusion (Mis‐TLIF) causes patients suffering from lumbar spinal stenosis (LSS) to experience less anxiety and better clinical efficacy than open transforaminal lumbar interbody fusion (TLIF).MethodsIn this retrospective cohort study, we analyzed 86 patients, including 46 male patients and 41 female patients, who suffered from single‐segmental lumbar spinal stenosis in our department between January 2016 and January 2018. They were divided into two groups: a control group (n = 46), for patients who underwent open TLIF surgery, and an experimental group (n = 40), for patients who underwent Mis‐TLIF surgery. All patients were evaluated based on operation time, intraoperative blood loss, hospital stay, visual analogue scale (VAS), Oswestry disability index (ODI), hospital anxiety depression scale (HADS), fusion rate, and complications (screw misplacement and loosening, cerebrospinal fluid leakage, infection, and delayed wound healing). Patient characteristics were compared within and between groups.ResultsThe average incision length was 3.64 ± 0.476 cm in the experimental group, which was smaller than that (8.11 ± 2.406 cm) in the control group (P < 0.05). The operation time of the experimental group was a little longer than that of the control group. The intraoperative blood loss and hospital stay in the experimental group were less than those in the control group.The mean preoperative low back pain VAS score was 7.525 ± 1.432 in the experimental group and 7.087 ± 1.799 in the control group (P > 0.05). The low back pain VAS scores on postoperative day 3 and at 3, 6, and 12 months postoperatively were 5.000 ± 0.987, 4.075 ± 0.997, 2.150 ± 0.834, and 1.450 ± 0.639 in the experimental group, respectively; these scores were lower than those in the control group (6.870 ± 1.572, P < 0.05; 4.630 ± 1.103, P < 0.05; 2.630 ± 1.103, P < 0.05; and 2.326 ± 1.034, P < 0.05, respectively). There was no obvious difference in the leg pain VAS scores between the two groups at all follow‐up points.The mean preoperative ODI score was 58.700% ± 19.703% in the experimental group and 61.696% ± 17.583% in the control group (P > 0.05). The ODI scores at postoperative months 3, 6, and 12 were 25.225% ± 5.554%, 20.150% ± 7.698%, and 16.125% ± 9.565% in the experimental group; these scores were lower than those in the control group (49.130% ± 14.805%, P < 0.05; 34.044% ± 15.148%, P < 0.05; and 29.282% ± 132.567%, P < 0.05, respectively).The mean preoperative HADS score was 14.475 ± 3.113 in the experimental group and 13.391 ± 2.824 in the control group (P > 0.05). However, the mean HADS scores on postoperative day 3 in the experimental group was 8.500 ± 2.000, decreasing obviously compared to the preoperative scores (P < 0.05). The mean postoperative HADS score on postoperative day 3 in the control group was 12.734 ± 1.949, which had not decreased significantly compared to the preoperative score (P > 0.05). The HADS scores in the experimental group was lower than that in the control group on postoperative day 3 (P < 0.05).In the correlation analysis, the incision length was correlated to the HADS scores on postoperative day 3 (r = 0.527, P < 0.05). The HADS scores on postoperative day 3 were positively correlated with the low back pain VAS scores on the same day (r = 0.388, P < 0.05). The HADS scores on postoperative day 3were positively correlated with the ODI scores at 3‐month (r = 0.460, P < 0.05), 6‐month (r = 0.429, P < 0.05), and 12‐month follow up (r = 0.349, P < 0.05).Fusion rates were not significantly different between the two groups. There was no screw misplacement and loosening, infection, or delayed wound healing in either group. The cerebrospinal fluid leakage rate in the control group was higher than that in the experimental group.ConclusionPatients undergoing Mis‐TLIF experience less anxiety and have better outcomes than those who undergo open TLIF. The lower level of anxiety experienced by patients undergoing Mis‐TLIF is positively correlated with postoperative VAS and ODI scores.     

Comparison of Outcomes between Robot‐Assisted Minimally Invasive Transforaminal Lumbar Interbody Fusion and Oblique Lumbar Interbody Fusion in Single‐Level Lumbar Spondylolisthesis

ObjectiveTo compare the safety and effectiveness of robot‐assisted minimally invasive transforaminal lumbar interbody fusion (Mis‐TLIF) and oblique lumbar interbody fusion (OLIF) for the treatment of single‐level lumbar degenerative spondylolisthesis (LDS).MethodsThis is a retrospective study. Between April 2018 and April 2020, a total of 61 patients with single‐level lumbar degenerative spondylolisthesis and treated with robot‐assisted OLIF (28 cases, 16 females, 12 males, mean age 50.4 years) or robot‐assisted Mis‐TLIF (33 cases, 18 females, 15 males, mean age 53.6 years) were enrolled and evaluated. All the pedicle screws were implanted percutaneously assisted by the TiRobot system. Surgical data included the operation time, blood loss, and length of postoperative hospital stay. The clinical and functional outcomes included Oswestry Disability Index (ODI), Visual Analog scores (VAS) for back and leg pain, complication, and patient''s satisfaction. Radiographic outcomes include pedicle screw accuracy, fusion status, and disc height. These data were collected before surgery, at 1 week, 3 months, 6 months, and 12 months postoperatively.ResultsThere were no significantly different results in preoperative measurement between the two groups. There was significantly less blood loss (142.4 ± 89.4 vs 291.5 ± 72.3 mL, P < 0.01), shorter hospital stays (3.2 ± 1.8 vs 4.2 ± 2.5 days, P < 0.01), and longer operative time (164.9 ± 56.0 vs 121.5 ± 48.2 min, P < 0.01) in OLIF group compared with Mis‐TLIF group. The postoperative VAS scores and ODI scores in both groups were significantly improved compared with preoperative data (P < 0.05). VAS scores for back pain were significantly lower in OLIF group than Mis‐TLIF group at 1 week (2.8 ± 1.2 vs 3.5 ± 1.6, P < 0.05) and 3 months postoperatively (1.6 ± 1.0 vs 2.1 ± 1.1, P < 0.05), but there was no significant difference at further follow‐ups. ODI score was also significantly lower in OLIF group than Mis‐TLIF group at 3 months postoperatively (22.3 ± 10.0 vs 26.1 ± 12.8, P < 0.05). There was no significant difference in the proportion of clinically acceptable screws between the two groups (97.3% vs 96.2%, P = 0.90). At 1 year, the OLIF group had a higher interbody fusion rate compared with Mis‐TLIF group (96.0% vs 87%, P < 0.01). Disc height was significantly higher in the OLIF group than Mis‐TLIF group (12.4 ± 3.2 vs 11.2 ± 1.3 mm, P < 0.01). Satisfaction rates at 1 year exceeded 90% in both groups and there was no significant difference (92.6% for OLIF vs 91.2% for Mis‐TLIF, P = 0.263).ConclusionRobot‐assisted OLIF and Mis‐TLIF both have similar good clinical outcomes, but OLIF has the additional benefits of less blood loss, less postoperative hospital stays, higher disc height, and higher fusion rates. Robots are an effective tool for minimally invasive spine surgery.     

Comparison of the Clinical Outcomes of Full‐Endoscopic Visualized Foraminoplasty and Discectomy Versus Microdiscectomy for Lumbar Disc Herniation

ObjectiveThis retrospective case‐control study aimed to evaluate and compare the clinical outcomes of full‐endoscopic visualized foraminoplasty and discectomy (FEVFD) with microdiscectomy (MD) for lumbar disc herniation (LDH).MethodsData from 198 patients who presented with LDH between January 2016 and December 2017 treated by either FEVFD or MD were retrospectively analyzed. The inclusion criteria were single‐level LDH, unilateral radiating leg pain with or without positive Lasegue''s sign, and failure of standard conservative treatment for at least 12 weeks. The patients were categorized into an FEVFD group (n = 102) or an MD group (n = 96), according to the surgical procedure performed. Operative time, time in bed after surgery, postoperative hospitalization time, complications, and reoperations were recorded. Visual analog scales (VAS) for leg and back pain, Oswestry Disability index (ODI), 36‐Item Short‐Form Health Survey physical function (SF36‐PF), and bodily pain (SF36‐BP) scores were assessed and compared between the two groups.ResultsThe demographic data and baseline characteristics of the two groups were not significantly different. Operative time for the FEVFD group (73.82 ± 20.73 min) was longer than that for the MD group (64.74 ± 17.37 min) (P = 0.003), and fluoroscopy time for the FEVFD group (1.71 ± 0.58s) was longer than that for the MD group (1.30 ± 0.33s) (P < 0.001). However, time in bed experienced in the FEVFD group (8.51 ± 2.10 h) was less than that in the MD group (9.24 ± 2.01 h) (P = 0.014), and postoperative hospitalization time experienced in the FEVFD group (2.89 ± 0.83d) was also shorter than that in the MD group (4.94 ± 1.35d) (P < 0.001). All patients completed 24 months of follow‐up. Postoperative scores at each follow‐up for the VAS for leg and back pain, ODI, SF36‐PF, and SF36‐BP all improved significantly for both groups, as compared to the preoperative data (P < 0.05). The mean preoperative and postoperative scores for the VAS for leg and back pain, ODI, SF36‐PF, and SF36‐BP were not significantly different between the two groups. According to the modified MacNab criteria, the outcomes of the procedures were rated as excellent or good by 92.16% and 93.75% of the patients in the FEVFD and MD groups, respectively. One patient suffered a nerve root injury during the discectomy, one patient suffered from a dural tear, and two patients suffered from a residual herniation in the FEVFD group. One patient in the MD group suffered from poor wound healing. Moreover, recurrence happened in two cases in the FEVFD group, and in one case in the MD group.ConclusionFEVFD and MD are both reliable techniques for the treatment of symptomatic LDH. FEVFD resulted in a more rapid recovery and equivalent clinical outcomes after 24 months of follow‐up.     

Oxidative Stress Induced Osteocyte Apoptosis in Steroid‐Induced Femoral Head Necrosis

ObjectiveTo investigate the effect and mechanism of Glucocorticoids (GCs) induced oxidative stress and apoptosis on necrosis of the femoral head in patients and rats.MethodsEight patients with steroid‐induced avascular necrosis of the femoral head (SINFH) and eight patients with developmental dysplasia of the hips (DDH) were enrolled in our study. In animal model, twenty male Sprague‐Dawley rats were randomly divided into two groups (SINFH group and NS group). The SINFH model group received the methylprednisolone (MPS) injection, while control group was injected with normal saline (NS). MRI was used to confirm SINFH rat model was established successfully. Then, the rats were sacrificed 4 weeks later and femoral head samples were harvested. Histopathological staining was preformed to evaluate osteonecrosis. TUNEL staining was performed with 8‐OHdG and DAPI immunofluorescence staining to evaluate oxidative injury and osteocyte apoptosis. Immunohistochemistry staining was used to detect Nox1, Nox2, and Nox4 protein expression.ResultsMRI showed signs of typical osteonecrosis of femoral head in SIHFH patients. Histopathological staining showed that the rate of empty lacunae in SINFH patients was significantly higher (56.88% ± 9.72% vs 19.92% ± 4.18%, T = −11.04, P < 0.001) than that in DDH patients. The immunofluorescence staining indicated that the TUNEL‐positive cell and 8‐OHdG‐positve cell in SINFH patients were significantly higher (49.32% ± 12.95% vs 8.00% ± 2.11%, T = −7.04, P = 0.002, 54.6% ± 23.8% vs 9.75% ± 3.31%, T = −4.17, P = 0.003) compared to the DDH patients. The immunohistochemistry staining showed that the protein expression of NOX1, NOX2 and NOX4 in SINFH patients were significantly increased (64.50% ± 7.57% vs 37.58% ± 9.23%, T = −3.88, P = 0.018, 90.84% ± 2.93% vs 49.56% ± 16.47%, T = −5.46, P = 0.001, 85.46% ± 9.3% vs 40.69% ± 6.77%, T = −8.03, P = 0.001) compared to the DDH patients. In animal model, MRI showed signs of edema of femoral head in MPS group, which represents SINFH rat model was established successfully. Histological evaluation showed the rate of empty lacunae in MPS group was significantly higher (25.85% ± 4.68% vs 9.35% ± 1.99%, T = −7.96, P < 0.001) than that in NS group. The immunofluorescence staining indicated that the TUNEL‐positive cell and 8‐OHdG‐positve cell (in MPS group were significantly increased (31.93% ± 1.01% vs 11.73% ± 1.16%, T = −32.26, P < 0.001, 47.59% ± 1.39% vs 22.07% ± 2.45%, T = −22.18, P < 0.001) compared to the NS group. The immunohistochemistry staining showed that the expression of NOX2 in MPS group was significantly increased (76.77% ± 8.34% vs 50.32% ± 10.84%, T = −4.74, P = 0.001) compare with NS group.ConclusionOur findings indicated that GC‐induced NOXs expression may be an important source of oxidative stress, which could lead to osteocyte apoptosis in the process of SINFH     

Relationships between Paraspinal Muscle and Spinopelvic Sagittal Balance in Patients with Lumbar Spinal Stenosis

ObjectiveTo investigate the relationships between measurements of paraspinal muscle and spinopelvic sagittal parameters and the predictive value of lumbar indentation value (LIV) on sagittal balance in patients with lumbar spinal stenosis.MethodsIt was a retrospective study. We collected the data of 110 patients, who were diagnosed as lumbar spinal stenosis from December 2018 to May 2019. The total cross‐sectional area (tCSA), functional cross‐sectional area (fCSA), and fatty infiltration (FI) of paraspinal muscle were measured. The spinopelvic sagittal parameters were also measured, including sagittal vertical axis (SVA), pelvic incidence (PI), pelvic tilt (PT), sacral slope (SS), lumbar lordosis (LL), thoracic kyphosis (TK), and PI minus LL (PI‐LL). Correlations between measurements of paraspinal muscle and sagittal parameters were investigated by Pearson correlation analysis. The multiple linear regression analysis was used to investigate the LIV, age, gender, and BMI for assessing spinopelvic sagittal balance. Receiver‐operating characteristic (ROC) curve was used to find out the most optimum cut‐off point of LIV for evaluating SVA.ResultsThere were 42 males and 68 females in this study and the mean age was 59.9 ± 10.9 years old. By Pearson correlation analysis, MF tCSA showed significant association with LL (r = 0.455, P < 0.01) and PI‐LL (r = −0.286, P < 0.01). MF fCSA had a significant correlation with LL (r = 0.326, P < 0.01) and PI‐LL (r = −0.209, P < 0.05). LIV was also significantly correlated to spinopelvic sagittal parameters, including SVA (r = −0.226, P < 0.05), LL (r = 0.576, P < 0.01), TK (r = 0.305, P < 0.01), and PI‐LL (r = −0.379, P < 0.01). By multiple linear regression analysis, LIV was independently associated with sagittal parameters, including PI‐LL and SVA. The cut‐off value of LIV for SVA ≤ 50 mm was 10.5 mm (AUC = 0.641). According to the best cut‐off value, patients were divided into two groups. For patients with LIV ≤ 10.5 mm, the percentage of SVA ≤ 50 mm was 54.5% (18/33), while it was 83.1% (64/77) for patients with LIV >10.5 mm.ConclusionsAs a new index to evaluate paraspinal muscle atrophy, the LIV was independently correlated to spinopelvic sagittal balance. Degeneration of paraspinal muscle was associated with spinopelvic sagittal balance.     

Application of Triggered EMG in the Intraoperative Neurophysiological Monitoring of Posterior Percutaneous Endoscopic Cervical Discectomy

ObjectiveTo describe the rationale and application of triggered EMG (T‐EMG) in intraoperative neurophysiological monitoring, and to explore the efficacy and safety of posterior percutaneous endoscopic cervical discectomy (PPECD) in the treatment of cervical spondylotic radiculopathy (CSR) under multimodal intraoperative neurophysiological monitoring (IOM).MethodsThis study was a retrospective cohort control study. The clinical data of 74 patients with single‐segment CSR from June 2015 to August 2018 were analyzed retrospectively, of whom 35 underwent IOM‐assisted PPECD with triggered EMG (T‐EMG group), while 39 were subjected to IOM‐assisted PPECD alone (IOM group). Operation time, hospital stay, and complications were recorded for both groups. The curative effect was evaluated according to the Visual Analog Scale (VAS) of neck and arm pain, Japanese Orthopaedic Association (JOA) score, and modified MacNab scale.ResultsOperations were successful and all patients were followed up for at least 24 (average 31.77 ± 9.51) months with no patient lost to follow‐up. No significant difference was found in preoperative baseline data between the T‐EMG and the IOM group (P > 0.05). Also, no significant difference was found in the operation time between the T‐EMG (108.29 ± 11.44 min) and the IOM (110.13 ± 12.70 min) (P > 0.05) group, but the difference in hospital stay (T‐EMG: 5.66 ± 0.99 days; IOM: 7.10 ± 1.43 days) was statistically significant (P < 0.05). The VAS for the neck and upper limbs in the two groups at 1 month post‐operation (T‐EMG: 2.09 ± 1.07, 2.26 ± 0.92; IOM:2.18 ± 1.05, 2.31 ± 0.77) and the last follow‐up (T‐EMG: 0.83 ± 0.62, 0.86 ± 0.55; IOM: 0.90 ± 0.50, 0.87 ± 0.61) were significantly different from the preoperative scores (T‐EMG: 6.14 ± 1.09, 7.17 ± 1.04; IOM: 6.18 ± 1.28, 7.15 ± 1.23) (P < 0.05). However, no significant difference was found between the two groups (P > 0.05). The 1‐month postoperative JOA scores for the two groups (12.69 ± 0.76; 12.59 ± 0.82) and those at the last follow‐up (14.60 ± 0.77; 14.36 ± 0.78) were significantly different from the preoperative scores (11.09 ± 0.98; 11.05 ± 0.89) (P < 0.05), but the difference between the two groups was not significant (P > 0.05). One patient in the T‐EMG group developed a transient aggravation of symptoms on the first day after surgery. In the IOM group, three patients had intraoperative cerebrospinal fluid leakage, and symptoms of C5 nerve root paralysis were presented in four patients following surgery. Compared with the IOM group, the T‐EMG group had fewer complications (1/35; 7/39, P < 0.05). At the last follow‐up, the modified MacNab criteria were 91.43% (32/35) and 89.7% (35/39) for the T‐EMG group and IOM group, respectively.ConclusionsTriggered EMG prevents the occurrence of neurological complications, which not only aids PPECD for CSR treatment in achieving satisfactory results, but also reduces average hospital stay and complication rates.     

CircCDR1as Suppresses Bone Microvascular Endothelial Cell Activity and Angiogenesis Through Targeting miR‐135b/ FIH‐1 Axis

ObjectiveThe current study investigated the role of CircCDR1as on angiogenesis of bone microvascular endothelial cells (BMECs) isolated from non‐traumatic ONFH.MethodsForty corticosteroid‐induced ONFH patients received THA were enrolled in our study. Expressions of CircCDR1as, miR‐135b, and FIH‐1 were detected by qRT‐PCR in affected necrosis tissue and non‐affected normal tissue. Bone microvascular endothelial cells (BMEC) were isolated from six patients and treated with 0.1 mg/mL hydrocortisone to establish a GC‐damaged model of BMECs. Circ CDR1as plasmid and miR‐135b mimic were transfected into BMECs. BMEC proliferation was assessed using MTT assays. The migration ability of cells was detected by scratch‐wound assays. Matrigel assay was performed to detect angiogenesis in vitro. Western blot assay was used to detect HIF‐1α, VEGF, and FIH‐1 expressions. FISH, RNA pull down, RIP, and luciferase assay were carried out to determine the interaction of CircCDR1as, miR‐135b, and FIH‐1.ResultsCircCDR1as was upregulated(2.02 ± 0.30 vs. 1.00 ± 0.10,P < 0.001) whereas miR‐135b was downregulated (0.55 ± 0.12 vs. 1.00 ± 0.10,P < 0.001) in affected tissues than in non‐affected tissues. Expression of CircCDR1as and FIH‐1 were negatively associated with miR‐135b in affected tissues (CircCDR1as with miR‐135b: r = −0.506, P < 0.001; FIH‐1 with miR‐135b r = −0.510, P < 0.001). Total blood tubule density was increased when CircCDR1as was silenced compared with NC (P < 0.01 vs. NC). The number of migrated BMECs were significantly increased in CircCDR1as silencing group compared with NC group (P < 0.05 vs. NC). In addition, CircCDR1as plasmids transfection increased the protein expressions of FIH‐1 (P < 0.05 vs. NC) and reduced the HIF‐1α as well as VEGF expression compared with NC group (P < 0.05 vs. NC). FISH, RNA pull down, RIP, and luciferase assay identified that FIH‐1 was a target of miR‐135b and could be modulated by CircCDR1as.ConclusionCircCDR1as decreases angiogenesis and proliferation of BMECs by sponging miR‐135b and upregulate FIH‐1.     

Clinical Outcomes and Quality of Life in Elderly Patients Treated with a Newly Designed Double Tube Endoscopy for Degenerative Lumbar Spinal Stenosis

ObjectiveTo evaluate the clinical outcome and quality of life in elderly patients in poor conditions with unilateral symptomatic degenerative lumbar spinal stenosis (DLSS) who were treated with percutaneous endoscopic lumbar discectomy (PELD) assisted by double tubes.MethodsThis study was designed retrospectively. From June 2017 to June 2018, 31 consecutive elderly patients who were presented with unilateral symptomatic DLSS, underwent PELD assisted by double tubes under local anesthesia. American Society of Anesthesiology score (ASA) was used to evaluate the patients'' conditions. The operative time, intraoperative blood loss, hospital stay, and complications were evaluated. Clinical outcomes were assessed by the visual analog scale (VAS), Oswestry disability index (ODI), and modified Macnab criteria. Short Form 36 (SF‐36) was used to evaluate the life quality. The CT or MRI was used to evaluate the spinal area.ResultsThirty‐one patients were enrolled and 25 cases achieved at least a 24‐month follow‐up. Three patients were lost to follow‐up and three patients died from other diseases. A total of 76% (19/25) of the patients presented an ASA score of more than 3. The mean operative time was 67.80 min, the mean blood loss was 18.2 ml, and the hospital stay was 6.92 days. The postoperative 12‐month follow‐up VAS score significantly decreased compared with that before the operation (1.12 ± 0.73 vs. 5.12 ± 1.81, p < 0.01). Although the VAS score decreased at the final follow‐up, there was no significant difference compared with that at the 12‐month follow‐up (0.92 ± 0.64 vs. 1.12 ± 0.73, p = 0.549). So did the ODI. Also, there was no difference in the ODI scores between the 12‐month follow‐up and the final follow‐up (12.52 ± 5.58 vs. 9.44 ± 6.32, p = 0.172). The overall excellent rate was 92% (23/25) at the final follow‐up. The scores of the physical function, mental function, and social function of SF‐36 after the operation improved significantly compared with those before operation (p < 0.05). But there was no difference in the physical function score (84.00 ± 6.29 vs 84.40 ± 6.18, p = 0.871), mental function score (81.76 ± 8.01 vs 81.68 ± 6.67, p = 0.974), or social function score (115.50 ± 13.64 vs 118.50 ± 12.03, p = 0.437) between the 12‐month follow‐up and the final follow‐up. There were no differences in the VAS, ODI, and SF‐36 between the L_4/5 and L₅S₁ groups before operation or at the final follow‐up (p > 0.05). The postoperative radiology indicated the lateral recess is opened and the area of the dural sac is expanded. Two cases (8.0%, 2/25) experienced recurrence and a secondary PELD was performed.ConclusionsPELD assisted by double tubes is effective for unilateral symptomatic DLSS in elderly patients with comorbidities and could improve life quality.     

Cervical Transdural Discectomy with Laminoplasty for the Treatment of Multi‐segment Cervical Spinal Stenosis Accompanied with Cervical Disc Herniation: Technical Note and Clinical Outcome

ObjectiveTo describe the surgical technique of cervical transdural discectomy with laminoplasty (CTDL) for the treatment of multi‐segment cervical spinal stenosis (CSS) accompanied with cervical disc herniation (CDH) and investigate its surgical outcomes and complications.MethodsThis was a clinical study. Between 2012 and 2018, 31 patients (13 males and 18 females) with multi‐segment CSS (over two cervical segments) accompanied with huge CDH and underwent CTDL were enrolled in this study. The details of CTDL technique with general anesthesia was described by the authors. The average follow‐up period of patients was 65.03 months (range from 24 to 126 months). Perioperative parameters such as age, sex, operative level, operative time, estimated blood loss, ambulation time, and operative complications were recorded. The results of clinical metrics such as the visual analog scale (VAS) and Japanese Orthopaedic Association (JOA) scores in the preoperative and during the follow‐up period were obtained and used to evaluate clinical outcomes. Radiographic improvement was evaluated by the compression ratio, sagittal maximum spinal cord compression (SMSCC), and cervical range of motion (ROM). The preoperative and postoperative follow‐up parameters (VAS, JOA, Compression ratio, SMSCC, and ROM) were assessed with paired t test. A P‐value <0.05 was considered statistically significant.ResultsIn the study, the mean age of the 31 patients was 55.23 ± 10.97 years. The mean operative time was 192.45 ± 24.17 min (ranging from 150 to 245 min), and intraoperative blood loss was 322.58 ± 129.00 mL (ranging from 150 to 600 mL). The VAS neck pain was improved significantly over the follow‐up period (P < 0.05, respectively). The VAS arm pain improved significantly from 6.26 ± 0.93 preoperatively to 1.74 ± 0.63 at 24 months postoperatively (P < 0.001). There was no significant difference in improvement of VAS arm pain between 24 months postoperatively and final follow‐up (P = 0.180). Compared with preoperative JOA score, JOA score was significantly improved at 24 months postoperatively (14.79 ± 1.84 vs 9.66 ± 2.81, P < 0.001). Meanwhile, there were no statistically significant differences between the final follow‐up and the postoperative JOA scores (15.08 ± 1.71 vs 14.79 ± 1.84, P = 0.051). Postoperative patients showed significantly higher index of compression ratio (58.30 ± 8.51 vs 27.17 ± 3.89, P < 0.001) and lower SMSCC (25.12 ± 5.67 vs 33.66 ± 5.38, P < 0.001). In addition, there was no significant difference between preoperative and postoperative cervical ROM (P = 0.740). One patient observed postoperative symptom of C₆ nerve root injury, which was resolved within 24 months after the surgery; meanwhile, the neurological monitoring also reflected the intraoperative stretching of the C₆ nerve root. Two cases involved postoperative cerebrospinal fluid (CSF) leakage which may have been related to laceration of dura mater.ConclusionsThis study suggested that CTDL technique could acquire satisfactory surgical outcomes for patients with multi‐segment CSS accompanied with CDH, but the surgical indications of the patients need to be selected strictly.     

Vertebral Collapse Prevented Following Teriparatide Treatment in Postmenopausal Kümmell's Disease Patients with Severe Osteoporosis

ObjectiveTo compare the preventive effects of teriparatide and alendronate on the progression of vertebral body collapse in postmenopausal single‐level Kümmell''s disease (KD).MethodsFrom March 2013 to December 2020, the medical records for 53 postmenopausal single‐level KD patients who received conservative treatment with teriparatide (25 patients, teriparatide group) or alendronate (28 patients, alendronate group) were retrospectively reviewed. Midsagittal computed tomography (CT) images were analyzed by ImageJ to assess the intravertebral bone formation (mineralized bone) by calculating the ratio of area of intravertebral mineralized bone (AIMB) to the area of fractured vertebral body (AFVB). The changes in radiological parameters of the fractured vertebral body including kyphosis angle (KA), anterior and posterior border heights (ABH and PBH) and spinal canal diameter (SCD), bone turnover biomarkers (BTMs), and bone mineral density (BMD) were analyzed to evaluate the therapeutic effect.ResultsAt month 12, the ratio of AIMB to AFVB was significantly greater in teriparatide group (54.28% ± 15.30%) than in alendronate group (35.57% ± 17.61%) (P < 0.001). Sagittal CT substantiated the formation of bone bridge in 16 patients in teriparatide group. No bone bridge was detected in alendronate group. The KA was significantly smaller and the ABH, PBH, and SCD was greater in teriparatide group than in alendronate group (all P < 0.001). The KA increments were significantly smaller in teriparatide group (3.98° ± 1.30°) than in alendronate group (11.43° ± 3.73°) (P < 0.001). The ABH and PBH decrement were significantly lower in teriparatide group (11.96% ± 1.93% and 2.80% ± 2.52%) than in alendronate group (37.04% ± 8.00% and 19.50% ± 8.22%) (both P < 0.001). The BTMs and BMD were significantly greater in the teriparatide group than in the alendronate group. In teriparatide group, KA increment was negatively correlated with the change in PINP (r = −0.781, P < 0.001) and the ratio of AIMB to AFVB (r = −0.592, P = 0.002) from baseline to month 12. The ABH decrement was negatively correlated with the change in PINP (r = −0.612, P = 0.001) and the ratio of AIMB to AFVB (r = −0.806, P < 0.001) from baseline to month 12.ConclusionsIn postmenopausal single‐level KD patients, conservative treatment with teriparatide was better than alendronate at preventing the progressive vertebral collapse.     

Non‐Anatomical Arthroscopic All‐Inside Repair of Medial Meniscus Posterior Root Tear to Posterior Cruciate Ligament for Patients with Normal Lower Limb Alignment

ObjectiveTo describe a non‐anatomical arthroscopic all‐inside repair of medial meniscus posterior root tear (MMPRT) to posterior cruciate ligament (PCL) technique for patients with normal lower limb alignment and to evaluate the short‐term clinical and radiologic outcomes.MethodsMMPRT directly to PCL was repaired with all‐inside horizontal mattress suturing technique rather than by the transtibial pullout suture technique or anchor suturing repair technique in 20 Laparade Type II MMPRT patients with normal lower limb alignment during 2018–2019. The clinical and radiological outcomes were evaluated retrospectively for at least 2 years follow‐up. The VAS score, Lysholm score, Tegner activity score were evaluated preoperatively and at the final follow‐up. The status of the medial meniscus posterior root were assessed on magnetic resonance imaging (MRI) preoperatively and at the final follow‐up.ResultsTwenty patients (mean age 54.5 ± 19.5 years) were included in the present study. The mean follow‐up duration was 32.5 ± 5.8 months. The VAS score was significantly decreased from preoperative 6.5 ± 1.5 to 2.1 ± 1.4 at the final follow‐up (P < 0.01). The mean Lysholm score was significantly improved from 43.7 ± 10.9 preoperatively to 85.7 ± 10.8 (P < 0.01). The median Tegner activity score was improved from 1.0 (range 1–4) to 3.0 (range 2–4, P < 0.01). On MRI, a total of 12 cases (60%) had complete healing, while eight cases (40%) had partial healing.ConclusionNon‐anatomical arthroscopic all‐inside repair of MMPRT to PCL may yield beneficial clinical outcomes and a higher rate of clinical healing in Type II MMPRT patients with normal lower limb alignment. It is an easy and reliable alternative technique to the transtibial pullout suture or anchor suture repair technique.     

Failure of Posterior Lower Lumbar/Lumbosacral Hemi‐Vertebra Resection: An Analysis of Reasons and Revision Strategies

ObjectiveTo investigate the causes of failed primary surgery and the revision strategies for congenital scoliosis (CS) patients with lower lumbar/lumbosacral (LL/LS) hemi‐vertebra (HV).MethodsFifteen CS patients with LL/LS HV (seven females and eight males) with a mean age of 20.4 ± 10.4 years undergoing revision surgery in our center were retrospectively reviewed. The radiographic parameters including Cobb angle, distance between C₇ plumb line and center sacral vertical line (C₇PL‐CSVL), thoracic kyphosis (TK), lumbar lordosis (LL) and sagittal vertical axis (SVA) were assessed at pre‐revision, post‐revision and the last follow‐up. The causes of failure in primary operation, and radiographic and clinical outcomes of revision procedures were analyzed.ResultsThe revision rate of patients undergoing LL/LS HV resection and correction surgery was 11.4%. The average time interval between primary surgery and revision surgery was 18.2 ± 10.6 months. The operation duration and estimated blood loss of revision surgery were 194 ± 56 min and 326 ± 74 ml, respectively. Reasons for failed primary operations were as follows: internal fixation fracture in 10 cases, curve progression in two cases, implant loose in two cases and post‐operative coronal imbalance in one case. The post‐revision Cobb angle was significantly improved from 29.9° ± 8.3° to 18.7° ± 6.7° (P < 0.001) with a correction rate of 37.5% ± 12.6%. At the final follow‐up, the average Cobb angle was 18.9° ± 6.2° and the correction was well maintained (P = 0.788). The C₇PL‐CSVL at pre‐revision, post‐revision and at last follow‐up were 23.2 ± 9.3 mm, 14.8 ± 4.8 mm and 14.9 ± 5.4 mm, respectively. Significant improvements (P = 0.004) were observed after revision surgery and there was no evident loss of correction (P = 0.703). There was no significant difference in TK, LL and SVA before and after revision surgery (all P > 0.05). At the last follow‐up, no significant correction loss of above coronal and sagittal parameters were observed (all P > 0.05). The revision methods were individualized according to the primary surgical procedures and the reasons for revision. The recommended revision strategies include incision of pseudarthrosis with sufficient bone graft, fixation of satellite rods, thorough residual HV excision, prolonged fusion to S₂ and transforaminal lumbar interbody fusion at lumbosacral region. Solid bony fusion and no implant‐related complication were detected during the follow‐up.ConclusionsThe causes of revision surgery for patients with congenital scoliosis (CS) due to lumbosacral HV were verified and implant failure with pseudarthrosis was the main reason for failed primary operation.     

Clinical Comparison of Selective versus Nonselective Decompression for Symptomatic Tandem Stenosis of the Cervical and Thoracic Spine: A Retrospective Cohort Study

ObjectiveThe aim of the present paper was to reveal the clinical differences between selective and nonselective decompression for symptomatic tandem stenosis of the cervical and thoracic spine (TSCTS).MethodsA total of 34 patients were eligible and included in the study. Among them, 8 patients underwent selective cervical decompression (CD), 15 patients underwent selective thoracic decompression (TD), and 11 patients underwent combined CD and TD (CTD) surgery. Age, sex, operative time, intraoperative blood loss, postoperative hospital stay, inpatient expenditure, preoperative upper Japanese Orthopaedic Association (JOA) rate, canal occupation rate, high‐intensity T2‐weighted image (T2WI) of the spinal cord, and preoperative and postoperative JOA scores were compared among the three groups.ResultsThe CD group had shorter operative time (138.8 ± 36.1 vs 229.7 ± 95.8 vs 328.6 ± 94.8, min, P < 0.001), less intraoperative blood loss (141.3 ± 116.7 vs 496.7 ± 361.8 vs 654.6 ± 320.5, mL, P = 0.004), and shorter postoperative hospital stay (4.6 ± 1.6 vs 9.0 ± 3.5 vs 10.3 ± 6.6, days, P = 0.008), as well as lower preoperative upper JOA rate (34.1 ± 5.6 vs 53.9 ± 8.4 vs 48.2 ± 15.2, %, P = 0.001) than the TD and CTD groups. The CTD group had higher inpatient expenditure than the CD and TD groups (87,850 ± 18,379 vs 55,100 ± 12,890 vs 55,772 ± 15,715, CNY, P < 0.001). The cervical canal occupation rates were similar among different groups (P > 0.05); however, the TD group showed a higher thoracic canal occupation rate than the CD group (58.3 ± 14.7 vs 43.3 ± 12.3, %, P = 0.035). All positive levels in high‐intensity T2WI of the spinal cord were decompressed. The preoperative JOA scores as well as the postoperative JOA scores at 6 months and at last follow‐up were comparable among the three groups (P > 0.05). Similarly, the JOA recovery rate showed no significant difference among the groups (P > 0.05).ConclusionSelective CD or TD alone demonstrated similar clinical effectiveness to nonselective and combined CTD for TSCTS. Individualized surgical decision should be made after meticulous assessments of clinical and radiological manifestations, general patient condition, and socioeconomic factors.     

Percutaneous Endoscopic Interlaminar Discectomy via Laminoplasty Technique for L5–S1 Lumbar Disc Herniation with a Narrow Interlaminar Window

ObjectiveTo improve the treatment effect of patients with L₅S₁ lumber disc herniation (LDH) with a narrow interlaminar window, we proposed an alternative approach to percutaneous endoscopic interlaminar discectomy (PEID) via the laminoplasty technique.MethodsFifteen L₅S₁ LDH patients (7 men and 8 women; age range, 22 to 56 years; median age, 34 years; 9 left, 6 right) were enrolled in the present study retrospectively. The interlaminar windows of all patients were narrow (the transverse diameter of the L₅S₁ interlaminar window is equal to or less than that of L_4–5). Percutaneous laminoplasty and endoscopic interlaminar discectomy surgery were undergone by all patients from July 2018 to July 2019. All operations were completed under local anesthesia. The target laminoplasty area was the safety zone, use of which avoids both transverse and exit nerve roots. Under fluoroscopic guidance or clear endoscopic visualization, the trephines were used to enlarge the interlaminar window, which allowed the working cannula to enter the spinal canal but avoid nerve roots and the dural sac. The preoperative/postoperative visual analogue scale (VAS) scores and Oswestry disability index (ODI) were statistically analyzed. The modified MacNab criterion was used to assess the clinical effects. The radiological outcomes were evaluated by MRI and CT. SPSS 19.0 software was used for the statistical evaluation.ResultsThe operative time ranged from 70 to 120 min, with a median time of 92 min, and the fluoroscopy times ranged from 8 to 12, with a median of 9.7 times. The body mass index (BMI) of patients ranged from 18.10 to 26.06, with a median of 22.04. All patients were followed up in the outpatient department for at least 12 months after surgery. At the last follow up, the average VAS‐Back score of the study patients was reduced from 5.33 ± 2.09 to 2.00 ± 1.20 (P < 0.001) and the average VAS‐Leg score was reduced from 7.53 ± 1.69 to 1.47 ± 0.92 (P < 0.001). The average ODI scores improved from 47.87 ± 11.41 to 12.93 ± 3.24 (P < 0.01). According to the modified MacNab criteria, 11 cases achieved excellent results and 4 cases achieved good results. All of the operations were successful. There wertr no nerve root injuries, dural tears, or other complications.ConclusionThe laminoplasty approach for PEID provides a safe and useful alternative for the treatment of L5–S1 LDH patients with a narrow interlaminar window.