Surgical Results of Lumbar Interbody Fusion Using Calcium Phosphate Cement

Clinical and radiological outcomes of lumbar interbody fusion using artificial fusion cages filled with calcium phosphate cements (CPCs) were retrospectively reviewed. Between 2002 and 2011, 25 patients underwent lumbar interbody fusion at Tokushima University Hospital, and 22 patients were enrolled in this study. Of these, 5 patients received autologous local bone grafts and 17 received CPC. Japan Orthopedic Association (JOA) score was used for clinical outcome assessments. Lumbar radiography and computed tomography (CT) were performed at 12, 24 months and last follow-up period to assess bony fusion. The mean JOA score of all patients improved from 9.3 before surgery to 21.0 at 24 months after surgery. Fusion had occurred in 5 of 5 patients in the local bone graft group and in 16 of 17 patients in CPC group at 24 months postoperatively. No surgically related complication was occurred in both groups. CPC is a useful and safe graft material for lumbar interbody fusion.     

Surgical and Clinical Results of Minimally Invasive Spinal Fusion Surgery in an Unselected Patient Cohort of a Spinal Care Unit

Objectives

To review the surgical results and to identify possible parameters influencing the clinical outcomes in an unselected patient collective undergoing minimally invasive lumbar interbody fusion in a spinal care unit.

Methods

A total of 229 adult patients who underwent minimally invasive lumbar spinal fusion between 2008 and 2016 were included in this retrospective analysis. Lumbar fusion was performed using transforaminal interbody fusion (TLIF) devices and posterolateral fusion. To eliminate confounding parameters, in all patients interbody fusion was indicated by lumbar degenerative pathologies, and surgery was performed using the same fusion device. Treatment efficacy was evaluated using scores describing pain (visual analogue scale [VAS]) and health impairment (EQ‐5D, Oswestry Disability Index [ODI]). The influence of patient age, obesity, active smoking status, and co‐morbidities on clinical outcome and perioperative complications was analyzed.

Results

The patient population reviewed had improved VAS (P _{(leg pain)} ≤ 0.0001, P _{(back pain)} ≤ 0.0001), ODI (P ≤ 0.0001), EQ‐VAS (P ≤ 0.0001), and EQ‐5D subscales “mobility”, “self‐care”, “pain”, and “anxiety” (P _(mobility) ≤ 0.0001, P _{(self‐care)} = 0.41, P _(pain) ≤ 0.0001, P _(anxiety) = 0.011) postoperatively. Neither advanced patient age, nor increased body mass index (BMI), hypertension, or active smoking status had a significantly limiting influence on the success of minimally invasive spinal surgeries (MIS). Duration of surgery strongly correlated with the number of spinal levels treated and with intraoperative blood loss (r = 0.774, P ≤ 0.0001, n = 208). Weak positive correlations were found between patient age and duration of surgery (r = 0.184, P = 0.005, n = 229), intraoperative blood loss (r = 0.165, P = 0.012, n = 229), and duration of hospitalization (r = 0.270, P ≤ 0.0001, n = 228), respectively. When compared to non‐smokers, smokers were younger (P ≤ 0.0001), and had a significantly lower BMI (P = 0.001), shorter durations of surgery (P ≤ 0.0001), decreased intraoperative blood loss (P = 0.022), and shorter hospital stays (P = 0.006), respectively. Complications occurred in 17 patients (7%) and were not affected by patient age, BMI, hypertension, or active smoking status.

Conclusion

Minimally invasive spinal surgery is a safe and effective treatment option and may be superior to open surgery in subpopulations with significant co‐morbidities and risk factors, such as elderly and obese patients as well as patients with an active smoking status.

     

高龄股骨粗隆间骨折髋关节置换手术策略的探讨

目的探讨高龄股骨粗隆间骨折患者行髋关节置换术的手术技巧及临床疗效。方法 2005年7月至2008年12月,选择性应用半髋关节置换治疗高龄股骨粗隆间骨折患者26例,其中男7例,女19例;年龄80-98岁,平均83岁。26例均为轻微外伤造成闭合性骨折。按Evans分型,b型8例,c型13例,d型5例。右侧9例,左侧17例。26例患者中25例合并有不同程度的高血压、糖尿病、冠心病、心功能不全等内科疾病情况,有3例一侧髋部骨折行钢板或关节置换术后又发生另一侧粗隆间骨折。26例患者均行骨水泥型双动股骨头置换。结果所有患者平均随访18个月（6-36个月）,平均手术时间87 min（60-120 min）,术中出血量350 mL（100-700 mL）,术后平均下地活动时间8.5 d（4-10 d）。术后发生严重并发症患者3例,均进行积极的专科及综合治疗,1例术后因心肌梗塞抢救无效3 d内死亡;1例术后发生弥漫性血管内凝血,经输新鲜血浆、红细胞等其他治疗,恢复良好;1例术后发生大面积脑梗塞,转神经内科治疗,7个月时随访患侧上、下肢肌力级。5例术后发生一过性精神障碍,对症治疗后均1周左右症状恢复正常。1年后随访时1例因肺部感染死亡,1例因心力衰竭死亡。所有切口均一期愈合,无切口感染,无髋关节脱位。术后3个月时参照Charnley髋关节评分,优10例,良11例,可3例,差1例,优良率84%。结论高龄股骨粗隆间骨折患者选择性行人工关节置换是内固定方法的有益补充,手术注意正确放置假体,避免肢体不等长,小心扩髓,避免术中骨折,简单固定大、小粗隆骨折,尽量缩短手术时间,减少手术创伤。     

Non Union of an Epiphyseal Fibular Fracture in a Pediatric Patient

There are few reports on delayed or nonunion in the pediatric ankle fracture. The authors present a case of a nonunion of a mid-epiphyseal fracture of the distal fibula, described as a type 7 pediatric fracture. Both the occurrence of this injury pattern and a nonunion has not been reported in the same patient. Operative reduction of the nonunion resulted in a satisfactory outcome.     

Unstable Ankle Fracture Fixation Using Locked Fibular Intramedullary Nail in High-Risk Patients

Open reduction internal fixation is the gold standard for unstable ankle fracture fixation; however, complications in patients with multiple medical comorbidities are common. Intramedullary nail fixation of the fibula can help to mitigate these difficulties. A retrospective chart review was performed on all patients who underwent fixation for unstable ankle fracture between January 2015 and March 2016 at our level I trauma center. Comorbidities in the patient sample included were one or several of diabetes, renal disease, hypertension, advanced age with osteoporosis, hemorrhagic blisters, and alcoholism. The primary outcomes studied were wound complications, infections, and hardware failure or failure of fixation. Eighteen patients with a mean age of 61 years underwent fibular intramedullary nail fixation, all of whom were considered at high risk for postoperative complications. Patients presented with Weber B or C fracture patterns. All patients had syndesmotic fixation through the nail by one or two 3.5-mm tricortical screws. A medial malleolus was added if needed for stability. The average follow-up time was 291.1 (range 9 to 14 months) days. The prescribed range of time to weightbearing was 2 to 6 weeks. All patients maintained reduction of the fracture and had no wound complications. No syndesmotic screws broke postoperatively, although most patients to failed comply with the postoperative non-weightbearing restrictions. Intramedullary nailing of the fibula with syndesmotic intranail fixation is minimally invasive, quick, and provides adequate fixation strength. It offers a viable treatment option for patients at high risk for complications or who are suspected to have difficulty with follow-up or compliance.     

骨水泥强化椎弓根螺钉治疗胸腰椎骨折

目的 探讨磷酸钙骨水泥强化椎弓根螺钉治疗胸腰椎骨折的临床疗效。方法 本组磷酸钙骨水泥强化椎弓根螺钉治疗胸腰椎骨折46例，平均65．6岁，按Saville分度法椎体骨量减少Ⅰ度7例，Ⅱ度9例，Ⅲ度21例，Ⅳ度9例。结果 41例获得随访，随访时间为9个月～3年，平均1．5年。41例获得骨性愈合，愈合时间4～5个月，38例椎体高度恢复。41例椎弓螺钉无松动，断裂或脱落。结论 磷酸钙骨水泥强化椎弓根钉治疗骨质疏松性胸腰椎骨折是一种比较理想的治疗方法。     

Impact of an Abdominal Binder on Speech Outcomes in People With Tetraplegic Spinal Cord Injury: Perceptual and Acoustic Measures

Background:

An abdominal binder (AB) is routinely used for patients who have suffered a spinal cord injury (SCI) resulting in tetraplegia. It is thought to restore abdominal pressure and consequently improve breathing capacity and reduce postural hypotension in patients who do not have functioning abdominal muscles.

Objective:

To examine the early effects of an AB on respiratory and speech outcomes.

Methods:

Thirteen individuals who sustained an acute motor complete SCI between C3 and T1 were assessed after a 6-week trial of using an elasticized AB from the time of first mobilizing in an upright wheelchair. Assessments were made using spirometry and perceptual and acoustics speech measures based on sustained phonation, sentence recitation, and passage reading.

Results:

Significant improvements were found in the AB-on condition for 3 of 5 respiratory parameters (vital capacity, forced vital capacity, and forced expiratory volume in 1 second). Predominantly mild voice and speech dysfunction were noted in participants. No significant difference was found for any of the acoustic and perceptual speech parameters (maximum phonation time, vocal intensity for sentence recitation, perceptual speech characteristics, or vocal quality) between the AB conditions.

Conclusions:

Despite the finding that an AB results in significant improvements in respiratory function for individuals with tetraplegic SCI, the current study did not provide evidence that an AB improves speech production.Key words: abdominal binding, lung function, speech, spinal cord injury, voiceRespiratory dysfunction as a result of weakened or paralyzed respiratory muscles is a well-documented consequence of spinal cord injury (SCI) and a major cause of morbidity and mortality.¹ Neuromuscular impairment of the respiratory muscles in SCI impacts inspiration and expiration,² with lesion level and completeness related directly to the amount of dysfunction. Higher lesions lead to greater respiratory compromise. Unlike lesions above C4, those at C4 level and below allow for at least partial diaphragmatic function, but respiratory function can still be considerably impaired. Respiratory dysfunction arises due to impairment of the intercostal muscles (innervated by thoracic nerves arising from T1-12), abdominal muscles (innervated from nerves arising from T6-12), and to a lesser extent accessory muscles (innervated by spinal nerves arising from C1-7).³ The majority of individuals with SCI below C4 are able to breathe independently, but paralysis of the intercostal muscles together with abdominal muscle weakness can result in reduced and/or paradoxical chest wall motion, reduced inspiratory function, and decreased active expiratory forces.^4,5Respiratory dysfunction in SCI leads to reduced pulmonary capacity, hypersecretions, ineffective cough, and accumulation of airway secretions ⁶ due to an individual’s inability to inhale deeply and expire forcefully.⁵ Reductions in pulmonary function have been documented to include decreased total lung capacity (60%-80% of predicted value),⁷ reduced vital capacity (50%-80% of predicted value),^{8, 9} reduced inspiratory and expiratory pressure and capacity,^{10, 11} and increased residual volumes.⁷ Reduced respiratory function also has the potential to affect speech, as the respiratory system is the driving force that generates air flow for speech production.¹² Reported perceptual speech deficits have been grouped into 3 clusters: impaired breath support, deviations in vocal quality, and atypical prosodic characteristics.^13–16 Characteristics such as short phrases, slow and shallow inspirations, reduced vocal loudness, vocal quality disturbances (eg, harshness, breathiness, strain), and impaired prosody of speech (eg, reduced pitch and loudness variation, altered rate and rhythm of speech)^{4, 13, 16} have been observed in individuals with SCI.A recent interview study of 33 participants that sought to understand how reduced lung function affects individuals with high SCI (C4 to C8 level injuries) reported 3 areas of limitations, 1 of which was voice function.¹⁷ Vocal function limitations identified were related to poor vocal endurance and vocal strength; this was most notable in social situations. The group appeared to see these limitations as part of normal life post SCI; self-management included compensatory strategies, education of communication partners, and use of specific breathing and speech techniques. Despite individuals with SCI and professionals identifying changes in speech production following high SCI, there has been limited research into effective and efficacious treatments.Treatment options to address the effects of respiratory insufficiency post SCI on speech may utilize either a behavioral or prosthetic approach.^{4, 18, 19} Behavioral approaches include resistance training of respiratory muscles,²⁰ endurance training of inspiratory muscles,²¹ or glossopharyngeal breathing (GPB).^{14, 22, 23} Of these behavioral approaches, GPB is the only one that has demonstrated a positive effect on speech production by increasing vital capacity, which in turn results in increased vocal loudness, utterance length, and phonatory stability. Speech comprehensibility and naturalness, however, have been acknowledged as being potentially compromised in GPB. This may limit GPB’s acceptability and suitability to all individuals with SCI who experience impaired speech function. An additional limitation to its clinical applicability may be that it is a difficult breathing technique to master and requires considerable practice and motivation.²⁴Prosthetic procedures offer another treatment option by enhancing postural support during respiration; these can be used in isolation or conjunction with behavioral techniques. The benefits of prosthetic approaches, such as binding of the paralyzed abdomen to improve respiratory function for speech, have been documented in case study reports of individuals with chronic SCI.^{12, 25} Abdominal trussing has been reported to improve both inspiratory capacity and vital capacity leading to greater ease in speaking, longer utterances, and listener preference for speech produced with the support of trussing.¹² Substantial evidence also supports an abdominal binder (AB) as a means of optimizing respiratory function along with managing early orthostatic hypotension,²⁶ increasing vital capacity,^{27, 28} improving total lung capacity and inspiratory capacity,^{26, 29} and increasing expiratory volumes and flow.^{28, 29} Self-report by individuals with SCI wearing an AB has revealed a perceived benefit in terms of breathing, cough, and general respiratory effort.^{29, 30} It could therefore be suggested that an AB has the potential to improve speech production in people with high SCI because it improves respiratory function. Previous case study reports of 2 individuals with chronic high SCI using phrenic nerve pacers have provided preliminary support for the beneficial effects of an AB on speech production in addition to increased tidal volumes.²⁵ Specifically, listener preference for speech samples produced while the speaker was wearing the AB was noted, as was increased vocal loudness in one participant. In a recent study of 14 individuals with high SCI less than 12 months post injury, vocal intensity (as measured acoustically) was not improved by the wearing of the AB, but improvements in maximum phonation time were observed.²⁸ These studies highlight the potential for an AB to improve respiratory function for speech and therefore speech production, but further investigation is needed before recommendations can be made about the use of an AB as a speech rehabilitation option for people with high SCI.Although the behavioral and prosthetic approaches have been shown to have potential as management techniques that could address speech production deficits caused by respiratory dysfunction, comprehensive studies with greater methodological rigor are needed to establish the physiologic, acoustic, and perceptual speech changes associated with these management approaches. The present study aims to determine the effect of an AB on the acoustic and perceptual characteristics of speech production in individuals with high SCI. It is hypothesized that high SCI patients will experience enhanced pulmonary function when wearing an AB that would result in improved speech production as compared to when not wearing an AB.     

同种异体骨圈椎体融合术稳定颈椎的生物力学评价

目的　评价同种异体皮质骨圈（ＡＦＣ）重建颈椎稳定性的即刻效果及自身强度。方法在８ 具新鲜成人颈椎标本上,模拟临床术式,对Ｃ４,５ 、Ｃ５,６ 行椎间盘切除术,分别将髂骨、ＡＦＣ 置于椎间隙,对节段进行压缩、植入物拔出测试（Ｃ４,５） 和脊柱三维运动稳定性评价（Ｃ５,６）。结果　（１）ＡＦＣ组的运动范围与正常组和髂骨组相比,除后伸运动范围略有增大外,其余方向的运动范围均减小。（２） 在压缩载荷为（５０２ ±１１４）Ｎ 时,ＡＦＣ组的椎骨有挤压破坏,而ＡＦＣ结构正常;在３００ Ｎ 的拔力作用下,骨圈与椎体间无松动。而在髂骨组中,当压力为（１３５ ±４２）Ｎ 时,植骨块被破坏;在６０ Ｎ 的拔力作用下,植骨块与椎体间产生松动移位。结论　ＡＦＣ 具有足够的支撑、抗滑、维持或增加椎间隙高度的功能,符合生物力学及临床要求。     

Atlantoaxial Joint Interlocking Following Type II Odontoid Fracture Associated with Posterolateral Atlantoaxial Dislocation: a Case Report and Review of Published Reports

A rare case of atlantoaxial lateral mass joint interlocking secondary to traumatic posterolateral C_1,2 complete dislocation associated with type II odontoid fracture is herein reported and the impact of atlantoaxial joint interlocking on fracture reduction discussed. A 72‐year‐old man presented with traumatic atlantoaxial lateral mass joint interlocking without spinal cord signal change, the diagnosis being confirmed by radiography and 3‐D reconstruction digital anatomy. Posterior internal fixation was performed after failure to achieve closed reduction by skull traction. After many surgical attempts at setting had failed because of interlocking of the lateral mass joints, reduction was achieved by compressing the posterior parts of the atlantal and axial screws. Odontoid bone union and C_1,2 posterior bone graft fusion were eventually obtained by the 12‐month follow‐up. The patient had a complete neurological recovery with no residual neck pain or radiculopathy.     

多节段腰椎融合术的应用价值

目的：比较３节段以下和３节段以上腰椎融合术病人的融合率及临床疗效,以确定多节段腰椎融合术的临床应用价值。方法：回顾两组因退行性腰椎病变而接受融合醉的病人（第１组为３节段以下;第２组为３节段及３节段以上）,通过动力Ｘ线侧位片、病历复习、病人回访及信访评价融合率和临床疗效。结果：第１线及第２组的融合率分别是９６％和７８％,临床疗效优良率分别是８９％和６３％。而第２组病人中５０岁以下年龄组融合率是８７％,临床疗效优良率是８７％。结论：３节段及３节段以上腰椎融合术融合率低且临床疗效不佳。术前全面仔细的临床及影像学检查,融合节段的正确和慎重选择是取得满意疗效的关键。多节段融合术尤其在高龄病人应持慎重态度。