【Abstract】Objective To discuss the clinical significance of postoperative application of gastrointestinal decompression after anastomosis of lower digestive tract. Methods Three hundred and sixty-eight patients undergoing excision and anastomosis of lower digestive tract were divided into two groups: the group with postoperative gastrointestinal decompression and the group without it. The clinical therapeutic outcomes and incidences of complications were compared between the two groups. Results The volume of gastric juice in the decompression group was about 200 ml every day after operation. Both groups had a smaller abdomenal circumference before operation than after operation （P＜0.001）. No difference in the time of first passage of gas from anus and defecation after operation was found between the two groups. The incidence of complications in the decompression group was obviously higher than that of non-decompression group (28.0% vs. 8.2%, P＜0.001); the incidence of pharyngolaryngitis of the former was up to 23.1%. There was also no difference found between these two groups regarding the hospital stay after operation.Conclusion The present study shows that application of gastrointestinal decompression after excision and anastomosis of lower digestive tract cannot effectively reduce the gastrointestinal tract pressure and has no obvious effect on prevention from postoperative complications. On the contrary, it may increase the incidence of pharyngolaryngitis and other complications. Therefore, it is more beneficial for the recovery of patients without gastrointestinal decompression.
Objective To determine the surgical indications for posterior expansive open-door laminoplasty (EOLP) extended to the C1 level. Methods Seventeen patients undergoing C3-7 or C2-7 open-door laminoplasty were included as the case group between September 2005 and January 2010, whose spinal cord injury symptoms were not alleviated or aggravated again because of the cervical stenosis at C1-4 level, and the causes of the surgery itself were eliminated, all of these patients underwent reoperation with decompress upward to C1 level. Fifteen patients with cervical stenosis who underwent C2-7 laminoplasty and C1 laminectomy were selected as the control group. There was no significant difference in gender, age, and disease duration between 2 groups (P gt; 0.05). The pre- and post-operative cervical curvature and spinal cord compression were evaluated according to the patients’ imaging data; the pre- and post-operative neurological recovery situation was evaluated by Japanese Orthopaedic Association (JOA) 17 score and spinal cord function Frankel grade; the neurological recovery rate (according to Hirabayashi et al. method) was used to assess the postoperative neurological recovery situation. Results In the case group, 8 patients underwent primary C3-7 laminoplasty. In 3 of these patients, there was a cervical stenosis at C1, 2 level, and discontinuous cerebrospinal fluid around the spinal cord was observed; 5 of them with a compression mass which diameter was exceed 7.0 mm in the C2-4 segments. The remaining 9 patients in the case group underwent primary C2-7 laminoplasty, and the diameter of the compression mass was exceed 7.0 mm in the C2-4 segments. In all 17 patients of the case group, reoperation was performed with the decompression range extended to the C1 level, and the follow-up time was 35-61 months with an average of 45.6 months. Cervical curvature: there were 11 cases of cervical lordosis, 4 cases of straight spine, and 2 cases of cervical kyphosis before operation; but after operation, 2 cases of cervical lordosis became straight spine and 1 straight case became kyphosis. The postoperative neurological improvement was excellent in 8 cases, good in 7, and fair in 2. In the control group, all the patients had a compression mass which anteroposterior diameter was exceed 7.0 mm in the C2-4 segments before operation. The follow-up time was 30-58 months with an average of 38.7 months. Cervical curvature: there were 13 cases of cervical lordosis and 2 cases of straight spine before operation; but after operation, 1 case of cervical lordosis became straight spine. The postoperative neurological improvement was excellent in 8 cases, good in 6, and fair in 1. No significant difference was found in the JOA score at pre- and post-operation between 2 groups (P gt; 0.05); however, there were significant differences (P lt; 0.05) in the JOA score between at last follow-up and at preoperation. Conclusion The initially surgical indications which can be used as a reference for EOLP extended to C1 are as follows:① Upper cervical (C1, 2) spinal stenosis: C1 posterior arch above the lower edge part of cerebrospinal fluid around the spinal cord signal is not continuous, and the anteroposterior diameter of the spinal canal actual is less than 8.0 mm as judgment standard. ②There is a huge compression at the lower edge of C2-4 vertebrae, and the most prominent part of the diameter is exceed 7.0 mm, which can not be removed through the anterior cervical surgery, or the operation is high-risk.
Objective To observe and measure the approach next to the erector spinae in the thoracic and lumbar segments of the spine and adjacent anatomical structures by the topographic method, to clarify the positioning method and safe range so as to provide the anatomical basis of the approach for spinal canal decompression. Methods Twelve formaldehyde-treated adult cadaver specimens were selected, including 6 males and 6 females with an average age of 43 years (range, 27-52 years) and with an average height of 166 cm (range, 154-177 cm). The related data of the approach at T1-S1 levels were respectively measured: the distance between the lateral edge of the erector spinae and the spinous process, the length of the approach, the angle between the approach and the horizontal plane, the size of intervertebral foramen, and the vertical distance between the segmental artery and the upper edge of the vertebrae. Results The distance between the lateral edge of the erector spinae and the spinous process ranged from (41.75 ± 3.29) mm to (74.54 ± 7.08) mm. The length of the approach ranged from (66.75 ± 10.81) mm to (97.13 ± 13.35) mm. The angle between the approach and the horizontal plane ranged from (38.38 ± 6.16)° to (53.67 ± 4.40)°. The vertical distance between the segmental artery and the upper edge of the vertebrae ranged from (9.50 ± 0.60) mm to (18.30 ± 1.56) mm. The size of foraminal was also measured. The spinal canal could reach when iliocostalis lateral edge was used as the starting point in the lumbar segments, and longissimus lateral edge as the starting point in the thoracic segments. It was confirmed that there was enough safe space for the spinal decompression without the resection of the articular process. Conclusion The approach next to the erector spinae can reach spinal canal to achieve the purpose of decompression through the intervertebral foramen. The minimally invasive approach is feasible and safe. It has the value of the operative application.
Objective To investigate the relationship between the expression of apoptosis-related gene Fas and recovery of neurological function after surgical decompression at different time points in acute spinal cord injury (SCI) rat model by cerclage. Methods A total of 100 13-week-old male Sprague Dawley rats (weighing, 255-376 g) were randomly divided into 4 groups (n=25). The rats only received laminectomy in group A as control; the rats were made the acute SCI models by cerclage in groups B, C, and D. The spinal cord decompression was performed in group B at 8 hours and in group C at 72 hours, no spinal cord decompression in group D. At 1, 3, 7, 14, and 21 days, Basso-Beattie-Bresnahan (BBB) score and inclined plane test were used to evaluate the recovery of neurological function; the neuronal apoptosis level of spinal cord was examined by TUNEL staining; HE staining and immunohistochemical staining were applied to analyze the expressions of Fas. Results The BBB score and inclined plane test score in group A were significantly better than those in groups B, C, and D at different time points (P lt; 0.05); group B was significantly better than groups C and D, and group C than group D at 3, 7, 14, and 21 days (P lt; 0.05). In group A, no bleeding, edema, or necrosis was found. The edema, hemorrhage, and neuron death were observed in spinal cord tissue of groups B, C, and D at 1 day after operation, especially in group D. The degree of cell degeneration in group B was lighter than that in groups C and D at 3 and 7 days after operation; few glial cells and fibroblast proliferation were found at damaged zone in group B at 14 and 21 days, but necrosis and cystic cavity in groups C and D. Fas and TUNEL expression was little in group A at different time points. Fas and TUNEL were expressed in groups B, C, and D; the expressions of Fas and TUNEL reached the maximum at 3 days, and then gradually decreased at 7 and 21 days. The number of positive cells was highest in group D, and the number of positive cells in group B was significantly less than that in groups C and D (P lt; 0.05). Conclusion Early decompression of SCI is beneficial to recovering the neurological function. The Fas signal pathway may play an important role in the apoptosis of neuron and glial cells after SCI.
Objective To discuss the effectiveness of anterolateral decompression and three column reconstruction through posterior approach for the treatment of unstable thoracolumbar fracture. Methods Between March 2009 and October 2011, 39 patients with unstable burst thoracolumbar fracture were treated. Of them, there were 32 males and 7 females, with an average age of 43.8 years (range, 25-68 years). The injury causes included falling from height in 17 cases, bruise in 10 cases, traffic accident in 4 cases, and other in 8 cases. The fracture was located at the T10 level in 1 case, T11 in 9 cases, T12 in 6 cases, L1 in 14 cases, L2 in 7 cases, L3 in 1 case, and L4 in 1 case. According to Frankel classification before operation, 5 cases were classified as grade A, 5 as grade B, 9 as grade C, 14 as grade D, and 6 as grade E. Before operation, the vertebral kyphosis Cobb angle was (26.7 ± 7.1)°; vertebral height loss was 37.5% ± 9.5%; and the space occupying of vertebral canal was 73.7% ± 11.3%. The time between injury and operation was 1-4 days (mean, 2.5 days). All patients underwent anterolateral decompression of spinal canal by posterior approach and three column reconstruction. After operation, the vertebral height restoration, correction of kyphosis, decompression of the spinal canal, and the recovery of nerve function were evaluated. Results Increase of paraplegic level, urinary infection, and pressure sore occurred in 1 case, 1 case, and 2 cases, respectively; no incision infection or neurological complications was observed in the other cases, primary healing of incision was obtained. The patients were followed up 12-36 months (mean, 27 months). The patients had no aggravation of pain of low back after operation; no loosening and breaking of screws and rods occurred; no titanium alloys electrolysis and titanium cage subsidence or breakage was observed. The imaging examination showed that complete decompression of the spinal canal, satisfactory restoration of the vertebral height, and good physiological curvature of spine at 2 years after operation. At last follow-up, 1 case was classified as Frankel grade A, 2 as grade B, 2 as grade C, 10 as grade D, and 24 as grade E, which was significantly improved when compared with preoperative one (Plt; 0.05). At immediate after operation and last follow-up, the Cobb angle was (6.3 ± 2.1)° and (6.5 ± 2.4)° respectively; the vertebral height loss was 7.9% ± 2.7% and 8.2% ± 3.0% respectively; and the indexes were significantly improved when compared with preoperative ones (P lt; 0.05). Conclusion The technique of anterolateral decompression and three column reconstruction through posterior approach is one perfect approach to treat unstable thoracolumbar fracture because of complete spinal cord canal decompression, three column reconstruction, and immediate recovery of the spinal stability after operation.
Objective To evaluate the long-term effectiveness of treating early-middle stage avascular necrosis of the femoral head (ANFH) with core decompression and bone grafting. Methods Between January 2000 and December 2006, 87 ANFH patients (114 hips) were treated with core decompression and bone grafting, including 54 cases (62.1%) of alcohol-induced ANFH, 26 cases (29.9%) of steroid-induced ANFH, and 7 cases (8.0%) of idiopathic ANFH. There were 74 males (97 hips) and 13 females (17 hips), aged 20-56 years (mean, 38 years). The disease duration was 3-46 months (mean, 18 months). According to Ficat staging, 16 hips were at stage I, 68 hips at stage II, and 30 hips at stage III. The Harris score and Ficat stage were compared between pre- and post-operation to assess the outcomes clinically and radiologically. The hip survival was analyzed by the Kaplan-Meier method. Results Eighty-seven patients were followed up 5 years to 11 years and 10 months (mean, 8 years and 9 months). The Harris hip score was significantly increased from 73.13 ± 7.17 at preoperation to 81.59 ± 13.23 at postoperation (t= — 9.318, P=0.000). The clinical success rate was 69.3% (79/114) and the radiological success rate was 54.4% (62/114). Kaplan-Meier survival analysis showed that the overall survival rate was 84.2% (96/114); the survival rates of Ficat stage I [100% (16/16)] and stage II [91.2% (62/68)] were higher than that of stage III [60.0%(18/30)] (P lt; 0.01); there was no significant difference between Ficat stage I and II (χ2=1.520, P=0.218). Conclusion Core decompression with bone grafting is a safe and effective procedure for the treatment of Ficat stages I-II (early stage) ANFH, and the long-term effectiveness is satisfactory. But the long-term effectiveness is unsatisfactory for the patients at the Ficat stage III (middle stage).
ObjectiveTo compare the clinical and radiographic outcomes between laminoplasty and laminectomy compression and fusion with internal fixation to treat cervical spondylotic myelopathy. MethodsBetween September 2006 and September 2009, 143 cases of multilevel cervical myelopathy (the affected segments were more than 3) were treated by laminoplasty in 87 cases (group A) and by laminectomy decompression and fusion with lateral mass screw fixation in 56 cases (group B). There was no significant difference in gender, age, disease duration, pathological type, and affected segments between 2 groups (P gt; 0.05). The operation time, intraoperative blood loss, improvement of neurological function [Japanese Orthopaedic Association (JOA) 17 score], and the incidences of complications were observed; the cervical curvature index (CCI), range of motion (ROM), and symptoms of neck and shoulder pain [visual analogue scale (VAS) and neck disability index (NDI) scores] were recorded and compared. ResultsThere was no significant difference in operation time and intraoperative blood loss between 2 groups (P gt; 0.05). All patients were followed up 18-30 months (mean, 24 months). C5 nerve root palsy occurred in 4 cases (4.60%) of group A and in 5 cases (8.93%) of group B, showing no significant difference (χ2=0.475, P=0.482). No complication of deep infection, pseudarthrosis, or screw loosening occurred. No closure of opened laminae was observed in group A; and no screw extrusion, breakage, or nerve injury was observed in group B. At last follow-up, neck axial symptoms appeared in 35 cases (40.23%) of group A and in 11 cases (19.64%) of group B, showing significant difference (χ2=6.612, P=0.009). No significant difference was found in JOA score, CCI, ROM, or VAS scores between 2 groups at preoperation (P gt; 0.05); the JOA score, ROM, and VAS scores of groups A and B and CCI of group A at last follow-up were significantly improved when compared with preoperative ones (P lt; 0.05). No significant difference was found in the JOA score, improvement rate, and VAS score between 2 groups (P gt; 0.05); however, significant differences were found in ROM and CCI between 2 groups (P lt; 0.05). There were significant differences (P lt; 0.05) in pain intensity, lifting, work, reaction, driving, and total score between 2 groups at last follow-up. ConclusionLaminectomy decompression and fusion with internal fixation can effectively relieve pain, but it will greatly reduce the ROM; laminoplasty has less complications and satisfactory outcome. The two methods have similar effectiveness in the improvement of neurological function.
Objective To assess the mid-term effectiveness of anterior decompression and fusion with nano-hydroxyapatite/polyamide 66 (n-HA/PA66) cage in treatment of cervical spondylotic myelopathy. Methods A retrospective study was made on 48 patients with cervical spondylotic myelopathy who underwent anterior decompression and fusion with n-HA/PA66 cage between August 2008 and January 2010. There were 33 males and 15 females with an average age of 54.5 years (range, 42-72 years). The disease duration was 3-12 months (mean, 6 months). The affected segments included 35 cases of single segment (C3, 4 in 7, C4, 5 in 18, and C5, 6 in 10) and 13 cases of double segments (C3-5 in 7 and C4-6 in 6). Of 48 patients, 28 was diagnosed as having intervertebral disc protrusion, 12 as having ossification of posterior longitudinal ligament, and 8 as having vertebral osteophyte; 35 patients underwent single segmental anterior corpectomy and fusion, and 13 patients underwent single segmental anterior discectomy and fusion. The pre- and post-operative radiographs (cervical anteroposterior and lateral X-ray films and three-dimensional CT scans) were taken to measure the segmental height and lordosis angle. Brantigan et al assessment standard and visual analogue scale (VAS) and Japanese Orthopaedic Association (JOA) scores were used to evaluate the graft fusion and the improvement of clinical symptoms, respectively. Results All patients were followed up for 46 months on average (range, 36-54 months). No cage breaking, displacement, or sliding was found. At last follow-up, 36 cases were rated as Brantigan grade E, 10 cases as grade D, and 2 cases as grade C; the fusion rate was 96%. Both segmental height and lordosis angle were corrected significantly at immediate and 6 months after operation and last follow-up than those before operation (P lt; 0.05), but no significant difference was found among different time points after operation (P gt; 0.05). At last follow-up, the cage subsidence was (1.3 ± 1.0) mm. The VAS and JOA scores at 6 months after operation and last follow-up were significantly improved when compared with preoperative scores (P lt; 0.05), and the scores at last follow-up were superior to ones at 6 months after operation (P lt; 0.05). Conclusion The mid-term effectiveness of anterior decompression and fusion with the n-HA/PA66 cage in patients with cervical spondylotic myelopathy is satisfactory because it can effectively restore and maintain segmental height and lordosis angle and promote osseous fusion.
Objective To investigate the effectiveness in the treatment of single segment thoracic vertebra tuberculosis by limited decompression combined with epidural absorbable haemostat covering and vertebral plate reconstruction based on one-stage posterior approach, debridement, bone fusion, and internal fixation. Methods Between September 2005 and March 2010, 90 cases of single segment thoracic vertebra tuberculosis were treated by using limited decompression combined with epidural absorbable haemostat covering and vertebral plate reconstruction based on one-stage posterior approach, debridement, bone fusion, and internal fixation in 44 patients (treatment group) and by one-stage posterior approach, bone fusion, and internal fixation in 46 patients (control group). There was no significant difference in gender, age, disease duration, affected segment, Cobb angle, Frankle grade, erythrocyte sedimentation rate (ESR), and Oswestry disability index (ODI) between 2 groups (P gt; 0.05). Results All incisions healed by first intension. All 90 cases were followed up 24-44 months (mean, 38 months). There was no significant difference in ESR between 2 groups at 1 week and 3 months after operation (P gt; 0.05). Postoperative iconography indicated that the bone fusion rate of the treatment group was 100% and no epidural cicatricial tissue or failure of internal fixation was observed, showing significant difference when compared with control group (3 cases having failure of internal fixation) (P=0.032). The Cobb angles were significantly corrected after operation when compared with preoperative angles in 2 groups (P lt; 0.05). At 2 years after operation and at last follow-up, the Cobb angle and correction loss in treatment group were significantly better than those in control group (P lt; 0.05). The ODI and Frankel grade were significantly improved at last follow-up when compared with preoperative ones in 2 groups (P lt; 0.05); the treatment group was significantly better than the control group in the ODI, improvement rate of ODI (P lt; 0.05), and in Frankel grade (Uc=4.368, P=0.000). Conclusion Compared with conventional operation method, it is an ideal operation method to use limited decompression combined with epidural absorbable haemostat covering and vertebral plate reconstruction based on one-stage posterior approach, debridement, bone fusion, and internal fixation for treatment of single segment thoracic vertebra tuberculosis, with minimal wound, less complications, and good function recovery.
Objective To investigate the effectiveness of spinal canal decompression with microendoscopic disectomy (MED) and pillar vertebral space insertion through pedicle of vertebral arch for thoracolumbar neglected fracture. Methods Between February 2006 and November 2009, 30 patients with thoracolumbar neglected fracture were treated by spinal canal decompression with MED and pillar vertebral space insertion through pedicle of vertebral arch. There were 22 males and 8 females with an average age of 36.2 years (range, 17-58 years). The disease duration was 6 weeks to 14 months with an average of 5.3 months. All patients had single vertebral compression fracture, including T9 in 1 case, T11 in 2 cases, T12 in 5 cases, L1 in 11 cases, L2 in 5 cases, L3 in 5 cases, and L4 in 1 case. The preoperative Cobb angle was (27.5 ± 7.5) ° . The preoperative height of vertebrae was (26.67 ± 5.34) mm. The visual analogue score (VAS) was 5.8 ± 1.4. According to Wolter classification for spinal canal stenosis, there were 17 cases of grade 1, 10 cases of grade 2, and 3 cases of grade 3. According to Frankel grade, 3 cases were in grade A, 8 cases in grade B, 13 cases in grade C, and 6 cases in grade D. Results The average operation time was 70 minutes (range, 40-120 minutes) and the average blood loss was 180 mL (range, 100-400 mL). The hematoma occurred in 1 case, and other incisions healed by first intension. No deep vein thrombosis of the lower extremity occurred. All patients were followed up 26 months on average (range, 24-46 months). The Cobb angle and vertebral height at 3 days and last follow-up were significantly improved when compared with ones before operation (P lt; 0.01). At last follow-up, the spinal canal stenosis was grade 0 in 27 cases and grade 1 in 3 cases according to Wolter classification. At 24 months after operation, the spinal function was obviously improved; 1 case was in grade A, 1 case in grade B, 3 cases in grade C, 9 cases in grade D, and 16 cases in grade E according to Frankle grade, showing significant differences when compared with preoperative ones (P lt; 0.05). The VAS score at 1 month after operation was significantly higher than that before operation (P lt; 0.01), then the score showed downtrend along with time, and it was significantly lower at 24 months after operation than before operation (P lt; 0.01). Conclusion Spinal canal decompression with MED and pillar vertebral space insertion for thoracolumbar neglected fracture has short surgical time, less blood loss, and satisfactory reduction, but higher technical requirement is necessary for MED.