Objective To evaluate the effectiveness of combined posterior decompression with laminoplasty and anterior decompression with fusion for the treatment of cervical spinal canal stenosis with reverse arch. Methods Between May 2009 and February 2012, 13 cases of cervical spinal canal stenosis with reverse arch underwent posterior decompression with laminoplasty surgery in prone position and then anterior decompression with fusion surgery in supine position. There were 7 males and 6 females with an average age of 43.5 years (range, 38-62 years) and an average disease duration of 25 months (range, 18-60 months). All the patients had neck axial symptoms and spinal cord compressed symptoms, and lateral computer radiology (CR) of the neck showed reverse arch of cervical vertebrae. Segments of intervertebral disc protrusion included C3-6 in 4 cases, C4-7 in 4 cases, and C3-7 in 5 cases. After operation, anteroposterior and lateral CR was used to observe the cervical curvature change and fixation loosening, MRI to observe the change of the compression on spinal cord, visual analogue scale (VAS) score to evaluate the improvement of axial symptom, and Japanese Orthopaedic Association (JOA) score to assess the nerve function improvement. Results All incisions healed by first intention. All patients were followed up 9-32 months (mean, 15.4 months). Internal fixator had good position without loosening or breaking and the compression on spinal cord improved significantly after operation. All the patients obtained bony fusion at 6 months after operation. The axial symptoms and the nerve function at last follow-up were improved. VAS score at last follow-up (3.25 ± 1.54) was significantly lower than that at preoperation (6.55 ± 1.52) (P lt; 0.05); JOA score at last follow-up (10.45 ± 4.23) was significantly higher than that at preoperation (7.05 ± 1.32) (P lt; 0.05); and cervical curvature value at last follow-up [(6.53 ± 3.12) mm] was significantly higher than that at preoperation [(3.22 ± 5.15) mm] (P lt; 0.05). Conclusion Combined posterior decompression with laminoplasty and anterior decompression with fusion for the treatment of cervical spinal canal stenosis with reverse arch is a safe and effective surgical method.
Objective To investigate the operational method of cervical vertebral flavectomy and its cl inical appl ication in the management of cervical canal stenosis. Methods From June 1997 to June 2007, 25 patients suffering from cervical spinal canal stenosis caused by obvious flaval l igament hypertrophy were given flavectomy. There were 22 males and 3 females, with an age range of 32 to 68 years (average 54 years). The course of disease was from 3 weeks to 7 years, with an average of 3 years and 7 months. All patients had degenerative cervical canal stenosis; of them, 5 cases had a history of cervical injury 2 to 3 weeks before operation (3 cases of fall ing injury and 2 cases of traffic accident injury). The X-ray film, CT, and MRI examinations showed that the compression locations were C4-7 in 12 cases, C3-7 in 9 cases, C5-7 in 3 cases, and C6,7 in 1 case. Spinous process and vertebral lamella were exposed by central posterior approach. The insertions of flaval l igaments were cut off at the superior vertebral lamella border, then the starting points of which were cut down from the anterior side of the upper vertebral lamella at their inferior border after l ifting up the flaval l igaments. The residual flaval l igaments in front of the vertebral lamella were scraped off by slope rongeur, the dura mater then could be seen to inflate from the intervertebral lamella space, showing the compression having been rel ieved. Twenty-five cases were all given posterior flavectomy. At 1 week to 3 months after operation, 12 patients received anterior cervical discectomy or vertebral gaining decompression with fusion by bone graft. Results The time for flavectomy was from 60 to 180 minutes, with an average of 95 minutes. The blood loss during operation was from 90 to 360 mL, with an average of 210 mL. The dura maters were lacerated by knife tips during operation with the cervical vertebrae in hyperflexion in 2 cases. Immediate suture and repair were performed and there were no postoperative cerebrospinal fluid leakage. All the incisions healed by first intension after operation. All of the 25 cases were followed up from 2 to 10 years, with an average of 3 years and 9 months. All patients had no compl ication of axial symptoms, and no restenosis at their operation site of cervical canal stenosis. The section area ratios of functional spinal canal to spinal cord were 1.12 ± 0.07 before operation and 2.11 ± 0.19 at 24 months after operation, showing significant difference (P lt; 0.05). The range of motion of cervical vertebrae was (39.4 ± 3.2)º befeore operation and (42.1 ± 2.9)° at 24 months after operation in 13 cases without anterior cervical discectomy fusion, showing no significant difference (P gt; 0.05); was (34.3 ± 3.4)° before operation and (29.2 ± 3.6)° at 24 months after operation in 12 cases with anterior cervical discectomy fusion, showing significant difference (P lt; 0.05). The bone graft achieved bony union 3-5 months after operation (average 3.8 months). The Japanese Orthopaedic Association (JOA) scores were 7.9 ± 2.2 before operation and 15.6 ± 1.4 at 24 months after operation, showing significant difference (P lt; 0.05), with an average improvement rate of 86.3%. Conclusion Cervical flavectomy could rel ieve compression to spinal cord and nerves caused by the flaval l igament hypertrophy without damaging the normal integral ity of bony canal, thus avoiding the compl ication of axial symptoms and so on which are encountered in open-door expansile cervical laminoplasty.
Objective To investigate the diagnostic value of MR imaging in cervical spinal canal stenosis combined with spinal cord injury. Methods From August 1998 to May 2008, 41 patients with cervical spinal canal stenosis and spinal cord injury were treated, including 34 males and 7 females aged 32-71 years (average 53.4 years, 27 patients being older than 60 years). Patients’ MRI data were retrospectively analyzed. Injury was caused by fall ing from height in 8 cases, traffic accidentin 19 cases, crush due to heavy objects in 3 cases and other reasons in 11 cases. The time from injury to operation ranged from 2 hours to 3 years. There were 12 cases of anterior spinal cord injury syndrome, 23 of central spinal cord syndrome and 6 of Brown-Sequard syndrome. JOA score of spinal cord function was 3-11 points (average 6.6 points). Results MR imaging diagnosis before operation showed abnormal signal changes within the spinal cord in 37 cases (41 sites), anterior and posterior longitudinal l igaments and discs (APLLD) injury in 28 cases (30 sites) and signal of edema and hematoma signals in anterior surface of cervical spines (EBC) in 34 cases (36 sites). Diagnosis during operation revealed edemas braises, contusions tears of posterior soft tissue in 18 cases (20 sites), appendix fracture in 6 cases (7 sites), formation of EBC in 20 cases (23 sites), APLLD injury in 34 cases (44 sites), intervertebral instabil ity without the rupture of l igament and intervertebral disc in 7 cases (10 sites). Significant difference was evident between the MRI diagnosis before operation and the intraoperative discoveries (P lt; 0.05). Conclusion The MR imaging diagnosis before operation do not correspond to the intraoperative discoveries, indicating that MRI diagnosis fails to make a relatively comprehensive and accurate diagnosis. So it is advisable to make a diagnosis based on cl inical symptoms.
Objective To study the changes of blood flow of the already-compressed cauda equina under dynamic burden, high frequency stimulation (HFS) and increased additional compression, and to clarify the mechanism of neurogenic intermittent claudication. Methods Thirty SD rats were divided into 5 groups, 6 in each. All groups were operated with laminectomy of the fifth lumbar verfebra. One hour after the measurement of blood flow,in 4experimental groups, the silicon sheets were inserted into the spinal canal of L4 and L6 to cause double level compression of cauda equina by 30%. Two hours after onset of compression, no dynamic burden was introduced to the subjects of the experimental group 1. Only HFS was introduced to the subjects of the experimental group 2 for 6 minutes. Both HFS and increased additional compression were introduced to the subjects of the experimental group 3 for 6 minutes. While only increased additional compression was introduced to the subjects of the experimental group 4 for 6 minutes. The subjects of control group only underwent laminectomy of the fifth lumbar vertebra and HFS 6 minutes. The blood flow of cauda equina was measured with laser Doppler flowmeter. Results In the first 2 hours, there was no significant change of cauda equina blood flow in the control group. During the time of HFS, the blood flow increased significantly to 186.4%±31.5% of initial value (Plt;0.05). In the experimental group 1, there was no blood flow change during the period of dynamic burden（110.4％±7.5％，Pgt;0.05）. After introduction of dynamic burden, there was no blood flow changes in the experimental group 2 (111.6％±17.6％，Pgt;0.05). The blood flow in the experimental group 3 decreased to 65.3%±10.7% of initial value (Plt;0.05); and the blood flow in the experimental group 4 decreased to 60.1%±9.2% of initial value (Plt;0.01). There was no significant difference between the experimental groups 3 and 4 (Pgt;0.05). Conclusion The results above show that during the period of increased impulse transmission, double level compression of cauda equina may limit the increase of blood flow, which maycause relative ischemia. If there is increased additional compression along with increased impulse transmission, the blood flow will decrease significantly, which will cause absolute ischemia.
OBJECTIVE: To study the changes of neural electrophysiology properties of cauda equina under double level compression and dynamic burdens, and to clarify the mechanisms of intermittent neurogenic claudication. METHODS: Thirty SD rats were divided into 5 groups (6 in each group). The laminectomy of L5 was performed in control group. In the experimental groups, the silicon sheets were inserted into the spinal canal of L4 and L6 to cause double level compression of cauda equina by 30%. Two hours after onset of compression, no dynamic burden was introduced in experimental group 1. Only high frequency stimulation(HFS) was introduced for 6 minutes in experimental group 2. Both HFS and additional increased compression were introduced for 6 minutes in experimental group 3. While only additional increased compression was introduced for 6 minutes in experimental group 4. After 6 minutes of dynamic burdens, all were returned to the status of static compression for another 30 minutes and then electrical examination was made. RESULTS: After 2 hours of compression, motor and sensory nerve conduction velocity (NCV) of all the four experimental groups decreased significantly (P lt; 0.05), but there was no significant difference between them. There was no significant change in the control group. There was no significant change of NCV in experimental group 1 during the last 30 minutes of experiment. NCV in the other three experimental groups decreased after introduction of dynamic burdens, especially in the experimental group 3. CONCLUSION: The above results showed that NCV of cauda equina decreased significantly under dynamic burdens during static compression. Two kinds of dynamic burdens introduced at the same time can cause more profound change than a single one.
ObjectiveTo investigate the effectiveness of posterior microscopic mini-open technique (MOT) decompression in patients with severe spinal canal stenosis resulting from thoracolumbar burst fractures.MethodsThe clinical data of 28 patients with severe spinal canal stenosis caused by thoracolumbar burst fractures, who were treated by posterior microscopic MOT, which performed unilateral or bilateral laminectomy, poking reduction, intervertebral bone graft via spinal canal, and percutaneous pedicle screw fixation between January 2014 and January 2016 were retrospectively analyzed. There were 21 males and 7 females with a mean age of 42.1 years (range, 16-61 years). The involved segments included T11 in 1 case, T12 in 4 cases, L1 in 14 cases, and L2 in 9 cases. According to AO classification, there were 19 cases of type A3, 9 of type A4. According to American Spinal Injury Association (ASIA) grading, 12 cases were grade C, 13 grade D, and 3 grade E. The time between injury and operation was 3-7 days (mean, 3.6 days). To evaluate effectiveness, the changes in the visual analogue scale (VAS), percentage of anterior height of injured vertebrae, Cobb angle, rate of spinal compromise (RSC), and ASIA grading were analyzed.ResultsAll patients were performed procedures successfully. The operation time was 135-323 minutes (mean, 216.4 minutes). The intraoperative blood loss was 80-800 mL (mean, 197.7 mL). The hospitalization time was 10-25 days (mean, 12.5 days). The incisions healed primarily, without wound infection, cerebrospinal fluid leakage, or other early complications. All the 28 patients were followed up 12-24 months (mean, 16.5 months). No breakage or loosening of internal fixation occurred. All fractures healed, and the healing time was 3-12 months (mean, 6.5 months). Compared with preoperative ones, the percentage of anterior height of injured vertebrae, Cobb angle, and RSC at immediate after operation and at last follow-up and the VAS scores at 1 day after operation and at last-follow were significantly improved (P<0.05). There was no significant difference in the percentage of anterior height of injured vertebrae and Cobb angle between at immediate after operation and at last follow-up (P>0.05). But the RSC at immediate after operation and VSA score at 1 day after operation were significantly improved when compared with those at last follow-up (P<0.05). The ASIA grading at last follow-up was 1 case of grade C, 14 grade D, and 13 grade E, which was significantly improved when compared with preoperative ones (Z=3.860, P=0.000).ConclusionMOT is an effective and minimal invasive treatment for thoracolumbar AO type A3 and A4 burst fractures with severe spinal canal stenosis, and it is beneficial to early rehabilitation for patients.
Objective To investigate the effectiveness of posterior short-segmental fixation with bone cement augmentation in treatment of stage Ⅲ Kümmell’s disease with spinal canal stenosis. Methods Between June 2012 and January 2017, 36 patients with stage Ⅲ Kümmell’s disease and spinal canal stenosis were treated by posterior short-segmental fixation and bone cement augmentation. There were 12 males and 24 females, aged 55-83 years (mean, 73.5 years). The disease duration ranged from 2 to 8 months, with an average of 4.6 months. Preoperative bone mineral density examination showed that all patients had different degrees of osteoporosis in the spines. The lesion segments included T10 in 4 cases, T11 in 7 cases, T12 in 8 cases, L1 in 9 cases, and L2 in 8 cases. The preoperative neural function was classified as grade B in 4 cases, grade C in 12 cases, grade D in 13 cases, and grade E in 7 cases according to Frankle classification. The operation time, intraoperative blood loss, and the volume of injected bone cement, and hospital stay were recorded. The visual analogue scale (VAS) score, Oswestry Disability Index (ODI), kyphotic Cobb angle, and the height of anterior edge of injured vertebra were recorded before operation, at 1 week after operation, and at last follow-up; and the leakage of bone cement was observed. Results All operations were completed successfully. The operation time was 90-145 minutes (mean, 110.6 minutes); the intraoperative blood loss was 198-302 mL (mean, 242.5 mL); the volume of injected bone cement was 8.3-10.5 mL (mean, 9.2 mL); the hospital stays were 7-12 days (mean, 8.3 days). All patients were followed up 12-26 months (mean, 24.5 months). At 1 week after operation, the neural function was classified as grade B in 2 cases, grade C in 8 cases, grade D in 12 cases, and grade E in 14 cases, which was significantly improved when compared with that before operation (Z=2.000, P=0.047). The VAS score, ODI, the height of anterior edge of injured vertebra, and Cobb angle were significantly improved at 1 week and last follow-up when compared with preoperative values (P<0.05); but there was no significant difference between 1 week and last follow-up (P>0.05). Two cases had asymptomatic cement leakage to the intervertebral disc at 1 week after operation; and 1 case had adjacent vertebral fracture at 8 months after operation. No complication such as loosening or breaking of internal fixator occurred during the follow-up. Conclusion Posterior short-segmental fixation with bone cement augmentation is a safe and effective surgical scheme for stage Ⅲ Kümmell’s disease combined with spinal canal stenosis, which can avoid the aggravation of nerve injury and complications related to staying in bed.