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Peng-Yuan Chang and Michael Y. Wang

In minimally invasive spinal fusion surgery, transforaminal lumbar (sacral) interbody fusion (TLIF) is one of the most common procedures that provides both anterior and posterior column support without retraction or violation to the neural structure. Direct and indirect decompression can be done through this single approach. Preoperative plain radiographs and MR scan should be carefully evaluated. This video demonstrates a standard approach for how to perform a minimally invasive transforaminal lumbosacral interbody fusion.

The video can be found here: https://youtu.be/bhEeafKJ370.

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Michael Y. Wang, Peng-Yuan Chang and Jay Grossman

OBJECTIVE

Over the past decade, Enhancing Recovery After Surgery (ERAS) programs have been implemented throughout the world across multiple surgical disciplines. However, to date no spinal surgery equivalent has been described. In this report the authors review the development and implementation of a “fast track” surgical approach for lumbar fusion.

METHODS

The first 42 consecutive cases in which patients were treated with the new surgical procedure were reviewed. A combination of endoscopic decompression, expandable cage deployment, and percutaneous screw placement were performed with liposomal bupivacaine anesthesia to allow the surgery to be performed without general endotracheal anesthesia.

RESULTS

In all cases the surgical procedure was performed successfully without conversion to an open operation. The patients' mean age (± SD) was 66.1 ± 11.7 years, the male/female ratio was 20:22, and a total of 47 levels were treated. The mean operative time was 94.6 ± 22.4 minutes, the mean intraoperative blood loss was 66 ± 30 ml, and the mean hospital length of stay was 1.29 ± 0.9 nights. Early follow-up showed a significant improvement in the mean Oswestry Disability Index score (from 40 ± 13 to 17 ± 11, p = 0.0001). Return to the operating room was required in 2 cases due to infection and in 1 case due to cage displacement. An iterative quality improvement program demonstrated areas of improvement, including steps to minimize infection, improve postoperative analgesia, and reduce cage osteolysis.

CONCLUSIONS

ERAS programs for improving spinal fusion surgery are possible and necessary. This report demonstrates a first foray to apply these principles through 1) a patient-focused approach, 2) reducing the stress of the operation, and 3) an iterative improvement process.

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Xinyu Liu, Lianlei Wang, Suomao Yuan, Yonghao Tian, Yanping Zheng and Jianmin Li

OBJECT

Lumbar spondylolysis and isthmic spondylolisthesis occur most commonly at only one spinal level. The authors report on 13 cases of lumbar spondylolysis with spondylolisthesis at multiple levels.

METHODS

During July 2007–March 2012, multiple-level spondylolysis associated with spondylolisthesis was diagnosed in 13 patients (10 male, 3 female) at Qilu Hospital of Shandong University. The mean patient age was 43.5 ± 14.6 years. The duration of low-back pain was 11.7 ± 5.1 months. Spondylolysis occurred at L-2 in 2 patients, L-3 in 4 patients, L-4 in all patients, and L-5 in 5 patients. Spondylolysis occurred at 3 spinal levels in 3 patients and at 2 levels in 10 patients. All patients had spondylolisthesis at 1 or 2 levels. Japanese Orthopaedic Association and visual analog scale scores were used to evaluate preoperative and postoperative neurological function and low-back pain. All patients underwent pedicle screw fixation and interbody fusion or direct pars interarticularis repair.

RESULTS

Both low-back pain scores improved significantly after surgery (p < 0.05). Postoperative radiographs or CT scans showed satisfactory interbody fusion or pars interarticularis healing. No breakage, dislodging, or loosening of the pedicle screw hardware was observed for any patient.

CONCLUSIONS

Multiple-level lumbar spondylolysis and spondylolisthesis occurred more often in men. Most multiplelevel lumbar spondylolysis occurred at 2 spinal levels and was associated with sports, trauma, or heavy labor. Multiplelevel lumbar spondylolysis occurred mostly at L3–5; associated spondylolisthesis usually occurred at L-4 and L-5, mostly at L-4. The treatment principle was the same as that for single-level spondylolisthesis.

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Xinyu Liu, Suomao Yuan, Yonghao Tian, Lianlei Wang, Yanping Zheng and Jianmin Li

OBJECT

The purpose of this study was to determine the efficacy of a modified vertebral column resection for the treatment of thoracolumbar angular kyphosis.

METHODS

A total of 13 patients (8 male, 5 female) with thoracolumbar kyphosis (kyphotic angle > 60°) were included in this study (Group A). There were 3 patients with failure of spinal formation (Type 1 deformity), 6 patients with old thoracic or lumbar compression fracture, and 4 patients with old spinal tuberculosis (including 1 case of T3–5 vertebral malunion). The average preoperative kyphotic angle was 67.3° (range 62°–75°). Each patient underwent an expanded eggshell procedure combined with the closing-opening technique for the treatment of thoracolumbar angular kyphosis. Sixteen patients who were previously treated with a closing-opening wedge osteotomy in the same spine classification group (kyphotic angle > 60°) were used as a control group (Group B).

RESULTS

In Group A, the average (± SD) operative time was 400 ± 60 minutes, and the average blood loss was 960 ± 120 ml. There were no surgery-related complications observed during or after the operations. The average local kyphotic angle was 20.3° (range 18°–24.5°), and the average correction rate was 68.7%. In Group B, the average operative time was 470 ± 90 minutes, and the average blood loss was 2600 ± 1600 ml (range 1200–8200 ml). There were segmental vessels and spinal canal venous plexus injury in 1 case, spinal cord injury in 1 case, dural tearing in 2 cases, pleural rupture in 2 cases, and hemothorax and pneumothorax in 1 case. Each patient had more than 2 years of follow-up. At the latest follow-up examination, the average regional kyphotic angle was 19.9° ± 9.1° (range 19°–34°), and there was no significant loss of correction (p > 0.05). There was greater blood loss and a higher complication rate in Group B than in Group A (p < 0.05).

CONCLUSIONS

An expanded eggshell procedure combined with the closing-opening technique for the treatment of thoracolumbar angular kyphosis resulted in significant reduction of the kyphotic angle, few complications, and good follow-up results. However, a larger series of patients and long-term follow-up results is still required to verify the effectiveness and safety of this method.

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I-Duo Wang and Dueng-Yuan Hueng

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Hongwei Wang, Yuan Zhang, Qiang Xiang, Xuke Wang, Changqing Li, Hongyan Xiong and Yue Zhou

Object

The main objective of this study was to analyze the epidemiological data obtained from patients with traumatic spinal fracture at 2 university-affiliated hospitals in Chongqing, China.

Methods

The authors retrospectively reviewed the hospital records of all patients who suffered traumatic spinal fracture and were treated at Xinqiao Hospital and Southwest Hospital (both affiliated with The Third Military Medical University) between January 2001 and December 2010. The demographic characteristics, injury characteristics, and clinical outcomes of patients over this 10-year period were compared.

Results

A total of 3142 patients (mean age 45.7 years, range 1–92 years) with traumatic spinal fractures were identified; 65.5% of the patients were male. The peak frequency of these injuries occurred in the 31- to 40-year-old age group. Accidental falls and traffic accidents were the most common causes of spinal fractures (58.9% and 20.9%, respectively). Traffic accidents tended to occur in younger patients, whereas accidental falls tended to occur in older patients. The most common area of fracture was the thoracolumbar spine (54.9%). Cervical spinal fractures were significantly more common in patients injured in traffic accidents, while lumbar spinal fractures were more common in accidental fall patients. Using the American Spinal Injury Association (ASIA) classification, 479 (15.3%) patients were classified as having ASIA A injuries; 913 (29.1%), ASIA B, ASIA C, or ASIA D; and 1750 (55.7%), ASIA E. ASIA A injuries were more common in patients who suffered thoracic spinal fractures (15.09%) than in those with fractures in other areas of the spine. A total of 954 (30.4%) patients had associated nonspinal injuries. Of these patients, 389 (40.78%) suffered a thoracic injury, and 191 (20.02%) sustained a head and neck injury. The length of hospitalization differed significantly between the accidental falls from high heights and falls from low heights, as did the mean cost of hospitalization (p < 0.05), but no significant difference was found between accidental falls from high heights and traffic accidents (p > 0.05). The length of hospitalization differed significantly among the 3 groups according to the ASIA classification, as did the mean cost of hospitalization (p < 0.05). Of patients with incomplete lesions, 39.3% improved 1 or more grades in ASIA classification during hospitalization.

Conclusions

Accidental falls emerged as the leading cause of traumatic spinal fracture in this study, and the numbers of fall-induced and sports-related injuries increased steadily with age. These results indicate that there should be increased concern for the consequences of fall- and sports-related injuries among the elderly.

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Chen Wang, Xiao-Jun Yuan, Ma-Wei Jiang and Li-Feng Wang

OBJECT

The purpose of this study was to explore the clinical features and outcome of medulloblastoma in Chinese children. The authors analyze the reasons that treatment is abandoned and attempt to provide evidence-based recommendations for improving the prognosis of medulloblastoma in this population.

METHODS

A total of 67 pediatric cases of newly diagnosed medulloblastoma were included in this study. All of the children were treated at Xinhua Hospital between January 2007 and June 2013. The authors retrospectively analyzed the clinical data, treatment modalities, and outcome. The male-to-female ratio was 2:1, and the patients’ median age at diagnosis was 51.96 months (range 3.96–168.24 months). The median duration of follow-up was 32 months (range 3–70 months).

RESULTS

At the most recent follow-up date, 31 patients (46%) were alive, 30 (45%) had died, and 6 (9%) had been lost to follow-up. The estimated 3-year overall survival and progression-free survival, based on Kaplan-Meier analysis, were 55.1% ± 6.4% and 45.6% ± 6.7%, respectively. Univariate analysis showed that standard-risk group (p = 0.009), postoperative radiotherapy (RT) combined with chemotherapy (p < 0.001), older age (≥ 3 years) at diagnosis (p = 0.010), gross-total resection (p = 0.012), annual family income higher than $3000 (p = 0.033), and living in urban areas (p = 0.008) were favorable prognostic factors. Multivariate analysis revealed that postoperative RT combined with chemotherapy was an independent prognostic factor (p < 0.001). The treatment abandonment rate in this cohort was 31% (21 of 67 cases).

CONCLUSIONS

There was a large gap between the outcome of medulloblastoma in Chinese children and the outcome in Western children. Based on our data, treatment abandonment was the major cause of therapeutic failure. Parents’ misunderstanding of medulloblastoma played a major role in abandonment, followed by financial and transportation difficulties. Establishment of multidisciplinary treatment teams could improve the prognosis of medulloblastoma in Chinese children.

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Xiao-Dong Wu, Wen Yuan, Hua-Jiang Chen, Yu Chen, Jian-Xi Wang, Peng Cao, Ying Zhang, Xin-Wei Wang, Li-Li Yang, Yuan-Yuan Chen and Nicholas Tsai

Object

Multilevel anterior cervical decompression and fusion is indicated for patients with multilevel compression or stenosis of the spinal cord. Some have reported that this procedure would lead to a loss of cervical range of motion (CROM). However, few studies have demonstrated the exact impact of the procedure on CROM. Here, the authors describe short- and midterm postoperative CROM following multilevel anterior cervical decompression and fusion.

Methods

Thirty-five patients underwent a 3- or 4-level anterior cervical decompression and fusion. In all patients, active CROM was measured preoperatively and at both the short-term (3–4 months) and midterm (12–15 months) follow-ups by using a CROM device. The preoperative and postoperative data were analyzed using ANOVA (α = 0.05).

Results

Patients had significantly less ROM in all planes of motion postoperatively. The greater limitation in CROM was observed at the short-term follow-up. However, at the midterm follow-up, an obvious increase in CROM was observed in each cardinal plane compared with that in the short-term (sagittal plane 17.4%, coronal plane 14.1%, and horizontal plane 19.5%). A gradual increase in the CROM in each cardinal plane was observed during the recovery period in 5 patients. In the 6 conventional motions, the major recovery of CROM was observed in flexion (27.5%), while relatively less recovery was seen in extension (10.5%).

Conclusions

Patients had an obvious reduction in active CROM following multilevel anterior cervical decompression and fusion. The greater limitation in CROM was observed at the short-term follow-up. In the midterm follow-up, however, an obvious recovery in CROM was observed in each cardinal plane, reducing the restriction of neck motion further.

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Yan-Chun Wu, Zan Ding, Jiang Wu, Yuan-Yuan Wang, Sheng-Chao Zhang, Ye Wen, Wen-Ya Dong and Qing-Ying Zhang

OBJECTIVE

Intracerebral hemorrhage (ICH) is associated with a poor prognosis and high mortality, but no study has elucidated the association between glycemic variability (GV) and functional outcome in ICH. The authors of this study aimed to determine whether GV is a predictor of 30-day functional outcome in ICH patients.

METHODS

The study recruited 366 patients with first-ever acute-onset ICH in the period during 2014 and 2015. Fasting blood glucose was assessed on admission and with 7-day continuous monitoring. Glycemic variability was calculated and expressed by the standard deviation (GluSD) and coefficient of variation (GluCV). Patients were divided into groups of those with diabetes mellitus (DM), stress hyperglycemia (SHG), and normal glucose (NG). Functional outcome was measured using the modified Rankin Scale.

RESULTS

The numbers of patients with DM, SHG, and NG were 108 (29.5%), 127 (34.7%), and 131 (35.8%), respectively. As compared with the DM patients, those with SHG had higher mortality (29.9% vs 15.7%, p < 0.05) and a poorer prognosis (64.6% vs 52.8%, p < 0.05). Poor prognosis was associated with both high GluSD (OR 1.54, 95% CI 1.19–1.99) and high GluCV (1.05, 1.02–1.09), especially in the DM group. The area under the receiver operating characteristic curve was greater for the GluSD (OR 0.929, 95% CI 0.902–0.956) and the GluCV (0.932, 0.906–0.958) model than the original model (0.860, 0.823–0.898) in predicting a poor outcome.

CONCLUSIONS

Stress hyperglycemia may be associated with increased mortality and a poor outcome in ICH, and increased GV may be independently associated with a poor outcome, particularly in ICH patients with DM.

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Xinyu Liu, Suomao Yuan, Yonghao Tian, Lianlei Wang, Liangtai Gong, Yanping Zheng and Jianmin Li

OBJECTIVE

This study aimed to evaluate the clinical outcomes of percutaneous endoscopic transforaminal discectomy (PETD), microendoscopic discectomy (MED), and microdiscectomy (MD) for treatment of symptomatic lumbar disc herniation (LDH).

METHODS

One hundred ninety-two patients with symptomatic LDH at L3–4 and L4–5 were included in this study. The mean (± SD) age of patients was 34.2 ± 2.6 years (range 18–62 years). The patients were divided into groups as follows: group A was treated with PETD and included 60 patients (31 men and 29 women) with a mean age of 36.2 years; group B was treated with MED and included 63 patients (32 men and 31 women) with a mean age of 33.1 years; and group C was treated with MD and included 69 patients (36 men and 33 women) with a mean age of 34.0 years. The Japanese Orthopaedic Association (JOA) scale for low-back pain (LBP), Oswestry Disability Index (ODI), creatine phosphokinase activity 3 days after surgery, and visual analog scale (VAS) scores for LBP and leg pain were used for evaluation of clinical results.

RESULTS

There were no significant differences in mean preoperative JOA score, ODI score, and VAS scores for LBP and leg pain among groups A, B, and C. Incision length, duration of the operation, blood loss, creatine phosphokinase, length of hospital stay, and postoperative incision pain according to the VAS were best in the PETD group (p < 0.05). The number of seconds of intraoperative fluoroscopy was highest in the PETD group (p < 0.05), whereas there was no difference between the MED and MD groups. Three cases from the MED group and 2 cases from the MD group had an intraoperative durotomy. No CSF leakage was observed after surgery. One case from the MED group and 3 cases from the MD group had incision infections. There were no neurological deficits related to the surgeries in any of the groups. Fifty-five (91.6%), 59 (93.7%), and 62 patients (89.9%) had at least 2 years of follow-up in groups A, B, and C, respectively. At the last follow-up, JOA scores, VAS scores of LBP and leg pain, and ODI scores were significantly better than preoperative correlates in all groups. There were no differences among the 3 groups in JOA scores, JOA recovery rate, ODI scores, and VAS scores for leg pain. The VAS score for LBP was best in the PETD group (p < 0.05). No lumbar instability was observed in any group. Three cases (5.5%) in the PETD group had recurrent LDH, and 2 recurrent cases (3.4%) were confirmed in the MED group.

CONCLUSIONS

PETD, MED, and MD were all reliable techniques for the treatment of symptomatic LDH. With a restricted indication, PETD can result in rapid recovery and better clinical results after at least 2 years of follow-up.