Song Yueming

Surgical treatment of kyphosis in children in healed stages of spinal tuberculosis.

Background Very less literature focuses on the treatment of kyphosis in healed stages of spinal tuberculosis (TB), especially in children. The purpose of this study was to evaluate the outcomes of anterior release, decompression, deformity correction, and instrumented fusion, followed by posterior osteotomy, deformity correction, and pedicle screw instrumented fusion, which is used to treat kyphosis in children in healed stages of spinal TB. Methods Sixteen children with kyphotic deformity of the spine in healed stages of TB underwent anterior release, decompression, deformity correction, and instrumented fusion, followed by posterior osteotomy, deformity correction, and pedicle screw instrumented fusion between 2003 and 2007 with at least 2 years of follow-up. Radiologic assessment including the angle of kyphosis and scoliosis, and neurologic status using the modified Frankel grade were analyzed before surgery, after surgery, and at the last follow-up. Fusion was evaluated on flexion-extension lateral radiographs. Results Good cosmetic results were achieved in all patients. Neurologic improvement was shown in all 4 patients with paraplegia. The mean preoperative angle of kyphosis was 55.8 degrees that reduced to 21.7 degrees, postoperatively. The difference in the mean angle of kyphosis was statistically significant (P<0.05). The mean angle of kyphosis at the last follow-up was 23.2 degrees. The mean correction loss was 1.5 degree, and there was no statistically significant difference in the mean angles of kyphosis between the postoperative and last follow-up measurements. The mean preoperative angle of scoliosis was 6.9 degrees that reduced to 0.8 degree postoperatively. The difference in the mean angle of scoliosis was statistically significant (P<0.05). The mean angle of scoliosis at the last follow-up was 0.9 degree. The mean correction loss was 0.2 degree and there was no statistically significant difference in the mean angles of scoliosis between the postoperative and last follow-up measurements. All patients returning for follow-up had bony fusion. There were no cases of failure of fixation. Conclusions Combined anterior and posterior osteotomy, deformity correction, and instrumented fusion halted progression of kyphosis and improved neurologic symptoms. Level of Evidence Therapeutic-level IV, retrospective study.

Convex short length rib resection in thoracic adolescent idiopathic scoliosis.

Background: Although it brings satisfactory rib hump correction, concomitant thoracoplasty with surgical correction of scoliosis decreases pulmonary function values. To achieve satisfactory rib hump correction and avoid impairment to pulmonary function, we design a new kind of thoracoplasty—convex short length rib resection (CSLRR). This study is to evaluate the effect and outcome of CSLRR in conjunction with pedicle screw instrumentation. Methods: Seventy patients with thoracic adolescent idiopathic scoliosis treated by pedicle screw instrumentation were retrospectively analyzed after a minimum follow-up of 2 years. Patients were divided into 3 groups: C-T group (conventional thoracoplasty, n =20), N-T group (no thoracoplasty, n=24), and CSLRR group (n=26). Patients were evaluated for height of rib hump, deformity correction, balance, pulmonary function, and complications. Results: The correction rates of hump height were 74.1% in the C-T group, 47.1% in the N-T group, and 63.2% in the CSLRR group, respectively. The CSLRR group showed significantly better correction of rib hump than the N-T group. In thoracic hypokyphosis correction, the CSLRR group was superior to the N-T group with statistical significance. There were no significant differences in proximal thoracic, main thoracic and lumbar Cobb angle, coronal and sagittal balance, and lumbar lordosis at the final follow-up among 3 groups. Three months after the operation, both absolute values and percent-predicted values of forced vital capacity and forced expiratory volume in 1 second in the N-T group and CSLRR group were better than that in the C-T group. Two years after the operation, absolute values of forced vital capacity and forced expiratory volume in 1 second in the N-T group and CSLRR group were better than that in the C-T group. There were 2 hemothorax in the C-T group and 1 pleural effusion in the CSLRR group. Conclusions: CSLRR showed significantly better rib hump and thoracic hypokyphosis correction without pulmonary function compromise in the treatment of thoracic adolescent idiopathic scoliosis with pedicle screw instrumentation. Level of Evidence: Therapeutic-level IV retrospective study.

Characteristics of crush syndrome caused by prolonged limb compression longer than 24 h in the Sichuan earthquake

Background To assess the characteristics, treatment and outcome of patients with crush syndrome caused by prolonged limb compression longer than 24 h in the Sichuan earthquake. Methods Following the Sichuan earthquake, 2728 patients were transferred to the West China Hospital of Sichuan University and 157 of those were admitted to the intensive care unit. The medical records of nine severe crush syndrome patients were retrospectively reviewed. Results The major associated injuries were in the lower extremities. Renal failure and oliguria developed in all patients. Creatine kinase peaked in all patients. Hyperkalaemia was seen in five patients, and six patients developed acidosis. All patients had amputations; five had two limbs amputated. One patient underwent fasciotomy. Adult respiratory distress syndrome developed in four patients and required mechanical ventilation. All patients underwent haemodialysis. Multiple organ failure and sepsis developed in eight patients, but no patients died. Conclusions Crush syndrome caused by extremely long compression has high rates of renal failure, multiple organ failure, sepsis and amputation. Early transportation and immediate intensive care therapy would have improved the outcome and survival rate.

Clinical and radiologic comparison of dynamic cervical implant arthroplasty and cervical total disc replacement for single-level cervical degenerative disc disease.

Anterior cervical discectomy and fusion, to date the most successful spine procedure for the surgical treatment of cervical radiculopathy, has limitations that have led to the development of non-fusion cervical procedures, such as cervical total disc replacement (TDR) and dynamic cervical implant (DCI) arthroplasty. We compared the clinical and radiological results of DCI and cervical TDR for the treatment of single-level cervical degenerative disc disease in Chinese patients. A retrospective review of 179 patients with cervical spondylotic myelopathy who underwent DCI or TDR between April 2010 and October 2012 was conducted, and 152 consecutive patients (67 patients single-level DCI and 85 single-level TDR) who completed at least 2years of follow-up were included. Clinical and radiological assessments were performed preoperatively and at 1week and 3, 6, 12, and 24months postoperatively. The most common operative level was C5/C6 (49.3%). The differences in blood loss, duration of surgery, and duration of hospitalization were not statistically significant. The Japanese Orthopaedic Association scale, Visual Analog Scale, Neck Disability Index, and Short Form-36 scores improved significantly after surgery in both the DCI and TDR groups (P<0.05), but the differences were not statistically significant at the final follow-up. The rate of occurrence of heterotopic ossification was 22.4% and 28.2% in the DCI and TDR groups, respectively. As an effective non-fusion technique, DCI is a more economical procedure. Further prospective, randomized studies with long-term follow-up periods are needed to determine the long-term effects.

Evaluation of bioabsorbable multiamino acid copolymer/α-tri-calcium phosphate interbody fusion cages in a goat model.

Study Design. A study of cervical interbody fusion using polyamino acid-based bioabsorbable fusion cages in a goat model. Objective. To compare interbody fusion of a bioabsorbable multiamino acid copolymer/&agr;-tri-calcium phosphate (MAACP/&agr;-TCP) fusion cage with an autologous tricortical iliac-crest bone graft and a titanium cage. Summary of Background Data. Polyamino acid is widely used as a carrier for drug delivery. To our knowledge, no study investigates interbody fusion cage made of polyamino acid. Methods. A total of 15 sheep underwent C3/C4 discectomy and fusion. The following stabilization techniques were used: group A, autologous tricortical iliac crest bone graft (n = 5); group B, MAACP/&agr;-TCP cage filled with autologous cancellous bone graft (n = 5); group C, titanium cage filled with autologous cancellous bone graft (n = 5). Radiographic scans to determine disc space height were performed before and after surgery and after 4, 8, and 12 weeks, respectively. After 12 weeks, the C3/C4 motion segment was isolated and sectioned to create a 5-mm thick parasagittal section from which lateral radiographs were obtained. All the radiographs were encoded and reviewed in a blinded fashion to evaluate interbody fusion within the cage devices according to a three-point radiographic score. Biomechanical testing was performed in flexion, extension, axial rotation, and lateral bending to determine range of motion (ROM). Histomorphological and histomorphometrical analyses were performed to evaluate fusion and foreign-body reactions associated with the bioabsorbable cages. Results. Radiographic results showed that the disc space height (DSH) in MAACP/&agr;-TCP cage group was better than that of bone graft group and the best radiographic score was found in MAACP/&agr;-TCP cage group. Biomechanical test showed that no significant difference was found in ROM between MAACP/&agr;-TCP cage group and titanium cage group whereas the value of ROM in bone graft group was the largest. Histologic evaluation showed a higher intervertebral bone volume/total volume ratio and a better interbody fusion in the MAACP/&agr;-TCP cage group than in the other two groups. Two MAACP/&agr;-TCP cages showed microcracks and the other three cages had maintained their original geometry. All MAACP/&agr;-TCP cages showed excellent biocompatibility. Conclusion. After 12 weeks, there was no significant difference between the MAACP/&agr;-TCP cage and the titanium cage in distractive properties and biomechanical properties. Compared with titanium cages, MAACP/&agr;-TCP cages showed an advanced interbody fusion. Although MAACP/&agr;-TCP cages developed cracks after only 12 weeks, they showed significantly better distractive properties, biomechanical properties, and an advanced interbody fusion than the tricortical iliac crest bone graft. Improvement should be made to insure the strength of MAACP/&agr;-TCP cage last at least 6 month after implantion.

A posterolateral approach to occipitoatlantoaxial ventral lesions: a report of the long-term follow-up of 23 cases.

Study Design: A retrospective study of consecutive patient series. Objectives: To report a technique of odontoidectomy using a transoccipitocervical posterolateral approach for occipitoatlantoaxial ventral lesions in a long-term follow-up study. Summary of Background Data: Occipitoatlantoaxial malformation and old traumatic dislocation usually cause compression of the high cervical spinal cord from a variety of different directions and angles, leading to high morbidity. The main objective of treatment is to relieve the anteroposterior compression and to restore the stability of the occipitocervical region. Currently, there are 2 approaches to perform the surgical procedure: (1) posterior decompression by suboccipital and occipitocervical fusion and internal fixation; and (2) decompression by a transoral approach to an odontoid resection. However, there are some short points, which need to be changed, such as the incomplete decompression (the former), narrow view, cerebrospinal fluid leakage, and the high infection rates. Methods: From 1999 to 2006, 23 patients with occipitoatlantoaxial ventral lesions were treated using a transoccipitocervical posterolateral approach for decompression. The procedure included an expansion of the foramen magnum, a resection of the posterior arch of atlas, a lateral occipitocervical epidural exposure to the odontoid and the C2 vertebra, and an excision of the odontoid. Thus, an anteroposterior decompression and occipitocervical spinal fusion was achieved. Neurological function, daily living ability, and the work ability of patients were assessed in a follow-up study. Results: A 28-year-old woman died of respiratory and circulatory failure 10 hours after operation. The remaining patients survived without postoperative infection. The neurological injury in 17 patients did not deteriorate, whereas 5 patients had decreased sensation in the upper limbs, and the elbow flexor muscle strength in 2 patients declined by 1 grade on the operation side. Short-term follow-up (3–6 mo, 22 cases) indicated that 19 patients recovered normal sensation with decreased limb muscle tension. Motor function was improved by >1 grade (5 patients with postoperative nerve injury recovered to preoperative levels or better). Long-term follow-up (>4 y) of 15 patients (10 patients by clinic visit and 5 patients by correspondence) indicated that the occipitoatlantoaxial regions were stable without local discomfort or loss of nerve function. Fourteen patients were able to care for themselves and some patients regained their ability to work. One patient felt no significant improvement after surgery and had no improvement in the quality of life. Conclusions: Transoccipitocervical posterolateral approach to occipitoatlantoaxial ventral lesions provides a broad and sterile operating field to perform anteroposterior decompression and occipitocervical spinal fusion simultaneously. Neurological improvement is significant, and the long-term follow-up results are satisfactory.

Anterior Retropharyngeal Reduction and Sequential Posterior Fusion for Atlantoaxial Rotatory Fixation With Locked C1-C2 Lateral Facet.

Study Design. Retrospective case series. Objective. To introduce a new type of atlantoaxial rotatory fixation (AARF) with a locked C1–C2 lateral facet and evaluate its therapeutic strategy. Summary of Background Data. AARF presenting with torticollis and limited neck motion is commonly seen in teenagers. Fielding and Hawkins’ classification is generally applied to AARF. Although conservative treatment is effective for acute AARF, it is often unsuccessful for chronic AARF, which ultimately requires surgery. We introduce a new type of chronic AARF with a locked C1–C2 lateral facet that does not fit into Fielding and Hawkins’ classification and describe the appropriate treatment. Methods. Eight patients who had chronic AARF with a unilaterally locked C1–C2 lateral facet were referred to our clinic. Reduction had failed after traction for 3 to 4 weeks. After open release and reduction using the anterior retropharyngeal approach, we applied posterior C1–C2 transpedicular screw fixation with an autologous iliac bone graft for stage I or II. Results. The anterior retropharyngeal approach provided direct access to the C1–C2 locked lateral facet. The patient in an overall poor condition (stage II) underwent delayed posterior C1–C2 arthrodesis. The others (stage I) underwent immediate posterior C1–C2 arthrodesis. All patients were followed up for an average of 14.8 months (5–37 mo). Three-dimensional computed tomography revealed C1-C-2 arthrodesis bone graft fusion after an average of 3.1 months (2–4 mo). There was no recurrence of symptoms and no dislocations or internal fixation device loosening or breakage. Conclusion. AARF with a locked C1–C2 lateral facet is a new type of AARF that cannot be classified using Fielding and Hawkins’ classification. The anterior retropharyngeal approach for the release and reduction of AARF, followed by posterior C1–C2 arthrodesis is an effective therapeutic strategy for AARF with a locked C1–C2 lateral facet. Level of Evidence: 4