Combined Anterior Posterior Surgery Research Articles

Posttraumatic glaucoma in southern China: A ten-year retrospective study.

To analyze posttraumatic glaucoma regarding its demographics, presentations, different causes, surgical modalities, and hospitalization burden among patients in southern China. This retrospective study investigated all individuals with posttraumatic glaucoma admitted to the Zhongshan Ophthalmic Center of Sun Yat-Sen University from January 2012 through December 2021. Out of 2211 cases, 64.82% had closed globe injury (CGI), 28.22% had open globe injury (OGI), and 6.96% had chemical injury (CI). The mean age of all patients was 44.45 ± 19.45 years old. Males (83.36%), rural patients (56.17%), and farmers (27.14%) predominantly had posttraumatic glaucoma. The most common external injury mechanism was blunt objects (37.82%). Compared with the other two groups, the majority of surgical modalities were cataract extraction (27.12%) in the CGI group, combined anterior-posterior surgery (34.79%) in the OGI group, and cyclocryotherapy/cyclophotoagulation (49.1%) in the CI group. The CI group had higher times of hospitalization (3.542 ± 0.242) and hospitalization duration (8.373 ± 0.743 days), whereas the OGI group had more operation expense ($ 1476.729 ± 11.047) and medical consumables expense per head ($ 962.578 ± 25.801). Blunt injury, males, adults, farmers, and rural patients were high-risk factors for posttraumatic glaucoma. Chemical-induced glaucoma management requires a longer hospitalization period, while OGI requires more medical expenditure. This knowledge provides a new reference for clinicians to accurately diagnose and intervene in posttraumatic glaucoma. It also suggests that more education and long-term surveillance are needed regarding the presence of glaucoma after ocular trauma.

Spinal infection after vertebral augmentation: a covert complication with serious havoc.

Vertebral augmentation, including percutaneous vertebroplasty (PVP) or kyphoplasty (PKP), is the current least invasive surgical option and has been widely used to treat the painful osteoporotic vertebral compression fractures (OVCF). However, the postoperative infections could be life-threatening, even though they rarely occur. Our studies aim to clarify the causation and outcomes of spinal infections following augmentation and meanwhile to identify the risk factors. A retrospective study was conducted on patients with OVCF who underwent PVP or PKP, and were subsequently admitted to our institution with postoperative spinal infection between January 2010 and December 2022. A total of 33 patients were finally included. The rate of spinal infection after augmentation in our single institute was 0.05% (2/3893). In addition to these 2 patients, the remaining 31 were referred from other hospitals. All 33 patients exhibited elevated inflammatory parameters, 14 patients presented with fever, and 9 patients experienced neurological deficits. Additionally, 29 patients had comorbidity and risk factors. Pathogens were identified in 26 patients, while only 7 patients were examined as culture negative. 27 patients underwent revision surgery and 6 patients only received conservative therapy. Anterior surgery was performed in 2 patients, while posterior surgery was performed in 20 patients. A combined anterior-posterior surgery was performed in 5 patients. At the final follow-up, 18 patients had unrestricted mobility, 10 patients required assistance from crutches or a walker for ambulation, 4 patients needed a wheelchair, and 1 patients died after revision surgery. Spinal infection after vertebral augmentation is rare, but it cannot be ignored. Surgeons should make every effort to detect the potential preoperative spondylitis or discitis. Once postoperative spinal infection is confirmed, a prompt intravenous antibiotic therapy is warranted. If medication therapy fails, revision surgery involving debridement and spinal reconstruction should be considered.

Oblique lateral interbody fusion for lumbosacral fractional curve correction in degenerative lumbar scoliosis.

In combined anterior-posterior adult spinal deformity surgery, the optimal combination of anterior and posterior procedures remains unclear. We aimed to demonstrate the radiological outcomes and relevant factors in oblique lateral interbody fusion (OLIF) for lumbosacral fractional curve (FC) correction combined with open posterior surgery in degenerative lumbar scoliosis (DLS). This study involved 42 consecutive patients with DLS who had a major curve (MC) ≥ 20° and an FC (L4 to S1) ≥ 10°, and underwent a combined anterior-posterior surgery Changes in the MC, FC, coronal balance distance, type of coronal imbalance, coronal/sagittal disc angle at L4-5 and L5-S1, L4 and L5 tilt, and sagittal parameters were examined. The associations between FC correction and demographic, surgical, and radiological factors were analysed. The FC decreased from 16.9 ± 7.3° preoperatively to 6.6 ± 4.4° at the last follow-up (P < 0.001). The coronal disc angle at L4-5 and L5-S1 were, respectively, 6.8 ± 2.2° and 6.0 ± 4.1° preoperatively and decreased to 2.2 ± 2.1 and 1.2 ± 1.3° at the last follow-up (both P < 0.001). The changes in FC were greater in uppermost instrumented level > T10 (P < 0.001), and associated with the preoperative FC (r = 0.820, P < 0.001), L4 tilt (r = 0.434, P = 0.007), and L5 tilt (r = 0.462, P = 0.003). OLIF at the FC combined with open posterior surgery is an effective combined anterior-posterior correction strategy in DLS.

Circumferential approach via dynamic position in OLIF combined with freehand screw pedicle fixation for lumbar tuberculosis requiring multilevel instrumentation: a 3-year retrospective study

PurposeTo advance a modified oblique lumbar interbody fusion (M-OLIF) achieving anterior debridement and posterior freehand instrumentation simultaneously in circumferential approach via dynamic position and compare with traditional combined anterior–posterior surgery (CAPS) in clinical and radiological evaluation.Patients and methodsInnovative freehand instrumentation in floating position was described. Consecutive patients having undergone surgeries for lumbar tuberculosis from 2017 January to 2019 December had been retrospectively reviewed. Patients with follow-ups for at least 36 months were included and divided into M-OLIF or CAPS group according to surgical methods applied. Outcomes included operation time, estimated blood loss, complication profile for safety evaluation; Vascular Analogue Scale (VAS) and Oswestry Disability Index (ODI) for efficacy evaluation; C-reactive protein and Erythrocyte Sedimentation Rate for tuberculosis activity and recurrence evaluation; X-ray and CT scan for radiological evaluation.ResultsTotally 56 patients had been enrolled in the study (26 for M-OLIF and 30 for CAPS). Compared with CAPS group, M-OLIF group illustrated significantly decreased estimated blood loss, operation time, hospital stay, and less postoperative morbidities. Meanwhile, M-OLIF group showed earlier improvement in VAS in 3 days and ODI in the first month postoperatively, without obvious discrepancy in further follow-ups. The overall screw accuracy in M-OLIF and CAPS group was 93.8% and 92.3% respectively, without significant difference in perforation distribution. ConclusionM-OLIF was efficient for lumbar tuberculosis requiring multilevel fixation, with reduced operation time and iatrogenic trauma, earlier clinical improvement compared with traditional combined surgery.

Effectiveness and postoperative rehabilitation of one-stage combined anterior-posterior surgery for severe thoracolumbar fractures with spinal cord injury

BACKGROUNDThoracolumbar fractures are generally combined with spinal cord injury to varying degrees, which may cause deterioration of the patients' condition and increase the difficulty of clinical treatment. At present, anterior or combined anterior-posterior surgery is preferred for severe thoracolumbar fractures.AIMTo investigate the effectiveness and postoperative rehabilitation of one-stage combined anterior-posterior surgery for severe thoracolumbar fractures with spinal cord injury.METHODSOne-hundred-and-twenty patients who received surgery for severe thoracolumbar fractures with spinal cord injury at our hospital from February 2018 to February 2020 were randomly enrolled. They were randomly divided into group 1 (one-stage combined anterior-posterior surgery, n = 60) and group 2 (one-stage anterior-approach surgery, n = 60). Treatment efficacy was compared between the two groups.RESULTSBlood loss was greater and the operation time was longer in group 1 than in group 2, and the differences were statistically significant (P < 0.05). Incision length, intraoperative X-rays, and length of hospital stay were not significantly different between the two groups (P > 0.05). Preoperative function of the affected vertebrae was not significantly different between the two groups (P > 0.05). In each group, the patients showed significant improvement after surgery. The anterior vertebral height ratio and the posterior vertebral height ratio in group 1 after surgery were significantly higher than those in group 2. The Cobb angle after surgery was significantly lower in group 1 than in group 2 (P < 0.05). The canal-occupying ratio of the affected vertebrae was not significantly different between the two groups (P > 0.05). Before surgery, there was no significant difference in the quality of life scores between the two groups (P > 0.05). The above indicators were significantly improved after surgery compared with before surgery in each group. In addition, these indicators were markedly better in group 1 than in group 2 after surgery (P < 0.05 for each).CONCLUSIONOne-stage combined anterior-posterior surgery effectively improves the function of the affected vertebrae and the life quality of patients with severe thoracolumbar fractures and spinal cord injury. This surgical approach is worthy of popularization in clinical use.

Long-term outcome after surgical treatment of Scheuermann's Kyphosis (SK).

A retrospective observational cohort study with a minimum follow-up of 10years of patients who underwent surgery for Scheurmann Kyphosis (SK). Evaluate the long-term clinical and radiological outcome of patients with SK who either underwent combined anterior-posterior surgery or posterior instrumented fusion alone. There is paucity of literature for long-term outcome studies on SK. The current trend is towards only posterior (PSF) surgical correction for SK. The combined strategy of anterior release, fusion and posterior spinal fusion (AF/PSF) for kyphosis correction has become historic relic. Long-term outcome studies comparing the two procedures are lacking in literature. 51 patients (30M: 21F) who underwent surgery for SK at a single centre were reviewed. Nineteen had posterior instrumentation alone (PSF) (Group 1) and 32 underwent combined anterior release, fusion with posterior instrumentation (AF/PSF) (Group 2). The clinical data included age at surgery, gender, flexibility of spine, instrumented spinal levels, use of cages and morcellised rib grafts (in cases where anterior release was done), posterior osteotomies and instrumentation, complications and indications for revision surgery. Preoperative flexibility was determined by hyperextension radiographs. The radiological indices were evaluated in the pre-operative, 2-year post-operative and final follow-up [Thoracic Kyphosis (TK), Lumbar lordosis (LL), Voustinas index (VI), Sacral inclination (SI) and Sagittal vertical axis (SVA)]. The loss of correction and incidence of JK (Junctional Kyphosis) and its relation to fusion levels were assessed. Complications and difference in outcome between the two groups were analyzed. The mean age at surgery for 51 patients was 20.6years who were followed up for a minimum of 10years (mean: 14years; range 10-16years). The mean age was 18.5 ± 2.2years and 21.9 ± 4.8years in groups 1 and 2, respectively. The mean pre- and 2-year post-operative ODIs were 32.6 ± 12.8 and 8.4 ± 5.4, respectively, in group 1 (p < 0.0001) and 30.7 ± 11.7 and 6.4 ± 5.7, respectively, in group 2 (p < 0.0001). The final SRS-22 scores in group 1 and 2 were 4.1 ± 0.4 and 4.0 ± 0.35, respectively (p = 0.88). The preoperative flexibility index was 49.2 ± 4.2 and 43 ± 5.6 in groups 1 and 2, respectively (p < 0.0001). The mean TKs were 81.4° ± 3.8° and 86.1° ± 6.0° for groups 1 and 2, respectively, which corrected to 45.1° ± 2.6° and 47.3° ± 4.8°, respectively, at final follow-up (p < 0.0001). The mean pre-operative LL angle was 60.0° ± 5.0° and 62.4° ± 7.6° in groups 1 and 2, respectively, which at final follow-up was 45.1° ± 4.4° and 48.1° ± 4.8°, respectively (p < 0.0001). The mean pre-operative and final follow-up Voustinas index (VI) in group 1 were 22.9 ± 2.9 and 11.2 ± 1.2, respectively, and in group 2 was 25.9 ± 3.5 and 14.0 ± 2.3, respectively. The mean pre-operative and final follow-up SI angle were 43.6° ± 3.3° and 31.2° ± 2.5° in group 1, respectively, and 44.3° ± 3.5° and 32.1° ± 3.5° in group 2, respectively (p < 0.0001). The pre-operative and final follow-up SVA in group 1 were -3.3 ± 1.0 cms and -1.3 ± 0.5 cms, respectively, and in group 2 was -4.0 ± 1.3cms and -1.9 ± 1.1cms, respectively (p < 0.0001). Though the magnitude of curve correction in the groups 1 and 2 was significant 36° vs 39° (p = 0.05), there was no significant difference in correction between the two groups. Proximal JK was seen in seven and distal JK in five patients were observed in the whole cohort. The long-term clinical outcomes for both PSF and AF/PSF are comparable with reproducible results. No difference was noted in loss of correction and outcome scores between the two groups. The correction of thoracic kyphosis (TK) had a good correlation with ODI. AF/PSF had much higher complications than PSF group. The objective of correcting the sagittal profile and balancing the whole spinal segment on the pelvis can be achieved through single posterior approach with fewer complications.

Cervical spine fracture-dislocation in patients with ankylosing spondylitis and severe thoracic kyphosis: Application of halo vest before and during surgical management

Cervical spine fracture-dislocation in patients with ankylosing spondylitis (AS) and severe thoracic kyphosis is extremely unstable. This study was performed to investigate the efficacy and safety of halo vest application before and during surgery for these patients. We retrospectively analyzed the case histories, operations, neurologic outcomes, follow-up data, and imaging records of 25 patients with AS and severe thoracic kyphosis who underwent surgical treatment of cervical fracture-dislocation in our department from 2008 to 2019. A halo vest was used to reduce and immobilize the fractured spinal column ends before and during surgery. The neurologic injury was evaluated using the American Spinal Injury Association (ASIA) impairment scale score, visual analog scale (VAS) score, and Japanese Orthopaedic Association (JOA) score before and after the operation. Twenty-two patients achieved closed anatomical reduction; two achieved successful reduction and one underwent failed reduction after halo vest application. No fracture site displacement occurred after movement into the prone position. No patients developed secondary neurological deterioration. The mean Cobb angle of thoracic kyphosis was 69.0° ± 12.3°. All patients underwent posterior or combined anterior-posterior surgery. The ASIA grade improved significantly (P < 0.01). The mean VAS and JOA scores also increased significantly after the operation (14.6 ± 3.0 vs. 10.4 ± 4.3 and 0.5 ± 0.6 vs. 4.6 ± 1.9, respectively; P < 0.01). One patient died 3 weeks after the operation. No other severe complications occurred. All patients had reached solid bony fusion by the 12-month follow-up. Use of a halo vest before and during the operation is safe and effective in patients with AS and severe thoracic kyphosis who develop cervical fracture-dislocation. This technique makes positioning, awake nasoendotracheal intubation, nursing, and the operation more convenient. It can also provide satisfactory reduction and rigid immobilization and prevent secondary neurologic deterioration.

Surgical management of complex post-tuberculous kyphosis among African patients: clinical and radiographic outcomes for a consecutive series treated at a single institution in West Africa.

Retrospective review of consecutive series. To assess the clinical and radiographic outcomes after surgical management of post-tuberculous kyphosis. Post-tuberculous (TB) kyphosis can lead to progressive pulmonary and neurological deterioration. Surgery is indicated to decompress neural elements and correct the spine deformity. Although posterior vertebral column resection (PVCR) has been established as the treatment of choice for severe TB kyphosis, there is paucity of studies on the clinical outcomes among patients treated in West Africa. Clinical and radiographic data of 57 patients (pts) who underwent surgical correction of post-TB kyphosis at a single site in West Africa between 2013 and 2018 (≥ 2-year follow-up in 36 pts, ≥ 1-year FU in 21 pts). Pre- and post-op SRS scores and radiographic outcomes were compared using Paired t test. 57 patients, 36M:21F. Mean age 19 (11-57years). 22/57 pts (39.3%) underwent pre-op halo gravity traction (HGT) for an average duration of 86days (8-144days). HGT pts had a higher baseline regional kyphosis (125.1 ± 20.9) compared to non-HGT pts (64.6 ± 31.8, p < 0.001). Post-HGT regional kyphosis corrected to 101.2 ± 23 (24° correction). 53 pts (92.9%) underwent posterior-only surgery and 4 (7.0%) combined anterior-posterior surgery. 39 (68.4%) had PVCR, 11 (19.3%) PSO, and 16 (28.1%) thoracoplasty. Intraoperative neuromonitoring (IOM) signal changes occurred in 23/57 pts (≈ 40%), dural tear in 5 pts (8.8%), pleural tear in 3 pts (5.3%), ureteric injury in 1 pt (1.7%), and vascular injury in 1 pt (1.7%). Post-op complications included four (7.0%) infection, three (5.3%) implant related, two (3.5%) radiographic (one PJK and one DJK), one (1.7%) neurologic, one (1.7%) wound problem, and two (3.5%) sacral ulcers. IOM changes were similar in the VCR (48.7%) and non-VCR (23.5%) pts, p > 0.05. Complication rates were similar among HGT and non-HGT groups. Significant improvements from baseline were seen in the average SRS Total and domains scores and radiographic measurements for patients who attained 2-year follow-up. PVCR ± HGT can provide safe and optimal correction in cases of severe post-TB kyphosis with good clinical and radiographic outcomes in underserved regions.

The usefulness and safety of the simultaneous parallel anterior and posterior combined lumbar spine surgery using intraoperative 3D fluoroscopy-based navigation (SPAPS)

BackgroundThe combined anterior-posterior surgery in the lateral decubitus position generally needs the intraoperative repositioning. However, prolonged surgical time and increased medical costs due to intraoperative repositioning have been problematic. In recent years, there have been reports of combined anterior-posterior procedure with a single position performing anterior and posterior fixation consecutively where the patient remains in the lateral decubitus position (single surgeon method-SS method). We had further advanced this method, and have adopted the Simultaneous Parallel Anterior and Posterior combined lumbar spine Surgery using intraoperative 3D fluoroscopy-based navigation (SPAPS method), where anterior and posterior procedure are performed independently by two spine surgeons. Methods66 cases that underwent SPAPS method (n=37) and SS method (n=29) from 2015 to 2019 at single institution were concluded in this study. The pre- and post-operative changes in the following were compared retrospectively between the two groups: surgical factors and clinical evaluations including JOA back pain evaluation questionnaire (JOABPEQ), visual analogue scale (VAS) on lower back pain, buttock/lower limb pain, and buttock/lower limb numbness, and Roland-Morris disability questionnaire (RDQ). ResultsThe SPAPS method was able to significantly reduce the surgical time (p=0.0025) compared to the SS method, and allowed a reduction of approximately 24.4 minutes per segment. The estimated blood loss were similar in both groups, and with regards to post-operative outcomes, both groups improved equally well. The rates of screw deviation and fusion were also similar. ConclusionsIn the case of performing the combined anterior-posterior surgery under a single position, the anterior and posterior procedure can be performed independently and simultaneously by two spine surgeons by utilizing the 3D fluoroscopy-based navigation. The surgical time can be significantly reduced by approximately 24.4 minutes per segment comparing to the SS method.

Adult sacrococcygeal teratoma: a retrospective study over eight years at a single institution.

To determine the clinical, imaging, and histological features, and surgical resection modalities and outcomes of adult sacrococcygeal teratoma (SCT). Adult patients with histopathologically diagnosed SCT were enrolled in our hospital between August 2010 and August 2018. Each patient's characteristics and clinical information were reviewed. There were 8 patients in the study (2 males, 6 females) with a median age of 34 years (range, 18-67 years). The time to clinical symptoms was 14 d to 35 years, with a median time of 4 years. Six patients presented with symptoms of sacrococcygeal pain, and four with signs of sacrococcygeal mass and ulceration in the sacrococcygeal region. Six patients were evaluated using a combination of computed tomography (CT) and magnetic resonance imaging (MRI). All patients showed a presacral tumor with heterogeneous intensity on CT images. All patients underwent surgical treatment, including 6 parasacral, 1 transabdominal, and 1 combined anterior-posterior surgery cases. Seven patients were histopathologically diagnosed with benign mature SCT, and have shown no recurrence. One patient had malignant SCT, with recurrence at 84 months after surgery. After a second surgery, the patient had no recurrence within 6 months follow-up after re-resection. Our retrospective study demonstrated: (1) adult SCT is difficult to diagnose because of a lack of typical clinical symptoms and signs; (2) a combination of CT and MRI examination is beneficial for preoperative diagnosis; (3) the choice of surgical approach and surgical resection modality depends on the size, location, and components of the tumor, which can be defined from preoperative CT and MRI evaluation; (4) most adult SCTs are benign; the surgical outcome for the malignant SCT patient was good after complete resection. Even for the patient with recurrent malignant SCT, the surgical outcome was good after re-resection.

One-stage combined anterior-posterior surgery for thoracic and lumbar spinal tuberculosis

Context: Surgical intervention is imperative when spinal tuberculosis (TB) is accompanied by severe spinal damage or kyphotic deformity. As one-stage anterior-only or posterior-only surgery for thoracic and lumbar spinal TB has many disadvantages, combined anterior-posterior surgery was proposed to be a more effective strategy. Objective: To examine the clinical outcomes of one-stage combined anterior-posterior surgery for patients with spinal TB. Design: Retrospective investigation design. Setting: All patients were enrolled at the Hangzhou Red Cross Hospital between August 2002 and October 2014. Participants: Sixty-seven patients with thoracic and lumbar spinal TB were studied. Interventions: All patients were treated with one-stage surgery using a combined anterior-posterior approach. Outcome measures: The patients were evaluated preoperatively and postoperatively by measuring their neurological function using the visual analogue scale (VAS) and the Frankel grades, and spinal deformity using the Cobb angle and radiological examinations. All patients were followed up for at least 11 months and up to 96 months. Results: There was a significant postoperative improvement in neurological outcomes, according to VAS scores and Frankel grades. Kyphotic angles were corrected significantly and were maintained during the final follow-up. Bone fusion was achieved within 4–7 months. Conclusion: One-stage surgical treatment via a combined anterior-posterior approach is an effective and feasible method for treating spinal TB.

Thoracolumbar trauma with delayed presentation

Thoracolumbar injuries presenting in a delayed manner are uncommon, and their etiologies are varied ranging from missed injuries, wrong initial management, and delayed presentation for treatment. While improvements in healthcare awareness and delivery systems worldwide have improved the acute management of spinal injuries, the diagnosis and management of delayed spinal injuries remains a challenge to the treating physician regarding intraoperative difficulties, perioperative complications, and subsequent rehabilitation. Sequel of delayed presentation such as neurological deficit, spinal deformity, capsular contractures, muscle wasting, pulmonary and urinary tract infections and pressure sores have a significant bearing on the outcomes of management of delayed spinal trauma. Indications for surgical management include axial pain, neurological deficit, and kyphotic deformity. Management options include anterior corpectomy and fusion, combined anterior posterior surgery, and an all-posterior spinal decompression and deformity correction.

One-stage surgical treatment of cervical spine fracture-dislocation in patients with ankylosing spondylitis via the combined anterior-posterior approach.

The aim of the article is to investigate the efficacy and safety of 1-stage surgical therapy via combined anterior–posterior approach on cervical spine fracture in patients with ankylosing spondylitis (AS).We retrospectively analyzed profiles of 12 AS patients with severe fracture-dislocation of cervical spine received 1-stage combined anterior–posterior surgery in our hospital from October, 2013, to October, 2015, including clinical characteristics, follow-up data, and imaging records. We compared the parameters before and after surgery on the basis of neurological function, bone fusion, Cobb angles of operation segment, Barthel index (BI) score, and incidence rate of complications.A total of 12 patients received 1-stage surgery via combined anterior–posterior approach within 3 days after injury. No severe complications and death occurred. All patients received the successfully anatomical reduction of fracture-dislocation, in which 9 achieved function restoration. The latest follow-up showed the neurological function status of patients was improved. The Cobb angles of operation segments were recovered; the rate of bone fusion was 66.7% at 3 months and 100% at 6 months post-operation. The BI score was improved, 4 cases of moderate dependence and 8 of slight dependence at the latest follow-up compared to 10 of severe dependence and 2 of moderate dependence preoperation. In no cases did severe complications from implanted instrumentation occur.It was high efficacy and safety that the surgical therapy was performed on cervical fracture-dislocation in AS patients by the 1-stage combined anterior–posterior approach. The key of the surgery is the robust stabilization and full decompression of fracture spine at early stage. In addition, if spinal anatomical reduction of fracture segments is difficult to be achieved, the functional restoration should be adopted during the surgery.

Surgical strategies based on four clinical classifications of lumbosacral junction tuberculosis

Objective To study the efficacy and safety of four surgical techniques of tuberculosis of lumbosacral junction retrospectively. Methods Between Jul 2001 and Jan 2013, 79 patients with lumbosacral spinal tuberculosis underwent surgery. Antituberculous chemotherapy and nutrition support prior to surgery were used for at least two weeks. 45 patients underwent single stage radical debridement, fusion and anterior instrumentation (A group). 18 patients underwent combined anterior and posterior spinal surgery (AP group), 10 patients underwent transpedicular drainage, posterior instrumentation, and fusion (P group), and 6 patients underwent anterior radical debridement (D group). All the patients were treated by antituberculous chemotherapy for 18 months and followed regularly. The operation duration, blood loss, clinical status, ESR, VAS, ODI, roentgenogram and 3D-CT were concerned to estimate the progress of tuberculosis. Radiographs were analyzed before surgery, immediately after surgery, and at the final follow-up examination to assess the result of anterior fusion and maintenance of correction. Results There was no injury of blood vessel, ureter or cauda equina during surgery. The mean follow-up period was 23 months (range 18-42 months). No obvious loss of deformity correction was observed. There was no recurrence, no tuberculous peritonitis, and no incidence of impotence or retrograde ejaculation in any of these patients. The average operating duration (min) were 144.31±23.18, 444.72± 141.63, 351.50±85.25, 90.00±29.66, respectively; The average blood loss (ml) were 266.67±104.45, 988.99±488.26, 890.00± 306.23, 200.00±104.88, respectively; The average Pre-op VAS were 4.71±1.79, 5.22±1.48, 3.30±1.64, 2.50±1.52, respectively; The average last follow-up VAS were 0.89±0.68, 0.90±0.74, 1.00±0.63, respectively; The average Pre-op ODI(%)were 29.64± 7.85, 32.17±7.59, 28.20±4.26, 20.67±4.63, respectively; The average last follow-up ODI(%)were 5.09±3.59, 4.78±3.78, 4.80± 3.39, 4.00±1.18, respectively; The average Pre-op lumbosacral angle (°)were 20.61±4.92, 23.78±5.84, 25.10±4.28, 21.67± 4.27, respectively; The average Post-op lumbosacral angle were 27.17±3.66, 30.56±5.31, 32.10±4.01, 24.83±2.32, respectively; The average last follow-up lumbosacral angle were 23.89±3.12, 27.00±5.46, 29.00±4.85, 23.33±2.50, respectively. Conclusion Single stage anterior interbody fusion with anterior instrumentation worked effectively to stabilize lumbosacral junction (less invasive, short surgical duration, no injury of posterior column). Anterior interbody fusion combined with posterior instrumentation was recommended for patients with extensive bone defect and low iliocava junction. Key words: Lumbar vertebrae; Sacrum; Tuberculosis, spinal; Treatment outcome; Follow-up studies

Incidence and risk factors for proximal junctional kyphosis: a meta-analysis.

To analyse the incidence and risk factors associated with proximal junctional kyphosis (PJK) following spinal fusion, we collect relative statistics from the articles on PJK and perform a meta-analysis. An extensive search of literature was performed in PubMed, Embase, and The Cochrane Library (up to April 2015). The following risk factors were extracted: age at surgery, gender, combined anterior-posterior surgery, use of pedicle screw at top of construct, hybrid instrumentation, thoracoplasty, fusion to sacrum (S1), preoperative thoracic kyphosis angle (T5-T12) >40°, bone mineral density (BMD) and preoperative to postoperative sagittal vertical axis (SVA difference) >5cm. Data analysis was conducted with RevMan 5.3 and STATA 12.0. A total of 14 unique studies including 2215 patients were included in the final analyses. The pooled analysis showed that there were significant difference in age at surgery >55years old (OR 2.19, 95% CI 1.36-3.53, p=0.001), fusion to S1 (OR 2.12, 95% CI 1.57-2.87, p<0.001), T5-T12 >40° (OR 2.68, 95% CI 1.73-4.13, p<0.001), low BMD (OR 2.37, 95% CI 1.45-3.87, p<0.001) and SVA difference >5cm (OR 2.53, 95% CI 1.24-5.18, p=0.01). However, there was no significant difference in gender (OR 0.98, 95% CI 0.74-1.30, p=0.87), combined anterior-posterior surgery (OR 1.55, 95% CI 0.98-2.46, p=0.06), use of pedicle screw at top of construct (OR 1.55, 95% CI 0.67-3.59, p=0.30), hybrid instrumentation (OR 1.31, 95% CI 0.92-1.87, p=0.13) and thoracoplasty (OR 1.55, 95% CI 0.89-2.72, p=0.13). The incidence of PJK following spinal fusion was 30% (ranged from 17 to 62%) based on the 14 studies. The results of our meta-analysis suggest that age at surgery >55years, fusion to S1, T5-T12 >40°, low BMD and SVA difference >5cm are risk factors for PJK. However, gender, combined anterior-posterior surgery, use of pedicle screw at top of construct, hybrid instrumentation and thoracoplasty are not associated with PJK.

Individualized transoral anterior surgery for complex craniocervical junction disorder with assistance of 3D printing technology

Objective To evaluate the value of 3D printing technology in transoral anterior surgery for complex craniocervical junction disorder. Methods From December 2009 to December 2013, 48 cases of atlantoaxial dislocation associated with complex craniocervical malformation were operated with the assistance of 3D printing technology. There were 19 males and 29 females, with mean 35 years of age (range, 6 to 59 years). Preoperative complications included 28 cases of atlas assimilation, 19 cases of os odontoideum, 17 cases of C2-3 fusion, 1 case of C2-5 fusion, 1 case of C1 posterior arch disconnection, and 1 case of C1 posterior arch aplasia. All cases had symptoms of spinal compression such as numbness and weakness of the extremity, standing or walking unsteady, etc. Preopoerative cervical MRI examinations showed the enlargement of anterior atlas-dens interval (ADI) or atlantoaxial dislocation. All cases' CT data in Dicom form were input into the Simpleware software to reconstruct 3D image, and then the image in STL form was imported to the 3D printer to make a fast prototyping model for the operation with same size as the cases' cervical spine. Based on above works, all cases underwent transoral anterior reduction plate (TARP) fixation in the craniocervical junction zone, including combined anterior-posterior surgery in 1 case. ADI was measured to evaluate the reduction of atlantoaxial dislocation, cervical-medullary angle (CMA) was measured to evaluate the improvement of compression on the medulla, and Japanese Orthopedic Association (JOA) scoring system was used to evaluate the improvement of spinal function. Results All cases went through successful surgery. Mean operation time was (145±45)min and mean blood loss was (53±15)ml. A total of 96 atlas lateral mass screws, 62 reverse axis pedicle screws and 36 axis vertebral body screws, 1 posterior axis pedicle screw and 1 axis translaminar screw were used. Postoperative CT scans showed all screw trajectories were good except that 4 reverse axis pedicle screws violated into the vertebrae artery foramen due to large outward inclination angle. No neurologic defect was found in all cases. Excellent rate of screw placement was 98%. Postoperative CT reconstruction images showed significant atlantoaxial reduction. ADI improved from (8.7±4.9)mm preoperatively to (2.7±1.9)mm postoperatively (P<0.05). CMA changed from preoperative (123±17)° to postoperative (159±18)° (P<0.05). All cases had obvious improvement of spinal compression symptoms. JOA scores improved from (9.5±1.7)points preoperatively to (15.7±0.9)points at 3 months postoperatively (P<0.05). All cases achieved bone union at a follow-up of 10-58 months. Conclusion 3D printing technology is helpful to the operation plan and manipulation for atlantoaxial dislocation associated with complex craniocervical deformities, which may improve the accuracy and safety during the procedure. Key words: Atlanto-axial joint; Dislocations; Imaging, three-dimensional; Computer-assisted design

Two-stage posterior correction in the treatment of severe rigid neuromuscular scoliosis: Case report

Background: Treatment of severe rigid scoliosis is challenging. Traditional methods such as combined anterior and posterior surgery with or without perioperative halo-gravity traction, or more aggressive one-stage posterior correction methods carry many drawbacks and potential risks. To overcome this, a staged posterior approach was raised. We report a patient successfully treated with this new method. Case Report: A 15-year-old boy was diagnosed to have neuromuscular scoliosis of unknown origin. The Cobb angle was 110 degrees at T9- L4, and 77 degrees at T2- T9. The preoperative pelvic tilt was 16 degrees. Bending views showed the flexibility about 10%. Two-stage correction was performed. The major curve magnitude reduced 40 degrees or 36.3% after the first-stage surgery, and 25 degrees or 35.7% after the second-stage surgery. The final correction rate was 59.1%. The postoperative pelvic tilt reduced to 6 degrees. No complication such as infection, neurological injury or respiratory compromise was found. Discussion: This two-stage approach has many advantages, including preventing pulmonary function deterioration, no need of halo traction, avoiding too much manipulation of the spinal cord during each surgery, and facilitating curve correction. However, we should also take into consideration of its large blood loss, nutritional demand and potential risk of infection. Conclusion: Two-stage posterior correction is a reasonable and suitable alternative correction strategy in the treatment of severe rigid scoliosis. However, further study is needed to verify its validity and safety.

Combined anterior and posterior segment surgery in the treatment of penetrating eye injuries with small intraocular foreign body

Objective To investigate the clinical efficacy of combined anterior and posterior segment surgery in early treatment of penetrating eye injuries with small intraocular foreign body. Methods Twenty-two eyes of 22 patients suffered penetrating eye injuries with small intraocular foreign bodies underwent the combined operations of anterior and posterior eye segment 2-4 days after emergent debridement and suturing and according to their conditions different surgical procedures were preformed. Anterior segment surgery included anterior chamber forming, iris suture laceration, cataract extraction and intraocular lens implantation and posterior segment surgery included vitrectomy, foreign body removal, retinal laser photocoagulation around the injury site and C3F8 gas or silicone oil tamponade. The surgery efficacy and the complications were analyzed from 3months to 12 months. Silicone oil was removed 4-5month after operation. Results Intraocular foreign bodies were removed in once operation in all cases. All the patients got the intraocular lens implantation at the same time during the surgery. No serious complication happened, such as endophthalmitis, intraocular lens shift, uveitis, retinal detachment, choroidal detachment or secondary glaucoma. All the cases got the best corrected visual acuity improved from light perception -0.1 before operation to 0.05-0.8. Conclusion Combined anterior and posterior segment surgery in early treatment of penetrating eye injury with small intraocular foreign body can achieve good clinical efficacy. Key words: Foreign body, intraocular; Injury, ocular, penetrating; Cataract, traumatic; Lens, intraocular; Vitrectomy

Prophylactic inferior vena cava filter placement prior to lumbar surgery in morbidly obese patients: Two-case study and literature review.

Background:Preoperative “prophylactic” placement of inferior vena cava (IVC) filters in morbidly obese patients (e.g., body mass index [BMI] >40 or BMI over 35 with hypertension/diabetes) undergoing multilevel decompressive lumbar laminectomies may reduce the risk of postoperative pulmonary embolism (PE), and death.Methods:Two patients, ages 69 and 68, with morbid obesity (BMI's of 40.4 and 37.5 both with hypertension and diabetes), received prophylactic IVC filters prior to L1–S1 laminectomies. Intraoperatively and postoperatively, both received alternating compression stocking prophylaxis, and received subcutaneous heparin 5000 U q12 h 48 h after surgery until discharge; none developed deep venous thrombosis (DVT) or PE, and both filters were uneventfully removed within 3 postoperative months.Results:The spinal surgical literature largely supports the placement of IVC filters for major risk factors; obesity (BMI >40), a history of DVT/PE, cancer, fusions, hypercoagulation syndromes, pulmonary/circulatory disorders, preoperative/postoperative immobility, staged procedures (five spinal levels), combined anterior-posterior surgery, iliocaval manipulation, age >80, and prolonged surgery (e.g., >261 min vs. >8 h). Although the safety and efficacy of prophylactic IVC filters for spine surgery in patients with morbidly obesity are well substantiated, those for bariatric patients are less clear.Conclusions:Prophylactic IVC filters were successfully placed/retrieved in 2 morbidly obese patients, ages 68 and 69, undergoing L1–S1 lumbar decompressions. Although the spine surgery literature documents the safety/efficacy of prophylactic IVC filters in patients with morbid obesity, the bariatric literature still has major concerns.

Surgical technique and clinical efficacy of giant cell tumor of axis

Objective To evaluate the prognostic effects of treatment of giant cell tumor of axis by tumor resection associated with biological reconstruction and internal fixation.Methods From 2009 to 2013,5 patients that had giant cell tumor of axis underwent combined anterior and posterior surgery program.The posterior use pedicle screw system to stabilize the cervical spine,then the anterior use stemocleidomastoid inner edge of the mandibular angle approach to reveal the axis.When the cortex of vertebrae was relatively complete,.When the cortical bone was destroyed,vertebra was resected and the ilium was taken to reconstruct the defect.Adjuvant radiotherapy and diphosphate treatment was used postoperatively.Regular follow-up for X-ray,3D CT and MRI examination were done to observe the tumor recurrence,healing of biological reconstruction and function of cervical vertebra.Results The follow-up time was 12-60 months.No recurrence of the tumor was observed in all patients.The 3 patients accepted beta-TCP implanting after curettage was observed with fuzzy internal structure 3 months after surgery,and the grafted bone fusion can be found 12 months after surgery.The 2 ilium grafted patients can be found with bone fusion with the adjacent vertebrae 6 months after surgery.The bend and stretch function of cervical vertebrae of the 5 patients returned to normal after 3months.The biological healing of bone graft,cervical stability and activity were satisfied.The local pain and neurological symptoms were relieved.Conclusion Anterior and posterior surgery program in combination with biological reconstruction and adjuvant radiotherapy provide an excellent option for treatment of giant cell tumor of axis.The dens could be retained to keep the function of occipital cervical when the odontoid bone cortex is not destructed. Key words: Axis; Giant cell tumor of bone; Bone transplantation