Thigh Numbness Research Articles

Navigation and Robotic-Assisted Single-Position Prone Lateral Lumbar Interbody Fusion: Technique, Feasibility, Safety, and Case Series

Single-position prone lateral interbody fusion is a recently introduced technical modification of the minimally invasive retroperitoneal transpsoas approach for lateral lumbar interbody fusion (LLIF). Several technical descriptions of single-position prone LLIF have been published with traditional fluoroscopy for guidance. However, there has been no investigation of either three-dimensional computed tomography-based navigation for prone LLIF or integration with robotic assistance platforms with the prone lateral technique. This study evaluated the feasibility and safety of spinal navigation and robotic assistance for single-position prone LLIF. Retrospective review of medical records and a prospectively acquired database for a single center was performed to examine immediate and 30-day clinical and radiographic outcomes for consecutive patients undergoing single-position prone LLIF with spinal navigation and/or robotic assistance. Nine patients were treated, 4 women and 5 men. Mean age was 65.4 years (range, 46-75 years), and body mass index was 30.2 kg/m2 (range, 24-38 kg/m2). The most common surgical indication was adjacent segment disease (44.4%), followed by pseudarthrosis (22.2%), spondylolisthesis (11.1%), degenerative disc disease (11.1%), and recurrent stenosis (11.1%). Postoperative approach-related complications included pain-limited bilateral hip flexor weakness (4/5) and pain-limited left knee extension weakness (4/5) in 1 patient (11.1%) and right lateral thigh numbness and dysesthesia in 1 patient (11.1%). All cages were placed within quarters 2-3, signifying the middle portion of the disc space. There were no instances of misguidance by navigation. Integration of spinal navigation and robotic assistance appears feasible, accurate, and safe as an alternative to fluoroscopic guidance for single-position LLIF.

Laparoscopic repair for recurrent inguinal hernia after previous laparoscopic approach

Background and aim Relaparoscopic repair of recurrent inguinal hernia carries a lot of challenges. The encountered complex surgical technique is assumed to have greater possibilities of surgical complications with consequent higher recurrence rates. The aim of this study was to evaluate the feasibility, safety, and reliability of laparoscopic approach for recurrent inguinal hernia after previous laparoscopic repair. Patients and methods Records of 33 patients with 34 recurrent inguinal hernias after previous laparoscopic management have been retrospectively revised. The performed procedure for second repair was transabdominal preperitoneal repair for all the cases. Data of perioperative complications, immediate postoperative course, and hernia recurrence were collected and analyzed. Results No intraoperative complications were encountered. Postoperative pain was recorded as moderate. The mean follow-up period ranged from 14 to 40 months with a mean of 24.82±6.9. During the follow-up period, three (9%) cases developed groin seroma and one (3%) case had transient thigh numbness. Of the patients, 85% returned to normal daily activities within 14 days postoperatively. Two patients had rerecurrence of the hernia and they were managed by Lichtenstein repair. Conclusion Relaparoscopic repair of recurrent inguinal hernia is safe and applicable. The procedure should be performed with experienced hands.

Protection of L1 nerve roots by pre-relieve tension in parallel endplate osteotomy for severe rigid thoracolumbar spine deformity

BackgroundThis is a retrospective study of the use of parallel endplate osteotomy (PEO) for correction of severe rigid thoracolumbar spine deformity.MethodsFrom July 2016 to January 2019, 12 patients with severe rigid thoracolumbar spine deformity underwent PEO on T12 or L1 vertebrae were studied.ResultsFollowing PEO at T12 or L1, the mean kyphosis and scoliosis correction rates reached 77.0 ± 8.9% and 75.5 ± 8.0%, respectively and the intraoperative estimated blood loss was 1950 ± 1050 mL, and the mean operative time was 6.98 ± 4.02 h. The SF-36 scores of physical function, role-physical, bodily pain, general health, vitality, social function, role-emotional and mental health changed from 63 ± 28, 50 ± 25, 50 ± 30, 34 ± 19, 53 ± 28, 45 ± 30, 30 ± 36 and 54 ± 18 at baseline to 83 ± 18, 69 ± 19, 72 ± 12, 66 ± 21, 75 ± 15, 72 ± 22, 66 ± 34 and 76 ± 12 at 1 year postoperatively, 83 ± 8, 68 ± 32, 83 ± 17, 73 ± 17, 82 ± 18, 76 ± 26, 70 ± 37 and 88 ± 12 at 18 months postoperatively, 86 ± 6, 83 ± 33, 90 ± 16, 81 ± 16, 89 ± 14, 88 ± 25, 83 ± 17 and 94 ± 10 at 24 months postoperatively, respectively (P < 0.01). Three patients had symptoms of L1 nerve root injury, as reflected by lower limb weakness and inner thigh numbness on knee extension and hip flexion, which was further confirmed by electromyography.ConclusionsPEO is easier to operate, and the spinal cord and nerve root are under direct vision and can effectively and safely correct severe rigid thoracolumbar spine deformity with satisfactory clinical results. However, it is important to identify, separate and protect L1 nerve roots during surgery in cases where patients have symptoms of back pain, muscle weakness and leg numbness on the convex side after surgery.

Early effectiveness of oblique lateral interbody fusion combined with pedicle screw fixation via small incision Wiltse approach for lumbar spondylolisthesis

To investigate the early effctiveness of oblique lateral interbody fusion (OLIF) combined with pedicle screw fixation via small incision Wiltse approach for the treatment of lumbar spondylolisthesis. Between January 2016 and December 2016, 21 patients with lumbar spondylolisthesis were treated with OLIF and pedicle screw fixation via small incision Wiltse approach. There were 9 males and 12 females, aged 57-73 years, with an average age of 64.5 years. The disease duration was 24-60 months, with an average of 34.6 months. All cases were spondylolisthesis at L 4 (15 cases of degreeⅠ, 6 cases of degreeⅡ); 1 case had vertebral arch isthmus, and 20 cases had spinal stenosis. Japanese Orthopaedic Association (JOA) scoring system was used to evaluate the effectiveness before operation and at last follow-up. Before operation and at 2 days after operation, anteroposterior and lateral X-ray films and CT were taken to measure the sagittal diameter and cross-sectional area of the spinal canal, and calculate the intervertebral height and degree of spondylolisthesis. At 6 months after operation, the intervertebral fusion was evaluated by CT. The operation time was 120-180 minutes, with an average of 155 minutes; the intraoperative blood loss was 100-340 mL, with an average of 225.5 mL. One patient had slight injury of lower endplate, 1 patient had numbness of thigh and weakness of hip flexion after operation, 1 patient had sympathetic nerve trunk injury. All the cases were followed up 12-18 months, with an average of 14.3 months. The symptoms of low back pain, leg pain, and numbness of lower limbs significantly relieved after operation, and there was no complication such as protrusion of fusion cage, screw breakage, and endplate collapse. At 2 days after operation, the intervertebral height, degree of spondylolisthesis, sagittal diameter of spinal canal, and cross-sectional area of spinal canal significantly improved compared with preoperative ones ( P<0.05). At 6 months after operation, CT showed that 1 patient had poor interbody fusion (grade Ⅲ), the other 20 patients had good interbody fusion (grade Ⅰ and Ⅱ), and the interbody fusion rate was 95.2%. At last follow-up, JOA score of lumbar spine significantly increased compared with that before operation ( t=24.980, P=0.000). OLIF combined with pedicle screw fixation via small incision Wiltse approach for the lumbar spondylolisthesis has minimally invasive features, such as less trauma, fewer complications, and higher intervertebral fusion rate. It is a safe and effective method.

Traction Time, Force and Postoperative Nerve Block Significantly Influence the Development and Duration of Neuropathy Following Hip Arthroscopy

To (1) evaluate the individual and combined effects of traction time and traction force on postoperative neuropathy following hip arthroscopy, (2) determine if perioperative fascia iliaca block has an effect on the risk of this neuropathy, and (3) identify if the these items had a significant association with the presence, location, and/or duration of postoperative numbness. Between February 2015 and December 2016, a consecutive cohort of hip arthroscopy patients was prospectively enrolled. Traction time, force, and postoperative nerve block administration were recorded. The location and duration of numbness were assessed at postoperative clinic visits. Numbness location was classified into regions: 1, groin; 2, lateral thigh; 3, medial thigh; 4, dorsal foot; and 5,preoperative thigh or radiculopathic numbness. A total of 156 primary hip arthroscopy patients were analyzed, 99 (63%) women and 57 (37%) men. Mean traction time was 46.5 ± 20.3minutes. Seventy-four patients (47%) reported numbness with an average duration of 157.5 ± 116.2days. Postoperative fascia iliaca nerve block was a significant predictor of medial thigh numbness (odds ratio, 3.36; 95% confidence interval, 1.46-7.76; P= .04). Neither traction time nor force were associated with generalized numbness (P= .85 and P= .40, respectively). However, among those who experienced numbness, traction time and force were greater in patients with combined groin and lateral thigh numbness compared with those with isolated lateral thigh or medial thigh numbness (P= .001 and P= .005, respectively). Postoperative neuropathy is a well-documented complication following hip arthroscopy. Concomitant pudendal and lateral femoral cutaneous nerve palsy may be related to increased traction force and time, even in the setting of low intraoperative traction time (<1hour). Isolated medial thigh numbness is significantly associated with postoperative fascia iliaca blockade. IV, case series.

Fascia Iliaca Blockade With the Addition of Liposomal Bupivacaine Versus Plain Bupivacaine for Perioperative Pain Management During Hip Arthroscopy: A Double-Blinded Prospective Randomized Control Trial

To determine in a prospective, randomized fashion whether liposomal bupivacaine extends the effectiveness of decreased pain scores and reduces narcotic requirements following hip arthroscopy when used in addition to a fascia iliaca blockade with plain bupivacaine alone. Double-blinded prospective randomized controlled trial of participants undergoing hip arthroscopy. Randomized to receive a fascia iliaca blockade with 40mL 0.25% plain bupivacaine (100mg; control group) or 20mL 0.5% plain bupivacaine (100mg) plus 20mL liposomal bupivacaine (266mg; study group). The primary outcome was Defense and Veterans Pain Rating Scale (DVPRS) scores in the postanesthesia care unit and on postoperative days (POD) 1, 2, 3, and 14. Secondary outcomes included postoperative opioid consumption and subjective loss of anterior thigh sensation. Seventy-four patients were enrolled, and 70 completed the study; 37 were randomized to the control group and 33 to the study group. There was no significant difference in postoperative DVPRS scores at any time point. There was no significant difference in total postoperative opioid use during any postoperative time points. While most patients reported anterior thigh numbness at discharge, significantly more patients in the study group reported anterior thigh numbness at POD2 (control, 19/37 numb vs study, 32/33 numb; P < .0001) and at POD3 (control, 8/37 numb vs study, 26/33 numb; P < .0001). In this prospective evaluation comparing plain bupivacaine versus the liposomal formulation administered via a fascia iliaca blockade there were no significant differences in postoperative pain scores and narcotic pill usage. Given the highly significant findings of prolonged anterior thigh numbness out to POD3 in patients who received liposomal bupivacaine, this formulation did exhibit prolonged effects; however, it did not provide improved pain control when used in this surgical population, likely due to the innervation of the hip capsule from differential nerve plexi. Given the 6-fold increased cost of using the liposomal formulation, we are unable to recommend its use via a fascia iliaca blockade for hip arthroscopy. Level I, therapeutic study.

Resection of a Pediatric Intramedullary Spinal Cord Tumor: 2-Dimensional Operative Video

This video is a case presentation and demonstration of surgical approach to a pediatric intramedullary spinal cord tumor (IMSCT). IMSCT can be associated with significant morbidity and aggressive resection is associated with more favorable long-term outcome. A 13-yr-old male presented to clinic for evaluation of rapidly progressive scoliosis to the left. A contrasted MRI revealed expansion of the spinal cord with edema from approximately T3 to T9 and an enhancing lesion at T6-7 associated with a small cyst. On neurological exam, the patient had good strength throughout, but decreased sensation in the T7-12 dermatomes and decreased deep tendon reflexes in his lower extremities. The procedure included T5 to T8 osteoplastic laminectomies and IMSCT resection followed by spinal reconstruction. Intraoperative ultrasound was used to verify the tumor's location and somatosensory and motor evoked potentials were monitored throughout the procedure. Intraoperative consultation with neuropathology suggested the mass was likely pilocytic astrocytoma; therefore, it was aggressively debulked using microsurgical techniques including an ultrasonic aspirator. There was a plane between the tumor and spinal cord white matter allowing for a gross total resection. Postoperatively the patient had good strength throughout and sensation was intact except for continued numbness of the anterior thigh bilaterally. Immediate postoperative MRI demonstrated complete resection of the tumor without residual enhancement and the patient was ultimately discharged home on postoperative day 8. Follow-up imaging remained stable at 2 mo and the patient continued to do well neurologically. All patient identifiers were removed from the presented material, thus, patient consent was not obtained.

Prospective evaluation of lateral femoral cutaneous nerve injuries during periacetabular osteotomy.

Periacetabular osteotomies (PAOs) are used to treat acetabular dysplasia in younger patients, but are not without morbidity. Lateral femoral cutaneous nerve (LFCN) injuries are commonly associated with the approach for PAOs, but the true incidence and rate of resolution is not known. The purpose of this prospective study was to determine the incidence of LFCN injuries after PAO using an innovative nerve conduction study (NCS) and to report the patient-reported outcomes. We prospectively enrolled 23 patients (24 hips) undergoing PAOs to have pre- and post-operative NCSs at a mean of 12 weeks post-operative. Patients were followed prospectively. Patients were contacted 3 years post-operatively via phone to determine the presence and severity of symptoms. Patient-reported outcome scores were also correlated with patient symptoms. Patients (91%) reported one or more LFCN symptoms post-operatively. The most common symptoms were numbness (91%), tingling (36%), pain (18%) and burning (9%). Patients (67%) had evidence of LFCN injury based on NCSs. Symptoms (40%) resolved 4 months post-operatively. Two-thirds of patients had continued symptoms at 3 years. Only 1 patient required treatment. The incidence of LFCN injury after PAO is 90%, two-thirds of which can be identified objectively by NCS. Numbness is the most common symptom. LFCN symptoms (40%) resolve by 4 months, but two-thirds of patients may continue to have thigh numbness up to 3 years after surgery. Fortunately, symptoms are not clearly associated with outcome score and treatment for this complication is rare.

New Intramuscular Electromyographic Monitoring with a Probe in Lateral Lumbar Interbody Fusion Surgery.

Introduction The lateral lumbar interbody fusion (LLIF) surgical approach is minimally invasive and safely accesses the target region. Therefore, it is widely used in cases of lumbar spinal stenosis and spinal deformity. Intraoperative neuromonitoring is necessary to avoid nerve injury, whereas postoperative anterior thigh symptoms are not necessarily prevented. Technical Note In our institute, 85 LLIF operations have been performed. The first 30 cases were excluded from the present study to avoid surgical learning curve effects; conventional monitoring was used in 30 cases, whereas a new method with a probe to monitor intramuscular potential was used in 25 other cases. Anterior thigh symptoms and motor deficits were assessed postoperatively. The location of the electromyographic threshold decrease was at the posterior part of the disc at L2-3, but at the anterior part at L4-5. Compared with conventional monitoring, the new intramuscular monitoring significantly decreased the prevalence of motor deficits of the iliopsoas at 1 day and 30 days; anterior thigh pain at 1 day, 30, and 90 days; and anterior thigh numbness at 30 and 90 days postoperatively. Conclusions Compared with conventional monitoring, the new intramuscular monitoring with a less invasive probe may reduce anterior thigh symptoms.

Transient obturator nerve block with fascia iliaca compartment block following local infiltration for open inguinal herniorrhaphy

BackgroundIlioinguinal nerve block is effective for analgesia after open inguinal herniorrhaphy. However, transient femoral nerve palsy can happen after the block. The ambulatory patients sometimes cannot discharge from the hospital with the motor deficiency. Here is described a case of fascia iliaca compartment block with complete obturator nerve block after surgical infiltration analgesia for open inguinal herniorrhaphy.Case presentationAn ambulatory open inguinal herniorrhaphy was performed for a 63-year-old male under general anesthesia. The mixture of short-/long-acting local anesthetics was injected by the surgeon into the subcutaneous tissue, between the Camper’s and Scarpa’s fasciae, into the inguinal canal, and between the internal oblique and transversus abdominis muscles. The patient could not adduct his ipsilateral hip joint at all 1 h after emergence. The flexion of the hip joint was weakened two more hours later, and numbness of the lateral thigh emerged. The complications completely resolved 7 h after surgery.ConclusionsSurgical infiltration analgesia as well as percutaneous ilioinguinal nerve block can cause both fascia iliaca plane block and obturator nerve block. Analgesia regimen should be carefully built for ambulatory surgery.

Learning Curve of Minimally Invasive Surgery Oblique Lumbar Interbody Fusion for Degenerative Lumbar Diseases

To characterize the learning curve for a single surgeon during his initial phases of performing minimally invasive surgery oblique lumbar interbody fusion. This was a prospective analysis of 49 consecutive patients who underwent a single-level minimally invasive surgery oblique lumbar interbody fusion performed by a single surgeon. Patients were divided into group A (first 24 patients) and group B (25 patients after initial 24 patients). The following data were compared between the 2 groups: surgical time, estimated blood loss, radiograph exposure time, clinical and radiographic results, and intraoperative and postoperative complications. The learning curve was assessed using a logarithmic curve-fit regression analysis. Average operative time was significantly longer in group A compared with group B. Compared with group B, group A had significantly more x-ray exposure time. Perioperative complications included thigh numbness and pain in 8 cases, psoas and quadriceps weakness in 3 cases, sympathetic nerve injury in 2 cases, and paralytic ileus in 1 case. All complications were transient and resolved within 3 months. The incidence of complications was 37.5% in group A and 20.0% in group B. Clinical and radiographic outcomes were basically identical in the 2 groups at last follow-up. Minimally invasive surgery oblique lumbar interbody fusion presents a learning curve to the practicing spine surgeon with regard to operative time, x-ray exposure time, and intraoperative and postoperative complications. Close attention to detail can minimize complications that may be associated with the learning curve.

Fascia iliaca blockade with the addition of liposomal bupivacaine vs. plain bupivacaine for perioperative pain management following hip arthroscopy.

A newer formulation of bupivacaine, encapsulated within carrier molecules, has garnered attention for its role in providing extended post-operative analgesia. The purpose was to evaluate the addition of liposomal bupivacaine to fascia iliaca blockade during hip arthroscopy. Retrospective cohort study of patients undergoing hip arthroscopy with a pre-operative fascia iliaca blockade with either liposomal bupivacaine (Group 1; 266mg + 20cc 0.5% plain bupivacaine) or bupivacaine (Group 2; 40cc 0.25% plain bupivacaine). All patients received standardized pre-operative oral pain medications. The primary outcome was the defense veteran pain rating scale (DVPRS). Secondary outcomes included duration of hospital admission, PACU opioid use, PACU pain scores, and duration of nerve blockade. Thirty-eight males and 30 females, mean age of 33 years (range 14-56). There was no difference in pre-operative DVPRS between the groups (n.s.). There was no difference in post-operative DVPRS pain scores at POD0 (3.7 vs. 3.9, n.s.), POD1 (4.2 vs. 3.8, n.s.), POD2 (4.2 vs. 3.7, n.s.), POD3 (3.9 vs. 3.7, n.s.) or POD14 (2.2 vs. 2.4, n.s.). Group 1 trended towards longer mean total hospital admission time (872 vs. 822min, n.s.), and greater mean morphine equivalents administered in the PACU (33 vs. 29mg, n.s.). 68% of patients in group 1 reported continued anterior thigh numbness at POD3, compared to 34% in group 2 (p = 0.008). Despite the advertised benefits of prolonged post-operative analgesia using liposomal bupivacaine, there were no significant differences in post-operative pain scores or PACU opioid consumption. Our results support that acceptable pain scores are successfully achieved at all time periods with the use of multimodal analgesia including fascia iliaca blockade despite the type of pain medication administered. III.

Choice of different tissue flaps in the treatment of urethro-rectal fistulas associated with urethral strictures

Objective To evaluate the clinical efficacy of different tissue flaps interposition in reconstructing urethra-rectal fistulas associated with posterior urethral strictures. Methods Twenty-nine patients with urethra-rectal fistulas associated with posterior urethral strictures (15 patients after traffic accident trauma, 9 after falling injury, and 5 after pelvic crush injury) were included in this study. Trans-perineal urethral reconstruction and fistula repair with perineal subcutaneous dartos pedicled flap transposition was performed in 15 patients in whom fistulas were near the anus (<5 cm) and the perineal subcutaneous tissues were rich in blood supply. An interposition gracilis muscle flap was placed in 14 patients with fistulas located farther from the anus (≥5cm) or poor perineal local tissue condition. Results After a mean follow-up of 24.5 months (5-67 months), successful repair was achieved in 12 of 15 patients (80.0%) undergoing perineal subcutaneous dartos pedicled flap transposition, and in 11 of 14 patients (78.6%) undergoing gracilis muscle transposition. The overall success rate was 79.3%. No long-term procedure related complications occurred except medial thigh numbness in 1 patient. Conclusions The perineal subcutaneous dartos pedicled flap is suitable for hypervascular and low-positioned urethra-rectal fistulas located less than 5 cm from the anus. For patients with high-positioned fistulas or poor perineal local tissue conditions, the gracilis muscle flap is recommended. The technique of vascularized tissue pedicled flap transposition is essential for urethra-rectal fistula repair. Key words: Urethra-rectal fistula; Urethral stricture; Surgery; Tissue flap

Minimally invasive anterior and lateral transpsoas approaches for closed reduction of grade II spondylolisthesis: initial clinical and radiographic experience.

OBJECTIVE Minimally invasive anterior and lateral approaches to the lumbar spine are increasingly used to treat and reduce grade I spondylolisthesis, but concerns still exist for their usage in the management of higher-grade lesions. The authors report their experience with this strategy for grade II spondylolisthesis in a single-surgeon case series and provide early clinical and radiographic outcomes. METHODS A retrospective review of a single surgeon's cases between 2012 and 2016 identified all patients with a Meyerding grade II lumbar spondylolisthesis who underwent minimally invasive lateral lumbar interbody fusion (LLIF) or anterior lumbar interbody fusion (ALIF) targeting the slipped level. Demographic, clinical, and radiographic data were collected and analyzed. Changes in radiographic measurements, Oswestry Disability Index (ODI), and visual analog scale (VAS) scores were compared using the paired t-test and Wilcoxon signed rank test for continuous and ordinal variables, respectively. RESULTS The average operative time was 199.1 minutes (with 60.6 ml of estimated blood loss) for LLIFs and 282.1 minutes (with 106.3 ml of estimated blood loss), for ALIFs. Three LLIF patients had transient unilateral anterior thigh numbness during the 1st week after surgery, and 1 ALIF patient had transient dorsiflexion weakness, which was resolved at postoperative week 1. The mean follow-up time was 17.6 months (SD 12.5 months) for LLIF patients and 10 months (SD 3.1 months) for ALIF patients. Complete reduction of the spondylolisthesis was achieved in 12 LLIF patients (75.0%) and 7 ALIF patients (87.5%). Across both procedures, there was an increase in both the segmental lordosis (LLIF 5.6°, p = 0.002; ALIF 15.0°, p = 0.002) and overall lumbar lordosis (LLIF 2.9°, p = 0.151; ALIF 5.1°, p = 0.006) after surgery. Statistically significant decreases in the mean VAS and the mean ODI measurements were seen in both treatment groups. The VAS and ODI scores fell by a mean value of 3.9 (p = 0.002) and 19.8 (p = 0.001), respectively, for LLIF patients and 3.8 (p = 0.02) and 21.0 (p = 0.03), respectively, for ALIF patients at last follow-up. CONCLUSIONS Early clinical and radiographic results from using minimally invasive LLIF and ALIF approaches to treat grade II spondylolisthesis appear to be good, with low operative blood loss and no neurological deficits. Complete reduction of the spondylolisthesis is frequently possible with a statistically significant reduction in pain scores.

Early complications associated with oblique lateral interbody fusion in the treatment of degenerative lumbar diseases

Objective To evaluate the early clinical outcomes and complications of oblique lateral interbody fusion (OLIF) in the treatment of degenerative lumbar diseases. Methods All of 83 patients, 29 males and 54 females with ages from 32 to 83 (average 60.8±13.7 y), underwent OLIF with or without posterior pedicle screw-rod instrumentations from October 2014 to February 2017. The index diagnosis was discogenic back pain in 17 cases, spondylolisthesis in 23, lumbar spinal canal stenosis in 25, and degenerative lumbar spinal kyphoscoliosis in 18 cases. The distribution of operative level was 5 at L1,2, 13 at L2,3, 38 at L3,4, and 69 at L4,5. The mean number of fusion level for each case was 1.5 segments. The operative duration, blood loss during operation, intra-operative and post-operative complications, the length of post-operative hospital stay were recorded. Clinical outcomes were evaluated using visual analogue scale (VAS) and Oswestry disability index (ODI). All patients were followed up for at least 3 months. Lumbar X-ray and CT scans were taken and the clinical outcomes were re-assessed during follow-up. Results Fifty-one in the 83 patients underwent supplementary posterior pedicle screw-rod instrumentation with OLIF procedures. The operation lasted for 43-295 min, with a mean duration of (153 ± 72) min. Mean operation time for each OLIF segment was 43±12 min. Blood loss during the operation was 30-800 ml, with a mean of 125±74 ml. Mean blood loss for each OLIF segment was 27±13 min. Average length of stay was 5.6 ± 3.2 d, ranging from 3-15 d. The VAS for back pain and leg pain and ODI scores were decreased apparently for each patient. The total incidence of complications was 22.9% (19/83), including 6.0% (5/83) of intra-operative complications (4 cases of cage subsidence, 1 case of segmental artery injury) and 16.9% (14/83) of post-operative ones. The latter consisted of ipsilateral hip flexor weakness in 6, ipsilateral anterolateral thigh pain in 2, ipsilateral lateral thigh numbness in 1, contralateral pain in flexion of hip in 1, ipsilateral sympathetic chain injury in 2, and pain in area of iliac bone donor site in 2. All symptoms were released or disappeared during follow-up. Conclusion OLIF as a novel minimally invasive technique can act as a safe and effective treatment for degenerative lumbar diseases, which can also reduce approach-related complications. Key words: Lumbar vertebrae; Intervertebral disc degeneration; Spondylolisthesis; Spinal stenosis; Scoliosis; Kyphosis; Spinal fusion; Intraoperative complications; Postoperative complications

Indirect decompression and reduction of lumbar spondylolisthesis does not result in higher rates of immediate and long term complications

Nerve root decompression and spondylolisthesis reduction is typically reserved for open surgery. MIS techniques have been thought to be associated with higher rates of neurological complications. This study aims to report acute and chronic neurologic complications encountered with MIS surgery for spondylolisthesis, specifically, the incidence of nerve root injury and clinical and radiographic outcomes. A retrospective review of 269 patients who underwent MIS LIF or ALIF treatment for lumbar degenerative or isthmic grade 1 or 2 spondylolisthesis was conducted. Immediate and long-term complication rates were the primary outcome. Only patients who had symptomatic anterolisthesis and 2-year outcome data were included in the study. 52 patients met inclusion criteria with 54 lumbar spondylolisthesis levels treated. Five patients (9.6%) experienced postoperative anterior thigh numbness, which completely resolved within 3months. There were no permanent neurologic deficits; however, 2 patients (3.8%) suffered a transient foot weakness that resolved with physical therapy by 3months follow-up. There was one incidence of wound breakdown that required revision and one incidence of L5/S1 endplate/sacral promontory fracture and relisthesis 3months postoperatively. Overall fusion rate was 98% at 6months. Indirect decompression and closed anatomical reduction for treatment of low-grade spondylolisthesis using ALIF and LIF with posterior percutaneous fixation was not associated with an increased risk of neurologic deficit. This study suggests that this technique is safe, reproducible, durable, and provides adequate fusion rates.

Treatment of Transverse with or without Posterior Wall Fractures of Acetabulum Using a Modified Smith-Petersen Combined with Kocher-Langenbeck Approach.

BackgroundThe aim of this study was to explore the surgical treatment of transverse with or without posterior wall fractures of the acetabulum.Material/MethodsWe surgically treated 21 consecutive cases of pure transverse (7 cases) and with posterior wall (14 cases) fractures of the acetabulum. The anterior column fractures were firstly reduced, temporarily fixed through a modified Smith-Petersen small incision, and finally fixed after the fixation of the posterior column and wall fractures, which were reduced and fixed through a Kocher-Langenbeck approach. The operative time, intra-operative blood loss, quality of reduction (Matta criteria), perioperative complications, osseous union, subsequent complications, and hip function evaluation were recorded.ResultsThe mean operative time was 198.1 min and the mean intra-operative blood loss was 938.1 ml. Anatomic reduction of the anterior column was obtained in 20 cases and was imperfect in 1 case. All posterior column and wall fractures were anatomically reduced. We followed up 18 cases for a mean duration of 16.3 (8–30) months. All the fractures achieved osseous union. The mean Harris score was 85.1 points, with an excellent result in 7 cases, good in 8, fair in 2, and poor in 1. According to modified Merle d’ Aubigne and Postel score system, the results were excellent in 2 cases, good in 15, and poor in 1. Avascular necrosis of the femoral head occurred in 1 case, heterotopic ossification in 3 cases, and numbness of the anterolateral thigh in 6 cases.ConclusionsFor transverse with or without posterior wall fractures of the acetabulum, reduction and fixation of anterior and posterior column should be done in sequence, and a modified Smith-Petersen small incision might be a good choice in reduction and fixation of the anterior column because it possesses advantages of direct visualization and minimal invasion.

Clinical research of the one-stage treatment for traumatic osteomyelitis in tibia by combining flap, vancomycin-loaded calcium sulfate and autogenous iliac bone

Objective To discuss the clinical effect of the phase-one treatment scheme for traumatic osteomyelitis in tibia by combining flap, vancomycin-loaded calcium sulfate and autogenous iliac bone. Methods From January, 2009 to July, 2014, 49 patients which had traumatic osteomyelitis in tibia and met the inclusive criteria were investigated and treated. By taking these patients as treatment group A(34 cases), they were treated by adopting the phase-one treatment scheme of combing tissue flap, vancomycin-loaded calcium sulfate and autogenous iliac bone. Fifteen patients who were treated by using the phase-one treatment scheme, namely, removing the lesion, implanting vancomycin-loaded calcium sulfate and repairing the defect by means of tissue flap, were chosen as control group B. Concerning treatment group A, drainage fluid was collected after operation every day to measure the concentration of vancomycin until drainage tube was removed. All the patients were followed up to study the following indexes: the standing time of drainage tube, the healing time of fracture, infection control rate, bone nonunion rate and other complications. Results All cases were followed up during 17 to 40 months after operation and no amputation was conducted for the affected limb. To repair soft tissue defect, flap and direct suture were adopted for 25 and 9 cases respectively in group A; The results indicated that all flaps survived, the poor healing of flap defect was observed for 2 cases which were healed after dressing change. However, to repair soft tissue defect, all group B cases used flaps; results revealed that distal flap necrosis was found in 2 cases applying neurocutaneous flap, with defect exudation and infection while the 2 cases were cured after debridement and dressing change without performing a second flap operation. In group A, 3 cases recurred during 5 months to 2 years after operation; in group B, it was 1; other complications included pintract infection, nonunion, numbness of anterolateral thigh, hematocele in iliac 1 region. In group B, refracture occurred for 2 cases at the original lesion location 18 and 25 months after healing and was cured after plate refixation and the graft of autogenous iliac bone; intraoperative pathology validated no recurrence of osteomyelitis. The standing time of drainage tube was (12.53±4.56) days on average for group A while (17.07±3.87) days for group B; The difference was statistically significant (P<0.05) . The healing time of fracture was (6.20±2.16) months on average for group A while(8.36±2.84) months for group B. The difference was statistically significant (P<0.05) . Conclusion In one stage treatment of localized and diffused traumatic osteomyelitis, the scheme of combining tissue flap, vancomycin-loaded calcium sulfate and autogenous iliac bone effectively shortened the healing time of fracture, increased the healing strength, and reduced the exudation after operation, without increasing infection recurrence rate. The scheme was superior to merely implanting vancomycin-loaded calcium sulfate. Key words: Surgical flap; Calcium sulfate; Vancomycin; Tibial osteomyelitis; Drug delivery

Perioperative Complications in 155 Patients Who Underwent Oblique Lateral Interbody Fusion Surgery

A retrospective multicenter survey. To investigate the perioperative complications of oblique lateral interbody fusion (OLIF) surgery. OLIF has been widely performed to achieve minimally invasive, rigid lumbar lateral interbody fusion. The associated perioperative complications are not yet well described. The participants were patients who underwent OLIF surgery under the diagnosis of degenerative lumbar diseases between April 2013 and May 2015 at 11 affiliated medical institutions. The collected data were classified into intraoperative and early-stage postoperative (≤1 mo) complications. The intraoperative complications were then subcategorized into organ damage (neural, vertebral, vascular, and others) and other complications, mainly related to instrumental failure. The collected data were also divided and analyzed based on whether the surgeon was certified to perform the surgery and the incidence of complications in the early (April 2013-March 2014) and late stages (April 2014-May 2015) of OLIF introduction. In the 155 included patients, 75 complications were reported (incidence rate, 48.3%). The most common complication was endplate fracture/subsidence (18.7%), followed by transient psoas weakness and thigh numbness (13.5%) and segmental artery injury (2.6%). Almost all these complications were transient, except for three patients who had permanent damage: one had ureteral injury and two had neurological injury. Postoperative complications included surgical site infection (1.9%) and reoperation (1.9%). Whether the primary operator was experienced did not affect the incidence of complications. Regarding the introductory stage, the incidence of complications was 50% in the early stage and 38% in the late stage. The overall incidence of perioperative complications of OLIF surgery reached 48.3%, of which only 1.9% resulted in permanent damage. Our analysis based on surgeon experience indicated that the OLIF procedure could be performed without increasing incidence of complications, under the guidance of experienced supervisors. 3.

The anatomy of the anterior approach: a cadaver study

BACKGROUND: This research investigated the anatomy underlying minimally invasive total hip arthroplasty when the anterior approach was used. METHODS: Ninety hips were dissected and in one cadaver, a complete hip replacement was performed. Simulations of the anterior approach surgical incisions were carried by the orthopaedic surgeon in order to see if injury to the lateral femoral cutaneous nerve (LFCN) could be avoided, when the correct anatomical landmarks were palpated. RESULTS: The data analysis revealed significant differences for the mean distances from the pubic tubercle to the straight head of the rectus femoris muscle. Statistical significance was detected for comparisons between males and females, for weight ranges and BMI categories. CONCLUSION: The study findings prove that the concerns relating to the course and distribution pattern of the LFCN and the lateral circumflex femoral artery (LCFA) using the anterior approach, could be overcome when the anatomy of the hip joint and the thigh is understood. However, it is important to note the possible variations in the course of the LFCN and the branching pattern of the LCFA In order to avoid intra-operative bleeding and possible thigh numbness post-surgery.