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Wiltse 入路与传统后正中入路手术治疗腰椎退行性疾病疗效的Meta分析
Wiltse approach versus the conventional posterior midline approach for lumbar degenerative diseases: A Meta-analysis

RA N Bing
, YAN Lei, CAI Lin

- , 2015,
Abstract: 目的:系统评价经椎间孔入路与传统后正中入路手术治疗腰椎退行性疾病(lumbar degenerative diseases, LDD)的疗效及安全性。方法:利用计算机检索The Cochrane Library,PubMed,EMbase,MEDLINE,SCI,中国知 网,中国生物医学文献数据库及万方数据库,检索文献的发表日期截至2014年2月;收集采用微创Wiltse入路经椎间 孔减压植骨融合手术(transforaminal lumbar interbody fusion,TLIF)与采用传统正中入路椎板切除减压椎间植骨融合手术 (posterior lumbar interbody fusion,PLIF)治疗LDD的随机或非随机同期对照试验。由2名评价者按照纳入与排除标准选 择试验、提取资料和评价质量后,采用 RevMan 5.2软件进行Meta分析。结果:纳入7个随机对照试验,8个非随机对照 试验,共1 127例患者。Meta分析结果显示:腰痛视觉模拟评分法[均数差(mean diff erence,MD)=?0.54,95%CI(?0.79, ?0.29),P<0.001],Oswestry功能障碍指数[MD=?4.20,95%CI (?6.16,?2.25),P<0.001],术中出血量[MD=?170.98, 95%CI(?225.10,?116.85),P<0.001],手术时间[MD=2.57,95%CI(?9.07,14.20),P=0.67],住院时间[MD=?3.08, 95%CI(?3.03,?1.57),P=0.0003]在两组之间差异均有统计学意义。结论:治疗LDD, TLIF较之PLIF,具有出血少、 术后住院时间短、腰背痛残留率低、功能恢复好,但手术时间无差别的优点。因此,在严格掌握Wiltse-TLIF治疗LDD 适应证的前提下,采用Wiltse-TLIF能更好地解决LDD患者的病痛
Posterolateral inter-transverse lumbar fusion in a mouse model  [cached]
Bobyn Justin,Rasch Anton,Little David G,Schindeler Aaron
Journal of Orthopaedic Surgery and Research , 2013, DOI: 10.1186/1749-799x-8-2
Abstract: Background Spinal fusion is a common orthopaedic procedure that has been previously modeled using canine, lapine, and rodent subjects. Despite the increasing availability of genetically modified mouse strains, murine models have only been infrequently described. Purpose To present an efficient and minimally traumatic procedure for achieving spinal fusion in a mouse model and determine the optimal rhBMP-2 dose to achieve sufficient fusion mass. Method MicroCT reconstructions of the unfused mouse spine and human spine were compared to design a surgical approach. In phase 1, posterolateral lumbar spine fusion in the mouse was evaluated using 18 animals allocated to three experimental groups. Group 1 received decortication only (n = 3), Group 2 received 10 μg rhBMP-2 in a collagen sponge bilaterally (n = 6), and Group 3 received 10 μg rhBMP-2 + decortication (n = 9). The surgical technique was assessed for intra-operative safety, efficacy, access and reproducibility. Spines were harvested for analysis at 3 weeks (Groups 1, 2) and 1, 2, and 3 weeks (Group 3). In phase 2, a dose response study was carried out in an additional 18 animals with C57BL6 mice receiving sponges containing 0, 0.5, 1, 2.5, 5 μg of rhBMP-2 per sponge bilaterally. Results The operative procedure via midline access was rapid and reproducible, and fusion of the murine articular processes was found to be analogous to the human procedure. Unlike reports from other species, decortication alone (Group 1) yielded no new bone formation. Addition of rhBMP-2 (Groups 2 and 3) yielded a significant bone mass that bridged the L4-L6 vertebrae. The subsequent dose response experiment revealed that 0.5 μg rhBMP-2 per sponge was sufficient to create a fusion mass. Conclusion We describe a new approach for mouse lumbar spine fusion that is safe, efficient, and highly reproducible. The technique we employed is analogous to the human midline procedure and may be highly suitable for genetically modified mouse models.
Combining Posterolateral Lumbar Fusion and Posterior Lumber Interbody Fusion Surgery for Treating Three-Level Lumber Spondylolysis and Single-Level Spondylolisthesis: Case Report  [PDF]
Yazhong Zhang, Yijie Liu, Jie Chen, Xuefeng Li, Heng Wang, Genlin Wang, Huilin Yang, Weimin Jiang
Journal of Biosciences and Medicines (JBM) , 2019, DOI: 10.4236/jbm.2019.78006
Abstract: Lumbar spondylolysis is a relatively common condition that can cause a variety of clinical manifestations related to the lumbar spine. However, multi-level lumbar spondylolysis is rare and accounts for less than 6% of lumbar spondylolysis. We report a case of three-level lumbar spondylolysis with single-level spondylolisthesis. A 47-year-old woman presented to us with low back pain for 9 years that progressively worsened and the pain was exacerbated with standing and walking. She was diagnosed with three-level lumbar spondylolysis at L3-5 and spondylolisthesis at L4. We performed posterolateral lumber fusion (PLF) and posterior lumbar interbody fusion (PLIF) surgery for her. During the same period, pain recovery and fusion rate of the patient were evaluated after surgery. The results were favorable and proved the efficacy of combining PLF and PLIF technique for treatment for three-level lumbar spondylolysis and single-level spondylolisthesis.
Degenerative lumbar scoliosis: features and surgical treatment
C. Faldini,S. Pagkrati,G. Grandi,V. Digennaro,O. Faldini,S. Giannini
Journal of Orthopaedics and Traumatology , 2006, DOI: 10.1007/s10195-006-0123-z
Abstract: Degenerative lumbar scoliosis is a de novo deformity of the spine occurring after the fourth or fifth decade of life in patients with no history of scoliosis in the growing age. We evaluated complications and functional and radiographic outcomes of twelve patients with degenerative lumbar scoliosis, treated by spinal decompression associated with posterolateral and/or interbody fusion. Mean lumbar scoliosis angle was 18° (SD=4°) and mean age at surgery was 57 years (SD=6 years). Average follow–up was 3.5 years. Surgical treatment consisted in decompression of one or more roots, associated with stabilization with pedicle screws and posterolateral fusion. To correct the deformity, the collapse of the disc was corrected by implanting a cage in the anterior interbody cage. Clinical symptoms and functional tolerance for daily activities improved after surgery. Radiographic evaluation showed a reduction in the deformity on the frontal and sagittal planes. There were no infections, evidence of pseudoarthrosis, instrumentrelated failures or re–operations in this series. In patients with persisting pain caused by degenerative scoliosis associated with spinal stenosis, in whom conservative treatment has failed, spinal decompression and segmented fusion with instrumentation represents a valid treatment option.
Dynamic Stabilization for Challenging Lumbar Degenerative Diseases of the Spine: A Review of the Literature  [PDF]
Tuncay Kaner,Ali Fahir Ozer
Advances in Orthopedics , 2013, DOI: 10.1155/2013/753470
Abstract: Fusion and rigid instrumentation have been currently the mainstay for the surgical treatment of degenerative diseases of the spine over the last 4 decades. In all over the world the common experience was formed about fusion surgery. Satisfactory results of lumbar spinal fusion appeared completely incompatible and unfavorable within years. Rigid spinal implants along with fusion cause increased stresses of the adjacent segments and have some important disadvantages such as donor site morbidity including pain, wound problems, infections because of longer operating time, pseudarthrosis, and fatigue failure of implants. Alternative spinal implants were developed with time on unsatisfactory outcomes of rigid internal fixation along with fusion. Motion preservation devices which include both anterior and posterior dynamic stabilization are designed and used especially in the last two decades. This paper evaluates the dynamic stabilization of the lumbar spine and talks about chronologically some novel dynamic stabilization devices and thier efficacies. 1. Introduction Today, low back pain is one of the most important problem in decreasing the quality of life as a result of lumbar disc degeneration [1–4]. It is thought that the origin of low back pain results from degenerative intervertebral disc and facet joints. Segmental instability significantly contributed to lower back pain. Instability associated with intervertebral disc degeneration is represented first by Knutsson in 1944 [5]. Knutsson also described the abnormal flexion-extention slipping in X-ray along with disc degeneration and told that segmental instability should be if sagittal slipping is greater than 3?mm in dynamic X-ray. Degeneration process of the lumbar spine and pathology of discogenic pain were described by Kirkaldy-Willis and Farfan in 1982 [2]. They explained that degenerative instability of the spine began primarily with disc degeneration which contains dehydration of intervertebral disc along with decrease in tension of the annulus fibrosis. It is followed by decrease of disc height, and then this process continues with hypertrophy of the facet joint and ligamentum flavum. At the end spinal stenosis and degenerative spondylolisthesis, which have caused low back pain, occur. Besides, Frymoyer and Selby revealed the concept of primary and secondary instabilities and put the degenerative disc disease, degenerative spondylolisthesis, and degenerative scoliotic deformities into the group of primary instability [6, 7]. Panjabi also well defined the term instability that leads to a pain,
The effects of stabilization exercise on pain, functional disability and muscle endurance in patients suspectedto lumbar segmental instability
Y. Javadian,H. Behtash,M. Akbari,M. Taghipour
Journal of Mazandaran University of Medical Sciences , 2008,
Abstract: Introduction: Lumbar segmental instability is one of the subgroups of non specific chronic low back pain and it seems that 30-40% of patients with LBP suffer from lumbar segmental instability. Pain intensity, functional disability and reduced muscle endurance are common in such patients. The aim of this study was to evaluate the effects of stabilization exercise on pain, functional disability and muscle endurance in patients suspected to lumbar segmental instability Material & methods: Following ethical approval, a randomized clinical trial was carried out on 30 patients suspected to lumbar segmental instability ranging from 18-45 years old. They were randomly divided into two groups; the first group underwent routine exercise only while the second group performed routine exercise plus stabilization training for 8 weeks. Outcome measure included pain intensity, functional disability, and flexion and extension range of motion and flexor, extensor and side support muscle endurance which were evaluated before and after treatment. Data were analyzed using paired t test and independent t test.Results: Muscle endurance and flexion range of motion increased in both groups although the increase was higher in stabilization training group (p=0.00). Pain intensity and functional disability significantly decreased in both groups (p=0.00), but decreasing of pain intensity and functional disability were more in stabilization training group (p=0.00). Conclusion: Stabilization training is more effective than routine exercise in improvement of pain intensity, functional disability, muscle endurance and range of motion in patients suspected to lumbar segmental instability. J Mazand Univ Med Sci 2008; 18(65): 63-73 (Persian)
Instrumented ligamentotaxis and stabilization of compression and burst fractures of dorsolumbar and mid-lumbar spines  [cached]
Moon Myung-Sang,Choi Won-Tae,Sun Doo-Hoon,Chae Jong-Woo
Indian Journal of Orthopaedics , 2007,
Abstract: Background : Controversy continues regarding the best treatment for compression and burst fractures. The axial distraction reduction utilizing the technique emplying the long straight rod or curved short rod without derotation to reduce fracture are practised together with short segment posterolateral fusion (PLF). Effects of the early postoperative mobilization without posterolateral fusion on reduction maintenance and fracture consolidation were not evaluated so far. The present prospective study is designed to assess the effectiveness of i) reduction and restoration of sagittal alignment, ii) no posterolateral fusion on the reduced, fractured vertebral body and injured disc, iii) fracture consolidation and iv) the fate of the unfused cephalad and caudal injured motion segments of the fractured vertebra. Materials and Methods : The study includes 15 Denis burst and two Denis type D compression fractures between T 12 and L 3 . The lordotic distraction technique was used for ligamentotaxis utilizing the contoured short rods and pedicle screw fixator. Three vertebrae including the fractured one were fixed. The patient′s after surgery were braced for ten weeks with activity restriction for 2-4 weeks. The patients were evaluated for change in body height, segittal curve, reduction of retropulsion, improvement in neural deficit. The unfused motion segments, residual postoperative pain and bone and metal failure were also evaluated. Results : The pre-operative and postreduction percentile vertebral heights at, zero (immediate post-operative), at three, six and 12 months followup were 62.4, 94.8, 94.6, 94.5 and 94.5%, respectively. The percentages of the intracanal fragment retropulsion at pre operative, and post operative at zero, 3, 6 and 12 months followup were 59.0, 36.2,, 36.0, 32.3, and 13.6% respectively. The pre-operative and postreduction percentile loss of the canal dimension and at zero, three, six and 12 months were 52.1, 45.0, 44.0, 41.0 and 29% respectively suggesting that the under-reduced fragment was being resorbed gradually by a remodeling process. The mean initial kyphosis of 33° became mean 2° immediately after reduction and mean 3° at the final follow-up. The fractured vertebral bodies consolidated in an average period of ten weeks (range 8-14 weeks). The restored disc heights were relatively well maintained throughout the observation period. All paraparetic patients recovered neurologically. There were no postoperative complications. Conclusion : Instrument-aided ligamentotaxis for compression and burst fractures utilizing the short cont
Intervertebral Disc Rehydration after Lumbar Dynamic Stabilization: Magnetic Resonance Image Evaluation with a Mean Followup of Four Years  [PDF]
Li-Yu Fay,Jau-Ching Wu,Tzu-Yun Tsai,Tsung-Hsi Tu,Ching-Lan Wu,Wen-Cheng Huang,Henrich Cheng
Advances in Orthopedics , 2013, DOI: 10.1155/2013/437570
Abstract: Objective. To compare the clinical and radiographic outcomes in patients of different ages who underwent the Dynesys stabilization. Methods. This retrospective study included 72 patients (mean age 61.4 years) with one- or two-level lumbar spinal stenosis who underwent laminectomy and the Dynesys (Zimmer Spine, Minneapolis) dynamic stabilization system. Thirty-seven patients were younger than 65-year old while the other 35 were older. Mean followup was 46.7 months. Pre- and postoperative radiographic and clinical evaluations were analyzed. Results. The mean calibrated disc signal (CDS) at the index level was significantly improved from preoperatively to postoperatively ( ). Screw loosening occurred in 22.2% of patients and 5.1% of screws. The improvement in CDS at index level was seen to be significant in younger patients but not in older patients. Overall, the mean visual analogue scale (VAS) of back pain, VAS of leg pain, and the Oswestry disability index (ODI) scores improved significantly after operation. There were no significant differences in pre- and postoperative VAS and ODI and screw loosening rates between the younger and older patients. Conclusions. There is significant clinical improvement after laminectomy and dynamic stabilization for symptomatic lumbar spinal stenosis. Intervertebral disc rehydration was seen in younger patients. 1. Introduction Instrumented spinal fusion is the treatment of choice for degenerative spondylosis with instability refractory to conservative treatment [1, 2]. Spine surgeons have also used modern biologics such as recombinant human bone morphogenetic protein-2 to increase the rate of spinal fusion in selected patients [3–7]. However, using biologics to enhance spinal fusion has been sometimes reported with complications postoperatively and during followup. Moreover, even autograft has been repeatedly reported with adverse events, such as donor site morbidity. Not to mention that loss of segmental motion and subsequent adjacent segmental degeneration have also been concerned for the spinal fusion surgery [8–10]. In the recent years, there is the emerging option of dynamic stabilization to spare spinal fusion and still yield satisfactory outcomes in the surgical management of lumbar spondylosis and back pain. Fischgrund and colleagues reported application of the Dynesys (Zimmer Spine, Minneapolis, USA), a pedicle-based lumbar dynamic stabilization system, as an effective alternative to treat lumbar spondylosis in 1994 [11–16]. Theoretically Dynesys can unload the intervertebral disc while providing a restricted
Evaluation of hydroxyapatite and beta-tricalcium phosphate mixed with bone marrow aspirate as a bone graft substitute for posterolateral spinal fusion  [cached]
Bansal Sanjay,Chauhan Vijendra,Sharma Sansar,Maheshwari Rajesh
Indian Journal of Orthopaedics , 2009,
Abstract: Background: Autologous cancellous bone is the most effective biological graft material. However, harvest of autologous bone is associated with significant morbidity. Since porous hydroxyapatite and beta-tricalcium phosphate are biodegradable materials and can be replaced by bone tissue, but it lacks osteogenic property. We conducted a study to assess their use as a scaffold and combine them with bone marrow aspirate for bone regeneration using its osteogenic property for posterolateral spinal fusion on one side and autologous bone graft on the other side and compare them radiologically in terms of graft incorporation and fusion. Materials and Methods: Thirty patients with unstable dorsal and lumbar spinal injuries who needed posterior stabilization and fusion were evaluated in this prospective study from October 2005 to March 2008. The posterior stabilization was done using pedicle screw and rod assembly, and fusion was done using hydroxyapatite and beta-tricalcium phosphate mixed with bone marrow aspirate as a bone graft substitute over one side of spine and autologous bone graft obtained from iliac crest over other side of spine. The patients were followed up to a minimum of 12 months. Serial radiographs were done at an interval of 3, 6, and 12 months and CT scan was done at one year follow-up. Graft incorporation and fusion were assessed at each follow-up. The study was subjected to statistical analysis using chi-square and kappa test to assess graft incorporation and fusion. Results: At the end of the study, radiological graft incorporation and fusion was evident in all the patients on the bone graft substitute side and in 29 patients on the autologous bone graft side of the spine ( P > 0.05). One patient showed lucency and breakage of distal pedicle screw in autologous bone graft side. The interobserver agreement (kappa) had an average of 0.72 for graft incorporation, 0.75 for fusion on radiographs, and 0.88 for the CT scan findings. Conclusion: Hydroxyapatite and beta-tricalcium phosphate mixed with bone marrow aspirate seems to be a promising alternative to conventional autologous iliac bone graft for posterolateral spinal fusion.
Adult's Degenerative Scoliosis: Midterm Results of Dynamic Stabilization without Fusion in Elderly Patients—Is It Effective?  [PDF]
Mario Di Silvestre,Francesco Lolli,Tiziana Greggi,Francesco Vommaro,Andrea Baioni
Advances in Orthopedics , 2013, DOI: 10.1155/2013/365059
Abstract: Study Design. A retrospective study. Purpose. Posterolateral fusion with pedicle screw instrumentation used for degenerative lumbar scoliosis can lead to several complications. In elderly patients without sagittal imbalance, dynamic stabilization could represent an option to avoid these adverse events. Methods. 57 patients treated by dynamic stabilization without fusion were included. All patients had degenerative lumbar de novo scoliosis (average Cobb angle 17.2°), without sagittal imbalance, associated in 52 cases (91%) with vertebral canal stenosis and in 24 (42%) with degenerative spondylolisthesis. Nineteen patients (33%) had previously undergone lumbar spinal surgery. Results. At an average followup of 77 months, clinical results improved with statistical significance. Scoliosis Cobb angle was 17.2° (range, 12° to 38°) before surgery and 11.3° (range, 4° to 26°) at last follow-up. In the patients with associated spondylolisthesis, anterior vertebral translation was 19.5% (range, 12% to 27%) before surgery, 16.7% (range, 0% to 25%) after surgery, and 17.5% (range, 0% to 27%) at followup. Complications incidence was low (14%), and few patients required revision surgery (4%). Conclusions. In elderly patients with mild degenerative lumbar scoliosis without sagittal imbalance, pedicle screw-based dynamic stabilization is an effective option, with low complications incidence, granting curve stabilization during time and satisfying clinical results. 1. Introduction Degenerative lumbar scoliosis, also described as de novo or “primary degenerative scoliosis” [1] is a frequent disease. Its incidence is reported to be from 6% to 68% [2–5] and increases with age [6]. These curves are located at thoracolumbar or lumbar level and need to be distinguished from degenerated preexisting idiopathic scoliosis; in fact, de novo scoliosis is developing after skeletal maturity without previous history of scoliosis. A recent prospective study [3] investigated 60 adults aged 50–84 years, without previous scoliosis. within 12 years, 22 cases (36.7%) developed de novo scoliosis with a mean angle of 13°. A previous study reported a similar incidence: Robin et al. [7] followed 160 adults with a straight spine for more than 7 years and found 55 cases of de novo scoliosis (34.4%). Decreased bone density was initially considered to be the cause of de novo lumbar scoliosis [2]. At present, asymmetric degenerative changes of the disc, vertebral body wedging, and facet joint arthritis are held to be the predominant causes [1, 3, 7–9], disc degeneration appearing to be the starting
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