ObjectiveTo investigate the effect of transforming growth factor β1 (TGF-β1) induced proliferation of ligamentum flavum cells and ligamentum flavum hypertrophy and its effect on connective tissue growth factor (CTGF) expression.MethodsThe ligamentum flavum tissue in lumbar intervertebral disc herniation was extracted and the ligamentum flavum cells were isolated and cultured by collagenase pre-digestion method. Morphological observation, immunofluorescence staining observation, and MTT assay were used for cell identification. The 3rd generation ligamentum flavum cells were divided into 5 groups. The cells of groups A, B, C, and D were respectively sealed with 3 ng/mL TGF-β1, 50 ng/mL CTGF, 3 ng/mL TGF-β1+CTGF neutralizing antibody, and 50 ng/mL CTGF+CTGF neutralizing antibody. Serum free DMEM was added to group E as the control. MTT assay was used to detect the effects of TGF-β1 and CTGF on the proliferation of ligamentum flavum cells. Western blot was used to detect the expression of CTGF protein. Real-time fluorescence quantitative PCR (qRT-PCR) was used to detect the expression of collagen type Ⅰ, collagen type Ⅲ, and CTGF genes.ResultsThe morphological diversity of cultured ligamentum flavum cells showed typical phenotype of ligamentum flavum fibroblasts; all cells expressed collagen type Ⅰ and vimentin, and some cells expressed collagen type Ⅲ; MTT identification showed that with the prolongation of culture time, the absorbance (A) value of each generation of cells increased gradually, and the A value of the same generation of cells at each time point was significantly different (P<0.05), there was no significant difference in A value between the cells of each generation at the same time point (P>0.05). After cultured for 24 hours, MTT assay showed that the A value of cells in groups A and B was significantly higher than that of group E (P<0.05). After adding CTGF neutralizing antibody, the A value of cells in groups C and D decreased, but it was still higher than that of group E (P<0.05). There were also significant differences among groups A, C and groups B, D (P<0.05). Western blot analysis showed that the relative expression of CTGF protein in groups A and B was significantly higher than that in group E (P<0.05), while the relative expression of CTGF protein in groups C and D was significantly lower than that in group E (P<0.05), and the difference between groups A, C and groups B, D was also significant (P<0.05). qRT-PCR detection showed that the mRNA relative expression of CTGF, collagen type Ⅰ, and collagen type Ⅲ in group A was significantly higher than that in group E (P<0.05). After adding neutralizing antibody, the mRNA relative expression of genes in group C was inhibited and were significantly lower than that in group A, but still significantly higher than that in group E (P<0.05). The mRNA relative expressions of collagen type Ⅰ and collagen type Ⅲ in group B was significantly higher than that in group E (P<0.05), but the mRNA relative expression of CTGF was not significantly different from that in group E (P>0.05); after neutralizing antibody was added, the mRNA relative expression of collagen type Ⅰ and collagen type Ⅲ in group D was inhibited and was significantly lower than that in group B, but still significantly higher than that in group E (P<0.05); there was no significant difference in the mRNA relative expression of CTGF between group D and groups B, E (P>0.05).ConclusionTGF-β1 can promote CTGF, collagen typeⅠ, collagen type Ⅲ gene level and protein expression in ligamentum flavum cells, and TGF-β1 can synergistically promote proliferation of ligamentum flavum cells through CTGF.
Objective To compare the effectiveness of posterior lumbar interbody fusion (PLIF) by unilateral fenestration and bilateral decompression with ultrasounic osteotome and traditional tool total laminectomy decompression PLIF in the treatment of degenerative lumbar spinal stenosis. Methods The clinical data of 48 patients with single-stage degenerative lumbar spinal stenosis between January 2017 and June 2017 were retrospectively analyzed. Among them, 27 patients were treated with unilateral fenestration and bilateral decompression PLIF with ultrasonic osteotome (group A), and 21 patients were treated with total laminectomy and decompression PLIF with traditional tools (group B). There was no significant difference in gender, age, stenosis segment, degree of spinal canal stenosis, and disease duration between the two groups (P>0.05), which was comparable. The time of laminectomy decompression, intraoperative blood loss, postoperative drainage volume, and the occurrence of operation-related complications were recorded and compared between the two groups. Bridwell bone graft fusion standard was applied to evaluate bone graft fusion at last follow-up. Visual analogue scale (VAS) score was used to evaluate the patients’ lumbar and back pain at 3 days, 3 months, and 6 months after operation. Oswestry disability index (ODI) score was used to evaluate the patients’ lumbar and back function improvement before operation and at 6 months after operation. Results The time of laminectomy decompression in group A was significantly longer than that in group B, and the intraoperative blood loss and postoperative drainage volume were significantly less than those in group B (P<0.05). There was no nerve root injury, dural tear, cerebrospinal fluid leakage, and hematoma formation during and after operation in the two groups. All patients were followed up after operation, the follow-up time in group A was 6-18 months (mean, 10.5 months) and in group B was 6-20 months (mean, 9.3 months). There was no complication such as internal fixation fracture, loosening and nail pulling occurred during the follow-up period of the two groups. There was no significant difference in VAS scores between the two groups at 3 days after operation (t=1.448, P=0.154); the VAS score of group A was significantly lower than that of group B at 3 and 6 months after operation (P<0.05). The ODI scores of the two groups were significantly improved at 6 months after operation (P<0.05), and there was no significant difference in ODI scores between the two groups before operation and at 6 months after operation (P>0.05). At last follow-up, according to Bridwell criteria, there was no significant difference in bone graft fusion between the two groups (Z=–0.065, P=0.949); the fusion rates of groups A and B were 96.3% (26/27) and 95.2% (20/21) respectively, with no significant difference (χ2=0.001, P=0.979 ). Conclusion The treatment of lumbar spinal stenosis with unilateral fenestration and bilateral decompression PLIF with ultrasonic osteotome can achieve similar effectiveness as traditional tool total laminectomy and decompression PLIF, reduce intraoperative blood loss and postoperative drainage, and reduce lumbar back pain during short-term follow-up. It is a safe and effective operation method.
Objective To explore decompression strategies for lateral lumbar spinal stenosis under unilateral biportal endoscopy (UBE) assistance. Methods A clinical data of 86 patients with lateral lumbar stenosis treated with UBE-assisted intervertebral decompression between September 2022 and December 2023 was retrospectively analyzed. There were 42 males and 44 females with an average age of 63.6 years (range, 45-79 years). The disease duration ranged from 6 to 14 months (mean, 8.5 months). Surgical levels included L2, 3 in 3 cases, L3, 4 in 26 cases, L4, 5 in 42 cases, and L5, S1 in 15 cases. According to Lee’s grading system, there were 21 cases of grade 1, 37 cases of grade 2, and 28 cases of grade 3 for lumbar spinal stenosis. Based on the location of stenosis and clinical symptoms, the 33 cases underwent interlaminar approach, 7 cases underwent interlaminar approach with auxiliary third incision, 26 cases underwent contralateral inclinatory approach, and 20 cases underwent paraspinal approach; then, the corresponding decompression procedures were performed. Visual analogue scale (VAS) score was used to evaluate lower back/leg pain before operation and at 1 and 3 months after operation, while Oswestry disability index (ODI) was used to evaluate spinal function. At 3 months after operation, the effectiveness was evaluated using the modified MacNab evaluation criteria. The spinal stenosis and decompression were evaluated based on Lee’s grading system using lumbar MRI before operation and at 3 months after operation. ResultsAll procedures were successfully completed with mean operation time of 95.1 minutes (range, 57-166 minutes). Dural tears occurred in 2 cases treated with interlaminar approach with auxiliary third incision. All incisions healed by first intention. All patients were followed up 3-10 months (mean, 5.9 months). The clinical symptoms of the patients relieved to varying degrees. The VAS scores and ODI of lower back and leg pain at 1 and 3 months after operation significantly improved compared to preoperative levels (P<0.05), and the indicators at 3 months significantly improved than that at 1 month (P<0.05). According to the modified MacNab evaluation criteria, the effectiveness at 3 months after operation was rated as excellent in 52 cases, good in 21 cases, and poor in 13 cases, with an excellent and good rate of 84.9%. No lumbar instability was detected on flexion-extension X-ray films during follow-up. The Lee’s grading of lateral lumbar stenosis at 2 days after operation showed significant improvement compared to preoperative grading (P<0.05). ConclusionFor lateral lumbar spinal stenosis, UBE-assisted decompression of the spinal canal requires the selection of interlaminar approach, interlaminar approach with auxiliary third incision, contralateral inclinatory approach, and paraspinal approach based on preoperative imaging findings and clinical symptoms to achieve better effectiveness.
Objective To evaluate the clinical outcomes ofa surgical approach for decompression of lumbar spinal stenosis, which was featured with reconstruction of posterior spinal structures and epidural space by spinous process-splitting, less osteotomy, laminar flap and keeping spinal process, lamina, outer ligmentum flavum intact. Methods From October 2001 to April 2003, 39 patients (19 males and 20 females, aging 36 to 77 years with a mean age of 49.6 years with lumbar stenosis underwent the surgical decompression procedure with reconstruction of posterior canal structures and epidural space. The involved locations were L3,4 to L5S1(5 cases),L4,5 to L5S1(18 cases), L4,5(11 cases) and L5S1(5 cases). The course of disease was 3 months to 16 years (40.4 months on average). The clinical outcomes after 1 year of operation Results All patients were followed up from 18 to 36 months. No intraoperative and postoperative complications were observed and all patients were satisfactory with the surgery. Computerized tomography showed that spinal and nerve root canal were satisfactorily enlarged 1 week postoperatively in all cases. Fusion of lamina and spinous process were detected on CT in 87.2% patients (34/39) 3 months after operation. No patients presented re-stenosis of lumbar spine and all patients presented bony fusion 1 year after surgery. Conclusion The approach of the current study was a reliable and effective method in the management of lumbar stenosis, it preserved thecontinuity of spinal process, interspinous ligaments, lamina and ligmentumn flavum and integrality of posterior spinal structures and epidural space. The integrity of the psoterior spinal structures can prevent the scar formation and improve the stability of lmbar spine postoperatively.
People’s understanding of lumbar spinal stenosis has become more and more comprehensive and reasonable, however, there are still many controversies about the concepts of " central lumbar canal” and " lateral lumbar spinal canal”, and there is no unified standard at present. In this paper, we redefine and differentiate the two concepts. We believe that some kinds of central canal stenosis caused by bilateral recess stenosis can be completely solved by bilateral percutaneous endoscopic transforaminal discectomy. At the same time, the concept of " lumbar lateral recess” is ambiguous. We redefine it as " lateral lumbar spinal canal” and propose " West China Hospital classification” to guide surgical decision-making, which has been widely recognized and applied.
Objective To evaluate the short-term effectiveness of local laminectomy and interlaminar lumbar instrumented fusion (ILIF) through a small incision for lumbar spinal stenosis. Methods Between November 2009 and January 2011, 16 patients with lumbar spinal stenosis were treated by local laminectomy and ILIF through a small incision. Therewere 7 males and 9 females with an average age of 52.8 years (range, 49-67 years). Sixteen patients had lumbar degenerative stenosis with an average disease duration of 4 years and 7 months (range, 2 years-9 years and 4 months). Four cases complicated by lateral recessus stenosis, 3 by lumbar disc herniation. Involved segments included L3, 4 in 2 cases, L4, 5 in 4 cases, L5, S1 in 4 cases, L3, 4 and L4, 5 (double segments) in 2 cases, L4, 5 and L5, S1 (double segments) in 4 cases. The effectiveness was evaluated with the pre- and post-operative Visual Analogue Scale (VAS) scores, Oswestry Disabil ity Index (ODI). The cross-sectional areas of spinal canal were measured by CT scanning and were compared between pre- and post-operation. Results The average operative time was 47 minutes (range, 35-80 minutes); the average blood loss was 145 mL (range, 120-350 mL); and the average hospital ization days were 7.8 days (range, 4-15 days). Cerebrospinal fluid leakage occurred in 1 case, and healing of incisions by first intention was achieved in the others. The patients were followed up 12-22 months (mean, 14.8 months). CT scanning showed interspinous fusion in 14 cases and possible fusion in 2 cases after operation, with an average fusion time of 4.6 months(range, 3-10 months). The postoperative VAS score, ODI, and cross-sectional area were significantly improved when compared with preoperative values (P lt; 0.05). Conclusion The ILIF can promote fusion between spinous processes, provide spine stabil ization, and protect the spinal cord. The procedure has small incision, simple method of fixation and fusion.
Objective To investigate the effectiveness of one-hole split endoscope (OSE) technique in the treatment of single segment lumbar spinal stenosis (LSS). Methods The clinical data of 32 single segment LSS patients treated with OSE technique for simple spinal canal decompression between January 2022 and December 2022, who met the selection criteria, were retrospectively analysed. There were 18 males and 14 females, the age ranged from 45 to 82 years, with an average of 65.1 years. The disease duration was 9-72 months, with an average of 34.9 months. The surgical segments included L3, 4 in 3 cases, L4, 5 in 19 cases, and L5, S1 in 10 cases. The incision length, operation time, intraoperative blood loss, intraoperative radiation exposure frequency, postoperative mobilization time, and the area of the patient’s lesion segment dural sac before operation and at 1 month after operation were recorded. Low back pain and leg pain were assessed by visual analogue scale (VAS) score before operation and at 3 days, 3 months, and 12 months after operation; functional recovery was assessed by Oswestry disability index (ODI) before operation and at 3 months and 12 months after operation; the effectiveness was assessed by modified MacNab criteria at last follow-up. Results All 32 patients successfully completed the operation, with an average incision length of 2.05 cm, an average operation time of 88.59 minutes, an average intraoperative blood loss of 46.72 mL, an average intraoperative radiation exposure frequency of 3.84 times, and an average postoperative mobilization time of 11.66 hours. All patients were followed up 12-16 months, with an average of 13.5 months. One patient experienced lower limb numbness, pain, and decreased muscle strength after operation, while the remaining patients did not experience complications such as dural tear or important nerve damage. The VAS scores of low back pain and leg pain and ODI in patients at various time points after operation were significantly better than preoperative ones, and each indicator further improved with time. The differences between time points were significant (P<0.05). At 1 month after operation, the area of the patient’s lesion segment dural sac was (123.13±19.66) mm2, which significantly increased compared to preoperative (51.25±9.50) mm2 (t=?18.616, P<0.001). At last follow-up, the improved MacNab criteria were used to evaluate the effectiveness, with 18 cases achieving excellent results, 11 cases being good, and 3 cases being fair, with an excellent and good rate of 90.6%. ConclusionThe effectiveness of using OSE technique for simple spinal canal decompression treatment of single segment LSS is satisfactory, with the advantages of minimal surgical trauma and fast recovery.
Objective Degenerative lumbar scol iosis and spinal stenosis are more common in elderly patients. Because of many factors, treatment choices are more complex. To investigate the step treatment strategy of degenerative lumbarscol iosis and spinal stenosis. Methods Between January 2005 and December 2009, 117 patients with degenerative lumbar scol iosis and spinal stenosis were treated with step treatment methods, including conservative therapy (43 cases), posterior decompression alone (18 cases), posterior short segment fusion (1-2 segments, 41 cases), and posterior long segment fusion ( ≥ 3 segments, 15 cases). Step treatment options were made according to patient’s will, the medical compl ications, the degree of the symptoms of low back and lower extremity pain, the size of three-dimensional lumbar scol iosis kyphosis rotating deformity, lumbar spine stabil ity (lateral sl ip, degenerative spondylolysis), and the overall balance of the spine. The visual analogue scale (VAS) score of low back and lower extremity pain, Oswestry disabil ity index (ODI), lumbar lordosis angle, and scol iosis Cobb angle were measured and compared before and after treatments. Results Seventy-two cases were followed up more than 12 months, and there was no death or internal fixation failure in all patients. Of them, 19 patients underwent conservative treatment; the mean follow-up period was 19.3 months (range, 1-5 years); no symptom deterioration was observed; VAS score of low back and lower extremity and ODI were significantly decreased at last follow-up (P lt; 0.05); and lordosis angle was decreased and scol iosis Cobb angle was increased, but there was no significant difference (P gt; 0.05). Twelve cases underwentposterior decompression alone; the average follow-up was 36 months (range, 1-5 years); VAS score of lower extremity and ODI were significantly decreased at last follow-up (P lt; 0.05); and scol iosis Cobb angle was increased and lordosis angle was decreased, but there was no significant difference (P gt; 0.05). Thirty-one patients underwent posterior short segment fusion; the mean follow-up period was 21.3 months (range, 1-3 years); postoperative hematoma, poor wound heal ing, cerebrospinal fluid leakage, and superficial infection occurred in 1 case, respectively, and were cured after symptomatic treatment; VAS score of low back and lower extremity and ODI were significantly decreased (P lt; 0.05); and postoperative lumbar scol iosis Cobb angle and lordosis angle were significantly improved at last follow-up (P lt; 0.05). Ten patients underwent posterior long segment fusion; the mean follow-up period was 17.1 months (range, 1-3 years); postoperative symptoms worsened in 1 case and was cured after physical therapy and drug treatment for 3 months, and deep infection occurred in 1 case and was cured after debridement and continuous irrigation drainage; VAS score and ODI were significantly decreased (P lt; 0.05); and postoperative scol iosis Cobb angle and lordosis angle were improved significantly at last follow-up (P lt; 0.05). Conclusion The treatment of degenerative lumbar scol iosis and spinal stenosis should be individual and step. Surgery treatment should be rely on decompression while deformity correction subsidiary. Accurate judgment of the responsible segment of symptoms, scol iosis and lordosis can prevent the operation expansion and increase safety of surgery with active control bleeding.
Objective To compare the effectiveness of unilateral biportal endoscopic transforaminal lumbar interbody fusion (UBE-TLIF) and endoscopic transforaminal lumbar interbody fusion (Endo-TLIF) in the treatment of single-segment degenerative lumbar spinal stenosis with lumbar spondylolisthesis. Methods Between November 2019 and May 2023, a total of 81 patients with single-segment degenerative lumbar spinal stenosis with lumbar spondylolisthesis who met the selection criteria were enrolled. They were randomly divided into UBE-TLIF group (39 cases) and Endo-TLIF group (42 cases). There was no significant difference in baseline data between the two groups (P>0.05), including gender, age, body mass index, surgical segment, and preoperative visual analogue scale (VAS) scores for low back and leg pain, Oswestry Disability Index (ODI), and serum markers including creatine kinase (CK) and C reactive protein (CRP). Total blood loss (TBL), intraoperative blood loss, hidden blood loss (HBL), postoperative drainage volume, and operation time were recorded and compared between the two groups. Serum markers (CK, CRP) levels were compared between the two groups at 1 day before operation and 1, 3, and 5 days after operation. Furthermore, the VAS scores for low back and leg pain, and ODI at 1 day before operation and 1 day, 3 months, 6 months, and 12 months after operation, and intervertebral fusion rate at 12 months after operation were compared between the two groups. Results All surgeries were completed successfully without occurrence of incision infection, vascular or nerve injury, epidural hematoma, dural tear, or postoperative paraplegia. The operation time in UBE-TLIF group was significantly shorter than that in Endo-TLIF group, but the intraoperative blood loss, TBL, and HBL in UBE-TLIF group were significantly more than those in Endo-TLIF group (P<0.05). There was no significant difference in postoperative drainage volume between the two groups (P>0.05). The levels of CK at 1 day and 3 days after operation and CRP at 1, 3, and 5 days after operation in UBE-TLIF group were slightly higher than those in the Endo-TLIF group (P<0.05), while there was no significant difference in the levels of CK and CPR between the two groups at other time points (P>0.05). All patients were followed up 12 months. VAS score of low back and leg pain and ODI at each time point after operation significantly improved when compared with those before operation in the two groups (P<0.05); there was no significant difference in VAS score of low back and leg pain and ODI between the two groups at each time point after operation (P>0.05). There was no significant difference in the intervertebral fusion rate between the two groups at 12 months after operation (P>0.05). ConclusionUBE-TLIF and Endo-TLIF are both effective methods for treating degenerative lumbar spinal stenosis with lumbar spondylolisthesis. However, compared to Endo-TLIF, UBE-TLIF requires further improvement in minimally invasive techniques to reduce tissue trauma and blood loss.
Objective To explore short-term effectiveness of floating island laminectomy surgery in treating thoracic spinal stenosis and myelopathy caused by ossification of the ligamentum flavum. Methods A total of 31 patients with thoracic spinal stenosis and myelopathy caused by ossification of the ligamentum flavum between January 2019 and April 2022 were managed with floating island laminectomy surgery. The patients comprised 17 males and 14 females, aged between 36 and 78 years, with an average of 55.9 years. The duration of symptoms of spinal cord compression ranged from 3 to 62 months (mean, 27.2 months). The lesions affected T1-6 in 4 cases and T7-12 in 27 cases. The preoperative neurological function score from the modified Japanese Orthopaedic Association (mJOA) was 4.7±0.6. Surgical duration, intraoperative blood loss, and complications were recorded. The thoracic MRI was conducted to reassess the degree of spinal cord compression and decompression after operation. The mJOA score was employed to evaluate the neurological function and calculate the recovery rate at 12 months after operation. Results The surgical duration ranged from 122 to 325 minutes, with an average of 204.5 minutes. The intraoperative blood loss ranged from 150 to 800 mL (mean, 404.8 mL). All incisions healed by first intention after operation. All patients were followed up 12-14 months, with an average of 12.5 months. The patients’ symptoms, including lower limb weakness, gait disorders, and pain, significantly improved. The mJOA scores after operation significantly increased when compared with preoperative scores (P<0.05), gradually improving with time, with significant differences observed among 1, 3, and 6 months (P<0.05). The recovery rate at 12 months was 69.76%±11.38%, with 10 cases exhibiting excellent neurological function and 21 cases showing good. During the procedure, there were 3 cases of dural tear and 1 case of dural defect. Postoperatively, there were 2 cases of cerebrospinal fluid leakage. No aggravated nerve damage, recurrence of ligamentum flavum ossification, or postoperative thoracic deformity occurred. ConclusionThe floating island laminectomy surgery is safe for treating thoracic spinal stenosis and myelopathy caused by ossification of the ligamentum flavum, effectively preventing the exacerbation of neurological symptoms. Early improvement and recovery of neurological function are achieved.