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Zhou X, Zhou Q, Jin X, Zhang J, Song Z. Stand-Alone Lateral Lumbar Interbody Fusion and Lateral Lumbar Interbody Fusion With Supplemental Posterior Instrumentation in the Treatment of Lumbar Degenerative Disease: A Meta-Analysis and Systematic Review. Global Spine J 2024:21925682241268333. [PMID: 39056565 DOI: 10.1177/21925682241268333] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/28/2024] Open
Abstract
STUDY DESIGN Systematic Review. OBJECTIVES Compare the outcomes of stand-alone lateral lumbar interbody fusion (LLIF) and LLIF with supplemental posterior instrumentation in the treatment of lumbar degenerative disease by a Meta-analysis. METHODS In this meta-analysis, we searched Pubmed, Embase, and Cochrane databases from inception to Aug 2023. In this study, only study reporting stand-alone LLIF(stand-alone group) and LLIF with supplemental posterior instrumentation (posterior instrumentation group) in the treatment of lumbar degenerative disease and we excluded duplicate publications, research without full text, incomplete information or inability to conduct data extraction, animal experiments, reviews, and systematic reviews. STATA 15.1 software was used to analyze the data. RESULTS Among the 15 included articles, the total number of patients was 1177, with 469 patients (638 fused segments) in the standalone group and 708 patients (1046 fused segments) in the posterior instrumentation group. The posterior instrumentation group was better than stand-alone group with significant differences in fusion rate, cage subsidence rate,the restoration of disc height and segmental lordosis, the improvement of ODI, and reoperation rate. While, comparing with posterior instrumentation group,the stand-alone group had less intraoperative blood loss. CONCLUSIONS Both stand-alone and instrumented LLIF were effective in improving the clinical outcomes of patients with lumbar degenerative disease. However, the stand-alone LLIF was associated with lower fusion rate, inferior maintenance of indirect decompression, and higher reoperation rate due to high-grade cage subsidence. For patients with risk factors of high-grade cage subsidence, the LLIF with posterior instrumentation may be a better choice.
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Affiliation(s)
- XiaoCheng Zhou
- Department of Orthopaedics, Hangzhou Fuyang Hospital of TCM Orthopedics and Traumatology, Hangzhou, China
| | - Qiujun Zhou
- Department of First Clinical Medical College, Zhejiang Chinese Medical University, Hangzhou, China
| | - Xiaoliang Jin
- Department of First Clinical Medical College, Zhejiang Chinese Medical University, Hangzhou, China
| | - Jinjie Zhang
- Department of Orthopaedics, The First Affiliated Hospital of Zhejiang Chinese Medical University(Zhejiang Provincial Hospital of Chinese Medicine), Hangzhou, China
| | - Zhoufeng Song
- Department of Orthopaedics, The First Affiliated Hospital of Zhejiang Chinese Medical University(Zhejiang Provincial Hospital of Chinese Medicine), Hangzhou, China
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Aguirre AO, Soliman MAR, Kuo CC, Kassay A, Parmar G, Kruk MD, Quiceno E, Khan A, Lim J, Hess RM, Mullin JP, Pollina J. Defining cage subsidence in anterior, oblique, and lateral lumbar spine fusion approaches: a systematic review of the literature. Neurosurg Rev 2024; 47:332. [PMID: 39009745 DOI: 10.1007/s10143-024-02551-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2024] [Revised: 06/27/2024] [Accepted: 07/03/2024] [Indexed: 07/17/2024]
Abstract
One of the most common complications of lumbar fusions is cage subsidence, which leads to collapse of disc height and reappearance of the presenting symptomology. However, definitions of cage subsidence are inconsistent, leading to a variety of subsidence calculation methodologies and thresholds. To review previously published literature on cage subsidence in order to present the most common methods for calculating and defining subsidence in the anterior lumbar interbody fusion (ALIF), oblique lateral interbody fusion (OLIF), and lateral lumbar interbody fusion (LLIF) approaches. A search was completed in PubMed and Embase with inclusion criteria focused on identifying any study that provided descriptions of the method, imaging modality, or subsidence threshold used to calculate the presence of cage subsidence. A total of 69 articles were included in the final analysis, of which 18 (26.1%) reported on the ALIF approach, 22 (31.9%) on the OLIF approach, and 31 (44.9%) on the LLIF approach, 2 of which reported on more than one approach. ALIF articles most commonly calculated the loss of disc height over time with a subsidence threshold of > 2 mm. Most OLIF articles calculated the total amount of cage migration into the vertebral bodies, with a threshold of > 2 mm. LLIF was the only approach in which most articles applied the same method for calculation, namely, a grading scale for classifying the loss of disc height over time. We recommend future articles adhere to the most common methodologies presented here to ensure accuracy and generalizability in reporting cage subsidence.
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Affiliation(s)
- Alexander O Aguirre
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, 100 High Street, Suite B4, Buffalo, NY, 14203, USA
- Department of Neurosurgery, Buffalo General Medical Center, Kaleida Health, Buffalo, NY, USA
| | - Mohamed A R Soliman
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, 100 High Street, Suite B4, Buffalo, NY, 14203, USA
- Department of Neurosurgery, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Cathleen C Kuo
- Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, NY, USA
| | - Andrea Kassay
- Division of Neurosurgery, University of Toronto, Toronto, ON, Canada
| | - Gaganjot Parmar
- Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, NY, USA
| | - Marissa D Kruk
- Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, NY, USA
| | - Esteban Quiceno
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, 100 High Street, Suite B4, Buffalo, NY, 14203, USA
- Department of Neurosurgery, Buffalo General Medical Center, Kaleida Health, Buffalo, NY, USA
| | - Asham Khan
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, 100 High Street, Suite B4, Buffalo, NY, 14203, USA
- Department of Neurosurgery, Buffalo General Medical Center, Kaleida Health, Buffalo, NY, USA
| | - Jaims Lim
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, 100 High Street, Suite B4, Buffalo, NY, 14203, USA
- Department of Neurosurgery, Buffalo General Medical Center, Kaleida Health, Buffalo, NY, USA
| | - Ryan M Hess
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, 100 High Street, Suite B4, Buffalo, NY, 14203, USA
- Department of Neurosurgery, Buffalo General Medical Center, Kaleida Health, Buffalo, NY, USA
| | - Jeffrey P Mullin
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, 100 High Street, Suite B4, Buffalo, NY, 14203, USA
- Department of Neurosurgery, Buffalo General Medical Center, Kaleida Health, Buffalo, NY, USA
| | - John Pollina
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, 100 High Street, Suite B4, Buffalo, NY, 14203, USA.
- Department of Neurosurgery, Buffalo General Medical Center, Kaleida Health, Buffalo, NY, USA.
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Jin C, Shang J, Chen X, Zheng J, He W, He L, Han W. Can zoledronic acid reduce the risk of cage subsidence after oblique lumbar interbody fusion combined with bilateral pedicle screw fixation in the elderly population? A retrospective study. J Orthop Surg Res 2024; 19:344. [PMID: 38849941 PMCID: PMC11162006 DOI: 10.1186/s13018-024-04828-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2024] [Accepted: 05/31/2024] [Indexed: 06/09/2024] Open
Abstract
BACKGROUND The objective of this study was to evaluate the potential of zoledronic acid for reducing the incidence of cage subsidence and enhancing interbody fusion rates following oblique lumbar interbody fusion (OLIF) surgery, particularly as the first reported evidence of the role of zoledronic acid combined with OLIF. METHODS A retrospective analysis was conducted on data from 108 elderly patients treated for degenerative lumbar diseases using OLIF combined with bilateral pedicle screw fixation from January 2018 to December 2021. Patients were divided into the zoledronic acid (ZOL) group (43 patients, 67 surgical segments) and the control group (65 patients, 86 surgical segments). A comparative analysis of the radiographic and clinical outcomes between the groups was performed, employing univariate and multivariate regression analyses to explore the relationships between cage subsidence and the independent variables. RESULTS Radiographic outcomes, including anterior height, posterior height, disc height, coronal disc angle, foraminal height, and lumbar lordosis, were not significantly different between the two groups. Similarly, no statistically significant differences were noted in the back visual analog scale (VAS) scores and Oswestry Disability Index (ODI) scores between the groups. However, at the 1-year follow-up, the leg VAS score was lower in the ZOL group than in the control group (P = 0.028). The ZOL group demonstrated a notably lower cage subsidence rate (20.9%) than did the control group (43.0%) (P < 0.001). There was no significant difference in the interbody fusion rate between the ZOL group (93.0%) and the control group (90.8%). Non-use of zoledronic acid emerged as an independent risk factor for cage subsidence (OR = 6.047, P = 0.003), along with lower bone mineral density, lower postoperative anterior height, and concave endplate morphology. The model exhibited robust discriminative performance, with an area under the curve (AUC) of 0.872. CONCLUSION The administration of zoledronic acid mitigates the risk of cage subsidence following OLIF combined with bilateral pedicle screw fixation in elderly patients; however, it does not improve the interbody fusion rate.
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Affiliation(s)
- Cong Jin
- Department of Orthopedics, Shaoxing People's Hospital, Zhongxing North Road, Shaoxing, Zhejiang, 312000, China
| | - JinXiang Shang
- Department of Orthopedics, Affiliated Hospital of Shaoxing University, Shaoxing, Zhejiang, 312000, China
| | - Xi Chen
- School of Medicine, Shaoxing University, Shaoxing, Zhejiang, 312000, China
| | - Jiewen Zheng
- School of Medicine, Shaoxing University, Shaoxing, Zhejiang, 312000, China
| | - Wei He
- Department of Orthopedics, Shaoxing People's Hospital, Zhongxing North Road, Shaoxing, Zhejiang, 312000, China
| | - Lei He
- Department of Orthopedics, Shaoxing People's Hospital, Zhongxing North Road, Shaoxing, Zhejiang, 312000, China.
| | - Weiqi Han
- Department of Orthopedics, Shaoxing People's Hospital, Zhongxing North Road, Shaoxing, Zhejiang, 312000, China.
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Yang G, Zhang X, Xu Z, Zhang L. Social Medical Insurances, Choices of Medical Institutions and the 'Siphon Effect' in the Health Service Market: Evidence from 2021 Yangtze River Delta Region of China. Risk Manag Healthc Policy 2024; 17:1287-1299. [PMID: 38770148 PMCID: PMC11104391 DOI: 10.2147/rmhp.s458178] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2024] [Accepted: 04/29/2024] [Indexed: 05/22/2024] Open
Abstract
Purpose The siphon effect in the health service market is notably pronounced in many countries. How to measure and identify the determinants contributing to the siphon effect presents a substantial challenge. This study aimed to analyse the effect of two different social medical insurances, the Basic Medical Insurance System for Urban Employees (BMISUE), and the Basic Medical Insurance System for Urban and Rural Residents (BMISURR), on the siphon effect in the health services market. Methods The data used in this study were from the 2021 Health Life Satisfaction Survey of Yangtze River Delta (HLSSYRD) conducted by Shanghai Jiao Tong University. The logistic model was used to evaluate the association between social medical insurances and individual choices of medical institutions, and the Propensity Score Matching method (PSM) was used to check the robustness of basic results. Results Residents covered by BMISUE were more likely to choose a general hospital when they first sought medical treatment (OR = 5.377, 95% CI: 4.887, 5.915) relative to those insured by BMISURR. Further analysis showed that BMISUE would accelerate the siphon effect of general hospitals, people insured by BMISUE were still more likely to choose general hospitals despite being close to primary hospitals compared to those insured by BMISURR (OR = 3.240, 95% CI: 2.945, 3.565). Heterogeneity analysis indicated BMISUE had a greater impact on residents aged 15-59 years and those with high income compared to older people and individuals with low income. Conclusion Different social medical insurances can substantially affect residents' first choice of medical institutions. BMISUE with higher benefits level could exacerbate the siphon effect in the health service market. More equitable medical security system should be strengthened to bridge the benefits gap between BMISUE and BMISURR.
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Affiliation(s)
- Guang Yang
- School of International and Public Affairs, Shanghai Jiao Tong University, Shanghai, People’s Republic of China
| | - Xiaodong Zhang
- Institute of Population Research, Peking University, Beijing, People’s Republic of China
- Oxford Institute of Population Ageing, University of Oxford, Oxford, UK
| | - Zhaopeng Xu
- School of International and Public Affairs, Shanghai Jiao Tong University, Shanghai, People’s Republic of China
| | - Lufa Zhang
- School of International and Public Affairs, Shanghai Jiao Tong University, Shanghai, People’s Republic of China
- Institute of Healthy Yangtze River Delta, Shanghai Jiao Tong University, Shanghai, People’s Republic of China
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Jiang L, Liu L, Dong L, Xu Z, Zhang X, Qian L. Comparison of instrumented and stand-alone lateral lumbar interbody fusion for lumbar degenerative disease: a systematic review and meta-analysis. BMC Musculoskelet Disord 2024; 25:108. [PMID: 38310205 PMCID: PMC10837938 DOI: 10.1186/s12891-024-07214-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2023] [Accepted: 01/18/2024] [Indexed: 02/05/2024] Open
Abstract
BACKGROUND Both instrumented and stand-alone lateral lumbar interbody fusion (LLIF) have been widely used to treat lumbar degenerative disease. However, it remains controversial as whether posterior internal fixation is required when LLIF is performed. This meta-analysis aims to compare the radiographic and clinical results between instrumented and stand-alone LLIF. METHODS PubMed, EMBASE and Cochrane Collaboration Library up to March 2023 were searched for studies that compared instrumented and stand-alone LLIF in the treatment of lumbar degenerative disease. The following outcomes were extracted for comparison: interbody fusion rate, cage subsidence rate, reoperation rate, restoration of disc height, segmental lordosis, lumbar lordosis, visual analog scale (VAS) scores of low-back and leg pain and Oswestry Disability Index (ODI) scores. RESULTS 13 studies involving 1063 patients were included. The pooled results showed that instrumented LLIF had higher fusion rate (OR 2.09; 95% CI 1.16-3.75; P = 0.01), lower cage subsidence (OR 0.50; 95% CI 0.37-0.68; P < 0.001) and reoperation rate (OR 0.28; 95% CI 0.10-0.79; P = 0.02), and more restoration of disc height (MD 0.85; 95% CI 0.18-1.53; P = 0.01) than stand-alone LLIF. The ODI and VAS scores were similar between instrumented and stand-alone LLIF at the last follow-up. CONCLUSIONS Based on this meta-analysis, instrumented LLIF is associated with higher rate of fusion, lower rate of cage subsidence and reoperation, and more restoration of disc height than stand-alone LLIF. For patients with high risk factors of cage subsidence, instrumented LLIF should be applied to reduce postoperative complications.
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Affiliation(s)
- Lianghai Jiang
- Department of Spine Surgery, Qingdao Municipal Hospital, Qingdao, People's Republic of China
| | - Lantao Liu
- Department of Spine Surgery, Qingdao Municipal Hospital, Qingdao, People's Republic of China
| | - Liang Dong
- Department of Orthopedic, Honghui Hospital, Xi'an Jiaotong University College of Medicine, Xi'an, People's Republic of China.
| | - Zhengwei Xu
- Department of Orthopedic, Honghui Hospital, Xi'an Jiaotong University College of Medicine, Xi'an, People's Republic of China
| | - Xiaobo Zhang
- Department of Orthopedic, Honghui Hospital, Xi'an Jiaotong University College of Medicine, Xi'an, People's Republic of China
| | - Lixiong Qian
- Department of Orthopedic, Honghui Hospital, Xi'an Jiaotong University College of Medicine, Xi'an, People's Republic of China
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Loniewski S, Farah K, Mansouri N, Albader F, Settembre N, Litré CF, Malikov S, Fuentes S. Da Vinci Robotic Assistance for Anterolateral Lumbar Arthrodesis: Results of a French Multicentric Study. World Neurosurg 2024; 181:e685-e693. [PMID: 37898271 DOI: 10.1016/j.wneu.2023.10.114] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2023] [Accepted: 10/23/2023] [Indexed: 10/30/2023]
Abstract
BACKGROUND The da Vinci robot (DVR) is the most widely used robot in abdominal, urological, and gynecological surgery. Due to its minimally invasive approach, the DVR has demonstrated its effectiveness and improved safety in these different disciplines. The aim of our study was to report its use in an anterior approach of complex lumbar surgery. METHODS In a retrospective multicenter observational study, 10 robotic-assisted procedures were performed from March 2021 to May 2022. Six oblique lumbar interbody fusion procedures and 4 lumbar corpectomies were performed by anterolateral approach assisted by the DVR. The characteristics of the patients and the intraoperative and postoperative data were recorded. RESULTS Six men and 4 women underwent surgery (mean age 50.5 years; body mass index 28.6 kg/m2). No vascular injuries were reported, and no procedures required conversion to open surgery. Mean surgical time were 219 minutes for 1-level oblique lumbar interbody fusion (3 patients), 286 minutes for 2-level oblique lumbar interbody fusion (3 patients), and 390 minutes for corpectomy (4 patients). Four patients experienced nonserious adverse events due to lumbar plexus nerve damage. One patient had a vertebral body plate fracture requiring posterior revision surgery, and 1 patient had a psoas hematoma requiring transfusion. No abdominal wall complications or surgical site infection were found. Seven patients were reviewed at 12 months, none had complications, and all showed radiological evidence of fusion. CONCLUSIONS The use of the DVR in lumbar surgery allows a safe minimally invasive transperitoneal approach, but to date, only hybrid procedures have been performed.
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Affiliation(s)
- Stanislas Loniewski
- Department of Neurosurgery, Hôpital Maison Blanche, CHU de Reims, Reims, France.
| | - Kaissar Farah
- Department of Neurosurgery, Hôpital de la Timone, Assistance Publique des Hôpitaux de Marseille, Marseille, France
| | - Nacer Mansouri
- Department of Neurosurgery, Hôpital Central, CHRU Nancy, Nancy, France
| | - Faisal Albader
- Department of Neurosurgery, Hôpital de la Timone, Assistance Publique des Hôpitaux de Marseille, Marseille, France
| | - Nicla Settembre
- Department of Vascular surgery, Hôpitaux de Brabois, CHRU Nancy, Nancy, France
| | - Claude-Fabien Litré
- Department of Neurosurgery, Hôpital Maison Blanche, CHU de Reims, Reims, France
| | - Serguei Malikov
- Department of Vascular surgery, Hôpitaux de Brabois, CHRU Nancy, Nancy, France
| | - Stéphane Fuentes
- Department of Neurosurgery, Hôpital de la Timone, Assistance Publique des Hôpitaux de Marseille, Marseille, France
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Godolias P, Frieler S, Tataryn ZL, McBride P, Nunna R, Ghayoumi P, Charlot K, Tran A, Al-Awadi H, Gerstmeyer JR, Ruetten S, Chapman JR, Oskouian RJ. Towards a More Realistic Appraisal of Complications Following Staged Lateral Lumbar Interbody Fusion: A Single Institution Series. Global Spine J 2024; 14:130-137. [PMID: 35446693 PMCID: PMC10676158 DOI: 10.1177/21925682221096621] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
STUDY DESIGN Retrospective cohort study. OBJECTIVES With steadily increasing implementation of far lateral approaches in spine surgery, surgeons can utilize the advantages of different approaches synergistically to ensure an optimal patient outcome. Our single institution study aimed to assess the complication rates of patients who underwent a lateral interbody fusion as the index procedure and additional anterior or posterior instrumentation as part of a planned staged surgical reconstruction effort. METHODS This study was approved by our institutional review board (STUDY2021000113). We included 576 patients who received a lateral lumbar interbody fusion (LLIF) as the index procedure followed by transforaminal lumbar interbody fusion (TLIF), posterior lumbar interbody fusion (PLIF) or anterior lumbar interbody fusion (ALIF) between 2016 and 2020. Primary outcomes were complications identified during the initial inpatient stay, which were categorized into approach-related and secondary complications. Secondary outcomes tracked up to 6 years post-surgery. RESULTS The overall complication rate was 19.2% (10.5% approach related, 8.7% secondary complications). Significant intraoperative hemorrhage (mean 659.3 mL vs 131.4 mL, P < .01) was the most common approach related complication with an incidence of 4%, followed by temporary hip flexor weakness in 2.6%. A permanent (femoral) nerve damage was verified in 1 patient. The most common secondary complication was impaired wound healing in 12 patients (2.1%). We identified a 7.1% (41 of 576 patients) rate of revision surgery, on average after 372 days (±34 days). CONCLUSIONS We recorded an overall complication rate of 19.2% for staged adult deformity corrective surgeries utilizing far lateral interbody fusions at several lumbar levels followed by a more comprehensive posterior surgical reconstruction.
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Affiliation(s)
- Periklis Godolias
- Seattle Science Foundation, Seattle, WA, USA
- Department of Orthopedics and Trauma Surgery, BG University Hospital Bergmannsheil, Ruhr University Bochum, Bochum, Germany
| | - Sven Frieler
- Department of Orthopedics and Trauma Surgery, BG University Hospital Bergmannsheil, Ruhr University Bochum, Bochum, Germany
| | | | | | - Ravi Nunna
- Seattle Science Foundation, Seattle, WA, USA
| | | | | | - Angela Tran
- Seattle Science Foundation, Seattle, WA, USA
| | | | - Julius R. Gerstmeyer
- Department of Orthopedics and Trauma Surgery, BG University Hospital Bergmannsheil, Ruhr University Bochum, Bochum, Germany
| | - Sebastian Ruetten
- Center for Spine Surgery and Pain Therapy, Center for Orthopedics and Traumatology of the St. Elisabeth Group–Catholic Hospitals Rhein-Ruhr, St. Anna Hospital Herne/Marien Hospital Herne University Hospital/Marien Hospital Witten, Herne, Germany
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Liu J, Geng Z, Wang J, Zhang Z, Zhang X, Miao J. Biomechanical differences between two different shapes of oblique lumbar interbody fusion cages on whether to add posterior internal fixation system: a finite element analysis. J Orthop Surg Res 2023; 18:962. [PMID: 38093357 PMCID: PMC10720077 DOI: 10.1186/s13018-023-04461-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2023] [Accepted: 12/10/2023] [Indexed: 12/17/2023] Open
Abstract
BACKGROUND Oblique lateral lumbar fusion (OLIF) is widely used in spinal degeneration, deformity and other diseases. The purpose of this study was to investigate the biomechanical differences between two different shapes of OLIF cages on whether to add posterior internal fixation system, using finite element analysis. METHODS A complete three-dimensional finite element model is established and verified for L3-L5. Surgical simulation was performed on the verified model, and the L4-L5 was the surgical segment. A total of the stand-alone group (Model A1, Model B1) and the BPSF group (Model A2, Model B2) were constructed. The four OLIF surgical models were: A1. Stand-alone OLIF with a kidney-shaped Cage; B1. Stand-alone OLIF with a straight cage; A2. OLIF with a kidney-shaped cage + BPSF; B2. Stand-alone OLIF with a straight cage + BPSF, respectively. The differences in the range of motion of the surgical segment (ROM), equivalent stress peak of the cage (ESPC), the maximum equivalent stress of the endplate (MESE) and the maximum stress of the internal fixation (MSIF) were compared between different models. RESULTS All OLIF surgical models showed that ROM declines between 74.87 and 96.77% at L4-L5 operative levels. The decreasing order of ROM was Model A2 > Model B2 > Model A1 > Model A2. In addition, the ESPC and MESE of Model A2 are smaller than those of other OLIF models. Except for the left-bending position, the MSIF of Model B2 increased by 1.51-16.69% compared with Model A2 in each position. The maximum value of MESE was 124.4 Mpa for Model B1 in the backward extension position, and the minimum value was 7.91 Mpa for Model A2 in the right rotation. Stand-alone group showed significantly higher ROMs and ESPCs than the BPSF group, with maximum values of 66.66% and 70.59%. For MESE, the BPSF group model can be reduced by 89.88% compared to the stand-alone group model. CONCLUSIONS Compared with the traditional straight OLIF cage, the kidney-shaped OLIF cage can further improve the stability of the surgical segment, reduce ESPC, MESE and MSIF, and help to reduce the risk of cage subsidence.
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Affiliation(s)
- Jianchao Liu
- Department of Spine Surgery, Tianjin Hospital, Tianjin University, No. 406 Jiefang South Rd, Hexi District, Tianjin, 300211, China
| | - Ziming Geng
- Department of Spine Surgery, Tianjin Hospital, Tianjin University, No. 406 Jiefang South Rd, Hexi District, Tianjin, 300211, China
| | - Jian Wang
- Department of Spine Surgery, Tianjin Hospital, Tianjin University, No. 406 Jiefang South Rd, Hexi District, Tianjin, 300211, China
| | - Zepei Zhang
- Department of Spine Surgery, Tianjin Hospital, Tianjin University, No. 406 Jiefang South Rd, Hexi District, Tianjin, 300211, China
| | - Xingze Zhang
- Department of Spine Surgery, Tianjin Hospital, Tianjin University, No. 406 Jiefang South Rd, Hexi District, Tianjin, 300211, China
| | - Jun Miao
- Department of Spine Surgery, Tianjin Hospital, Tianjin University, No. 406 Jiefang South Rd, Hexi District, Tianjin, 300211, China.
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Singhatanadgige W, Chatareeyagul P, Tanasansomboon T, Phutrakool P, Kotheeranurak V, Yingsakmongkol W, Limthongkul W. Should a Narrow Corridor Be a Contraindication for Performing Oblique Lateral Interbody Fusion Procedure or Not? Global Spine J 2023:21925682231216049. [PMID: 37962023 DOI: 10.1177/21925682231216049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2023] Open
Abstract
STUDY DESIGN Retrospective study. OBJECTIVES We investigated the effect of corridor width on the postoperative outcomes of patients who underwent the OLIF procedure. METHODS Patients who underwent OLIF surgery, which included L4-5, between 2015 and 2021 were retrospectively studied. The patients were divided into three groups by the width of the corridor: not more than 10 mm, between 10 and 20 mm, and 20 mm or more. We compared clinical and radiographic outcomes and complications between these groups. RESULTS A total of 81 patients were included. There were no significant differences in VAS leg and back pain scores, ODI scores, or complications between each group. The radiographic findings, including cage position, anterior and posterior disc height, segmental Cobb angle, and foraminal height, also showed no significant differences between each group. The only radiographic finding that showed a significant difference between each group was the angle of the cage. We found significantly less degree of angle in the wider than 20 mm group when compared to the other two groups. (P-value = .01). There was no recorded incidence of major vascular complications. CONCLUSIONS The width of oblique corridor does not affect clinical outcomes, complications, or radiographic findings, including position of the cage, anterior and posterior disc height, segmental angle, and foraminal height after OLIF procedure, including L4-5 level. Thus, the OLIF procedure can be performed safely even in patients with limited oblique corridors, especially at L4-5.
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Affiliation(s)
- Weerasak Singhatanadgige
- Department of Orthopedics, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Bangkok, Thailand
- Center of Excellence in Biomechanics and Innovative Spine Surgery, Chulalongkorn University, Bangkok, Thailand
| | | | - Teerachat Tanasansomboon
- Center of Excellence in Biomechanics and Innovative Spine Surgery, Chulalongkorn University, Bangkok, Thailand
| | - Phanupong Phutrakool
- Chula Data Management Center, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Vit Kotheeranurak
- Department of Orthopedics, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Bangkok, Thailand
- Center of Excellence in Biomechanics and Innovative Spine Surgery, Chulalongkorn University, Bangkok, Thailand
| | - Wicharn Yingsakmongkol
- Department of Orthopedics, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Bangkok, Thailand
- Center of Excellence in Biomechanics and Innovative Spine Surgery, Chulalongkorn University, Bangkok, Thailand
| | - Worawat Limthongkul
- Department of Orthopedics, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Bangkok, Thailand
- Center of Excellence in Biomechanics and Innovative Spine Surgery, Chulalongkorn University, Bangkok, Thailand
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10
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CreveCoeur TS, Sperring CP, DiGiorgio AM, Chou D, Chan AK. Antepsoas Approaches to the Lumbar Spine. Neurosurg Clin N Am 2023; 34:619-632. [PMID: 37718108 DOI: 10.1016/j.nec.2023.06.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/19/2023]
Abstract
Lumbar interbody fusion (LIF) is a well-established approach in treating spinal deformity and degenerative conditions of the spine. Since its inception in the 20th century, LIF has continued to evolve, allowing for minimally invasive approaches, high fusion rates, and improving disability scores with favorable complication rates. The anterior to the psoas (ATP) approach utilizes a retroperitoneal pathway medial to the psoas muscle to access the L1-S1intervertebral disc spaces. In contrast to the transpsoas arppoach, its primary advantage is avoiding transgressing the psoas muscle and the contained lumbar plexus, which potentially decreases the risk of injury to the lumbar plexus. Avoiding transgression of the psoas may minimize the risk of transient or permanent neurological deficits secondary to lumbar plexus injury. Indications for ATP approaches may expand as it is shown to be a safe and effective method of achieving spinal arthrodesis.
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Affiliation(s)
- Travis S CreveCoeur
- Department of Neurological Surgery, Neurological Institute of New York, Columbia University College of Physicians and Surgeons, 710 West 168th Street, New York, NY 10033, USA
| | - Colin P Sperring
- Department of Neurological Surgery, Neurological Institute of New York, Columbia University College of Physicians and Surgeons, 710 West 168th Street, New York, NY 10033, USA
| | - Anthony M DiGiorgio
- Department of Neurological Surgery, University of California San Francisco, San Francisco, CA 94143, USA
| | - Dean Chou
- Department of Neurological Surgery, Neurological Institute of New York, Columbia University College of Physicians and Surgeons, 5141 Broadway, New York, NY 10034, USA
| | - Andrew K Chan
- Department of Neurological Surgery, Neurological Institute of New York, Columbia University College of Physicians and Surgeons, 5141 Broadway, 3FW, Room 20, New York, NY 10034, USA.
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11
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Xu W, Liu W, Zhong F, Peng Y, Liu X, Yu L. Efficacy of OLIF combined with pedicle screw internal fixation for lumbar spinal stenosis on spinal canal changes before and after surgery. J Orthop Surg Res 2023; 18:724. [PMID: 37749636 PMCID: PMC10519078 DOI: 10.1186/s13018-023-04209-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2023] [Accepted: 09/14/2023] [Indexed: 09/27/2023] Open
Abstract
PURPOSE The purpose of the study was to evaluate the efficacy of OLIF combined with pedicle screw internal fixation in the treatment of lumbar spinal stenosis by assessing the changes in spinal canal before and after surgery. METHODS In this retrospective study, we included sixteen patients who underwent a combination of single-segment OLIF and pedicle screw internal fixation for the treatment of lumbar spinal stenosis at the Affiliated Hospital of Jiangxi University of Chinese Medicine between February 2018 and August 2022. The patients' pre- and post-operative data were compared. Intraoperative bleeding, duration of surgery, visual analogue score (VAS), Oswestry Disability Index (ODI), disc height (DH), cross-sectional area of vertebral canal (CSAVC), cross-sectional area of dural sac (CSADS), cross-sectional area of intervertebral foramen (CSAIF), spinal canal volume (SCV), spinal canal volume expansion rate, lumbar lordosis, and sagittal vertical axis were observed and recorded. The efficacy of OLIF combined with pedicle screw internal fixation for lumbar spinal stenosis on spinal canal changes before and after surgery was summarized. RESULTS The results showed that OLIF combined with pedicle screw internal fixation effectively restored disc height and increased the cross-sectional area of the spinal canal. It also had an indirect decompression effect. The intraoperative bleeding and duration of surgery were within acceptable ranges. The VAS and ODI scores significantly improved after surgery, indicating a reduction in pain and improvement in functional disability. The CSAVC, CSADS, CSAIF, SCV, and spinal canal volume expansion rate were all increased postoperatively. Additionally, there was improvement in lumbar lordosis and sagittal vertical axis. We conducted a follow-up of all patients at 1 year after the surgery. The results revealed that the parameter values at 1 year post-surgery showed varying degrees of decrease or increase compared to the immediate postoperative values. However, these values remained statistically significant when compared to the preoperative parameter values (P < 0.05). CONCLUSIONS OLIF combined with pedicle screw internal fixation effectively restores disc height and increases the cross-sectional area of the vertebral canal in patients with LSS, reflecting the indirect decompression effect. Measuring parameters such as DH, CSAVC, CSADS, CSAIF, SCV, and SCV expansion rate before and after surgery provides valuable information for evaluating the efficacy and functional recovery of the lumbar spine in LSS patients treated with OLIF surgery.
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Affiliation(s)
- Wangbing Xu
- Affiliated Hospital of Jiangxi University of Chinese Medicine, Nanchang, Jiangxi 330006, China
| | - Weibing Liu
- Jiangxi University of Chinese Medicine, Nanchang, Jiangxi 330004, China.
| | - Faming Zhong
- Affiliated Hospital of Jiangxi University of Chinese Medicine, Nanchang, Jiangxi 330006, China
| | - Yu Peng
- The Fourth Clinical Medical College, Guangzhou University of Chinese Medicine, Shenzhen, Guangdong 518033, China
| | - Xin Liu
- Jiangxi University of Chinese Medicine, Nanchang, Jiangxi 330004, China
| | - Liangkun Yu
- Jiangxi University of Chinese Medicine, Nanchang, Jiangxi 330004, China
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12
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Pu X, Wang D, Gu S. Advances in Hounsfield units value for predicting cage subsidence on spinal interbody fusion surgery. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2023; 32:3149-3157. [PMID: 37306798 DOI: 10.1007/s00586-023-07805-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/26/2023] [Revised: 01/26/2023] [Accepted: 05/28/2023] [Indexed: 06/13/2023]
Abstract
PURPOSE A growing number of studies have demonstrated that Hounsfield units (HU) value can effectively assess bone quality and predict cage subsidence (CS) after spinal surgery. The purpose of this review is to provide an overview of the utility of the HU value for predicting CS after spinal surgery and to raise some of the unresolved questions in this field. METHODS We searched on PubMed, EMBASE, MEDLINE, and Cochrane Library for studies correlating HU value to CS. RESULTS Thirty-seven studies were included in this review. We found that HU value can predicted the risk of CS effectively after spinal surgery. Moreover, the HU value of the cancellous vertebral body and the cortical endplate were used for predicting CS, in comparison, the measurement method of HU value in the cancellous vertebral body was more standardized, but which region is more important to CS remains unknown. Different cutoff thresholds of HU value have been established in different surgical procedures for predicting CS. The HU value may be superior to dual-energy X-ray absorptiometry (DEXA) for CS prediction; however, the usage standard of HU value has not been well established. CONCLUSIONS The HU value shows great potential for predicting CS and constitutes an advantage over DEXA. However, general consensuses about how CS is defined and HU is measured, which part of HU value is more important, and the appropriate cutoff threshold of the HU value for osteoporosis and CS still require exploration.
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Affiliation(s)
- Xingxiao Pu
- Department of Orthopedic Spine Surgery, Yan'an Hospital Affiliated to Kunming Medical University, 245# Panlong, Renmingdonglu, Kunming, 650051, Yunnan, People's Republic of China
| | - Daxing Wang
- Department of Orthopedic Spine Surgery, Yan'an Hospital Affiliated to Kunming Medical University, 245# Panlong, Renmingdonglu, Kunming, 650051, Yunnan, People's Republic of China.
| | - Shao Gu
- Department of Orthopedic Spine Surgery, Yan'an Hospital Affiliated to Kunming Medical University, 245# Panlong, Renmingdonglu, Kunming, 650051, Yunnan, People's Republic of China.
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Zhang X, Wang Y, Zhang W, Liu S, Liu Z, Wang K, Wu H. Perioperative Clinical Features and Long-term Prognosis After Oblique Lateral Interbody Fusion (OLIF), OLIF With Anterolateral Screw Fixation, or OLIF With Percutaneous Pedicle Fixation: A Comprehensive Treatment Strategy for Patients With Lumbar Degenerative Disease. Neurospine 2023; 20:536-549. [PMID: 37401071 PMCID: PMC10323359 DOI: 10.14245/ns.2244954.477] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2022] [Revised: 02/16/2023] [Accepted: 03/09/2023] [Indexed: 07/05/2023] Open
Abstract
OBJECTIVE To compare the efficacy of oblique lateral interbody fusion (OLIF), OLIF combined with anterolateral screw fixation (OLIF-AF), and OLIF combined with percutaneous pedicle screw fixation (OLIF-PF) in the treatment of single-level or 2-level degenerative lumbar disease. METHODS Between January 2017 and 2021, 71 patients were treated with OLIF and combined OLIF. The demographic data, clinical outcomes, radiographic outcomes, and complications were compared among the 3 groups. RESULTS The operative time and intraoperative blood loss in the OLIF (p<0.05) and OLIF-AF (p<0.05) groups were lower than in the OLIF-PF group. Posterior disk height improvement in the OLIF-PF group was better than in the OLIF (p<0.05) and OLIF-AF (p<0.05) groups. In terms of foraminal height (FH), the OLIF-PF group was significantly better than the OLIF group (p<0.05), but there was no significant difference between the OLIF-PF and OLIF-AF groups (p>0.05) or between the OLIF and OLIF-AF groups (p>0.05). There were no significant differences in fusion rates, the incidence of complications, lumbar lordosis, anterior disc height, and cross-sectional area among the 3 groups (p>0.05). The OLIF-PF group had significantly lower rates of subsidence than the OLIF group (p<0.05). CONCLUSION OLIF remains a viable option with similar patient-reported outcomes and fusion rates compared with surgeries that include lateral and posterior internal fixation while greatly reducing the financial burden, intraoperative time, and intraoperative blood loss. OLIF has a higher subsidence rate than lateral and posterior internal fixation, but most subsidence is mild and has no adverse effect on clinical and radiographic outcomes.
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Affiliation(s)
- Xiangyu Zhang
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Yutian Wang
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Weikang Zhang
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
| | | | - Zhenlei Liu
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Kai Wang
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Hao Wu
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
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Song Z, Chen X, Zhou Z, Chen W, Zhu G, Jiang R, Zhang P, Lin S, Wang X, Yu X, Ren H, Liang D, Cui J, Tang J, Jiang X. Different Moro Zones of Psoas Major Affect the Clinical Outcomes after Oblique Lumbar Interbody Fusion: A Retrospective Study of 94 Patients. J Clin Med 2023; 12:jcm12030989. [PMID: 36769637 PMCID: PMC9917587 DOI: 10.3390/jcm12030989] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2022] [Revised: 01/22/2023] [Accepted: 01/24/2023] [Indexed: 01/31/2023] Open
Abstract
Oblique lumbar interbody fusion (OLIF) has been driven to the maturity stage in recent years. However, postoperative symptoms such as thigh paresthesia resulting from intraoperative retraction of the psoas major (PM) have sometimes occurred. The aim of this study was to assess the different positions and morphology of PM muscles and their relationship with clinical outcomes after OLIF by introducing the Moro zones. Patients who underwent L4-5 OLIF at our institution between April 2019 and June 2021 were reviewed and all data were recorded. All patients were grouped by Moro zones into a Moro A cohort and a Moro I and II cohort based on the front edges of their left PM muscles. A total of 94 patients were recruited, including 57 in the Moro A group and 37 in the Moro I and II group. Postoperative thigh pain or numbness occurred in 12 (21.1%) and 2 (5.4%) patients in the Moro A group and the Moro I and II group, respectively. There was no difference in the psoas major transverse diameter (PMTD) between groups preoperatively, while longer PMTD was revealed postoperatively in the Moro A group. The operating window (OW) and psoas major sagittal diameter (PMSD) showed significant differences within and between groups. Thirteen patients had teardrop-shaped PM muscles, with 92.3% in the Moro A group showing significantly worse clinical scores at 1-week follow-up. The Moro zones of the PM affected the short-term outcomes after OLIF. Preoperative measurements and analysis of OW, PMSD and PM morphology should be performed as necessary to predict short-term outcomes.
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Affiliation(s)
- Zefeng Song
- First Clinical Medical College, Guangzhou University of Chinese Medicine, Guangzhou 510405, China
| | - Xingda Chen
- First Clinical Medical College, Guangzhou University of Chinese Medicine, Guangzhou 510405, China
| | - Zelin Zhou
- First Clinical Medical College, Guangzhou University of Chinese Medicine, Guangzhou 510405, China
| | - Wanyan Chen
- First Clinical Medical College, Guangzhou University of Chinese Medicine, Guangzhou 510405, China
| | - Guangye Zhu
- First Clinical Medical College, Guangzhou University of Chinese Medicine, Guangzhou 510405, China
| | - Rueishiuan Jiang
- First Clinical Medical College, Guangzhou University of Chinese Medicine, Guangzhou 510405, China
| | - Peng Zhang
- First Clinical Medical College, Guangzhou University of Chinese Medicine, Guangzhou 510405, China
| | - Shaohao Lin
- First Clinical Medical College, Guangzhou University of Chinese Medicine, Guangzhou 510405, China
| | - Xiaowen Wang
- First Clinical Medical College, Guangzhou University of Chinese Medicine, Guangzhou 510405, China
| | - Xiang Yu
- Department of Spinal Surgery, The First Affiliated Hospital of Guangzhou, University of Chinese Medicine, Guangzhou 510405, China
| | - Hui Ren
- Department of Spinal Surgery, The First Affiliated Hospital of Guangzhou, University of Chinese Medicine, Guangzhou 510405, China
| | - De Liang
- Department of Spinal Surgery, The First Affiliated Hospital of Guangzhou, University of Chinese Medicine, Guangzhou 510405, China
| | - Jianchao Cui
- Department of Spinal Surgery, The First Affiliated Hospital of Guangzhou, University of Chinese Medicine, Guangzhou 510405, China
| | - Jingjing Tang
- Department of Spinal Surgery, The First Affiliated Hospital of Guangzhou, University of Chinese Medicine, Guangzhou 510405, China
- Correspondence: (J.T.); (X.J.); Tel.: +86-15914305386 (J.T.); +86-13632494486 (X.J.)
| | - Xiaobing Jiang
- Department of Spinal Surgery, The First Affiliated Hospital of Guangzhou, University of Chinese Medicine, Guangzhou 510405, China
- Correspondence: (J.T.); (X.J.); Tel.: +86-15914305386 (J.T.); +86-13632494486 (X.J.)
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Spontaneous facet joint fusion in patients following oblique lateral lumbar interbody fusion combined with lateral single screw-rod fixation: prevalence, characteristics and significance. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2022; 31:3580-3589. [PMID: 36264348 DOI: 10.1007/s00586-022-07424-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/04/2022] [Revised: 09/06/2022] [Accepted: 10/10/2022] [Indexed: 12/13/2022]
Abstract
PURPOSE To explore the characteristics of spontaneous facet joint fusion (SFJF) in patients after oblique lateral lumbar interbody fusion combined with lateral single screw-rod fixation (OLIF-LSRF). METHODS We randomly selected 300 patients from 723 patients treated with OLIF-LSRF into a cross-sectional study based on the pilot study results. A novel fusion classification system was designed to evaluate the fusion status of the facet joints at three time points. Ultimately, the prevalence, characteristics, and significance of SFJF were analyzed. RESULTS A total of 265 (333 levels) qualified cases were included in our study. The novel classification for SFJF has excellent reliability (kappa > 0.75). The rate of SFJF was 15.20% (45/296 levels) at 3 months postoperatively, 31.34% (89/284 levels) at 6 months postoperatively, and 33.63% (112/333 levels) at the last follow-up. The circumferential fusion rate was 31.53% (105/333 levels) at the last follow-up. The location of SFJF was mostly on the right facet joint (P < 0.001), and the rate of SFJF increased significantly from 3 to 6 months after the operation (P < 0.001). The average age of patients with SFJF was older than that of patients without SFJF (P < 0.001). There was no significant difference in Visual Analog Scale or Oswestry Disability Index scores between patients with and without SFJF. CONCLUSION In the OLIF-LSRF procedure, SFJF occurs mostly at 3-6 months postoperatively, especially in elderly patients and at the right facet joint. OLIF-LSRF has the potential for circumferential fusion.
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Song L, Xiao J, Zhou R, Li CC, Zheng TT, Dai F. Clinical evaluation of the efficacy of a new bone cement-injectable cannulated pedicle screw in the treatment of spondylolysis-type lumbar spondylolisthesis with osteoporosis: a retrospective study. BMC Musculoskelet Disord 2022; 23:951. [PMID: 36329431 PMCID: PMC9632048 DOI: 10.1186/s12891-022-05904-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2022] [Accepted: 10/21/2022] [Indexed: 11/06/2022] Open
Abstract
Purpose To investigate the clinical efficacy and safety of a bone cement-injectable cannulated pedicle screw (CICPS) in the treatment of spondylolysis-type lumbar spondylolisthesis with osteoporosis. Methods A retrospective study was conducted on 37 patients (Dual-energy X-ray bone density detection showed different degrees of osteoporosis) with spondylolysis-type lumbar spondylolisthesis who underwent lumbar spondylolisthesis reduction and fusion using a new type of injectable bone cement screw from May 2011 to March 2015. Postoperative clinical efficacy was evaluated by the Visual Analogue Scale (VAS) scores and the Oswestry Disability Index (ODI). Imaging indexes were used to evaluate the stability of internal fixation of the devices 1, 3, 6, and 12 months after surgery and annually thereafter. The safety of the CICPS was assessed by the prevalence of intraoperative and postoperative complications. Results A total of 124 CICPS were implanted intraoperatively. Bone cement leakage occurred in 3 screws (2.42%), and no clinical discomfort was found in any patients. All 37 patients were followed up with an average follow-up time of 26.6 ± 13.4 months (12–58 months). In the evaluation of the clinical effects of the operation, the average postoperative VAS score of the patients decreased from 4.30 ± 1.58 before surgery to 0.30 ± 0.70 after surgery (P < 0.001), and the ODI decreased from 47.27% ± 16.97% before surgery to 3.36% ± 5.70% after surgery (P < 0.001). No screw was loose, broken or pulled out. Conclusion CICPS is safe and effective in the treatment of spondylolysis-type lumbar spondylolisthesis complicated by osteoporosis.
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Affiliation(s)
- Lei Song
- Department of Orthopaedics, First Affiliated Hospital, Army Medical University, Chongqing, 400038, People's Republic of China
| | - Jun Xiao
- Department of Special Service Physiological Training, Guangzhou Special Service Recuperation Center of PLA Rocket Force, Guangzhou, 515515, People's Republic of China
| | - Rui Zhou
- Department of Orthopaedics, First Affiliated Hospital, Army Medical University, Chongqing, 400038, People's Republic of China
| | - Cong-Can Li
- Department of Orthopaedics, First Affiliated Hospital, Army Medical University, Chongqing, 400038, People's Republic of China
| | - Ting-Ting Zheng
- Department of Orthopaedics, First Affiliated Hospital, Army Medical University, Chongqing, 400038, People's Republic of China.
| | - Fei Dai
- Department of Orthopaedics, First Affiliated Hospital, Army Medical University, Chongqing, 400038, People's Republic of China.
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Godolias P, Tataryn ZL, Frieler S, Nunna R, Charlot K, Tran A, Plümer J, Cibura C, Al-Awadi H, Daher Z, Dudda M, Schildhauer TA, Chapman J, Oskouian R. Complication rates following stand-alone lateral interbody fusion: a single institution series after 10 years of experience. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY & TRAUMATOLOGY : ORTHOPEDIE TRAUMATOLOGIE 2022:10.1007/s00590-022-03408-7. [PMID: 36239820 DOI: 10.1007/s00590-022-03408-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/08/2022] [Accepted: 09/28/2022] [Indexed: 06/16/2023]
Abstract
PURPOSE This retrospective single institution study's goal was to analyze and report the complications from stand-alone lateral lumbar interbody fusions (LLIF). METHODS This research was approved by the institutional review board (STUDY2021000113). We retrospectively reviewed the database of patients with adult degenerative spine deformity treated via LLIF at our institution between January 2016 and December 2020. RESULTS Stand-alone LLIF was performed in 158 patients (145 XLIF, 13 OLIF; mean age 65 y.; 88 f., 70 m.). Mean surgical time was 85 min (± 24 min). Mean follow-up was 14 months (± 5 m). Surgical blood loss averaged 120 mL (± 187 mL) and the mean number of fused levels was 1.2 (± 0.4 levels). Overall complication rate was 19.6% (31 total; 23 approach-related, 8 secondary complications). CONCLUSION Lateral interbody fusion appears to be a safe surgical intervention with relatively low complication- and revision rates.
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Affiliation(s)
- Periklis Godolias
- Department of Orthopedics and Trauma Surgery, St. Josef Hospital Essen-Werden, Propsteistrasse 2, 45239, Essen, Germany.
| | - Zachary L Tataryn
- Seattle Science Foundation, 550 17th Avenue, Suite 600, Seattle, WA, 98122, USA
| | - Sven Frieler
- Department of Orthopedics and Trauma Surgery, BG University Hospital Bergmannsheil, Ruhr University Bochum, Bürkle-de-la-Camp-Platz 1, 44789, Bochum, Germany
| | - Ravi Nunna
- Seattle Science Foundation, 550 17th Avenue, Suite 600, Seattle, WA, 98122, USA
| | - Kaarina Charlot
- Seattle Science Foundation, 550 17th Avenue, Suite 600, Seattle, WA, 98122, USA
| | - Angela Tran
- Seattle Science Foundation, 550 17th Avenue, Suite 600, Seattle, WA, 98122, USA
| | - Jonathan Plümer
- Department of Orthopedics and Trauma Surgery, BG University Hospital Bergmannsheil, Ruhr University Bochum, Bürkle-de-la-Camp-Platz 1, 44789, Bochum, Germany
| | - Charlotte Cibura
- Department of Orthopedics and Trauma Surgery, BG University Hospital Bergmannsheil, Ruhr University Bochum, Bürkle-de-la-Camp-Platz 1, 44789, Bochum, Germany
| | - Hamzah Al-Awadi
- Seattle Science Foundation, 550 17th Avenue, Suite 600, Seattle, WA, 98122, USA
| | - Zeyad Daher
- Seattle Science Foundation, 550 17th Avenue, Suite 600, Seattle, WA, 98122, USA
| | - Marcel Dudda
- Department of Trauma, Hand, and Reconstructive Surgery, University Hospital Essen, Hufelandstrasse 55, 45147, Essen, Germany
| | - Thomas A Schildhauer
- Department of Orthopedics and Trauma Surgery, BG University Hospital Bergmannsheil, Ruhr University Bochum, Bürkle-de-la-Camp-Platz 1, 44789, Bochum, Germany
| | - Jens Chapman
- Seattle Science Foundation, 550 17th Avenue, Suite 600, Seattle, WA, 98122, USA
| | - Rod Oskouian
- Seattle Science Foundation, 550 17th Avenue, Suite 600, Seattle, WA, 98122, USA
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Lin GX, Chen CM, Jhang SW, Zhu MT, Lyu P, Hu BS. Characteristics and hotspots of the 50 most cited articles in the field of pre-psoas oblique lumbar interbody fusion. Front Surg 2022; 9:1004839. [PMID: 36311953 PMCID: PMC9597085 DOI: 10.3389/fsurg.2022.1004839] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2022] [Accepted: 09/23/2022] [Indexed: 11/29/2022] Open
Abstract
PURPOSE In the past decade, the field of pre-psoas oblique lumbar interbody fusion (OLIF) has developed rapidly, and with it, the literature on OLIF has grown considerably. This study was designed to analyze the top 50 articles in terms of the number of citations through bibliometric research to demonstrate the research characteristics and hotspots of OLIF. METHOD Searching the Web of Science database yielded the 50 most cited publications in the OLIF field as of July 10, 2022. The publications were ranked according to the number of citations. The following sources were evaluated: the year of publications, the number of citations, authors, countries, institutions, journals, research topics, and keyword hotspots. RESULTS The most productive period was from 2017 to 2020, with 41 articles. The number of citations varied from 10 to 140, with an average of 35.52, and 1,776 citations were found. World Neurosurgery published the most articles (12), China produced the most articles (16), and the Catholic University of Korea produced the most studies (6). The corresponding author who produced the most articles was J.S. Kim (5), and the first author who produced the most publications was S. Orita (3). The main research topics were anatomical morphology, surgical techniques, indications, outcomes, and complications. The top 10 most cited keywords were "complications," "decompression," "spine," "surgery," "outcomes," "transpsoas approach," "spondylolisthesis," "anterior," "disease," and "injury." CONCLUSIONS Certain articles can be distinguished from others using citation analysis as an accurate representation of their impact due to their long-term effectiveness and peer recognition. With these publications, researchers are provided with research priorities and hotspots through influential literature in the field of OLIF.
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Affiliation(s)
- Guang-Xun Lin
- The School of Clinical Medicine, The Third Clinical Medical College, Fujian Medical University, China,Department of Orthopedics, The First Affiliated Hospital of Xiamen University, School of Medicine, Xiamen University, Xiamen, China
| | - Chien-Min Chen
- Division of Neurosurgery, Department of Surgery, Changhua Christian Hospital, Changhua, Taiwan,Department of Leisure Industry Management, National Chin-Yi University of Technology, Taichung, Taiwan,College of Nursing and Health Sciences, Dayeh University, Taiwan
| | - Shang-Wun Jhang
- Division of Neurosurgery, Department of Surgery, Changhua Christian Hospital, Changhua, Taiwan
| | - Ming-Tao Zhu
- Department of Neurosurgery, The First Affiliated Hospital of Xiamen University, School of Medicine, Xiamen University, Xiamen, China,Correspondence: Bao-Shan Hu Ming-Tao Zhu Pengfei Lyu
| | - Pengfei Lyu
- Department of Breast Surgery, The First Affiliated Hospital of Hainan Medical University, Haikou, China,Correspondence: Bao-Shan Hu Ming-Tao Zhu Pengfei Lyu
| | - Bao-Shan Hu
- Department of Orthopedics, The First Affiliated Hospital of Xiamen University, School of Medicine, Xiamen University, Xiamen, China,Correspondence: Bao-Shan Hu Ming-Tao Zhu Pengfei Lyu
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Xie T, Pu L, Zhao L, Lu Y, Yang Z, Wang X, Song Y, Zeng J. Influence of coronal-morphology of endplate and intervertebral space to cage subsidence and fusion following oblique lumbar interbody fusion. BMC Musculoskelet Disord 2022; 23:633. [PMID: 35788206 PMCID: PMC9252057 DOI: 10.1186/s12891-022-05584-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2022] [Accepted: 06/24/2022] [Indexed: 02/08/2023] Open
Abstract
Background Endplate morphology is considered to be one of the influencing factors of cage subsidence after lumbar interbody fusion (LIF). Previous radiographic evaluations on the endplate mostly used sagittal X-ray or MRI. However, there are few studies on the CT evaluation of the endplate and intervertebral space (IVS), especially the evaluation of coronal morphology and its influence on subsidence and fusion after LIF. We aimed to measure and classify the shapes of the endplate and IVS using coronal CT imaging and evaluate the radiographic and clinical outcomes of different shapes of the endplate/IVS following oblique lateral lumbar interbody fusion (OLIF). Methods A total of 137 patients (average age 59.1 years, including 75 males and 62 females) who underwent L4-5 OLIF combined with anterolateral fixation from June 2018 to June 2020 were included. The endplate concavity depth (ECD) was measured on the preoperative coronal CT image. According to ECD, the endplate was classified as flat (< 2 mm), shallow (2–4 mm), or deep (> 4 mm). The L4-5 IVS was further classified according to endplate type. The disc height (DH), DH changes, subsidence rate, fusion rate, and Oswestry Disability Index (ODI) in different endplate/IVS shapes were evaluated during 1-year follow up. Results The ECD of L4 inferior endplate (IEP) was significantly deeper than that of L5 superior endplate (SEP) (4.2 ± 1.1 vs 1.6 ± 0.8, P < 0.01). Four types of L4-5 IVS were identified: shallow-shallow (16, 11.7%), shallow-flat (45, 32.9%), deep-shallow (32, 23.4%), and deep-flat (44, 32.1%). A total of 45 (32.9%) cases of cage subsidence were observed. Only one (6.3%) subsidence event occurred in the shallow-shallow group, which was significantly lower than in the other three groups (19 shallow-flat, 6 deep-shallow, and 19 deep-flat) (P < 0.05). Meanwhile, the shallow-shallow group had the highest fusion rate (15, 93.8%) and the highest rate of reach minimal clinically important difference (MCID) ODI among the four types. For a single endplate, the shape of L4 IEP is the main influencing factor of the final interbody fusion rate, and the shallow shape L4 IEP facilitates fusion ( OR = 2.85, p = 0.03). On the other hand, the flat shape L5 SEP was the main risk factor to cage subsidence (OR = 4.36, p < 0.01). Conclusion The L4-5 IVS is asymmetrical on coronal CT view and tends to be fornix-above and flat-down. The shallow-shallow IVS has the lowest subsidence rate and best fusion result, which is possibly because it has a relatively good degree in matching either the upper or lower interface of the cage and endplates. These findings provide a basis for the further improvements in the design of OLIF cages. Supplementary Information The online version contains supplementary material available at 10.1186/s12891-022-05584-3.
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Affiliation(s)
- Tianhang Xie
- Department of Orthopedics, Orthopedic Research Institute, West China Hospital, Sichuan University, 37# Wuhou Guoxue road, Chengdu, 610041, China
| | - Liming Pu
- Department of Medical Statistics, School of Public Health, Sun Yat-Sen University, Guangzhou, China
| | - Long Zhao
- Department of Orthopedics, Orthopedic Research Institute, West China Hospital, Sichuan University, 37# Wuhou Guoxue road, Chengdu, 610041, China
| | - Yufei Lu
- Department of Orthopedics, Orthopedic Research Institute, West China Hospital, Sichuan University, 37# Wuhou Guoxue road, Chengdu, 610041, China
| | - Zhiqiang Yang
- Department of Orthopedics, Orthopedic Research Institute, West China Hospital, Sichuan University, 37# Wuhou Guoxue road, Chengdu, 610041, China
| | - Xiandi Wang
- Department of Orthopedics, Orthopedic Research Institute, West China Hospital, Sichuan University, 37# Wuhou Guoxue road, Chengdu, 610041, China
| | - Yueming Song
- Department of Orthopedics, Orthopedic Research Institute, West China Hospital, Sichuan University, 37# Wuhou Guoxue road, Chengdu, 610041, China
| | - Jiancheng Zeng
- Department of Orthopedics, Orthopedic Research Institute, West China Hospital, Sichuan University, 37# Wuhou Guoxue road, Chengdu, 610041, China.
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Kim H, Chang BS, Chang SY. Pearls and Pitfalls of Oblique Lateral Interbody Fusion: A Comprehensive Narrative Review. Neurospine 2022; 19:163-176. [PMID: 35378589 PMCID: PMC8987540 DOI: 10.14245/ns.2143236.618] [Citation(s) in RCA: 22] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2021] [Accepted: 01/13/2022] [Indexed: 12/12/2022] Open
Abstract
Lumbar degenerative disease is a common problem in an aging society. Oblique lateral interbody fusion (OLIF) is a minimally invasive surgical (MIS) technique that utilizes a retroperitoneal antepsoas corridor to treat lumbar degenerative disease. OLIF has theoretical advantages over other lumbar fusion techniques, such as a lower risk of lumbar plexus injury than direct lateral interbody fusion (DLIF). Previous studies have reported favorable clinical and radiological outcomes of OLIF in various lumbar degenerative diseases. The use of OLIF is increasing, and evidence on OLIF is growing in the literature. The indications for OLIF are also expanding with the help of recent technical developments, including stereotactic navigation systems and robotics. In this review, we present current evidence on OLIF for the treatment of lumbar degenerative disease, focusing on the expansion of surgical indications and recent advancements in the OLIF procedure.
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Affiliation(s)
- Hyoungmin Kim
- Department of Orthopedic Surgery, Seoul National University Hospital, Seoul, Korea
| | - Bong-Soon Chang
- Department of Orthopedic Surgery, Seoul National University Hospital, Seoul, Korea
| | - Sam Yeol Chang
- Department of Orthopedic Surgery, Seoul National University Hospital, Seoul, Korea
- Corresponding Author Sam Yeol Chang https://orcid.org/0000-0003-4152-687X Department of Orthopedic Surgery, Seoul National University Hospital, 101 Daehakro, Jongno-gu, Seoul 03080, Korea
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21
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Chang SY, Lee WS, Mok S, Park SC, Kim H, Chang BS. Anterior Thigh Pain Following Minimally Invasive Oblique Lateral Interbody Fusion: Multivariate Analysis from a Prospective Case Series. Clin Orthop Surg 2022; 14:401-409. [PMID: 36061851 PMCID: PMC9393273 DOI: 10.4055/cios21250] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2021] [Revised: 02/19/2022] [Accepted: 03/06/2022] [Indexed: 11/06/2022] Open
Affiliation(s)
- Sam Yeol Chang
- Department of Orthopedic Surgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Woo Seok Lee
- Department of Orthopedic Surgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Sujung Mok
- Department of Orthopedic Surgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Sung Cheol Park
- Department of Orthopedic Surgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Hyoungmin Kim
- Department of Orthopedic Surgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Bong-Soon Chang
- Department of Orthopedic Surgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
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22
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Incidence of major and minor vascular injuries during lateral access lumbar interbody fusion procedures: a retrospective comparative study and systematic literature review. Neurosurg Rev 2021; 45:1275-1289. [PMID: 34850322 DOI: 10.1007/s10143-021-01699-8] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2021] [Revised: 11/02/2021] [Accepted: 11/17/2021] [Indexed: 12/13/2022]
Abstract
During lateral lumbar fusion, the trajectory of implant insertion approaches the great vessels anteriorly and the segmental arteries posteriorly, which carries the risk of vascular complications. We aimed to analyze vascular injuries for potential differences between oblique lateral interbody fusion (OLIF) and lateral lumbar interbody fusion (LLIF) procedures at our institution. This was coupled with a systematic literature review of vascular complications associated with lateral lumbar fusions. A retrospective chart review was completed to identify consecutive patients who underwent lateral access fusions. The Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines were used for the systematic review with the search terms "vascular injury" and "lateral lumbar surgery." Of 260 procedures performed at our institution, 211 (81.2%) patients underwent an LLIF and 49 (18.8%) underwent an OLIF. There were no major vascular complications in either group in this comparative study, but there were four (1.5%) minor vascular injuries (2 LLIF, 0.95%; 2 OLIF, 4.1%). Patients who experienced vascular injury experienced a greater amount of blood loss than those who did not (227.5 ± 147.28 vs. 59.32 ± 68.30 ml) (p = 0.11). In our systematic review of 63 articles, major vascular injury occurred in 0-15.4% and minor vascular injury occurred in 0-6% of lateral lumbar fusions. The systematic review and comparative study demonstrate an increased rate of vascular injury in OLIF when compared to LLIF. However, vascular injuries in either procedure are rare, and this study aids previous literature to support the safety of both approaches.
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Yang H, Liu J, Hai Y. Is instrumented lateral lumbar interbody fusion superior to stand-alone lateral lumbar interbody fusion for the treatment of lumbar degenerative disease? A meta-analysis. J Clin Neurosci 2021; 92:136-146. [PMID: 34509241 DOI: 10.1016/j.jocn.2021.08.002] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2021] [Revised: 07/23/2021] [Accepted: 08/01/2021] [Indexed: 12/16/2022]
Abstract
The purpose of this meta-analysis was to compare the fusion rate and outcomes directly between patients who underwent stand-alone lateral lumbar interbody fusion (LLIF) and LLIF with supplemental posterior instrumentation. A comprehensive literature search was performed for relevant studies using PubMed, EMBASE, Web of Science, and Cochrane Library. The stand-alone and instrumented LLIF were compared by the fusion rate, the radiographic parameters, the cage subsidence rate, the clinical outcomes, the complication rate, and the reoperation rate. A total of 13 studies comprising 1090 patients with lumbar degenerative disease (LDD) were included. There was no significant statistical difference in the complication rate, and there was no significant clinical difference in the improvement of clinical outcomes at the last follow-up between patients who underwent stand-alone and instrumented LLIF. Nevertheless, lower fusion rate (RR, 0.92; 95% CI 0.87 to 0.98, P = 0.006), inferior restoration of disk height (WMD, -0.68; 95% CI -1.04 to -0.32, P < 0.001) and segmental lordosis (WMD, -1.28; 95% CI -2.30 to -0.27, P = 0.013), higher cage subsidence rate (RR, 1.68; 95% CI 1.36 to 2.07, P < 0.001), and higher reoperation rate (RR, 2.12; 95% CI 1.02 to 4.43, P = 0.045) were observed in the stand-alone group. Both stand-alone and instrumented LLIF were effective in improving the clinical outcomes of patients with LDD. However, the stand-alone LLIF was associated with lower fusion rate, inferior maintenance of indirect decompression, and higher reoperation rate due to high-grade cage subsidence. For patients with risk factors of high-grade cage subsidence, the LLIF with posterior instrumentation may be the better choice.
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Affiliation(s)
- Honghao Yang
- Department of Orthopedic Surgery, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
| | - Jingwei Liu
- Department of Orthopedic Surgery, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
| | - Yong Hai
- Department of Orthopedic Surgery, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China.
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