Craniofacial fibrous dysplasia: Systematic review of facial management

Craniofacial fibrous dysplasia (CFD) may be associated with major cosmetic or functional consequences. However, management recommendations for CFD are currently unavailable. Therefore, this systematic literature review aimed to review the existing approaches for CFD management and propose a management algorithm. The focus question was "What are the different options for CFD treatment and their complication rates?" The MEDLINE database was searched, and 33 articles evaluating a total of 1154 patients were reviewed. The bias assessment showed that 20 of the 33 studies had a high or intermediate risk of bias, mainly because of retrospective data collection and small patient numbers. Radical surgery showed a lower recurrence rate than debulking, but its use should be weighed against the morbidity caused by the reconstruction performed in this technique. Orbital decompression using a radical technique or debulking is effective in cases showing exophthalmos or dystopia. Surveillance is a viable option for asymptomatic and/or non-progressive lesions. In cases showing optic nerve compression, prophylactic decompression should be avoided, and decompression should be performed only when patients show diminished visual acuity or visual field defect. Although bisphosphonates have shown efficacy in pain management, their posology requires further discussion. A management algorithm is presented.

[Surgical management of acute traumatic spinal cord injury : Stability vs. functionality]

BACKGROUND

Traumatic spinal cord injuries represent a devastating condition in the lives of those affected, with physical, emotional, and economic burdens for the patients themselves, their social environment, and society as a whole.

OBJECTIVE

Surgical approach and techniques in traumatic spinal cord injuries.

RESULTS

Traumatic spinal cord injuries should be surgically treated as soon as possible, but at least within 24 h of injury. If accompanying dural injuries occur, suturing or applying a patch is the primary method of choice. Early surgical decompression is essential, particularly in cervical spinal cord injuries. Stabilization in terms of instrumentation or fusion is inevitable and should be carried out over short segments to maintain the functionality of the cervical spine. Long-distance dorsal instrumentation with prior reduction in thoracolumbar spinal cord injuries provides high stability and preserved functionality in patients. Injuries to the thoracolumbar junction often require a two-stage anterior treatment.

CONCLUSION

Early surgical decompression, reduction, and stabilization of traumatic spinal cord injuries within 24 h are recommended. While short-segment stabilization is recommended in the cervical spine in addition to decompression, instrumentation should be over long segments in the thoracolumbar spine to provide the necessary stability while maintaining functionality.

[Case-control study on robot-assisted core decompression and conventional core decompression for early necrosis of femoral head]

OBJECTIVE

To compare clinical effect of robot-assisted core decompression and conventional core decompression in treating ARCO Ⅰ stage necrosis of femoral head.

METHODS

A retrospective analysis was performed on 60(unilateral operation) patients who underwent core decompression for femoral head necrosis from February 2018 to February 2020. Among them, 30 patients(30 hips) were underwent robot-assisted core decompression (RCD group), including 19 males and 11 females, aged from 17 to 58 years old with an average of(38.50±10.61) years old;30 patients(30 hips) were underwent traditional core decompression surgery (CCD group), including 20 males and 10 females, aged from 20 to 55 years old with an average of (40.63±10.63) years old. Intraoperative fluoroscopy times, intraoperative blood loss and operation time between two groups, and Harris score, visual analogue scale (VAS) before opertaion and 24 months after operation were compared.

RESULTS

All patients were followed up, RCD group followed up from 21 to 26 months with an average of(23.40±1.65) months, CCD group followed up from 21 to 26 months with an average of (23.30±1.66) months, and had no difference between two groups(P>0.05). The number of intraoperative X-ray fluoroscopy, intraoperative blood loss and operative time in RCD group were (9.43±1.14) times, (153.80±22.04) ml, (33.40±1.87) min, respectively;while(19.67±1.32) times, (165.04±20.41) ml and (54.75±3.46) min in CCD group respectively;and there were statistical difference between two groups(P<0.05). In addition, there were no statistical difference between two groups in Harris score and VAS at 24 months after operation(P>0.05).

CONCLUSION

Compared with conventional core decompression, robot-assisted core decompression could reduce the number of intraoperative fluoroscopy, shorten operation time, and reduce risk of surgery.

[Manual therapy combined with posterior percutaneous endoscopic cervical decompression for the treatment of cervical spondylotic radiculopathy]

OBJECTIVE

To explore the clinical efficacy and safety of manual therapy combined with posterior percutaneous endoscopic cervical decompression(PECD) in the treatment of intractable cervical spondylotic radiculopathy.

METHODS

From May 2016 to May 2018, 23 CSR patients who responded poorly to conservative treatment for at least 6 weeks underwent the combination management. Firstly, the patients received the posterior percutaneous endoscopic cervical decompression routine care for the following 4 weeks and manual therapy for another 4 weeks. A total of 23 patients were followed up, including 14 males and 9 females, the age ranged from 29 to 78 years old with an average of (50.30±12.28) years, the course of disease was 3 to 24 months with an average of (9.74±5.76) months. The lesion segment involved C_4,5 in 4 cases, C_5,6 in 13 cases, C_6,7 in 6 cases. The visual analogue scale (VAS), neck disability index (NDI), changes of cervical physiological curvature and interbody stability, adverse events were observed before and after operation. The follow-up time points were before operation, 1 day after operation and 1, 3 and 6 months after operation.

RESULTS

All patients successfully completed the operation and manual treatment for 4 to 8 times. Among the 29 cases, 23 patients were followed up for more than 6 months. There was no spinal cord and nerve root injury during the treatment and follow-up. Operation time was from 80 to 120 min with a median of 90 min;intraoperative blood loss was from 35 to 80 ml with a median of 50 ml. NDI, VAS of neck, shoulder and arm each period after operation were significantly lower than those before PECD(P<0.05), while there were no significant improvement in cervical physiological curvature and target segment intervertebral space height(P>0.05);there was no significant change in interbody stability (P>0.05). After received the manual therapy, NDI significantly decreased (P<0.05), however, there was no significant difference in VAS of neck, shoulder and arm, physiological curvature of cervical spine and intervertebral space height of target segment compared with that before manual treatment (P>0.05);there was no significant change in interbody stability (P>0.05).

CONCLUSION

Manual therapy combined with PECD in the treatment of intractable cervical spondylotic radiculopathy can not only quickly improve the symptoms, but also alleviate the residual symptoms after PECD safely and effectively, and can not cause obvious signs of accelerated instability of cervical adjacent segments in the short term.

Do Obliquity and Position of the Oblique Lumbar Interbody Fusion Cage Influence the Degree of Indirect Decompression of Foraminal Stenosis?

Objective

Oblique lumbar interbody fusion (OLIF) is a surgical technique that utilizes a large interbody cage to indirectly decompress neural elements. The position of the cage relative to the vertebral body could affect the degree of foraminal decompression. Previous studies determined the position of the cage using plain radiographs, with conflicting results regarding the influence of the position of the cage to the degree of neural foramen decompression. Because of the cage obliquity, computed tomography (CT) has better accuracy than plain radiograph for the measurement of the obliquely inserted cage. The objective of this study is to find the correlation between the position of the OLIF cage with the degree of indirect decompression of foraminal stenosis using CT and magnetic resonance imaging (MRI).

Methods

We review imaging of 46 patients who underwent OLIF from L2-L5 for 68 levels. Segmental lordosis (SL) was measured in a plain radiograph. The positions of the cage were measured in CT. Spinal canal cross-sectional area (SCSA), and foraminal crosssectional area (FSCA) measurements using MRI were taken into consideration.

Results

Patients’ mean age was 69.7 years. SL increases 3.0±5.1 degrees. Significant increases in SCSA (33.3%), FCSA (43.7% on the left and 45.0% on the right foramen) were found (p<0.001). Multiple linear regression analysis shows putting the cage in the more posterior position correlated with more increase of FSCA and decreases SL correction. The position of the cage does not affect the degree of the central spinal canal decompression. Obliquity of the cage does not result in different degrees of foraminal decompression between right and left side neural foramen.

Conclusion

Cage position near the posterior part of the vertebral body increases the decompression effect of the neural foramen while putting the cage in the more anterior position correlated with increases SL.

[Early incision, decompression and screw fixation for the treatment of Lisfranc injuries with foot osteofascial compartment syndrome]

OBJECTIVE

To explore clinical effect of early incision and decompression combined with screw fixation in treating Lisfranc injury and foot osteofascial compartment syndrome.

METHODS

Clinical data of 5 patients with Lisfranc injury and foot osteofascial compartment syndrome were retrospective analysized from January 2017 to December 2018, including 4 males and 1 female, aged from 19 to 62 years old. All patients were suffered from closed injuries. The time from injury to treatment ranged from 1 to 14 h. According to Myerson classification, 1 patient was type A, 1 patient was type B, and 3 patients were type C. All patients were performed early incision decompression and screw fixation. Maryland foot functional scoring standard at 12 months after opertaion was used to evaluate clinical effect.

RESULTS

All patients were followed up for 10 to 48 months. All fractures were achieved bone union, and healing time ranged from 3 to 9 months. All metatarsal and tarsal joints were reached to anatomical reduction. No infection, osteomyelitis, loosening or breaking of internal fixation occurred. Postopertaive Maryland foot function score at 12 months was from 44 to 97, and 2 patients got excellent result, 2 good, and 1 poor.

CONCLUSION

Early incision and decompression with screw fixation for the treatment of Lisfranc injury and foot osteofascial compartment syndrome, which has advantages of simple opertaion, thoroughly decompression, screw fixation does not occupy space, stable decompression and fixation, and could receive satisfied clinical effect.

[Treatment of senile lumbar spinal stenosis by unilateral approach and bilateral decompression with large channel endoscopy]

OBJECTIVE

To evaluate clinical effect of unilateral approach and bilateral decompression via large channel endoscopic system for the treatment of lumbar spinal stenosis.

METHODS

The clinical data of 32 patients with lumbar spinal tenosis treated by unilateral approach and bilateral decompression via large channel endoscopy from February 2018 to February 2019 were retrospectively analyzed. There were 18 males and 14 females, aged 65 to 84 years old with an average of (70.6± 8.4) years. The course of disease was from 1 to 12 years. All 32 cases were accompanied by numbness or pain in the lower limbs, of which 28 cases were accompanied by intermittent claudication. Narrow segments were L_{3, 4} of 2 cases, L_{4, 5} of 19 cases, L₅S₁ of 13 cases, including double segments of 2 cases. Preoperative imaging showed 3 cases of central canal stenosis, 21 cases of bilateral lateral recess stenosis and 8 cases of mixed stenosis. Operation time and complications were recorded. X-ray, CT and MRI were analyzed at 3 days, 3 months and 1 year after operation. Visual analogue scale(VAS), Oswestry Disability Index (ODI), single continuous walking distance(SCWD) were observed before and after operation. Modified Macnab standard were used to evaluate the clinical effect at 1 year after operation.

RESULTS

All the patients were followed up for 12-24 (17.68±2.43) months and all operations were successfully completed with the operation time of 70-160(85.64±11.94) min. Spinal dural tear occurred in 1 case during the operation, and sensory disturbance in the other side of lower limb in a short period of time occurred in 2 cases, all improved after corresponding treatment. Postoperative imaging showed that the spinal canal was significantly enlarged and the nerve root was fully released. Before operation and 3 days, 3 months, 1 year after operation, VAS scores of low back pain were 4.62 ±1.41, 2.73 ±1.35, 1.21 ±1.17, 1.11 ±0.34, respectively;VAS scores of leg pain were 6.83 ± 1.71, 3.10±1.50, 1.08±0.19, 0.89±0.24, respectively. VAS scores of low back pain and leg pain each time point after operation were obvious improved (P<0.05); there was significant difference between 3 months and 3 days after operation(P<0.05), and there was no significant difference between 3 months and 1 year after operation (P>0.05). Before operation and 3 days, 3 months, 1 year after operation, ODI scores were 38.40 ±6.48, 18.42 ±2.40, 5.48 ±0.77, 3.05 ±0.28, respectively; SCWD was (47.48±5.32) m, (52.89±11.23) m, (245.43±18.94) m, (468.97±55.87) m, respectively. The differences in ODI score and SCWD postoperative time points were statistically significant compared with those before operation (P<0.05). The difference between 3 months and 3 days after operation was statistically significant (P<0.05). The difference between 1 year and 3 months after operation was statistically significant (P<0.05). According to Macnab standard to evaluate clinical effect at 1 year after operation, 15 cases got excellent results, 14 good, 3 fair.

CONCLUSION

It is a safe and effective way to treat lumbar spinal stenosis with unilateral approach and bilateral decompression via large channel endoscopic system. It has the advantages of sufficient decompression, less trauma, fast recovery, high safety and low incidence of postoperative complications. It can minimize the damage to the stable structure of the lumbar spine and is an ideal minimally invasive operation for the treatment of lumbar spinal stenosis.

[A case-control study of cervical spine Key-hole technique and anterior cervical Zero-P system in the treatment of cervical spondylotic radiculopathy]

OBJECTIVE

To explore the short-term clinical efficacy of single-stage cervical spondylotic radiculopathy (CSR) between the minimally invasive Key-hole technique and anterior cervical Zero profile intervertebral fusion system (Zero-P).

METHODS

A retrospective analysis was performed on 45 patients who underwent surgical treatment for CSR from January 2017 to January 2020, including 21 in Key hole group (12 males and 9 females), followed up for 10-22(13.2±2.3) months;24 cases in Zero-P group (14 males and 10 females), and the follow up period was 10 to 23(12.7±1.9) months. Perioperative conditions (incision length, intraoperative blood loss, operation time, length of hospital stay, and complications) were compared between two groups, and X-rays of cervical spine before and after surgery and at the final follow-up were taken to analyzed curvature of the cervical spine, visual analogue scale(VAS) of pain before and after surgery, Oswestry Disability Index(ODI) and Japanese Orthopaedic Association (JOA) score of cervical spine were recorded to evaluate clinical efficacy.

RESULTS

In Key-hole group and Zero-P group, the surgical incision length, intraoperative blood loss, operation time, final follow-up Cobb angle and immediate postoperative VAS score respectively were (1.2±0.2) cm, (5.3±0.3) cm;(35.3±9.7) ml, (120.2±13.5) ml;(56.4±11.3) min, (90.6±12.6) min;(3.2±3.9)°, (7.3±3.8)°;(2.8±1.2)points, (3.8±1.1) points;the Zero-P group was larger than the Key hole group, with statistical significance(P<0.05) . There were no statistically significant difference in length of hospital stay, ODI and JOA scores between two groups (P>0.05). After the follow-up, 1 case of neurostimulation symptoms in Key-hole group was relieved by conservative treatment, 2 cases improved after reoperation due to recurrence of cervical disc herniation;2 cases of neurostimulation symptoms in Zero-P group, 2 cases of throat discomfort, and 1 case dural tears were all relieved by conservative treatment.

CONCLUSION

The cervical spine Key-hole technology is similar to the anterior cervical Zero-P system in the treatment of CSR. The Key-hole technique has certain advantages in incision length, intraoperative blood loss, and operation time. It is a safe, effective and can be widely used cervical spine surgery method.

[Platelet-rich plasma combined with core decompression and bone grafting in the treatment of non traumatic necrosis of femoral head in ARCO stageⅡ]

OBJECTIVE

To observe the clinical effect of platelet rich plasma (PRP) combined with β tricalcium phosphate bioceramic bone in the treatment of non traumatic necrosis of the femoral head in ARCO stageⅡ.

METHODS

From January 2017 to December 2018, 100 patients (160 hips) with ARCO stageⅡnon traumatic necrosis of the femoral head were divided into PRP group and control group. In PRP group, 50 patients (80 hips), 22 males and 28 females, aged from 18 to 65 (43.47± 7.23) years, with a course of 4 to 18 (15.8±2.9) months, underwent core decompression and bone grafting combined with PRP implantation. There were 50 cases (80 hips) in the control group, including 27 males and 23 females, aged 20 to 63 (45.72± 7.43) years, and the course of disease was 6 to 19 (14.9±3.8) months. Hip X-ay film was followed up after operation. Harris score and VAS score were used to evaluate the curative effect, and the survival rate of hip joint was recorded.

RESULTS

All patients had good wound healing, no infection, thrombosis and other complications. All patients were followed up for 12 to 14 (12.0±0.4) months. Twelve months after operation, the image expression of PRP group was better than that of control group(P<0.05). Harris hip score and VAS score of pain at twelve months after operation were 89.98±6.17 and 1.68±1.02 in PRP group and 81.62±5.62 and 2.52±1.13 in control group, respectively. The survival rate of 96.25% in PRP group was significantly higher than 86.25% in control group. The postoperative score of two groups was higher than that before operation(P<0.05), but PRP group was better than control group at any time point statistical significance (P<0.05).

CONCLUSION

Platelet-rich plasma(PRP) combined with artificialbone for core decompression and bone grafting can change the situation of simple artificial bone implantation and uncertain curative effect, improve the success rate of this operation, effectively reduce the collapse rate of femoral head necrosis in the early and middle stage, delay or even avoid hip replacement.

[Acute stroke treatment in old age]

In patients over 80 years old, 4 of the 5 evidence-based acute treatments of ischemic stroke, i.e. stroke unit treatment, antiplatelet therapy, intravenous thrombolysis (IVT) and mechanical thrombectomy (MT) are effective but with a higher morbidity than in younger patients. The indications for the more invasive forms of treatment, such as IVT and MT are given in principle but have to be oriented to the individual patient comorbidities. In the case of failure of these procedures a consistent therapeutic target change to palliative measures is appropriate. Decompressive craniotomy in space-occupying media infarction can be indicated up to the relative age limit of 60 years and absolute age limit of 70 years. Patients over 80 years often do not undergo IVT or MT. Although the German approval for alteplase within the framework of IVT over the age of 80 years suggests a careful and critical review of the indications, its use is generally recommended.

[The surgical effect of secondary esotropia with diplopia after orbital decompression for thyroid-associated ophthalmopathy]

Objective: To evaluate the effect of extraocular muscle surgery in treating secondary esotropia with diplopia after orbital decompression for thyroid-associated ophthalmopathy (TAO). Methods: Retrospective case series study. Eleven secondary esotropic patients with diplopia after orbital decompression for TAO who underwent extraocular muscle surgery during March 2016 and October 2018 in Tianjin Eye Hospital were included. All patients had new onset esotropia after decompression surgery and underwent strabismus surgery. Deviation angle, diplopia, and ocular movement were observed preoperatively and postoperatively. Surgeries were carried out under the monitored anesthesia care combined with local anesthesia, and the eye alignment was adjusted to orthotropia with no diplopia in the operation with the technique of intraoperative adjustable suture and forced duction test results. All the patients were followed up. Results: The ages of the patients were from 26 to 42 years (1 male and 10 females). The deviation angles were 10-98 prism diopter. Orbital CT scan showed that the horizontal rectus thickness was increased at different levels, and the thickness of the medial rectus was increased more than that of the lateral rectus. Two patients had monocular medial rectus recession only, 2 had bilateral medial rectus recession only, 2 had monocular medial rectus recession combined with lateral rectus resection, and the other 5 had bilateral medial rectus recession with monocular lateral rectus resection. The recession of medial rectus muscle was 3.5 to 7.5 mm in 11 patients and 2.0 to 6.0 mm in 7 patients with the resection of lateral rectus muscle. Diplopia of the 11 patients disappeared with orthotropia at primary gaze position after the extraocular muscle surgery. The limitation of abduction changed from preoperative (-1.91±1.04) to postoperative (-0.64±0.81). All the patients were satisfied with the surgical results. At the end of the follow-up (6 to 24 months), the results of the patients were stable, and no over-correction was found. Conclusion: Extraocular muscle surgery with intraoperative adjustable suture technique can effectively treat TAO patients with secondary esotropia with diplopia after orbital decompression. (Chin J Ophthalmol, 2020, 56: 183-188).

[Acute stroke treatment in old age]

In patients over 80 years old, 4 of the 5 evidence-based acute treatments of ischemic stroke, i.e. stroke unit treatment, antiplatelet therapy, intravenous thrombolysis (IVT) and mechanical thrombectomy (MT) are effective but with a higher morbidity than in younger patients. The indications for the more invasive forms of treatment, such as IVT and MT are given in principle but have to be oriented to the individual patient comorbidities. In the case of failure of these procedures a consistent therapeutic target change to palliative measures is appropriate. Decompressive craniotomy in space-occupying media infarction can be indicated up to the relative age limit of 60 years and absolute age limit of 70 years. Patients over 80 years often do not undergo IVT or MT. Although the German approval for alteplase within the framework of IVT over the age of 80 years suggests a careful and critical review of the indications, its use is generally recommended.

Severe pancreatitis complicated by abdominal compartment syndrome managed with decompressive laparotomy: a case report

Background

Abdominal compartment syndrome (ACS) is an uncommon complication of severe pancreatitis. It is defined as a sustained intraabdominal pressure (IAP) > 20 mmHg (with or without an abdominal perfusion pressure (APP) < 60 mmHg), associated with new organ dysfunction/failure. ACS confers a poor prognosis and should be promptly diagnosed and managed. However, it is often missed on clinical examination, leading to a delay of diagnosis.

Case presentation

A 38-year old Sri Lankan man presented with severe alcohol-induced pancreatitis associated with abdominal compartment syndrome. Diagnosis was delayed due to false reassurance from clinical examination. The patient was managed with a decompressive laparotomy, after which he required treatment with continuous renal replacement therapy (CRRT), total parenteral nutrition (TPN) and broad-spectrum antibiotics for a prolonged period of time. Despite significant post-operative multi-organ failure, the patient survived.

Conclusions

Early trans-bladder measurement of IAP is important for severe pancreatitis. Serial measurements of IAP should be implemented early when any known risk factor for ACS is present in a critically ill patient.

Effectiveness of mini-open carpal tunnel release: An outcome study

Background

Carpal tunnel syndrome (CTS) is the most common peripheral entrapment neuropathy with a high morbidity and healthcare-related costs. Currently there is no consensus about the best treatment option. The purpose of this prospective cohort study conducted at a single institution was to evaluate the clinical outcomes and patient satisfaction following a mini-open carpal tunnel release for idiopathic CTS.

Methods

A total of 72 patients (53 female and 19 male patients; mean age, 57.8±15.3 years; range, 24–94 years) had a mini-open carpal tunnel release performed by a single senior surgeon between June 2015 and June 2016. The patients were evaluated preoperatively, and at 3 and 12 months post-intervention. At every follow-up, the Boston Carpal Tunnel Syndrome Questionnaire (BCTSQ) and visual analogue scale (VAS) scores for pain and satisfaction were completed. Digital sensibility (using Semmes- Weinstein monofilaments) was assessed and pinch and grip strengths were measured.

Results

Statistically significant and clinically relevant improvement was found in terms of digital sensibility, grip and pinch strength (except for 2-point pinch), BCTSQ scores and pain scores. The complication rate was minimal, and no major complications occurred. Two patients experienced recurrence. The availability of follow-up records (including patient-reported outcomes, BCTSQ and VAS scores, and the complication rate) at 1-year post-intervention varied between 69% and 74% (50–53 patients) depending on which parameter was assessed. Patient satisfaction was high (mean, 80.9±26.0; range, 0–100).

Conclusions

This study demonstrates that mini-incision carpal tunnel release is clinically effective in the short and long term.

[Orbital decompression for thyroid associated ophthalmopathy: transnasal endoscopic approach or external orbital approach?]

External orbital decompression, including medial wall, inferior wall, lateral wall and orbital fat decompression alone or in combination, has long been considered to be the standard treatment for thyroid related eye diseases. Deep lateral wall orbital decompression has better effect in the balance of eye position, correction of serious exophthalmos and severe oppression optic neuropathy. Recently, however, endoscopic orbital decompression is becoming increasingly popular with the development of endoscopic surgery technique in naso-orbit related diseases. Endoscopic orbital decompression has the advantages of avoiding an external incision scar. Nevertheless, the new method also has some disadvantages, for example, application limited to medial and inferior orbital wall orbital decompression, high incidence of esotropia, need for external lateral wall decompression and expensive cost for equipment. Both surgical approaches have advantages and disadvantages respectively for medial wall and inferior wall decompression. The operative result depends on the individualized surgical design and the experience of the surgeon rather than the choice of the surgical approach. As a result, the choice of the surgical approaches should be specifically based on the patient's conditions, patient's acceptance of the operation, experience of the surgeon and available resources. (Chin J Ophthalmol, 2018, 54: 484-487).

SURGICAL CORRECTION OF SEVERE AND FIXED CHIN-ON-CHEST DEFORMITY

Objective:

To describe a successful surgical treatment for the challenging severe and fixed chin-on-chest deformity due to isolated neck extensor myopathy (INEM).

Background data:

INEM is an idiopathic cause of dropped head syndrome (DHS) that results in severe cervicothoracic kyphosis, defined as chin-on-chest deformity. The existing literature on surgical management is limited, with outcomes ranging from poor to excellent. INEM may present to the spinal surgeon for consideration of surgical management.

Methods:

The authors present a technique that uses a staged posterior and anterior approach combined with osteotomies and corpectomy to correct the severe and fixed deformity. A state of the art anterior and posterior instrumentation system was used.

Results:

At the three-months follow-up, there was good deformity correction and the patient's satisfaction was high, with no neurological deterioration occurring.

Conclusions:

The technique illustrated in this study represents a successful option to treat this debilitating deformity. More evidence is needed to set up a definitive algorithm for the management of this condition. Level of evidence IV, Case Report.

Surgical Treatment for Traumatic Optic Neuropathy

Traumatic optic neuropathy (TON) is an important cause of severe visual loss after blunt or penetrating head and facial trauma. High-dose steroids and surgical interventions have been applied in the indirect TON. However, there is no convincing evidence that results of the treatment have any strong benefits in terms of improvement of visual acuity. Nevertheless, surgical decompression should be considered in the case of a direct bony compression to the optic nerve and a progressive visual loss in indirect TON. Neurosurgeon should be aware the surgical indication, optimal timing and relevant technique for the optic canal (OC) decompression. In this review article, we will focus on the surgical approaches to the OC and how to decompress it.

[Joint-preserving operative treatment of avascular necrosis of the femoral head]

The cause of avascular necrosis of the femoral head is multifactorial. Conservative treatment is only an option in the early stages. It is only symptomatic and not causative treatment. The implantation of an artificial hip joint should be postponed as the typically affected middle-aged males are right in the middle of their working life. Therefore, some joint-preserving operative therapies might be considered in stages ARCO I-III. Those range from core decompression to osteotomies and grafts, the advantages and disadvantages of which have to be weighted in each case. More recent therapies such as additive stem cells or platelet rich plasma (PRP) combined with core decompression have yet to prove their efficacy.

[Focus on the controversial problems of orbital decompression in the treatment of dysthyroid optic neuropathy]

Dysthyroid optic neuropathy (DON) is the most common cause of visual loss in thyroid associated ophthalmopathy, for which steroid pulse therapy and orbital decompression are the common treatments currently. While steroid pulse therapy was recommended as the first-choice for DON, orbital decompression remained as an indispensable therapy although controversies on such treatment still exist. The mechanism, approaches and outcomes of orbital decompression, as well as its advantages and disadvantages over steroid pulse therapy were retrospectively reviewed, and it was suggested that the combination therapy of steroid pulse therapy and surgical decompression might be the better choice for the treatment of DON. (Chin J Ophthalmol, 2018, 54: 488-490).

[Arthroscopy-guided core decompression and bone grafting combined with selective arterial infusion for treatment of early stage avascular necrosis of femoral head]

OBJECTIVE

To observe the clinical effects of arthroscopy-guided core decompression and bone grafting combined with selective arterial infusion for early stage avascular necrosis of femoral head.

METHODS

From January 2010 to December 2014, 76 patients(76 hips) diagnosed as Ficat II stage avascular necrosis of femoral head were randomly divided into experimental group and control group. In the experimental group, there were 27 males and 8 females aged from 24 to 55 years old with an average of (43.96±6.81) years, treated with arthroscopic-guided core decompression and bone grafting combined with selective arterial infusion. Along the direction of the femoral neck, an 8 mm-diameter tunnel to necrotic areas was drilled, then curettage of necrotic bone was performed under arthroscope, and the iliac bone was grafted. In the control group, there were 29 males and 12 females aged from 26 to 56 years old with an average of (44.62±7.33) years, treated with percutaneous core decompression combined with selective arterial infusion. The preoperative and postoperative Harris scores were recorded and the changes of X-rays were analyzed.

RESULTS

All the patients were followed up with an average of 30 months. Postoperative follow-up at 12 months showed that there was significant difference in imaging outcome between two groups(P<0.05), the experimental group was better than that of control group. According to Harris hip score system, at the final follow-up, Harris score of the experimental group was 86.72±4.37 on average, 6 cases got excellent results, 24 good, 4 fair and 1 poor. Harris score of the control group was 78.62±5.62 on average, 2 cases got excellent results, 20 good, 15 fair and 4 poor. After Ridit analysis, there was significant difference in the effect between the two groups(P<0.05). By pairing sample t test, there was significant difference between the preoperative and postoperative Harris score in the both groups(P<0.05). Between the two groups, there was no significant difference in preoperative Harris score(P>0.05), but there was significant difference in postoperative Harris score(P<0.05).

CONCLUSIONS

The two surgical procedures for early femoral head necrosis are effective. Using arthroscopic-guided core decompression method, the necrotic bone can be positioned and scraped more accurately, and can obtain better results.

[Effects of decompression combined with electro-acupuncture on rat with acute severe upper cervical spinal cord compression injury]

OBJECTIVE

To explore the effect and underlying mechanism of decompression(DE)combined with Governor Vessel(GV)electro-acupuncture(EA) on rats with acute severe upper cervical spinal cord compression injury.

METHODS

Thirty SPF rats were randomly divided into 5 groups(control group A, B and experiment group C, D, E), 6 rats in each group. The model of acute severe upper cervical spinal cord compression injury were made by forcing a balloon catheter put in atlas pillow clearance. The group A was blank one, the group B put balloon catheter in atlas pillow clearance without forcing, and the group C, D, E sustained compressed for 48 h. The group C received electric acupuncture intervention, selecting the Baihui and Dazhui point, having the continuous wave and frequency of 2 Hz, with the treatment time of 15 min and continuous treatment for 14 d; the group D received methylprednisolone intervention, injected by caudal vein; the group E did not received any intervention again. The arterial blood and injured spinal cord tissue of all the rats were obtained after 14 days' treatment, and BBB score was used to evaluate the change of each group hind limbs motor function, the contents of platelet activating factor(PAF) in injured spinal cord tissue and blood serum were assess by ELISA method; the Caspase-9 expression for each group after 14 days' treatment was assess by Western blot method.

RESULTS

BBB scores were(21.000±0.000) points at the 6 time points, that was, 1 h, 48 h after forcing in control group, 24 h, 3 d, 7 d, 14 d after treating in experiment group; the score of experimental groups (group C, D, E) were always lower than control groups(group A, B); compared with group E, group C and D were significantly higher(P<0.05); and there was no significant difference between group C and group D(P>0.05). The results of PAF by ELISA method to measure:the concentration of serum PAF, there was no statistical difference among group A, B, D, E (P>0.05), group C was lower than the other groups (P<0.05); the concentration of tissue PAF, there was no significant difference between group A and group B(P>0.05), group D was significantly higher than that of group A, B, and C(P<0.05), group E was the highest one than that of the other groups(P<0.05). Western blot med tests showed that the Caspase-9 protein expression in group A and B was similar (P>0.05), group C was higher than that of group A and B(P<0.05), group D was higher than group A, B and C(P<0.05), group E was the highest than that of group A, B, C and D (P<0.05).

CONCLUSIONS

Decompression and Governor Vessel electro-acupuncture on acute severe upper cervical spinal cord compression injury had a better effect compare with decompression and methylprednisolone or simple decompression only, its mechanism may be related to lower the PAF levels and downregulating Caspase-9 protein expression in spinal injury tissue.

Lumbar spine surgery in patients with rheumatoid arthritis (RA): what affects the outcomes?

BACKGROUND CONTEXT

Although the cervical spine is only occasionally involved in rheumatoid arthritis (RA), involvement of the lumbar spine is even less common. A few reports on lumbar spinal stenosis in patients with RA have appeared. Although disc space narrowing occurs in aging, postoperative adjacent segment disease (ASD) in patients with RA has not been subject to much analysis.

PURPOSE

The objective of this study was to investigate differences in ASD and clinical outcomes between lumbar spinal decompression with and without fusion in patients with RA.

STUDY DESIGN/SETTING

This is a retrospective comparative study.

PATIENT SAMPLE

A total of 52 patients with RA who underwent surgery for lumbar spinal disorders were included. Twenty-seven patients underwent decompression surgery with fusion and 25 underwent decompression surgery alone.

OUTCOME MEASURES

Intervertebral disc space narrowing and spondylolisthesis of the segment immediately cranial to the surgical site were measured using a three-dimensional volume rendering software. Pre- and postoperative evaluation of RA activity and Japanese Orthopaedic Association (JOA) scores were conducted.

MATERIALS AND METHODS

All patients had preoperative and annual postoperative lumbar radiographs and were followed up for a mean of 5.1 years (range 3.5-10.9 years). Pre- and postoperative (2 years after surgery) JOA scores were recorded and any postoperative complications were investigated. Degrees of intervertebral disc narrowing and spondylolisthesis at the adjacent levels were evaluated on radiographs and were compared between the two groups. Analysis was performed to look for any correlation between ASD and RA disease activities.

RESULTS

Postoperative JOA scores were significantly improved in both groups. The rate of revision surgery was significantly higher in the fusion group than that in the non-fusion group. The rate of ASD was significantly greater in the fusion group than that in the non-fusion group at the final follow-up examination. Both matrix metalloproteinase 3 (MMP-3) and the 28-joint disease activity score incorporating C-reactive protein levels (DAS28-CRP) were significantly associated with the incidence and severity of ASD.

CONCLUSIONS

Adjacent segment disease and the need for revision surgery were significantly higher in the fusion group than those in the non-fusion group. A preoperative high MMP-3 and DAS28-CRP are likely to be associated with postoperative ASD.

[A Chinese experts consensus of neurophysiological evaluating for microvascular decompression]

With the extensive development of microvascular decompression (MVD), perioperative neurophysiological monitoring technology is also developping rapidly in our country. To promote the standardization of neurophysiological monitoring for MVD in China, the experts consensus was published. This consensus includes five sections: indications, stimulation and recording methods, intraoperative assessment and warning criteria, influencing factors, and clinical application recommendations. Furthermore, recommendations for selection of electrophysiological monitoring and recording requirements were attached. This consensus will be helpful for the physiocian who is conducting or preparing for intraoperative monitoring.

[Therapeutic outcomes and influence factors of maximal orbital decompression in the treatment of severe dysthyroid optic neuropathy]

Objective: To evaluate the effectiveness of maximal orbital decompression in treatment for severe dysthyroid optic neuropathy (DON) of thyroid associated ophthalmopathy (TAO) and predictive factors of this therapy. Methods: The group consisted of 21 patients (30 eyes) with DON. The diagnosis was based on the following criteria: Deterioration of best corrected visual acuity (VA≤0.1), enlargement of extraocular muscles and sign of apical crowding in CT imaging, loss of colour vision.

EXCLUSION CRITERIA

VA of DON>0.1 or other diseases with visual function damage. Maximal 3-wall orbital decompression was undergone. Clinical outcomes were recorded and assessed including pre- and postoperative VA, age, clinical activity score (CAS), thyroid hormonal status and duration of DON. The pre- and postoperative VA were compared by Wlicoxon signed rank analysis. The relationships between the change of VA and age(<50 years vs ≥50 years), thyroid hormonal status(hyperthyroidism vs hypothyroidism), CAS(<3 vs ≥3), duration (<3 months vs ≥3 months), pre-VA(<0.01 vs ≥0.01) were made statistically by Mann-Whitney U-test, rank correlation analysis,and Logistic regression analysis. Results: Thirty eyes of 21 patients (11 male, 10 female) were included in this study. Hyperthyroidism was recorded in 13 cases, the other 8 cases with hypothyroidism. The average age at the time of diagnosis was 52.9 years (range, 33.0-71.0 years). The median of the duration of DON was 4.5 months (range, 1.0-12.0 months). Twenty-eight eyes (28/30, 93%) showed improvement of visual acuity after surgery (Z=-4.62, P=0.000). There was positive correlation between pre- and postoperative VA(r=0.38, P<0.05 ). Patients with VA of 0.01 or better had better postoperative VA than those with poorer VA (0.10 vs 0.50, Z=-2.09, P=0.037). There was negative correlation between the duration and degree of improvement of postoperative VA (r=-0.44, P<0.05). Other factors such as age, thyroid hormonal status, CAS were not statistical factors for postoperative VA (Z=-1.83--0.97, P>0.05 ) and improvement of postoperative VA (Z=-1.80--0.82, P>0.05). Conclusions: Maximal orbital decompression is safe and effective for management of visual damage in severe DON in this small sample study. Preoperative VA and duration of DON were important predictive factors for surgical outcome. Earlier diagnosis and treatment are possibly useful for improvement of prognosis of DON but large sample data are needed.(Chin J Ophthalmol, 2017, 53:416-423).

[Re-evaluate the value of orbital decompression for thyroid associated ophthalmopathy]

Thyroid-associated ophthalmopathy (TAO) is a common autoimmune syndrome affecting the thyroid and orbit. It can result in the fibrosis of extraoular muscles and hyperplasia of adipose tissue. The mechanism of TAO is not clear and there was few effective treatment. Recently, orbital decompression was performed on more and more patients. The surgery can improve the appearance of the patient and relieve the symptoms caused by the high orbital pressure. Therefore, it is necessary to re-evaluate the clinical value of the orbital decompression and surgical indications. The principles and techniques of orbital decompression with relative factors were discussed in this review. (Chin J Ophthalmol, 2017, 53: 401-403).

[Three-dimensional vector analysis after decompression surgery in thyroid-associated ophthalmopathy]

Objective: To analyze the change of globe position after different orbital decompression in thyroid-associated ophthalmopathy (TAO). Methods: It was a retrosective case series study. Twenty-nine TAO patients (33 eyes) underwent orbital decompression were collected between October 2014 and December 2016 at Eye & ENT Hospital of Fudan University. There were 17 males and 12 females, and the average age was 46 years (ranging from 21 to 66 years). Fifteen patients (17 eyes) underwent balanced decompression, 11 patients (11 eyes) underwent deep lateral decompression, and 4 patients (5 eyes) underwent medial decompression. CT scan was performed pre and postoperatively for each patient and a reference coordinate system was established on the three-dimensional reconstructed image. The eyeball vector EC from the eyeball center to the corneal apex was defined and the coordinates (X(E), Y(E), Z(E))(X(C), Y(C), Z(C)) were calculated. The angle M between EC and the midsagittal plane and the angle F between EC and the Frankfort plane were also calculated. Paired t test and one way ANOVA were used for statistical analysis. Results: The average value of X(C) before and after deep lateral decompression was 19.53 mm and 17.25 mm (t=10.87, P<0.05) and average value of X(E) was 7.73 mm and 5.69 mm (t=12.22, P<0.05). The average value of X(C) before and after medial decompression was 20.24 mm and 18.17 mm (t=7.93, P<0.05) and average value of X(E) was 7.14 mm and 5.52 mm (t=9.24, P<0.05). The average value of X(C) before and after balanced decompression was 22.16 mm and 18.83 mm (t=12.71 , P<0.05) and average value of X(E) was 10.20 mm and 6.67 mm (t=11.91, P<0.05). The average value of horizontal deviation angle M before and after medial decompression was 6.48° and 13.34° (t=- 8.41, P<0.05). The average value of angle M before and after balanced decompression was 1.42° and 6.76° (t=- 2.86, P<0.05). The average value of angle M before and after deep lateral decompression was 5.18° and 1.39° (t=2.57, P<0.05). Conclusions: The proptosis reduction was significant after deep lateral decompression, balanced decompression and medial decompression. Additionally, the horizontal deviation tended to increase after medial and balanced decompression, whereas the horizaontal deviation tended to decrease after deep lateral decompression. (Chin J Ophthalmol, 2017, 53: 424-429).

[Clinical effects of Dynesys system and transfacet decompression through Wiltse approach in the treatment of lumbar degenerative diseases]

Objective: To investigate the early clinical effects of Dynesys system and transfacet decompression by Wiltse approach in the treatment of lumbar degenerative diseases. Methods: From January 2010 to December 2013, 48 patients suffering from lumbar degenerative diseases were treated with Dynesys system in addition to transfacet decompression through Wiltse approach.There were 28 males and 20 females with age of (51.8±6.8). The preoperative diagnosis included lumbar spinal stenosis(10 cases); lumber intervertebral disc herniation (38 cases). There were 23 cases in L4/5, 16 cases in L5/S1 and 9 cases in both of L4/5 and L5/S1.Posterolateral fixation with Dynesys pedicle screw through Wiltse approach.Unilateral resection of the inferior articular facet of the superior vertebra and the superior articular facet of the inferior vertebra.Decompression of the vertebral canal until the never root was decompressed satisfactorily.In the end, Dynesys was performed according to normal procedure.VAS, ODI evaluating standards were applied to evaluate the therapeutic effect.The intervertebral space and ROM of the lumbar were observed by X ray. Results: All patients underwent surgery safely without severe complications occurred.The average following up time was 33.5 (24-60) months.Compared with preoperative parameters (7.7±1.3, 70.8±13.5), the scores of VAS and ODI decreased significantly after surgery (2.3±1.5, 23.6±12.2) and at the final follow-up (2.2±1.4, 20.0±9.8) (P<0.05). There were significant difference in the height of intervertebral space and ROM at the stabilized segment (P<0.05), but no significant changes were seen at the adjacent segments (P>0.05). X-ray scan showed neither instability or internal fixation loosen, breakage or distortion in follow-up. Conclusion: Dynesys system in addition to transfacet decompression through Wiltse approach is a therapy option for mild lumbar degenerative disease.This method can retention the structure of lumbar posterior complex and the activity of the fixed segment, reduce the risk of low back pain together with nerve root decompressed.The early clinical results are satisfactory.

[Posttraumatic nerve entrapment syndromes in the upper extremities]

Nerve entrapment syndromes in the upper extremities are common clinical disease patterns, less often as direct results of accidents. The most frequent compression syndrome is the carpal tunnel syndrome followed by the cubital tunnel syndrome. If the cause of the compression cannot be eliminated by conservative treatment options, an operative therapy is necessary. As the prognosis becomes worse with the duration of the nerve compression, it is important to initiate therapy at an early stage.

[Multi-wall orbital decompression for disfiguring proptosis in patients with mild or moderate thyroid eye disease]

Objective: To evaluate the efficacy of orbital decompression by transconjunctival medial and inferior wall combined transpalpebral lateral wall for disfiguring proptosis with mild or moderate thyroid eye disease (TED). Methods: It is a retrospective case series study. The clinical data of 18 TED cases (28 orbits) between Dec 2013 and Dec 2015 at the Institute of Orbital Diseases of the General Hospital of the Armed Police were reviewed. All the patients underwent mulit-wall orbital decompression to relieve remarkable proptosis, widen eyelid fissure, and swollen eyelid.

INCLUSION CRITERIA

1. Hertel value was 14-23 mm or over 2-7 mm than contralateral eye; 2.Orbitalpathy has been inactive with normal thyroid function for at least 6 months; 3.Orbital pressure is normal or (+). Clinical outcomes were recorded including best-corrected visual acuity, exophthalmometry, margin-to-central distance of upper and lower lids, diplopia, and CT scans before and 3 months after surgery. Results: The mean protosis of pre-and postoperation were (19.2±2.3) mm and (14.7±1.4) mm with mean reduction was (4.6±1.7) mm (t=14.08, P<0.01). Margin-to-central distance of the upperlid of pre- and postoperation were (5.1±1.2) mm and (4.9±1.3) mm with mean reduction was (0.2±0.5) mm (t=1.73, P=0.095). Margin-to-central distance of the lowerlid of pre-and postoperation were (5.9±0.9) mm and 4.3±0.7 mm with mean reduction was (1.6±0.8) mm (t=10.09, P<0.01). The difference of bilateral exophthalmos after surgery is 0-2.5 mm (median=1 mm). None of the patients showed new-onset diplopia at primary gaze and two patient showed surrounding gaze diplopia postoperatively. Two patients with diplopia relieved after surgery (Z=743.00, P=0.458). Conclusions: Transconjunctival and transpalpebral medial, inferior, and lateral walls decompression with a hidden incision was a controllable, safe, effective technique with minimal complications in relieving not only mild, moderate proptosis, but also retraction of lowerlid, and swollen eyelids. (Chin J Ophthalmol, 2017, 53: 128-135).

Quantitative Assessment of Orbital Volume and Intraocular Pressure after Two-Wall Decompression in Thyroid Ophthalmopathy

BACKGROUND

Surgical outcomes after orbital wall decompression have focused on the degree of exophthalmos and intraocular pressure. The aim of this research was to evaluate intraorbital volume using computed tomography (CT) images following two-wall decompression using a combined subcilliary and endoscopic approaches.

METHODS

A retrospective review was performed for all patients who had undergone the two-wall decompression method. The pre/postoperative CT images were used to evaluate changes in intraocular volume. Intraocular pressure was evaluated using applanation tonometry. Surgical details are discussed within the body of text.

RESULTS

Two-wall decompression thru the medial wall and floor was associated with an average intraorbital volume change of 7.3 cm³, with maximal accommodation up to 13 cm³. Changes in intraocular pressures were not statistically significant.

CONCLUSION

Two-wall decompression was effective in accommodation of up to 13 cm³ of soft tissue herniation. There was no statistically significant association between changes in volume to pressure.