| Part 1 Lumbosacral spine segment intervertebral disc finite element mechanical analysisObjective: Nucleus pulpous discectomy is a common treatment for lumbar dis herniation, but still about 5%- 15% of patients may suffer from recurrent lumbar disc herniation. The mechanism of recurrent lumbar disc herniation is yet not unified, and neither are the treatment methods. We built the Lumbosacral spine segment intervertebral disc finite element module using the method of finite element to analysis the spine's biochemical changes from before and after recurrent lumbar disc herniation, Laminectomy and semi-laminectomy. With the result provided by this analysis, we can form a digital research platform for studying the mechanism of this area.Method:We selected volunteers and patients with recurrent lumbar disc herniation. We give volunteers CT and MRI scan of the lumbosacral region, and CT scans the patients with recurrent lumbar disc herniation. After that we shall write image sequence to the disc in DICOM format. Import the image sequence into Mimics 15.0 to build the module of vertebra and nucleus pulpous. With the Polygon tool in Geomagic 12.0 to establish the module of annulus fibrosus and end plate. Using Croe 3.0 we establish the module of interbody fusion cage according to the detailed data. In the 3-Matic 7.0 by changing the coordinate system, we built a 3 dimensional finite model, and then output module files in *.CDB and *.TXT which can be identified by Ansys 4.0. Then we set material properties of the model, the contact between the each components, the following constraints 5th lumbar, put pressure or torque on third lumbar vertebra, algorism, post-processing results reading, post-processing finite element analysis in the Ansys 14.0.Outcome:Using Geomagic and Mimics software to build an accurate finite element model based on the CT and MRI imgae, and then validate the model. Assemble the three models mentioned above. And conduct mechanical analysis on the finite element model, check the condition of the fiber under rotation, changes in stress, flexion, extension and lateral bending. After Nucleus pulpous discectomy, the stability of the lumbar area is increased, and less stress was put on to that particular area. But after the cage implantation, the area above and below this cage may experience a change of stress, which may increase the risk of the herniation.Conclusion:The contrast analysis between recurrent lumbar disc herniation and interbody fusion cage: the interbody fusion cage strengthened the stability of the lumbar area, and Laminectomy reduced the movement of the lumbar spine. But due to the uneven stress put on the above the cage area and the below area of the cage, after implanting the cage the change of force, there is tendency of herniation. Also after the implantation by contrast Laminecotomy and Semi-Laminectomy, the above and below area of the cage was not affected clearly, but Laminecotomy is tend to be more likely to cause the herniation than Semi – Laminecomy.Part 2 Posterior versus transforaminal lumbar interbody fusion for treatment of recurrent lumbar disc herniation: a comparative retrospective studyObjective:Discectomy is one of the most common surgical procedures for treating lumbar disc herniation. Although there have been substantial improvements in its technique, approximately 5-15% of patients still experience recurrent lumbar disc herniation. In addition to the natural development of recurrent lumbar disc herniation still being unknown, there is no consensus on its management.We studied the clinical outcome and effects of transforaminal lumbar interbody fusion(TLIF) on recurrent lumbar disc protrusion(RLDP).Methods: We January 2010 to May 2012 in our department recurrent lumbar disc herniation surgery 51 people conducted a retrospective study, 26 patients underwent surgery as PLIF group(group1), 25 patients underwent surgery as TLIF(group 2), all patients had lumbar lateral lumbar disc lumbar MRI and CT examination, all patients had no special biochemical abnormalities. Records surgery surgical cases, and the incidence of complications after surgery pain, motor dysfunction, neurological recovery were analyzed in order to evaluate the therapeutic effects of two surgical methods.Results: All patients were surgical wounds get healed well. PLIF group blood loss was 690 ± 39.5ml, operation time was 149 ± 22 min, interbody fusion time 3.8 ± 0.49 month, bed time 5.0 ± 2.0day, fusion rate was 100%; TLIF group blood loss was 400 ± 58.5ml, The operation time 105 ± 16 min, interbody fusion time 3.2 ± 0.82 month, bed time 3.5 ± 1.5day, fusion rate was 100%; TLIF group blood loss and operative time was significantly lower than the PLIF group, and the difference was statistically significant(P <0.05); TLIF perioperative complication rate of 8.0% was significantly lower than the 15.4% PLIF group, the difference was statistically significant(P <0.05). All of the patients achieved improved neurological status after surgery. The VAS score improved from 7.15±1.18 preoperatively to 1.15±0.67 postoperatively(P<0.05) in the PLIF group and from 7.12±1.21 preoperatively to 1.06±0.65 postoperatively(P<0.05) in the TLIF group. The ODI score improved from 0.69±0.09 preoperatively to 0.20±0.08 postoperatively(P<0.05) in the PLIF group and from 0.67±0.11 preoperatively to 0.22±0.12 postoperatively(P<0.05) in the TLIF group. The JOA score improved from 16.1±1.3 preoperatively to 27.3±0.7 postoperatively(P<0.05) in the PLIF group and from 15.0±1.3 preoperatively to 26.6±1.7 postoperatively(P<0.05) in the TLIF group. The RRs were 87.8±4.5% and 84.0±10.1%, respectively, for the PLIF and TLIF groups. Although the JOA score had significantly improved at the final follow-up, there was no statistically signficant difference regarding the JOA score or the RR between the two groups. There was also no signficant difference in surgical outcomes based on the RR for the two groups(P=0.562).There was no statistically signficant difference regarding the JOA scores or recovery rates for the two groups. Furthermore, there was no signficant difference in surgical outcomes based on the recovery rates. Altogether, 24 patients in the PLIF group and 21 patients in the TLIF group had excellent or good results. None of the patients had a poor result(recovery rate <50%).Conclusions:PLIF and TLIF provide good outcomes for recurrent lumbar disc herniation. In clinical practice, however, TLIF may be preferred because of its shorter operative time, less blood loss, and fewer complications.Part 3 The clinical effects of traditional Chinese medicine comprehensive treatment in postoperative recurrent lumbar disc protrusionObjective: Recurrent lumbar disc protrusion(RLDP) is a common orthopedic disease which is both difficult and complicated. In Chinese medicine it belongs to the same category as low back pain arthralgia etc. Although non-surgical comprehensive treatment of the disease has made great achievements but there are still some patients that require surgery after the failure of conservative treatment. When such patients do choose to have surgery after the failure of conservative treatment they are already experiencing very serious neurological symptoms. Although surgery can directly resolve some of the pain in patients, but there are still some patients with more severe neurological symptoms due to postoperative residual. According to the principles of traditional Chinese medicine, we combined the patient's situation before and after the surgery and recovery status; and made very significant clinical results in the recovery of recurrent lumbar disc protrusion after reoperation. This study was designed to observe the system of traditional Chinese medicine comprehensive treatment and its clinical effects after recurrent lumbar disc protrusion surgery.methods: We randomly followed-up 23 patients who accepted conservative treatment in our hospital after surgery(study group) and 18 cases who went home after surgery and relied on self recovery(control group). Patients were followed up after one month, three months, and six months of surgery.Interbody fusion time was recorded. The neurological status(JOA) score was recorded in the analysis of post-operative recovery of neurological functions, in order to evaluate the therapeutic effects of traditional Chinese medicine comprehensive treatment.Results: By the end of the follow-up, all the patients showed interbody fusion. The Interbody fusion time was 3.1 ± 0.56 month, 3.9 ± 0.75 month respectively for observation group and control group. Preoperative and postoperative JOA scores were 13.17 ± 2.98, 18.05 ± 1.63 for observation group and 12.48 ± 2.7817.17 ± 2.89 in the control group. The JOA scores showed no significant difference between the two groups; Preoperative and postoperative JOA score in the two groups were statistically significant(P <0.05). Postoperative treatment up to one month, three months and six months, the JOA score was 18.05 ± 1.63,23.22 ± 2.16,25.11 ± 1.27,26.72 ± 1.13, respectively in the observation group. The JOA score for control group were 17.17 ± 2.89, 20.65 ± 3.21, 23.65 ± 2.88,25.70 ± 2.22 respectively. Post surgery within 1 month after treatment the JOA scores of the two groups were statistically significant(P <0.05), treatment after 1 month, three months the JOA scores in the two groups were statistically significant(P <0.05); After three months, 6 months JOA score in the two groups was statistically significant(P <0.05). After 1 month of treatment JOA scores were statistically significant(P <0.05) between the two groups, the observation group better than the control group; After 3 months of treatment JOA scores were statistically significant(P<0.05) between the two groups, the observation group better than the control group; After 6 months of treatment JOA scores were statistically significant(P<0.05) between the two groups, the observation group much better than in the control group.Conclusion: Although the JOA score showed no significant difference between the two groups six months during the recovery process after reoperation of recurrent lumbar disc protrusion, but after 1 month, 3 months post operation the JOA scores were significantly different between the two groups, and JOA score of observation group was better than the control group. Apparently traditional Chinese medicine comprehensive treatment for the final result of rehabilitation after reoperation will not achieve a decisive effect, but it plays an important role to facilitate early postoperative rehabilitation, vertebral fusion and treat neurological functional recovery. |
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