Effectiveness and postoperative rehabilitation of one-stage combined anterior-po

lNTRODUCTlON

因此，产生了由物流服务集成商、物流服务提供商构成的两级物流服务供应链，用于满足零售商面向客户的个性化、多样化的物流服务需求。由此形成了两级产品供应链与两级物流服务供应链的联动与融合，本文将重点研究两者联动的利益协调问题。

Thoracolumbar fractures refer to fractures at the thoracolumbar spine, which are mainly featured by local thoracic spinal pain and swelling and muscle tension on both sides of the fracture. Patients with thoracolumbar fractures may have difficulty in standing and turning over. Some may even suffer from movement disorder and significant impairment of daily life activities. The incidence of thoracolumbar fractures is relatively high, and is a common trauma at the Department of Orthopedics. The diagnosis of this disorder has become easier and faster in China due to the continuous improvement in medical technology[1,2]. Thoracolumbar fractures are generally combined with spinal cord injury to varying degrees, which may cause deterioration of the patients' condition and increase the difficulty of clinical treatment. The reasons for this are as follows: The fractured blocks and the intervertebral disc tissues protrude into the spinal canal, resulting in spinal cord contusion and compression. Therefore, fracture reduction, spinal compression, and spinal fixation and fusion at the affected segments are crucial steps in surgery[3]. China has witnessed a rapid development of medical science in recent years, and the diagnosis of thoracolumbar fractures is more rapid, while the selection of an appropriate treatment has become a primary concern[4]. At present, anterior or combined anterior-posterior surgery is preferred for severe thoracolumbar fractures. In this study, the application value, advantages, and disadvantages of these two surgical approaches were compared by reviewing the data of patients with thoracolumbar fractures treated at our hospital.

MATERlALS AND METHODS

Patients

The present study was approved by the hospital ethics committee. One hundred and twenty patients with severe thoracolumbar fractures and spinal cord injury treated at our hospital from February 2020 to February 2021 were randomly enrolled. The random sampling method was used to divide the patients into two groups, namely, group 1 and group 2, with 60 patients in each group. Informed consent was obtained from all patients. The two groups were not different significantly in terms of the basic information (＞ 0.05) (Table 1).

周桥似乎意识到了作为管理者的不足，他去书店买了一大堆关于管理和人际关系的书籍，有些放在办公室，有些放在床头，闲来就看看。

One-stage combined anterior-posterior surgery can effectively improve the function of affected vertebrae and the life quality of patients with severe thoracolumbar fractures and spinal cord injury.This surgical approach is worthy of promotion in clinical use.

(1) Cognitive impairment to varying degrees; (2) recent history of acute and chronic infections; (3) hearing impairment or incapable of communication; (4) pathological fractures caused by tumors, infections, or osteoporosis; (5) severe spinal degenerative diseases; and (6) history of drug dependence or drug allergy.

Methods

Patients in group 2 received anterior decompression plus bone grafting with internal fixation. General anesthesia was performed in the lateral position. A lateral-anterior extra-pleuroperitoneal approach was adopted to expose the affected vertebrae and the adjacent vertebrae. The ribs were resected selectively to prepare the bone graft. The lateral portion of the pedicle of the affected vertebral body was resected to expose the dural sac and nerve root sleeve fully. The posterior 3/4 portion of the vertebral body was resected, along with the superior and inferior intervertebral discs and the endplate cartilage.Decompression was performed to the medial margin of the contralateral pedicle. Extra care was taken not to injure the spinal cord. Further inspection was conducted to confirm that the compression was completely removed and the deformity was corrected. Next, an autologous tricortical iliac bone graft of an appropriate length was inserted between the superior and inferior vertebral bodies. The titanium plate was mounted and immobilized. The residual fractured blocks were placed into the iliac bone and the lateral gaps. Thorough hemostasis was performed, followed by washing with normal saline. The incision was sutured layer by layer.

本项目2014年11月底进场，1号交通洞作为地下泵站及其附属洞室群的主要施工通道，其施工进度直接影响到地下泵站及其附属洞室的施工进度。此时不是迁坟时节，由于迁坟、征地、移动果林附着的3路线缆等地面附着物较为困难，在增加大量投资的同时也需要耗费大量的时间，短期内1号交通洞无法施工，对此将1号交通洞进口段由设计的明挖改为洞挖施工。

Patients in group 1 received surgerythe combined anterior-posterior approach: The same steps were followed for anterior decompression as in group 2. The incision was maintained at a length of 10-12 cm as no anterior fixation would be performed. Grafting with large iliac bone blocks was performed for the fusion. If the harvested iliac bone blocks were thin, the fusion was performed using a titanium mesh cage. Posterior fixation was performedthe intermuscular space. Therefore, no damage would be caused to the posterior complex structure (Figure 1). The GSS-Ⅱ rod-screw system and Depuy pedicle screw system were used. It was unnecessary to perform canal decompression. Lateral fenestration of the vertebral body was performed if the superior and inferior intervertebral discs of the affected vertebra were not damaged, which was followed by intravertebral bone grafting. A closed thoracic drainage tube was indwelled for all patients receiving thoracotomy. The drainage tube was removed after confirming that there was no effusion or pneumatosis in the thoracic cavity. Costal bone was introduced for patients who received fusion using large iliac bone blocks. The fractured blocks harvested by spinal decompression were regrafted.

The early interventions after surgery were the same in both groups. Patients with nerve injury were treated with hormones and mannitol 4-5 d after surgery and with antibiotics 5-7 d after surgery. Fluid replacement was given to maintain electrolyte and acid-base balance. The indication for blood transfusion was assessed based on intraoperative blood loss and postoperative routine blood tests.Patients with osteoporosis received anti-osteoporosis treatment within 1 mo after surgery, and only then were they allowed to get out of bed. The time to ambulation was prolonged to 1.5 mo after surgery for those with severe osteoporosis. In addition, these patients were required to wear waist braces within the first 3 mo of ambulation.

Blood loss was greater and the operation time was longer in group 1 than in group 2, with significant difference. Incision length, intraoperative X-rays, and length of hospital stay were not significantly different between the two groups. Preoperative function of the affected vertebrae was not significantly different between the two groups. In each group, the patients showed significant improvement after surgery. The anterior vertebral height ratio and the posterior vertebral height ratio in group 1 after surgery were significantly higher than those in group 2. The Cobb angle after surgery was significantly lower in group 1 than in group 2. The canal-occupying ratio of the affected vertebrae was not significantly different between the two groups. Before surgery, there was no significant difference in the quality of life scores between the two groups. The above indicators were significantly improved after surgery compared with before surgery in each group. In addition, these indicators were markedly better in group 1 than in group 2 after surgery.

Observation indicators

The observation indicators were blood loss, incision length, operation time, intraoperative X-rays, length of hospital stay, anterior vertebral height ratio, posterior vertebral height ratio, Cobb angle, and canaloccupying ratio of the affected vertebra.

Quality of life (QOL) was scored in the two groups before treatment and at 2 mo after surgery. The total score of each item ranged from 0 to 60: scores ＜ 20, extremely poor; 20-50, fair; and 51-60, good[5].

Statistical analysis

其中，k值越小时，所计算出的距离越适合运用在高维空间中，并由此提出了分数距离度量，即利用k＜1的距离来衡量高维空间中数据间的距离。当k=2时，式（7）代表欧氏距离。

RESULTS

Comparison of surgical indicators

Blood loss was greater and the operation time was longer in group 1 than in group 2, with significant difference (＜ 0.05). Incision length, intraoperative X-rays, and length of hospital stay were not significantly different between the two groups (＞ 0.05) (Table 2).

Comparison of the function of the affected vertebrae

However, our study also has some limitations. First, this was a single-center study with limited number of patients enrolled, and the novel surgical approach is still expected to be attempted in more centers. Second, the follow-up was short in our study, and the long-term efficacy of the novel surgical approach remains to be further documented.

Comparison of the QOL scores between the two groups

Before surgery, there was no significant difference in the QOL scores between the two groups (＞ 0.05).The above indicators in each group were significantly improved after surgery compared with before surgery. In addition, these indicators were much better in group 1 than in group 2 after surgery (＜0.05) (Table 4).

DlSCUSSlON

Severe spinal fractures caused by high-energy trauma have become increasingly common in recent years. Spinal fractures, damaged spine structure, spinal dislocation, and space occupation by a large number of fractured blocks in the spinal canal may cause spinal cord compression and nerve injury[6,7]. At present, the clinical treatment for such a disorder aims to achieve sufficient spinal decompression,restore the support and immobilize the vertebrae, and hence promote bone union and recovery of nerve function. However, the conventional posterior approach may fail to achieve these goals[8,9].

公路工程施工管理过程中的常见问题及解决措施分析……………………………………………… 李军，汪常辉（7-230）

Surgical treatment for thoracolumbar fractures is usually intended to reconstruct the normal spinal structure and spinal stability, relieve compression, prevent late-stage thoracolumbar deformity and secondary nerve injury, and offer mechanical protection for recovery of nerve function[10,11]. Posterior spinal surgery is an invasive surgery, and the surgical indications of patients should be carefully assessed to prevent complications and ensure surgical success[12,13]. Given these facts, posterior open spinal surgery is generally intended to treat thoracolumbar fractures with spinal instability. Spinal instability is a disorder where the spine does not maintain normal anatomy when resisting loads. As a result, the nerve roots may have a secondary injury or mechanical injury, which further changes the spine structure and induces fracture malunion[14,15]. Certain rules should be followed during surgery,and the surgical approach is selected depending on the position of spinal compression. In addition, a pedicle screw-rod internal fixation system is used to improve surgical outcomes[16,17]. The present study showed that blood loss was greater and the operation time was longer in group 1 than in group 2(＜ 0.05). Incision length, intraoperative X-rays, and length of hospital stay were not significantly different between the two groups (＞ 0.05). In each group, the patients' condition was significantly improved after surgery compared with before surgery. The anterior vertebral height ratio and the posterior vertebral height ratio in group 1 after surgery were significantly higher than those in group 2.The Cobb angle after surgery was significantly lower in group 1 than in group 2 (＜ 0.05). However,the canal-occupying ratio of the affected vertebra was not significantly different between the two groups(＞ 0.05). Each group of patients achieved significant improvement after surgery. All of the relevant indicators in group 1 were significantly higher than those in group 2 after surgery (＜ 0.05). The reasons for these results might be due to the larger incision, greater blood loss, longer operation time,and difficulty in vertebral exposure. Anterior spinal surgery has the following advantages compared with the posterior approach: More thorough spinal decompression, lower risk of fixation loosening and disruption, removal of the fixation system after artificial joint fusion is unnecessary, and less likelihood of vertebral deformity, paralysis and sequelae after surgery[18,19]. The following defects have been reported for posterior spinal surgery: Degeneration and stenosis of the affected vertebrae and the superior adjacent intervertebral disc; multiple micromovements of the pedicle screws under excessive loading, which further causes loosening before bony fusion[20,21]; postoperative cutting of the screws within the cancellous bone, leading to reduction loss in those for whom osteoporosis is not confirmed before surgery; and fatigue fracture of the pedicle screws and implants due to overload[9]. Despite the above defects, posterior spinal surgery also has the following advantages. It is easier to perform surgerythis approach; only the superior and inferior adjacent segments of the affected vertebrae are immobilized with pedicle screws. In this way, the number of segments to be immobilized is reduced,while the motor function of the spine is preserved maximally[17]. This approach allows for posterior laminectomy with direct decompression. In addition, a well-designed implant enables sufficient stretching of the anterior and posterior longitudinal ligaments of the fibrous ring under the physiological curvature through three-dimensional adjustment. The implant can effectively achieve the reduction of fractured blocks in the vertebral canal in burst fractures through traction. Hence, indirect decompression is achieved without further damaging the stability of the bony structure[16]. The posterior approach not only allows bone grafting for fusion, but also fusion of the anterior affected bonethe pedicle. The combined anterior-posterior surgery integrates the advantages of both the anterior and posterior approaches. The combined approach can directly manage the displacement of a posterior column fracture and offer pre-support to assist in anterior reduction. The adjacent segments can be temporarily stabilized. In addition, the cage for anterior bone fusion can be conveniently placed by pressurizing and tightening. Moreover, excessive tilting or subsidence of the titanium mesh cage can be prevented. Therefore, the normal physiological loading state before the injury can be best reproduced[22]. Our study showed that the combined anterior-posterior surgery outperformed the posterior spinal surgery in promoting the functional recovery of the affected vertebrae and improved the patients’ QOL.The combined approach effectively restored the height of the affected vertebrae and corrected kyphosis.The combined approach also allows for sufficient anterior decompression, and the simple anterior approach does not enable temporary fixation, auxiliary reduction, and three-column fixation according to Denis' three-column concept. Therefore, the latter is usually associated with an unfavorable microenvironment for callus regeneration.

There were no significant differences in the preoperative function of the affected vertebrae between the two groups (＞ 0.05). Significant improvement was achieved in both groups after surgery. The anterior vertebral height ratio and the posterior vertebral height ratio in group 1 after surgery were significantly higher than those in group 2. The Cobb angle after surgery was significantly lower in group 1 than in group 2 (＜ 0.05). The canal-occupying ratio of the affected vertebrae was not significantly different between the two groups (＞ 0.05) (Table 3).

CONCLUSlON

(1) No conscious disturbance; (2) complete medical records; (3) thoracolumbar fractures confirmed by computed tomography (CT) or X-rays, combined with nerve injury; (4) fractured blocks occupying over 50% of the spinal canal; (5) patients tolerant to surgery; and (6) the degree of vertebral compression greater than 50%.

ARTlCLE HlGHLlGHTS

Research methods

One hundred and twenty patients with severe thoracolumbar fractures and spinal cord injury treated at our hospital from February 2020 to February 2021 were randomly enrolled, which were randomly divided into group 1 (one-stage combined anterior-posterior surgery) and group 2 (one-stage anteriorapproach surgery). Blood loss, incision length, operation time, intraoperative X-rays, length of hospital stay, anterior vertebral height ratio, posterior vertebral height ratio, Cobb angle, canal-occupying ratio of the affected vertebra, and quality of life scores were compared between the two groups.

由于干旱指数的周期变换很复杂，变化周期不固定，且在同一时段中又包含各种时间尺度的周期变化，表现出多时间尺度的特征，因此本文利用小波变换分析方法来研究干旱指数在不同尺度(周期)随时间的演变情况。

Research results

矗立在湖畔一处山崖峭壁上的布莱德城堡，为湖景增添了许多梦幻色彩。这座中世纪的城堡是斯洛文尼亚最大、最古老的城堡之一。古典建筑和湖光山色和谐地融为一体，在季节和光影的变化中，默默地向世人展现着自己多姿多彩的风貌。

(一)梁廷灿《历代名人生卒年表》谓金门诏“生于康熙十二年癸丑”。陶容、于士雄《历代名人生卒年表补》则对梁表进一步补充，著录生年一致，卒年则说据《光绪江都续志》“年八十卒”，著录为“乾隆十六年辛未”(北京图书馆出版社2002年版，第504页)。如果按“生于康熙十二年”而“年八十卒”推算，则金门诏卒年按虚岁当为乾隆十七年。另外，查核《光绪江都续志》并未载金门诏生卒年月，“年八十卒”不知何据。

Research conclusions

One-stage combined anterior-posterior surgery effectively improves the function of the affected vertebrae and the life quality of patients with severe thoracolumbar fractures and spinal cord injury.

All statistical analyses were performed using SPSS 22.0 software. Measurements were expressed as mean ± SD and analyzed by the-test. Counts were expressed as(%) and analyzed by thetest.＜0.05 indicated a significant difference.

本文的主要贡献在于将IMU固定在脚部,采用SVM分类器识别单步运动速度,当行人在1.5 m/s～4 m/s内运动时,我们认为单步运动速度识别误差将小于0.25 m/s。本文提出的方法存在一定的误差。但是由于同一人员运动状态改变时步长会发生显著变化,且已证明运动速度与运动步长之间有强相关关系。本文提出的方法存在一定误差,但是利用本文提出的方法,针对存在速度剧烈变化的运动过程,可以根据识别的单步运动状态改变行人的运动步长,相对于用户输入步长固定值,将有助于提高SHSs的追踪精度。

Research perspectives

One-stage combined anterior-posterior surgery is worthy of popularization in clinical use.

FOOTNOTES

Conceptualization: Zhang B contributed the conceptualization of the study; An Y, Wang JC,Song QP and Jiang YZ collected the data; An Y and Wang JC Formal analyzed the data; Wang JC, Song QP and Jiang YZ wrote the manuscript; Wang JC, Song QP and Zhang B reviewed and edited the manuscript.

The study was reviewed and approved by the Ethics Committee of Beijing Jishuitan Hospital (Approval No. 202110-05).

All study participants, or their legal guardian, provided informed written consent prior to study enrollment.

The authors declare that they have no conflicts of interest concerning this article. No benefits in any form have been or will be received from any commercial party related directly or indirectly to the subject of this study.

No additional data are available.

The authors have read the STROBE Statement - checklist of items, and the manuscript was prepared and revised according to the STROBE Statement - checklist of items.

This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BYNC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is noncommercial. See: https://creativecommons.org/Licenses/by-nc/4.0/

China

Bo Zhang 0000-0002-6320-7258; Jin-Chao Wang 0000-0003-0423-750X; Yu-Zhen Jiang 0000-0003-2248-7211; Qing-Peng Song 0000-0002-2146-6913; Yan An 0000-0003-4919-2106.

袁安将吴耕抱在怀里，李离掐着他的人中穴，上官星雨将玉玦取下来，代替火把举在手里。吴耕醒过来，张着嘴，蠕动着嘴唇，却说不出话。看到三人着急的神色，他又伸手指向自己的双耳。在铺天盖地的花雨里，在他想起跟父亲一起重返他们的吴家垴桃花源之后，他到底想到了什么样的幻象，让他激动如斯，无法说，也无法听？

Wang JL

A

Wang JL