Clinical Analysis of Single and Double Sacroiliac Screws in the Treatment of Tile C1 Pelvic Fracture

We investigated the difference between fixation of single and double sacroiliac screws in the treatment of Tile C1 pelvic fractures. The data of 54 patients with Tile C1 pelvic fractures who were admitted to the trauma center of the Red Society Hospital Affiliated to Xi’an Jiaotong University between August 2016 and August 2020 were retrospectively analyzed. All patients with posterior pelvic ring injuries underwent fixation with sacroiliac screws assisted by a percutaneous robotic navigation system. The operative time, amount of intraoperative blood loss, and postoperative follow-up time between the two groups (single sacroiliac and double sacroiliac screw groups) were compared. The Matta and Majeed scores at the last follow-up were compared between the groups to evaluate fracture reduction and functional recovery. Forty-nine patients were followed up for 17.2 (±4.5) months and 16.2 (±3.4) months in the single and double sacroiliac screw groups, respectively. All patients had excellent fracture reduction immediately after surgery, according to the Matta score. All fractures healed without complications. There was no statistically significant difference in preoperative general information, amount intraoperative blood loss, intraoperative anterior ring fixation method, and postoperative follow-up time between the two groups ( P > 0.05 ). The operative time of the single sacroiliac screw group was shorter than that of the double sacroiliac screw group ( P < 0.05 ). At the last follow-up, the Matta score of the double sacroiliac screw group was significantly better than that of the single sacroiliac screw group ( P < 0.05 ), and there was no statistically significant difference in the Majeed functional scores ( P > 0.05 ). For Tile C1 pelvic fractures, double sacroiliac screw fixation of posterior ring injuries can provide a more stable treatment with no statistically significant difference in functional recovery.

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Clinical assessment of three-dimensional printing assisted osteotomy guide plates in precise osteotomy of adult talipes equinovarus

10.21203/rs.2.24195/v1 ◽

2020 ◽

Author(s):

Yuan-Wei Zhang ◽

Liang-Yu Xiong ◽

Zu-Tai Huang ◽

Wen-Cheng Gao ◽

Xin Xiao ◽

...

Keyword(s):

3D Printing ◽

Blood Loss ◽

Clinical Efficacy ◽

Operative Time ◽

Three Dimensional ◽

Scoring Systems ◽

Intraoperative Blood Loss ◽

Significant Difference ◽

Talipes Equinovarus

Abstract Objectives: This current research is aimed to assess clinical efficacy and prognosis of three-dimensional (3D) printing assisted osteotomy guide plate in precise osteotomy of adult talipes equinovarus (ATE). Materials and Methods: We included a total of 27 patients of ATE malformation (including 12 males and 15 females) from January 2014 to June 2018 in current research. The patients were divided into the routine group (n=12) and 3D printing group (n=15) based on different operative methods. The parameters, including the operative time, intraoperative blood loss, complications, time to obtain bony fusion, functional outcomes based on American Orthopedic Foot and Ankle Society (AOFAS) and International Congenital Clubfoot Study group (ICFSG) scoring systems between the two groups were observed and recorded regularly. Results: The 3D printing group exhibits superiorities in shorter operative time, less intraoperative blood loss, higher rate of excellent and good outcomes presented by ICFSG score at last follow-up (P< 0.001, P< 0.001, P =0.019) than the routine group. However, there was no significant difference exhibited in AOFAS score at last follow-up and total rate of complications between the two groups (P=0.136, P =0.291). Conclusions: Operation assisted by 3D printing osteotomy guide plates for correcting the ATE malformation is novel and feasible, which might be an effective method to polish up the precise osteotomy of ATE malformation and enhance the clinical efficacy.

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Percutaneous vertebroplasty versus kyphoplasty for the treatment of neurologically intact osteoporotic Kümmell’s disease

BMC Surgery ◽

10.1186/s12893-021-01057-x ◽

2021 ◽

Vol 21 (1) ◽

Author(s):

Shou-qian Dai ◽

Rong-qing Qin ◽

Xiu Shi ◽

Hui-lin Yang

Keyword(s):

Blood Loss ◽

Bone Cement ◽

Percutaneous Vertebroplasty ◽

Cement Leakage ◽

Intraoperative Blood Loss ◽

Surgical Time ◽

Significant Difference ◽

Neurologically Intact ◽

Operation Cost

Abstract Background Percutaneous vertebroplasty (PVP) and kyphoplasty (PKP) have been widely used to treat neurologically intact osteoporotic Kümmell’s disease (KD), but it is still unclear which treatment is more advantageous. Our study aimed to compare and investigate the safety and clinical efficacy of PVP and PKP in the treatment of KD. Methods The relevant data that 64 patients of neurologically intact osteoporotic KD receiving PVP (30 patients) or PKP (34 patients) were analyzed. Surgical time, operation costs, intraoperative blood loss, volume of bone cement injection, and fluoroscopy times were compared. Occurrence of cement leakage, transient fever and re-fracture were recorded. Universal indicators of visual analogue scale (VAS) and Oswestry disability index (ODI) were evaluated separately before surgery and at 1 day, 6 months, 1 year, 2 years and the final follow-up after operation. The height of anterior edge of the affected vertebra and the Cobb’s angle were assessed by imaging. Results All patients were followed up for at least 24 months. The volume of bone cement injection, intraoperative blood loss, occurrence of bone cement leakage, transient fever and re-fracture between two groups showed no significant difference. The surgical time, the operation cost and fluoroscopy times of the PKP group was significantly higher than that of the PVP group. The post-operative VAS, ODI scores, the height of the anterior edge of the injured vertebrae and kyphosis deformity were significantly improved in both groups compared with the pre-operation. The improvement of vertebral height and kyphosis deformity in PKP group was significantly better than that in the PVP group at every same time point during the follow-up periods, but the VAS and ODI scores between the two groups showed no significant difference. Conclusion PVP and PKP can both significantly alleviate the pain of patients with KD and obtain good clinical efficacy and safety. By contrast, PKP can achieve better imaging height and kyphosis correction, while PVP has the advantages of shorter operation time, less radiation volume and operation cost.

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Treatment of thoracolumbar trauma by short-segment percutaneous transpedicular screw instrumentation: prospective comparative study with a minimum 2-year follow-up

Journal of Neurosurgery Spine ◽

10.3171/2013.11.spine13479 ◽

2014 ◽

Vol 20 (2) ◽

pp. 150-156 ◽

Cited By ~ 52

Author(s):

Petr Vanek ◽

Ondrej Bradac ◽

Renata Konopkova ◽

Patricia de Lacy ◽

Jiri Lacman ◽

...

Keyword(s):

Blood Loss ◽

Minimally Invasive ◽

Cobb Angle ◽

Control Group ◽

Working Ability ◽

Short Segment ◽

Transpedicular Screw ◽

Significant Difference ◽

Screw Group

Object The main aim of this study was to compare clinical and radiological outcomes after stabilization by a percutaneous transpedicular system and stabilization from the standard open approach for thoracolumbar spine injury. Methods Thirty-seven consecutive patients were enrolled in the study over a period of 16 months. Patients were included in the study if they experienced 1 thoracolumbar fracture (A3.1–A3.3, according to the AO/Magerl classification), had an absence of neurological deficits, had no other significant injuries, and were willing to participate. Eighteen patients were treated by short-segment, minimally invasive, percutaneous pedicle screw instrumentation. The control group was composed of 19 patients who were stabilized using a short-segment transpedicular construct, which was performed through a standard midline incision. The pain profile was assessed by a visual analog scale (VAS), and overall satisfaction by a simple 4-stage scale relating to performance of daily activities. Working ability and return to original occupation were also monitored. Radiographic follow-up was defined by the vertebral body index (VBI), vertebral body angle (VBA), and bisegmental Cobb angle. The accuracy of screw placement was examined using CT. Results The mean surgical duration in the percutaneous screw group was 53 ± 10 minutes, compared with 60 ± 9 minutes in the control group (p = 0.032). The percutaneous screw group had a significantly lower perioperative blood loss of 56 ± 17 ml, compared with 331 ± 149 ml in the control group (p < 0.001). Scores on the VAS in patients in the percutaneous screw group during the first 7 postoperative days were significantly lower than those in the control group (p < 0.001). There was no significant difference between groups in VBI, VBA, and Cobb angle values during follow-up. There was no significant difference in screw placement accuracy between the groups and no patients required surgical revision. There was no significant difference between groups in overall satisfaction at the 2-year follow-up (p = 0.402). Working ability was insignificantly better in the percutaneous screw group; previous working position was achieved in 17 patients in this group and in 12 cases in the control group (p = 0.088). Conclusions This study confirms that the percutaneous transpedicular screw technique represents a viable option in the treatment of preselected thoracolumbar fractures. A significant reduction in blood loss, postoperative pain, and surgical time were the main advantages associated with this minimally invasive technique. Clinical, functional, and radiological results were at least the same as those achieved using the open technique after a 2-year follow-up. The short-term benefits of the percutaneous transpedicular screw technique are apparent, and long-term results have to be studied in other well-designed studies evaluating the theoretical benefit of the percutaneous technique and assessing whether the results of the latter are as durable as the ones achieved by open surgery.

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Is It Necessary to Reduce Thoracolumbar Compression Fractures with Intermediate Screws in the Fractured Vertebra?

10.21203/rs.3.rs-542387/v1 ◽

2021 ◽

Author(s):

ZeJun Xing ◽

Shuai Hao ◽

XiaoFei Wu

Keyword(s):

Blood Loss ◽

Body Height ◽

Pedicle Screws ◽

Operation Time ◽

Short Segment ◽

Compression Fractures ◽

Significant Difference ◽

Before And After ◽

Screw Group

Abstract PurposeTo compare the efficacy and safety of percutaneous short-segment pedicle screws fixation (PPSF) with or without intermediate screws (IS) for the treatment of thoracolumbar compression fractures.MethodsFrom January 2016 to March 2019, a retrospective study of 38 patients with thoracolumbar compression fractures conducted. The patients were divided into a 4-screw group (without IS) and a 6-screw group (with IS) according to whether pedicle screws were placed in the fractured vertebrae. Combined positional reduction effects with the technique of pre-contoured lordotic rods were used to reduce the fracture by lengthening the anterior column of the fractured vertebrae. The posterior structure of the fractured vertebrae was undertaken as the fulcrum point for both groups. The operation time, intra-operative blood loss, visual analogue scale (VAS), anterior vertebral body height (AVBH), segment kyphosis（SK）before and after operation and complications were recorded.ResultsAlthough the operation time and blood loss in the 6-screw group were higher than in the 4-screw group, difference was not significant (P＞0.05). There was no significant difference in VAS, AVBH and SK between the two groups (P＞0.05). Nevertheless, these results were significant differences between the preoperative and the immediate postoperative, between preoperative and follow-up groups (P < 0.001). No neurologic injury was observed in either groups. ConclusionsIn the treatment of thoracolumbar compression fractures, percutaneous short-segment pedicle screws fixation without intermediate screws in the 4-screw construct may obtain the same clinical effect as that in the 6-screw construct.

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Effects of Preoperative Iodine Administration on Thyroidectomy for Hyperthyroidism: A Systematic Review and Meta-analysis

Otolaryngology ◽

10.1177/0194599819829052 ◽

2019 ◽

Vol 160 (6) ◽

pp. 993-1002 ◽

Cited By ~ 1

Author(s):

Chung-Hsin Tsai ◽

Po-Sheng Yang ◽

Jie-Jen Lee ◽

Tsang-Pai Liu ◽

Chi-Yu Kuo ◽

...

Keyword(s):

Postoperative Complications ◽

Blood Loss ◽

Operative Time ◽

Meta Analysis ◽

Thyroid Volume ◽

Vocal Cord Palsy ◽

Significant Heterogeneity ◽

Intraoperative Blood Loss ◽

Significant Difference ◽

And Control

Objective The current guidelines recommend that potassium iodide be given in the immediate preoperative period for patients with Graves’ disease who are undergoing thyroidectomy. Nonetheless, the evidence behind this recommendation is tenuous. The purpose of this study is to clarify the benefits of preoperative iodine administration from published comparative studies. Data Sources We searched PubMed, Embase, Cochrane, and CINAHL from 1980 to June 2018. Review Methods Studies were included that compared preoperative iodine administration and no premedication before thyroidectomy. For the meta-analysis, studies were pooled with the random-effects model. Results A total of 510 patients were divided into the iodine (n = 223) and control (n = 287) groups from 9 selected studies. Preoperative iodine administration was significantly associated with decreased thyroid vascularity and intraoperative blood loss. Significant heterogeneity was present among studies. We found no significant difference in thyroid volume or operative time. Furthermore, the meta-analysis showed no difference in the risk of postoperative complications, including vocal cord palsy, hypoparathyroidism/hypocalcemia, and hemorrhage or hematoma after thyroidectomy. Conclusion Preoperative iodine administration decreases thyroid vascularity and intraoperative blood loss. Nonetheless, it does not translate to more clinically meaningful differences in terms of operative time and postoperative complications.

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Robotic, laparoscopic or open hemihepatectomy for giant liver haemangiomas over 10 cm in diameter

10.21203/rs.2.13230/v5 ◽

2020 ◽

Author(s):

Minggen Hu ◽

Kuang Chen ◽

Xuan Zhang ◽

Chenggang Li ◽

Dongda Song ◽

...

Keyword(s):

Blood Loss ◽

Operative Time ◽

Liver Volume ◽

Future Liver Remnant ◽

Oral Intake ◽

Postoperative Recovery ◽

Postoperative Outcomes ◽

Intraoperative Blood Loss ◽

Liver Remnant ◽

Significant Difference

Abstract Background: To evaluate the clinical efficacy of robotic, laparoscopic, and open hemihepatectomy for giant liver haemangiomas.Methods: From April 2011 to April 2017, consecutive patients who underwent hemihepatectomy for giant liver haemangiomas were included in this study. According to the type of operation, these patients were divided into the robotic hemihepatectomy (RH) group, the laparoscopic hemihepatectomy (LH) group, and the open hemihepatectomy (OH) group. The perioperative and short-term postoperative outcomes were compared among the three groups. The study was reported following the STROCSS criteria.Results: There were no significant differences in age, sex, tumour location, body surface area (BSA), future liver remnant volume (FLR), standard liver volume (SLV), liver haemangioma volume, FLR/SLV, resected normal liver volume/resected volume, hepatic disease, rates of blood transfusion, liver function after 24 hours of surgery, operative morbidity and mortality among the three groups. Compared with patients in the RH group (n=19) and the LH group (n=13), patients in the OH group (n=25) had a significantly longer postoperative hospital stay (P< 0.05), time to oral intake (P < 0.05), and time to get-out-of-bed (P < 0.05); a higher VAS score after 24 hours of surgery (P < 0.05); and a shorter operative time (P < 0.05). There were no significant differences in these postoperative outcomes (P＞0.05) between the RH group and the LH group. When the setup time in the RH group was excluded, the operative time in the RH group was significantly shorter than that in the LH group (P＜0.05). There was no significant difference in the operative time between the RH group and the OH group (P＞0.05). The amount of intraoperative blood loss in the RH group was the lowest among the three groups (P＜0.05), and the amount of intraoperative blood loss in the LH group was less than that in the OH group (P＜0.05).Conclusion: Robotic and laparoscopic hemihepatectomies were associated with less intraoperative blood loss,better postoperative recovery and lower pain score. Compared with laparoscopic hemihepatectomy, robotic hemihepatectomy was associated with significantly less intraoperative blood loss and a shorter operative time.

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Blood Loss from Transverse Versus Longitudinal Uterine Incision in Abdominal Myomectomy: A Randomized Controlled Trial

10.21203/rs.2.9943/v3 ◽

2020 ◽

Author(s):

Alaa Elguindy ◽

Hosam Hemeda ◽

Mohamed Esmat Shawky ◽

Mohamed Elsenity ◽

Medhat Adel Elsayed ◽

...

Keyword(s):

Blood Loss ◽

Operative Time ◽

P Value ◽

Intraoperative Blood Loss ◽

Postoperative Fever ◽

Longitudinal Incision ◽

Abdominal Myomectomy ◽

Randomized Controlled ◽

Uterine Incision ◽

Significant Difference

Abstract Background: It is unclear whether transverse uterine incision is non-inferior to longitudinal incision during myomectomy with regard to bleeding. Our aim was to compare between transverse and longitudinal uterine incisions in myomectomy. Methods: A parallel randomized controlled single-blinded study in a university affiliated hospital, in the period between January 2017 and April 2018, in which 52 women candidates for abdominal myomectomy were randomized into transverse uterine incision or longitudinal uterine incision groups (26 in each group). Intraoperative blood loss (estimated directly by blood volume in suction bottle and linen towels and indirectly by difference between preoperative and postoperative hematocrit), operative time and postoperative fever were analyzed. Results: No statistically significant difference was found between transverse and longitudinal incisions regarding intraoperative blood loss (389.7 ± 98.56 ml vs 485.04 ± 230.6 ml respectively, p value=0.07), operative time (59.96 ± 16.78 min vs 66.58 ± 17.33 min respectively, p value=0.18), and postoperative fever (4% vs 8.33%, p value=0.6). Conclusion: Transverse uterine incision does not cause more blood loss than longitudinal incision and is a reasonable option during abdominal myomectomy. Trial registration: NCT03009812 at clinicaltrials.gov, registered January 2017

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Evaluation of percutaneous endoscopic lumbar discectomy in treatment of obese adolescents with lumbar disc herniation：A retrospective study

10.21203/rs.3.rs-389600/v1 ◽

2021 ◽

Author(s):

Haijiang Yu ◽

Bin Zhu ◽

Xiaoguang Liu

Keyword(s):

Propensity Score ◽

Blood Loss ◽

Operative Time ◽

Lumbar Disc ◽

Lumbar Discectomy ◽

Obese Patients ◽

Intraoperative Blood Loss ◽

Endoscopic Lumbar Discectomy ◽

Time Point

Abstract Background: Obese patients are at risk of complications such as poor wound healing and increased infection rates after spinal surgery. Percutaneous endoscopic lumbar discectomy (PELD) has advantages over conventional open surgery in the treatment of obese adult patients with lumbar disc herniation (LDH) because it can decrease perioperative complications and enhance satisfaction degrees of patients. However, no clinical studies have evaluated the efficacy of PELD in obese adolescents with LDH. This study aimed to evaluate the efficacy of PELD in the treatment of obese ALDH.Methods: We retrospectively collected clinical data from 208 patients with single-segment ALDH who underwent PELD treatment in our hospital between January 2015 and December 2019. According to the body mass index classification standard of obesity for adolescents in our country, the patients were divided into obese and non-obese groups (control group). Based on the preoperative baseline data of the two groups, propensity score matching was performed to select patients from the two groups for the comparative study. Perioperative data included operative time, intraoperative blood loss and length of postoperative hospitalization. The visual analog scale (VAS), Oswestry disability index (ODI) and modified MacNab criteria were recorded as the main indicators of the surgical outcome, and the recurrence rate and incidence of complications were recorded as the minor indicators. Results: The obese and control groups included 45 patients each after 1:1 propensity score matching. Both groups showed improvements in VAS and ODI scores after surgery and at each follow-up time point (p < 0.05). However, there was no significant statistical difference in VAS and ODI scores between the two groups at each follow-up time point (p >0.05). In addition, the differences in operative time, intraoperative blood loss, length of postoperative hospitalization, incidence of complications, and recurrence rate were not statistically significant between the two groups (p >0.05). At the final follow-up, there was no significant difference in the excellent and good rate of MacNab classification between the two groups (p >0.05). Conclusion: PELD is a safe and effective minimally invasive technique for the treatment of obese patients with ALDH. The efficacy of PELD in obese and non-obese patients with ALDH was comparable.

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Robotic, laparoscopic or open hemihepatectomy for giant liver hemangiomas of over 10 cm in diameter

10.21203/rs.2.13230/v3 ◽

2020 ◽

Author(s):

Minggen Hu ◽

Kuang Chen ◽

Xuan Zhang ◽

Chenggang Li ◽

Dongda Song ◽

...

Keyword(s):

Blood Loss ◽

Operative Time ◽

Liver Volume ◽

Future Liver Remnant ◽

Oral Intake ◽

Postoperative Recovery ◽

Postoperative Outcomes ◽

Intraoperative Blood Loss ◽

Liver Remnant ◽

Significant Difference

Abstract Background To evaluate the clinical efficacy of robotic, laparoscopic, and open hemihepatectomy for giant liver hemangiomas.Methods From April 2011 to April 2017, consecutive patients who underwent hemihepatectomy for giant liver hemangiomas were included into this study. According to the type of operation, these patients were divided into the robotic hemihepatectomy (RH) group, the laparoscopic hemihepatectomy (LH) group, and the open hemihepatectomy (OH) group. The perioperative and short-term postoperative outcomes were compared among the three groups. The study was reported following the STROCSS criteria.Results There were no significant differences in age, sex, tumor location, body surface area (BSA), future liver remnant volume (FLR), standard liver volume (SLV), liver hemangioma volume, FLR/SLV, resected normal liver volume / resected volume, hepatic disease, rates of blood transfusion, liver function after 24 hours of surgery, operative morbidity and mortality among the three groups. Compared with patients in the RH group (n=19), and the LH group (n=13), patients in the OH group (n=25) had significantly longer postoperative hospital stay (P< 0.05), time to oral intake (P < 0.05), time to get-out-of-bed (P < 0.05), a higher VAS score after 24 hours of surgery (P < 0.05) and a shorter operative time (P < 0.05). There were no significant differences in these postoperative outcomes (P>0.05) between the RH group and the LH group. When the setup time in the RH group was excluded, the operative time of the RH group was significantly shorter than the LH group (P<0.05). There was no significant difference in the operative time between the RH group and the OH group (P>0.05). The intraoperative blood loss of the RH group was the least among the three groups (P<0.05) and the intraoperative blood loss of the LH group was less than the OH group (P<0.05).Discussion Robotic, laparoscopic, and open hemihepatectomy were safe and efficacious treatments for giant liver hemangiomas. Robotic and laparoscopic hemihepatectomy were significantly better than open hemihepatectomy in intraoperative blood loss, postoperative recovery and pain score. Compared with laparoscopic hemihepatectomy, robotic hemihepatectomy was associated with significantly less intraoperative blood loss and shorter operative time.

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Efficacy and radiographic analysis of oblique lumbar interbody fusion for degenerative lumbar spondylolisthesis

Journal of Orthopaedic Surgery and Research ◽

10.1186/s13018-019-1416-2 ◽

2019 ◽

Vol 14 (1) ◽

Cited By ~ 1

Author(s):

Menghui Wu ◽

Jia Li ◽

Mengxin Zhang ◽

Xufeng Ding ◽

Dongxu Qi ◽

...

Keyword(s):

Blood Loss ◽

Interbody Fusion ◽

Radiographic Analysis ◽

Lumbar Interbody Fusion ◽

Intraoperative Blood Loss ◽

Significant Difference ◽

Degenerative Lumbar Spondylolisthesis ◽

Oblique Lumbar Interbody Fusion ◽

Lumbar Spondylolisthesis

Abstract Background To compare the clinical efficacy and radiographic analysis of oblique lumbar interbody fusion (OLIF) and traditional posterior lumbar interbody fusion (PLIF) in treating degenerative lumbar spondylolisthesis (DLS). Methods Grade I DLS patients admitted to the Third Hospital of Hebei Medical University were retrospectively reviewed. In sum, 78 patients that underwent OLIF (n = 31) and PLIF (n = 47) treatment of DLS were recruited. Clinical data including clinical and radiological evaluations were collected pre-operatively and at each follow-up. Japanese Orthopaedic Association (JOA) scores, Oswestry Disability Index (ODI), lumbar lordosis (LL), disc height (DH), and fusion rates were compared between the OLIF and PLIF groups. Results The operation time for both groups was 131.3 ± 14.6 min in the OLIF group and 156.9 ± 37.4 min in the PLIF group (P < 0.001). The intraoperative blood loss was 163.6 ± 63.9 ml in the OLIF group and 496.8 ± 122.6 ml in the PLIF group (P < 0.001). The length of the surgical incision was 4.63 ± 0.57 cm in the OLIF group and 11.83 ± 1.37 cm in the PLIF group (P < 0.001). The number of intraoperative and post-operative complications for both groups was 10 in the OLIF group and 20 in the PLIF group. Significant clinical improvement (P < 0.05) was observed in JOA scores and ODI when comparing pre-operative evaluation and final follow-up. After statistical analysis, there was no significant difference in the preoperative JOA scores between the two groups. There was no significant difference when comparing pre-operative LL and DH for either group. Post-operative reexamination was improved as compared to pre-operative exams. And the improvement of DH was better in the OLIF group as compared to the PLIF group. Conclusions For DLS patients, both OLIF and PLIF can achieve good results. Furthermore, OLIF displays marked advantages including smaller surgical incisions, shorter anesthesia times, decreased intraoperative blood loss, and post-operative pain better relieved.

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