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BACKGROUND: Platelet-rich plasma can promote the repair and regeneration of intervertebral disc tissue. Percutaneous transforaminal endoscopic discectomy is widely used in the treatment of lumbar disc herniation. In recent years, more and more scholars have focused on the combined treatment of lumbar disc herniation with the two techniques in order to achieve a better patient prognosis. OBJECTIVE: To investigate the clinical safety and effectiveness of percutaneous transforaminal endoscopic discectomy combined with platelet-rich plasma in the treatment of lumbar disc herniation. METHODS: The clinical data of 58 patients with lumbar disc herniation who met the inclusion and exclusion criteria at Sixth Medical Center of PLA General Hospital from June 2017 to May 2018 were retrospectively analyzed. Among them, 29 patients underwent percutaneous transforaminal endoscopic discectomy combined with platelet-rich plasma (observation group), and the remaining 29 patients underwent percutaneous transforaminal endoscopic discectomy only (control group). Visual Analogue Scale score for back and leg pain, lumbar JOA score, and Oswestry Disability Index were evaluated preoperatively, at 3, 6, and 12 months postoperatively, and at the last follow-up. Intervertebral space height, nucleus pulposus to cerebrospinal fluid signal strength ratio, and intervertebral disc Pfirrmann grading were measured preoperatively, at 6 and 12 months postoperatively, and at the last follow-up. The modified MacNab criteria were used to assess excellent and good rate of curative effect at the last follow-up. RESULTS AND CONCLUSION: (1) The Visual Analogue Scale score for back and leg pain, JOA score, and Oswestry Disability Index of the two groups postoperatively were significantly improved compared with those preoperatively (P < 0.05). Visual Analogue Scale score and Oswestry Disability Index were lower in the observation group than those in the control group at 3 and 6 months postoperatively (P < 0.05). The JOA score was higher in the observation group than that in the control group at 3 and 6 months postoperatively (P < 0.05). (2) The nucleus pulposus to cerebrospinal fluid signal strength ratio was higher in the observation group than that in the control group at the last follow-up (P < 0.05). Pfirrmann grading of the intervertebral discs was better in the observation group than that in the control group (P < 0.05). The excellent and good rate was 93% in the observation group and 83% in the control group, and the difference was not statistically significant (P > 0.05). (3) These findings indicate that percutaneous transforaminal endoscopic discectomy combined with platelet-rich plasma in the treatment of lumbar disc herniation has satisfactory clinical efficacy and can delay the degeneration of the intervertebral disc to a certain extent. [ABSTRACT FROM AUTHOR]

BACKGROUND: Unilateral biportal endoscopic technique has been widely used in lumbar interbody fusion in recent years, but there is little comparison between its clinical efficacy and that of minimally invasive transforaminal lumbar interbody fusion (MIS-TLIF) in the treatment of lumbar degenerative disease, whether the unilateral biportal endoscopic technique is a safe and effective lumbar fusion remains to be further demonstrated. OBJECTIVE: To compare the clinical efficacy of unilateral biportal endoscopic lumbar interbody fusion (UBE-LIF) and MIS-TLIF in the treatment of lumbar degenerative diseases and explore a more efficient lumbar fusion procedure. METHODS: Patients with single-level lumbar degenerative disease were enrolled in Affiliated Hospital of Guilin Medical College from October 2020 to February 2022, including 35 patients who underwent UBE-LIF and 286 patients who underwent MIS-TLIF. Propensity score matching was used to eliminate confounders. Four covariates including sex, age, disease type and surgical segment were matched 1:1 (caliper value 0.01). After matching, 29 patients from each group were included in the study. The perioperative operative time, hemoglobin loss and hospital stay were compared between the two groups. Visual analog scale score and Oswestry disability index were used to evaluate the functional recovery of the two groups before, 1, 6 months and 1 year after operation. The excellent and good rate of the two groups was evaluated by the modified MacNab standard at the last follow-up. The fusion of the two groups was evaluated by Lenke Dynamic X-ray film. RESULTS AND CONCLUSION: (1) The operative time in the MIS-TLIF group was shorter than that in the UBE-LIF group (P < 0.05). The amount of intraoperative hemoglobin loss in the MIS-TLIF group was higher than that in the UBE-LIF group. The hospital stay in the MIS-TLIF group was longer than that in the UBE-LIF group, and the differences were statistically significant (P < 0.05). (2) The visual analog scale scores for lumbago and leg pain, and Oswestry disability index were significantly reduced in both groups 1, 6 months, and 1 year after surgery compared to before surgery (P < 0.05). Except for the visual analog scale score for lumbago at 1 month after surgery, there was no significant difference in the visual analog scale score for lumbago and leg pain, and Oswestry disability index between the two groups at the above time points (P > 0.05). (3) At the last follow-up, the modified MacNab standard efficacy evaluation showed that the excellent and good rates were 93% (27/29) in the UBE-LIF group and 90% (26/29) in the MIS-TLIF group; there was no significant difference between the two groups (P > 0.05). (4) Lenke dynamic radiographic evaluation system evaluation for lumbar fusion exhibited that the fusion rate was 90% (grade A, 21 cases; grade B, 5 cases; grade C, 3 cases) in the UBE-LIF group; the fusion rate was 86% (grade A, 20 cases; grade B, 5 cases; grade C, 4 cases) in the MIS-TLIF group; there was no significant difference between the two groups (P > 0.05). (5) It is indicated that UBE-LIF and MIS-TLIF have similar clinical effects in the treatment of single-level lumbar degenerative disease with the advantages of less trauma, less bleeding and shorter hospital stay. In addition, the early postoperative lumbago was relatively mild and the learning curve was relatively smooth. Although the operative time in the UBE-LIF group was longer than that in the MISTLIF group, it was still a safe and effective operation. [ABSTRACT FROM AUTHOR]

Objective To compare the clinical effects of cortical bone trajectory screws and traditional pedicle screws in posterior lumbar fusion. Methods A retrospective study was conducted to analyze lumbar degeneration patients who underwent surgical treatment at our hospital between January 2016 and January 2019. A total of 123 patients who met the inclusion criteria were enrolled. The subjects were divided into two groups according to their surgical procedures and the members of the two groups were matched by age, sex, and the number of fusion segments. There were 63 patients in the traditional pedicle screws (PS) group and 60 in the cortical bone trajectory screws (CBTS) group. The outcomes of the two groups were compared. The primary outcome measures were perioperative conditions, including operation duration, estimated intraoperative blood loss (EBL), and length-of-stay (LOS), visual analog scale (VAS) score, Oswestry Disability Index (ODI) score, and interbody fusion rate. The secondary outcome measures were the time to postoperative ambulation and the incidence of complications. VAS scores and ODI scores were assessed before operation, 1 week, 1 month, 3 months, and 12 months after operation, and at the final follow-up. The interbody fusion rate was assessed in 1 year and 2 years after the operation and at the final follow-up. Results The CBTS group showed a reduction in operation duration ([142.8±13.1] min vs. [174.7±15.4] min, P<0.001), LOS ([9.5±1.5] d vs. [12.0±2.0] d, P<0.001), and EBL ([194.2±38.3] mL vs. [377.5±33.1] mL, P<0.001) in comparison with the PS group. The VAS score for back pain in the CBTS group was lower than that in the PS group at 1 week and 1 month after operation and the ODI score in the CBTS group was lower than that in the PS group at 1 month after operation, with the differences being statistically significant (P<0.05). At each postoperative time point, the VAS score for leg pain and the interbody fusion rate did not show significant difference between the two groups. The VAS score for back and leg pain and the ODI score at each time point after operation in both the CBTS group and the PS group were significantly lower than those before operation (P<0.05). No significant difference was found in the time to postoperative ambulation or the overall complication incidence between the two groups. Conclusion The CBTS technique could significantly shorten the operation duration and LOS, reduce EBL, and achieve the same effect as the PS technique does in terms of intervertebral fusion rate, pain relief, functional improvement, and complication incidence in patients undergoing posterior lumbar fusion. [ABSTRACT FROM AUTHOR]

Objective: To analyze the correlation between the amplitude changes of motor evoked potential (MEP), the 3D volume changes of spinal canal measuring by postoperative CT and the improvement rate of clinical symptoms after the spinal canal decompression in minimally invasive transforaminal lumbar interbody fusion (MIS-TLIF), and to explore the predictive value of the changes of both MEP amplitude and spinal canal volume in the assessment of long-term clinical prognosis in MIS-TLIF. Methods: A retrospective study of 68 patients with L4/5 spinal stenosis treated with MIS-TLIF was performed. The changes of both intraoperative MEP amplitude and 3D spinal canal volume during the spinal canal decompression, as well as the visual analogue scale (VAS) and Oswestry dysfunction index (ODI) scores in the long-term follow-up were all recorded. Results: The values of intraoperative MEP amplitude was 159.04% higher in 68 patients with MIS-TLIF after spinal canal decompression (P < 0.01) . The postoperative 3D spinal canal volume (4.89 ± 1.27) cm3 increased by 31.22% in comparison with preoperative date (3.78±1.08) cm³ (P < 0.01) . The VAS and ODI scores were improved to 78.55% and 80.60%, respectively at the last follow-up (P < 0.01) . The improvement rate of MEP amplitude on the decompression side was positively correlated with the improvement rate of postoperative spinal canal volume (r = 0.272, P = 0.025) . The improvement rate of postoperative spinal canal volume was positively correlated with the improvement rate of VAS and ODI at the last follow-up ( r = 0.656, r = 0.490, P < 0.01) . Moreover, the improvement rate of MEP amplitude on the decompression side was also positively correlated with the improvement rate of VAS and ODI at the last follow-up (r = 0.322 and 0.235, respectively, P < 0.05) . Conclusion: The increase of MEP amplitude after spinal canal decompression in patients with lumbar spinal stenosis treated by MIS-TLIF was closely correlated with both of the increase of spinal canal volume and the improvement of clinical symptoms. Therefore, MEP amplitude monitoring was not only the one of the important monitoring methods for predicting the prognosis of MIS-TLIF but also the reliably predictive value in the long-term clinical prognosis in MIS-TLIF. [ABSTRACT FROM AUTHOR]

BACKGROUND: Postoperative symptomatic intervertebral disc pseudocyst is a cystic lesion in the area of intervertebral disc surgery. It is usually found in patients undergoing MRI examination in the early postoperative period. At present, there is insufficient data on its clinical characteristics and pathogenesis, and its treatment method is still controversial. OBJECTIVE: To investigate the clinical characteristics, pathogenesis and treatment strategy of symptomatic intervertebral disc pseudocyst after discectomy. METHODS: Seven patients with symptomatic intervertebral disc pseudocysts after intervertebral discectomy in the Yongchuan Hospital Affiliated to Chongqing Medical University from January 2019 to September 2021 were enrolled in this study. There were 5 males and 2 females, at the age of 35-60 years. Clinical features and treatments were retrospectively analyzed. RESULTS AND CONCLUSION: (1) Among seven patients, five patients underwent percutaneous endoscopic lumbar discectomy and two underwent posterior microscopic endoscopic discectomy. Their symptoms were significantly relieved after surgery. However, the symptoms recurred after the operation. The postoperative MRI showed low signal on T1WI and high signal on T2WI in the original operation area, and it communicated with the intervertebral disc, which was diagnosed as symptomatic intervertebral disc pseudocyst. The average time for MRI to find the pseudocyst was about 32 days. (2) For seven patients with symptomatic intervertebral disc pseudocysts, four patients received analgesia and detumescence, bed rest and other symptomatic treatments; one patient received percutaneous endoscopic lumbar discectomy; two patients received microscopic endoscopic discectomy. Waist and leg pains were significantly relieved. At 1 month after operation, MRI showed the original pseudocyst was significantly reduced. (3) The results indicate that symptomatic intervertebral disc pseudocyst usually occurs in the early postoperative period. MRI can be the first choice for examination. When conservative treatment fails, interventional or surgical treatment can be performed and the outcome can be good. [ABSTRACT FROM AUTHOR]

Objective: To investigate the effect of Tiaodu Lijin acupuncture combined with lumbar core muscle strength training on lumbar function, lumbar back muscle mechanical effect and serum inflammatory factors in patients with lumbar disc herniation.Methods: 120 patients with Lumbar discheriation (LDH) who were admitted to The Second Affiliated Hospital of Hunan University of Traditional Chinese Medicine from June 2020 to March 2022 were selected, and they were randomly divided into control group (lumbar core muscle strength training, 60 cases) and observation group (Tiaodu Lijin acupuncture combined with lumbar core muscle strength training, 60 cases). The curative effect, pain and lumbar function indexes, lumbar back muscle mechanical effect and serum inflammatory factors were compared between the two groups. Results: Compared with the control group, the total clinical effective rate of the observation group was higher (P＜0.05). 15 d after treatment, the Japanese Orthopaedic Association (JOA) score of the observation group was higher than that of the control group, and the visual analogue scale (VAS) score was lower than that of the control group (P＜0.05). 15d after treatment, the buckling process averaged electromyography (AEMG), flexion/extension relaxation ratio (FRR) of the observation group were lower than those of the control group, and the straightening process AEMG were higher than those of the control group (P＜0.05). 15 d after treatment, the interleukin-6 (IL-6), tumor necrosis factor-α (TNF-α), interleukin-1β (IL-1β) and C-reactive protein (CRP) of the observation group were lower than those of the control group (P＜0.05). Conclusion: Tiaodu Lijin acupuncture combined with lumbar core muscle strength training in the treatment of LDH can reduce pain symptoms, improve the lumbar back muscle mechanical effect, reduce the level of serum inflammatory factors, and promote the recovery of lumbar function. [ABSTRACT FROM AUTHOR]

BACKGROUND: Percutaneous endoscopic interbody foraminal interbody fusion is an advanced minimally invasive method for the treatment of lumbar degenerative diseases. The traditional interbody fusion cage is not fully suitable for minimally invasive surgery. The choice of fusion cage for endoscopic lumbar fusion is still controversial. OBJECTIVE: To explore the clinical effect of percutaneous spinal endoscopic implantation of height adjustable titanium fusion cage for interbody fusion in the treatment of lumbar degenerative diseases. METHODS: A retrospective study investigated 55 patients who underwent percutaneous endoscopic lumbar fusion in the Department of Orthopedics of First Affiliated Hospital of Guangxi University of Chinese Medicine from December 2018 to June 2019. According to the different types of fusion cages implanted, they were divided into two groups. The stretch group (n=23) was implanted with a retractable height adjustable titanium fusion cage, and the general group (n=32) was used with an ordinary lumbar fusion cage. Postoperative complications were recorded in the two groups. The JOA score, Visual Analogue Scale score, and Oswestry Disability Index in the two groups were compared before and after treatment. This study was approved by the Ethics Committee of the First Affiliated Hospital of Guangxi University of Chinese Medicine. RESULTS AND CONCLUSION: (1) All 55 patients were followed-up for more than 12 months. All patients obtained bony fusion without complications, such as internal fixation loosening, fracture, fusion cage displacement, or settlement. (2) Compared with those before treatment, Visual Analogue Scale scores of low back pain and leg pain, JOA score, and Oswestry Disability Index were significantly improved in the two groups at 2 weeks, 3, 6, and 12 months after operation (P < 0.05). JOA score at 12 months and Oswestry Disability Index at 6 and 12 months were significantly better in the stretch group than those in the general group (P < 0.05). (3) Compared with those before treatment, the height of the intervertebral space, the height of the intervertebral foramen of the fusion segment, the lordosis angle of the operative segment, and the lumbar lordosis angle of the two groups were significantly improved after treatment (P < 0.05). The height of the intervertebral space, the height of the intervertebral foramen of the fusion segment, the lordosis angle of the operative segment, and the lumbar lordosis angle were better in the stretch group than those of the general group at 5 days and 12 months after treatment (P < 0.05). (4) It is concluded that percutaneous endoscopic lumbar fusion is a reliable minimally invasive method for the treatment of lumbar degenerative diseases. Its combination with highly adjustable titanium fusion cage can improve its clinical efficacy. [ABSTRACT FROM AUTHOR]

Objective: To study the clinical effect of acupuncture, massage and external application of traditional Chinese medicine on lumbar disc herniation and comparison of serum TXB2, IL-1 β and IL-10 levels. Methods: 80 lumbar disc protrusion who received therapy from January 2019 to December 2020 in our hospital were selected as research objects. According to random number table, those patients were divided into the observation group (n=41) and the control group (n=39). The control group was treated with external application of traditional Chinese medicine. The observation group was treated with acupuncture, massage and external application of traditional Chinese medicine. The therapeutic effects, JOA and VAS scores, serum TXB2, IL-1 β and IL-10 levels, lumbar function and lumbar joint range of motion, and the incidence of adverse reactions were compared between the two groups. Results: After treatment, The total effective rate of observation group was significantly higher than that of control group[95.12%(39/41) vs 71.79％(28/39)](P＜0.05). JOA was significantly higher than that of the control group[(23.19±3.21)scores vs (17.62±2.65)scores](P＜0.05). VAS score was significantly lower than that of the control group[(2.07±0.38)scores vs（3.58±0.61）scores] (P＜0.05). The levels of TXB2 and IL-1 β in serum were significantly lower than those in control group [(24.37±3.26) μg/L vs (34.08±4.72) μg/L, (0.12±0.03) ng/L vs (0.27±0.05) ng/L] (P＜0.05). Serum IL-10 level was significantly lower than that of the control group[(85.82±7.03) pg/mL vs (57.28±6.31) pg/mL] (P<0.05). Oswestry score was significantly lower than that of the control group[(37.81±6.23)％ vs(68.02±8.91)％] (P<0.05). The range of motion of the lumbar joint was significantly higher than that of the control group[(80.36±0.82)° vs(71.27±0.6) °] (P<0.05). There was no significant difference in adverse reactions between the two groups (P>0.05). Conclusion: Acupuncture, massage and external application of traditional Chinese medicine have significant clinical effect on lumbar disc herniation, which can effectively improve the clinical symptoms of patients, relieve pain, inhibit the expression of inflammatory factors TXB2 and IL-1 β, and promote the level of anti-inflammatory factor IL-10, which is safe and effective. [ABSTRACT FROM AUTHOR]

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Objective: To compare the clinical and radiological outcomes of cortical bone trajectory(CBT) screw and pedicle screw(PS) for transforaminal lumbar interbody fusion(TLIF) in degenerative lumbar diseases. Methods: 50 patients from May 2016 to May 2018 were enrolled into this retrospective study. CBT screw was applied in 25 patients(CBT-TLIF Group) and PS was applied in 25 patients(PS-TLIF Group). General condition, perioperative parameters and complications were recorded and analyzed. VAS of back pain, VAS for leg pain and ODI were used to evaluate the clinical efficacy. Bridwell classification was used to evaluate the fusion.Results: Average follow-up duration was 16.72±3.6 months. There is no difference between two groups in gender, age, diagnosis, and surgical segments. Operation duration and blood lost in the CBT-TLIF group was 171.88±25.75 min, 225.20±51.57 mL, and 221.24±33.53 min, 297.60±66.40 m L in PS-TLIF group. Significant difference was found in the above parameters between two group(P<0.05).Both groups had significant improvements in the ODI(Oswestry disability index) and VAS(Visual Analogue Scale) scores at 1 month after operation and the last follow up, but no significant difference was found between the two groups. Comparable fusion rates of both groups were also observed by radiography. Conclusions: CBT-TLIF and PS-TLIF had comparable functional outcomes and fusion rate,while CBT-TLIF had superiority in and operation duration and blood control. [ABSTRACT FROM AUTHOR]

BACKGROUND: For patients with significant lumbar instability, surgical resection of the herniated intervertebral disc and enlargement of the narrowed nerve root canal are needed to relieve the compression of the lumbar nerve root. Simultaneously, internal fixation and bone graft fusion are needed to restore the stability of the spine when resecting the herniated intervertebral disc and enlarging the nerve root canal so as to relieve the symptoms of lumbar and leg pain caused by compression of lumbar nerve root caused by instability factors. Some studies believe that CT examination can accurately reflect whether the intervertebral disc protrusion occurs, and clearly show the shape, size and location of the intervertebral disc protrusion. OBJECTIVE: CT imaging was used to evaluate clinical efficacy of bilateral pedicle screw fixation combined with interbody fusion for lumbar disc herniation. METHODS: Data of 80 cases of lumbar disc herniation treated in Dalian Municipal Central Hospital from August 2015 to July 2017 were retrospectively analyzed. All patients received bilateral pedicle screw fixation combined with interbody fusion. This study was approved by the Ethics Committee of Dalian Central Hospital on June 30, 2018. RESULTS AND CONCLUSION:(1) The operation was successfully performed in all patients. All patients were followed up.(2) The Visual Analogue Scale scores of low back and leg pain at 1, 3 months and final follow-up were significantly lower than those before operation(P < 0.05).(3) With the prolongation of time, the excellent and good rate of MacNab treatment in patients with lumbar disc herniation gradually increased(P < 0.05).(4) The ventral height of the intervertebral disc, the dorsal height of the intervertebral disc, the maximum height of the intervertebral foramen and the apex of the spinous process were significantly higher after treatment than that before treatment(P < 0.05). Imaging displayed that after treatment, the lumbar vertebral angle gradually recovered, and the intervertebral space height recovered. CT examination showed that the pedicle screw fixation was good, no breakage or loosening. Before and after treatment, there was a negative correlation of the ventral height of intervertebral disc, the dorsal height of intervertebral disc, the maximum height of intervertebral foramen, the distance between the apex of spinous process with Visual Analogue Scale score of low back pain and Visual Analogue Scale score of leg pain(P < 0.05).(5) Bilateral pedicle screw placement combined with vertebral fusion for the treatment of lumbar disc herniation has a significant clinical effect. CT imaging can be used not only to assess the condition but also to assess the ventral height of the intervertebral disc, the dorsal height of the intervertebral disc, the maximum height of the intervertebral foramen and the apex of the spinous process, the angle recovery of the lumbar spine, the location of the screw placement, and to identify whether the screw loosened or ruptured, and to evaluate the clinical efficacy. [ABSTRACT FROM AUTHOR]

BACKGROUND: In patients with double-segment disc herniation complicated with lumbar instability, we need to strengthen and fuse the severely degenerative segments, but the adjacent segments will have excessive movement displacement and flexion and extension angles. The degeneration of adjacent segments will accelerate. The instability of the vertebral body will be aggravated. The hyperplasia of the articular processes and the herniated discs will always plague clinicians and patients. OBJECTIVE: To observe the efficacy of the ISObar TTL dynamic fixation system versus rigid nail system in the treatment of double-segment lumbar disc herniation and lumbar instability. METHODS: 130 cases of double-segment lumbar disc herniation and lumbar instability were analyzed, including 72 cases of L3/4-L4/5 and 58 cases of L4/5-L5/S1. The laminae decompression and posterior bone graft fusion were performed for severely degenerative segment. For lightly degenerative segments, ISObar TTL dynamic fixation(68 cases; trial group) and traditional nail fixation(62 cases; control group) were performed. Two groups of patients signed the informed consent. This study was approved by the Hospital Ethics Committee. End of death. The patients were followed up for at least 8 years. Disc degeneration was assessed using the modified Pfirrmann eight-level grading system preoperatively, 1 week, 4 years, and 8 years postoperatively. Visual Analogue Scale was utilized to assess the improvement in waist and leg pain. RESULTS AND CONCLUSION:(1) Compared with preoperatively, waist and leg pain and Visual Analogue Scale scores were significantly improved 1 week, 4 years, and 8 years postoperatively in the trial and control groups(P < 0.05). No significant difference in waist and leg pain and Visual Analogue Scale scores was determined preoperatively and 1 week postoperatively in both groups(P > 0.05). Waist and leg pain and Visual Analogue Scale scores were significantly lower in the trial group than in the control group 4 and 8 years postoperatively(P < 0.05).(2) Compared with preoperatively, no significant difference in the modified Pfirrmann eight-level grading system was detected 1 week, 4 years, and 8 years postoperatively in the fusion segment of the trial and control groups(P > 0.05). There was no significant difference in the modified Pfirrmann eight-level grading system in the fusion segment between the trial and control groups preoperatively, 1 week, 4 years, and 8 years postoperatively(P > 0.05).(3) Compared with preoperatively, the modified Pfirrmann eight-level grading system was significantly improved 1 week, 4 years, and 8 years postoperatively in the trial and control groups(P < 0.05). The modified Pfirrmann eight-level grading system was not significantly different between the trial and control groups preoperatively and 1 week postoperatively(P > 0.05). The modified Pfirrmann eight-level grading system score was significantly lower in the trial group than in the control group 4 and 8 years postoperatively(P < 0.05).(4) The symptoms of double-segment lumbar disc herniation were remarkably improved with ISObar TTL dynamic fixation system and a rigid nail system during 8-year follow-up. However, ISObar TTL dynamic fixation system can relieve waist and leg pain more obviously, and can reduce the degeneration of adjacent intervertebral discs 4 and 8 years postoperatively. [ABSTRACT FROM AUTHOR]