The minimally invasive interbody selection algorithm for spinal deformity.

OBJECTIVE: Minimally invasive surgery (MIS) for spinal deformity uses interbody techniques for correction, indirect decompression, and arthrodesis. Selection criteria for choosing a particular interbody approach are lacking. The authors created the minimally invasive interbody selection algorithm (MIISA) to provide a framework for rational decision-making in MIS for deformity. METHODS: A retrospective data set of circumferential MIS (cMIS) for adult spinal deformity (ASD) collected over a 5-year period was analyzed by level in the lumbar spine to identify surgeon preferences and evaluate segmental lordosis outcomes. These data were used to inform a Delphi session of minimally invasive deformity surgeons from which the algorithm was created. The algorithm leads to 1 of 4 interbody approaches: anterior lumbar interbody fusion (ALIF), anterior column release (ACR), lateral lumbar interbody fusion (LLIF), and transforaminal lumbar interbody fusion (TLIF). Preoperative and 2-year postoperative radiographic parameters and clinical outcomes were compared. RESULTS: Eleven surgeons completed 100 cMISs for ASD with 338 interbody devices, with a minimum 2-year follow-up. The type of interbody approach used at each level from L1 to S1 was recorded. The MIISA was then created with substantial agreement. The surgeons generally preferred LLIF for L1-2 (91.7%), L2-3 (85.2%), and L3-4 (80.7%). ACR was most commonly performed at L3-4 (8.4%) and L2-3 (6.2%). At L4-5, LLIF (69.5%), TLIF (15.9%), and ALIF (9.8%) were most commonly utilized. TLIF and ALIF were the most selected approaches at L5-S1 (61.4% and 38.6%, respectively). Segmental lordosis at each level varied based on the approach, with greater increases reported using ALIF, especially at L4-5 (9.2°) and L5-S1 (5.3°). A substantial increase in lordosis was achieved with ACR at L2-3 (10.9°) and L3-4 (10.4°). Lateral interbody arthrodesis without the use of an ACR did not generally result in significant lordosis restoration. There were statistically significant improvements in lumbar lordosis (LL), pelvic incidence-LL mismatch, coronal Cobb angle, and Oswestry Disability Index at the 2-year follow-up. CONCLUSIONS: The use of the MIISA provides consistent guidance for surgeons who plan to perform MIS for deformity. For L1-4, the surgeons preferred lateral approaches to TLIF and reserved ACR for patients who needed the greatest increase in segmental lordosis. For L4-5, the surgeons' order of preference was LLIF, TLIF, and ALIF, but TLIF failed to demonstrate any significant lordosis restoration. At L5-S1, the surgical team typically preferred an ALIF when segmental lordosis was desired and preferred a TLIF if preoperative segmental lordosis was adequate.

Minimally invasive pedicle screw fixation utilizing O-arm fluoroscopy with computer-assisted navigation: Feasibility, technique, and preliminary results.

BACKGROUND: Pedicle screw misplacement is relatively common, with reported rates ranging up to 42%. Although computer-assisted image guidance (CaIG) has been shown to improve accuracy in open spinal surgery, its use in minimally invasive procedures has not been as well evaluated. We present our technique and review the results from a cohort of patients who underwent minimally invasive lumbar pedicle screw placement utilizing the O-arm imaging unit in conjunction with the StealthStation Treon System. METHODS: A retrospective review of patients who underwent minimally invasive pedicle screw fixation with CaIG was performed. Eleven consecutive patients were identified and all were included. Nine patients underwent a single-level transforaminal lumbar interbody fusion. Two patients underwent multi-level fusion. Inaccurate pedicle screw placement was determined by postoperative computed tomography (CT) and graded as 0-2, 2-4, 4-6, or 6-8 mm. RESULTS: A total of 52 screws were placed. Forty screws were inserted in eight patients who had postoperative CT, and a misplacement rate of 7.5% was noted including one lateral and two medial breaches. All breaches were graded as 0-2 mm and were asymptomatic. In the remaining three patients, post-instrumentation O-arm imaging did not demonstrate pedicle screw misplacement. CONCLUSION: Although this initial study evaluates a relatively small number of patients, minimally invasive pedicle screw fixation utilizing the O-arm and StealthStation for CaIG appears to be safe and accurate.

Cancer stem cell markers: what is their diagnostic value?

IMPORTANCE OF THE FIELD: Cancer resistance to conventional therapies has been attributed to cancer stem cells (CSCs). Although a variety of markers have been reported, a universal marker has not yet been found to identify CSCs. Better identification of these CSCs may lead to new therapies that selectively target these cells and thereby result in more effective treatment. This article categorizes the types of marker that have been identified and explores their potential diagnostic and therapeutic value. AREAS COVERED IN THIS REVIEW: A focused literature review of studies relating to CSCs and their identification was conducted. Databases evaluated include MEDLINE and Web of Science through 2009. WHAT THE READER WILL GAIN: The ideal identification method needs to be effective and practical in terms of application. The measurement of aldehyde dehydrogenase activity is simple to accomplish compared with other reported identification methods; however, cell surface antigens have been studied most frequently in the therapeutic targeting of CSCs. TAKE HOME MESSAGE: Although specific targeting methods have been reported for various cancers, there does not appear to be a proven universal marker for CSCs that would apply to all cancers. Each particular identification method appears to have advantages and disadvantages. From a therapeutic standpoint, targeting of these CSCs should improve prognosis.

Stress analysis of the interface between cervical vertebrae end plates and the Bryan, Prestige LP, and ProDisc-C cervical disc prostheses: an in vivo image-based finite element study.

STUDY DESIGN: Segmental motion and bone-implant interface stresses were analyzed at C5-C6 levels with Bryan, Prestige LP, and ProDisc-C cervical disc prostheses using an image-based finite element modeling technique. OBJECTIVE: To predict stress patterns at the interface between prosthesis and lower vertebral end plate to better understand the underlying mechanisms of subsidence and how the load transfer pattern of each disc design affects segmental motion. SUMMARY OF BACKGROUND DATA: Subsidence is one of the most commonly reported device-related complications in intervertebral disc arthroplasty. Although clinical outcomes have been reported regarding many types of cervical prostheses, few reports have analyzed the effects of stress from cervical artificial discs to the vertebral end plate. METHODS: Three-dimensional voxel finite elements were built for C5-C6 spine unit based on computed tomography images acquired from a patient with indication for cervical disc arthroplasty. Models of facet joints and uncovertebral joints were added and artificial disc designs were placed in the intervertebral disc space. Static analyses were conducted under normal physiologic loads in flexion, extension, and lateral bending with precompression. RESULTS: Bryan disc recovered highest range of motion (4.75 degrees ) due to the high elastic nucleus, and therefore imposed the lowest stresses superior to C6. The ProDisc-C and Prestige LP discs caused high stress concentrations around their central fins or teeth, and may initiate bone absorption. Analysis of Prestige LP disc may indicate possible subsidence posteriorly caused by the rear-positioned metal-to-metal joint. CONCLUSION: Rigidity of the cores ("nuclei") in Prestige LP and ProDisc-C prostheses guarantee initial maintenance of disc height, but high contact stress takes place at the bone-end plate interface if they are improperly placed or undersized. Anchorage designs add an additional factor that may increase propensity of subsidence, indicated by the high contact stress occurring at the end plate flanges of Prestige LP, and at midline keel fixation on the end plate of ProDisc-C. Although Bryan disc differs in these 2 concerns, it also creates much larger displacement during motion with more variation in disc height that may theoretically increase the load sharing of facet and/or uncovertebral joints compared to more rigid artificial discs.

Extended magnetic reconnection at the Earth's magnetopause from detection of bi-directional jets

Magnetic reconnection is a process that converts magnetic energy into bi-directional plasma jets; it is believed to be the dominant process by which solar-wind energy enters the Earth's magnetosphere. This energy is subsequently dissipated by magnetic storms and aurorae. Previous single-spacecraft observations revealed only single jets at the magnetopause--while the existence of a counter-streaming jet was implicitly assumed, no experimental confirmation was available. Here we report in situ two-spacecraft observations of bi-directional jets at the magnetopause, finding evidence for a stable and extended reconnection line; the latter implies substantial entry of the solar wind into the magnetosphere. We conclude that reconnection is determined by large-scale interactions between the solar wind and the magnetosphere, rather than by local conditions at the magnetopause.