The shift of segmental contribution ratio in patients with herniated disc during cervical lateral bending.

BACKGROUND: Abnormal intervertebral movements of spine have been reported to be associated with trauma and pathological conditions. The importance of objective spinal motion imaging assessment in the frontal plane was frequently underestimated. The clinical evaluation of the segmental motion contribution could be useful for detecting the motion pattern of individual vertebrae. Therefore the purpose of this study was to investigate the shift of segmental contribution ratio in patients with herniated disc during cervical lateral bending to provide additional insights to cervical biomechanics. METHODS: A total of 92 subjects (46 healthy adult subjects and 46 disc-herniated patients) were enrolled in this case-control study. The motion images during cervical lateral bending movements were digitized using a precise image protocol to analyze the intervertebral motion and contribution. RESULTS: Our results showed that the intervertebral angulation during cervical lateral bending for the C2/3 to C6/7 segments were 7.66°±2.37°, 8.37°±2.11°, 8.91°±3.22°, 7.19°±2.29°, 6.31°±2.11°, respectively for the healthy subjects. For the patients with herniated disc, the intervertebral angulation for the C2/3 to C6/7 segments were 6.87°±1.67°, 7.83°±1.79°, 7.73°±2.71°, 5.13°±2.05°, 4.80°±1.93°, respectively. There were significant angulation and translational differences between healthy subjects and the patients with herniated disc in the C5/6 and C6/7 segments (P=0.001-0.029). The segmental contributions of the individual vertebral segments were further analyzed. There was a significant increase in segmental contribution ratio of C3/4 (P=0.048), while a significant decrease in contribution ratio of C5/6 (P=0.037) was observed in the patients with herniated disc. Our results indicated that the segmental contribution shifted toward the middle cervical spine in the patients with herniated disc. CONCLUSIONS: The segmental contributions of cervical spine during lateral bending movement were first described based on the validated radiographic protocol. The detection of the shift of segmental contribution ratio could be helpful for the diagnosis the motion abnormality resulted from the disc or, facet pathologies, and arthritic changes of cervical spine.

Management of extremity neurilemmomas: clinical series and literature review.

BACKGROUND: Delicate enucleation of neurilemmoma preserves most of nerve fascicles and causes minimal nerve function impairment. Accurate preoperative diagnosis of neurilemmoma is based on clinical findings and image studies. MATERIALS AND METHODS: Between November 2003 and February 2013, operations for the treatment of neurilemmoma were performed on 14 patients (12 men and 2 women) at our institution. The image studies in this series were collected. The tumor mass was approached by splitting the epineurium. In a few cases, enucleation of the neurilemmoma caused some fascicles loss, but reconstruction with sural nerve grafts preserved nerve function. RESULTS: Before surgery, 7 patients received computed tomographic scan, 4 patients underwent magnetic resonance imaging, and 3 patients received sonography. Six patients presented with motor or sensory deficits immediately after tumor enucleation. Three patients recovered completely from the neurological defects with or without nerve reconstruction. CONCLUSIONS: Our results indicate that neurilemmoma can be removed by delicate enucleation with an acceptable risk of injury to the nerve trunk.

Segmental percentage contributions of cervical spine during different motion ranges of flexion and extension.

STUDY DESIGN: A blind, repeated-measure design was employed in the study. OBJECTIVE: To quantitatively measure the percentage contribution of segmental angular motion during different motion ranges of cervical flexion-extension for clinical applications and better understanding of cervical biomechanics. SUMMARY OF BACKGROUND DATA: Restriction of cervical motion is a major symptom in patients suffering from neck injuries or pathologies. Although segmental angular motion alternation is a criterion for the detection of neck related impairments, the percentage contribution throughout cervical movements is not well understood. METHODS: A total of 384 image sequences during cervical flexion-extension obtained from 48 healthy adult subjects were analyzed with a precise image protocol using dynamic videofluoroscopic techniques. RESULTS: The middle cervical spines demonstrated significantly greater angular percentage contributions at C3/4 (29.89%) and C4/5 (37.14%) angles during the initial 1/3 flexion movement; whereas the lower cervical spines revealed statistically greater angular contributions (C5/6: 22.57% to 29.45%; C6/7: 28.80% to 37.42%) from the middle to final 1/3 ranges of flexion movement (P<0.001). With regard to cervical extension motion, the majority of segmental percentage contributions statistically shifted initially from C5/6 level (30.21%) to C4/5 (24.96%) and C5/6 (26.12%) levels, and finally to the C3/4 (27.55%) and C4/5 (29.77%) segments (P<0.001). CONCLUSIONS: The segmental percentage contributions in this study might imply that the cervical flexion movement initially relied more on the middle cervical segments and later on the lower ones, whereas a motion pattern trend from lower to middle segments was observed during cervical extension.

Comparison of the intervertebral disc spaces between axial and anterior lean cervical traction.

The insufficient investigations on the changes of spinal structures during traction prevent further exploring the possible therapeutic mechanism of cervical traction. A blind randomized crossover-design study was conducted to quantitatively compare the intervertebral disc spaces between axial and anterior lean cervical traction in sitting position. A total of 96 radiographic images from the baseline measurements, axial and anterior lean tractions in 32 asymptomatic subjects were digitized for further analysis. The intra- and inter-examiner reliabilities for measuring the intervertebral disc spaces were in good ranges (ICCs = 0.928-0.942). With the application of anterior lean traction, the statistical increases were detected both in anterior and in posterior disc spaces compared to the baseline (0.29 mm and 0.24 mm; both P < 0.01) and axial traction (0.16 mm and 0.35 mm; both P < 0.01). The greater intervertebral disc spaces obtained during anterior lean traction might be associated with the more even distribution of traction forces over the anterior and posterior neck structures. The neck extension moment through mandible that generally occurred in the axial traction could be counteracted by the downward force of head weight during anterior lean traction. This study quantitatively demonstrated that anterior lean traction in sitting position provided more intervertebral disc space enlargements in both anterior and posterior aspects than axial traction did. These findings may serve as a therapeutic reference when cervical traction is suggested.

Kinematic patellar tracking from MR images for knee pain analysis.

Kinematic approaches using MR images have been regarded of more accuracy in knee pain (AKP) detection than stationary approaches. However, the challenge in segmenting femur, patellar and tibia due to the intensity non-uniformity caused by magnetic propagation degradation in MR images, and the strong adhesion of the soft tissue around the knee organs, has restricted the use of kinematic approaches. This paper proposes a combinatorial based kinematic patellar tracking (CKPT) for AKP detection. The CKPT uses a hybrid approach for extracting knee organs, where an edge-constrained wavelet enhancement followed by moment preserving segmentation is employed for conquering the soft tissue adhesion for extracting the femur and tibia from axial MR images, and a sliding window based moment preserving for resolving the segmentation difficulty associated with intensity non-uniformity in sagittal MR images. The location constraints are then applied for extracting landmark points from femur and patellar, and three inclination angles reflecting patellar position and orientation, during leg movement, are calculated as the measurement of patellar dislocation. The experiment shows that the hybrid approach can accurately extract femur, patellar and tibia. It also demonstrates the prominent of the calculated inclination angles in detecting AKP.

The quantitative measurements of the intervertebral angulation and translation during cervical flexion and extension.

The insufficient exploration of intervertebral translation during flexion and extension prevents the further understanding of the cervical biomechanics and treating the cervical related dysfunction. The objective of this study was to quantitatively measure the continuous intervertebral translation of healthy cervical spine during flexion and extension by videofluoroscopic technique. A total of 1,120 image sequences were analyzed for 56 healthy adult subjects by a precise image protocol during cervical flexion and extension. O: ur results showed there were no statistical angular differences among five spinal levels in either flexion or extension, except for the comparison between C2/3 (13.5 degrees) and C4/5 (22.6 degrees) angles. During cervical flexion, the smallest anterior translations were 0.7 mm at C2/3 level, followed by 0.9 mm at C6/7, 1.0 mm at C3/4, 1.1 mm at C5/6, and the largest 1.2 mm at C4/5 levels. The significantly greater translations were measured in the posterior direction at C3/4 (1.1 mm, P = 0.037), C4/5 (1.3 mm, P = 0.039), and C5/6 (1.2 mm, P = 0.005) levels than in the anterior one. The relatively fluctuant and small average posterior translation fashion at C6/7 level (0.4 mm) possibly originated from the variations in the direction of translation during cervical extension among subjects. Normalization with respect to the widths of individual vertebrae showed the total translation percentages relative to the adjacent vertebrae were 9.5, 13.7, 16.6, 15.0, and 8.6% for C2/3 to C6/7 levels, respectively, and appeared to be within the clinical-accepted ranges of translation in cervical spine. The intervertebral translations of cervical spine during flexion and extension movements were first described in quality and quantity based on the validated radiographic protocol. This analysis of the continuous intervertebral translations may be further employed to diagnose translation abnormalities like hypomobility or hypermobility and to monitor the treatment effect on cervical spines.

A pilot clinical trial of vaccination with dendritic cells pulsed with autologous tumor cells derived from malignant pleural effusion in patients with late-stage lung carcinoma.

BACKGROUND: The authors conducted a pilot clinical trial to explore the vaccination of patients with late-stage lung carcinoma with dendritic cells (DCs) pulsed with necrotic tumor cells derived from malignant pleural effusion specimens, and to evaluate the antitumor immune response induced by this therapy. METHODS: Autologous DCs were generated by culturing adherent mononuclear cells with interleukin-4 and granulocyte-macrophage-colony-stimulating factor for 7 days. Day-7 DCs were cocultured overnight with autologous necrotic tumor cells derived from pleural effusion specimens to allow internalization of tumor antigens. DCs were then treated with tumor necrosis factor-alpha for 16 hours. The antigen-loaded DCs were injected into each patient's inguinal lymph nodes under sonographic guidance. Eight patients with late-stage nonsmall cell lung carcinoma were treated in this manner. Patients were vaccinated once weekly for 4 weeks and then boosted twice biweekly. RESULTS: The authors found that there was no Grade II/III toxicity and autoimmune response in all patients after intranodal injection of the DC vaccine. Minor to moderate increases in T-cell responses against tumor antigens were observed after DC vaccination in six of eight patients. Five patients had progressive disease. One patient had minor tumor response and two patients had stable disease. The two patients who had longer disease control also had better T-cell responses. CONCLUSIONS: The results indicated that it was feasible to immunize patients with lung carcinoma intranodally with DCs pulsed with necrotic tumor cells enriched from pleural effusion specimens, and this approach may generate T-cell responses and provide clinical benefit in some patients.

Single photon emission computed tomography (SPECT) for low back pain induced by extension with no root sign.

BACKGROUND: Low back pain (LBP) is very common in the general population. Most patients with LBP will receive an X-ray examination on lumbar spine; however, the results are likely to show a negative finding or degenerative joint disease, which are not truly pathological factors. Among various imaging diagnostic tools for active bony lesions of lumbar spine, planar bone scintigraphy has a higher sensitivity, but its ability to locate anatomic lesions is less satisfactory. The purpose of this study was to investigate the role of SPECT for evaluation of LBP. METHODS: Fifty-two consecutive patients who had low back pain induced by extension were studied. They had no evidence of malignant tumor, immune disease, spinal infection and neurological disorder by history-taking and physical examination. All patients received planar bone scintigraphy and SPECT exams following an X-ray examination. The results of X-ray finding were grouped into 3 categories: (A) normal; (B) degenerative joint arthritis; (C) spondylolysis. The data of test results and clinical evaluation were then used for analysis. RESULTS: Twenty (38.5%) out of 52 patients examined by planar scan had abnormality, with 29 increased uptake lesions, compared with 28 (53.8%) out of 52 patients with 60 increased uptake lesions by SPECT with planar scan; SPECT disclosed 1-2 more lesions with improved location in 15 patients (p < 0.05). Of the 52 patients, 21 (40.4%) presented in group A, 21 (40.4%) in group B, and 10 (19.2%) in group C according to the X-ray examination. In group A, 9 out of 21 (42.9%) patients had an abnormal SPECT result, compared to 5 of 10 (50%) in group B, and 14 out of 21 (66.7%) in group C, respectively (p > 0.05). The location of abnormal uptake on L-spine included vertebral body and arch (57.1%), vertebral arch (28.6%), and vertebral body (14.3%). Most of lesions (91.5%) were distributed at the 4th and 5th lumbar vertebral segments. CONCLUSIONS: SPECT was more sensitive and located more lesions than planar bone scintigraphy, especially when the lesions were located at posterior element of vertebrae. Most of the lesions were distributed at the 4 th and 5 th lumbar vertebral segments. There was no significant statistical difference of abnormal SPECT related to X-ray finding. The use of SPECT was the first choice among all image modalities when cause of low back pain was assumed to arise from bone and joint disorder at clinical evaluation.