Utility of Advanced DWI in the Detection of Spinal Cord Microstructural Alterations and Assessment of Neurologic Function in Cervical Spondylotic Myelopathy Patients.

BACKGROUND: Diffusion-weighted imaging (DWI) can quantify the microstructural changes in the spinal cord. It might be a substitute for T2 increased signal intensity (ISI) for cervical spondylotic myelopathy (CSM) evaluation and prognosis. PURPOSE: The purpose of the study is to investigate the relationship between DWI metrics and neurologic function of patients with CSM. STUDY TYPE: Retrospective. POPULATION: Forty-eight patients with CSM (18.8% females) and 36 healthy controls (HCs, 25.0% females). FIELD STRENGTH/SEQUENCE: 3 T; spin-echo echo-planar imaging-DWI; turbo spin-echo T1/T2; multi-echo gradient echo T2*. ASSESSMENT: For patients, conventional MRI indicators (presence and grades of T2 ISI), DWI indicators (neurite orientation dispersion and density imaging [NODDI]-derived isotropic volume fraction [ISOVF], intracellular volume fraction, and orientation dispersion index [ODI], diffusion tensor imaging [DTI]-derived fractional anisotropy [FA] and mean diffusivity [MD], and diffusion kurtosis imaging [DKI]-derived FA, MD, and mean kurtosis), clinical conditions, and modified Japanese Orthopaedic Association (mJOA) were recorded before the surgery. Neurologic function improvement was measured by the 3-month follow-up recovery rate (RR). For HCs, DWI, and mJOA were measured as baseline comparison. STATISTICAL TESTS: Continuous (categorical) variables were compared between patients and HCs using Student's t-tests or Mann-Whitney U tests (chi-square or Fisher exact tests). The relationships between DWI metrics/conventional MRI findings, and the pre-operative mJOA/RR were assessed using correlation and multivariate analysis. P < 0.05 was considered statistically significant. RESULTS: Among patients, grades of T2 ISI were not correlated with pre-surgical mJOA/RR (P = 0.717  and 0.175, respectively). NODDI ODI correlated with pre-operative mJOA (r = -0.31). DTI FA, DKI FA, and NODDI ISOVF were correlated with the recovery rate (r = 0.31, 0.41, and -0.34, respectively). In multivariate analysis, NODDI ODI (DTI FA, DKI FA, NODDI ISOVF) significantly contributed to the pre-operative mJOA (RR) after adjusting for age. DATA CONCLUSION: DTI FA, DKI FA, and NODDI ISOVF are predictors for prognosis in patients with CSM. NODDI ODI can be used to evaluate CSM severity. LEVEL OF EVIDENCE: 3 TECHNICAL EFFICACY STAGE: 5.

ProDisc-C versus anterior cervical discectomy and fusion for the surgical treatment of symptomatic cervical disc disease: two-year outcomes of Asian prospective randomized controlled multicentre study.

PURPOSE: Our study aimed to evaluate non-inferiority of ProDisc-C to anterior cervical discectomy and fusion (ACDF) in terms of clinical outcomes and incidence of adjacent segment disease (ASD) at 24-months post-surgery in Asian patients with symptomatic cervical disc disease (SCDD). METHODS: This multicentre, prospective, randomized controlled trial was initiated after ethics committee approval at nine centres (China/Hong Kong/Korea/Singapore/Taiwan). Patients with single-level SCDD involving C3-C7-vertebral segments were randomized (2:1) into: group-A treated with ProDisc-C and group-B with ACDF. Assessments were conducted at baseline, 6-weeks, 3/6/12/18/24-months post-surgery and annually thereafter till 84-months. Primary endpoint was overall success at 24-months, defined as composite of: (1) ≥ 20% improvement in neck disability index (NDI); (2) maintained/improved neurologic parameters; (3) no implant removal/revision/re-operation at index level; and (4) no adverse/severe/life-threatening events. RESULTS: Of 120 patients (80ProDisc-C,40ACDF), 76 and 37 were treated as per protocol (PP). Overall success (PP) was 76.5% in group-A and 81.8% in group-B at 24-months (p = 0.12), indicating no clear non-inferiority of ProDisc-C to ACDF. Secondary outcomes improved for both groups with no significant inter-group differences. Occurrence of ASD was higher in group-B with no significant between-group differences. Range of motion (ROM) was sustained with ProDisc-C but lost with ACDF at 24-months. CONCLUSION: Cervical TDR with ProDisc-C is feasible, safe, and effective for treatment of SCDD in Asians. No clear non-inferiority was demonstrated between ProDisc-C and ACDF. However, patients treated with ProDisc-C demonstrated significant improvement in NDI, neurologic success, pain scores, and 36-item-short-form survey, along with ROM preservation at 24-months. Enrolment difficulties resulted in inability to achieve pre-planned sample size to prove non-inferiority. Future Asian-focused, large-scale studies are needed to establish unbiased efficacy of ProDisc-C to ACDF.

Usefulness of a combined approach of DIERS Formetric 4D® and QUINTIC gait analysis system to evaluate the clinical effects of different spinal diseases on spinal-pelvic-lower limb motor function.

BACKGROUND: To investigate the alterations in body movement and their compensatory characteristics under different spinal diseases through an objective and quantitative analysis of the spinal-pelvic-lower limb motor function. METHODS: A total of 120 subjects were recruited from October 2016 to April 2017. The patients were classified into 2 groups in which 65 patients with cervical spondylotic myelopathy (CSM) and 25 patients with idiopathic scoliosis (IS). The former group was evaluated with JOA score while those in the IS group underwent Lenke classification. A control group was set up with 30 healthy subjects. All the subjects were instructed to walk at a constant speed for one minute on a treadmill, and their spinal-pelvic-lower limb motions were monitored simultaneously with a DIERS Formetric 4D® grating system and a QUINTIC gait analysis system. RESULTS: The rotation angle of thoracic and lumbar vertebrae in IS group were larger than those in the control group (P < 0.05), and the knee joint angle A in the CSM group and IS group were larger than the control group (P < 0.05). In the CSM group, the knee joint angular velocity and angular acceleration were both greater than the control group (P < 0.05). And there was a negative linear correlation between the JOA score for the lower extremity of CSM patients and their knee joint angular acceleration. CONCLUSION: IS patients tend to demonstrate increased swing amplitude of the trunk. Those with CSM will also have larger knee joint angular velocity and angular acceleration.

Safety and Efficacy of Percutaneous Lumbar Discectomy and Percutaneous Disc Cementoplasty for Painful Lumbar Disc Herniation in Patients over 60 Years.

PURPOSE: To determine the safety and efficacy of percutaneous lumbar discectomy (PLD) and percutaneous disc cementoplasty (PDCP) for painful lumbar disc herniation (LDH) in patients >60 years of age. MATERIALS AND METHODS: Sixteen older patients (mean age, 71.00 ± 6.24 years) with painful LDH were treated with PLD and PDCP. The outcome data (the Macnab criteria, visual analog scale score, and Oswestry disability index) were collected preoperatively; at 1 week postoperatively; at posttreatment months 1, 3, and 6; and every 6 months thereafter. In addition, treatment duration, injection volume of bone cement, length of hospital stay, and complications were assessed. RESULTS: Treatment was successful in all patients. The pain relief rate at the last follow-up was 87.5%. Six, 8, and 2 patients showed excellent, good, and fair results, respectively; no patient showed a poor result. The average visual analog scale for back and leg pain decreased from 6.75 ± 1.06 and 7.00 ± 0.89 before the procedure to 2.81 ± 1.60 and 2.87 ± 1.75 at 1 month, 2.79 ± 1.58 and 2.71 ± 1.64 at 6 months, and 2.90 ± 1.73 and 3.00 ± 1.76 at 1 year, respectively. The scores were 2.44 ± 1.63 and 2.44 ± 1.71, respectively, at the last follow-up. The Oswestry disability index also changed after the procedure, with significant differences between baseline scores and those at each follow-up (P < .001). The mean procedure duration, injection volume of bone cement, and length of hospital stay were 55.69 ± 5.86 minutes, 2.50 ± 0.63 mL, and 7.06 ± 2.41 days, respectively. There were no complications. CONCLUSIONS: The combination of PLD and PDCP is feasible, safe, and effective for older patients with painful LDH.

Percutaneous albumin/doxycycline injection versus open surgery for aneurysmal bone cysts in the mobile spine.

PURPOSE: This study aimed to validate the safety and effectiveness of percutaneous doxycycline/albumin injection for spinal aneurysmal bone cysts (ABCs) as an alternative to open surgery. METHODS: From January 2000 to December 2016, 25 patients who had no/minor neurological deficits (modified Frankel scale D or E) and acceptable local stability (spinal instability neoplastic score < 12) were included in the study, of whom 14 were treated with percutaneous doxycycline/albumin injection (injection group) and 11 were treated with open surgery (surgery group). The demographic and clinical information of the injection and surgery groups were recorded and compared. RESULTS: In the injection group, lesion size was significantly reduced in all 14 patients, all patients showed complete neurological recovery, and 13 patients had complete relief of neck pain; their mean visual analogue scale (VAS) decreased from 3.4 to 0.5. No complication or recurrence was observed during the mean 30.7-month follow-up (range, 24-50 months). In the surgery group, 9 patients had complete neurological recovery and 2 patients had residual slight paresthesia; their mean VAS decreased from 3.4 to 0.5. Two had local recurrence during their follow-up at 66.5 months (range, 50-96 months). Compared with the surgery group, the injection group showed no significant difference in the rate of recurrence (P = 0.14) and complication (P = 0.36). CONCLUSIONS: Percutaneous doxycycline/albumin injection for spinal ABCs can be safely and effectively performed in well-selected cases. It could serve as an alternative treatment, especially for spinal ABCs lesions with acceptable local stability and in patients without severe neurological deficits. These slides can be retrieved under Electronic Supplementary Material.

Intraosseous schwannoma of the mobile spine: a report of twenty cases.

PURPOSE: To clarify the clinical features, surgical strategies, and outcomes of intraosseous schwannoma (IOS) of the mobile spine. METHODS: We retrospectively reviewed patients with primary benign spinal schwannoma who underwent surgery in our orthopedic department. RESULTS: A total of 101 patients with primary benign schwannoma located in the mobile spine underwent surgery in our orthopedic department from 2005 to 2015. Twenty-five patients presented with aggressive features. Twenty patients were regularly followed up, twelve with lesions in the cervical spine, six with lesions in the thoracic region, and two with lesions in the lumbar spine. Preoperative CT-guided biopsy was performed in fourteen cases; the accuracy of diagnosis was 100%, and IOS is not histologically different from conventional schwannoma. The computed tomography (CT) scan revealed expansile and osteolytic bone destruction in all these cases, with six patients having pathological fracture. On T2-weighted magnetic resonance imaging, the lobulated schwannomas showed heterogeneous signal intensity and significant heterogeneous enhancement on post-contrast images. Gross total resection was performed in seventeen patients and subtotal resection in three. Tumor-involved nerve roots resection were documented to decrease local recurrence in fourteen cases. The visual analog scale score decreased from 5.66 ± 1.79 preoperatively to 1.16 ± 1.77 at the final follow-up. No local recurrence was noticed at the final follow-up. CONCLUSION: CT-guided biopsy is effective for the preoperative diagnosis of spinal IOS. Total resection is the optimal treatment for IOS, whereas subtotal resection could be an alternative choice for high-risk cases. These slides can be retrieved under electronic supplementary material.

How does the sagittal spinal balance of the scoliotic population deviate from the asymptomatic population?

BACKGROUND: Previously, the sagittal spinal balance in both asymptomatic and scoliotic Caucasian people has been characterized and compared. Very recently, the sagittal spino-pelvic parameters among asymptomatic Chinese adults have been studied, and the results were compared with Caucasian adults, indicating that a difference did exist. Unfortunately, the distribution of sagittal standing posture patterns among the Chinese population has not been characterized in either asymptomatic or scoliotic groups. METHODS: We conducted a radiographic comparison study to define the deviation of sagittal balance in scoliotic patients from that of an asymptomatic population. A total of 126 asymptomatic and 117 idiopathic scoliotic (IS) young adults were recruited. Radiographic data from each subject were reviewed, and sagittal spinopelvic parameters were measured. The Roussouly type was then determined, as well as the relative position of the C7 plumbline with respect to the sacrum and hip axis. Comparison analyses were undertaken between the two different groups. RESULTS: The IS group had a larger pelvic incidence, pelvic tilt and sacral slope, but a smaller spinal tilt than the asymptomatic group (P < 0.05), while other sagittal parameters were similar. The distribution of Roussouly types was similar between the asymptomatic and IS groups, of which 49.2% and 45.3% belonged to Roussouly Type 3, respectively. Asymptomatic males and females had a similar distribution, which was different between the two genders in the IS group (P < 0.05), with more females possessing a neutral sagittal standing posture. In addition, more IS subjects had forward displacement of the C7 plumbline than asymptomatic ones (P < 0.05), while there was no difference between the two genders in either group. CONCLUSIONS: Although sagittal pelvic parameters were greater in the IS population, their sagittal spinal balance was maintained and there was no sagittal standing posture pattern correlated with IS. The occurrence of anterior displacement of the C7 plumbline was more common in IS patients than asymptomatic adults, but did not appear to be correlated with gender in both populations.

Percutaneous radiofrequency ablation for spinal osteoid osteoma and osteoblastoma.

PURPOSES: We sought to verify the efficacy and safety of RFA in spinal OO and osteoblastomas (OB) (Enneking Stage 2, S2). METHODS: We retrospectively reviewed patients treated in our hospital. Surgical resection was indicated for Enneking Stage 3 OB. RFA indications for spinal OO and OB (S2) were no neurological deficits, complete bone cortex around the lesion on computed tomography (CT), and cerebrospinal fluid between a lesion and the spinal cord/nerve root on magnetic resonance imaging. Abundant cerebrospinal fluid (more than 1.0 mm) between the lesion and nerve root/spinal cord was preferred to prevent neurological damage by heat. Otherwise, surgery was recommended. The minimum follow-up was 24 months. RESULTS: Ten patients were treated with CT-guided percutaneous RFA, including three with OB and seven with OO. No patients had neurological deficits or scoliosis. In OO patients, the average visual analog scale (VAS) scores were 7.6/10 (range 6-10) before RFA. In OB cases, the VAS scores were 8, 7, and 9 before RFA. Nine patients had a one-stage biopsy and then RFA, and one patient had a two-stage procedure (biopsy before RFA). The average RFA time for OO was 10 min (range 4-12). In the three OB cases, the RFA time was 12, 12, and 24 min. The time of the whole produce was 98 min (range 65-130 min). All 10 patients were followed-up. The average follow-up time of OO was 46.6 months (range 24-66). Six patients were free of pain, except one who suffered occasional pain with VAS 2/10. The three OB cases were free of pain at 24, 26, and 26 months. CONCLUSION: CT-guided percutaneous RFA is a safe and effective treatment for spinal OO and S2 OB, especially in lesions with no neurological deficits and intact cortical bone. Cerebrospinal fluid around the lesion is an appropriate indication for percutaneous RFA.

The relationship between changes of cervical sagittal alignment after anterior cervical discectomy and fusion and spino-pelvic sagittal alignment under roussouly classification: a four-year follow-up study.

BACKGROUND: Anterior cervical discectomy and fusion (ACDF) is widely used in the treatment of cervical degenerative disease; however, the variation of cervical sagittal alignment changes after ACDF has been rarely explored. The purpose of this study is to determine the relationship between changes of cervical sagittal alignment after ACDF and spino-pelvic sagittal alignment under Roussouly classification. METHODS: A cohort of 133 Chinese cervical spondylotic patients who received ACDF from 2011 to 2012 was recruited. All patients were categorized with Roussouly Classification. Lateral X-ray images of global spine were obtained, and preoperative and postoperative parameters were measured and analyzed, including C2-C7 angles (C2-C7), C0-C7 angles (C0-C7), external auditory meatus (EAM) tilt, sacral slope (SS), thoracic kyphosis (TK), lumbar lordosis (LL), spinal sacral angles (SSA), Superior adjacent inter-vertebral angle (SAIV), inferior adjacent inter-vertebral angle (IAIV) and et al. The Wilcoxon signed-rank test was used for intragroup comparisons preoperatively and at postoperative 48 months. RESULTS: Among the parameters, C2-C7 and C0-C7 showed significant increase, while EAM TK, and IAIV decreased significantly. In type I, EAM and TK decreased significantly, however SS showed a significant increase; in type II, TK showed a significant decrease, but SSA showed a significant increase; in type III, a significant increase of C0-C7 was observed with a significant decrease in EAM, nevertheless, LL, SS and SSA showed significant decreases; and in type IV, C2-C7 showed a significant increase and EAM decreased significantly. The percentage of lordotic alignment in cervical spine increased, which was presenting in type I, III and IV. Nevertheless, the amount of patients with straight cervical alignment increased in type II. CONCLUSION: The backward movement of head occurs is the compensatory mechanism in cervical sagittal alignment modifications after ACDF. The compensatory alteration of spino-pelvic sagittal alignment varied in different Roussouly type.

Surgical treatment options for aggressive osteoblastoma in the mobile spine.

PURPOSE: Osteoblastoma (OBL) is a benign bone tumor with considerable recurrence potential. Resection is the mainstay for the treatment of Enneking stage 3 (st. 3) OBL. This retrospective study aimed to verify the appropriate surgical strategy for st. 3 lesions in the mobile spine. METHODS: 19 cases of st. 3 OBL was diagnosed between 2001 and 2011. Clinical, radiological, surgical, and follow-up data were analyzed. This series included 14 men and 5 women and the mean age at diagnosis was 30.4 years. The lesions were located in the cervical spine in ten cases, in the thoracic spine in eight, and in the lumbar spine in one. Fourteen patients were surgically treated for the first time (intact cases), and five were referred to us after previous unsuccessful treatments (non-intact cases). RESULTS: Before 2008, 11 patients underwent curettage followed by radiotherapy, including 5 non-intact cases and 6 intact cases. Tumor recurrence was observed in all five non-intact cases and four of the six intact cases. After 2008, eight intact patients underwent intralesional vertebrectomy, including six who underwent piecemeal total vertebrectomy and two who underwent intralesional en bloc vertebrectomy. All the eight patients had embolization before surgery. 18 patients had an average 67.3 months (range 36-148 months) of follow-up. Recurrence was not observed in any of these eight cases with intralesional vertebrectomy. CONCLUSION: Intralesional total vertebrectomy might be an appropriate choice for intact st. 3 OBL spine lesions. More cases with longer follow-up periods should be recruited in the future to better understand the treatment options available for this disease.

Analysis of cervical and global spine alignment under Roussouly sagittal classification in Chinese cervical spondylotic patients and asymptomatic subjects.

PURPOSE: To explore the relationship between cervical spine and the global spine alignment and to postulate the hypotheses that a lordotic alignment of cervical spine is not the only standard to identify asymptomatic subjects, and the degenerative modification of cervical curves depends primarily on their spinal-pelvic alignment. METHODS: A cohort of 120 cases of Chinese asymptomatic subjects and a cohort of 121 cases of Chinese cervical spondylotic patients were recruited prospectively from 2011 to 2012. Roussouly Classification was utilized to categorize all subjects and patients according to their thoracic spine, lumbar spine and pelvic alignment. The cervical alignments were evaluated as lordosis, straight, sigmoid or kyphosis. Through the lateral X-ray images of neutral cervical and global spine, a number of parameters were measured and analyzed, including pelvic incidence, pelvic tilt, sacral slope, thoracic kyphosis (TK), lumbar lordosis, global cervical angles (angles between two lines parallel with posterior walls of C2 and C7), practical cervical angles (the addition of different cervical end plate angles from C3 to C7, and inter-vertebral angles from C23 to C67), T1 slope, spinal sacral angles (SSA), Hip to C7/Hip to Sacrum and C0-C2 angle. RESULTS: The percentages of cervical lordosis were 28.3% and 36.4% in asymptomatic and spondylotic group, respectively. The cervical spine alignments correlated with Roussouly types of global spine alignment in both asymptomatic and cervical spondylotic group (P < 0.001). And there were significant differences between Roussouly Type 2 and 4, Type 3 and 4, Type 1 and 3 in cervical angles in spondylotic group (P < 0.05). In the comparison of the two cohorts, significant differences were found in both general and practical cervical angles in Roussouly Type 4 (P = 0.00 and 0.01, respectively), and there were significant differences in inter-vertebral angle in Roussouly Type 2 at C4-5 and C5-6 levels (P = 0.04 and 0.04, respectively), and in Roussouly Type 3 at C6-7 level (P = 0.01). The SSA showed significant difference between Roussouly Type 2 and 4 in asymptomatic subjects (P = 0.00), and between Type 1 and 3, 1 and 4, 2 and 3, 2 and 4 in cervical spondylotic patients (P = 0.01, 0.02, 0.00 and 0.01, respectively). The T1 slope was significantly different among Roussouly types (P = 0.04) with its largest value in Type 1 in cervical spondylotic group. There are significant differences in C0-C2 angles in all Roussouly types (P = 0.01, 0.02, 0.00 and 0.01, respectively), as well as in the ratio of Hip to C7/hip to sacrum in Type 2 (P = 0.01), and Type 3 (P = 0.00) in the comparison of the two cohorts. The multiple linear regression of all parameters showed both general and practical cervical angles were significantly related to TK, C0-C2 and T1 slope (P = 0.01, 0.00 and 0.00, respectively). CONCLUSION: The cervical alignment correlates with their global spine and pelvic curves. And lordosis is not the only presentation in asymptomatic subjects. The degenerative modification of cervical disc angles was the compensation of global spine degeneration for horizontal gaze. Cervical angles are influenced by their TK angles, occipital-C2 joint and the tilt of T1 vertebral body. The occipital-C2 joint has a compensating mechanism in all Roussouly types in cervical spondylosis.

[Efficacy and survival rate analysis of lung cancer with spinal metastases].

OBJECTIVE: To explore the efficacy of surgical treatment and the prognosis factors of spinal metastases secondary to lung cancer. METHODS: From April 2005 to April 2012, 35 patients diagnosed as spinal metastases secondary to lung cancer were reviewed retrospectively. All the patients were divided into surgical group and conservative group. Severity of pain, neurological status and quality of life preoperatively and postoperatively were compared; and the relevance between their survival time and radiotherapy, medical therapy (chemotherapy and/or targeted therapy), surgical treatment, quality of life, and neurological status were evaluated. RESULTS: Of all the patients, 28 (80%, 28/35) had been followed up. The surgical group contained 22 cases and the conservative group 6. The severity of pain and quality of life improved significantly in the surgical group. The median of visual analog scale for pain reduced from 7 points to 3 points (z = 4.143, P < 0.05); the median of Karnorfsky performance score increased from 50 points to 60 points (z = 3.825, P < 0.05). For the 13 patients in the surgical group who had neurological deterioration, the improvement of Frankel grade was statistically different (z = 2.530, P < 0.05). The survival analysis indicated that medical therapy had significant association with longer survival (P = 0.001). However, surgery, radiotherapy, neurological status and quality of life had no direct relations with survival time. CONCLUSION: Surgical treatment for spinal metastases secondary to lung cancer can effectively relieve the pain, improve the quality of life and neurological status. The survival time is largely influenced by medical therapy.

[Medical therapy of polyostotic fibrous dysplasia of the spinal column].

OBJECTIVE: To discuss treatments of spinal polyostotic fibrous dysplasia (PFD) and their clinical outcomes. METHODS: A group of spinal PFD patients treated in orthopaedic department of Peking University Third Hospital from January 2005 to December 2010 was retrospectively reviewed. There were 3 males and 1 female. The age was 53, 17, 32, 38 years, respectively. Two cases underwent preoperative CT-guided biopsy and the other two had previous pathologic results. All the patients complained localized pain and VAS (visual analogue scale) ranged from 3 to 5. All the cases had pathologic fractures and 3 cases had neurological impairment. The surgical procedures for each patient were as follows: lesion resection combined with cervicothoracic fixation and fusion; reduction combined with occipitocervical fixation and fusion; vertebroplasty (VP); VP combined with posterior decompression and fixation. RESULTS: Fibrous dysplasia in each patient was confirmed by postoperative pathological examination. The operation time was 420, 150, 120, 300 minutes and blood loss was 3 400, 500, 200, 2 000 mL. The follow-up period was 84, 24, 34, 12 months. The primary symptoms were fully relieved without any surgery related complication. There was no symptom recurrence or lesion progress during the follow-up. No signs of radiological improvements (filling of lytic lesion, cortical thickening, or both) were detected. CONCLUSION: Spinal PFD is a rare disease and mostly affects adults. Conventional excision therapy is an effective and reliable treatment for spinal PFD, but vertebroplasty is less invasive. VP alone might be more appropriate for patients complaining only pain symptoms and/or with pathologic fractures. VP combined with limited decompression and stabilization may be more suitable for patients with neurological deficits.

Aggressive vertebral hemangioma of the thoracic spine without typical radiological appearance.

PURPOSE: Vertebral hemangioma (VH) is virtually vascular malformation, which is usually asymptomatic. Only 3.7 % of VH may become active and symptomatic, and 1 % may invade the spinal canal and/or paravertebral space. Treatment protocols for active or aggressive VHs are still in controversy. Reported treatments include radiotherapy, vertebroplasty, direct alcohol injection, embolization, surgery and a combination of these modalities. METHODS: A 41-year-old lady was presented with 18 month history of intermittent back pain. CT revealed T5 osteolytic lesion with epidural and paravertebral extension. The first CT guided biopsy yielded little information. RESULTS: Histopathological diagnosis of the second biopsy was VH. Vertebroplasty, posterior decompression and fixation were performed followed by postoperative radiotherapy. Her symptoms were resolved immediately after the operation. At 12 months follow-up, no recurrence was detected by CT with contrast enhancement. CONCLUSION: Surgical decompression, vertebroplasty and fixation are safe and effective for aggressive VH. More attention is needed in determining the algorithm for the diagnosis and treatment of aggressive VH.

[Reoperation to the ossification of the posterior longitudinal ligament].

OBJECTIVE: To discuss surgical approaches of ossification of the posterior longitudinal ligament (OPLL) of cervical spine. METHODS: Between June 2005 to July 2010, 36 patients with OPLL of cervical spine were reoperated. There were 23 male, 13 female, age from 39 to 72 years (mean 57 years). The time of the first operation to the reoperation were 4 months to 24 years, an average of 3.9 years. Among 20 patients underwent anterior corpectomy and fusion (ACD) at first operation, 14 cases combined stenosis of cervical spinal canal, 10 cases were insufficient decompression of OPLL, 5 cases injured of cervical spinal cord during the first operation, 1 case was adjacent disc herniation. Among 14 cases underwent expensive open-door laminoplasty (ELAP) at first operation, 6 cases were insufficient decompression of OPLL, 4 cases were inadequate decompressed segment, 2 cases were cervical segmental kyphosis, 2 cases were progression of OPLL combined with disc herniation. Among 2 cases underwent combined approach at first operation, 1 case was insufficient decompression of OPLL, the other was adjacent disc herniation. Their pre- and post-operative X-ray, CT and MRI were analyzed. The complications of reoperation were recorded. RESULT: There were 30 patients followed-up, with a period of 1.5 - 4.0 years, average 1.8 years. With 36 patients, none had deterioration, 2 patients had no recovery post-reoperation, 34 patients had 31.2% Japanese Orthopedic Association score improve rate. Among 22 cases underwent ELAP at second operation, 3 cases had postoperative segmental palsy. Among 14 cases underwent ACD at second operation, 3 cases had intraoperative dural defects. CONCLUSION: Surgical strategy for OPLL of cervical spine should consider the type of OPLL and stenosis of cervical spinal canal.

[Longterm outcome after the decompressive surgery for thoracic myelopathy due to the ossification of the ligamentum flavum].

OBJECTIVES: To investigate the long-term surgical outcome of thoracic myelopathy caused by the ossification of the ligamentum flavum (OLF) and evaluate the related risk factors. METHODS: Forty-four patients who underwent decompressive laminectomy with thoracic OLF between January 1990 and December 2005 and got more than 5 years follow-up were retrospectively reviewed. Among these 44 cases, there were 29 male and 15 female whose ages at operation were 52 years averagely (27-68 years). The 2-year follow-up results and long-term outcomes were classified according to the modified Epstein's standard, and then the rates of excellent or good (REG) were calculated. The correlation between the long-term REG and the patients' ages, durations of symptoms, decompressed levels, and dural leak were analyzed. RESULTS: The mean follow-up period of these 44 cases was 8.5 years (5-19 years). The REG at 2 years after laminectomy was 77.3% (34/44), while the long-term REG was 65.9% (29/44). There was one case who had suffered from an acute spinal cord injury got a poor post-operative outcome. The other 43 cases had chronic durations, including 22 cases whose pre-operative durations of symptoms were less than 12 months and 21 cases whose durations were equal to or more than 12 months. And the long-term REG of these two groups were 77.3% (17/22) and 57.1% (12/21) respectively (P>0.05). The REG of those cases whose decompression levels were limited in T1-T9 was 78.9% (15/19), while that of those cases whose laminectomy was relevant to thoracolumbar segment (T10-L2) was 58.3% (14/24) (P>0.05). There were 7 cases who had excellent or good short-term results and poor long-term outcomes. The reasons of these changes included coexistence of lumbar spinal stenosis in three cases and the growth of the OLF at the adjacent levels in four cases. CONCLUSIONS: Although the short-term results of the decompressive surgery for thoracic OLF is good, the regular long-term follow-up is necessary because the symptoms may reoccur or deteriorate secondary to lumbar spinal stenosis or the growth of OLF at the adjacent levels near former decompressive levels; the duration of symptoms which is more than one year and the decompression levels that is involved to T10-L2 segments are possibly related to the poor long-term outcomes.

Simvastatin induces estrogen receptor-alpha expression in bone, restores bone loss, and decreases ERα expression and uterine wet weight in ovariectomized rats.

We previously reported that simvastatin induces estrogen receptor-alpha (ERα) in murine bone marrow stromal cells in vitro. In this study, we investigated the effect of simvastatin on ERα expression in bone and uterus in ovariectomized (OVX) rats and evaluated bone mass, bone strength, and uterine wet weight. Three-month-old Sprague-Dawley female rats received OVX or sham operation. Six weeks later, the rats were treated orally with simvastatin (5 or 10 mg/kg/day), or intraperitoneally with 17-ß-estradiol (E(2)) or a combination of simvastatin and E(2) for 6 weeks. Uterine wet weight, bone mineral density (BMD) of lumbar vertebrae, biomechanics of lumbar vertebrae, and induction of ERα expression in the bone and uterus were analyzed. The 6-week simvastatin treatment improved lumbar vertebral BMD and boosted biomechanical performance of the vertebral body compared to the OVX control, suggesting that simvastatin can treat osteoporosis caused by estrogen deficiency. More interestingly, simvastatin could increase ERα expression and synergy with estradiol in bone while antagonizing estradiol in the uterus, along with uterus atrophy and uterine wet weight decreases. In conclusion, these data suggest that simvastatin exert opposing modulatory effects on ERα expression on bone and uterus in ovariectomized rats, inducing ERα expression and synergy with estrogen to perform anabolic effects on the bones while decreasing E2 efficacy and uterine wet weight. This finding may be helpful to explain the mechanism of statin treatment in osteoporosis caused by estrogen deficiency.

Langerhans cell histiocytosis with multiple spinal involvement.

To stress the clinical and radiologic presentation and treatment outcome of Langerhans cell histiocytosis (LCH) with multiple spinal involvements. A total of 42 cases with spinal LCH were reviewed in our hospital and 5 had multifocal spinal lesions. Multiple spinal LCH has been reported in 50 cases in the literature. All cases including ours were analyzed concerning age, sex, clinical and radiologic presentation, therapy and outcome. Of our five cases, three had neurological symptom, four soft tissue involvement and three had posterior arch extension. Compiling data from the eight largest case series of the spinal LCH reveals that 27.2% multiple vertebrae lesions. In these 55 cases, there were 26 female and 29 male with the mean age of 7.4 years (range 0.2-37). A total of 182 vertebrae were involved including 28.0% in the cervical spine, 47.8% in thoracic and 24.2% in the lumbar spine. Extraspinal LCH lesion was documented in 54.2% cases, visceral involvement in 31.1% and vertebra plana in 50% cases. Paravertebral and epidural extension were not documented in most cases. Pathological diagnosis was achieved in 47 cases including 8 open spine biopsy. The treatment strategy varied depending on different hospitals. One patient died, two had recurrence and the others had no evidence of the disease with an average of 7.2 years (range 1-21) of follow-up. Asymptomatic spinal lesions could be simply observed with or without bracing and chemotherapy is justified for multiple lesions. Surgical decompression should be reserved for the uncommon cases in which neurologic compromise does not respond to radiotherapy or progresses too rapidly for radiotherapy.

[Impact factors for hidden blood loss after primary total knee arthroplasty].

OBJECTIVE: To investigate the relative factors for hidden blood loss (HBL) after primary total knee arthroplasty (TKA). METHODS: A retrospective study of 422 consecutive patients who underwent primary TKA between October 2007 and August 2009 was carried on. There were 60 male and 362 female patients with a mean age of 65.7 years. The HBL was calculated according to Gross formula. The effect of patient gender, age, body mass index (BMI), pre-operative diagnosis, unilateral or simultaneous bilateral TKA, tourniquet time, type of prosthesis, postoperative anticoagulation method and deep vein thrombosis (DVT) on the postoperative HBL were analyzed. RESULTS: The HBL in patients underwent unilateral TKA was significantly lower than that in those underwent simultaneous bilateral TKA [(1284 ± 207) ml vs. (2248 ± 504) ml, P = 0.000]. Unvaried analysis showed that the HBL were associated with BMI, tourniquet time, prosthesis type and postoperative anticoagulation method. Multivariate linear regression analysis showed that the impact factors of postoperative HBL include BMI, tourniquet time and prosthesis type. CONCLUSIONS: BMI, bilateral simultaneous TKA, tourniquet time and intercondylar open prosthesis impact the HBL after primary TKA. However, the influence of gender, age, diagnosis, postoperative anticoagulation method and DVT on the HBL are not significant.

Diagnosis and treatment of Rosai-Dorfman disease of the spine: a systematic literature review.

PURPOSE: To review and summarize the clinical features, diagnosis, treatment strategies, and prognosis of spinal Rosai-Dorfman disease (RDD). METHODS: RDD is also termed as sinus histiocytosis with massive lymphadenopathy. We searched the databases of PubMed, Elsevier ScienceDirect, SpringerLink, and OVID. The keywords were Rosai-Dorfman disease and spine/central nervous system. Research articles and case reports with accessibility to full texts regarding spinal RDD were eligible for the inclusion. A total of 62 articles were included, and they contained 69 cases. We extracted the information of interest and analyzed them using SPSS statistics package. RESULTS: The average age was 33.1 ± 18.3 years. The ratio of males to females was 1.9/1. Overall, 63 cases presented with spine-related symptoms. A total of 27 cases (39.1%) had multi-organ lesions, and 12 cases had records of massive lymphadenopathy. Among 47 cases who first manifested spine-related symptoms, 93.6% were preoperatively misdiagnosed. The disease had a predilection for cervical spine (38.8%) and thoracic spine (40.3%). 62.9% of lesions were dura-based. Surgery remained the mainstream treatment option (78.8%), with or without adjuvant therapies. Total lesion resection was achieved in 34.8% of cases. The rate of lesion recurrence/progression was 19.5%, which was marginally lower for total resection than for non-total resection. CONCLUSION: Spinal RDD has no pathognomonic clinical and imaging features. Most cases first present with spine-relevant symptoms. Massive lymphadenopathy is not common, but a tendency for multi-organ involvement should be considered. Spinal RDD has a high recurrence rate; thus, total resection is the treatment of choice. Adjuvant therapies are indicated for multi-organ lesions and residual lesions. A wait and watch strategy is recommended for asymptomatic patients. Herein, a workflow of diagnosis and treatment of the spinal RDD is established.