The lower Osteotomy Level is Associated With Decreased Revision Surgery Due to Mechanical Complications After Three-Column Osteotomy in Patients With Adult Spinal Deformity: A Multi-Institutional Retrospective Study.

STUDY DESIGN: A multi-institutional retrospective study. OBJECTIVES: To investigate risk factors of mechanical failure in three-column osteotomy (3COs) in patients with adult spinal deformity (ASD), focusing on the osteotomy level. METHODS: We retrospectively reviewed 111 patients with ASD who underwent 3COs with at least 2 years of follow-up. Radiographic parameters, clinical data on early and late postoperative complications were collected. Surgical outcomes were compared between the low-level osteotomy group and the high-level osteotomy group: osteotomy level of L3 or lower group (LO group, n = 60) and osteotomy of L2 or higher group (HO group, n = 51). RESULTS: Of the 111 patients, 25 needed revision surgery for mechanical complication (mechanical failure). A lower t-score (odds ratio [OR] .39 P = .002) and being in the HO group (OR 4.54, P = .03) were independently associated with mechanical failure. In the analysis divided by the osteotomy level (LO and HO), no difference in early complications or neurological complications was found between the two groups. The rates of overall mechanical complications, rod failure, and mechanical failure were significantly higher in the HO group than in the LO group. After propensity score matching, mechanical complications and failures were still significantly more observed in the HO group than in the LO group (P = .01 and .029, respectively). CONCLUSIONS: A lower t-score and osteotomy of L2 or higher were associated with increased risks of mechanical failure. Lower osteotomy was associated with better correction of sagittal balance and a lower rate of mechanical complications.

A comparative study of surgical outcomes between anterior cervical discectomy with fusion and selective laminoplasty for cervical spondylotic myelopathy.

BACKGROUND: Few studies have directly compared anterior and posterior surgical approaches in cervical spondylotic myelopathy (CSM) patients with short-segment disease. We aimed to examine and compare surgical outcomes of anterior cervical discectomy with fusion (ACDF) and selective laminoplasty (S-LAMP) in CSM patients with 1- or 2-level disease. METHODS: Forty-six patients, who received surgeries for CSM, were prospectively investigated; 24 underwent ACDF and 22 underwent S-LAMP. Average follow-up was 3.5 years. The following pre- and postoperative radiographic measurements were recorded: (1) C2-7 angle, (2) local angle (lordotic Cobb angle at operative level), (3) cervical sagittal vertical axis (SVA) (center of gravity of the head-C7 SVA), and (4) C7 slope. Outcomes were evaluated using the Japanese Orthopedic Association scoring system for cervical myelopathy (C-JOA score), neck pain visual analog scale, and neck disability index (NDI). RESULTS: There were no significant differences in patient demographics between the two groups. Postoperatively, C2-7 angle, local angle, cervical SVA, C7 slope, C-JOA score, and neck pain and NDI scores were not significantly different between the two groups; however, the recovery rate of the C-JOA score was superior in the ACDF group (57.5%) compared to the S-LAMP group (42.1%). The recovery rate of the C-JOA score in the local lordosis subgroup (local angle ≥ 0°) showed no significant difference between the two surgical groups. However, in the local kyphosis subgroup (local angle < 0°), C-JOA score recovery rate was worse after S-LAMP (20.4%) than ACDF (57.9%); local angle also worsened postoperatively after S-LAMP. CONCLUSIONS: In patients with local lordosis at the segments of cervical spondylosis and spinal cord compression, S-LAMP showed equivalent surgical outcomes (neurological recovery, neck pain and NDI scores, and cervical alignment) to ACDF. However, in patients with local kyphosis, S-LAMP worsened the kyphosis and resulted in worse neurological recovery.

Multiple and early hyperbaric oxygen treatments enhance muscle healing after muscle contusion injury: a pilot study.

BACKGROUND: The optimal timing of hyperbaric oxygen (HBO2) treatments for the best recovery following muscle injury has yet to be determined. Thus, the optimal number and timing of HBO2 treatments for maximal muscle regeneration were explored. METHODS: The HBO2 treatment protocol consisted of 2.5 ATA 100% oxygen for 120 minutes. Muscle-injured rats were randomized to one of 10 groups: single HBO2 treatment immediately after injury (HBO 1T day 0), one day (HBO 1T day 1), three days (HBO 1T day 3) and five days (HBO 1T day 5) after injury; three HBO2 treatments from immediately after injury to two days after injury (HBO 3T day 0-2), from one to three days after injury (HBO 3T day 1-3), from three to five days after injury (HBO 3T day 3-5), from five to seven days after injury (HBO 3T day 5-7); five daily HBO2 treatments (HBO 5T); and no treatment (NT). RESULTS: HBO 5T and HBO 3T day 0-2, days 1-3 and days 3-5 significantly promoted CD206-positive cell infiltration, satellite cell differentiation and muscle regeneration compared to the NT group. CONCLUSION: Five HBO2 treatments and three HBO2 treatments within three days of injury promote muscle regeneration.

A Prospective Cohort Study of Dysphagia After Subaxial Cervical Spine Surgery.

STUDY DESIGN: Prospective observational cohort study. OBJECTIVE: To prospectively examine dysphagia after subaxial cervical spine surgery. SUMMARY OF BACKGROUND DATA: Although dysphagia after anterior cervical spine surgery is common and well-studied, it has rarely been examined in posterior subaxial cervical spine surgery. METHODS: This study analyzed 191 consecutive patients (132 male, 59 female; mean age, 64.9 yrs) who underwent subaxial cervical spine surgery for degenerative disease and completed 1 year of follow-up. Anterior decompression with fusion (ADF) was performed in 87 patients, posterior decompression with fusion (PDF) in 21, and laminoplasty (LAMP) in 83. Dysphagia was evaluated by a self-administered questionnaire using the Bazaz dysphagia scale before, 6 months, and 1 year after surgery. Diagnosis, levels and number of operative segments, C2-7 lordotic angle (CL), O-C2 angle (OC2A), C2-7 range of motion (ROM), Japanese Orthopedic Association for cervical myelopathy (C-JOA) score, and neck pain visual analog scale (VAS) were examined. RESULTS: Thirty-two patients (16.8%) reported dysphagia before surgery. New dysphagia after surgery, defined as more than or equal to 1 grade worsening of the Bazaz score after surgery compared with the preoperative status, was observed in 38 patients (19.9%) at 6 months and 32 patients (16.8%) at 1 year. The incidence of new dysphagia at 1 year was 25.3% in the ADF group, 23.8% in the PDF group, and 6.0% in the LAMP group. Fusion surgery (ACDF or PDF) and increased CL after surgery were found as risk factors at 1 year in multivariate analysis; receiver operating characteristic analysis determined a postsurgical change in CL cutoff of 5°. CONCLUSION: Fusion surgery and increased CL after surgery were risk factors for development of dysphagia after subaxial cervical spine surgery. Cervical alignment change due to anterior and posterior fusion surgery can cause postoperative dysphagia.Level of Evidence: 3.

Characterization of a novel compound that promotes myogenesis via Akt and transcriptional co-activator with PDZ-binding motif (TAZ) in mouse C2C12 cells.

Transcriptional co-activator with PDZ-binding motif (TAZ) plays versatile roles in the regulation of cell proliferation and differentiation. TAZ activity changes in response to the cellular environment such as mechanic and nutritional stimuli, osmolarity, and hypoxia. To understand the physiological roles of TAZ, chemical compounds that activate TAZ in cells are useful as experimental reagents. Kaempferol, TM-25659, and ethacridine are reported as TAZ activators. However, as each TAZ activator has a distinct property in cellular functions, additional TAZ activators are awaiting. We screened for TAZ activators and previously reported IB008738 as a TAZ activator that promotes myogenesis in C2C12 cells. In this study, we have characterized IBS004735 that was obtained in the same screening. IBS004735 also promotes myogenesis in C2C12 cells, but is not similar to IBS008738 in the structure. IBS004735 activates TAZ via Akt and has no effect on TAZ phosphorylation, which is the well-described key modification to regulate TAZ activity. Thus, we introduce IBS004735 as a novel TAZ activator that regulates TAZ in a yet unidentified mechanism.

VEGF and bFGF induction by nitric oxide is associated with hyperbaric oxygen-induced angiogenesis and muscle regeneration.

Hyperbaric oxygen (HBO) treatment promotes early recovery from muscle injury. Reactive oxygen species (ROS) upregulation is a key mechanism of HBO, which produces high O2 content in tissues through increased dissolution of oxygen at high pressure. Nitric oxide (NO), a type of ROS, generally stabilizes hypoxia-inducible factor (HIF) 1α and stimulates secretion of vascular endothelial growth factor (VEGF) and basic fibroblast growth factor (bFGF) from endothelial cells and macrophages, which then induces angiogenesis. The purpose of the present study was to investigate whether HBO could promote angiogenesis via induction of NO and induce muscle regeneration in contused rat skeletal muscles. The HBO protocol consisted of 2.5 atmospheres absolute (ATA) 100% oxygen for 120 minutes, once a day for 5 consecutive days. We also evaluated the effects of a ROS inhibitor (NAC) or NOS-specific inhibitor (L-NAME) on HBO. HBO significantly increased NO3-, VEGF, and bFGF levels and stabilized HIF1α within 1 day. HBO promoted blood vessel formation at 3-7 days and muscle healing at 5-7 days after contusion. Administration of both NAC and L-NAME before HBO suppressed angiogenesis and muscle regeneration even after HBO. HBO thus promoted angiogenesis and muscle regeneration mainly through generation of NO in the early phase after muscle contusion injury.

Retrospective analysis of surgical outcomes for atlantoaxial subluxation.

BACKGROUND: Atlantoaxial subluxation (AAS) is characterized by excessive movement at the junction between the atlas (C1) and axis (C2) as a result of either a bony or ligamentous abnormality. Surgical intervention is a therapeutic choice for AAS. In addition to C1 laminectomy (LAM), surgical fixation for subluxation or instability is performed by various techniques. While surgical treatment options for AAS have increased, the outcomes of different surgical techniques remain unclear. METHODS: The authors conducted a retrospective analysis of the outcomes of 30 consecutive spinal surgeries performed for AAS patients, C1 LAM in 11 cases and C1/2 fixation in 19 cases. We investigated the correlation between the clinical outcomes and the surgical methods. We also examined the factors related to poor outcomes (the recovery rate of the Japanese Orthopedic Association score for cervical myelopathy < 40%) following AAS surgeries. RESULTS: From a surgical method perspective, the patients in the C1 LAM group were older than those in the C1/2 fixation group (74.6 years vs 68.0 years), and the average recovery rate from the preoperative status was as follows: the C1 LAM group, 39.4%; the C1/2 fixation group, 49.8%. The C-JOA score was significantly improved after surgery in the C1/2 fixation group (from 9.8 to 13.1 points). The fixation technique seemed to successfully reduce C1/2 displacement. Each group exhibited a slight increase in the C1/2 angle and a decrease in the C2-7 angles after the operation. A higher preoperative atlantodental interval (ADI) was associated with good outcomes after the C1/2 fixation. The postoperative ADI was significantly reduced from 8.6 mm to 3.8 mm in the good outcome group after fixation. Patients with higher C1/2 angle showed good outcomes after C1 LAM. Despite the good neurological improvement, the C1/2 fixation method showed higher complication rates compared with C1 LAM method. CONCLUSIONS: The results of this study showed that the C1/2 fixation technique exhibited effectiveness in terms of neurological recovery. However, there was a high complication rate in surgeries for AAS, especially in the C1/2 fixation. C1 LAM would be considered for high-risk AAS cases such as elderly patients with multiple comorbidities.

Hyperbaric oxygen reduces inflammation, oxygenates injured muscle, and regenerates skeletal muscle via macrophage and satellite cell activation.

Hyperbaric oxygen treatment (HBO) promotes rapid recovery from soft tissue injuries. However, the healing mechanism is unclear. Here we assessed the effects of HBO on contused calf muscles in a rat skeletal muscle injury model. An experimental HBO chamber was developed and rats were treated with 100% oxygen, 2.5 atmospheres absolute for 2 h/day after injury. HBO reduced early lower limb volume and muscle wet weight in contused muscles, and promoted muscle isometric strength 7 days after injury. HBO suppressed the elevation of circulating macrophages in the acute phase and then accelerated macrophage invasion into the contused muscle. This environment also increased the number of proliferating and differentiating satellite cells and the amount of regenerated muscle fibers. In the early phase after injury, HBO stimulated the IL-6/STAT3 pathway in contused muscles. Our results demonstrate that HBO has a dual role in decreasing inflammation and accelerating myogenesis in muscle contusion injuries.

Elimination of CT-detected gas bubbles derived from decompression illness with abdominal symptoms after a short hyperbaric oxygen treatment in a monoplace chamber: a case report.

We report the case of a 54-year-old male compressed-air worker with gas bubbles detected by computed tomography (CT). He had complained of strong abdominal pain 30 minutes after decompression after working at a pressure equivalent to 17 meters of sea water for three hours. The initial CT images revealed gas bubbles in the intrahepatic portal vein, pulmonary artery and bilateral femoral vein. After the first hyperbaric oxygen treatment (HBO2 at 2.5 atmospheres absolute/ATA for 150 minutes), no bubbles were detected on repeat CT examination. The patient still exhibited abdominal distension, mild hypesthesia and slight muscle weakness in the upper extremities. Two sessions of U.S. Navy Treatment Table 6 (TT6) were performed on Days 6 and 7 after onset. The patient recovered completely on Day 7. This report describes the important role of CT imaging in evaluating intravascular gas bubbles as well as eliminating the diagnosis of other conditions when divers or compressed-air workers experience uncommon symptoms of decompression illness. In addition, a short treatment table of HBO2 using non-TT6 HBO2 treatment may be useful to reduce gas bubbles and the severity of decompression illness in emergent cases.

Hyperbaric oxygen therapy for a refractory skin ulcer after radical mastectomy and radiation therapy: a case report.

BACKGROUND: Radiation therapy is performed as an adjuvant therapy when indicated following surgical resection of malignant tumors. However, radiation exposure induces acute or chronic dermatitis, depending on the radiation dose, interval, tissue volume, or irradiated area of the body. Radiation-induced skin ulcers and osteomyelitis of the underlying bone are intractable late-stage complications of radiation therapy, and often require reconstructive surgery to cover exposed tissue. Hyperbaric oxygen therapy has been suggested as a treatment for delayed radiation injury with soft tissue and bony necrosis. CASE PRESENTATION: A 74-year-old Japanese female underwent left radical mastectomy for breast cancer (T3N3M0, stage IIIB) in 1987. Radiation therapy was initiated 6 weeks after the surgery. She received telecobalt-60 in a total dose of 50 Gy with 25 fractions to the left supraclavicular, parasternal and left axillary regions, and electron treatment (9 MeV) in a total dose of 50 Gy in 25 fractions to the left chest wall. After irradiation, her skin became thinner and more fragile on the left chest wall, but no severe infections were observed. She noticed a small ulcer that repeatedly healed and recurred in 2000. She visited the hospital where she received radiation therapy and was treated for a skin ulcer on the left chest wall in December 2012. A fistula developed and then pus was discharged in January 2013. She was referred to the hyperbaric medical center in February 2013, and the fistula (1.5 × 3 cm) with pus discharge was observed. She was diagnosed with a late-onset radiation-induced skin ulcer that developed 25 years after radical mastectomy. HBO2 (2.5 atmospheres absolute with 100% oxygen for 60 minutes) was indicated for the refractory ulcer and osteomyelitis of the ribs. The patient was treated with HBO2 a total of 101 times over the course of 1 year and completely recovered. CONCLUSIONS: Hyperbaric oxygen therapy can be performed safely for even more than 100 sessions in patients with radiation-induced skin ulcers and osteomyelitis. Hyperbaric oxygen therapy can be considered as an alternative, conservative treatment when surgical resection for late-onset, radiation-induced skin ulcers is not indicated because of fragile skin in the irradiated areas.