Projection of the Most Anterior Line of the Spinal Canal on Lateral Radiograph: An Anatomic Study for Percutaneous Kyphoplasty and Percutaneous Vertebroplasty.

ABSTRACTPurpose: To measure the projection of the most anterior line of the spinal canal on lateral radiographs of the vertebra (C3-L5) and evaluate the efficacy of the safety line (SL) in preventing intraspinal cement leakage in percutaneous kyphoplasty (PKP) and percutaneous vertebroplasty (PVP). Materials and Methods: Fifteen adult dry-bone spine specimens were analyzed. The projection of the SL was viewed on lateral radiographs. The distance between the SL and the posterior vertebral body line (PVBL) was measured. Two groups of patients were treated by PKP, and cement injection was stopped either before the PBVL (group 1) or before the SL (group 2) under lateral fluoroscopy. The rate of cement leakage was compared between the two groups. Results: The largest distance between the SL and PVBL was at L1 (5.22 ± 0.62 mm). From L1 to L5, the distance decreased progressively to 1.05 ± 0.64 mm. Similar variation was also observed from L1 to T1 (0.19 ± 0.18 mm). The postoperative computed tomography scan was more sensitive and accurate in detecting intraspinal leakage than radiography in group 1 (p = 0.000); however, there was no significant difference in sensitivity or accuracy between methods in group 2 (p = 0.063). The rate of intraspinal cement leakage was significantly higher in group 1 than group 2 (p = 0.000). Conclusions: The operator should frequently check to ensure that cement injection has stopped upon reaching the SL. Surgeons may benefit from this quantitative anatomical study of PKP and PVP.

Astragoloside IV Loaded Polycaprolactone Membrane Repairs Blood Spinal Cord Barrier and Recovers Spinal Cord Function in Traumatic Spinal Cord Injury.

Traumatic Spinal Cord Injury (SCI) is a serious challenge of CNS which may oftenly result in permanent paralysis and disability. The disruption of blood spinal cord barrier (BSCB) is a major step in the secondary injury of SCI. Until recently there are no restorative therapies for traumatic SCI. BSCB is considered to be a therapeutic target for SCI, however few biomaterials have been developed to restore the disrupted BSCB in SCI. In this study, an AST-PCL membrane was fabricated with a steady release of Astragoloside IV (AST) and its effects on BSCB repair as well as the functional recovery of SCI were evaluated. Firstly, this study demonstrated that AST-PCL (polycaprolactone) degradation media protects endothelial cells from apoptosis by down-regulating the expression of cleaved Caspase 3 and decreasing the ratio of Bax/Bcl-2, it also attenuates the stress fiber formation in vitro. Secondly, the rat model of traumatic SCI showed that AST-PCL treatment inhibits the disruption of BSCB permeability, as detected by MRI, Evan's Blue extravasation and water content. Thirdly, this study found that AST-PCL up-regulates the level of tight junction proteins including Occludin, Claudin5 and ZO-1. Furthermore, it is also demonstrated that AST-PCL treatment down-regulates Matrix metalloproteinase-9 secretion and diminishes neutrophil infiltration. Finally, this study found that AST-PCL treatment could significantly inhibit apoptosis, decrease tissue damage and improve functional recovery in SCI rats. Taken together, this study shows that AST-PCL might be an efficient biomaterial for BSCB repair and a potential drug therapy for SCI.

Feasibility of Modified Anterior Odontoid Screw Fixation: Analysis of a New Trajectory Using 3-Dimensional Simulation Software.

BACKGROUND: Anterior odontoid screw fixation (AOSF) has been suggested as the optimal treatment for type II and some shallow type III odontoid fractures. However, only the classical surgical trajectory is available; no newer entry points or trajectories have been reported. METHODS: We evaluated the anatomic feasibility of a new trajectory for AOSF using 3-dimensional (3D) screw insertion simulation software (Mimics). Computed tomography (CT) scans of patients (65 males and 59 females) with normal cervical structures were obtained consecutively, and the axes were reconstructed in 3 dimensions by Mimics software. Then simulated operations were performed using 2 new entry points below the superior articular process using bilateral screws of different diameters (group 1: 4 mm and 4 mm; group 2: 4 mm and 3.5 mm; group 3: 3.5 mm and 3.5 mm). The success rates and the required screw lengths were recorded and analyzed. RESULTS: The success rates were 79.03% for group 1, 95.16% for group 2, and 98.39% for group 3. The success rates for groups 2 and 3 did not differ significantly, and both were significantly better than the rate for group 1. The success rate was much higher in males than in females in group 1, but the success rate was similar in males and females in the other 2 groups. Screw lengths did not differ significantly among the 3 groups, but an effect of sex was apparent. CONCLUSIONS: Our modified trajectory is anatomically feasible for fixation of anterior odontoid fractures, but further anatomic experiments and clinical research are needed.

Acceptable Chin-Brow Vertical Angle for Neutral Position Radiography: Preliminary Analyses Based on Parameters of the Whole Sagittal Spine of an Asymptomatic Chinese Population.

OBJECTIVE: We sought to acquire the whole sagittal spine parameters and investigated the acceptable chin-brow vertical angle (CBVA) for neutral position radiography in an asymptomatic Chinese population. METHODS: The parameters measured in 257 asymptomatic volunteers included CBVA, occipital slope, orbital tilt, occipital incidence, C0-C2 Cobb angle, C2-C7 Cobb angle, C1-C7 Cobb angle, C2-C7 sagittal vertical axis and absolute rotation angle, cervical tilt, cranial tilt, T1 slope, and thoracic kyphosis, and others. We used Pearson correlation analyses to find relationships between CBVA and other variables. The subjects were divided into 5 groups according to the CBVA percentile: group A, 0%-20% CBVA; group B, 20%-40% CBVA; group C, 40%-60% CBVA; group D, 60%-80% CBVA; and group E, 80%-100% CBVA. We used analysis of variance to analyze differences among the 5 groups. RESULTS: Orbital tilt, Occipital incidence, C1-C7 Cobb angle, C2-C7 sagittal vertical axis, and cranial tilt all increased with increasing CBVA (P < 0.001). The occipital slope, C2-C7 Cobb angle, C2-C7 absolute rotation angle, cervical tilt, T1 slope, and thoracic kyphosis decreased with decreasing CBVA (P < 0.05). No correlations between other sagittal parameters and the CBVA were found. A slight deviation was found in groups B-D, with a greater deviation in groups A, C, and E. CONCLUSIONS: An acceptable range of -1.5° to 5.8° is recommended for the CBVA for cervical radiography in the neutral position. When spinal surgeons evaluate the cervical plane, the effects of the CBVA deviation on cervical curvature must be considered.

Anterior endoscopically assisted bone grafting for iatrogenic distraction of odontoid fracture after percutaneous anterior screw fixation: A case report.

RATIONALE: The complication of iatrogenic distraction of odontoid fracture after anterior screw fixation has not been reported in the literature. We treated the patient with endoscopically assisted bone grafting with good results. The new technique was not reported in the management of odontoid fracture or nonunion before. PATIENT CONCERNS: A 22-year-old man presented with neck pain after a motorcycle crash. The cervical spine radiograph and computed tomographic scan demonstrated the base of dens displaced 2 mm anteriorly. DIAGNOSES: Radiographic images showed a type II odontoid fracture. INTERVENTIONS: The patient was treated by percutaneous anterior screw fixation. The postoperative radiograph and CT demonstrated an iatrogenic distraction of the odontoid with a gap of 6 mm.The follow-up radiograph did not show any sign of bone union 1 month and a half later. A revision surgery was given by anterior endoscopically assisted bone grafting. The patient was encouraged to sit out of bed immediately after the surgery with the protection of a soft cervical collar for 3 months. OUTCOMES: No complications such as neural structures or vascular injuries were found. Bone union was achieved at the 1-year follow-up CT scans. Physical examination showed a full range of motion in the neck. LESSONS: We reported a case of iatrogenic odontoid distraction that was managed by anterior endoscopically assisted bone grafting. It is a technically feasible and minimally invasive procedure.

The effects of lactate and acid on articular chondrocytes function: Implications for polymeric cartilage scaffold design.

UNLABELLED: Poly (lactic-co-glycolic acid) (PLGA) and poly-l-lactate acid (PLLA) are biodegradable polymers widely utilized as scaffold materials for cartilage tissue engineering. Their acid degradation products have been widely recognized as being detrimental to cell function. However, the biological effects of lactate, rather than lactic acid, on chondrocytes have never been investigated. This is the major focus of this study. The amounts of lactate and the pH value (acid) of the PLGA and PLLA degradation medium were measured. The effects of PLGA and PLLA degradation medium, as well as different lactate concentrations and timing of exposure on chondrocytes proliferation and cartilage-specific matrix synthesis were investigated by various techniques including global gene expression profiling and gene knockdown experiments. It was shown that PLGA and PLLA degradation medium differentially regulated chondrocyte proliferation and matrix synthesis. Acidic pH caused by lactate inhibited chondrocyte proliferation and matrix synthesis. The effect of lactate on chondrocyte matrix synthesis was both time and dose dependent. A lactate concentration of 100mM and exposure duration of 8h significantly enhanced matrix synthesis. Lactate could also inhibit expression of cartilage matrix degradation genes in osteoarthritic chondrocytes, such as the major aggrecanase ADAMTS5, whilst promoting matrix synthesis simultaneously. Pulsed addition of lactate was shown to be more efficient in promoting COL2A1 expression. Global gene expression data and gene knock down experiments demonstrated that lactate promote matrix synthesis through up-regulation of HIF1A. These observed differential biological effects of lactate on chondrocytes would have implications for the future design of polymeric cartilage scaffolds. STATEMENT OF SIGNIFICANCE: Lactic acid is a widely used substrate for polymers synthesis, PLGA and PLLA in particular. Although physical and biological modifications have been made on these polymers to make them be better cartilage scaffolds, little concern has been given on the biological effect of lactic acid, the main degradation product of these polymers, on chondrocytes. Our finding illustrates the differential biological function of lactate and acid on chondrocytes matrix synthesis. These results can facilitate future design of lactate polymers-based cartilage scaffolds.

Pooled analysis of non-union, re-operation, infection, and approach related complications after anterior odontoid screw fixation.

BACKGROUND: Anterior odontoid screw fixation (AOSF) has been one of the most popular treatments for odontoid fractures. However, the true efficacy of AOSF remains unclear. In this study, we aimed to provide the pooled rates of non-union, reoperation, infection, and approach related complications after AOSF for odontoid fractures. METHODS: We searched studies that discussed complications after AOSF for type II or type III odontoid fractures. A proportion meta-analysis was done and potential sources of heterogeneity were explored by meta-regression analysis. RESULTS: Of 972 references initially identified, 63 were eligible for inclusion. 54 studies provided data regarding non-union. The pooled non-union rate was 10% (95% CI: 7%-3%). 48 citations provided re-operation information with a pooled proportion of 5% (95% CI: 3%-7%). Infection was described in 20 studies with an overall rate of 0.2% (95% CI: 0%-1.2%). The main approach related complication is postoperative dysphagia with a pooled rate of 10% (95% CI: 4%-17%). Proportions for the other approach related complications such as postoperative hoarseness (1.2%, 95% CI: 0%-3.7%), esophageal/retropharyngeal injury (0%, 95% CI: 0%-1.1%), wound hematomas (0.2%, 95% CI: 0%-1.8%), and spinal cord injury (0%, 95% CI: 0%-0.2%) were very low. Significant heterogeneities were detected when we combined the rates of non-union, re-operation, and dysphagia. Multivariate meta-regression analysis showed that old age was significantly predictive of non-union. Subgroup comparisons showed significant higher non-union rates in age ≥ 70 than that in age ≤ 40 and in age 40 to <50. Meta-regression analysis did not reveal any examined variables influencing the re-operation rate. Meta-regression analysis showed age had a significant effect on the dysphagia rate. CONCLUSIONS/SIGNIFICANCES: This study summarized the rates of non-union, reoperation, infection, and approach related complications after AOSF for odontoid fractures. Elderly patients were more likely to experience non-union and dysphagia.