Excessive swelling of nerve roots : Important factor for recurring sciatica after lumbar surgery.

OBJECTIVE: The aim of the study was to investigate the occurrence of unexpectedly swollen nerve roots and to investigate the relationship between nerve root edema and recurrent radicular pain. METHODS: During the period from August 2010 to August 2015, a total of 462 patients with degenerative lumbar disease underwent surgery in this study group. Magnetic resonance imaging (MRI) was used to evaluate the details of the nerve root. Of the patients with recurring radiating pain 13 met the inclusion criteria of the study group and 24 patients without any complications volunteered as the control group. The visual analog scale (VAS), Oswestry Disability Index (ODI), and medical outcomes study item short form health survey (SF-36) were used to evaluate the clinical outcomes. RESULTS: The preoperative diameter of the nerve root showed no significant difference between the two groups (P = 0.28). The postoperative nerve diameter of the study group was larger than that of the control group (P < 0.01). The initial operation improved the symptoms and the VAS was significantly decreased (P < 0.01). After recurrence of the neuralgia, the VAS score significantly increased (P < 0.01). The pain of the study group improved to the same level as that of the control group 4 weeks after subsequent surgery (P = 0.47), while the quality of life was still lower than that of the control group (P < 0.05). The scores collected 3 months after surgery showed that the clinical outcomes were not different between the two groups (P > 0.05). CONCLUSION: In surgery for degenerative lumbar disease accompanied by nerve root edema, excessive nerve root swelling is an important factor for recurrent radiating pain. With a properly carried out intervention in the re-exploration, the recurrent symptoms can be gradually relieved.

Influence of the posterior lumbar interbody fusion on the sagittal spino-pelvic parameters in isthmic L5-S1 spondylolisthesis.

STUDY DESIGN: Prospective study of the sagittal spino-pelvic parameters and deformity parameters in low-grade isthmic spondylolisthesis preoperation and postoperation. OBJECTIVE: To better understand how the surgery influences sagittal spino-pelvic alignment in low-grade spondylolisthesis. SUMMARY OF BACKGROUND DATA: Over the past decade, the importance of the sagittal spino-pelvic parameters was recognized. However, the postoperative change of sagittal balance parameters in low-grade spondylolisthesis was still unclear. METHODS: Forty-nine patients (mean age, 53.2±7.2 y) with low-grade L5-S1 isthmic spondylolisthesis and 60 normal volunteers (mean age, 44.5±8.4 y) were included in the study. Each subject had a radiograph that allowed measurement of sagittal spino-pelvic parameters before and after surgery. The follow-up duration was at least 2 years. Sagittal spino-pelvic parameters and deformity parameters were measured for comparison. RESULTS: Pelvic incidence, pelvic tilt (PT), sacral slope, lumbar lordosis (LL), lumbar 5 incidence, and lumbosacral angle of normal volunteers were smaller than those of spondylolisthesis patients. All of the parameters changed significantly after the posterior lumbar interbody fusion. Postoperative PT reduced by 4.9 degrees, which had no significant difference compared with the control group (P=0.601). The changes of slip degree and height of the intervertebral disk revealed correlation with the increase of LL (r=-0.483, P=0.003; r=0.365, P=0.010). CONCLUSION: The improvement of PT may play an important role in the reconstruction of the sagittal alignment and therapeutic outcome. The restoration of the slip degree and height of the intervertebral disk would increase the LL with a wedged cage. To get a better LL, the size and geometry of the cage was recommended to be evaluated before surgical treatment.

Changes in autophagy proteins in a rat model of spinal cord injury.

OBJECTIVE: Autophagy is involved in several neurodegenerative diseases and recently its role in acute brain injury has won increasing interest. Spinal cord injuries (SCIs) often lead to permanent neurological deficit. Therefore, in this study, we examined the pro?les of autophagy-linked proteins (MAP-LC3) after SCI to investigate whether the expression of autophagy contributes to neurological deficit after SCI. METHODS: Adult female Sprague-Dawley rats were used and randomly divided into control and SCI groups. All the rates received laminectomy at T8-T10 level. Those in the SCI group received additional exposure of the dorsal surface of the spinal cord, followed by a weight- drop injury. Thereafter we investigated the expression levels of MAP-LC3, beclin-1, Cathepsin D and the beclin-1-binding protein bcl-2 by western blot analysis at 12 h, 24 h, 3 d, 7 d, 21 d and 28 d. One-way ANOVA with Tukey post hoc test was used to compare data between groups. RESULTS: We observed significant increase in the level of LC3 (LC3-II/LC3-I) at 3 d and 7 d after SCI when compared with the sham group. While the level of beclin-1 and ratio of beclin-1/bcl-2 was found to have increased from 12 h to 24 h after injury. Cathepsin D expression was also elevated at 7 d (P<0.01). CONCLUSION: Based on the above mentioned data, we proposed that autophagy plays a role in the manifestation of cell injury following SCI.

A clinical morphologic study of the C2 pedicle and isthmus.

PURPOSE: This anatomic, radiographic study investigated locational differences in the C2 pedicle and isthmus [pediculoisthmic component (PIC)] and characterized its narrowest section for clinical application in posterior C2 screw fixation. METHODS: Structures surrounding the transverse foramina of 30 dry C2s and 10 C3s were compared morphologically. Spinal CT scans of 32 Chinese adults were subjected to volume rendering and multiplanar reconstruction to identify the narrowest C2 PIC, and correlative parameters were measured and analyzed. RESULTS: Inferior C2 and C3 structures were morphologically similar. In superior view, the C2 superior facets lay on the transverse foramen and the upper portion between superior and inferior facets was flat (average mediolateral angle, 11.1° ± 2.4°). In inferior view, the posteroinferomedial portion of the C2 transverse foramen displayed a partially tubular structure (average mediolateral angle of projection, 42.6° ± 4.9°). Average height and width were 11.6 and 6.9 mm. The inner medullary cavity was elliptical and the middle site of endosteal diameter was 3.3 ± 1.9 mm. Medial internal cortical bone was significantly thicker than lateral bone (P < 0.01). CONCLUSIONS: The PIC is located between superior and inferior C2 facets. The superior flat area is the isthmus and the inferomedial area connecting the inferior facet and vertebral body is the pedicle. The pedicle is partially tubular and projects posteromedially to the transverse foramen. The narrowest PIC section is the narrowest point of the C2 pedicle. Considering its thin lateral cortical bone, medial and superior pedicle screw placement and preoperative CT reconstruction are recommended.

[SOX9 enhanced chondrogenic differentiation potential of human umbilical cord mesenchymal stem cells through cellular aggregation].

OBJECTIVE: To explore the effects of transcription factor SOX9 on chondrogenic differentiation potential of human umbilical cord mesenchymal stem cells (hUC-MSCs). METHODS: hUC-MSCs were harvested from human umbilical cord and their phenotypic characteristics identified by flow cytometry. To confirm their multipotency, hUC-MSCs were induced to differentiate toward adiposity and osteogenesis. After transfection with the packaging lentivirus vectors containing SOX9 in vitro, the expression of green fluorescent protein (GFP) and the efficiency of transfection were detected by fluorescence microscopy. Their cellular proliferation capacity was detected by thiazolyl blue tetrazolium bromide (MTT) assay.hUC-MSCs modified with SOX9 were seeded into monolayer and cultured for 21 days in a defined, serum-free medium supplemented with transforming growth factor (TGF)-ß1. The untransduced cells or those transduced with GFP served as the controls. Morphologic changes of hUC-MSCs were observed daily and their chondrogenic differentiation was evaluated by reverse transcription-polymerase chain reaction (RT-PCR), Western blot, and immunofluorescent staining. And the accumulation of sulfated glycosaminoglycans was detected by Alcian blue staining. Meanwhile, the expressions of collagen I, X and cell adhesion molecule N-cadherin were assayed. RESULTS: The hUC-MSCs isolated from human umbilical cord stromas exhibited fibroblastic morphology and they were positive for CD29 (95.9%), CD44 (96.5%), CD90 (98.9%), CD105 (94.3%) and negative for hematopoietic stem cells surface markers CD34 (3.0%) and CD45 (2.6%). At Day 21, hUC-MSCs differentiated toward adiposity and osteogenesis. Both oil red O and alkaline phosphatase stains were intensely positive and it confirmed the multilineage potential of hUC-MSCs. An intense expression of GFP was observed under flourescence microscope and the transfection efficiency of cells with Lenti-GFP-SOX9 or Lenti-GFP was more than 90% respectively. SOX9 gene was over-expressed in hUC-MSCs at 48 h post-transduction. The proliferation of hUC-MSCs had no significant effect after the transfection of lentivirus vectors (P > 0.05). In vitro high-density monolayer culture of these SOX9-transfected hUC-MSCs demonstrated that spontaneous cell aggregation appeared at Day 14 of culturing and subsequently generated large cartilage nodules. However there was no phenomenon of cell aggregation occurring in the cells transducted by Lenti-GFP or untransduced vectors. The expressions of collagen II and Aggrecan were higher in SOX9 transducted cells than those in the controls. Alcian blue staining also showed abundant accumulation of sulfated glycosaminoglycans in the SOX9-induced cartilage nodules. The expression of collagen I had no difference in all groups and collagen X was inhibited in SOX9 transduced cells. N-cadherin was strongly up-regulated by SOX9 and might result in cellular aggregation and formation of large cartilage nodules. CONCLUSION: SOX9 may enhance the chondrogenic differentiation potential of human umbilical cord mesenchymal stem cells through cellular aggregation.

Spinal extradural arachnoid cyst following percutaneous vertebroplasty.

We report a rare complication of extradural arachnoid cyst following percutaneous vertebroplasty in a spinal metastasis patient. Percutaneous vertebroplasty has been established as a safe and effective treatment for osteoporotic vertebral fractures and vertebral metastatic lesions. To our knowledge, extradural arachnoid cyst following vertebroplasty has not been reported in literature. A 48-year-old woman diagnosed with adenocarcinoma underwent percutaneous vertebroplasty at the L3 vertebral level due to painful solitary spinal metastasis. At 5 months after surgery, the patient complained of low back pain radiating to the left lower extremity. MRI showed a large cystic lesion in the spinal canal at the L2-L3 level with compression to adjacent dura sac. On T1- and T2-weighted images, the signal within the cyst had the same intensity as cerebrospinal fluid. The patient underwent laminectomy for excision of the extradural cyst. Intraoperatively, a small communication between the cyst and the subarachnoid space was seen at the level of the L3 pedicle. Pathological examination revealed that the cyst wall was composed of non-specific fibrous connective tissue and the content of the cyst was the same as that of cerebrospinal fluid. Postoperatively, the patient's symptom was relieved immediately. The iatrogenic dural injury produced by puncture of the pedicle during vertebroplasty may be the cause of formation of the extradural arachnoid cyst.

Outcome of thoracolumbar burst fractures treated with indirect reduction and fixation without fusion.

Indirect reduction and fixation is not a new method in the treatment of thoracolumbar burst fractures but the indications and efficacy are controversial. The current study was designed to evaluate the efficacy of indirect reduction without fusion. Sixty-four patients with single-level thoracolumbar burst fractures were identified and treated by this method. The outcome was analyzed by the Frankel method, radiographic measurements, and at the latest follow-up the Denis Pain Scale and Oswestry disability index (ODI) were used to assess back pain and functional outcome. The average follow-up period was 40.1 months. The anterior vertebral height (AVH) was corrected from 55.2 to 97.2% post-operatively and decreased to 88.9% after hardware removal. The posterior vertebral height (PVH) increased from 88.9 to 99.1% post-operatively and decreased slightly after implant removal to 93.7%. The average pre-operative canal compromise was 41.4%, which decreased to 13.7% at last follow-up. Except for three paraplegic patients, neurological status significantly improved or stayed normal in the study's remaining 61 patients. Fifty-two of sixty-four patients had excellent or good function. At latest follow-up the average ODI score was 16.7 and the Denis pain score improved in all patients but one. Indirect reduction and fixation can not only restore vertebral column structure but also, more importantly, patients' functional outcome.

[Construction of lentiviral vector containing SOX9 gene and its expression in bone marrow mesenchymal stem cells].

OBJECTIVE: To construct the lentiviral vector containing SOX9 gene and to detect its expression in MSCs derived from rabbit bone marrow. METHODS: Human sox-9 gene coding region fragment was obtained by RT-PCR (reverse transcription-polymerase chain reaction) and then cloned into the plasmid of Pwpxl-MOD2 to form Pwpxl-MOD2/SOX9. Pwpxl-MOD2/SOX9, pRsv-REV, pMDlg-Prre and pMD2G were co-transfected into 293T cells to obtain recombinant virus containing SOX9 gene. Meanwhile, Pwpxl-MOD2, pRsv-REV, pMDlg-pRRE and pMD2G were transfected into another group of 293T cells as a control group packing into blank lentiviral vector. Then the packed lentiviral vector was transfected into MSCs which derived from rabbit bone marrow. The expression of SOX9 was detected by both RT-PCR and Western blot. Identification and proliferation of MSCs was determined by MTT after transfection. RESULTS: The sequencing and restriction analysis showed that SOX9 gene fragment was correctly connected and cloned into the plasmid Pwpxl-MOD in lentiviral vectors. After transfection, the expression of SOX9 gene in MSCs was confirmed by RT-PCR and Western blot. MTT showed the growth of MSCs had no significant effect after transfection with lentiviral vector. CONCLUSION: Lentiviral vector carrying SOX9 gene has been successfully constructed. There is a stable expression in transfected MSCs. Thus it will facilitate the exploratory development of gene and biological therapy for intervertebral disc degeneration.

[Open-door laminoplasty for the treatment of failed anterior cervical spine surgery].

OBJECTIVE: To evaluate the outcome of open-door laminoplasty for the treatment of failed anterior cervical spine surgery. METHODS: From February 2003 to June 2009, 15 patients underwent open-door laminoplasty for the failed anterior cervical spine surgery. The causes of revision and the progression of disease were analyzed. Japanese Orthopedic Association (JOA) scores and Nurick grade were adopted to record the improvement of neurological status and walking ability. RESULTS: Two patients were excluded for analysis because of lost follow-up and follow-up less than 12 months. The mean follow-up period after revision surgery for the other 13 patients was 26 months (ranged 13-52 months). The mean interval between the initial and revision surgery was 24 months (ranged 5 months to 6 years). The causes of revision were as following: degeneration of the adjacent segment in 2 cases, inadequate decompression in 5 cases, mis-diagnosis of ossification of posterior longitudinal ligament (OPLL) as myelopathy in 4 cases, and progression of OPLL in 2 cases. Posterior laminoplasty was recommended for each patient. After the operation, 13 patients improved neurologically with respect to JOA score, 12 patients improved their walking ability while 1 remained unchanged. The mean modified JOA scores improved from 10.5 to 13.8 (P<0.05), the average recovery rate was 53.0% after the revision operation. The mean overall Nurick grade was 3.1 preoperatively and 1.9 at the final follow-up (P<0.05), the mean improvement of the Nurick grade was 1.2. Complications included cerebrospinal fluid leakage in 1 case, new axial neck pain in 1 case, and transient C5 nerve root palsy in 1 case. CONCLUSIONS: Open-door laminoplasty is a straightforward and effective treatment for failed anterior cervical spine surgery due to inadequate decompression, progressive OPLL or degeneration of the adjacent segment. The merit of the open-door laminoplasty for failed anterior spine fusion is able to avoid high risk from initial anterior cervical spine surgery.

[Balloon kyphoplasty for osteoporotic vertebral compression fractures with osteonecrosis].

OBJECTIVE: To explore the clinical efficacy of the percutaneous balloon kyphoplasty for osteoporotic vertebral compression fractures with osteonecrosis. METHODS: The clinical data of 31 patients with osteoporotic vertebral compression fractures associated with osteonecrosis from January 2005 to January 2008 were analyzed retrospectively. There were 13 male and 18 female in this study. The mean age of the patients was 71 years (range from 57 to 84 years). The back pain lasted for 4.2 months (from 1 month to 10 years). Radiography, MRI and CT examination were performed. The patients were treated by percutaneous balloon kyphoplasty and the vertebral body tissue was extracted to perform common pathological examination. The anterior vertebral height was measured on a standing lateral radiograph before operation, after operation (one day after operation) and at the final follow-up. A Visual Analog Scale (VAS) and the Oswestry Disability Index (ODI) were chosen to evaluate pain status and functional activity. RESULTS: The mean follow-up was for 27 months (range, 18 to 48 months). The anterior vertebral body height of fracture vertebra was restored from (34.7 +/- 3.1)% preoperatively to (71.4 +/- 2.3)% postoperatively, and to (70.2 +/- 2.5)% at the final follow-up. There was a significant improvement between preoperative and postoperative values (P < 0.05) and no difference between postoperatively and at the final follow-up (P > 0.05). The VAS was 8.7 +/- 0.4 preoperatively, 2.3 +/- 0.7 postoperatively, and 1.9 +/- 0.2 at the final follow-up; and the ODI was 89.1 +/- 2.7 preoperatively, 31.7 +/- 3.1 postoperatively, and 29.1 +/- 2.7 at the final follow-up. There was statistically significant increment in the VAS and ODI postoperatively compared with preoperatively (P < 0.05), while there was no statistically significant differences between postoperatively and at the final follow-up (P > 0.05). There was a significant increment between preoperative and final follow-up values (P < 0.05). Asymptomatic cement leakage occurred in two cases. New vertebral fracture occurred in one case. CONCLUSION: Balloon kyphoplasty is a safe and effective procedure for osteoporotic vertebral compression fractures with osteonecrosis.

Efficacy of surgery and type of fusion in patients with degenerative lumbar spinal stenosis.

Degenerative lumbar spinal stenosis (DLSS) can be treated by several surgical procedures. However, the choice of procedure and use of instrumentation remain controversial. In this retrospective study of 81 patients with DLSS, 43 patients received decompression and posterolateral fusion without instrumentation, and the surgery for 38 patients was supplemented with posterior transpedicular screw fixation. Both surgeon-based (Fischgrund criteria) and patient-based (Medical Outcome Trust Short-Form 36 [SF-36] questionnaire) standards were used to assess the clinical outcomes. An excellent to good result was achieved in 71.6% of patients and there was no significant difference 6.2 years later between groups with or without instrumentation (Z=0.0358, p>0.05). SF-36 data revealed significant postoperative improvement (p<0.01), and there was no significant difference between the two groups (t=1.67, p>0.05). Successful fusion occurred in 87% of patients with instrumentation versus 67% of the patients without instrumentation (chi(2)=4.23, p<0.05). Thus, surgical treatment of DLSS generally results in satisfactory outcomes. Transpedicular screw fixation may not improve clinical outcomes and the use of posterior instrumentation should be adopted cautiously.

[Unilateral versus bilateral balloon kyphoplasty in the treatment of multi-vertebral osteoporotic compression fractures].

OBJECTIVE: To comparatively study the efficacy and safety of unilateral and bilateral balloon kyphoplasty in the treatment of painful multi-vertebral osteoporotic compression fractures. METHODS: From May 2002 to June 2007, 41 consecutive patients with painful multi-vertebral osteoporotic compression fractures underwent unilateral or bilateral kyphoplasty. The unilateral group included 3 male and 14 female with an average age of 70.4 (range 52 to 91 years old). The bilateral group included 4 men and 20 women with an average age of 72.4 (range 61 to 87 years old). Each procedure included insertion of inflatable balloon, fracture reduction and cement filling under "C"-arm monitoring. Preoperative and postoperative pain level, SF-36 score, radiographs and complications were recorded and analyzed. RESULTS: All 41 patients tolerated the operation well. The mean operation time were (86 +/- 32) min and (120 +/- 26) min for unilateral and bilateral groups respectively; the mean volume of cement injected into one level were (3.9 +/- 1.6) ml and (5.4 +/- 2.1) ml for unilateral and bilateral groups respectively. The mean follow-up were (32.5 +/- 17.2) months and (30.7 +/- 14.3) months for unilateral and bilateral groups respectively. The mean VAS pain score of unilateral group decreased significantly from 7.4 +/- 2.1 preoperatively to 2.7 +/- 1.9 postoperatively (t = 2.50, P < 0.05) and 3.1 +/- 2.2 at final follow-up, the mean VAS pain score of bilateral group decreased significantly from 7.9 +/- 2.1 preoperatively to 2.3 +/- 2.5 postoperatively (t = 2.41, P < 0.05) and 2.7 +/- 2.2 at final follow-up, no significant difference was found between two groups. Significant increase of the mean height of anterior and medial vertebral body were recorded after the operation and maintained at final follow-up. The mean correction of local kyphosis was 7.2 degrees +/- 4.9 degrees for unilateral group and 7.3 degrees +/- 5.9 degrees for bilateral group, no significant difference was found between two groups. Postoperatively, 6 of 8 subscales measured by SF-36 were significantly improved for both groups. Complications were found in 7 patients including 6 cases of cement leakage and 1 case of pulmonary embolization. CONCLUSION: As a minimally invasive procedure, unilateral or bilateral kyphoplasty is effective and relatively safe for multi-vertebral osteoporotic compression fracture.

[Preliminary experiences in minimally invasive transforaminal lumbar interbody fusion].

OBJECTIVE: To explore clinical application of minimally invasive transforaminal lumbar interbody fusion (TLIF) for the management of lumbar disorders and discuss its indications, surgical techniques and clinical effectiveness. METHODS: From Jan 2005 to Dec 2006, 31 selected patients (22 males and 9 females, aged from 41 to 63 years) with degenerative lumbar diseases were treated with minimally invasive TLIF assisted by METRx X-Tube micro-endoscopy system. The index diagnosis was lumbar disc herniation with Lumbar spinal stenosis in 7, lumbar disc herniation with segmental instability in 16, grade 1 to 2 of lumbar spondylolisthesis in 8. The surgical methods was performed with bilateral or unilateral pedicle screws insertion and a single rectangle cage posterolateral placement. The operating time, blood loss, blood transfusion, drainage, visual analogue scale (VAS), preoperative and postoperative JOA scores were observed as well as radiographic evaluation. The results were compared with standard TLIF group respectively. RESULTS: A total of 116 pedicle screws and 31 cages were implanted of which 4 patients were treated with unilateral pedicle screws fixation. Four pedicle screws were found misplaced in CT scans after surgery. The average operating time was 199 min, blood loss 359 ml, volume of transfusion 32 ml drainage 81 ml, and VAS was 2.37 about 72 hours after surgery, which had statistic difference compared with control group. There was no statistic difference on postoperative improvement rate and JOA scores in two groups. CONCLUSIONS: Minimally invasive TLIF minimizes paraspinal muscle trauma and blood loss, shortens the operating and recovery time. A good long-term outcome can be gained compared with standard procedures.

[Diagnosis and surgical treatment of thoracolumbar vertebral Chance fractures caused by a fall].

OBJECTIVE: To explore the diagnosis of Chance fractures of thoracolumbar spine and the clinical efficacy of segmental pedicle screw instrumentation in the treatment. METHODS: The clinical data of 16 patients with Chance fractures from January 2000 to January 2007 were retrospectively analyzed. All patients were treated with segmental pedicle screw instrumentation. Radiology and the Oswestry Disability Index (ODI) were used to evaluate the efficacy. RESULTS: One case associated with open dislocation of ankle and craniocerebral injury, 3 cases with calcaneus fracture and 1 with kidney contusion. All cases were followed up from 7 months to 6 years, with a mean of 2.6 years. There were no operation complications. The anterior vertebral body height of fracture vertebra was restored from preoperative (63.3 +/- 6.8)% to postoperative (92.1 +/- 4.0)%, at the follow-up (90.7 +/- 3.6)%. There was a significant improvement between preoperative and postoperative values (P < 0.01) and no difference between initial postoperative and final follow-up (P > 0.05). The mean ODI was 4.9. CONCLUSIONS: The injuries associated with Chance fracture caused by a fall and its mechanism are different from those with the safety belt injury. The segmental pedicle screw instrumentation can rebuild spinal stabilization and restore spinal alignment in treatment of Chance fractures.

[Determination of painful vertebrae treated by kyphoplasty in multiple-level vertebral compression fractures].

OBJECTIVE: To explore how to determine painful vertebrae treated by kyphoplasty in multiple-level osteoporotic vertebral compression fractures and clinical outcome. METHODS: From October 2002 to June 2005, 51 consecutive procedures with kyphoplasty were performed on 35 patients with multiple-level osteoporotic vertebral compression fractures. There were 51 painful vertebrae among 120 vertebral compression fractures. The painful vertebra was determined by the signal intensity changes in MR images, combined with radiography and local percussion pain before operation. Only painful vertebrae were treated by kyphoplasty. Preoperative, postoperative and final follow-up visual analog scale (VAS) and radiographic findings such as vertebral height and Cobb angle were recorded and analyzed. RESULTS: All patients tolerated the procedure well with immediate relief of their back pain after kyphoplasty and they can walk at 1-3 days after the procedure. There were 3 vertebrae (3/51) occurred asymptomatic extravasation of cement. 31 cases were followed up for mean 16.2 months (range 6-44 months). VAS reduced from preoperative 8.7 to final follow-up 2.1 (P <0. 01). At final follow-up the vertebral height had a recovery rate of 59.17%, and the mean Cobb angle was improved 10.1 degrees. There was a significant improvement between preoperative and final follow-up values (P < 0.01). CONCLUSIONS: The painful vertebra can be determined by signal intensity changes in MR series images in multiple-level osteoporotic vertebral compression fractures. Selecting painful vertebrae to be treated by kyphoplasty can make patients with multiple-level VCFs gain an excellent result.

Cement vertebroplasty combined with ethanol injection in the treatment of vertebral hemangioma.

BACKGROUND: A number of methods have been used in the treatment of symptomatic and aggressive vertebral hemangioma, but none of them is optimal. Vertebral hemangioma treated with cement vertebroplasty or ethanol injection alone showed relatively good results despite their limitations. METHODS: Between February 2002 and May 2004, twelve patients with vertebral hemangioma were subjected to combined cement vertebroplasty and ethanol injection, five of them were men and seven women, and aged from 26 to 54 years (mean, 41 years). The following levels of the spine were involved: T9: 1, T10: 3, T12: 2, L1: 1, L2: 2, L3: 2 and L4: 1. The clinical results and radiographic records of the patients were assessed after 2 years and 5 months of follow-up. RESULTS: The average score of back pain significantly decreased from 6.5 before operation to 1.7 one month after operation. No severe complications occurred during and after operation. During the period of follow-up, symptoms were not deteriorated. At the end of follow-up, neither radiographic sign of aggressive destruction nor collapse of the involved vertebra was observed. Significant improvement in the 12 patients was demonstrated on 7 of 8 SF-36 Health Scale except for mental health. CONCLUSIONS: Cement vertebroplasty combined with ethanol injection as a safe and effective technique is an alternative to the treatment of patients with vertebral hemangioma.

Early diagnosis and treatment of acute or subacute spinal epidural hematoma.

BACKGROUND: Despite low morbidity, acute or subacute spinal epidural hematoma may develop quickly with a high tendency to paralysis. The delay of diagnosis and therapy often leads to serious consequences. In this study we evaluated the effects of a series of methods for the diagnosis and treatment of the hematoma in 11 patients seen in our hospital. METHODS: Of the 11 patients (8 males and 3 females), 2 had the hematoma involving cervical segments, 2 cervico-thoracic, 4 thoracic, 1 thoraco-lumbar, and 2 lumbar. Three patients had quadriplegia, including one with central cord syndrome; another had Brown-Sequard's syndrome; and the other seven had paraplegia. Five patients were diagnosed at our hospitals within 3 - 48 hours after appearance of symptoms, and 6 patients were transferred from community hospitals within 21 - 106 hours after development of symptoms. Key dermal points, key muscles and the rectal sphincter were determined according to the American Spinal Injury Society Impairment Scales as scale A in two patients, B in 5 and C in 4. Emergency MRI in each patient confirmed that the dura mater was compressed in the spinal canal, with equal intensity or hyperintensity on T(1) weighted image and mixed hyperintensity on T(2) weighted image. Preventive and curative measures were taken preoperatively and emergency operation was performed in all patients. Open laminoplasty was done at the cervical and cervico-thoracic segments, laminectomy at the thoracic segments, laminectomy with pedicle screw fixation at the thoraco-lumbar and lumbar segments involving multiple levels, and double-sided laminectomy with the integrity of articular processes at the lumbar segments involving only a single level. During the operation, special attention was given to hematoma evacuation, hemostasis and drainage tube placement. RESULTS: Neither uncontrollable hemorrhage nor postoperative complications occurred. All patients were followed up for 1 - 6 years. A marked difference was noted between postoperative and preoperative scales (u = 3.66, P < 0.01). Most patients recovered after therapy, but the recovery of patients treated at our hospitals was superior to that of those transferred from community hospitals (t = 2.95, P < 0.05). Of the patients treated at our hospitals, 4 were cured and 1 was upgraded with scale from A to D, whereas none of those transferred from community hospitals recovered completely, even one remained scale C. CONCLUSIONS: Physical examination plus MRI is essential to early diagnosis of acute or subacute spinal epidural hematoma. Preventive and curative measures including emergency operation are helpful to the recovery of patients' nerve function.

Antioxidation of quercetin against spinal cord injury in rats.

OBJECTIVE: To observe the effect of quercetin on experimental spinal cord injury (SCI) in rats. METHODS: Sixty Sprague-Dawley rats were randomly divided into four groups: Group A only for laminectomy, Group B for laminectomy with SCI, Group C for SCI and intraperitoneal injection with a bolus of 200 mg/kg quercetin and Group D for SCI and intraperitoneal injection of saline. SCI model was made by using modified Allen's method on T(12). Six rats of each group were killed at 4 h after injury and the levels of free iron and malondialdehyde (MDA) of the involved spinal cord segments were measured by bleomycin and thiobarbituric acid (TBA) assays separately. The recovery of hind limb function was assessed by Modified Tarlov's scale and inclined plane method at 7 d, 14 d and 21 d after SCI. The histological changes of the damaged spinal cord were also examined at 7 d after SCI. RESULTS: After SCI, the levels of free iron and MDA were significantly increased in Groups B and D, while not in Group C. The Modified Tarlov's score and the inclined plane angles were significantly decreased in Groups B, C and D. The histological findings were not improved. CONCLUSIONS: After SCI, quercetin can reduce the level of lipid peroxidation, but not improve recovery of function.

The mitosis and immunocytochemistry of olfactory ensheathing cells from nasal olfactory mucosa.

OBJECTIVE: To culture olfactory ensheathing cells (OECs) of rats in vitro and to investigate its morphology, mitosis and immunocytochemistry, and to explore if the OECs could be a new donation for transplantation. METHODS: OECs were harvested from olfactory mucosa of Sprague Dawley rats based on the differing rates of attachment of the various cell types, followed by glial fibrillary acidic protein (GFAP), nerve growth factor (NGF), anti-low affinity receptor for NGF (NGFRp75), brain-derived neurotrophic factor (BDNF), neurotrophin-3 (NT-3) and S-100 immunocytochemistry. The morphological changes and mitosis were observed under a phase contrast microscope at different culture time. RESULTS: Three morphologically distinct types of cells, bipolar, multipolar and flat morphology were present in the primary culture of adult rat olfactory mucosa. Mitosis was characterized by a retraction of all processes, forming a sphere that divided into spherical daughter cells, the daughter cells sent out their processes. The OECs were immunoreactive for GFAP, NGFRp75, S-100, NGF, BDNF and NT-3. CONCLUSIONS: The OECs from nasal olfactory mucosa cultivated in the medium with fetal bovine serum could survive, divide, differentiate, and express the neurotrophin. It may become an accessible source for autologous grafting in spinal cord injury.

[Selectivity and individualization of transpedicular balloon kyphoplasty for aged osteoporotic spinal fractures].

OBJECTIVE: To investigate the selectivity and individualization of transpedicular balloon kyphoplasty for aged osteoporotic spinal fracture. METHODS: Twenty-two consecutive procedures were performed in 17 aged patients with osteoporotic spinal compression fractures from April 2002 to June 2004. The signal changes in different sequences were confirmed by magnetic resonance imaging before the procedures. This operation involved the percutaneous insertion of two inflatable bone tamps into a fractured vertebral body transpedicularly under fluoroscopic guidance. Every patient was treated individually, according to the results of radiography and CT scan before operation. Preoperative and postoperative complications, visual analogue scale, and radiographic findings such as vertebral height and Cobb angle were recorded and analyzed. RESULTS: All patients tolerated the procedure well with immediate relief of their back pain in 24 hours. There was no leakage of cement into the epidura. The mean loss percent of the anterior and middle vertebral heights were (35.32 +/- 13.15)% and (27.53 +/- 12.61)% before operation, and (14.21 +/- 12.43)% and (16.2 +/- 7.5)% after operation. The height restoration of vertebra was confirmed by X-ray after the procedure (P < 0.01). The mean kyphosis was improved from (25.3 +/- 4.2) degrees to (8.6 +/- 5.1) degrees. No complications occurred. No patient had nerve injury. The patients were allowed to walk next day after the procedure. CONCLUSION: The selectivity and individualization of transpedicular balloon kyphoplasty for aged osteoporotic spinal fractures has satisfactory short-term clinical efficacy. It is also an effective way to prevent complications.