Risk factors for early mortality in elderly patients with unstable isolated C2 odontoid fracture treated with halo-vest or surgery.

The aim of this study was to compare in-hospital mortality of three procedures -halo-vest immobilization, anterior spinal fixation (ASF), and posterior spinal fixation (PSF)- in the treatment of elderly patients with isolated C2 odontoid fracture. We extracted data for elderly patients who were admitted with C2 odontoid fracture and treated with at least one of the three procedures (halo-vest immobilization, ASF, or PSF) during hospitalization. We conducted a generalized propensity score-based matching weight analysis to compare in-hospital mortality among the three procedures. We further investigated independent risk factors for in-hospital death. The study involved 891 patients (halo-vest, n = 463; ASF, n = 74; and PSF, n = 354) with a mean age of 78 years. In-hospital death occurred in 45 (5.1%) patients. Treatment type was not significantly associated with in-hospital mortality. Male sex (odds ratio 2.98; 95% confidence interval 1.32-6.73; p = 0.009) and a Charlson comorbidity index of ≥ 3 (odds ratio 9.18; 95% confidence interval 3.25-25.92; p < 0.001) were independent risk factors for in-hospital mortality. In conclusion, treatment type was not significantly associated with in-hospital mortality in elderly patients with isolated C2 odontoid fracture. Halo-vest immobilization can help to avoid adverse events in patients with C2 odontoid fracture who are considered less suitable for surgical treatment.

Impact of the preoperative nutritional status on postoperative kyphosis in geriatric patients undergoing cervical laminoplasty.

PURPOSE: This study aimed to determine the association of preoperative malnutrition with an increased risk of cervical kyphosis after laminoplasty in geriatric patients with cervical spondylotic myelopathy (CSM). METHODS: Geriatric patients who underwent cervical laminoplasty were included. Malnutrition was defined as a geriatric nutritional risk index < 98 before surgery. The C2-7 angle and the global alignment parameters were analyzed on standing radiographs. The postoperative kyphosis was defined as a C2-7 angle < 0° during a 2-year follow-up. RESULTS: Ninety patients without preoperative kyphotic alignment were enrolled (mean age, 73.5 years old; 41.1% female). Twenty-one patients (23.3%) had malnutrition status (74.2 years old). Preoperatively, the global alignment parameters were comparable between the malnutrition and normal nutrition groups (SVA, 43.3 mm vs. 42.4 mm; T1S, 29.7° vs. 28.4°; TPA, 21.4° vs. 17.8°), with no significant difference in the C2-7 angle (15.1° vs. 15.2°). At 2 years postoperatively, the malnutrition group showed a significantly lower C2-7 angle than the normal nutrition group (9.3° vs. 15.8°, P = 0.03). Postoperative kyphosis was more prevalent in the malnutrition group (33.3% vs. 7.2%, P = 0.005). The preoperative nutritional status and C2-7 angle were independent predictors of postoperative kyphosis. The predictive C2-7 angles differed by preoperative nutritional status (malnutrition group, 11°; normal nutrition group, 7°). CONCLUSION: Among geriatric CSM patients, preoperative malnutrition was closely associated with the increased occurrence of cervical kyphosis after laminoplasty. Our results underscore the importance of preoperative nutritional assessment and management in geriatric populations undergoing cervical spine surgery, as malnutrition is a perioperative modifiable risk factor.

Conditioned medium from BV2 microglial cells having polyleucine specifically alters startle response in mice.

Repeat-associated non-AUG translation (RAN translation) is observed in transcripts that are causative for polyglutamine (polyQ) diseases and generates proteins with mono amino acid tracts such as polyalanine (polyA), polyleucine (polyL) and polyserine (polyS) in neurons, astrocytes and microglia. We have previously shown that microglia with aggregated polyQ led to defective differentiation and degeneration of neuron-like cells. However, it has not been determined whether only microglia containing a specific RAN product, but not other RAN products, is harmful in vitro and in vivo. Here we show that polyL-incorporating microglia specifically led to altered startle response in mice. Aggregated polyA, polyS and polyL induced aberrant differentiation of microglia-like BV2 cells. Differentiated PC12 cells treated with conditioned medium (CM) of polyS- and polyL- but not polyA-incorporating microglia-like BV2 cells showed retraction of neurites and loss of branch of neurites. Injection of the polyL-CM, but not polyA-CM and polyS-CM, into the lateral ventricle lowered startle response in mice. Consistently, polyL induced the highest expression of CD68 in BV2 cells. The lowered startle response was replicated in mice given the polyL-CM in the caudal pontine reticular nucleus (PnC), the key region of startle response. Thus, endogenous RAN proteins having polyL derived from polyQ diseases-causative genes in microglia might specifically impair startle response.

Effect of Intraoperative Tranexamic Acid on Perioperative Major Hemorrhage Requiring Transfusion in Patients Undergoing Elective Spine Surgery: A Propensity Score-Matched Analysis Using a National Inpatient Database.

STUDY DESIGN: Retrospective cohort study. OBJECTIVES: This study aimed to examine whether the use of intravenous TXA in elective spine surgery is associated with reduced perioperative massive hemorrhage requiring transfusion. METHODS: We extracted all patients who underwent decompression with or without fusion surgery for the cervical, thoracic, and lumbar spine between April 2012 and March 2019. The primary outcome was the occurrence of massive hemorrhage requiring transfusion, defined as at least 560 mL of blood transfusion within 2 days of spine surgery or the requirement of additional blood transfusion from 3-7 days postoperatively. Secondary outcomes were the occurrence of thrombotic complications (pulmonary embolism, acute coronary syndrome, and stroke) and postoperative hematoma requiring additional surgery. RESULTS: We identified 83,821 eligible patients, with 9747 (12%) patients in the TXA group. Overall, massive hemorrhage requiring transfusion occurred in 781 (.9%) patients. Propensity score matching yielded 8394 pairs. In the matched cohort, the TXA group had a lower proportion of massive hemorrhage requiring transfusion than the control group (.7% vs 1.1%; P = .002). There was no significant difference in the occurrence of thrombotic complications and postoperative hematoma requiring additional surgery between both groups. The multivariable regression analysis also showed that the use of TXA was associated with significantly lower proportions of massive hemorrhage requiring transfusion (odds ratio, .62; 95% confidence interval, .43-.90; P = .012). CONCLUSIONS: In this analysis using real-world data, TXA use in elective spinal surgery was associated with reduced perioperative massive hemorrhage requiring transfusion without increasing thrombotic complications. LEVEL OF EVIDENCE: Prognostic Level Ⅲ.

A simple scoring of beam walking performance after spinal cord injury in mice.

Precise evaluation of motor functions using simple and reproducible tests for mouse models of spinal cord injury (SCI) are required. Overground walking of SCI mice has been tested by Basso Mouse Scale for locomotion (BMS). In contrast, only a few works quantify walking performances of SCI mice on narrow beams, a different task. Here, we established a novel scoring system using a single beam walking apparatus for SCI mice. The scoring system uses binary judgments of values such as retention, moving forward and reaching the goal on a beam for rating. In addition, high score was given to SCI mouse when the mouse efficiently used hindlimbs for locomotion on the beam. A high rate of concordance of the score derived from positions of hindlimbs between two observers was obtained. Mice displayed the lowest total score on the beam immediately after the SCI, then the score gradually increased like time course of BMS score. Furthermore, the total scores reflected gradation of severity of SCI in 2 strains of mice. The beam walking score proved to be strongly correlated with that of BMS score, indicating that performances between overground walking and beam walking are partly correlated in SCI mice. Collectively, the novel scoring system offers an opportunity to easily evaluate motor performances of mice with SCI.

Dynamization-Posterior Lumbar Interbody Fusion for Hemodialysis-Related Spondyloarthropathy: Evaluation of the Radiographic Outcomes and Reoperation Rate within 2 Years Postoperatively.

STUDY DESIGN: Clinical case series. PURPOSE: This study aimed to report dynamization-posterior lumbar interbody fusion (PLIF), our surgical treatment for hemodialysisrelated spondyloarthropathy (HSA), and investigate patients' postoperative course within 2 years. OVERVIEW OF LITERATURE: HSA often requires lumbar fusion surgery. Conventional PLIF for HSA may cause progressive destructive changes in the vertebral endplate, leading to progressive cage subsidence, pedicle screw loosening, and pseudoarthrosis. A dynamic stabilization system might be effective in patients with a poor bone quality. Thus, we performed "dynamization-PLIF" in hemodialysis patients with destructive vertebral endplate changes. METHODS: We retrospectively examined patients with HSA who underwent dynamization-PLIF at our hospital between April 2010 and March 2018. The radiographic measurements included lumbar lordosis and local lordosis in the fused segment. The evaluation points were before surgery, immediately after surgery, 1 year after surgery, and 2 years after surgery. The preoperative and postoperative radiographic findings were compared using a paired t-test. A p-value of less than 0.05 was considered significant. RESULTS: We included 50 patients (28 males, 22 females). Lumbar lordosis and local lordosis were significantly improved through dynamization- PLIF (lumbar lordosis, 28.4°-35.5°; local lordosis, 2.7°-12.8°; p<0.01). The mean local lordosis was maintained throughout the postoperative course at 1- and 2-year follow-up (12.9°-12.8°, p=0.89 and 12.9°-11.8°, p=0.07, respectively). Solid fusion was achieved in 59 (89%) of 66 fused segments. Solid fusion of all fixed segments was achieved in 42 cases (84%). Within 2 years postoperatively, only six cases (12%) were reoperated (two, surgical debridement for surgical site infection; two, reoperation for pedicle screw loosening; one, laminectomy for epidural hematoma; one, additional fusion for adjacent segment disease). CONCLUSIONS: Dynamization-PLIF showed local lordosis improvement, a high solid fusion rate, and a low reoperation rate within 2 years of follow-up.

The Association Between the Rotator Cuff Status and the Severity and Recovery of Weakness in the Shoulder Abductor Strength in a Case of Proximal Type Cervical Spondylotic Amyotrophy.

STUDY DESIGN: Case series study. OBJECTIVE: We aimed to clarify the prevalence of rotator cuff tear (RCT), and the association between RCT and the severity and prognosis in patients with proximal type cervical spondylotic amyotrophy (CSA). METHODS: We retrospectively analyzed 35 proximal type CSA patients who were treated conservatively. The following data was collected: age, rotator cuff status on MRI, manual muscle test (MMT) score of shoulder abductor and biceps brachii muscles both at the first visit and final follow-up. We investigated the prevalence of RCT and the association between the rotator cuff status, and the severity and recovery of upper extremity weakness in patients with proximal type CSA. RESULTS: Of the 35 patients, 21 had an RCT on MRI, indicating that the prevalence of RCT in patients with proximal type CSA was 60%. An age-adjusted analysis showed that the presence of RCT was significantly associated with the MMT score of the shoulder abductor muscles both at the first visit and at the final follow-up. The presence of RCT was significantly associated with the recovery of the shoulder abductor muscles. The size of the RCT was negatively correlated with the MMT score of the shoulder abductor muscles at the final follow-up. The size of the RCT was independently correlated with the change of the MMT score of the shoulder abductor muscles. CONCLUSION: RCT was detected in >50% in patients with proximal type CSA, and the presence and severity of RCT can be used as prognostic factors for proximal type CSA patients who are treated conservatively.

Increased Cervical Spinal Instability is Associated With the Development of Proximal-type Cervical Spondylotic Amyotrophy.

STUDY DESIGN: Retrospective cohort study. OBJECTIVES: We aimed to clarify the clinical relationship between the etiology of proximal-type cervical spondylotic amyotrophy (CSA) and cervical sagittal alignment and instability. SUMMARY OF BACKGROUND DATA: Although several researchers have discussed hypotheses regarding the etiology of CSA, the trigger and mechanism underlying the onset remain unclear. METHODS: We retrospectively analyzed 52 proximal-type CSA patients (CSA group) and 60 control patients (Control group). The following data were collected: age; sex; cervical lordosis (CL); T1 slope (TS); TS-CL; C2-7 sagittal vertical axis (SVA) on x-ray in the neutral position; flexion angle; extension angle and range of motion (ROM) of C3/4, C4/5 and C5/6; and C3/4, C4/5 and C5/6 instability (translation of >3 mm for adjacent segmental segments) on dynamic x-ray. RESULTS: Compared with the Control group, the CSA group was associated with an older age (mean age, 67.6 vs. 61.1 years' old, P= 0.029) and male sex (78.8% vs. 50.0%, P= 0.002). In the CSA group, the radiographic parameters showed smaller C4/5 and C5/6 extension angles and C5/6 ROM values and a greater C3/4 flexion angle than the Control group. Furthermore, compared with the Control group, the CSA group was associated with C3/4 instability (13.5% vs. 3.3%, P= 0.049) and C4/5 (21.2% vs. 3.3%, P = 0.003). A logistic regression analysis, with adjusting for the age and sex, showed that the C3/4 flexion angle (odds ratio [OR], 1.2; 95% confidence interval [CI], 1.08- 1.40, P =0.002), C3/4 instability (OR, 7.3; 95% CI 1.25-42.96, P =0.027) and C4/5 instability (OR, 8.1; 95% CI, 1.56-42.19, P = 0.012) were independent risk factors of CSA. CONCLUSION: This study suggested that a wide C3/4 flexion angle and high C3/4 or C4/5 spinal instability were closely associated with the etiology of proximal-type CSA.

Cervical Kyphosis due to Neurofibromatosis Type 1 Treated by Circumferential Spinal Fusion using an Autologous Vascularized free Fibula Followed by Teriparatide Administration: A Case Report.

Introduction: Cervical kyphosis is sometimes observed in neurofibromatosis Type 1 (NF-1). If NF-1-associated cervical deformity is progressive, surgical intervention is needed to prevent further deterioration of the deformity. The rate of nonunion after spinal fusion is high in NF-1, especially dystrophic NF-1. Case Report: Cervical kyphosis is sometimes observed in neurofibromatosis Type 1 (NF-1). If NF-1-associated cervical deformity is progressive, surgical intervention is needed to prevent further deterioration of the deformity. The rate of nonunion after spinal fusion is high in NF-1, especially dystrophic NF-1. Conclusion: We administered the teriparatide after spinal fusion surgery for NF-1-associated cervical deformity and obtained complete bony fusion. The administration of teriparatide may be useful to achieve complete bone fusion in patients with NF-1-associated cervical deformity.

Paraplegia due to Thoracic Mobile Schwannoma after Myelography.

INTRODUCTION: Spinal mobile tumors are very rare. We herein report a case of paraplegia caused by migration and incarceration of thoracic mobile schwannoma after myelography. Case Presentation. A 25-year-old man who had weakness and numbness in both his legs also had pain radiating to the back that was induced by back flexion or extension and jumping. Magnetic resonance imaging (MRI) showed an intradural extramedullary lesion at the T10 and T11 levels. Myelography was performed but discontinued due to his back and lower limb pain. Computed tomography after myelography revealed a rostrally migrated intradural mass with a discrepancy in the exact location in comparison to the MRI findings. He underwent a second lumbar puncture and drained the cerebrospinal fluid (CSF) to aid the spinal cord, because the symptoms gradually worsened and led to paraplegia. After the drainage of the CSF, his symptoms were immediately resolved. The day after myelography, he underwent complete resection of the tumor with the diagnosis of schwannoma. One year after the surgery, he had been working despite having hyperreflexia in his lower limbs with no weakness or sensory disturbance. CONCLUSION: Severe neurological deficits associated with spinal cord damage can occur due to migration of mobile tumors.

Malignant Peripheral Nerve Sheath Tumor of the Cervical Spine Treated with Surgical Resection Followed by X-ray Radiotherapy or Carbon Ion Radiotherapy: A Report of Three Cases.

INTRODUCTION: Spinal malignant peripheral nerve sheath tumors (MPNSTs) are extremely rare. Because of vital surroundings, en bloc resection can be difficult in MPNSTs of the cervical spine. Herein, we report three cases of MPNST followed by radiotherapy or carbon ion radiotherapy (CIRT) after surgery. TECHNICAL NOTE: In case 1, the patient underwent subtotal resection from both a posterior and anterior approach following by adjuvant X-ray radiotherapy. The patient died 13 years after surgery due to liver cancer unrelated to MPNST. In case 2, recurrence spread to the spinal canal in 10 months after primary CIRT. The patient underwent resection of the spinal canal lesion with the residual lesion treated by additional CIRT. Recurrence could be controlled for at least 1 year. In case 3, the patient underwent partial resection for the spinal canal lesion with the residual lesion treated by CIRT. Intradural and extradural recurrences from outside of the CIRT field were observed at 3 years after surgery. CONCLUSIONS: Complete resection and adjuvant X-ray radiotherapy would be an effective treatment for MPNST of the cervical spine, even if en bloc resection with a wide margin is impossible. CIRT for the residual tumor after incomplete resection may have the potential to be an additional treatment option; however, further investigation is warranted.

Polyglutamine-containing microglia leads to disturbed differentiation and neurite retraction of neuron-like cells.

Expanded polyglutamine-containing proteins in neurons intrinsically contributes to neuronal dysfunctions and neuronal cell death in polyglutamine (polyQ) diseases. In addition, an expanded polyQ-containing protein in microglia also leads to apoptosis of neurons. However, detailed morphological analysis of neurons exposed to conditioned medium (CM) derived from polyQ-containing microglia has not been essentially carried out. Here, we introduced aggregated peptide with 69 glutamine repeat (69Q) into BV2 microglial cells. The 69Q-containing BV2 cells showed shorter branches. The CM from 69Q-containing microglia (69Q-CM) induced neurite retraction and fewer number of branch point of neurites of differentiated PC12 cells. Likewise, the 69Q-CM induces disturbed differentiation of PC12 cells with shorter total length of neurites and fewer number of branch point of neurites. Thus, the factor(s) released from polyQ-containing microglia affect both differentiation and degeneration of neuron-like cells.

Recurrent lumbar-origin osteoblastoma treated with multiple surgery and carbon ion radiotherapy: a case report.

BACKGROUND: Although osteoblastoma is an uncommon benign bone tumor, it sometimes behaves in a locally aggressive fashion. We herein report a case of recurrent lumbar spine osteoblastoma that was treated by repeated surgery and carbon ion radiotherapy. CASE PRESENTATION: A 13-year-old Japanese girl presented with left side lumbar pain. Computed tomography and magnetic resonance imaging of the lumbar spine demonstrated a tumorous lesion in the left side pedicle of L4. Although gross total resection of the mass, including the nidus, was performed in the initial surgery, recurrence was observed repeatedly in the short term and the pathological diagnosis of all of the resected tumors was conventional osteoblastoma. We finally performed carbon ion radiotherapy after the patient's 3rd palliative operation, and achieved a good outcome. No further recurrence has been observed in 10 years of follow-up. CONCLUSION: We performed carbon ion radiotherapy for a case of recurrent spinal osteoblastoma and achieved a good outcome without recurrence at 10 years after carbon ion radiotherapy treatment. To the best of our knowledge, this is the first case of osteoblastoma that was treated with carbon ion radiotherapy after multiple surgeries.

Intradural-Extramedullary Solitary Fibrous Tumor/Hemangiopericytoma with a Negative Result on Fluorodeoxyglucose-Positron Emission Tomography/Computed Tomography.

Intradural-extramedullary solitary fibrous tumor/hemangiopericytoma (SFT/HPC) is a rare entity. SFT/HPCs can recur after surgery, even if a benign histology of the tumor is observed. We herein report a 68-year-old woman with intradural-extramedullary SFT/HPC. On magnetic resonance imaging (MRI), the intradural-extramedullary mass was isointense on T1-weighted images and hypointense on T2-weighted images with heterogeneous gadolinium enhancement. Whole-body fluorodeoxyglucose-positron emission tomography/computed tomography (18F-FDG-PET/CT) was also performed, showing no accumulation. We performed surgery for the intradural-extramedullary mass, and the pathological findings of the resected specimen were a benign histology consistent with World Health Organization (WHO) grade I SFT/HPC. She had no evidence of tumor recurrence three years after the surgery for intradural-extramedullary SFT/HPC. 18F-FDG-PET/CT before surgery may be useful for predicting the postoperative behavior of spinal SFT/HPCs.

Intradural Extramedullary Spinal Sarcoidosis Mimicking Meningioma.

BACKGROUND: Spinal sarcoidosis is a rare subgroup of neurosarcoidosis. Although most sarcoid lesions develop in the intramedullary compartment, intradural extramedullary (IDEM) spinal sarcoidosis is an extremely rare entity. CASE PRESENTATION: We herein report a case of IDEM spinal sarcoidosis mimicking a meningioma. A 32-year-old man presented to the hospital with clumsy hands and was unable to walk without assistance. Magnetic resonance imaging (MRI) of the cervical spine revealed a dural tail sign that is common in meningiomas. The patient underwent gross total resection. The pathological findings consisted with a sarcoid leision of the spinal cord. The patient's myelopathy recovered after surgery. CONCLUSIONS: Physicians should be alert for the possibility of IDEM sarcoidosis mimicking a meningioma in the differential diagnosis of IDEM spinal cord tumors.

Spontaneous functional full recovery from motor and sensory deficits in adult mice after mild spinal cord injury.

The extent of spontaneous recovery in patients with a spinal cord injury (SCI) has not been thoroughly investigated. It is essentially not known whether SCI animals exhibit full recovery from both motor and sensory deficits as well. Here, we developed an appropriate condition to produce a mild SCI in mice. Mice given a mild contusion SCI showed transient low performances in the Basso Mouse Scale for locomotion (BMS), rotarod and beam walking tests after the SCI, which was followed by complete restoration in a short time. The SCI mice also showed functional full recovery from low sensitivity to light touch using dynamic touch test. Nevertheless, the fully-recovered SCI mice still exhibited significant loss of myelin in the spinal cord. These results suggest a high potential of adaptation of motor and sensory systems in mice and might provide insight into the prognoses of SCI patients.

Does successful rotator cuff repair improve muscle atrophy and fatty infiltration of the rotator cuff? A retrospective magnetic resonance imaging study performed shortly after surgery as a reference.

BACKGROUND: Muscle atrophy and fatty infiltration in the rotator cuff muscles are often observed in patients with chronic rotator cuff tears. The recovery from these conditions has not been clarified. METHODS: Ninety-four patients were included in this study. The improvement in muscle atrophy and fatty infiltration in successfully repaired rotator cuff tears was evaluated by magnetic resonance imaging at 1 year and 2 years after surgery and was compared with muscle atrophy and fatty infiltration observed on magnetic resonance imaging at 2 weeks after surgery to discount any changes due to the medial retraction of the torn tendon. The patients' muscle strength was evaluated in abduction and external rotation. RESULTS: Muscle atrophy and fatty infiltration of the supraspinatus were significantly improved at 2 years after surgery in comparison to 2 weeks after surgery. The subjects' abduction and external rotation strength was also significantly improved at 2 years after surgery in comparison to the preoperative values. Patients whose occupation ratio was improved had a better abduction range of motion, stronger abduction strength, and higher Constant score. Patients whose fatty infiltration was improved had a better range of motion in flexion and abduction, whereas the improvements of muscle strength and the Constant score were similar in the group that showed an improvement of fatty infiltration and the group that did not. CONCLUSION: Muscle atrophy and fatty infiltration can improve after rotator cuff repair. The strengths of abduction and external rotation were also improved at 2 years after surgery.

Gorham disease of the lumbar spine with an abdominal aortic aneurysm: a case report.

BACKGROUND CONTEXT: Reports of Gorham disease of the lumbar spine complicated by abdominal aortic aneurysms are rare. PURPOSE: We herein report the case of a patient with Gorham disease of the lumber spine involving an abdominal aortic aneurysm (AAA). STUDY DESIGN: Case report. METHODS: A 49-year-old man had a 1-month history of right leg pain and severe low back pain. Plain lumbar radiography revealed an osteolytic lesion in the L4 vertebral body. Computed tomography images demonstrated the presence of an extensive osteolytic lesion in the L4 vertebral body and an AAA in front of the L4 vertebral body. RESULTS: The patient underwent mass resection, spinal reconstruction, and blood vessel prosthesis implantation. During surgery, it was found that the wall of the aorta had completely disappeared and was shielded by the tumor mass; therefore, we speculated that the mass in the lumbar spine had directly invaded the aorta. CONCLUSIONS: The patient was able to walk without right leg or low back pain 1 year after undergoing surgery. No recurrence was demonstrated in the magnetic resonance images taken 1 year and 10 months after surgery.