A case report on deficiency of adenosine deaminase 2 with relapse-remission course and analysis of genotype-phenotype correlation.

Deficiency of adenosine deaminase 2 (DADA2) is a monogenic disease caused by biallelic mutations in adenosine deaminase 2 (ADA2). The varying phenotypes of the disease often lead to delayed diagnosis or misdiagnosis. We report an 11-year-old boy with DADA2 and provide a preliminary analysis of genotype-phenotype correlation. The age of onset of the disease was 8 years old. The disease successively involved the brainstem, muscles, joints, and cerebrum. After three relapse-remission episodes over 3 years, the patient was finally diagnosed with DADA2 by whole-exome sequencing. Compound heterozygous variants in the ADA2 gene (NM_001282225.2: c.1072G>A, p.Gly358Arg; c.419dupC, p.Arg141Lysfs*37) were found in the patient. He did not receive anti-TNF therapy and had no relapse after a 8-month follow-up. We identified a novel variant of the ADA2 gene, and the associated disease course may follow a relapse-remission pattern. Homozygous mutations of p.Gly358Arg can cause pure red cell aplasia, whereas compound heterozygous variations may lead to different phenotypes. Variants in the catalytic domain and frameshift mutations may also cause relatively benign phenotypes besides causing hematological disorders. Further studies are needed to clarify the genotypic-phenotypic relationship of this disease.

The Effect of Halo-Pelvic Traction on Bone Mineral Density of Vertebrae and Corresponding Risk Factors.

OBJECTIVES: Decreased bone mineral density (BMD) is associated with complications in implantation surgery for severe spinal deformity. In this quantitative study, we aimed to investigate the impact of halo-pelvic traction on vertebral bone mineral density (BMD) and identify the risk factors for a decrease in BMD. METHODS: Patients who underwent halo-pelvic traction at our hospital between 2019 and 2022 were included in the study. Patients' data, including height, weight, and BMD pre- and post-traction, were collected and analyzed. Quantitative computed tomography (QCT) was used to determine the BMD. The paired rank sum test was used to evaluate the changes in each measurement parameter. Linear regression was used to identify risk factors for a decrease in BMD. RESULTS: Fifteen patients were included in the study, nine women and six men, with an average age of 21.2 ± 7.3 years. Eleven patients had severe rigid scoliosis, while four had tuberculotic kyphosis. One expert measured the BMD values of 345 vertebrae using QCT. The average traction time was 143.3 ± 44.4 days. The average pre-traction BMD was 183.1 ± 73.8 mg/cm3 , and the average post-traction BMD was 140.5 ± 61.3 mg/cm3 (p < 0.01) Patients' height increased from an average of 151.3 ± 12.8 cm pre-traction to 165.5 ± 13.7 cm post-traction (p < 0.01), with traction length averaging 14.3 ± 6.2 cm (p < 0.01). The Cobb angle of the main curve declined from an average of 112.5° ± 24.4° pre-traction to 67.7° ± 19.8° post-traction (p < 0.01). Linear regression revealed a positive correlation between BMD loss and traction length and a negative correlation between BMD loss and correction rate. CONCLUSIONS: Halo-pelvic traction can lead to a decrease in the BMD of the spinal vertebrae, with traction length positively correlated with BMD loss and correction rate negatively correlated with BMD loss. To prevent osteoporosis, physicians should ensure a limited traction length while utilizing better management techniques.

Comparison of Long-Term Clinical and Radiographical Outcomes between the Anterior and Combined Anterior and Posterior Approaches for Treating Lumbosacral Tuberculosis.

OBJECTIVE: Both anterior and combined anterior and posterior approaches have been used to treat lumbosacral tuberculosis. However, long-term follow-up studies of each approach have not been conducted. We aimed to compare the long-term clinical and radiographical outcomes between the two approaches. METHODS: In this retrospective cohort study, we included 49 patients with a minimum 6-year follow-up between January 2008 and March 2012. Twenty-four patients underwent the anterior approach (anterior group), and 25 underwent the combined anterior and posterior approach (anterior-posterior group). Student's t test, Mann-Whitney U test, and Pearson's chi-square test were used to compare the two groups regarding clinical data, such as visual analogue scale scores, Oswestry disability index scores and neurological status, and radiographical data, such as lumbosacral angle, lumbar lordosis, and L5-S1 height. Furthermore, operative time, length of stay, and intraoperative and postoperative blood loss (IBL, PBL) were recorded. RESULTS: Both groups had satisfactory clinical and radiographical outcomes until the final follow-up. All patients achieved bony fusion, and no group differences were found in any of the clinical indices. Both groups corrected and maintained the lumbosacral angle, lumbar lordosis, and L5-S1 height. However, the operative time, length of stay, maximum Hb drop, IBL, and PBL of the anterior group (140.63 ± 24.73 min, 12.58 ± 2.45 days, 28.33 ± 9.70 g/L, 257.08 ± 110.47 ml, and 430.60 ± 158.27 ml, respectively) were significantly lower than those of the anterior-posterior group (423.60 ± 82.81 min, P < 0.001; 21.32 ± 3.40 days, P < 0.001; 38.48 ± 8.03 g/L, P < 0.001; 571.60 ± 111.04 ml, P < 0.001; and 907.01 ± 231.99 ml, P < 0.001). CONCLUSION: This retrospective study demonstrated long-term efficacy of the anterior approach with a single screw fixation, which was as effective as that of the combined anterior and posterior approach, with the advantage of less trauma.

Rare improperly treated traumatic vertical atlantoaxial dislocation: A case report and literature review.

BACKGROUND: Because of the severity and fatal outcome of traumatic vertical atlantoaxial dislocation (AAD), most patients may die in the early post-traumatic period. The post-injury management of patients with vertical AAD has been rarely reported. Improper treatment may lead to disastrous outcome and further aggravate the neurologic symptoms. CASE PRESENTATION: This report describes the perioperative management and outcome of a rare improperly treated patient with traumatic vertical AAD. The severe pulmonary infection of this patient prevented further surgery for vertical AAD. After placement of a halo vest, combined with effective antibiotic drug treatment, the patient's pulmonary infection was brought under control. The patient underwent atlantoaxial fusion using C1 lateral mass screws and C2 pedicle screws with the assistance of the halo vest. A computed tomography scan at 1 year follow-up indicated that the bone graft was fused and the patient was able to walk independently. CONCLUSION: Skull traction is contraindicated in patients with traumatic vertical AAD. Application of a halo vest can be used for temporary fixation of the cervical spine and atlantoaxial fixation should be performed to maintain the stability of atlantoaxial articulation.

Isolation, Purification, and Antioxidant Activities of Polysaccharides from Choerospondias axillaris Leaves.

The extraction, characterization and antioxidant activity of polysaccharides from Choerospondias axillaris leaves were investigated in the present study. Two purified polysaccharide fractions, CALP-1 and CALP-2, were isolated from crude Choerospondias axillaris leaf polysaccharides (CALP) by DEAE-52 cellulose chromatography and Sephadex G-100 column chromatography. The characteristics of CAL-1 and CALP-2 were determined by using High-performance Gel Permeation Chromatography (HPGPC), High-Performance Anion-Exchange Chromatography, HPAEC (HPAEC-PAD) and Fourier transform infrared spectroscopy (FTIR). CALP-1 with molecular weight of 11.20 KDa was comprised of Rhamnose, Arabinose, Galactose, Glucose, Xylose, Mannose and galacturonic acid in a molar ratio of 5.16:2.31:5.50:27.18:1.00:0.76:1.07. CAL-2 with molecular weight of 8.03 KDa consisted of Rhamnose, Arabinose, Galactose, Glucose, and galacturonic acid at a ratio of 1.38:3.63:18.84:8.28:1.45. FTIR revealed that CALP-1 and CALP-2 were acidic polysaccharides. The antioxidant activity of crude CALP, CALP-1 and CALP-2 was evaluated in vitro. The fraction CALP-2 was demonstrated to be of polysaccharide nature containing a large percentage of Galactose but no Xylose and Mannose. The antioxidant activity assays showed that CALP-1 and CALP-2 exhibited antioxidant and scavenging activities on hydroxyl and DPPH radicals in vitro. Compared with pure polysaccharide, crude CALP exhibited stronger anti-oxidant activities. These results will provide a better understanding of Choerospondias axillaris leaf polysaccharide and promote the potential applications of Choerospondias axillaris leaf polysaccharide in the pharmacological field and as a natural antioxidant.

Novel GRIA2 variant in a patient with atypical autism spectrum disorder and psychiatric symptoms: a case report.

BACKGROUND: As sequencing technology has advanced in recent years, a series of synapse-related gene variants have been reported to be associated with autism spectrum disorders (ASDs). The α-amino-3-hydroxy-5-methyl-4-isoxazole propionic acid (AMPA) receptor is a subtype of the ionotropic glutamate receptor, whose number or composition changes can regulate the strength and plasticity of synapses. CASE PRESENTATION: Here, we report a de novo GRIA2 variant (NM_001083619.3: c.2308G > A, p.Ala770Thr) in a patient with obvious behavior regression and psychiatric symptoms. It encodes GluA2, which is the crucial subunit of the AMPA receptor, and the missense variation is predicted to result in instability of the protein structure. CONCLUSIONS: The association between GRIA2 variants and onset of ASD symptoms is rare, and our study expands the spectrum of phenotypic variations. For patients with an unexplained etiology of ASD accompanied by psychiatric symptoms, genetic causes should be considered, and a complete genetic evaluation should be performed.

The role of multi-modal intra-operative neurophysiological monitoring in corrective surgeries for thoracic tuberculosis with kyphosis.

OBJECTIVE: The aim of this study was to assess the performance and utility of motor evoked potentials (MEP) and somatosensory evoked potentials (SSEP) during corrective surgery for thoracic tuberculosis with kyphosis (TTK). METHODS: 68 patients (mean age 31.7 ± 20.3 years) who underwent corrective surgery for TTK from 2012 to 2019 were included in this retrospective study. Patients were neurologicaly evaluated before and after surgery with systematic neurologic examinations. Intraoperative neurophysiological monitoring (IONM) with SSEP and MEP was carried out. A receiver operating characteristic (ROC) curve and area under ROC curve (AUC) were used to identify the diagnostic accuracy of potential recovery. RESULTS: IONM alerting occurred in 12 surgeries (12/68, 17.6%), of which 6 were SSEP alerting, 2 MEP alerting, and 4 combinations of both SSEP and MEP. Among the 12 cases where there was IONM alerting, 3 (25%) had postoperative neurological deficits(PND), whereas one patient had PND without IONM alerting. IONM sensitivity and specificity were 0.75 (95% CI 0.22-0.99) and 0.86 (95% CI 0.74-0.93) respectively. Positive predictive value (PPV) and negative predictive value (NPV) were 0.25 and 0.98 respectively. The AUC of evoked potential recovery in diagnosing PND was 0.884. CONCLUSION: Our study showed that multi-modal IONM with SSEP and MEP can effectively indicate a potential neural injury and predict PND during TTK corrective surgery. LEVEL OF EVIDENCE: Level IV, Therapeutic Study.

Metastatic Ceruminous Adenoid Cystic Carcinoma of the Lumbar Spine Causing Neurological Compromise: A Case Report.

Background: Ceruminous glands are modified apocrine glands of the external auditory canal (EAC). Malignant tumours within the ceruminous glands are extremely rare, and the most common histological type is adenoid cystic carcinoma (ADCC), which has high recurrence and metastasis risks. Although a few cases of metastatic ADCC from other head and neck glands have been reported, metastatic ADCC originating from the ceruminous gland are extremely rare. Case presentation: We present an unusual case of spinal metastases of ADCC from ceruminous glands. A 61-year-old woman complaining of low back pain and both lower limbs pain was referred to our department. The primary ceruminous tumour was resected 26 years ago and recurred 6 years later, which was treated by radiotherapy. Three years ago, she presented with low back pain and was diagnosed as multiple lungs and bone metastases. The patient underwent tumour excision, decompression and fusion. The biopsy revealed metastatic ADCC. The symptoms were alleviated after surgery. Conclusions: ADCC of EAC is a pernicious malignant tumour that is characterized by slow-growing patterns and a high predisposition to recurrence and metastasis. Differential diagnoses of ADCC and benign tumours in the EAC are challenging, particularly at early stages. We report a rare case of ceruminous ADCC with a prolonged clinical history as well as spinal metastasis and highlight the significance of regular follow-ups for patients undergoing tumour excision in the EAC.

The predictive ability of occipital to C3 angle for dysphagia after occipitocervical fusion in patients with combined C2-3 Klippel-Feil syndrome.

BACKGROUND: Improper occipitocervical alignment after occipitocervical fusion (OCF) may lead to devastating complications, such as dysphagia and/or dyspnea. The occipital to C2 angle (O-C2a), occipital and external acoustic meatus to axis angle (O-EAa) have been used to evaluate occipitospinal alignment. However, it may be difficult to identify the inferior endplate of the C2 vertebra in patients with C2-3 Klippel-Feil syndrome (KFS). The purpose of this study aimed to compare four different parameters for predicting dysphagia after OCF in patients with C2-3 KFS. METHODS: There were 40 patients with C2-3 KFS undergoing OCF between 2010 and 2019. Radiographs of these patients were collected to measure the occipital to C3 angle (O-C3a), O-C2a, occipito-odontoid angle (O-Da), occipital to axial angle (Oc-Axa), and narrowest oropharyngeal airway space (nPAS). The presence of dysphagia was defined as the patient complaining of difficulty or excess endeavor to swallow. Patients were divided into two groups according to whether they had postoperative dysphagia. We evaluated the relationship between each of the angle parameters and nPAS and analyzed their influence to the postoperative dysphagia. RESULTS: The incidence of dysphagia after OCF was 25% in patients with C2-3 KFS. The Oc-Axa, and nPAS were smaller in the dysphagia group compared to non-dysphagia group at the final follow-up (p < 0.05). Receiver-operating characteristic (ROC) curves showed that dO-C3a had the highest accuracy as a predictor of the dysphagia with an area under the curve (AUC) of 0.868. The differences in O-C3a, O-C2a, O-Da, and Oc-Axa were all linearly correlated with nPAS scores preoperatively and at the final follow-up within C2-3 KFS patients, while there was a higher R2 value between the dO-C3a and dnPAS. Multiple linear regression analysis showed that the difference of O-C3a was the only significant predictor for dnPAS (ß = 0.670, p < 0.001). CONCLUSIONS: The change of O-C3a (dO-C3a) is the most reliable indicator for evaluating occipitocervical alignment and predicting postoperative dysphagia in C2-3 KFS patients. Moreover, dO-C3a should be more than - 2° during OCF to reduce the occurrence of postoperative dysphagia.

A novel posterior multiple screws distraction reducer system versus anterior release, posterior internal distraction, and subsequent spinal fusion for severe scoliosis.

PURPOSE: We previously reported anterior release, posterior internal distraction, and subsequent spinal fusion (ARPIDF) for the correction of severe scoliosis with a satisfactory correction rate. However, surgical procedures were completed in 2-3 stages. Here we compare Cobb angle of ≥90° in scoliosis correction between a novel posterior multiple screws distraction reducer (MSDR) system and ARPIDF. METHODS: Thirty-six patients with severe scoliosis treated by MSDR or ARPIDF (n = 18 in both groups). We retrospectively analyzed and compared outcome measures between the two groups over a minimum follow-up duration of 2 years. The following variables were compared between the two groups: age at surgery, sex, etiology, flexibility of the main thoracic curve, number of fused segments and screws, operation time, estimated blood loss, hospitalization time, follow-up duration, various radiological parameters, complication rate, and Scoliosis Research Society-30 score. RESULTS: There were no significant between-group differences with respect to age, sex, etiology, flexibility of the main thoracic curve, number of fused segments and screws, and follow-up duration. Further, there was no significant difference in terms of preoperative, postoperative, and final follow-up findings of the radiographic data. However, the ARPIDF group had longer operation and hospitalization times and greater blood loss. In the ARPIDF group, 4 patient developed complications (infection, intraoperative neuromonitoring changes, transient dyspnea); none of these events occurred in the MSDR group. CONCLUSION: The use of MSDR helped achieve greater scoliosis correction with a shorter operation time, lower blood loss, and lower complication rate than the use of ARPIDF. MSDR facilitates safer and easier correction of severe scoliosis without increasing surgical risk.

Proximal junctional kyphosis in Lenke 5 AIS patients: the important factor of pelvic incidence.

BACKGROUND: The purpose of the study was to investigate whether pelvic incidence (PI) will affect the occurrence of PJK in Lenke 5 AIS patients after correction surgery and try to explore a better surgical scheme based on PI. METHODS: Lenke 5C AIS patients that underwent correction surgery with a minimum of a 2-year follow-up were identified. Demographic and radiographic data were collected preoperatively, postoperatively, and at the final follow-up. The comparison between the PJK and the Non-PJK group was conducted and the subgroup analysis was performed based on the preoperative value of PI to investigate the potential mechanism of PJK. Clinical assessments were performed using the Scoliosis Research Society (SRS)-22 questionnaire. RESULTS: The mean preoperative Cobb angle of the TL/L curve was 53.4°±8.6. At the final follow-up, the mean TL/L Cobb angle was drastically decreased to 7.3°±6.8 (P < 0.001). The incidence of PJK in Lenke 5 AIS was 18.6 %, 21.9 % (7/32) in the low PI group (PI < 45°) and 15.8 % (6/38) in the high PI group (PI ≥ 45°), and there was no statistical difference between the two groups (χ2 = 0.425, P = 0.514). For low PI patients, there is no significant difference where the UIV is located with regards to the TK apex between the PJK and Non-PJK subgroups (χ2 = 1.103, P = 0.401). For high PI patients, PJK was more likely to occur when UIV was cephalad to than caudal to the TK apex (31.25 % vs. 4.7 %, P = 0.038). There was no significant difference in the selection of LIV between the two groups. CONCLUSIONS: There is no difference in the incidence of PJK between the Lenke 5 AIS patients with low PI (< 45°) and high PI (≥45°), but the main risk factor of PJK should be different. For patients with low PI, overcorrection of LL should be strictly avoided during surgery. For patients with high PI, the selection of UIV should not be at or cephalad to the apex of thoracic kyphosis to retain more mobile thoracic segments.

[Predictive abilities of O-C2 angle, O-EA angle, and Oc-Ax angle for the development of dysphagia in patients after occipitocervical fusion].

OBJECTIVE: To compare the predictive abilities of O-C2 angle (O-C2a), O-EA angle (O-EAa), and Oc-Ax angle (Oc-Axa) for development of dysphagia in patients after occipitocervical fusion (OCF). METHODS: Between April 2010 and May 2019, 114 patients who underwent OCF and met the selection criteria were selected as the research objects. Among them, 54 were males and 60 were females; they were 14-76 years old, with an average of 50.6 years old. The follow-up time was 13-122 months (median, 60.5 months). The O-C2a, O-EAa, Oc-Axa, and the narrowest oropharyngeal airway space (nPAS) were measured by the lateral X-ray films before operation and at last follow-up, and the differences before and after operation (dO-C2a, dO-EAa, dOc-Axa, and dnPAS) were calculated. Patients were divided into two groups according to whether they had developed postoperative dysphagia. The general data including age, gender, fixed segment, proportion of patients with rheumatoid arthritis (RA), atlantoaxial subluxation (AS), and combined with anterior release surgery (ARS), and imaging indicators were compared between the two groups. The correlations between dO-C2a, dO-EAa, and dOc-Axa and dnPAS in 114 patients were analyzed to further compare the predictive value of three imaging indicators for occurrence of dysphagia after OCF. RESULTS: Dysphagia occurred after OCF in 31 cases with the incidence of 27.2%. There was significant difference in gender between the dysphagia group and the non-dysphagia group ( χ 2=7.940, P=0.005). There was no significant difference between the two groups in age, fixed segment, the proportion of patients with RA, the proportion of patients with AS, and the proportion of patients combined with ARS ( P>0.05). There was no significant difference in O-C2a and Oc-Axa of 114 patients before operation and at last follow-up ( P>0.05). The differences in O-EAa and nPAS were significant ( P<0.05). There was no significant difference in preoperative O-EAa, Oc-Axa, and nPAS between the dysphagia group and the non-dysphagia group ( P>0.05); the difference in the O-C2a was significant ( t=2.470, P=0.016). At last follow-up, the differences in the above imaging indicators were significant ( P<0.05). There were significant differences in the dO-C2a, dO-EAa, dOc-Axa, and dnPAS between the two groups ( P<0.05). Correlation analysis showed that the dO-C2a, dO-EAa, dOc-Axa were all positively correlated with dnPAS ( P<0.05). The dO-C2a≤-5°, postoperative O-EAa≤100°, postoperative Oc-Axa≤65° were all related to postoperative dysphagia ( P<0.05), and the highest risk factor suffering postoperative dysphagia was dO-C2a ≤-5° with a significant OR of 14.4. CONCLUSION: The dO-C2a, postoperative O-EAa, and postoperative Oc-Axa can be used as the predictive indexes of dysphagia after OCF, among which dO-C2a has the highest predictive value.

The effect of multiple-dose oral versus intravenous tranexamic acid in reducing postoperative blood loss and transfusion rate after adolescent scoliosis surgery: a randomized controlled trial.

BACKGROUND CONTEXT: Tranexamic acid (TXA) is widely used in surgery for adolescent idiopathic scoliosis (AIS) and has been proved to be efficacious in reducing intraoperative blood loss (IBL) and the transfusion rate. However, the routine TXA regimen was intraoperative administration alone, in which the concentration of TXA could not cover the whole process of hyperfibrinolysis. And, its ability to control the massive postoperative blood loss (PBL) may be insufficient. Thus, we promoted a multiple-dose regimen of TXA for patients with AIS who underwent surgical correction. PURPOSE: The primary aims were (1) to determine whether the multiple-dose regimen of TXA could reduce PBL and the postoperative transfusion rate, and (2) to compare the efficacy of oral administration with intravenous administration. The secondary aims were (3) to evaluate whether this regimen could alleviate inflammatory response, and (4) to assess the occurrence of drug-related side effects. STUDY DESIGN: Prospective, double-blinded, randomized controlled trial. PATIENT SAMPLE: A total of 108 patients with AIS who underwent posterior scoliosis correction and spinal fusion (PSS) were enrolled in this study. OUTCOME MEASURES: The primary parameters were PBL and postoperative transfusion rate. Other parameters such as total blood loss (TBL), maximum hemoglobin (Hb) decrease, volume of drainage, inflammation markers (interleukin-6 [IL-6] and C-reactive protein [CRP]), and occurrence of complications were also collected and compared. Multiple regression analysis was used to examine the variables that affected PBL. METHODS: Patients were randomized into three groups. All patients received intravenous TXA 50 mg/kg loading dose and 10 mg/kg/h maintenance dose during surgery. Group A received 1 g oral TXA at 4 hours, 10 hours, and 16 hours postoperatively; group B received 0.5 g intravenous TXA at 6 hours, 12 hours, and 18 hours postoperatively; group C received placebo. RESULTS: The mean PBL and postoperative transfusion rate in group A (957.8±378.9 mL, 13.89%) and B (980.3±491.8 mL, 11.11%) were significantly lower than those in group C [1,495.9±449.6 mL, mean differences=538.1 mL, 95% confidence interval (CI), 290.1-786.1 mL, p<0.001; 515.6 mL, 95% CI, 267.6-763.6 mL, p<.001]; (36.11%, p=.029, p=.013). Meanwhile, the mean TBL, maximum Hb decrease, and volume of drainage were also significantly lower in group A and B than in group C. IL-6 and CRP in group A and B were significantly lower than in group C from postoperative days 1 to 3. All these differences were not significant between groups A and B. No drug-related complications were observed in any patient. Multiple regression showed that the application of postoperative TXA and number of screws were significant parameters affecting PBL. CONCLUSIONS: A multiple-dose regimen of TXA, either by oral or intravenous application, could be a safe and effective means of controlling PBL and decreasing the postoperative transfusion rate in patients with AIS who underwent scoliosis surgery. In addition, it could inhibit postoperative inflammatory response.

Comparison of long-term clinical and radiographic outcomes between alternative-level and all-level fixation unilateral open-door laminoplasty.

BACKGROUND CONTEXT: Titanium mini-plate has been used in unilateral open-door laminoplasty to maintain the open angle of laminae. Previously, both all-level fixation (C3-C7) and alternative-level (C3, C5, C7) unilateral open-door laminoplasty have been proven to have satisfactory clinical outcomes. However, whether they could achieve similar long-term clinical and radiographic efficacy is still questionable. PURPOSE: To compare the long-term clinical and radiological outcomes between alternative-level and all-level fixation unilateral open-door laminoplasty with a mini-plate fixation system. STUDY DESIGN/SETTING: Retrospective comparative study. PATIENT SAMPLE: Ninety-one patients who underwent unilateral open-door laminoplasty. OUTCOME MEASURES: Clinical results including Japanese Orthopedic Association score, Visual Analogue Score, Neck Dysfunction Index score. Radiographic results including cervical curvature index, cervical range of motion, and the spinal canal expansive parameters, including anteroposterior diameter, Pavlov's ratio, and open angle. METHODS: Between April 2007 and June 2011, 91 patients with minimum 7-year postoperative follow-up were included. Thirty-eight underwent alternative-level fixation (group A) and 53 underwent all-level fixation (group B). Demographic data, including age, gender, operative time, blood loss, and cost, were collected and compared between the two groups. Clinical and radiographic data were obtained preoperatively, at 3 and 6 months and 1 and 3 years postoperatively, as well as at final follow-up. The difference between the two groups and between different time points within one group was compared. RESULTS: Both groups obtained satisfactory clinical outcomes till the final follow-up. No statistic difference was found in Japanese Orthopedic Association, Visual Analogue Score, and Neck Dysfunction Index between the two groups throughout the whole follow-up. Both groups maintained APD and Pavlov's ratio well till follow-up. However, statistic difference was found in the open angle between two groups at final follow-up (34.17±2.75° vs. 36.19±1.80°, p<.05). When we subdivided the cervical segments in group A, we found the mini-plate segments showed maintenance in open angle but a 4.52° decrease in suture segments. The mean cost in group B (17,669.82±1,157.65 $) was significantly higher than in group A (11,452.19±871.07 $; p<.05). CONCLUSIONS: Despite a difference in the maintenance of open angle, both fixation methods achieved satisfactory clinical outcomes. We believe alternative-level fixation is also a safe, effective, and economical fixation method.

miR-384-5p promotes spinal cord injury recovery in rats through suppressing of autophagy and endoplasmic reticulum stress.

BACKGROUND: Spinal cord injury (SCI) is one of the most serious neurological disorders and is characterized by high morbidity and disability. Unfortunately, there is a lack of effective treatment. Recently, the micro RNA, miR-384-5p, was reported to play a significant role in cell survival in response to different insults. METHODS: In vitro model of traumatic neuronal injury was induced by application of a sharp sterile blade to generate cuts in PC12 cells, and in vivo SCI was produced by applying vascular clips (force of 15 g) to the dura via T9-T10 laminectomy, and then, the role of miR-384-5p in the development of SCI was investigated. RESULTS: Dual-luciferase reporter assays confirmed that miR-384-5p regulates the gene expression of Beclin-1, an important promoter of autophagy. Quantitative polymerase chain reaction and western blot analyses revealed that treatment with miR-384-5p decreased mRNA and protein expression of Beclin-1 in the mechanically injured PC12 cells. In rats with spinal cord compression injuries, miR-384-5p expression was significantly decreased. Treatment with miR-384-5p increased spinal cord neuron survival and promoted locomotor function recovery in rats. Further study revealed that miR-384-5p administration decreased immunofluorescent labeling of Beclin-1 in spinal cord tissues and reduced autophagosome formation in neurons, as shown by transmission electron microscopy. These results indicated that miR-384-5p promotes recovery of rats with SCI by suppressing autophagy via direct targeting of Beclin-1. Moreover, miR-384-5p also inhibited the activation of endoplasmic reticulum (ER) stress by decreasing GRP78 expression in both in vitro and in vivo models. CONCLUSIONS: This study for the first time demonstrates that the protective role of miR-384-5p in the process of SCI is associated with simultaneous suppression of autophagy and ER stress and miR-384-5p could be a promising candidate for SCI therapeutics.

Predictive abilities of O-C2a and O-EAa for the development of postoperative dysphagia in patients undergoing occipitocervical fusion.

BACKGROUND CONTEXT: Dysphagia is a common postoperative complication in patients undergoing occipitocervical fusion (OCF). Previous studies had proposed the use of two measures-the occipital to C2 angle (O-C2a) and the occipital and external acoustic meatus to axis angle (O-EAa)-to predict postoperative dysphagia after OCF. However, these studies had small sample sizes and the predictive abilities of both measures are still not clear. PURPOSE: To evaluate the predictive ability of O-EAa and O-C2a for dysphagia after OCF. STUDY DESIGN: A retrospective clinical study. PATIENT SAMPLE: A total of 109 consecutive patients who had undergone OCF. OUTCOME MEASURES: Presence of postoperative dysphagia, O-C2a, C2 tilting angle (C2Ta), O-EAa, and the narrowest oropharyngeal airway space (nPAS). METHODS: Between April 2010 and June 2018, 109 consecutive patients who had undergone OCF were reviewed. Patients were divided into two groups according to the presence of postoperative dysphagia. Radiographic measurements, including O-C2a, C2Ta, O-EAa, and nPAS, were evaluated at preoperative and 1 month postoperative and the findings were compared. Simple linear regression was used to measure the correlations between the parameters and the presence of dysphagia, and the correlations within the parameters. Multiple regression analysis was used to examine the variables that affected the change of nPAS (dnPAS%). Sensitivity and specificity analyses were used to evaluate the effectiveness of the previously proposed measures ("O-C2a change≤-5°" and "postoperative O-EAa<100°") for prediction of post-OCF dysphagia. RESULTS: The incidence of dysphagia after OCF was 26.6% (29/109). Preoperative values for the radiographic parameters were similar between patients with and without dysphagia. In the dysphagia group, both O-C2a and O-EAa values showed a dramatic decrease after surgery, which was accompanied by a decrease in nPAS. Postoperative O-C2a, O-EAa, and nPAS in the dysphagia group were significantly smaller than those in the nondysphagia group (p<.05). The changes in O-EAa, O-C2a, and nPAS showed a linear correlation with the presence of dysphagia (p<.05). In addition, linear correlations were found between two of the three parameters. Multiple regression showed the change of O-C2a and O-EAa were significant predictors for dnPAS% (ß=0.200, p=.022 and ß=0.549, p=.000). The sensitivity and specificity of "O-C2a change≤-5°" in predicting dysphagia were 75.9% and 80.0% respectively, and those of "postoperative O-EAa<100°" were 75.9% and 62.5%, respectively. However, the sensitivity of the combination of these two values in predicting postoperative dysphagia was as high as 96.6%. CONCLUSION: Both O-EAa and O-C2a could be critical predictors for postoperative dysphagia. During surgery, ensuring that the O-EAa exceeds 100° and simultaneously avoiding an O-C2a reduction greater than 5° could effectively avert postoperative dysphagia.

Minimally invasive lateral lumbar intervertebral fusion versus traditional anterior approach for localized lumbar tuberculosis: a matched-pair case control study.

BACKGROUND CONTEXT: Minimally invasive lateral lumbar intervertebral fusion (LLIF) procedure has been reported as a feasible alternative to the traditional anterior approach for patients with lumbar tuberculosis. However, there is still no study in the existing literature comparing LLIF to traditional surgeries in the treatment of such patients. PURPOSE: To evaluate the clinical, radiological, and functional outcomes of LLIF versus the traditional anterior approach for treating localized lumbar tuberculosis. STUDY DESIGN: Retrospective case-control study. PATIENT SAMPLE: A total of 60 patients with single-level localized lumbar tuberculosis. OUTCOME MEASURES: The outcome parameters included incision length, operation time, blood loss, complications, segmental lordosis, fusion status, Frankel grade, erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), visual analog scale (VAS), and Oswestry Disability Index (ODI). METHODS: We matched 20 patients treated by LLIF with 40 patients undergoing traditional anterior surgery (ratio, 1:2) by age, sex, lesion level, and radiographic features. The LLIF group consisted of 12 men and eight women with a mean age of 42.2±11.1 years, while the traditional group consisted of 22 men and 18 women with a mean age of 40.0±14.5 years. Both the demographics and radiographic data were reviewed. Pre- and postoperative segmental lordosis Cobb angle was measured on lateral X-ray films, while fusion status was assessed on computed tomography scans. The VAS and ODI were used to evaluate functional outcomes. RESULTS: The average follow-up was 24 months in the LLIF group and 39 months in the traditional group. Incision length, operation time, and blood loss were significantly less in the LLIF group than in the traditional group. A similar improvement in segmental lordosis after operation was found in both groups. There was no significant difference between the two groups in neurological recovery, blood infection markers (ESR, CRP), functional outcome, or fusion rate, except for the postoperative VAS score, which was significantly lower in the LLIF group than in the traditional group (2.7±1.0 vs. 3.6±1.0, p=.003). Four patients in the traditional group received a transfusion and 4 patients had a superficial wound infection, while no patient in the LLIF group received a transfusion or experienced any infection; however, the difference between the two groups was not statistically significant (p=.291). CONCLUSIONS: Both LLIF and traditional anterior surgery are sufficient for treating patients with localized lumbar tuberculosis, but the LLIF approach results in significantly shorter operation time and less blood loss.

The Efficacy of Hemivertebra Resection for Hemimetameric Segmental Shift.

BACKGROUND: Hemimetameric segmental shift (HMMS) is defined as ≥2 contralateral hemivertebrae (HV) that are separated by at least 1 normal vertebra. Theoretically, the 2 HV tend to balance each other to produce minor spine deformities. However, curve progression has still been observed in HMMS. No research has yet specifically studied its surgical treatment. This study aimed to report efficacy of HV resection for HMMS. METHODS: From 2009 to 2015, 15 patients (5 male and 10 female) with HMMS underwent HV resection in our department. Average age at the time of surgery was 10.5 ± 4.7 years, and mean length of follow-up was 38.5 ± 7.1 months. Clinical outcomes and related complications were assessed by reviewing the medical records, operative notes, radiographic data, and scores on the Scoliosis Research Society-22 questionnaire. RESULTS: The segmental curve was 45.1° ± 10.6° preoperatively, 14.3° ± 7.8° postoperatively, and 15.3° ± 7.6° at the latest follow-up. The cranial compensatory curve was 17.1° ± 11.9°, 8.9° ± 6.3°, and 7.8° ± 6.5°. The caudal compensatory curve was 12.0° ± 11.0°, 4.5° ± 4.8°, and 4.3° ± 5.0°. Spinal balance was significantly improved in both coronal and sagittal planes and remained stable until the latest follow-up. Three domains of the Scoliosis Research Society-22 questionnaire, including general self-image, mental health, and satisfaction, were significantly improved at the latest follow-up compared with preoperative status. CONCLUSIONS: HV resection is a safe and effective treatment for HMMS that causes progressive or severe deformity.

Posterior hemivertebral resection for upper thoracic congenital scoliosis: be aware of high risk of complications.

The treatment of congenital hemivertebrae in the upper thoracic region is challenging. The objective of this study was to investigate the outcomes of posterior hemivertebral resection for the upper thoracic region. Twenty-one patients diagnosed with upper thoracic congenital scoliosis were included. All of them received hemivertebral resection surgery via the posterior-only approach with at least 2 years of follow-up. The radiographic parameters and Scoliosis Research Society-22 score were analyzed. All the intraoperative and postoperative complications were recorded retrospectively. The segmental main curve was 35.9° before surgery and 7.0° at the last follow-up, with an average correction rate of 80.2%. The total main curve was 44.1° before surgery and 11.6° at the last follow-up, with an average correction rate of 73.9%. The caudal compensatory curve was corrected from 20.2° to 7.1°, with an average correction rate of 64.9%. The segmental kyphosis was corrected from 30.9° to 8.9°, with an average correction rate of 65.5%. The total Scoliosis Research Society-22 score significantly improved in all patients at the last follow-up, mainly resulting from the improvement of the self-image, mental health, and satisfaction domains. The following complications were found: one pedicle fracture, two malpositioned screws, one transient neurologic deficit, one implant failure, and four postoperative curve progressions. Although good radiographic deformity correction and clinical results were achieved after surgery, the incidence rate of complications was high at 42.9%; great care should be taken to prevent them, especially for postoperative curve progression (19.0%).

Coronal and sagittal balance in Lenke 5 AIS patients following posterior fusion: important role of the lowest instrument vertebrae selection.

BACKGROUND: Lenke 5 AIS is a kind of three-dimensional deformity and literature reported it usually accompany with coronal or/and sagittal imbalance. However, the postoperative coronal and sagittal balance in these patients has rarely be analyzed previously and the predict factors for postoperative trunk balance are still unclear. To synthetically analysis coronal and sagittal balance of Lenke 5 AIS patients simultaneously and found out predict factors for postoperative coronal or/and sagittal imbalance. METHODS: Fifty-six Lenke 5 AIS patients who underwent posterior surgery and be followed up more than 2 years were included in this study. Coronal parameters included main curve Cobb angle, lumbosacral hemi-curve Cobb angle, preoperative LEV/LIV tilt and translation and C7-CSVL distance; While sagittal parameters included pelvic incidence(PI), sacral slope(SS), pelvic tilt(PT), lumbar lordosis(LL), thoracic kyphosis(TK), and sagittal vertical axis(SVA). Coronal imbalance was defined as C7-CSVL> 20 mm, and sagittal imbalance defined as (1) SVA > 40 mm or (2) PT < 20% PI/2 or PT > 20° or (3) PI-LL > 10°. And relative parameters were compared between balance and imbalance group to find out predict factors. RESULTS: All seven final coronal imbalance patients occurred in LIV = L5 group. Preoperative LIV tilt(11.4°) and translation(5.2 mm) in coronal imbalance group were abnormally lower than balance group (21.7° and 15.7 mm respectively). Eighteen patients performed final sagittal imbalance. The PI in these patients (37.7°) was significantly lower than balance group (48.0°). And most of finial sagittal imbalance patients also occurred in LIV = L5 group. CONCLUSIONS: LIV = L5 as a threshold point, represents higher risk of postoperative coronal and/or sagittal imbalance. Besides, large LEV-S1 curve in reduce-bending film and small PI is directly related to final coronal imbalance and sagittal imbalance respectively.