Efficacy and Safety of Condoliase Disc Administration as a New Treatment for Lumbar Disc Herniation.

INTRODUCTION: Condoliase is a newly approved drug that improves symptoms associated with lumbar disk herniation (LDH) by intradiscal administration. This study aimed to evaluate the mid-term outcomes of condoliase injection, examine the adverse events, including cases that required surgery after condoliase administration, and verify cases in which condoliase could be effective. METHODS: We enrolled patients with LDH who were treated conservatively for at least six weeks and received condoliase. We assessed the visual analog scale (VAS) score, Japanese Orthopaedic Association Back Pain Evaluation Questionnaire, Oswestry Disability Index, disk height, and disk degeneration for up to 6 months, and we examined the complications. Furthermore, a 50% or more improvement in leg pain VAS score was considered effective. Factors related to symptom improvement were investigated by determining whether lower limb pain improved in six months. RESULTS: In total, 84 patients were recruited (52 men, 32 women; mean age, 44.2 ± 17.1 [16-86 years]). The duration of illness was 6.7 ± 6.8 (1.5-30) months. All patient-based outcomes significantly improved at 4 weeks after the administration compared with pretreatment. The intervertebral disc height decreased significantly at four weeks after condoliase administration compared with that before administration. Progression of intervertebral disc degeneration occurred in 50% of the patients. Eleven patients underwent herniotomy due to poor treatment effects. Moreover, treatment in 77.4% of the patients was considered effective. A logistic regression analysis revealed that L5/S1 disk administration (p = 0.029; odds ratio, 5.94; 95% confidence interval, 1.20-29.45) were significantly associated with clinical effectiveness. CONCLUSIONS: Condoliase disk administration improved pain and quality of life over time. Condoliase disk administration was more effective in L5/S1 intervertebral administration.

Effect of Early vs Delayed Surgical Treatment on Motor Recovery in Incomplete Cervical Spinal Cord Injury With Preexisting Cervical Stenosis: A Randomized Clinical Trial.

Importance: The optimal management for acute traumatic cervical spinal cord injury (SCI) is unknown. Objective: To determine whether early surgical decompression results in better motor recovery than delayed surgical treatment in patients with acute traumatic incomplete cervical SCI associated with preexisting canal stenosis but without bone injury. Design, Setting, and Participants: This multicenter randomized clinical trial was conducted in 43 tertiary referral centers in Japan from December 2011 through November 2019. Patients aged 20 to 79 years with motor-incomplete cervical SCI with preexisting canal stenosis (American Spinal Injury Association [ASIA] Impairment Scale C; without fracture or dislocation) were included. Data were analyzed from September to November 2020. Interventions: Patients were randomized to undergo surgical treatment within 24 hours after admission or delayed surgical treatment after at least 2 weeks of conservative treatment. Main Outcomes and Measures: The primary end points were improvement in the mean ASIA motor score, total score of the spinal cord independence measure, and the proportion of patients able to walk independently at 1 year after injury. Results: Among 72 randomized patients, 70 patients (mean [SD] age, 65.1 [9.4] years; age range, 41-79 years; 5 [7%] women and 65 [93%] men) were included in the full analysis population (37 patients assigned to early surgical treatment and 33 patients assigned to delayed surgical treatment). Of these, 56 patients (80%) had data available for at least 1 primary outcome at 1 year. There was no significant difference among primary end points for the early surgical treatment group compared with the delayed surgical treatment group (mean [SD] change in ASIA motor score, 53.7 [14.7] vs 48.5 [19.1]; difference, 5.2; 95% CI, -4.2 to 14.5; P = .27; mean [SD] SCIM total score, 77.9 [22.7] vs 71.3 [27.3]; P = .34; able to walk independently, 21 of 30 patients [70.0%] vs 16 of 26 patients [61.5%]; P = .51). A mixed-design analysis of variance revealed a significant difference in the mean change in ASIA motor scores between the groups (F1,49 = 4.80; P = .03). The early surgical treatment group, compared with the delayed surgical treatment group, had greater motor scores than the delayed surgical treatment group at 2 weeks (mean [SD] score, 34.2 [18.8] vs 18.9 [20.9]), 3 months (mean [SD] score, 49.1 [15.1] vs 37.2 [20.9]), and 6 months (mean [SD] score, 51.5 [13.9] vs 41.3 [23.4]) after injury. Adverse events were common in both groups (eg, worsening of paralysis, 6 patients vs 6 patients; death, 3 patients vs 3 patients). Conclusions and Relevance: These findings suggest that among patients with cervical SCI, early surgical treatment produced similar motor regain at 1 year after injury as delayed surgical treatment but showed accelerated recovery within the first 6 months. These exploratory results suggest that early surgical treatment leads to faster neurological recovery, which requires further validation. Trial Registration: ClinicalTrials.gov Identifier: NCT01485458; umin.ac.jp/ctr Identifier: UMIN000006780.

Ventral Longitudinal Intraspinal Fluid Collection in Patients with Cervical Disc Herniation: A Report of Two Cases.

We encountered two cases of cervical disc herniation, wherein cerebrospinal fluid collection in the ventral epidural space between the cervical spine and the thoracic spine was noted. The patients, two women aged 71 and 43 years, were diagnosed with cervical disc herniation and underwent anterior cervical discectomy and fusion. Unexpected cerebrospinal fluid leakage was observed prior to exposure of the dura mater. Notably, the dura mater was intact following the removal of the herniated disc in both cases. No cerebrospinal fluid leakage symptoms were observed, and relief from the neurological symptoms related to the cervical disc herniation was observed in both cases following the surgery. Findings of preoperative magnetic resonance imaging and computed tomography myelography were carefully reviewed, retrospectively. Both patients presented with similar features including expansion of cerebrospinal fluid collection in the ventral epidural space between the cervical spine and the thoracic spine. These observed features were similar to those of superficial siderosis, which is a form of duropathy-a disease caused by dural defects. Therefore, the patients in this case study might have a subclinical duropathy with associated cervical disc herniation.

Implant failure of pedicle screws in long-segment posterior cervical fusion is likely to occur at C7 and is avoidable by concomitant C6 or T1 buttress pedicle screws.

The aim of this study was to investigate the incidence and characteristics of implant failure in posterior cervical long-segment fusion surgery. We retrospectively reviewed 51 cases of posterior cervical long-segment fusion surgery that used pedicle screws, lateral mass screws, or laminar screws. The cranial end of the fusion was C2 or C3, and the caudal end of the fusion was C7 or T1. All patients were observed with CT scans at 6 months postoperatively. We evaluated the loosening and breakage of the implanted screws or rods. In the 51 patients, 257 pedicle screws, 9 laminar screws and 233 lateral mass screws were placed. Implant failure occurred in 25 patients (49.0%). Screw loosening was found in 42 screws (8.4%). Screw breakage occurred in 6 (1.2%) screws. The implant failures were particularly observed in both ends of the fusion level. When C7 was the end of the lower instrumented level, the incidence was 40% without C6 pedicle screws, 33% with unilateral C6 pedicle screws, and 0% with bilateral C6 pedicle screws. The present study revealed that the incidence of implant failures of the screws in long-segment posterior cervical fusion surgery was higher, especially in the caudal end of the fusion levels. In cases where C7 was the lowest instrumented vertebra, buttress screw insertion to C6 is recommended to avoid implant failure of C7 pedicle screws.

Regenos spacers are not suitable for open-door laminoplasty because of serious adverse events caused by their insufficient mechanical strength.

We used a newly developed, high-porosity unidirectional porous hydroxyapatite spacer (Regenos spacer, not approved by the FDA). The aim of the present study was to elucidate the effectiveness of Regenos laminar spacers for open-door type laminoplasty. The present study included 39 patients who underwent open-door type laminoplasty with Regenos spacers from April 2015 to December 2016 and were followed up for at least 6 months after surgery. We grafted 68 Regenos spacers in 39 patients. Pre- and postoperative neurological status of patients were evaluated using JOA score and recovery rate. Breakage of Regenos spacers, laminar closure, and bone-hydroxyapatite spacer bonding were assessed using 12-month postoperative sagittal and axial CT images. The average preoperative JOA score was 9.5 ±â€¯3.2/17, and the average postoperative JOA score was 12.5 ±â€¯2.9/17. JOA score recovery rate was 34 ±â€¯41% at the latest follow-up visit. The bony fusion rate of the hinge sides was 87%. Breakage and deformity of implanted spacers was observed in 69% of patients and 59% of spacers with a CT sagittal view, and CT axial view at 12 months revealed fine cracks and collapse in 17 spacers in 14 patients. The average angle was -2.4 ±â€¯4.8°, including 46 of 68 spacers showing a negative value, resulting in a rate of laminar reclosure of 35%. Postoperative CT demonstrated good bone bonding rate. Nevertheless, clinical results with low recovery rates were obtained with complications related to the use of Regenos spacers.

Exploration of Spinal Cord Aging-Related Proteins Using a Proteomics Approach.

How aging affects the spinal cord at a molecular level is unclear. The aim of this study was to explore spinal cord aging-related proteins that may be involved in pathological mechanisms of age-related changes in the spinal cord. Spinal cords of 2-year-old and 8-week-old female Sprague-Dawley rats were dissected from the animals. Protein samples were subjected to 2-dimentional polyacrylamide gel electrophoresis followed by mass spectrometry. Screened proteins were further investigated with immunohistochemistry and Western blotting. Among the screened proteins, we selected α-crystallin B-subunit (αB-crystallin) and peripherin for further investigation because these proteins were previously reported to be related to central nervous system pathologies. Immunohistochemistry and Western blotting revealed significant upregulation of αB-crystallin and peripherin expression in aged rat spinal cord. Further exploration is needed to elucidate the precise mechanism and potential role of these upregulated proteins in spinal cord aging processes.

Paravertebral foramen screw fixation for posterior cervical spine fusion: biomechanical study and description of a novel technique.

OBJECTIVE Fusion surgery with instrumentation is a widely accepted treatment for cervical spine pathologies. The authors propose a novel technique for subaxial cervical fusion surgery using paravertebral foramen screws (PVFS). The authors consider that PVFS have equal or greater biomechanical strength than lateral mass screws (LMS). The authors' goals of this study were to conduct a biomechanical study of PVFS, to investigate the suitability of PVFS as salvage fixation for failed LMS, and to describe this novel technique. METHODS The authors harvested 24 human cervical spine vertebrae (C3-6) from 6 fresh-frozen cadaver specimens from donors whose mean age was 84.3 ± 10.4 years at death. For each vertebra, one side was chosen randomly for PVFS and the other for LMS. For PVFS, a 3.2-mm drill with a stopper was advanced under lateral fluoroscopic imaging. The drill stopper was set to 12 mm, which was considered sufficiently short not to breach the transverse foramen. The drill was directed from 20° to 25° medially so that the screw could purchase the relatively hard cancellous bone around the entry zone of the pedicle. The hole was tapped and a 4.5-mm-diameter × 12-mm screw was inserted. For LMS, 3.5-mm-diameter × 14-mm screws were inserted into the lateral mass of C3-6. The pullout strength of each screw was measured. After pullout testing of LMS, a drill was inserted into the screw hole and the superior cortex of the lateral mass was pried to cause a fracture through the screw hole, simulating intraoperative fracture of the lateral mass. After the procedure, PVFS for salvage (sPVFS) were inserted on the same side and pullout strength was measured. RESULTS The CT scans obtained after screw insertion revealed no sign of pedicle breaching, violation of the transverse foramen, or fracture of the lateral mass. A total of 69 screws were tested (23 PVFS, 23 LMS, and 23 sPVFS). One vertebra was not used because of a fracture that occurred while the specimen was prepared. The mean bone mineral density of the specimens was 0.29 ± 0.10 g/cm3. The mean pullout strength was 234 ± 114 N for PVFS, 158 ± 91 N for LMS, and 195 ± 125 N for sPVFS. The pullout strength for PVFS tended to be greater than that for LMS. However, the difference was not quite significant (p = 0.06). CONCLUSIONS The authors introduce a novel fixation technique for the subaxial cervical spine. This study suggests that PVFS tend to provide stronger fixation than LMS for initial applications and fixation equal to LMS for salvage applications. If placement of LMS fails, PVFS can serve as a salvage fixation technique.

Human Schwann cells exhibit long-term cell survival, are not tumorigenic and promote repair when transplanted into the contused spinal cord.

The transplantation of rodent Schwann cells (SCs) provides anatomical and functional restitution in a variety of spinal cord injury (SCI) models, supporting the recent translation of SCs to phase 1 clinical trials for human SCI. Whereas human (Hu)SCs have been examined experimentally in a complete SCI transection paradigm, to date the reported behavior of SCs when transplanted after a clinically relevant contusive SCI has been restricted to the use of rodent SCs. Here, in a xenotransplant, contusive SCI paradigm, the survival, biodistribution, proliferation and tumorgenicity as well as host responses to HuSCs, cultured according to a protocol analogous to that developed for clinical application, were investigated. HuSCs persisted within the contused nude rat spinal cord through 6 months after transplantation (longest time examined), exhibited low cell proliferation, displayed no evidence of tumorigenicity and showed a restricted biodistribution to the lesion. Neuropathological examination of the CNS revealed no adverse effects of HuSCs. Animals exhibiting higher numbers of surviving HuSCs within the lesion showed greater volumes of preserved white matter and host rat SC and astrocyte ingress as well as axon ingrowth and myelination. These results demonstrate the safety of HuSCs when employed in a clinically relevant experimental SCI paradigm. Further, signs of a potentially positive influence of HuSC transplants on host tissue pathology were observed. These findings show that HuSCs exhibit a favorable toxicity profile for up to 6 months after transplantation into the contused rat spinal cord, an important outcome for FDA consideration of their use in human clinical trials.

Drop finger caused by 8th cervical nerve root impairment: a clinical case series.

PURPOSE: Recently, it has been reported that impairment by an 8th cervical nerve root lesion can cause drop finger, namely C8 drop finger. Here, we report a clinical case series of C8 drop finger to reveal the clinical outcome of surgical treatments to allow for a better choice of treatment. METHODS: The present study included 17 consecutive patients who were diagnosed as having C8 drop finger, in which muscle strength of the extensor digitorum communis (EDC) showed a manual muscle testing (MMT) grade of 3 or less. We retrospectively investigated the clinical characteristics of C8 drop finger and recovery of muscle power was measured by subtraction of preoperative MMT of the EDC from the final follow-up values. RESULTS: Nine cases showed recovery of muscle power of EDC, whereas the remaining eight cases did not show any recovery including two cases of deterioration. None of the conservatively treated patients showed any recovery. Surgically treated cases included two cases of deterioration. In the cases showing recovery, recovery began 9.9 months after surgery on average and recovery took 13.8 months after surgery on average. There was a significant difference in the recovery of MMT grade between the groups treated conservatively and surgically (p = 0.049). Preoperative MMT grade of EDC showed a moderate correlation with postoperative recovery (r 2 = 0.45, p = 0.003). In other words, the severity of preoperative muscular weakness correlated negatively with postoperative recovery. CONCLUSIONS: C8 drop finger is better treated by surgery than conservative therapy.

Perioperative Complications in 155 Patients Who Underwent Oblique Lateral Interbody Fusion Surgery: Perspectives and Indications From a Retrospective, Multicenter Survey.

STUDY DESIGN: A retrospective multicenter survey. OBJECTIVE: To investigate the perioperative complications of oblique lateral interbody fusion (OLIF) surgery. SUMMARY OF BACKGROUND DATA: OLIF has been widely performed to achieve minimally invasive, rigid lumbar lateral interbody fusion. The associated perioperative complications are not yet well described. METHODS: The participants were patients who underwent OLIF surgery under the diagnosis of degenerative lumbar diseases between April 2013 and May 2015 at 11 affiliated medical institutions. The collected data were classified into intraoperative and early-stage postoperative (≤1 mo) complications. The intraoperative complications were then subcategorized into organ damage (neural, vertebral, vascular, and others) and other complications, mainly related to instrumental failure. The collected data were also divided and analyzed based on whether the surgeon was certified to perform the surgery and the incidence of complications in the early (April 2013-March 2014) and late stages (April 2014-May 2015) of OLIF introduction. RESULTS: In the 155 included patients, 75 complications were reported (incidence rate, 48.3%). The most common complication was endplate fracture/subsidence (18.7%), followed by transient psoas weakness and thigh numbness (13.5%) and segmental artery injury (2.6%). Almost all these complications were transient, except for three patients who had permanent damage: one had ureteral injury and two had neurological injury. Postoperative complications included surgical site infection (1.9%) and reoperation (1.9%). Whether the primary operator was experienced did not affect the incidence of complications. Regarding the introductory stage, the incidence of complications was 50% in the early stage and 38% in the late stage. CONCLUSION: The overall incidence of perioperative complications of OLIF surgery reached 48.3%, of which only 1.9% resulted in permanent damage. Our analysis based on surgeon experience indicated that the OLIF procedure could be performed without increasing incidence of complications, under the guidance of experienced supervisors. LEVEL OF EVIDENCE: 3.

Baastrup's Disease Is Associated with Recurrent of Sciatica after Posterior Lumbar Spinal Decompressions Utilizing Floating Spinous Process Procedures.

STUDY DESIGN: Retrospective case-control study. PURPOSE: To determine whether kissing spine is a risk factor for recurrence of sciatica after lumbar posterior decompression using a spinous process floating approach. OVERVIEW OF LITERATURE: Kissing spine is defined by apposition and sclerotic change of the facing spinous processes as shown in X-ray images, and is often accompanied by marked disc degeneration and decrement of disc height. If kissing spine significantly contributes to weight bearing and the stability of the lumbar spine, trauma to the spinous process might induce a breakdown of lumbar spine stability after posterior decompression surgery in cases of kissing spine. METHODS: The present study included 161 patients who had undergone posterior decompression surgery for lumbar canal stenosis using a spinous process floating approaches. We defined recurrence of sciatica as that resolved after initial surgery and then recurred. Kissing spine was defined as sclerotic change and the apposition of the spinous process in a plain radiogram. Preoperative foraminal stenosis was determined by the decrease of perineural fat intensity detected by parasagittal T1-weighted magnetic resonance imaging. Preoperative percentage slip, segmental range of motion, and segmental scoliosis were analyzed in preoperative radiographs. Univariate analysis followed by stepwise logistic regression analysis determined factors independently associated with recurrence of sciatica. RESULTS: Stepwise logistic regression revealed kissing spine (p=0.024; odds ratio, 3.80) and foraminal stenosis (p<0.01; odds ratio, 17.89) as independent risk factors for the recurrence of sciatica after posterior lumbar spinal decompression with spinous process floating procedures for lumbar spinal canal stenosis. CONCLUSIONS: When a patient shows kissing spine and concomitant subclinical foraminal stenosis at the affected level, we should sufficiently discuss the selection of an appropriate surgical procedure.

Outcome of posterior decompression with instrumented fusion surgery for K-line (-) cervical ossification of the longitudinal ligament.

We investigated the outcome of posterior decompression and instrumented fusion (PDF) surgery for patients with K-line (-) ossification of the posterior longitudinal ligament (OPLL) of the cervical spine, who may have a poor surgical prognosis. We retrospectively analyzed the outcome of a series of 27 patients who underwent PDF without correction of cervical alignment for K-line (-) OPLL and were followed-up for at least 1 year after surgery. We had performed double-door laminoplasty followed by posterior instrumented fusion without excessive correction of cervical spine alignment. The preoperative Japanese Orthopedic Association (JOA) score for cervical myelopathy was 8.0 points and postoperative JOA score was 11.9 points on average. The mean JOA score recovery rate was 43.6%. The average C2-C7 angle was 2.2° preoperatively and 3.1° postoperatively. The average maximum occupation ratio of OPLL was 56.7%. In conclusion, PDF without correcting cervical alignment for patients with K-line (-) OPLL showed moderate neurological recovery, which was acceptable considering K-line (-) predicts poor surgical outcomes. Thus, PDF is a surgical option for such patients with OPLL.

Postoperative Increase in Occiput-C2 Angle Negatively Impacts Subaxial Lordosis after Occipito-Upper Cervical Posterior Fusion Surgery.

STUDY DESIGN: Retrospective case series. PURPOSE: To elucidate the impact of postoperative occiput-C2 (O-C2) angle change on subaxial cervical alignment. OVERVIEW OF LITERATURE: In the case of occipito-upper cervical fixation surgery, it is recommended that the O-C2 angle should be set larger than the preoperative value postoperatively. METHODS: The present study included 17 patients who underwent occipito-upper cervical spine (above C4) posterior fixation surgery for atlantoaxial subluxation of various etiologies. Plain lateral cervical radiographs in a neutral position at standing were obtained and the O-C2 angle and subaxial lordosis angle (the angle between the endplates of the lowest instrumented vertebra (LIV) and C7 vertebrae) were measured preoperatively and postoperatively soon after surgery and ambulation and at the final follow-up visit. RESULTS: There was a significant negative correlation between the average postoperative alteration of O-C2 angle (DO-C2) and the average postoperative alteration of subaxial lordosis angle (Dsubaxial lordosis angle) (r=-0.47, p=0.03). CONCLUSIONS: There was a negative correlation between DO-C2 and Dsubaxial lordosis angles. This suggests that decrease of mid-to lower-cervical lordosis acts as a compensatory mechanism for lordotic correction between the occiput and C2. In occipito-cervical fusion surgery, care must be taken to avoid excessive O-C2 angle correction because it might induce mid-to-lower cervical compensatory decrease of lordosis.

Addition of instrumented fusion after posterior decompression surgery suppresses thickening of ossification of the posterior longitudinal ligament of the cervical spine.

Laminoplasty (LMP) is a widely accepted surgical procedure for ossification of the posterior longitudinal ligament (OPLL) of the cervical spine. Progression of OPLL can occur in the long term after LMP. The aim of the present study was to determine whether addition of the instrumented fusion, (posterior decompression with instrumented fusion [PDF]), can suppress progression of OPLL or not. The present study included 50 patients who underwent LMP (n=23) or PDF (n=27) for OPLL of the cervical spine. We performed open door laminoplasty. PDF surgery was performed by double-door laminoplasty followed by instrumented fusion. We observed the non-ossified segment of the OPLL and measured the thickness of the OPLL at the thickest segment with pre- and postoperative sagittal CT multi-planar reconstruction images. Postoperative CT scan revealed fusion of the non-ossified segment of the OPLL was obtained in 4/23 patients (17%) in the LPM group and in 23/27 patients (85%) in the PDF group, showing a significant difference between both groups (p=0.003). Progression of the thickness of the OPLL in the PDF group (-0.1±0.4mm) was significantly smaller than in the LMP group (0.6±0.7mm, p=0.0002). The proportion of patients showing the decrease in thickness of OPLL was significantly larger in the PDF group (6/27 patients; 22%) than in the LMP group (0/23 patients; 0%, p=0.05). In conclusion, PDF surgery can suppress the thickening of OPLL.

Dropped head syndrome after cervical laminoplasty: A case control study.

Dropped head syndrome (DHS) is characterized by apparent neck extensor muscle weakness and difficulty extending the neck to raise the head against gravity. The aim of the present study was to elucidate possible risk factors for DHS after cervical laminoplasty. Five patients who developed DHS after cervical laminoplasty (DHS group) and twenty age-matched patients who underwent laminoplasty without DHS after surgery (control group) were compared. The surgical procedure was single-door laminoplasty with strut grafting using resected spinous processes or hydroxyapatite spacers from C3 to C6 or C7. Analyses of preoperative images including the C2-C7 angle, C7-T1 kyphosis, T1 tilt, center of gravity line from the head-C7 sagittal vertical axis (CGH-C7 SVA) were performed on lateral plain cervical spine radiographs. Preoperative T2-weighted MRI at the C5 vertebral level was used to measure the cross-sectional area of the deep extensor muscles. Widths of the lateral gutters were assessed postoperatively using CT scans of the C5 vertebral body. The average preoperative C2-C7 angle was significantly smaller in the DHS group compared with the control group. The average preoperative C7-T1 angle was significantly larger in the DHS group compared with the control group. The average preoperative CGH-C7 SVA was significantly larger in the DHS group compared with the control group. In conclusion, patients with more pronounced preoperative C2-C7 kyphosis, C7-T1 kyphosis, and CGH-C7 SVA are more likely to develop DHS following laminoplasty.

Comparison of clinical outcomes between laminoplasty, posterior decompression with instrumented fusion, and anterior decompression with fusion for K-line (-) cervical ossification of the posterior longitudinal ligament.

PURPOSE: The K-line, which is a virtual line that connects the midpoints of the anteroposterior diameter of the spinal canal at C2 and C7 in a plain lateral radiogram, is a useful preoperative predictive indicator for sufficient decompression by laminoplasty (LMP) for ossification of the posterior longitudinal ligament (OPLL). K-line is defined as (+) when the peak of OPLL does not exceed the K-line, and is defined as (-) when the peak of OPLL exceeds the K-line. For patients with K-line (-) OPLL, LMP often results in poor outcome. The aim of the present study was to compare the clinical outcome of LMP, posterior decompression with instrumented fusion (PDF) and anterior decompression and fusion (ADF) for patients with K-line (-) OPLL. METHODS: The present study included patients who underwent surgical treatment including LMP, PDF and ADF for K-line (-) cervical OPLL. We retrospectively compared the clinical outcome of those patients in terms of Japanese Orthopedic Association score (JOA score) recovery rate. RESULTS: JOA score recovery rate was significantly higher in the ADF group compared with that in the LMP group and the PDF group. The JOA score recovery rate in the PDF group was significantly higher than that in the LMP group. CONCLUSIONS: LMP should not be used for K-line (-) cervical OPLL. ADF is one of the suitable surgical treatments for K-line (-) OPLL. Both ADF and PDF are applicable for K-line (-) OPLL according to indications set by each institute and surgical decisions.

Mid- to long-term outcomes of posterior decompression with instrumented fusion for thoracic ossification of the posterior longitudinal ligament.

Posterior decompression with instrumented fusion (PDF) surgery has been previously reported as a relatively safe surgical procedure for any type of thoracic ossification of the longitudinal ligament (OPLL). However, mid- to long-term outcomes are still unclear. The aim of the present study was to elucidate the mid- to long-term clinical outcome of PDF surgery for thoracic OPLL patients. The present study included 20 patients who had undergone PDF for thoracic OPLL and were followed for at least 5years. Increment change and recovery rate of the Japanese Orthopaedic Association (JOA) score were assessed. Revision surgery during the follow-up period was also recorded. Average JOA scores were 3.5 preoperatively and 7.1 at final follow-up. The average improvement in JOA score was 3.8 points and the average recovery rate was 47.0%. The JOA score showed gradual increase after surgery, and took 9months to reach peak recovery. As for neurological complications, two patients suffered postoperative paralysis, but both recovered without intervention. Six revision surgeries in four patients were related to OPLL. Additional anterior thoracic decompression for remaining ossification at the same level of PDF surgery was performed in one patient. Decompression surgery for deterioration of symptoms of pre-existing cervical OPLL was performed in three patients. One patient had undergone lumbar and cervical PDF surgery for de novo ossification foci of the lumbar and cervical spine. PDF surgery for thoracic OPLL is thus considered a relatively safe and stable surgical procedure considering the mid- to long-term outcomes.

Transplanted Peripheral Blood Stem Cells Mobilized by Granulocyte Colony-Stimulating Factor Promoted Hindlimb Functional Recovery After Spinal Cord Injury in Mice.

Granulocyte colony-stimulating factor (G-CSF) mobilizes peripheral blood stem cells (PBSCs) derived from bone marrow. We hypothesized that intraspinal transplantation of PBSCs mobilized by G-CSF could promote functional recovery after spinal cord injury. Spinal cords of adult nonobese diabetes/severe immunodeficiency mice were injured using an Infinite Horizon impactor (60 kdyn). One week after the injury, 3.0 µl of G-CSF-mobilized human mononuclear cells (MNCs; 0.5 × 10(5)/µl), G-CSF-mobilized human CD34-positive PBSCs (CD34; 0.5 × 10(5)/µl), or normal saline was injected to the lesion epicenter. We performed immunohistochemistry. Locomotor recovery was assessed by Basso Mouse Scale. The number of transplanted human cells decreased according to the time course. The CD31-positive area was significantly larger in the MNC and CD34 groups compared with the vehicle group. The number of serotonin-positive fibers was significantly larger in the MNC and CD34 groups than in the vehicle group. Immunohistochemistry revealed that the number of apoptotic oligodendrocytes was significantly smaller in cell-transplanted groups, and the areas of demyelination in the MNC- and CD34-transplanted mice were smaller than that in the vehicle group, indicating that cell transplantation suppressed oligodendrocyte apoptosis and demyelination. Both the MNC and CD34 groups showed significantly better hindlimb functional recovery compared with the vehicle group. There was no significant difference between the two types of transplanted cells. Intraspinal transplantation of G-CSF-mobilized MNCs or CD34-positive cells promoted angiogenesis, serotonergic fiber regeneration/sparing, and preservation of myelin, resulting in improved hindlimb function after spinal cord injury in comparison with vehicle-treated control mice. Transplantation of G-CSF-mobilized PBSCs has advantages for treatment of spinal cord injury in the ethical and immunological viewpoints, although further exploration is needed to move forward to clinical application.

Resolution of low back symptoms after corrective surgery for dropped-head syndrome: a report of two cases.

BACKGROUND: Cervical deformity can influence global sagittal balance. We report two cases of severe low back pain and lower extremity radicular pain associated with dropped-head syndrome. Symptoms were relieved by cervical corrective surgery. CASE PRESENTATION: Two Japanese women with dropped head syndrome complained of severe low back pain and lower extremity radicular pain on walking. Radiographs showed marked cervical spine kyphosis and lumbar spine hyperlordosis. After cervicothoracic posterior corrective fusion was performed, cervical kyphosis was corrected and lumbar lordosis decreased, and low back pain and leg pain were relieved in both patients. CONCLUSIONS: Cervical deformity can influence global sagittal balance. Marked cervical kyphosis in patients with dropped-head syndrome can induce compensatory thoracolumbar hyperlordosis. Low back symptoms in patients with dropped-head syndrome are attributable to this compensatory lumbar hyperlordosis. Symptoms of lumbar canal stenosis may result from cervical deformity and can be improved with cervical corrective surgery.

Mini-Open Anterior Retroperitoneal Lumbar Interbody Fusion: Oblique Lateral Interbody Fusion for Degenerated Lumbar Spinal Kyphoscoliosis.

STUDY DESIGN: Prospective case series. PURPOSE: To examine the clinical efficacy of mini-open anterior retroperitoneal lumbar interbody fusion: oblique lateral interbody fusion (OLIF) for degenerated lumbar spinal kyphoscoliosis. OVERVIEW OF LITERATURE: The existing surgical procedures for the treatment of spinal kyphotic deformity, including Smith-Petersen osteotomy, pedicle subtraction osteotomy, and vertebral column resection procedures, are invasive in nature. Extreme lateral interbody fusion to provide less invasive treatment of the deformity has been reported, but complications including spinal nerve and psoas muscle injury have been noted. In the current study, we examined the clinical efficacy and complications of OLIF for degenerated lumbar spinal kyphoscoliosis. METHODS: Twelve patients with degenerated lumbar spinal kyphoscoliosis were examined. All patients underwent OLIF surgery (using a cage and bone graft from the iliac crest) with open pedicle screws or percutaneous pedicle screws, without real-time monitoring by electromyography. Visual analog scale score and Oswestry disability index were evaluated before and 12 months after surgery, and fusion rate at OLIF cage, correction of the deformity, total blood loss, and surgical complications were also evaluated. RESULTS: Pain scores significantly improved after surgery (p<0.05). Fusion rate was found to be 90%, balance parameters also improved after surgery (p<0.05), and average total blood loss was less than 350 mL. There was no spinal nerve, major vessel, peritoneal, or urinary injury, or breakage of instrumentation. CONCLUSIONS: OLIF surgery for degenerated lumbar spinal kyphoscoliosis is less invasive than other procedures and good surgical results were produced without major complications.