Brain-Derived Neurotrophic Factor (BDNF) Enhances Osteogenesis and May Improve Bone Microarchitecture in an Ovariectomized Rat Model.

BACKGROUND: Brain-derived neurotrophic factor (BDNF) has gained attention as a therapeutic agent due to its potential biological activities, including osteogenesis. However, the molecular mechanisms involved in the osteogenic activity of BDNF have not been fully understood. This study aimed to investigate the action of BDNF on the osteoblast differentiation in bone marrow stromal cells, and its influence on signaling pathways. In addition, to evaluate the clinical efficacy, an in vivo animal study was performed. METHODS: Preosteoblast cells (MC3T3-E1), bone marrow-derived stromal cells (ST2), and a direct 2D co-culture system were treated with BDNF. The effect of BDNF on cell proliferation was determined using the CCK-8 assay. Osteoblast differentiation was assessed based on alkaline phosphatase (ALP) activity and staining and the protein expression of multiple osteoblast markers. Calcium accumulation was examined by Alizarin red S staining. For the animal study, we used ovariectomized Sprague-Dawley rats and divided them into BDNF and normal saline injection groups. MicroCT, hematoxylin and eosin (H&E), and tartrate-resistant acid phosphatase (TRAP) stain were performed for analysis. RESULTS: BDNF significantly increased ALP activity, calcium deposition, and the expression of osteoblast differentiation-related proteins, such as ALP, osteopontin, etc., in both ST-2 and the MC3T3-E1 and ST-2 co-culture systems. Moreover, the effect of BDNF on osteogenic differentiation was diminished by blocking tropomyosin receptor kinase B, as well as inhibiting c-Jun N-terminal kinase and p38 MAPK signals. Although the animal study results including bone density and histology showed increased osteoblastic and decreased osteoclastic activity, only a portion of parameters reached statistical significance. CONCLUSIONS: Our study results showed that BDNF affects osteoblast differentiation through TrkB receptor, and JNK and p38 MAPK signal pathways. Although not statistically significant, the trend of such effects was observed in the animal experiment.

Anatomical Consideration for Anterior Approach of Cervicothoracic Junction: A Computed Tomography Image Analysis.

Background: In the cervicothoracic junction (CTJ), there is limited working space to perform the posterior-only approach. Therefore, a combined anterior approach is required in some cases. However, the great vessels and sternum obstruct the anterior corridor and make the anterior approach difficult. We analyzed relevant anatomical structures encountered during the anterior approach in the CTJ and evaluated the feasibility of previously reported surgical corridors. Methods: We retrospectively examined 49 patients who underwent neck computed tomography angiography between January 2015 and May 2020. Using the coronal images, we measured the intercarotid artery angle (ICAA), intercarotid artery distance (ICAD), shape of the brachiocephalic trunk (BCT), and position of the BCT base. We then measured the most cranial level requiring manubriotomy for the anterior approach (ML), the most caudal level accessible through the superior corridor (SC), and the most caudal level through the inferior corridor (IC) according to the surgeon's line of sight using the sagittal axis image. Results: The mean ICAA and ICAD were 50.83° ± 15.23° and 33.38 ± 12.11 mm, respectively. Notably, BCT shape was of the convex type in most cases (42.9%), followed by the straight type (36.7%). In addition, the base of BCT was most commonly located inside the body (49%). Moreover, ICAA and ICAD were significantly greater in men. Although men mostly had the BCT base inside the body (64.3%), female mostly had it on the edge of the body (47.6%). Notably, ML showed the highest frequency (16.3%) in the T1 lower and upper bodies. Furthermore, through SC and IC, it was possible to approach the T4 lower body and T6 midbody, respectively. SC showed the highest frequency (16.3%) in the T3 lower body, and IC showed the highest frequency (20.4%) in the T5 midbody. Conclusions: ICAA and ICAD were larger and higher in men. BCT was convex and located inside the body in most cases. The accessible level of ML, SC, and IC were T1, T3, and T5, respectively. For the anterior approach in the CTJ, preoperative vascular and accessible level analysis of corridors is essential to decide on the appropriate corridor and reduce complications.

Surgical outcome of locked facet in distractive flexion injury of the subaxial cervical spine: Single institution retrospective study.

The optimal surgical treatment for patients suffering from distractive flexion injury of the subaxial cervical spine with a locked facet (LF) is unknown. Closed reduction via an anterior or posterior approach is a treatment option for LF. We examined the surgical outcomes of patients treated for locked facet distractive flexion injury (LF-DFI) in this case series, with a particular emphasis on the surgical approach and reduction maneuver. We retrospectively analyzed the patients with distractive flexion injury of the subaxial cervical spine who underwent surgery at our hospital between November 2006 and April 2021. Patients who did not have facet subluxation or dislocation or those who achieved LF reduction prior to skin incision were excluded from this study. The patients were divided into 2 groups based on their initial approach, anterior or posterior approach. Perioperative clinical outcomes, including the American Spinal Cord Injury Association scale score, radiological changes, and complications were analyzed. This study enrolled 12 patients with LF-DFI. Four and 8 patients underwent the anterior and posterior approaches, respectively. The LF was reduced using an anterior approach with traction between the vertebral bodies in the anterior approach group and using a posterior approach with partial facetectomy in the posterior approach group. The preoperative American Spinal Cord Injury Association scale scores were as follows: A, 1 patient; B, 1 patient; C, 3 patients; D, 4 patients; and E, 3 patients. Nine patients showed no neurologic deterioration after surgery, whereas 2 had an aggravated neurologic status. Postoperatively, patients who underwent posterior open reduction did not exhibit worsened neurologic symptoms, whereas 2 patients who underwent the anterior approach showed worsened neurologic symptoms. At the final follow-up, all patients achieved radiological fusion, and no complications other than neurologic deterioration were identified. In terms of worsening postoperative neurologic status, a posterior approach using partial facetectomy for LF reduction is considered a safer surgical technique than an anterior approach. To avoid iatrogenic intraoperative cord injury, we recommend posterior approach in patients with LF-DFI.

High reliability and accuracy of dynamic magnetic resonance imaging in the diagnosis of cervical Spondylotic myelopathy: a multicenter study.

BACKGROUND: Cervical spondylotic myelopathy (CSM) is a critical condition that results in significant neurologic deterioration. An accurate diagnosis is essential for determining its outcome and prognosis. The pathology is strongly associated with dynamic factors; therefore, dynamic magnetic resonance (MR) image could be crucial to accurately detect CSM. However, very few studies have evaluated the reliability and accuracy of dynamic MR in CSM. In this study, we aimed to compare intra- and interobserver reliabilities and accuracy of dynamic MR in detecting CSM using sagittal MR scans of the neck in the flexed, neutral, and extended position. METHODS: Out of 131 patients who underwent surgical treatments for CSM, 107 were enrolled in this study. The patient underwent three-types of sagittal MR scans that were obtained separately in different neck positions (neutral, flexion, and extension postures). The MR scans of the cervical spine were evaluated independently by three spine professionals, on the basis of tabled questionnaires. For accuracy, we performed a receiver operator characteristic analysis, and the overall discriminating ability of each method was measured by calculating the area under the ROC curve. The Cohen's kappa coefficient and the Fleiss-generalized kappa coefficient was used to the inter- and intra-observer reliabilities. RESULTS: The intraobserver reliability (using the Cohen's kappa coefficient) and interobserver reliability (using the Fless kappa coefficient) were respectively 0.64 and 0.52 for the neutral sagittal MR. The accuracy of neutral sagittal MR in detecting CSM was 0.735 (95% CI, 0.720 to 0.741) while that of extension sagittal MRI was 0.932 (96% CI, 0.921 to 0.948). CONCLUSIONS: Dynamic MR significantly showed better diagnostic reliability and accuracy in detecting CSM compared to conventional MR. In particular, extension MR scans could provide a more accurate diagnosis than other images.

Bicortical Laminar Screws for Posterior Fixation of Subaxial Cervical Spine: A Radiologic Analysis With Computed Tomography Images.

STUDY DESIGN: Retrospective radiological analysis. OBJECTIVES: Translaminar screw (TLS) placement is one of the fixation techniques in the subaxial cervical spine. However, it can be difficult to use in small diameter of the lamina. This study proposed a novel bicortical laminar screw (BLS) and analyzed the related parameters using computed tomography (CT). METHODS: Cervical CT images taken at our institution from January 2013 to March 2017 were used for measurement. On the axial images, the maximum screw length (MSL) and trajectory angle (TA) of BLS and TLS were measured, together with the distance from the midline (DM) to the BLS entry point and the lamina width (LW). On the parasagittal images, the height of the lamina (LH) was measured. RESULTS: MSL of BLS and TLS were 21.00 and 20.97 mm, 19.02 and 20.91 mm, 18.45 and 21.01 mm, and 20.00 and 21.01 mm in C3, C4, C5, and C6, respectively. TA of the BLS and TLS were 21.24° and 34.90°, 19.05° and 34.22°, 18.65° and 33.61°, and 18.30° and 34.51° at C3, C4, C5, and C6, respectively. DM were 6.44, 5.77, 5.68, and 6.03 at C3, C4, C5, and C6, respectively. LW and LH were 3.52 and 12.44 mm, 2.87 and 12.49 mm, 2.76 and 12.42 mm, and 3.18 and 13.30 mm at C3, C4, C5, and C6, respectively. CONCLUSION: We suggest that BLS fixation is a feasible alternative option for posterior fixation to the lamina of the subaxial cervical spine. It may be especially useful when pedicle screw, lateral mass screw, and TLS are not appropriate.

Pain Relief After Selective Nerve Root Block as a Predictor of Postoperative Functional Outcome in Patients with Degenerative Lumbar Spinal Stenosis Patients Undergoing Decompressive Surgery.

STUDY DESIGN: Retrospective study of data collected prospectively. OBJECTIVE: To investigate changes in the degree of lower leg radiating pain (LLRP) after selective nerve root block (SNRB) and to evaluate associations of this change with postoperative improvements in symptom severity, functional outcomes, and quality of life. SUMMARY OF BACKGROUND DATA: SNRB is routinely performed as an initial treatment for lumbar foraminal or lateral recess stenosis with LLRP. The degree of improvement after SNRB has been suggested to predict the improvement in postoperative pain and functional outcomes. However, there have been no studies on the predictive value of this parameter. METHODS: We enrolled 60 patients who underwent SNRB followed by decompressive surgery. They were divided into three groups. The degree of improvement was evaluated as a percentage of the pre-injection values. Functional outcomes of the spine were assessed using the Oswestry Disability Index (ODI) and Roland-Morris Disability Questionnaire (RMDQ). Quality of life was assessed using the 36-item Short Form Survey (SF-36) physical component score (PCS) and mental component score (MCS). The degree of LLRP was measured preoperatively and at 6, 12, and 24 months after surgery. These functional outcomes were evaluated preoperatively and at 12 and 24 months after surgery. RESULTS: The improvement in LLRP in the short term (6 hours after SNRB) was found to be statistically significantly associated with the improvement in LLRP at 12 months after SNRB (P = 0.044, correlation coefficient = 0.261). No relationship between pain improvement after SNRB and functional outcome was identified. CONCLUSION: The degree of improvement in symptoms 6 hours after SNRB can predict the degree of improvement in LLRP at 12 months after surgery. However, symptomatic improvement after SNRB does not predict postoperative functional outcome or quality of life.Level of Evidence: 4.

Reciprocal change of occipitocervical parameters after anterior cervical discectomy and fusion.

To evaluate the reciprocal changes in occipitocervical parameters according to the recovery of cervical lordosis (CL) after anterior cervical discectomy and fusion (ACDF) in patients with sagittal imbalance. Sixty-five cases that underwent ACDF were followed. They were divided according to the recovery of the CL: Group 1 (ΔCL > 5°, 30 cases) and Group 2 (ΔCL < 5°, 35 cases). The following parameters were measured: occiput-cervical inclination (OCI), CL, occiput-C2 angle (OC2A), distance between external occipital protuberance and spinous process of C2 (OC2D), distance between spinous processes of C2 and C7 (C27D), and shortest distance between the plumb line of C2 body and posterosuperior corner of C7 (C27SVA). Overall, all parameters changed significantly after ACDF. Preoperative CL and preoperative C27D showed a correlation with ΔCL. ΔCL was negatively correlated with ΔC27D and ΔC27SVA. In Group 1, CL increased from - 2.60 ± 1.88° to 11.57 ± 1.83°, OC2A decreased from 23.96 ± 2.05° to 19.87 ± 1.36°, OC2D increased from 82.96 ± 1.48 mm to 86.50 ± 1.81 mm, C27D decreased from 95.61 ± 2.66 mm to 87.01 ± 2.50 mm, and C27SVA decreased from 24.14 ± 2.20 mm to 17.06 ± 2.14 mm. In Group 2, only OCI decreased significantly after ACDF. ACDF can increase CL postoperatively in patients with cervical sagittal imbalance. Patients with significant CL recovery after ACDF showed a reciprocal change in occipitocervical parameters. (OC2A, OC2D).

Clinical and radiological outcomes between biportal endoscopic decompression and microscopic decompression in lumbar spinal stenosis.

BACKGROUND CONTEXT: Numerous minimal invasive techniques treating lumbar spinal stenosis have been introduced. Clinical results using biportal endoscopic spinal surgery has recently been introduced as a treatment option for lumbar spinal stenosis. The purpose of this study was to compare the clinical and radiologic outcome between microscopic unilateral laminotomy bilateral decompression and biportal endoscopic unilateral laminotomy bilateral decompression in patients with degenerative lumbar spinal stenosis. METHOD: A total of 89 patients were evaluated for this study. Only single-level patients were enrolled for accurate comparison. Patients that underwent biportal endoscopic surgery were assigned to Group A, and patients that underwent microscopic surgery were designated Group B. Clinical outcomes were evaluated using modified Macnab criteria, Oswestry Disability Index, and Visual Analog Scale. Postoperative complications were checked until final follow up. Plain radiographs before and after surgery were compared to analyze the change of alignment. RESULT: There was a significant difference between Group A and B in VAS of back on postoperative 2 months. Other clinical measurements except for postoperative 2 months VAS of back showed no significant difference. There were no significant differences between Group A and Group B regarding preoperative and postoperative radiological findings. CONCLUSION: Two different decompression techniques preserve the spinal structure and exhibit a favorable clinical outcome and have the advantage of not causing postoperative instability in the short term follow up. Biportal endoscopic surgery may leads to less postoperative back pain than microscopic surgery, which may allow early ambulation and shorter hospitalization period.

Effect of thoracic and pelvic anteroposterior diameters on spinal sagittal alignment.

PURPOSE: This study aimed to analyze the effect of the thoracic anteroposterior diameter (TAPD) and pelvic anteroposterior diameter (PAPD) on global sagittal alignment in asymptomatic patients with normal sagittal alignment. PATIENT SAMPLE: The study investigated 2042 adult patients who initially presented at our hospital with a hip and knee problem without history of symptoms related to the entire spine. Only 57 patients with normal global sagittal alignment (C2-7 sagittal vertical axis (SVA) and C7-S1 SVA of <10 mm) were considered. METHODS: The whole-spine standing lateral radiographs were obtained to analyze the following parameters: pelvic incidence (PI), pelvic tilt (PT), sacral slope (SS), lumbar lordosis (LL), thoracic inlet angle (TIA), T1 slope, cervical spinal parameters (angle of C0-2, C2-7, and C0-7), TAPD, and PAPD. Statistical analysis was performed using Pearson correlation coefficients and multiple regression analyses. RESULTS: All the parameters showed a normal distribution. TAPD had a significant relationship with thoracic kyphosis (TK; r = 0.458), TIA (r = 0.677), and C0-2 angle (r = 0.294) but no significant relationship with T1 slope and other cervical parameters. PAPD had a significant relationship with PI (r = 0.309) and PT (r = 0.463) but no significant relationship with LL, SS, and TK. The multiple regression analysis showed that TIA = 21.974 + 0.405 (TK) + 0.188 (TAPD) (p < 0.0001). CONCLUSIONS: TAPD and PAPD are associated with TIA, TK, C0-2 angle, PI, and PT, all of which act as key factors in spinal sagittal alignment. Although they did not directly correlate with other cervical parameters, T1 slope, and LL, TAPD and PAPD might have indirect effects on cervical and lumbar spinal sagittal alignment through their relationships with TIA, TK, and PI.

Radiologic criteria to predict injury of the transverse atlantal ligament in unilateral sagittal split fractures of the C1 lateral mass.

Unilateral sagittal split fracture (USSF) of the C1 lateral mass (LM) has been recently recognized as a rare variant of C1 atlas fracture. To date, there has been no study to investigate whether radiologic criteria can be applied to determine the presence or absence of transverse atlantal ligament (TAL) injury in USSF of the C1 LM.Twenty six consecutive cases of USSF of the C1 LM were included in this study. According to Dickman classification, 16 cases were TAL injury, and 10 cases were TAL intact. Radiologic parameters were measured and compared between the 2 groups.Total LM displacement (LMD) of the 2 sides (5.9 ±â€Š2.0 mm vs 1.2 ±â€Š2.0 mm), unilateral LMD of the fracture side (4.3 ±â€Š1.2 mm vs 1.0 ±â€Š1.1 mm), atlanto-dental interval (ADI) (2.0 ±â€Š0.9 mm vs 1.5 ±â€Š0.4 mm), and fracture gap (6.9 ±â€Š2.7 mm vs 2.1 ±â€Š1.1 mm) were statistically higher in the TAL injury group than the TAL intact group. However, basion-dental interval, clivus canal angle, and atlanto-occipital joint axis angle were not different between the 2 groups. Total LMD and unilateral LMD positively correlated with ADI and fracture gap. The incidence of fracture gap larger than 7 mm was statistically higher in the TAL injury group than the TAL intact group (81% vs 30%).In conclusion, total LMD > 5.9 mm or unilateral LMD > 4.3 mm suggests the presence of TAL injury in USSF of the C1 LM. The possibility of diagnostic error for TAL injury can be further reduced in USSF of the C1 LM by considering the fracture gap larger than 7 mm.

Clinical and radiological outcomes of conservative treatment for unilateral sagittal split fractures of C1 lateral mass.

OBJECTIVE: The aim of this study was to assess the effect of transverse atlantal ligament (TAL) integrity on clinical and radiological outcomes in patients with unilateral sagittal split fracture (USSF) of the C1 lateral mass (LM). METHODS: Twenty-six consecutive patients (16 men and 10 women; mean age: 52 years (range: 32-69)) with C1 LM USSF were included in this study. Sixteen were TAL injury group (nine of type I injuries and seven of type II injuries according to Dickman's classification) and ten were TAL intact group. All cases were conservatively treated with a rigid brace for TAL intact or by halo-vest stabilization for TAL injury for three months. The mean follow-up was 16 months (range, 12-47 months). The results were compared with radiological assessment of fracture healing, LM displacement and Neck visual analog scale. RESULTS: At the last follow-up, for TAL intact group, total LM displacement (LMD), unilateral LMD of fracture side, atlanto-dental interval, basion-dental interval, clivus canal angle, and atlanto-occipital joint axis angle were maintained compared to initial presentation. However, for TAL injury group, all radiological parameters were worsened. The worsening of radiological parameters was more severe in type I injury than type II injury except for total LMD and unilateral LMD. Neck visual analog scale significantly decreased and patient's satisfaction was higher in TAL intact group compared to TAL injury group. CONCLUSION: Conservative treatment for USSF of C1 LM with TAL injury failed to achieve healing of the fracture, which resulted in lateral displacement of C1 LM. This caused coronal and sagittal malalignment of occipitocervical junction, resulting in unsatisfactory clinical outcomes. Our results suggest that early surgical stabilization should be considered in USSF of C1 LM with TAL injury, especially type I injury. However, conservative treatment may be sufficient for a USSF of the C1 LM with TAL intact. LEVEL OF EVIDENCE: Level III, Therapeutic Study.

Pharmacological target therapy of neuropathic pain and patient-reported outcomes in patients with chronic low back pain in Korea: Results from the NLBP Outcomes Research.

A number of studies have demonstrated an association of neuropathic pain and chronic low back pain (CLBP), but the outcome difference in each medical management is poorly understood. This study is aimed to investigate treatment patterns of neuropathic pain in CLBP patients and to explore patient-reported outcomes (PROs) including quality of life (QoL) and functional disability by treatment patterns.Data were extracted from the neuropathic low back pain (NLBP) outcomes research. It was a multicenter and cross-sectional study in which 1200 patients were enrolled at 27 general hospitals, from 2014 to 2015. Of total, 478 patients classified as neuropathic pain were used for this subgroup analysis. The patients were divided into 2 groups according to treatment patterns (with vs. without the targeted therapy [TT] of neuropathic pain). Demographic and clinical features were collected by chart reviews and PROs were measured by patient's survey. QoL was assessed by EuroQoL 5-dimension (EQ-5D) questionnaire. Functional disability was measured by the Quebec Back Pain Disability Scale (QBPDS). Multiple linear regression analyses were conducted to compare the PROs between TT group and non-targeted therapy (nTT) group.Among the NLBP patients (mean age 63years, female 62%), EQ-5D index, EuroQoL-Visual Analog Scale (EQ-VAS), and QBPDS Scores (mean ±â€Šstandard deviation) were 0.40 ±â€Š0.28, 54.98 ±â€Š19.98, and 46.03 ±â€Š21.24, respectively. Only 142 (29.7%) patients had pharmacological TT of neuropathic pain. Univariate analyses revealed no significant mean differences between TT group and nTT group in the EQ-5D index (0.41 ±â€Š0.27 and 0.39 ±â€Š0.28), EQ-VAS (56.43 ±â€Š18.17 and 54.37 ±â€Š20.69), and QBPDS (45.31 ±â€Š21.32 and 46.31 ±â€Š21.24). After adjustment with covariates, TT group had higher scores of EQ-5D index (ß = 0.07; P < 0.01) and EQ-VAS (ß = 4.59; P < 0.05) than the nTT group. The TT group's QBPDS score was lower than the nTT group, although its statistical significance still has not been reached (ß = -4.13; P = 0.07).We found that considerable proportion of the NLBP patients remains untreated or undertreated. Although TT group had significantly better QoL than nTT group, only 29.7% of NLBP patients had pharmacological TT. Therefore, clinicians should consider using TT for better QoL of neuropathic pain patients.

Accuracy of thoracic pedicle screw placement using freehand technique and triggered EMG in adolescent idiopathic scoliosis: Is it different between concave and convex side?

PURPOSE: To evaluate and compare the accuracy of the placement of thoracic pedicle screws between concave and convex side curve using freehand technique and triggered electromyogram (EMG). METHODS: Three-hundred sixty eight thoracic pedicle screws were included for the evaluation of accuracy from postoperative computed tomography (CT) scans in 24 patients with adolescent idiopathic scoliosis with a mean follow-up of 27 months (range 24-58 months). All screws had stimulation thresholds greater than 6 mA. We divided the screws into two groups: (1) group A: concave side curve-254 screws (2) group B: convex side curve-114 screws. RESULTS: The mean age at surgery was 12.8 years (range 11-17 years). The preoperative Cobb angle was 57.5° (range 50-75°). There were 41 total breaches (medial = 21, lateral = 20, p = 0.66) with an overall incidence of 11.1%. The overall breach rate did not attain statistically significant difference (group A = 11.8%, group B = 9.6%, p = 0.59). The rate of medial breaches was also similar for both concave and convex side (group A = 6.1%, group B = 5.9%, p > 0.05). No postoperative neurological or vascular complications were noted in both groups. CONCLUSION: Thoracic pedicle screw placement using both freehand technique and triggered EMG for adolescent idiopathic scoliosis surgery is safe and reliable. The overall accuracy rate is 88.9% with similar breaches on the concave and convex side on postoperative CT scans.

Clenching Reduction Technique for Osteosynthesis of Atypical C2 Fractures with the Combining Use of Laminar and Pedicle Screw: A Technical Note.

Atypical C2 fractures refer to all fracture types of the C2 body excluding odontoid fractures and traumatic spondylolisthesis of C2. A 55-year-old male patient presented with neck pain after a vehicular accident. Computed tomography (CT) showed an oblique fracture line of the C2 vertebral body through the pedicle and lamina with fracture gap and posterior displacement. We used a clenching reduction technique to treat this fracture by using an ipsilateral laminar screw and contralateral pedicle screw. The final follow-up CT scan showed complete bone union. Neck motion was preserved including rotation. For this unstable atypical C2 fracture, the clenching reduction technique proved to be a safe and effective technique while salvaging neck motion.

Does Additional Uncinate Resection Increase Pseudarthrosis Following Anterior Cervical Discectomy and Fusion?

STUDY DESIGN: Retrospective comparative study. OBJECTIVE: To investigate whether unilateral or bilateral uncinate resection (UR) combined with anterior cervical discectomy and fusion (ACDF) increases the risk of pseudarthrosis at long-term follow-up. SUMMARY OF BACKGROUND DATA: Uncoforaminotomy (or UR), performed along with ACDF, facilitates better and faster improvement of arm pain. As uncovertebral joints are important for maintaining stability, they may affect the fusion process by causing segmental instability if resected during ACDF. METHODS: We retrospectively examined 167 patients (89 men, 78 women; mean age, 58.4 ±â€Š10.5 yr) who consecutively underwent single- or double-level ACDF and were followed for >2 years. UR was not performed in 46 patients (N-UR group). UR of at least one foramen was performed in 121 patients (UR group), including unilateral UR in 89 patients (U-UR group) and bilateral UR in 32 patients (B-UR group). Demographic data, fusion rate, visual analog scale (VAS) scores for neck/arm pain, and neck disability index (NDI) scores were compared between the N-UR and UR groups. Moreover, the fusion rates after the single- and double-level procedures were compared among the groups. RESULTS: There was no difference in sex, age, weight, height, body mass index (BMI), and smoking history between the N-UR and UR groups. The fusion rates after single-level ACDF were not significantly different among the N-UR, U-UR, and B-UR groups (91.4%, 97.8%, and 88.2%; P = 0.290). Solid fusion was achieved in all groups after double-level ACDF (72.7%, 95.5%, and 86.7%), although the rates did not significantly differ among the groups (P = 0.071). The improvement in the VAS score for arm pain was significantly better in the UR group than in the N-UR group at short-term follow-up (P < 0.001). CONCLUSION: Unilateral or bilateral UR does not affect the fusion rate after single- or double-level ACDF. Hence, if necessary, additional UR can be performed during ACDF without concern regarding nonunion. LEVEL OF EVIDENCE: 4.

Prevalence of Neuropathic Pain and Patient-Reported Outcomes in Korean Adults with Chronic Low Back Pain Resulting from Neuropathic Low Back Pain.

STUDY DESIGN: A noninterventional, multicenter, cross-sectional study. PURPOSE: We investigated the prevalence of neuropathic pain (NP) and patient-reported outcomes (PROs) of the quality of life (QoL) and functional disability in Korean adults with chronic low back pain (CLBP). OVERVIEW OF LITERATURE: Among patients with CLBP, 20%-55% had NP. METHODS: Patients older than 20 years with CLBP lasting for longer than three months, with a visual analog scale (VAS) pain score higher than four, and with pain medications being used for at least four weeks before enrollment were recruited from 27 general hospitals between December 2014 and May 2015. Medical chart reviews were performed to collect demographic/clinical features and diagnosis of NP (douleur neuropathique 4, DN4). The QoL (EuroQoL 5-dimension, EQ-5D; EQ-VAS) and functional disability (Quebec Back Pain Disability Scale, QBPDS) were determined through patient surveys. Multiple linear regression analyses were performed to compare PROs between the NP (DN4≥4) and non-NP (DN4<4) groups. RESULTS: A total of 1,200 patients (females: 65.7%; mean age: 63.4±13.0 years) were enrolled. The mean scores of EQ-5D, EQ-VAS, and QBPDS were 0.5±0.3, 55.7±19.4, and 40.4±21.1, respectively. Among all patients, 492 (41.0%; 95% confidence interval, 38.2%-43.8%) suffered from NP. The prevalence of NP was higher in male patients (46.8%; p<0.01), in patients who had pain based on radiological and neurological findings (59.0%; p<0.01), and in patients who had severe pain (49.0%; p<0.01). There were significant mean differences in EQ-5D (NP group vs. non-NP group: 0.4±0.3 vs. 0.5±0.3; p<0.01) and QBPDS (NP group vs. non-NP group: 45.8±21.2 vs. 36.3±20.2; p<0.01) scores. In the multiple linear regression, patients with NP showed lower EQ-5D (ß=-0.1; p<0.01) and higher QBPDS (ß=7.0; p<0.01) scores than those without NP. CONCLUSIONS: NP was highly prevalent in Korean patients with CLBP. Patients with CLBP having NP had a lower QoL and more severe dysfunction than those without NP. To enhance the QoL and functional status of patients with CLBP, this study highlights the importance of appropriately diagnosing and treating NP.

Efficacy and Safety of Transdermal Buprenorphine versus Oral Tramadol/Acetaminophen in Patients with Persistent Postoperative Pain after Spinal Surgery.

PURPOSE: Control of persistent pain following spinal surgery is an unmet clinical need. This study compared the efficacy and safety of buprenorphine transdermal system (BTDS) to oral tramadol/acetaminophen (TA) in Korean patients with persistent, moderate pain following spinal surgery. METHODS: Open-label, interventional, randomized multicenter study. Adults with persistent postoperative pain (Numeric Rating Scale [NRS] ≥ 4 at 14-90 days postsurgery) were enrolled. Patients received once-weekly BTDS (n = 47; 5 µg/h titrated to 20 µg/h) or twice-daily TA (n = 40; tramadol 37.5 mg/acetaminophen 325 mg, one tablet titrated to 4 tablets) for 6 weeks. The study compared pain reduction with BTDS versus TA at week 6. Quality of life (QoL), treatment satisfaction, medication compliance, and adverse events (AEs) were assessed. FINDINGS: At week 6, both groups reported significant pain reduction (mean NRS change: BTDS -2.02; TA -2.76, both P < 0.0001) and improved QoL (mean EQ-5D index change: BTDS 0.10; TA 0.19, both P < 0.05). The BTDS group achieved better medication compliance (97.8% versus 91.0%). Incidence of AEs (26.1% versus 20.0%) and adverse drug reactions (20.3% versus 16.9%) were comparable between groups. IMPLICATIONS: For patients with persistent pain following spinal surgery, BTDS is an alternative to TA for reducing pain and supports medication compliance. This trial is registered with Clinicaltrials.gov: NCT01983111.

Radiological analysis of minimal safe distance and optimal screw angle to avoid facet violation in open-door laminoplasty using precontoured plate.

PURPOSE: This study aimed to present radiologic analysis of minimal safe distance (MSD) and optimal screw angle (OSA) that enables to fix screws in a lateral mass safely without facet joint violation in open-door laminoplasty using a plate. METHODS: A retrospective analysis was made of 22 patients (male: 17; female: 5), average age 62 years. Seventy-nine lateral mass screws were fixed among a total of 158 screws. MSD that doesn't allow 5-mm screws to violate a facet joint was measured for C3-C7 and a comparative analysis was performed. If the MSD is not secured, the OSA to be given to the cephalad direction is calculated to avoid violation of the facet joint. RESULTS: The screws violating inferior facet joints accounted for 34.1% of the screws fixed in inferior lateral mass. Joint surface to distal mini-screw distances were 3.18 ± 1.46 mm and 4.75 ± 1.71 mm in groups of facet joint violation and non-facet violation (FV), respectively ( p = 0.001). When 5-mm screws were inserted into a lateral mass, MSD was 4.39 ± 0.83 mm. The average MSD of C3, C4, and C5 was 4.05 ± 0.78 mm, 4.10 ± 0.70 mm, and 4.26 ± 0.74 mm, respectively. There was no significant differences among levels ( p > 0.05). The average MSD of C6 and C7 was 4.92 ± 0.81 mm and 4.80 ± 0.96 mm, respectively, showing significant differences from those of C3, C4, and C5 ( p < 0.05). If 6 mm of the MSD isn't secured, OSA showed in the cephalad direction of 11.5° for 5 mm and 22° for 4 mm approximately. CONCLUSION: We suggest that mini-screw on lateral mass can be fixed safely without FV, if they are fixed at MSD of 6 mm from a joint surface. Facet joint violation doesn't occur if an OSA is given in the cephalad direction in case of not enough MSD for mini-screws.

Neuropeptide Y improves cisplatin-induced bone marrow dysfunction without blocking chemotherapeutic efficacy in a cancer mouse model.

Cisplatin is the most effective and widely used chemotherapeutic agent for many types of cancer. Unfortunately, its clinical use is limited by its adverse effects, notably bone marrow suppression leading to abnormal hematopoiesis. We previously revealed that neuropeptide Y (NPY) is responsible for the maintenance of hematopoietic stem cell (HSC) function by protecting the sympathetic nervous system (SNS) fibers survival from chemotherapy-induced bone marrow impairment. Here, we show the NPY-mediated protective effect against bone marrow dysfunction due to cisplatin in an ovarian cancer mouse model. During chemotherapy, NPY mitigates reduction in HSC abundance and destruction of SNS fibers in the bone marrow without blocking the anticancer efficacy of cisplatin, and it results in the restoration of blood cells and amelioration of sensory neuropathy. Therefore, these results suggest that NPY can be used as a potentially effective agent to improve bone marrow dysfunction during cisplatinbased cancer therapy. [BMB Reports 2017; 50(8): 417-422].

Occipitocervical inclination: new radiographic parameter of neutral occipitocervical position.

PURPOSE: To describe occipitocervical inclination (OCI), a new parameter that could compensate for defects in existing radiographic parameters, and to define occipitocervical neutral position. METHODS: Neutral, flexion, and extension lateral cervical spine radiographs of 200 patients (100 male and 100 female patients) judged to be normal were analyzed. The mean age was 45.19 years (range 11-74; 42.84 for male and 47.53 for female patients). For OCI, the angle formed by the line connecting the posterior border of the C4 vertebral body and McGregor's line was measured. Occipitocervical angle (OCA) and occipitocervical distance (OCD) were measured and compared with OCI. RESULTS: OCI on standard, neutral lateral cervical radiographs was 102.51° ± 8.87°. There was no significant gender difference in neutral OCI 102.81° ± 7.93° for male and 102.21° ± 9.74° for female patients (P = 0.631). The mean neutral OCA was 38.69° ± 9.23°, and the mean neutral OCD was 22.98 ± 5.10 mm. Pearson's correlation coefficient for the value of the cervical lordosis angle and that of neutral OCI was r = 0.274 (P < 0.001). Intraclass correlation coefficient values for inter- and intraobserver reliability for OCI were significantly higher than those for OCA (P < 0.001) and tended to be higher than those for OCD (P = 0.087). CONCLUSIONS: OCI is a very useful parameter for the determination of neutral position during occipitocervical fusion for patients with altered C0-C2 anatomy.