Electrophysiological evidence of diabetes' impacts on central conduction recoveries in degenerative cervical myelopathy after surgery.

OBJECTIVES: To assess the impact of diabetes mellitus (DM) on the postoperative motor and somatosensory functional recoveries of degenerative cervical myelopathy (DCM) patients. METHODS: Motor and somatosensory evoked potentials (MEP and SSEPs) and modified Japanese Orthopedic Association (mJOA) scores were recorded in 27 diabetic (DCM-DM group) and 38 non-diabetic DCM patients (DCM group) before and 1 year after surgery. The central motor (CMCT) and somatosensory (CSCT) conduction time were recorded to evaluate the conductive functions of the spinal cord. RESULTS: The mJOA scores, CMCT and CSCT improved (t test, p < 0.05) in both of the DCM-DM and DCM groups 1 year after surgery. The mJOA recovery rate (RR) and CSCT recovery ratio were significantly worse (t test, p < 0.05) in the DCM-DM group compared to the DCM group. DM proved to be a significant independent risk factor for poor CSCT recovery (OR = 4.52, 95% CI 2.32-7.12) after adjusting for possible confounding factors. In DCM-DM group, CSCT recovery ratio was also correlated with preoperative HbA1 level (R = - 0.55, p = 0.003). Furthermore, DM duration longer than 10 years and insulin dependence were risk factors for lower mJOA, CMCT and CSCT recoveries among all DCM-DM patients (t test, p < 0.05). CONCLUSIONS: DM may directly hinders spinal cord conduction recovery in DCM patients after surgery. Corticospinal tract impairments are similar between DCM and DCM-DM patients, but significantly worsened in chronic or insulin-dependent DM patients. The dorsal column is more sensitively affected in all DCM-DM patients. Deeper investigation into the mechanisms and neural regeneration strategies is needed.

Healing pattern classification for thoracolumbar burst fractures after posterior short-segment fixation.

BACKGROUND: Thoracolumbar burst fractures can be treated with posterior short-segment fixation. However, no classification can help to estimate whether the healed vertebral body will have sufficient stability after implant removal. We aimed to develop a Healing Pattern Classification (HPC) to evaluate the stability of the healed vertebra based on cavity size and location. METHODS: Fifty-two thoracolumbar burst fracture patients treated with posterior short-segmental fixation without fusion and followed up for an average of 3.2 years were retrospectively studied. The HPC was divided into 4 types: type I - no cavity; type II - a small cavity with or without the violation of one endplate; type III - a large cavity with or without the violation of one endplate; and type IV - a burst cavity with the violation of both endplates or the lateral cortical shell. The intraobserver and interobserver intraclass correlation coefficients (ICCs) of the HPC were assessed. The demographic characteristics and clinical outcomes of the cohort were compared between the stable group (types I and II) and the unstable group (types III and IV). Logistic regression was conducted to evaluate risk factors for unstable healing. RESULTS: The intraobserver and interobserver ICCs of the HPC were 0.86 (95% CI = 0.74-0.90) and 0.77 (95% CI = 0.59-0.86), respectively. While the unstable healing group (types III and IV) accounted for 59.6% of the patients, most of these patients were asymptomatic. The preoperative Load Sharing Classification (LSC) comminution score may predict the occurrence of unstable healing (OR = 8.4, 95% CI = 2.4-29.7). CONCLUSIONS: A reliable classification for assessing the stability of a healed vertebra was developed. With type I and II healing, the vertebra is considered stable, and the implant can be removed. With type III healing, the vertebra may have healing potential, but the implant should not be removed unless type II healing is achieved. With type IV healing, the vertebra is considered extremely unstable, and instrumentation should be maintained. Assessing the LSC comminution score preoperatively may help to predict unstable healing after surgery.

Protective effects of Rhizoma smilacis glabrae extracts on potassium oxonate- and monosodium urate-induced hyperuricemia and gout in mice.

BACKGROUND: Rhizoma smilacis glabrae (RSG, tufuling) has been widely used in traditional Chinese medicine for deoxidation, dampness relief, and easing joint movement. The chemical composition of RSG has been systematically confirmed, and some of its compounds have been revealed to possess antioxidant, anti-inflammatory, immunomodulatory, hypouricemic, and hepatoprotective effects. PURPOSE: We aimed to clarify whether a RSG extract attenuates hyperuricemia, paw edema, and renal injury in mice with potassium oxonate (PO)- and monosodium urate (MSU)-induced chronic hyperuricemia and gout. METHODS: RSG water extract was obtained and analyzed by HPLC-DAD-MS/MS. To establish a murine model with chronic hyperuricemia and gout, PO was orally administered daily from day 0 to day 24, whereas MSU was injected into the tibiotarsal joint on day 21. The mice in the drug intervention groups were treated once daily with doses of allopurinol or RSG extract from day 21 to day 24. The diameter of the ankle joints was measured with calipers. Serum TNF-α and IL-1ß concentrations, hepatic XOD activity, and uric acid, creatinine, and blood urea nitrogen (BUN) levels were also determined. The right kidney and articular cavities were fixed, cut into sections, and stained with hematoxylin and eosin. RESULTS: Nine compounds in the RSG water extract were unambiguously identified as 5-O-caffeoylshikimic acid, neoastilbin, astilbin, taxifolin, neoisoastilbin, isoastilbin, engeletin, isoengeletin, and trans-resveratrol. The RSGE treatment dose-dependently reduced PO- and MSU-induced paw edema, serum TNF-α, IL-1ß, IL-6, IL-12, uric acid, and BUN, while significantly elevated serum IL-10, urinary uric acid and creatinine levels as compared with the respective values in the hyperuricemic and gouty mice group (vehicle group). Moreover, the hepatic XOD activity was dose-dependently reduced by the RSGE treatment. In addition, RSGE treatment not only ameliorated the infiltration of inflammatory cells, tubular dilation and vacuole formation in renal tubular, but also improved the synovial hyperplasia, reduced inflammatory cells infiltration into the synovium, and diminished the erosive damage in the cartilage. CONCLUSION: The murine model with chronic hyperuricemia and gout be built in present study is consistent with the clinical symptoms of patients with long-standing hyperuricemia and acute gouty arthritis. RSG water extract has potent efficacy in ameliorating murine hyperuricemia and gout induced by PO and MSU.

Sagittal Alignment Outcomes in Lordotic Cervical Spine: Does Three-Level Anterior Cervical Discectomy and Fusion Outperform Laminoplasty?

STUDY DESIGN: A prospective cohort study. OBJECTIVE: To compare the radiological outcomes between three-level anterior cervical discectomy and fusion (ACDF) and plate-only open-door laminoplasty (LAMP) in patients with lordotic cervical spine. SUMMARY OF BACKGROUND DATA: Both three-level ACDF and LAMP are important surgical methods for multilevel cervical spondylotic myelopathy, but the cervical sagittal alignment outcomes and the lordosis preserving abilities between the two specific approaches have not been carefully compared. METHODS: Sixty patients, all of whom had lordotic cervical spines and underwent three-level ACDF (n = 22) or LAMP (n = 38) for the treatment of multilevel cervical spondylotic myelopathy, were prospectively studied. Upright neutral cervical lateral radiographs were assessed preoperatively, at 3 days after surgery, and at the last follow-up (1.5 years). The primary radiological outcomes are C2-7 Cobb angle, and the secondary outcomes include C2-7 sagittal vertical axis , disc height, Harrison angle, and Ishihara index. The relationship between preoperative parameters and follow-up outcomes were assessed. RESULTS: Preoperative cervical sagittal alignment parameters were similar between the two groups. Patients in the ACDF group obtained larger C2-7 Cobb angles than those the LAMP group early after surgery. However, the lordosis in the ACDF group decreased significantly during follow-up, leading to similar outcomes between the two groups. The lordosis-preserving ability of ACDF is significantly poorer than that of LAMP. Secondary radiological parameters also showed similar trends. In both groups, the preoperated Ishihara index was significantly related to follow-up C2-7 Cobb angles. For patients with Ishihara index less than 20, ACDF is more likely to produce a larger C2-7 Cobb angled at the time of follow-up. CONCLUSION: In patients with lordotic cervical spine, the sagittal alignment outcomes of the two approaches were similar, and the lordosis-preserving ability was poorer in ACDF. Further research should focus on the factors related to the lordosis-preserving ability of multilevel ACDF. LEVEL OF EVIDENCE: 3.

Wallis Interspinous Spacer for Treatment of Primary Lumbar Disc Herniation: Three-Year Results of a Randomized Controlled Trial.

BACKGROUND: Limited data have been reported showing whether the second-generation Wallis interspinous spacer improves function after lumbar spine decompression or discectomy. METHODS: We evaluated Wallis interspinous spacer placement in patients with low back pain or sciatica secondary to a confirmed diagnosis of primary lumbar disc herniation. The patients were treated from July 2008 to July 2011 at 1 institution. Of the 77 patients, 40 allocated to undergo posterior lumbar discectomy with Wallis implantation and 37 without Wallis implantation. The primary outcomes were the visual analog scale score, Japanese Orthopedics Association score, and Oswestry Disability Index. The secondary outcomes were the intervertebral disc height, range of motion of the operated segments, complications, and operating time. RESULTS: At 3 years, the improvements in the primary outcomes were not different between the 2 groups (P > 0.05). The disc height was significantly greater in the Wallis group than in the control group (P < 0.001). Two patients in the Wallis group and three patients in the control group underwent further surgery to treat repeated prolapse of the index segment or an adjacent segment. No significant difference was found in the complication rate between the 2 groups (P > 0.05). CONCLUSIONS: We found that discectomy combined with Wallis implantation was not beneficial for pain relief or lumbar function improvement compared with lumbar discectomy alone. Although the Wallis implant was associated with maintenance of the intervertebral disc height and limited range of motion of the spine, it is probably incapable of preventing recurrent herniation or adjacent segment degeneration.

Efficacy of the Wallis interspinous implant for primary lumbar disc herniation : a prospective randomised controlled trial.

PURPOSE: To investigate the efficacy of the Wallis implant after lumbar discectomy compared with discectomy alone for primary lumbar disc herniation. Seventy-seven patients with primary lumbar disc herniation were randomly assigned to undergo either posterior lumbar discectomy with (n=40, Wallis group) or without (n=37, control group) Wallis implantation. The primary outcomes were visual analogue scale score, Japanese Orthopedics Association score, and Oswestry Disability Index. The secondary outcomes were intervertebral disc height, range of motion of the operated segments, complications, and operating time. The primary outcomes at 1 week after treatment (P> 0.05) were not different between groups. The Wallis group had better scores at 12 months (P< 0.05) and the last follow-up visit (P< 0.05), higher disc height (P< 0.001), and significantly longer operating time (P =0.006) than the control group. Combined treatment appears beneficial for pain relief and lumbar function improvement by maintaining intervertebral disc height and limiting the range of motion of the spine compared with lumbar discectomy alone. However, its actual clinical benefit remains controversial because of the longer operating time and the relatively small difference in the visual analogue scale score and Oswestry Disability Index between the groups.

Diabetes mellitus is associated with increased risk of surgical site infections: A meta-analysis of prospective cohort studies.

BACKGROUND AND OBJECTIVE: Observational studies have suggested an association between diabetes mellitus and the risk of surgical site infections (SSIs), but the results remain inconclusive. We conducted a meta-analysis of prospective cohort studies to elucidate the relationship between diabetes mellitus and SSIs. METHODS: We searched PubMed, Embase, and Web of Science databases and reviewed the reference lists of the retrieved articles to identify relevant studies. Associations were tested in subgroups representing different patient characteristics and study quality criteria. The random-effect model was used to calculate the overall relative risk (RR). RESULTS: Fourteen prospective cohort studies (N = 91,094 participants) were included in this meta-analysis, and the pooled crude RR was 2.02 (95% confidence interval, 1.68-2.43) with significant between-study heterogeneity observed (I(2) = 56.50%). Significant association was also detected after we derived adjusted RRs for studies not reporting the adjusted RRs and calculated the combined adjusted RR of the 14 studies (RR, 1.69; 95% confidence interval, 1.33-2.13). Results were consistent and statistically significant in all subgroups. Stratified analyses found the number of confounders adjusted for, sample size, and method of diabetes case ascertainment might be the potential sources of heterogeneity. Sensitivity analysis further demonstrated the robustness of the result. CONCLUSIONS: This meta-analysis suggests diabetes mellitus is significantly associated with increased risk of SSIs. Future studies are encouraged to reveal the mechanisms underlying this association.

Multidisciplinary treatment based on surgery leading to long-term survival of a patient with multiple asynchronous rare primary malignant neoplasms: A case report and literature review.

Patients that present with multiple primary malignant neoplasms are increasingly encountered, but the treatment of such patients presents specific challenges and long-term survival is rare. The present study reports the case of a 45-year-old female diagnosed with three rare, distinct primary malignant neoplasms, including epithelioid hemangioendothelioma (EHE) of the brain, Ewing's sarcoma of the lumbar 2 vertebra and a malignant solitary fibrous tumour (SFT) of the liver, at different time points. The patient underwent multidisciplinary treatment according to the diagnoses, including radial resection of all primary lesions, chemotherapy (consisting of vincristine, dactinomycin, cyclophosphamide and adriamycin) and radiotherapy, to treat Ewing's sarcoma and metastases of EHE and malignant SFT. Following these treatments, the patient survived for >14 years. Multidisciplinary treatment regimens based on surgery can lead to long-term survival of patients with multiple asynchronous rare primary malignant neoplasms. The present study reported that multidisciplinary treatment regimens based on surgery can lead to the long-term survival of patients with multiple asynchronous rare primary malignant neoplasms.

The security analysis of transpedicular screw fixation in the lower cervical spine and a case report.

STUDY DESIGN: This study evaluated the anatomical parameters of the lower cervical spine by imaging methods and reported a case. OBJECTIVE: To explain low neurovascular injury rate and provide some suggestions in cervical transpedicular screw fixation (CTSF). SUMMARY OF BACKGROUND DATA: Because of anatomical complexity and possible severe complications, application of CTSF was limited. However, recent studies have indicated that although cervical pedicular screw perforations may happen, severe complications seldom occur. METHODS: In 20 patients, several anatomical parameters were obtained on computed tomographic angiography (CTA) images of C3-C6, including the inner diameter of vertebral artery (d), the maximal width (A) and height (B) of the transverse foramen, the shortest distance between vertebral artery and cervical pedicle (h), and the angle between the longitudinal axis of pedicle and the hypothetical screw that just touches the vertebral artery (largest safe angle, LSA). Another 35 patients were chosen to measure the shortest distance between cervical pedicle and cervical spinal cord (H) and the angle between the longitudinal axis of pedicle and the hypothetical screw that just touches the cervical spinal cord (smallest angle, SA) on magnetic resonance imaging (MRI) of C4-C7. RESULTS: Between the left and the right sides, there was no statistically significant difference for d, A, B, h, and LSA at C3-C6 or H and SA at C4-C7. d, h, and H were, respectively, 3.97 ± 0.65 mm, 0.89 ± 0.44 mm, and 6.56 ± 2.10 mm, and there was no statistically significant difference among C3-C6 for d and h or among C4-C7 for H. LSA at C6 was larger than that at C3, C4, and C5; it increased from C5 to C7. CONCLUSION: There was an "escaping space" for the vertebral artery and spinal cord. CTSF in the superior part of pedicle was relatively safer from accidental perforation of the vertebral artery than CTSF in the inferior part, and in C6 and C7, CTSF was safer from this injury than in C3, C4, and C5.

[Lumbar interspinous non-fusion techniques: comparison between Coflex™ and Wallis].

OBJECTIVE: To compare the short-term clinical outcome of non-fusion techniques using interspinous implantation Coflex(TM) and Wallis treatment in patients with lumbar spine degenerative diseases. METHODS: Forty-one cases of lumbar stenosis, 18 of lumbar disc herniation, and 34 of lumbar stenosis with lumbar disc herniation were evaluated. Among the 43 cases receiving Coflex(TM) implantation, 41 had operations in one segment and 2 in 2 segments. In the other 50 cases with Wallis implantation, 47 had fixation of 1 segment and 3 had 2 segments fixed. JOA Score, Oswestry Disable Index (ODI) and VAS were used to evaluate the short-term clinical results. RESULTS: The average operating time was 64.55 min in Coflex(TM) implantation with an average blood loss of 81.82 ml. The average operating time was 82.71 min in Wallis implantation, which caused an average blood loss of 89.66 ml. Significant improvements in the JOA Score, ODI and VAS were noted after the operations. CONCLUSION: The two interspinous non-fusion techniques, Coflex and Wallis, produce good short-term clinical outcome in the treatment of lumbar spine degenerative diseases.

[Application of lumbar-pelvic fixation in lumbosacral reconstruction after resection of sacral tumors].

OBJECTIVE: To evaluate the short-term clinical results of a new approach of lumbar-pelvic fixation for lumbosacral reconstruction after resection of sacral tumors. METHODS: Fifteen patients with sacral tumors underwent lumbar-pelvic fixation using TSRH-3D, CDH-M8 or ISOLA with iliac screws. The lumbosacral stability was evaluated according to the X-ray result to assess the feasibility and therapeutic effect of this approach. RESULTS: X-ray showed that high lumbosacral stability was achieved in all the 15 cases after the operation, and satisfactory therapeutic effect was obtained. CONCLUSION: Lumbar-pelvic fixation with iliac screw is feasible for lumbosacral reconstruction after resection of the sacral tumors, which provides strong internal fixation and produce good clinical outcomes.

[Comparison of surgical treatment in single thoracolumbar-lumbar adolescent idiopathic scoliosis: anterior versus posterior surgery].

OBJECTIVE: To retrospectively compare the clinical outcomes of anterior and posterior surgical treatment in single thoracolumbar-lumbar adolescent idiopathic scoliosis. METHODS: Between January 2004 and August 2008, 22 female patients, averaged 14.5 years old (12 to 18 years), of thoracolumbar-lumbar adolescent idiopathic scoliosis were corrected by anterior correction and fusion. At the same time, 20 female patients, average 14.8 years old (11 to 19 years), were corrected by posterior segmental pedicle screw correction and fusion. Operation time, SRS-24 score, intraoperative blood loss, and coronal and sagittal plane correction were compared between the two groups. RESULTS: All patients were followed up for 12 to 63 months, the mean follow-up time was 28.3 months. Operation time was (334 + or - 36) min in anterior group and (292 + or - 17) min in posterior group; intraoperative blood loose was (940 + or - 207) ml in anterior group and (596 + or - 227) ml in posterior group; fusion levels were (5.2 + or - 0.8) in anterior group and (6.7 + or - 1.2) in posterior group. There were statistically significant difference in operation time, intraoperative blood loss and fusion levels (P < 0.05). Coronal correction was (93 + or - 5)% in anterior group and (88 + or - 5)% in posterior group. SRS-24 scores averaged 98 in anterior group and averaged 94 in posterior group. There was no statistical difference in coronal correction or SRS-24 scores (P > 0.05). CONCLUSIONS: Posterior surgery has the same correction results compared with anterior surgery in treating thoracolumbar-lumbar adolescent idiopathic scoliosis. Posterior surgery takes less operation time, brings less trauma but has longer fusion levels.