Cryogen spray cooling mitigates inflammation and injury-induced CISD2 decline in rat spinal cord hemisection model.

Therapeutic strategies for traumatic spinal cord injury generally involve rectifying concomitant destruction to the spinal cord from inflammation, mitochondrial dysfunction, and eventual neuronal apoptosis. Elevating the expression of spinal cord injury-attenuated CDGSH iron-sulfur domain-2 has been shown to mitigate the pathologies above. In the current work, hypothermia was induced via continuous cryogen spray cooling in a rat spinal cord hemisection model. Spinal cord injury was shown to elevate the mRNA expression of proinflammatory mediators, including NFκB, iNOS, TNF-α, and regulated upon activation, normal T-cell expressed and secreted as well as lower CDGSH iron-sulfur domain-2 expression. Cryogen spray cooling treatment was shown to attenuate inflammatory reactions and elevate CDGSH iron-sulfur domain-2 expression. Immunohistochemical analysis of the glial fibrillary acidic protein, caspase-3 and NeuN in spinal cord injured rats that underwent cryogen spray cooling treatment revealed notable reductions in injury-induced astrocytic activation, apoptosis, neuronal loss, and decline in CDGSH iron-sulfur domain-2 expression. These results demonstrate the CDGSH iron-sulfur domain-2 preserving effects of cryogen spray cooling, which could contribute to the prevention of astrocytic activation, astrocyte-mediated neuroinflammation, apoptosis, and neuron loss.

Human adipose-derived stem cells for the treatment of intracerebral hemorrhage in rats via femoral intravenous injection.

Human adipose-derived stem cells (huADSC) were generated from fat tissue of a 65-year-old male donor. Flow cytometry and reverse transcription polymerase chain reaction (RT-PCR) analyses indicated that the huADSC express neural cell proteins (MAP2, GFAP, nestin and ß-III tubulin), neurotrophic growth factors (BDNF and GDNF), and the chemotactic factor CXCR4 and its corresponding ligand CXCL12. In addition, huADSC expressed the characteristic mesenchymal stem cell (MSC) markers CD29, CD44, CD73, CD90, CD105 and HLA class I. The huADSC were employed, via a right femoral vein injection, to treat rats inflicted with experimental intracerebral hemorrhage (ICH). Behavioral measurement on the experimental animals, seven days after the huADSC therapy, showed a significant functional improvement in the rats with stem cell therapy in comparison with rats of the control group without the stem cell therapy. The injected huADSC were detectable in the brains of the huADSC treated rats as determined by histochemistry analysis, suggesting a role of the infused huADSC in facilitating functional recovery of the experimental animals with ICH induced stroke.

The Correlation Between Restoration of Lumbar Lordosis and Surgical Outcome in the Treatment of Low-grade Lumbar Degenerative Spondylolisthesis With Spinal Fusion.

STUDY DESIGN: Retrospective clinical study. OBJECTIVE: To investigate the relationship between the restoration of the lumbar lordosis (LL) and the surgical outcome of patients undergoing spinal fusion for low-grade lumbar degenerative spondylolisthesis. SUMMARY OF BACKGROUND DATA: Correlation between low back pain and the loss of LL in the treatment of low-grade lumbar degenerative spondylolisthesis has seldom been reported. METHODS: Between May 2005 and July 2011, 59 patients with low back pain and neurogenic claudication due to low-grade lumbar degenerative spondylolisthesis underwent spinal decompression and fusion by a senior surgeon. Ten patients were lost to follow-up. The mean age of the remaining 49 patients (10 men and 39 women) was 64.0 years (range, 47-88 y). Patients were categorized on the basis of the spino-pelvic posture: type 1 [pelvic incidence (PI)<45 degrees] (n=12), type 2 (45 degrees≤PI≤60 degrees) (n=24), and type 3 (PI>60 degrees) (n=13). The LL restoration ratio was calculated by the actual LL divided by the predicted LL. The clinical results were evaluated using a visual analogue scale and the Oswestry Disability Index. Postoperative 36-inch spinal films were used to assess the sagittal balance. RESULTS: The mean follow-up period was 43.2 months (range, 28-62 mo). Forty-eight patients showed significant improvement with respect to visual analogue scale and Oswestry Disability Index regardless of whether the LL was restored higher or lower. Postoperative 36-inch spinal films showed the C7 plumb line to be within an average of 4.4 cm (range, 0.6-5.6 cm) from the posterior-superior corner of the S1 vertebrae. CONCLUSIONS: Patients with smaller PI tended to be restored higher, and those patients with a larger PI were more likely to be restored lower. For patients with normal sagittal balance, the surgical outcomes in the treatment of low-grade lumbar degenerative spondylolisthesis with spinal fusion are not correlated with restoration of the LL.

Surgical experience with symptomatic thoracic ossification of the ligamentum flavum.

OBJECT: Symptomatic thoracic ossification of the ligamentum flavum (OLF) is rare, and its prognostic factors remain unclear. The authors retrospectively studied 24 patients with surgically treated thoracic OLF to delineate its prognostic factor. METHODS: The clinical manifestations, radiological studies, surgical records, and pathological findings were reviewed. Preoperative and postoperative neurological data were reappraised using the American Spinal Injury Association and modified Japanese Orthopaedic Association (JOA) scoring systems. Spearman rank-correlation coefficients and nonparametric tests were used to analyze the correlations between the variables of patient characteristics, preoperative duration of symptoms, preoperative neurological status, associated spinal disorder(s) other than thoracic OLF, and the final functional outcome. CONCLUSIONS: Decompressive surgery is indicated in patients in whom symptomatic thoracic spinal cord compression is caused by intruding OLF. Magnetic resonance imaging can provide sufficient clues for the diagnosis of thoracic OLF. Higher preoperative modified JOA scores of 3 and 4 are positively correlated with better postoperatiVe functional recovery than lower scores. Surgery should be performed as soon as possible before independent ambulatory function is impaired.

Comparison of the kinematic features between the in vivo active and passive flexion-extension of the subaxial cervical spine and their biomechanical implications.

STUDY DESIGN: An in vivo motion analysis of active and passive kinematic cervical flexion-extension. OBJECTIVE: The study was aimed at investigating the differences between the active and passive kinematic sagittal motions of the subaxial cervical spine. SUMMARY OF BACKGROUND DATA: The biomechanical behavior of the cadaver spinal column is different from that of the in vivo spine. Two major issues were concerned: the complex neuromuscular control of the in vivo cervical spinal motion and the unknown true nature of the passive cervical spinal motion. The kinematic characteristics of active and passive spinal motions need to be clarified. METHODS: The active and passive motion patterns of the subaxial spine in the sagittal plane were recorded by digital video fluoroscopy. The motion of functional units from C3-C4 to C6-C7 of the cervical spine were processed using Image J, an image processing software, in both active and passive cervical motions. The Cobb's angle was measured in serial flexion and extension motions, and a comparison of this angle in both active and passive motions was made in 12 patients with degenerative disc herniation. RESULTS: The difference between active and passive gentle flexion was minimal, and the degree of their correlation was high. The differences in the degree of gentle extension between active and passive motion were variable, and their correlation was low. During early passive flexion, the degree of flexion at the upper level was less and that at the lower level was more as compared to that observed at the respective levels in early active flexion. CONCLUSION: In gentle flexion, the active and passive cervical spinal motions are closely approximated, which implies that the active neuromuscular control mainly plays the buffer-and-brake mechanism without placing additional load on the spine. In contrast, the degree of passive extension is limited, and active neuromuscular control may place additional load on the spine.

Hirayama disease.

OBJECT: Controversy exists over the choice of surgical candidates and prognosis of Hirayama disease. The purpose of this study was to examine the outcomes of patients with cervical flexion myelopathy who received surgical treatment. METHODS: A retrospective study was conducted. From May 2002 through December 2006, 6 young patients with cervical flexion myelopathy were seen in the Department of Neurosurgery at Chang Gung Memorial Hospital. The neurological and radiological findings in all 6 patients met the criteria for Hirayama disease. All patients had evidence of a tight dural canal or forward migration of the posterior wall of the dural canal in dynamic MR imaging studies. Five patients were treated with surgical decompressive procedures (4 anterior and 1 posterior) and 1 patient received conservative treatment. Duration of follow-up ranged from 13 months to 4 years. RESULTS: Motor function improved in 3 of 5 surgically treated patients and sensory function improved in 2. Neurological symptoms were unchanged in the conservatively treated patient. During follow-up MR imaging in the surgical group, anterior effacement during neck flexion was noted in 1 patient treated with a posterior approach. CONCLUSIONS: Hirayama disease is so rare that it is easily misdiagnosed. Diagnosis is achieved via clinical presentation, neurophysiological examination, and neuroradiological imaging studies (dynamic MR imaging). The anterior decompressive approach may be better for patients showing anterior effacement and severe cervical kyphosis during neck flexion in MR imaging.

Clinical practice guidelines in severe traumatic brain injury in Taiwan.

BACKGROUND: Severe TBIs are major causes of disability and death in accidents. The Brain Trauma Foundation supported the first edition of the Guidelines for the Management of Severe Traumatic Brain Injury in 1995 and revised it in 2000. The recommendations in these guidelines are well accepted in the world. There are still some different views on trauma mechanisms, pathogenesis, and managements in different areas. Individualized guidelines for different countries would be necessary, and Taiwan is no exception. METHODS: In November 2005, we organized the severe TBI guidelines committee and selected 9 topics, including ER treatment, ICP monitoring, CPP, fluid therapy, use of sedatives, nutrition, intracranial hypertension, seizure prophylaxis, and second-tier therapy. We have since searched key questions in these topics on Medline. References are classified into 8 levels of evidence: 1++, 1+, 1-, 2++, 2+, 2-, 3, and 4 based on the criteria of the SIGN. RESULTS: Recommendations are formed and graded as A, B, C, and D. Grade A means that at least one piece of evidence is rated as 1++, whereas grade B means inclusion of studies rated as 2++. Grade C means inclusion of references rated as 2+, and grade D means levels of evidence rated as 3 or 4. Overall, 42 recommendations are formed. Three of these are rated as grade A, 13 as grade B, 21 as grade C, and 5 as grade D. CONCLUSIONS: We have completed the first evidence-based, clinical practice guidelines for severe TBIs. It is hoped that the guidelines will provide concepts and recommendations to promote the quality of care for severe TBIs in Taiwan.

Axial and coronal orientation of subaxial cervical zygapophysial joints and their effect on axial rotation and lateral bending.

STUDY DESIGN: Computerized tomography and image processing methodologies were used to analyze the axial and coronal orientation of cervical zygapophysial joints in asymptomatic adults. Surface motions of axial rotation and lateral bending were simulated. OBJECTIVE: The study was designed to obtain the normal distribution and variation of facet orientation (FO) in axial and coronal planes to investigate factors affecting FO and to study the effects of FO on axial rotation and lateral bending. SUMMARY OF BACKGROUND DATA: The FO of the subaxial cervical spine is usually evaluated in the sagittal plane. Cervical spine axial and coronal FO is usually considered to be horizontal. The literature reveals no statistical data for axial or coronal FO. METHODS: Serial thin-sliced computed tomography scans of the cervical spine in asymptomatic adults were input into Image J, National Institutes of Health, image processing software. Bilateral zygapophysial joint angles from C2-C3 to C6-C7 were measured in the axial and coronal planes and collected from 100 subjects. The effect of gender, age, and correlation was analyzed. The surface motions of axial rotation and lateral bending were simulated in Abaqus CAE 6.5. Mathematical facet contact and range of motion were computed. RESULTS: The FO was widely distributed at each level. Gender had no significant association with FO. Age affected FO at most levels. Axial and coronal FO were significantly correlated. The zygapophysial joint of internally rotated/inverted FO contacted more perpendicularly to each other, and mathematical range of motion was smaller. CONCLUSION: The axial or coronal FO of the subaxial cervical spine was found with more variability. Age was significantly related to FO. Geometrically, internally rotated/inverted FO of axial rotation/lateral bending was morerestricted. The extent of axial rotation and lateral bending was correlated with each other.

Efficacy of topical microfibrillar collagen mixed with steroid hormone and morphine for postoperative pain control during lumbar laminectomy: a preliminary report.

BACKGROUND: Current inpatient management of postoperative pain in lumbar surgery includes the use of intramuscular opioid analgesics, nonsteroidal anti-inflammatory drugs, or patient-controlled analgesia; however, all types of medications are associated with side effects that can limit their usefulness in the inpatient setting. METHODS: In a well-conducted non-randomized prospective trial, 80 consecutive patients who underwent elective multilevel lumbar laminectomy surgery were identified. Two types of trials with different doses of steroids were used. Patients' preoperative medical records, pain scores, narcotics consumption, costs for the regimen, hospital stay, unwanted complications, and walking ability were evaluated postoperatively. RESULTS: Pain in patients after lumbar surgery can be dramatically controlled postoperatively. Seventy-eight patients (97.5%) were able to walk without support on the first postoperative day. Major side effects were found in 5 patients (6.2%). CONCLUSIONS: This experience indicates that pain-control agents with epidural sustained-released preparation seem to be beneficial in early mobilization, are cost effective, and require lower analgesic consumption by patients. Similar pain control can be obtained with lower doses of methylprednisolone. In spite of its clinical attractiveness, improvements in the side effects of complications from epidural morphine and the combination of steroids and microfibrillar collagen have yet to be realized.

Clinical results of a single central interbody fusion cage and transpedicle screws fixation for recurrent herniated lumbar disc and low-grade spondylolisthesis.

BACKGROUND: The posterior lumbar interbody fusion (PLIF) procedure allows restoration of the weight-bearing capacity to a more physiological ventral position and maintenance of disc space height. However, the procedure can be technically difficult and may cause complications. It has always been performed bilaterally with paired cages; a single central cage has not been commonly used. METHODS: Twenty-eight patients who met the interbody fusion criteria from March 1999 through November 2001 were included in the study. Surgery was performed from the posterior with a single central cage supplemented with transpedicle screws. The follow-up period ranged from 8 to 39 months with a mean of 14.4 months. Clinical outcomes were assessed. Dynamic radiography for fusion mass was interpreted by an independent radiologist. RESULTS: Overall, 92.86% of the patients were satisfied with their conditions after surgery. Radiography study showed the rate of bony fusion being 82.14%. Fibrous union was noted in five patients. No migration of the cage was observed. One patient experienced laceration of the dura without clinical sequelae. One patient had transient paresthesia and recovered within 2 weeks. One patient had transient bladder atony and recovered within 3 days. Overall, the complications were negligible and none of the patients sustained a motor deficit and permanent complication. CONCLUSIONS: The PLIF procedure using a single, central cage combined with bilateral pedicle screws fixation obtained satisfactory outcome within a short-term or long-term follow-up period. Since the implant-related complications have seldom been observed, it may be used as an alternative option for recurrent lumbar disc herniation or low grade spondylolisthesis with apparent degenerative disc disease.

Morphologic characteristics of atlantoaxial complex in rheumatoid arthritis and surgical consideration among Chinese.

STUDY DESIGN: A morphometric study of lateral mass from C1 to C2 and involving 42 patients with rheumatoid arthritis (RA). OBJECTIVE: To provide anatomic data on the lateral mass of the upper cervical spine and quantitatively assess structure feature of a C1-C2 lateral mass in RA and its association with adjacent structures. SUMMARY OF BACKGROUND DATA: No anatomic study on C1-C2 lateral mass in Chinese RA patients exists, nor is there a study describing the risk of transarticular screws fixation in these patients. METHODS: Forty-two patients with RA were obtained for study of the bony structure of the C1-C2 lateral mass. Using reconstructed CT scan, the anatomic variability of bony structure to rheumatoid inflammatory change was assessed via C2 isthmus width and height measurement. The mediolateral diameter, superoinferior diameter, and sagittal length of the atlantoaxial lateral mass were also calculated. Additionally, the possible screw trajectory angles were assessed. RESULTS: Forty-two patients displayed bony erosion of the C1-C2 mass. The dimension change of the C2 isthmus was weakly correlated with age and rheumatoid history. Furthermore, predominant destruction on either side of lateral mass is noted in 21.4% (n = 9) of patients. The mean shortest isthmus height of C2 is 4.69 +/- 1.66 mm, while its mean shortest width is 5.14 +/- 1.23 mm. Furthermore, the average distance between the anterior margin of C1 lateral mass and the same side posterior cortex of the C2 inferior facet is 36.53 +/- 3.94 mm. Meanwhile, the distance of coronal aspect of C1 lateral mass is 11.20 +/- 1.92 mm. The medial/lateral and caudo-cephalic inclinations of the isthmus with respect to the C2 inferior facet are 86.66 +/- 7.69 degrees and 40.82 +/- 7.29 degrees. Bilateral 3.5-mm screw placement could be safely achieved in only 30.9% (n = 13) of patients with chronic RA with upper cervical lesions. CONCLUSIONS: The work provides detailed bony data on the rheumatoid C2 isthmus and C1 structure. Anatomic variation in either side or both sides of the C2 isthmus is severe during erosion in patients with RA. Unilateral C1-C2 transarticular screw, modification of screw diameter, or alternative techniques for C1-C2 arthrodesis should be considered in most Chinese rheumatoid cases.

Cervical degenerative disease at flexion-extension MR imaging: prediction criteria.

PURPOSE: To determine if there are any neutral-position imaging criteria that can help predict functional cord impingement at flexion-extension cervical magnetic resonance (MR) imaging. MATERIALS AND METHODS: Sixty-two patients with cervical degenerative disease were evaluated with regard to the dynamic changes of canal stenosis at flexion-extension MR imaging. Functional cord impingement was considered if the cord was impinged or more impinged after neck flexion or extension. Selection criteria for neutral-position MR imaging, such as cervical curvature, canal space, degenerative stage, intramedullary high signal intensity on T2-weighted images, and resting instability, were evaluated for their ability to predict functional cord impingement at flexion-extension MR imaging (Fisher exact test, logistic regression analysis). RESULTS: MR images in 19 (31%) of 62 patients showed functional cord impingement at extension MR imaging compared with images in two (3%) patients at flexion MR imaging. Statistically significant differences were found for the criteria cervical degeneration stage (P <.001) and spinal canal space (P =.037) for predicting functional cord impingement at extension MR imaging. In contrast, no significant differences were found among selection criteria for flexion MR imaging. Probabilities of functional cord impingement at extension MR imaging were calculated with different combinations of degenerative stages and canal spaces. Probability could increase to 79% if the patient had both stabilization degeneration (disk protrusion or osteophytic formation with hypertrophy of the ligamentum flavum) and C7 canal space of 10 mm or less. CONCLUSION: None of the selection criteria evaluated in this study has the ability to predict functional cord impingement at flexion MR imaging; however, prediction of impingement at extension MR imaging can increase from 31% to 79% if proper criteria are selected.