Risk factors for proximal junctional kyphosis after posterior long-segment internal fixation for chronic symptomatic osteoporotic thoracolumbar fractures with kyphosis.

BACKGROUND: This study aimed to analyze the risk factors for proximal junctional kyphosis (PJK) for patients with chronic symptomatic osteoporotic thoracolumbar fractures (CSOTLF) and kyphosis who underwent long-segment internal fixation. METHODS: We retrospectively reviewed the records of patients with CSOTLF complicated with kyphosis who underwent posterior multilevel internal fixation in our hospital between January 2013 and January 2020. The patients' age, sex, body mass index (BMI), bone mineral density (BMD), smoking status, cause of injury, comorbidities, injury segments, and American Spinal Injury Association (ASIA) grading non-surgical data; posterior ligament complex (PLC) injury, upper and lower instrumented vertebral position (UIV and LIV, respectively), number of fixed segments surgical data, proximal junctional angle (PJA), sagittal vertebral axis (SVA), pelvic incidence (PI), lumbar lordosis (LL), pelvic incidence-lumbar lordosis mismatch (PI-LL), pelvic tilt (PT), and sacral slope (SS) surgical indicators were collected. Patients were divided into postoperative PJK and non-PJK groups. RESULTS: This study included 90 patients; among them, 30 (31.58%) developed PJK postoperatively. All patients were followed up for > 24 months (mean 32.5 months). Univariate analysis showed significant differences in age, BMI, BMD, PLC injury, UIV, and LIV fixation position, number of fixation stages, and preoperative PJA, SVA, PI-LL, and SS between the two groups (P < 0.05). Additionally, no significant differences were observed in sex, smoking, cause of injury, complications, injury segment ASIA grade, and preoperative PT between the two groups (P > 0.05). Multifactorial logistic regression analysis showed that age > 70 years (OR = 32.279, P < 0.05), BMI > 28 kg/m2 (OR = 7.876, P < 0.05), BMD T value < - 3.5 SD (OR = 20.836, P < 0.05), PLC injury (OR = 13.981, P < 0.05), and preoperative PI-LL > 20° (OR = 13.301, P < 0.05) were risk factors for PJK after posterior long-segment internal fixation in elderly patients with CSOTLF complicated with kyphosis. CONCLUSION: CSOTLF patients undergoing posterior long segment internal fixation are prone to PJK, and age > 70 years, BMI > 28 kg/m2, BMD T value < - 3.5 SD, preoperative PI-LL > 20° and PLC injury may increase their risk.

The feasibility of inserting a C1 pedicle screw in patients with ponticulus posticus: a retrospective analysis of eleven patients.

BACKGROUND: Ponticulus posticus is a common anatomic variation that can be mistaken for a broad posterior arch during C1 pedicle screw placement. When the atlas lateral mass screws are placed via the posterior arch, injury to the vertebral artery may result. To our knowledge, there are few clinical studies that have analyzed the feasibility of C1 pedicle screw fixation in patients with ponticulus posticus, in clinical practice. PURPOSE: To evaluate the feasibility of inserting a C1 pedicle screw in patients with ponticulus posticus. METHODS: Between January 2008 and January 2012, 11 consecutive patients with atlantoaxial instability, and with a ponticulus posticus at C1, underwent posterior fusion surgery in our institution. According to preoperative computed tomography (CT) reconstruction, a complete ponticulus posticus was found unilaterally in nine patients and bilaterally in two. Postoperative CT reconstructive imaging was performed to assess whether C1 pedicle screw placement was successful. Patients were followed up at regular intervals and evaluated for symptoms of ponticulus posticus syndrome. RESULTS: Thirteen C1 pedicles (atlas vertebral artery groove), each with a complete ponticulus posticus, were successfully inserted with thirteen 3.5- or 4.0-mm diameter pedicle screws, without resection of the bony anomaly. No intraoperative complications (venous plexus, vertebral artery, or spinal cord injury) occurred. The mean follow-up period was 21 (range 14-30) months. Postoperative CT reconstructive images showed that all 13 pedicle screws were inserted in the C1 pedicles without destruction of the atlas pedicle cortical bone. In the follow-up period, none of the patients demonstrated clinical symptoms of ponticulus posticus syndrome or developed bone fusion. CONCLUSION: Three-dimensional CT imaging should be considered prior to C1 pedicle screw fixation in patients with ponticulus posticus, to avoid mistaking the ponticulus posticus for a widened dorsal arch of the atlas. If there is no ponticulus posticus syndrome preoperatively, C1 pedicle screw fixation can be successfully performed without removing the bony anomaly.

The impact of posterior temporary internal distraction on stepwise corrective surgery for extremely severe and rigid scoliosis greater than 130°.

AIM: To investigate the efficacy and safety of temporary internal distraction corrective surgery for extremely severe scoliosis. METHODS: Eleven scoliosis patients (3 males and 8 females) with curves ≥130° (mean 148.8°; range 130°-157°) who underwent a two-stage surgery, including a posterior temporary internal distraction correction and definitive posterior spinal correction with posterior pedicle screw instrumentation from 2008 to 2011 were retrospectively reviewed. Minimum follow-up was 2-years (mean 41.8 months; range 27.0-63.0 months). The analysis focused on the impact of temporary internal distraction on curve correction, pulmonary function tests (PFTs), complications and surgical outcomes. Neurosurveillance of sensory (somatosensory-evoked potentials) and motor (motor-evoked potentials) potential was performed in all cases. Posterior instrumentation was used in all patients. RESULTS: After the use of internal distraction, the preoperative major curve (mean 148.8°; range 130°-157°) was corrected to a mean of 79° (range 63°-87°), the T5-T12 kyphosis Cobb angle (mean 79°; range 30°-97°) was corrected to a mean of 59° (range 20°-75°), the coronal imbalance (mean 0.8 cm; range -3.6 to 2.8 cm) was improved to a mean of 0.6 cm (range -1.5 to 2.0 cm), the forced vital capacity percentage (FVC%) was improved from 59.3 ± 11.6 to 68.7 ± 13.7, and the forced expiratory volume in 1 s (FEV1%) was improved from 61.4 ± 13.6 to 71.3 ± 9.3. The average increase in body height was 6.7 cm, and the dorsum razor was corrected to 3-5 cm. During definitive surgery, the final major curves were corrected to a mean of 55° (range 32°-72°), the T5-T12 kyphosis Cobb was corrected to 35° (range 15°-68°), the coronal imbalance was improved to 0.5 cm (range -1.2 to 1.8 cm), the FVC% was improved to 71.2 ± 8.3, the FEV1% was improved to 76.3 ± 16.7, the increase in body height was 3.1 cm, and the dorsum razor was corrected to 1-3 cm. The mean interval time between the two surgeries was 3.5 months. None of the patients exhibited postoperative neurologic deficits or infections. No instrument complications were found during the final follow-up. CONCLUSIONS: Temporary internal distraction in a two-stage corrective surgery provided patients who had extremely severe and rigid scoliosis, an effective and safe solution for scoliosis without significant complications.

An alternative long-term culture system for highly-pure mouse spermatogonial stem cells.

Increasing evidence suggests that spermatogonial stem cells (SSCs) have great clinical potential to give rise to a variety of cell types besides all spermatogenic lineage cells. The development of an efficient method for long-term culture of highly-pure SSCs is essential for further studies related to SSC biological events. Here, we describe an in vitro culture system obtaining mouse SSC cultures of high purity, viability, and proliferation. For establishing long-term cultures of SSCs, we mainly focused on isolation procedures and culture conditions. These included co-coating of extracellular substrates, that is, poly-L-lysine (PLL) and laminin, as well as combinatiorial use of three milder enzymes and simultaneously less trypsin to minimize enzyme-mediated degradation of SSCs. Furthermore, a unique purification procedure was performed to effectively eliminate contaminating non-SSCs. Finally, a critical step is to ensure SSC maintenance and expansion by utilizing optimal culture medium. Obtained data suggest that applying our optimally modified method, SSCs can be cultured for over 90 days with high purity (around 93.5%). Moreover, SSCs isolated and expanded using our protocol fulfills all criteria of SSCs without losing their stemness-characterized by SSC-phenotypic gene expression and long-term self-renewal. This study describes for the first time a protocol allowing isolation and expansion of SSCs suitable for numerous studies related to SSC-based clinical therapies of various diseases.

Transoral anterior release, odontoid partial resection, and reduction with posterior fusion for the treatment of irreducible atlantoaxial dislocation caused by odontoid fracture malunion.

PURPOSE: Several techniques have been introduced to manage irreducible atlantoaxial dislocation (IAAD). However, no study has reported the surgical method for the management of IAAD caused by odontoid fracture malunion. This study aimed to introduce a surgical method of transoral anterior release, odontoid partial resection, and reduction with sequential posterior fusion for the treatment of IAAD caused by odontoid fracture malunion. We also evaluated the clinical efficacy of this surgery. METHODS: This study included seven cases of IAAD caused by odontoid fracture malunion, collected from January 2008 to January 2011. Anterior atlantoaxial release was performed through anterior transoral approach, followed by partial resection of the odontoid process. C1-C2 were then fixed through pedicle screws and rods, and then fused posteriorly by single stage. Neurologic status was evaluated using the Japanese Orthopaedic Association (JOA) scoring system. RESULTS: All seven patients had complete release, and satisfactory reduction. Bony fusion was seen in all patients postoperatively. The patients were followed up for an average of 19.6 months (ranged from 9 to 36 months). The average of patients JOA scores at the final follow-up was significantly higher than that of their preoperative scores. Furthermore, the average improvement in neurological function was 87.4 %. No screw loosening, implant migration or implant failures, atlantoaxial redislocation, or signs of instability were observed in any of the patients during the follow-up period. CONCLUSIONS: Transoral anterior release, odontoid partial resection, and reduction combined with posterior fusion are effective, reliable, and safe procedures for the treatment of IAAD caused by odontoid fracture malunion.

The beneficial effect of Batroxobin on blood loss reduction in spinal fusion surgery: a prospective, randomized, double-blind, placebo-controlled study.

OBJECTIVE: Our objective was to evaluate the efficacy and safety of Batroxobin on blood loss during spinal operations. METHODS: After obtaining approval from the ethics committee at the hospital along with informed written consent, we performed a double-blind, randomized, placebo-controlled study with 100 patients who were randomized equally into 2 groups (Batroxobin and placebo). Patients received either 2 ku IV 15 min before surgery and followed 1 ku IM of Batroxobin following surgery, or an equivalent volume of placebo (normal saline). Cost of Batroxobin treatment is amounted to 84.75 euros. The primary outcomes were intraoperative, 24 h postoperative, and total perioperative blood loss. Secondary outcomes were hemoglobin (Hb), red blood cell count (RBC), the volume of blood/fluid transfusion intraoperatively, and 24 h postoperatively. Safety evaluation parameters were the incidence of venous thrombosis in the lower extremities, active partial thromboplastin time, prothrombin time, thrombin time, and fibrinogen. The data were analyzed using the Statistical Package for the Social Science Version 12.0. The results were presented as mean ± SEM. The Mann-Whitney test and Independent Student t test, when appropriate, were used to compare the 2 groups, and differences were considered significant if the P value was <0.05. RESULTS: 88 patients were included in the analysis while 12 patients were withdrawn from the study due to extended surgical duration, change of surgical procedure, or after the patients' request. The total perioperative blood loss was approximately 31% lower in patients given Batroxobin versus placebo (700.5 ± 45.81 vs 485.7 ± 30.01 mL, P = 0.001). The Batroxobin group had significantly less intraoperative blood loss (326.1 ± 24.16) compared to the placebo group (556.0 ± 43.58), but there was no difference in the amount of blood/fluid transfused, postoperatively Hb, or RBC between the two groups. After the operation, coagulation parameters were not significantly different between the 2 groups at the days 1 or 3 postoperatively. No adverse events related to the use of Batroxobin were recorded. There were no cases of superficial wound infection. None of the subjects died during the study. CONCLUSIONS: In this study, prophylactic use of Batroxobin provided an effective and cheap method for reducing blood loss without coagulopathy during or after operations. The use of Batroxobin for patients undergoing one-level PLIF surgery safely and effectively reduced the total amount of perioperative blood loss.

Vertebral column resection for complex congenital kyphoscoliosis and type I split spinal cord malformation.

INTRODUCTION: Congenital progressive kyphoscoliosis associated with split spinal cord malformation (SSCM) is a very rare disease. METHODS AND RESULTS: Here, we present the case of a 23-year-old woman who was found kyphoscoliosis when she was 10 years old and developed rapidly. Thereafter, no management was proposed before her consultation at our center. On examination, numbness was found in the right low limbs, kyphoscoliosis was detected in thoracolumbar, the trunk deviated to the right on standing view and curvature of the thoracolumbar spine was left-sided, the left rib hump was severe and there was little muscle tissue felt under the right side paravertebral area, the pelvis was oblique with the right side higher than the left side, the right arcus costarum was 5 cm below the right iliac crest. One-stage corrective surgery was determined, at first, halo-wheelchair traction gradually with increased traction weights out of hospital for a month; then, after a reasonable correction achieved without any neurological deficits. The one-stage operation was taken through single posterior segmental pedicle screw instrumented fusion with VCR between T12 and L1. Post-operative recovery was uneventful and there were no complications, she was discharged 10 days post operation. At 2 years follow-up, the patient's outcome is excellent with balance and correction of the deformity. CONCLUSION: Based on the Grand Round case and relevant literature, we discuss the different options for the treatment of congenital kyphoscoliosis associated with type I SSCM. In the patient whose kyphoscoliosis is severe and rigid, we recommend an initial release followed by halo-wheelchair traction gradually to correct the deformity, once optimal correction acquires during the traction, the posterior instrumented fusion with VCR upper the bony spur could be done safely without the resection of bony spur.

Is the 4 mm height of the vertebral artery groove really a limitation of C1 pedicle screw insertion?

PURPOSE: To explore the feasibility and effectiveness of C1 pedicle screw fixation in patients whose atlas vertebral artery groove (defined as the C1 pedicle) height is less than 4 mm, but with a medullary canal. METHODS: From January 2010 to January 2013, 7 patients (6 males, 1 female) with atlantoaxial instability whose C1 pedicle height was less than 4.0 mm on one or both sides were treated by C1 pedicle screw fixation at our institution. Thirteen of the 14 C1 pedicles were less than 4.0 mm in height, but all had a medullary canal. Patients were followed up at regular intervals. Postoperative computed tomography (CT) scans were performed to assess if C1 pedicle screw placement was successful. Clinical outcomes were evaluated according to postoperative complications, the American Spinal Injury Association grading system, and bone graft status. RESULTS: Thirteen C1 pedicles with a height less than 4.0 mm were inserted by 13 3.5- or 4.0-mm-diameter pedicle screws, and one C1 pedicle whose height was 4.1 mm was inserted by a 4.0-mm-diameter pedicle screw. In addition, 14 pedicle screws were inserted in the axis. The mean follow-up period was 23 (range 8-38) months. No neurologic or vascular complications occurred in any of the seven patients. Postoperative CT three-dimensional reconstruction images showed that all 14 pedicle screws were inserted in the C1 pedicles without destruction of the atlas pedicle cortical bone. All patients demonstrated bony fusion 6 months postoperatively. CONCLUSION: If there is a medullary canal in the C1 pedicle, a 3.5- or 4.0-mm-diameter pedicle screw can be safely inserted into the atlas and C1 pedicle screw fixation can be performed without any impact on fixation stability and clinical efficacy, even if the C1 pedicle height is less than 4.0 mm.

The height for screw index (HSI) predicts the development of C2 nerve dysfunction associated with C1 lateral mass screw fixation for atlantoaxial instability.

PURPOSE: To propose a new measure, the height for screw index (HSI), as a predictor of C2 nerve dysfunction in patients who have received posterior C1 lateral mass screw (C1LMS) fixation for atlantoaxial instability and to examine whether the HSI scores correlated with the development of C2 nerve dysfunction through retrospective analysis of 104 C1LMS inserted in 52 patients with atlantoaxial instability. METHODS: The medical records of patients who underwent C1LMS fixation were retrospectively reviewed. C1LMS, 3.5 mm in diameter, was inserted for atlantoaxial stabilization. The sagittal plane of the planned C1LMS trajectory was reconstructed from CT images. The HSI was defined as the difference in height between C2 ganglion and its corresponding foramen. C2 nerve function was assessed using a validated visual analog scale questionnaire. Each foramen receiving C1LMS was considered as a single unit and patients were categorized to group 1, HSI ≥4.0 mm; group 2, HSI <4.0 mm. RESULTS: The mean HSI score was 4.7 ± 0.8 mm (range 3.1-6.5 mm) with 85 (81.7 %) units in group 1, and 19 (18.3 %) units in group 2. Fourteen (13.5 %, 14/104) units developed C2 nerve dysfunction. C2 nerve dysfunction was reported in 4 units in group 1, and 10 units in group 2, respectively. The percentage of C2 nerve dysfunction was significantly higher in group 2 than that in group 1 (P < 0.001, Pearson Chi-square test). CONCLUSIONS: The HSI score correlates with the development of C2 nerve dysfunction in patients receiving C1LMS fixation for atlantoaxial instability and may be a useful predictor of C2 nerve dysfunction.

Ginsenoside Rd attenuates mitochondrial permeability transition and cytochrome C release in isolated spinal cord mitochondria: involvement of kinase-mediated pathways.

Ginsenoside Rd (Rd), one of the main active ingredients in Panax ginseng, has multifunctional activity via different mechanisms and neuroprotective effects that are exerted probably via its antioxidant or free radical scavenger action. However, the effects of Rd on spinal cord mitochondrial dysfunction and underlying mechanisms are still obscure. In this study, we sought to investigate the in vitro effects of Rd on mitochondrial integrity and redox balance in isolated spinal cord mitochondria. We verified that Ca2+ dissipated the membrane potential, provoked mitochondrial swelling and decreased NAD(P)H matrix content, which were all attenuated by Rd pretreatment in a dose-dependent manner. In contrast, Rd was not able to inhibit Ca2+ induced mitochondrial hydrogen peroxide generation. The results of Western blot showed that Rd significantly increased the expression of p-Akt and p-ERK, but had no effects on phosphorylation of PKC and p38. In addition, Rd treatment significantly attenuated Ca2+ induced cytochrome c release, which was partly reversed by antagonists of Akt and ERK, but not p-38 inhibitor. The effects of bisindolylmaleimide, a PKC inhibitor, on Rd-induced inhibition of cytochrome c release seem to be at the level of its own detrimental activity on mitochondrial function. Furthermore, we also found that pretreatment with Rd in vivo (10 and 50 mg/kg) protected spinal cord mitochondria against Ca2+ induced mitochondrial membrane potential dissipation and cytochrome c release. It is concluded that Rd regulate mitochondrial permeability transition pore formation and cytochrome c release through protein kinases dependent mechanism involving activation of intramitochondrial Akt and ERK pathways.

Morphology of the atlas pedicle revisited: a morphometric CT-based study on 120 patients.

PURPOSE: To quantify the dimensions of the atlas pedicles and to analyze the relationship between extra medullary height (EMH) with intra medullary height (IMH) of the atlas pedicle. METHODS: The images of the patients who had CT scanning and three-dimensional (3D) reconstruction involving atlantoaxial complex between June 2011 and April 2012 and meet our inclusion criteria were studied retrospectively. After reformatting the original images, the EMH and IMH of the atlas pedicles were measured. RESULTS: Extra medullary height and IMH were, respectively, 4.83 ± 1.13 and 1.29 ± 1.10 mm for males and 3.75 ± 0.93 and 0.60 ± 0.83 mm for females, with statistical difference (P < 0.05). EMH and IMH had some correlation (correlation coefficient r = 0.804) but showed a large variability. Of 240 pedicles of 120 cases, 47.92% (115 pedicles) were ≥1 mm; 12.08% (29 pedicles) were between 0 and 1 mm; and 40% (96 pedicles) were 0. CONCLUSION: The EMH and the IMH of the atlas pedicles were measured by using CT images of the atlas, providing anatomic parameters for surgery. They showed a certain correlation but with a high variability. C1 pedicle screw fixation was well performed when the medullary canal was ≥1 mm, but the surgical procedure should be careful when it was between 0 and 1 mm, and avoided when there was no medullary canal in the atlas pedicle! So 3D CT reconstruction should be conducted to obtain data and establish individualized fixation strategy preoperatively.

Surgical treatment of the lower cervical brucellosis with osteoporosis in the northwest region of China: review of 22 cases.

OBJECTIVE: To analyze the surgical treatment of patients with cervical brucellosis with osteoporosis over a 4-year period in Northwest China. METHODS: From 2013 to 2018, 22 patients (12 males and 10 females) with lower cervical spine brucellosis (C3-C7) underwent anterior lesion debridement, decompression, bone grafting and internal fixation combined with posterior bone graft fusion and internal fixation (ADDF+PIF). The follow-up period averaged 37.4 months (ranging from 24 to 57 months). RESULTS: Involvement of 1 vertebra was observed in 3 patients, involvement of 3 vertebrae was observed in 9 patients, and involvement of 3 vertebrae was observed in 10 patients. Before surgery, 1 patient had Frankel grade B, 2 had grade C, 9 had grade D, and 10 had grade E. In the final follow-up, 12 patients had neurological deficits, 10 patients improved by one grade, 6 patients improved by two grades, and the neurological status of 6 patients remained unchanged. In all cases, it was observed that bone fusion required 6.8 months on average. The kyphosis Cobb angle was enhanced from an average of 11.5° preoperatively (range 0°-24°) to 0.13° postoperatively (range 1°-5°), and there was no vital loss of correction in the follow-up. CONCLUSIONS: ADDF+PIF is an effective and safe treatment for patients with lower cervical brucellosis with osteoporosis.

Relationship between degenerative scoliosis and lower extremity mechanical parameters based on EOS imaging system.

OBJECTIVE: This study aimed to assess the correlation between coronal imbalance and lower-limb physiological parameters in degenerative scoliosis using the biplanar whole body imaging system (EOS). MATERIALS AND METHODS: A total of 101 successive EOS images were selected between January 2018 and December 2021. Of the selected images, 63 patients were in the degenerative scoliosis group (DSG) and 38 patients were in the control group (CG). Two independent observers performed measurements of the parameters and compared the two groups. RESULTS: Among parameters examined, significant inter-group differences were found for coronal pelvic tilt angle (CPT), bilateral femoral length difference (ΔFL), and bilateral total lower limb length (ΔTL) difference. Additionally, the knee and ankle joints had more severe degeneration on the main curved side in patients with degenerative scoliosis. In the left curved group, 18 (42.86%) and 24 (57.1%) patients had more severe degeneration in the left knee and left ankle, respectively. In the right lateral bending group, 13 (61.9%) and 14 (66.7%) patients had more severe degeneration in the right knee and right ankle, respectively. Statistical differences were found in the degree of degeneration in both knee and ankle joints bilaterally. CONCLUSION: This study showed that biomechanical parameters of the lower limbs are affected in cases of degenerative scoliosis with altered coronal balance. The lower limb on the main curve side became shorter compared to its counterpart, and joint degeneration of the knee and ankle joints became more severe.

lncRNA HHIP-AS1/HHIP modulates osteogenic differentiation of BM-MSCs by regulating Hedgehog signaling pathway.

BACKGROUND: lncRNA, a type of non-coding RNA, plays an important role in the osteogenic differentiation of bone marrow-derived mesenchymal stem cells (BM-MSCs). In this study, lncRNA and mRNA microarrays were performed to study the change of gene expression during osteogenic differentiation of BM-MSCs. We focused on Hedgehog interacting protein (HHIP), because HHIP mRNA and lncRNA HHIP-AS1 were gradually down-regulated on days 0, 7, and 14 during osteogenic differentiation. In addition, the gene coding lncRNA HHIP-AS1 is located on the anti-sense of Hhip gene, implying the potential interaction between lncRNA HHIP-AS1 and HHIP mRNA. METHODS: BM-MSCs with over-expressed or silenced lncRNA HHIP-AS1 were constructed to explore the biological role of HHIP-AS1 in osteogenic differentiation. BM-MSCs were lysed to determine the alkaline phosphatase activity. Fluorescence in situ hybridization and immunofluorescence were performed to analyze HHIP-AS1, HHIP, RUNX2 and osteocalcin. RESULTS: Overexpression of lncRNA HHIP-AS1 increased HHIP expression, which suppressed Hedgehog signaling pathway, as indicated by the reduction of SMO, Gli1 and Gli2. The suppression of Hedgehog signal was associated with the inhibited osteogenesis. HHIP knockdown abolished the suppression of osteogenesis induced by lncRNA HHIP-AS1 overexpression. Through binding to HHIP mRNA, lncRNA HHIP-AS1 recruited ELAVL1 to HHIP mRNA, whereby increasing the mRNA stability and the protein level. CONCLUSIONS: This study revealed that down-regulation of HHIP due to lncRNA HHIP-AS1 reduction promoted the osteogenic differentiation of BM-MSCs though removing the suppression of Hedgehog signal.

Posterior Ligament-Bone Injury Classification and Severity Score: A Novel Approach to Predict the Failure of Anterior-only Surgery for Subaxial Cervical Facet Dislocations.

STUDY DESIGN: Clinical case series. OBJECTIVE: The aim of this study was to propose a novel posterior ligament-bone injury classification and severity (PLICS) score system that can be used to reflect the severity of subaxial cervical fracture dislocations (SCFDs) and predict the failure of anterior-only surgery; and to measure the intraobserver and interobserver reliability of this system. SUMMARY OF BACKGROUND DATA: The approach selection for SCFDs is controversial. Although the anterior approach is familiar for most surgeons, postoperative hardware failure and/or delayed cervical deformity is a nonnegligible complication. METHODS: Ten patients were randomly selected for intraobserver reliability evaluation on two separate occasions, one month apart. Another 30 patients were randomly selected, and the interobserver reliability was measured by comparing results of each case between each reviewer and averaging. To analyze the difference in the PLICS score, 354 patients fulfilled the follow-up were divided into stable and unstable groups according to whether radiologically stable was observed during follow-up. RESULTS: For the intraobserver reliability, the mean intraclass correlation coefficient for the 10 reviewers was 0.931. For the interobserver reliability, the mean interobserver correlation coefficient for the three elements was 0.863. Among 16 patients with PLICS score ≥7, two patients in the stable group manifested with severe injury of the posterior ligamentous complex (PLC); extremely unstable lateral mass fractures with or without severe injury of PLC were detected in the 14 patients of the unstable group. CONCLUSION: The proposed PLICS score system showed excellent intraobserver and interobserver reliability. When a PLICS score is >7 or 7 accompanied by extremely unstable lateral mass fractures, the risk of postoperative failure after an anterior-only reconstruction is high and supplemental posterior strengthening can be considered.Level of Evidence: 4.

Reliability and application of the new morphological classification system for chronic symptomatic osteoporotic thoracolumbar fracture.

BACKGROUND: We propose a new classification system for chronic symptomatic osteoporotic thoracolumbar fracture (CSOTF) based on fracture morphology. Research on CSOTF has increased in recent years; however, the lack of a standard classification system has resulted in inconvenient communication, research, and treatment. Previous CSOTF classification studies exhibit different symptoms, with none being widely accepted. METHODS: Imaging data of 368 patients with CSOTF treated at our hospital from January 2010 to June 2017 were systematically analyzed to develop a classification system. Imaging examinations included dynamic radiography, computed tomography scans, and magnetic resonance imaging. Ten investigators methodically studied the classification system grading in 40 cases on two occasions, examined 1 month apart. Kappa coefficients (κ) were calculated to determine intraobserver and interobserver reliability. Based on the radiographic characteristics, the patients were divided into 5 types, and different treatments were suggested for each type. Clinical outcome evaluation included using the visual analog score (VAS), the Oswestry disability index (ODI), and the American Spinal Injury Association (ASIA) impairment scale. RESULTS: The new classification system for CSOTF was divided into types I-V according to whether the CSOTF exhibited dynamic instability, spinal stenosis or kyphosis deformity. Intra- and interobserver reliability were excellent for all types (κ = 0.83 and 0.85, respectively). The VAS score and ODI of each type were significantly improved at the final follow-up compared with those before surgery. In all patients with neurological impairment, the ASIA grading after surgery was significantly improved compared with that before surgery (P < 0.001). CONCLUSIONS: The new classification system for CSOTF demonstrated excellent reliability in this initial assessment. The treatment algorithm based on the classification can result in satisfactory improvement of clinical efficacy for the patients of CSOFT.

The Healing Rate of Type II Odontoid Fractures Treated With Posterior Atlantoaxial Screw-rod Fixation: A Retrospective Review of 77 Patients.

BACKGROUND: In theory, temporary posterior atlantoaxial screw-rod fixation for type II odontoid fractures is a way to preserve rotatory motion. However, the healing rate of type II odontoid fractures treated in this way is unknown; that is, the risk associated with conducting a temporary screw-rod fixation for type II odontoid fractures is unknown. This study investigates the healing rate of type II odontoid fractures treated with posterior atlantoaxial screw-rod fixation by CT imaging and evaluates the feasibility of conducting a temporary screw-rod fixation for type II odontoid fractures. METHODS: Patients with type II odontoid fracture who underwent posterior atlantoaxial screw-rod fixation in our spine center from January 2011 to December 2014 were identified. Patients older than 65 years or younger than 18 years were excluded. Those who were confirmed to have healing odontoid fractures on CT imaging were included. Those in whom fracture healing was not confirmed were asked to undergo a CT examination. Fracture healing was confirmed on the basis of the presence of bridging bone across the odontoid fracture site on CT imaging. RESULTS: Seventy-seven patients (56 men and 21 women) were included in the study. The average age of the patients was 40.7 ± 11.6 years (range, 18 to 64 years). The mean duration of follow-up was 26.4 ± 4.6 months (range, 24 to 40 months). Fracture healing was observed in 73 patients (94.8%). DISCUSSION: The healing rate of type II odontoid fractures (with an age range of 18 to 64 years) treated with modern posterior atlantoaxial fixation is relatively high. For patients at that age range, posterior atlantoaxial temporary screw-rod fixation for type II odontoid fractures can be conducted with a low risk of nonunion. LEVEL OF EVIDENCE: Level IV, therapeutic.

Intradural Lumbar Disc Herniation: A Case Report and Literature Review.

BACKGROUND: Lumbar disc herniation into the dural space is a very rare phenomenon of degenerative lumbar lesions in the elderly population, and its potential pathogenesis and natural course remain unclear. CASE DESCRIPTION: We describe a rare case of intradural lumbar disc herniation. A 68-year-old man presented with progressive lower back pain and radiating pain and numbness in both legs for 3 years. Magnetic resonance imaging revealed a large herniated disc at L4-L5. Posterior discectomy and fusion of the L4-L5 was performed after conservative treatment failed. Intraoperatively, only minimal disc fragments in the epidural space were found after meticulous probing following laminectomy of the L4-L5 vertebrae. The dorsal dura mater was saturated, tense, and bulged at the L4-L5 levels; additionally, an intradural mass was palpable and confirmed by intraoperative ultrasonography. Subsequently, dorsal middle durotomy was performed. Upon opening the dural sac, a large cauliflower-like mass similar to nucleus pulposus tissue was found near the arachnoid membrane. The mass was dissociative and could be completely resected. The dorsal dural incisions were closed after careful exploration, followed by fixation and fusion of the L4-L5 levels. Pathological examination revealed disc tissue with central balloon-type cystic degenerative changes. The patient's lower back pain and radiating pain and numbness of both legs improved remarkably postoperatively, and he became asymptomatic at 3 months postoperatively. CONCLUSION: Intradural lumbar disc herniation should be highly suspected when intraoperative findings are incompatible with findings from the preoperative imaging examination, and it could be further confirmed via intraoperative ultrasonography and pathological examination of the resected tissue from the dural space. Prompt surgery is recommended, and surgical results are usually favorable. We also reviewed the literature and discussed the potential pathogenesis, natural course, diagnosis, and treatment of intradural lumbar disc herniation.

One-stage surgical management for lumber brucella spondylitis with anterior debridement, autogenous graft, and instrumentation.

Literature reporting on lumber brucella spondylitis (LBS) is rare, therefore, the purpose of this study was to evaluate the outcomes of one-stage surgical management for lumber brucella spondylitis by anterior debridement, autogenous grafts, and instrumentation. This was a retrospective cohort study including 16 patients with lumber brucella spondylitis by treated from January 2009 to October 2011 in our department. All cases underwent one-stage anterior internal fixation, debridement, and bone fusion; clinical and radiographic results were analyzed and compared. All patients were followed up for an average of 35.3 ±â€Š8.1 months (range, 24-48 months). Brucella spondylitis was completely cured in all patients with bone fusion achieved in 4.8 ±â€Š1.3 months. Visual analog scale (VAS) scores were significantly improved between the preoperative and last follow-up visit and neurological function classification showed significant improvement after surgical intervention. Preoperatively, the Cobb angle was 20.7 ±â€Š9.8°, and measured 8.1 ±â€Š1.3° at the last follow-up visit. The outcomes of follow-up demonstrated that one-stage surgical treatment with anterior debridement, fusion, and instrumentation can be an effective and feasible treatment method for lumber brucella spondylitis.

The clinical outcomes and surgical strategy for cervical spine tuberculosis: A retrospective study in 78 cases.

Literature on the treatment of cervical spinal tuberculosis (CSTB) is uncommon, the surgical approaches to cervical spinal tuberculosis were controversial. The aim of the study was to evaluate the clinical outcomes of 3 surgical techniques in CSTB patients, and to determine the most appropriate approach for CSTB patients. Between April 2006 and June 2012, we performed a retrospective review of clinical and radiographic data that were collected from 850 consecutive spinal tubercular patients, including 87 patients who were diagnosed and treated for CSTB in our hospital. Apart from 9 patients being treated conservatively, the remainder (78 cases) underwent surgery by anterior debridement, interbody fusion and instrumentation (A group), posterior instrumentation and anterior debridement, fusion and instrumentation in a single or two-stage operation (AP group), or posterior debridement, fusion and posterior instrumentation (P group). The patients were evaluated preoperatively and postoperatively on the basis of hematologic, radiographic examinations, and neurologic function. The 78 patients were followed up for a mean duration of 41.2 ±â€Š7.2 months (range, 24-65 months). Postoperatively, the preoperative erythrocyte sedimentation rate (ESR) value returned to normal within 3 to 6 months in all patients, and solid bone fusion was achieved in 3 to 8 months. The patients exhibited significant improvement in deformity and neurological deficit postoperatively, while the visual analog scale for pain showed significant improvement in all patients at the last follow up visit. The follow-up outcomes demonstrated that all 3 surgical methods were viable management options for CSTB. Individualized therapeutic strategies should be selected according to the patient's general condition, focal characteristics, and the surgeon's experience.