bluuebunny/crossref_metadata_2025 huggingface dataset:
Hybrid Constructs in the Surgical Treatment of Degenerative Cervical Disc Disease: Five-Year Clinical and Radiological Follow Up
Authors: Szollosi Balazs , Varga Péter Pál
Published: April 2016

Introduction

In most of the patients with multisegmental cervical degenerative disc disease the certain segments can show different stages of degeneration and instability. This condition may require an individual surgical strategy and the use of hybrid constructs with the combination of fusion and motion presevation implants. Our study was designed to investigate the clinical and radiological outcome of the combination of cervical fusion and arthroplasty in a prospective cohort.

Material and Methods

36 patients with symptomatic cervical radiculopathy and/or myelopathy underwent hybrid cervical surgery between 2007 and 2010 (14 two-level, 16 three-level and 6 four-level surgeries were performed). VAS for pain, Neck Disability Index, neurologic function and the radiographic parameters (range of motion at the level of prosthesis and the cranial adjacent segment, the intervertebral disc height of the adjacent segment, cervical lordosis, heterotopic ossification) were evaluated during the study period.

Results

Improvement in pain was significant and sustained 5 year after the surgery (dVAS= 5.0, p < 0.05). The segment of the prosthesis ultimately showed the preservation of motion when compared with preoperative values (the preoperative mean flexion/extension ROM was 8.2° while the postoperative ROM was 7.6°). The mean cervical spine lordosis was preoperatively 1.7°, postoperatively 16.2° ( p < 0.05). None of the patients has required further surgery because of symptomatic adjecent segment disease.

Conclusion

The results of the study support the theoretic advantage of the use of hybird constructs in selected cases. In our cohort, the 5-year clinical and radiological outcome of the multilevel cervical hybrid surgeries are promising. However, long-term follow up studies are required to prove its role in the surgical treatment of the multisegmental degenerative cases.
Adjacent Segment Degeneration and Adjacent Segment Disease in Patients with Cervical Arthroplasty with 5 Years Follow-Up
Authors: Isais Abraham , Gonzalez-Moga Amado , Santos Hugo
Published: April 2016

Introduction

Among the practical advantages of the cervical arthroplasty, the preservation of the movement could reduce the presentation of cases of adjacent segment disease and adjacent segment degeneration compared with anterior cervical fusion. It is estimated that ~90% of patients managed with anterior cervical fusion will present a new onset or progression of a degenerative adjacent levels, exhibiting symptoms during the first 10 years. Currently there are reports of reoperation of cases treated with this technique due to the presence of nonunion, bone collapse, migration of the implants and the development of adjacent segment disease.

Material and Methods

During the period between January 2005 and July 2010 were included 153 patients with an average age of 47.69 years (range 40–60 years, 56 men), who had a diagnosis of symptomatic cervical disc disease of 1 or 2 levels. All were treated by cervical arthroplasty prosthesis using the Mobi-C, Activ-C and ProDisc-C systems, searching for the presence of adjacent segment disease or degeneration according to the classification of Hillbrand. The monitoring was performed with clinical examination and radiological control in all patients with visits at 15, 30 and 60 days and periodically thereafter 6 months.

Results

The follow-up time was 60 months and only 11 cases (9.40%) of the 117 patients who were managed with radiculopathy in 1 level showed adjacent segment degeneration during the 5 years of follow up. The average time that the degeneration was observed was 30 months, without observing changes in the first year of follow-up in any of the cases. In patients where 2 levels were handled, we found 3 cases of degeneration (8.33%), drawing attention that these were presented earlier manner (12–18 months) compared with only 1 level affected group. We found 7 cases (5.98%) in which adjacent segment disease was presented in patients with 1 level affected and 4 cases (11.11%) of involvement in patients with 2 levels affected. It was observed that 81.81% occurred in the upper segment and 18.19% in the lower segment. All patients who developed adjacent segment disease required revision surgery (11 cases), showing a positive trend during the monitoring period. No infections, spinal injuries or dural tears occurred. We did not observed the presence of collapse or migration of the implants. No mortality was documented during the study.

Conclusion

Cervical arthroplasty is an excellent tool for management of cervical radiculopathy, favoring the intervertebral movement and reducing stress, whereby the occurrence of adjacent segment degeneration and adjacent segment disease are diminished compared with anterior cervical fusion according to that reported in the literature.
Clinical and Radiological Outcome at the 10 Year Follow up of Total Cervical Disc Replacement
Authors: Mehren Christoph , Heider Franziska , Zillner Bernhard , Siepe Christoph , Korge Andreas , Mayer Michael
Published: April 2016

Introduction

There is still a lack of facts about long term impacts after implantation of a total cervical disc replacement (cTDR). The aim of this current analysis was to evaluate the long- term clinical results and efficacy, the radiographic findings of the index level as well as the adjacent level in a cohort of cTDR patients treated with ProDisc C (Synthes, Paoli, USA) 10 years after surgery.

Material and Methods

Clinical outcome scores and patient satisfaction rates were acquired within the framework of an ongoing single center prospective non randomized clinical trial. The patient's employment status, complications, reoperations and further treatments due to symptomatic adjacent segment disease (ASD) were recorded. X-ray evaluation included the incidence of heterotopic ossifications (HO) according as well as the rates and timing of ASD. Follow up was recorded 1, 5 und 10 years after surgery.

Results

38 patients were available for final FU, resembling a 80,8% FU rate after a mean FU of 122,9 months. The overall results revealed a highly significant improvement from baseline VAS and NDI levels at all postoperative FU stages ( p < 0,0001). VAS scores demonstrated a statistically significant improvement (VAS neck 6.4 to 1.9; VAS arm 6.3 to 2.1 at the last FU). The NDI baseline values showed a stable improvement (21/50 to 6/50). Patient satisfaction rates remained stable throughout the postoperative course, with 78.9% of patients reporting a ‘highly statisfactory’ or a ‘satisfactory’ outcome in 21,1%. The radiographic results demonstrated a noteworthy incidence of HO as well as a progression of the HO in process of time. HO Grade I appeared in 10%, Grade II in 10%, Grade III in 32%, and Grade IV in 26%. The overall complication rate (excluding HO) was 12%. The incidence of ASD was 32.3%. 70% of ASD were asymptomatic, none of the ASD patients need further surgery. Within this group of patients with ASD 80% of the patients presented with a high-grade HO with loss or reduced function of the prosthesis in the 5 year FU.

Conclusion

The results demonstrate that cTDR is a viable treatment option resulting in improved clinical outcomes and low rates of subsequent surgical procedures. The progression of HO with a high amount of non functional TDR may leads to the high figures of ASD.
Surgical Treatment for Cervical Dislocation with Quadriplegia in a Young Child Aged 5 Years Old: a Case Report and Review of the Literature
Authors: Elmorshidy Essam
Published: April 2016

Introduction

Cervical dislocations with quadriplegia are extremely rare in young children (5 years and less) and many surgeons have no experience with this type of injury. Here we report on a case of a boy 5 years old with dislocated C3/C4 with incomplete quadriplegia and its treatment.

Material and Methods

The clinical and radiological findings were described. Because closed reduction failed, we decided to perform open reduction and fixation with a simple wiring technique through a posterior approach. We also reviewed the related literature.

Results

There was a significant improvement in neurological function during the follow-up period, and no complications developed. The boy was able to walk supported after 3 month although there is some residual spasticity

Conclusion

Cervical dislocation with quadriplegia in young children is a great challenge. Closed reduction and rigid immobilization remains the 1st choice, however surgery may be indicated in children if closed reduction fails, marked instability or neurological deterioration.
Correlation between Spinal Coronal Profile and Proximal Femur Bone Mineral Density in Adolescent Idiopathic Scoliosis
Authors: Andalib Ali
Published: April 2016

Introduction

Although Adolescent Idiopathic Scoliosis patients have lower Bone Mineral Density (BMD) but relationship between BMD and curve pattern, intensity of curve, or its progress in these patients is controversial. Some studies have shown a significant difference between left and right proximal femur BMDs in AIS patients. Since the curve pattern relationship with density of bilateral proximal femur has not been identified, this study aims to investigate the relationship between Spinal Coronal Profile and differences in BMD on either sides of proximal femur in patients with AIS.

Material and Methods

This study is prospective and included 50patients with AIS who underwent posterior or anterior and posterior correction and fusion surgery between December 2013 and december 2014. The mean age at the time of surgery was 16.6 ± 5.8 years. Bilateral proximal femur BMD and Z-score was calculated before surgery by dual-energy X-ray absorptiometry. We evaluated correlations between coronal parameters, obtained from preoperative radiographs, and the BMD ratio using Paired Samples Test analysis.

Results

Patients with Lenke type 1 curve (28; all with a right convex curve)have no significant difference between bilateral proximal femur density but in patients with Lenke type 5curve(22;all with a left convex curve)have greater bone mineral density on right side(concave).

Conclusion

The bilateral proximal femur BMD difference was significantly correlated with the coronal balance in AIS patients. When the patient have coronal imbalance the proximal femur BMD was greater in the concave side.
Low-density Pedicle Screw Constructs for Adolescent Idiopathic Scoliosis: Evaluation of Effectiveness and Cost
Authors: Tannous Oliver , Jazini Ehsan , Banagan Kelley , Belin Eric , Gelb Daniel
Published: April 2016

Introduction

Optimal screw density and technique in treatment of idiopathic scoliosis remain unknown. We sought to find if low-density (LD) screw construct can achieve curve correction similar to that achieved with high-density (HD) constructs in adolescent scoliosis at substantial cost savings.

Materials and Methods

Patients treated operatively for idiopathic scoliosis at our center between 2007 and 2011 were identified through a retrospective database review. Each patient was treated with an LD screw construct. Radiographic outcomes included assessment of screw density, percent correction of major and fractional lumbar curves at follow-up, T5−T12 kyphosis, and angle of lowest instrumented vertebra (LIV). Costs were calculated and compared with costs of HD constructs.

Results

Forty-five patients met inclusion criteria. Ages ranged from 12 to 19 years (mean age, 14.9 years). Average construct density was 1.2 screws per fused level (range, 1.07−1.33 screws). Mean percent curve correction at latest follow-up: major curve, 67.2%; fractional lumbar curve, 69%. Average postoperative thoracic kyphosis: 30 degrees. Mean LIV angle: 5.6 degrees. Total screw cost was $13,370 per case in the LD group compared with $22,340 per case if all levels had been instrumented with 2 screws.

Conclusions

Our LD screw construct is among the lowest density constructs reported in the literature and achieves curve correction comparable to that reported for HD constructs at substantially lower cost.
Selection of Lowest Instrumented Vertebra in the Management of Thoracolumbar and Lumbar Adolescent Idiopathic Scoliosis using Pedicle Screw Instrumentation
Authors: Nadeem Umair , Shah Abdullah , Zaman Atiq uz Zaman , Aziz Amer
Published: April 2016

Introduction

The aim of surgical treatment for adolescent idiopathic scoliosis (AIS) is correction of the three dimensional deformity, achievement of stability and preservation of as many distal motion segments as possible. In Thoracolumbar/ Lumbar adolescent idiopathic scoliosis (TL/L AIS) correction of C-shaped coronal curve into S-shaped saggital curve is a considerable challenge to a spine surgeon. In this regard, selection of Lowest Instrumented Vertebra (LIV) is of particular importance and remains controversial in literature. We conducted a retrospective study involving Lenke V patients to determine the exact distal fusion level (LIV) in the management of thoracolumbar/lumbar adolescent idiopathic scoliosis (TL/L AIS) using pedicle screw instrumentation.

Material and Methods

Analysis of radiographic parameters of 32 TL/L AIS was done. The patients were grouped according to the Lowest Instrumented Vertebra; Group I (fusion to L3, n = 25) and Group II (fusion to L4, n = 7). The Group I was subdivided into Group IA (L3 crosses the mid-sacral line with rotation of less than grade II on bending films, n = 14) and Group IB (L3 does not cross the mid-sacral line or rotation is grade II or more on bending films, n = 11). All of the patients in the Group II had the same location and rotation of L3 in bending films as that of patients in the Group IB. Patients with lowest instrumented vertebral tilt (LIVT) of more than 10° or coronal balance of more than 15 mm were considered to have unsatisfactory results.

Results

In these 3 groups, there was a significantly lesser correction in the TL/L curve and LIVT in the Group IB. Unsatisfactory results were obtained in 1 patients (7.1%) of the Group IA, in 7 patients (63.3%) of the Group IB, and in 1 patient (12.5%) of the Group II, which was found to be statistically significant.

Conclusion

In TL/L AIS patients undergoing treatment with pedicular screw instrumentation, the curve can be fused to L3 with good radiographic outcomes when L3 crosses the mid-sacral line with rotation of less than grade II on bending films. Otherwise, L4 should be selected as the Lowest Instrumented Vertebra.
Intra-wound Vancomycin Reduces the Infection in Growth-Friendly Spine Surgery
Authors: Haller Justin , Hulet Andy , Ding Qian , Presson Angela , Heflin John , Smith John
Published: April 2016

Introduction

Patients with Early Onset Scoliosis (EOS) who require growth-friendly spine surgery are known to be at high risk for infections and/or wound dehiscence. Several studies in pediatric and adult patients undergoing spine surgery have shown that vancomycin powder applied to the wound before closure significantly reduces the risk of post-operative infection. There are currently no studies that evaluate the efficacy of intra-wound vancomycin in reducing infection for patients undergoing growth-friendly spine surgery.

Methods

Data from 116 patients in a prospectively collected database with EOS of multiple diagnoses were reviewed. Patients were divided into two groups. From May 2002 through June 2013, there were 1036 VEPTR procedures in which no patient received intra-wound vancomycin. Beginning in June 2013, there were 161 consecutive EOS procedures having VEPTR surgery and all had intra-wound vancomycin powder. Patient groups were compared based on age, gender, diagnosis, type of surgery, ambulatory status, and bowel/bladder incontinence. Additionally, complications related to intra-wound vancomycin powder were reviewed.

Results

The pre- and post-vancomycin groups were similar with regard to age, gender, diagnosis, ambulatory status, and bowel/bladder incontinence. The groups were significantly different with regard to type of surgery (Table 1). Prior to the use of intra-wound vancomycin, the infection rate in VEPTR surgery was 5.7%. The patients receiving intra-wound vancomycin had a significantly reduced infection rate of 1.2%. ( p < 0.031). Using multivariate logistic generalized estimating equation model to control for surgery type, infection rate was lower in the patients who received intra-wound vancomycin as compared with the patients who did not receive intra-wound vancomycin (1.2% versus 4.4%, p = 0.066). There were no complications related to the administration of intra-wound vancomycin.

Conclusion

Intra-wound vancomycin is safe and reduces infection rates for patients undergoing growth-friendly spine surgery.
Assessment of a Learning Strategy among Spine Surgeons
Authors: Gotfryd Alberto , Corredor José Alfredo , Teixeira William Jacobsen , Martins Delio Eulálio , Milano Jeronimo , Lutaka Alexandre Sadao
Published: April 2016

Introduction

AOSpine educational program was developed to expand knowledge and to promote integration among spine surgeons around the world. Nowadays, however, there are no available data of the effectiveness of the learning process and the level of competence acquired by participants in such activities. The aim of this study is to evaluate, objectively, the knowledge transfer provided thorough theoretical and practical activities during AOSpine courses for spine surgeons.

Material and Methods

During two principles courses of spine surgery, sixty-two participants underwent to pre-course assessment about their professional experience and preferences of adolescent idiopathic scoliosis (AIS) classification, as well as a test of curves by means of Lenke classification of two AIS clinical cases. Two learning strategies were used during the course: oral lectures and practical exercises. A post-course questionnaire was applied to retest the same deformity cases. Differences of correct answers of clinical cases between pre and post course were analyzed, revealing the number of participants who improve in the accuracy of the classification after the course.

Results

A total of 62 participants were included in the study, wherein 51 (82%) were orthopedic surgeons and 11 (18%) neurosurgeons. Analysis showed a decrease in the number of participants with wrong answer in both cases, after the course. In the first case, statistical significant differences were observed in both, curve pattern (83.3%, p = 0.005) and lumbar spine modifier (46.6%, p = 0.049). No statistical significant improvement was seen in sagittal thoracic modifier (33.3%, p = 0.309). On the second case, statistical improvement was obtained in curve pattern (27.4%, p = 0.018). No statistical significant improvement was seen regarding lumbar spine modifier (9.8%, p = 0.121) and sagittal thoracic modifier (12.9%, p = 0.081).

Conclusion

This study showed, objectively, that learning strategies used during AOSpine courses, improved the knowledge of participants. This knowledge acquisition was demonstrated through the decreased number of participants with wrong answers of two clinical cases, after the course. Teaching strategies must to be continually improved to ensure optimal level of knowledge transfer.
Innate Lymphoid Cells are Present at Healthy Patients Spinal Enthesis, Providing a Potential Mechanism for Spondyloarthropathy Pathogenesis
Authors: Cuthbert Richard , Fragkakis Evangelos M. , Giannoudis Peter , Dunsmuir Robert , Millner Peter , McGonagle Dennis
Published: April 2016

Background

The pathogenesis of murine spondyloarthropathy (SpA) has been intimately linked to the presence of Interleukin(IL)-23 responsive, innate like lymphocytes at different anatomical regions including spinal enthesis. Human SpAs are associated with Single nucleotide polymorphisms (SNPs) in genes related to the IL-23 pathway and drugs that block IL-12/23 have shown efficacy. We hypothesized that the normal human enthesis has a population of resident innate lymphoid cells (ILCs) that could be involved in governing entheseal immune homeostasis. In particularly entheseal resident type 3 ILCs (ILC3s) may be critical, since ILC3s in other tissues have been shown to produce inflammatory cytokines in response to IL-23.

Methods

Normal spinal enthesis were harvested from healthy patients undergoing spinal surgery and enzymatically digested prior to fluorescence activated cell sorting (FACS). Cellular immunophenotyping and cell sorting was performed on enthesis samples harvested from 6 patients; ILC3s, were identified as lineage (CD3- TCRγδ- TCRαβ- CD19- CD14- CD11c- CD1a- CD303- FcεRI- CD34- CD123-) and cellular surface marker CRTH2 negative with positive expression of CD45, CD127, CD117. ILC2s, which have been linked to fibrotic reactions, were identified as lineage negative with positive expression of CD45, CD127 and CRTH2. The expression of RORγt transcript was tested in sorted populations by RTqPCR. Anterior cruciate ligament (femoral enthesis) was obtained from subjects with knee OA and injured enthesis undergoing repair were also collected and analyzed by immunohistochemistry (IHC).

Results

All sorted samples contained ILC3s, median proportion 0.09% (range 0.015–0.63). Transcript analysis confirmed the expression of RORγt, transcript, an ILC3 related transcription factor, in sorted ILC3 populations, with ILC3s expressing 51-fold greater relative expression in comparison to unsorted digests. 5 of 6 sorted samples contained ILC2s, median proportion 0.20% (range 0–0.49). RORγt expression was detected in knee OA and there was widespread expression of RORγt in inflammatory infiltrates in injured enthesis as shown by IHC.

Conclusions

Our findings show that ILCs are present in the normal human spinal enthesis and may be greatly increased in frequency following injury. These findings provide strong evidence of ILC presence in normal human enthesis and suggest a potential link between cellular dysregulation of the IL-23/17 axis and SpA pathology at sites of micro damage.
Stand-Alone Cages in Anterior Cervical Discectomy & Fusion: Mid-term Outcomes
Authors: ElAbed Khaldoun
Published: April 2016

Introduction

To review and analyze the clinical outcome and radiological changes of one-level and two-level anterior cervical discectomy and fusion (ACDF) with stand-alone Trabecular Metal™ cages. ACDF using a stand-alone cage is a popular procedure with little published long-term follow-up, we reviewed our cases performed between 2001–2011.

Material and Methods

Patients between 36 and 64 years of age, diagnosed with cervical radiculopathy, who underwent ACDF were available for at least 3 years follow-up and included in this study. All levels were low-cervical (below C4). Clinical outcomes were assessed using Odom's Criteria, VAS, and by assessing axial neck pain, radicular arm pain, upper extremity weakness, and upper extremity numbness. Fusion was assessed by lateral radiographs looking for bone breaching and radiolucent lines around the device, in addition to dynamic radiographs, postoperative cervical lordosis was measured by the Drexler Method

Results

Ninety patients were included in the study, 51 patients underwent two-level ACDF modified Robinson approach, and 39 patients underwent one-level ACDF. Mean age was 44 ± 10.4 years and mean follow-up time was 4.5 ± 2.6 years. Patients reported excellent or good outcomes (90%), VAS improved in 90% of patients from a mean of 3 preoperatively, to a mean of 9 at 1 year, and a mean of 8 at 3 years follow up. Improvement in axial neck pain (80%), radicular arm pain (95%), upper extremity weakness (85%), and upper extremity numbness (90%). No cage extrusion or migration occurred. Subsidence occurred in 8% of levels fused. Clinical improvements were not related to the occurrence of subsidence. Radiographs confirmed restoration of cervical lordosis above 45 degrees, with maintenance over the follow up period. There was symptomatic anterior osteophytes formation or calcifications of anterior longitudinal ligament in 25% of patients at the final follow-up; the reoperation rate was 3.6%. There was no persistent dysphagia, or voice complaints, no dural tear, tracheal or oesophageal perforation. One patient developed deep MRSA infectious infarction of spinal cord, treated with antibiotics, and recovered totally upon one-year follow up. Based on the 3 criteria for fusion, 90% of patients confirmed fusion at 1 year follow up.

Conclusion

Mid- to long-term results show that ACDF with Trabecular Metal™ cages is safe and effective treatment of single and two-level cervical disc radiculopathy and neck pain.
Global Tilt: A Single Parameter Incorporating the Spinal and Pelvic Parameters Correlates with Health-Related Quality of Life Parameters
Authors: Yilgor Caglar , Enercan Meric , Hamzaoglu Azmi , Pellise Ferran , Perez-Grueso Francisco Javier Sanchez , Acaroglu Emre , Obeid Ibrahim , Kleinstuck Frank , Alanay Ahmet ,   ESSG European Spine Study Group
Published: April 2016

Introduction

Surgical goals and alignment objectives mostly depend on sagittal plane parameters. SVA, C7 tilt and T1 tilt account for spinal balance and PI, PT, SS, PI-LL account for pelvic compensatory mechanism, which are all affected by patient positioning. GT is the angle between the line drawn from the center of C7 to the center of the sacral endplate and a line drawn from the center of the sacral endplate to the center of the femoral head. GT is a single parameter that takes both balance and pelvic compensation into account as a single parameter. GT has been shown to be less affected by patient positioning compared with SVA and PT. Aim was to analyze the correlation of GT with HRQoL parameters and compare with other sagittal plane parameters.

Material and Methods

A retrospective analysis of a multicenter, prospective, consecutive patient series. 337 patients (285F,52M) with adult spinal deformity were included, (mean age: 58.2± 15.7). Pelvic parameters (PT, PI, SS), sagittal balance parameters (SVA, T1 tilt), GT and lordosis gap(LGap) were measured by using Surgimap. HRQoL instruments included: Oswestry Disability Index(ODI), Short Form-36, SRS-22. Correlation analysis between radiographic pelvic and sagittal balance parameters, GT and LGap was pursued. Kruskal-Wallis test was used to compare GT, SVA and PT for ODI < 20, 20–40 and > 40 disability groups.

Results

Global tilt significantly correlated with ODI, SRS-22 pain, function, self image, and subtotal scores and SF-36 PCS ( p < 0.01) similar to SVA, PT and LGap. None of the radiographic parameters correlated with SRS-22 mental health or SF-36 MCS (Table 1). GT was more sensitive in detecting ODI disability groups when compared with SVA and PT ( p < 0.01)

Conclusion

GT has a similar or better correlation with HRQoL domains compared with PT and SVA. This information adds another important feature of this parameter in addition to being a single parameter taking into account both the spinal balance and pelvic compensation and being less affected by patient positioning.
Is Sacro-femoral-pubic Angle a Good Indicator of Pelvic Tilt?
Authors: You Jee Young , Le Phuong , Cho Woojin
Published: April 2016

Introduction

The spino-pelvic alignment is increasingly recognized as crucial in the assessment of patients with spinal deformities. Three pelvic parameters originally described include pelvic incidence (PI), pelvic tilt (PT) and sacral slope (SS). PT, a positional parameter, has been demonstrated to correlate with quality of life and clinical outcomes. Although measuring the PT on sagittal radiographs is simple, underexposed films and malposition of X-rays often result in poor visibility of the femoral heads. In 2012, a novel measurement, the sacro-femoral-pubic (SFP) angle was introduced to estimate the PT using coronal films. The formula PT = 75 – (SFP angle) was derived to correlate the two parameters. Subsequently, the formula was validated in predicting the pelvic tilt in patients with lumbar and thoracic scoliosis. However, more recently another study showed that the SFP angle correlated poorly with the PT. The objective of our study was to analyze whether a correlation exists between the SFP angle and PT in our patient population and to validate the conventional formula (PT = 75 – (SFP angle). We also aimed to identify factors that may contribute to the formula if our data sample fails to validate the formula.

Materials and Methods

A retrospective chart review was performed on 106 adult patients who visited an orthopedic spine surgeon of a university hospital. Entire spine posteranterior and lateral spine radiographs were used to measure the PT and SFP, and correlation between PT and SFP was calculated. The validity of the conventional Eq. (75 - SFP =PT) was also tested. In addition, clinical data including age, body mass index (BMI), and gender and other radiographic data including PI, sagittal balance, and presence of scoliosis were analyzed to see if there was any influence of those on using the formula.

Results

The conventional Eq. (75 - SFP =PT) did not fit our data. However, the regression model to correlate PT and SFP angle yielded the following formula: PT = 62 – 0.72*SFP (R-square = 0.36). The higher the PI, the greater the tendency of the conventional formula to underestimate the PT and with a lower PI, the conventional formula tended to overestimate the PT (R = −0.38, p < 0.001). Age, BMI, and gender and sagittal balance did not determine significantly whether the conventional formula worked or not. The conventional formula worked poorer on the patients with scoliosis than patients without scoliosis.

Conclusion

The conventional Eq. 75 - SFP =PT did not match our data. However, SFP angle may correlate with PT, but possibly by a nonlinear formula which indicates that there might be additional factors that can contribute to creating such formula such as PI. In reality, however, like PT, PI is obtained from lateral view X-rays. Therefore, a lateral X-ray image with good visibility of the femoral heads would be the best way to measure the PT.
The Prevalence of High-Intensity Zone in Symptomatic Patients and Its Correlation with the Disc Degeneration and Segmental Motion
Authors: Yang Jui-Jung , Huang Hsiang-Ming , Acosta Frank , Chen Thomas , Buser Zorica , Wang Jeffrey C.
Published: April 2016

Introduction

The high intensity zone (HIZ) represents a high signal change on lumbar spine T2 MRI images. HIZ has been involved in disc degeneration and its presence was associated with inflammation and vascular granular tissue within the annulus fibrosus. Aim of our study was to investigate the HIZ prevalence, its relationship with disc degeneration and the effect on lumbar segmental motion using kinetic magnetic resonance imaging (kMRI).

Material and Methods

kMRI images of 353 symptomatic patients were analyzed. Data including age, gender, and radiologic assessments based on neutral images including disc degeneration grade of all lumbar spine units from L1/2 to L5/S1 and the presence of HIZ were recorded for all the patients. Demographics and disc degeneration were used for calculating HIZ prevalence. Dynamic flexion and extension images from 168 patients were used for segmental motion comparison between the discs with HIZ and without HIZ. Patients with isthmic or degenerative spondylolisthesis grade 2 or higher, Modic disc or Schmorl's node were excluded due to the potential effect on lumbar kinematics. We used chi-square test and multivariate logistic regression for our statistical analysis.

Results

Among 353 patients, 107 had HIZ in at least one lumbar disc. The overall HIZ prevalence was the highest in age group 40–49 years of age, followed by 50–59 years irrespectively of disc level. The HIZ prevalence was the highest in grade IV degenerative discs, followed by grade III degenerative discs. For L4/5 segment, HIZ prevalence was the highest in age group 50–59 years and disc degeneration grade IV. For L5/S1 segment, HIZ prevalence was the highest in age group 40–49 years and disc degeneration grade III. The multivariate logistic regression model indicated that the age groups (30–39 and 40–49 years), levels (L4/5 and L5/S1) and disc degeneration grades (III and V) were risk factors for HIZ. The segmental angular motion was signicantly greater in discs with HIZ than those without HIZ on L4/5 and L5/S1. However, the differences were reduced to insignificant when adjusted for disc degeneration grade.

Conclusion

HIZ prevalence was the highest in the middle age patients (30–39 and 40–49 years) and in the moderately degenerated discs (III and IV). The lower prevalence was observed in the older patients and grade V degenerative discs. The possible reason of increased segmental angular motion at L4/5 and L5/S1 discs with HIZ may be due to the moderate disc degeneration than HIZ itself.
Novel Circulating microRNA Signature as a Potential Non-invasive Test in LDH Patients: a Cohort Study
Authors: Zhou Xiaoya , Chen Lili , Grad Sibylle , Alini Mauro , Pan Haobo , Lu William , Huang Shishu , Peng Songlin
Published: April 2016

Introduction

Lumbar disc herniation (LDH) is one of the major causes for back and sciatic pain that costs large medical expense. Accumulating evidence has indicated that microRNAs (miRNAs), a small non-coding RNA molecule, are associated with disc degeneration, the profile of miRNAs in the LDH patients with indication for laminectomy remains unclear.

Material and Methods

MicroRNA profiling was performed on plasma samples of 4 groups: LDH-young group ( n = 8, average age is 31), LDH-old group ( n = 8, average age is 56), healthy control-young group ( n = 4, average age is 20), healthy control-old group ( n = 6, average age is 58). The miRNAs expression were further validated by qRT-PCR.

Results

The miRNAs with p-values < 0.05 and fold change values ≥2 or ≤ 0.5 compared with healthy control were regarded as dysregulated miRNAs. 61 miRNAs were upregulated and 302 were downregulated in LDH-young group compared with healthy control-young group. In addition, there are 46 upregulated miRNAs and 115 downregulated in LDH-old group compared with healthy control-old group. In particular, 12 upregulated and 71 downregulated miRNAs expressed significant differences both in the LDH-young group vs healthy control-young group and the LDH-old group vs healthy control-old group. Among them, miR-224 was upregulated 4.04-, 16.99-fold in LDH-young and LDH-old groups compared with healthy control-young and healthy control-old groups, respectively ( p < 0.01 for both). Besides, relative to old groups, miR-130b and miR-147b were downregulated significantly in young groups, both of which were reported to be associated with disc degeneration.

Conclusion

The selected miRNAs might play a vital role in the molecular pathogenesis of LDH and further research for the understanding of the functionality and pathological mechanism of the miRNAs in LDH is important and would shed new light on LDH.
Association Analysis of Col9A1, Col9A2, Col9A3, Aggrecan and TNF-α Gene Polymorphisms with Early Onset of Disc Herniation in Indian Population
Authors: Rajsekar Kavitha , Narayanasamy Nandita , Kuhar Meenakshi , Vaishya Sandeep , Shanmuganathan Rajasekaran , Devaraj Niranjali
Published: April 2016

Introduction

Intervertebral disc being an avascular tissue, the extracellular matrix protein play a major role in its structural stability. The pathophysiology underlying the process of Disc Herniation is still not clear but genetic factors play a vital role in the early occurrence of the disease. The study was initiated to determine the association of Collagen9A1, Collagen9A2, Collagen9A3 and TNF-α gene polymorphisms in Disc herniated patients in comparison to healthy individuals in Indian population.

Methods

Pre Operative blood samples were collected from 20 patients under going surgery for disc herniation between the age group of 20–60years and 10 samples from healthy individuals with no history of Intervertebral disc disease. DNA was isolated, primers designed for selected exonic regions in the triple helical binding sites for Collagen and for complete 2763 bp of TNF-α and VNTR in exon 12 for aggrecan, performed PCR and samples sequenced for analysis of polymorphic variants. Genotypic and phenotypic distributions were compared with Healthy controls. Hardy Weinberg calculations were done to correlate the allelic/genotypic frequencies in the both study groups.

Results

The PCR sample analysis resulted in identification of 11 variants in complete TNF-α gene, 8 variants in Col9A1, 6 variants in Col9A2 and 3 variants in Col9A3 gene.Polymorphic variants pro620thr, gln621arg and a splicesite variant at intron-exon29 A > C for Col9A1,gln326arg for Col9A2 and ser2 gly and ala16 to arg for TNF-α were statistically significant. These variants were predominant in lower age groups of 40 years. Aggrecan showed the allele 14 and 15 to be common among both the study groups. The healthy subjects for Collagen9 did not show any variant where as TNF-α showed 3 variants which were not statistically significant.

Conclusion

The SNP at amino acid proline 620, glutamine 621 in Col9A1, glutamine 326 in Col9A2 and arginine 103 for Col9A3 are important for the stability of the triple helical structure of collagen9 and can be directly corelated to the early occurrence of the disease in younger patients. There was no association between an aggrecan VNTR polymorphism and disc herniation. The TNF-α gene variants were not directly correlated to the onset or progression of the disease but could influence their expression levels which could trigger additional inflammatory response as in rheumatoid arthritis. PCR genetic markers can be used as a diagnostic tool to identify the progression of the disease as in Ankylosing spondilosis. This is a first report on Indian population in Disc Herniated patients.
Functional Outcomes of Microdiscectomy- Does Obesity affect Early Postoperative Outcomes?
Authors: Foodoul Mazin , Baco Abdul Moeen , Attia Ahmed
Published: April 2016

Introduction

Lumbar Disc pathology remains one of the leading causes of back pain with a multitude of surgical options. Choosing the best management option remains a challenge for many practitioners due to the individualized needs and variables of each patient. Obesity poses a challenge to surgeons regarding anesthesia, positioning and adequate exposure which required longer incisions. Studies showed that in selected patient population, microdiscectomy achieved favorable short and long term outcomes with most patients achieving a good to excellent recovery on Macnab Classification up to 10 years post operatively. Studies also showed that obesity was not associated with increased risk of herniated nucleus pulposus after microdiscectomy, However, increased BMI was associated with significantly increased estimated blood loss (EBL) and operative time without affecting the surgical outcomes such as length of hospital stay, recurrent disc herniation, and intra-operative durotomy.

Methods

Study subjects were identified through the microdiscectomy registry at Hamad Medical Corporation. 50 patients who had microdiscectomy over one year prior to the closure of the study were enrolled. The study population was divided into two groups according to their BMI. Group A had BMI less than 25 kg/m2while group B included those with a BMI equal to and above 25 kg/m2. Patients' medical records were reviewed for demographics, complications and radiographic findings. Patients were interviewed and Short Form 12 (SF-12) and Visual Analogue Scale (VAS) scores were obtained and compared with their preoperative counterparts.

Results

Statistical analysis showed no significant differences in SF-12 or VAS scores between the 2 groups at one year follow up.

Conclusion

In the early post operative period, quality of life and pain following microdiscectomy is not affected by the patient's BMI.
Qualitative Grading on Magnetic Resonance Imaging as a Tool for Decision Making in Lumbar Spinal Stenosis
Authors: Soman Shardul , Modi Jayprakash
Published: April 2016

Introduction

Several parameters exist for assessment of lumbar spinal stenosis (LSS) but none has shown to be an absolute criteria for defining the condition. Moreover these parameters lack clinical correlation to help physicians to decide on the plan of management.

Aim

To assess the clinical relevance of the qualitative grading described for LSS and to formulate a protocol for management of these group of patients.

Materials and Methods

A prospective study was undertaken between the period of 2014–15 using the qualitative grading based on T2 weighted MRI1 to assess the clinical outcome of 83 patients with clinical signs and symptoms suggestive of lumbar spinal stenosis at a single level to divide them into 7 morphological categories A 1–4,B, C, and D. Patients with more than two level stenosis, congenital stenosis, instability, having undergone previous surgery, other neurological disease were excluded. The diagnosis and the qualitative grading was done by a Senior surgeon not part of the study. Irrespective of the grade every patient underwent a minimum three month period of conservative management after which depending on the Oswestry Disability Index (ODI) and Visual Analogue Scale (VAS) for pain was grouped into success or failure and the failed patients were advised for decompression surgery in form of laminectomy at the involved level. These patients were further grouped into success or failure after a period of three months after surgery. A 15 point decrease in ODI and a VAS scale of less than 5 on admission into the study was considered as a success.

Results

Out of the 83 patients there were 57 failure in conservative group while out of these 50 were operated of which only 10 did not match the success criteria, while the other 7 either refused surgery or were lost to follow up. As per the grading in types A1 and 2 only 2 patients out of 17 failed conservative trial while in all the other grades from A3 to D there was a gradual decline in success of conservative trial. In patients with grades C and D all patients failed conservative trial and required surgery. In comparison for grades A3 to D operative outcome had a significantly better outcomes as measured by the Chi-square test with p-value < 0.05 considered significant.

Conclusion

We conclude that the qualitative grading can be used as a tool for decision making in LSS. Patients with grade A4, B, C and D should be advised for an early surgery to achieve a good functional outcome as there was a high incidence of failure of conservative management in these patients. While in patients with grade A1 to A3 a conservative management is to be recommended. Reference Schizas C, Theumann N, Burn A, et al. Qualitative grading of severity of lumbar spinal stenosis based on the morphology of the dural sac on magnetic resonance images. Spine 2010;35(21):1919–1924
The Relation between Spinal Instability and Response to Palliative Radiotherapy for Symptomatic Spinal Metastases
Authors: Versteeg Anne , van der Velden Joanne , Verkooijen Helena , Fisher Charles , Oner F. C. , van Vulpen Marco , Weir Lorna , Verlaan Jorrit-Jan
Published: April 2016

Background and Purpose

Up to 70% of cancer patients with terminal illness have bone metastases, with the spinal column being most affected. The standard local treatment for painful spinal metastases is conventional external beam radiotherapy. However, ~30–40% of the patients do not achieve adequate pain relief. It is not well understood why some patients respond and others do not. Considering the limited life expectancy of these patients it is crucial to optimize treatment selection to ensure fast, effective and lasting symptom relief. We hypothesized that pain resulting from mechanical instability of the vertebra responds less well to radiotherapy than pain originating from local tumor effects. The aim of this study was to investigate the relationship between spinal instability, defined by the Spinal Instability Neoplastic Score (SINS), and the response to palliative radiotherapy for symptomatic spinal metastases.

Material and Methods

A prospective international multicenter observational study of patients who underwent irradiation of symptomatic spinal metastases was performed between January 2013 and December 2014. Patients were excluded if they were diagnosed with multiple myeloma, if they had previous surgery on the same level or if they had substantial neurological deficits (ASIA ≤C). The SINS was calculated by an observer blinded to outcome using the radiotherapy planning computed tomography scans. Pain response was rated using the International Bone Metastases Consensus Working Party Endpoints. The association between SINS and response was estimated by multivariate logistic regression analysis.

Results

A total of 155 patients were included, 91 male and 64 female (mean age 66 ± 11 years). Thirteen patients (8%) died within four weeks following treatment, 18 (12%) patients were lost to follow-up. Neither median nor mean SINS was significantly different for patients with or without response. In multivariate analysis, the SINS was not significantly associated with response (adjusted odds ratio 0.94; 95% confidence interval 0.81–1.10; p = 0.449). The WHO performance score, however, was related to radiotherapy response.

Conclusion

No significant relationship was observed between degree of mechanical spinal instability, as reflected by the SINS, and response to radiotherapy. Trying to explain our findings, it can be argued that some components of SINS reflect current mechanical instability while other components are indicative of impending instability. Future studies should aim to optimize the definition of instability to better predict treatment outcome.
Surgical Treatment of a C3-osteoblastoma with Cord Compression and Encompassing the Vertebral Artery via Combined Approach
Authors: Samadian Mohammad , Hallajnejad Mohammad , Nejad Ali Mousavi , Zadeh Kaveh Ebrahim , Rezaei Omidvar
Published: April 2016

Background

Osteoblastoma is a rare and benign osteoid-producing primary bone tumor that affects mainly the long bones. 36% of these tumors are observed around the spine and the vast majority arises around the posterior. Case Presentation: This report describes a case of C3 osteoblastoma occurring in a 22-years old male. He represented with cervical pain and quadriparesia. Cervical CT and MRI demonstrated an osteolytic mass that invade anterior and posterior elemant of C3 and cause severe cord compression. Because of the close proximity of the osteoblastoma to the vertebral artery canal and cord total resection of tumor was a challenging decision. To prevention of vertebral artery injury, laminectomy and partial resection of tumor was done with posterior approach and bilateral vertebral arteries preserved and then fussed with lateral mass screw. For best reconstruction and stability, total C3 corpectomy and anterior fusion with allograft and plate was done via anterior cervical approach.

Conclusions

Osteoblastoma in cervical spine with involvement of anterior and posterior part of vertebrae is a rare pathology and can encase vertebral artery. This case has favorable prognosis after 2 sessions surgery and adequate rehabilitation.