bluuebunny/crossref_metadata_2025 huggingface dataset:
Surgical Outcomes of Cervical Disc Herniation Causing Deltoid Palsy: Multicenter Study
Authors: Park Jong-Beom , Chung Jae-Yoon , Chang Han
Published: May 2015

Introduction

In general, deltoid palsy develops in patients with cervical disc herniation (CDH) at the level of C4–5, resulting in compression of the C5 nerve root. Because of duplicate nerve innervation, however, deltoid palsy can also develop when CDH is at the levels of C3–4 and C5–6. To date, little has been known about the surgical outcomes of CDH causing deltoid palsy. We report on by far the largest series of CDH causing deltoid palsy focusing on surgical outcomes in the literature.

Patients and Methods

A total of 61 patients with CDH causing deltoid palsy (less than grade 3) were identified among 13 surgeons and included in this study. Average age of the patients was 51.4 years (range, 25–69 years), with 49 males and 12 females. Overall, 35 patients were soft disc and 26 patients were hard disc. Overall, 32 patients had single-level CDH (22 C4–5, 9 C5–6 and 1 C3–4), 22 had two-level (19 C4–5-6, 2 C3–4-5 and 1 C5–6-7), 4 had three-level (4 C4–5-6–7), 3 had four-level (3 C3–4-5–6-7). All the patients underwent surgery for deltoid palsy and arm pain not responding to conservative treatment: 57 ACDF, 2 ADR, and 2 foraminotomy and discectomy. Average follow-up was 20.7 months (range, 6–83 months). The severity of deltoid palsy was classified into five grades according to manual motor power test, and the severity of radiculopathy was recorded on a visual analog scale (VAS) of arm pain (0–10 points). The degree of improvement in both the severity of deltoid palsy and arm pain following surgery was evaluated. Patients with accompanying myelopathy, shoulder diseases, or peripheral neuropathy were excluded from the study.

Results

Average duration of deltoid palsy was 11.9 weeks (range, 1–156 weeks). Both deltoid palsy and radiculopathy improved significantly with surgery (2.4 vs. 4.5 grades, p < 0.001) and (6.4 vs. 2.1 points, p < 0.001), respectively. Of 61 patients, 36 (59%) patients achieved full recovery of deltoid palsy with an average time of 8.4 weeks (range, 1–54 weeks). Longer duration of deltoid palsy negatively affected the degree of improvement of deltoid palsy after surgery (correlation coefficient −0.351; p < 0.01). Severity of preoperative deltoid palsy, type of disc (soft disc or hard disc), and gender did not affect the degree of improvement of deltoid palsy after surgery.

Conclusion

This study demonstrates that surgical decompression significantly improves the degree of deltoid palsy and radiculopathy because of the CDH irrespective of the type of disc. The longer the duration of deltoid palsy preoperatively, the lower the degree of improvement of deltoid palsy postoperatively. Thus, early surgical decompression is recommended for improvement of deltoid palsy in patients with CDH.
The Impact of Dynamic Alignment, Motion, and Center of Rotation on Myelopathy Grade and Regional Disability in Cervical Spondylotic Myelopathy
Authors: Liu Shian , Lafage Renaud , Smith Justin , Protopsaltis Themistocles , Lafage Virginie , Challier Vincent , Shaffrey Christopher , Kim Han Jo , Arnold Paul , Chapman Jens , Schwab Frank , Massicotte Eric , Yoon S. Tim , Fehlings Michael , Ames Christopher
Published: May 2015

Introduction

Cervical stenosis is a defining feature of CSM. Matsunaga et al proposed that elements of stenosis are both static and dynamic, where the dynamic elements magnify the canal deformation of the static state. We hypothesize that dynamic motion may be associated with myelopathy severity and neck disability and present novel methods of dynamic motion analysis in CSM.

Patients and Methods

Post hoc analysis of a prospective, multicenter database of patients with CSM. A total of 110 patients (34%) met inclusion criteria symptomatic CSM, age over 18 years, baseline flexion/extension radiographs, and HRQOLs (mJOA, NDI, SF-36, and Nurick grade). The mean age was 57 ± 12 years with 41% female ( n = 46). Correlations with HRQOLs were analyzed for regional and focal parameters in flexion and extension. Baseline dynamic parameters (F/E cone relative to a fixed C7, center of rotation, range of motion arc relative to the COR) were also analyzed for correlations to HRQOLs.

Results

At baseline, the mean HRQOLs demonstrated disability and the mean radiographic parameters demonstrated sagittal malalignment. Among regional parameters, there was a significant correlation between increased C2–C7 angle in flexion and Nurick grade ( R = 0.189, p = 0.048) with no significant correlations in extension. Focal parameters including C7 slip were significantly correlated with disability (Flex R = −0.377, p = 0.003; Ext R = −0.261, p = 0.027). Reduced flexion/extension motion cones, a more posterior center of rotation, and smaller range of motion correlated with worse HRQOLs.

Conclusion

Dynamic motion analysis may play an important role in understanding CSM. Focal parameters demonstrated a significant correlation with worse HRQOLs especially C7 slip in flexion and extension. Novel methods of motion analysis demonstrated reduced motion cones correlated with worse myelopathy grades. More posterior center of rotation and smaller range of motion were both correlated with worse general health scores (PCS and Nurick).
Safety of Cervical Spine Implant Anterior Cervical Decompression and Fusion with Zero Profile Interbody Fusion Device: A Retrospective Study
Authors: Vadhva Mukta , Khatri Manoj
Published: May 2015

Introduction

To assess the safety of Zero Profile Interbody fusion (Zero P) device in anterior cervical decompression and fusion (ACDF) for degenerative cervical stenosis. Patients and Method: A total of 89 consecutive patients treated with Zero P interbody device from September 2009 to September 2012 were included in this retrospective study. Inclusion criterion: Degenerative cervical stenosis with myelopathy, persistent radiculopathy after at least 3 months of failed conservative management. Exclusion criterion: Pediatric population; patients with infection, metastatic disease, and trauma. There were 39 females, 50 males with mean age of 55 years (ranging from 24 to 84 years). Overall, 56 (64%) had surgery at one level, 31 (35%) at two levels, 1 (1%) at three levels. Total number of levels operated were 121. Common levels operated were C56 (62%) and C67 (47%). Majority were operated because of the radicular symptoms, 56 (64%) had radicular symptoms, 28(31%) had myelopathy, and 5 (5%) myeloradiculopathy.

Results

All had a minimum of 6 months' follow-up (maximum 2 years). No patient had cage subsidence or extrusion. Overall, 1 patient had superficial infection which settled with antibiotics, 10 (11%) had dysphagia which settled in 6 to 12 weeks

Conclusion

Our study demonstrates that ACDF with Zero P can be considered a safe option in management of the patients with cervical degenerative stenosis. We would also recommend a prospective randomized study as a follow-up on to this retrospective study. Preoperative kyphosis or lordosis did not change the outcome or make the surgical technique any more difficult, hence, this implant can also be used in these circumstances.
High Glucose-Induced Oxidative Stress Accelerates Premature Stress-Induced Senescence of Young Intervertebral Disc Cells
Authors: Park Jong-Beom , Park Eun-Young
Published: May 2015

Introduction

Diabetes mellitus (DM) is a major health problem worldwide. Approximately 10% of all DM cases are type 1 (Juvenile onset) and the prevalence of type 1 DM among the under 20s continuously rise. DM is known to be an important etiologic factor for premature disc degeneration. Previous studies have reported higher incidence of degenerative disc diseases in patients with DM, relatively young age, than in the patients without DM. A glucose-mediated increase of oxidative stress is a major causative factor for the development of diseases associated with DM through senescence. However, little is known about relationship among DM, mitochondrial damage, oxidative stress, senescence of young intervertebral disc cells, and disc degeneration. The aim of this study was to investigate the effect of high glucose on mitochondrial damage, oxidative stress, senescence of nucleus pulposus (NP) cells, and disc degeneration.

Material and Methods

Young nucleus pulposus (NP) and annulus fibrosus (AF) cells were isolated from 4-week-old rats, cultured and placed in either 10% FBS (normal control) or 10% FBS plus two high glucose concentrations (0.1 and 0.2 M) (experimental conditions) for 1 and 3 days. We identified and quantified the mitochondrial damage (mitochondrial transmembrane potential) and reactive oxygen species (ROS) for 1 and 3 days. We also identified and quantified the occurrence of senescence and telomerase activity. Finally, we determined the expressions of proteins related to replicative senescence (p53–p21) and stress-induced senescence (p16–pRB) pathways.

Results

Two high glucoses enhanced the disruption of mitochondrial transmembrane potential (mitochondrial damage) in young NP and AF cells for 1 and 3 days compared with normal control. Two high glucoses increased the occurrence of senescence of young NP and AF cells in a dose- and time-dependent manner. Telomerase activity declined in a dose- and time-dependent manner. Both high glucoses increased the expression of p16 and pRB proteins in young NP and AF cells for 1 and 3 days. However, compared to normal control, the expressions of p53 and p21 proteins were decreased in young NP and AF cells treated with both high glucoses for 1 and 3 days.

Conclusion

The current study demonstrated that high glucose-induced oxidative stress accelerates premature stress-induced senescence of young NP and AF cells in a dose- and time-dependent manner rather than replicative stress. This may result in dysfunction of young NP and AF cells, leading to accelerated premature disc degeneration. Therefore, the prevention of excessive generation of oxidative stress by strict blood glucose control is important to prevent or to delay premature disc degeneration in young patients with DM.
Surgical Treatment of Thoracolumbar Fractures with Osteosynthesis
Authors: Nemirovsky Carlos Eduardo , Nirino Carlos Mariano
Published: May 2015

Introduction

The aim of this study is to describe the results obtained in 44 patients, all between 20 and 65 years, operated between 2011 and 2013 with the diagnosis of thoracic and lumbar vertebral fractures posttraumatic, treated in our department. In all cases, we used the same technique, which consists of fixing two levels above and two levels below the fractured vertebrae including it in the osteosynthesis system getting full or partial reduction of the fracture. After the fracture consolidation, we proceeded to the removal of the implant between 6 to 9 months after surgery. The indication was always surgical treatment with temporary fixation without arthrodesis. After the removal of the osteosynthesis material, all patients recovered the capacity of flexo-extension of the thoracolumbar spine. The patients returned to their previous levels of daily life and sport. It took them 35 days on an average to return to work and from 6 to 9 months to their sports activities. Patients were followed for 1 year after surgery.

Patients and Methods

A total of 44 patients were evaluated, 34 men and 10 women. The complaint was for posttraumatic back or low back pain by falls from their own height standing or sitting, in the 72% of cases, with no more than 48 hours of evolution that did not get better with rest and got worse with mobilization. The rest of the cases were traffic accidents. All patients were studied by MRI and X-rays. All fractures were treated by the same surgeon within the first 72 hours of making the diagnosis. Fractures were divided as follows: D9 (1 case), D10 (7 cases), D11 (6 cases), D12 (11 cases), L1 (10 cases), L2 (7 cases), L3 (1 case) and L4 (1 case). Overall, 83% of cases were type A fractures according to the AO classification, and the remaining 17% were type B, which were associated with rupture of the posterior wall and invasion of the spinal canal. Only two fractures had neurological and motor compromise C, according to Frenkel classification. The rest of the fractures had Frenkel E.

Results

All patients returned to their usual physical activities, even those who played sports with the exception of the two Frenkel C. As postoperative complications, patients had scar hygromas that were cured with puncture and compressive bandage. Everyone referred complete or partial improvement of their symptoms. Only in one case, we had a postoperative complication which was the rupture of one of the lower transpedicular screws of the system at 3 months; after the removal of the implant at 6 months, the pain disappeared without complications.

Conclusion

This method, temporary fixation without arthrodesis of five levels, is usually used in our department to treat thoracolumbar fractures. Patients had no postoperative complications except one patient who presented a ruptured of a transpedicular screw but no reoperation was needed. In all cases, there was a complete remission of symptoms and return to normal activity.
Posterior Percutaneous Transpedicular Stabilization and Chrome-Densitometry 3D TC Evaluation at Month 12: Our Experience in Unstable Thoracolumbar Vertebral Fractures
Authors: Vanni Daniele , Sirabella Francesco Saverio , Guelfi Matteo , Pantalone Andrea , Sparvieri Antonio , Galzio Renato , Salini Vincenzo , Magliani Vincenzo
Published: May 2015

Introduction

The concepts of “tissue-sparing surgery” and “mini-invasiveness” are gradually involving the surgical approach to spine pathologies, both traumatic and degenerative.

Patients and Methods

The aim of the study is to evaluate the fracture healing model in case of unstable thoracolumbar vertebral fractures surgical treatment, treated by posterior percutaneous transpedicular stabilization (PPTS). Since March 2011, 89 patients with this fracture pattern, without neurologic involvement (according to ASIA classification) were enrolled in the study. Patients were randomly divided into two homogeneous samples. PPTS (with rods and screws) and standard posterior open approach were performed in patients of groups A (46 patients) and B (43 patients, control), respectively. A clinical and radiographical follow-up was performed respectively at months 1, 3, 6, 12 (according to visual analog scale [VAS] and Oswestry Disability Index [ODI]) and at months 1, 6, 12 (dynamic radiographic studies in the last two times). Segmental kyphosis and wedge-shaped deformity amount of the involved vertebral bodies, were measured pre- and postsurgery. At month 12, a CT scan with 3D reconstruction and analysis of chrome-densitometry was obtained. The data were analyzed by mean of the Kaplan–Meier curve (results yielding p < 0.05 were considered statistically significant).

Results

Clinically, in group A, we have observed a progressive and more rapid VAS and ODI scores improvement. Vertebral body collapse or kyphosis progression was not observed. There were no “fixation failure” and no patient underwent revision surgery. The 3D reconstructions and the chrome-densitometry evaluation at month 12 showed a more homogeneous and organized trabecular architecture recovery in group A (vs. group B). The PPTS acts as an “angular stability” fixation system; it allows a “biological” healing process (according to Wolf law), producing better clinical and radiographical results.

Conclusion

Unstable thoracolumbar fractures PPTS is an effective alternative to the classic open standard treatment. The advantage of mini-invasive spine surgery and “biological” healing process explain these better results and faster recovery times. This technique represents a safe and effective treatment, in terms of clinical and radiographical findings.
Custom Made (PMMA) Intervertebral Spacer in TLIF Preliminary Results of a Prospective Randomized Trial
Authors: Ronai Marton
Published: May 2015

Introduction

The use of bone cement in orthopedic surgery has been quite current for many years. In spine surgery, it has been used first for replacing defects after corpectomy. Then, vertebroplasty and kyphoplasty got used worldwide. Sporadically, some surgeons used cement to refill the intervertebral space after discectomy, combined with dorsal stabilization and fusion. Most recently in our institution, we started to perform routinely percutaneous cement discoplasty, for elderly patients. We also use PMMA as a spacer in TLIF. In a previous retrospective analysis, we reviewed results with this kind of surgeries. The aim of this study was to validate the use of custom-made PMMA spacer in TLIF with a high level of evidence in a randomized, prospective study.

Patients and Methods

In our study, we planned to collect 100 consecutive patients to whom we perform one level TLIF in the lumbar spine. The patients are randomized in three groups by the GraphPad QuickCalcs software. Group A is standard TLIF with PEEK spacer positioned in the anterior part of the intervertebral space. Group B is standard TLIF with PMMA spacer placed in the anterior part of the intervertebral space. Group C is standard TLIF with PMMA spacer positioned in the posterior part of the intervertebral space. Patients between the age of 18 and 65 years were included. Patients with a high-grade spondylolisthesis, metabolic bone disease, spinal infection, cancer, and severe scoliosis (Cobb over 30 degrees) were excluded. We evaluate the clinical results with standard questioners. Radiological evaluation focuses on bony fusion, loosening of any instrument implanted (PMMA spacer or screws), osteolysis around the cement, subsidence, changes in segmental, and overall lordosis according to the position of the spacer.

Results

Until today, 40 patients have a minimum of 1-year follow-up. We present these early results. On CT scan 6 months after surgery, we could observe completed fusion in 78.5% of the operated segments. The fusion rate was higher in the PMMA spacer groups (B + C), but the difference is not significant. We found six subsidence (15%), from four was in the PEEK spacer group (A) meaning, that the subsidence rate was significantly higher in this group. We found radiolucent zone around the implant (loosening) in only two cases (5%), one in the group A and one in group B. The overall clinical result was very good in 61%, good in 28%, and poor in 11% of the cases without significant difference between the groups.

Conclusion

With this preliminary results, we can estimate that the use of custom-made PMMA spacer in TLIF even in younger population provides good results noninferior to preformed PEEK spacer, and it even has some following advantages on preformed cages: (1) It fits better to irregularity of the end plates than preformed spacers, which can correlate with the difference in subsidence rate. (2) It requires smaller annular window to implant.
Functional Outcome of Anterior Decompression and Cage in Caries Spine: A Study of 850 Cases in Ghurki Hospital
Authors: Aziz Amer
Published: May 2015

Introduction

Tuberculosis is the leading cause of death in third world countries, from a single infectious disease. It paralyses the society when it affects the spine because of its resultant neurological deficit in the form of quadriplegia, paraplegia, loss of bladder and bowel control, bed sores, and continuous financial burden on family and whole society. Early spinal decompression and stabilization with standalone cage have dramatic results in terms of improvement in neurology, relief of pain, and correction of deformity. The objective of the study is to determine outcome of anterior decompression and stabilization with locally made standalone cage and bone graft in caries spine in terms of improvement of neurology, relief of pain, and improvement of kyphotic angle.

Patients and Methods

It is a prospective case series study including 850 cases who were treated at GTTH from 2003 to 2010. After preoperative assessment of pain, neurology, and measurement of angle of deformity, all patients were treated with anterior decompression and then stabilization was achieved with bone graft and standalone locally made cage. After surgery, patients were followed at 6 weeks, 3 months, 6 months, and 1 year to assess neurology, relief of pain, and kyphotic angle.

Results

Neurology improved in 92% of patients, pain relieved in 95% of cases, and there was mean correction of 18 degrees in kyphotic angle at the end of 1-year follow-up.

Conclusion

Early diagnosis and early intervention give excellent results. After anterior decompression, stabilization with cage and bone graft results in significant improvement of neurology, relief of pain, and correction of kyphotic deformity. There is no need for added instrumentation.
Role of Single Stage Posterior Pedicle Screw Fixation and Transpedicular Decompression with Chemotherapy, in Treatment of Thoracic, Thoracolumbar, and Lumbar Spinal Tuberculosis
Authors: Das Kalidutta
Published: May 2015

Introduction

Tuberculosis of spine being an anterior disease, anterior decompression, and fixation has been long considered as the gold standard. Recently, the posterior approach surgery has gained popularity, based on the principle of adequate debridement and stable fixation with much lower complication rates. This retrospective study aims at evaluating the role of a posterior stabilization with transpedicular posterior alone decompression for tuberculosis of spine.

Patients and Methods

A total of 55 patients surgically treated with posterior pedicle screw fixation and transpedicular decompression along with chemotherapy for tuberculosis of spine between January 2009 and May 2013 and had a minimum of 12 months' follow-up were included in the study. Their functional outcome (VAS score), neurological outcome (ASIA grading) and radiological outcome (X-ray and MRI) were assessed. Patients with kyphotic angle > 30 degrees, more than three contiguous discal involvement and multifocal lesions were excluded from the study.

Results

Mean age of patients was 47.2 years. Thoracic spine was involved in 29, thoracolumbar in 16, and lumbar in 10 patients. Mean follow-up was of 23.2 months. Most common indication for surgery was instability pain. VAS score improved from an average of 9.2 to 2.4 in postoperative period and 3.2 at follow-up. Neurological improvement was seen in all patients with neurological deficits preoperatively. Mean kyphosis angle was 20.6 ± 4.8 degrees and was corrected postoperatively to 7.4 ± 3.2 degrees (> 50%). At the latest follow-up, there was a mean loss of correction of 3.1 degrees resulting in 6.1 degrees of final correction. Bony fusion was achieved in 73% patients with no patient having any clinical signs of pseudoarthrosis.

Conclusion

Posterior stabilization and transpedicular decompression have shown an improvement in the functional outcome and the neurological status in most of the patients without the need of an anterior decompression and fusion. Good maintenance of spinal alignment and fusion along with resolution of the inflammatory process on MRI can be satisfactorily attained through posterior stabilization and transpedicular decompression when accompanied by chemotherapy. However, further follow-up is necessary to monitor for possible disease recurrence or implant failure.
May Latent Bacterial Infection Provoke Degenerative Disc Disease?
Authors: Velnar Tomaz , Gradisnik Lidija , Bunc Gorazd , Vorsic Matjaz , Ravnik Janez
Published: May 2015

Introduction

As a chronic condition, the degenerative disc disease is a significant health problem. Several factors, such as genetics, mechanical stress, inflammatory and biochemical changes, vascular aspects, as well as infection may initiate degenerative processes, most commonly affecting the nucleus pulposus. It has been proposed that disc degeneration might be initiated by possible long-lasting low-grade infection.

Materials and Methods

The aim of the study was to assess the incidence of bacterial infection in the lumbar intervertebral disc specimens obtained from patients with disc herniation. In a prospective study, 62 patients were included (49% women and 51% men, average age 56 years, range 22–83 years). No experience of previous invasive spinal diagnostic procedures was reported. Disc specimens from levels L1 to S1 were collected during discectomies and microbiologically tested on blood, thioglycolate, and nutrient agars. MRI and CT were used as diagnostic methods and comparison of microbiological results to clinical signs and imaging was done.

Results

In included patients, affected discs were removed. All microbiological cultures of disc specimens remained sterile after 1 week. Clinically, no signs of discitis were observed. The absence of an acute infection was confirmed by routine laboratory tests. Although clinical signs corresponded well to the MRI and CT imaging results, no connection with microbiological tests was found.

Conclusion

The exact pathobiology of degenerative disc disease is unknown. According to some studies, intradiscal bacteria may initiate a low-grade infection, playing a role in intervertebral disc degeneration. Our observations do not support this fact. Microbiological samples remained sterile in all patients, meaning that intervertebral disc is a sterile environment and bacterial infection is unlikely the cause of degeneration. Positive disc cultures in other studies may have resulted from specimen contamination after disc removal. However, the hypothesis of disc infection cannot completely be excluded because of slow growing and special growth conditions requiring bacteria that were not tested in our study. The potential role of low-grade bacterial infection contributing to the pathogenesis of degenerative disc disease thus remains uncertain. The genesis of disc degeneration might originate in the immune system and repeated episodes of injury and reparation that could culminate to progressive tissue damage.
Arthrodesis with Pedicle Screw Fixation in Thoracolumbar Infectious Discitis
Authors: Tejeda Martin
Published: May 2015

Introduction

Primary infection of spine disc is a pathology that we see more frequently, mainly because of the decompensated diabetes mellitus, and whose treatment is with antibiotics and limited physical activity for a long time.

Objective

Describe the outcome of surgical treatment of surgical debridement, culture/biopsy, and fusion with pedicle fixation in the same surgical procedure in a group of patients with intractable and/or clinical/radiographic instability with infectious discitis of thoracolumbar spine pain, trying to improve pain and functional limitation time.

Patients and Methods

A group of 15 adult patients from January 2010 to December 2013 with infectious discitis, detected with laboratory tests, imaging (X-ray, CT, and MRI) with a history of diabetes mellitus with thoracolumbar pain with various treatment regimens were studied with visual analog scale of 7 to 10/10, limited functional scale (Oswestry 70–80%), severe limitation of travel (within 100 m), to surgical debridement + culture/biopsy + pedicle fixation was performed and a clinical/radiographical follow-up of 6 months to 3 years.

Results

A significant decrease in pain intensity (60% of the initial pain intensity in the visual analog scale) was found, achieving a progressive improvement in functional scale in a period of time average of 6 to 8 months without detecting recurrence of infection, nor have major complications or deaths registered in monitoring patients with clinical and radiographical stability during the follow-up.

Conclusion

In this study, the results encourage aggressive treatment with instrumentation to improve intractable cases of pain and/or instability to shorten the period of immobility and inactivity of patients.
Reliability Analysis of the AOSpine thoracolumbar Spine Injury Classification System by a Worldwide Group of Naive Spinal Surgeons
Authors: Kepler Christopher , Vaccaro Alexander , Koerner John , Dvorak Marcel , Kandziora Frank , Rajasekaran Shanmuganathan , Aarabi Bizhan , Vialle Luiz , Fehlings Michael , Schroeder Gregory , Reinhold Maximilian , Audigé Laurent , Schnake Klaus , Bellabarba Carlo , Oner Cumhur
Published: May 2015

Introduction

The AOSpine Thoracolumbar Spine Injury Classification System was recently published and combines elements of both the Magerl system and the Thoracolumbar Injury Classification System (TLICS); however, the worldwide applicability has yet to be established.

Material and Methods

A previously described classification system of thoracolumbar injuries which consists of a morphologic classification of the fracture, a grading system for the neurologic status and relevant patient-specific modifiers was applied to 25 cases by 100 spinal surgeons from across the world twice independently, in grading sessions 1 month apart. The results were analyzed for classification reliability using the Kappa coefficient (κ).

Results

The overall Kappa coefficient for all cases was 0.56 which represents moderate reliability. Kappa values describing interobserver agreement were 0.80 for type A injuries, 0.68 for type B injuries, and 0.72 for type C injuries, all representing substantial reliability. The lowest level of agreement for specific subtypes was for fracture subtype A4 (Kappa = 0.19). Intraobserver analysis demonstrated overall average Kappa statistic for subtype grading of 0.68 also representing substantial reproducibility.

Conclusion

In a worldwide sample of spinal surgeons without previous exposure to the recently described AOSpine Thoracolumbar Spine Injury Classification System, we demonstrated moderate interobserver and substantial intraobserver reliability. These results suggest that most spine surgeons can reliably apply this system to spine trauma patients as or more reliably than previously described systems.
Combined Endovascular and Surgical Treatment of Type I Spinal Dural Arteriovenous Fistulas
Authors: Vukic Miroslav , Ozretic David , Rados Marko , Marasanov Sergej , Rozankovic Marjan , Lupret Velimir , Nemir Jakob , Duric Kresimir Sasa
Published: May 2015

Introduction

Spinal dural arteriovenous fistulas (SDAVFs) are rare but most common form of spinal vascular malformations, accounting for approximately 70% of all such lesions. They are low-flow vascular shunts fed by radicular arteries. Patients most often present with myelopathy. The presumed pathophysiological mechanism is venous hypertension and congestion of the cord with edema. We present our experiences and results in combined endovascular and surgical treatment of type I SDAVFs.

Patients and Methods

We conducted a retrospective review of prospectively collected data from patients with a diagnosis of SDAVFs who underwent treatment at University Hospital Centre Rebro Zagreb between January 2012 and June 2014. The complication and recurrence rates from clinical and imaging follow-up in these patients are analyzed.

Results

A total of 14 patients with a diagnosis of SDAVFs were treated in our institution during the analyzed period. Of these, 12 patients underwent endovascular embolization as first-line therapy. Onyx was used in 1 patient and NBCA in 11 patients. Two patients underwent surgical ligation as the initial therapeutic procedure. Patients in both groups showed significant improvement in clinical status after treatment on the Aminoff-Logue Scale. One patient in the endovascular group developed spinal infarction because of the accidental embolization of posterior spinal artery. Six patients in embolization group had recurrence of the fistula during the course of follow-up requiring surgical ligation. Two patients in the surgical group had recurrence of fistula during the course of follow-up and were reoperated.

Conclusion

Although most type I SDAFs are amenable to endovascular embolization, microsurgical obliteration as first option is indicated in specific anatomic situations and usually the only solution for recurrent cases. The combined endovascular and microsurgical approach offers best results after careful selection of patients based on imaging.
Does Intrawound Application of Vancomycin Influence Bone Healing in Spinal Surgery?
Authors: Eder Claudia , Schenk Stefan , Trifinopoulos Jana , Kuelekci Buesra , Kienzl Melanie , Schildboeck Sabrina , Ogon Michael
Published: May 2015

Introduction

Surgical site infections represent a major complication of spinal surgery. The application of lyophilized vancomycin into the wound is reported to significantly decrease infection rates. As concentrations applied locally can exceed the minimal bacterial inhibitory concentration for more than a 1000-fold, toxic side effects on local tissue may be possible.

Materials and Methods

Primary osteoblast cell cultures were generated from bone tissue samples of 10 patients. Samples were incubated in absence or presence of 3, 6, or 12 mg/cm2 vancomycin according to a planned phase I clinical trial protocol. Changes in pH, osteoblast migration, proliferation, and viability were analyzed. Alkaline phosphatase and mineralization patterns were studied.

Results

The application of more than 3 mg/cm2 vancomycin induced a decline of pH toward the acidic range. The migration potential of osteoblasts was decreased from 100% (control samples) to zero (12 mg/cm2 vancomycin) in a dose-dependent manner. Cell proliferation was significantly inhibited at dosages above 3 mg/cm2. Significant cell death was observed if the dosage applied exceeded 6 mg/cm2. The synthesis of alkaline phosphatase was markedly reduced in all dosages applied and calcium deposition was significantly decreased in dosages above 3 mg/cm2.

Conclusion

As bone remodeling requires the immigration, proliferation, and differentiation of osteoblasts at the fusion site, high dosages of intrawound vancomycin might interfere with regenerative processes and increase the risk of nonunion. To allow an appropriate balance of infection risk and the risk of nonunion, the minimal local concentration required should be determined by controlled in vivo studies.
Mesenchymal Stem Cells Derived from Vertebrae Show Best Biological Properties
Authors: Brodano Giovanni Barbanti , Maroni Giorgia , Trombi Luisa , Valtieri Mauro , Griffoni Cristiana , Boriani Stefano , Magli Maria Cristina
Published: May 2015

Introduction

Due to their properties and characteristics, human mesenchymal stem cells (MSCs) appear to have great therapeutic potential, because they can contribute to the tissue regeneration. Many different populations of MSCs that differ for the embryonic origin and the anatomical localization have been described and to understand whether they have equivalent biological properties is a critical issue for their therapeutic application. Spine fusion is frequently used to treat traumatic, degenerative, and oncological spine diseases. Autologous bone graft has been considered the gold standard for spine fusion procedures because of its osteogenic, osteoinductive, and osteoconductive ability. However, its use is associated with significant disadvantages, including donor site pain, increased operative time, insufficient availability, and nonunion postlumbar fusion. Various bone substitutes have been developed to promote spinal fusion. Also, MSCs have been successfully tested for spinal fusion in several small and large animal models.

Material and Methods

To define the properties of MSCs for the use in clinical applications, we proposed to analyze the cellular and molecular characteristics of human adult MSCs derived from different body locations, such as bone marrow from the iliac crest (Ic-MSCs), sternum (St-MSCs), and vertebrae (vMSCs), as well as colon (Co-MSCs) and dental pulp (DPSCs), to identify the cell population showing better biological properties for spine fusion clinical application.

Results

MSCs from different sources presented very different growth kinetics. While iliac crest and sternum-derived MSCs could be maintained in culture for about 3 months, undergoing a limited expansion, mesenchymal cultures derived from dental pulp and colon grew much more rapidly, but could not be maintained longer. Strikingly, vMSCs continued to propagate at high rate even after 3.5 months ex vivo. MSCs from different sources were also induced to osteogenic, adipogenic, and chondrogenic differentiation following exposure to specific inducing agents. We observed that vMSCs generate mature cells of all mesenchymal lineages with greater efficiency, resulting into the best population both in terms of expansion and differentiation.

Conclusion

This finding could be very interesting and open new perspectives for the improvement of spine fusion, which is a mandatory step for the success of spinal surgical procedures. In the course of a surgical procedure for spinal fusion, vertebral bone marrow can be harvested simultaneously with the preparation of the site for pedicle screw insertion. Then multipotent MSCs can be isolated from vertebral bone marrow during the progress of the surgical procedure and reintroduced in the fusion site (using homologous or autologous bone tissue or biomaterials as scaffold), without any additional surgical time or any other donor site involvement.
Developing a Mouse Model to Study Mesenchymal Stem Cell Survival, Proliferation, and Migration in Lumbar Posterolateral Spinal Fusion
Authors: Lina Ioan , Holmes Christina , Liauw Jason , Lo Sheng-Fu Larry , Elder Benjamin , Theodros Debebe , Witham Timothy
Published: May 2015

Introduction

While spinal fusion surgery has advanced over the past decade, a great deal is unknown regarding the underlying mechanisms that contribute to spinal fusion failure or pseudoarthrosis. Clinically, bone marrow aspirate has been successfully used alongside a variety of grafting materials to augment fusion (Neen et al. Spine (Phila Pa 1976). 2006;31(18):E636; Carter et al. Spine J. 2009;9(6):434). To date, studies evaluating these procedures have focused on radiographic monitoring and endpoint analysis. Little is known about the survival and proliferation of these transplanted mesenchymal cells or how much they contribute to bone formation compared with host cells from adjacent decorticated bone. Insights into these cell dynamics will give us a deeper understanding of the biological processes underlying spinal fusion and allow for evaluation and development of fusion therapies that reduce rates of pseudoarthrosis.

Material and Methods

A total of 40 FVB/NJ mice underwent posterolateral lumbar spinal fusion surgery and were divided into four groups based upon the fusion graft employed: syngeneic iliac crest bone graft ( n = 10), Vitoss bone-matrix alone ( n = 10), Vitoss bone-matrix with syngeneic bone marrow cells (2.5 × 106 cell/side) ( n = 10), and Vitoss bone-matrix with transgenic luciferase-expressing syngeneic bone marrow cells (2.5 × 106 cell/side) ( n = 10). Bone marrow cells were isolated from the long bones of either syngeneic FVB/NJ mice or syngeneic FVB mice which constitutively express the luciferase gene (FVB-Tg (CAG-luc,-GFP) L2G85Chco/J mice). The in vivo survival, distribution, and proliferation of the luciferase-expressing bone marrow-derived cells were monitored via bioluminescence imaging over a period of 8 weeks. Spinal fusion was assessed 4, 6, and 8 weeks postsurgery via micro-CT imaging, as well as via manual palpation at 8 weeks. Immunohistochemistry was performed to assess fusion bone growth as well as determine the number of donor versus host cells within the fusion mass.

Results

Bioluminescent imaging data demonstrated quantifiable cellular viability within the fusion mass as early as 24 hours following surgery, with increasing bioluminescent signal over the first 2 weeks postsurgery, thus indicating cellular proliferation. Bioluminescence decreased between weeks 4 and 8 suggesting a loss of transplanted mesenchymal progenitor cells within the fusion mass at later time points. Correlations with histology and micro-CT imaging of the developing fusion mass are currently under analysis.

Conclusions

We have demonstrated a novel murine model which enables noninvasive in vivo monitoring of implanted transgenic luciferase-expressing bone marrow cells following spinal fusion surgery. Future applications of this model will include the assessment of additional therapeutics for improving spinal fusion in translational research studies.
Investigating Human VANGL1, as a Candidate Gene for Adolescent Idiopathic Scoliosis
Authors: Simony Ane , Andersen Malene Rask , Larsen Lars Allan , Andersen Mikkel O.
Published: May 2015

Introduction

The human VANGL1 genes has been predicted to be associated with idiopathic scoliosis, as a mutation (c.676C > T, L226F) was identified in a family with dominant inheritance of the disease. A previous investigation of the gene revealed the candidate to segregate, with all but one family member (Sharma, et al. ASHG 2012 Annual Meeting Program Guide. 2012). Adolescent idiopathic scoliosis (AIS) is generally considered multigenetic, but the determining genes remain yet to be characterized. In this study, we have examined VANGL1 as a contributor to the phenotype of AIS.

Materials and Methods

We have conducted automated Sanger sequencing of the seven coding exons of VANGL1 gene in a disease cohort of 170 AIS patients ( n = 340) and 177 controls ( n = 354). Localization of mutated VANGL1 proteins was investigated in cell systems using immunofluorescence microscopy.

Results

Two novel mutations, each in separate individuals within the considered disease cohort, were identified. One mutation is situated in the third coding exon, which encodes the transmembrane parts of the VANGL1 protein. This mutation is a c.407T > A (I136N) conversion, for which the patient is heterozygotes. Furthermore, this mutation was also identified in the dizygotic unaffected twin of the patient. The second mutation was found in the seventh coding exon, which encodes the C-terminal of the VANGL1 protein. This mutation is a c.1318T > G (F440V) conversion, for which the patient is also heterozygotes. Neither of the identified mutations was present in the sequenced controls or in 2000 Danish exomes (Lohmueller et al. Am J Hum Genet 2013;93:1072–1086). The F440V mutation results in altered localization of the VANGL1 protein, from very clear membrane association to a cytoplasmic distribution, with possible retainment in endoplasmic reticulum and the Golgi apparatus, near the cell nucleus.

Conclusion

Our results show that mutations in the VANGL1 gene can cause AIS and suggest that defects in planar cell polarity may be an underlying cause of AIS. Examination of the expression of VANGL1 in juvenile or adult stages of life is wanted, as well as examinations of effects on downstream targets of mutated VANGL1 and polarity in affected cells.
Lidocaine and Bupivacaine Toxicity on Human Intervertebral Disc Cells in Vitro
Authors: Velnar Tomaz , Gradisnik Lidija , Bunc Gorazd
Published: May 2015

Introduction

The treatment and diagnostics of discogenic low back pain often employ local anesthetic agents. Lidocaine and bupivacaine are most commonly used for controlling and relieving the pain in interventional spine procedures. It is known that these local anesthetics may be cytotoxic to the intervertebral disc cells following the intradiscal injections and that they may provoke or accelerate the intervertebral disc degeneration. However, the potential effects of these agents still remain unclear, as many studies so far have been accomplished on animal cells. The purpose of the study was to evaluate the effect of various local anesthetics on human intervertebral disc cells in vitro and to compare the cytotoxicity of lidocaine, bupivacaine, and its mixture to saline control solution.

Materials and Methods

Annulus fibrosus and nucleus pulposus cells were isolated from human lumbar intervertebral disc fragments following discectomies. They were cultured in the microtiter plates and exposed to various concentrations of lidocaine, bupivacaine, as well as their mixture. The saline solution was used for control. Three different dilutions (undiluted, 1:2, and 1:4) of anesthetic agents were tested. The cells were treated for 6, 24, and 48 hours. They were then examined with the crystal violet cell staining. The percentage of live cells after treatment was determined.

Results

Human intervertebral disc cells demonstrated a time- and dose-dependent response to lidocaine and bupivacaine. Nucleus pulposus cells were more susceptible than annulus fibrosus cells to the toxic effects of both anesthetic agents. Lidocaine was the most toxic in all three tested concentrations (undiluted, 1:2, and 1:4) with the cell survival of 0, 10, and 20%, respectively. Bupivacaine presented less cytotoxicity than lidocaine with the survival rates of 10, 60, and 80%, respectively. Lidocaine–bupivacaine mixture showed an intermediate toxicological effect. The cell death was mainly caused by necrosis rather than apoptosis.

Conclusions

When incubating the human intervertebral disc cells in vitro with a combination of anesthetic agents commonly used for discography, the cytotoxic effects were observed in a dose- and time-dependent manner. According to our study, lidocaine and its mixtures should be avoided due to their high toxicity to the intervertebral disc cells. Bupivacaine was the least toxic, especially when used in 1:4 dilutions and may be thus recommended for the intradiscal diagnostics. It is assumed that the genesis of disc degeneration might be contributed also by the toxic effects of the anesthetics used, culminating to progressive tissue damage after the diagnostic measures.
Hyaluronate, Collagen, and Ionic Distribution: A Relation Study with Annulus Fibrosus Cells (Fibroblast-Like Cells)
Authors: Martins Delio , Medeiros Valquiria , Demerov Gabriela , Accardo Camila , Paredes-Gamero Edgar , Wajchenberg Marcelo , Reginato Rejane , Nader Helena , Puertas Eduardo , Faloppa Flavio
Published: May 2015

Introduction

Degenerative disc disease has been associated with low back pain and many therapies have been proposed for its treatment. The correlation between disc degeneration and back pain is still to be determined, however, studies tend to analyze potential therapies including gene applications and molecular biology to deal with this complex public health problem. Precise methods to quantify disc components are mandatory for any type of proposed therapy. The aim of this study was to correlate glycosaminoglycan amounts with the quantitation of cellular ions and collagen fiber distributions in different intervertebral disc sections.

Materials and Methods

In total, 14 intervertebral discs were used from 14 tails of 24 to 30-month old cattle. All of the discs were dehydrated, separated in seven sections and digested in sodium-free papain buffer. Sulfated glycosaminoglycan measurements were performed in the samples according to DMMB and agarose electrophoresis methods; hyaluronate was determined by an ELISA-like fluorimetric method, total cells were measured using the PicoGreen technique, ions were quantified by an automated procedure, and collagen fiber birefringence was analyzed with polarized light microscopy.

Results

Significant differences were observed between electrophoresis and DMMB ( p < 0.01); GAGs were up to six times higher when using electrophoresis in annulus (mean/SD = 3.82/1.96) and were almost two times higher in the nucleus (mean/SD = 1.63/0.21). The correlation between HA and GAG ( p < 0.001), cell number, sodium ( p = 0.007), and hyaluronate ( p = 0.034) were significant. Thin collagen fibers were largest in the nucleus ( p < 0.001). Fibroblast-like cells were negatively correlated with hyaluronate and sodium concentrations. Collagen thin fibers (collagen II) were more related to hyaluronate.

Conclusion

In summary, this report demonstrated a positive correlation between hyaluronate and glycosaminoglycan; and a negative correlation between hyaluronate and cell number, suggesting that fibroblast-like cells are also sensitive to changes in hyaluronate and ionic concentrations. Hyaluronate could be closely related to thin collagen fibers (collagen type II).

Acknowledgments

This work was supported by INFAR/UNIFESP Confocal and Flow Cytometry Facility and by grants from the “Fundacao de Amparo à Pesquisa do Estado de São Paulo” (FAPESP: Grant number: 2009/54793–6). D.E.M. was supported by a PhD's fellowship grant from CAPES (Coordenacao de Aperfeicoamento de Pessoal de Nível Superior).