bluuebunny/crossref_metadata_2025 huggingface dataset:
Neurological manifestations of the acquired immunodeficiency syndrome (AIDS): Experience at UCSF and review of the literature
Authors: Levy Robert M. , Bredesen Dale E. , Rosenblum Mark L.
Published: December 2007

✓In this review of the acquired immunodeficiency syndrome (AIDS), the authors have evaluated a total of 352 homosexual patients with AIDS or generalized lymphadenopathy managed at the University of California, San Francisco (UCSF), between 1979 and 1984. Of an initial unselecled group of 318 patients, 124 (39%) were neurologically symptomatic, and one-third already had their neurological complaints at the time of presentation. An additional 210 AIDS patients with neurological symptoms have been reported in the literature. Thus, a total of 366 neurologically symptomatic patients with AIDS or lymphadenopathy are reviewed.

Central nervous system (CNS) complications, encountered in 315 patients, included the following viral syndromes: subacute encephalitis (54), atypical aseptic meningitis (21), herpes simplex encephalitis (nine), progressive multifocal leukoencephalopathy (six), viral myelitis (three), and varicella-zoster encephalitis (one). Non-viral infections were caused by Toxoplasma gondii (103), Cryptococcus neoformans (41), Candida albicans (six), Mycobacteria (six), Treponema pallidum (two), coccidioidomycosis (one), Mycobacterium tuberculosis (one), Aspergillus fumigatus (one), and Escherichia coli (one). Neoplasms included primary CNS lymphoma (15), systemic lymphoma with CNS involvement (12), and metastatic Kaposi's sarcoma (three). Cerebrovascular complications were seen in four patients with hemorrhage and five with infarction. Five patients in the UCSF series had multiple intracranial pathologies, including two cases of simultaneous Toxoplasma gondii infections and primary CNS lymphoma, two cases of coexistent Toxoplasma gondii and viral infections, and one case of combined Toxoplasma gondii and atypical mycobacterial infection.

Cranial or peripheral nerve complications, seen in 51 patients, included cranial nerve syndromes secondary to chronic inflammatory polyneuropathy (five), lymphoma (five), and Bell's palsy (five). Peripheral nerve syndromes included chronic inflammatory polyneuropathy (12), distal symmetrical neuropathy (13), herpes zoster radiculitis (six), persistent myalgias (two), myopathy (two), and polymyositis (one).

In light of the protean behavior of AIDS and the problems related to the clinical, radiological, and serological diagnosis of the unusual and varied associated nervous system diseases, patients with AIDS and neurological complaints require a rigorous and detailed evaluation. The authors' experience suggests that biopsy of all CNS space-occupying lesions should be performed for tissue diagnosis prior to the institution of other therapies.
Use of osteogenic protein-1 in patients at high risk for spinal pseudarthrosis: a prospective cohort study assessing safety, health-related quality of life, and radiographic fusion
Authors: Furlan Julio C. , Perrin Richard G. , Govender Preneshlin V. , Petrenko Yuriy , Massicotte Eric M. , Rampersaud Yoga R. , Lewis Stephen , Fehlings Michael G.
Published: December 2007

Object

The capability of osteogenic protein (OP)–1 to induce bone formation has led to an increasing interest in its use in fusion surgery. This prospective study examines the safety and efficacy of OP-1 use in patients considered to be at a high risk for developing pseudarthrosis following reconstructive spinal surgery.

Methods

Outcome measures included documentation of adverse events, radiographic evaluation of fusion by an independent musculoskeletal radiologist blinded to treatment, the Oswestry Disability Index (ODI), and the 36-Item Short Form Health Survey (SF-36). The health-related quality of life (HRQOL) assessments (ODI and SF-36) were given at baseline and at 3, 6, 12, 18, and 24 months after the surgical OP-1 implant.

Results

The study consisted of 17 male and 13 female patients, with a mean age of 53 years (range 20–77 years). Fourteen patients underwent operations for cervical disease, and 16 for lumbar disease, with a median postoperative follow-up of 24 months (range 13–46 months). There were significant improvements in the physical health (from 28.7 ± 1.5 to 34.2 ± 3; p = 0.025) and mental health (from 43.7 ± 2 to 47.5 ± 3.1; p = 0.015) summary scores on the SF-36. The mean postoperative ODI score at 6, 9, 12, and 18 months was significantly lower than the baseline ODI score, after taking into consideration a 10-point measurement error (p = 0.0003, p = 0.003, p = 0.004, and p = 0.032, respectively). At 24 months, however, the differences in ODI scores were no longer significant. Of the 30 patients, 24 (80%) were deemed to have a solid fusion. There were no allergic reactions to OP-1 and no symptomatic postoperative hematomas.

Conclusions

Our results suggest that the use of OP-1 is safe and may contribute to high fusion rates, as demonstrated by radiographs, reduced levels of disability, and improved HRQOL in patients considered to be at a high risk for developing a nonunion after spinal reconstructive surgery.
Anterior lumbar interbody fusion in comparison with transforaminal lumbar interbody fusion: implications for the restoration of foraminal height, local disc angle, lumbar lordosis, and sagittal balance
Authors: Hsieh Patrick C. , Koski Tyler R. , O'Shaughnessy Brian A. , Sugrue Patrick , Salehi Sean , Ondra Stephen , Liu John C.
Published: December 2007

Object

A primary consideration of all spinal fusion procedures is restoration of normal anatomy, including disc height, lumbar lordosis, foraminal decompression, and sagittal balance. To the authors' knowledge, there has been no direct comparison of anterior lumbar interbody fusion (ALIF) with transforaminal lumbar interbody fusion (TLIF) concerning their capacity to alter those parameters. The authors conducted a retrospective radiographic analysis directly comparing ALIF with TLIF in their capacity to alter foraminal height, local disc angle, and lumbar lordosis.

Methods

The medical records and radiographs of 32 patients undergoing ALIF and 25 patients undergoing TLIF from between 2000 and 2004 were retrospectively reviewed. Clinical data and radiographic measurements, including preoperative and postoperative foraminal height, local disc angle, and lumbar lordosis, were obtained. Statistical analyses included mean values, 95% confidence intervals, and intraobserver/interobserver reliability for the measurements that were performed.

Results

Our results indicate that ALIF is superior to TLIF in its capacity to restore foraminal height, local disc angle, and lumbar lordosis. The ALIF procedure increased foraminal height by 18.5%, whereas TLIF decreased it by 0.4%. In addition, ALIF increased the local disc angle by 8.3° and lumbar lordosis by 6.2°, whereas TLIF decreased the local disc angle by 0.1° and lumbar lordosis by 2.1°.

Conclusions

The ALIF procedure is superior to TLIF in its capacity to restore foraminal height, local disc angle, and lumbar lordosis. The improved radiographic outcomes may be an indication of improved sagittal balance correction, which may lead to better long-term outcomes as shown by other studies. Our data, however, demonstrated no difference in clinical outcome between the two groups at the 2-year follow-up.
In vitro biomechanical comparison of transpedicular versus translaminar C-2 screw fixation in C2–3 instrumentation
Authors: Reddy Chandan , Ingalhalikar Aditya V. , Channon Scott , Lim Tae-Hong , Torner James , Hitchon Patrick W.
Published: December 2007

Object

In instrumentation of the upper cervical spine, placement of pedicle screws into C-2 is generally safe, although there is the potential for injury to the vertebral arteries. Owing to this risk, translaminar screws into C-2 have been used. The aim of this study was to compare the stability of the in vitro cadaveric spine using C-2 laminar compared with C-2 pedicle screws in C2–3 instrumentation.

Methods

Eight fresh frozen human cadaveric cervical spines (C1–6) were potted at C1–2 and C5–6. Pure moments in increments of 0.3 Nm to a maximum of 1.5 Nm were applied in flexion, extension, right and left lateral bending, and right and left axial rotation. Each specimen was tested sequentially in three modes: 1) intact; 2) C2 pedicle screw–C3 lateral mass fixation; and 3) C2 laminar screw–C3 lateral mass fixation. The sequence of fixation testing was randomized. Motion was tracked with reflective markers attached to C-2 and C-3.

Results

Spinal levels with instrumentation showed significantly less motion than the intact spine in all directions and with all loads greater than 0.3 Nm (p < 0.05). Although there was no significant difference between C2 pedicle screw–C3 lateral mass fixation and C2 laminar screw–C3 lateral mass fixation, generally the former type of fixation was associated with less motion than the latter.

Conclusions

When pedicle screws in C-2 are contraindicated or inappropriate, laminar screws in C-2 offer a safe and acceptable option for posterior instrumentation.
A comparison of the effectiveness of mitomycin C and 5-fluorouracil in the prevention of peridural adhesion after laminectomy
Authors: Sun Yu , Wang Li-Xin , Wang Lei , Sun Si-Xin , Cao Xiao-Jian , Wang Peng , Feng Li
Published: December 2007

Object

The effectiveness of the topical application of mitomycin C (MMC) or 5-fluorouracil (5FU) in preventing peridural adhesion after laminectomy was compared in this study.

Methods

Laminectomies were performed at L-1 in 30 rats. Cotton pads soaked with 0.1 mg/ml MMC, 25 mg/ml 5FU, or 9 mg/ml saline (control) were applied to the operative sites. To evaluate neurological deficits pre- and postoperatively, somatosensory evoked potentials were monitored and the Basso-Beattie-Bresnahan locomotion test was performed. Four weeks postlaminectomy the rats were killed, and peridural scar adhesion was evaluated histologically. The level of hydroxyproline, the area of peridural scar tissue, and the number of fibroblasts were determined. The degree of peridural adhesion was classified according to the Rydell standard.

Results

No obvious adhesion formed in the rats in the MMC group, but severe peridural adhesions were found in those in the 5FU and control groups. The content of hydroxyproline, the area of peridural scar tissue, and the number of fibroblasts in the MMC group were significantly lower than those in the 5FU and control groups.

Conclusions

The topical application of MMC rather than 5FU may be a successful method of preventing post-laminectomy peridural adhesions.
A porous bioactive titanium implant for spinal interbody fusion: an experimental study using a canine model
Authors: Takemoto Mitsuru , Fujibayashi Shunsuke , Neo Masashi , So Kazutaka , Akiyama Norihiro , Matsushita Tomiharu , Kokubo Tadashi , Nakamura Takashi
Published: December 2007

Object

Porous biomaterials with adequate pore structure and appropriate mechanical properties are expected to provide a new generation of devices for spinal interbody fusion because of their potential to eliminate bone grafting. The purpose of this study was to evaluate the fusion characteristics of porous bioactive titanium implants using a canine anterior interbody fusion model.

Methods

Porous titanium implants sintered with volatile spacer particles (porosity 50%, average pore size 303 μm, compressive strength 116.3 MPa) were subjected to chemical and thermal treatments that give a bioactive microporous titania layer on the titanium surface (BT implant). Ten adult female beagle dogs underwent anterior lumbar interbody fusion at L6–7 using either BT implants or nontreated (NT) implants, followed by posterior spinous process wiring and facet screw fixation. Radiographic evaluations were performed at 1, 2, and 3 months postoperatively using X-ray fluoroscopy. Animals were killed 3 months postoperatively, and fusion status was evaluated by manual palpation and histological examination.

Results

Interbody fusion was confirmed in all five dogs in the BT group and three of five dogs in the NT group. Histological examination demonstrated a large amount of new bone formation with marrowlike tissue in the BT implants and primarily fibrous tissue formation in the NT implants.

Conclusions

Bioactive treatment effectively enhanced the fusion ability of the porous titanium implants. These findings, coupled with the appropriate mechanical properties in load-bearing conditions, indicate that these porous bioactive titanium implants represent a new generation of biomaterial for spinal interbody fusion.
Quadriparesis due to the delayed formation of a compressive epidural cerebrospinal fluid collection following suboccipital craniectomy with duraplasty for Chiari malformation Type I
Authors: Oberer Daniel M. , Aaronson Oran S. , Cheng Joseph S.
Published: December 2007

✓ The authors describe a previously undocumented complication of suboccipital craniectomy combined with duraplasty for the treatment of Chiari malformation Type I and propose techniques to prevent its occurrence. Although there have been reports of epidural pseudomeningoceles in the setting of spontaneous intracranial hypotension and intracranial hygromas following suboccipital craniectomy with duraplasty, the authors believe this case to be the first instance of quadriparesis caused by the delayed formation of a compressive epidural cerebrospinal fluid collection after suboccipital craniectomy with duraplasty. This complication is significant and must be recognized given the potential severity of neurological insult and the number of these procedures performed yearly in both the pediatric and adult populations.
Hypertrophic spinal pachymeningitis associated with heavy-chain disease
Authors: Yunokawa Kazuki , Hagiyama Yoshitaka , Mochizuki Yu , Tanaka Nobuhiro , Ochi Mitsuo
Published: December 2007

✓The authors present a case of concurrent hypertrophic spinal pachymeningitis (HSP) and heavy-chain disease (HCD). The patient was a 71-year-old woman presenting with leg paralysis and fever. Laminectomy was performed for thoracic HSP, and chemotherapy was administered for HCD. Because the dura mater was not surgically opened, marked hypertrophy remained postoperatively. Once the HCD was controlled by chemotherapy, the fever subsided and the hypertrophy was resolved. No previous reports have supported a link between the two diseases. Idiopathic HSP may be secondary to rare conditions such as HCD, and systemic examinations should be performed to the fullest extent possible to investigate the possibility of some underlying disease.
Wrong-sided and wrong-level neurosurgery: a national survey
Authors: Jhawar Balraj S. , Mitsis Demytra , Duggal Neil
Published: December 2007

Object

Perhaps the single greatest error that a surgeon hopes to avoid is operating at the wrong site. In this report, the authors describe the incidence and possible determinants of incorrect-site surgery (ICSS) among neurosurgeons.

Methods

The authors asked neurosurgeons to complete an anonymous survey. These surgeons were asked to report the number of craniotomies and lumbar and cervical discectomies performed during the previous year, as well as whether ICSS had occurred. They were also asked detailed questions regarding the potential determinants of ICSS.

Results

There was a 75% response rate and a 68% survey completion rate. Participating neurosurgeons performed 4695 lumbar and 2649 cervical discectomies, as well as 10,203 craniotomies. Based on this self-reporting, the incidence of wrong-level lumbar surgery was estimated to be 4.5 occurrences per 10,000 operations. The ICSSs per 10,000 cervical discectomies and craniotomies were 6.8 and 2.2, respectively. Neurosurgeons recognized fatigue, unusual time pressure, and emergent operations as factors contributing to ICSS. For spine surgery, in particular, unusual patient anatomy and a failure to verify the operative site by radiography were also commonly reported contributors.

Conclusions

Neurosurgical ICSSs do occur, but are rare events. Although there are significant limitations to the survey-based methodology, the data suggest that the prevention of such errors will require neurosurgeons to recognize risk factors and increase the use of intraoperative imaging.
Cervical spinal motion before and after surgery in patients with Chiari malformation Type I associated with syringomyelia
Authors: Ono Atsushi , Suetsuna Futoshi , Ueyama Kazumasa , Yokoyama Toru , Aburakawa Shuichi , Takeuchi Kazunari , Numasawa Takuya , Wada Kanichiro , Toh Satoshi
Published: December 2007

Object

There have been few reports about the cervical spinal motion in patients with Chiari malformation Type I (CM-I) associated with syringomyelia. To investigate this phenomenon, the relationship between the preoperative cervical range of motion (ROM) and the stage of cerebellar tonsillar descent as well as the cervical ROM before and after foramen magnum decompression (FMD) were evaluated.

Methods

Thirty patients who had CM-I associated with syringomyelia and who underwent FMD participated in the study. The ROM and lordosis angle of the cervical spine were measured on x-ray films. In addition, the relationship between preoperative degree of cerebellar tonsillar descent and the ROM between the levels of the occiput (Oc) and C2 was investigated.

Results

The mean flexion–extension ROM at Oc–C2 was 15.5° before and 14.1° after surgery, and the mean flexion–extension ROM of C2–7 was 55.1° before and 52.8° after surgery. The mean pre- and postoperative lordosis angles at C2–7 were 16.8 and 19.1°, respectively. There was no significant difference between the values measured before and after surgery. There was no correlation between the degree of cerebellar tonsillar descent and the ROM at Oc–C2.

Conclusions

Foramen magnum decompression is an excellent surgical technique that has no effect on the postoperative cervical ROM and cervical alignment.
Effect of autologous platelet gel on early and late graft fusion in anterior cervical spine surgery
Authors: Feiz-Erfan Iman , Harrigan Mary , Sonntag Volker K. H. , Harrington Timothy R.
Published: December 2007

Object

In a double-blind randomized study, platelet concentrate was used to treat 50 patients who underwent anterior cervical fusion with allograft bone and internal fixation, predominantly for degenerative disc disease or soft herniated cervical disc. The goal in this study was to compare the outcomes in patients treated with and without the platelet gel.

Methods

Patients were assessed radiographically at 6, 12, and 52 weeks and at 2 years if needed. Clinically, patients were evaluated with the visual analog scale, Neck Disability Index, Short Form–36, and a modified Prolo Scale.

Results

Follow-up included 90% of the patients at 1 year and 84% at 2 years. The overall fusion rate was 84%.

Conclusions

Whereas patients with degenerative discs treated with platelet gel demonstrated early fusion at the 12-week follow-up interval, no consistent early fusion was obtained with the use of the platelet gel preparation in patients with a soft disc herniation.
Multiple cervical arcocristectomies for the treatment of cervical spondylotic myelopathy: surgical technique and results
Authors: Amaral Sergio H. , Silva Marcelo N. , Giraldi Mauricio , Viterbo Marcelo B. S. , Pereira Clemente A. B.
Published: December 2007

Object

In the surgical treatment of cervical spondylotic myelopathy, a posterior approach is recommended for patients with multilevel cervical stenosis. In this article the authors describe the multiple cervical arcocristectomy technique and results.

Methods

This surgical technique involves the removal of the upper half of the cervical laminae and was performed in 17 patients between 1997 and 2005 with a mean follow-up of 55 months.

Results

Sixteen patients showed immediate improvement in myelopathic symptoms, and all of them had long-term improvement with no complications and a relatively short surgical time.

Conclusions

Multiple cervical arcocristectomy is a surgical technique that offers physiological and biomechanical advantages in the treatment of the spondylotic myelopathy.
A new paradigm for staging pedicle screw–based spinal procedures: rationale, feasibility, safety, and efficacy
Authors: Ringstrom Mark J. , Sullivan Humbert G. , Fundell Larry J. , Nigogosyan Mark A.
Published: December 2007

Object

The aims of this study were to present the rationale for and the evolution of a staged, two-procedure paradigm for spinal surgery requiring pedicle screw instrumentation, and to evaluate the feasibility, safety, and efficacy of the technique.

Methods

The rationale for the new algorithm is presented for consideration in the form of unproven hypotheses subject to verification by subsequent studies. The first stage of the two-staged algorithm, performed in an interventional radiology (IR) setting, involves percutaneous placement of either headless pedicle screws or K-wire fragment placeholders of the trajectory for pedicle screws. The second stage, performed days or weeks later, involves open surgical completion of instrumentation placement and other surgical objectives. The techniques for IR percutaneous K-wire fragment and percutaneous screw placement evolved over the duration of the study.

Instrumentation was placed in 126 pedicles in 25 patients. Efficacy was equated to the accuracy of screw placement, which was evaluated using computed tomography (CT). Algorithms incorporating correction for metal artifact were developed to determine deviation of the screws and K-wire fragments from proper position. Over 1500 measurements were made to evaluate K-wire fragment and screw position in the 116 instrumented pedicles for which CT data were available.

Results

Accuracy of placement (relative to both cortical and pedicle breaches or to only pedicle breaches) was 98 to 100% for K-wire fragments, 96 to 98% for screws following K-wire fragments, and 100% for percutaneous screws. The only adverse consequence of pedicle screw placement by this method was one infection that occurred 8 months postoperatively.

Conclusions

The staged, two-procedure paradigm for pedicle screw placement proved, within the limits of this study, to be feasible, safe, and effective; therefore, the unproven rationale behind the new paradigm merits further evaluation in a larger cohort of patients with randomized, matched controls.
A preliminary biomechanical evaluation in a simulated spinal fusion model
Authors: Ferrara Lisa A. , Gordon Illya , Coquillette Madeline , Milks Ryan , Fleischman Aaron J. , Roy Shuvo , Goel Vijay K. , Benzel Edward C.
Published: December 2007

Object

A preliminary in vitro biomechanical study was conducted to determine if the pressure at a bone graft–mortise interface and the load transmitted along a ventral cervical plate could be used as parameters to assess fusion status.

Methods

An interbody bone graft and a ventral plate were placed at the C3–4 motion segment in six fresh cadaveric goat spines. Polymethylmethacrylate (PMMA) was used to simulate early bone fusion at the bone graft site. The loads along the plate and the simultaneous pressures induced at the graft–endplate interfaces were monitored during simulated stages of bone healing. Each specimen was nondestructively tested in compression loading while the pressures and loads at the graft site were recorded continuously. Each specimen was tested under five conditions (Disc, Graft, Plate, PMMA, and Removal).

Results

The pressure at the interface of the bone graft and vertebral endplate did not change significantly with the addition of the ventral plate. The interface pressure and segmental stiffness did increase following PMMA augmentation of the bone graft (simulating an intermediate phase of bone fusion). The load transmitted along the ventral plate in compression increased after the addition of the bone graft, but decreased after PMMA augmentation. Thus, there was an increase in pressure at the graft–endplate interface and a decrease in load transferred along the ventral plate after the simulation of bone fusion. Upon removal of the ventral plate, the simulated fusion bore most of the axial load, thus explaining a further increase in graft site pressure.

Conclusions

These observations support the notions of load sharing and the redistribution of loads occurring during and after bone graft incorporation. In the clinical setting, these parameters may be useful in the assessment of fusion after spine surgery. Although feasibility has been demonstrated in this preliminary study, further research is needed.
Refinement of interbody implant testing in goats: a surgical and morphometric rationale for selection of a cervical level
Authors: Agazzi Siviero , van Loveren Harry R. , Trahan Creighton J. , Johnson Wesley M.
Published: December 2007

Object

The authors provide a surgical description of the ventral approach to the cervical spine in a goat model and identify selection of the most appropriate level for testing interbody devices. These constructs are designed for implantation in humans during anterior cervical discectomy and fusion. Such description and guidelines for level selection have never been published in either the medical or veterinarian literature.

Methods

The study comprised three phases: surgical, anatomical, and morphometric. Six goats underwent ventral approaches and were later killed; their necks were dissected and the cervical spines were processed to obtain clean specimens of the vertebral bodies. Measurements were made at each level using a contact digitizer.

Results

The anterolateral bone spurs, called alar processes, and the increased thickness of the longus colli muscle are the surgically relevant characteristics in the goat. The morphometric analysis showed that C2–3 is the most suitable level for implantation of interbody devices. The vertebral endplates at the C2–3 level are relatively flat and parallel to each other, and are perpendicular to the spinal canal axis. More distally, the endplates adopt a more curved arrangement, and the endplate angle becomes significantly greater than 90°. The authors describe anatomical landmarks that are important to safely and effectively perform a ventral cervical spinal approach in the goat.

Conclusions

The authors' model identifies C2–3 as the most appropriate level for animal testing of cervical implants because of its similarity to human anatomy. Further study with rigorous biomechanical range of motion evaluation of each caprine cervical level is needed.
Use of the scapular spine in lumbar fusion procedures: cadaveric feasibility study
Authors: Tubbs R. Shane , Wartmann Christopher T. , Louis Robert G. , Shoja Mohammadali M. , Cormier Jason , Loukas Marios
Published: December 2007

Object

Graft sources for lumbar fusion include synthetic materials, donor grafts, and autologous bone such as the iliac crest. Considering the data indicating that autologous bone grafts generate the best results for fusion, the next logical step is to seek alternative donor sites in an attempt to reduce the complications associated with these procedures. To the authors' knowledge, autologous scapula has not been explored as a potential source for posterior lumbar fusion graft material. Therefore, the following study was performed to verify the utility of this bone in these procedures.

Methods

Six adult cadavers (mean age 71 years), four formalin-fixed and two fresh specimens, were used in this study. With the cadaver in the prone position, an incision was made over the spine of the scapula. Soft tissues were stripped from the middle of this region of the scapula, and bone segments were removed with a bone saw and used for a posterior lumbar fusion procedure.

Results

A mean length of 11.5 cm was measured for the spine of the scapula and the mean thicknesses of this bone at its medial part, segment just medial to the spinoglenoid notch, and acromion were 1 cm, 2.2 cm, and 2.5 cm, respectively. No obvious injury to surrounding vessels or nerves was found using this procedure, and adequate fusion was achieved with it.

Conclusions

Following clinical testing, such a bone substitute as autologous scapular spine might be a reasonable alternative to iliac crest grafts for use in posterior lumbar fusion procedures.
Chyloretroperitoneum following anterior spinal deformity correction
Authors: Upadhyaya Cheerag D. , Park Paul , La Marca Frank
Published: December 2007

✓ Chyloretroperitoneum is an uncommon complication following spinal surgery. The authors present the case of a patient in whom conservative treatment and initial surgical measures failed to relieve varied symptoms of postsurgical chyloretroperitoneum. Following attempts at conservative management, a peritoneal window was surgically created to divert lymphatic flow from the retroperitoneal space into the peritoneal space, where it was resorbed. This unique surgical technique provides yet another option in the treatment of refractory chyloretroperitoneum following anterior lumbar spinal surgery. The authors describe their technique and review retroperitoneal lymphatic anatomy along with similar case reports in the literature.
Cervicothoracic epidural hematoma after chiropractic spinal manipulation therapy
Authors: Domenicucci Maurizio , Ramieri Alessandro , Salvati Maurizio , Brogna Christian , Raco Antonino
Published: December 2007

✓A spinal epidural hematoma is an extremely rare complication of cervical spine manipulation therapy (CSMT). The authors present the case of an adult woman, otherwise in good health, who developed Brown–Séquard syndrome after CSMT. Decompressive surgery performed within 8 hours after the onset of symptoms allowed for complete recovery of the patient's preoperative neurological deficit. The unique feature of this case was the magnetic resonance image showing increased signal intensity in the paraspinal musculature consistent with a contusion, which probably formed after SMT. The pertinent literature is also reviewed.
Degenerative lumbar spinal stenosis: analysis of results in a series of 374 patients treated with unilateral laminotomy for bilateral microdecompression
Authors: Costa Francesco , Sassi Marco , Cardia Andrea , Ortolina Alessandro , De Santis Antonio , Luccarell Giovanni , Fornari Maurizio
Published: December 2007

Object

Surgical decompression is the recommended treatment in patients with moderate to severe degenerative lumbar spinal stenosis (DLSS) in whom symptoms do not respond to conservative therapy. Multilevel disease, poor patient health, and advanced age are generally considered predictors of a poor outcome after surgery, essentially because of a surgical technique that has always been considered invasive and prone to causing postoperative instability. The authors present a minimally invasive surgical technique performed using a unilateral approach for lumbar decompression.

Methods

A retrospective study was conducted of data obtained in a consecutive series of 473 patients treated with unilateral microdecompression for DLSS over a 5-year period (2000–2004). Clinical outcome was measured using the Prolo Economic and Functional Scale and the visual analog scale (VAS). Radiological follow-up included dynamic x-ray films of the lumbar spine and, in some cases, computed tomography scans.

Results

Follow-up was completed in 374 (79.1%) of 473 patients—183 men and 191 women. A total of 520 levels were decompressed: 285 patients (76.2%) presented with single-level stenosis, 86 (22.9%) with two-level stenosis, and three (0.9%) with three-level stenosis.

Three hundred twenty-nine patients (87.9%) experienced a clinical benefit, which was defined as neurological improvement in VAS and Prolo Scale scores. Only three patients (0.8%) reported suffering segmental instability at a treated level, but none required surgical stabilization, and all were successfully treated conservatively.

Conclusions

Evaluation of the results indicates that unilateral microdecompression of the lumbar spine offers a significant improvement for patients with DLSS, with a lower rate of complications.
Spinal dumbbell tumors: an analysis of a series of 118 cases
Authors: Ozawa Hiroshi , Kokubun Shoichi , Aizawa Toshimi , Hoshikawa Takeshi , Kawahara Chikashi
Published: December 2007

Object

The authors analyzed a series of 118 cases of spinal dumbbell tumors to elucidate the feature of the tumors.

Methods

Of 674 cases of spinal cord tumors, the incidence of dumbbell tumors was studied. The tumors were analyzed, and the authors focus on the distribution of age and sex, the pathological diagnoses, their locations, Eden classification, and the surgical methods used.

Results

The incidence of dumbbell tumors was 18%. The mean patient age was 43 years, which was younger than that for all spinal cord tumors (mean 50 years). There were 11 patients younger than 10 years of age. The rate of dumbbell tumors in the cervical spine was significantly higher than that of all spinal cord tumors. Fifteen (18%) of the 81 schwannomas were observed in the C-2 nerve root, thus having a higher incidence than those in the other nerve roots. In 99 cases (84%), the tumors were removed through a hemilaminectomy with or without a facetectomy and posterior fusion. Of 118 cases, 69% of the tumors were schwannomas, and malignant tumors were found in 10 cases (8.5%). Seven (64%) of 11 patients younger than 10 years of age had malignant tumors. Three patients older than 10 years of age had malignant tumors, thus accounting for 2.8% of the 107 older patients.

Conclusions

The incidence of dumbbell tumors was 18%, and they are not uncommon. Malignant dumbbell tumors were more common in children younger than 10 years of age than in older patients.
Cervical malalignment after laminoplasty: relationship to deep extensor musculature of the cervical spine and neurological outcome
Authors: Iizuka Haku , Nakajima Takashi , Iizuka Yoichi , Sorimachi Yasunori , Ara Tsuyoshi , Nishinome Masahiro , Takagishi Kenji
Published: December 2007

Object

The goal of this study was to investigate the relationship between preservation of the insertion of the deep extensor musculature of the cervical spine at C-2 and postoperative cervical alignment, especially differences between cases involving male and female patients, as well as the relationship between the loss of cervical lordosis and neurological outcome after laminoplasty.

Methods

The authors reviewed the records of 50 patients who underwent laminoplasty to elevate the C-3 lamina with repair of the deep extensor musculature (Group A) and 31 patients who underwent laminoplasty by C-3 dome laminotomy or laminectomy (Group B). They compared the degree of cervical lordosis after laminoplasty with preoperative measurements. Neurological function at last follow-up was also compared with preoperative assessments.

Results

In Group A, the mean values for pre- and postoperative cervical lordosis were 14.5 and 10.9°, respectively (p > 0.18). In female patients, however, the pre- and postoperative means were 14.4 and 3.7°, respectively (p < 0.004). In Group B, the overall means for pre- and postoperative cervical lordosis were 17.3 and 19.1°, respectively (p > 0.48); the corresponding means for female patients were 15.0 and 14.1° (p > 0.83). The mean percentages of neurological recovery were 54.1% in Group A and 54.8% in Group B.

Conclusions

Preservation of the insertion of the deep extensor musculature to the C-2 spinous process prevented significant changes in cervical alignment after laminoplasty, even among female patients. Neurological recovery was not affected by the loss of cervical lordosis.
Association of methylenetetrahydrofolate reductase genetic polymorphisms with atlantoaxial dislocation
Authors: Pradhan Mandakini , Behari Sanjay , Kalra Samir K. , Ojha Priti , Agarwal Sarita , Jain Vijendra K.
Published: December 2007

Object

Genetic mechanisms of atlantoaxial dislocation (AAD) have not previously been elucidated. The authors studied association of polymorphisms in the methylenetetrahydrofolate reductase (MTHFR) gene, which encodes enzymes of the folate pathway (implicated in causation of neural tube defects [NTDs]), in patients with AAD.

Methods

Molecular analysis of MTHFR polymorphisms (677C→T, cytosine to thymine and, 1298A→C, adenine to cytosine, substitutions) was carried out using polymerase chain reaction and restriction enzyme digestion in 75 consecutive patients with AAD and in their reducible (nine patients, 12%) and irreducible (66 patients, 88%) subgroups. Controls were 60 age- and sex-matched patients of the same ethnicity. Comparisons of genotype and allele frequencies were performed using a chi-square test (with significance at p < 0.05).

Results

The CT genotype frequency of MTHFR 677C→T polymorphism was significantly increased in the full group of patients with AAD (odds ratio [OR] 3.00, 95% confidence interval [CI] 1.28–7.14, p = 0.005) as well as in the irreducible subgroup (OR 2.81, 95% CI 1.17–6.86, p = 0.01). The frequency of T alleles was also higher in the AAD group (25.3%) than in controls (15%). The comparison of the combined frequency of CT and TT genotypes with the frequency of the CC genotype again showed significant association in AAD (OR 2.63, 95% CI 1.98–5.90, p = 0.009) and the irreducible (OR 2.5, 95% CI 1.1–5.74, p = 0.016) subgroup. There was, however, no significant association of MTHFR 1298A→C polymorphism with AAD.

Conclusions

Both MTHFR 677C→T polymorphism and higher T allele frequency have significant associations with AAD, especially the irreducible variety. Perhaps adequate supplementation of periconceptional folic acid to circumvent effects of this missense mutation (as is done for prevention of NTDs) would reduce the incidence of AAD.
The effect of ketoprophen on lumbar spinal fusion healing in a rabbit model
Authors: Urrutia Julio , Mardones Rodrigo , Quezada Felipe
Published: December 2007

Object

Several reports have shown that nonsteroidal antiinflammatory drugs (NSAIDs) have an inhibitory effect in osteogenesis and reduce heterotopic ossification in humans. A deleterious effect of NSAIDs in posterolateral intertransverse process fusion has also been suggested. The authors used a validated rabbit model to try to determine the influence of the NSAID ketoprophen on the fusion rate in lumbar spinal arthrodesis.

Methods

Thirty New Zealand male rabbits underwent posterolateral (intertransverse process) bilateral spinal fusions at a single level, using autologous bone graft obtained from both iliac crests. The animals were randomized after the operation, so that 15 rabbits received ketoprophen as a postoperative analgesic and the other 15 received the postoperative analgesic tramadol. The animals were killed 8 weeks after surgery, and fusion status was determined by inspection, palpation, anteroposterior radiographs, and histological analysis.

Results

A solid fusion was obtained in eight rabbits (53%), and pseudarthrosis in seven rabbits (47%) in each group.

Conclusions

These findings suggest that the use of ketoprophen after intertransverse spinal fusion at a single level does not decrease the fusion rate, compared with tramadol.
Physical limitations to tissue engineering of intervertebral disc cells: effect of extracellular osmotic change on glycosaminoglycan production and cell metabolism
Authors: Takeno Kenichi , Kobayashi Shigeru , Negoro Kohei , Uchida Kenzo , Miyazaki Tsuyoshi , Yayama Takafumi , Shimada Seiichiro , Baba Hisatoshi
Published: December 2007

Object

In this study, the authors examined how physiological levels of extracellular osmolality influence proteoglycan accumulation in nucleus pulposus cells in a 3D culture system.

Methods

Cells were isolated from the nucleus pulposus of caudal discs obtained from 18- to 24-month-old bovines. They were cultured for 6 days in alginate beads at 4 million cells/ml in Dulbecco modified Eagle medium containing 6% fetal bovine serum under 21% O2. Medium osmolality was altered by NaCl addition between 270 and 570 mOsm and monitored using a freezing point osmometer. The cell viability profile was determined by manual counting after trypan blue staining. Profiles across intact beads were determined by manual counting by using fluorescent probes and a transmission electron microscope. Lactate production was measured enzymatically, and glycosaminoglycan (GAG) accumulation was measured using a dimethylmethylene blue assay. Rate of sulfate GAG synthesis was measured using a standard [35S]sulfate radioactive method.

Results

The cell viability was similar for the high- and low-osmolality cultures. However, confocal microscopy showed that the cells were the largest at 270 mOsm and became smaller with increasing osmotic pressure. The GAG production was largest at 370 mOsm, the capacity for GAG production and cell metabolism (lactate production) was low under hypoosmolality and hyperosmolality, and cell death was observed on electron microscopy.

Conclusions

In the authors' model, the prevailing osmolality was a powerful regulator of GAG accumulation by cultured nucleus cells. Thus, these results indicate that GAG synthesis rates are regulated by GAG concentration, with implications both for the cause of degeneration and for tissue engineering.
Long-term survival enhanced by cordectomy in a patient with a spinal glioblastoma multiforme and paraplegia
Authors: Marchan Edward M. , Sekula Raymond F. , Jannetta Peter J. , Quigley Matthew R.
Published: December 2007

✓Spinal glioblastomas multiforme (GBMs) are rare lesions of the central nervous system with a prognosis as poor as that of their intracranial counterpart. The authors present a case of a 50-year-old man with a GBM of the spinal cord treated with surgical removal of the mass and cordectomy after the onset of paraplegia. Six years later, the patient developed hepatitis C and received interferon therapy. Six months after the start of interferon therapy, magnetic resonance imaging revealed a right cerebellar mass pathologically consistent with a GBM. Despite aggressive treatment, the patient died 1 month later. Although intracranial dissemination of spinal GBMs has been reported, this case illustrates the longest reported interval between the occurrence of a spinal GBM and its intracranial dissemination. Thus, cordectomy should be considered as a reasonable alternative in patients with complete loss of neurological function at and below the level where they harbor a malignant spinal cord astrocytoma.
Management of Sexual Dysfunction in Postmenopausal Breast Cancer Patients Taking Adjuvant Aromatase Inhibitor Therapy
Authors: Derzko Christine , Elliott S. , Lam W.
Published: December 2007

Treatment with aromatase inhibitors for postmenopausal women with breast cancer has been shown to reduce or obviate invasive procedures such as hysteroscopy or curettage associated with tamoxifeninduced endometrial abnormalities. The side effect of upfront aromatase inhibitors, diminished estrogen synthesis, is similar to that seen with the natural events of aging. The consequences often include vasomotor symptoms (hot flushes) and vaginal dryness and atrophy, which in turn may result in cystitis and vaginitis. Not surprisingly, painful intercourse (dyspareunia) and loss of sexual interest (decreased libido) frequently occur as well. Various interventions, both non-hormonal and hormonal, are currently available to manage these problems. The purpose of the present review is to provide the practitioner with a wide array of management options to assist in treating the sexual consequences of aromatase inhibitors. The suggestions in this review are based on recent literature and on the recommendations set forth both by the North American Menopause Association and in the clinical practice guidelines of the Society of Gynaecologists and Obstetricians of Canada. The complexity of female sexual dysfunction necessitates a biopsychosocial approach to assessment and management alike, with interventions ranging from education and lifestyle changes to sexual counselling, pelvic floor therapies, sexual aids, medications, and dietary supplements—all of which have been reported to have a variable, but often successful, effect on symptom amelioration. Although the use of specific hormone replacement—most commonly local estrogen, and less commonly, systemic estrogen with or without an androgen, progesterone, or the additional of an androgen in an estrogenized woman (or a combination)—may be highly effective, the concern remains that in patients with estrogen-dependent breast cancer, including those receiving anti-estrogenic adjuvant therapies, the use of these hormones may be attended with potential risk. Therefore, non-hormonal alternatives should in all cases be initially tried with the expectation that symptomatic relief can often be achieved. First-line therapy for urogenital symptoms, notably vaginal dryness and dyspareunia, should be the non-hormonal group of preparations such as moisturizers and precoital vaginal lubricants. In patients with estrogen-dependent breast cancer (notably those receiving anti-estrogenic adjuvant therapies) and severely symptomatic vaginal atrophy that fails to respond to non-hormonal options, menopausal hormone replacement or prescription vaginal estrogen therapy may considered. Systemic estrogen may be associated with risk and thus is best avoided. Judicious use of hormones may be appropriate in the wellinformed patient who gives informed consent, but given the potential risk, these agents should be prescribed only after mutual agreement of the patient and her oncologist.
Broad Funding for Oxaliplatin in Ontario (Finally!)
Authors: Jonker Derek , Maroun J. , Spithoff K.
Published: December 2007

Since the presentation of trials such as the Intergroup N9741 study (National Cancer Institute of Canada CO.15) and the MOSAIC (Multicenter International Study of Oxaliplatin/5-FU–LV in the Adjuvant Treatment of Colon Cancer) trial at the 2003 American Society of Clinical Oncology meeting, oncologists have broadly accepted that oxaliplatin is part of the standard management of colorectal cancer, both in the metastatic and adjuvant settings [...]
Anemia is a Common but Neglected Complication of Adjuvant Chemotherapy for Early Breast Cancer
Authors: Goldrick A. , Olivotto Ivo A. , Alexander C. S. , Speers C. H. , Barnett J. , Allan S. J. , Truong P. T.
Published: December 2007

In this study, we set out to determine the frequency and severity of anemia and the corrective interventions used during adjuvant chemotherapy for breast cancer. We conducted a retrospective electronic chart review of 702 patients who received adjuvant breast cancer chemotherapy at four BC Cancer Agency centres in 2002 and 2003. For these patients, we recorded the initial hemoglobin reading and the date of the first hemoglobin reading in the ranges 110–119 g/L, 100– 109 g/L, 90–99 g/L, and <90 g/L. We also recorded any discussion about, or delivery of, interventions for anemia [transfusion, epoetin (EPO) or both]. Median age of the study population was 51 years, and it varied with chemotherapy type. Among the patients, 12% had a hemoglobin reading <120 g/L before the start of chemotherapy. Overall, the proportion of patients with at least one hemoglobin reading <120 g/L was 78%; <110 g/L, 54%; <100 g/L, 31%; and <90 g/L, 14%. Depending on chemotherapy type, a hemoglobin reading <100 g/L occurred in 5% to 54% of patients. Intervention rates increased as hemoglobin declined. For 99 patients with a hemoglobin reading <90 g/L, a discussion of anemia was documented in the treatment chart in 49% of cases, a transfusion was delivered in 23%, EPO was used in 11%, and transfusion and EPO were both delivered in 5%. Anemia was relatively common and varied with chemotherapy type. Documentation of a discussion of anemia occurred in fewer than 20% of the patients with a hemoglobin reading of 90–99 g/L and in only half the patients with a hemoglobin reading <90 g/L. Intervention rates were low at hemoglobin readings for which randomized trials have shown that intervention can improve quality of life.