Practicality of using the figure-of-eight bandage to prevent fatal wound dehiscence after spinal tumor surgery for upper thoracic metastasis

OBJECT

Serious postoperative wound problems can frequently develop after surgery with perioperative RT for upper thoracic metastatic lesions. The figure-of-eight bandage can restrict excessive shoulder motion, which could prevent wound dehiscence. The purpose of this study was to describe the efficacy of using the figure-of-eight bandage to prevent postoperative wound dehiscence.

METHODS

Between February 2005 and July 2015, we retrospectively evaluated the medical records of cancer patients who underwent surgery with or without RT for spinal metastasis involving the upper thoracic spine. From January 2009, all patients received figure-of-eight bandaging immediately postoperatively, which was then maintained for 2 months. The outcome measures were the incidence and successful management of wound dehiscence following application of the figure-of-eight bandage.

RESULTS

One hundred and fifteen patients (71 men and 44 women) were enrolled in the present study. A figure-of-eight bandage in conjunction with a thoracolumbosacral orthosis (TLSO) was applied to 78 patients, while only TLSO was applied to 37 patients. The overall rate of wound dehiscence was 4.34% and the mean duration before wound dehiscence was 27.0 days (range, 22-31 days) after surgery. In the TLSO-only group, wound dehiscence occurred in four patients (10.81%), meanwhile there was only one case (1.33%) of wound dehiscence in the group that had received the figure-of-eight bandage with TLSO. Three of four patients with wound dehiscence in the TLSO only group died from unresolved wound problems and another patient was treated with wound closure followed by the application of the figure-of-eight bandage. The only patient with wound dehiscence among the patients who received both the figure-of-eight bandage and TLSO was managed by primary wound closure without further complication.

CONCLUSION

Current study suggests that the figure-of-eight bandage could prevent wound dehiscence and be used to treat wound problems easily.

Airway Management Protocol After Anterior Cervical Spine Surgery: Analysis of the Results of Risk Factors Associated With Airway Complication

STUDY DESIGN

Retrospective comparative cohort analysis.

OBJECTIVE

To evaluate the effect of postoperative airway management protocol (ASAN Extubation Protocol, AEP) on incidence of airway complications for patients undergoing anterior cervical spine surgery (ACSS).

BACKGROUND

Postoperative airway compromise remains crucial for patients undergoing ACSS. Despite the potential severity of these complications, the data in the published literature addressing this issue is sparse.

METHODS

A retrospective cohort study was performed regarding airway complications (postoperative airway edema requiring unplanned reintubation or tracheostomy) between groups of patients undergoing ACSS before and after applying our standardized protocol (AEP) for postoperative extubation. The AEP was developed based on 5 clinical risk factors reported having relation to airway complication. Postoperative patients with any oneor more risk factors were kept intubated for at least overnight and extubation was conducted according to the amount of prevertebral soft tissue swelling.

RESULTS

A total of 538 ACSS patients were identified from 2008 to 2016. The nonprotocol group (before protocol application, 275 patients) and the Protocol group (after protocol, 263 patients) were compared; airway complication rates were significantly different between two groups (nonprotocol: 3.64% (10/275) vs.

PROTOCOL

0.76% (2/263), P = 0.024). The possible factors that may increase airway complication include operative indications (P = 0.002), trauma (P = 0.000), medical comorbidity risk (P = 0.011), combined anterior and posterior surgery (P = 0.002), and operation time longer than 5 hours (P = 0.045). In multivariate analysis, medical comorbidity risk, trauma, and airway protocol adoption were significant factors. AEP reduced the airway complication rate by odds ratio 0.125 (P = 0.013).

CONCLUSION

Postoperative airway complication is not very common after ACSS. AEP contributed to reduce the incidence of airway complications. The potentially life-threatening event of loss of airway patency, even though it is a rare complication, should be cautiously analyzed with identification of risk factors before the surgery.

LEVEL OF EVIDENCE

2.

Morphological analysis of interbody fusion following posterior lumbar interbody fusion with cages using computed tomography

Posterior lumbar interbody fusion (PLIF) using cages in conjunction with pedicle screw fixation is considered the gold standard for surgical treatment of degenerative lumbar spine disorders due to its biomechanical stability and high fusion rate. However, research regarding patterns of fusion in the interbody space during the early postoperative period is lacking.Sixty consecutive patients were recruited from May 2013 to June 2015. All patients underwent PLIF using 2 titanium cages filled with local bone chips from decompressed lamina and facet bone in conjunction with pedicle screw fixation. Computed tomography scans were obtained 3 to 6 months following surgery in order to evaluate the partial fusion state. Computed tomography (CT) classification of fusion morphology was divided into 8 groups and then into compartments according to fusion space, and the rate of fusion for each was calculated. Further follow-up was conducted to confirm fusion state and assess outcomes.The most frequent pattern of interbody fusion was bilateral intra-cage fusion with unilateral lateral bridging of extra-cage areas (N = 36, 43.4%); the least frequent was interspace bridging of the 2 cages alone (N = 0, 0%). The fusion rate for the intra-cage area (Compartment 1) reached 100%. However, the fusion in the lateral space outside of cages (Compartment 2) was not satisfactory, though reasonable (72.3%). All patients were confirmed as achieving adequate fusion at the final follow-up, with improved clinical outcomes.Widening of the contact area between the vertebral body and cages is recommended to promote increased interbody fusion during the early postoperative period.

Widening of the safe trajectory range during subaxial cervical pedicle screw placement: advantages of a curved pedicle probe and laterally located starting point without creating a funnel-shaped hole

OBJECTIVE

The small diameter of cervical pedicles and a large transverse cervical pedicle angle are challenges that have led spinal surgeons to investigate how they could achieve a wider safety trajectory and reduce the insertion angle during cervical pedicle screw (CPS) placement. In this paper, the authors detail the advantages of using a curved pedicle probe and a laterally located entry point for overcoming these challenges.

METHODS

From March 2012 to May 2016, the authors performed posterior cervical fusions using CPSs on 119 consecutive patients. The lateral mass screw conversion and the CPS breach rate were analyzed. Using preoperative CT, it was determined that θlat is similar to the anatomical pedicle angle, and θmed is the minimally acceptable medial angle. The actual insertion medial angle (θins) was determined by postoperative CT. To identify how much of the medial angle on θins could be reduced from the anatomical pedicle angle (θlat), and how much closer to θmed, (θins−θmed) / (θlat−θmed) was calculated. To verify shifting of the entry point and widening of the trajectory, the mean df/Df (i.e., shifted facet point/planned facet point) values were analyzed.

RESULTS

The total number of planed CPSs was 759, the conversion rate was 4.61% (35/759), and the accuracy rate was 95.9% (694/724). The authors could calculate that θins could be expected near the 90%, 80%, 80%, 80%, and 110% value of θlat on C-3, C-4, C-5, C-6, and C-7 levels, respectively, with the (θins−θmed) / (θlat−θmed) equation. The mean df/Df values were 0.64, 0.62, 0.63, 0.63, and 1.24 on the C3–7 levels, respectively.

CONCLUSIONS

Through the use of a curved pedicle probe and a laterally located starting point, the planned and laterally located entry point medial shift was made during CPS placement. The entry point shift yielded a wider, safe trajectory and reduced the burden of making a large medial angle, similar to an anatomical cervical pedicle lateral angle, for safe CPS placement without creating a funnel-shaped hole.

Prognostic Factor Analysis for Management of Chronic Neck Pain: Can We Predict the Severity of Neck Pain with Lateral Cervical Curvature?

Objective

Although little is known about its origins, neck pain may be related to several associated anatomical pathologies. We aimed to characterize the incidence and features of chronic neck pain and analyze the relationship between neck pain severity and its affecting factors.

Methods

Between March 2012 and July 2013, we studied 216 patients with chronic neck pain. Initially, combined tramadol (37.5 mg) plus acetaminophen (325 mg) was administered orally twice daily (b.i.d.) to all patients over a 2-week period. After two weeks, patients were evaluated for neck pain during an outpatient clinic visit. If the numeric rating scale of the patient had not decreased to 5 or lower, a cervical medial branch block (MBB) was recommended after double-dosed previous medication trial. We classified all patients into two groups (mild vs. severe neck pain group), based on medication efficacy. Logistic regression tests were used to evaluate the factors associated with neck pain severity.

Results

A total of 198 patients were included in the analyses, due to follow-up loss in 18 patients. While medication was successful in reducing pain in 68.2% patients with chronic neck pain, the remaining patients required cervical MBB. Lateral cervical curvature, such as a straight or sigmoid type curve, was found to be significantly associated with the severity of neck pain.

Conclusion

We managed chronic neck pain with a simple pharmacological management protocol followed by MBB. We should keep in mind that it may be difficult to manage the patient with straight or sigmoid lateral curvature only with oral medication.

Is There Additive Therapeutic Effect When GCSF Combined with Adipose-Derived Stem Cell in a Rat Model of Acute Spinal Cord Injury?

Objective

Functional and neural tissue recovery has been reported in many animal studies conducted with stem cells. However, the combined effect of cytokines and stem cells has not yet been adequately researched. Here, we analyzed the additive effects of granulocyte colony-stimulating factor (GCSF) on adipose-derived stem cells (ADSCs) infusion in the treatment of acute spinal cord injury (SCI) in rats.

Methods

Four days after intrathecal infusion tubes implantation in Sprague-Dawley rats, SCI was induced with an infinite horizon impactor. In the Sham group (n=5), phosphate-buffered saline was injected 3, 7, and 14 days after SCI. GCSF, ADSCs, and ADSCs with GCSF were injected at the same time in the GCSF (n=8), ADSC (n=8), and ADSC+GCSF groups (n=7), respectively.

Results

The ADSC and ADSC+GCSF groups, but not the GCSF group, showed significantly higher Basso-Beattie-Bresnahan scores than the Sham group during 8 weeks (p<0.01), but no significant difference between the ADSC and ADSC+GCSF groups. In the ladder rung test, all four groups were significantly different from each other, with the ADSC+GCSF group showing the best improvement (p<0.01). On immunofluorescent staining (GAP43, MAP2), western blotting (GAP43), and reverse transcription polymerase chain reaction (GAP43, nerve growth factor), the ADSC and ADSC+GCSF groups showed higher levels than the Sham and GCSF groups.

Conclusion

Our analyses suggest that the combination of GCSF and ADSCs infusions in acute SCI in the rat does not have a significant additive effect. Hence, when combination agents for SCI stem cell therapy are considered, molecules other than GCSF, or modifications to the methodology, should be investigated.

Endovascular management of aneurysms associated with spinal arteriovenous malformations

Background

Spinal aneurysms are rare among spinal arteriovenous malformations (SAVMs). There are few reports of endovascular management of spinal aneurysms associated with SAVM.

Objective

To present endovascular management of aneurysms associated with SAVM.

Methods

Of 91 patients with SAVMs,eight (9%) presented with aneurysms. Of these, three were male and five were female with a median age of 18 years (range 11–38). We evaluated the presenting pattern, lesion level, type of the target aneurysm related to the presenting pattern and AVM nidus, and the result obtained after embolization or open surgery. Clinical status was evaluated by Aminoff–Logue (ALS) gait and micturition scale scores.

Results

The presenting patterns were subarachnoid hemorrhage (SAH, n=3) or mass effect caused by extrinsic (n=4) or intrinsic (n=1) cord compression. Aneurysms were located in four cervical, two thoracic, and two lumbar enlargement areas. There were two prenidal (arterial), three nidal, and three postnidal (venous) aneurysms. The mean diameter of the aneurysms was 9 mm (range 3–27). Glue embolization (n=6), open surgery (n=1), and combined surgery and embolization (n=1) was performed to obliterate the aneurysms. Obliteration of the target aneurysms resulted in improvement of symptoms and clinical stabilization of SAVMs in all patients during a mean of 55 months (range 7–228) of follow-up.

Conclusions

Identification of a symptomatic aneurysm should be associated with clinical presentation pattern. Targeted obliteration of the aneurysm by embolization and/or surgery resulted in improvement of symptoms and stabilization of SAVM.

Vertebral Artery Injury in C2-3 Epidural Schwannoma Resection: A Case Report and Literature Review

The incidence of vertebral artery (VA) injury (VAI) in posterior approach tumor resection surgery is extremely rare, but it can lead to serious complication. In this case, a 57-year-old man underwent surgery for resection of the tumor involving left epidural space and neural foramen at C2-3 level. Iatrogenic VAI occurred suddenly during tumor resection procedure using pituitary forceps. Immediate local hemostasis and maintaining of perfusion for reducing the risk of posterior circulation ischemia were performed. Intraoperative angiogram of both VA and emergent trapping embolization were done as well. It may reduce the risk of immediate postop complication, and further delayed occurrence. The patient had no complication after VAI by appropriate intraoperative management. Preoperative angiographic work up and preparation of endovascular team cooperation are positively necessary as well as a warning for the VAI during cervical spine surgery.

Enhanced axonal regeneration by transplanted Wnt3a-secreting human mesenchymal stem cells in a rat model of spinal cord injury

BACKGROUND

While pure mesenchymal stem cell (MSC) treatment for spinal cord injury (SCI) is known to be safe, its efficacy is insufficient. Therefore, gene-modified stem cells are being developed to enhance the effect of pure MSCs. We investigated the effect of stem cell therapy through the transfection of a Wnt3a-producing gene that stimulates axonal regeneration.

METHOD

MSCs obtained from the human umbilical cord blood (hMSCs) were multiplied, cultivated, and transfected with the pLenti-Wnt3a-GFP viral vector to produce Wnt3a-secreting hMSCs. A total of 50 rats were injured with an Infinite Horizon impactor at the level of the T7-8 vertebrae. Rats were divided into five groups according to the transplanted material: (1) phosphate-buffered saline injection group (sham group, n = 10); (Pertz et al. Proc Natl Acad Sci USA 105:1931-1936, 39) Wnt3a protein injection group (Wnt3a protein group, n = 10); (3) hMSC transplantation group (MSC group, n = 10); (4) hMSCs transfected with the pLenti vector transplantation group (pLenti-MSC group, n = 10); (5) hMSCs transfected with the pLenti+Wnt3a vector transplantation group (Wnt3a-MSC group, n = 10). Behavioral tests were performed daily for the first 3 days after injury and then weekly for 8 weeks. The injured spinal cords were extracted, and axonal regeneration markers including choline acetyltransferase (ChAT), growth-associated protein 43 (GAP43), and microtubule-associated protein 2 (MAP2) were investigated by immunofluorescence, RT-PCR, and western blotting.

RESULTS

Seven weeks after the transplantation (8 weeks after SCI), rats in the Wnt3a-MSC group achieved significantly higher average scores in the motor behavior tests than those in the other groups (p < 0.05). Immunofluorescent stains showed greater immunoreactivity of ChAT, GAP43, and MAP2 in the Wnt3a-MSC group than in the other groups. RT-PCR and western blots revealed greater expression of these proteins in the Wnt3a-MSC group than in the other groups (p < 0.05).

CONCLUSIONS

Wnt3a-secreting hMSC transplantation considerably improved neurological recovery and axonal regeneration in a rat SCI model.

Postoperative Nonpathologic Fever After Spinal Surgery: Incidence and Risk Factor Analysis

BACKGROUND

Although there are many postoperative febrile causes, surgical-site infection has always been considered as one of the major causes, but it should be excluded; we encountered many patients who showed delayed postoperative fever that was not related to wound infection after spinal surgery. We aimed to determine the incidence of delayed postoperative fever and its characteristics after spinal surgery, and to analyze the causal factors.

METHODS

A total of 250 patients who underwent any type of spinal surgery were analyzed. We determined febrile patients as those who did not show any fever until postoperative day 3, and those who showed a fever with an ear temperature of greater than 37.8°C at 4 days after surgery. We collected patient data including age, sex, coexistence of diabetes mellitus or hypertension, smoking history, location of surgical lesion (e.g., cervical, thoracic, lumbar spine), type of surgery, surgical approach, diagnosis, surgical level, presence of revision surgery, operative time, duration of administration of prophylactic antibiotics, and the presence of transfusion during the perioperative period, with a chart review.

RESULTS

There were 33 febrile patients and 217 afebrile patients. Multivariate logistic regression showed that surgical approach (i.e., posterior approach with anterior body removal and mesh graft insertion), trauma and tumor surgery compared with degenerative disease, and long duration of surgery were statistically significant risk factors for postoperative nonpathologic fever.

CONCLUSIONS

We suggest that most spinal surgeons should be aware that postoperative fever can be common without a wound infection, despite its appearance during the late acute or subacute period.

A Phase III Clinical Trial Showing Limited Efficacy of Autologous Mesenchymal Stem Cell Therapy for Spinal Cord Injury

BACKGROUND

In our previous report, 3 of 10 patients with spinal cord injury who were injected with autologous mesenchymal stem cells (MSCs) showed motor improvement in the upper extremities and in activities of daily living.

OBJECTIVE

To report on the results of a phase III clinical trial of autologous MSCs therapy.

METHODS

Patients were selected based on the following criteria: chronic American Spinal Injury Association B status patients who had more than 12 months of cervical injury, and no neurological changes during the recent 3 months of vigorous rehabilitation. We injected 1.6 × 10 autologous MSCs into the intramedullary area at the injured level and 3.2 × 10 autologous MSCs into the subdural space. Outcome data were collected over 6 months regarding neurological examination, magnetic resonance imaging with diffusion tensor imaging, and electrophysiological analyses.

RESULTS

Among the 16 patients, only 2 showed improvement in neurological status (unilateral right C8 segment from grade 1 to grade 3 in 1 patient and bilateral C6 from grade 3 to grade 4 and unilateral right C8 from grade 0 to grade 1 in 1 patient). Both patients with neurological improvement showed the appearance of continuity in the spinal cord tract by diffusion tensor imaging. There were no adverse effects associated with MSCs injection.

CONCLUSION

Single MSCs application to intramedullary and intradural space is safe, but has a very weak therapeutic effect compared with multiple MSCs injection. Further clinical trials to enhance the effect of MSCs injection are necessary.

Analysis of equivalent parameters of two spinal cord injury devices: the New York University impactor versus the Infinite Horizon impactor

BACKGROUND CONTEXT

The New York University (NYU) impactor and the Infinite Horizon (IH) impactor are used to create spinal cord injury (SCI) models. However, the parameters of these two devices that yield equivalent SCI severity remain unclear.

PURPOSE

To identify equivalent parameters, rats with SCIs induced by either device set at various parameters were subjected to behavioral and histologic analyses.

STUDY DESIGN

This is an animal laboratory study.

METHODS

Groups of eight rats acquired SCIs by dropping a 10 g rod from a height of 25 mm or 50 mm by using the NYU device or by delivering a force of 150 kdyn, 175 kdyn, 200 kdyn, or 250 kdyn by using the IH impactor. All injured rats were tested weekly for 8 weeks by using the Basso, Beattie, and Bresnahan (BBB) test and the ladder rung test. On the 10th week, the lesion volume of each group was measured by using a 9.4 Tesla magnetic resonance imaging (MRI), and the spinal cords were subjected to histologic analysis using anterograde biotinylated dextran amine (BDA) tracing and immunofluorescence staining with an anti-protein kinase C-gamma (PKC-γ) antibody.

RESULTS

Basso, Beattie, and Bresnahan test scores between the 25 mm and the 200 kdyn groups as well as between the 50 mm and and 250 kdyn groups were very similar. Although it was not statistically significant, the mean scores of the ladder rung test in the 200 kdyn group were higher than the 25 mm group at all assessment time points. There was a significantly different cavity volume only between the 50 mm and the 200 kdyn groups. Midline sagittal images of the spinal cord on the MRI revealed that the 25 mm group predominantly had dorsal injuries, whereas the 200 kdyn group had deeper injuries. Anterograde tracing with BDA showed that in the 200 kdyn group, the dorsal corticospinal tract of the caudal area of the lesion was labeled. Similar labeling was not observed in the 25 mm group. Immunofluorescence staining of PKC-γ also revealed strong staining of the dorsal corticospinal tract in the 200 kdyn group but not in the 25 mm group.

CONCLUSIONS

The 25 mm injuries generated by the NYU impactor are generally equivalent to the 200 kdyn injuries generated by using the IH impactor. However, differences in the ladder rung test scores, MRI images, BDA traces, and PKC-γ staining demonstrate that the two devices exert qualitatively different impacts on the spinal cord.

Current Concept of Stem Cell Therapy for Spinal Cord Injury: A Review

Spinal cord injury (SCI) is a catastrophic condition associated with significant neurological deficit, social, and financial burdens. Over the past decades, various treatments including medication, surgery, and rehabilitation therapy for SCI have been performed, but there were no definite treatment option to improve neurological function of patients with chronic SCI. Therefore, new treatment trials with stem cells have been studied to regenerate injured spinal cord. Among various types of stem cells, bone marrow derived mesenchymal stem cells is highly expected as candidates for the stem cell therapy. The result of the current research showed that direct intramedullary injection to the injured spinal cord site in subacute phase is most effective. Neurological examination, electrophysiologic studies, and magnetic resonance imaging are commonly used to assess the effectiveness of treatment. Diffusion tensor imaging visualizing white matter tract can be also alternative option to identify neuronal regeneration. Despite various challenging issues, stem cell therapy will open new perspectives for SCI treatment.

Concomitant origin of the anterior or posterior spinal artery with the feeder of a spinal dural arteriovenous fistula (SDAVF)

Background/objective

The concomitant origin of the anterior spinal artery (ASA) or the posterior spinal artery (PSA) from the feeder of a spinal dural arteriovenous fistula (SDAVF) is rare and the exact incidence is not known. We present our experience with the management of SDAVFs in such cases.

Methods

In 63 patients with SDAVF between 1993 and 2015, the feeder origin of the SDAVF was evaluated to determine whether it was concomitant with the origin of the ASA or PSA. Embolization was attempted when the patient did not want open surgery and an endovascular approach was regarded as safe and possible. The outcome of the procedure was evaluated as complete, partial, or no obliteration. The clinical outcome was evaluated by Aminoff–Logue (ALS) gait and micturition scale scores.

Results

Nine patients (14%) had a concomitant origin of the ASA or PSA with the feeder. There were two cervical, five thoracic, and two lumbar level SDAVFs. A concomitant origin of the feeder was identified with the ASA (n=7) and PSA (n=2). Embolization was performed in four patients and open surgery was performed in five. Embolization resulted in complete obliteration in three patients and partial obliteration in one. Using the ALS gait and micturition scale, the final outcome improved in six while three cases remained in an unchanged condition over 2–148 months.

Conclusions

The concomitant origin of the ASA or PSA with the feeder occurs occasionally. Complete obliteration of the fistula can be achieved either by embolization or open surgery. Embolization can be carefully performed in selected patients who are in a poor condition and do not want to undergo open surgery.

Neuralgias of the Head: Occipital Neuralgia

Occipital neuralgia is defined by the International Headache Society as paroxysmal shooting or stabbing pain in the dermatomes of the greater or lesser occipital nerve. Various treatment methods exist, from medical treatment to open surgical procedures. Local injection with corticosteroid can improve symptoms, though generally only temporarily. More invasive procedures can be considered for cases that do not respond adequately to medical therapies or repeated injections. Radiofrequency lesioning of the greater occipital nerve can relieve symptoms, but there is a tendency for the pain to recur during follow-up. There also remains a substantial group of intractable patients that do not benefit from local injections and conventional procedures. Moreover, treatment of occipital neuralgia is sometimes challenging. More invasive procedures, such as C2 gangliotomy, C2 ganglionectomy, C2 to C3 rhizotomy, C2 to C3 root decompression, neurectomy, and neurolysis with or without sectioning of the inferior oblique muscle, are now rarely performed for medically refractory patients. Recently, a few reports have described positive results following peripheral nerve stimulation of the greater or lesser occipital nerve. Although this procedure is less invasive, the significance of the results is hampered by the small sample size and the lack of long-term data. Clinicians should always remember that destructive procedures carry grave risks: once an anatomic structure is destroyed, it cannot be easily recovered, if at all, and with any destructive procedure there is always the risk of the development of painful neuroma or causalgia, conditions that may be even harder to control than the original complaint.

Optogenetic Inhibition of the Subthalamic Nucleus Reduces Levodopa-Induced Dyskinesias in a Rat Model of Parkinson's Disease

BACKGROUND

The inhibition of neuronal activity by electrical deep brain stimulation is one of the mechanisms explaining the amelioration of levodopa-induced dyskinesia. However, electrical deep brain stimulation cannot specifically activate or inactivate selected types of neurons.

OBJECTIVES

We applied optogenetics as an alternative treatment to deep brain stimulation for levodopa-induced dyskinesia, and also to confirm that the mechanism of levodopa-induced dyskinesia amelioration by subthalamic nucleus deep brain stimulation is mediated through neuronal inhibition.

METHODS

6-hydroxydopamine-induced hemiparkinsonian rats received injections of hSynapsin1-NpHR-YFP adeno-associated virus (AAV) or hSynapsin1-YFP AAV. Two weeks after viral injections, all rats were treated with daily injections of levodopa. Then, the optic fiber was implanted into the ipsilateral subthalamic nucleus. We performed various behavioral tests to evaluate the changes in levodopa-induced dyskinesias after optogenetic expression and illumination in the subthalamic nucleus.

RESULTS

The behavioral tests revealed that optical inhibition of the subthalamic nucleus significantly ameliorated levodopa-induced dyskinesia by reducing the duration of the dyskinesias as well as the severity of axial dyskinesia.

CONCLUSIONS

These findings will provide a useful foundation for the future development of optogenetic modulation systems that could be considered as an approach to dyskinesia therapy.

Cauda equina lymphoma mimicking non-neoplastic hypertrophic neuropathy of the cauda equina: A case report

Spinal cauda equina lymphoma (CEL) is very rare, with only about 14 cases reported in the English medical literature. Magnetic resonance image findings and the gross appearance of CEL at surgery are similar to those of non-neoplastic hypertrophic neuropathy of the cauda equina (HNCE); however, their prognosis and treatment are very different. We report a case of CEL and discuss the differences from non-neoplastic HNCE.

Clinical analysis of spinal stereotactic radiosurgery in the treatment of neurogenic tumors

OBJECT

In this study the authors sought to evaluate clinical outcomes after using stereotactic radiosurgery (SRS) to treat benign and malignant spinal neurogenic tumors.

METHODS

The authors reviewed a total of 66 procedures of spinal SRS performed between 2001 and 2013 for 110 tumors in 58 patients with spinal neurogenic tumors, which included schwannomas, neurofibromas, and malignant peripheral nerve sheath tumors (MPNSTs). The clinical and radiological findings were evaluated in patients with benign neurogenic tumors. For the 4 patients with MPNSTs, the authors reported overall survival and results of additional immunohistochemical staining to predict the survival difference among the patients.

RESULTS

Of the 92 benign neurogenic tumors, 65 tumors that were serially followed up using MRI after SRS showed significant change in mean tumor volume, from a mean of 12.0 ± 2.6 cm3 pre-SRS to 10.8 ± 2.5 cm3 post-SRS (p = 0.027), over an average of 44 months. The local control rate of benign neurogenic tumors was 95.4%. The 34 patients who presented with clinical symptoms of pain showed a significant symptomatic improvement. The initial mean visual analog scale (VAS) score was 6.0 and decreased dramatically to 1.0 after SRS during an average follow-up period of 10.9 months (median of 8.1 months). Although the proportions of transient swelling and loss of intramural enhancement were significantly different among the groups, there was no statistically significant correlation between those 2 factors and local tumor control (p = 0.253 and 0.067, respectively; Fisher’s exact text). Cross-table analysis also indicated that there was no statistically significant relationship between groups with loss of intramural enhancement and transient swelling. The median survival of neurofibromatosis Type 1 (NF1)-related and sporadic MPNSTs was 1.13 and 5.8 years, respectively. Immunohistochemical results showed that S100 was expressed in a sporadic MPNST or neurofibroma, whereas topoisomerase-IIa was expressed in NF1-related MPNSTs.

CONCLUSIONS

SRS is an effective treatment modality for benign neurogenic tumors, while MPNSTs showed heterogeneity in their responses to SRS.

Surgical Treatment of a Life-Threatening Large Retropharyngeal Hematoma after Minor Trauma : Two Case Reports and a Literature Review

Only a few cases of anterior longitudinal ligament (ALL) injury related with retropharyngeal hematoma without fracture have previously been reported. The treatment of choice for retropharyngeal hematoma is generally considered to be conservative care, but we believe that early surgery of this pathology would be better in certain situations. Here, we describe two cases with life-threatening large retropharyngeal hematomas related with ALL injuries and operated on at an early stage. Two previously healthy patients visited the emergency room with neck pain and dyspnea after falling. Serious neck swelling was observed and lateral neck X-ray showed severe widening of the prevertebral space. Due to dyspnea progression, emergency endotracheal intubation was performed. Although there was no primary cause of the retropharyngeal hematoma on preoperative examination, ALL tearing was intraoperatively confirmed during early surgery. The in-hospital evolutions of the patients were favorable after surgery. We should bear in mind the possibility of ALL injury and perform early surgery where possible given the earlier convalescence and good prognosis.

Intraoperative direct puncture and embolization (IOPE) using a glue material for spinal cord arteriovenous fistula: a case report

INTRODUCTION

Spinal arteriovenous fistula (AVF) is treated by embolization or surgery. However, transarterial embolization or surgery is difficult in rare cases when the fistula site is very complicated to access especially as in fistular nidus supplied by posterior and anterior spinal artery. We present the case which was treated with intraoperative direct puncture and embolization (IOPE) using glue material, since the usual transarterial or transvenous neurointerventional approach was difficult to embolize the AVF.

METHODS

A 36-year-old woman presented with progressive leg weakness and pain after a 20-year history of lower back pain. She had pelvic and spinal AVF combined with arteriovenous malformation (AVM). Despite prior treatment of the pelvic lesion with radiotherapy and coil embolization, the spinal lesion persisted and caused repeated subarachnoid hemorrhages. A spinal angiogram revealed a tortuous and long feeder of the AVF which had growing venous sac, as well as AVM. Two embolization trials failed because of the long tortuosity and associated anterior spinal artery. Four months later, drastic leg weakness and pain occurred, and IOPE was performed using a glue material.

RESULTS

The subsequent recovery of the patient was rapid. One month later, the use of a strong opioid could be discontinued, and the patient could walk with aid. A follow-up spinal angiogram revealed that the venous sac of the AVF had disappeared.

CONCLUSION

In spinal AVF which is not feasible to access by usual intervention approach and to dissect surgically, IOPE with glue material can be considered for the treatment.

A unilateral open door laminoplasty technique: prospective analysis of the relationship between midline extensor muscle preservation and postoperative neck pain

Since laminoplasty was first introduced, several techniques have been developed to reduce postoperative neck pain and progressive kyphosis following this procedure. We describe the importance of deep muscle preservation to prevent postoperative neck pain following cervical posterior surgery, using the inter-muscular plane. We performed cervical laminoplasty on 10 patients from March to July 2012. The mean follow-up duration was 14.6 (range 12-18) months, and the mean age was 58.8 (48-68) years. There were eight men and two women in the study cohort, which consisted of eight cases of cervical spondylotic myelopathy and two cases of ossification of the posterior longitudinal ligament. The Japanese Orthopaedic Association (JOA) score and neck disability index (NDI) score were assessed before and at 6 and 12 months after surgery. The numeric rating scale (NRS) for neck pain was evaluated at 1, 3, 6, and 12 months after surgery. CT scan was performed immediately after the operation, and a radiograph was performed preoperatively and during the follow-up evaluation at 1, 3, 6, and 12 months after surgery. The preoperative JOA and NDI scores improved in all patients. Although there were two patients who complained of moderate postoperative neck pain (NRS 4 and 5), their condition gradually improved. Seven patients had mild or no neck pain (below NRS 3) at the 12 month follow-up. In addition, the cervical alignment was well maintained in all but one patient. Although larger prospective cohorts, longer follow-up periods, and comparative analyses are still needed, the clinical and radiological outcomes observed in the short 12 month period in this small cohort are promising.

Enhanced efficacy of human brain-derived neural stem cells by transplantation of cell aggregates in a rat model of Parkinson's disease

Objective

Neural tissue transplantation has been a promising strategy for the treatment of Parkinson's disease (PD). However, transplantation has the disadvantages of low-cell survival and/or development of dyskinesia. Transplantation of cell aggregates has the potential to overcome these problems, because the cells can extend their axons into the host brain and establish synaptic connections with host neurons. In this present study, aggregates of human brain-derived neural stem cells (HB-NSC) were transplanted into a PD animal model and compared to previous report on transplantation of single-cell suspensions.

Methods

Rats received an injection of 6-OHDA into the right medial forebrain bundle to generate the PD model and followed by injections of PBS only, or HB-NSC aggregates in PBS into the ipsilateral striatum. Behavioral tests, multitracer (2-deoxy-2-[¹⁸F]-fluoro-D-glucose ([¹⁸F]-FDG) and [¹⁸F]-N-(3-fluoropropyl)-2-carbomethoxy-3-(4-iodophenyl)nortropane ([¹⁸F]-FP-CIT) microPET scans, as well as immunohistochemical (IHC) and immunofluorescent (IF) staining were conducted to evaluate the results.

Results

The stepping test showed significant improvement of contralateral forelimb control in the HB-NSC group from 6-10 weeks compared to the control group (p<0.05). [¹⁸F]-FP-CIT microPET at 10 weeks posttransplantation demonstrated a significant increase in uptake in the HB-NSC group compared to pretransplantation (p<0.05). In IHC and IF staining, tyrosine hydroxylase and human β2 microglobulin (a human cell marker) positive cells were visualized at the transplant site.

Conclusion

These results suggest that the HB-NSC aggregates can survive in the striatum and exert therapeutic effects in a PD model by secreting dopamine.

Optogenetic inactivation of the subthalamic nucleus improves forelimb akinesia in a rat model of Parkinson disease

BACKGROUND

The inhibition of neuronal activity by electrical deep brain stimulation is one of the mechanisms explaining the therapeutic effects in patients with Parkinson disease (PD) but cannot specifically activate or inactivate different types of neurons. Recently, a new technology based on optogenetics has been developed to modulate the activity of specific neurons. However, the therapeutic effects of optical inactivation in the subthalamic nucleus (STN) have not been fully investigated.

OBJECTIVE

To perform various behavioral tests to evaluate changes in motor functions in a PD rat model after optogene expression and, unlike previous studies, to assess the therapeutic effects of direct optogenetic inactivation in the STN.

METHODS

6-Hydroxydopamine-induced hemiparkinsonian rats received injections of hSynapsin1-NpHR-YFP adeno-associated virus or an equivalent volume of phosphate-buffered saline. Three weeks after injection of adeno-associated virus or phosphate-buffered saline, the optic fiber was implanted into the ipsilateral STN. A stepping test, a cylinder test, and an apomorphine-induced rotation test were performed in 3 sequential steps: during light-off state, during light stimulation, and again during light-off state.

RESULTS

Stepping tests revealed that optical inhibition of the STN significantly improved 6-hydroxydopamine-induced forelimb akinesia. PD motor signs, as assessed by cylinder and apomorphine tests, were not affected by optical inhibition. Immunofluorescence revealed that halorhodopsin was highly expressed and colocalized with vesicular glutamate transporter 2 in the STN.

CONCLUSION

Optogenetic inhibition in the STN may be effective in improving contralateral forelimb akinesia but not in changing forelimb preference or reducing dopaminergic receptor supersensitivity. These findings are useful as a basis for future studies on optogenetics in PD.

A rat model of striatonigral degeneration generated by simultaneous injection of 6-hydroxydopamine into the medial forebrain bundle and quinolinic acid into the striatum

A double toxin-double lesion strategy is well-known to generate a rat model of striatonigral degeneration (SND) such as multiple system atrophy-parkinsonian type. However, with this model it is difficult to distinguish SND from Parkinson's disease (PD). In this study, we propose a new rat model of SND, which is generated by simultaneous injection of 6-hydroxydopamine into the medial forebrain bundle and quinolinic acid into the striatum. Stepping tests performed 30 min after intraperitoneal L-dopa administration at 6 weeks post-surgery revealed an L-dopa response in the PD group but not the SND group. Apomorphine-induced rotation tests revealed no rotational bias in the SND group, which persisted for 2 months, but contralateral rotations in the PD group. MicroPET scans revealed glucose hypometabolism and dopamine transporter impairment on the lesioned striatum in the SND group. Tyrosine hydroxylase immunostaining in the SND group revealed that 74.7% of nigral cells on the lesioned side were lost after lesion surgery. These results suggest that the proposed simultaneous double toxin-double lesion method successfully created a rat model of SND that had behavioral outcomes, multitracer microPET evaluation, and histological aspects consistent with SND pathology. This model will be useful for future study of SND.

Consensus of clinical neurorestorative progress in patients with complete chronic spinal cord injury

Currently, there is a lack of effective therapeutic methods to restore neurological function for chronic complete spinal cord injury (SCI) by conventional treatment. Neurorestorative strategies with positive preclinical results have been translated to the clinic, and some patients have gotten benefits and their quality of life has improved. These strategies include cell therapy, neurostimulation or neuromodulation, neuroprosthesis, neurotization or nerve bridging, and neurorehabilitation. The aim of this consensus by 31 experts from 20 countries is to show the objective evidence of clinical neurorestoration for chronic complete SCI by the mentioned neurorestorative strategies. Complete chronic SCI patients are no longer told, "nothing can be done." The clinical translation of more effective preclinical neurorestorative strategies should be encouraged as fast as possible in order to benefit patients with incurable CNS diseases. This manuscript is published as part of the International Association of Neurorestoratology (IANR) special issue of Cell Transplantation.

Midline Splitting Cervical Laminoplasty Using Allogeneic Bone Spacers: Comparison of Fusion Rates between Cervical Spondylotic Myelopathy and Ossification of Posterior Longitudinal Ligament

OBJECTIVE

To analyze factors associated with fusion using allogeneic bone spacers for midline splitting cervical laminoplasty (MSCL).

METHODS

During April 2012 and September 2013, seventeen patients with cervical spondylotic myelopathy (CSM) or ossification of posterior longitudinal ligament (OPLL) underwent MSCL with allogeneic bone spacers by a single surgeon. Mean follow up periods was 11.3 months (range, 6-19 months). Clinical outcomes were evaluated by the Japanese Orthopedic Association (JOA) scores at preoperative and postoperative 6 months. Simple cervical X-rays were taken preoperatively, immediate postoperatively, 3, and 6 months after operation. Computed tomography (CT) scans were performed preoperatively, immediate postoperatively and 6 months postoperatively. The differences between two diseases were analyzed on cervical lordosis, canal dimension, anteroposterior (AP) distance, fusion between lamina and allogeneic bone spacer and affecting factors of fusion.

RESULTS

All surgeries were performed on 59 levels. There were no significant differences on the changes of lordosis (p=0.602), canal dimension (p=0.554), and AP distance (p=0.924) as well as JOA scores (p=0.257) between CSM and OPLL groups. Overall fusion rate was 51%. Multivariate analysis on the factor for the fusion rates between lamina and spacers showed that the immediate postoperative contact status between lamina and spacers in CT as significant factor of fusion (p=0.024).

CONCLUSION

The present study suggests that CSM and OPLL did not show difference of surgical outcome in MSCL using allogeneic bone spacer. In addition, we should consider the contact status between lamina and bone spacer for the better fusion rates for this surgery.

Are human dental papilla-derived stem cell and human brain-derived neural stem cell transplantations suitable for treatment of Parkinson's disease?

Transplantation of neural stem cells has been reported as a possible approach for replacing impaired dopaminergic neurons. In this study, we tested the efficacy of early-stage human dental papilla-derived stem cells and human brain-derived neural stem cells in rat models of 6-hydroxydopamine-induced Parkinson's disease. Rats received a unilateral injection of 6-hydroxydopamine into right medial forebrain bundle, followed 3 weeks later by injections of PBS, early-stage human dental papilla-derived stem cells, or human brain-derived neural stem cells into the ipsilateral striatum. All of the rats in the human dental papilla-derived stem cell group died from tumor formation at around 2 weeks following cell transplantation. Postmortem examinations revealed homogeneous malignant tumors in the striatum of the human dental papilla-derived stem cell group. Stepping tests revealed that human brain-derived neural stem cell transplantation did not improve motor dysfunction. In apomorphine-induced rotation tests, neither the human brain-derived neural stem cell group nor the control groups (PBS injection) demonstrated significant changes. Glucose metabolism in the lesioned side of striatum was reduced by human brain-derived neural stem cell transplantation. [¹⁸F]-FP-CIT PET scans in the striatum did not demonstrate a significant increase in the human brain-derived neural stem cell group. Tyrosine hydroxylase (dopaminergic neuronal marker) staining and G protein-activated inward rectifier potassium channel 2 (A9 dopaminergic neuronal marker) were positive in the lesioned side of striatum in the human brain-derived neural stem cell group. The use of early-stage human dental papilla-derived stem cells confirmed its tendency to form tumors. Human brain-derived neural stem cells could be partially differentiated into dopaminergic neurons, but they did not secrete dopamine.

Staging accuracy of endoscopic ultrasound performed by nonexpert endosonographers in patients with resectable esophageal squamous cell carcinoma: is it possible?

The accuracy of endoscopic ultrasound (EUS) is operator-dependent. According to learning curve study, the accuracy of EUS T-staging for esophageal cancer has been reported to be greater in an investigator who had performed at least 100 EUS examinations. We determined comparative study regarding T-staging accuracy of EUS for esophageal squamous cell carcinoma between expert and nonexpert endoscopic ultrasonographers. We retrospectively identified 73 consecutive patients with esophageal squamous cell carcinoma who underwent EUS and endoscopic mucosal resection, endoscopic submucosal dissection, or surgery. EUS was performed by expert (Group 1) and nonexpert (Group 2) endoscopic ultrasonographers in multitertiary hospitals. Groups 1 and 2 were 37 and 36 patients during 2005-2011, respectively. Forty-two patients (57.5%) of the overall patients underwent surgical exploration. Correct endoscopic ultrasonographic T-staging of Group 1 was observed in 34 (91.9%) patients, while that of Group 2 was observed in 26 (72.2%) patients. And there was significant difference in correct endoscopic ultrasonographic T-staging between Group 1 and Group 2 (P = 0.035). The incorrect endoscopic ultrasonographic T-staging of Group 1 were three cases that were overstaging (8.1%), but in Group 2 there were seven overstaging (19.4%) and three understaging (8.3%). There was no significant difference in overstaging or understaging of incorrect endoscopic ultrasonographic T-staging between Group 1 and Group 2 (P = 0.528). This study first provides evidence that endoscopic ultrasonographic T-staging of nonexpert endoscopic ultrasonographers was inferior to be correct, compared with that of expert endoscopic ultrasonographers. EUS staging for esophageal cancer should be performed by expert endoscopic ultrasonographers to provide appropriate management strategy.

High-resolution impedance manometry facilitates assessment of pharyngeal residue and oropharyngeal dysphagic mechanisms

The utility of high-resolution impedance manometry (HRIM) for evaluating oropharyngeal dysphagia (OPD) has been investigated. These approaches are limited because of the sophisticated methodology. A method of transforming HRIM into a simple and useful diagnostic tool for evaluating OPD is needed. A videofluoroscopic swallowing study (VFSS) and HRIM were performed by independent blinded examiners in 26 consecutive healthy volunteers (12 men; median age, 56.5 years) and 10 OPD patients (five men; median age, 59.5 years). Upper esophageal sphincter (UES) relaxation parameters were measured using a standard HRIM protocol. Peristalsis and bolus transit of the pharyngoesophageal (PE) segment were assessed using an HRIM-modified protocol in which the catheter was pulled back 10 cm. PE bolus transits were evaluated with an impedance contour pattern (linear vs. stasis) method. A significant difference was observed between the manometric measures of healthy volunteers and OPD patients for only the duration of pharyngeal contraction (0.49 ± 0.19 vs. 0.76 ± 0.33 s, P = 0.04). The percentage agreement and kappa value for detecting pharyngeal residue between the VFSS and the impedance analysis were 100% and 1.00, respectively. HRIM allowed for comprehensive assessment of abnormal pharyngeal components that caused pharyngeal residue on VFSS in two patients; reduced base of the tongue versus weak pharyngeal contraction in one, and reduced relaxation of the UES versus reduced laryngeal elevation in the remaining patient. Our findings demonstrated that HRIM using a simple methodology (i.e., pull-back of the catheter) detected pharyngeal residue through a simple analysis of the impedance contour pattern (linear vs. stasis). Furthermore, HRIM facilitated a comprehensive assessment of OPD mechanisms and recognition of subtle abnormalities not yet visible to the naked eye on VFSS.

Changes of the Electrophysiological Study in Dogs with Acute Spinal Cord Injury

Objective

This study describes a method for inducing spinal cord injuries in dogs by using balloon catheters via laminectomy and the subsequent changes in the electrophysiological response.

Methods

Female Beagle (Orient Bio, Seongnam, Korea) dogs weighing 10 kg at the time of injury were used. Under inhalation anesthesia, a posterior midline approach laminectomy was performed. A silicone balloon catheter (size 6 Fr; Sewoon Medical, Cheonan, Korea) was then inserted into the vertebral canal at the center of T10. The balloon was inflated to the maximum volume for 1, 2, or 3 days. Open field testing was performed for evaluating motor functions of the hindlimbs. Motor evoked potentials (MEPs) induced by electrical and magnetic stimulation were recorded before and after spinal cord injury.

Results

Open field testing yielded locomotor scores of 0 or 1 for dogs subjected to compression for 3 days. These dogs showed no obvious improvement throughout the observation period, and the tonus of their hindlimbs was flaccid. In contrast, motor functions of dogs that had experienced compression for 1 or 2 days were variable, and all dogs showed spastic tonus in their hindlimbs. In dogs subjected to after compression for 3 days, electrically stimulated MEPs for the hindlimbs showed a significant amplitude reduction. Further, hindlimb movements were not evoked by magnetic stimulation of the cervical spine and vertex area.

Conclusion

Compression for 3 days with a balloon catheter is a safe, reproducible, and reliable method for evaluating electrophysiological changes in a dog model of complete spinal cord injury.

Analysis on bilateral hindlimb mapping in motor cortex of the rat by an intracortical microstimulation method

Intracortical microstimulation (ICMS) is a technique that was developed to derive movement representation of the motor cortex. Although rats are now commonly used in motor mapping studies, the precise characteristics of rat motor map, including symmetry and consistency across animals, and the possibility of repeated stimulation have not yet been established. We performed bilateral hindlimb mapping of motor cortex in six Sprague-Dawley rats using ICMS. ICMS was applied to the left and the right cerebral hemisphere at 0.3 mm intervals vertically and horizontally from the bregma, and any movement of the hindlimbs was noted. The majority (80%± 11%) of responses were not restricted to a single joint, which occurred simultaneously at two or three hindlimb joints. The size and shape of hindlimb motor cortex was variable among rats, but existed on the convex side of the cerebral hemisphere in all rats. The results did not show symmetry according to specific joints in each rats. Conclusively, the hindlimb representation in the rat motor cortex was conveniently mapped using ICMS, but the characteristics and inter-individual variability suggest that precise individual mapping is needed to clarify motor distribution in rats.

Vascular changes caused by deep brain stimulation using double-dose gadolinium-enhanced brain MRI

We retrospectively analyzed the clinical data of 32 patients with medically intractable idiopathic Parkinson's disease who had undergone staged bilateral deep brain stimulation of the subthalamic nuclei from January 2007 to May 2011. The vascularture of the patients who received two deep brain stimulations was detected using double-dose gadolinium-enhanced brain MRI. The dimensions of straight sinus, superior sagittal sinus, ipsilateral internal cerebral vein in the thalamic branch and ipsilateral anterior caudate vein were reduced. These findings demonstrate that bilateral deep brain stimulation of the subthalamic nuclei affects cerebral venous blood flow.

The result of S1 double screw fixation in patients not suited for L4 and/or L5 pedicle screw insertion

BACKGROUND

Variable methods are available for sacropelvic fixation. The usefulness of S1 double screw fixation for deformity surgery is established, but its effectiveness in cases where the L4 and/or L5 pedicle screw is not appropriate has not been reported.

METHODS

We reviewed medical records to identify long-segment, lumbar spine fixation involving S1 double screws. Nine such patients were treated between November 2006 and November 2012 at our center: all patients had infectious spondylitis involving L4 and/or L5. Two patients were excluded due to a limited follow-up period (< 6 months). The remaining seven patients were enrolled. We used dynamic X-rays or three-dimensional computed tomography (3D-CT) to assess any change in the lumbar alignment angle and to evaluate bony fusion with the graft material.

RESULTS

The mean observation period of the seven patients was 16.9 months (range: 6-25). The mean age was 63.43 years (range: 55-73). Four patients were women. The average number of fusion levels was 3.5 ± 1.1. The ideal positioning and maintenance of the S1 double screws and bony fusion with the graft materials were confirmed using serial imaging. Lordosis in the lumbar region was immediately restored after surgery (27.0 ° ± 10.4 to 35.1 ° ± 10.7), and maintained with slight decrease (31.6 ° ± 8.8) throughout the follow-up period.

CONCLUSIONS

S1 double screws provided stability when L4 and/or L5 pedicle screw fixation was not possible. Our results suggest that S1 double screws are a viable option for sacropelvic fixation in selected patients.

Enhanced neuroregenerative effects by scaffold for the treatment of a rat spinal cord injury with Wnt3a-secreting fibroblasts

BACKGROUND

Wnt proteins are bifunctional axon guidance molecules, several of which appear to mediate guidance of corticospinal tract axons along the spinal cord. Here, we studied increasing effect on regeneration by Wnt-containing alginate scaffolds on spinal cord injury (SCI).

METHODS

A total of 32 rats were injured at the T7-8 level with an NYU impactor. According to transplantation materials, rats were classified into four groups: a Wnt3a-secreting fibroblast transplantation group (Wnt group, n = 8), a Wnt3a-secreting fibroblast with alginate transplantation group (Wnt + alginate group, n = 8), an alginate transplantation group (alginate group, n = 8), and a contusion-only group (sham group, n = 8). Behavioral tests were performed on the first, second, and third days after injury, and then weekly for 8 weeks. Five of the eight rats from each group were selected for manganese-enhanced magnetic resonance imaging (ME-MRI). Two rats from each group were examined for GAP43 and MAP2 expression using monoclonal and polyclonal primary antibodies, respectively.

RESULTS

Seven weeks after transplantation (8 weeks after SCI), Wnt + alginate group rats achieved an average Basso-Beattie-Bresnahan locomotor score of 19.0, which was significantly higher than that of other groups. ME-MRI at 8 weeks after SCI revealed significantly higher relative signal intensities in the Wnt + alginate group. Gap43 and Map2 immunostaining, showed strong positive in the Wnt + alginate group.

CONCLUSION

The Wnt + alginate complex exerted significantly enhanced recovery in a rat SCI model compared to alginate or Wnt3a alone. These results suggest that alginate scaffolds facilitate the regeneration of axon working with Wnt3a protein that promotes regeneration of the injured spinal cord.

Analysis of molecular expression in adipose tissue-derived mesenchymal stem cells : prospects for use in the treatment of intervertebral disc degeneration

Objective

Recent studies have shown encouraging progress toward the use of autogenic and allogenic mesenchymal stem cells (MSCs) to arrest, or even lead to partial regeneration in, intervertebral disc (IVD) degeneration. However, this technology is still in its infancy, and further development is required. The aim of this study was to analyze whether rat adipose-derived mesenchymal stem cells (ADMSC) can differentiate towards IVD-like cells after treatment with transforming growth factor β3 (TGF-β3) in vitro. We also performed quantitative analysis of gene expression for ADMSC only, ADMSCs treated with TGF-β3, and co-cultured ADMSCs treated with TGF-β3.

Methods

ADMSCs were sub-cultured to homogeneity and used in fluorocytometry assays for CD11, CD45, and CD90/Thy1. ADMSCs were differentiated in spheroid culture towards the chondrogenic lineage by the presence of TGF-β3, dexamethasone, and ascorbate. We also co-cultured pure ADMSCs and nucleus pulposus cells in 24-well plates, and performed immunohistochemical staining, western blotting, and RT-PCR for quantitativeanalysis of gene expression.

Results

Results of fluorocytometry were positive for CD90/Thy1 and negative for CD11 and CD45. TGF-β3-mediated induction of ADMSCs led to the expression of the differentiation markers of intervertebral disc-like cells, such as aggrecan, collagen II, and sox-9. Co-cultured ADMSCs treated with TGF-β3 showed higher expression of differentiation markers and greater extracellular matrix production compared with ADMSCs treated with TGF-β3 alone.

Conclusion

ADMSC treated with TGF-β3 may be an attractive source for regeneration therapy in degenerative IVD. These findings may also help elucidate the pathologic mechanism of MSC therapy in the degeneration of IVD in vivo.

Langerhans cell histiocytosis followed by Hodgkin's lymphoma

A 22-year-old man was referred to our institution due to lower back pain and was diagnosed with Langerhans cell histiocytosis of the thoracic and lumbar spine. The patient achieved complete remission with radiotherapy and chemotherapy. One year later, right cervical lymphadenopathy was observed and Hodgkin's lymphoma was confirmed on biopsy. The patient was treated with chemotherapy and autologous stem cell transplantation, and experienced no further symptoms. Further, no evidence of recurrence was observed on follow-up imaging. This report discusses the association between Langerhans cell histiocytosis and Hodgkin's lymphoma.

Endoscopic submucosal dissection with sentinel node navigation surgery for early gastric cancer

We combined endoscopic submucosal dissection (ESD) and sentinel node navigation surgery with the purpose of achieving complete resection of early gastric cancer while preserving the organ and assessing pathological nodal status. A total of 13 patients with cT1( ≤ 3 cm)N0 early gastric cancer underwent combined ESD and sentinel node navigation surgery (ESN) at a single tertiary referral center. Sentinel node navigation surgery using indocyanine green was performed during ESD and all suspected sentinel nodes were removed laparoscopically and examined intraoperatively. ESN was converted to gastrectomy with D2 dissection if there was evidence of metastasis on frozen section. ESN was completed in 12 patients and in 1 patient was converted to gastrectomy after sentinel node navigation surgery. En bloc tumor resection was achieved in all cases. Two patients underwent additional gastrectomy because they had tumor-positive vertical margins. In all cases ESN was conducted without intraoperative or postoperative adverse events. ESN is a feasible minimally invasive procedure that allows en bloc tumor resection to be achieved while assessing the pathological status of the lymph nodes.

Midline-Splitting Open Door Laminoplasty Using Hydroxyapatite Spacers : Comparison between Two Different Shaped Spacers

Objective

Although hydroxyapatite (HA) spacer has been used for laminoplasty, there have been no reports on factors associated with fusion and on the effects of HA shape.

Methods

During January 2004 and January 2010, 45 patients with compressive cervical myelopathy underwent midline-splitting open door laminoplasty with winged (33 cases) and wingless (12 cases) HAs by a single surgeon. Minimal and mean follow up times were 12 and 28.1 months, respectively. Japanese Orthopedic Association (JOA) score was used for clinical outcome measurement. Cervical X-rays were taken preoperatively, immediately post-operatively, and after 3, 6, and 12 months and computed tomography scans were performed preoperatively, immediately post-operatively and after 12 months. Cervical lordosis, canal dimension, fusion between lamina and HA, and affecting factors of fusion were analyzed.

Results

All surgeries were performed on 142 levels, 99 in the winged and 43 in the wingless HA groups. JOA scores of the winged group changed from 10.4±2.94 to 13.3±2.35 and scores of the wingless group changed from 10.8±2.87 to 13.8±3.05. There was no significant difference on lordotic and canal dimensional change between two groups. Post-operative 12 month fusion rate between lamina and HA was significantly lower in the winged group (18.2 vs. 48.8% p=0.001). Multivariate analysis showed that ossification of the posterior longitudinal ligament, male gender, and wingless type HA were significantly associated with fusion.

Conclusion

Clinical outcome was similar in patients receiving winged and wingless HA, but the wingless type was associated with a higher rate of fusion between HA and lamina at 12 months post-operatively.

Long-term results of spinal cord injury therapy using mesenchymal stem cells derived from bone marrow in humans

BACKGROUND

Although the transplantation of mesenchymal stem cells (MSCs) after spinal cord injury (SCI) has shown promising results in animals, less is known about the effects of autologous MSCs in human SCI.

OBJECTIVE

To describe the long-term results of 10 patients who underwent intramedullary direct MSCs transplantation into injured spinal cords.

METHODS

Autologous MSCs were harvested from the iliac bone of each patient and expanded by culturing for 4 weeks. MSCs (8 × 10) were directly injected into the spinal cord, and 4 × 10 cells were injected into the intradural space of 10 patients with American Spinal Injury Association class A or B injury caused by traumatic cervical SCI. After 4 and 8 weeks, an additional 5 × 10 MSCs were injected into each patient through lumbar tapping. Outcome assessments included changes in the motor power grade of the extremities, magnetic resonance imaging, and electrophysiological recordings.

RESULTS

Although 6 of the 10 patients showed motor power improvement of the upper extremities at 6-month follow-up, 3 showed gradual improvement in activities of daily living, and changes on magnetic resonance imaging such as decreases in cavity size and the appearance of fiber-like low signal intensity streaks. They also showed electrophysiological improvement. All 10 patients did not experience any permanent complication associated with MSC transplantation.

CONCLUSION

Three of the 10 patients with SCI who were directly injected with autologous MSCs showed improvement in the motor power of the upper extremities and in activities of daily living, as well as significant magnetic resonance imaging and electrophysiological changes during long-term follow-up.

Radiological and pathological evaluation of the spinal cord in a rat model of electrical injury-induced myelopathy

BACKGROUND

No study has reported an animal-based experimental model of electrical injury to the spinal cord. This paper presents the first systematic establishment of an animal model of electrical injury to the spinal cord with subsequent pathophysiologic analysis.

METHOD

The voltage required for the electrical shock was generated by an electroconvulsive therapy apparatus (57800 ECT unit; UGO BASILE, Italy). We used one side ear as the entry site and the contralateral hind limb as the exit site. Seven electrical shock (frequency, 120 Hz; pulse width, 0.9 ms; duration, 3 s; current, 99 mA) was applied to each rat and used rat showing hind limb weakness. Radiologic and histologic evaluations were performed at one day, one, two and four weeks after injury.

RESULTS

Twelve rats showed the hind limb weakness among the total 18 rats. Manganese-enhanced magnetic resonance imaging showed interruption of spinal cord enhancement in the thoracic area. Histological examination showed a greater decrease in the number of neurons in the ventral horn versus the dorsal horn.

CONCLUSION

This study demonstrates a novel design and analysis of an animal-based experimental model of spinal cord injury by electrical etiology. This model is useful for experimental studies of injuries to the spinal cord.

Evaluation of a multiple system atrophy model in rats using multitracer microPET

BACKGROUND

A double toxin-double lesion strategy is appropriate for mimicking of striatonigral degeneration. Because knowledge of human pathology is limited, animal models must be well characterized prior to testing of therapeutic approaches to treat multiple system atrophy. In double-toxin animal models, however, reduced contralateral rotation after apomorphine injection is restored within a few weeks via an unknown mechanism; the animals thus revert to PD status. We assessed this phenomenon using multitracer microPET and tissue staining.

METHODS

Five adult male Wistar rats received injections of 6-hydroxydopamine (6-OHDA) into the right medial forebrain bundle (MFB), followed 3 weeks later by injections of quinolinic acid (QA) into the ipsilateral striatum. Apomorphine-induced rotation tests were performed 1 week after each injection, and 6 and 10 weeks after QA injection. Rotarod tests were performed weekly after 6-OHDA injection. MSA-p status was characterized by microPET 5 and 10 weeks after QA injection using the tracers 2-deoxy-2-[(18)F]-fluoro-D-glucose ([(18)F]-FDG) and [(18)F]-N-(3-fluoropropyl)-2-carbomethoxy-3-(4-iodophenyl)nortropane ([(18)F]-FP-CIT). Histological changes were evaluated by tyrosine hydroxylase (TH) and cresyl violet staining.

RESULTS

The numbers of apomorphine-induced rotations increased contralaterally after 6-OHDA lesions were created, but decreased significantly after QA administration (p = 0.007). Five weeks after QA injection, however, contralateral rotation again increased and persisted for 1 month. Rotarod rotation differed significantly between the intact and PD states (p < 0.05), but not between the PD and MSA-p states. MicroPET revealed glucose hypometabolism and dopamine transporter (DAT) impairment on the lesioned side of the striatum 1 and 2 months after QA lesion surgery. Loss of nigral cells was confirmed by TH immunostaining, and striatal atrophy was observed upon cresyl violet staining.

CONCLUSION

Pathological changes consistent with MSA-p can be generated by the double toxin-double lesion method and persist during follow-up. Behavioral tests, such as drug-induced rotation and rotarod tests, are not appropriate for long-term follow-up in the MSA-p model, suggesting the need for development of more appropriate behavioral tests.

Efficacy of decompression and fixation for metastatic spinal cord compression: analysis of factors prognostic for survival and postoperative ambulation

OBJECTIVE

The goals of surgical intervention for metastatic spinal cord compression (MSCC) are prolonging survival and improving quality of life. Non-ambulatory paraplegic patients, either at presentation or after treatment, have a much shorter life expectancy than ambulatory patients. We therefore analyzed prognostic factors for survival and postoperative ambulation in patients surgically treated for MSCC.

METHODS

We assessed 103 patients with surgically treated MSCC who presented with lower extremity weakness between January 2001 and December 2008. Factors prognostic for overall survival (OS) and postoperative ambulation, including surgical method, age, sex, primary tumor site, metastatic spinal site, surgical levels, Tokuhashi score, and treatment with chemo- or radiation therapy, were analyzed retrospectively.

RESULTS

Median OS was significantly longer in the postoperatively ambulatory group [11.0 months; 95% confidence interval (CI), 9.29-12.71 months] than in the non-ambulatory group (5.0 months; 95% CI, 1.80-8.20 months) (p=0.035). When we compared median OS in patients with high (9-11) and low (0-8) Tokuhashi scores, they were significantly longer in the former (15.0 months; 95% CI, 9.29-20.71 months vs. 9.0 months; 95% CI, 7.48-10.52 months; p=0.003). Multivariate logistic regression analysis showed that preoperative ambulation with or without aid [odds ratio (OR) 5.35; 95% CI 1.57-18.17; p=0.007] and hip flexion power greater than grade III (OR 6.23; 95% CI, 1.29-7.35; p=0.038) were prognostic of postoperative ambulation.

CONCLUSION

We found that postoperative ambulation and preoperative high Tokuhashi score were significantly associated with longer patient survival. In addition, preoperative hip flexion power greater than grade III was critical for postoperative ambulation.

Radiographic Analysis of Instrumented Posterolateral Fusion Mass Using Mixture of Local Autologous Bone and b-TCP (PolyBone®) in a Lumbar Spinal Fusion Surgery

OBJECTIVE

Although iliac crest autograft is the gold standard for lumbar fusion, the morbidity of donor site leads us to find an alternatives to replace autologous bone graft. Ceramic-based synthetic bone grafts such as hydroxyapatite (HA) and b-tricalcium phosphate (b-TCP) provide scaffolds similar to those of autologous bone, are plentiful and inexpensive, and are not associated with donor morbidity. The present report describes the use of Polybone® (Kyungwon Medical, Korea), a beta-tricalcium phosphate, for lumbar posterolateral fusion and assesses clinical and radiological efficacy as a graft material.

METHODS

This study retrospectively analyzed data from 32 patients (11 men, 21 women) who underwent posterolateral fusion (PLF) using PolyBone® from January to August, 2008. Back and leg pain were assessed using a Numeric Rating Scale (NRS), and clinical outcome was assessed using the Oswestry Disability Index (ODI). Serial radiological X-ray follow up were done at 1, 3, 6 12 month. A computed tomography (CT) scan was done in 12 month. Radiological fusion was assessed using simple anterior-posterior (AP) X-rays and computed tomography (CT). The changes of radiodensity of fusion mass showed on the X-ray image were analyzed into 4 stages to assess PLF status.

RESULTS

The mean NRS scores for leg pain and back pain decreased over 12 months postoperatively, from 8.0 to 1.0 and from 6.7 to 1.7, respectively. The mean ODI score also decreased from 60.5 to 17.7. X-rays and CT showed that 25 cases had stage IV fusion bridges at 12 months postoperatively (83.3% success). The radiodensity of fusion mass on X-ray AP image significantly changed at 1 and 6 months.

CONCLUSION

The present results indicate that the use of a mixture of local autologous bone and PolyBone® results in fusion rates comparable to those using autologous bone and has the advantage of reduced morbidity. In addition, the graft radiodensity ratio significantly changed at postoperative 1 and 6 months, possibly reflecting the inflammatory response and stabilization.

Evaluation of efficacy and safety of fentanyl transdermal patch (Durogesic D-TRANS) in chronic pain

PURPOSE

Opioids are used in controlling several types of pain. This study was designed to evaluate the efficacy and safety of the fentanyl transdermal patch-type system (Durogesic® D-TRANS).

METHODS

Patients who complained of chronic moderate to severe pain were enrolled. Administration dosages of fentanyl patch started from 12.5 μg/h and could be increased by 12.5 μg/h or 25 μg/h, if the average pain score of 4 or higher occurred within 72 h. The total administration period was 12 weeks. The type, location, characteristics, and duration of pain were evaluated. Also, on day 0, weeks of 4, 8, and 12, the physician's assessment of pain intensity, the patient's assessment of pain intensity, the assessment of impact of pain on functions, and the assessment of the impact of pain on sleep were assessed. In addition, side effects were evaluated during the study duration.

RESULTS

A total of 65 cases were enrolled, and the final evaluated cases were 41. Before treatment, the average physician's assessment of pain intensity was 6.70 ± 1.41, and the average patient's assessment of pain intensity was 7.02 ± 1.63. In the final visit, the average physician's assessment of pain intensity was 2.58 ± 1.72, and the average patient's assessment of pain intensity was 2.86 ± 1.78.

CONCLUSIONS

This prospective study shows that the fentanyl patch is effective in alleviating moderate to severe chronic noncancer pain including neuropathic pain down to mild pain. Therefore, the fentanyl patch should be considered before other invasive intervention procedures in chronic moderate to severe noncancer pain.